Estudio prospectivo,aleatorizado y controlado para evaluar la utilidad de la radiopelvimetría en la inducción de parto en primigrávidas

Introduction

There are very few studies published in the scientific literature to assess the real value of the x-ray pelvimetry (X-PM). The current recommendations on its use are based on a single meta-analysis that includes only four studies with a very low level of scientific evidence.

Objectives

To evaluate the usefulness of the X-PM in induction in primiparous women for the diagnosis of pelvic-cephalic disproportion and analysing its influence on the duration of pregnancy, neonatal mortality and the rate of caesarean sections.

Materials and methods

The observational, prospective, randomised, double-blind, study, in a population of 264 primigravid pregnant women in whom induction of labour was an indication.

Results

X-ray pelvimetry did not influence the rate of caesarean section or the perinatal results, and has a low predictive value as a prognostic factor in the method of delivery.     

Cesárea humanizada

Objective

To demonstrate the absence of short-term negative effects in cesarean sections followed by skin-to-skin contact, with or without the presence of a companion, and the greater satisfaction of these women.

Material and method

A satisfaction survey was designed for use in all women who had undergone a cesarean section. A total of 300 questionnaires were analyzed.

Results

Among women accompanied by companions, 98.2% considered this measure to be a source of support. The puerperium was normal in 94.2% of accompanied women versus 87.2% of those who were unaccompanied (p = 0.69).

Conclusions

No negative effects on the mother or newborn are associated with either skin-to-skin contact after delivery or the presence of a companion during cesarean section.     

Complicaciones maternas a corto plazo en pacientes con cesárea

Objective

To determine whether patients who undergo cesarean section are at higher risk of complications than those who have a vaginal birth and to describe the complications observed.

Subjects and methods

We reviewed the clinical records of 1017 patients who gave birth at the Materno- Vall d’Hebron Maternity and Child Hospital in the first trimester of 2007.

Results

For a cesarean rate of 22%, the incidence of maternal complication was 18%, while for vaginal birth the incidence was 6% (RR 3.1, 95% CI 2.4-15.1). The most frequent complications were wound infection (7.5%), transfusions (5.3%) and hemorrhage (3.1%); endomyometritis was more common in the group with vaginal births (1.6% vs. 1.3%).

Conclusions

Cesarean section is associated with a three times higher risk of complications than vaginal birth. The lower incidence of endomyometritis after cesarean sections may be a consequence of antibiotic prophylaxis, but further studies are required to draw firm conclusions on this topic.     

Recuperación del parto vaginal de nalgas y versión cefálica externa

Objective

To review the obstetric and neonatal outcomes of the application of an updated vaginal breech delivery protocol 10 years after this practice had been discontinued.

Methods

Breech presentations were referred to a dedicated breech unit at 36 weeks where the external cephalic version was offered. If breech presentation persisted, the patients were selected to undergo attempted vaginal delivery if the following criteria were met: a) estimated fetal weight of 2.500-3.600 g; b) frank or complete breech presentation; c) absence of hyperextension of the fetal head; and d) a clinically adequate pelvis. Intrapartum criteria included: a) progression of labor of ≥ 1 cm/hour in the first hour; b) In the second stage, 90 minutes were allowed for adequate descent of the breech, and 1 hour of active pushing, and c) the availability of an on-call expert.

Results

A total of 93 patients showed single live pregnancies in breech presentation after external cephalic version. Sixty-nine patients (73.4%) underwent elective prelabor cesarean delivery, and 24 (26.6%) progressed to attempted vaginal breech delivery, which was successful in 19 (20.1%). Cesarean indications for breech presentation were reduced from 5.7% in 2009 to 2.02% after the application of external cephalic version and vaginal breech delivery (P<.001). We observed no fetal deaths, no Apgar test at 5 minutes of less than 7, no umbilical artery pH of less than 7, and no fetal injuries.

Conclusions

. When antepartum and intrapartum criteria are met, vaginal breech delivery is safe. The availability of an on-call expert allows vaginal breech delivery to be safely performed. The combination of external cephalic version and vaginal breech delivery decreases the cesarean rate for breech presentation.     

Clasificación de cesáreas por Grupos de Robson en dos periodos comparativos en el Hospital de Manacor

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 Robsońs 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.     

Idoneidad de las indicaciones de cesárea. Una aplicación en la gestión de la práctica clínica

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.     

Finalización electiva versus manejo expectante en el control de la gestación prolongada: estudio prospectivo de 200 gestantes

Objective

To compare elective termination versus expectant management in low-risk prolonged pregnancy.

Material and method

We performed a controlled randomized clinical trial comparing the results of active and expectant approaches in the management of low-risk prolonged pregnancy in a sample of 200 women between February 2003 and June 2005 at the Maternity Ward of the Canary Islands University Hospital.

Results

The study group consisted of 200 patients. There were 102 in the active management group and 98 in the expectant management group. No between-group epidemiologic differences were found. Labor was not induced in a significantly higher proportion of patients in the active than in the expectant group [51% vs 35.7%, p = 0.02; OR 0.53 (95% CI 0.3-0.94)] i.e. the induction rate was significantly higher in the expectant group. The proportion of patients with meconium-stained amniotic fluid during labor was significantly lower in the active management group [15.7% vs 28.6% p = 0.02; OR 0.47 (95% CI 0.23-0.93)]. No significant differences were found in the type of delivery, although the proportion of cesarean sections was noticeably lower in the active management than in the expectant management group [(12.7% vs 18.4%, p = 0.3; OR 0.65 (95% CI 0.3-1.41)]. No significant differences were found in perinatal outcomes between the two groups.

Conclusions

Elective termination of low-risk pregnancies with unfavorable cervical findings at week 42 seems to reduce the rate of cesarean section without impairing perinatal outcome.     

Adecuación de la profilaxis antibiótica en el parto por cesárea

Objective

To evaluate compliance with a protocol for antibiotic prophylaxis in cesarean sections and its influence on the incidence of surgical wound infection.

Patients and methods

A prospective cohort study was carried out to assess compliance with our antibiotic prophylaxis protocol. Percentages of compliance and the cumulative incidence of infection were calculated. The effect of compliance with the protocol for antibiotic prophylaxis on surgical wound infection was estimated with the relative risk.

Results

We included 680 patients. Overall compliance with the protocol was 95.7%. The most frequent cause of lack of compliance was the time of administration (96.6%). The cumulative incidence of infection was 2.5% and there was no association between compliance with the protocol and the infection rate (RR = 4.5; 95% CI: 0.55-38.4; P>.05).

Conclusions

Compliance with the protocol for antibiotic prophylaxis was high. The cumulative incidence of surgical wound infection was low and was unrelated to antibiotic prophylaxis.     

Histerectomía radical laparoscópica total en el cáncer de cérvix. Factibilidad,morbilidad y supervivencia

Objective

To assess feasibility, perioperative morbidity and medium term survival of total laparoscopic radical hysterectomy in cervical cancer.

Material and methods

A total of 31 consecutive patients diagnosed FIGO clinical stage IA2 (n = 4), IB1 (n = 22), IIA (n = 2) and IB2 (n = 3) in Son Llàtzer hospital (Palma de Mallorca) that were programmed for a total laparoscopic radical hysterectomy were studied. We analyzed tumor histological characteristics, surgical technique, perioperative variables, postoperative complications and mid-term survival results.

Results

Feasibility rate was 96%. The most frequently operative complication was accidental bladder incision (3 cases). Postoperative complications rate was 20% (6 cases) which includes one surgical reintervention. Average operative time was 258 minutes (range: 180-360). Blood transfusion rate was 17% (n = 5) and mean hospital stay was 7.8 days (range: 2-29). After one month after surgery 72% of patients had a normal miccional function. Mean tumoral size was 26.5 mm and lymphatic positive nodes rate was 17% (n = 5). Mean follow-up time was 26 months. Tumor relapse rate was 17% (n = 5) and survival-free disease of 100% for IA2 stage, 82.6% of IB1/IIA stages and 66.7% for IB2 stage.

Conclusions

Total laparoscopic radical hysterectomy is a feasible technique in most of the patients with cervical cancer. It needs more operative time than abdominal route but it presents less perioperative morbidity, less blood transfusion and less ospitalization days. The medium term survival is comparable with conventional abdominal route.     

Hidrocefalia materna con shunt ventrículo-peritoneal y gestación

Objectives

To analyse the course of pregnant patients with a ventriculo-peritoneal shunt as well as the possible effects on the foetus.

Material and methods

The study included 16 patients with a ventriculo-peritoneal shunt (VPS) whose pregnancies were monitored in our hospital from 01/01/1983 to 30/04/2006.

Results

The ages of the 16 patients study were between 16 and 39 years. There were 27 pregnancies, of which 4 ended in early abortion, 14 by caesarean and 9 vaginal births (5 of them with instruments). The VPS were mainly placed during childhood, and there were several causes of the hydrocephaly: 3 infectious, 5 tumours, 4 malformations, 2 primary causes and 2 accident trauma. Only 4 pregnancies had premature births and one caesarean was performed urgently due to neurological problems in the mother with signs of intracranial hypertension (IH). All the newborns had a good weight at birth (mean of 3172 g), with Apgar score and arterial and venous pH within the normal range.

Conclusions

Fertility is not affected in patients with SVP and with no effects seen in the foetus. Although the rate of caesarean's (60%) may be higher than in the general population, vaginal birth is not contraindicated and there was no increase in complications. The risk of IH during pregnancy is low (< 7%).     

Foley catheter or prostaglandin E2 inserts for induction of labour at term: an open-label randomized controlled trial (PROBAAT-P trial) and systematic review of literature

Objective

To assess the safety and effectiveness of a transcervical Foley catheter compared to vaginal prostaglandin E2 inserts for term induction of labour.

Study design

We conducted an open-label randomized controlled trial in five hospitals in the Netherlands. Women with a singleton term pregnancy in cephalic presentation, intact membranes, unfavourable cervix, and no prior caesarean section were enrolled. Participants were randomly allocated by a web-based randomization system to induction of labour with a 30 ml Foley catheter or 10 mg slow-release vaginal prostaglandin E2 inserts in a 1:1 ratio. Due to the nature of the intervention this study was not blinded. The primary outcome was the caesarean section rate. Secondary outcomes were maternal and neonatal morbidity and time from intervention to birth. Additionally, we carried out a systematic review and meta-analysis of similar studies.

Results

We analyzed 226 women: 107 received a Foley catheter and 119 inserts. Caesarean section rates were comparable (20% versus 22%, RR 0.90, 95% CI 0.54–1.50). Secondary outcomes showed no differences. We observed no serious maternal or neonatal morbidity.Meta-analysis showed comparable caesarean section rates, but significantly fewer cases of hyperstimulation during the ripening phase when a Foley catheter was used.

Conclusions

We found, in this relatively small study, no differences in effectiveness and safety of induction of labour with a Foley catheter and 10 mg slow release vaginal prostaglandin E2 inserts. Meta-analysis confirmed a comparable caesarean section rate, and showed fewer cases of hyperstimulation when a Foley catheter was used.     

Enfermedad residual después de cirugía conservadora por cáncer de mama

Objective

To evaluate which factors are related to the presence of residual tumor after lumpectomy for breast cancer with a view to determining the excisional biopsy margins that guarantee a complete excision.

Material and methods

The records of 118 women with invasive breast carcinoma who were treated with lumpectomy in our service between June 2004 and December 2006 were retrospectively reviewed. The parameters evaluated were age, palpability, diagnostic method, type of initial and definitive surgery, histologic type, tumor size, lymphovascular invasion, presence/absence of extensive intraductal component (EIC), estrogen receptors, surgical margins, reexcision, and the presence of residual tumor.

Results

Residual disease was found in 27%. In the univariate analysis, only margins (P=.015), EIC (P=.026) and size (P=.025) were significantly associated with the presence of residual tumor. With simple lineal regression analysis, only margins (P=.008) and EIC (P=.025) showed a significant association.

Conclusions

We believe that a minimum margin of 2 mm is enough to guarantee the absence of residual breast cancer if there is no EIC. In patients with margins ≤ 2 mm, the presence of EIC is an indication of high risk of residual disease.     

Why do primigravidae request caesarean section in a normal pregnancy? A qualitative study in Iran

Objective

to gain a deeper understanding of why Iranian primigravidae request caesarean section without any medical indication.

Design

qualitative study. Data were gathered through semi-structured interviews, and thematic analysis was undertaken.

Setting

four health care centres at Hamadan University of Medical Sciences, Hamadan, Iran.

Participants

14 primigravidae who requested caesarean section without any medical indication.

Findings

reasons for requesting caesarean section were related to fear of childbirth (labour pain, injury to mother or infant), complications after vaginal delivery (vaginal prolapse, urinary incontinence, sexual dysfunction), trust in obstetricians, and lack of trust in maternity ward staff.

Key conclusions and implications for practice

the main reasons given for requesting caesarean section show that there is urgent need for effective antenatal assessment to enable pregnant women to ask questions and express their concerns. In order to promote vaginal birth, there is a need to develop antenatal education and strategies to enhance women's knowledge, confidence and competence about vaginal birth. Health care providers should be re-educated about the observance of medical ethics and professional rules in their practices, and change their attitudes and behaviours to vaginal birth. Evaluation, improvement and change in maternity care policies are recommended to promote natural childbirth.     

Comparación de la efectividad de la pulsioximetría y el electrocardiograma fetal en las situaciones de riesgo de pérdida de bienestar fetal

Objective

To evaluate the effectiveness of pulse oximetry and fetal electrocardiogram in the management of labor with fetal heart rate patterns associated with a risk of loss of fetal well-being.

Subjects and methods

We performed an open, randomized, experimental trial with two groups: pulse oximetry was used in one group and the STAN® technique was used in the other. Each group included 40 women with single, term pregnancies in cephalic presentation and fetal heart rate patterns associated with a risk of loss of fetal well-being. The overall cesarean section rate, indications of risk of fetal distress, and neonatal acid-base balance were evaluated.

Results

No significant differences were found in the rate of cesarean section (47.5 vs 40%; P = .33), indications of risk of fetal distress (32.5 vs 37.5%; P = .41), or neonatal outcomes.

Conclusions

The use of pulse oximetry and STAN®21, as auxiliary methods to cardiotocographic recording, showed no superiority in reducing the cesarean section rate or improving neonatal outcomes.     

Ayuno vs. dieta líquida. Estudio aleatorizado controlado para evaluar la duración de la labor de parto,tasa de cesáreas y satisfacción con la labor

Aim

To evaluate the benefits of allowing oral intake of clear liquids in terms of labor duration, the cesarean section rate, and personal satisfaction.

Methods

A randomized controlled trial was carried out to assess the effects of a clear liquid diet in a low risk population. The primary outcome was labor duration. The secondary outcome was the incidence of cesarean section. A satisfaction survey was performed within the first 2 h after delivery to evaluate the patient's perception of labor.

Results

A total of 348 patients were randomized. The mean duration of labor was 257.75 min in the liquid diet group and 288.40 min in the fasting group (p = NS). There was no statistically significant difference (per-protocol analysis and intention-to-treat analysis) in the cesarean section rate.Patients reported greater satisfaction when allowed to drink during labor than when fasting.

Conclusion

A clear liquid diet during labor did not alter the duration of labor or the cesarean section rate. Allowing a liquid diet during labor was associated with a better perception of the birth process and a higher degree of satisfaction.