Orientadores: Jose Guilherme Cecatti, Maria Laura Costa do Nascimento / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-26T00:58:50Z (GMT). No. of bitstreams: 1 Ferreira_EltonCarlos_M.pdf: 3220735 bytes, checksum: adb82ed562a5753986a41b8a54b80cb0 (MD5) Previous issue date: 2014 / Resumo: Objetivo: avaliar a distribuição dos partos segundo o Sistema de Classificação em Dez Grupos de Robson (RTGCS) explorando os dados da Rede Brasileira de Vigilância da Morbidade Materna Grave (RBVMMG) e do Hospital da Mulher (CAISM) da Universidade Estadual de Campinas (UNICAMP), Brasil; e comparação de ambos com os dados do estudo Global Survey da Organização Mundial de Saúde (WHO). Método: Foram realizadas duas abordagens. A primeira foi uma análise secundária de um estudo de corte transversal multicêntrico que ocorreu em 27 maternidades brasileiras de referência, localizadas nas cinco regiões do país e participantes da RBVMMG. Foi realizada a codificação dos dados para alocação de todas as mulheres segundo o RTGCS e as mulheres foram classificadas de acordo com o espectro clínico de gravidade e a condição subjacente de morbidade materna grave. Para a segunda abordagem, foi realizado um estudo de corte transversal, com avaliação das mulheres admitidas para parto no CAISM no período de janeiro 2009 a julho de 2013. As mulheres foram agrupadas segundo a RTGCS e, adicionalmente, a distribuição das mulheres entre os diferentes grupos foi comparada entre os casos que tiveram morbidade materna grave, operacionalmente definida pela necessidade de internação em unidade de terapia intensiva (UTI), com os demais casos sem complicações graves. Para as duas abordagens (RBVMMG e CAISM), realizou-se também uma comparação com resultados publicados de outro grande estudo, realizado em diferentes contextos e países, fundamentalmente com os dados para o Brasil, disponíveis no estudo Global Survey da WHO. Resultados: Para a RBVMMG, das 7247 mulheres que compuseram o estudo, 73.2% foram submetidas à cesariana (CS). O grupo 10, grupo com provável indicação de cesárea por complicação materna e/ou fetal, foi o mais prevalente com 33.9% e também aquele com maior contribuição para a taxa geral de cesárea, 28%. Os grupos que tiveram maior gravidade (¨near miss¨ e óbito materno) foram, em ordem decrescente, os grupos 7 e 9, o grupo 8 e o grupo 10. O grupo 3 teve um caso de resultado materno grave (¨near miss¨ + óbito materno) para cada 29 casos de condição potencialmente ameaçadora da vida. Nas mulheres desse grupo submetidas a CS, essa relação atingiu valores de 1:10. Em todos os grupos avaliados, a hipertensão foi o fator de gravidade mais frequente. Na segunda abordagem, foram admitidas 12.771 parturientes durante o período do estudo. A taxa de cesariana encontrada foi de 46.6%. O grupo 1 foi o mais prevalente com 28.1%, sendo o grupo 5 aquele que mais contribui para a taxa geral de cesárea (12.7%). Apresentaram, proporcionalmente, mais internação em UTI os grupos 10 (46.8%), 5 (13.3%) e 2 com 9.8%. Conclusões: O estudo evidenciou uma alta taxa de cesárea nas duas populações avaliadas e o uso do RTGCS mostrou-se útil, evidenciando grupos clinicamente relevantes com alta taxa de parto por cesárea. Estudos futuros serão necessários para melhor avaliar a associação entre cesárea e morbidade materna grave, assim como definir possíveis intervenções e a taxa de cesárea esperada para esse grupo específico de mulheres / Abstract: Objective: To evaluate the distribution of delivering women according to the Robson¿s Ten Group Classification System (RTGCS) exploring the data from the Brazilian Network for the Surveillance of Severe Maternal Morbidity (RBVMMG) and from a tertiary hospital (CAISM), University of Campinas, Brazil; comparing both data with that from the WHO Global survey. Method: Two approaches were proposed. The first, a secondary analysis of a database obtained from a multicenter cross-sectional study taking place in 27 referral obstetric units located in the five geographical regions of Brazil, members of the Brazilian Network for the Surveillance of Severe Maternal Morbidity (RBVMMG), was carried out. For this analysis, data was organized following information necessary to classify all women into one of the RTGCS and cases from each of the 10 groups were classified according to case severity and underlying cause of severe morbidity. Subsequently, certain Robson groups were subdivided for further analysis. For the second approach, a cross-sectional study of data from women delivering at CAISM from January 2009 to July 2013 was carried out. Women were grouped according to RTGCS and, additionally, the distribution of women among the different groups was compared between cases who had severe maternal morbidity (SMM), operationally defined by intensive care unit (ICU) admission, with the other cases without severe complications. For both approaches (RBVMMG and CAISM), patients distributed among groups were compared to another Brazilian study population, available on the WHO Global Survey study. Results: For RBVMMG, among the 7247 women considered, 73.2% underwent cesarean section (CS). Group 10 had the highest prevalence rate (33.9%), also contributing most significantly (28%) to the overall CS rate. Groups associated with a severe maternal outcome (maternal ¨near miss¨ or maternal death), in decreasing order were: groups 7 and 9, 8 and 10. Group 3 had one case of severe maternal outcome (maternal ¨near miss¨ + maternal death) for every 29 cases of potentially life-threatening conditions. When evaluating only women undergoing CS in this group, ratios of 1:10 were achieved, indicating a worse outcome. Among all groups evaluated, hypertension was the most common condition of severity. For CAISM, of the 12771 women, 46.6% underwent CS. Group 1 had the highest prevalence rate (28%) and Group 5 contributed most significantly to overall CS rates. ICU admission was proportionally higher in groups 10 (46.8%), 5 (13.3%) and 2 with 9.8%.Conclusions: The study demonstrated a high cesarean section rate in the two populations studied and the use of RTGCS proved to be extremely useful, showing clinically relevant groups with high rates of cesarean section. Future studies are needed to better evaluate the association between cesarean section and severe maternal morbidity, as well as to define possible interventions and the expected cesarean section rate for this particular group of women / Mestrado / Saúde Materna e Perinatal / Mestre em Ciências da Saúde

Objetivo: Determinar potenciales factores de riesgo para diabetes mellitus gestacional (DMG). Métodos: Estudio de casos y controles realizado en el Hospital Alberto Sabogal mediante recolección de historias clínicas del 2009 a 2014. Se define como caso las gestantes con diagnóstico de DMG mediante una prueba de tolerancia oral a la glucosa (PTOG), previa glucosa en ayunas anormal y control a la gestante sin valores indicativos de DMG. Las variables de interés fueron paridad, antecedente de cesáreas, abortos y recién nacido con mayor peso. Modelos de regresión logística fueron calculados para estimar odd ratios (OR) e intervalos de confianza al 95% (IC95%). Resultados: Se incluyeron 84 casos y 336 controles. En el modelo multivariado, la multiparidad incrementó el riesgo de DMG (OR= 3,54; IC95% 1,55 – 8,14). También, antecedente de abortos, a partir del segundo aborto (OR= 3,40, IC95% 1,55 – 7,44) y cesáreas previas (1 cesárea OR= 3,5 IC95% 1,89 – 6,47 y 2+ cesáreas OR=8,35 IC95% 3,50 – 19,95). La multiparidad, dos o más abortos y mayor número de cesáreas son factores de riesgo para DMG. / Objectives: To identify risk factors for gestational diabetes mellitus (GDM). Methods: A case-control study was performed in Alberto Sabogal Hospital, collecting medical records from 2009 to 2014. A case was defined as a pregnant women diagnosed with GDM by an oral glucose tolerance test (OGTT) after an abnormal fasting glucose and control was defined as a pregnant women without GDM indicative values. The study outcome was GDM. The variables of interest were multiparity, previous cesarean section, abortions, newborn with the greatest weight. Logistic regression were used to calculate the odds ratio (OR) and a confidence interval of 95% (IC95%). Results: 84 cases and 336 controls were included. In the multivariate model, multiparity increased risk of GDM (OR= 3.54, 95% CI 1.55 to 8.14). As well history of abortions, from the second abortion (OR= 3.40, 95% CI 1.55 to 7.44) and previous cesarean section are also related (cesarean section 1 OR= 3.5 95% CI 1.89 to 6.47 and 2+ cesarean OR= 8.35 95% CI 3.50 to 19.95). Multiparity, two or more abortions, a biggest number of cesarean sections are GDM risk factors.

Cesarean birth rates are associated with increased maternal morbidity. This project evaluated a quality improvement (QI) initiative implemented to reduce cesarean births among Nulliparous Term Singleton Vertex (NTSV) obstetric populations, the largest contributor to cesarean births. Variations in labor management practice contribute to cesarean birth rate; implementation of labor management bundles have been endorsed to influence practice- and system-level changes in the promotion of vaginal births. The problem addressed in this project was an organizational NTSV cesarean section rate of 30%. The purpose of the project was to use secondary data to evaluate a previously implemented labor management bundle at a large hospital in the northwestern United States. The model of improvement was used as a framework for the QI initiative and this evaluation project. The practice-focused question asked in this project was: Did NTSV cesarean birth rates change after implementation of an evidenced-based standardized labor management bundle? Archived data were collected on cesarean birth rates for 3 time periods: prebaseline, 1 year postimplementation, and 2 years postimplementation. Chi-squareï? tests compared the differences between observed and expected results of data following implementation of labor management bundles. Results show no statistically significant difference between the pre- and post- implementation periods in the NTSV laboring population. Results suggest use of labor management practice bundles alone may not lead to expected outcomes improvements and that operationalization of such practices are sensitive to institutional and/or patient population contexts. This project may serve to promote positive social change by framing evidence-based practice as a process that must attend to contextual considerations.

Att amma är karakteristiskt för alla däggdjur och ett beteende som utvecklats under miljontals år. Amning är en global folkhälsoangelägenhet, då bröstmjölken och amningen ger ett dominerande skydd för både barnets och mammans fysiska, kognitiva och mentala hälsa. Enligt Svenska Barnmorskeförbundet ingår det i barnmorskans kompetensbeskrivning attarbeta hälsofrämjande och förebyggande, det inkluderar amning. Barnmorskan ska främja amning, ge information till blivande föräldrar om amningens hälsofördelar samt främja hud mot hudkontakt postpartum. I Sverige har andelen kejsarsnitt varit relativt bestående sedan år 2004, runt 17 procent av alla födslar. År 2015 var den värdsliga siffran 20 procent, vilket innebar att var femte förlossning i världen under året 2015, rapporterades in som kejsarsnitt. Efter ett kejsarsnitt kan mor och barn separeras från varandra postpartum, vilket ökar risken för försenad amningsinitiering jämfört med en vaginal förlossning. Detta på grund av separation de första timmarna postpartum som visat sig vara en avgörande tidpunkt för att etablera amningen. Syftet med föreliggande litteraturstudie var att beskriva om, och i så fall vilka faktorer, som kan påverka exklusiv amning upp till sex månader efter kejsarsnitt hos mödrar med normal, fullgången graviditet. Metoden som användes var en litteraturstudie. Den utfördes baserat på 16 vetenskapliga artiklar, med kvalitativ och kvantitativ ansats. Inhämtat material söktes i databaserna CINAHL och PubMed, dessa analyserades genom en integrerad analys på ett strukturerat och systematiskt sätt. Resultatet presenterade femtiosex faktorer som kan påverka exklusiv amning sex månader efter ett kejsarsnitt. Faktorerna redovisas med hjälp av fyra bärande huvudkategorier; förlossningsvård, modern, barnet och amning. Därtill framkom även elva subkategorier. Resultatet visade att kejsarsnitt påverkade den omedelbara hud mot hudkontakten, som är främjande för den exklusiva amningen postpartum. Även maternella postoperativa komplikationer och livsstilsfaktorer, moderns amningsintention, barnets hälsotillstånd postpartum, amningsstöd, bröst- och amningskomplikationer samt modersmjölksersättning, sågs påverka exklusiv amning. Slutsatsen som kan dras är att föda med kejsarsnitt hotar den omedelbara hud mot hudkontakten som visat sig vara essentiell för den exklusiva amningen postpartum. Det sombland annat visade en lyckad exklusiv amning var kvinnans positiva avsikt och inställning till amning innan födseln. Mer utbildning behövs för all vårdpersonal inom vårdkedjan för kejsarsnitt. På så vis skulle möjligheten kunna öka till att samtliga yrkesgrupper strävar efter gemensamma beslut som gynnar hud mot hudkontakt mellan mamma och barn, och samvård utan separation i största möjliga mån. / Breastfeeding is characteristic of all mammals and a behavior that has evolved over millions of years. Breastfeeding is a global public health issue, as breast milk and breastfeeding provide a dominant protection for both the baby's and the mother's physical, cognitive and mental health. According to The Swedish Association of Midwives (Svenska Barnmorskeförbundet), it is included in the midwife's competence description, that midwives must work to promote health and health prevention, this includes breastfeeding. The midwife must promote breastfeeding, provide information to expectant parents about the health benefits of breastfeeding, and promote skin-to-skin contact postpartum. In Sweden, the proportion of caesareans has been relatively permanent since 2004, around 17 percent of all births. In 2015, the worldly figure was 20 percent, which meant that every fifth birth in the world in 2015 was reported as a caesarean section. After a caesarean section, mother and child can be separated from each other. That might increase the risk of delayed initiation of breastfeeding compared to a vaginal birth. This is due to separation the first hours postpartum which has been proved to be a crucial time to establish breastfeeding. The aim of this literature study was to describe, if and which factors, that could affect exclusive breastfeeding up to six months after a cesarean section, including mothers with a normal and full-term pregnancy. The method performed was a literature study. It was carried out based on 16 scientific articles, with a qualitative and quantitative approach. Collected material was searched in the databases CINAHL and PubMed, these were analyzed through an integrated analysis in a structured and systematic way. Result of the study features fifty-sixfactors that could affect exclusive breastfeeding six months after a caesarean section. The factors are presented using four main categories: maternity care, mother, baby and breastfeeding. In addition, eleven subcategories emerged. The results showed that cesarean section affected the immediate skin-to-skin contact, which is conducive to the exclusive postpartum breastfeeding. Maternal postoperative complications and lifestyle factors, the mother's breastfeeding intention, the child's health condition postpartum, breastfeeding support, breast and breastfeeding complications and breast milk replacement, were also seen to affect exclusive breastfeeding. Conclusion that can be drawn, is that a caesarean section threatens the immediate skin-to-skin contact that has been shown to be essential for the exclusive postpartum breastfeeding. However, the mother’s positive intention and attitude to breastfeeding before giving birth, lead to a successful exclusive breastfeeding. More training is needed for all healthcare staff within the chain for caesarean section. In this way, the possibility could increase, that all professional groups would strive for similar decisions that would be in favor for skin-to-skin contact between mother and child, and cohabitation without need for separation, as much as possible.

Bakgrund Att förlösas med kejsarsnitt fortsätter att öka internationellt och något nationellt och är även förenligt med risker. Kejsarsnittsfrekvensen varierar stort i Sveriges olika län och tros delvis bero på att kriterier och rutiner för kejsarsnitt skiljer sig åt. Syfte Att beskriva hur operationssjuksköterskans roll i det interprofessionella teamet vid kejsarsnitt framställs i riktlinjer vid svenska sjukhus som utför kejsarsnitt Metod En totalundersökning av Sveriges sjukhus riktlinjer vid kejsarsnitt ledde till att en tvärsnittsstudie med kvantitativ deskriptiv design användes. Riktlinjerna färgkodades utifrån ett systemteoretiskt perspektiv och en granskningsmall gjordes för att enhetligt kunna beskriva hur operationssjuksköterskans roll framställs i respektive riktlinje. Ett reliabilitetstest på mallen gjordes och Cronbach’s alfa beräknades till 0,891. Resultat 29 av 41 av Sveriges sjukhus som utför kejsarsnitt är representerade i studien. Operationssjuksköterskans roll identifierades slutligen utifrån fyra strukturer; direkt omnämnd, indirekt omnämnd, del i det interprofessionella teamet och beskriven utifrån variabler. Vid analys av riktlinjerna utifrån granskningsmallen, framkom det att i elektiva riktlinjer var det 4 sjukhus som hade över 75 % av variablerna i sina riktlinjer, vid akuta 8 och urakuta 11. Slutsats Riktlinjerna är mer samstämmiga i beskrivningen av operationssjuksköterskans roll vid urakuta riktlinjer dock inte alltid med en arbetsbeskrivning. En tydlig framställning av operationssjuksköterskans roll skulle kunna uppnås genom att använda variabler i den framtagna granskningsmallen och därmed bidra till ökad patientsäkerhet och mer likvärdig vård. / Background Cesarean delivery continues to increase internationally and somewhat nationally and also includes risks. The frequency varies greatly in Sweden's counties and is believed to be partly due to that the criteria and routines for cesarean sections differ. Aim To describe how the operating room nurse in the interprofessional team in cesarean section is stated in guidelines at Swedish hospitals that perform cesarean sections.  Method A total survey of Sweden's hospital guidelines for cesarean sections led to the use of a cross-sectional study with a quantitative descriptive design. The guidelines were color-coded based on a systems theory perspective and a review template was made to be able to uniformly describe how the operating room nurse is presented in each guideline. A reliability test on the template was done and Cronbach's alpha was calculated to be 0.891. Result 29 of 41 of Sweden's hospitals that perform cesarean sections are represented in the study. The operating room nurse was ultimately identified based on four structures; directly mentioned, indirectly mentioned, part of the interprofessional team and described based on variables. When analyzing the guidelines based on the review template, it emerged that in elective guidelines, there were 4 hospitals that had over 75 percent of the variables in their guidelines, in acute 8 and in emergency 11.  Conclusion The guidelines are more consistent in the description of the operating room nurse in emergency procedures, although not always with a work description. A clear presentation of the operating room nurse could be achieved by using variables in the developed review template and thus contribute to increased patient safety and more equal care.

Thesis (MPH.) -- University of Limpopo, 2022 / The burden of labour and delivery-related complications are health problems that are life-threatening for the fetus and pregnant women. Mokopane hospital in Waterberg of Limpopo Province reports many maternal health complications. There has not been an investigation into the burden of delivery complications and therefore this study aims to investigate the burden of labour and delivery complication experienced by women giving birth at Mokopane hospital of Limpopo province. Purpose: of this study was to explore the burden of labour and delivery-related complications among pregnant women at Mokopane hospital of Limpopo province. Methods: A cross-sectional, retrospective descriptive study was conducted. The study followed a quantitative approach and the researcher completed a questionnaire using clinical records from all delivery files of mothers delivered at maternity between January 2017 to December 2019 Mokopane hospital. Findings: The major finding of this study was the majority of women were at a low risk of pregnancy (69%) followed by a high risk of pregnancy (24%). The study further revealed that (73.7%) of women at Mokopane hospital were delivered through the normal virginal procedure and (25.8%) delivered through Caesarean section. Moreover, about 86% of the mothers were normal after delivery whilst 14% were sick or had complications. Conclusion: This study, therefore, recommends that educational programs about labour and delivery-related complications and related programs should be prioritised for pregnant women. KEY CONCEPTS The burden: Is the intensity or severity of disease and its possible impact on daily life (Gidron 2013). In the context of this study, the burden will refer to the death and loss of health due to labour and delivery-related complications among pregnant women at Mokopane hospital of Limpopo Province. Labour: This is the process of rhythmic uterine contractions which results in cervical dilatation, a descent of the presenting part; and delivery of the fetus, placenta, and membrane. (Anthony & Van Der Spuy, 2002; Clark, Van de Velde, & Fernando, 2016). In the context of this study, labour will be defined as a physiologic process during which the fetus, membranes, umbilical cord, and placenta are expelled from the uterus. Delivery related complication: Is an acute condition arising from a direct cause of maternal death, such as antepartum or postpartum haemorrhage, obstructed labour, postpartum sepsis, a complication of abortion, pre-eclampsia or eclampsia, ectopic pregnancy and ruptured uterus, or indirect causes such as anaemia, malaria and tuberculosis. (WHO, 2018). In the context of this study, delivery related complications will include amongst others severe antenatal bleeding, Postpartum haemorrhage, nonconvulsive hypertensive disorder of pregnancy (pre-eclampsia), Eclampsia: preeclampsia plus convulsions, Convulsions, Prolonged labour, Premature rupture of the membranes, Retained placenta. Pregnant women: Is a woman who is in the period from conception to birth in which the egg is fertilised by a sperm and then implanted in the lining of the uterus then develops into the placenta and embryo, and later into a foetus (Martin, 2015). In the context of this study, a pregnant woman will be described as a woman who is carrying a developing embryo or fetus within her body.

Introduktion: Omedelbart kejsarsnitt är ett akut kirurgiskt ingrepp som utförs när det finns medicinska komplikationer som kräver omgående intervention för att skydda modern eller barnets liv. Proceduren utförs under tidspress och nästan alltid med generell anestesi, vilket innebär att de preoperativa förberedelserna ofta är begränsade. Anestesisjuksköterskans roll är avgörande i dessa situationer för att säkerställa en effektiv hantering av ingreppet. Stressfaktorer för anestesisjuksköterskor är påtagliga i dessa akuta situationer där snabba och korrekta beslut måste fattas under press. Metod: En kvalitativ intervjustudie har utförts med induktivt förhållningssätt för att beskriva anestesisjuksköterskors erfarenhet av omedelbart kejsarsnitt. Data analyserades med hjälp av en kvalitativ innehållsanalys. Resultat: Anestesisjuksköterskors erfarenheter vid omedelbart kejsarsnitt kan delas in i fyra kategorier: att känna stress och adrenalinpåslag när larmet går, att samarbeta under operation, att hantera stressmoment, och att arbeta strukturerat och vara förberedd. Diskussion: Studien betonar behovet av tydlig kommunikation och samarbete för att minska stress och förbättra resultatet vid omedelbara kejsarsnitt. Simuleringsövningar och kompetensbaserad utbildning är centrala för att stärka beredskapen hos anestesisjuksköterskan. Slutligen kan personlighetsdrag och emotionell intelligens påverka hur anestesisjuksköterskor hanterar stressiga situationer som vid omedelbart kejsarsnitt. Slutsats: Anestesisjuksköterskor var i aktuell studie väl förberedda och kapabla att hantera omedelbara kejsarsnitt tack vare kunskap och kommunikation, tydliga rutiner och standardisering, erfarenhet och personliga egenskaper. Det visar att förberedelse, kompetens, rutiner och samarbete är avgörande för hantering av dessa akuta situationer. Ytterligare forskning behövs för att optimera hanteringen genom träningsprogram samt förbättra kommunikation och rutiner för att öka anestesisjuksköterskans beredskap inför omedelbart kejsarsnitt.

Introdução: A leucemia linfoblástica aguda (LLA) é a neoplasia pediátrica com maior incidência no mundo. Sua etiologia é resultante de múltiplas interações entre herança genética e exposição a agentes ambientais potencialmente carcinogênicos nos períodos pré-natal, nascimento e pós-natal. O parto cesáreo tem sido apontado como fator de risco para LLA em crianças. No Brasil, país com altas taxas de cesariana, são poucos os estudos que avaliaram a associação de cesariana com LLA na infância. Objetivos: Investigar a associação de cesariana e condições pré-natal e pós-natal com LLA em crianças nascidas no estado de São Paulo. Métodos: Estudo caso-controle de base populacional. Os casos de LLA, crianças nascidas no estado de São Paulo a partir de 1999, foram recrutados em oito hospitais de 2003 a 2009. Os controles foram emparelhados com os casos por sexo, idade e cidade de nascimento. As informações utilizadas nesse estudo foram obtidas em entrevistas com as mães ou responsáveis pelas crianças por meio de questionário estruturado. Informações adicionais foram adquiridas no banco de Declarações de Nascidos Vivos (DNV), que integra o Sistema de Informações de Nascidos Vivos (SINASC) da Secretaria Municipal de Saúde de São Paulo e do Ministério da Saúde. Após o linkage probabilístico dos bancos de dados, a amostra final comporta 133 casos e 459 controles, relação de 3,4 controles por caso. Análises de regressão logística não condicional e condicional foram conduzidas para estimar a associação entre cesariana, condições pré-natal e pós-natal e LLA, com estimava dos odds ratios (OR) e respectivos intervalos de 95% de confiança (IC 95%). Três modelos de regressão logística foram elaborados: 1) ajuste por idade e sexo da criança, idade e escolaridade da mãe; 2) ajuste pelas variáveis anteriores, mais raça e número de consultas; 3) ajuste por todas as variáveis anteriores e a inclusão de idade gestacional e peso ao nascer. Resultados: A análise de regressão logística não condicional, com base no Modelo 2, revelou discreto risco de LLA na exposição à cesariana (OR=1,10; IC95% 0,71-1,70), proteção na condição de mãe com 12 ou mais anos de escolaridade (OR=0,46; IC95% 0,24-0,89) e idade da criança de 6 a 8 anos no diagnóstico (OR=0,30; IC95% 0,13-0,67). Resultados similares foram observados na análise de regressão logística condicional no Modelo 2: cesariana (OR=1,18; IC95% 0,69-2,00), mães com 12 ou mais anos de escolaridade (OR=0,56; IC95% 0,25-1,24). Conclusões: Há uma tênue associação entre cesariana e LLA na infância, sem significância estatística. Alta escolaridade da mãe e crianças na faixa etária entre 6 e 8 anos foram fatores de proteção para LLA. Crianças com síndrome de Down apresentaram seis vezes o risco de LLA. Os resultados obtidos por análise regressão logística condicional foram similares aos da regressão logística não condicional. / Introduction: Acute lymphoblastic leukemia (ALL) is the most common pediatric neoplasia worldwide. Its etiology results from multiple interactions between genetic inheritance and exposure to potentially carcinogenic environmental agents during the prenatal, birth, and postnatal periods. Cesarean section has been identified as a risk factor for ALL in children. In Brazil, a country with high Cesarean section rates, few studies have evaluated the association of Cesarean section with ALL in childhood. Objectives: To investigate the association of Cesarean section, prenatal and postnatal conditions with ALL in children born in the state of São Paulo. Methods: Population-based case-control study. The cases of ALL, children born in the state of São Paulo from 1999, were recruited in eight hospitals from 2003 to 2009. Controls were matched with cases by sex, age and city of birth. The information used in this study were obtained through interviews with mothers or guardians of the children, using a structured questionnaire. Additional information were get from the Live Births Database, stored in the Live Birth Information System at the São Paulo Municipal Health Department and at the Brazilian Ministry of Health. After the databases probabilistic linkage, the final sample entails 133 cases and 459 controls, 3.4 controls per case ratio. Non-conditional and conditional logistic regression analyzes were conducted to estimate the association between cesarean section, pre- and postnatal conditions, and ALL with estimation of odds ratios (OR) and respective 95% confidence intervals (95% CI). Three models of logistic regression were elaborated: 1) adjustment by age and sex of the child, age and schooling of the mother; 2) adjustment for the previous variables, more race and number of queries; 3) adjustment for all previous variables and the inclusion of gestational age and birth weight. Results: The nonconditional logistic regression analysis, based on Model 2, revealed a slight risk of ALL on cesarean section exposure (OR = 1.10, 95% CI 0.71-1.70), protection on the condition of mothers with 12 or more years of schooling (OR = 0.46, 95% CI 0.24-0.89), and age of child from 6 to 8 years at diagnosis (OR = 0.30, 95% CI, 0.13-0, 67). In the conditional logistic regression analysis in Model 2, similar results were observed: cesarean (OR = 1.18, 95% CI 0.69-2.00), mothers with 12 or more years of schooling (OR = 0.56, 95% CI, 0.25-1.24). Conclusions: There is a weak association between cesarean section and ALL in childhood, with no statistical significance. Mother with high education level and children in the age range between 6 and 8 years were protective factors for ALL. Children with Down syndrome had a six-fold risk of ALL. The results obtained by conditional logistic regression analysis were similar to those of non-conditional logistic regression.

INTRODUÇÃO: O Brasil ocupa o primeiro lugar entre os países com maiores taxas de cesariana no mundo. Pouco se sabe a respeito das consequências futuras deste procedimento, sobre a saúde materna. Este estudo investigou a influência da técnica anestésico-cirúrgica e analgesia pós-operatória, no aparecimento de dor crônica após a cesariana. Procuramos também identificar os fatores de risco de dor crônica pós-cesariana. MÉTODO: Este estudo prospectivo com distribuição aleatória foi conduzido em 443 pacientes que foram submetidas à cesariana (eletivas e emergenciais), com diferentes doses de bupivacaína 0,5% hiperbárica e opioides na raquianestesia, bem como uso de anti-inflamatórios não esteroidais peri-operatório. Os grupos foram: G8SMA- 8 mg bupivacaína hiperbárica + 2,5 mcg sufentanil + 100 mcg morfina; G10SMA- 10 mg bupivacaína hiperbárica + 2,5 mcg sufentanil + 100 mcg morfina; G12,5MA- 12,5 mg bupivacaína hiperbárica + 100 mcg morfina; G15MA- 15 mg bupivacaína hiperbárica + 100 mcg morfina; G12,5M - 12,5 mg bupivacaína hiperbárica + 100 mcg morfina. Somente as pacientes do grupo G12,5M não receberam AINE no peri-operatório. Dor em repouso e em movimento foram avaliadas no pós-operatório imediato. Fatores peri-operatórios, cirúrgicos e obstétricos foram investigados. Contato telefônico foi realizado, após três e seis meses do procedimento cirúrgico, para identificação das pacientes com dor crônica. RESULTADOS: A incidência de dor crônica nos grupos foi: G8SMA= 20%, G10SMA= 13%; G12,5MA= 7,1%; G15MA= 2,2% e G12,5M= 20,3%. Pacientes que apresentaram escores de dor mais elevados no período pós- operatório imediato, que referiram doenças crônicas em tratamento, que apresentaram maior tempo em trabalho de parto sem analgesia, tiveram maior incidência de dor crônica (p<0,05). CONCLUSÃO: A incidência de dor crônica diminui com emprego de doses maiores de anestésicos locais e uso de anti-inflamatórios não esteroidais. Escores mais elevados de dor no período pós-operatório imediato tiveram associação com aparecimento de dor crônica após a cesariana. Os fatores de risco encontrados foram: doença crônica em tratamento, maior tempo em trabalho de parto sem analgesia e escores de dor elevados no pós- operatório imediato / INTRODUCTION: Brazil holds first place in cesarean section rate in the world. Little is known about the consequences upon maternal health. This study investigated the influence of anesthetic, surgical techniques and postoperative analgesia on chronic pain after cesarean section. We also tried to identify risk factors for chronic pain after cesarean section. METHODS: A prospective randomized study was conducted among 443 patients who underwent elective or emergency cesarean section with different doses of hyperbaric bupivacaine 0.5% and opioids in spinal anesthesia, associated or not to non steroidal anti-inflamatory drugs. The groups were: G8SMA- 8mg hyperbaric bupivacaine + 2.5 mcg sufentanil + 100 mcg morphine; G10SMA- 10 mg hyperbaric bupivacaine + 2.5 mcg sufentanil + 100 mcg morphine; G12.5MA- 12.5 mg hyperbaric bupivacaine + 100 mcg morphine; G15MA- 15 mg hyperbaric bupivacaine + 100 mcg morphine; G12.5M- 12.5 mg hyperbaric bupivacaine + 100 mcg morphine (only in this group, non-steroidal anti-inflammatory drug was not used). Pain at rest and during movement were evaluated on the first two postoperative days using the verbal numerical rating scale. Perioperative, surgical and obstetric factors were investigated. Phone survey was conducted after three and six months to identify patients with chronic pain RESULTS: Incidences of chronic pain in groups were: G8SMA= 20%, G10SMA= 13%; G12.5MA= 7.1%; G15MA= 2.2% and G12.5M= 20.3 %. Patients with co-morbidities, and who had been more than 15 hours in labor before the cesarean (without analgesia) had more chance to have chronic pain than those who did not have pain. Patients who had higher pain scores on the two postoperative days were associated to chronic pain (p<0.05).!! CONCLUSION: The incidence of chronic pain decreases with higher doses of local anesthetic and the use of non-steroidal anti-inflammatory drugs. Patients who had higher pain scores in the immediate postoperative period were more likely to develop chronic pain. The only predictors of chronic pain were: previous history of disease, longer time in labor, intensity of postoperative pain and the use of lower doses of local anesthetic in spinal anesthesia

INTRODUÇÃO: Clonidina intratecal pode prolongar a duração da raquianestesia, possivelmente com maior duração da analgesia pós-operatória em cesáreas. Neste estudo, avaliamos o uso de clonidina como medicação adjuvante na anestesia para cesárea, pelas vias intratecal e intravenosa e seus efeitos na dor pós-operatória e repercussões neonatais. MÉTODOS: em ensaio clínico prospectivo, aleatorizado, duplo-cego, controlado por placebo, 64 mulheres submetidas à cesárea eletiva sob raquianestesia foram aleatorizadas e alocadas em três grupos, a depender de como receberiam a clonidina adjuvante: clonidina intratecal 75 mcg, clonidina intravenosa 75 mcg, e solução fisiológica 0,9% (controle). O desfecho primário foi dor pós-operatória aguda. Os desfechos secundários foram dor pós-operatória tardia (após três meses), eventos adversos maternos e neonatais. RESULTADOS: não foram encontradas diferenças nos escores de dor ou no consumo de opioides no período pós-operatório precoce. Clonidina intratecal e intravenosa causaram maiores índices de sedação intraoperatória, em comparação com o grupo controle {RASS: 0 [(-1)-(0)] vs. 0 [(-1)-(-1)] vs. 0 [(-1)-(-1)] para controle, intratecal e intravenosa, respectivamente, p < 0,001}. Não houve diferença para efeitos adversos ou desfechos neonatais entre os grupos. CONCLUSÕES: clonidina intratecal e clonidina intravenosa não tiveram efeito na dor pós-operatória pós-cesárea. Ambas causaram maior sedação intraoperatória / BACKGROUND: Intrathecal clonidine may prolong the duration of spinal anesthesia, possibly with longer duration of postoperative analgesia in cesarean sections. In this study, we evaluated the use of clonidine as an intrathecal or intravenous adjuvant medication for cesarean section anesthesia and its effects on postoperative pain and neonatal outcomes. METHODS: In a prospective, randomized, double-blind, placebo-controlled clinical trial, 64 women undergoing elective cesarean section under spinal anesthesia were randomized and allocated to three groups, depending on how they would receive adjuvant clonidine: 75 mcg intrathecal clonidine, 75 mcg intravenous clonidine, and 0.9% saline solution (control). The primary outcome was acute postoperative pain. Secondary outcomes were late postoperative pain (after three months), maternal and neonatal adverse events. RESULTS: no differences were found in pain scores or opioid use in the acute postoperative period. Intrathecal and intravenous clonidine caused higher rates of intraoperative sedation compared to the control group {RASS: 0 [(-1)-(0)] vs. 0 [(-1)-(-1)] vs. 0 [(-1)-(-1)] for control, intrathecal and intravenous, respectively, p < 0.001}. There was no difference for adverse effects or neonatal outcomes among groups. CONCLUSIONS: intrathecal clonidine and intravenous clonidine had no effect on post-cesarean postoperative pain. Both caused higher intraoperative sedation