536
PUERPERAL I NFECTI ON FROM THE PERSPECTI VE OF HUMANI ZED DELI VERY CARE AT A
PUBLI C MATERNI TY HOSPI TAL
Elisân gela Eu r ipedes Resen de Gu im ar ães1 Tânia Cout o Machado Chianca2 Adr iana Cr ist ina de Oliv eir a2
Guim arães EER, Chianca TCM, Oliveira AC. Puerperal infect ion from t he perspect ive of hum anized delivery care at a public m at ernit y hospit al. Rev Lat ino- am Enferm agem 2007 j ulho- agost o; 15( 4) : 536- 42.
This is an epidem iological, prospective and non- concurrent study of the cohort type about puerperal infection from t he perspect ive of hum anized delivery care, based on inform at ion from 5,178 records of pat ient s who went through the experience of hum anized delivery. The study aim ed at describing the wom en who underwent hum anized delivery, determ ining the incidence and tim e for m anifestation of puerperal infections and investigating the association bet ween t he infect ion and t he risk fact ors. An accum ulat ed puerperal infect ion rat e of 2.92% was found. The risk fact ors associat ed t o puerperal infect ion in Cesarean delivery were t he durat ion of labor and t he num ber of digit al ex am inat ions. No v ar iable behav ed as a r isk fact or for infect ion in nor m al deliv er y . Cesar ean deliv er y w as an im port ant risk fact or for puerperal infect ion. The result s reinforce t he need t o develop alt ernat ive form s of delivery care t hat provides effect ive condit ions for norm al delivery, in order t o reduce t he num ber of Cesarean sect ions.
DESCRI PTORS: puer per al infect ion; par t ur it ion; hum anizing deliv er y
I NFECCI ÓN PUERPERAL DEL PUNTO DE VI STA DE LA ATENCI ÓN HUMANI ZADA AL PARTO
EN MATERNI DAD PÚBLI CA
Se t rat a de un est udio epidem iológico, t ipo cohort e, prospect ivo y no concurrent e, sobre infección puerperal del punt o de vist a de la at ención hum anizada a los part os. En est e est udio, se obj et ivó caract erizar las puérperas som et idas al part o hum anizado; det erm inar la incidencia de las infecciones en el puerperio, así com o el int ervalo de m anifest ación, y t am bién verificar la asociación ent re la infección y los fact ores de riesgo. Los dat os fueron obt enidos de 5178 pront uarios de puérperas que pasaron por la experiencia del part o hum anizado. Fue verificada una t asa de incidencia de infección en el puerperio acum ulada del 2,92% . Los fact ores de riesgo asociados a la infección en el puerperio en la m odalidad del part o cesareano fueron la duración del t rabaj o de part o ( p= 0,002) y el núm ero de t oques ( p= 0,011) . Ninguna variable se com port ó com o fact or de riesgo para infección en el part o norm al. Sin em bargo, el part o cesarea se com port ó com o im port ant e fact or de riesgo para la infección puerperal ( p= 0,000) . Considerando que el m odelo act ual de at ención hum anizada al part o ha buscado cam bio de paradigm a en las pr áct icas asist enciales, siendo bast ant e favor able al par t o nor m al, se cr ee que ese m odelo puede est ar cont ribuyendo direct am ent e para la reducción en los índices de infección puerperal. Los result ados refuerzan la necesidad de est im ular la realización de part os norm ales y la dism inución de los part os cesáreos.
DESCRI PTORES: infección puer per al; par t o; par t o hum anizado
I NFECÇÃO PUERPERAL SOB A ÓTI CA DA ASSI STÊNCI A HUMANI ZADA AO PARTO EM
MATERNI DADE PÚBLI CA
Trat a- se de est udo epidem iológico, t ipo coort e, prospect ivo e não concorrent e, sobre infecção puerperal sob a ót ica da assist ência hum anizada ao par t o. Obj et iv ou- se car act er izar as puér per as subm et idas ao par t o hum anizado; det erm inar a incidência das infecções puerperais, bem com o o int ervalo de m anifest ação, além de ver ificar a associação ent r e a infecção e os fat or es de r isco. Os dados for am obt idos de 5.178 pr ont uár ios de puérperas que passaram pela experiência do parto hum anizado. Verificou- se taxa de incidência de infecção puerperal acum ulada de 2,92% . Os fatores de risco associados à infecção puerperal na m odalidade de parto cesáreo foram a duração do trabalho de parto ( p = 0,002) e o núm ero de toques ( p = 0,011) . Nenhum a variável se com portou com o fator de risco para infecção na m odalidade parto norm al; porém , o parto cesariano com portou- se com o im portante fat or de risco para a infecção puerperal ( p = 0,000) . Considerando que o m odelo at ual de assist ência hum anizada ao parto tem buscado m udança de paradigm a nas práticas assistenciais, sendo bastante favorável ao parto norm al, acredita- se que esse m odelo possa estar contribuindo diretam ente para a redução nos índices de infecção puerperal. Reforça- se aqui a necessidade de est im ular a realização de part os norm ais e a dim inuição de cesarianas.
DESCRI TORES: infecção puer per al; par t o; par t o hum anizado
Disponible en castellano/ Disponível em língua portuguesa SciELO Brasil w w w .scielo.br/ rlae 1
RN, MSc in Nursing, Facult y at Goiás Cat holic Universit y Nursing Depart m ent , Brazil, e- m ail: [email protected] .br; 2 RN, PhD in Nursing, Facult y at Minas Gerais Federal Universit y School of Nursing, Brazil
Art igo Original
I NTRODUCTI ON
I
t i s k n o w n t h a t t h e d e l i v e r y t y p e , t h e insufficient not ificat ion of post par t um infect ion casesdu e t o t h e lack of su r v eillan ce af t er disch ar ge, t h e
early discharge of puerperal wom en and t he pat ient ’s
r e t u r n o u t si d e t h e i n st i t u t i o n w h e r e t h e d e l i v e r y
occu r r ed , as w ell as en v ir on m en t al, in d iv id u al an d
m at erial fact ors have been relat ed wit h t he incidence
o f p u e r p e r a l i n f e ct i o n s( 1 ). Th e y a r e a s o u r c e o f c o n c e r n t o t h e e x t e n t t h a t , a s n u r s e s , w e a r e
com m it t ed t o t he pr ev ent ion and cont r ol of hospit al
in f ect ion s.
Now aday s, t he hum anizat ion of deliv er y and
it s influence on puerperal infect ions has been valued.
However, various obst et ric inst it ut ions have not worked
w i t h t h i s p h i l o so p h y, sy st e m a t i ca l l y i g n o r i n g t h e
r o u t i n e s a n d c o n d u c t s t h e Mi n i s t r y o f H e a l t h
r ecom m en d s f or h u m an izat ion . At t h ese u n it s, t h e
d eliv er y occu r s in a t ot ally st r an g e an d en ig m at ic
environm ent , in which t he part urient wom an is isolat ed
f r om h er f am ily an d car e du r in g t h e act in v olv es a
lar ge n u m ber of in t er v en t ion s, w h ich can in f lu en ce
t he incr ease in infect ions.
H u m a n i z a t i o n d o e s n o t s i m p l y a i m t o
decrease t he num ber of Cesarean birt hs, but t o deliver
hum anized car e t o deliv er y and bir t h and t o r ecov er
w o m e n ’ s c e n t r a l p o s i t i o n i n t h e b i r t h p r o c e s s ,
respect ing her dignit y and aut onom y, besides breaking
w it h t he unnecessar y int er vent ionism w it h r espect t o
deliv er ies. I n r ecent y ear s, w it h a v iew t o changing
t he delivery care m odel at a m om ent t hat is considered
int ervent ionist , t he Minist ry of Healt h has im plem ent ed
m e a s u r e s a n d r e c o m m e n d a t i o n s b a s e d o n c a r e
h u m an izat ion( 2 ).
Ca r e h u m a n i z a t i o n a c k n o w l e d g e s t h e
f u n d a m e n t a l r i g h t s o f m o t h e r s a n d b a b i e s. Th i s
includes t he right t o choose t he place of delivery, t he
people and pr ofessionals inv olv ed, t he for m s of car e
dur ing t he deliv er y, r espect for deliver y as a highly
per sonal, sex ual and fam ily ex per ience, besides t he
m in im al r ealizat ion of in t er v en t ion s in t h e n at u r al
deliv er y pr ocess( 3 ).
The hospit al, in t ur n, is t he place w her e w e
find t he m ost sophist icat ed t echnological devices t hat
h a v e b een co n si d er ed n ecessa r y t o a cco m p l i sh a
deliver y. I n t his cont ex t , t he w om an is t he obj ect of
t h e p r o cess, as sh e h as t o su b m i t h er sel f t o t h e
procedures defined by t he care t eam . I n t he hospit al
en v ir on m en t , d eliv er y h as b een ch ar act er ized as a
su r g i ca l e v e n t . Al m o st a l w a y s, i n st e a d o f b e i n g
privat e, int im at e and fem ale, it is experienced publicly,
w it h t he pr esence of ot her social act or s( 2).
I n t urn, professionals and healt h syst em users
h av e ack n ow ledged h ospit al in f ect ion con t r ol as an
essent ial param et er of car e qualit y. Qualit y needs t o
be aim ed f or in h ospit al car e, of f er in g a ser v ice of
less r isk and gr eat er efficacy t o t he populat ion( 4). Hospit al infect ion is considered as t he infect ion
acquired aft er t he pat ient ’s adm ission, which m anifest s
it self during t he hospit alizat ion or aft er discharge and
can b e r elat ed w it h t h e h osp it alizat ion or h osp it al
p r oced u r es( 5 ).
Th e lan d m ar k in k n ow led g e ab ou t h osp it al
i n f ect i o n s i s d u e t o Sem m el w ei s, a g y n eco l o g i st
-obst et r ician w ho suspect ed t hat puer per al infect ions
could be t ransferred t o t he wom en t hrough t he hands
of phy sicians and st udent s( 6).
Nowadays, despit e scient ific and t echnological
ad v an ces i n d i f f er en t k n o w l ed g e ar eas, p u er p er al
infect ion rem ains a big problem , due t o it s prevalence,
m or bidit y and ev en let halit y.
I n t er n at i on al l y, p u er p er al i n f ect i on r an g es
bet w een 3% and 20% , w it h a m ean r at e of 9% . I n
Br azil, t h ese r at es v ar y bet w een appr ox im at ely 1 %
an d 7 . 2 %( 7 ). How ev er, it sh ou ld be h igh ligh t ed t h at t h e s e i n f e c t i o n r a t e s m a y b e u n d e r e s t i m a t e d ,
consider ing t he high num ber of Cesar ean deliv er ies,
w h i ch i s a n i m p o r t a n t r i sk f a ct o r, f a i l u r e s i n t h e
su r v e i l l a n ce sy st e m , a s w e l l a s t h e i n e x p r e ssi v e
aw ar en ess an d in v olv em en t of p eop le f or a b et t er
pr esent at ion of r ealit y.
Th e Ce n t e r s f o r D i s e a s e Co n t r o l ( CD C)
d e f i n e s p u e r p e r a l i n f e ct i o n a s a n y i so l a t i o n o f a
m i cr o o r g a n i sm i n t h e e n d o m e t r i u m , t e m p e r a t u r e
increase t o 38° C in t he period aft er a recent delivery,
p r e se n ce o f co n si st e n t a n d su d d e n t a ch y ca r d i a ,
p u r u l e n t u t e r i n e d i s c h a r g e a n d a b d o m i n a l p a i n
accom pan ied by u t er in e t en der n ess.
Now ad ay s, in Br azil, d eliv er y in t er v en t ion s
m ain ly occu r in h osp it al u n it s, w it h less ch oice of
n o r m al d el i v er y an d ab u si v e u se o f t h e Cesar ean
d eliv er y p r oced u r e. Br azil is con sid er ed on e of t h e
co u n t r i e s i n t h e w o r l d w i t h t h e h i g e st Ce sa r e a n
deliver y r at e, w hich has cont r ibut ed t o t he incr eased
r i s k o f m a t e r n a l m o r t a l i t y , e s p e c i a l l y d u e t o
infect ion( 2).
H o s p i t a l d e l i v e r y c a r e s h o u l d b e s a f e ,
g u ar an t eein g , b esid es t h e b en ef it s of t ech n olog ical
538
dur ing t he deliver y, per m it t ing her t o be t he subj ect
of t he process and t o define what she believes is best
for her and her son.
N o w a d a y s , d e l i v e r i e s h a v e b e e n
a c c o m p l i s h e d i n h o s p i t a l e n v i r o n m e n t s w i t h a l l
t echnological and scient ific r esour ces and, despit e all
i n f e c t i o n p r e v e n t i o n a n d c o n t r o l m e a s u r e s ,
post part um infect ions seem t o persist in t he scenario
o f t h ese i n st i t u t i o n s. Th e co n cer n cau sed b y t h i s
problem gave rise t o t he int erest in st udying puerperal
infect ions from t he perspect ive of hum anized delivery
car e, w it h a v iew t o char act er izing puer per al w om en
su b m it t ed t o h u m an ized d eliv er y, d et er m in in g t h e
incidence and int erval in which t he puerperal infect ions
a r e m a n i f est ed , b esi d es v er i f y i n g t h e a sso ci a t i o n
bet w een infect ions and r isk fact or s.
METHODOLOGY
Th is is an epidem iological, pr ospect iv e an d
n on - con cu r r en t coh or t st u d y, also called h ist or ical
cohort( 8), which was carried out at a public m at ernit y hospit al of t he Municipal Healt h Secr et ar y in Goiânia
( GO) , Br azil. This inst it ut ion aim s t o deliv er car e t o
w om en and adolescent s dur ing t he pr enat al, deliver y
and puer per al phase, in w hich car e hum anizat ion is
being im plant ed as a w or k philosophy.
For t he st udy, w e select ed puer peral w om en
subm it t ed t o hum anized delivery who at t ended t o t he
crit eria of having been t hrough t he hum anized delivery
ex p er ien ce at t h e MNC (Nascer Cid ad ão Mat er n it y
Hospit al) in t he per iod fr om Decem ber 2000 t o July
2003, which fit t ed int o t he crit eria est ablished t o call
NNI SS ( Nat ion al Nosocom ial I n f ect ion s Su r v eillan ce
Sy st em ) pat ien t s, pr oposed by t h e CDC( 9 ). Recor ds of post par t um infect ion w er e v er ified in t heir pat ient
files upon adm ission and unt il t he first t hirt y days aft er
giv ing bir t h.
The st udy populat ion consist ed of t he pat ient
f iles of all pu er per al w om en w h o w en t t h r ou gh t h e
hum anized delivery experience at t he MNC. From t he
e x p e c t e d s t u d y p o p u l a t i o n ( 5 , 2 0 3 ) , t w e n t y - f i v e
pu er per al w om en w er e ex clu ded as t h eir deliv er ies
h ad occu r r ed at h om e an d t h ey w er e sen t t o t h e
m at ernit y hospit al aft er t he deliver y. Thus, t he st udy
sam ple in clu ded t h e in for m at ion con t ain ed in 5 , 1 7 8
f iles.
We analyzed puerperal infect ion in hum anized
d e l i v e r i e s a n d t h e i r p o s s i b l e r i s k f a c t o r s . Th e
cat eg or izat ion of p u er p er al in f ect ion w as b ased on
t he absence ( no) or pr esence ( y es) of t he infect ion,
which could be charact erized as endom et rit is, surgical
sit e infect ion and episiot om y infect ion.
Th e f o l l o w i n g i n d ep en d en t v ar i ab l es w er e
co n si d er ed : d el i v er y m o d e ( n o r m al an d Cesar ean
d eliv er y ) ; r u p t u r e of ov u lar m em b r an es ( in t act or
b r o k e n ) ; t i m e o f m e m b r a n e r u p t u r e ( p e r i o d i n
m in u t es f r om t h e r u p t u r e of t h e m em b r an es u n t il
d eliv er y ) . An ex p ect ed m em b r an e r u p t u r e t im e of
u p t o si x h o u r s w a s co n si d e r e d ) ; a m n i o t i c f l u i d
ch ar act er ist ic ( d iscolor ed , m econ ial an d p u r u len t ) ;
dur at ion of labor ( per iod in hour s and m inut es fr om
t he par t ur ient w om an’s adm ission in t he labor phase
unt il t he end of t his phase. An ex pect ed labor dur at ion
of up t o 12 hour s is consider ed) ; digit al ex am inat ions
( u p t o 6 , b e t w e e n 7 a n d 1 3 a n d m o r e t h a n 1 3
e x a m i n a t i o n s ) ; d u r a t i o n o f d e l i v e r y ( p e r i o d i n
m in u t es) . For n or m al deliv er y, t h e per iod f r om t h e
st ar t of t he ex pulsion of t he fet us unt il t he ex pulsion
of t h e p lacen t a w as con sid er ed an d , f or Cesar ean
d e l i v e r y, f r o m t h e s t a r t o f a n e s t h e s i a u n t i l t h e
c o m p l e t e c l o s u r e o f t h e s u r g i c a l i n c i s i o n . T h e
m ax im u m t im e ex p ect ed t o p er f or m t h e p r oced u r e
is on e h ou r ) ; t y p e of an est h esia ( g en er al, sp in al,
epidur al and local) ; use of ant im icr obial agent; age
and w eight gain.
For t he ordinal variables, int erval codes were
est ablished t o designat e t he groupings t o be processed
by st at ist ical analysis. An inst rum ent w as elaborat ed,
based on t h e classificat ion an d diagn osis cr it er ia of
p u er p er al in f ect ion s( 7 ), so as t o cov er t h e sp ecif ic v ar iables of t h e h u m an ized deliv er y an d bir t h car e
m o d e a n d t h e i n cl u si o n o f d a t a a b o u t i n f ect i o n s,
required t o fill out t he prot ocol est ablished by t he NNI S
Sy st em( 9 ).
I n f or m at ion w as collect ed f r om t h e pat ien t
f iles of t h e u ser s su b m it t ed t o h u m an ized d eliv er y
car e at t he MNC, aft er t he appr ov al of t he r esear ch
p r o j ect ( Pr o t o co l No 0 9 0 / 0 3 ) b y t h e I n st i t u t i o n a l
Rev i ew Bo a r d a t Mi n a s Ger a i s Fed er a l Un i v er si t y
( UFMG/ COEP) , in com pliance wit h Resolut ion No 196/
96 on r esear ch inv olv ing hum an beings.
EPI - I NFO soft w ar e, v er sion 2 0 0 2 , w as used
for dat a ent ry and t reat m ent . A specific dat abase was
cr ea t ed , i n w h i ch d a t a w er e st a t i st i ca l l y t r ea t ed .
Sim ple f r equ en cy dist r ibu t ion an d cen t r al t en den cy
m easur es lik e m ean, m edian and st andar d dev iat ion
w er e u sed f or t h e descr ipt iv e an aly sis of n u m er ical
v ar iab les. Puerperal infect ion from t he perspect ive...
Guim arães EER, Chianca TCM, Oliveira AC.
To a s s e s s t h e a s s o c i a t i o n b e t w e e n t h e
i n d e p e n d e n t a n d d e p e n d e n t v a r i a b l e s , n o n
p ar am et r ical sig n if ican ce t est s w er e u sed , su ch as
Chi- squar e, Fisher ’s Ex act t est , as w ell as st at ist ical
significance m easur es lik e Relat iv e Risk ( RR) , w it h a
9 5 . 0 % c o n f i d e n c e i n t e r v a l , w h i c h a s s e s s e s t h e
associat ion bet ween infect ion and suspect ed risk fact or.
RESULTS AND DI SCUSSI ON
Th e 5 , 1 7 8 p u er p er al w o m en su b m i t t ed t o
h u m an ized deliv er y at t h e MNC w er e m ost ly ( 5 9 % )
w om en ov er 2 0 ( m ean an d m edian of 2 2 y ear s) . A
large num ber of prim iparous adolescent deliveries was
ident ified. The adolescent s ( bet ween 10 and 20 years
o l d ) c o r r e s p o n d e d t o 4 1 % o f t h e p o p u l a t i o n .
Mot her hood dur ing adolescence can be consider ed a
public healt h issue, in v iew of psy chosocial pr oblem s
it m ay result in( 10).
As t o t he associat ion bet w een t he par t ur ient
w om en’s age r ange and t he puer per al infect ion, t he
dat a did not reveal a st at ist ically significant difference
for puerperal infect ion in part urient wom en up t o t he
age of 20 or older t han 20.
What t he w om en’s w eight is concer ned, w e
found t hat 2,121 ( 41% ) gained up t o 10kg during t heir
pr egnancy ; 2, 712 ( 52% ) bet w een 11 and 20k g and
3 4 5 ( 7 % ) m or e t h an 2 1 k g . Th e m ean w eig h t g ain
w as 12.2kg. Alt hough lit er at ur e indicat es an incr ease
i n t h e i n c i d e n c e o f i n f e c t i o n i n p a t i e n t s w i t h
pr oblem at ic clinical condit ions and obese pat ient s, in
t h i s s t u d y, w e f o u n d n o s t a t i s t i c a l l y s i g n i f i c a n t
differ ence bet w een t he w eight gain v ar iable and t he
puerperal infect ion( 6). This can be j ust ified by t he good cl i n i cal co n d i t i o n s a w o m an g i v i n g b i r t h n o r m al l y
p r esen t s.
As t o t he rupt ure of t he m em branes, we found
no st at ist ically significant associat ion bet ween t he t wo
t r ea t m en t m o d es, n o r m a l a n d Cesa r ea n , a n d t h e
p u e r p e r a l i n f e c t i o n . A l t h o u g h s o m e s t u d i e s o n
endom et rit is in vaginal birt hs have dem onst rat ed t hat
t h e c o m b i n a t i o n b e t w e e n t h e r u p t u r e o f t h e
m em branes and a long labor const it ut es an im port ant
r i s k f a c t o r f o r t h e f r e q u e n c y a n d s e v e r i t y o f
infect ions( 11).
No st at ist ically sig n if ican t associat ion w as
found bet ween m em brane rupt ure t im e and puerperal
i n f e c t i o n , n e i t h e r f o r n o r m a l n o r f o r Ce s a r e a n
deliv er ies. How ev er, differ ent aut hor s have ex am ined
t h is associat ion an d h av e f ou n d qu it e con t r ov er sial
r esu lt s( 1 2 ). I n a st u d y ab ou t in f ect ion in p ar t u r ien t w om en subm it t ed t o Cesar ean deliv er ies, t he abov e
m e n t i o n e d a u t h o r s e v i d e n ce d t h a t t h e se w o m e n
pr esent ed colonizat ion of t he am niot ic fluid six hour s
aft er t he rupt ure of t he m em branes and also ident ified
a 27% pr ev alence of posit iv e am niot ic fluid cult ur es
in pat ient s w it h r upt ur ed m em br anes.
As t o t he charact erist ics of t he am niot ic fluid,
n o st at ist ically sig n if ican t d if f er en ce w as ob ser v ed
bet w een t his v ar iable and t he pr esence of puer per al
infect ion in nor m al and Cesar ean deliv er ies. St udies
accom plished t o cor r elat e t he pr esence of m econium
in t he am niot ic fluid and increased m at ernal infect ion
r at es ident ified t hat m econium r aises t he phosphat e
lev el, in act iv at in g t h e zin c- p r ot ein com p lex , w h ich
favors t he part urient wom an’s increased suscept ibilit y
t o puer per al infect ion( 13).
I n t his st udy, w e found t hat t he durat ion of
labor and Cesar ean deliv er y ar e r isk fact or s for t he
dev elopm en t of pu er per al in f ect ion , w it h a r elat iv e
r isk of 2. 16 - [ 1. 36- 3. 44] . How ever, w hen t he labor
durat ion var iable is associat ed w it h nor m al deliver y,
i t d i d n o t a p p e a r a s a r i sk f a ct o r f o r p u e r p e r a l
in f ect ion .
Th e n u m b er of d ig it al ex am in at ion s d u r in g
nor m al deliv er ies did not const it ut e a r isk fact or for
puerperal infect ion. How ever, a significant associat ion
w as obser v ed bet w een t h e n u m ber of ex am in at ion s
and infect ion in case of Cesarean delivery, which can
also be relat ed wit h t he durat ion of labor. Subsequent
s t a t i s t i c a l a n a l y s e s a r e n e e d e d t o p r o v e t h i s
associat ion . A p- v alu e = 0 . 0 1 1 w as fou n d, sh ow in g
t hat infect ion risk t ends t o increase w it h t he num ber
of digit al ex am inat ions.
A Ce s a r e a n d e l i v e r y r a t e o f 2 3 % w a s
i d e n t i f i e d , w h i c h i s s t i l l h i g h i n v i e w o f t h e
char act er ist ics of t he m at er nit y hospit al under st udy
and t he rat e recom m ended by t he WHO, i.e. bet ween
10 and 15%( 14). This fact can be j ust ified by t he short t er m ( t hr ee y ear s) t he hospit al has been funct ioning
an d by t h e pr ofession als’ adapt at ion pr ocess t o t h e
pr ocedur es, st andar ds and est ablished r out ines.
An associat ion w as f ou n d of t h e r isk fact or
t ype ( p = 0.000 and Relat ive Risk of 4.40- [ 3.19- 6.06] ) ,
r e su l t i n g i n a st a t i st i ca l l y si g n i f i ca n t a sso ci a t i o n
b et w een t h e d eliv er y m od e v ar iab le an d p u er p er al
infect ion. Hence, t he par t ur ient w om en subm it t ed t o
Cesar ean deliv er y pr esent ed a 4. 4 t im es higher r isk
540
nor m al deliver y. This fact has been pr ov ed b y som e
a u t h o r s w h o , i n a n a l y zi n g t h e d e l i v e r y t y p e a n d
puer per al infect ion, found t hat r ising incidence lev els
o f Ce s a r e a n d e l i v e r i e s h a v e c o n t r i b u t e d t o t h e
i n c r e a s e i n p u e r p e r a l i n f e c t i o n r a t e s . Ce s a r e a n
deliv er y is r elat ed w it h a h igh er in ciden ce of post
-o p er at i v e i n f ect i -o u s m -o r b i d i t y i n c-o m p ar i s-o n w i t h
nor m al deliv er y( 15) ( Table 1) .
Tab le 1 - Dist r ib u t ion of p u er p er al in f ect ion cases
according t o delivery m ode. Goiânia - Dec. 2000- Jul.
2 0 0 3
per iod, w it h t h e h igh est peak in in fect ion in ciden ce
l e v e l s i n Ja n u a r y 2 0 0 1 , w i t h 1 . 4 % . Th i s h i g h e r
incidence lev el could be ex plained by t he adapt at ion
p r ocess t o t h e st an d ar d s, r ou t in es an d p r oced u r es
t he m at ernit y hospit al was going t hrough during t hat
per iod, coinciding w it h t he y ear of inaugur at ion.
I n t he group of 147 puerperal infect ion cases
t hat were analyzed, 74 ( 50.3% ) occurred in Cesarean
d e l i v e r i e s a n d w e r e c o n s i d e r e d a s s u r g i c a l s i t e
infect ion, wit h an incidence level of 1.47% ; 57 ( 77% )
w er e con sid er ed su p er f icial; 1 4 ( 1 9 % ) d eep an d 3
( 4 % ) o r g a n / s p a c e i n f e c t i o n s . Th e i n f e c t i o n s
cat egor ized as en dom et r it is cor r espon ded t o 3 1 . 3 %
( 4 6 cases) , w it h an incidence lev el of 0 . 9 1 % , w hile
ep i si o t o m y i n f ect i o n s ( 2 7 cases) co r r esp o n d ed t o
18.4% , wit h an incidence level of 0.54% . Twent y- five
of t hese ( 93% ) were considered superficial and 2 ( 7% )
as deep.
I t is r em ar k able t hat m ost infect ions in t his
st udy w er e sur gical sit e infect ions ( SSI ) , w hich m ay
b e r e l a t e d t o t h e s u r g i c a l i n c i s i o n s i n v o l v e d i n
Cesar ean d eliv er ies.
I n on ly on e case of deep SSI , a cu lt u r e of
t h e w ou n d secr et ion w as p er f or m ed , r ev ealin g t h e
p r esen ce of St ap h y lococcu s ep id er m id is. Th is m ay
indicat e cont am inat ion caused by cont act , t hrough t he
p a r t u r i e n t w o m e n ’ s s k i n , a s a c o n s e q u e n c e o f
precarious washing and asepsis of t he skin. No cult ure
result s were found in 146 files, in which t he inst it ut ion
did not perform t he t est s due t o t he lack of m at erial
r esour ces for t his end.
This st udy proved expect at ions t o t he ext ent
t h at t h e u se of an t ibiot ic pr oph y lax is in t h e per iod
befor e t he deliv er y did not show an associat ion w it h
t h e occu r r en ce of pu er per al in f ect ion in an y of t h e
d el i v er y m o d es. Ho w ev er, t h e p o st p a r t u m u se o f
ant ibiot ics t her apy in w om en subm it t ed t o Cesar ean
and nor m al deliv er y show ed a st at ist ically significant
associat ion, wit h p = 0.000. These result s im ply t hat
t h e u se of an t ib iot ics in t h e p ost p ar t u m p er iod is
associat ed w it h t h e pr esen ce of pu er per al in f ect ion
or t h at pat ien t s n eedin g an t ibiot ics t h er apy pr esen t
g r eat er p r ed i sp o si t i o n t o p u er p er al i n f ect i o n . Th e
sch e m e a n d i n d i ca t i o n s f o r p r o p h y l a x i s m u st b e
det er m ined aft er a det ailed assessm ent .
The int er v al in w hich t he puer per al infect ion
m an if est ed it self in h u m an ized car e t o n or m al an d
Cesar ean d eliv er ies in all 1 4 7 in f ect ion cases w as
w it hin 30 day s aft er t he dischar ge, m or e specifically
bet w een t he fift h and t w ent y- sixt h day aft er hospit al
y r e v il e D e d o m n o i t c e f n i l a r e p r e u P l a t o
T R.R 95%C..I s
e
Y No
l a m r o
N 63(42.8%) 3,911(75.8%) 3,974 1.00 -n a e r a s e
C 84(57.2%) 1,120(22.3%) 1,204 4.40 [3.19-6.06]
l a t o
T 147(100%) 5,031(100%) 5,178
2,92% (147)
97,08 % (5.031)
No Yes
Observat ion: p = 0.000
Figures bet ween parent heses refer t o percent ages relat ed t o t he t ot al of t he colum n
RR. = Relat ive Risk. 95% C.I . = 95% confidence int erval
W h a t d e l i v e r y d u r a t i o n i s co n ce r n e d , n o
st at ist ically sig n if ican t associat ion w as f ou n d w it h
puer per al infect ion. A cut - off point of one hour w as
u s e d f o r t h e d u r a t i o n o f t h e d e l i v e r y, a n d n o
a sso ci a t i o n w a s e v i d e n ce d b e t w e e n a p r o ce d u r e
dur at ion of m or e t han one hour and t he occur r ence
of puer per al infect ion in w om en subm it t ed t o nor m al
an d Cesar ean d eliv er ies.
Th e t y p e o f a n e s t h e s i a u s e d d u r i n g t h e
d eliv er ies, in t u r n , sh ow ed n o associat ion w it h t h e
pr esence of puer per al infect ion.
An accum ulat ed incidence lev el of puer per al
i n f e ct i o n w a s f o u n d w i t h i n t h e p r e v i e w e d l i m i t s
( 2.92% ) , in com parison wit h norm ally described rat es
( Figure 1) , which range from 1% t o 7.2% in Brazil( 7).
Figur e 1 - Puer per al infect ion in hum anized deliv er y
care. Goiânia - dec. 2000 - j ul. 2003
We calcu lat ed t h e m on t h ly in ciden ce lev els
o f p u e r p e r a l i n f e c t i o n i n t h e p a r t u r i e n t w o m e n
su b m it t ed t o h u m an ized d eliv er y d u r in g t h e st u d y Puerperal infect ion from t he perspect ive...
Guim arães EER, Chianca TCM, Oliveira AC.
d i sch a r g e ( 1 0 0 % ) . Th e p u e r p e r a l w o m e n ’ s e a r l y
d i sch a r g e i m p e d e s a d i a g n o si s w h i l e st i l l a t t h e
m at er nit y hospit al. Thus, post - dischar ge sur v eillance
is considered very im port ant . Especially in procedures
wit h a short post - operat ive hospit alizat ion period, t he
p r e se n ce o f a n a p p r o p r i a t e su r v e i l l a n ce sy st e m
becom es incr easin gly im por t ant( 7 ).
CONCLUSI ONS
This st udy allows us t o conclude t hat :
- The incidence level of puerperal infect ion was 2.92%
( 1 4 7 / 5 0 3 1 ) . Th is r at e is con sider ed low , in v iew of
l ev el s n o r m al l y accep t ed b y t h e At l an t a CDC an d
t h ose descr ibed in Br azilian lit er at u r e ( bet w een 1 %
a n d 7 . 2 % ) , w h i ch d o es n o t d i sca r d su sp i ci o n s o f
in su f f icien t n ot if icat ion of pu er per al in f ect ion r at es,
a s l i t e r a t u r e d a t a i n d i c a t e t h e s e c a n a l s o b e
u n d er est im at ed .
- All infect ions found w er e diagnosed and not ified in
t h e per iod af t er h ospit al disch ar ge an d cat egor ized
as endom et rit is, surgical sit e infect ion and episiot om y
in f ect ion . Th e p u er p er al in f ect ion s ap p ear ed w it h in
t hir t y day s aft er t he deliv er y.
- Th e v ar iables of age, w eigh t , m em br an e r u pt u r e,
t i m e o f m e m b r a n e r u p t u r e , a m n i o t i c f l u i d
charact erist ic, anest hesia t ype and use of prophylact ic
ant im icrobial agent did not behave as risk fact ors for
pu er per al in f ect ion .
- Th e v a r i a b l e s t h a t b e h a v e d a s r i sk f a ct o r s f o r
puerperal infect ion in case of Cesarean delivery w ere
labor du r at ion an d n u m ber of digit al ex am in at ion s.
Non e of t h e v ar iab les b eh av ed as a r isk f act or f or
infect ion t he nor m al deliv er y m ode.
- Cesarean delivery also behaved as a risk fact or for
p u er p er al i n f ect i o n . Hen ce, t h e p ar t u r i en t w o m en
su b m it t ed t o Cesar ean d eliv er y d isp lay ed a h ig h er
risk of infect ion in com parison wit h wom en subm it t ed
t o nor m al deliv er y.
As t he current hum anized delivery care m odel
h a s a t t e m p t e d t o c h a n g e t h e p a r a d i g m o f c a r e
pr act ices, is v er y m u ch in f av or of n or m al deliv er y
an d aim s t o decr ease Cesar ean deliv er y r at es, it is
believed t hat t his m odel m ay be cont ribut ing direct ly
t o t h e d e cr e a se i n p u e r p e r a l i n f e ct i o n r a t e s. We
r ecom m en d t h at , b ased on t h e p u er p er al in f ect ion
result s ident ified in t his st udy, educat ional m echanism s
be creat ed t o raise t he m edical t eam ’s awareness, so
as t o br eak w it h t he par adigm of m edicalizat ion and
int er v ent ion in deliv er ies, and inv est m ent s be m ade
in t he t r aining pr ocess of obst et r ic nur ses.
We reinforce t he need t o im plant an effect ive
hospit al infect ion cont rol service, t hrough a prospect ive
su r v ei l l an ce m et h od , as ear l y as u p on ad m i ssi on ,
including post-discharge follow-up. This can allow for the
im plem ent at ion of syst em ized act ions direct ed at t his
populat ion, as well as t o est ablish infect ion prevent ion
an d con t r ol m easu r es, besides get t in g t o k n ow t h e
m icrobiological profile of t he det ect ed infect ions.
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Recebido em : 3.6.2005 Aprovado em : 10.5.2007
Puerperal infect ion from t he perspect ive...
Guim arães EER, Chianca TCM, Oliveira AC.
