Cesarean Law: a turning point in the fight against the Brazilian epidemic of cesarean section?

In the opposite direction to the process that had been gradually changing birth forms and indicators in Brazil, in 2019 the State of São Paulo (located in southeastern Brazil) enacted Law 17. 137, which guarantees all pregnant women the choice of a cesarean section from the 39 weeks of pregnancy, regardless of the obstetric indication. That is a preliminary qualitative analysis of a doctoral investigation, we are looking for show some points of inflection of this law to combat the cesarean epidemic. Affiliated to the theoretical-methodological approach of discursive practices and the production of meanings in daily, it investigates the discourses that support the current policies to encourage humanized obstetric care based on scientific evidence, built over the last 20 years, and those who supported the approval of this legal norm, known as the Cesarean Law. One of the inflection points of Law concerns the quality of prenatal care and the way that women receive information about childbirth during pregnancy. Because lack of information and insecurity are important factors in the choice of women by the type of delivery. Iatrogenic prematurity is one of the biggest problems of Brazilian cesarean section epidemic. Thus, even after 39 weeks of pregnancy, there is no guarantee of baby's maturity. Since the 90's, the Brazilian government had been encouraging the insertion of midwives and nurse midwives in the childbirth care of all women at regular risk and encouraged the creating of childbirth centers as well an adequate classification of gestational risk. At this point, the law affronts the current organization of the system, as it prioritizes attendance by doctors over professional midwives. The cesarean rates and other health indicators are not available yet after the approval of the law in São Paulo state. However, we can postulate that it will mean a setback in the fight against the epidemic of cesarean sections in Brazil.

Key messages

The Cesarean law approved in the state of São Paulo / BR presents inflection points in the fight against the cesarean section epidemic. The Cesarean law approved in the state of São Paulo / BR ignores important issues in the Brazilian obstetric scenario.

Long-term physical training and left ventricular remodeling after anterior myocardial infarction: results of the Exercise in Anterior Myocardial Infarction (EAMI) trial. EAMI Study Group

OBJECTIVES

The aim of this multicenter randomized study was to investigate whether long-term physical training would influence left ventricular remodeling after anterior myocardial infarction.

BACKGROUND

Exercise is currently recommended for patients after myocardial infarction; however, the effects of long-term physical training on ventricular size and remodeling still have to be defined.

METHODS

Patients with no contraindications to exercise were studied 4 to 8 weeks after anterior Q wave myocardial infarction and 6 months later by echocardiography at rest and bicycle ergometric testing. After the initial study, patients were randomly allocated to a 6-month exercise training program (n = 49) or a control group (n = 46). A computerized system was used to derive echocardiographic variables of ventricular size, function and topography.

RESULTS

After 6 months, a significant (p < 0.01) increase in work capacity (from 4,596 +/- 1,246 to 5,508 +/- 1,335 kp-m) was observed only in the training group, whereas global ventricular size, regional dilation and shape distortion did not change in either the control or the training group. However, compared with patients with an ejection fraction > 40%, patients with an ejection fraction < or = 40% had more significant (p < 0.001) ventricular enlargement at entry and demonstrated further (p < 0.01) global and regional dilation after 6 months, in both the control and the training group (end-diastolic volume from 77 +/- 14 to 85 +/- 17 ml/m2 in the control group and from 74 +/- 11 to 77 +/- 15 ml/m2 in the training group; regional dilation from 46 +/- 18% to 57 +/- 21% in the control group and from 42 +/- 18% to 44 +/- 26% in the training group). Ventricular size and topography did not change in patients with an ejection fraction > 40%.

CONCLUSIONS

Patients with poor left ventricular function 1 to 2 months after anterior myocardial infarction are prone to further global and regional dilation. Exercise training does not appear to influence this spontaneous deterioration. Thus, postinfarction patients without clinical complications, even those with a large anterior infarction, may benefit from long-term physical training without any additional negative effect on ventricular size and topography.

EAMI--exercise training in anterior myocardial infarction: an ongoing multicenter randomized study. Preliminary results on left ventricular function and remodeling. The EAMI Study Group

To determine the effects of a 6-month exercise training program on left ventricular (LV) function and remodeling, 49 consecutive patients (pts) with first Q anterior myocardial infarction (51 +/- 8 years), in I-II NYHA class, were studied 4 to 8 weeks after the acute episode and 6 months later by 2D-ECHO and upright bicycle ergometric test. At entry, pts were randomly allocated to physical training (T = 25pts) or control (C = 24pts). Global endocardial surface area (ESA), LV volumes and EF, extent of abnormal wall motion (%WMA), of regional dilatation (%REG DIL), and the shape distortion (DIST) index were analyzed. After 6 months, a significant increase in work capacity (4,589 +/- 1,417 to 5,379 +/- 1,485 KPM/min, p less than 0.03) and in lactic anaerobic threshold (45 +/- 13 to 63 +/- 15 W, p less than 0.01) was observed only in T. Initial ESA, EDV, EF, %WMA, %REG DIL, and DIST index were similar and they did not change after 6 months in both groups. However, pts with less than 40%EF had greater (p less than 0.0001) EDV and %WMA with marked DIST index at entry and showed further (p less than 0.01) deterioration after 6 months both in C and in T (EDV, ml/m2: 68 +/- 12 to 77 +/- 18 in C, 71 +/- 12 to 74 +/- 18 in T; %REG DIL: 39 +/- 20 to 49 +/- 24 in C, 32 +/- 12 to 35 +/- 23 in T; DIST index: 0.16 +/- 0.07 to 0.21 +/- 0.09 in C, 0.2 +/- 0.07 to 0.22 +/- 0.1 in T). These variables did not change in pts with greater than 40%EF. Thus, from these preliminary data, pts with less than 40%EF at entry are prone to further global and regional LV deterioration. Physical training does not seem to increase this spontaneous deterioration.

[Epidemiology of ischemic cardiopathy in a large iron foundry]

This work examines the coronary disease distribution in a large iron-foundry (7000 workers) with different ways of work and productive technologies, taking into consideration the high incidence and the multiple etiology of risk factors of cardiovascular diseases in the general population. In particular we studied the frequency of coronary disease and its consequence on the workers as far as retirement, death and job modification are concerned.

[Monitoring of laborers previously exposed to aromatic amines, in accordance with Circulars No. 46 of 12/6/1979 and No. 61 of 4/6/1981 of the Ministry of Labor]

The present report deal, a year after its beginning, with the results of a programme for health control regarding 592 ex-employees of Società Bergamasca Industrie Chimiche. Azo dyes were obtained from benzidine and beta-naphthylamine in this factory from 1947 to 1968. The report analyses the organizing difficulties and the troubles which caused a scarce performance of the programme at different levels: the subjects interested in the control, the Commission responsible for the district, the doctors in charge, the laboratories, the hospital division. In the end some proposals are advanced referring to the provision of the ministerial circular letter no 46, dated june 12, 1979, about the medical control of workers who leave the hazardous working job.