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PubMed1994

[Birth difficulties in sheep and goats--evaluation of patient outcome from seven lambing periods in an obstetrical clinic].

The incidence of parturition difficulties from 239 sheep and 21 does from the last seven lambing periods was recorded at a clinic for obstetrics. Without exception the does were housed under extensive conditions by hobby-breeders. The sheep also originated predominantly from hobby-breeders and in a smaller amount from professional breeders, both practising extensive housing. The incidence of manual deliveries (m.d.) in both species was lower (39.3% in sheep; 42.8% in does) than that of caesarean sections (c.s; 57.3% in sheep; 47.7% in does). In a small amount the obstetrics were solved via fetotomy. The practical proceedings concerning the different methods of therapies including analgesia, surgical approaches and postoperative treatments are described. In sheep ringwomb was the dominating reason for dystocia for m.d. (43.5%) as well as for c.s. (73.7%), followed by obstetrics due to fetal abnormal presentation and/or position or posture (25.2% m.d.; 1.1% c.s.), secondary oversized fetuses due to postmortal emphysema and edema (19.1% m.d.; 10.7% c.s.), followed by primary relative or absolute oversized fetuses (1.0% m.d.; 4.8% c.s.) and simultaneously presentation of multiple fetuses (4.2% m.d.). Other causes of dystocia remained scarce (i.e. uterine torsion, hydrallantois, abdominal or perineal hernia). There rested an amount of sheep (7.1%) with preterm s.c. because of continuous pressure and pain symptoms followed by infections or injuries of the prolapsed vagina and/or rectum, pregnancy toxemia and other reasons. The main indication for fetotomy in sheep were fetuses with postmortal edema and emphysema (80.0%), deformity of the kids (20.0%) respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1994

The obstetric management of fetal distress and its association with cerebral palsy.

OBJECTIVE: To determine the relation between the obstetric management of fetal distress and cerebral palsy. METHODS: The obstetric details of all 78 children with cerebral palsy born in a geographically defined area between 1975-1980 were compared with those of 591 control children. RESULTS: Fetal distress was identified more frequently in children with cerebral palsy who were born at term (24%) than among controls (11%). There was an inappropriate response to fetal distress in 12% of children with cerebral palsy but in only 3% of controls. CONCLUSIONS: If fetal distress in some way causes subsequent cerebral palsy, then the data in this study suggest that its complete elimination might be expected to reduce the birth prevalence of cerebral palsy by 15.6%. "Perfect" obstetric management of fetal distress might reduce the birth prevalence of cerebral palsy by 9% in term infants or 6% overall.

Case-Control Studies↗
PubMed1994

Drug therapy for obstetric emergencies.

Drug therapy for the treatment of obstetric emergencies frequently consists of medications not commonly used by the emergency physician such as Rho(D) immune globulin, 15-methyl prostaglandin F2a (carboprost), and ritodrine hydrochloride. This article focuses on those agents for which emergency use is confined to the obstetric emergency or where the administration of a commonly used drug acquires unique characteristics because of the clinical situation. In either case, a thorough understanding of the indications, contraindications, dose, route of administration, and side effects of these drugs will allow prompt and effective management of a variety of obstetric emergencies.

Emergencies↗
PubMed1993

Discharge against medical advice in an obstetric unit.

Obstetricians have increasingly petitioned courts for orders sanctioning treatment refused by pregnant patients. To speculate on the potential role of forced detention, we reviewed the clinical records of 39 obstetric patients who were discharged against medical advice (AMA) with several diagnoses: preterm labor (27), medical complications of pregnancy (9) and trauma (3). These patients were matched for chronologic age, gestational age and clinical examination at the time of admission and compared to a group of compliant patients who accepted and followed the treatment plan for hospitalization. No perinatal morbidity and/or mortality or other adverse outcome could be documented in the AMA group despite their refusal to continue undergoing admission and therapy. No difference could be demonstrated between the AMA group and the compliant group for obstetric complications, gestational age at delivery, newborn weight and percentage of appropriate-weight-for-gestational-age infants. These data suggest that failure to comply with major obstetric recommendations and hospitalization in these clinical settings might not adversely influence perinatal outcome.

Female↗
PubMed1993

[Recent advances in diagnosis of disseminated intravascular coagulation in obstetrics and gynecology].

Since obstetrical DIC is an acute serious situation, complicated time-consuming tests do not help to make a prompt diagnosis of DIC. Lowered ESR, prolonged bleeding time and defective patterns of thrombelastography are the suggestive findings of DIC, which are available at the bed-side. Obstetrics-specific DIC scoring system, in which high scores were given for clinical items, rather than laboratory tests, showed a good correlation with the regular DIC score in Japan. Since blood samples obtained from pregnant or parturient women showed different patterns of coagulation and fibrinolysis from the nonpregnant condition, attention should be paid to diagnose obstetrical DIC as accurately as possible.

Biomarkers↗
PubMed1993

Obstetrics and the general surgeon.

From a small Pacific island country of Tuvalu, an analysis of 132 obstetric and gynecologic patients operated upon by one general surgeon during a 20.5 month period from 1988 to 1989 was performed. The operations comprised 50 percent of all surgical procedures and were associated with complicated pregnancy and delivery in 48 percent of the patients, birth control and infertility in 34 percent and gynecologic neoplasms, infections and bleeding ex utero in 18 percent. There was no mortality and 11 patients had lesser complications. Of the 38 cesarean sections, 76 percent were emergency operations. The main indications for cesarean section were dystocia in 55 percent of the patients and previous cesarean section in 24 percent. There was no maternal mortality. The complication rate was 13 percent and included two neonatal deaths. The cesarean birth rate during the study period was 7.6 percent, a nearly fivefold increase from the previous 9.5 years. With other factors remaining unchanged, the increase in cesarean birth rate corresponded to a decrease in neonatal death rate from 35.7 to 15.7 per 1,000 live-born infants. It is concluded that a considerable share of work of a general surgeon in developing countries consists of obstetric and gynecologic procedures. This should be taken into consideration when training and recruiting surgeons for that kind of work. A general surgeon with obstetric experience can perform cesarean section with an acceptable morbidity rate and should not hesitate to do it whenever labor does not progress as expected. The decision to operate can be based on physical examination with close cooperation with the midwife. In developing countries, increasing cesarean birth rates alone seem to reduce considerably the neonatal death rates.

Adolescent↗
PubMedDate not supplied

Metronidazole: utilization in the obstetric and gynecologic patient.

BACKGROUND: Obstetric and gynecologic complications associated with bacterial vaginosis and trichomoniasis have heightened awareness of these conditions, and thus metronidazole's role in obstetric and gynecologic practice continues to increase. GOAL OF THIS STUDY: To review the clinical indications for metronidazole in the obstetric and gynecologic setting, as well as the pharmacokinetics and potential adverse effects of the drug. STUDY DESIGN: Review of the current literature concerning metronidazole. RESULTS AND CONCLUSIONS: Metronidazole remains a valuable agent for the treatment of anaerobic and protozoal infections with little evidence of resistance. Although issues of mutagenicity and carcinogenicity remain theoretical concerns, current data do not support the existence of these risks in humans.

Antitrichomonal Agents↗
PubMed1996

Uterine packing in the combined management of obstetrical hemorrhage.

Uterine packing to control obstetrical hemorrhage has been generally discouraged over the past several decades. Intractable uterine hemorrhage postpartum or following an abortion is an extremely vexing management problem for the physician and continues to be a leading cause of maternal mortality. Uterine packing should be considered as a presurgical management tool after lacerations of the lower genital tract, uterine rupture, or retained products have been ruled out and when conventional therapy fails to control uterine hemorrhage. We describe two obstetrical patients with intractable uterine hemorrhage who were managed with uterine packing in combination with other methods of therapy. Causes of obstetrical hemorrhage and techniques of packing the uterus are discussed.

Abortion, Therapeutic↗
PubMed1996

[Neurologic aspects of vesico-vaginal fistula of obstetrical origin].

OBJECTIVE: To study the electromyographic alterations of the urethral sphincter, perineal muscles and lower limbs observed in women with obstetric vesicovaginal fistula. METHODS: We compared a group of 22 women with obstetric vesicovaginal fistula with a control group of 10 women without fistula. Each woman underwent a neurological examination of the perineum and lower limbs and electromyography of the lower limbs and urethral sphincter. According to the classification proposed by MENSAH, the fistulas were classified as simple (54.5%), complex (31.8%) and complicated (13.6%). RESULTS: Twenty women with VVF presented a peripheral nerve lesion. Five of these patients had a clinical and electromyographic lesion; while the other fifteen patients had a subclinical lesion. 68.18% of the fistula patients presented a clinical neuropathy in the perineum. This lesion was detected on electromyography in all patients with fistula. The severity of this denervation lesion ranged from moderate (36.37%) to severe (63.63%). No neurological lesions were detected in the control group. The degree of denervation has more severe in young women (21-25 years) and in primiparous women. In contrast, the severity of denervation did not appear to be related to the history of the fistula. The risk of treatment failure increased proportionally to the severity of denervation. 73% of fistulas with severe denervation remained "unsuturable", or required multiple operations with disappointing results in the form of persistent vesicosphincteric dysfunction. CONCLUSION: Although the psychosocial impairment and upper urinary tract repercussions have been well evaluated, the peripheral neurological lesion has always been underestimated in the management of obstetric vesicovaginal fistulas. The authors consider that the fistula is only the apparent manifestation of "neurovesical damage", which remains the decisive factor in the prognosis and which largely explains the high frequency of treatment failure.

Adult↗
PubMed1996

[Obstetrical complications of adenomyosis. Literature review and two case reports].

Adenomyosis of the uterus is a frequent disorder often associated with pregnancy. Diagnosis is difficult during pregnancy and usually is made after an obstetrical complication. In a review of the literature from 1904 to 1994, only 31 cases of obstetrical complications related to adenomyosis have been reported. We report two cases revealed by obstetrical complications: one causing spontaneous rupture of the uterus during labor in a primiparous woman and the other with cornual ectopic pregnancy diagnosed, due to an episode of massive intraperitoneal bleeding.

Adult↗
PubMedDate not supplied

Effect of prenatal care on obstetrical outcome.

The purpose of this study was to examine the demographic and obstetrical outcomes of women with poor prenatal care. A 7-year (1987-1993) computerized perinatal database with 29,225 consecutive deliveries was collected prospectively from a single inner city tertiary medical center. Data from 23,181 women who had documented prenatal visits during their pregnancies were used in the analysis. Overall, 21,004 (90.6%) of the mothers had at least 3 prenatal visits (C), while 2,177 (9.4%) had 2 or fewer visits (NC). The proportion of NC did not change significantly over the years (P = 0.47, by trend test). The NC group was 2.3 times more likely to be unmarried (79.8% vs. 59.4%; P < 0.001), have greater parity (mean +/- SD 2.1 +/- 1.9 vs. 1.2 +/- 1.2; P < 0.001), 6.3 times more likely to be staff patients (have no private insurance), and 1.5 times more likely to be black. The average maternal age was 24 years for both groups (P = 0.65). NC mothers delivered at an earlier gestational age (37.3 +/- 3.3 vs. 39.0 +/- 2.6 weeks; P < 0.001), had lower birth weights (BW) (2,810 +/- 743 vs. 3,203 +/- 607 g for singleton births; P < 0.001), and their infants had longer neonatal hospital stays (8.4 +/- 17.3 vs. 4.8 +/- 10.4 days; P < 0.001) compared with C mothers. Moreover, after adjusting for various confounding factors known to effect BW, C mothers delivered infants which were on the average 550 g heavier than the NC mothers. The neonates of NC had consistently lower Apgar scores and were more likely be delivered in breech presentation (5.7% vs. 3.1%) and to be transferred to the neonatal intensive care unit (11.6% vs. 5.2%; P < 0.001). However, the NC group had fewer cesarean deliveries (9.4% vs. 14.2%; P < 0.001) but more thick meconium fluid (12.4% vs. 8.9%; P < 0.001). In conclusion, the women not seeking adequate prenatal care are more likely to be unmarried, black, and staff patients having several children at home. NC mothers tend to have poor obstetrical outcomes and on the average their neonatal stay in the hospital is twice as long as women obtaining adequate prenatal care.

Adolescent↗
PubMedDate not supplied

Obstetric care in the Netherlands: manpower substitution and differential costs.

Trends in the Netherlands show an expanded role for obstetricians in hospital-based prenatal and natal care, as well as a shift in postnatal care away from hospitals to domiciliary care. While general practitioners attend a steadily declining share of total births, midwives continue to play a central role in supporting over 40 per cent of all births and in attending nearly two thirds of all home births, which, in the Netherlands, is the preferred option for more than a third of childbearing women. As shown in the figures, shifts of births into hospitals and of postnatal care out of hospitals produce opposite effects on obstetric expenditures. Cost differences are primarily associated with variation in location of care, and only secondarily with variation in provider of care, underscoring the importance of contrasting styles of obstetric management and their influence on costs. In the context of these observed transitions, the increasing popularity of policlinical deliveries constitutes a pivotal force whose impact to date appears to have been neglected by planners and health care decision makers.

Costs and Cost Analysis↗
PubMed1992

The association of low socio-economic status in metropolitan Adelaide with maternal demographic and obstetric characteristics and pregnancy outcome.

The South Australian perinatal statistics collection for 1988 was used to consider the association of low socio-economic status in metropolitan Adelaide (South Australia) with maternal demographic and obstetric characteristics and pregnancy outcome in 12047 singleton births. Socio-economic status--low, middle or high--was inferred from the socio-economic rating of the postcode of residence. Chi-squared analyses were carried out to test for significant trends in proportions of pregnancy and pregnancy outcome variables across the socio-economic groupings. There was trend for the proportions of adverse obstetric and perinatal outcomes to decrease with increasing level of socio-economic status. Logistic regression analysis, adjusted for maternal age, marital status, race, parity and gestational age, confirmed the findings of the trend analyses, namely that mothers from the poor socio-economic areas were at a greater risk for poor pregnancy outcome. These poor outcomes included Apgar scores of less that 7 at both 1 and 5 minutes after birth, delay in onset of regular breathing of 5 minutes or longer; the need for intubation; the use of narcotic antagonists; low birthweight of under 2500 g; the need for special nursey care; and neonatal death.

Adult↗
PubMed1994

Delayed repair of obstetric injuries of the anorectum and vagina. A stratified surgical approach.

PURPOSE: We categorized the various types of post-obstetric injuries of the anorectum and vagina encountered in a five-year period. The operative procedures used to repair these injuries and the functional outcome after surgery were assessed. METHODS: Between 1986 and 1991, 52 patients were surgically treated for obstetric injuries of the anorectum and vagina; 48 patients were available for follow-up study. Four clinical injury types were identified: Type I, incontinent and sphincter (11 patients); Type II, rectovaginal fistula (16 patients); Type III, rectovaginal fistula and incontinent and sphincter (11 patients); and Type IV, cloaca-like defect (10 patients). The mean age of the patients was 30 years, the mean duration of symptoms before surgery was 13 months, and the mean follow-up period was 16 months. The major component of surgical repair for each injury type was: Type I, overlap repair of external anal sphincter; Type II, rectal mucosal advancement flap; Type III, overlap repair of external anal sphincter and rectal mucosal advancement flap; and Type IV, overlap repair of external anal sphincter, anterior levatorplasty, and anal and vaginal mucosal reconstruction. Fecal diversion was not performed in any patient. Specific questions were asked at the most recent follow-up assessment to determine results. RESULTS: Continence status postoperatively was classified as perfect, impaired, or poor; poor was defined as no improvement or worse. Postoperative continence (perfect impaired, or poor) was, respectively: Type I (11 patients), 64 percent, 36 percent, and 0 percent; Type II (16 patients), 56 percent, 0 percent, and 44 percent; Type III (11 patients), 64 percent, 36 percent, and 0 percent; and Type IV (10 patients), 90 percent, 10 percent, and 0 percent. Vaginal discharge of stool was eliminated in all patients with a rectovaginal fistula. Subjectively, 92 percent of the patients had excellent or good results. Complications included wound hematoma (n = 2), fecal impaction (n = 2), urinary retention (n = 1), and urinary tract infection (n = 1). CONCLUSION: Patients with Type II injuries had the worst results (P < 0.001). These patients should be evaluated for anal incontinence before surgery to assess the need for a concomitant sphincteroplasty.

Adult↗
PubMed1992

Obstetrical epidural anaesthesia in a rural Canadian hospital.

Few rural hospitals offer obstetric epidural analgesia services and of those that do, there is a paucity of information about these anaesthetics. A retrospective review was conducted of all obstetrical epidurals from 1984-1988 in an 85-bed hospital in Saskatchewan to examine the indications, complications, and infant outcomes. During that period there were 1224 deliveries. From a total of 915 vaginal deliveries, 42 (4.6%) received an epidural. Caesarean sections numbered 309: 183 (59.3%) were with epidural analgesia of which 69 were urgent and 114 elective. The overall complication rate was 23% with the most important being hypotension (12%), dural punctures (1.8%), inadequate block requiring an intravenous supplement (4.0%) or a general anaesthetic (3.1%). Infant outcomes were favourable except for two unrelated intra-uterine deaths preceding labour.

Anesthesia, Epidural↗
PubMed2004

[Survey on practice of regional anaesthesia in Germany, Austria, and Switzerland. Part 3: Methods in obstetric anaesthesia].

The practice of regional anaesthesia in German speaking countries was investigated by a survey. The last part of the trilogy contains the presentation and evaluation of the data about the methods in obstetric anaesthesia. In 2002 questionnaires were mailed to 750 randomly selected departments of anaesthesia, 384 hospitals (51.2%) responded of which 278 had an obstetric unit. Caesarean section rate was 22.5+/-8.2% and for elective caesarean section spinal anaesthesia was mostly used. General anaesthesia was never used in 58.3% of Swiss, 10.2% of German, and 21.1% of Austrian hospitals. For non-elective caesarean section 42.1% of the hospitals often used a spinal anaesthesia, and 44.8% sometimes, in Switzerland these were 92.9% and 7.1%, respectively. Pain relief for labour was usually achieved with epidural anaesthesia or drugs. The trend from general to regional anaesthesia for caesarean section is continued, as is the trend from local infiltrative techniques to epidural anaesthesia for vaginal delivery. Switzerland was in the forefront for these developments.

Adult↗
PubMed1986

Obstetric malpractice litigation: the pathologist's view.

In obstetric malpractice litigation, there are two main bases of defense: the clinical basis and the pathogenesis basis. The malpractice suit in most cases involves an infant delivered at term that later develops cerebral palsy. Despite the fact that much information has been elucidated about the pathogenesis of cerebral palsy, the defense is often jeopardized by an inadequate presentation of relevant causal mechanisms, pathogenesis. Studies in recent years with correlated clinical and pathologic investigations have provided evidence that the occurrence of cerebral palsy is a time marker, reflecting cerebral damage incurred during the premature period, and does not result from the events of labor and delivery at term. There is broad need generally and in legal situations for clinicians and pathologists to become knowledgeable in comprehensively correlating obstetric factors with fetal-neonatal systemic pathologic conditions and with neuropathologic effects.

Brain↗
PubMed1986

The role of obstetric factors in perinatal mortality trends.

In the Perinatal Unit of the New Jersey Medical School, Newark the combined neonatal mortality and stillbirth rates declined from more than 51 per 1000 to less than 17 per 1000 between 1971 and 1983. This change is comparable to the reduction of perinatal mortality rates nationwide since the Second World War. Because the improvement in the fetal and neonatal survival rates occurred in a static population and against well identifiable changes in the structure, equipment, policies and management patterns of the obstetric unit, it was possible to assess the impact of various factors upon perinatal outcome. In the environment of this institution adherence to conservative concepts of obstetric management, avoidance of manipulative and extraction procedures, an increase of the rate of cesarean sections from about 7 to 15% and emphasis upon infection control appeared to be the crucially important factors. Antepartum sonography and fetal stress and non-stress testing significantly impacted upon the results. The role of intrapartum electronic monitoring was less clearly definable and seemed to be effective only in the hands of experienced physicians. The results did not seem to be adversely affected by the fact that the program de-emphasized invasive procedures, including fetal scalp pH sampling.

Adolescent↗