Sistema de Gestão da Qualidade em uma Maternidade Universitária:
Estratégia para a Redução Sustentada da Taxa de Cesarianas
Resumo
Introdução: No Uruguai, a taxa de cesarianas superou os partos vaginais, configurando um problema de saúde pública pelos custos e morbimortalidade associados.
Objetivo: Apresentar a primeira estratégia integral bem-sucedida para reduzir cesarianas na Maternidade Universitária do Hospital Manuel Quintela (2022–2024).
Métodos: Implementaram-se intervenções sistêmicas baseadas em melhoria contínua. Foram elaborados oito protocolos de boas práticas, dois com impacto direto nas indicações de cesariana (indução do parto e monitorização fetal). Realizaram-se treinamentos e simulações para profissionais médicos e não médicos.
Resultados: Ocorreram 555 nascimentos em 2022, 586 em 2023 e 646 em 2024. A taxa de cesarianas caiu de 49% (2022) para 48% (2023) e 37% (2024), com reduções consistentes em todos os grupos de Robson, especialmente 1 e 2.
Conclusões: A redução das cesarianas exige organização institucional, protocolos baseados em evidências e participação ativa da equipe assistencial.
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Referências
Uruguay. Ministerio de Salud Pública. Estadísticas vitales. MSP, 2020. Disponible en: https://uins.msp.gub.uy/index.html#nac. Acceso: 23 de junio de 2025.
Winger A, Rae M, Cox C. Health costs associated with pregnancy, childbirth, and postpartum care. Peterson-KFF Health System Tracker. Peterson Center on Healthcare, 2025. Acceso: 25 de noviembre de 2024. Disponible en:
Lagrew DC, Low LK, Brennan R, Corry MP, Edmonds JK, Gilpin BG, et al. National partnership for maternal safety: consensus bundle on safe reduction of primary cesarean births. Obstet Gynecol. 2018;131(3):503–13. doi:
1097/AOG.0000000000002471
Cóppola F. Cesáreas en Uruguay. Rev Méd Urug. 2015;31(1):7-14.
Ochiai E, Kigenyi T, Sondik E, Pronk N, Kleinman DV, Blakey C, et al. Healthy People 2030 leading health indicators and overall health and well-being measures. J Public Health Manag Pract. 2021;27(Suppl 6):S235–41. doi: 10.1097/PHH.0000000000001424
Organización Mundial de la Salud. Recomendaciones de la OMS: intervenciones no clínicas para reducir las cesáreas innecesarias. OMS, 2018. Disponible en: https://www.who.int/publications/i/item/9789241550338
Morena AL, Gaias LM, Larkin C. Understanding the role of clinical champions and their impact on clinician behavior change. Front Health Serv. 2022;2:896885. doi: 10.3389/frhs.2022.896885
White VanGompel E, Perez S, Datta A, Wang C, Cape V, Main E. Cesarean overuse and the culture of care. Health Serv Res. 2019;54(2):417–24. doi: 10.1111/1475-6773.13123
Vadnais MA, Hacker MR, Shah NT, Jordan J, Modest AM, Siegel M, et al. Quality improvement initiatives lead to reduction in nulliparous term singleton vertex cesarean delivery rate. Jt Comm J Qual Patient Saf. 2017;43(2):53–61. doi: 10.1016/j.jcjq.2016.11.008
Callaghan-Koru JA, DiPietro B, Wahid I, Mark K, Burke AB, Curran G, et al. Reduction in cesarean delivery rates associated with a state quality collaborative in Maryland. Obstet Gynecol. 2021;138(4):583–92. doi: 10.1097/AOG.0000000000004540
Vadnais MA, Hacker MR, Shah NT, Jordan J, Modest AM, Siegel M, et al. Quality improvement initiatives lead to reduction in nulliparous term singleton vertex cesarean delivery rate. Jt Comm J Qual Patient Saf. 2017;43(2):53–61. doi: 10.1016/j.jcjq.2016.11.008
California maternal quality care collaborative. Toolkit to support vaginal birth and reduce primary cesareans. CMQCC, 2022. Acceso: 25 de noviembre 2024. Disponible en: https://www.cmqcc.org/files/Vbirth-Toolkit-withSupplement_Final_11.30.22_2.pdf
Howell EA, Sofaer S, Balbierz A, Kheyfets A, Glazer KB, Zeitlin J. Distinguishing high-performing from low-performing hospitals for severe maternal morbidity. Obstet Gynecol. 2022;139(6):1061–9. doi: 10.1097/
AOG.0000000000004806
Howell EA, Sofaer S, Balbierz A, Kheyfets A, Glazer KB, Zeitlin J. Distinguishing high-performing from low-performing hospitals for severe maternal morbidity. Obstet Gynecol. 2022;139:1061–9. doi:10.1097/
AOG.0000000000004806
Philips Healthcare. Sistema de monitoreo AVALON. Disponible en: https://www.philips.es/healthcare/product/HC866074/avalon-cl-sistemainalambrico-de-monitoreo-fetal
Ayres-de-Campos D, Bernardes J, Garrido A, Marques-de-Sá J, PereiraLeite L. SisPorto 2.0: automated analysis of cardiotocograms. J Matern Fetal Med. 2000;9(5):311–8. doi: 10.1002/1520-6661(200009/10)9:5<311::AIDMFM12>3.0.CO;2-9
Page K, Early A, Breman R. Improving nurse self-efficacy and continuous labor support with the Promoting Comfort in Labor Safety Bundle. J Obstet Gynecol Neonatal Nurs. 2021;50(3):316–27. doi: 10.1016/j.jogn.2021.01.006
American College of Obstetricians and Gynecologists. Informed consent and shared decision making in obstetrics and gynecology. ACOG Committee Opinion No. 819. Obstet Gynecol. 2021;137:e34–41. doi: 10.1097/
AOG.0000000000004247
Montori VM, Ruissen MM, Hargraves IG, Brito JP, Kunneman M. Shared decision-making as a method of care. BMJ Evid Based Med. 2023;28(4):213–7. doi: 10.1136/bmjebm-2022-112068
Agency for Healthcare Research and Quality. The SHARE Approach. 2024. Disponible en: https://www.ahrq.gov/sdm/share-approach/index.html
Bell CH, Muggleton S, Davis DL. Birth plans: a systematic integrative review. Midwifery. 2022;111:103388. doi: 10.1016/j.midw.2022.103388
Vivas Maiques C, Moreno Prat M, Vilariño Cerdá B, García Serra H. Balint group experience during the COVID pandemic. Aten Primaria. 2021;53(10):102177. doi: 10.1016/j.aprim.2021.102177
Tizón JL. Sobre los Grupos Balint, el movimiento Balint y el cuidado de la relación médico-paciente. Aten Primaria. 2005;36(8):453–5. doi: 10.1157/13081060
Alliance for Innovation on Maternal Health. Impact statements. AIM, 2022. Disponible en: https://saferbirth.org/wp-content/uploads/AIMImpactStatements.pdf
Coppola F. Protocolos Clínicos de una Maternidad Universitaria para el Equipo de Atención Materno Fetal. An Fac Med (Univ Repúb Urug). 2024;(supl). Disponible en: https://revistas.udelar.edu.uy/OJS/index.php/anfamed/article/view/2525/2231
Friedman E. The graphic analysis of labor. Am J Obstet Gynecol. 1954;68(6):1568–75. doi: 10.1016/0002-9378(54)90311-7
Zhang J, Troendle J, Mikolajczyk R, Sundaram R, Beaver J, Fraser W. The natural history of the normal first stage of labor. Obstet Gynecol. 2010;115(4):705–10. doi: 10.1097/AOG.0b013e3181d55925
Norman SM, Tuuli MG, Odibo AO, Caughey AB, Roehl KA, Cahill AG. The effects of obesity on first stage of labor. Obstet Gynecol. 2012;120(1):130–5. doi: 10.1097/AOG.0b013e318259589c
Blankenship SA, Woolfolk CL, Raghuraman N, Stout MJ, Macones GA, Cahill AG. First stage of labor progression in large-for-gestational-age fetuses. Am J Obstet Gynecol. 2019;221(6):640.e1–11. doi: 10.1016/j.
ajog.2019.06.042
American College of Obstetricians and Gynecologists. First and second stage labor management. Clin Pract Guideline No. 8. Obstet Gynecol. 2024;143(1):144–62. doi: 10.1097/AOG.0000000000005447
Barquet J, Bettanin J, Martinez C, Salgado V, Pintos S, Cóppola F, García R. Protocolo de inducción del parto. An Fac Med (Univ Repúb Urug). 2024;(supl). Disponible en: https://revistas.udelar.edu.uy/OJS/index.php/anfamed/article/view/2532/2238
De Vivo V, Carbone L, Saccone G, Magoga G, De Vivo G, Locci M, et al. Early amniotomy after cervical ripening: systematic review and meta-analysis. Am J Obstet Gynecol. 2020;222(4):320–9. doi: 10.1016/j.ajog.2019.07.049
Barquet J, Sena F, Sardena K, Oholeguy P, Bettanin J, Salgado V, et al. Protocolo de monitorización fetal intraparto. An Fac Med (Univ Repúb Urug). 2024;(supl). Disponible en: https://revistas.udelar.edu.uy/OJS/index.php/anfamed/article/view/2534/2240
American College of Obstetricians and Gynecologists. External cephalic version. Practice Bulletin No. 221. Obstet Gynecol. 2020;135(5):e203–12. doi: 10.1097/AOG.0000000000003837
Le HL, Nguyen HVQ, Le TM, Vo LH. Accurate evaluation of mode of delivery with angle of progression. Rev Bras Ginecol Obstet. 2025;47:e-rbgo5. doi: 10.61622/rbgo/2025rbgo5
American College of Obstetricians and Gynecologists. Macrosomia. Practice Bulletin No. 216. Obstet Gynecol. 2020;135(1):e18–35. doi: 10.1097/AOG.0000000000003606
Grobman WA, Rice MM, Reddy UM, Tita AT, Silver RM, Mallett G, et al. Labor induction vs expectant management in low-risk nulliparous women. N Engl J Med. 2018;379(6):513–23. doi: 10.1056/NEJMoa1800566
Nethery E, Levy B, McLean K, Sitcov K, Souter VL. Effects of the ARRIVE trial on elective induction. Obstet Gynecol. 2023;142(2):242–50. doi: 10.1097/AOG.0000000000005217
Wood R, Freret TS, Clapp M, Little S. Induction at 39 weeks and cesarean delivery after ARRIVE trial. JAMA Netw Open. 2023;6(8):e2328274. doi: 10.1001/jamanetworkopen.2023.28274
Jelks AT, Yao AQ, Byrne JD. Impacts of 39-week induction across a delivery unit. AJOG Glob Rep. 2023;3(2):100168. doi: 10.1016/j.xagr.2023.100168
World Health Organization. Robson Classification: Implementation Manual. Geneva: WHO; 2017. Disponible en: https://iris.paho.org/handle/10665.2/49659
American College of Obstetricians and Gynecologists. QualityImprovement Strategies for Safe Reduction of Primary Cesarean Birth. ACOG Committee Statement. Obstet Gynecol. 2025;145(5):542-552. doi: 10.1097/AOG.0000000000005888
Main EK, et al. Reduction in severe maternal morbidity from hemorrhage using a multihospital quality-improvement project. Am J Obstet Gynecol. 2017;216(3):298.e11. doi: 10.1016/j.ajog.2017.01.017
Lassi ZS, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD007754. DOI: 10.1002/14651858.CD007754.pub3.
Copyright (c) 2026 Francisco Cóppola, Maria Noel Marin, Paula Oholeguy, Maria Juliana Barquet, Lucia Diz, Agustina Michelini, Victoria Salgado, Julieta Betanin, Camila Martínez, Lucía Rodríguez Chiancone, Lucía Pedrozo, Magalí Ferencz, Florencia Silvera Delfino, Francisca Paz Navarro Ulloa, Pamela Villacis, Mariana De Nava, Mercedes Abadie, Mercedes Catani, Valeria Correa, María Silvariño, Romina Ferreira Trindade, Valentina Zubiaurre, Fernanda Blasina
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