Propuesta de medicina perioperatoria en México: protocolo Enhance Recovery After Surgery aplicada a cesárea / Proposal for perioperative medicine in Mexico: Enhance Recovery After Surgery protocol applied to cesarean section

Resumen: El manejo perioperatorio de los pacientes programados de cirugía electiva está cambiando, dejando atrás la experiencia o los hábitos adquiridos en la práctica. Está demostrado que una rápida recuperación postquirúrgica acorta el tiempo de hospitalización y recuperación, asimismo contribuye a la disminución de complicaciones perioperatorias y costos. Con la creación del protocolo recuperación acelerada después de cirugía (ERAS, por sus siglas en inglés: Enhanced Recovery After Surgery), se desarrolló una combinación de estrategias relacionadas al cuidado del paciente desde el momento en que se decide su intervención quirúrgica hasta el egreso hospitalario. Estas guías basadas en evidencia científica son un conjunto de estrategias multimodales cuyo fundamento se basa en la recuperación temprana de las funciones fisiológicas del paciente. En un principio fueron creadas para cirugías de colon y recto; y posteriormente extrapoladas a diferentes especialidades, siendo incluida en pacientes gineco-obstetras con el beneficio de ir más allá en la mejora de los resultados clínicos, al contar con el potencial de acelerar la recuperación de una paciente obstétrica que está en transición a la maternidad y cuidado del recién nacido. El objetivo de este artículo es realizar una revisión de los principales componentes del protocolo ERAS y su aplicación en cirugía cesárea para mejorar la calidad de la atención brindada.

Abstract: The perioperative management of patients scheduled for elective surgery is changing and thus leaving behind the expertise or the habits previously acquired during practice. It has been demonstrated that the quick postsurgical recovery shortens both the time in hospital and recovery, and also contributes to the decrease of perioperative complications and costs. With the creation of the Protocol of Enhanced Recovery After Surgery (ERAS), there came the development of a combination of strategies related to the patient's care; from the moment the surgical intervention is decided to the discharge from hospital. These based on scientific evidence guidelines are a set of multimodal strategies whose foundations rely on the early recovery of the patient's physiological functions. At first the guidelines were created for colon and rectal surgeries, however, they have been transferred to different specialties, including obstetric and gynecological patients, with the benefit of going further in the improvement of clinical results, as it counts on the potential of accelerating the recovery of the obstetrical patient in transition to both motherhood and care to the newborn. The objective of this article is to review the main components of ERAS protocol and its application in the cesarean section surgery so as to enhanced the quality in the provision of care.

Un perfil de las obstetras en Paraguay / A Profile of midwifery in Paraguay

Introducción: Este estudio trata de desarrollar un perfil descriptivo de las obstetras en Paraguay. El estudio incluyó tres componentes: investigación de los antecedentes de los documentos oficiales y entrevistas a informantes claves para completar cuestionarios, entrevistas cualitativas con parteras y obstetras del Paraguay, y la observación de los participantes. Métodos: Los datos de los documentos oficiales y los cuestionarios fueron tabulados utilizando estadística descriptiva, entrevistas individuales y entrevistas de grupos pequeños de obstetras, estudiantes de obstetricia y médicos gineco-obstetras y se llevaron a cabo en cinco regiones de salud del Paraguay. Resultados: Participaron veintidós obstetras, nueve estudiantes de obstetricia, nueve gineco-obstetras y cinco dirigentes de las organizaciones profesionales de la salud. Tres temas destacados surgieron de las entrevistas. El primero fue la evolución del rol de la obstetra en el sistema de salud, sobre todo en la capital, Asunción. El segundo fue qué tanto las obstetras como los médicos gineco-obstetras informaron acerca de que las mujeres no tenían preparación suficiente para el parto y el periodo prenatal.

Introduction: This study sought to develop adescriptive profile of midwifery in Paraguay. Itinvolved three components: background research from official documents and key informant interviewsto complete questionnaires, qualitative interviews with Paraguayan midwives and obstetricians, and participant observation. Methods: Data from official documents and questionnaires weretabulated using descriptive statistics. Individual interviews and small-group interviews of midwives, student midwives, and obstetricians were conductedin five health departments of Paraguay. Results: Twenty-two midwives, nine student midwives, nine obstetricians, and five leaders of professional health organizations participated. Three salientthemes were identified from the interviews. Firstwas the changing role of the midwife in the health system, particularly in the capital city of Asunción.Second, midwives and obstetricians both reported that women were not sufficiently prepared for laborand birth during the antenatalperiod. Limited antenatal education and childbirth classes existed and midwives felt that this was amajor barrier to vaginal birth. Finally, access tomidwife-provided antenatal care is perceived to belimited. Obstetricians are now providing antenatal care more often than they used to, and in some public hospitals they also attend vaginal deliveries. Limiting the utilization of midwives may well be amajor contributor to the rising rates of caesarean sections. Midwives are not fulfilling their potentialto prepare women for labor and birth, despitetheir high-level professional training. They havethe potential to improve antenatal preparation forlow-intervention birth, and this would be a moreeffective use of human resources for both obstetricians and midwives.

Development and Evaluation of Breastfeeding Promotion Program for Mothers with Breast Engorgement following Cesarean Birth

PURPOSE: This study was to develop a breastfeeding promotion program and to test effects of the program on levels of breast discomfort, breast size, sodium in breast milk, and type of feeding in mothers with breast engorgement following cesarean birth. METHODS: A non-synchronized non-equivalent control group pretest-posttest design was used in this study. The participants were 70 postpartum mothers who were admitted to a postpartum care center and experienced breast engorgement following cesarean birth. The planned nursing intervention was the breastfeeding promotion program consisting of breast massage and 1:1 breastfeeding education, counseling, and support focusing on individualized problem solving provided for 10 days. Fifty-three women completed the program (experimental group 26, control group, 27). Measurements were level of breast discomfort, breast size, sodium in breast milk and type of feeding at pre and posttest. RESULTS: Women who participated in the program experienced lower scores for breast discomfort, greater decrease in breast size, lower levels of sodium in breast milk, and practiced breastfeeding more than those in the control group. CONCLUSION: Results indicate that this breastfeeding promotion program is effective in reducing breast engorgement and improving breastfeeding practices, and is therefore recommended to enhance breastfeeding promotion practice in postpartum care centers.

Induction of labor in patients with a previous cesarean birth / 대한산부인과학회잡지

OBJECTIVE: To determine the efficacy and safety of labor induction in patients previously delivered by a low transverse cesarean section. METHOD: A retrospective review was done at Chonnam National University Hospital, Kwangju, Korea. All patients with a previous cesarean section who required labor induction from April, 1986 to June, 1999 were identified. Outcome of labor induction, including mode of delivery, maternal and perinatal morbidity, and birth trauma were evaluated. RESULTS: Trial of labor was undertaken by 1256 women(55.8%) who had previously been delivered by a low transverse cesarean section. 973 patients(77.5%) with a previous cesarean birth had a spontaneous onset of labor. Labor was induced in 283 patients(22.5%) with a previous cesarean birth. Successful vaginal delivery rate were 82.9%(807/973) in spontaneous labor and 79.2%(224/283) in induced labor group (p= NS). There were no differences in uterine dehiscence and rupture rate, perinatal and maternal mortality rate, and the rate of infants with low 1 or 5-minute Apgar scores between patients attempting a trial of labor after cesarean, spontaneous and induced. CONCLUSION: we conclude that labor induction in patients with a previous low transverse cesarean section is a safe procedure requiring close peripartum maternal and fetal surveillance.