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PubMed2000

Maternal stress and obstetric and infant outcomes: epidemiological findings and neuroendocrine mechanisms.

This review examines the associations between antenatal maternal stress and obstetric and infant outcomes using preterm delivery as the key outcome indicator. This was done by means of a Medline search focusing predominantly on prospective, controlled studies which investigated both the associated epidemiological factors and putative neuroendocrine mechanisms. There is evidence from a number of United States studies in economically deprived African American women for an association between perceived maternal life event (LE) stress and preterm delivery. The findings from the European studies are conflicting, partly because they combine outcome measures ie. preterm delivery and low birth weight. However the three largest Scandinavian epidemiological studies examining preterm delivery and controlling for confounders such as smoking, age and obstetric history, have confirmed this association. These studies taken together suggest that this may be a robust finding not limited to socioeconomically deprived African American samples and independent of other significant risk factors. Two small prospective studies examining the relationship between the hypothalamic-pituitary-adrenal (HPA) axis, psychosocial status and premature delivery have reported a significant association between a set of adverse psychosocial factors on the one hand, and levels of adrenocorticotrophic hormone (ACTH), corticotrophin releasing hormone (CRH) and cortisol levels, and on the other hand, a significant correlation between CRH levels and premature delivery. Clearly, these findings remain preliminary and indicate a complex relationship between perceived stress in pregnancy, the HPA axis and premature delivery. The impact of antenatal maternal stress on infant temperament and psychopathology remains to be examined more fully in prospective controlled trials.

Animals↗
PubMed1990

A controlled study of the effect of prepared childbirth classes on obstetric outcomes.

After the development and initiation of prepared childbirth classes in a large, inner-city hospital, a case-controlled study was designed to assess their impact on obstetric outcomes. Prepared couples were matched with nonattenders on six variables: race, patient status (clinic or private), parity, marital status, age, and socioeconomic status. Statistically significant differences between the groups were found. Prepared couples were more likely to receive little or no pain medication and less conduction anesthesia than controls. Consequently, 79 percent of their deliveries were spontaneous, compared to 51 percent for controls (P less than 0.001). Despite the increased pushing ability of the class attenders, over 80 percent of women in both groups had an episiotomy, which was, in turn, significantly associated with a second-, third-, or fourth-degree laceration, thus bringing into question its routine use. Further studies to identify additional factors associated with positive obstetric outcomes are warranted.

Adolescent↗
PubMedDate not supplied

Obstetric ultrasound: application in a clinic setting.

A brief review of the medical literature indicates areas of concern related to the safety of obstetric ultrasound usage. Questions raised in the medical literature dictate the need for conservative and appropriate use of ultrasound until long-term follow-up studies have been completed. The current use of diagnostic ultrasound in a prenatal clinic setting is explored. In the meantime, health-care providers should follow guidelines for obstetric ultrasound use to prevent indiscriminate patient exposure.

Diagnostic Tests, Routine↗
PubMedDate not supplied

Intravenous meperidine infusion for obstetric analgesia.

OBJECTIVE: To provide safe, satisfying obstetric analgesia when epidural analgesia was unavailable. DESIGN: Randomized, controlled study of women in labor. SETTING: A regional hospital offering primary- and secondary-level obstetric care. PARTICIPANTS: Thirty-nine women with low-risk, single, term pregnancies and anticipated vaginal delivery. INTERVENTIONS: Women in the intermittent intramuscular (IM) injection group received meperidine 50-100 mg, every 2 hours, as required. Those in the intravenous (IV) infusion group received an initial bolus of meperidine 25 mg, a basal infusion rate of 60 mg/h, and intermittent boluses of 25 mg/h as required. Each participant had a maximum of 200 mg of meperidine available to her during labor. MAIN OUTCOME MEASURE: Pain intensity was measured on a 10-cm visual analogue scale. Pain ratings were recorded when analgesia was initiated and every 30 minutes thereafter, until delivery. RESULTS: Women who received IV meperidine reported significantly lower levels of pain (p = .0015) than women in the IM group. However, women in the IV group received significantly higher doses of meperidine (mean = 121 mg) than those in the IM group (mean = 82 mg; p = .0007). When pain scores were compared on a smaller group of participants (n = 18) who received similar doses of meperidine (100-150 mg), women in the IV group still reported lower pain scores (p = .0092). No significant differences were found between the groups in length of labor, maternal vital signs, fetal heart rate, Apgar scores, level of maternal sedation, or patient-reported side effects. CONCLUSION: IV meperidine infusion was superior to intermittent IM injections for pain relief during labor.

Adolescent↗
PubMedDate not supplied

Maternal hypothermia: implications for obstetric nurses.

Hypothermia, a core body temperature of less than 95 degrees F (35 degrees C), is a common intraoperative complication among adult patients and may occur in obstetric patients. Obstetric patients are predisposed to hypothermia because of vasodilation from pregnancy, administration of anesthetics and pharmacologic agents, and inherent blood loss with rapid fluid replacement during delivery. Morbidity associated with hypothermia occurs from complications such as hypotension, cardiac arrhythmias, increased oxygen consumption or respiratory depression, and disseminated intravascular coagulation. Interventions include preventive measures such as maintaining reasonable ambient room temperatures, avoiding infusion of cold solutions, and promptly assessing postoperative temperature, as well as corrective measures--rewarming the patient, placing the patient on dry surfaces, minimizing additional heat loss, and providing external heat sources.

Body Temperature Regulation↗
PubMed1981

Metabolic effects of obstetric regional analgesia and of asphyxia in the newborn infant during the first two hours after birth. I. Arterial blood glucose concentrations.

Effects of obstetric regional analgesia and of asphyxia on the arterial blood glucose concentrations were investigated in 83 newborn infants divided into a control group, an asphyxia group, a continuous epidural, and a paracervical + pudendal block group. Lidocaine was used in the analgesia groups. All infants except those of the asphyxia group had 1-minute Apgar scores greater than or equal to 7.1) In the asphyxiated infants high blood glucose values and strong correlations between blood glucose concentrations and different signs of asphyxia (Apgar score, base deficit and lactate) were found. 2) In infants whose mothers were given regional analgesia the results were: (a) high glucose values in 20% of the infants and an association between increased glucose concentrations in these infants and signs of fetal distress, (b) low blood glucose values (less than 1.67 mmol/l) in 27% of the infants. It is recommended that the blood glucose is checked in the newborns after obstetric regional analgesia.

Anesthesia, Obstetrical↗
PubMed1975

The general practitioner and changes in obstetric practice.

Compared with the 1960s fewer general practitioners today are obtaining a postgraduate diploma in obstetrics, and the future more stringent criteria for practitioners wishing to undertake this will probably restrict the numbers of family doctors wishing to practise in this field. More deliveries are being performed in institutions--either in consultant or general-practitioner units. Morever, within a decade probably few G.P.s will attend during normal labour or delivery, which can and should be conducted by midwives. In future, therefore, G.P.s should have a new role in obstetrics, being responsible for some antenatal supervision and postnatal care, including postnatal examinations, taking a cervical smear, and advice on birth control.

Birth Rate↗
PubMed1990

Obstetric accidents: a review of 64 cases.

OBJECTIVE: To identify the causes of obstetric accidents. DESIGN AND SETTING: Analysis of case records at the Medical Protection Society's London office covering the five years 1982-6. SUBJECTS: Cases that had come to litigation which had resulted in stillbirth, perinatal or neonatal death, central nervous system damage to the baby, or maternal death and in which there was an opinion from a senior obstetrician consulted by the society. Of 147 cases reviewed, 64 met the criteria for the study. MAIN OUTCOME MEASURES: The principal findings of the expert reviewers. RESULTS: Three major topics of concern emerged common to most of the 64 cases. These were inadequate fetal heart monitoring, mismanagement of forceps, and inadequate supervision by senior staff. In 11 of the 64 cases cardiotocography was omitted, in 19 cases the trace was missing, in six cases the trace was unreadable, and in 14 of the remaining 28 cases signs of fetal distress went unnoticed or were ignored. In 31 cases forceps were used to aid delivery or were tried and abandoned in favour of caesarean section. In 16 cases two or more attempts to use forceps were made. Five infant deaths were directly attributed to mismanaged forceps. In 20 cases senior staff were criticised by the expert reviewer for failure to come to the labour ward. In many of these cases they may have given advice over the telephone, but the inadequacy of records made it impossible to tell. In these cases the labour and birth were managed by junior staff, usually a senior house officer. In six cases when senior staff did come they suggested that no action was needed. CONCLUSION: These few cases should not be dismissed as isolated incidents in obstetric practice in Britain. They reflect more general problems--namely, concerning the ability of junior doctors to interpret fetal heart traces accurately, their ability to use forceps, and the participation of senior staff in running a labour ward and delivery suite.

Adolescent↗
PubMed1971

Place of the general practitioner in the obstetric service.

A survey of perinatal mortality in Northern Ireland has shown that despite a progressive fall in the proportion of deliveries at home the perinatal mortality rate in domiciliary practice has risen in recent years. Overall, however, the perinatal mortality rate for all deliveries compares well with English figures. It seems that as the proportion of deliveries in hospital and general-practitioner obstetric unit rises a hard core of high risk patients is left who insist on delivery at home. Three prerequisites for good general-practice obstetrics are careful selection of cases, intelligent antenatal care, and close co-operation between the general practitioner and the consultant.

Delivery, Obstetric↗
PubMed1979

The influence of obstetric procedures and social and cultural factors on breast-feeding rates at discharge from hospital.

The influence of obstetric factors on breast-feeding rates at discharge from St. Thomas's Hospital in 1969 and 1970 has been examined in 1356 primiparous mothers delivering healthy babies. Induction of labour and assisted delivery were significantly associated with lower breast-feeding rates. The association could not be explained by differences in social class, country of origin, birthweight, anaesthesia in labour, or medical reasons for induction and assisted delivery. The most likely explanation is that induction and assisted delivery are associated with delay in starting breast-feeding. However, trends in obstetric management of labour and delivery are unlikely to have a large influence on the incidence of breast-feeding compared with the influence of social and cultural factors.

Anesthesia, Obstetrical↗
PubMed1993

Assessing introduction of spinal anaesthesia for obstetric procedures.

To assess the impact of introducing spinal anaesthesia for obstetric operative procedures on use of general anaesthesia and quality of regional anaesthesia in a unit with an established epidural service a retrospective analysis of routinely collected data on method of anaesthesia, efficacy, and complications was carried out. Data were collected from 1988 to 1991 on 1670 obstetric patients requiring an operative procedure. The introduction of spinal anaesthesia in 1989 significantly reduced the proportion of operative procedures performed under general anaesthesia, from 60% (234/390) in 1988 to 30% (124/414) in 1991. The decrease was most pronounced for manual removal of the placenta (88%, 48/55 v 9%, 3/34) and emergency caesarean section (67%, 129/193) v 38%, 87/229). Epidural anaesthesia decreased in use most significantly for elective caesarean section (65%, 77/118 v 3% 3/113; x2=139, p<0.0001). The incidence of severe pain and need for conversion to general anaesthesia was significantly less with spinal anaesthesia (0%, 0/207 v 3%, 5/156; p<0.05). Hypotension was not a problem, and the incidence of headache after spinal anaesthetic decreased over the period studied. Introducing spinal anaesthesia therefore reduced the need for general anaesthesia and improved the quality of regional anaesthesia.

Anesthesia, Epidural↗
PubMed1983

Neurological sequelae in high- and low-optimality obstetrics.

Neonatal neurological findings and the results of a neurological follow-up examination at 4 years of age were compared in two groups of subjects. The first group contained 39 children with an extremely low obstetrical optimality score, the second one contained 38 children with an extremely high obstetrical optimality score. More children were neurologically deviant in the first group than in the second one, both shortly after birth and at 4 years. The predictive power of the neonatal neurological examination was less in the low-optimality group, probably due to false-negative diagnoses in preterm infants.

Brain↗
PubMed2002

Obstetric complications and schizophrenia: historical and meta-analytic review.

OBJECTIVE: This paper reviews the literature on obstetric complications as a risk factor for schizophrenia. The authors trace the evolution of this literature through different methods and carry out a quantitative review of the results from prospective, population-based studies. METHOD: Relevant papers were identified by a MEDLINE search, by examination of reference lists of published papers, and through personal contact with researchers in the field. Studies were grouped in chronological order according to common themes or methods. Meta-analytic techniques were used to summarize the findings of prospective population-based studies. RESULTS: The meta-analytic synthesis of the prospective population-based studies revealed that three groups of complications were significantly associated with schizophrenia: 1) complications of pregnancy (bleeding, diabetes, rhesus incompatibility, preeclampsia); 2) abnormal fetal growth and development: (low birthweight, congenital malformations, reduced head circumference), and 3) complications of delivery (uterine atony, asphyxia, emergency Cesarean section). Pooled estimates of effect sizes were generally less than 2. CONCLUSIONS: Current methods of investigating the relationship between obstetric complications and schizophrenia are reaching the limit of their usefulness. Lack of statistical power to measure small and interactive effects and lack of detailed information about the prenatal period are major problems with current approaches. A combination of disciplines and approaches will be needed to elucidate the mechanisms underlying these small but important associations.

Adolescent↗
PubMed1985

Contemporary issues in obstetrics and gynecology for the consultation-liaison psychiatrist.

Medical advances in obstetrics and gynecology, combined with the depersonalization of health care and changes in sexual and reproductive behaviors in the general population, lead to challenging new problems for the psychiatric consultant who deals with reproductive issues. The author describes contemporary issues encountered in consultation-liaison work with the obstetrics and gynecology service in a general hospital. They include the reproductive implications of medical illnesses, the stress of deciding whether to continue a pregnancy known to carry genetic risk, the intrusiveness of certain options for dealing with infertility, parental expectations for a perfect baby, and the difficulties some traditional practitioners have in adapting their practice styles to the changing needs of the patient population.

Abortion, Therapeutic↗
PubMed1995

Obstetric skills at district and sub-district hospitals.

A new policy for emergency obstetric care (EOC) which should be provided at district and sub-district hospitals has been adopted in Bangladesh. Therefore a survey of the obstetric skills of doctors at these institutions was performed. The current skills of the doctors was compared with their self-perceived skills when they left their medical college hospitals. Although in many cases self learning had occurred it was shown that, unless a doctor had been competent to perform a skill under indirect supervision, competency was often not reached.

Bangladesh↗
PubMed2000

Social and professional influences of the technology of electronic fetal monitoring on obstetrical nursing.

Electronic fetal monitoring (EFM) is one example of a biomedical technology that rapidly diffused from an experimental innovation into a standard medical practice. First developed in the 1950s, EFM became commercially available in the early 1970s and quickly transformed intrapartum obstetrical practice. Assessments and interventions, which practitioners had previously based primarily on laboring women's subjective reports of bodily sensations, were now being based on quantifiable objective data from uterine activity and fetal heart rate transducers. Despite concerns of over-medicalization of the natural event of birth, iatrogenesis related to the increased incidence of operative deliveries, and escalating costs, EFM became widely accepted as routine and necessary by both practitioners and patients. By presenting the confident expectations and cautious reservations of various practitioners and patients to EFM, this article explores the rapid diffusion of EFM within the social context of the 1970s. A special focus is given to the perspective of intrapartum obstetrical nurses, because they have been the primary users of this perinatal technology since its introduction.

Diffusion of Innovation↗
PubMed2004

Challenges that opioid-dependent women present to the obstetric anaesthetist.

A retrospective casenote review was performed to identify anaesthetic challenges relevant to the opioid-dependent obstetric population. Medical records showed that of the 7,449 deliveries during a 24 month period, 85 women (1.1%) were taking regular opioids such as methadone and/or heroin. Of these 67 (79%) received anaesthetic services, ten of whom (11.7%) were referred antenatally. Forty opioid-dependent women (47%) received epidural analgesia in labour compared with the overall hospital rate of 38%. Twenty-three women (27%) delivered by caesarean section: five received general anaesthesia, five combined spinal anaesthesia, five spinal anaesthesia and eight epidural anaesthesia. Twenty opioid-dependent women (23.5%) had documented problems related to labour analgesia and 17 (74%) had problems with analgesia after caesarean section. A variety of postoperative analgesia methods were administered in addition to maintenance methadone. Fourteen patients (16.5%) had difficult intravenous access and seven "arrest" calls were documented. One anaesthetist was exposed to hepatitis C. This review demonstrates the demands placed on obstetric anaesthetic services by opioid-dependent women. Early antenatal referral for anaesthetic review is recommended.

Adult↗
PubMedDate not supplied

Obstetric anesthesia training centers in the U.S.A.--1975.

The current status of obstetric anesthesia training in the United States is reviewed. The 39 anesthesia residency training programs having full time chiefs of obstetric anesthesia were surveyed regarding clinical practice, physical facilities, teaching and research. This paper reports the results and compares them to recommendations of JCAH, ACOG and ASA, concerning standards of patient care and resident teaching.

Anesthesia, Obstetrical↗