Posições maternas e sua influência no desfecho do parto e nascimento: um estudo caso-controle / Faculdade de Farmácia, Odontologia e Enfermagem, Universidade Federal do Ceará

Objetivou-se avaliar as posições maternas e sua influência nos desfechos do parto e nascimento. Trata-se de um estudo observacional, correlacional, do tipo caso-controle, realizado entre os meses de fevereiro de 2019 a abril de 2020 em uma maternidade de referência em Fortaleza-Ceará. A população foi composta por todas as mulheres nulíparas que tiverem parto vaginal na instituição durante a pesquisa e que atenderam aos critérios de inclusão e exclusão definidos para o estudo. Foram 138 mulheres para o grupo controle (nulíparas em trabalho de parto e que pariram em posições não verticalizadas) e 60 mulheres para o grupo caso (nulíparas em trabalho de parto e que pariram em posições verticalizadas). Os dados foram coletados a partir de um formulário com perguntas fechadas, compilados e analisados no SPSS e utilizou-se Teste Estatístico de Fisher e aplicou-se Odds-Ration e Intervalo de Confiança quando significativos. O projeto foi submetido ao comitê de ética em pesquisa e aprovado segundo o parecer nº 3.545.134. Verificou-se associação entre a faixa etária e ocorrência do parto na posição vertical (p=0,011), sendo observado que mulheres com idade superior a 34 anos possuem 12,59 mais chances (OR=12,59; IC=1,44-110,30) de parirem em posições verticalizadas. Em relação às condições do períneo, não houve associação entre as variáveis posição do parto e a presença de lacerações perineais. Constatouse a presença de associação entre o parto realizado por enfermeiro e o parto na posição vertical (p<0,001) com aumento de 4,53 vezes de chances a mais da ocorrência do parto na posição vertical quando realizado por esses profissionais. Foi possível detectar diferenças significativas quando houve orientação médica (p=0,045), observando um aumento em 86% da chance de realizar o parto na posição vertical quando a orientação foi de outros profissionais e não foi do médico. Quanto à vitalidade neonatal, quase a totalidade tiveram índice de Apgar ≥ 7 no primeiro e no quinto minuto de vida, indicando boa vitalidade. Foi verificado relação estatística entre a posição de parir e a satisfação da mulher (p=0,021). Para as mulheres que realizaram o parto vertical, existe uma chance de 6,63 vezes maior de serem muito satisfeitas com o parto, quando comparada aquelas insatisfeitas ou pouco insatisfeitas. Conclui-se que há uma menor prevalência de práticas não recomendadas nas posições verticalizadas, os profissionais enfermeiros destacam-se no estímulo a essas posições e há uma maior satisfação materna em mulheres que pariram em posições verticalizadas. No tocante aos desfechos neonatais, ambas as posições foram satisfatórias para os neonatos. (AU)

Comparison of Caesarean sections and instrumental deliveries at full cervical dilatation: a retrospective review

INTRODUCTION@#This study aimed to compare instrumental vaginal deliveries (IDs) and Caesarean sections (CSs) performed at full cervical dilatation, including factors influencing delivery and differences in maternal and neonatal outcomes.@*METHODS@#A retrospective review was conducted of patients who experienced a prolonged second stage of labour at Singapore General Hospital from 2010 to 2012. A comparison between CS and ID was made through analysis of maternal/neonatal characteristics and peripartum outcomes.@*RESULTS@#Of 253 patients who required intervention for a prolonged second stage of labour, 71 (28.1%) underwent CS and 182 (71.9%) underwent ID. 5 (2.0%) of the patients who underwent CS had failed ID. Of the maternal characteristics considered, ethnicity was significantly different. Induction of labour and intrapartum epidural did not influence delivery type. 70.4% of CSs occurred outside office hours, compared with 52.7% of IDs (p = 0.011). CS patients experienced a longer second stage of labour (p < 0.001). Babies born via CS were heavier (p < 0.001), while the ID group had a higher proportion of occipitoanterior presentations (p < 0.001). Estimated maternal blood loss was higher with CSs (p < 0.001), but neonatal outcomes were similar.@*CONCLUSION@#More than one in four parturients requiring intervention for a prolonged second stage of labour underwent emergency CS. Low failed instrumentation rates and larger babies in the CS group suggest accurate diagnoses of cephalopelvic disproportion. The higher incidence of CS after hours suggests trainee reluctance to attempt ID. There were no clinically significant differences in maternal and neonatal morbidity.

Perineal trauma in a low-risk maternity with high prevalence of upright position during the second stage of labor / Trauma perineal em uma maternidade de baixo risco com alta prevalência de parto vertical durante o período expulsivo

Abstract Objective Perineal trauma is a negative outcome during labor, and until now it is unclear if the maternal position during the second stage of labormay influence the risk of acquiring severe perineal trauma. We have aimed to determine the prevalence of perineal trauma and its risk factors in a low-risk maternity with a high incidence of upright position during the second stage of labor. Methods A retrospective cohort study of 264 singleton pregnancies during labor was performed at a low-risk pregnancymaternity during a 6-month period. Perineal trauma was classified according to the Royal College of Obstetricians and Gynecologists (RCOG), and perineal integrity was divided into three categories: no tears; first/ second-degree tears + episiotomy; and third and fourth-degree tears. A multinomial analysis was performed to search for associated factors of perineal trauma. Results From a total of 264 women, there were 2 cases (0.75%) of severe perineal trauma, which occurred in nulliparous women younger than 25 years old. Approximately 46% (121) of the women had no tears, and 7.95% (21) performed mediolateral episiotomies. Perineal trauma was not associated with maternal position (p = 0.285), health professional (obstetricians or midwives; p = 0.231), newborns with 4 kilos or more (p = 0.672), and labor analgesia (p = 0.319). The multinomial analysis showed that white and nulliparous presented, respectively, 3.90 and 2.90 times more risk of presenting perineal tears. Conclusion The incidence of severe perineal trauma was low. The prevalence of upright position during the second stage of labor was 42%. White and nulliparous women were more prone to develop perineal tears.

Resumo Objetivo O trauma perineal é um desfecho negativo durante o parto, e é incerto, até omomento, se a posiçãomaternal durante o período expulsivo pode influenciar o risco de evoluir com trauma perineal severo. Nós objetivamos determinar a prevalência de trauma perineal e seus fatores de risco em uma maternidade de baixo risco com alta prevalência de posição vertical durante o período expulsivo. Métodos Um estudo de coorte retrospectivo de 264 gestações únicas durante o trabalho de parto foi realizado durante 6 meses consecutivos. O trauma perineal foi classificado de acordo com o Royal College of Obstetricianns and Gynecologists (RCOG). A integridade perineal foi dividida em três categorias: períneo íntegro; trauma perineal leve (primeiro e segundo graus + episiotomia); e trauma perineal severo (terceiro e quarto graus). Uma análise multinomial foi realizada para buscar variáveis associadas ao trauma perineal. Resultados De um total de 264 mulheres, houve 2 casos (0,75%)de trauma perineal severo m nulíparas com menos de 25 anos. Aproximadamente 46% (121) das mulheres não tiveram trauma perineal e 7,95% (21) realizaram episiotomias mediolaterais. Não houve correlação do trauma perineal com a posição de parto (p = 0,285), tipo de profissional que realizou o parto (p = 0,231), recém-nascidos com 4.000 gramas ou mais (p = 0,672), e presença de analgesia de parto (p = 0,319). Uma análise multinomial evidenciou que mulheres brancas e nulíparas apresentaram, respectivamente, um risco 3,90 e 2,90 vezes maior de apresentar trauma perineal. Conclusão A incidência de trauma perineal severo foi baixa. A prevalência de parto vertical durante o período expulsivo foi de 42%. Mulheres brancas e nulíparas foram mais suscetíveis a apresentar trauma perineal.

Ventajas y desventajas del parto vertical en contraste con el parto horizontal: una revisión de la literatura / Advantages and Disadvantages of Upright Position in Contrast to Supine Position: A Review of Literature / Vantagens e desvantagens do parto vertical em contraste com o parto horizontal: uma revisão da literatura

El parto vertical es una práctica ancestral que puede ofrecer ventajas para la madre y su recién nacido. Objetivo: integrar los hallazgos que informa la literatura sobre ventajas y desventajas del parto vertical en contraste con el parto horizontal. Método: revisión integrativa de la literatura publicada en el periodo 2005-2015. Se seleccionaron quince estudios, luego de un proceso de búsqueda y crítica de literatura. Los datos se extrajeron, analizaron y compararon con apoyo en la herramienta ATLAS.ti, versión 7.0. Resultados: esta revisión integró los hallazgos de los artículos seleccionados, de los cuales emergieron doce subtemas que se clasificaron en los dos temas planteados: ventajas y desventajas del parto vertical en contraste al parto horizontal. Se encontraron las siguientes ventajas: disminución en el tiempo en la segunda etapa, menos desgarros de tercer y cuarto grado, menor edema vulvar, menor necesidad de instrumentación, menor necesidad de episiotomía, menos casos de presión del fondo uterino, menos casos de placenta retenida, menor dolor, mejor percepción de la materna y mejores resultados fetales y neonatales. Como desventajas se encontraron: mayor sangrado y dificultad de mantener la posición. Conclusión: esta revisión encontró que el parto en posición vertical tiene más ventajas en contraste a la posición horizontal, lo que beneficia fisiopsicológicamente tanto a la madre como al neonato.

Upright position is an ancestral practice which can offer advantages to the mother and her newborn. Objective: To intégrate findings from literature on advantages and disadvantages of upright position in contrast to supine position. Methodology: Integrative review of literature published in the period 2005-2015. Fourteen studies were selected after a search process and review of literature. Data were extracted, analyzed, and compared through ATLAS.ti 7.0. Outcomes: This review integrated the findings from the selected articles. Twelve subtopics were grouped into the two topics proposed: Advantages and disadvantages of upright position in contrast to supine position. Among the advantages of this review are: Shorter duration of the second stage of labor, less third- and fourth-degree tears, less vulvar edema, less need for instrumentation, less need for episiotomies, less cases of uterine fundal pressure, less cases of retained placenta, less pain, better mother's perception, and better fetal and neonatal outcomes. As disadvantage, more bleeding and difficulty in maintaining the position. Conclusión: This review found that upright position birth has more advantages in contrast to supine position, thus benefitingphysio-psychologically both to the mother and her newborn.

O parto vertical é uma prática ancestral que pode oferecer vantagens para a mãe e seu recém-nascido. Objetivo: integrar os achados que a literatura informa sobre as vantagens e as desvantagens do parto vertical em contraste com o parto horizontal. Metodologia: revisão integrativa da literatura publicada no período 2005-2015. Foram selecionados 15 estudos, logo de um processo de busca e crítica da literatura. Os dados foram extraídos, analisados e comparados com apoio na ferramenta ATLAS.ti, versão 7.0. Resultados: esta revisão integrou os achados dos artigos selecionados dos quais surgiram 12 sub-temas que foram classificados nos dois temas estabelecidos: vantagens e desvantagens do parto vertical em contraste com o parto horizontal. Foram encontradas as seguintes vantagens: diminuição do tempo na segunda etapa, menos desgarres de terceiro e quarto grau, menor edema vulvar, menor necessidade de instrumentação, menor necessidade de episiotomia, menos casos de pressão do fundo uterino, menos casos de placenta retida, menor dor, melhor percepção da materna e melhores resultados fetais e neonatais. Como desvantagens foram encontradas: maior sangramento e dificuldade de manter a posição. Conclusão: esta revisão indicou que o parto em posição vertical possui mais vantagens comparado com a posição horizontal, beneficiando fisio-psicologicamnte tanto a mãe como o neonato.

Percepção de puérperas sobre a posição vertical no parto / Percepción de puerperas acerca de la posición vertical en el parto / Perception of puerperas on the vertical position in childbirth

Objetivo descrever a percepção de puérperas acerca da posição vertical adotada no trabalho de parto e parto. Método estudo descritivo de abordagem qualitativa desenvolvido em 2014, em uma maternidade de referência de Teresina, Piauí, Brasil. As participantes foram oito puérperas com histórico de parto normal na posição vertical. Os dados foram analisados por meio da técnica de análise de conteúdo. Resultados emergiram quatro categorias: tipo de conhecimento das mulheres sobre as posições verticais; percepção da presença da enfermeira obstetra no processo de parturição como incentivo às posições verticais; recordações da vivência de partos em outras posições; e percepções das puérperas sobre o parto na posição vertical. Conclusões as puérperas avaliaram positivamente a posição vertical de sua escolha e a relacionaram à maior autonomia da mulher no parto, menor intervenção profissional, descida mais rápida do feto, redução do tempo de trabalho de parto, diminuição da dor e maior conforto.

Objetivo describir percepciones de puérperas acerca de la posición vertical adoptada en el trabajo de parto y parto. Método estudio descriptivo, cualitativo, desarrollado en 2014, en maternidad de referencia de Teresina, Piauí, Brasil. Las participantes fueron ocho puérperas con historia de parto normal en posición vertical. Datos analizados por medio de la técnica de análisis de contenido. Resultados surgieron cuatro categorías: tipo de conocimiento de las mujeres sobre posiciones verticales; percepción de la presencia de enfermera obstetra en el proceso de parturición como incentivo a posiciones verticales; recuerdos de la vivencia de partos en otras posiciones; y percepciones de puérperas sobre parto en posición vertical. Conclusiones las puérperas evaluaron positivamente la posición vertical de su elección y la relacionaron a la mayor autonomía de la mujer en el parto, menor intervención profesional, descenso más rápido del feto, reducción del tiempo de trabajo de parto, disminución del dolor y mayor confort.

Objective to describe the perception of puerperae about the vertical position adopted in labor and delivery. Method this is a descriptive study using a qualitative approach developed in 2014 in a reference maternity hospital in Teresina, Piauí, Brazil. Participants were eight puerperal women with a normal vertical birth. Data were analyzed using the content analysis technique. Results four categories emerged: women's knowledge in terms of vertical positions; perception of the obstetric nurse's presence in the parturition process as an incentive to vertical positions; memories of the experience of childbirth in other positions; and perceptions of puerperal mothers on birth in the upright position. Conclusions the puerperae positively evaluated the vertical position of their choice and related it to the greater autonomy of women in childbirth, less professional intervention, faster descent of the fetus, reduction of labor time, decrease of pain and greater comfort.

Mueller-Hillis maneuver and angle of progression: Are they correlated? / Manobra de Mueller-Hillis e ângulo de progressão: eles estão correlacionados?

Summary Objective: Mueller-Hillis maneuver (MHM) and angle of progression (AOP) measured by transperineal ultrasound have been used to assess fetal head descent during the second stage of labor. We aimed to assess whether AOP correlates with MHM in the second stage of labor. Method: A prospective observational study including women with singleton pregnancy in the second stage of labor was performed. The AOP was measured immediately after the Mueller-Hillis maneuver. A receiver-operating characteristics (ROC) curve analysis was performed to determine the best discriminatory AOP cut-off for the identification of a positive MHM. A p-value less than 0.05 was considered statistically significant. Results: One hundred and sixty-six (166) women were enrolled in the study and 81.3% (n=135) had a positive MHM. The median AOP was 143º (106º to 210º). The area under the curve for the prediction of a positive maneuver was 0.619 (p=0.040). Derived from the ROC curve, an AOP of 138.5º had the best diagnostic performance for the identification of a positive MHM (specificity of 65% and a sensitivity of 67%). Conclusion: An AOP of 138º seems to be associated with a positive MHM in the second stage of labor.

Resumo Objetivo: A manobra de Mueller-Hillis (MHM) e o ângulo de progressão da apresentação (AOP) medido através de ecografia transperineal têm sido utilizados para avaliar a descida do polo cefálico durante o segundo estágio do trabalho de parto. O objetivo do nosso trabalho foi avaliar se o AOP se correlaciona com a MHM no segundo estágio do trabalho de parto. Método: Conduzimos um estudo observacional e prospectivo. Incluímos mulheres com gravidez unifetal com feto em apresentação cefálica, no segundo estágio do trabalho de parto. O AOP foi medido imediatamente após a manobra de Mueller-Hillis. Foi construída uma curva ROC (receiver-operating characteristics) para determinar o melhor AOP para a identificação de uma manobra positiva. Um valor p inferior a 0,05 foi considerado estatisticamente significativo. Resultados: Cento e sessenta e seis mulheres (166) foram incluídas no estudo, e em 81,3% (n=135) a MHM foi positiva. A mediana do AOP foi de 143º (106º a 210º). A área abaixo da curva para a previsão de uma manobra positiva foi 0,619 (p=0,040). Derivado da curva ROC, um AOP de 138,5º teve o melhor desempenho diagnóstico para a identificação de uma MHM positiva (especificidade de 65% e sensibilidade de 67%). Conclusão: Um AOP de 138º parece estar associado com uma MHM positiva no segundo estágio de trabalho de parto.

Effect of pre-pregnancy maternal body mass index on pregnancy outcomes in nulliparous women in the Islamic Republic of Iran

This study was conducted to evaluate the effect of pre-pregnancy BMI on pregnancy outcomes. BMI was calculated measured in 360 nulliparous women. According to BMI, pregnant women were placed into three groups: group I [lean group BMI . 19.8], group II [normal weight group BMI = 19.9.24.9], and group III [obese group BMI . 25]. Data were analyzed using SPSS 16. The mean duration of the first and the second stage of labour were significantly different between three groups [P < 0.001]. Cesarean section ratio in group I was lower than group II [OR = 0.15; P = 0.013]. Instrumental delivery in group III was more than group II [OR=4.6; P = 0.002]. Risk of nonreactive non-stress test [NST] was significantly different between groups II and III [OR = 5.7; P = 0.009]. Induction ratio in group I was lower than group II [OR=0.43; P = 0.002]. Deviation of BMI from the normal level is associated with adverse outcomes of pregnancy and delivery

Complicaciones maternas de la cesárea en gestantes a término en periodo expulsivo en un hospital general de Lima, Perú / Maternal complications of cesarean sections performed in the expulsive period of labor in a general hospital in Lima, Peru

Objetivo: Describir las complicaciones maternas de la cesárea en gestantes a término en periodo expulsivo en un hospital general. Material y métodos: Estudio descriptivo, observacional, retrospectivo, tipo serie de casos, realizado en el Hospital Nacional Cayetano Heredia entre el 1 de enero de 2011 hasta el 31 diciembre de 2012. Se incluyeron 67 gestantes a término operadas en periodo expulsivo. Se revisaron las historias clínicas de las pacientes, se registraron las características clínicas y las complicaciones maternas. Resultados: En el periodo de estudio se realizaron 4 218 cesáreas, siendo el 1,84% hechas en periodo expulsivo. En general, 59/ 67 (88,1%) presentaron algún tipo de complicación. Se observaron 8 casos de hipotonía uterina (11,9%) y 2 (2,9%) de atonía. En 5 (7,4%) pacientes ocurrieron desgarros de segmento adyacente a la histerotomía, siendo 2 de ellos asociados a compromiso de cuerpo uterino y vagina, y 4 (5,9%) casos a laceración de arteria uterina, uno fue bilateral. No se produjeron lesiones en tracto urinario ni digestivo y tampoco hubo necesidad de reintervención quirúrgica. Cuatro pacientes presentaron hemorragia puerperal, dos asociados a hipotonía uterina post cesárea. En 56 (83,5%) casos ocurrió anemia post operatoria. Hubo 1 (1,5%) caso de endometritis, 3 (4,5%) infecciones de herida operatoria. Conclusiones: La cesárea realizada en período expulsivo ocasiona complicaciones frecuentes, algunas muy severas. (AU)

Objective: To determine the maternal complications of cesarean sections performed in the expulsive period of labor in a general hospital. Methods: Case series performed at Hospital Nacional Cayetano Heredia from January 1st, 2011 to December 31st, 2012. Sixty-seven pregnants in whom a cesarean section was performed during the expulsive period of labor were included. Clinical charts were reviewed to gather clinical information. Results: A total of 4218 cesarean sections were performed during the study period, 1.84% were performed during the expulsive period of labor. Overall, 88.1% (59/67) had any kind of complication. Eight cases of uterine hypotonia (11.9%) were observed, and 2 of uterine atonia (2.9%). Detachment of the segment close to the uterine incision was observed in 5 patients (7.4%), in two cases affection of the vagina and uterus was observed, and 4 cases (5.9%) of laceration of the uterine artery, one with bilateral laceration, were observed. No urinary tract or digestive tract lesions were observed; there was also no need to perform re-interventions. Four patients presented puerperal hemorrhage; two were associated with uterine hypotonia. Post-operative anemia was observed in 56 patients (83.5%). There was one case (1.5%) of endometritis and 3 (4.5%) of wound infections. Conclusions: Cesarean sections performed in the expulsive period of labor are associated with frequent complications; some of them are very severe. (AU)

Perineal trauma after vaginal delivery in healthy pregnant women / Trauma perineal após parto vaginal em parturientes saudáveis

CONTEXT AND OBJECTIVE: Despite all the medical care provided during delivery labor, perineal injury is still prevalent and may lead to diverse pelvic floor disorders. The aim here was to investigate the prevalence of obstetric and anal sphincter injuries (OASIS) in healthy pregnant women after vaginal delivery. DESIGN AND SETTING: Cross-sectional study involving 3,034 patients with singletons in a secondary hospital for low-risk cases. METHODS: A standardized questionnaire was prepared and applied to medical files that had been completely filled out (classification of the Royal College of Obstetricians and Gynecologists, RCOG) in order to identify OASIS and analyze risk factors associated with mild and severe perineal lacerations. RESULTS: The women's mean age was 25 years; more than half (54.4%) were primiparae. Almost 38% of the participants had perineal lacerations; these were severe in 0.9% of the cases. Previous vaginal delivery (odds ratio, OR: 1.64 [1.33-2.04]) and forceps delivery (OR: 2.04 [1.39-2.97]) were risk factors associated with mild perineal injuries (1st and 2nd OASIS classifications). Only remaining standing for prolonged periods during professional activity (OR: 2.85 [1.34-6.09]) was associated with severe perineal injuries. CONCLUSION: The prevalence of severe perineal injuries was concordant with data in the literature. The variable of standing position was considered to be a risk factor for severe perineal injury and should be further investigated. .

CONTEXTO E OBJETIVOS: Apesar do cuidado médico executado durante o trabalho de parto, os traumas perineais ainda são prevalentes e podem levar a várias desordens do assoalho pélvico. O objetivo foi investigar a prevalência de injúrias obstétricas e do esfíncter anal em mulheres saudáveis após parto vaginal. DESENHO E LOCAL DE ESTUDO: Estudo transversal envolvendo 3.034 pacientes com recém-natos únicos de um hospital secundário de baixo risco. MÉTODOS: Um questionário padronizado foi preparado e aplicado aos prontuários completamente preenchidos (classificação do Royal College of Obstetricians and Gynecologists) para identificar as lesões obstétricas e do esfíncter anal e analisar fatores de risco associados com lacerações perineais leves e graves. RESULTADOS: A média de idade das mulheres era 25 anos; mais da metade (54,4%) era primípara. Quase 38% das participantes tiveram lacerações perineais; estas foram graves em 0,9% dos casos. A presença de parto vaginal prévio (odds ratio, OR, 1,64 [1,33-2,04]) e o parto fórceps (OR 2,04 [1,39-2,97]) foram fatores de risco associados às lesões perineais leves (primeira e segunda classificações de lesão esfíncter e anal). Somente a posição em pé prolongada durante a atividade profissional (OR 2,85 [1,34-6,09]) estava associada com lesões perineais graves. CONCLUSÃO: A prevalência de trauma perineal grave concordou com dados da literatura. A variável posição em pé foi considerada fator de risco para trauma perineal grave e necessita ser investigada. .

[Comparison of the effects of one-step acupressure of spleen point 6 [SP-6] and gall bladder 21 [GB-21] on the duration and type of delivery in nulliparous women referred to hospitals in Shiraz University of Medical Sciences, Iran: a randomized clinical trial]

Sedatives constitute an important part of modern obstetric care. One of the under-investigation methods is the effect of acupressure on reduction of the duration of labor stages. This study was performed aiming at comparison of the effects of one-step acupressure of spleen point 6 [SP-6] and gall bladder 21 [GB-21] on the duration and type of delivery and Apgar of newborne in nulliparous women. This clinical trial study was performed on 150 nulliparous women. Women were randomly assigned to three groups, including gallbladder 21 acupressure, spleen point 6 acupressure, and control. In first two groups, pressure was performed at 3-4cm cervical dilatation for 20 minutes. In the control group, contact with no pressure was done on the acupressure points and with the same condition of the intervention group. The collected data was analyzed using paired t-test, independent t-test, and one-way variance analysis. In this study, the duration of the active stage of labor in the intervention group was less than control group [p<0.05], but no significant difference was observed in the two intervention groups [p>0.05]. Also, duration of the second stage of labor in the control group was more than two experimental groups, but the difference was not significant [p>0.05]. The three groups, had no significant difference in the fifth minute Apgar score [p>0.05]. The number of cesarean sections in the intervention groups were more than control group [p<0.05]. According to the results of this study, the acupressure in SP-6 and GB-21 points, in the one-step intervention was equally effective in reducing the duration of active stage of labor

Impact of female genital mutilation on second stage of labour in primigravida at Omdurman Maternity Hospital, Sudan 2010

To find out the impact of female genital mutilation [FGM] on the second stage of labour at Omdurman Maternity Hospital [OMH]. A descriptive cross-sectional study, for primigravidae delivered vaginally in 2010. After an informed consent circumcised women, were included as study group and uncircumcised ladies as control group. Data was collected by trained registrars using a structured questionnaire to collect frequency of postpartum haemorrhage [PPH], perineal tear, birth asphyxia, neonatal death and hospital stay. A total of 1961 primigravidae, delivered in 2010 at OMH, 629[32.1%] were circumcised and 1332[67.9%] were uncircumcised. There was no significant difference in the mode of delivery and episiotomy. FGM places women at a greater risk during childbirth, endangering their health and their babies compared to uncircumcised.

Low Apgar scores at 5 minutes in a low risk population: maternal and obstetrical factors and postnatal outcome / Baixos índices de Apgar no quinto minuto de vida em população de baixo risco: fatores maternos e obstétricos e resultados pós-natais

OBJECTIVE: To evaluate the association between Apgar scores of less than seven at five minutes (AS5min < 7) and antenatal factors and postnatal outcomes. METHODS: A retrospective cohort and case-control study of 27,252 consecutive term newborns in a low risk obstetrical population between January 2003 and December 2010. Maternal and infant databases were reviewed from all cases with AS5min < 7 (n = 121; 0.4%) and 363 cases with AS5min > 7 at 5 minutes who were randomly selected by a computer program. The main outcomes were neonatal death, newborn respiratory distress, need for orotracheal intubation and neonatal intensive care unit (NICU), and hypoxic-ischemic-encephalopathy. RESULTS: After multiple regression analysis, repeated late decelerations on cardiotocography (OR: 2.4; 95% CI: 1.4-4.1) and prolonged second stage of labor (OR: 3.3; 95% CI: 1.3-8.3) were associated with AS5min < 7, as well as neonatal respiratory distress (OR: 3.0; 95% CI: 1.3-6.9), orotracheal intubation (OR: 2.5; 95% CI: 1.2-4.8), need for NICU (OR: 9.5; 95% CI: 6.7-16.8), and hypoxic-ischemic-encephalopathy (OR: 14.1; 95% CI: 3.6-54.7). No other antenatal factors were associated with AS5min < 7 (p > 0.05). CONCLUSION: Repeated late decelerations and prolonged second stage of labor in the low-risk population are predictors of AS5min < 7, a situation associated with increased risk of neonatal respiratory distress, need for mechanical ventilatory support and NICU, and hypoxic-ischemic-encephalopathy.

OBJETIVO: Avaliar a associação entre índice de Apgar menor que sete no 5º minuto, os fatores pré-natais e resultados pós-natais. MÉTODOS: Trata-se de estudo retrospectivo com 27.252 recém-nascidos em maternidade escola com população de baixo risco obstétrico, de janeiro de 2003 a dezembro de 2010. Prontuários de todos os casos com índice de Apgar < 7 no 5º minuto (n = 121; - 0,4%) e de 363 casos com Apgar > 7 no 5º minuto, escolhidos ao acaso, foram revisados. Os principais desfechos estudados foram: óbito neonatal, insuficiência respiratória neonatal, necessidade de intubação orotraqueal e de unidade terapia intensiva (UTI) neonatal e encefalopatia hipóxico-isquêmica. RESULTADOS: Após análise de regressão múltipla, desacelerações tardias (DIP II) (OR: 2,4; IC95%: 1,4-4,1) e período expulsivo prolongado (OR: 3,3; IC 95%: 1,3-8,3) se associaram com Apgar < 7 no 5º minuto; assim como com insuficiência respiratória ao nascimento (OR: 3,0; IC 95%: 1,3-6,9), intubação traqueal (OR: 2,5; IC 95%: 1,2-4,8), necessidade de UTI neonatal (OR: 9,5; IC 95%: 6,7-16,8) e encefalopatia hipóxico-isquêmica (OR: 14,1; IC 95%: 3,6-54,7). Nenhuma outra variável prénatal se associou com Apgar < 7 no 5º minuto (p < 0,05). CONCLUSÃO: DIP II e período expulsivo prolongado estão associados com Apgar < 7 no 5º minuto em população obstétrica de baixo risco; situação essa relacionada com maior risco de insuficiência respiratória no parto, necessidade de suporte ventilatório e encefalopatia hipóxico-isquêmica.

[Comparing the effects of spontaneous pushing versus Valsalva pushing technique on outcome of delivery in primiparous women]

The valsalva pushing technique is used routinely in the second stage of labor in many countries, and it is accepted as standard obstetric method in Iran. The purpose of this study was to determine the effects of spontaneous pushing, versus, valsalva pushing technique in birth on outcome of delivery in primiparas. This clinical trial study was conducted on 100 primiparas. Samples were randomized to either a spontaneous pushing group [open glottis pushing while breathing out] or a valsalva type pushing group [closed glottis pushing while holding their breath]. The length of stages of delivery, perineal tears, postpartum hemorrhage and satisfaction were evaluated in mothers and apgar scores at 1 and 5 minutes were evaluated in newborns. Data were analyzed using statistical Mann-Whitney, Chi-square and independent t-test. The duration of expulsion phase of the second stage of labor was significantly longer in valsalva-type pushing [P=0.004]. The result indicated that the incidence of episiotomy in spontaneous pushing group [P=0.003] and postpartum hemorrhage in valsalva pushing group [P=0.002] was more. The baby fared better with spontaneous pushing, with higher 1- minute apgar score. After the birth, women expressed greater satisfaction with spontaneous pushing. Educating women for the spontaneous pushing technique in the first stage of labor and providing support for spontaneous pushing in the second stage result in a shorter second stage without interventions and in improved newborn outcomes

Indicações do parto a fórceps / Indications for forceps deliveries

A solução do parto no período expulsivo é um desafio, ainda nos dias de hoje. Apesar de ser praticado em cerca de 10% dos partos no mundo ocidental, há discussões sobre as indicações do parto vaginal operatório, a escolha do instrumento e sua aplicação sequenciada. Foi feita revisão da literatura, que se mostrou pobre em ensaios clínicos. A evidência maior do uso do fórceps repousou em estudos observacionais, muito dos quais com tamanho amostral limitado. Também, foram consultadas as diretrizes de algumas sociedades (ACOG, SOGC, RCOG e FEBRASGO) para as recomendações. Concluiu-se que ainda há necessidade da prática do fórceps, mas que esse ato deve ser realizado por obstetra experiente e em ambiente que permita a prática da cesárea. As indicações fetais para parto a fórceps são a parada de progressão e o sofrimento fetal, e as indicações maternas são aquelas em que o esforço expulsivo é fator de risco para complicações (cardiopatias, pneumopatias, encefalopatias). A falha do fórceps ou do vácuo é indicação para cesárea, não sendo recomendado o seu uso sequenciado. Foi verificado que há necessidade de programas de treinamento na prática do fórceps.

The solution of second stage of childbirth is still a challenge. Despite being practiced in 10% of births in the Western world, there are discussions about the indications for operative vaginal deliveries, choice of instrument and its application. Literature review was conducted, which proved to be poor in clinical trials. The best evidence rested in observational studies, many of which with limited sample size. Some guidelines were consulted (ACOG, SOGC, RCOG and FEBRASGO) for recommendations. It was concluded that there is still need for the practice of forceps, but this surgery must be performed by experienced obstetrician and in an environment that allow the practice of caesarean section. Fetal indications for forceps deliveries are lack of progression in the second stage and fetal distress. Maternal indications are those in which the expulsive effort is risk factor for complications (heart, lung or cerebral diseases). The failure of the forceps or vacuum is indication of caesarean section, not being recommended its use in sequence. There is a need for training programs in the practice of forceps.

Abdominal muscle electrical activity during labor expulsive stage: a cross-sectional study / Atividade elétrica muscular abdominal durante os esforços expulsivos do parto: um estudo transversal

BACKGROUND: During the second stage of labor, the progression of the fetal expulsion depends on many factors related to maternal and fetal parameters, including the voluntary abdominal pushing. OBJECTIVES: This study aimed to correlate the maternal and fetal parameters that may influence the voluntary maternal pushes during the second stage of labor by using surface electromyography. METHODS: The electromyographic activity of the rectus abdominis and external oblique muscles were measured during the second stage of labor in 24 Brazilian pregnant women. The diastasis of the rectus abdominis, the body mass index and the uterine fundal height were analyzed as maternal parameters and the fetal weight, cephalic circumference, APGAR scores and arterial pH and CO2 were analyzed as fetal parameters. The oxytocin usage and the expulsive phase duration were considered. RESULTS: A negative correlation between the rectus abdominis diastasis and the rectus abdomini muscle electromyographic parameters was found (r=-0.407 p=0.04). No statistically significant correlations were found among the rectus abdominis and external oblique muscles electromyography and the other maternal or fetal parameters, as well as among expulsive phase duration and the oxytocin usage. CONCLUSIONS: This study suggests that the rectus abdominis diastasis may be an influential parameter in generating voluntary pushes during the second stage of labor, however it cannot be considered the only necessary parameter for a successful labor.

CONTEXTUALIZAÇÃO: Durante o segundo estágio do parto, a progressão da expulsão fetal depende de vários fatores ligados a parâmetros maternos e fetais, dentre eles, o esforço abdominal voluntário. OBJETIVOS: Correlacionar os parâmetros maternos e fetais que podem influenciar os esforços voluntários durante a fase do segundo estágio do parto por meio da eletromiografia de superfície. MÉTODOS: As atividades eletromiográficas dos músculos retoabdominal e oblíquo externo foram medidas durante o segundo estágio do parto em 24 gestantes. A diástase do músculo retoabdominal, o índice de massa corpórea e a altura de fundo de útero foram analisados como parâmetros maternos, e o peso fetal, o perímetro cefálico, os índices de Apgar e o pH e pCO2 arterial foram analisados como parâmetros fetais. O uso de ocitocina e o tempo do período expulsivo foram considerados. RESULTADOS: Encontrou-se uma correlação negativa entre a diástase umbilical e os parâmetros eletromiográficos do músculo retoabdominal (p=0,04; r=-0,407). Não se encontrou correlação significativa entre a eletromiografia dos músculos retoabdominal e oblíquo externo e os demais parâmetros maternos e fetais, bem como entre o tempo do período expulsivo e o uso da ocitocina. CONCLUSÕES: O presente estudo sugere que a diástase umbilical pode ser um parâmetro influente na geração de esforços voluntários durante o período expulsivo do parto, porém não deve ser considerada de forma isolada para o sucesso do andamento do trabalho de parto.

Effect of prolonged second stage of labor on maternal and neonatal outcomes

OBJECTIVE@#To discuss the effect of prolonged second stage of labor on maternal and neonatal outcomes.@*METHODS@#A total of 101 primiparas with the length of second stage of labor longer than 2 h were selected and pregnant women with the length less than 2 h served as control. The maternal and neonatal outcomes of two groups were observed and compared.@*RESULTS@#A total of 62.1%(18/11) with the length of second stage of labor between 120 min and 180 min, 46.7%(28/32) between 181 min and 240 min and 12 longer than 241 min underwent vaginal delivery. The longer the length of second stage of labor, the lower score of Apgar scale for infants in 1 min, and the higher the incidence of asphyxia. But there was no difference in scale in 5 min. As second stage of labor prolonged, the incidences of cesarean section and of postpartum hemorrhage increased.@*CONCLUSIONS@#Almost half of puerperas with the length of second stage of labor longer than 2 h underwent vaginal delivery. The prolonged second stage of labor can decrease the score of Apgar scale in 1 min, increase the incidence of asphyxia, but has no effect on scale in 5 min. It still need more evidence from evidence medicine to definition of time and treatment of second stage of labor.

Assistência ao segundo e terceiro períodos do trabalho de parto baseada em evidências / Assistance to the second and third periods of labor based on evidence

A conduta ideal a ser adotada no segundo período do trabalho de parto deveria se basear no balanço entre a probabilidade de um parto vaginal, que deve ser maximizada, contra os riscos maternos e perinatais, que devem ser minimizados. Entretanto, ainda não existe consenso sobre o manejo do período expulsivo, a começar por sua definição e os limites estabelecidos para sua duração. Realizou-se uma revisão da literatura em busca das melhores evidências disponíveis sobre a assistência ao trabalho de parto. Foram abordados aspectos como duração do período expulsivo, posição e puxos das pacientes, monitorização fetal, necessidade de episiotomia, manobras para redução do trauma perineal, parto instrumental, acolhimento do recém-nascido e ligadura do cordão umbilical. Também foi abordada a conduta no terceiro e quarto períodos. Não há evidências suficientes para delimitar a duração ideal do período expulsivo; porém, há guidelines, como os do American College of Obstetricians and Gynecologists (ACOG), que estabelecem limites de acordo com a paridade e a utilização ou não de analgesia. Posições não supinas devem ser priorizadas durante o segundo estágio, respeitando-se a preferência das parturientes. A monitorização da frequência cardíaca fetal deve ser intermitente, reservando-se a monitorização contínua para casos especiais. O uso rotineiro de cardiotocografia intraparto associa-se com o aumento das indicações de cesariana. A episiotomia não deve ser realizada de rotina, documentando-se diversos benefícios quando o procedimento pode ser evitado: menos perda sanguínea, menor uso de suturas, menos dor e menos complicações perineais. O parto instrumental só está indicado em situações especiais, e a decisão por vácuo ou fórceps deve considerar potenciais vantagens e desvantagens, habilidade do operador e opinião da parturiente. O contato precoce pele a pele entre mãe e bebê deve ser estimulado, e o cordão umbilical deve ser ligado tardiamente...

The ideal management of the second stage of labor should be based in the balance between the vaginal delivery probability, which should be maximized, against the maternal and perinatal risks, which should be minimized. Notwithstanding, there is no consensus about second stage management, beginning with its definition and the limits for its duration. A literature review was conducted in search of the best available evidence about labor and delivery management. Several aspects were analyzed, such as maternal position, pushing, fetal monitoring, episiotomy, perineal protection, instrumental delivery, neonatal care and cord clamping. The third and fourth stages management was also considered. There is not enough evidence to establish the ideal duration of the second stage of labor, but American College of Obstetricians and Gynecologists (ACOG) guidelines suggest limits according to parity and analgesia utilization. Nonsupine positions should be considered according to the woman's preference. Fetal heart rate monitoring should be intermittent, and continuous monitoring should be used only in special conditions. Routine use of intrapartum cardiotocography is associated with the increased rate of cesarean sections. The episiotomy should not be routinely performed, and several benefits are documented when this procedure can be avoided: reduced blood loss, fewer sutures, less pain and fewer perineal complications. Instrumental delivery is indicated only in special conditions, and the decision for forceps or vacuum should take into account potential advantages and disadvantages, the operator's skills and the woman's opinion. Early skin contact between mother and baby should be encouraged and late cord clamping should be performed. The safest and most effective recommendation for the third stage management is routine use of oxytocin for preventing postpartum hemorrhage.

Effects of a pushing intervention on pain andbirthing experiences among women duringthe second stage of labor

Midwifery care for women during second-stage of labor is complex. It involves frequent and assessments of mother and fetus, promoting fetal descent, and supporting each woman's ability to cope with labor pain. Several studies have compared specific categories of pushing methods and pushing positions with regard to the length of the second stage of labor, pain, perineal outcomes and the Apgar scores of newborn infants. To evaluate maternal labor pain, duration of the second stage of labor, the women's bearing-down experiences and the newborn infant Apgar scores when spontaneous pushing is used in an upright position. This study was conducted using a quasi-experimental design. Two groups were included, study and control groups. Each group consisted of 40 women. The study group received comfort measures from the investigator, while the control group received routine nursing care. The women in study group had significantly shorter second stage of labor than the women in the control group [p=0.000], the women in the study group had more positive pushing experiences than the women in the control group [p<0.002]. The spontaneous pushing method and upright position are worthy of further promulgation in hospital. Additionally, in order to allow women to understand the benefits of different pushing techniques and postures, midwives and nurses should provide information during prenatal preparations for childbirth. Suggestions here women should be discouraged from lying supine or semi-supine in the second stage of labor and should be encouraged to adopt any other position such as sitting or squatting position that find most comfortable. In addition to women should be informed that in second stage they should be guided by their own urge to push. If pushing is ineffective or if requested by the women, strategies to assist birth can be used, such as support, change of position, emptying of the bladder and encouragement

[Effect of trained female relative on active phase length during labor among low risk pregnancies]

One of the most serious and stressful event in womens life is laber. They need comprehensive support to enable them to encounter with the stress of labor. Prolonged labor is associated with maternal and neonatal complications, prenatal morbidity and increase cesarean danger. To study the effect of trained female relative on active phase length during labor among low risk Pregnancies in Astara Shahid Beheshti hospital in 2009. This randomized control trial study was carried out on 90 low risk pregnant women. They were randomly divided to two 45 members groups. Both the case and control groups had socio- demographic characteristics. The case group got a support from trained relative during labor until 2 hours after delivery and control group received routine care. Data was collected by using restructured questionnaire which included length of labor, use of Oxytocin and type of delivery. Data was analyzed by x[2] and T test in SPSS [11.5]. Finding showed there is no statistically significant difference between demographic characteristics: [mean of age was 24.3- 24.6 years old, mean of number of Pregnancy was 1.6, mean of number of delivery was 1, mean of term of Pregnancy was 273.7- 273.9 days, mean of cervix spasm was 3.44-3.7 cm, length of second stage] and kind of delivery in two groups [p<0.663]. The mean duration of active phase in case group was 143.5 minute versus 253.5 minute in control group [p<0.001].The 24.5% of case and 55.5% of control groups used oxytocin [p=0.046]. Labor support by a minimally trained female friend or relative who selected by the mother can be reduce the mean duration of active phase of labor