J Hum Growth Dev. 2018; 28(2):148-153 Impact of type of delivery on thoracoabdominal mobility of newborns ORIGINAL ARTICLE Impact of type of delivery on thoracoabdominal mobility of newborns Valéria Lidyanne Silva Gomes1, Pedro Henrique Silva de Open acess Farias2, Danilo Alves Pinto Nagem3, Danielle Cristina Gomes4, Glauco Francisco de Araújo Silva2, Cristiane Aparecida Moran5, Simone Nascimento Santos Ribeiro6, Silvana Alves Pereira4 1Universidade Federal do Rio Abstract Grande do Norte, Faculdade de Ciências da Saúde do Trairi, Santa Introduction: In newborns delivered by cesarean section, Cruz, RN, Brasil. there is less chest compression and little amount of 2Universidade Federal do Rio fluid is drained by gravity, which temporarily reduces Grande do Norte, Setor de E-Saúde, thoracoabdominal mobility. Hospital Universitário Ana Bezerra, Santa Cruz, RN, Brasil. Objetive: The objective of this study is to evaluate the impact of the type of delivery on newborns Thoracoabdominal 3Universidade Federal do Rio Mobility. Grande do Norte, Departamento de Bioengenharia, Natal, RN, Brasil. Methods: This is a cross-sectional study with newborns of gestational age between 37 and 41 weeks, of both sexes, 4Universidade Federal do Rio with up to 72 hours of life, breathing in ambient air and born by Grande do Norte, Programa de Pós-Graduação em Ciências da normal delivery or cesarean section. The Thoracoabdominal Reabilitação, Santa Cruz, RN, Mobility was evaluated by videogrammetry using MATLAB Brasil. Software and considered, in metric units (cm2), as the difference between the highest and lowest thoracoabdominal 5Universidade Federal de Santa expansibility for each respiratory cycle. Catarina, Curso de Fisioterapia, Campus Araranguá, SC Brasil. Results: Twenty-six infants were included, 11 were male and 50% were born by cesarean section. The mean gestational 6Hospital Sofia Feldman, Seção de Fisioterapia , Belo Horizonte-MG, age was 39 ± 0,9 and 28 ± 18 hours of life. The mobility, Brasil difference between greater and lesser expansion, of the thoracic area in vaginal and cesarean delivery was 6 ± 3 cm2 Corresponding author: and 7 ± 5 cm2 and the abdominal area was 29 ± 22 cm2 and apsilvana@gmail.com 21 ± 14 cm2, respectively. This difference was not statistically Manuscript received: March 2018 significant between the two types of delivery for the thoracic Manuscript accepted: April 2018 Version of record online: June 2018 area, but was statistically different for the abdominal area (p= 0.01). And the higher the respiratory rate, the lower the abdominal mobility (r= -0.57, p= 0.02). Conclusion: The data indicate that the type of delivery seems to influence abdominal mobility and respiratory rate. In the studied sample, newborns with cesarean section presented lower abdominal mobility. Keywords: respiratory mechanics, photogrammetry, newborn, labor obstetric. Suggested citation: Gomes VLS, Farias PHS, Nagem DAP, Gomes DC, Silva GFA, Moran CA, et al. Impact of type of delivery on thoracoabdominal mobility of newborns. J Hum Growth Dev. 2018; 28(2):148-153. DOI: http://dx.doi.org/10.7322/jhgd.127865 DOI: http://dx.doi.org/10.7322/jhgd.127865 148 Impact of type of delivery on thoracoabdominal mobility of newborns J Hum Growth Dev. 2018; 28(2):148-153 INTRODUCTION To sustain life, at birth the lungs undergo a rapid worsening. However, many of these studies are limited to transition from an organ filled with fluid unable to perform retrospective data, which may compromise the assessment sufficient exchange for an air-filled organ that is capable of of progression of discomfort and respiratory mobility4-6. performing all gas exchange1. In a newborn with respiratory distress, alteration However, several mechanisms work together to of thoracoabdominal mobility is a commonly perceived reduce and eliminate the amount of pulmonary fluid. In finding7. Often, this respiratory discomfort is evaluated this transition, most of the fluid is eliminated through the through the number of respiratory incursions and the quality upper airways and oral cavity, and the remainder through of thoracic expandability, the lower the thoracoabdominal the process of labor and passage through the vaginal mobility and the greater the respiratory rate, the worse the canal. The residual fluid, which is in the lungs, is absorbed clinical condition of the newborn5,7. However, in clinical through the pulmonary capillaries2. practice, noninvasive methods capable of quantifying In the cesarean birth newborns, there is less respiratory evolution are preferable and also more reliable thoracic compression and little fluid is drained by gravity, when compared to the subjective evaluation of the quality thus maintaining large volumes of fluid, interstitial and of thoracic expandability8-10. alveolar, in the first hours of life, transiently decreasing Considering that cesarean delivery can be a thoracoabdominal mobility3. difficult factor in the respiratory evolution of newborns It is estimated that the non-absorption of this fluid and that thoracoabdominal mobility is directly related to during cesarean delivery can lead to respiratory discomfort the clinical condition of the newborn, the present study and cause a change in thoracoabdominal mobility, with aims to evaluate the impact of the type of delivery on the increased energy expenditure and progressive clinical thoracic and abdominal mobility in newborns (NBs). METHODS This is a cross-sectional, pragmatic study aimed allocated to the following points: (1) anterior-superior iliac at evaluating the influence of the type of delivery on spines; (2) the level of the anterior axillary line and (3) the thoracoabdominal mobility of term newborns. The the xiphoid process displaced laterally. These references research was made in a University Hospital and approved served as an anchor for the geometric delimitation of by the Ethics and Research Comittee of the Faculdade de the thoracic and abdominal compartment in the images Ciências da Saúde do Trairi of the Universidade Federal acquired during the videogram, as shown in Figure 1. do Rio Grande do Norte (FACISA/UFRN) - nº 851.215, Acquisition of Videos following the norms that regulate the research in humans contained in the resolution 466/2012 of the National Health Council. The recruitment of the sample was non- probabilistic and for convenience conducted between 3 January and November 2015, from the admissions of the Hospital Universitário Ana Bezerra (Santa Cruz – RN). The sample consisted of newborns with gestational age between 37 and 41 weeks, of both sexes, with up to 72 hours of life. All were breathing in ambient air and were in the inactive alert stage (stage 4 of the Brazelton scale). Newborns with congenital malformation, genetic syndrome, heart failure, respiratory diseases or who had been fed in less than 30 minutes were not included in the study, being excluded from the analysis of the videos those that evolved to stage 5 or 6 of the Brazelton scale, during the evaluation. Procedures for Data Collection Data collection was performed in the bath room, with the newborns on a fixed bench, with a distance of 120 Figure 1: Positioning of the newborn during the cm from the floor, routinely used for general care of the experiment, allocation of the adhesive markers newborn. In order to capture the videos, the methodology and delimitation of the thoracic and abdominal adapted from the study by Ricieri and Rosário Filho8, compartment at the time of the analysis of the presented in the study by Oliveira et al.10, Gomes et images, Santa Cruz, Rio Grande do Norte, Brazil, al.11 and Guerra et al.12 was used. The newborns were 2016. placed supine on a support bed with the surface coated with a black, hypoallergenic and disposable EVA sheet of Source: Authors approximately 50 cm in length and 0.2 mm in thickness. (Figure 1). After positioning, adhesive markers were DOI: http://dx.doi.org/10.7322/jhgd.127865 149 J Hum Growth Dev. 2018; 28(2):148-153 Impact of type of delivery on thoracoabdominal mobility of newborns To capture the videos, the digital camera (Sony thoracic and abdominal area10. Cyber-shot DSC-H20® 10.1 Megapixels), fixed by a tripod with height of 120 cm and positioned within a distance Data Analysis of 30 cm of the newborn was used. After adjusting the Statistical data were analyzed in the SPSS markers, the newborn was filmed for 120 seconds. The 20 program. For the normality test, the Shapiro- capture time of 120 seconds was determined to guarantee wilk, t-student test was used to evaluate the means of analysis of the respiratory cycle in 1 minute, since the thoracoabdominal mobility between the two types of newborns have frequent pauses in respiration. delivery and the Spearman rank correlation test, for to evaluate the correlation of birth rates with the individual Interpretation of Videos characteristics of the newborns; significance to the results The videos were treated by the MATLAB Software for p<0.05. and the mobility was considered in metric units (cm2), as the difference of the greater and lesser expansibility to the Of the 26 newborns included, 18 were male and RESULTS 50% were born cesarean. The descriptive data of the undergoing cesarean delivery had a higher respiratory rate sample and the homogeneity between the groups are when compared to normal delivery (Table 1). shown in Table 1. In this analysis only the respiratory rate The mobility, difference between the greatest and was different between the groups (p = 0.03). Newborns Table 1: Characteristics of the population studied (n=26), Santa Cruz, Rio Grande do Norte, Brazil, 2016. Variables Birth type Normal Cesarean p NB (n) 13 13 - Sex Male 7 11 0.15-(x2) Female 6 2 0.34 (x2) GA (wks) 39 ±0,62 39±1.04 0.32 (t) Weight (grams) 3152±5.23 3369±5.20 0.16 (t) Apgar 1 min 7±1.92 7±1.05 0.4 (t) Apgar 5 min 8±1.05 9±0.55 0.69 (t) CP (cm) 34±1.82 34±2.15 0.55 (t) Len. (cm) 48±1.74 49±1.90 0.36 (t) RF (ipm) 48±11.88 57±9.98 0.03*(t) Hours of life 28±19 29±17 0.52 (t) Legend: NB: new-born; n: number of individuals; GA: gestational age; wks: weeks; min: minutes; CP: Cephalic perimeter; cm: centimeters; Len.: Length; RF: Respiratory Frequency; ipm: incursions per minute; *p<0.05; p: probability of significance used t-student (t) and chi-square tests (x2). lowest expansibility, of the thoracic area in vaginal and 1 5 cesarean deliveries was 6 ± 3 cm2 and 7 ± 5 cm2 and the abdominal area was 29 ± 22 cm2 and 21 ± 14 cm2, p = 0 ,1 4 1 0 respectively. This difference was not statistically significant between the two types of delivery for the thoracic area, 5 but was statistically different for the abdominal area (p = A 0.01). Figure 2 presents this analysis. 0 The correlation of mobility with birth weight, Apgar scores, length, respiratory rate and hours of life did 6 0 not present significant difference, except for abdominal p = 0 ,0 1 * mobility with respiratory rate. In this analysis it was 4 0 verified that, the higher the respiratory rate, the lower the 2 0 abdominal mobility. Table 2 presents this result. B 0 The data indicate that the type of delivery seems to a l e o rmo s a r N C e T ip o d e p a r to Figure 2: Graphical representation of the values of Thoracic Mobility (A) and Abdominal Mobility (B) for vaginal (normal) and cesarean delivery of the 26 newborns studied. p <0.05 = statistical significance factor. Santa Cruz, Rio Grande do Norte, Brazil, 2016. DOI: http://dx.doi.org/10.7322/jhgd.127865 150 M o b ilid a d e A b d o m in a l (c m 2 ) M o b ilid a d e T o r á c ic a (c m 2 ) Impact of type of delivery on thoracoabdominal mobility of newborns J Hum Growth Dev. 2018; 28(2):148-153 Table 2: Correlations between thoracoabdominal mobility and the variables studied in the 26 newborns. Variables of the 26 infants studied Mobility Thoracic Mobility Abdominal r p r p Weight 0.21 0.29 0.08 0.69 Length 0.88 0.67 0.23 0.25 Apgar 1st minute 0.47 0.81 0.33 0.09 Apgar 5st minute -0.03 0.98 0.15 0.44 Respiratory Frequency -0.85 0.67 -0.57 0.02* Hours of Life -0.24 0.23 -0.17 0.39 Legend: r: Pearson's correlation; p: probability of significance; *p<0.05. Correlation is significant when p≤0.05. DISCUSSION influence abdominal mobility and respiratory rate. In the subjective data, which may compromise their interpretation. sample studied, cesarean births presented lower abdominal In our study we present a clear and objective model mobility. of evaluation of the thoracic and abdominal mobility Studies investigating the types of cesarean deliveries in newborns. This method was previously used to infer and normal deliveries of second-line pregnant women respiratory mechanical behaviors of relevant clinical utility demonstrate that cesarean delivery neonates more frequently for respiratory physiotherapy10-12, and in all the studies required neonatal intensive care because they had a higher have presented numerical results on the variation of the occurrence of transient tachypnea, non-specific respiratory movement of the thorax and the abdomen. dysfunction and sepsis11-13. A retrospective study, with more The method is objective and configured within than 3,000 elective cesareans performed with a gestational a mathematical sequence in MATLAB software, which age greater than or equal to 37 weeks, shows that cesarean demonstrates objectivity and accuracy in the analysis of delivery with elective progression, even in the full-term the results. It has been shown to be a useful resource in the period, increases the risk of respiratory morbidity13. evaluation of patients who do not voluntarily control the Infants born by cesarean delivery with elective synergy of muscle work during respiration12. progression had a higher prevalence of neonatal transient The use of photogrammetry for the analysis of tachypnea when compared to newborns by cesarean section respiratory movement allows establishing evidence related with spontaneous progression (12.3%), which may justify to thoracic and abdominal kinetics, this information can our results14. be used to infer respiratory mechanical behavior even in This study includes newborns coming from a school patients who do not voluntarily control respiration, as in hospital that encourages cesarean delivery only with the newborns8-12. pregnant woman already in spontaneous progression, an However, some limitations should be considered. important peculiarity for interpretation of our results. We present a cross-sectional study without a group of Two other studies15,16 demonstrate, by retrospective cesarean deliveries with elective progression, absence models, that cesarean delivery is a complicate in the of the thoracic perimeter and we lost 25% of our sample transition from the fetus to the extra uterine life in which it during the interpretation phase of the images. We would reflects the respiratory adaptation. need to longitudinally follow a larger group of newborns In our sample, although we presented a model with cesarean deliveries with elective progression (without algorithm (MATLAB) to quantify the thoracoabdominal the parturition process) and with gestational age different mobility, we did not show this variation for the thoracic area. from those included in this study. We believe that this result comes down to the parturition Although it is essential to the adaptations described process pertinent to the hospital profile. In addition, our as limitations in this study, the evaluation of the thoracic mean gestational age for cesarean delivery was 39 weeks, and abdominal mobility by MATLAB in the different types which allows for pulmonary maturation, since the condition of delivery was effective in newborns. Demonstrating of late cesarean delivery, performed at 39 weeks, decreases efficiency in the quantification of changes in respiratory admissions of newborns due to respiratory complications17. mechanics, which can serve as an objective and practical Several other studies15-18 have shown that tool for the use of the different professionals of a care team, the incidence of respiratory dysfunction is inversely besides being an evaluation method of low cost and easy proportional to gestational age. However, these researches applicability. have concluded their hypotheses, based on retroactive or The data indicate that the type of delivery seems CONCLUSION to influence abdominal mobility. 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Timing of elective cesarean section and neonatal morbidity: a population-based study. J Matern Fetal Neonatal Med. 2016;29(15):2461-3. DOI: https:// dx.doi.org/10.3109/14767058.2015.1087500 DOI: http://dx.doi.org/10.7322/jhgd.127865 152 Impact of type of delivery on thoracoabdominal mobility of newborns J Hum Growth Dev. 2018; 28(2):148-153 Resumo Introdução: Nos recém-nascidos de parto cesáreo, ocorre menor compressão torácica e pouca quantidade de líquido é drenada por ação da gravidade, o que diminui, transitoriamente, a mobilidade toracoabdominal. Objetivo: O objetivo do estudo é avaliar o impacto do tipo de parto na mobilidade torácica e abdominal em recém-nascidos. Método: Trata-se de um estudo transversal com recém-nascidos de idade gestacional entre 37 a 41 semanas, de ambos os sexos, com até 72 horas de vida, respirando em ar ambiente e nascidos de parto normal ou parto cesáreo. A mobilidade torácica e abdominal foram avaliadas pela videogrametria por meio do Software MATLAB e considerada, em unidades métricas (cm2), como a diferença da maior e menor expansibilidade toracoabdominal para cada ciclo respiratório. Resultados: Foram inclusos 26 recém-nascidos 11 do sexo masculino e 50% nascidos de parto cesáreo. A idade gestacional média foi de 39 ± 0,9 sem e tinham 28 ± 18 horas de vida. A mobilidade, diferença entre a maior e menor expansibilidade, da área torácica no parto vaginal e cesáreo foi 6 ± 3 cm2 e 7 ± 5 cm2 e da área abdominal foi de 29±22 cm2 e 21± 14 cm2, respectivamente. Esta diferença não foi estatisticamente significante entre os dois tipos de parto para a área torácica, mas mostrou- se diferente estatisticamente para a área abdominal (p = 0,01). E para os recém-nascidos de parto cesáreo, quanto maior a frequência respiratória, menor a mobilidade abdominal (r = -0,57; p = 0,02). Conclusão: Os dados indicam que o tipo de parto parece influenciar a mobilidade abdominal e a frequência respiratória. Na amostra estudada os recém-nascidos de parto cesáreo apresentaram menor mobilidade abdominal. Palavras-chave: mecânica respiratória, fotogrametria, recém-nascido, trabalho de parto. © The authors (2018), this article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://c reativecommons. org/ licenses/ by/ 4.0 / ), which permits unrestricted use, distribution, and reproduction in any medium, pro- vided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://c reativecommons. org/p ublicdo- main/ zero/ 1. 0/) applies to the data made available in this article, unless otherwise stated. DOI: http://dx.doi.org/10.7322/jhgd.127865 153