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PubMed1993

Attitudes of Florida family practice residents concerning obstetrics.

BACKGROUND: The cost of liability insurance for obstetrical care and the fear of eventual litigation are reasons commonly cited by family physicians for not delivering babies. METHODS: Separate surveys were mailed to residency directors and third-year residents in Florida family practice residency programs to determine the attitude and practice plans of recently trained family physicians in regard to obstetrics. RESULTS: Three hundred twenty residents completed civilian family practice residency programs in Florida from 1986 through 1990. Only nine (2.8%) delivered babies the first year after residency. The major reasons that third-year residents gave for not planning to deliver babies included fear of being sued and the cost of malpractice insurance. Residents' estimates of first-year insurance costs were 350% higher than actual premiums. Furthermore, residents believed that the risk of being sued for the obstetrics portion of their practice would exceed the risk for the nonobstetric portion. CONCLUSIONS: Residents' estimates of the cost of malpractice insurance and their malpractice risk for delivering babies appear to be greatly exaggerated. These views are primarily obtained from nonresidency sources.

Attitude of Health Personnel↗
PubMed1993

How to critically evaluate positions on obstetric ethics.

We identify three tools for the critical evaluation of positions on obstetric ethics. The first is the distinction between descriptive and normative obstetric ethics. The second comprises the "Six Cs" of rigorous ethical analysis and argument: clarity, consistency, coherence, clinical applicability, clinical adequacy and completeness. The third is the avoidance of pitfalls that might arise from failing to acknowledge the inherent limitations of fields that contribute to normative obstetric ethics: law, region, professional consensus, uses of authority and philosophy.

Bioethical Issues↗
PubMed1995

Is obstetrics-gynecology a primary care specialty?

Suddenly everyone wants more primary care physicians. For several years, we collected data from senior medical students to relate their attitudes and beliefs about several clinical problems common to primary care to their choices of residencies. Because the Texas Medical Association's Special Committee on Primary Care included obstetrics-gynecology as a primary care specialty, we reviewed our data to see if the personal traits and professional role characteristics of seniors choosing obstetrics-gynecology differed materially from those of seniors choosing family medicine, internal medicine, or pediatrics. Results of this analysis put obstetrics-gynecology about as firmly in the primary care group as if the experimental design had planned it that way.

Family Practice↗
PubMedDate not supplied

Obstetric physicians: are they needed? The workload of a medical complications in pregnancy clinic.

Obstetric physicians are physicians whose training and particular expertise lie in the care of the medical complications of pregnancy. We present an audit of the work of our bi-weekly obstetric medicine clinic at Queen Charlotte's Hospital, London, over a 10-month period from July 1994 to April 1995 inclusive, and discuss the need for obstetric physicians, with reference to individual medical conditions which complicate pregnancy.

Female↗
PubMed1977

[Possibilities and limitations of obstetric intensive medicine: a cost-savings analysis (author's transl)].

With the increasing use of obstetrics intensive supervision methods, perinatal mortality could be decreased from greater than 2.5% to less than 1.0% between 1965-1975. Cases of clinically relevant acidosis in the umbilical artery (pH less than 7.10) declined from 2.41% to 0.51% between 1973-1975. On the basis of these results and the statistical data from Hagberg (14), it can be concluded that 1 child out of every 1.000 births can be preserved from a severe infantile cerebral paresis and 1 child from severe mental retardation via obstetric intensive supervision. The cost for obstetric intensive medicine per 1.000 births was 370.000 Swiss francs in 1975. As a result of the decline in cerebrally damaged and mentally retarded children, expenditures of between 1.3 to 1.9 million Swiss francs were avoided. This means a savings of 1 to 1.5 million Swiss francs.

Blood Chemical Analysis↗
PubMed1996

[Obstetrical epidural analgesia: an epidemiological in Bourgogne and Franche-Comté 1993].

Many publications report the number of epidural analgesias carried out for the last years in English-speaking countries. On the other hand, very little information exists about the incidence of obstetrical epidural analgesia performed in South and Central Europe, particularly in France. A retrospective study within the regions of Bourgogne and Franche-Comté was carried out for the year 1993 firstly, to determine the number of obstetrical epidural analgesias performed and the drugs used; and secondly, to describe the organization and the problems encountered. The result of this study leads to one major question: what is the best type of organization in order to guarantee the highest safety, given the increasing demand for epidural analgesia in obstetrics?

Analgesia, Epidural↗
PubMed1997

Obstetrical data management systems.

Obstetrical data management systems (OBDMSs) are computer systems designed to interface with fetal and maternal monitors. This allows monitoring and charting records to be created and maintained electronically and to be viewed from centralized workstations. In theory, these systems could eliminate paper record keeping from the obstetrics department altogether, although currently at least some paper documentation, such as fetal monitoring strips, is being kept. We evaluated five OBDMSs, one of which is no longer on the market and which we did not rate. Of the remaining systems, three were rated Acceptable; the fourth was rated Acceptable-Not Recommended because it lacks several important features and functions. This Evaluation also includes a Technology Overview, in which we discuss how OBDMSs function. The Overview incorporates a supplementary article, "Obstetrical Care Monitoring and Documentation," describing the monitoring and documentation typically performed during a pregnancy. And in the Selection and Use Guide, we discuss issues involved in choosing, purchasing, and implementing an OBDMS.

Computer Systems↗
PubMed1997

[Obstetric hysterectomy. Review of 675 cases at the Instituto Nacional de Perinatología].

A retrospective study of 675 patients subject to obstetric hysterectomy from January 1st, 1985 to December 31st, 1995 at the Instituto Nacional de Perinatología was carried out. The incidence of this procedure reached its highest level in patients from 26 to 40 years, which represented 60.5% (409 cases) of the studied population. Patients with one previous cesarean section comprised 34.8% of total obstetric hysterectomies, followed by women with two to three previous cesarean sections (24.5% and 22.2%, respectively). As for gestational age, it reached term in 51.1% (345 cases), pre-term in 38% (257), post-term in 1.4% (10), and less than 20 weeks in 9.3% (63 cases). Main indications for obstetric hysterectomy included placenta accreta in 34.07% (230 cases), uterine atony in 32.4% (219), deciduomyometritis in 6.3% (43 cases), and uterine rupture in 4.5% (31). Most frequent complications included hypovolemia (12.1%), bladder injury (5.4%), and ureteral injury (0.7%). Postoperative complications included anemia (61.6%), febrile syndrome (7.5%), mechanic ileum (7.5%), wall abscess (3.4%), and vesicovaginal fistula (1.6%). A total of eight maternal deaths (1.1%) was reported.

Adolescent↗
PubMed1997

A regional perinatal database in southern Sweden--a basis for quality assurance in obstetrics and neonatology.

BACKGROUND: In order to ensure as few avoidable adverse outcomes of pregnancy as possible, it is necessary to continuously evaluate the quality of both obstetric and neonatal care. The eleven southernmost hospitals in Sweden have joined together in a project of developing a regional database, with special emphasis on rapid output of information in order to identify changing trends. METHODS: A regional computerized database has been developed, collecting variables and quality indicators agreed upon by all participants. Specific protocols have been designed for obstetric care, neonatal care and autopsy findings. All participating units transfer information on paper forms or via local computerized information systems. The regional database thus receives data on about 20,000 deliveries annually. RESULTS: Data collection started on September 1, 1994. The first results are due in March 1996, and thereafter on a regular basis every 3 months. Special methods for rapid analysis of raw data have been developed with the help of commercially available data analysis tools. CONCLUSIONS: It is possible to construct an information system with different computer platforms and different database tools at each participating facility, as long as the database systems are locally controllable. That a software is commercially available is no guarantee that data transfer to a central database is possible. Experience from participating sites also indicates that a specialized database is needed for registering obstetric data, as general computerized record-keeping systems are unable to cope with an event concerning more than one subject at a time.

Female↗
PubMed1997

Women's recall of obstetric complications in south Kalimantan, Indonesia.

The search for indicators for monitoring progress toward safe motherhood has prompted research into population-based measures of obstetric morbidity. One possible such measure is based on women's reports of their past childbirth experiences. In this prospective study in three hospitals in South Kalimantan, Indonesia, the accuracy of women's reporting of severe birth-related complications was examined. The findings of this study suggest that poor agreement exists between the way women report their experience of childbirth and the way doctors diagnose obstetric problems, although the degree of agreement varies with the type of complication. Questionnaires relying on women's experience of childbirth will tend to overestimate the prevalence of medically diagnosed obstetric problems such as those associated with excessive vaginal bleeding or dysfunctional labor. Questions suggestive of eclampsia may be more promising, although the small number of eclamptic women in this study precludes firm conclusions.

Adult↗
PubMedDate not supplied

[Meaning of assimilation pelvis according to Kirchhoff in modern obstetrics].

OBJECTIVE: To what extent is the cesarean section indication "arrest of labour" due to pathological forms of the pelvis and what is the meaning of the assimilation pelvis in modern obstetrics. PATIENTS: NMR-pelvimetries were performed in 166 post partum women from June 1993 to August 1995. The patients were divided into 4 groups. Group 1: patients who had had cesarean section owing to arrest of labour (n = 56), group 2: patients who had had cesarean section due to breech presentation (n = 20), group 3: patients who had had cesarean section owing to another indication (threatening fetal asphyxia, multiple pregnancy, premature delivery, placental abruption, gestosis, n = 40), group 4: patients who had a spontaneous delivery (control group, n = 50). After analysing the NMR pictures all the pelves were alloted to one of the case studies according to their pelvic form. The diagnosis "assimilation pelvis" was made according to the criteria of Kirchhoff (1949). The four groups were compared and analysed. RESULTS: In group 1 an assimilation pelvis was found in 61%. The obstetrically most unfavourable canal pelvis occurred most frequently, amounting to 29%. In only 9% we found a contracted pelvis. In group 2 the proportion of the assimilation pelvis was even higher, rising to 65%. Only 35% of all pelves had a normal shape. In group 3 we found an assimilation pelvis in 50% of all cases. 66% of all patients with spontaneous delivery had a normal pelvis. An assimilation pelvis was found in 34%. In these cases duration of labour was prolonged by 4 hours on average (mean value: 9.5 hours). CONCLUSIONS: Due to its frequency in our days the assimilation pelvis plays a major obstetrical role. This is true in particular when there is a pathological course of labour. From this results that pelvic parameters other than the conjugata vera will be of diagnostic importance, especially those parameters which are able to characterise the assimilation pelvis with its high promontory, the steepness of the pelvic inlet, the lengthening of the birth canal and the decrease of the hollow of the sacrum. We take the view that the angle of the pelvic inlet, the pelvic inclination and the direct length of the pelvis are of outstanding importance.

Breech Presentation↗
PubMed1997

[Optimal world-wide obstetrical care; a WHO report].

'Safe motherhood; care in normal birth: a practical guide' is a document produced by an international technical working group of the World Health Organization. This report addresses issues of care during normal birth irrespective of country or region. Routine interventions and non-interventions in the physiological processes of pregnancy and labour are analysed and assessed for their scientific validity. Scientific foundation of obstetric practice is considered an important step towards worldwide demystification of obstetric practice, which now often relies on authority, culture and habit. For risk assessment, the cornerstone of the Dutch system of obstetric care, an evidence-based strategy is imperative. This requires scientific training in schools of midwifery.

Delivery of Health Care↗
PubMed1998

Involvement of Victorian general practitioners in obstetric and postnatal care.

OBJECTIVE: To assess the current nature and extent of general practice (obstetric) involvement and the effect of gender on the provision of maternity care in Victoria. METHOD: A postal survey to a community derived sample of 1104 Victorian general practitioners (with oversampling of female GPs) in August 1994 with hierarchical data analysis techniques used to account for the clustered (divisional) nature of the sampling frame. RESULTS: A 70% response rate was achieved (715 out of an eligible sample of 1022). Three hundred and sixty-two (45.6%) GPs were providing shared care, 127 (17.7%) intrapartum care and 656 (92%) were involved in seeing women for their routine 6 week postnatal checkup. Male and female GPs were equally qualified and as likely to be vocationally registered (90% vs 92%). Female GPs were less likely than male GPs (11% vs 25%) to be involved in intrapartum care (OR = 0.4, 95% CI = 0.3-.06). Female GPs were more likely than male GPs (50% vs 41%) to be involved in shared care (OR = 1.4, 95% CI = 1.01-2.0), and postnatal care (OR = 3.7, 95% CI = 2.5-5.4). Provincial city (population > 15,000) GPs were more likely to provide shared care than other GPs. Fifty-two per cent of GPs providing shared care held a Diploma of Obstetrics. After accounting for the gender differences associated with practice location, rural GPs were more likely to provide intrapartum care (OR = 10.6, 95% CI = 3.5-32.4). CONCLUSION: General practitioners play an important role in all facets of maternity care. Female and male GPs differ in their type of obstetric practice. If GPs are to maintain an intrapartum role, prompt action is required to increase the number of GPs involved in intrapartum care. The training requirements for shared care should be reviewed and a more suitable postnatal care curriculum should be developed.

Adult↗
PubMed1976

[Documentation of obstetric case reports by means of video-terminals as a part of the Vienna General medical information system "WAMIS" (author's transl)].

A report is given on the introduction of a complete documentation system of obstetric case reports by means of video-terminals and printer-terminals in both departments of Obstetrics and Gynaecology of the 1niversity of Vienna. The special routine for the admission of patients, which produces the heading of the case report is demonstrated, as well as the sheets of collecting the data in respect to case history, antenatal examinations, labour room reports and details of obstetric operations. The computer prints the case history using the collected data. These computer-printed case reports replace the customary handwritten reports. Laboratory data, therapeutic measures and final diagnosis are computed in the same way. The advantages of this form of organization of data collection for clinical purposes and research work are discussed.

Austria↗
PubMedDate not supplied

Designing a system for ambulatory obstetric case management.

The authors describe the development of critical pathways for ambulatory obstetric case management. When case management was identified as needed, but published work in outpatient obstetrics could not be found, four nurses used this opportunity to design a cost-effective system leading to quality outcomes. The driving force was the need for a format that directed comprehensive consistent care delivered by a large multidisciplinary health care team. Design issues included capturing leading edge standards of care and user friendly formats for all caregivers. Throughout a period of 2 years, a trifold format was developed for all obstetric patients, and 15 bifold formats were developed for patients with specific high-risk diagnoses. The format design facilitated cost-effective quality care and is expected to improve patient outcomes. A research study has been initiated to measure effectiveness of the design.

Ambulatory Care↗
PubMed1994

Differences in obstetrical intervention rates between Dutch hospitals.

Within the framework of the project 'Obstetric Peer Review' (Verloskundige Onderlinge Kwaliteitsspiegeling, VOKS) differences between Dutch hospitals concerning various obstetrical interventions were investigated. Using data of the Perinatal Database of the Netherlands from hospitals with at least 2000 newborns in the 5-year period 1987-1991, remarkable differences in frequencies of labour induction, caesarean section and vaginal operative deliveries can be shown, even when these interventions were considered within homogeneous subgroups with respect to pregnancy- or delivery-related complications. The incidence of caesarean section (and labour induction and vaginal operative delivery) appeared to depend more on the specific hospital policy than might be explained by populations differences alone. These intervention differences between hospitals clearly demonstrated the need to carry out a multivariate analysis to compare hospitals in a relevant and unbiased way, while adjusting for these population differences. This will estimate the intervention risks in a way which allows a fair comparison of hospital intervention policies.

Cesarean Section↗
PubMed2000

Epidural analgesia-anaesthesia in obstetrics.

Epidural analgesia is the most effective and innocuous technique for obstetrics. Pain relief is its main indication but maternal diseases that might be decompensated by labour and delivery are also accepted indications. Low doses of long-acting local anaesthetics alone or in combination with low doses of fentanyl or sufentanil provide good quality analgesia and are safe for mother and fetus. Test doses in parturients lack sufficient specificity and sensitivity for detecting inadvertent intravascular injection, and subarachnoid migration of the catheter is possible at any time during the procedure. Therefore, every injection must be considered as a test dose and only fractionated injections must be made. Epidural block to T10 is needed for labour and to level T4 for Caesarean section. Maintenance of the block with a continuous infusion, or patient-controlled epidural analgesia with a background continuous infusion, provides more stable analgesia than by intermittent injection. Technical difficulties, dural tap, bloody tap, hypotension and insufficient block are most frequent complications of epidural block in obstetrics. Excessive motor block prolongs the second stage of labour and increases the frequency for instrumental delivery and is therefore considered a complication.

Analgesia, Epidural↗
PubMed2000

Obstetric management of a protracted labor in a captive western lowland gorilla.

This article discusses the cooperative efforts of a team of physicians and veterinarians resulting in the successful assisted vaginal delivery of a Western lowland gorilla at the Woodland Park Zoo in Seattle, Washington. A 10-year-old, captive-born female gorilla, gravida 3, para 0, aborta 2, was observed to be in labor at term after spontaneous rupture of membranes. After 36 hours of observation, she had not yet delivered her infant. A team of physicians and veterinarians intervened. After induction of general anesthesia, an assessment of fetal and maternal status was made. With ultrasonographic monitoring of fetal cardiac activity, labor was augmented with administration of intravenous oxytocin. A vaginal delivery was performed with a vacuum extractor, resulting in the birth of a viable, 2.4-kg female infant. The infant survived the neonatal period and was hand reared until she was successfully introduced to the gorilla troop at the age of 1 year. Although there are several cases of cesarean delivery in captive gorillas, this is the first reported use of labor augmentation and assisted vaginal delivery in this captive species. Captive breeding is the key to survival of the Western lowland gorilla. The collaborative work of physicians and veterinarians is an integral part of this successful program. It is reported that in the captive population approximately 30% of newborns die in the first year, with more than half of the deaths occurring just before birth or within the first day of life. This does not include early spontaneous pregnancy losses. With aggressive management of pregnancy and labor complications, it may be possible to reduce perinatal morbidity and mortality in the captive gorilla population. Because gorillas are closely related to humans, with the only closer relative being the chimpanzee, it is probable that the basic principles of obstetric management in humans can be safely and appropriately applied to the captive gorilla population. With the exception of this report and the cited cesarean delivery reports, there are no other references to cross-species studies of active intervention in gorillas with human obstetric techniques. It is hoped that an increased awareness on the part of obstetricians of the importance of their knowledge and skill to zoos will lead to more successful outcomes in the captive gorilla population.

Animals↗