Strategies to reduce the caesarean section rate in a private hospital and their impact.

There is a concern around the world of an increasing caesarean section rate. It was estimated that between 2010 and 2015, caesarean section rates increased by almost 50%. There are several implications for this, considering that caesarean sections are associated with higher costs and worse clinical outcomes. In this context, several interventions have been considered to increase vaginal delivery rates, including the Adequate Childbirth Project (PPA) in Brazil. This study aimed to verify the impact of the strategies adopted internally in the Hospital Israelita Albert Einstein (HIAE) located in São Paulo, Brazil, regarding the reduction of caesarean sections and their perinatal results. Actions to support our study were implemented in two phases based on the PPA schedule. These actions involved three axes: a multidisciplinary team, pregnant women and facility improvements. All pregnant women admitted for childbirth at the HIAE between 2014 and 2019 were included in this study. The overall rate of vaginal delivery in this study population and among primiparous women and the percentage of admissions to the neonatal intensive care unit (NICU) were analysed in three periods: before the implementation of PPA actions (period A), after the first phase of the project (period B) and after its second phase (period C). The results showed an increase in the average vaginal delivery rate from 23.57% in period A to 27.88% in period B, and to 30.06% in period C (AxB, p<0.001; BxC, p=0.004). There was a decrease in the average of NICU admissions over the periods (period A 19.22%, period B 18.71% and period C 13.22%); a significant reduction was observed when periods B and C (p<0.001) were compared.

Simplified correction of a meningomyelocele-like defect in the ovine fetus

PURPOSE: To develop a simplified technique for antenatal correction of a meningomyelocele -like defect in fetal sheep to allow direct skin closure. METHODS: A spinal defect was surgically created at 75 days of gestation in the fetuses of 36 pregnant sheep, 23 survived the surgery. At 102 days gestation, the defect was corrected in 14 cases (9 were left untreated). Skin surrounding the defect was dissected below the dermis to permit its edges to be approximated and sutured, without interposing any material to its edges. An interface material intended to protect the neural tissue from skin adhesion was used and the skin defect was completely closed over it. Pregnancy was allowed to continue up to 138 days gestation, the fetuses were submitted to macroscopic and microscopic analysis. RESULTS: The defect was successfully corrected in 90.9% in the experimental group, and spontaneous closure occurred in 22.3% in the control group (p 0.05). The survival rate after the creation and correction of the defect was 63.4% and 78% respectively. CONCLUSION: This simplified technique was successful in the correction a meningomyelocele-like defect, in the fetal sheep.

OBJETIVO: Desenvolver uma técnica simplificada de correção pré-natal de defeito semelhante à mielomeningocele em fetos de ovelha permitindo um fechamento direto da pele. MÉTODOS: Um defeito espinhal foi cirurgicamente criado com 75 dias de gestação, em 36 fetos de ovelha, 23 sobreviveram à cirurgia. Após 102 dias de gestação, o defeito foi corrigido em 14 casos (9 não foram tratados). A pele em volta do defeito foi dissecada abaixo da derme para permitir a aproximação direta das bordas através de sutura, sem a interposição de nenhum material entre a pele. Um material de interface foi colocado entre o tecido neural exposto e a pele, com o objetivo de evitar a adesão da medula à pele, que foi completamente fechada sobre o defeito. A gravidez foi mantida até 138 dias, os fetos foram submetidos a análises macroscópicas e microscópicas. RESULTADOS: O defeito foi corrigido em 90.9% no grupo experimental, e o fechamento espontâneo ocorreu em 22.3% no grupo controle (p 0.05). A taxa de sobrevivência após a criação do defeito e posteriormente a sua correção foi de 63,4% e 78%, respectivamente. CONCLUSÃO: Esta técnica simplificada teve sucesso na correção do defeito semelhante à mielomeningocele em feto de ovelha.