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PubMed1999

[Obstetric analgesia: peridural analgesia versus combined spinal and peridural analgesia].

OBJECTIVE: To compare the analgesic efficiency, side effects and obstetrical repercussions of epidural analgesia (EP) and combined spinal-epidural analgesia (CSE). STUDY DESIGN: Prospective, randomized, double or single-blind studies as required, approved by the ethical committee of the institution. PATIENTS: The study included 80 parturients, in active labour with a singleton in vertex presentation and a cervical dilatation of 3 cm or less, randomly allocated to receive either EP (n = 40) or CSE (n = 40). METHOD: In the EP group, sufentanil (20 micrograms) and 0.25% bupivacaine (6-8 mL) were injected into the epidural space. In those of the CSE group, sufentanil (10 micrograms) was first injected into the subarachnoid space, followed by an epidural injection of the same agents at the same quantities as for the EP group. Additional analgesia was obtained in both groups by top-ups of 6-8 mL of 0.25% bupivacaine at the request of the patients. Analgesia, course of labour, obstetrical outcome, and neonatal status were assessed. Statistical analysis was performed using Anova, chi 2 analysis, Yates' correction or Fisher's exact test, with a P < 0.05 considered as significant. RESULTS: Both groups had similar demographic and obstetric data. The onset of analgesia was more rapid in CSE group (8 +/- 11 min vs. 12 +/- 7 min, P < 0.05), however the duration was similar. Technical incidents were more frequent in the CSE group (30% vs. 7%, P < 0.05). The technique of analgesia did not influence the bupivacaine amounts required for its maintenance. The incidence of adverse effects were comparable with the exception of vertigo, which was more frequent in the EP group (57% vs. 28%, P < 0.05). The first stage of labour was increased by 30% in the CSE group (281 +/- 130 min vs. 216 +/- 97 min, P < 0.05), without significant prolongation of labour length. Durations of second stage and expulsion were similar in both groups, despite the administration of a lower dose of bupivacaine in the CSE group (33 +/- 17 mg vs. 46 +/- 12 mg, P < 0.05). The rates of instrumental deliveries and Caesarien sections were comparable. The Apgar scores were satisfactory at 5 min. CONCLUSION: In the early phase of labour, the CSE technique using intrathecal sufentanil has no significant benefit when compared to the EP technique using bupivacaine and sufentanil. In the CSE group, technical incidents were more frequent and the length of the first stage of labour was increased.

Adult↗
PubMed1997

Obstetric factors and mother-to-infant transmission of HIV-1.

Mother-to-infant HIV transmission has been reported to occur during pregnancy (in utero), at delivery, or postpartum (breast feeding). There are a multiplicity of variables or cofactors that may influence such transmission. Among the obstetric factors reported to be more strikingly associated with mother-to-infant transmission are preterm delivery, low birth weight and birth order in twin pregnancies. Perhaps the most controversial issue in obstetric management is the association of mode of delivery and transmission. Some large studies and metaanalyses have found a protective effect of cesarean section varying from odds ratios of 0.8 to 0.56. Unfortunately, those large studies have not included the duration of rupture membranes in their analyses. When such a variable (duration of ruptured membranes) is taken into account, the protective effect of the cesarean section may disappear. The impact of such obstetric variables on transmission can be explained by the hypothesis that a significant proportion of the perinatal transmission occurs intrapartum and is related to the dose exposure (time and concentration) of the presenting part to the genital tract virus load and to the maternal blood virus load. Currently, routine cesarean section is not recommended as a strategy for the prevention of vertical transmission. Although prospective studies are underway to elucidate the effect of cesarean section on transmission, the results are academic if recent potent antiviral agents are demonstrated to reduce or minimize the viral load in blood and in cervicovaginal secretions. Meanwhile, the current management of the delivery process should have as a goal the reduction of the presenting part to the cervicovaginal secretions by preserving the intactness of the membranes and by the proper use of invasive procedures when clinically indicated.

Acquired Immunodeficiency Syndrome↗
PubMed1998

Obstetric care for renal allograft recipients or for women treated with hemodialysis or peritoneal dialysis during pregnancy.

Pregnancies in women on dialysis and in women who have had renal transplant are no longer uncommon. Optimal obstetric outcomes require a multidisciplinary team approach, patient counseling, and clinicians who are knowledgeable and experienced in taking care of these patients. Counseling should begin before pregnancy, and all reproductive age women on dialysis and who have undergone renal transplant should receive family planning counseling. Preconceptional counseling should be provided to those patients who desire pregnancy. If the patient presents in early pregnancy, she should be informed about the maternal and fetal risks associated with her pregnancy. Prenatal care must include intensive surveillance for hypertension, preeclampsia, preterm labor, intrauterine growth restriction, anemia, infection, and renal allograft rejection. Aggressive treatment of complications is mandatory. There are limitations to our current knowledge about pregnancies in these patients. It is important for clinicians who provide care for these patients to be aware of these limitations when making obstetric management decisions. Cesarean section should be reserved for usual obstetric indications. Breast-feeding is not advised in patients taking cyclosporin or azathioprine. Transplant patients have unique gynecologic needs, so they should be encouraged to pursue follow-up gynecologic care after the pregnancy.

Adult↗
PubMed1999

Obstetric history in women with surgically corrected adult urinary incontinence or pelvic organ prolapse.

STUDY OBJECTIVE: To compare obstetric histories of women who had surgical correction of urinary incontinence or pelvic organ prolapse with a similar group who did not. DESIGN: Case control study (Canadian Task Force classification II-2). SETTING: Urban, community-based, private practice teaching hospital. PATIENTS: Four hundred eighty women (age 51.4 +/- 13.0 yrs) who underwent corrective surgery for urinary incontinence, pelvic organ prolapse, or both, and whose obstetric history was obtainable through chart review. The control group was composed of 150 women (age 50.7 +/- 9.6 yrs) having routine screening mammography who completed a questionnaire regarding obstetric, gynecologic, and urologic history. MEASUREMENTS AND MAIN RESULTS: Patients and controls did not differ significantly in terms of age, race, height, weight, body mass index, or smoking history. Women who underwent surgery were of greater parity (2.5 +/- 1.2 vs 2.0 +/- 1.2, p <0.001), less often nulliparous (3% vs 18%, p <0.001), less likely to have had a cesarean delivery (4% vs 15%, p <0.001), and more likely to have had a vaginal delivery (94% vs 77%, p <0.001) than those with no surgery. The odds ratio of patients who had a vaginal delivery compared with controls was 4.7 (2.3-8.3), and that for cesarean delivery was 0.22 (0.11-0.43). Analysis of specific delivery information found that, compared with controls, patients were older by 4 years at time of their first delivery (28.9 +/- 4.9 vs 24.9 +/- 4.9 yrs, p <0.001) and more commonly received epidural analgesia intrapartum (87% vs 40%, p = 0.004). Comparisons within the patient group, categorized by indication for surgery, revealed that women who had surgery for either prolapse alone or for both prolapse and incontinence were most likely to have had vaginal deliveries (85% incontinence alone vs 94% prolapse alone vs 97% both, p <0.001). CONCLUSION: Increased parity, vaginal childbirth, maternal age at time of delivery, and use of epidural analgesia are associated with need for operative correction of pelvic organ prolapse or adult urinary incontinence. Conversely, cesarean delivery is associated with less need for surgical correction of incontinence or pelvic organ prolapse.

Case-Control Studies↗
PubMedDate not supplied

The incidence of transient radicular irritation after spinal anesthesia in obstetric patients.

BACKGROUND AND OBJECTIVES: Transient radicular irritation (TRI) has been described after spinal anesthesia, particularly with 5% hyperbaric spinal lidocaine. The purpose of this study was to determine the incidence of TRI in obstetric patients. METHODS: All obstetric patients undergoing spinal anesthesia during a 9-month period were enrolled in the study (n = 303). Details of the anesthetic technique were recorded at the time of anesthesia. A blinded anesthesia nurse contacted each patient on postoperative day 2 and asked about symptoms of TRI. RESULTS: Most patients received either intrathecal hyperbaric bupivacaine 0.75 % (n = 232) or lidocaine 5 % (n = 67) through pencil-point needles. Cerebrospinal fluid was used to dilute the spinal lidocaine in 63% of patients. Patients receiving bupivacaine were more often in the supine position, underwent significantly longer procedures, and more often received intrathecal opioid. The incidence of TRI after lidocaine spinal anesthesia was 0% (95% confidence interval 0-4.5%). CONCLUSIONS: The incidence of TRI after spinal lidocaine anesthesia in the obstetric population is low.

Adult↗
PubMed2004

Factors affecting academic promotion in obstetrics and gynaecology in Canada.

OBJECTIVE: (1) To determine if women faculty members in departments of Obstetrics and Gynaecology were less likely than men to achieve promotion; and (2) to assess gender differences in attitudes towards promotion. METHODS: Department chairs at the 16 medical schools in Canada were approached to participate in this study. A questionnaire was mailed to the obstetricians/gynaecologists in faculties of medicine at the 15 Canadian medical schools that agreed to participate. Likelihood of promotion for women and men was compared using survival analysis, controlling for other factors. Survival (event) time was the time in years between completion of residency and achieving promotion. RESULTS: The response rate was 72% (376/522). Overall, 37% of respondents were women, and 63% were men. The women respondents were younger than the men, with a mean age of 43.4 +/- 7.9 years compared to 52.8 +/- 8.9 years. Of those in an academic stream, 39% of women (29/75) and 62% of men (90/145) had attained senior academic ranks. Completing residency more recently was associated with a higher likelihood of promotion to Assistant Professor (hazard ratio [HR], 1.05; P <0.001). The likelihood of promotion to Professor was lower for women than for men (HR, 0.40; P = 0.05). Having a mentor was associated with a higher likelihood of promotion to Professor (HR, 2.33; P = 0.002). Women were more likely to perceive barriers to promotion, such as family care responsibilities (P <0.001). CONCLUSION: Independent of the respondent's gender, recent completion of residency and having a mentor were the most significant factors increasing the likelihood of promotion in Canadian medical school departments of Obstetrics and Gynaecology. As women were found to be less likely than men to achieve promotion to Professor, mentoring and strategies that focus on facilitating promotion for women should be encouraged to ensure there are academic leaders in obstetrics and gynaecology in the future.

Achievement↗
PubMed2005

Gynaecological and obstetric management of women with inherited bleeding disorders.

OBJECTIVE: The prevalence of bleeding disorders, notably von Willebrand disease (vWD), among adult women with objectively documented menorrhagia is consistently reported to be 10% to 20% and is even higher in adolescents presenting with menorrhagia. This consensus document has been developed by a multidisciplinary committee consisting of an anesthesiologist, 2 hematologists, and an obstetrician/gynaecologist and has been endorsed by their relevant specialty bodies. It has been prepared with the express purpose of providing guidelines for both women with inherited bleeding disorders and for their caregivers regarding the gynaecological and obstetric management of these women, including appropriate anesthesia support where indicated. OPTIONS: Diagnostic tools and specific medical and, where appropriate, surgical alternatives to management are reviewed and evidence-based recommendations presented. EVIDENCE: A MEDLINE search of the English literature between January 1975 and November 2003 was performed using the following key words: menorrhagia, uterine bleeding, pregnancy, von Willebrand, congenital bleeding disorder, desmopressin/DDAVP, tranexamic acid, oral contraceptives, medroxyprogesterone, therapy, hysterectomy, anesthesia, epidural, spinal. Recommendations from other society guidelines were reviewed. RECOMMENDATIONS: 1. Inherited bleeding disorders should be considered in the differential diagnosis of all patients presenting with menorrhagia (II-2B). The graphical scoring system presented is a validated tool which offers a simple yet practical method that can be used by patients to quantify their blood loss (II-2B). 2. Because underlying bleeding disorders are frequent in women with menorrhagia, physicians should consider performing a hemoglobin/hematocrit, platelet count, ferritin, PT (INR) and APTT in women with menorrhagia. In women who have a personal history of other bleeding or a family history of bleeding, further investigation should be considered, including a vWD workup (factor VIII, vWF antigen, and vWF functional assay) (II-2B). 3. Treatment of menorrhagia in women with inherited bleeding disorders should be individualized (III-B). 4. An inherited bleeding disorder is not a contraindication to hormonal therapy (oral contraceptives [II-1B], depot medroxyprogesterone acetate (DMPA) [II-3B], danazol [II-2B], GnRH analogs [II-3B]) or local treatments (levonorgestrel-releasing IUS [II-1B]) and non-hormonal therapy (antifibrinolytic drug tranexamic acid [II-1B]) as well as desmopressin (II-1B). These therapies represent first line treatment. Blood products should not be used for women with mild bleeding disorders (III-A). 5. In women who no longer want to preserve their fertility, conservative surgical therapy (ablation) and hysterectomy may be options (III-B). Clinicians may consult the "SOGC Clinical Practice Guideline: Guidelines for the Management of Abnormal Uterine Bleeding" for an in-depth discussion of the available therapeutic modalities, both medical and surgical. To minimize the risk of intraoperative and post-operative hemorrhage, coagulation factors should be corrected preoperatively with post-operative monitoring (II-1B). 6. Girls growing up in families with a history of vWD or other inherited bleeding disorders should be tested pre-menarchally to determine whether or not they have inherited the disease to allow both the patient and her family to prepare for her first and subsequent menstrual periods (III-C). 7. In adolescents presenting with menorrhagia, an inherited bleeding disorder should be excluded (III-B). When possible, investigation should be undertaken before oral contraceptive therapy is instituted, as the hormonally induced increase in factor VIII and vWF may mask the diagnosis (II-B). 8. Pregnancy in women with inherited bleeding disorders may require a multidisciplinary approach. A copy of their recommendations should be given to the patient and she should be instructed to present it to the health care provider admitting her to the birthing centre. Women with severe bleeding disorders or with a fetus at risk for a severe bleeding disorder should deliver in a hospital (level three) or where there is access to consultants in obstetrics, anesthesiology, hematology, and pediatrics (III-C). 9. Vacuum extraction, forceps, fetal scalp electrodes, and fetal scalp blood sampling should be avoided if the fetus is known or thought to be at risk for a congenital bleeding disorder. A Caesarean section should be performed for obstetrical indications only (II-2C). 10. Epidural and spinal anesthesia are contraindicated if there is a coagulation defect. There is no contraindication to regional anesthesia if coagulation is normalized. The decision to use regional anesthesia should be made on an individual basis (III-C). 11. The risk of early and late postpartum hemorrhage is increased in women with bleeding disorders. Women with inherited bleeding disorders should be advised about the possibility of excessive postpartum bleeding and instructed to report this immediately (III-B). 12. Intramuscular injections, surgery, and circumcision should be avoided in neonates at risk for a severe hereditary bleeding disorder until adequate workup/preparation are possible (III-B). The quality of evidence reported in this document has been described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam (Table 1).

Blood Coagulation Disorders↗
PubMed1995

A comparison of the investment in hospital-based obstetrical ultrasound in Wales and Washington state.

The purpose of this study was to examine differences in the way Britain and the United States invest in and deploy a new medical technology. We used structured interviews to obtain information on the technical sophistication and approximate replacement value of all hospital-based obstetrical ultrasound machines in every maternity hospital in Washington state and Wales. The supply of hospital-based ultrasound machines--approximately two machines per 1,000 births--was similar in both countries. Wales had fewer advanced ultrasound machines than Washington state, and they were based exclusively in high-volume district general hospitals; there were no obstetric ultrasound machines in the private sector. In Washington state, the majority of advanced machines were in small and medium-sized hospitals, and many private offices had ultrasound machines. The approximate replacement value of hospital-based machines was three times as high per birth in Washington state as in Wales. In the case of obstetrical ultrasound, centralization of facilities, a relatively small private sector, and global budgeting lead to lower expenditures per patient within the National Health Service without compromising access to care.

Birth Rate↗
PubMed2001

Obstetric complications and risk for severe psychopathology in childhood.

The purpose of the study was to assess the association of obstetric complications with risk for mental disorders resulting in hospitalization before the age of 15. Records from all births in Denmark from 1973 through 1993 were linked to records of all psychiatric hospitalizations. Diagnoses were grouped into seven broad categories. A reference population of 10% of births in Denmark from 1973 to 1990 was used for comparison. Obstetric complications were associated with the range of mental disorders occurring in childhood. The strongest predictors were a variable indicating the interaction of birth weight with speed of growth and the 5-minute Apgar score. There was no diagnostic group that stood out as different with respect to obstetric complications. These results are consistent with the hypothesis of the continuum of reproductive casualty.

Adult↗
PubMed2002

Adverse obstetric outcome in fetuses that are smaller than expected at second trimester routine ultrasound examination.

BACKGROUND: Adverse obstetric outcome in fetuses that are smaller than expected at second trimester routine ultrasound examination. AIM: To assess the obstetric outcome when the interval between the estimated date of delivery by last menstrual period and the estimated date of delivery by second trimester ultrasound exceeds 14 days. MATERIALS AND METHODS: Population-based prospective cohort study. Included were all women (n = 16 302) with a singleton pregnancy, in one Norwegian county from 1989 to 1999, with a reliable menstrual history and whose second trimester ultrasound examination was conclusive with a 35-60-mm biparietal diameter. RESULTS: Adverse outcome was defined as preterm birth (< 37 weeks), perinatal death, low birthweight (< 2500 g) and small-for-gestational age (< 2 standard deviation). The risk for perinatal death (odds ratio = 2.3), preterm birth (odds ratio = 1.7), low birth weight (odds ratio = 1.5), and small-for-gestational age (odds ratio = 1.5) was highly significantly increased in deliveries where the discrepancy between the two terms was more than 14 days. The increased risk is not explained by differences in parity, maternal age, smoking, fetal malformations, or use of oral contraceptives before pregnancy. CONCLUSION: Fetuses that are smaller than expected at the mid-second trimester ultrasound corresponding to a discrepancy of more than 14 days have an increased risk for adverse obstetric outcome.

Adult↗
PubMed2003

Delayed sphincter repair for obstetric ruptures: analysis of failure.

OBJECTIVE: The aim of this study was to examine the clinical results after anterior anal sphincter repair in patients with obstetric trauma and to evaluate possible risk factors for poor outcome. PATIENTS AND METHODS: In years 1990-99 anterior anal sphincter repair for anal incontinence due to obstetric trauma was performed in 39 patients at Helsinki University Central Hospital. Clinical examination with Parks' classification and patients' questionnaire with endoanal ultrasound (EAUS) were done before and after surgery. Pudendal nerve terminal motor latency (PNTML) was measured postoperatively. The median follow-up time after the operation was 22 months (range 2-99). RESULTS: The follow-up results of the patients' questionnaire for 12 patients (31%) were good, for 15 patients (38%) acceptable and for 12 patients (31%) poor. Postoperative EAUS showed sphincter overlap in 28 (72%) patients but a defect was still found in 11 (28%) patients. A defect found on postoperative EAUS correlated with poor clinical result according to Parks' (R = 0.8, P < 0.01) and patients' questionnaire results (R = 0.7, P < 0.01). Patients with poor clinical results (Parks III/IV) were statistically significantly older (median 63 years, range 26-73) than those with favourable results (Parks I/II) (median 45 years, range 27-79) (P < 0.05). Further, the duration of incontinence symptoms correlated with poor functional results (R=0.4, P < 0.05). CONCLUSION: After obstetric trauma anterior anal repair gives acceptable short-term clinical results. EAUS investigation is easy and harmless to perform and should be used pre- and post-operatively. Advanced age, pre-operative signs of perineal descent, long-lasting severe incontinence symptoms and a persistent defect on postoperative EAUS seem to be related to poor clinical result.

Adult↗
PubMed2001

Drugs in pregnancy. Drugs for obstetric conditions.

For many reasons, including the fear of fetal anomaly, the recognition of pregnancy being a normal physiological process and maternal choice, few drugs are prescribed and used during pregnancy. Nevertheless, there are certain common obstetric conditions that are associated with significant maternal and perinatal morbidity and mortality where drugs play an important and necessary part in treatment. These conditions include termination of pregnancy, threatened preterm labour, induction of labour and post-partum haemorrhage. This chapter deals with the role of drug therapy in these obstetric scenarios. A large amount of obstetric clinical trial research has been dedicated to the management of these conditions.

Abortifacient Agents↗
PubMed1999

[Recent developments in obstetric regional anesthesia. A review of experiences at the Eppendorf University Hospital].

OBJECTIVES: The study investigates changes of anaesthesia practice in obstetric patients of a University Hospital over a six years' period. METHODS: Between 1993 and 1998 data of 7476 deliveries were collected by the perinatal documentation system of the Obstetric Department and by computerized anaesthesia protocols of the Department of Anesthesiology. Since combined spinal-epidural anaesthesia with sufentanil was introduced in 1997, all patients with subarachnoid techniques were prospectively examined between 1997 and 1998. RESULTS: While the total number of deliveries decreased over the years, the number of patients undergoing anaesthetic treatment increased continuously. In parallel, the number of patients with regional anaesthesia increased between 1993 and 1998 from 14.3% to 34.8%. The cesarean delivery rate increased from 23.7% to 28.7% with an increasing number of patients receiving regional anaesthesia for cesarean section (1993: 25.3% vs. 1998: 62.1%). The number of emergency cesarean deliveries performed in regional anaesthesia increased to 19.3% in 1998. The number of neonates with an umbilical artery pH below 7.2 decreased from 18% in 1993 to 11% in 1998. The success rate of regional anaesthesia increased from 88.2% in 1993 to 97.5% in 1998. Combined spinal-epidural anaesthesia provided greater pain reduction when compared with epidural anesthesia (VAS -81 +/- 12 vs. -68 +/- 18). Early vasopressor administration resulted in a decrease of hypotension from 40% to 14% in spinal and from 21% to 13% in combined spinal-epidural anaesthesia. The incidence of postdural puncture headache after subarachnoid anaesthesia was 2.4%. DISCUSSION: Epidural and subarachnoid application of sufentanil appears to enhance the success rate of obstetric regional anaesthesia. Subarachnoid techniques such as spinal or combined spinal-epidural anaesthesia showed a high effectiveness, low incidence of side effects and high degree of patients' satisfaction.

Anesthesia, Conduction↗
PubMed2005

[Comments on a report by the BQS on obstetric quality indicators].

When re-evaluating an epidemiologically oriented BQS expertise concerning the quality indicators in obstetrics, we examined three essential methods in obstetrics to verify their scientific evidence and their clinical relevance. In doing so we ascertained that recording the fetal heart rate sub part, analysing fetal blood and determining the blood gas of the umbilical blood are entirely appropriate quality indicators during delivery from a clinical and medical point of view -- although to varying extents. Above all, these three indicators prove to be essentially better evidence-based than described in the BQS expertise. The search for an optimum of evidence-based data in medicine ends in certain fields such as, for example, in obstetrics there where no further randomized studies can be carried out for methodological or ethical reasons. This lack of evidence for the optimum grade I which can clearly be understood from an epidemiological point of view, however, should not lead to an evidence nihilism that fails to accept or admit existing evidence of the weaker grades II and III.

Evidence-Based Medicine↗
PubMed1993

[Obstetric complications, incidence and indications of cesarean section in uterus myomatosus].

An increasing percentage of patients with uterine leiomyomas was observed in the Department of Obstetrics, University of Freiburg, on comparing the years 1970-79 (0.25%) and 1980-89 (0.64%). While first trimester bleeding, pain and premature labour, being typical obstetrical complications, were encountered in a comparable frequency, atonic bleeding was observed more often during the nineteen-eighties. Pain and premature labour were often present, if the leiomyomas were large, irrespective of both their number or localization. Atonic bleeding was observed more frequently, if large leiomyomas were present. A correlation between the presence of uterine leiomyomas and placental deficiency, premature birth, and EPH gestosis seems uncertain. The total complication rate among all pregnant patients with uterine leiomyomas was 65% from 1980-89. The Caesarean section rate among patients with uterine leiomyomas increased during the evaluated time span, and reached 51% during the 1980's, as compared to a general frequency of Caesarean sections of 19% during the latter time period; this increase in frequency seems to be rather in keeping with a generally increasing Caesarean section rate as opposed to a changing indication for surgery in patients with myomas. The myomas themselves caused Caesarean sections in 50% of cases, while in the remaining 50% of patients, Caesarean sections were performed for general obstetrical reasons. The probability to be delivered by Caesarean section was especially high amongst patients with multiple myomas or with an isthmic myoma. Our study supports a conservative approach in the case of pregnancy and uterine leiomyomas.

Adult↗
PubMed1996

[Expectations of obstetrics in a large city: prepartum survey].

In recent years, obstetrics has been facing ever greater expectations on the part of its patients. An increasing number of women show a marked interest in experiencing pregnancy and delivery in a more aware and, above all, active manner. The study at hand presents the results of a survey conducted at seven obstetric departments in Vienna in which a total of 431 primiparous women were questioned with regard to their knowledge, their wishes and expectations, as well as their preparations in view of the imminent delivery. The information lag, particularly among less educated women, still appears to be considerable: 20% of the women had no clear idea as to the role of the midwife, and approximately a quarter of them only had a vague notion of the meaning of the term "Caesarean section". 62% of the women identified their gynaecologist as the main source of information. For the atmosphere during the actual delivery to be perceived as pleasant, the parturient has to be in the care of well-trained and friendly staff. Furthermore, it is interesting to note that well-informed women are less inclined to be afraid of pain and consequently tend to be more relaxed during delivery. The correlation between stress and obstetric complications is sufficiently documented. The results of this survey indicate that in future increased emphasis will have to be on education and information, as well as on meeting women's expectations in respect of expert care.

Adult↗
PubMed1995

[Diagnostic and clinical value of Doppler ultrasound in obstetrics].

The diagnostic value (efficiency) of Doppler ultrasound in obstetrics is assessed by studying the association or correlation between Doppler measurement parameters and pregnancy outcome parameters, without influencing the clinical management. The clinical value (efficacy) is however assessed by studying the ability to improve the outcome of pregnancy if Doppler ultrasound is used in obstetrical management for the purpose of possible intervention. The accepted method for assessment of the diagnostic value is the observational study, and the best method for the assessment of the clinical value is the randomised controlled management study (clinical trial). Observational studies concerning the diagnostic value have been widely reported in the literature. According to these studies significant relationships between abnormal Doppler findings and the following obstetrical problems were found: intrauterine growth retardation, preterm delivery, acidosis determined by fetal blood sampling, abnormal intrapartum fetal heart rate, neonatal depression and acidosis, and admission to neonatal intensive care unit. However from these studies it cannot be concluded that pregnancy outcome will be improved by using this information clinically. This problem can only be properly addressed by appropriate clinical management studies. The majority of the published randomised controlled trials showed beneficial effect from Doppler ultrasound application in high-risk pregnancy management. These effects included a significant decrease in the duration of antenatal and neonatal hospital stay, the rate of labour induction, and the rate of emergency Caesarean section. At the same time there was no difference in the gestational age at delivery or in the total Caesarean section rate. None of these trials alone was large enough to demonstrate a statistically significant reduction in perinatal mortality. However cumulative meta-analysis allows pooling to evaluate the results from separate but similar studies. The results from such an analysis showed that in high-risk pregnancies managed with Doppler there is a significant decrease of 50 per cent in perinatal mortality and in stillbirths of anatomically normal fetuses. It is important to note that there was no increase in neonatal or maternal morbidity associated with the use of Doppler ultrasound, and that the reduction in perinatal mortality was not the result of a delay in timing fetal death.

Blood Flow Velocity↗
PubMed1991

[Clinic interns, individual performance appraisal and obstetric quality assurance].

Obstetrical management and fetal outcome were individually analysed annually from 1987 to 1990, using computerised equipment. The individual results were discussed anonymously with all colleagues, but every colleague knew his own results. Clinical methods and obstetrical management had not been changed during the investigation period. The number of high-risk pregnancies increased significantly, whereby the incidence of risk-related surgical interventions decreased at the same rate. The number of FBA and EDA increased significantly (p less than 0.001). The mean umbilical artery pH increased during the last four years from 7.27 to 7.30 (p less than 0.05), i.e. that each colleague achieved an improvement. The incidence of acidotic values in the umbilical artery decreased significantly (pH less than 7.20 from 13.2% to 7.1%, pH less than 7.10 from 3.6% to 1.2% p less than 0.01). The rate of caesarean section increased (p less than 0.05) and the number of vaginal operative deliveries did not change significantly. As early as one year after the introduction of the individual efficiency control, a significant improvement in obstetrical results could be demonstrated.

Clinical Competence↗