The flying squad. Commentary.
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Ambulances↗
Biomedical subjects
B M Hibbard
Publications and source records attributed to B M Hibbard.
Serious non-fatal complications associated with extradural block in obstetric practice.
A retrospective study of serious non-fatal complications of extradural block in obstetric practice was carried out using a postal questionnaire. Two hundred and three obstetric units in the United Kingdom (responsible for 2,580,000 deliveries from 1982 to 1986 inclusive) responded. A total of 505,000 extradural blocks were performed, 84% for relief of pain in labour and 16% for Caesarean section. Of 108 events reported, five were associated with permanent disability. Neuropathy involving a single spinal nerve, acute toxicity from the local anaesthetic, and problems associated with accidental dural puncture were the commonest complications. This investigation indicates the need for a prospective study. Although rare, serious complications could be reduced further by meticulous technique, while early diagnosis and treatment of untoward events would reduce the incidence of permanent disability.
Anesthesia, Epidural↗
The obstetric forceps--are we using the appropriate tools?
A total of 166 pairs of obstetric forceps of three different types in regular use in two major obstetric units was measured and compared with manufacturers' master instruments and drawings. As well as linear measurements of blade, shank and handle the distances between the tips and maximum distance between the blades, and the mean radius of the cephalic curve were determined. The purpose of the study was to assess the suitability of instruments in common use for present day practice. It was found that the measurements differed significantly from the original descriptions and there were wide variations between instruments of the same type, even when supplied by the same manufacturer. In some cases the blades had not been packed in matching pairs in the Central Sterile Supplies Department. It is suggested that critical reappraisal of the forceps in current use in many obstetric units is overdue. As well as a need for reconsidering the type of forceps used the dimensions of individual pairs should be checked.
Equipment Design↗
The availability of epidural anaesthesia and analgesia in obstetrics.
This survey analyses the provision of obstetric epidural services on national and regional bases and also by size of obstetric unit. Epidural anaesthesia and analgesia in obstetrics is not readily available to all women who wish for it, or in whom it is recommended on medical grounds, in spite of the recommendations of the Social Services Committee and other advisory bodies. Deficiencies in the provision of facilities are obvious but further analysis at a local level is required to determine the reasons and the remedies.
Analgesia↗
Antenatal care--past achievements & future needs. Mabel Liddiard Memorial Lecture.
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Female↗
Should women at high risk of neural tube defect have an amniocentesis?
As part of an investigation into the practical problems of a maternal serum alphafetoprotein (AFP) neural tube defect (NTD) screening programme carried out in Mid Glamorgan, South Wales, between 1977 and 1979, obstetricians were recommended to refer women with high risk pregnancies directly for counselling, high resolution ultrasonography, and amniocentesis without first carrying out serum screening. Out of 15 687 pregnant women one-third attended too late to be screened. A total of 637 was classed as high risk, mostly at greater risk than 1 in 50 because of a previously affected pregnancy or an affected close relative. Compliance with recommended procedure was relatively low as many were screened. There were 10 pregnancies with a recurrence of NTD, of which one was not tested at all, two were not detected (one closed meningocele and one closed iniencephalic), and seven were detected and the pregnancies terminated. All the latter, as well as the iniencephalic, would have been detected from a serum AFP determination and a high resolution ultrasound scan alone. It is concluded that these investigations are sufficient for high risk pregnancies and that amniocentesis is not really cost effective or necessary unless either of these investigations is abnormal. As numbers in this study were small it is suggested that these conclusions should be tested in a larger study.
Amniocentesis↗
Obstetric anaesthetic and analgesic services in Wales.
A survey of obstetric anaesthetic services in Wales covering 21 major units in which over 31 000 deliveries take place annually showed inadequacies in staffing at consultant and resident anaesthetist level. At least 20 additional consultant sessions were required to meet the recommendations of the Association of Anaesthetists of Great Britain and Ireland. If patients' requests for epidural analgesia are to be met some reorganisation and centralisation of facilities is needed.
Anesthesia, Epidural↗
Precision in estimating gestational age and its influence on sensitivity of alphafetoprotein screening.
The interpretation of maternal serum alpha-fetoprotein (AFP) concentrations in relation to fetal neural tube defects depends on accurate assessment of the gestational age. In a quadruple-blind study three antenatal methods of assessment--namely, menstrual dates, clinical examination, and ultrasound scanning--were correlated with postnatal assessment using the Dubowitz scoring system. The best agreement to +/- 1 week was obtained using menstrual dates and ultrasound in combination, such agreement being found in 91 (77%) of the 118 women studied. Since serum AFP concentrations vary with gestational age, precise gestational dating is necessary. In many cases, particularly in women who are unsure of their dates or have irregular menstrual cycles, ultrasound examination is needed to supplement clinical findings.
Clinical Trials as Topic↗
The outcome of pregnancy after cone biopsy of the cervix: a case-control study.
We investigated the outcome of pregnancy after cone biopsy of the cervix. We found that preterm delivery and low birth weight were commoner and the mean duration of labour longer in women who had a cone biopsy than amongst matched controls. Rapid labour (under two hours) was not significantly more common after cone biopsy.
Abortion, Spontaneous↗
Perinatal mortality and morbidity associated with eclampsia.
Out of all the women who were delivered in Cardiff maternity units during 1965-74, 43 developed eclampsia, an incidence of 72/100 000 deliveries. The incidence in residents of Cardiff was 53/100 000 deliveries. None of the mothers with eclampsia died, but 10 of the 47 babies were lost, all but one having been born to women with antepartum eclampsia. The perinatal deaths were mainly associated with chronic placental insufficiency and preterm delivery. The extent to which the wide range of complex drug regimens used influenced perinatal outcome is not clear, although polypharmacy should be avoided. Because eclampsia is rare we advocate that its management should be planned and rehearsed and that a simple, standardised treatment regimen should be used. Failing placental function may be detected by monitoring fetal growth by ultrasound.
Adult↗
Pre-eclampsia/eclampsia.
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Delivery, Obstetric↗
The management of severe pre-eclampsia and eclampsia.
With improving standards of antenatal care, severe pre-eclampsia dn eclampsia are becoming less common and experience in the management of these conditions is lessening. Co-ordinated plans for the care of patients should be established by obstetricians and anaesthetists working as a team. A suitable regime for drug therapy in severe pre-eclampsia or eclampsia is the following: Initial management Diazepam 10 mg slowly i.v. Pethidine 100-150 mg i.m. or i.v. in incremental dosage, or extradural blocks, if analgesia is also required. Hydrallazine 20 mg i.v. initially, followed by 5 mg at intervals of 20 min until the diastolic pressure is less than 110 mm Hg. Then, preferably by syringe pump in a concentration of 2 mg/ml, at a rate of 2-20 mg/h. If vomiting occurs this can be controlled by administration of atropine. Subsequent management Sedation and anticonvulsant therapy. Continue diazepam and, in severe cases, institute chlormethiazole infusion. Continue analgesia with pethidine or extradural block. Control of hypertension by adjusting the dose of hydrallazine. If tachycardia exceeds 120 beat/min give propanolol 2-4 mg i.v. Plasma protein depletion with groww oedema is treated by administration of salt-free albumin or plasma protein fraction. Diuretic therapy is indicated if there is gross oedema or signs suggestive of acute renal failure. Oliguria associated with increased blood urea may be a result of renal failure or dehydration. The latter should be evident from the patient's condition and central venous pressure, but i.v. fluids and frusemide 20-40 mg can be used as a therapeutic test. Mannitol reduces cerebral oedema and may be given if diuresis has been first produced with frusemide. Potassium chloride is given if the plasma potassium decreases to less than 3 mmol/litre. Heparin therapy is considered if there is clinical evidence of disseminated intravascular coagulation.
Chlormethiazole↗
Controlled trial of bromocriptine, quinoestrol, and placebo in suppression of puerperal lactation.
2-bromo-alpha-ergocryptine (bromocriptine) in a dosage of 2-5 mg twice daily caused a rapid fall in plasma prolactin. It was more effective than either a single dose of 4 mg quinoestrol or a placebo in suppressing puerperal lactation, as judged by milk flow and the relief of breast pain and congestion. Patients who received quinoestrol were more comfortable than those who received placebo.
Bromocriptine↗
Folates and the fetus.
Folate metabolism is sometimes deranged in the early weeks of pregnancy at the time of placentation and organogenesis. Maternal folate deficiency may result in general impairment of fetal growth, which is reflected in low birthweight. Such women also have a high incidence of abortion, abruptio placentae and fetal malformation. Megaloblastic anaemia is the commonest and most easily recognised manifestation of folate deficiency.
Abortion, Spontaneous↗