Difficult Delivery Research Articles

The Albert Lasker Medical Awards. RU-486 as an antiprogesterone steroid. From receptor to contragestion and beyond.

The steroid RU-486 (mifepristone) is an antiprogesterone that works at the receptor level. It can interrupt pregnancy very early on (contragestion), mostly by interfering with the process of implantation and decidua function. It also may facilitate surgical evacuation of the uterus and certain difficult deliveries. It impedes ovulation when taken during the follicular phase. Also, RU-486 is the first antiglucocorticosteroid available for clinical use. It deserves further studies to assess its wide range of therapeutic potential.

Congenital Difficulties With Swallowing and Breathing Associated With Maternal Polyhydramnios: Neurocristopathy or Medullary Infarction?

Two babies with congenital difficulties in swallowing and breathing are presented and contrasted. Both were associated with maternal polyhydramnios, but one was due to medullary infarction and the other to a malformation ("neurocristopathy"). In the former case, isolated tenth and twelfth cranial nerve palsies provided the clue as to the correct etiology, whereas the latter baby had dyscoordination of swallowing and breathing with sleep apnea ("Ondine's curse"). It is somewhat ironic that the case without a difficult delivery had the infarct, probably prenatal in onset, whereas the one with a difficult delivery had the congenital malformation. Neural crest cells are known to migrate widely and to develop greatly different functions, but the fact that their central associations of neural tube origin may also be affected has not previously been emphasized in the etiopathogenesis of the congenital malformation. A variety of syndromes with combinations of many defects may be seen in which too many or too few cells are formed, with more or less serious consequences especially for the respiratory and gastrointestinal systems.

Progesterone antagonists on the horizon.

The pharmacology and potential uses of RU-486, the only anti- progesterone to reach clinical trials, including luteolytic, abortifacient, menstrual regulator, postcoital contraceptive, oral contraceptive and other uses, are reviewed. RU-486 acts on the progesterone receptors in the endometrium, specifically the decidua, with a half life of 24 hours. Although it has anti-glucocorticoid activity enough to reverse the clinical and biochemical effects of Cushings disease, it has not anti-glucocorticoid activity at doses used for early abortion. It blocks progesterone and thereby reduces beta-hCG levels in women who will successfully abort, and also increases prostaglandin (PG) secretion and cervical maturation. If hCG remains the same or rises, pregnancy has not been terminated. RU-486 is more effective and also causes less bleeding in pregnancies of less than 6 weeks. PGs and the Chinese "vacation pill" enhance the action of RU- 486. So far the drug has not been 100% effective as a once-a-month pill, nor has it been completely studied for post-coital contraception. RU-486 has potential as an oral contraceptive, since it both inhibits gonadotropin secretion and ovulation. It is effective in cervical ripening and dilatation, and could be used for evacuation in case of fetal death, to aid in difficult delivery and to avoid cesarean section, and to treat progesterone-sensitive tumors.

Induction of twinning in crossbred heifers by ipsilateral frozen embryo transfer

Induction of twinning by means of nonsurgical ipsilateral transfer of two frozen embryos or of demi-embryos was attempted in 297 virgin crossbred dairy heifers that were kept at the following locations: in stables at our breeding station (Group 1), in a mountain field (Group 2) and at a private farm (Group 3). Of these, 187 heifers (63%) were diagnosed pregnant at 25 d after embryo transfer and 134 heifers (45%) were diagnosed pregnant at 60 d after transfer by ultrasonic echography or by palpation per rectum. At calving, 118 heifers produced 46 sets of twins and 72 single calves, for a total of 164 calves sixteen pregnant heifers aborted fetuses between 2 and 7 mo. The pregnancy rate of Group 1 (39%) was lower than that of Group 2 (48%) or Group 3 (50%). Abortion and mortality rates for Group 3 (8% and 8%, respectively) were significantly lower (P<0.05) than for Group 1 (16% and 12%) or Group 2 (13% and 18%). Twin calves had lower birth weights (P<0.05) than singles, but at 270 to 330 d of age, there was no significant difference between the weights of single and twin calves. Dystocia or difficult delivery was not observed heifers producing twins. Retention of the placenta was observed in twin calving heifers, with placenta retention levels the highest in Group 2 (33%) than followed by Group 1 (14%) and Group 3 (10%). When gestation periods were compared between single and twin calves in Groups 1 and 2, the gestation period of single calves was 5.0 to 7.0 d shorter than that of twin calves. No significant difference was observed between the gestation periods of single and twin births in Group 3.

Aetiology of congenital hypothyroidism in Finland.

In Finland a nationwide screening programme for congenital hypothyroidism (CHT) has operated since 1980 with complete coverage. Among the total of 307,000 newborns screened, the incidence per 100,000 was 24.6 for thyroid dysgenesis and 4.0 for dyshormonogenesis. We conclude that, when screening is based on cord serum TSH, the false-positive results are caused mainly by difficult delivery. The most important factors associated with dyshormonogenesis were CHT in the family, origin from a geographic risk area, and origin of both mother and father from the same community. These reflect the autosomal recessive inheritance. The risk factors for dysgenesis were female gender, CHT in the family, birth in a geographic risk area, and birth during a risk period of the year.

Induction of twinning in dairy or crossbred heifers by ipsilateral frozen embryo transfer.

Induction of twinning by ipsilateral nonsurgical transfer of frozen two or demi-embryos was attempted in 129 virgin dairy or crossbred heifers that had been kept under a stable in our station (group-1), mountain field (group-2) and private farm (group-3) conditions. Ninety seven heifers (75%) were diagnosed pregnant by rectal palpation at 35 to 60 days of gestation; 86 heifers produced 37 sets of twins and 49 single calves. Pregnancy rate of group-1 was lower compared to those of groups-2 and -3 (63%, 88%, 78%, respectively). Abortion and mortality rates of group-3 were significantly lower (P less than 0.05) than those of groups-1 and -2 (8% and 6%, 12% and 16%, 18% and 24%). Twin calves had a lower birth weight (P less than 0.05) than singles. But there was no significant difference in weight between singles and twin calves at 270-330 days of age. Dystocia and difficult delivery were not observed in females producing twins. The incidence of retained placentas in twin calving cows (17%) was higher than that of single calving cows (2%). The interval to conceive postpartum was longer in twin calving cows (95 +/- 41 days) than in single calving cows (87 +/- 26 days). Gestation length was 5.0 days shorter for twin calving cows (P less than 0.05).

髄液鼻漏症例

A 32-year-old woman developed cerebrospinal fluid (CSF) rhinorrhea 13 years after a head injury due to a traffic accident. She had been well until she experienced a difficult delivery 4 years earlier. Since then she had had watery rhinorrhea on exertion. She had suffered twice from meningitis of unknown origin. On a clinic visit for another problem, CSF rhinorrhea was suspected and a further history of fever and photophobia was elicited. RI cisternography and metrizamide CT revealed evidence of right CSF rhinorrhea. A fistula was confirmed at operation, and the defect was successfully sealed of with autogenous fascia and tissue adhesive (Biobond®).

Embolism of cerebral tissue to lungs

Two patients with head injury and pulmonary emboli of brain tissue are described. Both patients developed persistent bleeding with elevations of prothrombin time, partial thromboplastin time, and decreased platelet counts. Postmortem examination identified multiple skull fractures, subdural and subarachnoid blood, cortical tears, and intraparenchymal hemorrhages. Lacerations of dural venous sinuses were documented in each case. Multiple pulmonary arteries contained plugs of cerebral tissue, including fragments of cerebral and cerebellar cortex, and white matter. The literature concerning brain tissue emboli is reviewed. In neonates, three patients who survived longer than 1 hour were found to have evidence of persistent hemorrhage. Among both children and adults, our two cases are the only ones reported with associated clotting abnormalities. Brain tissue embolism in neonates occurs after difficult vaginal deliveries, often in conjunction with the use of forceps. Tears of the tentorium cerebelli or falx cerebri have been documented at postmortem examination in the majority of these cases. By contrast, brain tissue embolism in children and adults occurs in association with severe closed or penetrating head injury. In several cases, as in the two reported here, postmortem examination has demonstrated a large cerebral venous defect as the probable site of entry of brain tissue into the systemic circulation. (Neurosurgery 23:511-516, 1988)

Embolism of Cerebral Tissue to Lungs: Report of Two Cases and Review of the Literature

Two patients with head injury and pulmonary emboli of brain tissue are described. Both patients developed persistent bleeding with elevations of prothrombin time, partial thromboplastin time, and decreased platelet counts. Postmortem examination identified multiple skull fractures, subdural and subarachnoid blood, cortical tears, and intraparenchymal hemorrhages. Lacerations of dural venous sinuses were documented in each case. Multiple pulmonary arteries contained plugs of cerebral tissue, including fragments of cerebral and cerebellar cortex, and white matter. The literature concerning brain tissue emboli is reviewed. In neonates, three patients who survived longer than 1 hour were found to have evidence of persistent hemorrhage. Among both children and adults, our two cases are the only ones reported with associated clotting abnormalities. Brain tissue embolism in neonates occurs after difficult vaginal deliveries, often in conjunction with the use of forceps. Tears of the tentorium cerebelli or falx cerebri have been documented at postmortem examination in the majority of these cases. By contrast, brain tissue embolism in children and adults occurs in association with severe closed or penetrating head injury. In several cases, as in the two reported here, postmortem examination has demonstrated a large cerebral venous defect as the probable site of entry of brain tissue into the systemic circulation.

Spinal cord birth injury: Value of computed tomographic myelography

The value of myelography in the assessment of spinal cord injury in the early neonatal period has not been documented, although this study has been recommended frequently in the literature. Eight neonates are reviewed who presented with the clinical features of spinal cord injury and who had myelography performed. Clinical features included difficult delivery, absent respiration, flaccid paralysis, sensory level, and neurogenic bladder. Myelography revealed that 7 patients had the early changes of swollen cord and 1 patient had the late changes of cord atrophy. None of the neonates had surgical intervention. One neonate died at 3 days of age, while 2 others died after prolonged ventilation. Of the 5 infants who survived, 3 still require ventilation and have spastic quadriparesis, 1 has almost recovered completely and 1 had spontaneous respiration and limb movement but brisk deep tendon reflexes when last examined at 1 month of age. Myelography, which was performed in the early neonatal period in our infants, was abnormal in all patients. Myelography is useful in confirming the diagnosis, outlining the level and extent of the lesion, and excluding extramedullary compression. Myelography may assist in the assessment of prognosis but did not alter management in our patients.

Future of maternity 'flying squads' in doubt.

MPs from rural constituencies throughout the country have expressed concern at the threat to maternity services following a proposal from the Association of Anaesthetists to scrap emergency 'flying squads'. The flying squads provide emergency services to outlying maternity units in cases of difficult deliveries.

Traditional midwives in Botswana: strengthening links between women

On the basis of observations in Botswana attention is directed to the potential value of mobilizing the numerous and largely anonymous traditional midwives (TMS) for active cooperation in primary health care outlining strategy for implementing such a policy of cooperation. In Botswana most TMS are socially and culturally integrated into the local community and represent a valuable source of information on cultural conceptions of crucial importance to childbearing women. They demonstrate the value of close personal interaction with the pregnant and delivering woman. Many TMS seem to realize the limitations of their own capability in difficult deliveries and maintain close communication with the local hospital to which they refer patients when indicated. In Botswana the most important question facing health planners is how to provide optimal maternal and child health care for those groups who need it most but who reject the use of modern services. Cooperation with the traditional midwives in the local community may be the answer to this question. At the central level a National Task Force or committee should be formed representing both the modern and the traditional maternity care sectors. The committee should be assigned the task of proposing a comprehensive national policy for the formalized exchange of knowledge and views between traditional and modern midwives and active grandmothers. Activities at the central level should be focused on the appropriate education of the modern midwives and student midwives to increase their cultural sensitivity and emphasize the importance of human qualities of care. Emphasis at the regional level should be on the organization of educational seminars for both modern and traditional midwives. At the local level it is crucial for the modern health worker to maintain a trusting relationship with the local TMS.

MECHANICAL LOAD OF BIRTH AND INTRAVENTRICULAR HEMORRHAGE

We made the clinical observation that VLBWI's covered by hematomas after birth (“bruised babies”) had a relative high incidence of Intraventricular Hemorrhage (IVH). To quantify this observation one of us (E.H., obstetrician) classified in 132 VLBWI's (Gestational Age below 211 days, mean GA 28 w +o 1 d, mean birth weight 1,069 gr) the birth mode into mechanically difficult or easy, without knowing the outcome. The two groups of infants were compared in respect to frequency of IVH II° to IV°. The overall-rate of IVH was 23%. IVH was found in 68% (19 out of 28) after difficult and in 12% (12 from 104) after easy delivery (p below 10−6) After vaginal delivery the ratio was 100% vs. 4% (8 from 8 vs. 1 from 24; p below 10−6), after cesarean section 55% vs. 14% (11 from 20 vs. 11 from 80; p below 0.000,1). There were no differences in GA between infants with difficult or easy delivery (27 w + 6 d vs. 28 w + 2 d) nor between infants with or without IVH (28 w + 0 d vs. 28 w + 1 d).

Behavioural phenomena related to normal and difficult deliveries in dairy cows.

Behavioural aspects of parturition, as well as the behaviour of cows and calves in the earliest post-partum period were studied in a group of 75 Polish Black and White cows. Distinction was made between unassisted deliveries, deliveries that required a little help (traction by not more than 2 persons) and difficult deliveries, requiring veterinary help. Of the cows 14% gave birth without prior behavioural signs of an approaching delivery, 72% manifested clear signs of preparturient unrest and 70% showed outflow of allantoic fluids before the calf appeared. A large variation was seen in the timing of these preparatory phases. Prolonged unrest, a cessation of labour and no appearance of the calf's feet were the clearest signs that a difficult delivery would follow. After the appearance of the feet, only 48% of the cows were able to expell the fetus within 1 h. Spontaneous expulsion of fetal membranes occurred characteristically within 12 h after parturition. Of the cows whose deliveries were unaided or aided, 86 were in recumbent position during the final phase of expulsion of fetus. The majority (64%) of cows with difficult delivery were standing. Cows separated from their calves lie down earlier after calving than those kept with their newborn. From the latter category those after a difficult delivery spent most time licking their calves, partly in lying position. After a difficult delivery calves started their first attempts to stand later, stood later, and when kept with their mothers, suckled later, than did other calves. The behavioural differences between calves from unaided and partly aided deliveries were small. (Abstract retrieved from CAB Abstracts by CABI’s permission)

Vaginal delivery after 3 previous caesarean sections.

A patient who had had 3 previous Caesarean sections was permitted a trial of scar in her subsequent confinement. Labour occurred spontaneously at 39 weeks, and was closely monitored. After an uneventful labour of 3 1/2 hours, a Wrigley forceps lift-out was performed. There was no maternal or neonatal morbidity and the uterine scar was intact.

Congenital Agastria

SummaryCongenital agastria has never before been reported. Congenital microgastria is rare but is well documented. We have cared for a Melanesian child in whom there was no radiological, anatomical, or physiological evidence of either a rudimentary stomach or a pylorus. The esophagus joined the first part of the duodenum directly. At this esophago‐duodenal junction there was microscopic evidence of fundic‐type gastric mucosa. The intestine was normally rotated and there was a functioning spleen. The child also had a severe micrognathia and a cleft soft palate and required a tracheostomy to relieve upper airway obstruction. The combination of micrognathia and agastria presented a difficult nutritional delivery problem. A jejunal pouch was constructed and placed between the esophagus and duodenum to provide some storage capacity. The child grew and developed well for almost 3 years. He suffered three episodes of severe acute enteritis, probably related to lack of the protective acid‐pepsin barrier against ingested microorganisms. Unfortunately, the third episode of acute enteritis caused his death 3 months after returning home to his own country.

Obstetrics and posture in pelvic anatomy

To investigate the obstetric impact on the shape of the human pelvis, the pelvic dimensions of 500 female patients were compared with regard to the duration of their gestations, and to the weight of their newborns. It was demonstrated that there is no relationship between these variables. Similar observations were made on several mammals in which the dimensions of the pelvis are not influenced by the duration of gestation or fetal weight, although they are very responsive to sitting or erect posture. The pelvis in Australopithecus was shaped more to satisfy erect posture and bipedal locomotion than to allow increase in fetal size, which occurred much later, since the encephalization process was on the way only after the pelvis had taken more or less its present shape. Adjustments of the human female pelvis to the increased size of the fetal head are minor, compared with the adjustments to erect posture, because erect posture preceded encephalisation and was therefore first to make its demands on the pelvis. The modern human pelvis is certainly tight and frequently leads to difficult delivery. Socioeconomic factors such as diet, heavy physical work in adolescence, and early pregnancy also can be contributing factors to the multiple variety of shapes in the present female pelvis.

Stress factors among overwhelmed mothers of toddlers in immigrant families in France

This study analyzes “microsystem” variables that are associated with stress in the lives of 191 North African low SES immigrant families. Four domains of potential stress factors were analyzed for 36 overwhelmed mothers compared to the 155 non‐overwhelmed mothers: (1) ecological stressors (lack of toilet, bath, etc.; overcrowded apartment; more than three children); (2) medical stressors (difficult pregnancy or delivery; frequent maternal or child illnes); (3) interpersonal problems (father or mother reports major problems in relationship with toddler; father feels overwhelmed); (4) child behavior stressors (retarded language; sleep or feeding difficulties; severe behavior problems). Few ecological or medical stressors differentiated overwhelmed from non‐overwhelmed mothers. However, in the families of the overwhelmed mothers the following factors were significantly more frequent: Poor father‐child relationship; severe toddler behavior problems; and father feeling overwhelmed. The importance of interperso...

The timing of hospital admission and progress of labour

We set out to study the relationship between the timing of hospital admission and the progress of labour. In all there were 591 healthy primiparous women with normal pregnancies and who anticipated normal deliveries; 436 of them had come because of contractions. When the intrinsic speed of labour (estimated from the status of the cervix at the time of admission in relation to the duration of regular contractions) was allowed for, women coming early (regular contractions for 4 h or less before admission) as compared to those coming late stayed longer in the hospital before delivery but had a shorter total length of labour. They had more interventions during labour, more caesarean sections, longer postpartum hospital stay, and their children had more diagnoses of difficult delivery. Women who came because of ruptured membranes without contractions had shorter labours, more interventions during labour, longer postpartum stay and their children had more discharge diagnoses and longer hospital stay than women coming late. This study suggests that too early admission to the hospital may negatively affect the progress of labour, and controlled trials are needed to confirm or to disprove this suggestion.

Homozygous alpha-thalassaemia: clinical presentation, diagnosis and management. A review of 46 cases.

Forty-six hydropic infants with homozygous alpha-thalassaemia born during a period of 10 years have been reviewed. The incidence was 1:1550 total births, and accounted for 81% of all non-immune hydrops. The male to female ratio was 1:1.4. There was increased incidence of anaemia, pregnancy induced hypertension, antepartum haemorrhage, malpresentation, prematurity, fetal distress, difficult vaginal delivery, caesarean section, retained placenta, postpartum haemorrhage and congenital abnormalities. Antenatal diagnosis by DNA hybridization with subsequent abortion of the affected fetuses is the best method to decrease maternal morbidity and to reduce the incidence of hydrops fetalis in couples at risk. For those with no previous history, but with early onset hypertension and/or polyhydramnios, sonography is useful in making an earlier diagnosis, and in reducing avoidable morbidity, because DNA analysis can be done before caesarean section and aggressive neonatal management is instituted.