Nelson Lourenço Maia Filho

Fatores determinantes para as expectativas de primigestas acerca da via de parto

OBJETIVO: conhecer as expectativas de primigestas com relacao a via de parto, bem como os motivos de sua escolha, procurando melhorar a qualidade do relacionamento medico-paciente. METODOS: foi realizado estudo do tipo qualitativo por meio da analise do sujeito coletivo, incluindo primigestas atendidas de setembro a novembro de 2003 nos pronto-socorros dos servicos da Faculdade de Medicina de Jundiai. Foi aplicado questionario especialmente elaborado para responder aos objetivos propostos pela pesquisa o questionario e baseado nas duvidas apresentadas por pacientes que frequentaram o servico meses antes da elaboracao do projeto. O consentimento livre e esclarecido, assinado pela gestante e por um dos pesquisadores responsaveis. Foi obtido para fins de padronizacao da amostra a selecao das pacientes seguiu criterios de inclusao: idade maior que 16 anos, primigestas, que estivessem recebendo assistencia pre-natal e consentimento pos-informado lido e esclarecido. Foram considerados criterios de exclusao pacientes mentalmente incapacitadas e gestantes de alto risco com doencas que pudessem interferir na escolha da paciente. RESULTADOS: a populacao estudada teve como perfil mais prevalente mulheres com mais de 21 anos, brancas, casadas, com segundo grau completo e que estavam no terceiro trimestre da gestacao. A via de parto de preferencia da maioria das mulheres (90%) foi o parto vaginal normal, sendo que as principais justificativas foram: a praticidade para sua realizacao (94%) e o medo do sofrimento e dor no pos-parto causados pela cesarea. Encontramos relacao entre a preferencia pelo parto vaginal com mulheres de maior idade, casadas, nao havendo diferenca significativa entre as racas. CONCLUSAO: estes resultados nos mostram enorme contraste entre a preferencia das mulheres e os altos indices de cesarea no Brasil. Concluimos que deve haver falha de informacao, falta de dialogo entre os profissionais da saude e a paciente sobre as possiveis dificuldades, duvidas e anseios que permeiam a escolha por determinada via de parto. Do ponto de vista etico concluimos que os obstetras devem questionar cada indicacao para a realizacao de uma cesarea e respeitar a autonomia da escolha materna sem ignorar os verdadeiros criterios clinicos que levam a decisao medica pela via de parto.

Applying the Maternal Near Miss Approach for the Evaluation of Quality of Obstetric Care: A Worked Example from a Multicenter Surveillance Study

Objective. To assess quality of care of women with severe maternal morbidity and to identify associated factors. Method. This is a national multicenter cross-sectional study performing surveillance for severe maternal morbidity, using the World Health Organization criteria. The expected number of maternal deaths was calculated with the maternal severity index (MSI) based on the severity of complication, and the standardized mortality ratio (SMR) for each center was estimated. Analyses on the adequacy of care were performed. Results. 17 hospitals were classified as providing adequate and 10 as nonadequate care. Besides almost twofold increase in maternal mortality ratio, the main factors associated with nonadequate performance were geographic difficulty in accessing health services (P < 0.001), delays related to quality of medical care (P = 0.012), absence of blood derivatives (P = 0.013), difficulties of communication between health services (P = 0.004), and any delay during the whole process (P = 0.039). Conclusions. This is an example of how evaluation of the performance of health services is possible, using a benchmarking tool specific to Obstetrics. In this study the MSI was a useful tool for identifying differences in maternal mortality ratios and factors associated with nonadequate performance of care.

Combined spinal-epidural block versus continuous epidural block in labor analgesia for primiparous women: newborns and women outcomes

PURPOSE To compare maternal and perinatal results, after the use of continuous peridural versus combined rachidian and peridural analgesia in primiparous parturients. METHODS Randomized clinical trial with 128 primiparous pregnant women in labor, divided into two groups: peridural analgesia (CPA) with 65 women, and combined continuous rachidian and peridural analgesia (CRPA) with 63, all of them admitted in the pre-labor period at two maternities in Jundiai, in the state of São Paulo. The variables studied were: latency of analgesia onset, pain intensity, total time until complete dilation, Apgar index at the first and fifth minutes, labor duration, degree of motor blockade, adverse effects such as vomiting, pruritus, arterial hypotension and degree of maternal fulfillment. Inclusion criteria were: primiparous, physical condition ASA 1 and 2, an only foetus, cephalic presentation, term delivery, 3 to 6 cm cervical dilation, and analgesia required by the obstetrician. Women with morbidity, membrane rupture, fetal abnormality and use of opioids up to four hours before were excluded. The Mann-Whitney test was used for the statistical analysis of non-parametric continuous variables, and Fishers exact and Pearsons chi2 tests, for the categoric variables. RESULTS There was no difference between the groups concerning the length of cervical dilation, labor duration, maternal hemodynamic parameters, newborn vitality, analgesic complementation during labor and type of delivery. Analgesia onset was quicker in the CRPA group, and the CPA group presented less motor blockade. Differences concerning adverse effects such as nausea, vomiting, pruritus and hypotension have not been observed, but hypotension was more frequent in the CPA group (6.3 versus 3.1%). CONCLUSIONS Both techniques have proved to be safe and efficient, but CRP has provided an earlier onset, with quicker pain relief. The lesser motor blockade in the CPA group has allowed the parturients more active movements in bed and more effective collaboration during the expulsion period. Most women were pleased with the analgesia they got. The doses of local anesthetics and opioids used in both analgesic techniques and the complementary doses, equal in both groups, neither had any significant adverse effect nor affected newborn vitality.

Efetividade de duas diferentes doses de misoprostol por via vaginal para preparo cervical e indução do parto

PURPOSE: to compare the effectiveness and safety of two different doses of misoprostol (12.5 mg and 25 mg) administered vaginally for cervical ripening and labor induction in term pregnancies with an indication for interruption. METHODS: this was a pilot randomized controlled single blinded trial, including 40 pregnant women treated with one of the two different doses of misoprostol. The independent variable was the dose of misoprostol and the main dependent variables were the mode of delivery, time between induction and delivery, perinatal complications and maternal side effects. The main control variables were maternal age, gestational age, literacy, parity, skin color and conditions of the cervix at the beginning of induction. For data analysis Students t test, c2, exact Fisher, Wilcoxon and Kolmogorov-Smirnof tests were used, besides survival analysis. RESULTS: the groups using 12.5 and 25 mg were similar and did not present any significant difference regarding time for onset of uterine contractions (20.9±20.4 and 16.6±9.8 h, respectively), time between onset of uterine contractions and delivery (7.8±3.4 and 6.9±5.0 h), vaginal delivery (65 and 80%) and maternal and perinatal side effects (similar Apgar scores and hyperstimulation syndrome in both groups). CONCLUSION: the higher percentage of vaginal births and the shorter time for delivery using 25 mg, although not significant, does not allow to recommend the dose of 12.5 mg as more advantageous for cervical ripening and labor induction in term pregnancies.

Comparação entre conduta ativa com ocitocina e conduta expectante na rotura prematura de membranas em gestações a termo

Objetivos: comparar, em uma populacao de gestantes brasileiras com rotura prematura de membranas a termo (RPM-T), as condutas expectante ou ativa com ocitocina. Metodos: ensaio clinico prospectivo, randomizado e multicentrico, avaliando as variaveis relativas ao tempo para o inicio do trabalho de parto e parto e tempo de internacao hospitalar materna e neonatal. Foram selecionadas 200 gestantes com RPM-T, atendidas em quatro instituicoes publicas do estado de Sao Paulo de novembro de 1995 a fevereiro de 1997. As pacientes foram divididas aleatoriamente em dois grupos de conduta: ativa, com inducao do trabalho de parto com ocitocina iniciando ate 6 h de RPM, e expectante, aguardando-se o inicio espontâneo do trabalho de parto por um periodo maximo de 24 h. Os dados foram analisados com o auxilio dos programas Epi-Info e SPSS-PC+, utilizando-se os testes estatisticos do c2, t de Student e Log-rank. Resultados: indicam que as diferencas entre a utilizacao da conduta ativa com ocitocina e a conduta expectante dizem respeito ao maior tempo necessario no grupo de conduta expectante para o inicio do trabalho de parto e parto, alem da maior proporcao de mulheres e recem-nascidos com internacao superior a tres dias. Conclusoes: o tempo entre a admissao e o parto, o periodo de latencia e o tempo entre a rotura das membranas e o parto foram maiores quando se adotou conduta expectante.