Atención al parto normal, edad materna avanzada e indicadores de práctica clínica y de morbilidad materna y neonatal

Résumé

Aims To analyze the main clinical practice outcome indicators and the rates of maternal and neonatal morbidity following the implementation of the Clinical Practice Guideline for Normal Childbirth Care (CPGNCB), among the group of candidate women versus non-candidates. To determine the professional profile that attends low-risk deliveries at the Marqués de Valdecilla University Hospital. To analyze the association between advanced maternal age (AMA) and maternal and neonatal morbidity. Methodology Cross-sectional study. The study population comprised the total number of hospital births attended at the Marqués de Valdecilla University Hospital between 1 January 2014 and 31 December 2014 (n=3315). For the study of maternal and fetal morbidity following the implementation of the CPGNCB, a comparison was made between the group of candidates for the application of CPGNCB and the group of non-candidates. The definition of a “pregnant woman who is a candidate for the application of the CPGNCB” was: a pregnant woman with a hospital birth, without pathologies during pregnancy (maternal, amniotic liquid or foetal), with a controlled pregnancy, simple foetus, non-induced delivery, at term, in which the neonatal status is that of a “live newborn”, in accordance with the National Clinical Practice Guide for Normal Delivery Care and international guidelines. For the study of the association between advanced maternal age and maternal and neonatal morbidity, we compared childbirth between women aged 35 years, or older, with a reference group of women aged between 24 and 27 years. We accessed secondary registers for the main indicators of care and results, using the chi-squared test or the Student’s t-test for between-groups comparisons for the categorical and quantitative variables, respectively. As association measure, crude (ORc) and adjusted Odds Ratios (ORa) were estimated by non-conditional logistic regression with their Confidence Intervals at 95% (95%CI). Results In total, 1863 births (56.20%) were candidates for the application of the Clinical Practice Guidelines for Care of Normal Birth. In 50.86% of these candidate births, the pregnant women received an episiotomy, compared to 60.96% in the group of non-candidates (p<0.001). Regarding caesarean sections, these were carried out in 19.32% of the candidate births, compared to 26.79% in the group of non-candidate births (p<0.001). Furthermore, there were statistically significant differences between groups according to the type of birth, the need for instrumental birthing methods, the existence of perineal tears, Apgar scores and the requirement for the newborn to be admitted to the neonatal care unit. As for the professional profile that attends births, 74.17% of eutocic births in the candidate group were attended by midwives, compared to the group of non-candidates in which 60.24% of eutocic births were attended by midwives, p<0.001. Regarding the study of the relationship between AMA and maternal and neonatal morbidity, our study showed that repeated abortions were more common among women of AMA: ORa=2.68; 95%CI (1.52-4.73). A higher prevalence of gestational diabetes was observed in first time mothers: ORa=8.55; 95%CI (1.12-65.43). In addition, the possibility of an instrumental delivery was multiplied by 1.6 and the possibility of a cesarean by 1.5 among women of AMA, reaching these results statistical significant significance, and observing a dose-response pattern (the greater the age, the greater the risk). Lastly, there were associations between AMA and preeclampsia, preterm birth (<37 weeks) and low birthweight although, but without reaching statistical significance. Conclusions Our results suggest a differential clinical practice in line with the recommendations of the CPGNCB. Nonetheless, improvements are necessary regarding care provided to women and newborns as the percentages of episiotomies and caesarean sections are still high compared to the current standards and the results of other studies. Our research shows that 74% of the eutocic births were attended entirely by midwives. Our results support the association between AMA and suffering repeated abortions. Likewise, being of AMA was associated with a greater risk of suffering from gestational diabetes, especially among primiparous women, as well as being associated with both instrumental deliveries and cesareans among both primiparous and multiparous women.