Olímpio Barbosa de Moraes Filho

Fatores associados à realização de cesariana em hospitais brasileiros

OBJETIVO: Avaliar a prevalencia de cesariana em hospitais brasileiros. METODOS: Estudo transversal com dados do Sistema Global de Dados para a Saude Materna e Perinatal, da Organizacao Mundial da Saude, para os estados de Sao Paulo, Pernambuco e Distrito Federal. Analisaram-se dados de 15.354 mulheres que tiveram parto entre setembro/2004 e marco/2005, segundo caracteristicas sociodemograficas e reprodutivas e do hospital. Foram realizadas analises bivariada - com calculos de razoes de prevalencia e respectivos intervalos de confianca- e multivariada por regressao de Poisson. RESULTADOS: A razao de prevalencia de cesarianas foi significativamente maior entre mulheres com maior idade, entre as casadas/unidas, e com maior indice de massa corporal. As condicoes apresentadas durante a gravidez ou parto, como diagnostico de HIV da parturiente, maior peso e perimetro cefalico do recem-nascido, e maior numero de consultas de pre-natal, se associaram a maior razao de prevalencia de cesariana. Na analise de regressao mostraram associacao direta com o desfecho: maior idade e escolaridade da parturiente; presenca de hipertensao/eclâmpsia, doencas cronicas e de outras condicoes medicas; maior perimetro cefalico do recem-nascido, ser primipara, ter tido cesariana na ultima gravidez, e ter recebido analgesia peridural ou raquidiana durante o trabalho de parto. Embora a proporcao de cesarianas tenha sido maior nos hospitais com indice de complexidade alto, a diferenca nao foi estatisticamente significante, assim como para as demais caracteristicas dos hospitais. CONCLUSOES: As condicoes da gravidez, do recem-nascido e as caracteristicas sociodemograficas e reprodutivas da parturiente associaram-se independentemente a realizacao de cesariana. O indice de complexidade hospitalar nao esteve associado, provavelmente pela homogeneidade da amostra de hospitais.OBJECTIVE To assess the prevalence of cesarean sections in Brazilian hospitals. METHODS A cross-sectional study was carried out with data from the World Health Organizations Global Data System for Maternal and Perinatal Health, for the Brazilian states of São Paulo, Pernambuco and the Federal District. Data relating to 15,354 women who gave birth between September/2004 and March/2005 were analyzed, according to sociodemographic, reproductive, and hospital-related characteristics. Bivariate analyses - with calculations of the prevalence ratios and respective confidence intervals - and multivariate Poisson regression analyses were performed. RESULTS The prevalence ratio of cesarean sections was significantly higher among older women, who were married/living with a partner and with higher body mass index. The following conditions during pregnancy or birth were associated with higher cesarean section prevalence ratio: parturient being diagnosed as HIV-positive, heavier weight and greater head circumference of the newborn, and more prenatal consultations. In regression analysis, the following variables showed direct association with the outcome: parturient being older and with higher schooling level, presence of hypertension/eclampsia, chronic condition or some other medical condition, newborns greater head circumference, being primiparous, having had a cesarean in the last pregnancy and having received an epidural block or rachidian analgesic during labor. Although the proportion of cesareans was higher in hospitals with a high complexity index, the difference was not statistically significant, as well as for other characteristics of hospitals. CONCLUSIONS The conditions of the pregnancy, newborn and the sociodemographic and reproductive characteristics of the parturient were independently associated with cesarean delivery. The hospital complexity index was not associated with cesarean delivery, probably due to the homogeneity of the hospital sample.

A randomized controlled trial comparing vaginal misoprostol versus Foley catheter plus oxytocin for labor induction

Objective. To compare effectiveness and safety of 25 μg vaginal misoprostol versus Foley catheter and oxytocin for cervical ripening and labor induction in pregnant women with unripe cervices. Design. Randomized controlled trial. Setting. A public maternity in Recife, Brazil. Sample. A total of 240 pregnant women. Methods. Women with a term or post‐term, live, singleton fetus in cephalic presentation, intact membranes, Bishop score <6, not in labor, medically indicated for labor induction. They were randomly divided in Group 1, where 119 women received 25 μg of intravaginal misoprostol every 6 hours for a maximum of four doses; and Group 2, where 121 women had a 14‐F Foley catheter inserted into their cervical canal. Once past the internal os, the balloon was inflated. Intravenous oxytocin was initiated after the balloon was spontaneously extruded from the cervix or after 24 hours. Results. There were no significant differences between the groups regarding baseline characteristics. Misoprostol was more effective in inducing labor than Foley catheter and oxytocin. Mean induction‐to‐vaginal delivery time with misoprostol was shorter (17.3 vs. 20.2 hours, p = 0.016). There were more vaginal deliveries in the misoprostol group at 12 (p < 0.001) and 18 (p = 0.007) hours, but the difference was no longer statistically significant at 24 and 48 hours. There were no significant differences in uterine contraction abnormalities, puerperal infection or neonatal outcomes. Conclusions. Vaginal misoprostol is more effective than and as safe as Foley catheter and oxytocin for induction of labor in term and post‐term pregnancy.

Prevalência e fatores associados à prática da episiotomia em maternidade escola do Recife, Pernambuco, Brasil

OBJETIVO: Determinar a prevalencia e fatores associados a realizacao de episiotomia em centro de referencia de Pernambuco. METODOS: Estudo retrospectivo, tipo corte transversal, no periodo de janeiro a dezembro de 2006 com 495 mulheres (escolhidas de uma populacao total de 2564) submetidas a parto normal na Maternidade Professor Monteiro de Moraes do Centro Integrado de Saude Amaury de Medeiros (CISAM) da Universidade de Pernambuco. Os fatores avaliados foram aspectos que antecederam o parto, caracteristicas do trabalho de parto e resultados perinatais. Para verificar associacao entre as variaveis preditoras e realizacao da episiotomia, foram utilizados testes Qui quadrado, exato de Fisher e T de Student, quando pertinentes, a um nivel de significância de 5%. A razao de prevalencia e intervalo de confianca a 95% foram calculados, alem da analise de regressao logistica. RESULTADOS: A prevalencia de realizacao de episiotomia foi de 29,1% (n=144). Apos analise bivariada, encontrou-se associacao significativa da episiotomia com adolescencia (RP 1,74; IC95% 1,33-2,28), idade superior a 35 anos (RP 0,35; IC95% 0,14-0,90), primiparidade (RP 4,73; IC95% 3,33-6,71), ausencia de parto vaginal previo, grupo que inclui alem das primiparas pacientes que foram submetidas a parto cesariano em gestacao anterior (RP 5,44; IC95% 3,67-8,06) e doencas associadas no momento do parto (RP 1,71; IC95% 1,30-2,25). Nao foi encontrada relacao significativa com idade gestacional no parto, duracao do trabalho de parto acima de seis horas (tempo medio da fase ativa do trabalho de parto), periodo expulsivo maior que 30 minutos (considerado prolongado), uso de misoprostol ou ocitocina, alteracoes da frequencia cardiaca fetal, presenca de meconio, turno de realizacao do parto (noturno ou diurno), indice de Apgar, no primeiro e quinto minutos e peso do recem- nascido. A presenca de laceracoes perineais foi maior no grupo nao submetido a episiotomia, porem so foram descritas laceracoes de primeiro e segundo graus. Apos analise de regressao logistica os fatores que permaneceram associados a episiotomia foram doencas maternas (RA 1,99; IC95% 1,20-3,28) e ausencia de parto vaginal anterior (RA 9,85; IC95% 6,04-16,06). CONCLUSAO: A prevalencia da realizacao de episiotomia na instituicao foi de 29%. As variaveis que continuaram relacionadas a episiotomia foram doencas maternas e ausencia de parto vaginal anterior.

Misoprostol sublingual versus vaginal para indução do parto a termo

OBJETIVO: comparar efetividade e seguranca de uso de comprimido sublingual de 25 µg de misoprostol com o comprimido vaginal de 25 µg do misoprostol na inducao do parto com idade gestacional e > 37 semanas e colo uterino desfavoravel. METODOS: realizou-se ensaio clinico controlado e aleatorizado, nao cego, na Maternidade Monteiro de Morais (CISAM-UPE), em Recife, no periodo de outubro de 2003 a fevereiro de 2004. Participaram do estudo 123 gestantes com idade gestacional e > 37 semanas, indice de Bishop <8 e fora de trabalho de parto, que apresentavam indicacao para interrupcao da gravidez. As gestantes aleatoriamente receberam 25 µg de misoprostol sublingual ou 25 µg de misoprostol vaginal a cada seis horas, ate uma dose maxima de oito comprimidos (200 µg). Para verificar diferencas entre os grupos foram utilizados media, desvio padrao, teste t de Student, c2 para tendencia e teste de Mann-Whitney. O valor de significacao estatistica adotado foi de 5%. RESULTADOS: nao houve diferenca significativa entre o numero de mulheres que tiveram parto por via vaginal no grupo do misoprostol sublingual e no vaginal (65,5% vs 75,8%, p=0,22). Tambem nao foi significativa a diferenca do intervalo de tempo entre o inicio da inducao e o parto (24 horas e 42 minutos vs 20 horas e 37 minutos, respectivamente, p=0,11) entre os grupos. Os grupos, sublingual e vaginal, nao mostraram tambem diferencas significativas em relacao a sindrome de hiperestimulacao (1,7% vs 3,2%, p=0,95), as incidencias de meconio (5,2% vs 4,8%, p=0,74), ao indice de Apgar <7 no quinto minuto (3,4% vs 4,8%, p=0,98) e a outros efeitos adversos. CONCLUSAO: o misoprostol na dose de 25 mg por via sublingual apresentou a mesma efetividade e seguranca quando comparado com a mesma dose vaginal para inducao do parto. O misoprostol por via sublingual parece representar mais uma opcao a ser considerada na inducao do parto.

Métodos para indução do parto

The interest of modern obstetrics in labor induction can be demonstrated by the huge amount of scientific articles published during the last few years. The advances of medicine in general and particularly of obstetrics allowed that more risky pregnancies reach term or near term, with a maternal or fetal indication for pregnancy interruption before the spontaneous onset of labor and delivery. This leads the obstetrician to the situation of choosing between cesarean section and labor induction. With the aim of helping the obstetrician to make the choice for labor induction and thus collaborate with the reduction in cesarean section rates, it is necessary that an accessible, cheap, safe, effective, easy to be used method with good acceptability is available. Although several methods of labor induction reported in medical literature do exist, it is known that there is no ideal method. However, among them, two are highlighted. The first is oxytocin, which has the advantages of promoting physiologic uterine contractions of labor and reverting uterine hypercontractility when suspended. The other method is misoprostol, nowadays the most used, which ripens the uterine cervix and induces uterine contractions of labor. However, there are still some controversies regarding its ideal dose, route and safety.

Análise dos fatores de risco anteparto para ocorrência de cesárea

OBJETIVOS: criar um modelo preditivo para ocorrencia de cesarea na Maternidade Professor Monteiro de Morais apos avaliacao dos fatores de risco anteparto das gestantes que pariram no periodo de 1 de setembro de 1999 a 31 de agosto de 2000, e posteriormente verificar a eficiencia do servico na indicacao de cesarea. METODOS: foi realizado estudo longitudinal, do tipo caso-controle com 3626 gestantes, no qual se verificou quais os fatores anteparto foram considerados de risco para cesarea, no periodo de 1 de setembro de 1999 a 31 de agosto de 2000. Posteriormente, criou-se modelo preditivo ideal, o qual permitiu quantificar o risco de cesarea para cada paciente na presenca de um ou mais fatores de risco. A seguir, aplicou-se o modelo a amostra do estudo a fim de verificar o grau de concordância entre o risco previsto de cesarea e a realizacao do ato cirurgico, ou seja, a eficacia na indicacao de cesariana. RESULTADOS: aplicando-se o modelo preditivo na amostra, verificou-se que na ausencia dos fatores de riscos anteparto, o risco basal de cesarea foi de 15,2%. O grau de concordância entre o previsto pelo modelo logistico e a ocorrencia de cesarea foi de 86,6%. CONCLUSOES: o modelo logistico permitiu identificar o risco basal de cesarea e quantificar a probabilidade de cesarea a partir da introducao do fator de risco. O modelo pode ser considerado util e eficaz, uma vez que houve concordância entre o acerto e o previsto em 86,6% para cesariana, e 53,6% das pacientes submetidas ao parto normal, de fato, nao tinham fator de risco para cesarea.

Factors associated with cesarean sections in Brazilian hospitals

OBJETIVO: Avaliar a prevalencia de cesariana em hospitais brasileiros. METODOS: Estudo transversal com dados do Sistema Global de Dados para a Saude Materna e Perinatal, da Organizacao Mundial da Saude, para os estados de Sao Paulo, Pernambuco e Distrito Federal. Analisaram-se dados de 15.354 mulheres que tiveram parto entre setembro/2004 e marco/2005, segundo caracteristicas sociodemograficas e reprodutivas e do hospital. Foram realizadas analises bivariada - com calculos de razoes de prevalencia e respectivos intervalos de confianca- e multivariada por regressao de Poisson. RESULTADOS: A razao de prevalencia de cesarianas foi significativamente maior entre mulheres com maior idade, entre as casadas/unidas, e com maior indice de massa corporal. As condicoes apresentadas durante a gravidez ou parto, como diagnostico de HIV da parturiente, maior peso e perimetro cefalico do recem-nascido, e maior numero de consultas de pre-natal, se associaram a maior razao de prevalencia de cesariana. Na analise de regressao mostraram associacao direta com o desfecho: maior idade e escolaridade da parturiente; presenca de hipertensao/eclâmpsia, doencas cronicas e de outras condicoes medicas; maior perimetro cefalico do recem-nascido, ser primipara, ter tido cesariana na ultima gravidez, e ter recebido analgesia peridural ou raquidiana durante o trabalho de parto. Embora a proporcao de cesarianas tenha sido maior nos hospitais com indice de complexidade alto, a diferenca nao foi estatisticamente significante, assim como para as demais caracteristicas dos hospitais. CONCLUSOES: As condicoes da gravidez, do recem-nascido e as caracteristicas sociodemograficas e reprodutivas da parturiente associaram-se independentemente a realizacao de cesariana. O indice de complexidade hospitalar nao esteve associado, provavelmente pela homogeneidade da amostra de hospitais.OBJECTIVE To assess the prevalence of cesarean sections in Brazilian hospitals. METHODS A cross-sectional study was carried out with data from the World Health Organizations Global Data System for Maternal and Perinatal Health, for the Brazilian states of São Paulo, Pernambuco and the Federal District. Data relating to 15,354 women who gave birth between September/2004 and March/2005 were analyzed, according to sociodemographic, reproductive, and hospital-related characteristics. Bivariate analyses - with calculations of the prevalence ratios and respective confidence intervals - and multivariate Poisson regression analyses were performed. RESULTS The prevalence ratio of cesarean sections was significantly higher among older women, who were married/living with a partner and with higher body mass index. The following conditions during pregnancy or birth were associated with higher cesarean section prevalence ratio: parturient being diagnosed as HIV-positive, heavier weight and greater head circumference of the newborn, and more prenatal consultations. In regression analysis, the following variables showed direct association with the outcome: parturient being older and with higher schooling level, presence of hypertension/eclampsia, chronic condition or some other medical condition, newborns greater head circumference, being primiparous, having had a cesarean in the last pregnancy and having received an epidural block or rachidian analgesic during labor. Although the proportion of cesareans was higher in hospitals with a high complexity index, the difference was not statistically significant, as well as for other characteristics of hospitals. CONCLUSIONS The conditions of the pregnancy, newborn and the sociodemographic and reproductive characteristics of the parturient were independently associated with cesarean delivery. The hospital complexity index was not associated with cesarean delivery, probably due to the homogeneity of the hospital sample.

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.

Não-fechamento dos peritônios visceral e parietal na operação cesariana

Purpose: to determine whether nonclosure of the visceral and parietal peritoneum is of benefit for the intraoperative or postoperative course of cesarean section. Methods: six hundred and ninety-eight women scheduled for cesarean section were randomized to either closure of both visceral and parietal peritoneum (n = 349) or no peritoneal closure (n = 349), at the Maternidade da Encruzilhada (CISAM) in Recife, from November 1997 to December 1998. Statistical analysis compared intraoperative and postoperative outcome between the two groups. There was no difference regarding age, parity, gestational age, antibiotic prophylaxis, headache after spinal anesthesia, cystitis, ruptured membranes and indications for cesarean section. Results: operating time, number of absorbable sutures and use of analgesics were significantly lower in the group without closure. The incidence of febrile morbidity, wound infection and endometritis was similar in the two groups. There was no difference in the need for antiphysetics, antiemetics and mineral oil. The average hospital stay was similar in the two groups. Conclusions: nonclosure of the visceral and parietal peritoneum at cesarean section was not associated with adverse effects on the postoperative course; on the contrary, it reduced the use of analgesics, and intraoperatively it reduced operating time and the number of absorbable sutures.

Amniotic fluid volume associated with fetal anomalies diagnosed in a reference center in the Brazilian Northeast

PURPOSE to determine factors associated to amniotic fluid volume and frequencies of fetal anomalies, in a reference center in Pernambuco. METHODS a transversal study performed in high-risk pregnant women submitted to obstetrical morphological ultrasound, from March 2002 to March 2006, at an institution from Recife, Pernambuco, Brasil. The intrauterine diagnosis was confirmed after birth. Sociodemographic and obstetrical characteristics, amniotic liquid volume and presence of fetal anomalies were the variables studied. Fishers exact, chi2, and Students t tests, at a significance level of 5% were applied to verify the correlation among the variables. Prevalence rate and confidence interval at 95% were calculated. Multiple logistic regression analysis was performed at a significance level of 5%. RESULTS Two hundred and fifty-seven pregnant women (56.2%) with congenital anomalies and 200 (43.8%) without anomalies, confirmed in the postnatal, were included in the study. The average of maternal ages and gestation periods were 24.8+/-6.5 years and 35.9+/-3.7 weeks, respectively. The fetal anomalies were discovered in the central nervous system (50.6%) and genitourinary tract (23.0%). The presence of congenital anomalies were significantly linked with reduced liquid/oligohydramnios (p=0.0002) and increased liquid/polyhydramnios (p<0.0001). Intrauterine mortality was more frequent in the group with anomalies, as compared to the healthy fetuses (10.5 versus 2.5%; p<0.01). CONCLUSIONS The rate of congenital anomalies in the high-risk pregnant women group was 56.2%. Most of the central nervous system malformations were diagnosed intrauterus. Changes in the amniotic fluid were the factors more strongly associated with congenital anomalies.