Current Obstetric Practice Research Articles

A survey of current obstetric anaesthesia practice in Switzerland

INTRODUCTION The practice of obstetric anaesthesia and analgesia has been surveyed nationally and regionally in parts of Canada] ,2 the USA, 3 the UK 4 and various constituent parts, s-7 Sweden, 8,9 Finland 1° and Western Australia.ll The main purpose of our investigation was to obtain information regarding the availability and organization of epidural services in obstetric units throughout Switzerland. Institutional guidelines, per- sonnel resources and professional groups involved in providing epidural analgesia as well as other forms of analgesia were also recorded. METHODS In the summer of 1992, a confidential questionnaire (see Appendix) was sent to all university, public and private hospitals listed in the

Prenatal screening for group B Streptococcus: I. Impact of antepartum screening on antenatal prophylaxis and intrapartum care

OBJECTIVE: Our purpose was to evaluate current obstetric practice regarding screening and prophylaxis for group B Streptococcus and to evaluate the impact of screening on antepartum and intrapartum care. STUDY DESIGN: A total of 1232 members of the Society of Perinatal Obstetricians were asked to indicate their practices regarding screening for group B Streptococcus. Respondents were then asked their practices regarding antepartum and intrapartum prophylaxis on the basis of screening cultures, prior antimicrobial treatment, and other risk factors for neonatal sepsis. RESULTS: Of the 925 respondents (75.1%), 30.8% performed routine screening in all pregnancies: first prenatal visit (42.3%), 26 to 28 weeks (41.3%), and 34 to 38 weeks (22.1%). In addition, 65.9% would screen patients only under high-risk situations. Although 70.5% sample multiple sites, respondents were inconsistent regarding the sites from which cultures are obtained: distal vagina (64.2%), cervix (53.9%), proximal vagina (40.0%), anal canal (38.5%), and urethra (4.3%). A total of 34.7% of respondents would treat the patient at the time of a positive culture. Knowledge of maternal group B Streptococcus carriage would significantly alter intrapartum prophylaxis in low-risk (60.3% vs 0.5%) and various high-risk populations (74.0% to 98.4% vs 11.3% to 55.0%). However, no consensus as to optimal practice was identified. CONCLUSIONS: This survey demonstrates significant inconsistencies in screening and prophylaxis for group B Streptococcus by specialists in maternal-fetal medicine. In addition, it reveals that the recommendations of The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics are not routinely followed by these specialists. Knowledge of group B Streptococcus carriage significantly increases antepartum and intrapartum treatment regardless of the presence of other risk factors for neonatal sepsis. The impact of this practice on neonatal therapy warrants further evaluation.

The contribution of dystocia to the cesarean section rate

Our purpose was to examine the indications for performing cesarean sections in current obstetric practice and to define and measure the true contribution of dystocia ("difficult labor") to the overall cesarean section rate. A prospective audit was done of all cesarean sections performed during 1991 at The Queen Mother's Hospital, Glasgow, a teaching hospital and tertiary referral center. The cesarean section rate for 1991 was 16.3%. Dystocia was the primary indication in 16% of all cesarean sections in 1991 but was actually a contributing factor, directly or indirectly, in the decision to operate in up to 38% of all cesarean sections that year. Seventy-eight percent of patients delivered because of dystocia were in spontaneous labor. We advocate more widespread use of a policy of active management in nulliparous women who labor spontaneously. If dystocia is addressed successfully, then many repeat cesarean sections may also be avoided. Improved management of dystocia in nulliparous women, such as the use of a policy of active management of labor, may be the most useful approach to reducing the cesarean section rate in modern obstetric practice.

External cephalic version at term

It is remarkable that, for all the sophistication of current obstetric practice, uncertainty should persist concerning the management of as fundamental a problem as breech presentation, particularly with respect to the place of external cephalic version (ECV). This review will focus on information available for guiding clinical decisions, and practical aspects of the procedure.

Doppler velocimetry in pregnancy

Since the late 1970s, Doppler velocimetry has been investigated extensively for use in obstetrics. Initially, this technique showed promise for the management of certain complications of pregnancy; this promise has yet to be fulfilled. Doppler velocimetry of either the uterine or umbilical vessels, which showed some merit in selecting growth-retarded fetuses at particular risk, has neither become a screening tool for intrauterine growth retardation nor proven clinically successful in improving fetal outcome. Likewise, its use for other complications of pregnancy (eg, postdate pregnancy, twin pregnancy, and diabetes) has not led to improved pregnancy outcome. More recently this technique has been used to study other vascular beds. Changes in the Doppler characteristics of these vascular beds may demonstrate the fetal response to its environment. These investigations provide the potential for a better understanding of fetal physiology; however, it has yet to be shown by prospective evaluation that their application results in improved pregnancy outcome. This review defines the uses and limitations of Doppler ultrasound in current obstetric practice.

Continuous Emotional Support During Labor in a US Hospital

The continuous presence of a supportive companion (doula) during labor and delivery in two studies in Guatemala shortened labor and reduced the need for cesarean section and other interventions. In a US hospital with modern obstetric practices, 412 healthy nulliparous women in labor were randomly assigned to a supported group (n = 212) that received the continuous support of a doula or an observed group (n = 200) that was monitored by an inconspicuous observer. Two hundred four women were assigned to a control group after delivery. Continuous labor support significantly reduced the rate of cesarean section deliveries (supported group, 8%; observed group, 13%; and control group, 18%) and forceps deliveries. Epidural anesthesia for spontaneous vaginal deliveries varied across the three groups (supported group, 7.8%; observed group, 22.6%; and control group, 55.3%). Oxytocin use, duration of labor, prolonged infant hospitalization, and maternal fever followed a similar pattern. The beneficial effects of labor support underscore the need for a review of current obstetric practices.

281 The role of external cephalic version in current obstetrical practice

281 The role of external cephalic version in current obstetrical practice

Guidelines for Establishing a Maternal Serum Alpha-Fetoprotein Screening Program

Maternal serum alpha-fetoprotein (MSAFP) screening of all pregnant women between 15 and 20 weeks gestational age is generally recognized as a standard of care in current obstetric practice. There are many factors to consider when deciding to establish MSAFP testing as an in-house procedure versus ship-out testing by a reference laboratory at fee-for-service cost. In this report, we review clinical and analytical aspects of MSAFP testing, along with appropriate guidelines for establishing an on-site MSAFP screening program.

Fetal monitoring. Current practice in England and Wales

SummaryA postal questionnaire on antepartum tests of fetal well-being was sent to all obstetricians in England and Wales to establish current practice with respect to availability, use and obstetricians' opinions of procedures used by them. The result of the survey showed that current obstetric practice favours clinical and biophysical assessments and not biochemical parameters.

The problem of grandmultiparity in current obstetric practice

A retrospective analysis of 646 Arab grandmultiparas who booked for hospital confinement between 1983 and 1985 was carried out. The results were compared with that of non-grandmultiparas during the same period. In the grandmultiparas, the incidences of gestational diabetes, hypertension rheumatic heart disease, antepartum, postpartum hemorrhage and macrosomic infants were increased. However, contrary to some previous reports the incidences of anemia, cesarean sections, induced labor, dysmaturity and perinatal deaths were decreased. This is thought to be due to the provision of modern specialist perinatal care and improved socio-economic standards.

The silencing of women in childbirth or Let's hear it from Bartholomew and the boys

This article traces the beginnings and growth of the author's research into 18th and 19th century obstetric discourse in an effort to develop a perspective on the male theories about the female body inherent in current obstetric and gynecological practice. The author first discusses previous work within feminism to theorise about women and childbirth and the search for an authentic female practice of birth. She then focuses on the issue of power, and using examples from the texts of men midwives and obstetricians, argues that the obstetric discourses reveal the power of obstetric science to control the way women labour and give birth.

Antenatal Nonstress Cardiotocography

EDITORIAL COMMENT: There are problems with the interpretation of the value of antenatal cardiotocography in current obstetric practice. For example, a recent review by Thacker and Berkelman concluded that although nonstress and contraction stress cardiotocographs are used extensively in the United States of America, ‘neither have been demonstrated to be useful diagnostic tests’ (1). These authors stated that antepartum fetal surveillance techniques are potentially useful screening tests but still ‘require critical evaluation, with large randomized, controlled trials, to determine their efficiency and safety before their further diffusion into obstetrical practice’ (1).This issue of the journal contains audits of the indications and results of antenatal cardiotocography (using nonstress testing) performed in the Fetal Monitoring Departments of 2 of the University Teaching Hospitals in Melbourne. It is evident that antepartum cardiotocography has become popular with clinicians; 42% of patients at the Queen Victoria Medical Centre were tested and 32% at the Mercy Maternity Hospital, although the tests were ordered on clinical indications and not as a routine. The results showed that when there was evidence of satisfactory fetal reserve the perinatal mortality rate was less than 0.3% after malformations incompatible with life were excluded. Both studies showed a highly significant increase in the incidence of fetal growth retardation and low Apgar scores in infants born from pregnancies with abnormal cardiotocography. The Mercy Maternity Hospital data also showed that the perinatal mortality rate was increased from less than 1% to nearly 4% when fetal reserve was reduced, and to almost 20% when there was evidence of critical reserve (presence of late decelerations plus loss of beat to beat variation). These papers do not consider the management of patients who have evidence of critical fetal reserve. Since the perinatal mortality rate in these cases is approximately 20%, such a finding warrants immediate delivery, usually by Caesarean section.The clinician's problem is what to do with the patient who has evidence of reduced fetal reserve on cardiotocography. This is an important consideration since this group constitutes about 8% of the patients tested by antenatal cardiotocography — the critical reserve group comprising only 1–2% of those tested. Oats and colleagues from the Mercy Maternity Hospital give clinical details of all the perinatal deaths that occurred in their patients with normal antenatal cardiotocography or with evidence of reduced fetal reserve. These authors have designated those cases in which they regard, in retrospect, the perinatal death as being possibly avoidable, and the reader can also see the number of unexplained deaths that occurred within a week of the test being performed.The great advantage of antenatal cardiotocography is that it allows the clinician to defer delivery when there is evidence of satisfactory fetal reserve and so avoid the problems of prematurity when there is no absolute maternal indication for delivery. The reader can also see from the cases quoted that the clinician should not defer delivery when there is evidence of reduced reserve when the pregnancy has reached practical viability — 37 weeks' gestation. It is possible that recognition of reduced reserve with appropriate clinical action accounts for the varying incidence of critical reserve reported from different centres.

The anaesthetist and the obstetric flying squad

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.

The Midforceps Operation: A Review of 50 Cases

ABSTRACT Current obstetric practice tends to discourage the use of midforceps delivery in patients with prolonged second-stage labor, but many obstetricians feel that there is a place for judicious...

Prolonged Pregnancy

The problem of prolonged pregnancy has been considered by many workers, some of whom have recommended induction of labor before or soon after term. More recent investigations have found no difference in the oxygen content of fetal scalp blood sampled before the onset of labor in patients presenting with premature ruptured membranes, as compared with those having amniotomy for induction at 42 weeks of gestation. The present study was designed to assess the risk of prolonged pregnancy in current obstetrical practice and the outcome of a conservative induction policy. Information from 2000 consecutive deliveries was collected prospectively, coded, and analyzed. A gestation period of 42 weeks or more was recorded for 142 patients who were then regarded as postmature. On further assessment, 81 of them (i.e., 4 per cent of all patients studied) were designated “certain postmature.” Thirty of the 81 patients had their labors induced at 42 weeks of gestation; spontaneous labor was awaited in 51 patients and had started before 44 weeks in all of them. The remaining 61 patients were designated “uncertain postmature.” Of these, 16 had labor induced at 42 weeks, and 45 of them were managed conservatively, with labor starting before 44 weeks of apparent gestation. The overall induction rate in the 2000 women was 9.8 per cent, and there was no perinatal death after 41 weeks of gestation. In the “certain postmature” group, the induced, compared with the noninduced patients, had fewer vaginal deliveries (53.3 per cent and 82.4 per cent, respectively; P < 0.01) and more cesarean sections. Eight of the induced patients had cesarean sections (three for fetal distress, four for failure to progress, and one for failed trial of forceps), as compared with five in the noninduced group (four for failure to progress and one for failed trial of forceps). Six of the induced patients required instrumental delivery (one for fetal distress and five for failure to progress), as compared with four in the noninduced group (three for fetal distress and one for failure to progress). In the “uncertain postmature” group, the induced, as compared with the noninduced patients, had a significantly longer first stage of labor (7.1 hours, as compared with 4.0 hours; P < 0.01) and a much greater cesarean rate (31.2 per cent, as compared with 2.2 per cent; P < 0.01). There was no difference in the frequency of instrumental deliveries. Neonatal outcome was assessed with the Apgar score at one and at five minutes, and the need for intubation or transfer to the special-care baby unit. In the “certain postmature” group, 17.3 per cent of the babies had Apgar scores of 5 or less at one minute, as compared with 9.3 in the total population (P < 0.02), but there were no other differences in neonatal outcome. There were no significant differences in neonatal outcome between patients who were induced and those who were allowed to go into spontaneous labor. In the “uncertain postmature” group, there were too few babies with perinatal morbidity to allow for statistical comparisons.

Breast-feeding Infants

Sir .—In the marginal comment Successful Breast-feeding in theJournal(1981;135:595-596) Dr Lawrence makes the statement, Before any infant is discharged, it is appropriate to establish that the infant is no longer losing weight or has begun to gain even if he has not regained his birth weight. I take exception to this view in that it is not practical or in keeping with the current obstetric and pediatric practices of discharging the mother and infant from the hospital within a few days after delivery. In a 1980 series of 200 full-term breast-fed infants in our practice, fully 43% were still losing weight at the time of discharge, and, thus, a longer hospital stay for them would have been required by the previously cited criteria (18% were discharged on the second day after delivery, 40% were discharged on the third day after delivery, and 28% were discharged on the fourth

The Way We Teach: Reproductive Biology

At the University of Nottingham, students are taught aspects of reproductive biology throughout the Part I Basic Medical Science Course. Teachers from the Departments of Physiology and Pharmacology, Human Morphology, Biochemistry, Obstetrics and Gynaecology, and Psychiatry are involved, and an obstetrician in training (the author) has been appointed full-time lecturer in Physiology and Pharmacology to provide an additional link between the basic science and clinical content of the course. The Part II course includes an Honours Year, to give students an opportunity to explore further the application of scientific method in clinical practice. One project, in which students were involved in physiological measurement used in current obstetric practice, is described here. In addition to carrying out practical tasks, students were required to submit written reports and to prepare a learning resource on fetal acid-base balance for use by their junior colleagues. Supervision was provided by obstetric and paediatric registrars and senior house officers, and senior midwives, while staff in the Department of Physiology and Pharmacology assisted students with data analysis. Each project task was assessed by a supervisor and an independent observer. The project proved acceptable to students, supervisors and hospital staff, and avoided interfering with the other responsibilities of a busy obstetric unit. It is intended to repeat the exercise with minor modifications.