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A case of gestational diabetes complicating the pregnancy of a hypoparathyroid gravid patient is presented. Labor was induced by prostaglandin E2 vaginal tablets, but delivery was by cesarean section. Separate treatment of the two endocrinopathies was successful. After the induction of labor, hypocalcemia and hypoglycemia were seen, and they may have been caused by the prostaglandin E2.
OBJECTIVE: To determine whether known historical risk factors of brachial plexus injury differ between affected neonates and healthy controls. METHODS: The files of all 62 children with Erb's palsy who were diagnosed after birth were reviewed. The control group consisted of 124 randomly selected uninjured infants born within the same period. RESULTS: Compared with the control group, the mothers of the neonates with brachial plexus injury were found to be significantly older (32.1+/-5.2 years vs. 28.9+/-5.8 years, P = 0.01), and had a significantly higher incidence of diabetic pregnancy (69% vs. 14.5%, P = 0.001); the infants had a significantly higher mean birth weight (3846+/-576 g vs. 3220+/-582 g, P = 0.0001) and higher incidence of birth weight > or = 4000 g (27% vs. 4.8%, P = 0.0001). Two of the infants in the study group (3.2%) were born by elective cesarean section. CONCLUSIONS: Brachial plexus injury is associated with several non-predictable or preventable risk factors.
OBJECTIVE: Evaluate possible advantages or disadvantages of the sitting over the horizontal position during the second stage of labor. DESIGN AND METHODS: Clinical trial randomly selecting 127 volunteers for the sitting position and 121 for the horizontal position during the second stage of labor. Duration of the second stage and of expulsion of the placenta, vulvo vaginal and perineal lacerations, blood lost and Apgar score were evaluated. RESULTS: There was a non-significant decrease of 3.4 min in the duration of the second period in the vertical position in comparison with the horizontal position. There was a similar difference in the duration of delivery of the placenta, but also non-significant. Blood loss was slightly greater among women delivering in vertical position, but the difference did not reach significance. Breastfeeding did not show any influence on blood loss and on the time for delivering the placenta. The incidence of perineal trauma was 44.1% for vertical position and 47% for horizontal position in the whole group and of 47.8% and 71.2% in the group with history of episiotomy. This last difference was statistically significant. The results of this study are in the line of other studies that suggest some advantages and possible disadvantages of the vertical position. CONCLUSIONS: Mothers should be given the choice of the posture to be assumed during parturition. The supine position should not be imposed and episiotomy should not be a routine.
OBJECTIVE: To evaluate the obstetric outcomes associated with persistent occiput posterior position of the fetal head in term laboring patients. METHODS: We performed a cohort study of 6434 consecutive, term, vertex, laboring nulliparous and multiparous patients, comparing those who delivered infants in the occiput posterior position with those who delivered in the occiput anterior position. We examined maternal demographics, labor and delivery characteristics, and maternal and neonatal outcomes. RESULTS: The prevalence of persistent occiput posterior position at delivery was 5.5% overall, 7.2% in nulliparas, and 4.0% in multiparas (P <.001). Persistent occiput posterior position was associated with shorter maternal stature and prior cesarean delivery. During labor and delivery, the occiput posterior position was associated with prolonged first and second stages of labor, oxytocin augmentation, use of epidural analgesia, chorioamnionitis, assisted vaginal delivery, third and fourth degree perineal lacerations, cesarean delivery, excessive blood loss, and postpartum infection. Newborns had lower 1-minute Apgar scores, but showed no differences in 5-minute Apgar scores, gestational age, or birth weight. CONCLUSION: Persistent occiput posterior position is associated with a higher rate of complications during labor and delivery. In our population, the chances that a laboring woman with persistent occiput posterior position will have a spontaneous vaginal delivery are only 26% for nulliparas and 57% for multiparas.
BACKGROUND: Subdural haematomas are thought to be uncommon in babies born at term. This view is mainly based on findings in symptomatic neonates and babies in whom subdural haemorrhages are detected fortuitously. We aimed to establish the frequency of subdural haemorrhages in asymptomatic term neonates; to study the natural history of such subdural haematomas; and to ascertain which obstetric factors, if any, are associated with presence of subdural haematoma. METHODS: We did a prospective study in babies who were born in the Jessop wing of the Central Sheffield University Hospitals between March, 2001, and November, 2002. We scanned neonates with a 0.2 T magnetic resonance machine. FINDINGS: 111 babies underwent MRI in this study. 49 were born by normal vertex delivery without instrumentation, 25 by caesarean section, four with forceps, 13 ventouse, 18 failed ventouse leading to forceps, one failed ventouse leading to caesarean section, and one failed forceps leading to caesarean section. Nine babies had subdural haemorrhages: three were normal vaginal deliveries (risk 6.1%), five were delivered by forceps after an attempted ventouse delivery (27.8%), and one had a traumatic ventouse delivery (7.7%). All babies with subdural haemorrhage were assessed clinically but no intervention was needed. All were rescanned at 4 weeks and haematomas had completely resolved. INTERPRETATION: Presence of unilateral and bilateral subdural haemorrhage is not necessarily indicative of excessive birth trauma.
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OBJECTIVE: Our study was designed to explain determinants of nonprogressive labor in nulliparous patients. STUDY DESIGN: One hundred consecutive nulliparous patients have got a cesarean section for active-phase arrest of labor after two hours of active management. Intrauterine pressure was monitored for all of them and a X-ray pelvimetry was done after surgery. RESULTS: Eighty-three percent of patients showed X-ray data considered as normal; hypotonic labor was found in 50% of cases and occiput posterior position in 60%. CONCLUSIONS: Our results suggest that occiput position and functional dystocia are more common in case of nonprogressive labor than abnormal measurements of the obstetrical pelvis.
Data concerning 16 triplet and higher-order deliveries (resulting in a total of 56 infants) are reviewed. The vaginal delivery rate was 81%. Maternal morbidity was more serious after abdominal delivery. Prematurity (less than 36 weeks gestation) rate amounted to 68%. Overall perinatal and neonatal mortalities for infants born after 28 weeks gestation and weighing at least 1000 g were 7% and 3%, respectively. We doubt that neonatal outcome could have been markedly improved by performing more cesareans. The importance of antenatal care is stressed.
Preliminary observations fail to indicate a higher risk to the twin babies as a result of labor induction or Cesarian section, so that a systematic clinical trial will now be possible.
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BACKGROUND: Post partum hemorrhage is a major cause of maternal death, particularly in developing countries, and most cases are due to an atonic uterus. Hemorrhage can occur despite active management of the third stage of labor. Presently, misoprostol (Cytotec, Searle Pharmaceuticals) is the only thermostable uterotonic agent potentially available which would be economically beneficial for developing countries where refrigeration of drugs poses a problem. The objective of the study was to compare intra-muscular Syntometrine (Sandoz Pharmaceuticals) (ampoule=5 iu oxytocin and 500 mcg ergometrine maleate) plus Syntocinon (Sandoz Pharmceuticals) (10 iu oxytocin diluted in 500 ml normal saline) intravenous infusion versus 800 mcg misoprostol per rectum for treatment of primary post partum hemorrhage in a developing country. METHODS: Randomized single blinded two-center study, set in both a township and teaching hospital in South Africa. Sixty-four women with primary post partum hemorrhage due to an atonic uterus were recruited. The primary outcome measure was whether the hemorrhage ceased within 20 minutes of administering the first line treatment, once hemorrhage was clinically recognized. RESULTS: There was a 28.1% difference between the misoprostol arm and the Syntometrine and Syntocinon arm (p=0.01). This result had a greater than 80% power. Misoprostol performed better. CONCLUSION: 800 mcg misoprostol per rectum is effective at treating primary post partum hemorrhage.
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OBJECTIVE: to evaluate the feasibility of a randomised controlled trial (RCT) examining the effect of three options (augmentation, conservative and water) for the management of dystocia in nulliparae. The main objectives were to explore the feasibility of trial procedures in the clinical environment, consent rates and acceptability of the management options to women, local incidence of dystocia in nulliparae and the size of the subsequent study. DESIGN: a two part study: a pilot, RCT with follow-up through to delivery with postnatal maternal surveys, and a case review of nulliparae with dystocia. SETTING: a large maternity unit in the South of England in May-July 1997 inclusive. PARTICIPANTS: nulliparae with dystocia in the first stage of labour who had an otherwise uncomplicated obstetric background. INTERVENTIONS: women in the pilot RCT received one of three management options: labouring in a waterbirth pool, conservative management or augmentation of labour, which is the standard management of women with dystocia condition in the Unit. FINDINGS: it is feasible to conduct an RCT of management of dystocia in the Unit. Seventy per cent (95% confidence interval 47% to 87%) of women approached agreed to participate. Conservative management was the least acceptable option to women and has been dropped from the subsequent trial. The audit provided some idea of possible differences in operative delivery and epidural rates depending on augmentation or not. A sample of 220 women should be large enough to detect moderate changes and will require a 2-year recruitment period. CONCLUSIONS: a subsequent trial is feasible and is now underway. It has the potential to provide information enabling women and practitioners to have a greater choice of care options in the presence of dystocia, or provide a good basis for an even larger trial.
Elective induction was practised in 1875 of 10 537 deliveries (17.8%). Duration of delivery was, if anything, shortened after elective induction, compared with spontaneous delivery. There was no evidence of soft-tissue dystocias after elective induction. The Apgar score was 8-10 in 95.7% of children born after elective induction. pH of umbilical-artery blood in 95.7% of children after elective induction was greater than or equal to 7.2. There was a striking increase in the incidence of occiput posterior position with elective induction (2.7% of cases). The incidence of operative vaginal delivery was as frequent after elective as after all other forms of delivery. The incidence of section was 4.7% after elective induction, 11.5% in the entire series, intra-uterine asphyxia being an indication in 1.7%, compared with 2.5% for the total group. The frequency of operations was inversely proportional to the cervical index. Perinatal mortality was 0.53 per thousand (one case) after elective induction, 10.15 per thousand in the total group, 5.9 per thousand in those with indication for early induction. Perinatal mortality decreased from 23.0 per thousand to 7.2 per thousand from 1967 to 1974.