Identification of high risk labours by labour nomogram.
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The labour stencil representing the expected cervimetric progress of normal labour was used in 741 consecutive spontaneous labours to identify high-risk labours which needed oxytocic stimulation. Uterine contractions were stimulated if progress extended two hours past the nomogram, which resulted in shorter labours, fewer instrumental deliveries and caesarean sections, and babies with higher Apgar scores than in those dysfunctional labours which were not stimulated. According to the protocol used 36% of primigravid and 13% of multigravid labours needed acceleration. The remaining patients did not need any oxytocic interference during the first stage. This selection of patients is important to prevent a major obstetric advance being abused and discredited at a time when the profession and public are questioning the safety of active labour. (+info)
Insulin-like growth factor-binding protein-1 in umbilical artery and vein of term fetuses with signs suggestive of distress during labor.
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Insulin-like growth factor-binding protein-1 (IGFBP-1) is believed to be an inhibitory factor for fetal growth. The regulation of IGFBP-1 secretion in the fetus is uncertain, although insulin and oxygen tension (PO2) and saturation are thought to play a role. We studied IGFBP-1 levels in umbilical cord artery (UA) and vein (UV) of 98 singleton fetuses at term with clinical signs of distress during labor, i.e. meconium-stained liquor or/and an abnormal fetal heart rate tracing. Blood gas values and serum C-peptide and IGFBP-1 concentrations were measured in both UA and UV. Twenty-five fetuses had an UA pH<7.20. The concentrations of IGFBP-1 were similar in UA and UV and were highly correlated (r=0.98). IGFBP-1 levels were inversely correlated with birth weight, with increased concentrations in small-for-gestational age fetuses (< or =10th weight percentile). IGFBP-1 levels were negatively correlated with C-peptide concentrations, and remained so after correction for birth weight (r=-0.37 for both UA and UV; P<0.001); more specifically, IGFBP-1 levels were increased in the lowest C-peptide quartile (<0.23 nmol/l) compared with the other quartiles. In addition, IGFBP-1 levels were inversely correlated with PO(2) values (r=-0.39 in UA and r=-0.34 in UV; P<0.001); quartiles of UA and UV PO2 showed a gradual increase in IGFBP-1 concentrations with lower PO2 values. A regression model with C-peptide and PO2 values as independent variables predicted IGFBP-1 concentrations (R2 of model was 0.25 and 0.22 for UA and UV respectively; P<0.001). Other blood gas values (pH, PCO2, HCO3- and base deficit) did not correlate with IGFBP-1 levels. The data of this study indicate that serum IGFBP-1 levels in term fetuses are determined by both insulin and PO2 levels, and suggest that acute hypoxemia stimulates IGFBP-1 secretion in the fetus. (+info)
Intrapartum epidural catheter migration: a comparative study of three dressing applications.
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We compared three types of catheter fixation application for their ability to minimize the incidence and magnitude of epidural catheter movement during labour. Patients were randomized to have their epidural catheter secured by a Tegaderm dressing (group T; n = 35), a Tegaderm dressing plus filter-shoulder fixation (group F; n = 39), or a Niko Epi-Fix dressing (group N; n = 37). The length of catheter visible at the patient's skin surface was recorded (to the nearest 0.5 cm) after insertion and before removal; the difference was defined as 'catheter movement'. Outward movement of the catheter was greatest when a Niko Epi-Fix was used (P < 0.01). Concerning minimization of displacement of the epidural catheter per se, only a Tegaderm dressing with additional filter-shoulder fixation proved more effective than using a Niko Epi-Fix dressing (P < 0.05). (+info)
Use of remifentanil in a patient with peripartum cardiomyopathy requiring Caesarean section.
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We describe a case of a 26 yr old primigravida at 39 weeks' gestation, with a diagnosis of peripartum cardiomyopathy, requiring urgent Caesarean section. The patient presented in severe heart failure and active labour. A general anaesthetic, using a target-controlled infusion of propofol and an intravenous infusion of remifentanil, was used to provide stable anaesthesia and analgesia for a successful delivery. The unusual diagnosis of peripartum cardiomyopathy and the potential benefits of the use of remifentanil in high-risk obstetric surgery are discussed. (+info)
Saline infusion sonohysterography in nonpregnant women with previous cesarean delivery: the "niche" in the scar.
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OBJECTIVE: To apply an existing diagnostic imaging test (saline infusion sonohysterography) to characterize the "filling defect" of a previous cervical cesarean delivery scar in the nonpregnant uterus. METHODS: Forty-four patients with histories of cesarean delivery who underwent saline infusion sonohysterography for a variety of gynecologic indications were included. During the procedure, the area below the bladder recess was examined using transvaginal sonography. A filling defect or "niche" was defined as a triangular anechoic structure at the presumed site of a previous cesarean delivery scar. The depth of the niche was measured. Uterine size, the presence of fibroids and polyps, and the number of previous cesarean deliveries were noted. RESULTS: All patients had a niche indenting the anterior uterine-cervical wall. The mean +/- SD depth of the niche was 6.17 +/- 3.6 mm. There was no correlation between the number of cesarean deliveries and the depth of the niche. Thirty-six percent of our patients had fibroids, and 18% had endometrial polyps. CONCLUSION: Saline infusion sonohysterography was able to detect filling defects in women who previously had cesarean deliveries. We hope that by focusing our attention on the transvaginal sonographic appearance of the detectable uterine scar (niche) with or without the use of saline infusion sonohysterography in the nonpregnant uterus, it will train our eyes to look for the scar in the pregnant uterus. In addition, our study patients had a high prevalence of abnormal uterine bleeding. The role of the cesarean delivery scar in women with unscheduled bleeding needs to be further evaluated. (+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)
A labour-saving manoeuvre.
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Slow progress in the first stage of labour was treated in 792 mothers by digital dilatation. This manoeuvre is described. Partial dilatation was converted to complete dilatation in 94.4 per cent of all cases, the incidence of success being 90.0 per cent in primiparae and 96.0 per cent in multiparae. Difficulties are described, but serious complications were conspicuously absent.The manoeuvre was helpful with mothers unable to resist premature bearing down, and especially valuable for reducing delay before applying forceps for fetal distress. The early perinatal loss of 20 (in the first 200 cases) was reduced to 3.3 (in the last 599 births) after a change of technique. (+info)
Clavicle fracture in labor: risk factors and associated morbidities.
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OBJECTIVE: Neonatal clavicle fracture has been previously reported to occur in association with shoulder dystocia, suggesting liability on behalf of the obstetrician. However, clavicle fracture is often inconsistently diagnosed, and shoulder dystocia commonly subjectively defined. Using a formal pediatric diagnosis protocol and an objective definition of shoulder dystocia, we sought to determine the incidence, antecedents, and associated morbidities of clavicle fracture and the potential association with shoulder dystocia. STUDY DESIGN: All deliveries at Harbor-UCLA Medical Center complicated by clavicle fracture from January 1996 to March 1999 were studied. Deliveries with clavicle fracture were compared to all vaginal deliveries during this period. RESULTS: Among 4297 deliveries, twenty-six were complicated by clavicle fracture (0.5%). Clavicle fracture was significantly associated with increased maternal age and birth weight greater than 4 kg, though not associated with shoulder dystocia or operative vaginal delivery. Clavicle fracture was associated with meconium passage and with neonatal orthopedic abnormalities. CONCLUSION: Neonatal clavicle fracture is associated with infant birth weight greater than 4 kg, but not with the occurrence of objectively defined shoulder dystocia. However, infants with clavicle fracture may be at increased risk for additional complications. (+info)