Maternal Discomfort Research Articles

Demonstrating programme impact on maternal mortality.

Reducing maternal mortality if one of the primary goals of safe mother hood programmes in developing countries. Maternal mortality is not, however, a feasible outcome indicator with which to judge the success of these programmes. This is due to an unfortunate combination of obstacles to measurement--some general to assessing the mortality impact of health programmes and some peculiar to estimating maternal mortality. There is a need to promote alternative views and measures of programme success, and alternative uses for information on maternal deaths.

Herpes gestationis

Herpes gestationis is a rare autoimmune disease of pregnancy characterized by itching and skin lesions. The disease causes prominently maternal discomfort, but fetal and neonatal complications have been reported; however the frequency and severity of fetal illness are still debated. We describe three cases of herpes gestationis diagnosed and managed at our institution in the last 3 years.

Amnihook versus amnicot for amniotomy in labour

In a study of 100 women in established labour we investigated two devices currently used for amniotomy, the Amnihook, a long rigid instrument and the Amnicot, a finger stall with a plastic hook on the end. No overall difference was found in operator ease of use or maternal discomfort. There were significantly fewer babies with long scratches p = 0.02, Odds ratio 0.19 (95% CI 0.05 to 0.68) and the mean scratch length was almost halved in the Amnicot group (p < 0.05, 95% CI for difference between means 0.653 to 6.71). Our findings support the theoretical advantage of a reduction in fetal scalp trauma using a flexible device for amniotomy.

Transvaginal chorionic villus sampling using transabdominal ultrasound guidance: a new technique for first-trimester prenatal diagnosis.

Transvaginal chorionic villus sampling (CVS) using concurrent transabdominal ultrasound guidance was performed in 20 women who desired CVS but could not be offered transcervical or transabdominal approaches because of uterine position and placental location. Satisfactory amounts of chorionic villi were obtained in all 20 cases with no maternal discomfort, an occurrence that contrasts with our experience in transvaginal CVS using endovaginal ultrasound guidance. We believe that transvaginal CVS using concurrent transabdominal ultrasound guidance warrants consideration as an alternative technique for first-trimester CVS in selected patients.

Transvaginal chorionic villus sampling using transabdominal ultrasound guidance.

Transvaginal chorionic villus sampling (CVS) using concurrent transabdominal ultrasound guidance was performed in six women who desired CVS but could not be offered transcervical or transabdominal approaches because of uterine position and placental location. Satisfactory amounts of chorionic villi were obtained in all six cases with no maternal discomfort, an occurrence that contrasts with our experience in transvaginal CVS using endovaginal ultrasound guidance. We believe that transvaginal CVS using concurrent transabdominal ultrasound guidance warrants consideration as an alternative technique for first-trimester CVS in selected patients.

Posture and epidural catheter insertion. The relationship between skill, experience and maternal posture on the outcome of epidural catheter insertion

This study was undertaken to investigate the outcome of epidural catheter insertion in the sitting or lateral position in mothers during labour. An initial prospective randomised study period (144 patients) suggested that the sitting position offered some superiority over the lateral in terms of technical ease of insertion. It was concluded, by minimising the subjective aspects in a follow-up, prospective nonrandomised study period (152 patients), that the determining factor lies in the skill and experience of the anaesthetist. There was no significant difference in complication rates or maternal discomfort between the two positions in either study period.

Acute Polyhydramnios in Twin Pregnancy a Retrospective Study with Special Reference to therapeutic Amniocentesis

Acute polyhydramnios in monozygotic twin pregnancy causes severe maternal discomfort and carries a high risk of premature labor. During the years 1980 to 1987, 36 patients with this complication were delivered in Sweden, giving an incidence of 1/20,000 births, or 1/200 twin births. In 18 patients (group A) who were treated with one or more amniotic taps, the delivery was postponed by 2 weeks, as compared with one week in 18 conservatively treated patients (group B). The peri- and neonatal death rate was 47% in group A and 58% in group B. Our own experience is that amniotic taps are safe if the amniotic fluid is removed slowly under prophylactic tocolysis. It gives symptomatic relief to the mother and may postpone labor until the gestational age of the twins is more compatible with survival.

No episiotomy?!

A method is presented which with careful manipulation of the vagina around the crowning head reduces the incidence of an episiotomy or a perineal tear. Using the method described, the overall result obtained was an intact perineum in 68% of vaginal deliveries (which included forceps deliveries). An episiotomy was performed in only 7% of deliveries--all associated with the use of forceps.

Maternal considerations in the use of pelvic examinations in labour

In a randomised controlled trial involving 307 women maternal discomfort associated with a policy of rectal examinations for routine management in labour was compared with that associated with an alternative policy of using vaginal examinations. The women, irrespective of parity showed a clear preference for the vaginal examination policy: 28% in the rectal examination group compared with only 11% in the vaginal examination group described their examinations as ‘very uncomfortable’. Furthermore, there was no evidence that the vaginal examination policy was associated with an increased risk of maternal or neonatal morbidity. The continuing use of routine rectal examinations in labour should be reassessed and greater consideration given to maternal feelings.

Oral Ranitidine in Labor

Comment: These reviewers question the wisdom of prophylactic antacids or H2 blockers to all women in labor. We do not question the increased risk of the parturient to the catastrophe of pulmonary aspiration of both acid and particulate material. However the danger of particulate aspiration may be increased by the use of oral antacid in suspension and is not decreased by H2 blockers which also interfere with hepatic metabolism and slow breakdown of amide type local anesthetics.1 The vast majority of women in labor today do not require general anesthesia and need not have consciousness and upper airway reflexes sufficiently obtunded by narcotics and sedatives that prevent protection of the airway should vomiting occur. Properly administered conduction analgesia, in which hypotension and local anesthetic toxicity are avoided, do not depress the protective upper airway reflexes. In an emergency procedure requiring general anesthesia, rapid alkalinization of gastric contents is reliably achieved by oral administration of 30 ml 0.3 M sodium citrate or similar soluble antacids (e.g., Bicitra, Alka Seltzer, Gold). Why then do many insist on increasing the workload of labor floor nurses and making mothers uncomfortable by giving them unpleasant and often nauseating mixtures of particulate antacids that, if aspirated, may increase pulmonary problems.2 The administration of expensive systemic H2 blockers that have rare but potential serious side effects is also questionable. Should not the above preparations be reserved for obstetric patients undergoing elective general anesthesia or having symptoms of gastric reflux? Would it not be more prudent to invest the time and money spent on these questionable prophylactic methods in the assurance that the parturient has adequate monitoring throughout labor and delivery and in providing methods of pain relief that do not compromise the upper airway reflexes? H2 blockers may have a role in prophylaxis or treatment when elective general anesthesia is to be used, or if the patient suffers gastric reflux. In the rare incidence when emergency general anesthesia is required, the use of a soluble antacid and an H2 blocker will be effective in immediately elevating and maintaining the gastric pH above the critical level of 2.5 to 3.0. We suggest that the limited benefits derived from routine prophylactic elevation of gastric pH are more than offset by their costs in money, time, maternal discomfort, and maternal risk.

EXPERIENCES WITH LUMBAR EXTRADURAL ANALGESIA FOR CAESAREAN SECTION

The results of 324 Caesarean sections conducted under lumbar extradural block are discussed. In addition to pre-loading with fluid i.v. and the avoidance of aorto-caval compression, more recent modifications have been to administer bupivacaine in incremental doses, to be less concerned with the size of the total dose, and to provide the mother with supplementary oxygen until delivery. As a result of these modifications, the frequency of maternal discomfort and hypotension has been reduced, and the need for supplementary analgesia or a vasopressor has become a rarity. Administration of diazepam after delivery is still occasionally advisable. The technique has many advantages for both mother and infant and with a good obstetric service, few disadvantages. Prolongation of the interval between incision of the myometrium and delivery appears to be less detrimental to the infant than is the case when general anaesthesia is used.

The Effects of Prenatal and Perinatal Complications on Development at One Year of Age

35 variables descriptive of birth and obstetric complications, prematurity, maternal discomfort, and demographic status were studied for a sample of 322 infants. Factor analyses of these variables resulted in 7 major factors that were used to predict developmental status at 1 year of age for 233 of the subjects. Factors identified as "prematurity," "delivery and related variables," "ethnicity," and "complications" made significant independent contributions to Cattell DQ at 1 year. When Cattell DQs were corrected for the effects of gestational age, only delivery and related variables remained critical, confirming the importance of this factor for later development.

THE USE OF OBSTETRIC FORCEPS.

Routine episiotomy in primiparas has become an accepted procedure; use of low forceps will spare the baby considerable trauma and prevent much maternal discomfort. The vertex posterior presentation is a common indication for use of obstetric forceps. Another indication is breech presentation. Midforceps delivery has a limited place in obstetrics. High forceps delivery has been largely discarded. If the application of forceps or the rotation or delivery proves difficult, it is wise to resort to cesarean section.