Portal Evidências

Staples can be placed during the making of an incision, with the aim of decreasing blood loss from the cut edges.The objective of this review was to assess the effects of using a stapler with absorbable staples to extend the uterine incision at lower segment caesarean section.We searched the Cochrane Pregnancy and Childbirth Group trials register.Randomised and quasi-randomised trials of extending the uterine incision using a stapler compared with extending the incision digitally or with scissors in women having a lower segment transverse incision caesarean section.Eligibility and trial quality were assessed.Four trials involving 526 women were included. There was no difference in total operating time between the stapling technique and other techniques to extend the incision (weighted mean difference -1.17 minutes, 95% confidence interval -3.57 to 1.22). However stapling devices increased the time needed to deliver the baby (weighted mean difference 0.85 minutes, 95% confidence interval 0.48 to 1.23). Blood loss was lower with the use of staples (weighted mean difference -41.22 millilitres, 95% confidence interval -50.63 to -31.8). No significant differences between stapling and other techniques were detected for other perinatal morbidity outcomes.There is not enough evidence to justify the routine use of stapling devices to extend the uterine incision at lower segment caesarean section. There is a possibility that stapling could cause harm, by prolonging the time to deliver the baby.(ocultar)

Approximately 70% of women will experience some degree of perineal trauma following vaginal delivery and will require stitches. This may result in perineal pain and superficial dyspareunia.The objective of this review was to assess the effects of absorbable synthetic suture material as compared with catgut on the amount of short and long term pain experienced by mothers following perineal repair.We searched the Cochrane Pregnancy and Childbirth Group's Trials Register.Randomised trials comparing absorbable synthetic (polyglycolic acid and polyglactin) with plain or chromic catgut suture for perineal repair in mothers after vaginal delivery.Trial quality was assessed independently by two reviewers. Data were extracted by one reviewer and checked by the second reviewer.Eight trials were included. Compared with catgut, the polyglycolic acid and polyglactin groups were associated with less pain in first three days (odds ratio 0.62, 95% confidence interval 0.54 to 0.71). There was also less need for analgesia (odds ratio 0.63, 95% confidence interval 0.52 to 0.77) and less suture dehiscence (odds ratio 0.45, 95% confidence interval 0.29 to 0.70). There was no significant difference in long term pain (odds ratio 0.81, 95% confidence interval 0.61 to 1.08). Removal of suture material was significantly more common in the polyglycolic acid and polyglactin groups (odds ratio 2.01, 95% confidence interval 1.56 to 2.58). There was no difference in the amount of dyspareunia experienced by women.Absorbable synthetic suture material (in the form of polyglycolic acid and polyglactin sutures) for perineal repair following childbirth appears to decrease women's experience of short-term pain. The length of time taken for the synthetic material to be absorbed is of concern. A trial addressing the use of polyglactin has recently been completed and this has been included in this updated review.(ocultar)

Expectant management of the third stage of labour involves allowing the placenta to deliver spontaneously or aiding by gravity or nipple stimulation. Active management involves administration of a prophylactic oxytocic before delivery of the placenta, and usually early cord clamping and cutting, and controlled cord traction of the umbilical cord.The objective of this review was to assess the effects of active versus expectant management on blood loss, post partum haemorrhage and other maternal and perinatal complications of the third stage of labour.We searched the Cochrane Pregnancy and Childbirth Group trials register.Randomised trials comparing active and expectant management of the third stage of labour in women who were expecting a vaginal delivery.Trial quality was assessed and data were extracted independently by the reviewers.Five studies were included. Four of the trials were of good quality. Compared to expectant management, active management (in the setting of a maternity hospital) was associated with the following reduced risks: maternal blood loss (weighted mean difference -79.33 millilitres, 95% confidence interval -94.29 to -64.37); post partum haemorrhage of more than 500 millilitres (relative risk 0.38, 95% confidence interval 0.32 to 0.46); prolonged third stage of labour (weighted mean difference -9.77 minutes, 95% confidence interval -10.00 to -9.53). Active management was associated with an increased risk of maternal nausea (relative risk 1.83, 95% confidence interval 1.51 to 2.23), vomiting and raised blood pressure (probably due to the use of ergometrine). No advantages or disadvantages were apparent for the baby.Routine 'active management' is superior to 'expectant management' in terms of blood loss, post partum haemorrhage and other serious complications of the third stage of labour. Active management is, however, associated with an increased risk of unpleasant side effects (eg nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in a maternity hospital. The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries).(ocultar)

Acupuncture has traditionally been used to treat asthma in China and is used increasingly for this purpose internationally.The objective of this review was to assess the effects of acupuncture for the treatment of asthma or asthma-like symptoms.We searched the Cochrane Airways Group Specialised Register (last searched August 2008), the Cochrane Complementary Medicine Field trials register, AMED, and reference lists of articles. We also contacted trialists and researchers in the field of complementary and alternative medical research.Randomised and possibly randomised trials using needle acupuncture or other forms of stimulation of acupuncture. Any form of control treatment was considered (no treatment in addition to conventional asthma treatment, sham or placebo interventions, active comparator interventions). Studies were included provided outcome was assessed at one week or more.At least two reviewers independently assessed trial quality. A reviewer experienced in acupuncture assessed the adequacy of the active and sham acupuncture used in the studies. Study authors were contacted for missing information.Twelve studies met the inclusion criteria recruiting 350 participants. Trial reporting was poor and trial quality was deemed inadequate to generalise findings. There was variation in the type of active and sham acupuncture, the outcomes measured and time-points presented. The points used in the sham arm of some studies are used for the treatment of asthma according to traditional Chinese medicine. Two studies used individualised treatment strategies and one study used a combination strategy of formula acupuncture with the addition of individualised points. No statistically significant or clinically relevant effects were found for acupuncture compared to sham acupuncture. Data from two small studies were pooled for lung function (post-treatment FEV1): Standardised Mean Difference 0.12, 95% confidence interval -0.31 to 0.55).There is not enough evidence to make recommendations about the value of acupuncture in asthma treatment. Further research needs to consider the complexities and different types of acupuncture.(ocultar)

Acupuncture and related techniques are promoted as a treatment for smoking cessation in the belief that they may reduce nicotine withdrawal symptoms.The objectives of this review are to determine the effectiveness of acupuncture and the related interventions of acupressure, laser therapy and electrostimulation, in smoking cessation in comparison with no intervention, sham treatment, or other interventions.We searched the Cochrane Tobacco Addiction Group specialized register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, BIOSIS Previews, PsycINFO, Science and Social Sciences Citation Index, AMED and CISCOM. Date of last search January 2005.Randomized trials comparing a form of acupuncture, acupressure, laser therapy or electrostimulation with either no intervention, sham treatment or another intervention for smoking cessation.We extracted data in duplicate on the type of smokers recruited, the nature of the acupuncture and control procedures, the outcome measures, method of randomization, and completeness of follow up.We identified 24 reports of studies. The only comparison for which there were sufficient studies to combine meaningfully was acupuncture compared with sham acupuncture. The fixed-effect odds ratio (OR) for the short-term effect was 1.36 (95% confidence interval 1.07 to 1.72), but the studies are heterogeneous and the result is strongly influenced by one individual positive study. The significant short-term effect was lost with the random-effects model for pooling, or by removing the outlying study that led to heterogeneity. The long-term result shows no effect of acupuncture compared with sham acupuncture. There was no consistent evidence that acupuncture is superior to no treatment, and no evidence that the effect of acupuncture was different from that of other anti-smoking interventions, or that any particular acupuncture technique is superior to other techniques.There is no consistent evidence that acupuncture, acupressure, laser therapy or electrostimulation are effective for smoking cessation, but methodological problems mean that no firm conclusions can be drawn. Further research using frequent or continuous stimulation is justified.(ocultar)

Up to half the people with tuberculosis do not complete their treatment. Strategies to improve adherence to diagnostic and treatment regimens are therefore important.To assess the effects of various interventions aimed at promoting adherence to anti-tuberculosis treatment and completion of TB diagnostic protocols.We searched the Cochrane Controlled Trials Register, the Cochrane Infectious Diseases Group trials register, Medline, Embase, Lilacs and reference lists of articles. We contacted experts in the field.Randomised and quasi-randomised trials of interventions to promote adherence with curative or preventive chemotherapy and diagnostic protocols for tuberculosis.Two reviewers independently assessed trial quality and extracted data.Fourteen trials were included. Reminder cards sent to defaulters, a combination package of a monetary incentive and health education and more supervision of clinic staff increased the number of people completing their tuberculosis treatment. Intensive counselling/education did not help in one study. Direct observation showed better clinical outcomes in one study, and no difference in another. Return to the clinic for reading of a tuberculin skin test was enhanced by monetary incentives, assistance by lay health workers, contracts and telephone prompts but not by health education.We have found evidence of benefit for a number of specific interventions to improve adherence to anti-tuberculous therapy and completion of diagnostic protocols. These should be implemented by health care providers where appropriate to local circumstances. Future studies in low income countries are a priority and should measure adherence and clinical outcomes.(ocultar)

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 83 interventions reported in 70 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.(ocultar)

Home-like birth settings have been established in or near conventional labour wards for the care of pregnant women who prefer and require little or no medical intervention during labour and birth.Primary: to assess the effects of care in a home-like birth environment compared to care in a conventional labour ward. Secondary: to determine if the effects of birth settings are influenced by staffing or organizational models or geographical location of the birth centre.We searched the Cochrane Pregnancy and Childbirth Group trials register (18 May 2004) and handsearched eight journals and two published conference proceedings.All randomized or quasi-randomized controlled trials that compared the effects of a home-like institutional birth environment to conventional hospital care.Standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group were used. Two review authors evaluated methodological quality. Double data entry was performed. Results are presented using relative risks and 95% confidence intervals.Six trials involving 8677 women were included. No trials of freestanding birth centres were found. Between 29% and 67% of women allocated to home-like settings were transferred to standard care before or during labour. Allocation to a home-like setting significantly increased the likelihood of: no intrapartum analgesia/anaesthesia (four trials; n = 6703; relative risk (RR) 1.19, 95% confidence interval (CI) 1.01 to 1.40), spontaneous vaginal birth (five trials; n = 8529; RR 1.03, 95% CI 1.01 to 1.06), vaginal/perineal tears (four trials; n = 8415; RR 1.08, 95% CI 1.03 to 1.13), preference for the same setting the next time (one trial; n = 1230; RR 1.81, 95% CI 1.65 to 1.98), satisfaction with intrapartum care (one trial; n = 2844; RR 1.14, 95% CI 1.07 to 1.21), and breastfeeding initiation (two trials; n = 1431; RR 1.05, 95% CI 1.02 to 1.09) and continuation to six to eight weeks (two trials; n = 1431; RR 1.06, 95% CI 1.02 to 1.10). Allocation to a home-like setting decreased the likelihood of episiotomy (five trials; n = 8529; RR 0.85, 95% CI 0.74 to 0.99). There was a trend towards higher perinatal mortality in the home-like setting (five trials; n = 8529; RR 1.83, 95% CI 0.99 to 3.38). No firm conclusions could be drawn regarding the effects of staffing or organizational models.When compared to conventional institutional settings, home-like settings for childbirth are associated with modest benefits, including reduced medical interventions and increased maternal satisfaction. Caregivers and clients should be vigilant for signs of complications.(ocultar)

Amnioinfusion aims to prevent or relieve umbilical cord compression or amniotic fluid infection during labour by infusing a solution into the uterine cavity.To assess the effects of amnioinfusion on maternal and perinatal outcome for potential or suspected umbilical cord compression or potential amnionitis.The Cochrane Pregnancy and Childbirth Group Trials Register (November 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2004) and PubMed (1966 to November 2004).Randomized trials of amnioinfusion compared with no amnioinfusion in women with babies at risk of umbilical cord compression; and women at risk of intrauterine infection.Eligibility and trial quality were assessed by the review author. Data were extracted and analyzed using RevMan software.Fourteen studies were included, most with fewer than 200 participants. Transcervical amnioinfusion for potential or suspected umbilical cord compression was associated with the following reductions: fetal heart rate decelerations (four studies, 227 women: relative risk (RR) 0.54; 95% confidence interval (CI) 0.43 to 0.68); caesarean section overall (nine studies, 953 women: RR 0.52; CI 0.40 to 0.69); Apgar score less than seven at five minutes (seven studies, 828 women: RR 0.54; CI 0.30 to 0.97); low cord arterial pH (six studies, 660 women: RR 0.45; CI 0.31 to 0.64); neonatal hospital stay greater than three days (one study, 305 women: RR 0.40; CI 0.26 to 0.62); postpartum endometritis (five studies, 619 women: RR 0.45; CI 0.25 to 0.81); maternal hospital stay greater than three days (two studies, 465 women: RR 0.41; CI 0.27 to 0.63). Transabdominal amnioinfusion showed similar trends, though numbers studied were small. Transcervical amnioinfusion to prevent infection in women with membranes ruptured for more than six hours was associated with a reduction in puerperal infection (one study, 68 women: RR 0.50; CI 0.26 to 0.97).Amnioinfusion appears useful to reduce the occurrence of variable fetal heart rate decelerations, improve short-term measures of neonatal outcome, and lower the use of caesarean section, mainly for 'fetal distress' diagnosed by fetal heart rate monitoring alone. However, most of the included studies were small, and there were methodological shortcomings. In one trial puerperal infection was reduced. The trials reviewed are too small to address the possibility of rare but serious maternal adverse effects of amnioinfusion. More research is needed to confirm the findings, assess longer-term measures of fetal outcome, and the impact on caesarean section when the diagnosis of fetal distress is more stringent.(ocultar)