Ruth Hitomi Osava

Risk factors for birth‐related perineal trauma: a cross‐sectional study in a birth centre

AIM AND OBJECTIVES To identify maternal, newborn and obstetric factors associated with birth-related perineal trauma in one independent birth centre. BACKGROUND Risk factors for birth-related perineal trauma include episiotomy, maternal age, ethnicity, parity and interventions during labour including use of oxytocin, maternal position at time of birth and infant birth weight. Understanding more about these factors could support the management of vaginal birth to prevent spontaneous perineal trauma, in line with initiatives to reduce routine use of episiotomy. DESIGN Cross-sectional study. METHODS Data were retrospectively collected from one independent birth centre in Brazil, during 2006-2009. The dependent variable (perineal trauma) was classified as: (1) intact perineum or first-degree laceration, (2) second-degree laceration and (3) episiotomy (right mediolateral or median). RESULTS There were 1079 births during the study period. Parity, use of oxytocin during labour, position at time of giving birth and infant birth weight were associated with second-degree lacerations and episiotomies. After adjusting for parity, oxytocin, maternal position at the expulsive stage of labour and infant birth weight influenced perineal outcomes among primiparae only. CONCLUSIONS Although the overall rate of episiotomies in this study was low compared with national data, it was observed that younger women were most vulnerable to this intervention. In this age group in particular, the use of oxytocin as well as semi-upright positions at the time of birth was associated with second-degree lacerations and episiotomies. RELEVANCE TO CLINICAL PRACTICE The use of upright alternative positions for birth and avoidance of use of oxytocin could reduce the risk of perineal trauma from lacerations and need to perform episiotomy.

Parto domiciliar planejado: resultados maternos e neonatais

The hospitalization of all women in labour, in the interests of thesafety and well-being of mother and baby introduced mechanical,impersonal and interven...

Care in a birth center according to the recommendations of the World Health Organization

Birth centers are maternal care models that use appropriate technology when providing care to birthing women. This descriptive study aimed to characterize intrapartum care in a freestanding birth center, in light of the practices recommended by the World Health Organization (WHO), with 1,079 assisted births from 2006 to 2009 in the Sapopemba Birth Center, São Paulo, Brazil. Results included the use of intermittent auscultation (mean=7 controls); maternal positions during delivery: semi-sitting (82.3%), side-lying (16.0%), other positions (1.7%), oral intake (95.6%); companionship (93.3%); exposure to up to three vaginal examinations (85.4%), shower bathing (84.0%), walking (68.0%), massage (60.1%), exercising with a Swiss ball (51.7%); amniotomy (53.4%), oxytocin use during the first (31.0%) and second stages of labor (25.8%), bath immersion (29.3%) and episiotomy (14.1%). In this birth center, care providers used practices recommended by the WHO, although some practices might have been applied less frequently.Birth centers are maternal care models that use appropriate technology when providing care to birthing women. This descriptive study aimed to characterize intrapartum care in a freestanding birth center, in light of the practices recommended by the World Health Organization (WHO), with 1,079 assisted births from 2006 to 2009 in the Sapopemba Birth Center, Sao Paulo, Brazil. Results included the use of intermittent auscultation (mean=7 controls); maternal positions during delivery: semi-sitting (82.3%), side-lying (16.0%), other positions (1.7%), oral intake (95.6%); companionship (93.3%); exposure to up to three vaginal examinations (85.4%), shower bathing (84.0%), walking (68.0%), massage (60.1%), exercising with a Swiss ball (51.7%); amniotomy (53.4%), oxytocin use during the first (31.0%) and second stages of labor (25.8%), bath immersion (29.3%) and episiotomy (14.1%). In this birth center, care providers used practices recommended by the WHO, although some practices might have been applied less frequently.

LOW-LEVEL LASER THERAPY FOR PAIN RELIEF AFTER EPISIOTOMY: A DOUBLE-BLIND RANDOMISED CLINICAL TRIAL

AIMS AND OBJECTIVES To evaluate the effectiveness of a low-level laser therapy for pain relief in the perineum following episiotomy during childbirth. BACKGROUND Laser irradiation is a painless and non-invasive therapy for perineal pain treatment and its effects have been investigated in several studies, with no clear conclusion on its effectiveness. DESIGN A double-blind randomised controlled clinical trial. METHOD One hundred and fourteen women who underwent right mediolateral episiotomies during vaginal birth in an in-hospital birthing centre in São Paulo, Brazil and reported pain ≥ 3 on a numeric scale (0-10) were randomised into three groups of 38 women each: two experimental groups (treated with red and infrared laser) and a control group. The experimental groups were treated with laser applied at three points directly on the episiotomy after suturing in a single session between 6-56 hours postpartum. We used a diode laser with wavelengths of 660 nm (red laser) and 780 nm (infrared laser). The control group participants underwent all laser procedures, excluding the emission of irradiation. The participants and the pain scores evaluator were blinded to the type of intervention. The perineal pain scores were assessed at three time points: before, immediately after and 30 minutes after low-level laser therapy. RESULTS The comparison of perineal pain between the three groups showed no significant differences in the three evaluations (p = 0.445), indicating that the results obtained in the groups treated with low-level laser therapy were equivalent to the control group. CONCLUSIONS Low-level laser therapy did not decrease the intensity of perineal pain reported by women who underwent right mediolateral episiotomy. RELEVANCE TO CLINICAL PRACTICE The effect of laser in perineal pain relief was not demonstrated in this study. The dosage may not have been sufficient to provide relief from perineal pain after episiotomy during a vaginal birth.

Caracterização das cesarianas em centro de parto normal

OBJECTIVE To estimate the prevalence of cesarean sections in a birth center of a hospital and identify factors associated. METHODS Cross-sectional study including medical records of 2,441 births assisted in a birth center in the city of São Paulo, southeastern Brazil, between March and April 2005. The dependent variable (type of delivery) included vaginal delivery and cesarean section. The independent variables were grouped into four categories: demographic characteristics; current and past obstetric history; intrapartum care; and perinatal outcomes. Prevalence ratios and 95% confidence intervals (95% CI) were estimated to assess the association between type of delivery and maternal and newborn variables. RESULTS Of all deliveries, 14.9% were cesarean sections. Cesarean section in the current pregnancy was associated with past cesarean sections (PR = 3.19, 95%CI: 2.64,3.84); gestational age > 40 weeks (PR = 1.32, 95%CI: 1.09;1.61); cervical dilation of up to 4 cm on admission (PR = 3.22, 95%CI: 2.31;4.50); and meconium-stained amniotic fluid (PR = 2.5, 95%CI: 2.05;3.06). Regarding newborn characteristics cesarean section was associated with birth weight >4 kg (PR = 1.86, 95%CI: 1.29;2.66). Among women with history of past cesarean sections, having had also a prior vaginal delivery was a protective factor for cesarean section in the current pregnancy (PR = 0.46, 95%CI: 0.30;0.71). Factors related to fetal conditions including fetal stress, meconium-stained amniotic fluid, breech presentation and macrosomia accounted for 47.8% (175) while those related to the mechanism of birth including arrest disorders, functional dystocia and malposition accounted for 31,3% (115) of all indications for a cesarian section [corrected]. CONCLUSIONS Prevalence of c-section was consistent with World Health Organization recommendations. Increased risk of c-section was associated with prior history of c-sections, cervical dilation of at least 4 cm upon admission, gestational age > 40 weeks, meconium-stained amniotic fluid, and birthweight > 4 kg.OBJETIVO: Estimar a prevalencia de cesarianas em um centro de parto normal intra-hospitalar e identificar fatores associados. METODOS: Estudo transversal com analise de prontuarios de 2.441 partos assistidos em marco e abril de 2005 em um centro de parto normal intra-hospitalar de Sao Paulo, SP. A variavel dependente (tipo de parto) foi classificada como parto normal e operacao cesariana. As variaveis independentes foram categorizadas em quatro grupos: demograficas; historia obstetrica pregressa e atual; assistencia intraparto; e resultados perinatais. A razao de prevalencia e o intervalo de 95% de confianca (IC95%) foram calculados para identificar associacao entre tipo de parto e variaveis maternas e do recem-nascido. RESULTADOS: Do total de partos, 14,9% foram operacoes cesarianas. Ter sido submetida a cesariana na gestacao atual esteve associado a cesariana em gestacao anterior (RP = 3,19; IC95%: 2,64;3,84), idade gestacional > 40 semanas (RP = 1,32; IC95%: 1,09;1,61), ser admitida com cervicodilatacao ate 4 cm (RP = 3,22; IC95%: 2,31;4,50), liquido amniotico meconial (RP = 2,5; IC95%: 2,05;3,06). Quanto ao recem-nascido, a cesariana associou-se a peso > 4kg (RP = 1,86; IC95%: 1,29;2,66). Entre as mulheres com cesariana em gestacao anterior, ter tambem parto normal previo foi fator de protecao para cesariana na gestacao atual (RP = 0,46; IC95% 0,30;0,71). Fatores relacionados a condicao fetal, como estresse fetal, liquido amniotico meconial, apresentacao pelvica e macrossomia corresponderam a 47,8% (175) das indicacoes para a realizacao da cesariana; condicoes ligadas ao mecanismo do parto, como parada de progressao, distocia funcional e distocia de rotacao totalizaram 31,3% (115) das indicacoes. CONCLUSOES: A prevalencia de cesariana mostrou-se dentro dos limites propostos pela Organizacao Mundial da Saude. Mulheres com cesariana em gestacao anterior, admitidas com ate 4 cm de dilatacao, idade gestacional > 40 semanas, com liquido amniotico meconial e recem-nascido > 4 kg tiveram maior risco para cesariana.

Assistencia em um centro de parto segundo as recomendacoes da Organizacao Mundial da Saude

Birth centers are maternal care models that use appropriate technology when providing care to birthing women. This descriptive study aimed to characterize intrapartum care in a freestanding birth center, in light of the practices recommended by the World Health Organization (WHO), with 1,079 assisted births from 2006 to 2009 in the Sapopemba Birth Center, São Paulo, Brazil. Results included the use of intermittent auscultation (mean=7 controls); maternal positions during delivery: semi-sitting (82.3%), side-lying (16.0%), other positions (1.7%), oral intake (95.6%); companionship (93.3%); exposure to up to three vaginal examinations (85.4%), shower bathing (84.0%), walking (68.0%), massage (60.1%), exercising with a Swiss ball (51.7%); amniotomy (53.4%), oxytocin use during the first (31.0%) and second stages of labor (25.8%), bath immersion (29.3%) and episiotomy (14.1%). In this birth center, care providers used practices recommended by the WHO, although some practices might have been applied less frequently.Birth centers are maternal care models that use appropriate technology when providing care to birthing women. This descriptive study aimed to characterize intrapartum care in a freestanding birth center, in light of the practices recommended by the World Health Organization (WHO), with 1,079 assisted births from 2006 to 2009 in the Sapopemba Birth Center, Sao Paulo, Brazil. Results included the use of intermittent auscultation (mean=7 controls); maternal positions during delivery: semi-sitting (82.3%), side-lying (16.0%), other positions (1.7%), oral intake (95.6%); companionship (93.3%); exposure to up to three vaginal examinations (85.4%), shower bathing (84.0%), walking (68.0%), massage (60.1%), exercising with a Swiss ball (51.7%); amniotomy (53.4%), oxytocin use during the first (31.0%) and second stages of labor (25.8%), bath immersion (29.3%) and episiotomy (14.1%). In this birth center, care providers used practices recommended by the WHO, although some practices might have been applied less frequently.

Fatores maternos e neonatais associados ao mecônio no líquido amniótico em um centro de parto normal

OBJECTIVE To identify the frequency and maternal and neonatal factors associated with meconium-stained amniotic fluid at birth. METHODS Cross-sectional study carried out with 2,441 births at an in-hospital birth center in the city of São Paulo (Southeastern Brazil) in March and April, 2005. The association between meconium-stained amniotic fluid and the independent variables (maternal age, parity, previous c-section or not, gestational age, obstetric history, oxytocin use in the labor, cervical dilation at admission, mode of current delivery, newborn weight, Apgar score at the 1st and 5th minute) was expressed as prevalence ratio (PR). RESULTS Meconium-stained amniotic fluid was verified in 11.9% of the births; 68.2% of these were normal births and 38.8% c-sections. Meconium was associated with: primiparity (PR=1.49, 95%CI 1.29; 1.73), gestational age ≥ 41 weeks (PR = 5.05, 95%CI 1.93;13.25), oxytocin in labor (PR = 1.83, 95%CI 1.60; 2.10), c- section (PR = 2.65, 95%CI 2.17; 3.24) and Apgar scores < 7 at the 5th minute (PR = 2.96, 95%CI 2,94;2,99). Neonatal mortality was 1.6/1,000 live births. Meconium-stained amniotic fluid was found in 50% of neonatal deaths and it was associated with higher rates of surgical deliveries. CONCLUSIONS Oxytocin use, worse conditions of the newborn after the delivery and increased c-section rates were factors associated with meconium-stained amniotic fluid. Routine use of oxytocin in the intrapartum period could be evaluated due to its association with meconium-stained amniotic fluid.OBJETIVO: Analizar la frecuencia y los factores maternos y neonatales asociados al meconio en el liquido amniotico en el parto. METODOS: Estudio transversal con 2.441 nacimientos en un centro de parto normal hospitalario en Sao Paulo, SP, en marzo y abril de 2005. La asociacion entre meconio en el liquido amniotico y las variables independientes (edad materna, paridad, tener o no cesarea previa, edad de gestacion, antecedentes obstetricos, uso de ocitocina en el trabajo de parto, dilatacion cervical en la admision, tipo de parto actual, peso del RN, indice de Apgar de 1o y 5o minutos de vida) fue expresada como el cociente de prevalencia. RESULTADOS: Se verifico meconio en el liquido amniotico en 11,9% de los partos; 68,2% de estos fueron normales y 38,8%, con cesarea. El meconio estuvo asociado a: primiparidad (RP = 1,49; IC95% 1,29;1,73), edad de gestacion ≥ 41 semanas (RP = 5,05; IC95% 1,93;13,25), ocitocina en el parto (RP = 1,83, IC95% 1,60;2,10), cesarea (RP = 2,65; IC95% 2,17;3,24) e indice de Apgar < 7 no 5o minuto (RP = 2,96, IC95% 2,94;2,99). La mortalidad neonatal fue 1.6/1.000 nacidos vivos; meconio en el liquido amniotico fue encontrado en 50% de las muertes neonatales y asociado a mayores tasas de partos quirurgicos. CONCLUSIONES: Empleo de ocitocina, peores condiciones del recien-nacido posterior al parto y aumento de tasas de cesarea fueron factores asociados al meconio. La utilizacion rutinaria de ocitocina en el intraparto podria ser revisada por su asociacion con meconio en el liquido amniotico.

Factors associated with maternal intrapartum transfers from a freestanding birth centre in São Paulo, Brazil: A case control study

OBJECTIVES to identify factors associated with maternal intrapartum transfer from a freestanding birth centre to hospital. DESIGN case-control study with retrospective data collection. PARTICIPANTS AND SETTINGS cases included all 111 women transferred from a freestanding birth centre in Sao Paulo to the referral hospital, from March 2002 to December 2009. The controls were 456 women who gave birth in the birth centre during the same period who were not transferred, randomly selected with four controls for each case. METHODS data were obtained from maternal records. Factors associated with maternal intrapartum transfers were initially analysed using a χ(2) test of association. Variables with p<0.20 were then included in multivariate analyses. A multiple logistic regression model was built using stepwise forward selection; variables which reached statistical significance at p<0.05 were considered to be independently associated with maternal transfer. FINDINGS during the study data collection period, 111 (4%) of 2,736 women admitted to the centre were transferred intrapartum. Variables identified as independently associated factors for intrapartum transfer included nulliparity (OR 5.1, 95% CI 2.7-9.8), maternal age ≥35 years (OR 5.4, 95% CI 2.1-13.4), not having a partner (OR 2.8, 95% CI 1.5-5.3), cervical dilation ≤3 cm on admission to the birth centre (OR 1.9, 95% CI 1.1-3.2) and between 5 and 12 antenatal appointments at the birth centre (OR 3.8, 95% CI 1.9-7.5). In contrast, a low correlation between fundal height and pregnancy gestation (OR 0.3, 95% CI 0.2-0.6) appeared to be protective against transfer. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE identifying factors associated with maternal intrapartum transfer could support decision making by women considering options for place of birth, and support the content of appropriate information about criteria for admission to a birth centre. Findings add to the evidence base to support identification of women in early labour who may experience later complications and could support timely implementation of appropriate interventions associated with reducing transfer rates.

Cesarean sections in a birth center

OBJECTIVE To estimate the prevalence of cesarean sections in a birth center of a hospital and identify factors associated. METHODS Cross-sectional study including medical records of 2,441 births assisted in a birth center in the city of São Paulo, southeastern Brazil, between March and April 2005. The dependent variable (type of delivery) included vaginal delivery and cesarean section. The independent variables were grouped into four categories: demographic characteristics; current and past obstetric history; intrapartum care; and perinatal outcomes. Prevalence ratios and 95% confidence intervals (95% CI) were estimated to assess the association between type of delivery and maternal and newborn variables. RESULTS Of all deliveries, 14.9% were cesarean sections. Cesarean section in the current pregnancy was associated with past cesarean sections (PR = 3.19, 95%CI: 2.64,3.84); gestational age > 40 weeks (PR = 1.32, 95%CI: 1.09;1.61); cervical dilation of up to 4 cm on admission (PR = 3.22, 95%CI: 2.31;4.50); and meconium-stained amniotic fluid (PR = 2.5, 95%CI: 2.05;3.06). Regarding newborn characteristics cesarean section was associated with birth weight >4 kg (PR = 1.86, 95%CI: 1.29;2.66). Among women with history of past cesarean sections, having had also a prior vaginal delivery was a protective factor for cesarean section in the current pregnancy (PR = 0.46, 95%CI: 0.30;0.71). Factors related to fetal conditions including fetal stress, meconium-stained amniotic fluid, breech presentation and macrosomia accounted for 47.8% (175) while those related to the mechanism of birth including arrest disorders, functional dystocia and malposition accounted for 31,3% (115) of all indications for a cesarian section [corrected]. CONCLUSIONS Prevalence of c-section was consistent with World Health Organization recommendations. Increased risk of c-section was associated with prior history of c-sections, cervical dilation of at least 4 cm upon admission, gestational age > 40 weeks, meconium-stained amniotic fluid, and birthweight > 4 kg.OBJETIVO: Estimar a prevalencia de cesarianas em um centro de parto normal intra-hospitalar e identificar fatores associados. METODOS: Estudo transversal com analise de prontuarios de 2.441 partos assistidos em marco e abril de 2005 em um centro de parto normal intra-hospitalar de Sao Paulo, SP. A variavel dependente (tipo de parto) foi classificada como parto normal e operacao cesariana. As variaveis independentes foram categorizadas em quatro grupos: demograficas; historia obstetrica pregressa e atual; assistencia intraparto; e resultados perinatais. A razao de prevalencia e o intervalo de 95% de confianca (IC95%) foram calculados para identificar associacao entre tipo de parto e variaveis maternas e do recem-nascido. RESULTADOS: Do total de partos, 14,9% foram operacoes cesarianas. Ter sido submetida a cesariana na gestacao atual esteve associado a cesariana em gestacao anterior (RP = 3,19; IC95%: 2,64;3,84), idade gestacional > 40 semanas (RP = 1,32; IC95%: 1,09;1,61), ser admitida com cervicodilatacao ate 4 cm (RP = 3,22; IC95%: 2,31;4,50), liquido amniotico meconial (RP = 2,5; IC95%: 2,05;3,06). Quanto ao recem-nascido, a cesariana associou-se a peso > 4kg (RP = 1,86; IC95%: 1,29;2,66). Entre as mulheres com cesariana em gestacao anterior, ter tambem parto normal previo foi fator de protecao para cesariana na gestacao atual (RP = 0,46; IC95% 0,30;0,71). Fatores relacionados a condicao fetal, como estresse fetal, liquido amniotico meconial, apresentacao pelvica e macrossomia corresponderam a 47,8% (175) das indicacoes para a realizacao da cesariana; condicoes ligadas ao mecanismo do parto, como parada de progressao, distocia funcional e distocia de rotacao totalizaram 31,3% (115) das indicacoes. CONCLUSOES: A prevalencia de cesariana mostrou-se dentro dos limites propostos pela Organizacao Mundial da Saude. Mulheres com cesariana em gestacao anterior, admitidas com ate 4 cm de dilatacao, idade gestacional > 40 semanas, com liquido amniotico meconial e recem-nascido > 4 kg tiveram maior risco para cesariana.

Avaliação do viés de classificação da laceração perineal no parto normal

Objective: To evaluate the bias of perineal laceration classification, between the researcher and nurse midwives who functioned as experts within the research project. Methods: The PDSA Cycle (Plan, Do, Study and Act) was used, with independent assessments of the perineal conditions of 26 women before (step 1) and after (step 2) presenting the research protocol to nurse midwives. Data were collected in 2007 at Amparo Maternal, an institution located in São Paulo-SP. Fourteen nurse midwives and one researcher participated. Results: In step 1, we obtained 72.7% repeatability and agreement between the researcher and nurse midwives. During step 2, these characteristics decreased to 66.7%, indicating the persistence of bias in determining the degree of perineal laceration. Conclusion: The lack of 100% repeatability and agreement between the researcher and expert nurse midwives highlights the need for adopting a more precise classification for the degree of laceration, through education of these professionals.Objective: To evaluate the bias of perineal laceration classification, between the researcher and nurse midwives who functioned as experts within the research project. Methods: The PDSA Cycle (Plan, Do, Study and Act) was used, with independent assessments of the perineal conditions of 26 women before (step 1) and after (step 2) presenting the research protocol to nurse midwives. Data were collected in 2007 at Amparo Maternal, an institution located in São Paulo-SP. Fourteen nurse midwives and one researcher participated. Results: In step 1, we obtained 72.7% repeatability and agreement between the researcher and nurse midwives. During step 2, these characteristics decreased to 66.7%, indicating the persistence of bias in determining the degree of perineal laceration. Conclusion: The lack of 100% repeatability and agreement between the researcher and expert nurse midwives highlights the need for adopting a more precise classification for the degree of laceration, through education of these professionals.Objective: To evaluate the bias of perineal laceration classification, between the researcher and nurse midwives who functioned as experts within the research project. Methods: The PDSA Cycle (Plan, Do, Study and Act) was used, with independent assessments of the perineal conditions of 26 women before (step 1) and after (step 2) presenting the research protocol to nurse midwives. Data were collected in 2007 at Amparo Maternal, an institution located in Sao Paulo-SP. Fourteen nurse midwives and one researcher participated. Results: In step 1, we obtained 72.7% repeatability and agreement between the researcher and nurse midwives. During step 2, these characteristics decreased to 66.7%, indicating the persistence of bias in determining the degree of perineal laceration. Conclusion: The lack of 100% repeatability and agreement between the researcher and expert nurse midwives highlights the need for adopting a more precise classification for the degree of laceration, through education of these professionals.