A multifaceted model for improving the appropriateness of indications for cesarean delivery / Un modelo multifacético para mejorar la adecuación de las indicaciones de cesárea

Background: We evaluated the effectiveness of a multifaceted strategy to improve the appropriateness of the indications for cesarean delivery in 41 hospitals belonging to the Spanish National Health Service. Methods: We implemented indications for emergency and elective cesareans and analyzed their appropriateness prospectively. We provided staff with feedback and training courses and allocated the necessary resources. The results were published. A pre-post design without a control group was used. Results: The total number of deliveries in both periods was 23,711 and 29,627; of these, 5,380 and 6,371, respectively, were cesarean deliveries. The general cesarean rate decreased by 1.19 percentage points, and the overall appropriateness rate increased by 15.45% (95%CI, 13.78-17.13): 8.65% (95%CI, 6.24-11.07) for elective cesarean and 20.15% (95%CI, 17.93-22.36) for emergency cesareans. Appropriateness improved across all 5 indications for emergency cesarean, ranging from 10.87% (95%CI, 6.85-14.89) for fetal distress to 29.97% (95%CI, 24.49-35.45) for cephalopelvic disproportion. Conclusion: This strategy appears to be effective for increasing the appropriateness of the indications for cesarean delivery and reducing the complications and costs associated with the cesarean deliveries avoided

Objetivo: evaluar la efectividad de una estrategia dirigida a mejorar la adecuación de las indicaciones de cesáreas en 41 hospitales del Sistema Nacional de Salud. Métodos: implantación de un protocolo de las indicaciones de cesáreas urgentes y programadas, el análisis prospectivo de su adecuación, retroalimentar a los profesionales, impartir cursos de formación, asignar recursos necesarios y difundir los resultados. Se utilizó un diseño pre-post sin grupo control. Resultados: el número de partos en los periodos pre y post fue 23.711 y 29.627, y el de cesáreas, 5.380 y 6.371, respectivamente. El porcentaje global de cesáreas descendió 1,19, y el de adecuación global aumentó 15,45 (IC 95%: 13,78-17,13); 8,65 (IC 95%: 6,24-11,07) en el conjunto de programadas y, 20,15 (IC 95%:17,93-22,36) en el conjunto de las urgentes. La mejora en la adecuación se observó en las cinco indicaciones de cesáreas urgentes y osciló entre 10,87 (IC 95%: 6,85-14,89) en el grupo de riesgo de pérdida de bienestar fetal y 29,97 (IC 95%: 24,49-35,45) en el de desproporción pelvifetal. Conclusión: esta estrategia parece ser efectiva para aumentar la adecuación de las indicaciones de cesáreas y reducir las complicaciones y los costes asociados con las cesáreas evitadas

Predictive modeling of emergency cesarean delivery.

OBJECTIVE: To increase discriminatory accuracy (DA) for emergency cesarean sections (ECSs). STUDY DESIGN: We prospectively collected data on and studied all 6,157 births occurring in 2014 at four public hospitals located in three different autonomous communities of Spain. To identify risk factors (RFs) for ECS, we used likelihood ratios and logistic regression, fitted a classification tree (CTREE), and analyzed a random forest model (RFM). We used the areas under the receiver-operating-characteristic (ROC) curves (AUCs) to assess their DA. RESULTS: The magnitude of the LR+ for all putative individual RFs and ORs in the logistic regression models was low to moderate. Except for parity, all putative RFs were positively associated with ECS, including hospital fixed-effects and night-shift delivery. The DA of all logistic models ranged from 0.74 to 0.81. The most relevant RFs (pH, induction, and previous C-section) in the CTREEs showed the highest ORs in the logistic models. The DA of the RFM and its most relevant interaction terms was even higher (AUC = 0.94; 95% CI: 0.93-0.95). CONCLUSION: Putative fetal, maternal, and contextual RFs alone fail to achieve reasonable DA for ECS. It is the combination of these RFs and the interactions between them at each hospital that make it possible to improve the DA for the type of delivery and tailor interventions through prediction to improve the appropriateness of ECS indications.

Comparación lactato-pH intramuestral en sangre capilar fetal para el estudio del bienestar fetal intraparto / Comparison of lactate and pH in the same sample from fetal scalp blood to study intrapartum fetal wellbeing

Objetivos: Validación intraparto de la determinación de lactato y pH en la misma muestra de sangre capilar de calota fetal. Sujetos y método: Doscientos cincuenta mujeres de parto en los hospitales de Manacor, Inca y Son Llàtzer de Mallorca. Determinación intramuestral de pH y lactato en sangre fetal. Resultados: En el 32,54% de las determinaciones hubo discordancia de grupo (normalidad, prepatológico o patológico) entre el resultado del pH y el resultado del lactato. Conclusiones: Es posible que el lactato y el pH no expresen de igual manera la condición de bienestar fetal en términos de acidosis. No deberíamos hoy por hoy sustituir la medición de pH intraparto por la de lactato en sangre de cuero cabelludo fetal (AU)

Objectives: To validate lactate and pH determination in the same sample from fetal scalp blood. Subjects and method: We included 250 women who delivered in the Inca, SonLlatzer and Manacor hospitals in Mallorca (Spain).Lactate and pH were determined in the same fetal blood sample. Results: There was group discordance (prepathologic, normal, and pathologic) in 32.54% of the samples. Conclusions: Lactate and pH may not express fetal well being in the same manner. Currently, pH determinations should not be switched to lactate determinations in fetal scalp blood (AU)

Quality of life of menopausal women in the island of Majorca: a population based study.

OBJECTIVES: To explore demographic and epidemiological characteristics surrounding menopause among women of Majorca, estimate their health related quality of life (QOL), and ascertain wheather they differ from those of the mainland population of menopausal women. METHODS: A cross-sectional population-based study was conducted with a sample of 428 women. The Cervantes questionnaire for measuring QOL during menopause was used. RESULTS: Among women in Majorca, the mean QOL is better than the national mean of the Spain reference population. It declines with age and levels off at menopause. In menopausal women, QOL improves slightly in tandem with educational level. 29% of menopausal women were on some form of therapy, most commonly a mix of estrogens and gestagens (36%). Only a weak association was detected between being menopausal and QOL. CONCLUSION: The Cervantes questionnaire allows periodic study sample cut-offs to determine whether changes in sociodemographic and disease-related variables are also accompanied by changes in self-perceived QOL. It is much better in menopausal women in Majorca than in those in the Spanish mainland.

Clasificación de cesáreas por Grupos de Robson en dos periodos comparativos en el Hospital de Manacor / Cesarean section classification according to Robson's Groups in two comparative periods at the Manacor Hospital

Objetivo. Identificar los grupos de mujeres en los que cambian las tasas de cesáreas durante dos periodos comparativos. Sujetos y métodos. Revisamos los partos del Hospital de Manacor en 2000-1 y 2005-6, mediante el análisis retrospectivo de las historias clínicas, agrupándolos según la Clasificación de Robson. Resultados. El porcentaje de cesáreas aumentó del 14 al 18,6%, con un incremento significativo entre las mujeres con feto único en cefálica a término inducidas, o sometidas a cesárea electiva, que son quienes más contribuyen al porcentaje de cesáreas del hospital. Conclusión. Ha aumentado el porcentaje de cesáreas. Con la Clasificación de Robson sabemos qué pacientes contribuyen a ese incremento (AU)

Objective. To identify groups of women with changes in cesarean rates in two different periods. Subjects and methods. Deliveries in the Manacor Hospital in 2000-2001 and 2005-2006, were analyzed through a retrospective review of clinical records and were grouped using Robsonìs classification. Results. The cesarean rate increased from 14 to 18.6% with a statistically significant increase among women with a single cephalic pregnancy at term who underwent labor induction or elective cesarean section. These two groups were the major contributors to the cesarean rate at our hospital. Conclusion. A trend towards an increase in the rates of cesarean section was found during the study period. Robson's Classification allowed us to identify the groups of women contributing to this increase (AU)

Tumores malignos ginecológicos sincrónicos. Casuística del Hospital de Manacor / Synchronous malignant gynecological tumors. Casuistics of the Manacor Hospital

Objetivo: El presente estudio pretende que el ginecólogo clínico tome conciencia de la existencia de tumores ginecológicos de aparición sincrónica en una misma paciente durante el proceso diagnóstico de una neoplasia ginecológica, sobre todo en casos de antecedentes de cáncer de tipo familiar. Se describen varios síndromes consistentes en la aparición de tumores de tipo familiar que facilitan la presencia de tumores ginecológicos sincrónicos. Sujetos y métodos: Se analiza la casuística del Hospital de Manacor desde 1997 hasta 2006. Resultados: Los casos de tumores ginecológicos sincrónicos suponen el 0,83% de los tumores intervenidos en el período estudiado. Conclusiones: Aunque infrecuentes, estos tumores ginecológicos sincrónicos deben de tenerse en cuenta para que no pasen inadvertidos, sobre todo en pacientes con historia de cáncer familiar o portadoras de algunos síndromes genéticos. Una exploración dirigida a eliminar la presencia de otra neoplasia, aparte de la que estamos diagnosticando, es conveniente (AU)

Objective: To alert clinicians to the possibility of synchronous tumors in patients with gynecological cancer. An important tool in diagnosis is the family history. We describe several familial syndromes involving the development of synchronous gynecological tumors. Subjects and methods: We studied all cases of synchronous gynecological tumors in the Manacor Hospital from 1997 to 2006. Results: Synchronous gynecologic tumors represented 0.83% of all gynecological neoplasms treated in our center in the period studied. Conclusions: This kind of tumor is uncommon but should be considered by clinicians, especially in women with a familial history of cancer or in those with certain genetic syndromes. Examination aimed at excluding the presence of synchronous tumors is recommended (AU)

Síndrome obstructivo congénito de las vías aéreas altas (síndrome de CHAOS). Causa infrecuente de hídrops fetal / Congenital high airway obstruction syndrome (CHAOS syndrome). An infrequent cause of fetal hydrops

La obstrucción congénita de las vías respiratorias altas corresponde a una malformación rara e infrecuente, cuyo diagnóstico prenatal ya ha sido descrito con anterioridad. Reconocerlo prenatalmente nos va a permitir ofrecer a la paciente las posibles opciones que haya que seguir, como conducta prenatal, opciones que van a poder mejorar sustancialmente los resultados finales, respecto a los casos no diagnosticados anteparto, en los que tendremos que aplicar maniobras de urgencia obligada, que presentarán un resultado imprevisible. Actualmente, la mayoría de los casos descritos en la literatura científica corresponden a embarazos con diagnóstico prenatal, lo que ha permitido la práctica de una cesárea programada llevada a cabo mediante el sistema EXIT (tratamiento intraparto ex útero), obteniendo resultados óptimos en alguno de ellos

Congenital high airway obstruction syndrome (CHAOS) is an uncommon malformation. Prenatal diagnosis of this malformation by ultrasound has previously been described. Prenatal identification will allow us to offer patients the possibility of prenatal counseling and to substantially improve perinatal outcomes in comparison with those in fetuses without a prenatal diagnosis, in which emergency maneuvers must be performed with unpredictable results. Currently, most of the cases described in the literature correspond to pregnancies with a prenatal diagnosis, which has allowed cesarean section to be successfully performed with the EXIT procedure (ex utero intrapartum treatment). Excellent results have sometimes been obtained

Idoneidad de las indicaciones de cesárea. Una aplicación en la gestión de la práctica clínica / Appropriateness of indications for cesarean section. Application of quality management to clinical practice

Objetivo: Describir el sistema de gestión de calidad en el ámbito de las cesáreas del Servicio de Ginecología y Obstetricia del Hospital de Manacor y evaluar la adecuación de las cesáreas practicadas en ese servicio en el bienio 2004-2005. Sujetos y métodos: Se consensuaron indicaciones basadas en pruebas científicas para practicar cesáreas urgentes y programadas y sus criterios de calidad, y se revisaron todas las historias clínicas para evaluar su idoneidad en ese bienio conforme a estándares prefijados. Resultados: En todos los bimestres se cumplieron los objetivos de adecuación prefijados (100% de las programadas y más del 90% de las urgentes), excepto en julio-agosto de 2004 y mayo-junio de 2005 (adecuación de las programadas: 92%), y en julio-agosto de 2004 (adecuación de las urgentes: 84%). Conclusiones: Para disminuir su variabilidad injustificada, es necesario estandarizar, basar en evidencias y evaluar periódicamente la adecuación de las indicaciones de las cesáreas

Objectives: To describe the quality management system applied by the Obstetrics and Gynecology Service of the Manacor Hospital, Majorca (Spain) to the process of cesarean section, and to assess the appropriateness of caesarean sections performed in this service between 2004 and 2005. Subjects and methods: Consensus was reached on evidence-based indications for emergency and elective cesarean sections and on their quality criteria. All clinical records were reviewed to assess the appropriateness of cesarean sections performed from 2004-2005 according to previously established standards. Results: In all two-monthly periods, appropriateness was achieved according to previously established standards (100% of elective interventions and > 90% of emergency cesarean sections), except in July-August, 2004 and May-June 2005 (appropriateness of elective cesarean sections = 92%), and in July-August 2004 (appropriateness of emergency interventions = 84%). Conclusions: To reduce unjustified variability in clinical practice, cesarean section indications must be standardized, based on scientific evidence, and regularly assessed