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PubMed1995

Obstetric outcome in singleton pregnancies after assisted reproduction.

OBJECTIVE: To compare the obstetric outcome of singleton pregnancies after various procedures of assisted reproduction with a control group. METHODS: Maternal and perinatal outcome in 355 assisted-reproduction singleton pregnancies (study group) with a duration of 140 days or more were compared retrospectively with a control group matched for age and parity. All assisted-reproduction pregnancies resulted from treatment in one university hospital, and all control subjects delivered in the obstetric department of the same hospital. The controls consisted of 643 women, also with singleton pregnancies, who were matched for age and parity. RESULTS: In the study group, the frequencies of pregnancy-induced hypertension and placenta previa were increased. More patients in the study group were delivered by elective cesarean. Pregnancies after assisted reproduction were of shorter duration, with an increased incidence of preterm birth. Infants in the study group had a lower mean birth weight than did those in the control group and were more frequently referred to a neonatal care unit. CONCLUSION: Singleton pregnancies resulting from assisted reproduction represent obstetric risk cases, and the patients should be offered special attention during the pregnancy, which will probably be their only one.

Adult↗
PubMedDate not supplied

Tropical obstetrics and gynaecology. 3. Vesico-vaginal fistula--a tropical disease.

The predominantly obstetric origin of vesico-vaginal fistulae in the tropics is contrasted with the mainly surgical aetiology of those in Europe by analysis of 543 cases treated in Nigeria and in the United Kingdom. Reasons are given for the high incidence in tropical countries of obstructed labour and hence of vesico-vaginal fistulae. The general management of patients with obstetric fistulae is described, followed by the principles of their surgical treatment and postoperative nursing care. The importance of success at the first attempt at repair is stressed, and the small place for managing failures by urinary diversion is mentioned. It is concluded that obstetric fistulae should be preventable in the tropics, having now been effectively eliminated from industrialized countries.

Cesarean Section↗
PubMed1989

Active patients: the integration of modern and traditional obstetric practices in Nepal.

This paper describes the integration of modern and traditional obstetric practices in a provincial hospital in the Maithili-speaking area of southern Nepal. The doctors and nurses consciously distance themselves from the traditional practices of their obstetrical patients, whom they view as 'ignorant'; but because hospital resources are insufficient to impose the normative form of modern medical organization, patients and their relatives assert a more active role in providing hospital-based care. In consequence, mothers are delivered according to both modern, clinical as well as local cultural practices. Recent WHO policy has cast modern medicine as the agent in the integration of traditional healing within national health systems. This essay shows that in poor countries the powers of agency may not be exclusively in the hands of the medical profession. Patients, and others in their social networks, have become agents, constraining and negotiating the terms on which modern medicine is to be integrated within their traditional obstetric practices.

Attitude of Health Personnel↗
PubMed2006

[Initial training in obstetric anaesthesia].

Obstetric anaesthesia is a "young" discipline, with constant novelties from a clinical, scientific and academic standpoint. While there is still no official sub-specialty in obstetric anesthesia, this field has become more diversified because of the growing maternal request for labor analgesia, a constant and perhaps even increasing rate of caesarean deliveries of 20-30% depending on institutions and countries, and also due to the raise in "high risk" pregnancies in women carrying various medical conditions such as complex congenital cardiopathies. In their anesthesia training, most residents rotate in the delivery room for three months on average, which should allow them to acquire good practical skills when performing regional analgesia and anesthesia for labor and delivery. It has been shown that performing 75 epidurals in the obstetric context is sufficient to provide good technical expertise, when appropriate supervision is provided by a present and devoted staff. General anaesthesia remains the critical point, because this technique is less and less performed in pregnant women. It should be recommended to develop training programs to improve the technical skills for intubation in pregnant women, which is why anaesthesia simulators may have an important role in the future. In terms of the theoretical knowledge, good academic training programs are required. The physiology of pregnancy and the physiopathology of pregnancy-related disorders justify a thorough and rigorous teaching in order to reduce both maternal and neonatal morbidity and mortality.

Analgesia, Epidural↗
PubMed2006

French trainees in obstetrics and gynaecology theoretical training and practice of vaginal breech delivery: a national survey.

OBJECTIVE: To survey French trainees in Obstetrics and Gynaecology and evaluate their theoretical training and practice of vaginal breech delivery (VBD). STUDY DESIGN: We conducted a national survey between January and April 2004 among the 817 French trainees undergoing a 5-year training program in obstetrics and gynaecology. Trainees in years 1-3 were considered as juniors, and those in years 4 and 5 as seniors. Respondents were invited to specify whether they had received theoretical teaching in the management of VBD, and to indicate the number of VBDs they had performed during their training. RESULTS: The questionnaire was returned by 156 (19%) trainees and of these 140 questionnaires were suitable for analysis. Overall, 35% of the respondents had never been taught the management of a VBD. Among the senior trainees, 33% had performed less than four VBDs, and 23% had not received any teaching on how to manage a VBD. CONCLUSION: The level of theoretical training and practice in the management of VBD seems to have diminished and does not bring the French trainees in obstetrics and gynaecology to the required standard of competence.

Breech Presentation↗
PubMed2005

Complementary and alternative medicine in obstetrics.

OBJECTIVE: To identify, survey and review randomized controlled studies of the use of complementary and alternative medicine (CAM) for obstetric treatment or health promotion. METHODS: The MEDLINE database was searched to identify randomized controlled trials of CAM treatment and therapies in obstetrics. Studies examining modalities for treatment or improvement of health status were reviewed. RESULTS: Fifty-four articles assessing a variety of health modalities met the criteria for inclusion. Acupressure and ginger for prenatal nausea and vomiting, moxibustion for version of breech presentation, sterile water injections for back pain relief in labor, and perineal massage to prevent perineal trauma have three or more studies demonstrating beneficial effect. Other interventions have been studied less, and evidence for them is limited. CONCLUSIONS: Some CAM interventions have evidence of effectiveness for use in obstetric patients, while others require further investigation before they can be considered for use in practice.

Complementary Therapies↗
PubMed2006

The effect of addressing demand for as well as supply of emergency obstetric care in Dinajpur, Bangladesh.

PURPOSE: The Dinajpur SafeMother Initiative (DSI) was designed to test the impact of several interventions on use of obstetric services in government health facilities in Northwestern Bangladesh during 1998-2001. INTERVENTION: Facility-based interventions included upgrading health facilities. The sub-district hospitals or Upazila Health Centers (UHCs) had earlier been upgraded to provide basic emergency obstetric care (BEmOC). This project undertook activities designed to improved the quality of care in the facilities which included team-building among providers, case reviews and a stakeholders' committee. CARE introduced a community mobilization intervention, which included birth planning, community support systems for funding, transportation, blood donation etc. for care of women with complications. METHODS: The intervention area received all interventions. The only intervention in the comparison area was the upgrading of the health facilities to provide basic EmOC. There were no interventions in the control area. RESULTS: Met need increased by 13% in comparison area but nearly 24% in intervention area. There was no substantial change in the control area. At the end of the project, knowledge of obstetric danger signs was much greater in intervention area than in the other 2 areas. CONCLUSION: We conclude, therefore, that the best results are achieved through a combination of facility improvement, quality of care activities and targeted community mobilization activities.

Adolescent↗
PubMed2006

Can the process indicators for emergency obstetric care assess the progress of maternal mortality reduction programs? An examination of UNFPA Projects 2000-2004.

BACKGROUND: In view of the disappointing progress made in the last 20 years in reducing maternal mortality in low-income countries and before going to scale in implementing the new evidence-based strategies, it is crucial to review and assess the progress made in pilot countries where maternal mortality reduction programs focused on emergency obstetric care. OBJECTIVE: To review the process indicators recommended for monitoring emergency obstetric care and their application in field situations, examining the conditions under which they can be used to assess the progress of maternal mortality reduction programs. METHODS: Five of the six UN recommended process indicators were monitored annually for 5 years in selected districts of Morocco, Mozambique, India and Nicaragua. Trends are presented and discussed. RESULTS: With specific variations due to different local situations in the four countries and in spite of variations in quality of data collection, all indicators showed a consistent positive trend, in response to the inputs of the programs. CONCLUSIONS: The UN process indicators for emergency obstetric care should continue to be promoted, but with two important conditions: (1) data collection is carefully checked for quality and coverage; (2) efforts are made to match process and outcome indicators (maternal and perinatal mortality, incidence of complications).

Emergency Medical Services↗
PubMed2006

Impact of walking epidural analgesia on obstetric outcome of nulliparous women in spontaneous labour.

BACKGROUND: To explore the effects of walking epidural analgesia on obstetric and neonatal outcomes, we performed a case-control study. METHOD: Each nulliparous woman receiving walking epidural analgesia using 0.0625% bupivacaine (n = 44) was matched to two nulliparous historical controls receiving 0.125% or 0.25% bupivacaine (n = 88 each) for epidural analgesia while recumbent. RESULTS: Maternal and obstetric parameters, fetal status and presentation, and oxytocin use were comparable among groups. Those receiving walking epidural analgesia walked for a mean of 60 min (range: 20-75 min). In the control groups the mean total durations of labour were shorter (58 min in the 0.125% group and 99 min in the 0.25% group, P < 0.05). Significantly fewer walking epidural analgesia cases than controls required instrumental vaginal delivery (P < 0.05). No other differences in obstetric or fetal outcome were observed and no mother fell or stumbled while walking. CONCLUSION: Although it was associated with a prolonged first stage of labour, walking epidural analgesia appeared safe for nulliparous women and their babies.

Adult↗
PubMed1987

Obstetric outcome of patients with a previous episode of spurious labor.

The obstetric performance of patients admitted with spurious labor was evaluated. The incidence of fetal distress in labor was significantly higher in those who had spurious labor (16.7%) than in those who were established in labor within 24 hours of admission (3.8%). An equivocal or ominous fetal heart rate trace on admission was related to the occurrence of fetal distress in labor in both the spurious labor group and the normal labor group. Positive predictive value of a normal test was low in the spurious labor group. Obstetric interventions such as augmentation (35.7%) and operative deliveries (41.0%) were significantly higher in the spurious labor group than in the normal labor group (19.7% and 18.8%, respectively). The induction rate in the spurious labor group was 15.5%. The use of oxytocin for augmentation and induction of labor seems to contribute to the increased incidence of fetal distress and operative deliveries in the spurious labor group. The spurious labor group also had a higher incidence of fetal distress than the control group even among the patients who did not receive oxytocin. The results suggest that patients with an episode of spurious labor constitute a high-risk group with a considerable risk of fetal distress and obstetric interventions in subsequent labor.

Delivery, Obstetric↗
PubMed1996

A randomized prospective trial of the obstetric forceps versus the M-cup vacuum extractor.

OBJECTIVE: Our purpose was to determine the efficacy of the obstetric forceps versus the M-cup, a new vacuum extractor cup, and maternal-neonatal complication rates. STUDY DESIGN: Over a 10-month period operative vaginal deliveries were randomized between the obstetric forceps and the M-cup vacuum extractor cup. Maternal demographics, indication for intervention, analgesia, position, station, degree of asynclitism, fetal caput-molding, and time from application to delivery were prospectively recorded. Episiotomy and extensions, lacerations, and the reason for abandonment of the randomized instrument were noted in both groups. Fetal weight, Apgar scores, cord arterial gases, hyperbilirubinemia, phototherapy, and any evidence of fetal trauma were documented at delivery or in the nursery. RESULTS: Six hundred thirty-seven women were randomized, 315 in the forceps group and 322 in the M-cup group. There were no differences in maternal demographic variables. The station, position, degree of asynclitism, or requirement for rotation was not different between the groups. The corrected efficacy rates were forceps 92% and M-cup 94% (p = 0.217). The M-cup deliveries were accomplished more rapidly than forceps deliveries (p < 0.001) and were associated with a lower rate of episiotomy (p < 0.001), third-degree (p < 0.001) and fourth-degree (p = 0.002) lacerations, but blood loss as clinically estimated (p = 0.232) or as measured by hemoglobin levels (p = 0.166) was not significantly different. Forceps deliveries were associated with fewer clinically diagnosed cephalhematomas (p = 0.015) than M-cup deliveries were, but there were no differences in the number of neonates diagnosed with hyperbilirubinemia (p = 0.377) or in the number of infants treated with phototherapy (p = 0.660). CONCLUSIONS: The M-cup vacuum extractor cup appears to be as efficient (and faster) than the obstetric forceps but is associated with significantly more fetal cephalhematomas, whereas maternal injuries are more common with the forceps.

Adult↗
PubMed1997

Is the obstetric outcome of in vitro fertilized singleton gestations different from natural ones? A controlled study.

OBJECTIVE: To determine whether singleton IVF pregnancies carry adverse maternal or fetal outcome when compared with naturally conceived gestations. DESIGN: An analysis of the obstetric outcome of singleton IVF pregnancies in comparison with matched, naturally conceived singleton controls. SETTING: In vitro fertilization unit and obstetric service at a tertiary medical center. PATIENT(S): Two hundred sixty consecutive singleton IVF pregnancies and 260 naturally conceived singleton controls matched 1:1 for maternal age, parity, ethnic origin, and location and date of delivery. INTERVENTION(S): In vitro fertilization-ET. MAIN OUTCOME MEASURE(S): The rate of antenatal obstetric complications, nonvertex presentation, cesarean section, preterm labor, low birth weight, small and very small for gestational age, neonatal intensive care unit admissions, and perinatal mortality. RESULT(S): The rates of most antenatal complications were similar in both groups. Urinary tract infection was the only complication diagnosed significantly more frequently after IVF (7.3% versus 1.2%); however, the rates of severe urinary tract infection necessitating hospitalization were similar. The incidence of nonvertex presentation was also similar. The cesarean section rate was significantly higher among IVF patients (41.9% versus 15.5%). The rates of preterm labor, low birth weight, small and very small for gestational age, neonatal intensive care unit admissions, and perinatal mortality were comparable. CONCLUSION(S): When controlling for maternal age, parity, ethnic origin, and location and date of delivery, singleton IVF pregnancies do not carry an increased risk for prematurity, low birth weight, or maternal or fetal complications. Still, these pregnancies are associated with a high rate of cesarean sections.

Adult↗
PubMed2000

Occipitoposterior position: associated factors and obstetric outcome in nulliparas.

OBJECTIVE: To determine factors associated with term delivery in the occipitoposterior position and examine obstetric outcomes from that delivery position in nulliparas. METHODS: We did a retrospective analysis of population-based data of 16,781 nulliparas who delivered at term (37-42 weeks) with singleton, cephalic presentations. Factors examined for possible association with occipitoposterior position were fetal weight, maternal age, completed weeks of gestation, epidural analgesia in labor, labor induction, and oxytocin augmentation. Obstetric outcome measures were mode of delivery and percentage of infants with Apgar scores less than 8 at 5 minutes. RESULTS: The frequency of occipitoposterior position was 4. 6%. Fetal weight, epidural analgesia, and oxytocin augmentation were strongly associated with delivery in the occipitoposterior position (odds ratios 1.18, 2.21, 1.44, respectively, P <.001, logistic regression). There was a higher incidence of instrument and emergency cesarean deliveries in occipitoposterior compared with occipitoanterior labors (43.7% versus 24.4%, 41.7% versus 13.7%, respectively, P <.001, the chi(2) test). There was no significant difference in percentage of infants with low Apgar scores at 5 minutes between those who delivered occipitoposterior or occipitoanterior. CONCLUSION: Epidural analgesia and oxytocin augmentation are associated with increased incidence of occipitoposterior position, which leads to increased operative obstetric intervention for delivery.

Adolescent↗
PubMed1993

StORQS: Washington's Statewide Obstetrical Review and Quality System: overview and provider evaluation.

The Foundation for Health Care Quality (Washington) used three administrative public databases and indicators recommended by the Joint Commission and the American College of Obstetrics and Gynecology to build algorithms to measure quality of obstetric care in the state of Washington. Analyses demonstrated a high degree of variability across hospitals for major processes of care such as cesarean section, vaginal birth after cesarean section, and forceps deliveries. Eighty-five percent of the participating hospitals concluded that important aspects of care were being measured. Ninety-four percent found the information useful in describing their performance compared with other hospitals. Sixty-two percent believed the information was useful for initiating quality improvement projects. Of the 25 indicators tested in the project, indicators rated as most useful were the same 10 obstetric indicators chosen by the Joint Commission after alpha testing.

Cesarean Section↗
PubMed1999

Definitions in obstetric anaesthesia: how should we measure anaesthetic workload and what is 'epidural rate'?

Crude delivery rate is used to calculate requirements for consultant anaesthetic sessions in the UK, but this calculation is arbitrary and ignores differences in case-mix between units. The term 'epidural rate' is commonly used to indicate regional anaesthetic activity but has never been defined. We challenge both these concepts and illustrate our argument by applying different definitions of obstetric anaesthetic activity to prospectively collected maternity data from 31 211 deliveries over 5 years in two hospitals. Number of anaesthetic interventions is a more accurate reflection of obstetric anaesthetic activity than number of deliveries, with Northwick Park Hospital having about 200-600 more deliveries per year than Chelsea & Westminster Hospital but about 300-400 fewer anaesthetic interventions per year. 'Epidural rate' varied by up to 30% according to the definition used. We conclude that number of anaesthetic interventions should replace crude number of deliveries as a measure of obstetric anaesthetic activity, and that the term 'regional anaesthesia rate' should replace 'epidural rate'.

Anesthesia, Epidural↗
PubMed1998

Management of faecal incontinence following obstetric injury.

BACKGROUND: Faecal incontinence is common in women and the major aetiological factor is childbirth. Increasing numbers of women with faecal incontinence are presenting to surgical clinics. METHODS: A literature review was performed on Medline database for English language publications an obstetric injury. The incidence, presentation, assessment and treatment of faecal incontinence following obstetric injury were evaluated. RESULTS AND CONCLUSIONS: Third-degree tear occurs in association with less than 1 per cent of vaginal deliveries, but occult sphincter injury occurs at one-third of deliveries and may be significant in later life. Incontinence may result from sphincter damage or nerve injury, or both. Risk factors for these injuries can be identified. Clinical evaluation, anorectal physiology and endoanal ultrasonography allow accurate planning of subsequent surgery. Overlapping anterior anal sphincter repair provides symptomatic control of continence in 80 per cent of patients. Repair of an acute anal sphincter injury after a third-degree tear is controversial and a defined policy should be agreed between obstetric and colorectal teams.

Anal Canal↗
PubMed2001

Obstetric and diabetic care for pregnancy in diabetic women: 10 years outcome analysis, 1985-1995.

AIM: Ten-year outcome analysis of all pregnancies in diabetic women in a population of 1.5 million people. METHODS: Ascertainment of patients through the regional obstetrical computer, and by direct contact with each obstetrical unit. Retrospective assessment of early miscarriage of pregnancy from hospital records. Data are presented for the six smallest obstetrical units, the four smaller district hospitals, two larger teaching hospitals and for the regional referral centre. RESULTS: Nine hundred and eighty-six fetal outcomes were identified, 753 in mothers treated with insulin before the pregnancy, 131 in mothers in whom insulin was started for the first time during the pregnancy and 102 in mothers treated by diet only. Overall perinatal mortality rates were 35.8 per 1000 for those mothers booked and delivered at a local maternity unit, 28.9 per 1000 for those booked and delivered at the regional centre, but 75.0 per 1000 for those who had booked locally but were transferred to the centre mid-pregnancy. Information on blood glucose control before and during pregnancy was relatively poorly documented. For the available data at the regional centre, only 160 of the 416 mothers had an identifiable preconception HbA1c measurement (mean 7.9%, range 3.3-16.8%): at booking 360 of these mothers had a mean HbA1c of 7.5% and by the third trimester mean HbA1c was 6.3% (range 3.3-13.2%). CONCLUSIONS: The outcome of pregnancy in a diabetic mother in Northern Ireland remains a higher risk than for the general population. There is evidence that results in the regional centre are better, but problems arise when transfers occur mid-pregnancy. Measurement and recording of blood glucose control at all stages before and during pregnancy is incomplete. Diabet. Med. 18, 546-553 (2001)

Abortion, Spontaneous↗
PubMed1986

[Status of obstetrical anesthesia in Germany].

A study on actual trends in obstetric analgesia and anaesthesia was conducted on data received from 385 German departments of obstetrics with a total of 267441 deliveries. On the basis of these extensive data quantitative results could be obtained about analgesic procedures for spontaneous deliveries, operative-vaginal deliveries, Caesarean sections and in cases of foetal or maternal risks. The type of analgesics and local anaesthetics used, their side effects and complications were recorded. In addition the cooperation and interaction between obstetricians and anesthesiologists in practising and monitoring obstetrical analgesia and anaesthesia are described.

Analgesia↗