The prognostic significance of hyperextension of the fetal head detected antenatally with ultrasound.
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OBJECTIVES: The purpose of this study was to evaluate the clinical significance of hyperextension of the fetal head detected by ultrasound prior to the onset of labour. METHODS: Over a 10-year period, we retrospectively identified all fetuses who had hyperextension of the fetal head reported on antenatal ultrasound. Hyperextension referred to persistence of the cervical spine in extreme extension, with an extension angle of at least 150 degrees persisting for the duration of the scan. Follow-up information was obtained from Hospital medical records and obstetrical care providers. RESULTS: Follow-up was obtained on 57 of the 65 fetuses (87.7%) identified over the study period. Ten of the 57 fetuses had normal structural fetal surveys and had sonographically identified resolution prior to delivery. All 10 patients delivered at term and had newborns with normal neonatal courses. Twenty-six of 57 fetuses had no sonographic findings other than persistent hyperextension, and 19 of these 26 fetuses (73%) had normal neonatal courses. Twenty-one of 57 fetuses (37%) had structural anomalies sonographically identified in addition to hyperextension of the fetal head. All 21 of these pregnancies ended in either termination or fetal or neonatal demize. CONCLUSIONS: Although resolution of isolated hyperextension of the fetal head is associated with a normal neonatal outcome, persistent isolated hyperextension of the fetal head can be associated with either a normal or an abnormal neonatal outcome. Fetuses with hyperextended heads and antenatally diagnosed structural anomalies have dismal outcomes. The identification of a fetus with hyperextension of the fetal head should prompt a detailed search for structural abnormalities. (+info)
Use by general practitioners of obstetric beds in a consultant unit: a further report.
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Of 1,700 women booked for delivery by general practitioner obstetricians in a consultant unit, 1,399 had uncomplicated deliveries and the co-operation between practitioner and consultant was an obvious advantage for the 257 who were transferred completely to consultant care during pregnancy, labour, or puerperium. The scheme, which started in 1964, has enabled general practitioners to continue to give complete obstetric care to their patients. The number of participating practitioners has, however, declined from 80 to 16 indicating that many preferred to concentrate on antenatal work. (+info)
Birth trauma to muscles in babies born by breech delivery and its possible fatal consequences.
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Dissection and histological examination was made of the muscles of 86 babies who died after breech delivery, and of 38 babies who died after vertex presentation. A control group of 50 surviving breech-delivered babies was examined clinically and the results compared. It was concluded that the most common type of birth trauma to a baby born by breech delivery is injury to muscles and soft tissues of the back and lower extremities, which is often extensive. In some severly injured babies histological examination of organs revels signs of crush syndrome and disseminated intravascular coagulation. It is suggested that the extensive muscle trauma forms the background of these fatal conditions. (+info)
Is internal podalic version a lost art? Optimum mode of delivery in transverse lie.
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AIM: To study the changing trend in the delivery of transverse lie, and its effect on neonatal outcome, in a developing country. SUBJECTS AND METHOD: This is a retrospective study involving records of 12 years of all patients with transverse lie. Neonatal outcome of births by internal podalic version (IPV) and lower segment caesarean section (LSCS) were compared. RESULTS: In the first six years, 37.3% of transverse lie underwent IPV and 62.7%, LSCS. In the next six years, 15.8% underwent IPV and 84.2%, LSCS. 87.7% and 12.3% of live babies were delivered by LSCS and IPV respectively. 52% of the live born IPV were discharged compared to 95% of LSCS babies. Neonatal outcome was best when IPV was performed on second twin. CONCLUSION: IPV has a role in the delivery of second twin, pre-viable and dead babies. (+info)
Intrapartum fetal head position I: comparison between transvaginal digital examination and transabdominal ultrasound assessment during the active stage of labor.
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OBJECTIVE: To test the null hypothesis that no correlation exists between transvaginal digital and the gold standard technique of transabdominal suprapubic ultrasound assessments of fetal head position during labor. A secondary objective was to compare the performance of attending physicians vs. senior residents in depicting fetal head position by transvaginal digital examination in comparison with ultrasound, respectively. METHODS: Consecutive patients in active labor at term with normal singleton cephalic-presenting fetuses were included. All participants had ruptured membranes, cervical dilation > or = 4 cm and fetal head at ischial spine station -2 or lower. Transvaginal sterile digital examinations were performed by either senior residents or attending physicians and followed immediately by transverse suprapubic transabdominal ultrasound assessments. Examiners were blinded to each other's findings. Power-analyses dictated number of subjects required. Statistical analyses included Chi-square, Cohen's Kappa test and logistic regression analysis. P < 0.05 was considered statistically significant. RESULTS: One hundred and two patients were studied (n = 102). In only 24% of patients (n = 24), transvaginal digital examinations were consistent with ultrasound assessments (P = 0.002, 95% confidence interval, 16-33). Logistic regression revealed that cervical effacement (P = 0.03) and ischial spine station (P = 0.01) significantly affected the accuracy of transvaginal digital examination. Parity, gestational age, combined spinal epidural anesthesia, cervical dilation, birth weight and examiner experience did not significantly affect accuracy of the examination. The accuracy of the transvaginal digital exams was increased to 47% (n = 48) (95% confidence interval, 37-57) when fetal head position at transvaginal digital examination was recorded as correct if reported within +/- 45 degrees of the ultrasound assessment. The rate of agreement between the two assessment methods for attending physicians vs. residents was 58% vs. 33%, respectively (P = 0.02) with the +/- 45 degrees analysis. CONCLUSIONS: Using ultrasound assessment as the gold standard, our data demonstrate an overall high rate of error (76%) in transvaginal digital determination of fetal head position during active labor, consistent with the null hypothesis. Attending physicians exhibited an almost two-fold higher success rate in depicting correct fetal head position by physical examination vs. residents in the +/- 45 degrees analysis. Intrapartum ultrasound increases the accuracy of fetal head position assessment during active labor and may serve as an educational tool for physicians in training. (+info)
Intrapartum fetal head position II: comparison between transvaginal digital examination and transabdominal ultrasound assessment during the second stage of labor.
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OBJECTIVE: To test the null hypothesis that no correlation exists between transvaginal digital examination compared with the gold standard technique of transabdominal suprapubic ultrasound assessment of fetal head position during the second stage of labor. A secondary objective was to compare the performance of attending physicians vs. senior residents in depicting fetal head position by transvaginal digital examination in comparison with ultrasound assessment. METHODS: Consecutive patients in the second-stage of labor at term with normal singleton cephalic-presenting fetuses and ruptured membranes were included. Transvaginal digital examinations were performed by either attending physicians or senior residents and were followed immediately by transverse suprapubic transabdominal sonographic assessments performed by a single sonographer. Examiners were blinded to each other's findings. Power analysis dictated sample size. Exact binomial confidence intervals around observed rates were compared with chi 2 and Cohen's kappa-tests. Logistic regression was applied. P < 0.05 was considered significant throughout. RESULTS: One hundred and twelve patients were studied. The absolute error of transvaginal digital examinations was recorded in 65% of patients (95% confidence interval, 56-74%). Parity, pelvic station, combined spinal epidural anesthesia, length of first or second stages of labor, use of oxytocin augmentation, gestational age, mode of delivery, birth weight, and examiner experience did not significantly affect examination accuracy. Stratification, when the transvaginal digital examination was recorded as correct if occurring within +/- 45 degrees of the ultrasound assessment, reduced the error of the transvaginal digital examinations to 39% (95% confidence interval, 30-49%). Independent variables again did not affect examination accuracy in this assessment modality. Rates of agreement between the two methods for attending physicians compared with residents were not significantly different. The overall degrees of agreement were 40% (95% confidence interval, 26-55%) and 68% (95% confidence interval, 53-80%) (kappa = 0.25 and 0.30) for the absolute agreement and +/- 45 degrees assessment modalities, respectively, for attending physicians, and 31% (95% confidence interval, 20-44%) and 55% (95% confidence interval, 42-68%) (kappa = 0.14 and 0.12) for senior residents. CONCLUSION: Using ultrasound assessment as the gold standard, our data demonstrate a high rate of error (65%) in transvaginal digital determination of fetal head position during the second stage of labor. The performance of senior residents in transvaginal digital examinations did not differ significantly from that of attending physicians. Intrapartum ultrasound increases the accuracy of fetal head position assessment during the second stage of labor. (+info)
Role of pelvimetry in active management of labour.
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All cases referred for pelvimetry in 1970-1 and all breech presentations referred for pelvimetry in 1972-4 were reviewed. Indications for pelvimetry fell into four main categories: high head in the antenatal clinic (47-8%); high head in labour (13-9%); breech presentation (20-9%); and previous caesarean section (14-8%). In the first two categories pelvimetry rarely if ever influenced management, and it should not be performed routinely. In breech presentation and cases of caesarean section pelvimetry seemed to be of value, but in the latter group it should be performed puerperally to avoid the known radiation hazard to the fetus. A fairly close correlation between obstetric conjugate and pelvic capacity was shown, which suggested that a 3400-g baby might pass through a pelvis of obstetric conjugate of 10 cm as a cephalic trial of labour, but would need an obstetric conjugate of 11-7 cm for safe vaginal breech delivery. (+info)
Comparison of the perinatal morbidity and mortality of the presenting twin and its co-twin.
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OBJECTIVE: To compare the perinatal outcome of the presenting twin to its co-twin. STUDY DESIGN: All live nonanomalous twin gestations delivered at >25 weeks' gestation between 1984 and 1994 (N=461) were identified. Twin A was compared to twin B regarding the following variables: presentation, Apgar score (AS) <4 at 1 minute, AS <7 at 5 minutes, birth weight, gender, traumatic delivery, meconium-stained amniotic fluid, cord prolapse, need for mechanical ventilation, intraventricular hemorrhage, respiratory distress syndrome, sepsis, seizures, perinatal mortality, and length of nursery stay. RESULTS: Except for differences in presentation, the perinatal outcome was similar in both twins regarding variables studied. This continued to hold true after subdividing according to mode of delivery, when infants with birth weight < or = 1500 g were considered separately, and when vaginally delivered cephalic twin A was compared to the noncephalic co-twin. However, differences in some outcome variables became evident when pregnancies with only one affected member were analyzed separately. CONCLUSIONS: When all twin pairs are considered, the outcome of the second-born twin is similar to that of the first-born regardless of the mode of delivery, presentation, or birth weight < or = 1500 g. If only those twin pairs with one affected and one unaffected twin are considered, it becomes apparent that the presenting twin is at increased risk for infection-related morbidities whereas the co-twin is at risk for other complications. (+info)