Conselho Nacional de Desenvolvimento CientÃfico e TecnolÃgico / Objetivos: avaliar a influÃncia da via de parto sobre os resultados perinatais, em mulheres que tiveram parto prematuro (PP); avaliar caracterÃsticas demogrÃficas e obstÃtricas como determinantes da via de parto. Sujeitos e mÃtodos: estudo transversal, a partir dos prontuÃrios de mulheres que tiveram PP, acompanhadas no ServiÃo de Medicina Materno-Fetal da Maternidade-Escola Assis Chateaubriand â Universidade Federal do CearÃ. Foram analisadas 195 gestantes e os 195 recÃm-nascidos (RNs) oriundos dessas gestaÃÃes, Ãnicas, sem complicaÃÃes clÃnicas maternas, fetais e obstÃtricas, apresentando idade gestacional (IG) entre 22 e 36 semanas e seis dias e com peso fetal igual ou acima de 500 gramas. As caracterÃsticas demogrÃficas e obstÃtricas e os resultados perinatais foram avaliados na populaÃÃo geral e em cada grupo (partos vaginal e abdominal), sendo posteriormente comparados entre si. Para a avaliaÃÃo estatÃstica comparativa entre os dois grupos, utilizou-se o teste de Mann-Whitney. O cÃlculo da razÃo de risco ajustado foi realizado atravÃs do software SAS versÃo 9.1.3 e atravÃs de RegressÃo LogÃstica e Multivariada. Todos foram considerados estatisticamente significantes quando p<0.05. Resultados: a maioria das gestantes (81.5%) foi admitida em trabalho de parto prematuro (TPP) ativo espontÃneo e 43.1% apresentaram bolsa rota. Agentes tocolÃticos e corticosteroides foram usados, respectivamente, em 41.6% e 58.3% das mulheres em prÃdromo de TPP e a maioria dos partos (74.4%) ocorreu por via vaginal. No momento do parto, a IG mÃdia foi 32.6 semanas. Quando os dois grupos foram comparados, o prÃdromo de TPP, a bolsa rota e a administraÃÃo de tocolÃticos e corticoides aumentaram, significativamente, o risco de cesÃrea (RRs 6.10, 1.64, 1.95 e 1.82, respectivamente), enquanto o TPP ativo diminuiu, significativamente, esse risco (RR 0.16, IC 95% - 0.11 a 0.25). O peso mÃdio dos RNs foi 1873g, sendo classificados como adequados para IG em 76.7%. Necessitaram de internamento em UTI 62.1% dos casos, 21% usaram surfactante, 90.8% necessitaram de ventilaÃÃo mecÃnica, 4.6% apresentaram tocotraumatismos e o Ãndice de Ãbito neonatal foi de 8.7%. Quando se compararam os dois grupos, a cesÃrea aumentou, significativamente, a chance do Ãndice de Apgar ao 5Â minuto ser &#8805; 7 (RR 1.06, IC 95% - 1.01 a 1.13). ApÃs regressÃo logÃstica de COX, ajustada para fatores que poderiam influenciar nos resultados perinatais, nÃo foram observadas diferenÃas estatisticamente significativas entre os dois grupos. ConclusÃes: nÃo foram encontradas diferenÃas estatisticamente significativas nos resultados perinatais entre RNs de partos vaginal e abdominal de mulheres que tiveram parto prematuro. Quanto Ãs caracterÃsticas obstÃtricas, o prÃdromo de TPP, a bolsa rota e o uso de agentes tocolÃticos e corticoides aumentaram, significativamente, o risco de cesÃrea, enquanto o TPP ativo diminuiu, significativamente, esse risco. / Objectives: to evaluate the influence of route of delivery on perinatal outcomes, in women who had preterm delivery; to evaluate demographic and obstetric characteristics as determinants of mode of delivery. Subjects and methods: it is a cross-sectional study from the charts of women who had preterm delivery, followed in the Service of Maternal-Fetal Medicine of Maternidade-Escola Assis Chateaubriand â Universidade Federal do CearÃ. There were analyzed 195 pregnant women and 195 newborns coming from these singleton pregnancies, without clinical maternal, fetal and obstetric complications, presenting gestational age between 22 and 36 weeks and six days and fetal weight equal or above 500 grams. Demographic and obstetric characteristics and perinatal outcomes were evaluated in the general population and in each group (vaginal and abdominal delivery), being later compared with each other. For comparative statistical analysis among the two groups, it was utilized the Mann-Whitney test. The calculation of the reason of adjusted risk was accomplished through the software SAS version 9.1.3 and through Logistical and Multinomial Regression. All were considered statistically significant when p < 0.05. Results: the majority of pregnant women (81.5%) was admitted in active spontaneous preterm labor and 43.1% had premature rupture of the membranes. Tocolytic agents and corticosteroids were used, respectively, in 41.6% and 58.3% of women in false preterm labor and most of deliveries (74.4%) happened by vaginal route. At the moment of delivery, the average gestational age was 32.6 weeks. When the two groups were compared, false preterm delivery, premature rupture of the membranes and the administration of tocolytic drugs and corticosteroids increased, significantly, the risk of cesarean section (RRs 6.10, 1.64, 1.95 e 1.82, respectively), while the active preterm delivery decreased, significantly, this risk (RR 0.16, 95% CI - 0.11 a 0.25). The mean weight of the newborns was 1873g and they were classified as appropriate for gestational age in 76.7%. They needed for admission to the intensive care unit in 62.1% of cases, 21% required surfactant, 90.8% needed mechanic ventilation, 4.6% presented neonatal injury and the index of neonatal death was 8.7%. When the two groups were compared, the cesarean section significantly increased the chance of the Apgar score at 5Â minute to be &#8805; 7 (RR 1.06, 95% CI - 1.01 a 1.13). After logistic regression of COX adjusted for factors that could influence perinatal outcomes, had not been observed statistically significant differences between the two groups. Conclusions: it had not been found statistically significant differences in perinatal outcomes among newborns of vaginal delivery and cesarean section in women who had preterm delivery. Regarding obstetric characteristics, false preterm delivery, premature rupture of the membranes and the use of tocolytic agents and corticosteroids increased, significantly, the risk of cesarean section while the active preterm delivery decreased, significantly, this risk.

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No. of bitstreams: 2 Dissertação - Charlise Fortunato Pedroso - 2016.pdf: 1888405 bytes, checksum: 7e4406a4bbeeb6bce12caecdf06bb72b (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2016-04-14 / Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG / Reports of pain in the preoperative period are frequent and may be influenced by socioeconomic, clinical, psychological and behavioral factors and by health conditions. However, little is known about this pain in the preoperative period of cesarean section, one of the surgeries performed more frequently in the global surgical setting. The aim of the study was to identify the prevalence, characteristics and factors associated with pain in the preoperative period immediately prior to cesarean section. This was a cross-sectional analysis of data from the baseline of research matrix, cohort study, open and prospective, the data of which were collected in the wards and apartments of a private hospital, contracted to the Health Unic System (SUS), of the city of Goiânia, Brazil. The recruitment of women (n = 1082) was made between February 2014 and July 2015. The study sample consisted of 877 women. The outcome variable investigated was the report of any pain reported by women in the immediate preoperative period. The pain characteristics include intensity, measured by means of numeric pain scale of 11 points (END) which allows the intensity measured by numbers representing the amount of pain felt (zero (0) = no pain; 1 , 2.3 and 4 = mild pain; 5:06 = moderate pain, 7.8 and 9 = severe pain, and ten (10) = worst possible pain), location; onset and duration of painful episodes. The associated variables were: symptoms of anxiety and depression, assessed through the Hospital Anxiety and Depression Scale (HADS), as well as sociodemographic, clinical and behavioral variables and health related conditions. For the statistical analysis, logistic regression was used to identify factors associated with preoperative pain. In the multivariate analysis, variables that presented p-values <0,10 were included. For all tests p-values <.05 were considered significant. The prevalence of preoperative pain was 27.5% (CI: 95%:24.6-30.5). The locations most mentioned by the women included the lower back (29.9%), pelvic/genital region (22.4%) and head (12.9%). The pain appeared with more prevalence in the final trimester of pregnancy (37.8%), being considered by the majority of the participants as a daily complaint (68.5%). The intensity was classified as strong in 44.8% of cases. Preoperative pain was associated with pregnancyrelated pain (OR: 3.50; 2.23-5.252) and symptoms of anxiety (OR: 1.61; 1.14-2.28; p=.006). The evaluation of pain in the preoperative period should include negative aspects, such as anxiety, in order to use therapies for its management proper. In the prenatal care, it is essential to evaluate the characteristics of pain that arises after the confirmation of the pregnancy, in order to implement strategies to avoid prolonged contact with this experience and consequent impairments in the postoperative period. Nurses are responsible for part of this mission, together with obstetric nurses, who can and should fulfill their role as promoters of health / Relatos de dor no período pré-operatório são frequentes e podem sofrer influência de fatores socioeconômicos, clínicos, psicológicos e de comportamentos e condições de saúde. No entanto, pouco se conhece sobre a dor referida no período pré-operatório de cesariana, uma das cirurgias realizadas com maior frequência no cenário cirúrgico mundial. O objetivo da pesquisa foi identificar a prevalência, as características e os fatores associados à dor referida no período pré-operatório imediato de cesariana. Trata-se de análise transversal de dados da linha de base da pesquisa matriz, tipo coorte, aberta e prospectiva, cujos dados foram colhidos nas enfermarias e apartamentos de um hospital privado, conveniado ao Sistema único de Saúde, no município de Goiânia, Goiás, Brasil. O recrutamento das mulheres (n=1082) foi feito entre fevereiro de 2014 e julho de 2015. A amostra deste recorte compôsse de 877 mulheres. A variável de desfecho investigada foi o relato de qualquer dor referida pelas mulheres no período pré-operatório imediato. As características da dor incluíram a intensidade, mensurada por meio da Escala Numérica de Dor de 11 pontos (END), a qual permite a medida da intensidade por meio de números que representam a quantidade de dor sentida (0 (zero)=nenhuma dor; 1,2,3 e 4=dor leve; 5 e 6=dor moderada; 7,8 e 9=dor forte; e 10 (dez)=pior dor possível), localização; início e duração dos episódios dolorosos. As variáveis de associação foram: sintomas de ansiedade e depressão, avaliados por meio da Escala Hospitalar de Ansiedade e Depressão (HADS), além de variáveis sociodemográficas, clínicas, comportamentos e condições relacionados à saúde. Para análise estatística, foi utilizada a regressão logística a fim de identificar os fatores associados à dor pré-operatória. Na análise multivariada, as variáveis que apresentaram valores de p<0,10, foram incluídas. Valores de p<0,05 foram considerados significativos para todos os testes. A prevalência de dor pré-operatória foi de 27,5% (IC:95%:24,6-30,5). Os locais mais referidos pelas mulheres incluíram a região lombar (29,9%), pélvica/genital (22,4%) e cabeça (12,9%). A dor apareceu com maior prevalência no último trimestre de gestação (37,8%), sendo considerada pela maioria das participantes como uma queixa diária (68,5%). A intensidade foi classificada como forte em 44,8% dos casos. Dor pré-operatória esteve associada com dor relacionada à gestação (OR:3,50; 2,23-5,252) e sintomatologia para ansiedade (OR:1,61;1,14-2,28; p=0,006). A avaliação da dor no período pré-operatório inclui comportamentos negativos como a ansiedade, com vistas à utilização de terapêuticas para o adequado manejo. No pré- natal é fundamental a avaliação da dor que surgiu após a constatação da gravidez e suas características, a fim de implementar estratégias que contribuam na redução de convívio com essa experiência e, consequentemente, com os prejuízos no pós-operatório. Ao enfermeiro cabe parte dessa missão, juntamente com as enfermeiras obstetrizes, que podem e devem ocupar seu papel de promotoras da saúde.

No Brasil, a saúde, como direito do cidadão e dever do Estado, é garantida pela constituição de 1998. Em 1983 foi criado o PAISM, propondo a perspectiva de atendimento integral à saúde da mulher, com o objetivo de considerar, no âmbito da saúde, também o entorno social, emo cional e psicológico da mulher, bem co mo as questões relacionadas à contra cepção. No entanto, sua implantação ainda não se realizou efetivamente até o momento atual, o que pode ser observa do pela alta prevalência de gestações indesejadas, dificuldade de acesso a informações sobre planejamento familiar, predomínio da esterilização cirúrgica feminina como método contraceptivo e da cesárea como via de parto, aspectos que ferem os direitos sexuais e reprodu tivos das mulheres. Um novo contexto tem se desenhado a partir da implanta ção da Lei 9 263, que regulamenta o planejamento familiar, e pela qual a este rilização cirúrgica é aprovada e passa a ser ofertada pelo sistema público de saúde, o que,por sua vez, permite a desvinculação da esterilização com o parto. O presente estudo tem por objeti vo conhecer as características das mu lheres que se esterilizaram pelo SUS, em Ribeirão Preto, entre 2000 e 2004, segun do o tipo de parto, cesárea e parto vagi nal. A amostra foi composta por 235 mulheres esterilizadas nos primeiros cinco anos de oferta da esterilização cirúrgica (2000-2004). Os dados foram coletados através de entrevistas domici liares, utilizando-se questionário estrutu rado. Os resultados demonstraram que a maioria das mulheres esterilizadas era branca, casada, com escolaridade até o ensino fundamental e pertencia à catego ria socioeconômica C e D. A maioria foi esterilizada entre 30 e 39 anos de ida de, com média de 33,3 e mediana de 33 anos, 52,3% faziam uso da pílula como método contraceptivo antes da esteriliza ção. Elas têm, em média, 3,2 filhos e 51,7% teve o primeiro filho entre 13 e 19 anos de idade. Este estudo indicou que as mulheres esterilizadas, em sua maioria, têm mais filhos, começaram a ter filhos mais cedo, usaram mais contra ceptivos enquanto esperavam pela cirurgia e se esterilizaram mais tarde quando comparadas aos resultados de outros estudos. Em relação ao tipo de parto, 71,2% dos partos ao longo da trajetória reprodutiva dessas mulheres foram vaginais, enquanto 28,8% cesáre as, o que aponta para o importante aspecto da desvinculação da esteriliza ção com a cesárea, como objetiva a Lei, e que essas mulheres que tiveram, em sua maioria, partos vaginais, estão tendo melhor acesso à esterilização. / The Brazilian Constitution of 1998 guarantees that health is a citizen right and a duty of the State. The PAISM (Women Health Comprehensive Program) was created emphasizing a comprehensive approach aiming to consi der the social, emotional and psychologi cal issues as part of health condition as well as contraception. However its imple mentation has not been completed up to now. This can be observed by the high prevalence of unwanted pregnancies, difficult access to family planning information, predominance of female surgical sterilization as a contraceptive method and the cesarean section. All these aspects are obstacles to sexual and reproductive rights. Since the implementation of the Federal Legal Act 9263 which regulates Family Planning Provision and approves surgical steriliza tion offering it in the public health system it is possible a disconnection between birth delivery and the surgical procedu re of sterilization. The objective of this study is to know the characteristics of women sterilized by SUS (Unified Health System) in Ribeirão Preto, betwen 2000 and 2004, according to the type of delive ry, cesarean or vaginal. The sample in cludes 235 sterilized women during the first five years of the surgical sterilizati on provision (2000-2004) Data was col lected through household interviews using a structured questionnaire. The results showed that the most sterilized women were white, married, with 8 years of schooling or less and belonged to socioeconomic category C or D. They were sterilized between 30 and 39 years old, with the average of 33.3 years old and median age of 33, 52.3% were using oral contraceptives before sterilization. They were found to have an average of 3,2 children and 51.7% had the first child between 13 and 19 years old. This study indicated that steri lized women had more children, started giving birth earlier and used contracepti ves while they waited for the surgery, and were sterilized later when compa red to the results of other studies. As to delivery types, 71,2% of deliveries along the reproductive history of these women were vaginal while 28% were cesarean what points out the important aspect of the disconnection between sterilization and the cesarean, as deter mined by law, and that these women who had mostly vaginal deliveries are having a better access to sterilization.

<p>This study was undertaken to investigate the involutional changes of the uterus and uterine cavity by ultrasound (US), gray-scale and Doppler, after normal delivery, and to compare with the corresponding findings from women with puerperal complications, particularly retained placental tissue (RPT). The overall design was exploratory and prospective, with the use of descriptive statistics for analysis. </p><p>Forty-two women with uncomplicated vaginal term delivery were examined on post-partum days 1, 3, 7, 14, 28 and 56. The AP diameters of the uterus and uterine cavity and morphological findings were recorded. The maximum AP diameters of the uterus and uterine cavity diminished from 92.0 mm on day 1 to 38.9 mm at day 56 and from 15.8 mm at day 1 to 4.0 mm at day 56, respectively. The uterus was most often empty in the early and late puerperium while a mixed echo pattern over the whole cavity was found during mid puerperium (I).</p><p>Seventy-nine women with secondary post partum hemorrhage (SPH) were examined on the day they presented with clinical symptoms. US revealed an echogenic mass in the uterine cavity in 17 of 18 patients treated surgically and histology confirmed placental tissue in 14 of these. Sixty-one patients with either an empty cavity or mixed echo pattern had an uneventful puerperal course after conservative treatment (II).</p><p>AP diameters and morphological findings for 55 women with endometritis, 28 after caesarean section and 20 after manual evacuation of the placenta overlapped extensively with normal references (III).</p><p>The physiological vascular involution studied in 45 women after normal delivery showed that PI and RI indices did not change significantly until day 28 postpartum. The presence of at least one uterine artery notch was found in 13.3% of the women at day 1 and in 90.6% at day 56 postpartum (IV).</p><p>PI and RI values were measured and compared with reference values in 20 women with clinical suspicion of RPT who were to undergo surgical evacuation. Mean resistance indices were below the 10th percentile for eight of these 20 women, but overlapping was considerable. Doppler US has limited value as a diagnostic tool for RPT. The absence of a hyper-vascular area in the myometrium does not exclude RPT but an echogenic mass in the cavity is a sign of RPT (V).</p>

This study was undertaken to investigate the involutional changes of the uterus and uterine cavity by ultrasound (US), gray-scale and Doppler, after normal delivery, and to compare with the corresponding findings from women with puerperal complications, particularly retained placental tissue (RPT). The overall design was exploratory and prospective, with the use of descriptive statistics for analysis. Forty-two women with uncomplicated vaginal term delivery were examined on post-partum days 1, 3, 7, 14, 28 and 56. The AP diameters of the uterus and uterine cavity and morphological findings were recorded. The maximum AP diameters of the uterus and uterine cavity diminished from 92.0 mm on day 1 to 38.9 mm at day 56 and from 15.8 mm at day 1 to 4.0 mm at day 56, respectively. The uterus was most often empty in the early and late puerperium while a mixed echo pattern over the whole cavity was found during mid puerperium (I). Seventy-nine women with secondary post partum hemorrhage (SPH) were examined on the day they presented with clinical symptoms. US revealed an echogenic mass in the uterine cavity in 17 of 18 patients treated surgically and histology confirmed placental tissue in 14 of these. Sixty-one patients with either an empty cavity or mixed echo pattern had an uneventful puerperal course after conservative treatment (II). AP diameters and morphological findings for 55 women with endometritis, 28 after caesarean section and 20 after manual evacuation of the placenta overlapped extensively with normal references (III). The physiological vascular involution studied in 45 women after normal delivery showed that PI and RI indices did not change significantly until day 28 postpartum. The presence of at least one uterine artery notch was found in 13.3% of the women at day 1 and in 90.6% at day 56 postpartum (IV). PI and RI values were measured and compared with reference values in 20 women with clinical suspicion of RPT who were to undergo surgical evacuation. Mean resistance indices were below the 10th percentile for eight of these 20 women, but overlapping was considerable. Doppler US has limited value as a diagnostic tool for RPT. The absence of a hyper-vascular area in the myometrium does not exclude RPT but an echogenic mass in the cavity is a sign of RPT (V).

Nearly one in three women in the United States undergoes major abdominal surgery in childbirth. According to the World Health Organization, in industrialized countries, the cesarean operation provides no health benefits when rates surpass one in six. In fact, the reverse applies; as a result of cesareans both women and their babies suffer disproportionate morbidity and mortality compared to cases of vaginal births. Furthermore, the decision to perform a cesarean relies mostly on subjective physiological indicators and varies according to the sociodemographic characteristics of the birthing woman. By regressing multiple clinical and sociodemographic factors against the method of birth, this research determines the risk factors of undergoing surgery in childbirth in the U.S. Results reveal medicalized childbirth to be a capricious system where sociodemographic factors determine a woman’s chance of major abdominal surgery.

婦產科醫師乃為目前人力短缺情形最為嚴重之科別，本研究首先欲觀察臺灣婦產科是否因為人力萎縮，使得產科醫師工作量提高？進一步討論產科醫師工作負荷量之增加，是否會偏向選擇較療程較簡易之醫療服務，即以剖腹接生方式取代自然接生。本研究利用健保資料庫之「住院醫療費用清單明細檔」，篩選2006年至2010年醫師接生之案件，發現從2006年至2009年，產科醫師平均接生次數有增加之趨勢。若以之衡量醫師工作量，產科醫師其工作負荷量確實有因人力減少而增加。另外，以固定效果模型估計結果皆發現，醫師工作量對剖腹產機率有正向顯著之影響，表示工作負荷量之增加確實會提高產科醫師採取剖腹接生之機率。支持本文對於工作負荷量增加會偏向選擇較簡單之醫療行為之預測。

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 5 uppsatser.

Thesis (M.S.)--University of Michigan, 1987. / "A research report submitted in partial fulfillment of the requirents for the degree ..."

Thesis (M.S.)--University of Michigan, 1987. / "A research report submitted in partial fulfillment of the requirents for the degree ..."