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PubMed1997

Adverse psychological impact of operative obstetric interventions: a prospective longitudinal study.

OBJECTIVE: This paper reports the findings of a prospective longitudinal study of 272 nulliparous pregnant women, which investigated as one of its objectives the psychological sequelae of obstetric procedures. METHOD: Participants completed structured interviews and standardised, published psychometric questionnaires, including the Rosenberg Self-Esteem Scale and the Profile of Mood States late in pregnancy and again early in the postpartum period. RESULTS: Little evidence was found to support the notion that the total number of obstetric interventions was linked to a deterioration in postpartum mood. Significant adverse psychological effects were associated with the mode of delivery. Those women who had spontaneous vaginal deliveries were most likely to experience a marked improvement in mood and an elevation in self-esteem across the late pregnancy to early postpartum interval. In contrast, women who had Caesarean deliveries were significantly more likely to experience a deterioration in mood and a diminution in self-esteem. The group who experienced instrumental intervention in vaginal deliveries fell midway between the other two groups, reporting neither an improvement nor a deterioration in mood and self-esteem. CONCLUSIONS: The findings of this study suggest that operative intervention in first childbirth carries significant psychological risks rendering those who experience these procedures vulnerable to a grief reaction or to posttraumatic distress and depression.

Adult↗
PubMed2005

[Obstetrical forceps: yesterday, today and tomorrow. Toward a new classification of obstetrical forceps].

OBJECTIVE: Obstetrical forceps are used worldwide since more than 400 years. In 2003 forceps deliveries accounted for 6.3% of all deliveries of the AURORE Grand-Lyon perinatal network. Although more than 400 different forceps have been described, obstetrics handbooks neither describe experimental forceps nor provide any chapter dedicated to instrumental delivery training. Our aim was to provide junior obstetricians with information that will allow them to select the best instrument and to let them know about experimental as well as pedagogic forceps. PATIENTS AND METHODS: International literature review using the terms "forceps" and "delivery" and a four year experimental work involving a close collaboration between obstetricians and biomechanics of the INSA engineering school. RESULTS: Two instruments are presented as well as a new forceps classification. DISCUSSION AND CONCLUSION: This classification distinguishes between three types of forceps: operational forceps designed to delivers neonates, experimental forceps designed to study biomechanics and training forceps designed for resident training. For the first time the classic blind forceps procedure is transformed in a full screen real time procedure.

Equipment Design↗
PubMed1975

[A comment about premature births (author's transl)].

Prenatal case histories and labours of 908 mothers who delivered prematurely at the University of Heidelberg, Department of Gynaecology and Obstetrics in Mannheim, between the years 1966-1971 were compared with a freely selected group of 782 mothers who delivered healthy mature infants with birth weights over 2500 g. (Premature infants -- under 2501 g; Stillborn infants -- under 2501 g and a minimum 35 cm crown-heel length). A tendency to premature delivery was observed in primipara, multipara with at least 4 previous deliveries, unmarried mothers, and in women with a preceding miscarriage or with closely spaced pregnancies less than 24 months apart. Bleeding during pregnancy, EPH-Syndrome, inadequate prenatal care, premature amnion rupture, abruptio placentae, pathological presentation and complications during labour were more frequently observed in mothers who delivered prematurely than those at full term. Histo-pathological changes of the placentas were found in 11,2% in cases of premature births as opposed to 3,6% in full term cases.

Abruptio Placentae↗
PubMedDate not supplied

[Obstetric-perinatal status 1990 in the Oder region (a contribution to the obstetric-perinatal care in East Brandenburg)].

On the background of the first All-German-Perinatal-Study in 1992 the results in obstetrics and perinatology in the Oder-Region (east part of the State of Brandenbourg) in 1990 are described. In comparison to the results in a previous study (1985) we found a drastical decline in the number of births (newborns 1985: 10244; 1990: 7723); in addition to the changing in the reproduction- and health-care behaviour, too, we have noted a decreasing perinatal mortality from 7.5% in 1985 to 4.9% in 1990. The ameliorated monitoring-rate (cardiotocography-rate) of the fetus (1985: 71%, 1990: 88.4%) and the decreasing still-birth-rate may be the main cause of this phenomenon. Clinic-births were the most common deliveries, the house-birth was the great exception; only 0.2% of all deliveries occurred at home or otherwhere. Our data support that there is no difference, except the birth-rate, in relation to the situation in the "old" Federal Republic of Germany.

Birth Rate↗
PubMed1995

[Obstetrical prognosis of the post-cesarean uterus. 641 cases].

OBJECTIVES: A retrospective study of decisions made in a gynaecology department between January 1990 and December 1993 were analyzed in order to assess management of the post-cesarean uterus. METHOD: Among 9092 women who delivered in the department during the study period, there were 641 patients with a post-cesarean uterus, due to a single prior cesarean section in 451. Results were analyzed and compared with those reported in the literature. RESULTS: Among the 451 patients with a single scar, 184 (41%) delivered by elective cesarean section and in 267 (59%) a decision was made during labour. In this group of 267 patients with a single cicatrix who underwent a labour tests, 227 (85%) had a vaginal delivery compared with 40 (15%) in which the decision for cesarean section was made during labour. CONCLUSION: The results observed were comparable with those found in the literature. Management of pregnancy with post-cesarean uterus is now quite similar to that of a normal uterus. Epidural anaesthesia and ocytotin therapy as well as epidural labour triggering have had an important effect.

Extraction, Obstetrical↗
PubMed1989

[Forceps at a university hospital. Critical study of the evolution of the procedure].

A retrospective study was carried out using the obstetric summaries in a computer between the years 1981 and 1986. The percentage of instrumental deliveries using forceps or spatula was significantly reduced whereas the caesarean section rate stayed the same: the majority of forceps deliveries during the year 1986 (14.5% of all deliveries) were carried out under epidural analgesia (70% of the deliveries) and the mean of these (75%) were carried out for delay. This is a definite change as compared with 1981 and it appears to be linked mainly to an increase in the number of epidural analgesics (70% for forceps deliveries in 1986) and a new appreciation of fetal distress. The maternal results were better because most episiotomies were lateral (60% of cases) which meant that only 1.5% of cases affected the sphincters. The immediate neonatal results were good, but do not seem to have been improved by the changes that have been observed, although the methodology for assessing the state of the neonate has improved.

Extraction, Obstetrical↗
PubMed1981

[Clinical obstetrics and perinatal mortality in 13 years (author's transl)].

Reported in this paper is a critical analysis of perinatal mortality which dropped from three to 1.1 per cent, between 1966 and 1978. The number of caesarean sections went up from two to 8.25 per cent, over the same period of time, with all indications having been foetal. No direct relationship was evident with intensive heart rate control of the foetus. The number of low-weight infants, that is less than 2,500 g in birth-weight, did not decrease in the period under review, in spite of tocolysis and cerclage. Perinatal mortality was conspicuous particularly for decline in intra-uterine and postpartum foetal deaths. There was a steady drop in uncorrected perinatal mortality, while the corrected figure remained constant over the past four years, though the rate of caesarean sections had been rising continuously. Therefore, perinatal mortality cannot be further reduced by continued increase in the number of caesarean sections. However, less low-weight births as well as improved monitoring and care of pregnant women will be answered to the problem. --Maternal mortality over the entire period under review amounted to 0.39 per thousand, against a total of 17 871 deliveries.

Breech Presentation↗
PubMedDate not supplied

A reevaluation of the association between instrument delivery and epidural analgesia.

BACKGROUND AND OBJECTIVES: Over 100 papers in the medical literature suggest pro or con that epidural analgesia is associated with an increase in the incidence of instrument delivery. This two-component study was performed to evaluate the influence of epidural labor analgesia on the incidence of instrument delivery. METHODS: Component 1 was a retrospective analysis of the medical records of 14,804 mothers having a vaginal delivery before and after implementation of an active epidural service. Component 2 was a case control study designed to determine factors, in addition to epidural analgesia, associated with an increase in instrument delivery. In component 2 11 factors describing maternal, fetal, anesthetic, and obstetric factors were analyzed for each of 609 consecutive patients having an instrument delivery and 246 controls having a spontaneous vaginal delivery. RESULTS: In component 1, despite a tenfold increase in the use of epidural analgesia, there was a similar association between epidural use and instrument delivery in both time periods. Additionally, the epidural-forceps association was twice as strong for parous patients as for nulliparous patients (odds-ratios 9.74 and 4.52, respectively). In component 2, five factors were significantly (P > .0001) associated with instrument delivery conclusions. CONCLUSIONS: While epidural analgesia was one factor, the others were gestational age > 41 weeks, a second stage of labor > 2 hours, an occiput posterior or transverse fetal position, and previous cesarean section. These four factors are individually and independently associated with an increase in the incidence of instrument delivery independent of epidural use.

Adolescent↗
PubMed1990

[Prevention of HIV infections in surgical gynecology and obstetrics].

In professionally conditioned HIV infections of medical personnel, blood has so far been the only source of infection that is of any importance. Hence, measures to prevent such infections must primarily aim at avoiding any contact with blood from HIV-infected patients. Since the HIV status of the patients and possibly alos other infections transmitted by blood (hepatitis) are often unknown, the following protective measures must be applied in all patients as a matter of routine. Fundamentally, gloves must always be worn when coming into contact with blood, body fluids, mucosa and non-intact skin. In operative procedures and deliveries, barrier methods must be employed to protect the eyes, nose, mouth and skin, as well as technical procedures during surgery and organisational measures to prevent any possible injuries or lesions caused by operative interventions and to reduce the number of persons exposed to risk. So far, needle pricks have been the most frequent mode of infection. Hence, used cannules should be treated with utmost care; do not return them into their protective cover but throw them directly into solid waste containers. After contamination, blood and other body fluids should be eliminated immediately. In case of massive contamination with material containing HIV, chemoprophylaxis should be given careful consideration.

Cesarean Section↗
PubMed1990

[Urine flow measurement in pregnancy and the puerperium].

To elucidate effects of gestation on micturition, 337 standardised urine flow measurements with weight transducers were performed on 296 women in normal pregnancy (n = 128), under oral or intravenous tocolysis (n = 103), after spontaneous delivery (n = 20) or obstetric surgery (n = 26) as well as on non-pregnant probands (n = 19) with clinically intact urinary tract for comparison. Average micturition frequency was calculated, as well (n = 86). However, only general trends were discernible from mean value calculations because of wide scatter of uroflow parameters: In normal pregnancy, significant increase in flow rate was observed only in the second trimenon. Major opposite effects were recordable from beta-adrenergics (Fenoterol) only in intravenous tocolysis. Micturition frequency was at its highest level towards the end of pregnancy. Post-partum, only flow rates after forceps delivery were worse than those in the non-pregnant control group, on the other hand after spontaneous delivery flow rates were even better than in the controls. Yet, even significant differences stayed within normal range, so that in general severe disadvantages should not be expected from voiding alterations during pregnancy. Uroflow measurements and frequency/volume charts are not required in the care of pregnant women unless conspicuous findings are derived from analyses of micturition habits, types, and frequencies.

Adult↗
PubMed2003

[Obstetrical considerations regarding marginal fetal viability of very early premature infants].

As a result of the impressive progress in perinatal medicine the frontier of extrauterine viability has been shifted to a continuously decreasing gestational age. Optimal results require a close collaboration between obstetrician and neonatologist following well defined protocols. The quality of interdisciplinary efforts in perinatal medicine is not only measured by survival rates but by the number of survivors with good chances of normal development. Before 24 weeks survival rate drops below 10% and more than half of the few survivors show signs of more or less severe handicaps. Interventional medicine, be it prenatally, during or after birth, is not recommended. Comfort care and support is given to the parents as well as the infant after birth. Beyond 26 weeks chances of survival rapidly increase above 50% while the rate of handicapped among the survivors drops below 50%. Starting with 26 weeks full monitoring of the fetus and operative interventions for delivery of the fetus together with expert neonatal treatment to assure optimal survival are recommended. In the grey zone of 24 and 25 weeks management must be individualized considering the special circumstances of the individual case and taking into account the basic expectations of the parents. Prenatally the most common clinical scenarios can be assigned to one of three categories, which are described in some detail.

Cesarean Section↗
PubMed2005

[Shoulder dystocia from a legal standpoint].

Even though a shoulder dystocia occurs very seldom it plays an important part in obstetrical medical opinions since it is quite often associated with infant plexus brachialis injuries. In legal medical discussions it is necessary to determine whether there were certain antepartal risks, if diagnosis and therapy were carried out correctly and whether a shoulder dystocia resp. plexus brachialis injury could have been prevented. In general one is looking for answers to prevent both serious complications. In the past a great number of articles were published referring to these answers. Especially in Anglo-American literature of the last few years one can find more and more indications that a clear cause-effect between shoulder dystocia and plexus brachialis injuries does not exist in every case. Also the value of typical or historical factors concerning association between the two are criticised in different publications. In addition the therapy strategies for shoulder dystocia treatments are momentarily analyzed in scientific discussions. Which treatment should be used first? Which ones are actually effective or do they even increase the risk of plexus brachialis injuries? Answers to these questions are given in the following abstract.

Birth Injuries↗
PubMed1997

Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial.

OBJECTIVE: To study the effects of antenatal perineal massage on subsequent perineal outcomes at delivery. DESIGN: A randomised, single-blind prospective study. SETTING: Department of Obstetrics and Gynaecology, Watford General Hospital. PARTICIPANTS: Eight hundred and sixty-one nulliparous women with singleton pregnancy and fulfilling criteria for entry to the trial between June 1994 and October 1995. RESULTS: Comparison of the group assigned to massage with the group assigned to no massage showed a reduction of 6.1% in second or third degree tears or episiotomies. This corresponded to tear rates of 75.1% in the no-massage group and 69.0% in the massage group (P = 0.073). There was a corresponding reduction in instrumental deliveries from 40.9% to 34.6% (P = 0.094). After adjustment for mother's age and infant's birthweight these reductions achieved statistical significance (P = 0.024 and P = 0.034, respectively). Analysis by mother's age showed a much larger benefit due to massage in those aged 30 and over and a smaller benefit in those under 30. CONCLUSION: Antenatal perineal massage appears to have some benefit in reducing second or third degree tears or episiotomies and instrumental deliveries. This effect was stronger in the age group 30 years and above.

Adult↗
PubMed1994

[Labor induction with prostaglandin E2 in post-term pregnancy-- results of a multicenter study].

Post-term pregnancy has been the indication for induction of delivery in 542 patients from a multicenter study with 1472 patients undergoing induction with prostaglandin E2 given as vaginal tablet (3 mg) or as intracervical gel (0.5 mg), according to cervical ripeness. The obstetric characteristics of these 542 patients were compared to the data of the Baden-Wuerttemberg obstetrical trial as controls. Although cervical ripeness parameters differed significantly from those of the controls, birth intervals were significantly shorter in the study group. Fetal outcome parameters (umbilical artery pH, Apgar values, frequency of admission to pediatric ward) turned out to be more favorable in the study group. Frequency of operative vaginal deliveries (12.7%) and of Cesarean sections (15.5%) was significantly higher in the study group as compared to the reference group (operative vaginal deliveries 8.1%, secondary Cesarean sections 7.3%). If we relate these frequencies to data from prospective, randomized studies comparing active management of post-term pregnancies, it can be demonstrated that active management in general is associated with lower frequencies of operative deliveries. Additionally, the data from our study with active management of post-term pregnancy revealed even lower frequencies for operative deliveries as seen from actively managed post-term deliveries in the literature reviewed. Hence, the induction protocol adapted to cervical ripeness reported in this study is an efficient and safe management for post-term pregnancy minimizing the rate of operative deliveries.

Administration, Intravaginal↗
PubMed2005

Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study.

This study was conducted to evaluate the effects of pregnancy and childbirth on postpartum sexual function. Nulliparous, English-literate women were enrolled who had presented to the UNC Hospital's obstetrical practice; these women were 18 years of age and older and at 30-40 weeks' gestation. Questionnaires were completed regarding sexual function prior to pregnancy, at enrollment, and at 2, 6, 12, and 24 weeks postpartum. Demographic and delivery data were abstracted from the departmental perinatal database. One hundred and fifty women were enrolled. At 6, 12, and 24 weeks postpartum, 57, 82, and 90% of the women had resumed intercourse. At similar postpartum timepoints, approximately 30 and 17% of women reported dyspareunia; less than 5% described the pain as major. At these times, 39, 60, and 61% of women reported orgasm. Orgasmic function was described as similar to that prior to pregnancy or improved by 71, 77, and 83%. Delivery mode and episiotomy were not associated with intercourse resumption or anorgasmia; dyspareunia was only associated with breast-feeding at 12 weeks (RR = 3.36, 95% CI = 1.77-6.37). Most women resumed painless intercourse by 6 weeks and experienced orgasm by 12 weeks postpartum. Function was described as similar to or improved over that prior to pregnancy.

Adult↗
PubMed1996

Oral misoprostol versus mifepristone for cervical dilatation before vacuum aspiration in first trimester nulliparous pregnancy: a double blind prospective randomised study.

OBJECTIVE: To compare the effectiveness of oral misoprostol and mifepristone for cervical priming before first trimester termination of nulliparous pregnancy. DESIGN: Prospective double blind randomised study. SETTING: Department of Obstetrics and Gynaecology, University of Hong Kong. PARTICIPANTS: One hundred nulliparous women undergoing termination of pregnancy between 8 and 12 weeks of gestation were recruited for this prospective randomised trial. The women were allocated to either the oral misoprostol or mifepristone group. Subjects in misoprostol group were given placebo and misoprostol 400 micrograms 36 h and 12 h respectively before vacuum aspiration. Subjects in mifepristone group were given 200 mg mifepristone and placebo 36 h and 12 h respectively prior to operation. MAIN OUTCOME MEASURES: Baseline pre-operative cervical dilatation, the incidence of side-effects, the amount of blood loss and duration of procedure. RESULTS: There were no significant differences in the baseline cervical dilatation, incidence of side-effects, amount of blood loss and duration of procedure. CONCLUSIONS: Misoprostol and mifepristone are of similar effectiveness for cervical priming prior to vacuum aspiration in nulliparous women. Misoprostol has additional advantages of being widely available and inexpensive.

Abortifacient Agents, Nonsteroidal↗
PubMed1988

How small is too small? Considerations in evaluating the outcome of the tiny infant.

An aggressive approach to the obstetric and neonatal care of the pregnant mother and her infant in the late second trimester has led to an increase in survival. Surviving infants have a high rate of neonatal morbidity, including bronchopulmonary dysplasia and intraventricular hemorrhage. No long-term follow-up reveals handicap rates of 22 to 35 per cent, with multiple sensory and neurodevelopmental handicaps. With current methods of care, the biologic threshold of extrauterine survival is 23 to 24 weeks' gestation, or a birth weight of 500 to 600 gm. There is no simple arithmetical answer to the question of "how small is too small?" It should be apparent from the information presented in this article that the state of the art is constantly in flux. New developments have, to date, continued to decrease the threshold of viability. Application of the full weight of the available technology results in only a few infants of less than 23 to 24 weeks' gestation or with birth weights of less than 500 to 600 gm surviving. The future continues to lie in the development of the methodology to prolong the sojourn in utero, rather than in dramatic biophysical, biochemical, and technologic advances.

Birth Weight↗
PubMed2006

Predicting operative delivery.

OBJECTIVE: Unplanned operative delivery (vaginal or abdominal) is associated with maternal anxiety, maternal and neonatal morbidity and increased resource use. We aimed to identify potential predictors for emergency operative delivery. METHODS: This was a prospective observational study of 202 nulliparous women in a tertiary antenatal unit between 36 and 40 weeks' gestation. The assessment included an interview, a vaginal examination for Bishop score (optional), and a translabial ultrasound examination performed with the woman in a supine position and after voiding to determine cervical length, bladder position on Valsalva, and fetal head engagement. Clinical data were obtained from the institutional obstetric database and patient records. RESULTS: In the late third trimester, body mass index (P = 0.016), maternal age at due date (P < 0.0001), history of Cesarean section in first-degree relatives (P = 0.009), Bishop score (P = 0.0004), cervical length (P = 0.001), bladder position on Valsalva (P = 0.003) and head engagement (P < 0.0001) were significantly associated with delivery mode. On multivariate logistic regression analysis, the best model for predicting normal vaginal delivery contained maternal age, history of Cesarean section, Bishop score and bladder position on Valsalva and had excellent ability to discriminate between normal vaginal delivery and operative delivery (c = 0.85). The model with the best ability to discriminate between vaginal delivery and Cesarean section contained the same parameters plus body mass index; this model performed even better (c = 0.87). CONCLUSIONS: Identification of women at increased risk of operative delivery appears feasible. A combination of clinical and ultrasound variables yielded a model that is likely to predict delivery mode accurately in up to 87% of cases. Such a model may become useful as an entry criterion for intervention trials in women at low or very high risk of operative delivery.

Adult↗