Portal de Boas Práticas em Saúde da Mulher, da Criança e do Adolescente

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Pushing/bearing down methods for the second stage of labour

Lemos A, Amorim MM, Dornelas de Andrade A, de Souza AI, Cabral Filho JE, Correia JB. Pushing/bearing down methods for the second stage of labour. Cochrane Database Syst Rev. 2015 Oct 9;(10):CD009124. doi: 10.1002/14651858.CD009124.pub2. Review. Update in: Cochrane Database Syst Rev. 2017 Mar 26;3:CD009124. PubMed PMID: 26451755. Maternal pushing during the second stage of labour is an important and indispensable contributor to the involuntary expulsive force developed by uterus contraction. Currently, there is no consensus on an ideal strategy to facilitate these expulsive efforts and there are contradictory results about the influence on mother and fetus.This review is based on a total of 20 included studies that were of a mixed methodological quality.Timing of pushing with epidural is consistent in that delayed pushing leads to a shortening of the actual time pushing and increase of spontaneous vaginal delivery at the expense of an overall longer duration of the second stage of labour and double the risk of a low umbilical cord pH (based only on one study). Nevertheless, there was no difference in the caesarean and instrumental deliveries, perineal laceration and episiotomy, and in the other neonatal outcomes (admission to neonatal intensive care, five-minute Apgar score less than seven and delivery room resuscitation) between delayed and immediate pushing. Futhermore, the adverse effects on maternal pelvic floor is still unclear.Therefore, there is insufficient evidence to justify routine use of any specific timing of pushing since the maternal and neonatal benefits and adverse effects of delayed and immediate pushing are not well established.For the type of pushing, with or without epidural, there is no conclusive evidence to support or refute any specific style or recommendation as part of routine clinical practice. Women should be encouraged to bear down based on their preferences and comfort.In the absence of strong evidence supporting a specific method or timing of pushing, patient preference and clinical situations should guide decisions.Further properly well-designed randomised controlled trials are required to add evidence-based information to the current knowledge. These trials should address clinically important maternal and neonatal outcomes and will provide more complete data to be incorporated into a future update of this review.

Position in the second stage of labour for women with epidural anaesthesia

Kemp E, Kingswood CJ, Kibuka M, Thornton JG. Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database Syst Rev. 2013 Jan 31;(1):CD008070. doi: 10.1002/14651858.CD008070.pub2. Review. Update in: Cochrane Database Syst Rev. 2017 Feb 24;2:CD008070. PubMed PMID: 23440824. Epidural analgesia for pain relief in labour prolongs the second stage of labour and results in more instrumental deliveries. It has been suggested that a more upright position of the mother during all or part of the second stage may counteract these adverse effects.There are insufficient data to say anything conclusive about the effect of position for the second stage of labour for women with epidural analgesia. Women with an epidural should be encouraged to use whatever position they find comfortable in the second stage of labour. Future research should involve large trials of positions that women can maintain and predefined endpoints. One large trial is ongoing.

Selective versus routine use of episiotomy for vaginal birth

1: Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017 Feb 8;2:CD000081. doi: 10.1002/14651858.CD000081.pub3. Review. PubMed PMID: 28176333; PubMed Central PMCID: PMC5449575. To assess the effects on mother and baby of a policy of selective episiotomy ('only if needed') compared with a policy of routine episiotomy ('part of routine management') for vaginal births. In women where no instrumental delivery is intended, selective episiotomy policies result in fewer women with severe perineal/vaginal trauma. Other findings, both in the short or long term, provide no clear evidence that selective episiotomy policies results in harm to mother or baby.The review thus demonstrates that believing that routine episiotomy reduces perineal/vaginal trauma is not justified by current evidence. Further research in women where instrumental delivery is intended may help clarify if routine episiotomy is useful in this particular group. These trials should use better, standardised outcome assessment methods.

Position in the second stage of labour for women without epidural anaesthesia

Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2012 May 16;(5):CD002006. doi: 10.1002/14651858.CD002006.pub3. Review. Update in: Cochrane Database Syst Rev. 2017 May 25;5:CD002006. PubMed PMID: 22592681. For centuries, there has been controversy around whether being upright (sitting, birthing stools, chairs, squatting, kneeling) or lying down have advantages for women delivering their babies. The findings of this review suggest several possible benefits for upright posture in women without epidural, but with the possibility of increased risk of blood loss greater than 500 mL. Until such time as the benefits and risks of various delivery positions are estimated with greater certainty, when methodologically stringent data from trials are available, women should be allowed to make choices about the birth positions in which they might wish to assume for birth of their babies.

Diretriz Nacional de Assistência ao Parto Normal: Relatório de Recomendação

Brasil. Ministério da Saúde. Diretriz Nacional de Assistência ao Parto Normal: relatório de recomendação/ Ministério da Saúde, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Departamento de Gestão e Incorporação de Tecnologias em Saúde. – Brasília: Ministério da Saúde, 2016. 381 p. O nascimento no ambiente hospitalar se caracteriza pela adoção de várias tecnologias e procedimentos com o objetivo de torná-lo mais seguro para a mulher e seu filho ou filha. Se por um lado, o avanço da obstetrícia moderna contribuiu com a melhoria dos indicadores de morbidade e mortalidade materna e perinatais, por outro permitiu a concretização de um modelo que considera a gravidez, o parto e o nascimento como doenças e não como expressões de saúde, expondo as mulheres e recém-nascidos a altas taxas de intervenções, que deveriam ser utilizadas de forma parcimoniosa e apenas em situações de necessidade e não como rotina. Esse excesso de intervenções deixou de considerar os aspectos emocionais, humanos e culturais envolvidos no processo, esquecendo que a assistência ao nascimento se reveste de um caráter particular que vai além do processo de adoecer e morrer. Quando as mulheres procuram ajuda, além da preocupação sobre a sua saúde e a do seu filho ou filha, estão também em busca de uma compreensão mais ampla e abrangente da sua situação, pois para elas e suas famílias o momento da gravidez e do parto, em particular, é único na vida e carregado de fortes emoções. A experiência vivida por eles neste momento pode deixar marcas indeléveis, positivas ou negativas, para o resto das suas vidas. O escopo da Diretriz e as perguntas a serem respondidas foram definidas com a participação de um grupo ampliado de interessados (grupo consultivo), entre eles, sociedades e associações médicas, de enfermagem e das mulheres, agências reguladoras, pesquisadores, profissionais e conselhos de profissionais de saúde, além de áreas técnicas do Ministério da Saúde - da Mulher e da Criança - e a CONITEC. O documento resultante do consenso obtido pelo grupo ampliado, foi apresentado à CONITEC na 42 ª Reunião da CONITEC, realizada nos dias 02 e 03 de dezembro de 2015, onde os membros da CONITEC apreciaram a proposta da Diretriz do Parto Normal que será disponibilizada em consulta pública com recomendação preliminar favorável.

Perineal techniques during the second stage of labour for reducing perineal trauma

Aasheim V, Nilsen ABV, Reinar LM, Lukasse M.Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD006672. DOI: 10.1002/14651858.CD006672.pub3.Most vaginal births are associated with tr auma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including per ineal massage, warm or cold compresses, and perineal management techniques h ave been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011. Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques. Most studies did not report data on our secondary outcomes. We downgraded evidence for r isk of bias, inconsistency, and imprecision for all comparisons.

Principais Questões sobre DIU de cobre nas maternidades

O DIU é um método contraceptivo conhecido pelas mulheres, mas pouco utilizado. A oferta de DIU de cobre nas maternidades visa reduzir a gravidez não planejada e melhorar o acesso a esse método contraceptivo.

Controle térmico do recém-nascido pré-termo

Controlar a temperatura dos recém-nascidos, especialmente dos pré-termo, resulta em maior sobrevida e melhor prognóstico.

Heat loss prevention in very preterm infants in delivery rooms: a prospective …

Trevisanuto D, Doglioni N, Cavallin F, Parotto M, Micaglio M, Zanardo V. Heat loss prevention in very preterm infants in delivery rooms: a prospective, randomized, controlled trial of polyethylene caps. J Pediatr. 2010 Jun;156(6):914-917.e1. doi: 10.1016/j.jpeds.2009.12.021. Epub 2010 Mar 15. PubMed PMID: 20227728. To evaluate in preterm infants whether polyethylene caps prevent heat loss after delivery better than polyethylene occlusive wrapping and conventional drying.For very preterm infants, polyethylene caps are comparable with polyethylene occlusive skin wrapping to prevent heat loss after delivery. Both these methods are more effective than conventional treatment.

Safety and efficacy of Trans-warmer mattress for preterm neonates: results of a randomized …

1: Chawla S, Amaram A, Gopal SP, Natarajan G. Safety and efficacy of Trans-warmer mattress for preterm neonates: results of a randomized controlled trial. J Perinatol. 2011 Dec;31(12):780-4. doi: 10.1038/jp.2011.33. Epub 2011 Apr 28. PubMed PMID: 21527905. To compare the admission temperatures, incidence of hypothermia and discharge outcomes of preterm neonates managed with Trans-warmer mattress (TWM) initiated in the delivery room (DR) and controls. In this quasi-randomized controlled trial, the admission temperatures of preterm neonates on whom TWM was used were significantly higher compared to controls with a reduction in the incidence of hypothermia. A TWM initiated in the DR may be a simple efficacious method of reducing hypothermia in preterm neonates.

Variations in incubator temperature and humidity management: a survey of …

Deguines C, Décima P, Pelletier A, Dégrugilliers L, Ghyselen L, Tourneux P. Variations in incubator temperature and humidity management: a survey of current practice. Acta Paediatr. 2012 Mar;101(3):230-5. doi: 10.1111/j.1651-2227.2011.02492.x. Epub 2011 Nov 4. PubMed PMID: 21995429. To describe and assess routine procedures and practices for incubator temperature and humidity management in France in 2009. We observed large variations in incubator temperature and humidity management approaches from one neonatal care unit to another. There is a need for more evidence to better inform practice. A task force should be formed to guide clinical practice.

Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation …

1: Perlman JM, Wyllie J, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, Kim HS, Liley HG, Mildenhall L, Simon WM, Szyld E, Tamura M, Velaphi S; Neonatal Resuscitation Chapter Collaborators. Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (Reprint). Pediatrics. 2015 Nov;136 Suppl 2:S120-66. doi: 10.1542/peds.2015-3373D. Epub 2015 Oct 14. PubMed PMID: 26471381. Thetransitionfromintrauterinetoextrauterinelifethatoccursatthetime of birth requires timely anatomic and physiologic adjustments to achieve the conversion from placental gas exchange to pulmonary respiration. This transitionisbroughtaboutbyinitiationof airbreathingandcessationofthe placental circulation. Air breathing initiates marked relaxation of pulmonary vascular resistance, with considerable increase in pulmonary blood flow and increased return of now-well-oxygenated blood to the left atrium and left ventricle, as well as increased left ventricular output. Removal of the low-resistance placental circuit will increase systemic vascular resistance and blood pressure and reduce right-to-left shunting acrosstheductusarteriosus. The systemic organs must equally and quickly adjust to the dramatic increase in blood pressure and oxygen exposure. Similarly, intrauterine thermostability must be replaced by neonatal thermoregulation with its inherent increase in oxygen consumption.