The quality of cardiotocography in obstetric practice

Geijn, H.P. van [Promotor

Uterine contractions clustering based on surface electromyography: an input for pregnancy monitoring

Tese de mestrado em Bioestatística, apresentada à Universidade de Lisboa, através da Faculdade de Ciências, em 2018Inicialmente a investigação da contratilidade uterina recorria à utilização de dois métodos: o tocograma externo e o cateter de pressão intrauterino. Ambos os métodos apresentam limitações ao nível da avaliação do risco de parto prematuro e na monitorização da gravidez. O EHG (Electrohisterograma) é um método alternativo ao tocograma externo e ao cateter de pressão intrauterino. Este método pode ser aplicado de forma invasiva no músculo uterino, ou de forma não invasiva através de elétrodos colocados no abdómen. O EHG tem sido considerado uma ferramenta adequada para a monitorização da gravidez e do parto. O índice de massa corporal tem um impacto quase impercetível no EHG, sendo esta uma das principais características deste método. O EHG pode também ser utilizado para identificar as mulheres que vão entrar em trabalho de parto e ainda auxiliar na tomada de decisão médica quanto à utilização da terapia tocolítica (antagonista da oxitocina), evitando deste modo a ingestão de medicação desnecessária e os consequentes efeitos secundários. Na literatura existem apenas cinco casos publicados em que foi realizada uma separação dos principais eventos do sinal EHG: contrações, movimentos fetais, ondas Alvarez e ondas LDBF (Longue Durée Basse Fréquence). Em três das publicações a separação dos eventos foi feita manualmente e nos restantes casos algoritmos, como redes neuronais, foram aplicados ao EHG. As ondas Alvarez e as Braxton-Hicks são as mais reconhecidas. As ondas Alvarez foram descritas pela primeira vez nos anos cinquenta e as Braxton-Hicks foram descritas pela primeira vez em 1872 sendo detetadas através de palpação. As ondas Alvarez são ocasionalmente sentidas pela mulher. Estas ondas estão localizadas numa pequena área do tecido uterino sem propagação e podem levar a contrações com maior intensidade e, consequentemente, ao parto pré-termo. As Braxton-Hicks são contrações ineficientes registadas a partir da 20ª semana de gravidez que se tornam mais frequentes e intensas com o decorrer da gravidez. Estas contrações são menos localizadas que as ondas Alvarez e, durante o parto, propagam-se por todo o tecido uterino num curto período de tempo. As Braxton-Hicks estão associadas a uma diminuição do ritmo cardíaco fetal. As ondas LDBF são contrações de longa duração associadas a hipertonia uterina, quando há contração do tecido uterino sem retorno ao relaxamento muscular, o que representa um risco na gravidez. Neste trabalho foram utilizadas duas bases de dados. Na base de dados da Islândia existem 122 registos de 45 mulheres, dos quais apenas 4 correspondem a partos pré-termo. Na base de dados TPEHG (Term-Preterm EHG) existem 300 registos, dos quais 38 correspondem a partos pré-termo. Neste trabalho foram escolhidos canais bipolares, visto que estes reduzem o ruído idêntico, como o ECG (Eletrocardiograma) materno ou movimentos respiratórios. Para ambas as bases de dados os sinais originais de EHG foram processados e filtrados. Na estimação espetral foram considerados dois métodos: paramétricos e não paramétricos. O método Welch foi escolhido pois representa um bom compromisso entre ambos. Este método foi utilizado para calcular o espectro de cada evento detetado no sinal EHG. Para detetar os eventos no sinal EHG foram considerados cinco métodos baseados na energia ou amplitude. O método Wavelet foi o escolhido pois após uma inspeção visual, este era o método que delineava melhor as contrações. Na base de dados da Islândia foram identificadas 3136 contrações e na TPEHG foram encontradas 4622 contrações. O objetivo principal desta tese é obter clusters de contrações detetadas no sinal EHG. No entanto, as contrações são séries temporais não estacionárias, e a sua classificação visual é inviável a longo termo e também difícil de aplicar na prática clínica. Existem vários parâmetros que podem ser extraídos do sinal EHG, mas o espectro das contrações foi o método escolhido visto que este representa o sinal EHG e tem sempre a mesma dimensão, independentemente da duração da contração. As distâncias espetrais têm sido utilizadas com sucesso no reconhecimento áudio. Neste trabalho foi realizada uma aplicação desse método ao processamento do EHG, no qual foram realizados os ajustes necessários. Para comparar os espectros foram estudadas 8 distâncias diferentes: Itakura-Saito, COSH, Itakura, Itakura simétrica, Kullback-Leibler, Jeffrey, Rényi e Jensen-Rényi. Apenas as distâncias simétricas foram selecionadas para um estudo mais detalhado visto que estas são, segundo a literatura, as distâncias mais adequadas aquando do clustering. Após comparação das distâncias simétricas, a divergência de Jeffrey foi a selecionada para a comparação dos espectros. Nesta tese foram avaliados três métodos diferentes de clustering: o linkage, o K-means e o K-medoids. O linkage é um método hierárquico. Os clusters que resultam do agrupamento hierárquico estão organizados numa estrutura chamada dendrograma. No agrupamento hierárquico, não é necessário predeterminar o número de clusters, o que torna este um método ideal na exploração dos dados. O K-means e o K-medoids são métodos de partição, nos quais os dados são separados em k clusters decididos previamente. Os clusters são definidos de forma a otimizar a função da distância. No algoritmo K-means, os clusters baseiam-se na proximidade entre si de acordo com uma distância predeterminada. A diferença entre o K-medoids e o K-means é que o K-medoids escolhe pontos de dados como centros, chamados de medoides, enquanto K-means usa centróides. Após uma comparação dos diferentes métodos de clustering foi escolhido neste trabalho foi o average linkage, visto que este apresentava melhores resultados quer na separação dos espectros quer na silhueta. É então apresentado um método inovador no qual se utiliza todo o espectro das contrações detetadas automaticamente no EHG para o clustering não supervisionado. Esta técnica é uma contribuição para a classificação automática das diferentes contrações, especialmente aquelas mais reconhecidas na literatura: Alvarez e Braxton-Hicks. Era expectável encontrar um cluster isolado com as ondas LDBF, visto que estas representam um risco para o feto. O principal objetivo era juntar num cluster os espectros semelhantes das contrações, e relacioná-lo com o respetivo tipo de contração. Essa tarefa foi concluída através da identificação positiva de Alvarez e Braxton-Hicks. O clustering forneceu ainda algumas pistas sobre ondas Alvarez que não foram encontradas com o algoritmo de deteção de contrações, situação para a qual um método alternativo é apresentado. É sugerido que as ondas Alvarez sejam detetadas com métodos baseados na frequência, como, por exemplo, a frequência instantânea, no entanto este método não foi desenvolvido neste trabalho. Em relação às ondas LDBF, estas foram encontradas no cluster das Braxton-Hicks. É sugerido que a deteção das ondas LDBF seja baseada na sua caraterística mais distinta: a longa duração. Verificou-se que os casos pré-termo e os registos pré-parto não ficaram isolados num cluster, não se tendo encontrado uma relação entre a idade gestacional e o tipo de contração. Conclui-se que as contrações mais curtas apresentam maior amplitude do que as contrações com maior duração. Baseado em estudos anteriores sobre a eletrofisiologia do útero, supõem-se que o início do trabalho de parto pré-termo e termo esteja associado a sequências específicas de diferentes tipos de contrações, nas quais as ondas Alvares desempenham um papel importante. As contrações identificadas como Alvarez e Braxton-Hicks não são usadas como tal na prática clínica apesar de a maioria das contrações detetadas pelo tocograma serem Braxton-Hicks. O interesse pelas ondas Alvarez diminuiu rapidamente visto que estas ondas são praticamente indetetáveis pelo método de referência de deteção de contrações: o tocograma. As capacidades e a resolução do EHG levaram à renovação do estudo das contrações mais subtis, incluindo as Alvarez. Este trabalho é uma contribuição para a investigação nesta área.An innovative technique is introduced wherein where an unsupervised clustering method using as feature the whole spectrum of automatically detected contractions on the EHG (Electrohysterogram) is presented as a contribution to the automatic classification of the different uterine contractions, at least those that have been most recognized in the literature: Alvarez and Braxton-Hicks. It was expected to also be able to cluster the LDBF (Longue Durée Basse Fréquence) components, as these pose a fetal risk. The main task was to have the spectral contractions descriptions clustered and linked to the respective contraction type. That task was completed with positive identification of the Alvarez and Braxton-Hicks. The clustering process also provided clues regarding the missed Alvarez waves in the contraction detection algorithm, for which an alternative technique is suggested but not developed in this work. Regarding the LDBF they were found in the Braxton-Hicks cluster. It is suggested the LDBF´s to be detected based in their most prominent feature: the long duration. It is presented the rationale behind the selection of a cost function to be used in the spectral distance’s algorithm. Spectral distances have been successfully used in audio recognition and this works represents an application to the EHG processing, for which the necessary adjustments have to be implemented. It was found that no single cluster pointed to the preterm cases, or indeed to the pre-labor subject recordings. It is hypothesized, based on previous studies in uterine electrophysiology, that the initiation of pre-term or term labor should be associated with triggering contraction sequences of different types, where the Alvarez waves play a major role. Alvarez and Braxton-Hicks, labeled as such, are not typically used in the clinical environment despite most of the Tocogram detected contractions being the latter. Alvarez waves are not usually detectable by the Tocogram. Alvarez were firstly detected invasively in the early fifties, and Braxton-Hicks in 1872 using routine palpation techniques. The interest in Alvarez components declined rapidly since being practically undetectable by the de facto reference in the contraction detection: the Tocogram. The EHG capabilities and resolution made it possible to revive the research on the most subtle uterine contractions, Alvarez included and this work is a contribution in this research area

A description of the methods of the Nulliparous Pregnancy Outcomes Study: monitoring mothers-to-be (nuMoM2b)

OBJECTIVE: The primary aim of the "Nulliparous Pregnancy Outcomes Study: monitoring mothers-to-be" is to determine maternal characteristics, which include genetic, physiologic response to pregnancy, and environmental factors that predict adverse pregnancy outcomes. STUDY DESIGN: Nulliparous women in the first trimester of pregnancy were recruited into an observational cohort study. Participants were seen at 3 study visits during pregnancy and again at delivery. We collected data from in-clinic interviews, take-home surveys, clinical measurements, ultrasound studies, and chart abstractions. Maternal biospecimens (serum, plasma, urine, cervicovaginal fluid) at antepartum study visits and delivery specimens (placenta, umbilical cord, cord blood) were collected, processed, and stored. The primary outcome of the study was defined as pregnancy ending at <37+0 weeks' gestation. Key study hypotheses involve adverse pregnancy outcomes of spontaneous preterm birth, preeclampsia, and fetal growth restriction. RESULTS: We recruited 10,037 women to the study. Basic characteristics of the cohort at screening are reported. CONCLUSION: The "Nulliparous Pregnancy Outcomes Study: monitoring mothers-to-be" cohort study methods and procedures can help investigators when they plan future projects

Improvement of signal-to-noise ratio in uterine EMG recordings.

The objective of this study is to remove or, at least, reduce the noise in uterine EMG recordings, which at their present noise level render the data unusable. Predicting when true labor will start and recognizing when labor actually starts are important for both normal and complex pregnancies. For normal pregnancy, the prognosis of labor is important for reducing unnecessary hospital costs. About 10% of the four million babies born each year in the United States are born prematurely. At $1,500 a day for neonatal intensive care, this comprises national health care expenses of well over$5 billion. Spectral analysis, filter design, and 1/3 octave analysis were applied to analyze the uterine EMG recordings. Signal-to-noise ratio was increased with IIR Butterworth bandstop filter. The spectral band between 0.25 and 0.4 Hz shows matching of the Toco belt via spectral analysis. Nevertheless, 1/3 octave analysis gives the highest correct detection percentage compare with frequency analysis and filter design

Preliminary Study on the Efficient Electrohysterogram Segments for Recognizing Uterine Contractions with Convolutional Neural Networks

Background. Uterine contraction (UC) is the tightening and shortening of the uterine muscles which can indicate the progress of pregnancy towards delivery. Electrohysterogram (EHG), which reflects uterine electrical activities, has recently been studied for UC monitoring. In this paper, we aimed to evaluate different EHG segments for recognizing UCs using the convolutional neural network (CNN). Materials and Methods. In the open-access Icelandic 16-electrode EHG database (122 recordings from 45 pregnant women), 7136 UC and 7136 non-UC EHG segments with the duration of 60 s were manually extracted from 107 recordings of 40 pregnant women to develop a CNN model. A fivefold cross-validation was applied to evaluate the CNN based on sensitivity (SE), specificity (SP), and accuracy (ACC). Then, 1056 UC and 1056 non-UC EHG segments were extracted from the other 15 recordings of 5 pregnant women. Furthermore, the developed CNN model was applied to identify UCs using different EHG segments with the durations of 10 s, 20 s, and 30 s. Results. The CNN achieved the average SE, SP, and ACC of 0.82, 0.93, and 0.88 for a 60 s EHG segment. The EHG segments of 10 s, 20 s, and 30 s around the TOCO peak achieved higher SE and ACC than the other segments with the same duration. The values of SE from 20 s EHG segments around the TOCO peak were higher than those from 10 s to 30 s EHG segments on the same side of the TOCO peak. Conclusion. The proposed method could be used to determine the efficient EHG segments for recognizing UC with the CNN

Unsupervised Classification of Uterine Contractions Recorded Using Electrohysterography

Pregnancy still poses health risks that are not attended to by current clinical practice motorization procedures. Electrohysterography (EHG) record signals are analyzed in the course of this thesis as a contribution and effort to evaluate their suitability for pregnancy monitoring. The presented work is a contributes with an unsupervised classification solution for uterine contractile segments to FCT’s Uterine Explorer (UEX) project, which explores analysis procedures for EHG records. In a first part, applied processing procedures are presented and a brief exploration of the best practices for these. The procedures include those to elevate the representation of uterine events relevant characteristics, ease further computation requirements, extraction of contractile segments and spectral estimation. More detail is put into the study of which characteristics should be chosen to represent uterine events in the classification process and feature selection methods. To such end, it is presented the application of a principal component analysis (PCA) to three sets: interpolated contractile events, contractions power spectral densities, and to a number of computed features that attempt evidencing time, spectral and non-linear characteristics usually used in EHG related studies. Subsequently, a wrapper model approach is presented as a mean to optimize the feature set through cyclically attempting the removal and re-addition of features based on clustering results. This approach takes advantage of the fact that one class is known beforehand to use its classification accuracy as the criteria that defines whether the modification made to the feature set was ominous. Furthermore, this work also includes the implementation of a visualization tool that allows inspecting the effect of each processing procedure, the uterine events detected by different methods and clusters they were associated to by the final iteration of the wrapper model

Effectiveness of nipple stimulation on acceleration of uterine contraction during first stage of labour among primi gravida mothers in annalakshmi hospital at Tirunelveli district

A Quasi experimental study to assess the effectiveness of nipple stimulation on acceleration of uterine contraction among primi gravida mothers in Annalakshmi hospital at Vallioor, was conducted by Mrs. P. Anitha in partial fulfillment of the requirement for the degree of Master of Science in nursing at the Sri. K. R. N. Ramachandran Naidu college of Nursing, under the Tamilnadu Dr. M. G. R Medical University. OBJECTIVES: 1. To assess the pre test level of acceleration of uterine contraction during first stage of labor among primi gravida mothers in experimental and control group. 2. To find out the effectiveness of nipple stimulation on acceleration of uterine contraction during first stage of labour among primi gravida mothers in experimental and control group. 3. To compare the pre and post test level of acceleration of uterine contraction during first stage of labour among primi gravida mothers in experimental group. 4. To compare the pre and post test level of acceleration of uterine contraction during the first stage of labour among primi gravida mothers in control group. 5. To associate the post test level of acceleration of uterine contraction during first stage of labour among primi gravida mothers in experimental and control group with their selected demographic variables. HYPOTHESES: All hypotheses were tested at 0.05 level. H1: Mean post test level of acceleration of uterine contraction among primi gravida mothers in experimental group was significantly higher than the mean post test level of acceleration of uterine contraction in control group. H2: There was a significant difference between mean pre and post test level of acceleration of uterine contraction among primi gravida mothers in experimental group. H3: There was a significant difference between mean pre and post test level of acceleration of uterine contraction among primi gravida mothers in control group. H4: There was a significant association between post test level of acceleration of uterine contraction among primi gravida mothers in experimental group with their selected demographic variables. H5: There was a significant association between post test level of acceleration of uterine contraction among primi gravida mothers in control group with their selected demographic variables. The study was based on Wiedenbach’s model. The Quantitative research approach was used. The study conducted in Annalakshmi Hospital, Vallioor. The design adopted for the study was quasi experimental with pre test post test control group design to evaluate the effectiveness of nipple stimulation on acceleration of uterine contraction. The purposive sampling was used to select 30 samples for experimental group, 30 samples for control group. The data collection tools developed for generating the necessary data were questionnaire and uterine contraction assessment scale was used to assess the nipple stimulation on acceleration of uterine contraction. The content validity of the tools were established by five clinical experts. The reliability of rating scale (r=0.8) was established by inter- rater observer method. The instrument was found to be reliable. Pilot study was conducted to find out the feasibility of the study and to plan for data analysis. Data collection was done and the data obtained were analyzed in terms of both descriptive and inferential statistics. SIGNIFICANT FINDINGS OF THE STUDY: 1. There was a significant difference between mean pre test and post test level of acceleration of uterine contraction among primi gravida mothers in experimental group (t=9.27, p<0.05). 2. There was a significant difference between mean pre and post test level of acceleration of uterine contraction among primi gravida mothers in control group (t=0.83, p<0.05). 3. There was a significant difference between mean pre test level of acceleration of uterine contraction among primi gravida mothers in experimental and control group (t=0.545, p<0.05). 4. There was a significant difference between mean post test level of acceleration of uterine contraction among primi gravida mothers in experimental and control group (t=7.969, p<0.05). 5. There was a significant association between mean post test level of acceleration of uterine contraction among primi gravida mothers in experimental and control group with their selected demographic variables (p<0.05). On the Basis of the Findings of the Study it is recommended that: 1. A study can be conducted to assess the knowledge and practice of nipple stimulation for acceleration of uterine contraction among nurse midwives. 2. A study can be conducted to assess the knowledge and attitude of other alternative therapies for labor management among nurse midwives. 3. A study can be conducted to assess the effectiveness of other nursing measures such as aromatherapy on acceleration of uterine contraction among primi gravida mothers. CONCLUSION: This study assessed the effectiveness of nipple stimulation on acceleration of uterine contraction among primi gravida mothers. There is a significant difference between experimental and control group at p>0.05 level. The primi gravida mothers who were received nipple stimulation had a significant acceleration of uterine contraction compared to the primi gravida mothers who were not received nipple stimulation

Healthy Children: Investing in the Future

This OTA assessment addresses the effectiveness and costs of selected strategies for promoting and maintaining the health of children and to identify strategies whose implementation could substantially improve children’s health or lower health care costs

Organización y desincronización de los ritmos circadianos en enfermeras y matronas italianas: actividades sociales y laborales

INTRODUCTION: Biological rhythms are present in all living organisms. The circadian rhythm (from the latin circa dies), with a duration of approximately 24 hours, is the most commonly studied in human beings. Biological rhythms are characterized by multiple molecular mechanisms aiming at synchronization and adaptation of organism to the temporal variations of environment. The circadian individual preference (chronotype) represents the phenotypic manifestation of such a complex mechanism, in many behavioral and daily living aspects. As far the late 70’s of the last century, Horne and Ostberg identified individual differences in circadian attitudes and defined different chronotypes by means of a self-assessed questionnaires with a defined score. Belonging to a defined chronotype seems to have an impact on everydays activities including working. On the other hand, the biological circadian rhythms could be disrupted by everydays activities leading to desynchronization. It has been reported two main types of desynchronization: fast (jet lag) and slow (shift work). Recently, also tlso the change due to Daylight Saving Time (DST) has been identified as a desynchronizing condition with possible negative impact on health. Thus, the starting hypothesis of this doctoral thesis is that social and working activities and chronotype may be closely related, and desynchronization, eg, shift work and DST, should be taken into consideration in Italian midwives. OBJECTIVES: General To determine the effect of chronotype and desynchronization of circadian rhythms (shift work and DST) on social and working activities in Italian midwives. Specific - To assess individual circadian preferences, effects on sleep, and quality of life perceived by midwives. - To determine the effect of the chronotype on social and working activities. - To evaluate the association between the biannual DST and labor activity. - To determine the effect of shift work and the time change on social and work activities. MATERIAL AND METHODS: Two approaches were used: a) Observational study: by the use of validated questionnaires administered through social networks, registered midwives belonging to the Italian Board of Nursing of Midwifery were investigated during 2019. The variables evaluated were individual circadian preference, work shift, working experience, fear of medication errors and sociodemographic, such as age and educational level. A cluster analysis was carried out to know the association between variables. b) Retrospective case-control study using administrative databases: the certificates of attendance at birth generated during the period 2016-2018 in the Region of Emilia-Romagna of Italy were considered. The number of spontaneous deliveries two weeks before (control) and after DST (cases) were analyzed. Further variables, such as gestational age, type of delivery, delivery time, newborn’s weight, Apgar test 5 minutes after delivery, and the use of analgesia during delivery, were evaluated. Univariate and multivariate analyses (logistic regression analysis) were carried out. RESULTS: In the first part of the work, 401 midwives (98.8% women) were enrolled. The mean age was 38.5 }10.1 years and the most common chronotypes were intermediate (50.3%) and moderately morning (39%). Nearly fifty percent of cases self-perceived risk of medication error “at least once”. Perception of risk of medication error was associated with midwifes aged between 31-35 years, undergoing shift work, with a working experience between 6-10 years, and having an intermediate chronotype. In the second study, 7415 spontaneous deliveries were evaluated, the mean age of the women was 31.4 } 10.1 years, and gestational age 39.3 } 1.4 weeks. No significant differences were found between the number of deliveries before and after DST. There were no significant differences for the mode of delivery, gestational age and the number of spontaneous deliveries. Gestational time, newborn weight, Apgar test 5 minutes after delivery, and use of analgesia did not show statistical significance as well. Mother’s age was the only variable found to be independently associated with delivery during the two weeks after DST. CONCLUSIONS The chronotype and shift work in Italian midwives influence professional self-perception, specifically the perception of risk of medication error. Younger midwives, with lower working experience, engaged in shift work and belonging to an Intermediate chronotype, seem to be at higher risk of potential medication error. Morning hours seem to represent highest risk frame for female healthcare workers and shift work is not always aligned with individual circadian preference. Thus, some suggested practical applications could include, for example, assessment of individual chronotype and sleep attitude in healthcare personnel, specific training programs, and intervention strategies, such as time-scheduled naps during night-shifts. As for the potential rhythm disruption operated by DST, the present study did not find any differences in the number of deliveries in the weeks following time shifts. This finding is in agreement with previous data obtained at quite different conditions of latitude, climate, and light exposure. It is possible that the multihormonal etiology of labor may explain this phenomenon. Further studies extended to different latitudes and ethnicities, could be very useful to verify the possibility of a generalization.INTRODUCCIÓN: Los ritmos biológicos están presentes en todos los organismos vivos. El ritmo circadiano (del latín circa dies), con una duración aproximada de 24 horas, es el más estudiado en seres humanos. Los ritmos biológicos se caracterizan por múltiples mecanismos moleculares que se encargan de la sincronización y adaptación del organismo a las variaciones temporales del entorno. La preferencia individual circadiana (cronotipo) representa la manifestación fenotípica, de un mecanismo tan complejo, en muchos aspectos conductuales y de la vida diaria. Ya a finales de la década de los 70 del siglo pasado, Horne y Ostberg identificaron diferencias individuales en las actitudes circadianas y definieron diferentes cronotipos mediante cuestionarios autoevaluados con una puntuación definida. La pertenencia a un cronotipo definido parece tener un impacto en las actividades cotidianas, incluido el trabajo. Por otro lado, los ritmos circadianos biológicos podrían verse interrumpidos por las actividades cotidianas que conducen a la desincronización. Se ha informado de dos tipos principales de desincronización: rápida (jet lag) y lenta (trabajo por turnos). Recientemente, también se ha identificado el cambio debido al horario de verano o Daylight Saving Time (DST) como una condición desincronizante con posible impacto negativo en la salud. Por tanto, la hipótesis de partida de la presente tesis doctoral es que las actividades sociales y laborales y el cronotipo pueden estar estrechamente relacionados, y la desincronización, por ejemplo, el trabajo por turnos y el horario de verano, debe tenerse en cuenta en las matronas italianas. OBJETIVOS: General: Determinar el efecto del cronotipo y la desincronización de los ritmos circadianos (trabajo por turnos y DST) sobre las actividades sociales y laborales de las matronas italianas. Específicos: - Evaluar las preferencias circadianas individuales, los efectos sobre el sueño y la calidad de vida percibida por las parteras. - Determinar el efecto del cronotipo en las actividades sociales y laborales. - Evaluar la asociación entre DST y la actividad laboral. - Determinar el efecto del trabajo por turnos y DST en las actividades sociolaborales. MATERIAL Y MÉTODOS: Se emplearon dos enfoques: a) Estudio observacional empleando cuestionarios validados a través de redes sociales, durante el año 2019. Los sujetos de estudios fueron matronas colegiadas en la Italian Board of Nursing and Midwifery. Las variables estudiadas fueron la preferencia circadiana individual, así como datos laborales (turno de trabajo, experiencia laboral, presencia de errores de medicación) y sociodemográficos (edad, nivel de estudios, sexo). Se llevo a cabo un análisis por clúster para conocer la asociación entre variables. b) Estudio caso-control retrospectivo empleando bases de datos administrativas, concretamente los certificados de asistencia al parto generados durante el periodo 2016-2018 en la Región de Emilia- Romagna, Italia. Se analizo el número de partos espontáneos 2 semanas antes (control) y después del DST (casos). También se analizaron otras variables secundarias como la edad gestacional, tipo de parto, tiempo de parto, peso del recién nacido, test de Apgar a los 5 minutos del parto y el uso de analgesia durante el parto. Se llevo a cabo un análisis univariante y multivariante (análisis de regresión logística). RESULTADOS: En la primera parte del trabajo, participaron 401 matronas (98,8% mujeres), con una edad media de 38,5 }10,1 años y siendo los cronotipos más comunes los intermedios (50.3 %) y moderadamente matutinos (39%). El 48.1% de los casos auto percibían que habían tenido “al menos una vez” riesgo de error de medicación. La percepción de riesgo de error de medicación se asoció con profesionales con una edad entre 31-35 años, que trabajaban a turnos, con una experiencia laboral entre 6-10 años, y un cronotipo intermedio. Por otra parte, en el segundo enfoque, se evaluaron 7415 partos espontáneos, siendo la edad media de las mujeres de 31,4 }10,1 años, con una edad gestacinal de 39,3 }1,4 semanas y siendo el 64,7% italianas. No se encontraron diferencias significativas entre el número de partos antes y después del DST. No hubo diferencias significativas para el modo de parto, edad gestacional y el número de partos espontáneos. El tiempo gestacional, peso del recién nacido, test de Apgar a os 5 minutos del parto y uso de analgesia tampoco mostraron una significación estadística. La única variable que se asociaba independientemente con el parto durante las dos semanas posteriores al DST fue la edad de la madre. CONCLUSIONES: El cronotipo y el trabajo a turnos en las matronas italianas influyen en el ámbito laboral, concretamente en la percepción de riesgo de error de medicación. Las matronas más jóvenes, con menor experiencia laboral, que realizan trabajo por turnos y pertenecen a un cronotipo intermedio, parecen tener un mayor riesgo potencial de error de medicación. Las horas de la mañana parecen representar el periodo de mayor riesgo para las trabajadoras de la salud y el trabajo por turnos no siempre está alineado con la preferencia circadiana individual. Por tanto, algunas aplicaciones prácticas sugeridas podrían incluir, por ejemplo, la evaluación del cronotipo individual y patrón del sueño en el personal sanitario, programas de formación específicos y estrategias de intervención, como las siestas programadas durante los turnos de noche. En cuanto a la posible alteración del ritmo operada por DST, no se encontraron diferencias en el número de partos en las semanas posteriores al cambio de hora. Este hallazgo está de acuerdo con datos anteriores obtenidos en condiciones bastante diferentes de latitud, clima y exposición a la luz. Es posible que la etiología multihormonal del trabajo de parto pueda explicar este fenómeno. Otros estudios extendidos a diferentes latitudes y etnias podrían ser útiles para la generalización de los hallazgos encontrados

Oxytocin receptor antagonists for inhibiting preterm labour (Review)

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