Análisis de la amniotomía precoz frente a amniotomía tardía en las inducciónes de trabajo de parto y su posible riesgo de distocia

• Autores: María Sanz Guijo
• Directores de la Tesis: Ismael Ortuño Soriano (dir. tes.), Miguel Ángel Herráiz Martínez (dir. tes.), Paloma Posada Moreno (codir. tes.)
• Lectura: En la Universidad Complutense de Madrid ( España ) en 2018
• Idioma: español
• Número de páginas: 218
• Tribunal Calificador de la Tesis: Jorge Diz Gómez (presid.), Jacinto Gómez Higuera (secret.), Daniel Muñoz Jiménez (voc.), Gloria Seguranyes Guillot (voc.), Esther Garcia Garcia (voc.)
• Programa de doctorado: Programa de Doctorado en Cuidados en Salud por la Universidad Complutense de Madrid
• Enlaces
  • Tesis en acceso abierto en: Docta Complutense (pdf)
• Resumen
  • español

    La inducción de trabajo de parto (IDP) contribuye al aumento de la tasa de cesáreas y dentro del proceso de IDP, la amniorrexis artificial (AF) es una de las técnicas más utilizadas. La AF es un buen mecanismo de inducción, no obstante, no es una técnica exenta de riesgos. En la actualidad, en la atención al parto normal, la AF está desaconsejada y todas las investigaciones coinciden en que el riesgo intrínseco de la técnica, se ve reducido cuando se retrasa el momento de realizarla. El objetivo principal es determinar si el momento de la realización de la AF en la IDP influye en la finalización del parto, en parto vaginal o cesárea. Se realizó un estudio de cohortes, de carácter retrospectivo, con dos cohortes de gestantes, que se distribuyeron en función del tipo de AF, AF tardía o precoz. Se recogieron variables relacionadas con el bienestar fetal, tiempos de duración de la inducción y finalización del parto entre otras. Y se construyó un modelo predictivo para conocer las variables que con mayor peso influían en la finalización del parto en cesárea. Se revisaron un total de 544 historias clínicas. Los resultados obtenidos muestran una mayor tasa de amniorrexis artificial tardía en el grupo de partos vaginales frente a las cesáreas [85,7%vs14,3% (p < 0.001)]. El tiempo total de inducción fue inferior en el grupo de la amniorrexis artificial tardía. Como factores pronóstico para la finalización del parto en cesárea se hallaron la nuliparidad, la edad mayor de 35 años, el antecedente de cesárea, el Bishop al ingreso en la unidad de dilatación y un tiempo superior a 12 horas de aplicación de prostaglandinas. Las conclusiones del estudio son: la AFT se presentó como factor protector para la realización de una cesárea, para la finalización del parto antes de las primeras 24 horas del inicio de la IDP y la aparición de alteraciones patológicas del registro cardiotocográfico fetal. Las variables predictivas con mayor peso dentro del modelo construido fueron la nuliparidad y la puntuación de Bishop al ingreso en la unidad de dilatación.The induction of labor (IL) contributes to the increase in the rate of caesarean sections and within the IL process, artificial amniorrhexis (AA) is one of the most used techniques. AF is a good induction mechanism, however, it is not a risk-free technique. Currently, in the normal delivery care, the AA is not recommended and all the investigations coincide in that the intrinsic risk of the technique is reduced when the time to perform it is delayed. The main objective is to determine if the time of performing the AF in the PID at the end of labor, vaginal birth or cesarean section. A retrospective cohort study was conducted with two cohorts of pregnant women, which were distributed according to the type of AF, late or early AF. Variables related to fetal well-being, duration of induction and end of labor, among others, were collected. And a predictive model was constructed to know which variables with greater weight influenced the cesarean delivery. A total of 544 clinical histories were reviewed. The results obtained show a higher rate of late artificial amniorrhexis in the group of vaginal births compared to cesarean sections [85.7% vs14.3% (p < 0.001)]. The total induction time was lower in the group of late artificial amniorrhexis. Prognostic factors for cesarean delivery were nulliparity, age over 35 years, antecedent cesarean section, Bishop on admission in the dilatation unit and a time longer than 12 hours of prostaglandin application. The conclusions of the study are: AFT was presented as a protective factor for the performance of a cesarean section, for the termination of labor before the first 24 hours after the start of PID, and the appearance of pathological changes in the fetal cardiotocographic record. The predictive variables with the greatest weight within the constructed model were nulliparity and Bishop's score upon admission to the dilatation unit.

  • English

    The World Health Organization (WHO) in its latest report disseminates the need to rationalize the cesarean section rate. They advise not to exceed figures at 10%, however, in Spain, we find an average of 24%, reaching higher levels depending on the autonomous community. These figures are similar in the rest of European territory, the United States and higher in the South American continent. One of the clinical practices that contribute to the increase in the rate of caesarean sections is the induction of labor. The medical indications from both fetal and maternal well-being point of view make it essential to perform it. One of the reasons that cause a greater indication of inductions for medical reasons in relation to the other indications of induction is the chronologically prolonged gestation (CPG). CPG involves a series of risks, which is why international and national scientific societies have reached the consensus of ending pregnancy by inducing labor at week 41 + 3 of gestation. However, this causes the risk of caesarean section to increase through induction, both through the induction process and through CPG. One of the mechanisms that are carried out within the induction is artificial amniorrhexis. The artificial amniorrhexis is the mechanism by which a professional breaks the bag of waters intentionally. It is a procedure that midwives perform routinely in inductions of labor, almost in 100% of patients. It is known as a good mechanism of mechanical induction, since it activates the different mechanisms of delivery and accelerates them. However, it is not a risk-free technique. Risks are described, such as fetal distress, dystocia of the fetal position and cord prolapse, among others. In addition, there are no protocols that tell us what the best time is to do it in the induction process. Currently in the process of normal delivery, this technique is not recommended and all agree that the intrinsic risk to the technique is reduced the longer the time is delayed. Therefore, different investigations have emerged in the field of inductions, in order to know what the best time is to perform artificial amniorrhexis within the induction and thus be able to reduce complications. There is little literature on the subject and controversy among the authors. Therefore, in this research, it is intended to know if late artificial amniorrhexis works influences the decrease in the rate of caesarean sections in inductions for chronologically prolonged gestations...