Indicações de cesariana baseadas em evidências: parte II: [revisão] / Evidence-based cesarean section indications: part II: [review]

A alta incidência de cesarianas desnecessárias é motivo de preocupação mundial. Estudos demonstraram que os benefícios conferidos ao feto pela cesariana são pequenos. Além de o procedimento se associar a maiores taxas de mortalidade materna, aproximadamente quatro a cinco vezes maiores que o parto vaginal, está também associado ao aumento da morbidade e mortalidade perinatal. Assim, a decisão para realização de uma cesariana deve ser criteriosa e discutida com a paciente. Realizou-se uma revisão da literatura em busca das melhores evidências disponíveis sobre indicações de cesariana. Foram abordadas algumas indicações, como placenta prévia, descolamento prematuro de placenta, vasa prévia, placenta acreta, infecção por HIV, herpes genital, hepatites e por HPV, condiloma genital, gestação múltipla, prolapso do cordão umbilical, distensão segmentar e ruptura uterina. Observou-se que a cesariana está formalmente indicada em algumas situações particulares, como na placenta prévia total. Em outros casos, pode haver indicação de cesárea intraparto, porém situações como HPV e gemelaridade não representam per se indicações de cesárea. Quando essas são relativas, tanto a mulher como seus familiares devem ser informados, e sua opinião deve ser considerada antes de se decidir pela realização da cesárea.

The increasing rate of unnecessary cesareans is a world preoccupation. Studies demonstrated that fetal benefits by cesarean are small, and the procedure is associated with higher rates of maternal death, 4-5-fold greater in relation with vaginal delivery, and increased perinatal morbidity and mortality. Indeed, the decision for a cesarean delivery should be rigorous and discussed with the patient. A literature review was performed searching the best current evidences evaluable. Indications for cesarean section were analyzed such as placenta praevia, abruptio placentae, vasa praevia, accretism, HIV infection, genital herpes, hepatitis, HPV and condiloma, multiple pregnancy, umbilical cord prolapse, distension and rupture uterine. In special circumstances like total placenta praevia an elective cesarean section is indicated. In other cases, an intrapartum cesarean section should be performed but situations like HPV and multiple pregnancy are not considered indications for cesarean per se. When relative indications for cesarean are present, both women and her family should be informed and their opinion considered when deciding for an operative delivery.

Potential role of traditional birth attendants in neonatal healthcare in rural southern Nepal.

The potential for traditional birth attendants (TBAs) to improve neonatal health outcomes has largely been overlooked during the current debate regarding the role of TBAs in improving maternal health. Randomly-selected TBAs (n=93) were interviewed to gain a more thorough understanding of their knowledge, attitudes, and practices regarding maternal and newborn care. Practices, such as using a clean cord-cutting instrument (89%) and hand-washing before delivery (74%), were common. Other beneficial practices, such as thermal care, were low. Trained TBAs were more likely to wash hands with soap before delivery, use a clean delivery-kit, and advise feeding colostrum. Although mustard oil massage was a universal practice, 52% of the TBAs indicated their willingness to consider alternative oils. Low-cost, evidence-based interventions for improving neonatal outcomes might be implemented by TBAs in this setting where most births take place in the home and neonatal mortality risk is high. Continuing efforts to define the role of TBAs may benefit from an emphasis on their potential as active promoters of essential newborn care.

Practices of rural Egyptian birth attendants during the antenatal, intrapartum and early neonatal periods.

Neonatal deaths account for almost two-thirds of infant mortality worldwide; most deaths are preventable. Two-thirds of neonatal deaths occur during the first week of life, usually at home. While previous Egyptian studies have identified provider practices contributing to maternal mortality, none has focused on neonatal care. A survey of reported practices of birth attendants was administered. Chi-square tests were used for measuring the statistical significance of inter-regional differences. In total, 217 recently-delivered mothers in rural areas of three governorates were interviewed about antenatal, intrapartum and postnatal care they received. This study identified antenatal advice of birth attendants to mothers about neonatal care and routine intrapartum and postpartum practices. While mothers usually received antenatal care from physicians, traditional birth attendants (dayas) conducted most deliveries. Advice was rare, except for breastfeeding. Routine practices included hand-washing by attendants, sterile cord-cutting, prompt wrapping of newborns, and postnatal home visits. Suboptimal practices included lack of disinfection of delivery instruments, unhygienic cord care, lack of weighing of newborns, and lack of administration of eye prophylaxis or vitamin K. One-third of complicated deliveries occurred at home, commonly attended by relatives, and the umbilical cord was frequently pulled to hasten delivery of the placenta. In facilities, mothers reported frequent use of forceps, and asphyxiated neonates were often hung upside-down during resuscitation. Consequently, high rates of birth injuries were reported. Priority areas for behaviour change and future research to improve neonatal health outcomes were identified, specific to type of provider (physician, nurse, or daya) and regional variations in practices.

Aspecto estético en el cierre primario de las gastrosquisis / Aesthetical prospects in gastroschisis primary closure

Se presenta la experiencia con el cierre primario de la gastrosquisis conservando el cordón umbilical para mejorar el aspecto estético de los pacientes.Se presentan 6 niños operados por gastrosquisis durante un año utilizando la técnica de conservación del cordón umbilical.Todos fueron del sexo masculino con peso entre 1500 y 3000 gr.El diámetro del defecto sobrepasó los 5 cm y las vísceras exteriorizadas correspondieron a estómago,intestino delgado y colon,En todos los casos se realizó cierre primario sin utilización de malla y conservación del cordon umbilical.Se describe la técnica quirúrgica empleada.La evolución fue similar que en otras técnicas previamente utilizadas,con resultados estéticos superiores.La preservación del cordón umbilical mejora la estética,mantiene un ombligo normal,disminuye el tiempo de cirugía y no aumenta la morbilidad postoperatoria

Cisto gigante de cordão umbilical: caso raro e inédito na literatura / Giant umbilical cord cyst

O autor apresenta um caso raro e inédito, na literatura mundial, de um cisto congênito gigante de cordäo umbilical.

Delivery practices in west Uttar Pradesh.

The present study has been planned to identify healthy and unhealthy delivery practices in rural U.P. specially with reference to five cleans recommended under national C.S.S.M. programme. A total 120 women who had delivered in recent past were interviewed. Only in 3.1 percent deliveries, proper washing of floor was done, in 43 percent deliveries the cord cutting instrument was not sterilized and in about 65 percent deliveries mustard oil and ghee was used as first cord applicant.

Cirugía endoscópica fetal en un caso de embarazo gemelar complicado con secuencia de perfusión arterial reversa: secuencia TRAP / Fetal endoscopic surgery in a twin pregnancy complicated with sequence of reversal arterial perfusion: TRAP sequency

Presentamos el primer caso de cirugía endoscópica fetal realizado en nuestro país en un caso de embarazo gemelar complicado con la denominada secuencia de perfusión arterial reversa (secuencia TRAP) en el que se realizó ligadura del cordón umbilical del feto acardio-acéfalo a las 26 semanas de gestación

Cicatrices abdominales deformantes: tratamiento quirúrgico con expansión tisular / Deforming abdominal scars: surgical treatment by tissue expansion

Se operaron tres pacientes femeninas adolescentes que presentaban cicatrices deformantes peri o infraumbilicales. Se les reconstruyó la región anterolateral con cirugía plástica utilizando el principio de la expansión tisular. Dos de las pacientes presentaban además un defecto de la aponeurosis parietal. En todas se obtuvo magnífico resultado estético y funcional.

Onfalocele y gastrosquisis: análisis de 22 años de labor / Omphalocele and gastroschisis: an analysis of 22 years of work

Se realiza una revisión de la literatura hasta el momento actual, acerca del onfalocele y la gastrosquisis y posteriormente un estudio comparativo entre los resultados obtenidos en el tratamiento de estas enfermedades, en los períodos iniciales de nuestro hospital, después del perfeccionamiento de la neonatología en nuestro centro y en los últimos 6 años de trabajo. Se observa la constante renovación en los métodos terapéuticos en el mundo para estas entidades. Se demuestra en nuestras estadísticas una incidencia en ascenso de la gastrosquisis y un aumento de la supervivencia, sobre todo a expensas de ésta. Se informa una letalidad actual global del 40% con el empleo del tratamiento quirúrgico

Tratamiento actual del tétanos neonatal / Present treatment of tetanus neonatorum

Tomando como base un caso de tétanos neonatal se actualiza su tratamiento, el cual debe tener siguientes finalidades: a) evitar la proliferación de los microorganismos mediante administración de penicilina y resección del cordón umbilical; b) contrarrestar la toxina circulante con aplicación de antitoxina o gammaglobulina humana hiperinmune, y c) modificar el estado espástico condicionado por la neurotoxina fija al tejido nervioso, con medicamentos que actuén sobre el sistema nervioso central (hipnóticos y sedantes), nervioso periférico (agentes curarizantes) o musculoesquelético (relajantes musculares). Estas finalidade sólo se pueden lograr en una unidad de cuidados intensivos que cuente con los recursos humanos y técnicos para sostener el buen general del paciente y permitirle sobrevivir sin secuelas