7/24/2019 El Tiempo y La Anestesia Obstétrica

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El tiempo y la anestesia obstétrica: de la cosmología caótica a lacronobiología

 

Nilton Bezerra do Vale, TSA, M!"# $%cio &l'(io Bezerra do Vale, M!""# )osé*+mlo -rz, TSA, M!"""

IProfessor Adjunto; Doutor em FarmacologiaIIAnestesiologista da MEJC da UFRNIIIMédico !stetra da "ecretaria de "a#de do RN

Corres$ondence to

 

S.MMA*/

BA-01*2.N! AN! 2B)E-T"VES: %em$oral c&cles 'dar()lig*t; !irt*)deat*; etc+,- along.it* en/ironmental conditions 's&nc*roni0ers,- influence la!or $*&siolog& !ecause of t*e$resence of endogenous cloc(s 'oscillators, t*at interact .it* social diuturnal clues+ In t*isre/ie.- t*e most im$ortant c&clic anest*etic1o!stetric $arameters in $arturient care arelisted+-2NTENTS: C*rono!iological anal&sis of t*e main e/ents in t*e o!stetric $at*o$*&siolog&of Mulier sapiens2 I, Em!r&ogenesis 1 ris( of teratogenesis; II, From $rematurit& to $ost1didacticism2 from eutocic la!or to cer/ical cerclage; III, Nig*t and la!or2 *ig*er incidence of nocturnal la!or '$*&siological facilitation, and da&lig*t cesarean section 'c*oice of t*eo!stetrician,; I3, %*e moon and la!or 1 non1conclusi/e results; 3, %*e nig*t s*ift ino!stetric anest*esia2 ris(ier $rofessional contingenc&; 3I, P*ases of cesarean section2remo/al of t*e fetus2 UD stage 'uterotom& 1 deli/er&, as !rief as $ossi!le; effecti/ecorrection of *&$otension and /alori0e $re1anest*etic fasting; 3II, circadian /ariation ofd&stocia2 $ain; uterine contraction; !lood loss; *&$ertension '4%N,; ris( of allerg& andast*ma+ In t*e nocturnal $*ase- t*e intensit& of contraction and ris( of *emorr*age- allerg&-and ast*ma are greater+ n t*e ot*er *and- 4%N in eclam$sia does not s*o. circadian/ariation; 3III, !stetric c*rono$*armacolog&2 local anest*etics- analgesics- *&$notics-

general anest*etics- and neuromuscular !loc(ers+ C*ronoenerg& e5$lains t*e matinal $ea(of o$ioid analgesia- /es$ertine of local anest*etic- and nocturnal of in*alational anest*etics+-2N-$.S"2NS: %*e c*rono!iological a$$roac* of la!or anest*esia em$*asi0es t*eo!stetric im$ortance of circadian r*&t*micit& in la!or *umani0ation and safet&+

0ey3ords: ANE"%4E"IA- !stetrics; C4RN6I7892 re$roduction- la!or; "UR8ER9-!stetric2 cesarean section+

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*ES.MEN

).ST"&"-AT"VA / 2B)ET"V2S: Ciclos tem$orales 'claro)oscuro; nacer)morir- etc+,- & lascondiciones am!ientales 'sincroni0adores,- influ&en en la fisiolog:a del $arto en funcin de lae5istencia de relojes endgenos 'osciladores,- <ue interact#an con $istas sociales diuturnas+En esta re/isin- fueron a!ordados los $ar=metros anestésico1o!stétricos c:clicos m=s

im$ortantes en la atencin a la $arturiente+-2NTEN"!2: An=lisis crono!iolgico de los $rinci$ales e/entos de la fisio$atolog:ao!stétrica de la Mulier sapiens2 I, Per:odo de la em!riogénesis & riesgo de teratogénesis; II,de la $rematuridad al $ostdatismo2 del $arto eutcico al cerclaje uterino; III, 7a noc*e & el$arto2 ma&or incidencia nocturna del $arto 'facilitacin fisiolgica,- & diurna de la ces=rea'o$cin del o!stetra,; I3, 7a luna & el $arto 'resultado no conclusi/o,; 3, guardia nocturnaen la Anestesia !stétrica2 contingencia $rofesional de m=s riesgos; 3I, %iem$os de laces=rea2 retirada fetal2 tiem$o UD 'uterotom& 1 deli/er&,- el m=s corto $osi!le; correccinefica0 de la *i$otensin arterial & /alori0acin del tiem$o de a&uno $reanestésico; 3II,3ariacin circadiana de la distocia2 dolor; contraccin uterina; $érdida sangu:nea;*i$ertensin arterial sistémica '4A",; riesgo de alergia & asma !rn<uica+ En la fasenocturna- e5iste una ma&or intensidad de contraccin & m=s riesgos de *emorragia- dealergia & de asma+ En contra$osicin- *a& una falta de /ariacin circadiana de la 4A" en laeclam$sia; 3III, Cronofarmacolog:a o!stétrica2 anestésicos locales- analgésicos- *i$nticos-anestésicos generales & !lo<ueadores neuromusculares+ 7a cronergia e5$lica el $icoanalgésico matinal de los o$ioides- el /es$ertino de los anestésicos locales & el nocturno delos anestésicos generales in*alatorios+-2N-$.S"2NES: El a!ordaje crono!iolgico de la atencin anestésica al $arto en lamaternidad- enfati0a la im$ortancia o!stétrica del ritmo circadiano en la *umani0acin &seguridad del $arto+

"NT*2!.-T"2N

Unli(e o/i$arous animals .*ose offs$rings are !orn in less t*an t*ree *ours- a!le to ada$tto en/ironmental conditions- t*e !irt* of mammals '/i/i$arous, is more $rolonged 'moret*an si5 *ours, and t*e ne.!orns 'N6, are un$rotected and de$endent on t*e $ermanentcare of t*eir $arents+ "e/en million &ears of >*umanoid> e/olution $ro/idedaustralo$it*ecines .it* a uni<ue anatomic $attern2 a large and tri$le 're$tilian- lim!ic- and*uman, !rain ca$a!le of de/elo$ing instincts- emotions- imagination- and !i$edalism+Ence$*ali0ation stimulated t*e de/elo$ment of *is)*er o.n culture as a conse<uence of

s$eec*- /ocali0ation- migration- life in grou$s- and t*e use of roc(s as useful instruments

?1@

+Primordiall&- t*e !i$ed female *ad a solitar& $ainful la!or de$endent on t*e la.s of sur/i/al-since s*e .as not as influenced !& instincti/e forces as ot*er mammals+ A Jesuit re$orted'3I Centur&, t*at nati/e 6ra0ilian females deli/ered alone- in t*e jungle- near a stream to.as* t*emsel/es2 >their screams during labor echoed so strongly in the jungle that theysounded as if someone was being eaten by a beast >B+ Alt*oug* la!or is $*&siological- $ainduring /aginal deli/er& can !e iatrogenic caused !& *os$ital routines suc* as !ed rest-induction or acceleration .it* o5&tocin- risteller maneu/er- and e$isiotom&+ Currentl&-/aginal la!or is considered as t*e >natural> met*od for t*e deli/er& of t*e offs$ring of Homo

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sapiens and cesarean section is t*e surgical $rocedure to sa/e t*e fetus- .*en t*e life of t*emot*er and)or fetus is in danger--+

4istorical Aspects o5 $abor and -esarean Section

%*e .ord o!stetrician comes from Obstetrix - t*e 7atin .ord for mid.ife 'o!stare G to stand

!&,- due to t*e common $osition of o!stetricians in front of t*e $arturient to *old t*e N6 in/aginal deli/er&+ %*e .ord anest*esia 'αν G no; αiσθησiς G sensiti/it&, .as used for t*e firsttime !& Dioscorides- a surgeon and !otanist- in I 6+C+ .*en *e descri!ed in *is !oo( 'DeMateria Medica, t*e *&$notic1sedati/e actions of $o$$&- mandragora- and aconitum e5tract'atro$inic action, --+

Vaginal !eli(ery

%*e e/olution of t*e African australo$it*ecines to .al(ing erect .as t*e most im$ortant!e*a/ioral attitude t*at ena!led man to lea/e t*e natural *a!itat of a <uadru$ed $rimate'tree to$s of African forests, loo(ing for t*e inde$endent life of a !i$ed- *unting on t*esa/anna and resting in ca/es- in t.o to t*ree million &ears of sur/i/al+ Alt*oug* .al(ing

erect made man more /isi!le to $redators- t*e $anoramic /ie. of Homo erectus guaranteedmore safet& and t*e $ossi!ilit& of *unting- flig*t- or fig*ting+ Hal(ing on t.o feetguaranteed 4omo erectus a $anoramic /ie. and free *ands to start t*e e$ic tre( fromcentral Africa ' t*ousand &ears after t*e ice age,- loo(ing for more caloric animal $roteinand fat+ %*e e5clusi/e use of t*e t*um! allo.ed man to t*ro. offensi/e o!jects duringfig*ts or *unting- ma(ing *im t*e onl& creature ca$a!le of causing injur& to anot*er fromafar+ %*e e5clusi/e imagination ca$acit& along .it* an increase in t*e /olume of gra& matter!& increasing t*e circum/olutions inside t*e s(ull .as res$onsi!le for t*e definiti/e e5it from*istorical o!scurit&?-+ %.el/e t*ousand &ears ago 't*e last defrost, Homo sapiens crossedt*e Nile and t*e Red "ea in a /ictorious saga to con<uer e/er& continent t*roug* /ales-mountains- deserts- la(es- seas- and oceans at K (m a &ear1@+ %o ensure t*is man .it*creati/it& and t*at *e .ould ascend to t*e $ost of lord of t*e $lanet- t*e *uman !rain 'Lof t*e !od& mass, uses ? !illion neurons and one trillion s&na$ses- consuming t*e energ&'A%P, of just one fuel- i+e+- @L of t*e glucose a/aila!le in t*e !od&- in aero!icmitoc*ondrial reaction .it* t*e unsto$$a!le e5$enditure of L of t*e $lasma o5&gencoming from t*e *eart 'L of t*e cardiac out$ut, after $ulmonar& *ematosis+ According to$aleoant*ro$ological studies- Homo .as t*e first $rimate to *unt- create com$le5 tools-s$ea(- use fire- cam$- care for t*e .ea(- and also t*e first one to !elie/e t*at !irt* anddeat* *ad a su$ernatural connection+ Unfortunatel&- ada$tation to !eing a !i$ed demandedreformulation of t*e $el/is to ma(e it an instrument ca$a!le of su$$orting loads+ %*e female$el/is !ecame ada$ti/el& narro.er in t*e region of t*e /aginal canal- ma(ing la!oranatomicall& more difficult1@+ %*e difficult& to dilate t*e uterine cer/i5 '$redominance ofelastic fi!ers 1 L,- t*e narro. !irt* canal- and t*e greater si0e of t*e *ead of t*e *umanfetus .*en com$ared to ot*er mammals- made *uman la!or t*e most $ainful among$rimates+ Fortunatel&- a ne. anatomical ada$tation com$ensated t*e narro.ing of t*e

$el/is in Mulier sapiens in relation to t*e greater relati/e si0e of t*e !rain of N62 t*e greaterimmaturit& of t*e central ner/ous s&stem 'CN", among t*e offs$rings of all $rimates-allo.ing t*e $ost1deli/er& com$ensation of structural *ead deformities of t*e N6 secondar&to t*e $assage t*roug* t*e narro. !irt* canal or to t*e use of force$s+ %*e *uman N6 is t*emost defenseless offs$ring- since *e communicates .it* t*e mot*er t*roug* *ig* intensit&cr&ing ' to d!,- !ut t*is does not guarantee sur/i/al for more t*an K *ours in case ofmaternal a!sence+ %*is im$lies t*e need of a s*ort1and medium1term solid union !et.eenmale and female- since t*e immaturit& of t*e CN" demands s$ecial $arental care for a longtime1@+

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%*e secular !elief t*at t*e macro cosmos 'i+e+- t*e sun- $lanets- and stars, interferes .it*t*e organic micro cosmos 'cells and atoms, is still $art of medical t*in(ing- .it* e/entualre$ercussions on *uman !e*a/ior and $*&siological functions+ C*rono!iolog& from t*e

'8ree(2 κρονος G time; βiος G life; λογος G stud&, studies t*e da&1nig*t 'lig*t1dar(,circadian c&cle t*at leads to ada$ti/e c*anges in $at*o$*&siological $arameters toguarantee antici$ati/e *omeostasis of !irt*- gro.t*- aging- and deat* of Homo sapiens+

"ince t*e earl& da&s- sur/i/al on Eart* of t*e !eings !est tem$orall& ada$ted .as !ased ont*e e/olutionist (no.ledge of c*aotic en/ironmental and organic modifications regardingda&s 'ultradian and circadian,- seasons- and &ear 'infradian,+ %*us- *unting- feeding- flig*t-and t*e struggle of da&time animals 'genre 4omo, are $otentiated !& t*e increasedintensit& of t*e autonomous function of t*e s&m$at*etic ner/ous s&stem and adrenal glandunder t*e sunlig*t+ In t*e dar(ness of nig*t- $aras&m$at*etic *&$eracti/it& and *&$o$*&sealmelanin facilitate digestion- fertilit&- slee$- !irt*- and deat*-?+ Alt*oug* la!or is more$ainful in t*e dar( $*ase- nocturnal la!or is more fre<uent due to geo$*&sical factors- suc*as $*ases of t*e moon and nocturnal neuro*umoral c*anges in t*e last da&s of gestation'increase in *istamine- o5&tocin- $rostaglandins- serotonin- and melatonin,- ensurings*orter la!or under t*e moon lig*t- a nocturnal $rotection against nig*t d.elling $redators1

?? +

Alt*oug* Je*o/a* .as t*e first to use general in*alational anest*esia for t*e !irt* of E/efrom a ri! from Adam 'Genesis, 2:2,- t*ere are !i!lical Judaic1C*ristian re$orts on t*eglor& and damnation of la!or in t*e life of a .oman+ According to t*e creationism $oint of/ie.- la!or- after e5$ulsion from t*e 8arden of Eden- .ould !e c*aracteri0ed !& $unis*mentand $ain 'Genesis, !:",- >with pain you shall gi#e birth>- i+e+- similar to Rac*el 'Genesis,

!$:",- .*ose son .as called >son of my trouble>- it .ould !e fore/er associated .it*$ain?+ %*e Ne. %estament ratifies la!or $ain- according to "aint Paul ' %hessalonians $:!,>as labor pains in a pregnant woman, and they will not escape>- and "aint Jo*nsRe/elations '&e#elations 2:2,2 >she was pregnant and cried out in pain as she was about

to gi#e birth> ?+ For centuries C*ristianit& acce$ted $ain as just $unis*ment from 8od- .*ic*s*ould !e acce$ted .it* su!mission