Ampliando o debate

Abstract

The authors thank their colleagues for having accepted being discussants of this article on obstetric interventions during labor and delivery of Brazilian women considered to be of habitual obstetric risk. The contribution by each of them made expanded and enriched the discussion, by shifting it from the scientific realm of health to the context of culture, ethics and social relations as a whole.It is with great excitement and motivation that we respond to their comments, addressing some selected aspects only, due to space limitations of this section.Guilherme Cecatti made some important notes on methodological issues, particularly addressing the lack of information on the use of forceps in Brazil, in the article. This was suppressed, given the many outcomes addressed in our investigation. However, considering that one of the core purposes of our paper was to present an overview of birthcare in Brazil in women considered at normal obstetric risk, we thank Cecatti the chance of commenting about this topic. The frequency of forceps use was very low, of 1.4% for all women, and of 1.9% for those of habitual obstetric risk, with higher prevalence seen in the Southeastern region, capital cities, and users of the Brazilian Unified National Health System (SUS), as well as in adolescents, white, and primiparous women, without differentiation of the obstetric risk group. In regards to obstetric aspects, there was a higher frequency of all other interventions for those women in which forceps was used, particularly peridural anesthesia, use of ocytocin, Kristeller's maneuver, and episiotomy, which reached the high proportions of 60%, 56% and 86%, respectively. Some studies have shown that the frequency of forceps use in Brazil is low, and the main reason for this obstetric procedure to have been dropped almost entirely was the lack of medical training to qualify doctors to perform surgical vaginal delivery care, and their concern with law suits 1,2 . In our investigation, we had no way to assess the proper use of forceps, and therefore we cannot state whether or not this low rate of use is a positive factor, more so when such procedure is associated to high prevalence of Kristeller's maneuvre, and higher severe morbidity rates and maternal near miss 3 .Another aspect mentioned by Cecatti was the decision, by the authors, to include in the study women of habitual obstetric risk previously submitted to a c-section. It is correct to imagine that these women may present higher risks during labor and delivery compared to those who did not previously experience a c-section. However, it seemed appropriate not to consider a previous csection an excluding factor for normal obstetric risk because: (a) in this group, the proportion of women previously submitted to a c-section was the same of the obstetric risk group, 20%. This means that in regards to this aspect, there was no difference between the two groups; (b) scientific evidences show successful experiences in having a vaginal delivery after having had a c-section 4 . The most i...

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