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PubMed2003

Endosonography in the evaluation of anal function after primary repair of a third-degree obstetric tear.

BACKGROUND: Disruption of the anal sphincter occurs in 0.6%-6% of women during delivery and almost half have persistent defecatory symptoms despite primary repair. Our aim was to prospectively analyse anal endosonography and rectoanal manometry after primary repair of a third-degree obstetric tear in order to compare the findings with the clinical outcome. METHODS: Twenty-one women aged 27-41 (mean 31.5 years) who had undergone primary suture of a third-degree disruption of the anal sphincter were interviewed on their pelvic floor function and explored by manometry and endosonography 4 months after delivery. RESULTS: Twelve women had anal incontinence. External sphincter defect was identified on endosonography in 22% continent and in 91% incontinent women (P < 0.01). The presence of an external sphincter defect was associated with anal incontinence in 91.7%. Surgical repair was identified on endosonography in 88% continent women and in 25% incontinent women (P < 0.03). The combination of a visible surgical repair and absence of defect was highly associated with normal continence (91.7%). Squeezing pressures were higher in continent women (87 +/- 23 cm H2O) than in incontinent women (48 +/- 36 cm H2O; P = 0.04), but no anal pressure threshold could achieve better results than endosonography in predicting the clinical outcome. CONCLUSION: After primary repair of a third-degree obstetric tear, endosonographic pattern of the anal sphincter correlates with the continence status.

Adult↗
PubMed1996

Practice patterns of anesthesiologists regarding situations in obstetric anesthesia where clinical management is controversial.

A survey consisting of 47 questions, 40 regarding clinical practice and 7 regarding demographics, was mailed to 153 directors of obstetric anesthesia in academic practice and to 153 anesthesiologists in private practice. Questions relating to the following areas of practice were asked: 1) preoperative laboratory testing; 2) preeclampsia and possible coagulopathies; 3) epidural catheter placement in women with "spinal problems"; and 4) use of epidural opioids and intravenous supplementation. Surveys were returned by 113 (74%) academic anesthesiologists and 94 (61%) private practice anesthesiologists. By univariate analysis, 14 questions showed a significant difference in response between those in academic and private practice, but only eight remained significant after accounting for the amount of clinical time currently devoted to obstetric anesthesia (>50% or < or = 50%). These eight questions related to preoperative laboratory testing in the healthy parturient, preoperative laboratory testing in the preeclamptic patient, and the use of intravenous supplementation during a cesarean section with regional anesthesia. Although there were some differences in the responses between anesthesiologists in academic and private practice, overall the responses were similar.

Academic Medical Centers↗
PubMed1993

Anesthetic and obstetric outcome in morbidly obese parturients.

BACKGROUND: Large studies reporting anesthetic outcome for morbidly obese parturients are lacking. This study compares the anesthetic and obstetric outcome in morbidly obese parturients and matched control parturients. METHODS: Anesthesia records were prospectively collected for all patients delivering between September 1978 and November 1989 whose weight exceeded 136.4 kg (300 pounds) at the time of delivery. A retrospective control patient group was collected by matching the first patient weighing less than 136.4 kg, delivered in the same month by the same obstertrician, to the corresponding morbidly obese parturient. Anesthetic and obstetric outcome variables were extracted from medical records and analyzed. RESULTS: Sixty-two percent of 117 morbidly obese women underwent cesarean section, while only 24% of control patients delivered abdominally (P < 0.05). Forty-eight percent of all laboring morbidly obese parturients required emergency cesarean section, compared with 9% of control laboring parturients (P < 0.05). Epidural anesthesia was used successfully for labor and cesarean delivery in 74 of 79 morbidly obese women and 66 of 67 control patients. When compared with control patients, initial epidural anesthesia failure was significantly more likely in morbidly obese women, requiring epidural catheter replacement. Difficult tracheal intubation occurred in 6 of 17 morbidly obese women, compared with 0 of 8 control women (P = 0.06). Morbidly obese women had increased incidences of antepartum medical disease, prolonged cesarean section operation times, serious postoperative complications, and increased hospital stays. CONCLUSIONS: The high incidences of antepartum medical disease and emergency cesarean section complicate anesthetic care in the morbidly obese parturients. Epidural anesthesia is feasible; however, the high initial failure rate necessitates early catheter placement, critical block assessment and catheter replacement when indicated, and provision for alternative airway management.

Adult↗
PubMed1977

A national survey of medical school obstetrics and gynecology departments, 1965 to 1975.

Representatives of 108 departments of obstetrics and gynecology completed a written questionnaire in 1976 designed to assess the changes that had occurred in the teaching resources of the departments for the years 1965, 1970, and 1975. There was a statistically significant increase in the number of students per clerkship during that decade. In addition, there was an increase in the numbers of full-time faculty members, residents, beds, and patients. As a consequence, the teaching ratios improved. This might explain in part the increased numbers of medical students selecting obstetrics and gynecology as a career.

Education, Medical↗
PubMed1997

Complementary and alternative medicine. Part I: Clinical studies in obstetrics.

Studies in which complementary and alternative medicine (CAM) interventions were used in the care of obstetric patients were identified by searching The National Library of Medicine's electronic database. This paper is a selected review of both randomized and nonrandomized clinical trials. There are a number of CAM therapeutic practices that may have potential benefit for patients. Additional clinical research with appropriate scientific methodology is warranted to determine the merit and value of integrating some CAM modalities into conventional medical obstetric care.

Analgesia, Obstetrical↗
PubMed2001

Difficult airway in obstetric anesthesia: a review.

UNLABELLED: Failed intubation and ventilation are important causes of anesthetic-related maternal mortality. The purpose of this article is to review the complex issues in managing the difficult airway in obstetric patients. The importance of prompt and competent decision making in managing difficult airways, as well as a need for appropriate equipment is emphasized. Four case reports reinforce the importance of a systematic approach to management. The overall preference for regional rather than general anesthesia is strongly encouraged. The review also emphasizes the need for professional and experienced team cooperation between the obstetrician and the anesthesiologist for the successful management of these challenging cases. LEARNING OBJECTIVES: After completion of this article, the reader will be able to break down the complex issues in managing the difficult airway in the obstetric patient, outline the reasons for difficult intubations in pregnancy, and describe the evaluation used to predict a difficult intubation.

Adult↗
PubMed1997

Occult obstetric trauma and anal incontinence.

Obstetric trauma is by far the commonest cause of anal incontinence in women. Denervation and reinnervation of the pelvic floor and anal sphincter following vaginal delivery has been previously demonstrated. The advent of anal endosonography, however, has enabled the identification of occult anal sphincter defects following vaginal delivery. It is now possible to identify risk factors and change obstetric practice accordingly so as to minimize anorectal morbidity.

Anal Canal↗
PubMed2005

Short-term and long-term effects of obstetric anal sphincter injury and their management.

PURPOSE OF REVIEW: During the past decade increasing attention has focused on the problem of obstetric anal sphincter damage. Although risk factors are now well known, the effects of such damage have received less study. This review focuses on the early and long-term problems that may arise subsequent to anal sphincter injury following childbirth and assesses therapeutic options. RECENT FINDINGS: Up to 25% of women experience altered faecal continence after vaginal delivery, with 4% having persistent symptoms. In those women who have sustained a recognized tear to the sphincter, the quality of primary repair is crucial. Nevertheless, evidence clearly supporting the superiority of overlap over approximation repair is still lacking. The importance of pudendal nerve damage in the aetiology of postpartum faecal incontinence is gaining increasing attention. Augmented biofeedback physiotherapy is the gold standard for treatment of women with such injury, whereas sacral nerve stimulation represents a newer treatment option. SUMMARY: The short-term and long-term effects of obstetric anal sphincter injury warrant increased attention, because with increasing longevity more women are surviving into their 80s and the prevalence of faecal incontinence in this population will increase if measures are not taken to address the problem. Prevention of such injury is not always possible and management options must be further explored. Adequate primary treatment of third-degree tears is of paramount importance.

Anal Canal↗
PubMed1981

Obstetric pain relief in a district hospital. The provision of a limited epidural service.

The effectiveness of the various methods used to provide obstetric pain relief in a District General Hospital was assessed. More than 70% of mothers were generally satisfied with the pain relief they received, but the majority would, in retrospect, have liked some additional analgesia at some stage. Seventeen per cent would have liked an epidural. Neither the social group of the mothers nor their duration of residence in the area of the hospital affected the demand for additional pain relief. The demand for epidurals was greater in social groups I and II. The effect of the obstetric pain relief service on the workload of available trained staff was assessed: most of the demands were made between the hours of 0900 and 2100 hours.

Anesthesia, Epidural↗
PubMed1982

The anaesthetist and the obstetric department.

The author retired from active practice as a consultant anesthetist in the British National Health Service during 1980 at the age of 60. He kept a detailed diary for the last full year as a consultant. One of the editors suggested that the diary, augmented by his considered views culled from the experiences of a professional lifetime, could form the basis of a series of essays on various aspects of the life and practice of a consultant anesthetist during the second half of the twentieth century. This essay considers the special and increasing responsibility of the anaesthetist in the obstetric department, both for the provision of analgesia in the labour ward and anaesthesia for operative obstetrics, and a link between others who are vitally concerned in the provision of safe perinatal care for both mother and child.

Anesthesia, Obstetrical↗
PubMed1986

The anaesthetist and the obstetric flying squad. Could complacency creep in?

The demands made upon the Bristol obstetric flying squad over the past 14 years have been analysed. During this period, the number of calls received per year has decreased dramatically. The reasons for this are discussed in the context of current obstetric practice. The management of retained placenta is reviewed. Of importance to anaesthetists is the gross reduction in the number of cases where it is necessary to give anaesthesia 'in the field'. This may lead to complacency and lack of familiarity with the equipment carried by the flying squad.

Anesthesia, Obstetrical↗
PubMed2006

A national survey of obstetric anaesthetic handovers.

The handover of patient information between shifts enables continuity of care and increases patient safety. We surveyed UK practice during handovers in obstetric anaesthesia. A questionnaire was sent to 239 lead consultant obstetric anaesthetists to record routine practice in their unit and individual opinion about handover procedures. Responses were received from 168 anaesthetists, a 70% response rate. Handover policies were available in 10% of units. Most (76%) responding units had an allocated time for handover. In most units (76%), the duration of handover was reported as being < 15 min but the actual duration and depth of any discussion involved were not specified. Handovers were rarely documented in writing (7%). Consultant anaesthetists were most likely to be present at the morning handover and few handovers were multidisciplinary. Four percent of units reported critical incidents following inadequate handovers in the past 12 months. We identify features in handover procedures that could be improved.

Anesthesia, Obstetrical↗
PubMed1992

Ten ml bupivacaine 0.125% with 12.5 micrograms epinephrine is a reliable epidural test dose to detect inadvertent intravascular injection in obstetric patients. A double-blind study.

A double-blind study was designed in order to determine the specificity and sensitivity of an epidural test dose to detect inadvertent intravenous injection in obstetric patients undergoing epidural analgesia. Forty unselected obstetric patients were given an intravenous injection of 10 ml bupivacaine 0.125% with 12.5 micrograms epinephrine (test dose) or 10 ml normal physiologic saline. The maternal heart rate was monitored by the direct ECG mode of a fetal monitor and registered simultaneously with the tocogram. The primary investigator was blinded to the solution he injected into an antecubital vein. After the injection was given, he recorded his judgment of which solution he had administered. Eight other anesthesiologists made similar judgments on the basis of the recordings plus various levels of additional information (presence or absence of epidural analgesia, time of injection, subjective signs and symptoms). In contrast to the primary investigator, the blood pressure values were not given to them. For the primary investigator, the specificity of the test dose was 100% and the sensitivity 97.5%. The judgments of the 8 other anesthesiologists resulted in an excellent specificity (99.1%) and a good sensitivity (91.9% with information on time of injection and subjective signs and symptoms). The better performance of the primary investigator is probably due to the availability of blood pressure data.

Analgesia, Epidural↗
PubMed1991

Undergraduate obstetrics and gynaecology in the United Kingdom and the Republic of Ireland, 1989.

Undergraduate obstetrics and gynaecology has given rise to concern at a time when the community has become increasingly sensitive about genital structure and function and human reproduction. A survey of clinical schools in the United Kingdom and the Republic of Ireland shows that an average of 11 weeks is available for undergraduate learning in the discipline. Nearly all schools provide written aims and objectives for clinical students. Pelvic examination is taught in what is concluded to be a sensible and responsible manner; students are expected to conduct an average minimum of eight deliveries. Family planning instruction is seen as generally inadequate. Comparison of clinical courses with those in Australia and New Zealand shows striking similarities. Undergraduate courses need to be under constant review and revision so that the best students are encouraged to see obstetrics and gynaecology as a desirable career path.

Clinical Competence↗
PubMed1995

Obstetric outcome of Bangladeshi women in east London.

OBJECTIVE: To study the obstetric outcome of women of Bangladeshi origin in comparison with the white caucasian population in East London. DESIGN: A retrospective study of 16718 pregnancies over a five year period (1987-1991). SETTING: An East London teaching hospital district. SUBJECTS: Six thousand four hundred and sixty Bangladeshi women compared with 7592 white caucasian women. MAIN OUTCOME MEASURES: Maternal: antenatal complications; induction and augmentation rates; analgesia and anaesthesia; instrumental delivery and caesarean section rates; third stage complications. Fetal: gestation and weight at birth; perinatal mortality rates. RESULTS: The following statistically significant findings were noted: Bangladeshi women had a longer reproductive age span and were of greater parity including grand multiparity. They suffered fewer antenatal complications except for gestational diabetes. They had lower induction rates and, among the parous group, lower augmentation rates. During labour they required less analgesia but more commonly had general anaesthesia for caesarean section deliveries. They required instrumental delivery less often but there was no difference in overall caesarean section rate for the two groups. However, overall Bangladeshi women had a lower elective caesarean section rate, although parous Bangladeshi women had a higher emergency section rate. In the third stage there were no differences in the complication rates for the nulliparous women, however the parous Bangladeshi women had a higher postpartum haemorrhage rate and a lower perineal repair rate consistent with their higher parity. Whilst preterm births were more common in Bangladeshi women, significant prematurity (less than 28 weeks gestation) was less common. Similarly, although Bangladeshi babies weighed less at birth, they had fewer babies weighing less than 1500 grammes. There was no statistically significant difference in the perinatal mortality rate between the two groups, being 8.1 per thousand births overall. Whilst there was a statistically insignificant decline in death rates over the five-year period, between the groups there was no consistent difference. CONCLUSION: Pregnant Bangladeshi women in East London constitute a relatively high parity, low risk population who have less obstetric intervention and yet manage an equivalent (or better) perinatal outcome compared to their white caucasian neighbours.

Adolescent↗
PubMed2001

Obstetric practice and faecal incontinence three months after delivery.

OBJECTIVE: To determine whether obstetric and maternal factors relate to faecal incontinence at three months postpartum. SETTING: Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand). POPULATION: All women who delivered during one year in the three maternity units. METHODS: Postal questionnaire at three months postpartum, to obtain information on faecal incontinence, linked to obstetric casenote data. MAIN OUTCOME MEASURES: Prevalence of faecal incontinence. RESULTS: 7879 questionnaires were returned, a 71.7% response rate. The prevalence of faecal incontinence was 9.6%, with 4.2% reporting this more often than rarely. Logistic regression, confined to primiparae, showed that forceps delivery was a predictor of an increased risk of symptoms (OR = 1.94, 95% CI 1.30 to 2.89) while vacuum extraction was not associated. Caesarean section was marginally associated with a reduced risk (OR = 0.58, 95% CI 0.35 to 0.97). Older maternal age, Indian sub-continent ethnic origin and body mass index 'not known' also showed significant associations. No associations were found for induced labour, duration of second stage labour, episiotomy, laceration or birthweight. CONCLUSIONS: Women delivered by forceps had almost twice the risk of developing faecal incontinence, whereas vacuum extraction was not associated with faecal incontinence at three months postpartum. Caesarean section appears to offer some protection.

Adult↗
PubMed1987

Summary of labour and obstetric audit by microcomputer.

A microcomputer is used directly by the clinician, immediately after delivering a baby, to produce a summary letter to the referring physician and for the case notes. The programme is easy to use, and accepted by a wide range of medical users. In addition to producing a summary, the information is added to the obstetric data base, which may be interrogated by a computer novice. The system is now used to produce yearly obstetric audits of the Queen Victoria Medical Centre.

Australia↗
PubMed1995

General practitioner obstetric practice in rural and remote Western Australia.

The objective of this study was to examine the practice of obstetrics by general practitioners in rural and remote areas of Western Australia (WA). A questionnaire was mailed to all rural and remote GPs in June, 1994. The response rate was 67%. Questionnaires asked GPs to self-report how many deliveries they had performed in the previous year and how many of those deliveries were by Caesarean section or assisted by forceps or ventouse. Comparisons were made with perinatal statistics for the entire State of WA. GPs reported an average of 28 deliveries per year. The Caesarean section rate of 8% was lower than the rate of 21% for all WA in 1993. Ventouse was used more often than forceps to assist the delivery of a baby. Intervention rates for ventouse, forceps and Caesarean section were lower in rural and remote areas of WA than the State as a whole; there was also less use of epidural analgesia. More than half of these GPs currently practising obstetrics hold the Dip RACOG or DRCOG. Medical indemnity is an increasing issue for many GPs. For 6 of the 7 country health regions, close to 80% of women deliver within the health region in which they reside.

Delivery, Obstetric↗