Maniobra Kristeller, consecuencias físicas y éticas según sus protagonistas / Kristeller Maneuver, physical and ethical consequences according to its central characters

Introducción: La maniobra Kristeller consiste en hacer presión del fondo uterino en el período expulsivo, la segunda etapa del trabajo de parto. Objetivo: Determinar la prevalencia, características de la aplicación de la maniobra Kristeller y consecuencias físicas y éticas en puérperas de un hospital de alta complejidad en Lima, Perú. Métodos: Diseño descriptivo transversal y prospectivo. Se incluyeron 250 puérperas de parto vaginal, con gestación única a término, atendidas en el Hospital Nacional Hipólito Unanue, entre agosto y diciembre de 2016. Se usó cuestionario -Stop Kristeller- realizado por la Asociación Española El parto es nuestro. Se les aplicó un cuestionario validado por expertos a las puérperas durante su estancia. Se realizó análisis descriptivo mostrando los resultados en frecuencias y porcentajes. Resultados: Se evidenció que a 116 de ellas (46,4 por ciento) se les realizó la maniobra Kristeller. Con respecto a las características de la realización de la maniobra 77,6 por ciento refirió que se realizó con las palmas de las manos, más del 70 por ciento refirió que fue entre una y tres veces y 75,9 por ciento señaló que solo una persona la realizó. El 32,8 por ciento reportó haber sufrido desgarro vaginal y 51,7 por ciento refirió que no solicitaron su consentimiento para realizar la maniobra. Conclusiones: Existe elevada prevalencia de la utilización de la maniobra, las características de su aplicación siguen pautas descritas por Samuel Kristeller, entre las consecuencias físicas encontradas están los desgarros perineales superficiales y profundos y en muchos casos las condiciones bioéticas no se cumplieron(AU)

Introduction: The Kristeller maneuver consists in making fundal pressure during the second stage of labor. Objective: To determine the prevalence, characteristics of the application of Kristeller maneuver and the physical and ethical consequences in puerperal women of a highly complex hospital in Lima, Peru. Methods: A cross-sectional and prospective descriptive study was carried out in 250 puerperal women of vaginal delivery, with single gestation at term, assisted at Hipólito Unanue National Hospital, from August to December 2016. This research used the Stop Kristeller questionnaire - prepared by the Spanish Association El parto es nuestro. A questionnaire validated by experts was applied to the puerperal women during their stay. A descriptive analysis was made and the results in frequencies and percentages are shown. Results: It was showed that 116 of them (46.4 percent) underwent Kristeller maneuver. Regarding the characteristics of the maneuver performance, 77.6 percent reported that it was performed with hand palms, more than 70 percent reported that this maneuver was done between one and three times and 75.9 percent indicated that only one person performed it. Vaginal tear was reported in 32.8 percent and 51.7 percent reported their consent to perform the maneuver was not requested. Conclusions: There is high prevalence of the use of this maneuver. The characteristics of its application follow the guidelines described by Samuel Kristeller. Superficial and deep perineal tears are among the physical consequences and in many cases, bioethical conditions were not fulfilled(AU)

Distócia de ombro / Shoulder dystocia

A Distócia de Ombro é definida, de acordo com os Colégios Americano e Britânico de Obstetrícia e Ginecologia, como parto que necessita de manobras obstétricas adicionais, após falência da tração da cabeça fetal para liberar os ombros. Apesar de sua baixa incidência, é uma complicação com importante morbidade para o recém nascido e que pode levar a intercorrências maternas, sendo entretanto passível de ser evitada. Esse artigo de revisão se propõe a sumarizar a epidemiologia, fisiopatologia, conduta e complicações, enfocando os fatores de risco e as manobras mais utilizadas, dada a importância de ambos na prevenção dessa complicação. (AU)

The Shoulder Dystocia is defined, according to British and American Colleges of Obstetrics and Gynecology, as delivery which requires additional obstetric maneuvers after failure of traction of the fetal head to release the shoulders. Despite its low incidence, it is a complication with significant morbidity for the newborn and wich can lead to maternal complications. Despite of this, is able to be avoided. This review aims to summarize the epidemiology, pathophysiology, management and complications, focusing on risk factors and the most commonly used maneuvers, due to the importance of both in preventing this complication. (AU)

Caracterização das cesarianas em centro de parto normal / Cesarean sections in a birth center / Caracterización de las cesáreas en centro de parto normal

OBJETIVO: Estimar a prevalência de cesarianas em um centro de parto normal intra-hospitalar e identificar fatores associados. MÉTODOS: Estudo transversal com análise de prontuários de 2.441 partos assistidos em março e abril de 2005 em um centro de parto normal intra-hospitalar de São Paulo, SP. A variável dependente (tipo de parto) foi classificada como parto normal e operação cesariana. As variáveis independentes foram categorizadas em quatro grupos: demográficas; história obstétrica pregressa e atual; assistência intraparto; e resultados perinatais. A razão de prevalência e o intervalo de 95 por cento de confiança (IC95 por cento) foram calculados para identificar associação entre tipo de parto e variáveis maternas e do recém-nascido. RESULTADOS: Do total de partos, 14,9 por cento foram operações cesarianas. Ter sido submetida a cesariana na gestação atual esteve associado a cesariana em gestação anterior (RP = 3,19; IC95 por cento: 2,64;3,84), idade gestacional > 40 semanas (RP = 1,32; IC95 por cento: 1,09;1,61), ser admitida com cervicodilatação até 4 cm (RP = 3,22; IC95 por cento: 2,31;4,50), líquido amniótico meconial (RP = 2,5; IC95 por cento: 2,05;3,06). Quanto ao recém-nascido, a cesariana associou-se a peso > 4kg (RP = 1,86; IC95 por cento: 1,29;2,66). Entre as mulheres com cesariana em gestação anterior, ter também parto normal prévio foi fator de proteção para cesariana na gestação atual (RP = 0,46; IC95 por cento 0,30;0,71). Fatores relacionados à condição fetal, como estresse fetal, líquido amniótico meconial, apresentação pélvica e macrossomia corresponderam a 47,8 por cento (175) das indicações para a realização da cesariana; condições ligadas ao mecanismo do parto, como parada de progressão, distócia funcional e distócia de rotação totalizaram 31,3 por cento (115) das indicações. CONCLUSÕES: A prevalência de cesariana mostrou-se dentro dos limites propostos pela Organização Mundial da Saúde. Mulheres com cesariana em gestação anterior, admitidas com até 4 cm de dilatação, idade gestacional > 40 semanas, com líquido amniótico meconial e recém-nascido > 4 kg tiveram maior risco para cesariana.

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 percent confidence intervals (95 percent CI) were estimated to assess the association between type of delivery and maternal and newborn variables. RESULTS: Of all deliveries, 14.9 percent were cesarean sections. Cesarean section in the current pregnancy was associated with past cesarean sections (PR = 3.19, 95 percentCI: 2.64,3.84); gestational age > 40 weeks (PR = 1.32, 95 percentCI: 1.09;1.61); cervical dilation of up to 4 cm on admission (PR = 3.22, 95 percentCI: 2.31;4.50); and meconium-stained amniotic fluid (PR = 2.5, 95 percentCI: 2.05;3.06). Regarding newborn characteristics cesarean section was associated with birth weight >4 kg (PR = 1.86, 95 percentCI: 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 percentCI: 0.30;0.71). Factors related to fetal conditions including fetal stress, meconium-stained amniotic fluid, breech presentation and macrosomia accounted for 47.8 percent (175) while those related to the mechanism of birth including arrest disorders, and functional and rotation dystocia accounted for 31.3 percent (115) of all indications for a cesarean section. 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 la prevalencia de cesáreas en un centro de parto normal intra-hospitalario e identificar factores asociados. MÉTODOS: Estudio transversal con análisis de prontuarios de los 2.441 partos asistidos en marzo y abril de 2005 en Centro de Parto Normal de Sao Paulo, Sureste de Brasil. La variable dependiente (tipo de parto) fue clasificada como parto normal y operación cesárea. Las variables independientes fueron categorizadas en cuatro grupos: demográficas; historia obstétrica anterior y actual; asistencia intraparto; y resultados prenatales. La tasa de prevalencia y el intervalo con 95 por ciento de confianza (IC95 por ciento) fueron calculados para identificar asociación entre tipo de parto y variables maternas y del recién nacido. RESULTADOS: Del total de partos, 14,9 por ciento fueron operaciones cesáreas. Haber tenido parto por cesárea en la gestación actual estuvo asociada a cesárea en gestación anterior (RP=3,19; IC95 por ciento: 2,64;3,84), edad gestacional >40 semanas (RP=1,32;IC95 por ciento: 1,09;1,61), ser admitida con dilatación cervical hasta 4 cm (RP=3,22; IC95 por ciento: 2,31;4,50), liquido amniótico meconial (RP=2,5; IC95 por ciento: 2,05;3,06). con relación al recién nacido, la cesárea se asoció al peso>4kg (RP=1,86; IC 95 por ciento: 1,29;2,66). Entre las mujeres con cesárea en gestación anterior, tener también parto normal previo fue factor de protección para cesárea en la gestación actual (RP=0,46; IC95 por ciento: 0,30;0,71). Factores relacionados a la condición fetal, como estrés fetal, liquido amniótico meconial, presentación pélvica y macrosomia correspondieron a 41,8 por ciento (175) de las indicaciones para la realización de la cesárea; condiciones ligadas al mecanismo del parto, como parada de progresión, distoccia funcional y distoccia de rotación totalizaron 31,3 por ciento (115) de las indicaciones. CONCLUSIONES: La prevalencia de cesárea se mostró dentro de los límites propuestos por la Organización Mundial de la Salud. Mayor riesgo para cesárea fue asociado a cesárea en gestación anterior, dilatación cervical hasta 4 cm, edad gestacional >40 semanas, presencia de liquido amniótico meconial y peso del recién nacido >4 kg.

Advancing parity is associated with high milk production at the cost of body condition and increased periparturient disorders in dairy herds

The objectives of this study were to determine the effects of parity on milk production, body condition change, periparturient health, and culling in Korean dairy herds. The data utilized included; milk yield, body condition score, cow parity, calving condition, periparturient disorders, culling, and reproductive status, which were recorded from 1290 calvings in eight dairy herds. The mean milk yield in cows over 305 days increased with increasing parity (p < 0.01). Cows with parities of 3, 4, and 5 or higher lost more body condition than those with a parity of 1 during month 1 of lactation (p < 0.01), and body condition recovery by cows with parities of 4 and 5 or higher was slower (p < 0.01) than recovery by cows with parities of 1, 2, or 3 until month 3 of lactation. The risk of retained placenta, metabolic disorder, and endometritis also increased with advancing parity (p < 0.05). Moreover, the incidence of ovarian cysts was lower in cows with a parity of one than in cows with greater parities (p < 0.01). Culling rate due to reproductive failure also increased with advancing parity (p < 0.01). These results suggest that parity increases milk yield, body condition loss during early lactation, the risk of periparturient disorders, and culling due to reproductive failure in dairy herds.

Shoulder dystocia: fifteen years' experience in Ramathibodi Hospital.

Although shoulder dystocia does not occur frequently the adverse effect to the patient and especially to infants can be catastrophic. The purpose of this study was to evaluate the incidence, the factors which may be related to or predispose to this condition and the consequence to the patients and their infants. All cases of shoulder dystocia which occurred during the fifteen year period from January 1982 to December 1996 were scrutinized. There were 17 cases of shoulder dystocia from a total of 109,923 deliveries giving the incidence of 1.6 per 10,000 deliveries. Of these 17 patients, 11 (65%) were delivered by vacuum extraction. Two patients had postpartum hemorrhage requiring blood transfusion. Infants' birthweights ranged between 3350 to 5160 grams. Erb's palsy occurred in 6 infants and all made full recovery subsequently.

Shoulder dystocia. 18 years experience at prince Hashem Ben Al Hussein hospital

To study the problem of shoulder dystocia regarding fetal and maternal features and its complications. A retrospective study of the records of 64,800 deliveries that occurred in the period between 1979 and 1997 was carried out. The study was conducted at the Obstetric and Gynecology Department at Prince Hashem Ben AI-Hussein Hospital, Zarqa, Royal Medical Services. Patients were divided into two groups:- those before and those after 1989. The frequency of shoulder dystocia was calculated for both groups. Maternal characteristics and fetal morbidity were compared in both groups. A total of 250 cases of shoulder dystocia were encountered. Whereas 231 cases of shoulder dystocia out of 28000 deliveries [0.825%] were found in the period 1979 through 1989, only 19 cases out of 36800 deliveries [0.051%] were reported in the period 1989 through 1997. The frequency of shoulder dystocia dropped from 0.825% to 0.051%. Shoulder dystocia represents an obstetric emergency because it holds a very high perinatal and maternal morbidity. The warning signs of shoulder dystocia should be taken seriously and the best method of delivery for each patient should be selected to avoid its occurrence anti to manage it quickly and properly should it occur

Presentación de frente: revisión de los años 1984-1988 / Brow presentation: review of the years 1984-1988

Se revisaron 116 historias de pacientes con embarazos simples y presentación de frente atendidas en la Maternidad Concepción Palacios entre 1984 y 1988 en 115699 partos de vértice, dando una incidencia de 0,10// o sea 1 por cada 997 partos. La edad osciló entre 15 y 38 años, promedio 26. Fueron primigestas 25,86// y 74,14// tenían 2 o más gestaciones. En 81,90// fueron embarazos a término, 11,21// pretérmino y 6,90// postérmino. En 78,45// se hizo el diagnóstico durante el trabajo de parto y en 21,55// mediante estudio radiológico y ecosonograma. La variedad naso anterior se encontró en 45,69//, la naso transversa en 20,69//, la naso posterior en 18,10// y en 15,52// se desconoció. En 57,76// se hizo cesárea y en 42,25// parto vaginal. La puntuación de Apgar al nacer fue de 8 y 10 en 41,38//, 4 y 7 en 30,17// y menor en 11,21//. La morbilidad materna fue de 16,38// y la fetal de 27,59//. Hubo 3 muertes neonatales y 2 mortinatos

Embarazo en adolescentes

El estudio comprendido 874 gestantes adolescentes de 18 años o menos, del 1 de enero de 1987 al 1 de enero de 1988, siendo 292 del Hospital A. Loayza y 582 de la Maternidad de Lima, con incidencia de 8.70 y 9.78 por ciento respectivamente. Las edades fluctuaron entre 13 y 18 años, siendo la mayoría solteras y convivientes, con bajo grado de instrucción. Tuvieron control prenatal el 61.51 por ciento de las pacientes de la Maternidad y el 78.42 por ciento de las del Hospital A. Loayza. La incidencia de morbilidad durante la gestación fue de 22.16 por ciento y de 35.27 por ciento respectivamente, siendo las principales la vulvovaginitis, enfermedad hipertensiva del embarazo, infección urinaria, ruptura prematura de menbranas y anemia. La mayoría de los recién nacidos tuvieron un peso entre 2501 y 3500 grs, y un score Apgar mayor de 7. El porcentaje de cesareas fue de 9.45 y 14.38 por ciento respectivamente, siendo la principal indicación la incompatibilidad fetopélvica. La endometritis fue la complicación puerperal más frecuente en ambas sedes