Indication For Operative Delivery Research Articles

Analysis of Variables that Influence the Success Rates of Induction of Labor with Misoprostol: A Retrospective Observational Study.

Determine the predictive criteria for success in inducing labor for live fetuses using misoprostol in pregnant women. Secondarily, the objective is to determine the rates of vaginal or cesarean delivery, duration of induction, interval of administration of misoprostol, the main causes of induction of labor and indication for operative delivery. Medical records of 873 pregnant women admitted for cervical maturation from January 2017 to December 2018 were reviewed in a descriptive observational study of retrospective analysis, considering the following response variables: age, parity, Bishop Index, doses of misoprostol, labor induction time. Logistic regression models were used to predict success with misoprostol in non-operative deliveries. Of the 873 patients evaluated, 72% evolved with vaginal delivery, 23% of the cases were cesarean, 5% forceps or vacuum-extractor. For non-operative delivery the predictive variables at admission were age, parity, gestational age and dilation. During hospitalization, fewer vaginal touches, amniotomy or amniorrhexis with clear fluid lead to a shorter induction time and a greater chance of non-operative delivery. False positives and false negatives of the model were always below 50% and correct answers above 65%. At admission, age less than 24 years, previous normal births, lower the gestational age and greater the dilation, were predictive of greater probability of non-operative delivery. During hospitalization, the less vaginal touches and occurrence of amniotomy/amniorrhexis with clear liquid indicate shorter induction time. Future studies with a prospective design and analysis of other factors are necessary to assess the replicability, generalization of these findings.

Technology for predicting abnormal labor

BACKGROUND: Abnormal labor is the most common complication of labor. It occurs in 10-15% cases of labor and is an indication for operative delivery in a third of all cases. Until now, there are no effective ways to predict abnormal labor. Meanwhile, the use of high-tech forecasting methods is not available for a wide range of obstetric institutions in the Russian Federation.
 AIM: The aim of this study was to create a technology for predicting abnormal labor, based on generally available methods of laboratory and instrumental research.
 MATERIALS AND METHODS: Based on the data collected in the Regional Clinical Hospital Perinatal Center, Chita, Russia in 2018-2021, the retrospective analysis of 200 cases of labor was carried out. The total sample was divided into four study groups: 100 women with normal labor activity (group 1), 30 women with uterine inertia (group 2), 30 women with incoordinate uterine activity (group 3), and 50 women with excessive uterine activity (group 4). The groups were comparable in terms of age, anthropometric parameters and extragenital pathology. All women on the eve of labor (1-2 days) underwent general clinical and ultrasound examination. Statistical processing of the results was carried out using the IBM SPSS Statistics version 25.0 software.
 RESULTS: The technology for predicting abnormal labor is implemented based on a multilayer perceptron, with the percentage of incorrect predictions being 21.3%. The structure of the trained neural network included nine input neurons: labor parity, gestational age, leukocyte count, erythrocyte sedimentation rate, total protein concentration, amniotic fluid index, biparietal size, as well as fetal head and abdomen circumference.
 CONCLUSIONS: An integrated approach based on generally available laboratory and instrumental research methods, such as complete blood count and biochemical blood test, as well as ultrasound examination, on the eve of labor allows for predicting the abnormal labor development with an accuracy of up to 70%. The use of this technology in clinical practice will help, in the future, not only to prevent abnormal labor, but also to reduce the incidence of adverse obstetric and perinatal outcomes.

Is Unfavourable Cervix prior to Labor Induction Risk for Adverse Obstetrical Outcome in Time of Universal Ripening Agents Usage? Single Center Retrospective Observational Study.

Cervical assessment on the Bishop scale prior to induction of labor (IOL) is one of the strongest prognostic criteria in relation to the success of the procedure. The commonly used preinduction methods are mainly aimed at reducing the percentage of cesarean sections. Our study has analyzed obstetric results of patients who had unripe cervix (Bishop score <7) before IOL and used preinduction (Foley catheter or misoprostol vaginal insert releasing 7 mcg of misoprostol per hour for 24 hours) with obstetric results of patients in whom, due to favourable cervix, only a low-dose infusion of oxytocin was used. We reviewed the medical records of 1010 single pregnancies in whom IOL was performed. We divided the patients into two groups: group A (where preinduction was used) and group B (Bishop score ≥7 points) where preinduction was not used. Patients in group A were more likely to complete the delivery by caesarean section (OR = 4.58, 95% CI 3.22-6.51), and more likely to have events that were indications for operative delivery: unreassuring fetal heart rate trace (OR = 3.29, 95% CI 2.07-5.23) and arrested labor or failed induction (OR = 3.4, 95% CI 2.06-5.62). The groups did not differ in the percentage of vacuum extraction, postpartum haemorrhage, and meconium stained amniotic fluid. In group B, more infants were born with umbilical cord blood pH <7.1 (1.38% vs. 0%), both groups included no deliveries of newborns with Apgar score ≤3 points, the groups did not differ in terms of the percentage of newborns with Apgar score between 4 and 7 at birth (OR = 0.66, 95% CI 0.29-1.49). The immature cervix and the need to use labor preinduction is a risk factor for caesarean section. The necessity of preinduction does not impair neonatological results.

De-medicalization of birth by reducing the use of oxytocin for augmentation among first-time mothers \u2013 a prospective intervention study

BackgroundThe use of synthetic oxytocin for augmentation of labor is rapidly increasing worldwide. Hyper-stimulation is the most significant side effect, which may cause fetal distress and operative delivery. We performed an intervention consisting of an educational program and modified guidelines to achieve a more appropriate use of oxytocin.MethodsThis prospective intervention study included 431 first-time mothers at term with spontaneous onset of labor before (October 2012 to May 2013), and 664 after the intervention (April 2014 to April 2015). Our outcomes were prevalence and duration of oxytocin treatment, mode of delivery, indication for operative delivery, episiotomy, anal sphincter tears, bleeding, labor duration, pain relief and the effect of oxytocin on mode of delivery.ResultsAfter the intervention, 52.9% were diagnosed with dystocia, compared with 68.9% before (p < 0.001). Oxytocin was not always used in accordance with the guidelines, but a significant reduction in oxytocin rates from 63.3% to 54.1% (p < 0.001) was obtained. More women without dystocia according to the existing guidelines were augmented after the intervention (18.9% vs 8.4%, p < 0.001). Assessing all labors, the median duration of oxytocin treatment was reduced by 72% (from 90 to 25 min) without increasing the median duration of labor (385 min in both groups). There was a moderate reduction in operative vaginal deliveries from 26.9 to 21.5% (p = 0.04), and dystocia as an indication for these deliveries increased (p = 0.01). There was a moderate increase in caesarean sections from 6.7 to 10.2% (p = 0.05), but no increase in dystocia as an indication for these deliveries. Women receiving oxytocin were more likely to have an operative vaginal birth, even after adjusting for birth weight, epidural analgesia and labor duration, OR: 2.1 (CI 1.1-4.0) before and OR 2.7 (CI 1.6-4.5) after the intervention.ConclusionsOur intervention led to a significant reduction in the use of oxytocin. However, more than half of the women remained diagnosed with dystocia. Operative vaginal births seem to be associated with oxytocin treatment. Therefore, augmentation with oxytocin should be used with caution and only when medically indicated. Even more modified guidelines for augmentation than the ones applied in this study might be appropriate.

Intrapartum transperineal ultrasound used to predict cases of complicated operative (vacuum and forceps) deliveries in nulliparous women.

The objective of this study was to investigate the predictive value of intrapartum transperineal ultrasound in the identification of complicated operative (vacuum or forceps) deliveries in nulliparous women. Prospective observational study of nulliparous women with an indication for operative delivery who underwent intrapartum transperineal ultrasound before fetal extraction. Managing obstetricians were blinded to the ultrasound data. Intrapartum transperineal ultrasound was performed immediately before blade application, both at rest and concurrently with contractions and active pushing. Operative delivery was classified as complicated when one or more of the following situations occurred: three or more tractions; a third-/fourth-degree perineal tear; significant bleeding during the episiotomy repair; major tear or significant traumatic neonatal lesion. A total of 143 nulliparous women were included in the study (82 vacuum-assisted deliveries and 61 forceps-assisted deliveries), with 20 fetuses in occiput posterior position. Forty-seven operative deliveries were classified as complicated deliveries (28 vacuum-assisted deliveries, 19 forceps-assisted deliveries). No differences in obstetric, intrapartum or neonatal characteristics were observed between the study groups, with the following exceptions: birthweight (3229±482 uncomplicated deliveries vs. 3623±406 complicated deliveries; p<0.003) and number of vacuum tractions (1.4 uncomplicated deliveries, 4.5 complicated deliveries; p<0.0005). The strongest predictors of a complicated delivery, using the area under the receiver-operating characteristics curve (AUC), were the angle of progression with active pushing (AoP2) (AUC 86.9%) and the progression distance with active pushing (PD2) (AUC 74.5%). The optimal cut-off value for predicting a difficult operative delivery was an AoP2 of 153.5° (sensitivity 95.2%; false-positive rate 5.9%) or PD2 of 58.5mm (sensitivity 95.2%; false-positive rate 7.1%). The sonographic parameters AoP2 and PD2 can be used to predict cases of complicated operative deliveries in nulliparous women.

Аналіз випадків абдомінального розродження при аномаліях пологової діяльності

The objective: analysis of the frequency of cesarean sections, their structure according to the indications from the mother; study of the dynamics of the frequency of cesarean sections in case of abnormalities of labor activity (ALA) as indications for operative delivery on the basis of Kyiv City Maternity Hospital No. 1 for 2001-2011. Patients and methods. During the study, the frequency of cesarean sections in general, the frequency of urgent cesarean sections, the structure of cesarean sections according to the indications from the mother's side, the frequency of cesarean sections in ALA were studied and analyzed, and the dynamics of the cesarean section rate in ARP as well as one of the main indications with Mother's side. The history of the delivery of labor was used, which culminated in the abdominal route. Results. An increase in the level of cesarean sections was noted. The number of urgent cesarean sections is gradually decreasing. There has been a significant reduction in the incidence of cesarean sections in anomalies of labor, which are not amenable to drug treatment. Conclusion. The professional management of births, adequate justified use of medicines, the use of modern medical means in practice, an objective assessment of the obstetrical situation, cardiotocoagraphic support, timely and adequate use of epidural analgesia positively influenced the increase in the number of deliveries through the natural birth canal, which is a priority in the professional activity of the obstetrician-gynecologist. Key words: caesarian section, anomalies of labor activity.

MULTIPLE PREGNANCY, ANTENATAL CARE PROBLEMS AND THEIR SOLUTIONS RESULTS

Aim of the work. The aim of our study is to summarize the course of pregnancy and delivery in multiple pregnancies in modern conditions. Materials and methods. The analysis of the pregnancy course, labor and perinatal outcomes was carried out in 182 women with diochorionic and 86 patients with monochorionic twins and 40 women with a singleton pregnancy. Multiple pregnancies were proved to be a monochorionic (MH) and diochorionic (DH) that is a high risk factor for perinatal complications. The research included clinical and laboratory examination metods, study of hormonal function of fetoplacental complex (FPC), transvaginal ultrasound examination. Statistical processing of data was carried out using the package of applied programs Microsoft Office Excel 2010 and StatSoft Statistica 6.1. Results and discussion. In the analysis of pregnancy the abortion threat was detected in 51 (59.3%) women with monochorionic and 34 (62%) women with diochorionic twins. Preeclampsia during pregnancy complicated in 26 (30.2%) and 43 (23.6%) patients, with monochorionic and diochorionic placentation type, respectively. A frequent complication of both the MH and DH twins was anemia, which was found in more than half of the surveyed (56.9 and 51%, respectively). Delivery in the case of multiple pregnancies is also much more complicated and is terminated surgically three times more often than in singleton births. The most frequent indications for operative delivery were first breech fetus, fetal distress during pregnancy and childbirth, FGR, severe preeclampsia, premature detachment of normally situated placenta, anomalies of labor activity. These perinatal losses were equally observed both after cesarean section and after spontaneous labor and amounted to 4% at monochorionic and 1.7% at diochorionic twins. The frequency dependence of identified lesions at pregnancy with twins was established by chorionic. Careful observation of the patients with multiple pregnancies in the antenatal period, the prevention of the most frequent complications, ultrasound monitoring of early pregnancy allows a differentiated approach to the management of pregnancy and childbirth, helping to reduce perinatal morbidity and mortality. Conclusions. Multiple pregnancies occur with a large number of complications compared with singletons. Thus, the increase of frequency of multiple pregnancy influences the obstetric and perinatal indicators, pushing this issue in a number of the most pressing issues of modern obstetrics and perinatology.

Indications for operative delivery between 1999-2010 and induction of labor and epidural analgesia on the risk of operative delivery – A population based Swedish register study

ObjectivesThe aim of this study was to describe the distribution of indications for vacuum extraction (VE) and emergency cesarean section (EMCS) from 1999 to 2010. Furthermore, we investigated the association of induction of labor and epidural analgesia (EA) on the risk of operative delivery. Study designPopulation based register study with data from the Swedish Medical Birth Register during 1999–2010 including all 415230 primiparous women giving birth in gestational week 37+0 to 41+6. Main outcome measuresIndication for operative delivery as well as VE and EMCS. ResultsAmong the VE deliveries the indication “signs of fetal distress” increased while “multiple indications” decreased. For EMCS, “prolonged labor” increased steadily while “multiple indications” decreased. The total rate of induction of labor increased from 8.2% in 1999 to 11.9% in 2010, and was associated with an increased risk of both EMCS (OR 3.37) and VE (OR 1.5). The total rate of EA increased from 43.7% in 1999 to 49.8% in 2010, and was associated with a double risk for VE (OR=2.23) and with an increased risk of EMCS (OR=1.64). ConclusionThere have been changes in the distribution of indications for VE and EMCS during the study period. A growing number of mothers are being induced and more mothers receive EA. These factors seem to have influenced the rate of operative deliveries. Our findings underline the importance of carefully considering the advantages, disadvantages and risks with EA and induction of labor.

Headache and adverse pregnancy outcomes: a prospective study

To investigate the association between headache, namely migraine and tension-type headache, and adverse pregnancy outcome. Prospective cohort study conducted in three tertiary care centres in Italy: 376 pregnant women suffering from headache and 326 non-headache pregnant women as controls were recruited. The diagnosis of headache was made at the beginning of pregnancy, according to the criteria of the International Classification of Headache Disorders (ICHD-II). Women were followed up until delivery, and gestational age at delivery, mode of delivery, indications for operative delivery or caesarean section, birth weight, and centile of neonatal weight at birth were carefully recorded. Main outcome measures of the study were: preterm delivery, newborns small for gestational age, and foetal losses. Odds ratios and 95% confidence intervals were calculated. The incidence of preterm delivery (Adj OR, 95% CI 2.74, 1.27-5.91) was significantly higher in women suffering from headache than in controls. There was no statistically significant difference in small for gestational age newborns between the groups. Fewer women in the headache group had preterm elective caesarean section or induction of labour, than did controls, indicating a higher chance of spontaneous preterm delivery. Multivariate analysis showed that the association between headache, either migraine or tension-type, and adverse perinatal outcomes was statistically significant regardless of pre-eclampsia. Women with headache should be considered at risk for adverse perinatal outcomes and should, therefore, be included in a high-risk pregnancy protocol of care throughout pregnancy.

The impact of non-significant variable decelerations appearing in the latent phase on delivery mode: a prospective cohort study

BackgroundVariable decelerations are the most frequent fetal heart rate changes that are related to labor. The objective of the study was to estimate the impact of non-significant variable decelerations (NSV) appearing during the latent phase of labor on delivery mode and neonatal outcome.MethodsWomen at term, who were in the latent phase of labor and had a singleton pregnancy, were prospectively included. Women were divided into three groups. All had a fetal heart rate tracing with normal baseline and variability. The study group was composed of women who had in addition NSV, Category II, according to the National Institute of Child Health and Human Development categorization system. Women who had Category I tracings composed the control group. Women who had non-repetitive severe variables (SV) composed a second control group (Category II-SV). Main outcome compared was mode of delivery. Secondary outcome was cord pH. One-way analysis of variance was used to compare the continuous demographic and clinical variables of the three groups. Backwards stepwise logistic regression using significant univariables was performed to determine which predicted operative delivery. P < 0.05 was considered significant.ResultsOf 1005 women who delivered during the study period 186 had Category II- NSV tracings (study group), 76 had Category II-SV and 251 had Category I tracings. Mode of delivery and indications for operative delivery were similar between women in Category II-NSV compared to Category I. In addition mean cord pH did not differ between the two groups. Conversely, women in Category II-SV, had a higher rate of cesarean or vacuum deliveries compared to the other groups (p = 0.0001). Beside, they had a significantly higher number of neonates born with cord pH between 7.0 to 7.1 (p = 0.03).ConclusionsNon-significant variable decelerations in early stages of labor are probably a non-ominous sign for neonatal outcome and have no impact on delivery mode.

Perinatale Morbidität in Schwangerschaften von präkonzeptionellen Diabetikerinnen und Gestationsdiabetikerinnen im Vergleich mit Nichtdiabetikerinnen. Ergebnisse der Niedersächsischen Perinatalerhebung

Pregnancies of women with glucose tolerance disorders are still associated with high maternal and perinatal morbidity. In the present population-based study, we investigated the fetal and neonatal risks and complications in pregnancies of women with preconceptional and gestational diabetes in comparison with pregnancies of non-diabetic women. A total of 913,255 pregnancies with 926,685 newborns documented by the Perinatal Registry of Lower Saxony, Germany, between 1987 and 1999 was retrospectively evaluated. In particular, the obstetric parameters of 3439 women with preconceptional diabetes mellitus (PDM, n = 3485 neonates), 4051 women with gestational diabetes mellitus (GDM, n = 4155 neonates) and 905,765 non-diabetic women (NDM, n = 919.053 neonates) were analysed. The diabetes groups had a higher rate of preterm birth < 31st week of gestation (PDM vs. NDM odds ratio [OR] 2.341; GDM vs. NDM OR 1.483) and between the 32nd and 37th weeks of gestation (OR 3.688 and 2.418, respectively). The incidences of pathological cardiotocograms (OR 1.519 and 1.258, respectively) and acidosis as indication for operative delivery (OR 5,015 and 2,102, respectively) were increased in the diabetes groups. There was a higher prevalence of birth weight > 4500 g (OR 2.775 and 2.742, respectively) and >95. percentile (OR 4.268 and 3.610, respectively) in newborns of diabetic women. The higher rate of umbilical arterial pH < 7.00 (OR 2.481 and 1.195, respectively) as well as Apgar score at 1 minute <7 (OR 2.971 and 1.897, respectively) indicated a poorer neonatal outcome in pregnancies of women with diabetes mellitus. The frequency of necessary intubation of the infants was significantly higher in the diabetes group (OR 3.384 and 1.317, respectively). There also was an increased prevalence of intrauterine fetal death in pregnancies of diabetic women (OR 4.197 and 2.511, respectively). Pregnancies of women with diabetes mellitus are still correlated with higher perinatal risks and complications. The neonatal morbidity in pregnancies with gestational diabetes mellitus was more similar to that of pregnancies with preconceptional diabetes mellitus than to the morbidity in the group of non-diabetic women. Changes of the parameters within the observation period were the same in all three groups and therefore cannot be attributed to a primary more intensive prenatal care of diabetic women.

Influence of Uterine Myomas on Course and Outcome of Pregnancy

Purpose and Introduction: Uterine myomas are present in 1.4 % of all pregnancies. They increase incidence of spontaneous abortions, preterm labor and fetal malpresentation, as well as degeneration and infection of myomas. Some of them must be operated and removed before or during the pregnancy and during the cesarean section. Our study shows how uterine myomas influence the course of pregnancy or the way of its termination. We paid special attention to the group of patients who previously had myomectomy. We seeked for an answer if myomectomy should be an indication for operative delivery or not. Materials and Method: We analyzed 122 pregnancies which were followed and terminated in the Institute for Gynecology and Obstetrics in two years' interval. The patients were divided in 3 groups. Group 1: 23 patients who previously had myomectomy and had normal ultrasound finding during the actual pregnancy. Group 2: 10 patients who previously had myomectomy and had new myomas. Group 3: 89 patients who had one or more myomas and had no operations before. Results and Discussion: Vaginal delivery was performed in 23.7 % cases, they were all spontaneous. Operative deliveries were performed in 76.3 % pregnancies. In group 1 this percentage was 87 % and in group 2 even 90 % due to previous myomectomy. During the cesarean section we performed myomectomy in 33.6 %. There were no significant intrapartal or postpartal hemorrhages. In group 2 we found 2 incomplete uterus ruptures during the elective cesarean sections. Conclusion: We suggest to take special care of patients with previous myomectomy and new myomas because they are at great risk to develop uterine rupture in pregnancy and labor with great danger for fetus and mother.

The Risk of Cesarean Delivery With Neuraxial Analgesia Given Early versus Late in Labor

The recommendation that epidural anesthesia be delayed in nulliparous women until there is 4–5 cm of cervical dilatation rests on an increased risk of cesarean delivery at less than 4.0 cm. It is not clear whether this is a result of the analgesia or other factors. The authors postulated that neuraxial analgesia administered early in labor using intrathecal opioid, as part of a low-dose local anesthetic technique, would not increase the risk of operative delivery. A randomized trial enrolled 728 nulliparous women at term who either were in spontaneous labor or had spontaneous rupture of membranes and whose cervical dilatation was less than 4.0 cm. The participants received either intrathecal fentanyl, with bupivacaine added as needed, or systemic (intravenous and intramuscular) hydromorphone when they first asked for analgesia. Epidural analgesia was started at the second request for analgesia in the intrathecal group, and at cervical dilatation of 4.0 or more, or at the third request for pain relief in the systemic group. Rates of cesarean delivery did not differ significantly between the 2 groups, and there also were no significant differences in the rate of instrumental vaginal delivery or indications for operative delivery. The maximum rate of oxytocin infusion was, however, higher in women given systemic analgesia. Neither type of insurance (private or public) nor different obstetric providers made a difference. Times from initial analgesia to complete dilatation and vaginal delivery were significantly shorter when intrathecal analgesia was used. The intrathecal group had less nausea and vomiting, and neuraxial analgesia lasted longer in this group than in women given systemic analgesia. There was no significant group difference in worrisome fetal heart rate tracings. The findings in this randomized trial indicate that nulliparous women in spontaneous labor, or having spontaneous membrane rupture, may receive neuraxial analgesia early in the course of labor without adverse effects. Early neuraxial analgesia does not appear to increase the number of cesarean deliveries compared with systemic opioid analgesia, and it may shorten labor.

Vacuum extraction: Does duration predict scalp injury?

To identify variables that increase the chance of neonatal scalp injury during vacuum extraction. We conducted a prospective observational study of 134 vacuum extraction-assisted deliveries at Olive View-UCLA Medical Center in 1995. Data collected included parity, gestational age, duration of first and second stages of labor, indication for operative delivery, station and position of fetal head, duration of vacuum application, number of "pop-offs," neonatal weight, and descriptions of scalp marks or injury. Cranial imaging studies were obtained if clinically indicated. There were 28 infants with scalp trauma, including 17 superficial lacerations, six large caputs, and 12 cephalohematomata; one infant had subgaleal, subdural, and subarachnoid hemorrhages. Logistic regression analysis showed duration of vacuum application to be the best predictor of scalp injury, followed by duration of second stage of labor and paramedian cup placement. Duration of vacuum application ranged from 0.5 to 26 minutes, with a median length of 3 minutes. The proportion of injuries was greater for applications exceeding 10 minutes (6 of 9) than for those 10 minutes or shorter (22 of 121, P < .01). We did not encounter any cases of clinically important scalp injury. Cosmetic scalp trauma occurred in 21% of our newborns delivered by vacuum extraction and was more common after longer vacuum applications, longer second stages, and paramedian cup placement.

The Management of Recurrent Genital Herpes Infection in Pregnancy

Objective To determine clinical practice amongst bstetricians in the UK in the antepartum and intrapartum management of pregnant women with recurrent genital herpes infection. Methods All Members and Fellows of the Royal College of Obstetricians and Gynaecologists resident in the UK were sent a questionnaire requesting information concerning their management of pregnant women with recurrent genital herpes infection. Results There was a 76% response rate to the questionnaire. Of the 1201 obstetricians who responded, only 369 (31%) admitted to having a formal policy governing the management of herpes in pregnancy within their unit. However, regular screening was advocated by 718 (60%), of whom 463 (64%) performed regular antenatal swabs for viral culture. At the time of presentation in labour 974 obstetricians (81)routinely examined the genitals for evidence of a recurrence. When asked in what circumstances caesarean section would be considered an appropriate method of delivery in women with genital herpes infection, 1107 (92%) felt that visible active lesions at the time of labour was sufficient. However, when the membranes had been ruptured for more than four hours in the presence of genital lesions, only 678 (56%) considered this an indication for caesarean section. Caesarean section was more likely to be considered appropriate in this situation by obstetricians who performed antenatal screening (χ2= 30.38, P < 0.0001). Five hundred and ninety-six obstetricians (50%) felt that a positive viral culture obtained at antenatal screening from the most recent occasion prior to presentation in labour was an indication for caesarean section, although of this group 192 (32%) said they did not perform antenatal screening by viral culture. The reporting of a recurrence by the patient without visible evidence of disease was considered an appropriate indication for caesarean section by 438 respondents (36%). Maternal request for caesarean section regardless of recurrences at delivery was onsidered an acceptable indication for operative delivery by 745 obstetricians (62%). Conclusions 1. There seems to be little agreement amongst obstetricians in the UK regarding the management of recurrent genital herpes infection in pregnancy. 2. The management possibilities are reviewed and suggestions are made for a more cohesive approach to the problem.

Comparison of outcome of labetalol or hydralazine therapy during hypertension in pregnancy in very low birth weight infants

Ninety-seven women with moderate to severe preeclampsia (PE) were allocated at random to labetalol or hydralazine treatment. Of these, 22 women with severe PE gave birth to neonates with VLBW (very low birth weight < or = 1500 g). Seven were allocated to labetalol treatment (Group A), eight to hydralazine treatment (Group B) and seven women received both drugs due to poor blood pressure control with a single drug therapy (Group C). No difference in cesarean section rate or in the indication for operative delivery could be seen. Gestational age was 29.9 weeks (25.4-32.5) in Group A, 28.6 weeks (26.6-33.4) in Group B and 27.3 weeks (26.7-31.1) in Group C (median and range). Birth weight did not differ between groups and 13 of the 22 infants weighed below 1000 g. There was a tendency to lower Apgar scores at five minutes in the hydralazine group. Time spent in the neonatal intensive care unit did not differ between groups. Five of the 11 neonates with gestational age (GA) < or = 28 weeks and three of the seven neonates in GA 29-30 weeks died. Neither the number of infants requiring intermittent positive pressure ventilation or duration of O2- treatment, nor number of infants with respiratory distress syndrome differed between groups. We did not find any difference in the outcome of the VLBW infants when the hypertensive mother had been treated with either hydralazine or labetalol.

Comparison between metal cup and silicone rubber cup vacuum extractor

A total of 400 primiparous patients who were delivered by vacuum extractor were studied. The patients were divided in two groups: Group A included 200 patients who were delivered by metal cup vacuum extractor and Group B consisted of 200 patients who were delivered by rubber cup vacuum extractor. There were no statistically significant differences in the mean maternal age, mean gestational age, mean neonatal birth weight, indications for operative delivery, occipital positions and head stations between the two groups. No differences were found in the rates of birth canal trauma (11% vs. 12.5%), major neonatal scalp trauma (6.5% vs. 5.5%), neonatal jaundice (15.5% vs. 13.5%) and Apgar score. From this study we can conclude that both metal and silicone cups are equally satisfactory for vacuum extraction.

International collaborative effort (ICE) on birth weight, plurality, perinatal, and infant mortality: IV. Differences in obstetrical delivery practice: Norway, Scotland and the United States

We have carried out a comparative study on differences in operative obstetrical practice during the 1970s and 1980s, in Norway, Scotland and the United States of America. It was based on information from official sources in each country. We compared rates of cesarean section (CS) and operative vaginal delivery according to maternal age, parity and gestational age at delivery, birthweight, fetal presentation, and other characteristics of the child, indications for operative delivery, and hospital size and teaching status. While all three countries had rising CS rates, the Scottish rates, which lay between those of the U.S.A. and Norway, rose more slowly than in the latter. In 1985, the rates were 22.8% in the U.S.A., 13.5% in Scotland and 12.0% in Norway. Use of forceps and vacuum extractor declined in the U.S.A. and Scotland, but increased in Norway. CS rates in mothers aged 35 and over were uniformly high in 1970 and rose relatively little. Specific CS rates for very low birthweight children, breech presentation and twins rose to 30-50% in all three countries with some national trend differences. Rate ratios of operative delivery between large and small hospitals fell from about 2-3 in the 1970s to approximately 1.5 in 1985, least markedly in Scotland. The impact of previous CS as an indication for CS cannot be resolved because of notification and recording differences.

KETAMINE AND DIAZEPAM AS ANAESTHESIA FOR FORCEPS DELIVERY A COMPARATIVE STUDY

In a clinically controlled trial in forceps delivery, a comparison was made between the general anaesthesia induced by ketamine and that by a combination of diazepam and N2O. Local anaesthesia was added in the diazepam group for episiotomy and suturation. The indication for operative delivery was in all cases a prolonged second stage of labour. In the katamine group, awareness was noted in four cases out of 13, even if the analgesic effect was found to be good. Four patients showed marked, short-lasting elevation of blood pressure and seven had unpleasant dreams. All thirteen mothers in the diazepam group found the anesthesia effective and the recovery pleasant. The blood pressure was stable. One mother in each group required ventilation with oxygen due to respiratory depression of short duration. Three of the children in the ketamine group and two in the diazepam group had subnormal Apgar score with slight acidosis. This was probably not attributable to the anaesthesia.

Ketamine and Diazepam as Anaesthesia for Forceps Delivery. A Comparative Study

In a clinically controlled trial in forceps delivery, a comparison was made between the general anaesthesia induced by ketamine and that by a combination of diazepam and N2O. Local anaesthesia was added in the diazepam group for episiotomy and suturation. The indication for operative delivery was in all cases a prolonged second stage of labour. In the katamine group, awareness was noted in four cases out of 13, even if the analgesic effect was found to be good. Four patients showed marked, short-lasting elevation of blood pressure and seven had unpleasant dreams. All thirteen mothers in the diazepam group found the anesthesia effective and the recovery pleasant. The blood pressure was stable. One mother in each group required ventilation with oxygen due to respiratory depression of short duration. Three of the children in the ketamine group and two in the diazepam group had subnormal Apgar score with slight acidosis. This was probably not attributable to the anaesthesia.