Primary care follow-up of recent mothers submitted to cesarean section and their newborns in reference service

Objective: To investigate the following up of parturients undergoing cesarean delivery and their newborns (RN), emphasizing the achievement of health care actions in primary health care. Methods: follow-up observational study on recent mothers and their RNs after cesarean delivery at the General Hospital at the Federal University of Minas Gerais, performed from March of 2010 to March of 2011. The information was obtained through telephone contact with the recent mothers and analyzed in the Statistical Package for Social Sciences software. The study was approved by the Research Ethics Committee of the Institution. Results: 500 (65.6%) out of 762 women undergoing Cesarean delivery were contacted, 126 (25.2%) were assisted in Basic Health Units (UBS) until 30 days postpartum and 34 (6.8%) had notified surgical wound infection. Post-discharge follow-up information was obtained for 456 RNs, excluding 21 deaths or stillbirths and 23 children who remained hospitalized. The recent mothers reported the following health actions for their children: 327 (71.7%) with consultation until 30 days postpartum, 439 (96.3%) with anti-hepatitis B vaccination, 428 (93.9%) with BCG vaccination, 450 (98.7%) with “foot test”, and 147 (32.2%) with hearing Primary care follow-up of recent mothers submitted to cesarean section and their newborns in reference service Roberta Maia de Castro Romanelli1, Lêni Márcia Anchieta2, Maria Cândida Ferrarez Bouzada1, Regina Amélia Lopes Pessoa de Aguiar3, Henrique Vitor Leite3, Wanessa Trindade Clemente4, Keyla Christy Christie Mendes S. Cunha2, Klaus Zanuncio Protil5, Letícia Maria de Oliveira Aleixo Carvalho5, Bruna Barbosa Coimbra5, Stella D’Ávila de Souza5, André Tunes de Paula5, Lucas Vieira Rodrigues5, Lúcia Maria Horta Figueiredo Goulart2 1 Médica. Pós-doutora. Professora do Departamento de Pediatria da Faculdade de Medicina da Universidade Federal de Minas Gerais – UFMG. Belo Horizonte, MG – Brasil. 2 Médica. Doutora. Professora do Departamento de Pediatria da Faculdade de Medicina da UFMG. Belo Horizonte, MG – Brasil. 3 Médica. Doutor. Professora do Departamento de Ginecologia e Obstetrícia da Faculdade de Medicina da UFMG. Belo Horizonte, MG – Brasil. 4 Médico. Pós-doutor. Departamento de Propedêutica Complementar da Faculdade de Medicina da UFMG. Belo Horizonte, MG – Brasil. 5 Acadêmico(a) do curso de Medicina da Faculdade de Medicina da UFMG. Belo Horizonte, MG – Brasil. Financiamento: Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG). Pró-reitoria de Pesquisa da Universidade Federal de Minas Gerais (PRPq – UFMG) – Programa Institucional de Bolsas de Iniciação Científica (PRPq – 01/2011). Pró-reitoria de Extensão da Universidade Federal de Minas Gerais (PROEX –UFMG) – Programa de Bolsas de Extensão (PBEXT 2012). Seguimento em atenção primária de puérperas submetidas à cesariana e seus recém-nascidos de serviço de referência DOI: 10.5935/2238-3182.20140100

Primary care follow-up of recent mothers submitted to cesarean section and their newborns in reference service The objective of this study was to evaluate the clinical follow-up and assistance in primary care services of puerperae who underwent cesarean section, and their NBs, in a reference university hospital, including the evaluation of preventive health actions recommended by the Ministry of Health.

METHODS
This was an observational prospective study for the follow-up of puerperae and their newborns after cesarean section delivery carried out at the General Hospital of the Federal University of Minas Gerais (HC/UFMG) and tertiary reference for healthcare services in the city of Belo Horizonte and State of Minas Gerais, from March 2010 to March 2011.
Because the hospital assists a high-risk population, the follow-up of pregnant women undergoing cesarean section is performed as part of an active surveillance of 30 days post-surgical postpartum mandatory care according to the technical standard based on the National Healthcare Safety Network. 10 In addition, information about the postpartum care follow-up in the basic health units (UBS) was collected with information about NBs to evaluate their insertion in the UBS.
All patients who underwent a cesarean section childbirth in the reference maternity and their newborns followed by active surveillance were included.The exclusion criteria were not agreeing in participating in the study or having a dead NBs or NBs remaining at the Progressive Care Neonatal Unit (UNCP) in the maternity.Follow-up was lost when telephone contact with those puerperae was not possible; information was obtained from 456 mother-child binomial for this comparative statistical analysis.
After discharge, telephone calls to obtain information after childbirth were performed by trained and supervised students in addition to active searches in medical charts.The follow-up was conducted with telephone calls at 15 and 30 days to identify information about the early and late puerperal period, respectively.Data collection included information about assistance at the UBSs, preventive recommended actions (vaccination, universal neonatal screening, and hearing screening), and main complications in puerperae and NBs.

INTRODUCTION
The integral assistance to the mother-child binomial starts with the prenatal follow-up and assistance at childbirth and postpartum, which must be conducted in an integrated way between the different levels of assistance.In the primary care context, pregnant women must be followed-up systematically and all needed and recommended propaedeutic should be offered.In the case of follow-up needed at the time of childbirth, parturients are guided to seek the reference maternity of their region. 1,2fter childbirth, health community agents identify the return of puerperae and their newborns (NB) to their homes, restarting the primary care follow-up.In addition to the clinical examination of mother and NB, early routine public health actions are conducted on the fifth day of life including guarantee vaccination (if not administered in the maternity), breastfeeding evaluation, the 'little foot' screening test (sickle cell anemia, hypothyroidism, phenylketonuria, and cystic fibrosis), and scheduling for hearing screening, if not already conducted in the maternity ward. 1,3,4espite the greater access of pregnant women to prenatal care and improvements in childbirth assistance, there are difficulties for the integration between basic and tertiary assistance services, especially because the deficiency in reference and counter-reference among sectors involved in healthcare. 5,68][9] Thus, these patients have mandatory postpartum follow-up such as determined for patients who underwent surgery. 10he care and assistance toward the NB can be also harmed when complications occur in the puerpera.
Primary care follow-up of recent mothers submitted to cesarean section and their newborns in reference service with a total of 506 newborns.In five cases, newborns were stillborn, and 16 NBs died within 30 postpartum days (Figure 1).
Considering the 21 neonatal death and stillbirth cases, the median gestational age was 38 weeks (ranging from 28 to 41 weeks) and a median weight of 2.465 g (ranging from 440 to 4. 015 g) (Figure 3).
The 16 NBs who remained in the unit died with the median of one day of life (ranging from 0 to 27 days) (Figure 4).The 13 deaths occurred in the first seven days of life and seven of them on the first day of life.
The coefficient of neonatal mortality among followed-up patients was 31.6 deaths per 1,000 live births (16 in 506 live births), with an early mortality coefficient of 25.7 per 1,000 and late mortality coefficient of 5.9 per 1,000 live births.
On the 30 th postpartum day, 23 NBs remained hospitalized at the UNCP.Thus, considering the followup of 456 puerperae who were discharged with their children, 327 (71.7%) of them reported having taken their children to pediatric consultation.The median time for NB assistance in the UBSs was 11 days (ranging from two to 30 days).and range of continuous variables.The comparative analysis considered the Chi-square test or Fisher's exact test, with statistical significance if p<0.05.
This study was approved by the Ethics Committee in Research of the Federal University of Minas Gerais (ETIC 476/10).

RESULTS
Out of 2,604 deliveries during the studied period, 762 (29.3%) pregnant women were submitted to cesarean and 500 (65.6%) were contacted by phone after delivery (Figure 1).The length of hospital stay before discharge showed a median of three days (ranging from one to 29 days) (Figure 2).
Out of the 500 contacted puerperae, 27 (5.4%) received medical care after discharge within up to 15 days after delivery, and 126 (25.2%) were assisted within 30 days in UBSs.The other 347 women did not receive assistance during the follow-up period.
Out of the 500 cesarean section in which contact with patients was possible, six were twin births,  Primary care follow-up of recent mothers submitted to cesarean section and their newborns in reference service atitis B and BCG vaccines besides conducting the universal neonatal screening; and one third of them (n=147; 32.2%) reported having performed the hearing screening (Table 1).
The main NBs complications reported by the contacted puerperae after discharge were jaundice in 129 (28.3%) and difficulties in breastfeeding in 45 (9.9%).
Out of the 500 contacted puerperae, 34 (6.8%) were diagnosed with IFC, identified during telephone contacts.The comparative analysis considered the 456 binomials followed-up after discharge, taking into consideration the presence or absence of maternal IFC, according to the NHSN criteria. 10No statistical difference was observed when considering puerperae assistance in UBSs (p=0.28),NBs assistance in UBSs (p=0.53), and complications diagnosed in NBs (0.81) (Table 2).
When the administration of hepatitis B and BCG vaccines, universal neonatal screening, and hearing screening were considered, no statistical difference was observed between the groups of mothers with and without IFC (p<0.001);some mothers did not remember about these public health actions.When the answer "I don't know" was excluded from the analysis, there was no difference between the groups (Table 2).

DISCUSSION
The HC/UFMG is a tertiary reference service for high-risk pregnant women for Belo Horizonte and other regions in the State of Minas Gerais, which makes the risk of maternal and fetal complications higher with increased likelihood of morbidity and mortality.The profile of the assisted population requires increased need for counter-reference and primary care assurance, which is the focus of this study.
Out of the 456 mothers discharged with NBs and contacted within 30 days after discharge, over 90% reported having vaccinated their NBs with anti-hep-    Primary care follow-up of recent mothers submitted to cesarean section and their newborns in reference service unnecessary interventions are performed, including cesarean sections in relation to private assistance as demonstrated in other Brazilian studies. 17,18urthermore, as for the counter-reference to primary care, it was noticed that only 25% of women received medical care in the first 30 postpartum days compared to 71.7% who cited having taken their NBs to consultations.However, they may have been assisted by other professional in the assigned health team.It is considered that women can prioritize their children's assistance, although they should receive all guidelines for their own assistance during postpartum, including the evaluation of their health status and interaction with the NB; verification of complications; and guidance on breastfeeding and family planning.The revaluation of early postpartum is indicated within 10 days and late postpartum within 42 days. 1,2During telephone contacts, puerperae were encouraged to seek assistance and, when necessary, assistance was facilitated when leaving the hospital, guiding them to the emergency room in case of emergency and surgical wound revaluation or scheduling for family planning, with a structured flow after observation of this demand.
Assistance to NBs showed a median of 11 days.Although the health actions on the fifth day include evaluation of the general terms and conditions of the child, such as jaundice and umbilical stump, the follow-up consultation should be scheduled as soon as possible. 4mong the health actions contemplated by the "the actions on the fifth day", there were high rates of adherence (98.7%) to the National Program of Neonatal Screening for the identification of phenylketonuria, congenital hypothyroidism, sickle cell disease/ hemoglobinopathies, and cystic fibrosis. 19,20However, this screening was performed only for NBs who remained hospitalized after the fifth day of life in the HC/UFMG.Vaccination against hepatitis B (96.3%) and BCG (93.9%) showed high adherence, which are the first vaccines included as part of the Integral Assistance to Child's Health. 1,4It is noticed that vaccination against Hepatitis B may not be informed to mothers because the routine in this reference hospital is to vaccinate to all children up to 12 hours after birth.Conversely, the hearing screening recommended with otoacoustic emissions, 21 which is an action instituted in Minas Gerais since 2007, 22 was the health action with least adherence (32.2%) according to maternal information.In the HC-UFMG, the hearing screening is performed only in NBs at risk who stay The neonatal mortality coefficient observed in the studied population (31.9 per 1,000 live births) is considered high because according to the Millennium Development Goals, a childhood mortality rate below 17.9 per 1, 000 live births is expected to be reached. 5,11oreover, this study evaluated only the neonatal period in which the mortality rate is higher and corresponding to 60% to 70% of infant mortality in the country. 5In addition, the service assessed is a reference for high risk patients, including congenital malformations, which leads to increased number of deaths.
The rate observed in this study showed a higher proportion of deaths in the first days.The need to prevent these deaths in the period in which the higher infant mortality occurs, increasing since 1990, 12 is highlighted with a focus on the prenatal diagnosis.
The performance of cesarean section in the cases of extreme prematurity is a protective factor for neonatal mortality, 13,14 however, it increases the risk of death in the event of late preterm birth. 15he cesarean rates have increased, particularly in countries with highly medicalized assistance models, noting that Brazil is among the countries with the highest rates recorded, reaching up to 48% of all childbirths. 16However, the studied population was assisted by the public health system, where fewer section and, consequently, more maternal morbidity and mortality, including infections 5 that should have compulsory surveillance and notification. 10Nevertheless, this maternal complication was not observed with the fulfilment of the basic health actions in NBs.

CONCLUSION
The appropriate mother-son follow-up between assistance levels allows identifying assistance demands to health and basic actions that improve reference and counter-reference services and, consequently, maternal and child assistance in the UBS. in the Neonatal Intensive Care Unit.During telephone contacts, the difficulty in scheduling an exam in the UBS was identified through the mothers' reports.With this information, the Municipal Health Secretary was contacted and exam scheduling was facilitated.
Regarding clinical complications in NBs, jaundice was the most frequent and described by 28.3% contacted mothers, breastfeeding difficulty was the second problem reported by 9.9% mothers.These complications reflect the importance of the actions on the fifth day, which include evaluation of NB and mother with attention to jaundice and breastfeeding. 1,4lthough the length of stay in the HC/UFMG for the mother-child binomial is 48 postpartum hours for the assessment of the minimum recommended criteria, 23 the importance of reassessing jaundice is emphasized to prevent hyperbilirubinemia encephalopathy, 24 and breastfeeding to prevent early weaning with the identification of technical problems such as breast lesions or oral moniliasis. 2,4,25When children with complications had not yet been evaluated, mothers were guided to seek assistance and encouraged to breastfeed.
Another important aspect in the follow-up of women who had undergone cesarean delivery is the identification of puerperal infections, especially IFC, which must be monitored up to 30 postpartum days because it is a surgical procedure. 19When necessary, the identification of cases and hospital assistance was facilitated by the intervention and guidance of the student team responsible for telephone contacts and active searches of post-operative infections.
Mothers were grouped as with and without IFC in the comparative analysis.There was no significant association between IFC and assistance to mother and NB in the UBS in the first 30 days after delivery and with complications in the NB.Therefore, the puerpera care was not associated with IFC since access to care and assistance actions are universal and preventive.
When the health actions recommended to NBs were individually evaluated (vaccination against hepatitis B, BCG, universal neonatal screening, and hearing screening), 3,4 mothers that could not give this information were identified, which leads to questions about the adequacy of the guidance provided or their understanding of the necessary guidance about NB follow-up.
It should be noted that the approach only of patients submitted to cesarean sections could be a bias in this study.However, it is known that the medicalization of assistance has contributed to a high number of procedures, including high rates of cesarean

Figure 2 -
Figure 2 -Hospital stay after childbirth of puerperae who underwent caesarean and their newborns, General Hospital from UFMG, 2010 to 2011.!

Table 2 -
Comparison between puerperae who underwent caesarean section, with and without surgical wound infections(IFC), and puerperae follow--up, NB follow up, and complications in the NB, General Hospital from UFMG, 2010-2011