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PubMed1989

Llama medicine. Obstetrics, neonatal care, and congenital conditions.

Obstetrical care of the llama is very similar to other food animal and equine obstetrics. Understanding the few unique llama characteristics such as birthing from a standing position, no licking of the neonate by the mother, and the epidermal membrane covering the newborn, help give confidence when treating llamas. Dystocia is rare in the llama but when veterinary assistance is required, understanding the shape of the female pelvis aids in manipulations. Llama neonatal care is minimal for the healthy cria, but intensive care of a compromised cria is extremely demanding, and not always rewarding. The suggestions presented in this article are the result of 4 years' experience in providing care to many ill neonatal llamas. Several methods have been adapted from equine neonatal medicine used at the Veterinary Medical Teaching Hospital at the University of California. Basic physiological information concerning llama neonates, healthy and ill, is still being investigated. It is judicious to identify and discuss congenital problems in neonates prior to intensive support.

Agammaglobulinemia↗
PubMed2003

Planning for hemorrhage. Steps an anesthesiologist can take to limit and treat hemorrhage in the obstetric patient.

Obstetric hemorrhage continues to be a significant cause of maternal mortality and morbidity. Blood transfusion in such circumstances may be life saving but involves exposing the patient to additional risks. Limiting blood transfusion and using autologous blood when possible may reduce some of these risks. This article outlines the techniques that may be used to limit and more effectively treat hemorrhage in the obstetric patient, with particular attention paid to reducing the use of allogeneic blood transfusion.

Anesthesia, Obstetrical↗
PubMed2004

Breast-feeding problems after epidural analgesia for labour: a retrospective cohort study of pain, obstetrical procedures and breast-feeding practices.

Various clinical practices have been found to be associated with breast-feeding problems. However, little is known about the effect of pain, obstetrical procedures and analgesia on breast-feeding behaviour. We designed a retrospective study with a questionnaire concerning pain, obstetrical procedures and breast-feeding practices mailed to 164 primiparae in Lapland. Altogether 99 mothers (60%) returned completed questionnaires that could be included in the analysis, which was carried out in two steps. Firstly, all accepted questionnaires were grouped according to the success or failure to breast-feed fully during the first 12 weeks of life. Secondly, an ad hoc cohort study was performed on the sub-sample of 64 mothers delivered vaginally. As many as 44% of the 99 mothers reported partial breast feeding or formula feeding during the first 12 weeks. Older age of the mother, use of epidural analgesia and the problem of "not having enough milk" were associated with the failure to breast-feed fully. Caesarean section, other methods of labour analgesia and other breast-feeding problems were not associated with partial breast feeding or formula feeding. In the sub-sample, 67% of the mothers who had laboured with epidural analgesia and 29% of the mothers who laboured without epidural analgesia reported partial breast feeding or formula feeding (P = 0.003). The problem of "not having enough milk" was more often reported by those who had had epidural analgesia. Further studies conducted prospectively are needed to establish whether a causal relationship exists between epidural analgesia and breast-feeding problems.

Adult↗
PubMedDate not supplied

Subarachnoid catheter placement after wet tap for analgesia in labor: influence on the risk of headache in obstetric patients.

BACKGROUND AND OBJECTIVES: The incidence of postdural puncture headache (PDPH) after epidural wet tap for obstetric patients may be as high as 75%. We have studied how subsequent placement of a subarachnoid catheter immediately after confirmation of a wet tap, and leaving the catheter in place for 24 hours affects the incidence of PDPH. METHODS: Over a 5-year interval, 115 consecutive patients who had unintentional dural puncture were divided into 3 groups by consecutive assignment. Group A had an epidural catheter placed at another interspace. Group B had a subarachnoid catheter placed for labor analgesia that was removed immediately after delivery. Group C had a subarachnoid catheter that was left in place for 24 hours after delivery. Data were collected retrospectively. The incidence of PDPH and blood patch was compared between groups. RESULTS: The overall incidence of PDPH was 46.9% and need for blood patch 36.5%, significantly less in both subarachnoid catheter groups, 31% in B and 3% in group C, compared with group A (PDPH 81%) (P <.001). CONCLUSION: Subarachnoid catheter placement after wet tap in obstetric patients reduces the PDPH rate and does so to a greater extent if left in place for 24 hours after delivery.

Adult↗
PubMed2003

Investigating adverse outcomes in obstetrics.

Investigation of adverse outcomes in health care requires a systematic and systemically oriented approach. This is true in obstetrics where, in Western countries such as Canada, adverse outcomes in the form of maternal mortality are rare. A model for such investigation is presented, based on answers to 3 questions: What? How? and Why? These questions correspond to Donabedian's 3 components of quality assurance: Outcome, Process, and Structure, respectively. Aspects of Reason's model of accidents are also included, in the form of "active failures" and "latent conditions." The latter are divided into 5 basic contributory factors, 4 of which are derived from Helmreich's model of human factors influencing behaviour in flight-crew environments. To illustrate its basic nature, the model is applied to a previously well-investigated air crash at Dryden, Ontario, and 3 obstetric cases of maternal mortality. Application of the model to the reactive investigation of close calls is discussed, as is application to the proactive interrogation of the system for the presence and nature of hazards that pose threats to safety.

Canada↗
PubMed2005

The current crisis in obstetrics.

Of the issues leading to legal actions in obstetrics, the most important are events occurring before delivery that are deemed to account for the birth of a physically or mentally challenged child. In determining causation in the clinical setting, the diagnosis of fetal asphyxia can be made using blood gas and acid-base assessment. However, there are many subsidiary questions that in most cases cannot be answered, including when the asphyxia began, the severity and nature of the asphyxia during the exposure, the quality of the cardiovascular compensation, and when the brain damage occurred. When scientific proof is not available, the dilemma for the court is the requirement to reach a conclusion about the timing of brain damage on the balance of probabilities. Although it is of value, clinical risk scoring using fetal heart rate (FHR) monitoring may result in false positive predictions of fetal asphyxia. The problem in FHR monitoring is the lack of a detailed algorithm for the interpretation of FHR patterns with appropriate recommendations for management. Until such an algorithm is developed, health care workers cannot be expected to respond to fetal heart rate patterns consistently. Responsibility for the crisis in obstetrics must rest with the members of the health care disciplines who provide expert testimony. Progress made in research encourages us to assume that more is known about the causes of brain damage in the clinical setting than in fact is known. Similarly, health care professionals, parents, and lawyers often assume current methods of prediction and diagnosis to be more effective than they actually are.

Blood Gas Analysis↗
PubMed1999

Obstetric complications predict treatment response in first-episode schizophrenia.

BACKGROUND: Understanding the role of obstetric complications (OCs) in schizophrenia could potentially shed light on the heterogeneity in the aetiology and course of schizophrenia. Many investigators have reported an association between OCs and schizophrenia, but few have examined the association between OCs and treatment outcome. We investigated this question in a sample of patients studied during their first episode of schizophrenia, schizoaffective or schizophreniform disorder. METHOD: OC histories were obtained for 59 patients participating in the Hillside First Episode Study. Cox proportional hazards regression analysis was used to estimate the effect of OCs on treatment response during the first episode of schizophrenia. RESULTS: Twelve of the 59 patients (20%) had positive histories of OCs. This group exhibited lower rates of treatment response than those with negative OC histories (hazard ratio controlling for sex = 0.28; 95% CI = 0.13, 0.62). The positive OC group also had significantly greater lateral ventricle volume, baseline disorganization and number of live births. The effect of OC history on treatment response held when these three variables were controlled for. CONCLUSION: A history of obstetric complications predicted poor response to treatment in the first episode of schizophrenia. This large effect was based on a small sample of 59 patients. Thus, replication is called for.

Adolescent↗
PubMed1999

Observations on obstetric practice in a multicultural setting.

Singapore provides a rich environment for investigations into ethnic differences in pregnancy outcome, as it is populated by Malays, Indians, and Chinese. Years of clinical practice and obstetric research in this environment have affirmed the observation that many factors interact in determining length of gestation and birth weight, and that these factors have differential affects among these three different ethnic groups. Although technological advances have furthered our understanding of obstetrical outcomes and provided essential tools to promote the survival of premature infants, the persistent use of uniform growth standards hampers our ability to assure positive outcomes for women of different ethnicity. Recognition of ethnic differences has resulted in declines in certain negative pregnancy outcomes for women in Singapore. The development of race-specific uterine growth curves will enhance the provision of perinatal care for all women.

China↗
PubMed2003

Survey of anaesthetic support staff in obstetric units in England and Wales.

In order to determine the current level of support provided to anaesthetists on the labour suite, a postal questionnaire was sent to the lead consultants of the 257 obstetric units in England and Wales. One hundred and ninety-five replied, a response rate of 76%. Of those who replied, only 1% of units experienced frequent delays to elective obstetric lists due to lack of an anaesthetic assistant and 141 units (72%) had a designated assistant for the labour ward. However, 58 units experienced delays waiting for an anaesthetic assistance in emergency situations (29%). One hundred and sixty-eight units (86%) had an operating department practitioner/nurse (ODP/N) resident on call for the hospital, but not exclusively for the maternity unit. In 76% of units, midwives assisted the anaesthetist when inserting regional blocks in labour. More than one-third of respondents thought that it would be appropriate to have a dedicated ODP/N resident on call for the labour ward who would also assist with labour analgesia blocks.

Analgesia, Epidural↗
PubMed2001

A proposed role for hCG in clinical obstetrics.

The role of human chorionic gonadatropin (hCG) in the maintenance of early pregnancy is well known. Recent data suggests that hCG may play a role in the maintenance of the later stages of pregnancy as well, by directly and indirectly promoting uterine quiescence. If hCG acts as an endogenous tocolytic in normal pregnancy, then it may be an ideal candidate for therapy of preterm labor as well. We present compelling in vitro as well as in vivo data, which support the role of hCG in the maintenance of normal uterine quiescence. Additionally, we will present in vivo and in vitro data that confirms the ability of hCG to directly promote relaxation of uterine contractions. This review provides a basis for future study of the use of hCG in clinical obstetrics. Given the limited effectiveness of tocolytic therapies available at the time, hCG may provide a promising pharmacological approach to the pervasive problem of preterm labor in human pregnancy. While further work is needed, initial data strongly support this novel use of hCG in clinical obstetrics.

Chorionic Gonadotropin↗
PubMed2002

[Comparability of obstetric and perinatal data from England and Germany using standard-primip-groups - maternal and neonatal outcome].

OBJECTIVE: Aim of the study was to assess whether different birth management of an english and german department can influence the maternal and neonatal outcome. MATERIAL AND METHODS: The database consisted of routinely published data from 1986-95 for two clinical units in Solihull (England) and Ibbenbueren (Germany) comprising 34 820 and 9 053 deliveries respectively. In order to standardise the obstetric risk profiles the heterogeneous primary groups were subdivided into "standard primip groups". A statistical comparison using the "binomial confidence interval method" was carried out. RESULTS: In the standardised comparison induction of labour, duration of labour 1-6 hours, vaginal delivery from cephalic presentation, elective caesarean section, both for cephalic and breech presentation, transfer to the childrens hospital were less frequent in Solihull. On the other hand, Solihull showed more frequent oxytocin administration, fetal blood analysis, epidural anaesthesia, episiotomies, duration of labour > 13 hours, forceps, ventouse and emergency caesarean section deliveries from cephalic presentation, vaginal deliveries or emergency caesarean sections from breech presentation, resuscitation of the newborn using mask and/or drugs, maternal blood loss > 1 000 ml as well as abnormalities of placental separation. Despite the different management of the departments being compared no significant differences in the incidence of perinatal hypoxia as determined by Apgar scores at 5 minutes nor in the fetal mortality rate between the units could be identified. CONCLUSION: Using standardised data the quality of obstetric and perinatal care in England and Germany can be reliably compared. Different birth management does not significantly influence the neonatal outcome.

Breech Presentation↗
PubMed1998

Declines in patient volume: an obstetrics and gynecology teaching program's response.

Historically, University teaching hospitals have been the primary providers of health care to the indigent population. With the advent of managed health-care plans, the university hospitals have seen a rapid decline in their obstetrical patient populations. This decrease is reflected in the numbers of deliveries and gynecological surgeries. From 1990 to 1995, these changes resulted in a significant decline in deliveries at our hospital, the Lyndon B. Johnson General Hospital. To reverse this ominous trend, we instituted a variety of changes resulting in a more patient-centered system and found an improvement in the numbers of obstetrical patients. In the following report, we describe these changes and the subsequent outcome.

Delivery, Obstetric↗
PubMed1990

[Risk assessment of active obstetrical intervention in relation to delivery time interval in the control of vaginal twin delivery].

In connection with the vaginal delivery of twins, different opinions exist among obstetricians as to whether the time interval between the birth of both twins influences the often reported higher perinatal mortality and morbidity of the second twin. During the period from January 1, 1982, to December 12, 1987, we had 176 twin deliveries (1.5%), among a total number of 11,395, from which, after vaginal birth of twin A, in 96 cases twin B was born alive. In this study group, we analysed retrospectively our active obstetrical management in respect of relations between time interval on the one hand and perinatal mortality, operation frequency and foetal outcome of the second born twin on the other. The perinatal mortality rate, as defined by the WHO was 4.2% and excluding stillborns and children with a birth weight of less than 1,000 g, only 0.3%. We could not identify the influence of the time interval on perinatal mortality, which was equal for both twins. The frequency of surgical interventions rose from 12.8% when twin B was born within 20 min, to 38.8% when it was delivered after this time interval. An adverse foetal outcome judged by APGAR-score could not be proved. Shortening the time interval by active obstetrical management is of value in order to reduce potential risks for the mother and the second born twin, but it should be borne in mind, that the results of our study are positively influenced by the primary selection criteria of mode of delivery.(ABSTRACT TRUNCATED AT 250 WORDS)

Apgar Score↗
PubMed1989

[The obstetric risk in adolescent primiparous females].

The obstetric risks in primiparae between 12 and 17 years of age have been reviewed in cases treated at our hospital from 1982 to 1987. We looked for intrauterine foetal deaths, premature deliveries (birth weight less than 2500 g), breech presentations, preeclampsia, Caesarean sectio rate, forceps rate, and thirdstage complications. The risks found in the group of 476 young primiparae were compared to those amongst the 26,768 overall deliveries during the same period. The incidence of breech presentations, preterm deliveries and forceps deliveries was about the same as in the general group. Intrauterine foetal death, thirdstage complications, Caesarean section deliveries, and, especially preeclampsia, were (markedly) less common than in the overall group. As a result, we no longer consider youthful mothers from our area a higher obstetric risk.

Adolescent↗
PubMed1985

[Manual obstetrical examination method. Current status in West Germany].

Until the middle of the eighteenth century the manual method of obstetrical examination involved exterior examination in addition to vaginal exploration. During the post-Semmelweis era, that is particularly following the introduction of the rubber glove, vaginal examination was omitted in favour of combined rectal and exterior examination. Since about the 1970 the vaginal form of examination is again preferred, although this procedure is described with some controversy in most present-day textbooks on obstetrics and midwifery. Representative sample examination tests performed by 625 obstetricians and 1478 various clinics showed clearly that for the purpose of controlling uncomplicated pregnancies and births, most physicians employ the vaginal form of examination. Moreover, even in those cases involving pathological pregnancies and risk the vaginal examination is preferred, possibly all too unreservedly so.

Adult↗
PubMed1982

[The problem of domiciliary obstetric practice (author's transl)].

UNLABELLED: From a group of 8,020 well-documented and electronically recorded deliveries at the Tübingen University Gynaecological Clinic during 1976-1979 we selected 1147 (14.3%) according to strict criteria and subjected them to further analysis. These 1147 pregnant women had one feature in common, namely, that there were absolutely no signs of any risk factor prior to delivery (Table 1). RESULT: 83% only of these children were delivered spontaneously; in 0.8% of the cases it was necessary to effect Caesarean section, and in another 15% vaginal-surgical delivery proved necessary. In 10% threatening and in 0.9% acute foetal asphyxia was the guiding sign for appropriate obstetric measures. In 31.4% of the cases we found a twisted cord, whereas the frequency rate of acidosis (pHNA less than 7100) was 7%. Apgar counts below 7 were seen in 2.3% and indices below 3 in 0.1% of the cases. Perinatal mortality was approximately 1:1000. Complications requiring follow-ups were seen in the first week post partum in every 20th child. It is concluded that domiciliary obstetric practice cannot be medically recommended since it involves a risk rate for both mother and child which is considered too high.

Adult↗
PubMed2002

Acute renal failure complicating severe preeclampsia requiring admission to an obstetric intensive care unit.

OBJECTIVE: To determine risk factors and outcomes for women with severe preeclampsia and renal failure. STUDY DESIGN: Retrospective study from 1995 to 1998 of all women with renal failure who were admitted to the obstetric intensive care unit at Groote Schuur Hospital, South Africa. A total of 89 women were identified with severe preeclampsia defined as blood pressure > or = 160/110 mm Hg and > or = 2+ proteinuria, renal failure defined as a creatinine level of > or = 1.13 mg/dL, and oliguria defined as < 100 mL urine produced in 4 hours; 72 charts were available for analysis. A comparison was made between the 3 groups, which were defined by the maximum recorded creatinine levels. RESULTS: Of the 72 women, 31 women (43%) were primiparous and 41 (57%) were multiparous. Median gestation at delivery was 32 weeks (range, 21-40 weeks). The median maximum creatinine was 3.85 mg/dL (range, 1.13-12.50 mg/dL). Twelve women (16%) had a history of chronic renal disease or hypertension, and 36 women (50%) had HELLP syndrome and 23 (32%) abruptio placentae. All women with severe renal impairment had either abruptio placentae or hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Perinatal mortality was 38% (27/72). However, in this series only 7 women (10%) required dialysis in the short term and none required long-term dialysis or kidney transplant. There were no maternal deaths. CONCLUSIONS: In women with severe preeclampsia and renal failure, major obstetric complications were common and perinatal outcome was poor. However, the need for dialysis was infrequent, with only 10% women requiring transient dialysis, and there were no cases of chronic renal failure that required dialysis or kidney transplant.

Abruptio Placentae↗
PubMed2004

Impact of private health insurance incentives on obstetric outcomes in NSW hospitals.

The purpose of this study is to analyse the impact of changes in Australian private health insurance coverage as seen in NSW public and private hospital birth profies, and identify trends in obstetric outcomes from 1997-2001. NSW Midwives Data Collection unit record data is analysed for women who gave birth to a live singleton baby of term gestation (> or = 37 weeks) and cephalic presentation in NSW hospitals during 1997- 2001. Use of private hospitals for childbirth has increased in conjunction with increases in private health insurance coverage. Although some obstetric interventions have increased for both public and private hospitals over time, clinical factors do not explain the large differences in birth interventions and outcomes between NSW public and private hospitals. Incentives to increase private health insurance coverage appear to be having a negative impact on childbirth, in terms of higher birth intervention and operative birth rates in NSW private hospitals.

Anesthesia, Obstetrical↗