Royal Maternity Hospital Research Articles

'Because of Poverty brought into Hospital: ... ' A Casenote-Based Analysis of the Changing Role of the Edinburgh Royal Maternity Hospital, 1850 1912

Although the shift from a social to a medical function which occurred in nineteenth-century general hospitals has been explored, the occurrence of such a change in maternity hospitals has not been considered. Recent analyses of such institutions have examined particular aspects only, and thus give a somewhat static picture. This paper uses analysis of patient records (themselves an under-exploited resource) to explore the changing function of the Edinburgh Royal Maternity Hospital from a provider of shelter during childbirth to the destitute to a source of skilled medical care. It concludes that, although the Hospital had adopted the outward features of a medical institution by 1890, its casebooks suggest that its purpose only decisively changed in the early twentieth century, and thus can perhaps be more appropriately linked with national anxiety regarding the health of babies and their mothers.

Improvement in the Process of Induction of Labour Using Isosorbide Mononitrate (IMN) for Cervical Ripening

Cervical ripening has been shown to reduce associated operative morbidity prior to induction of labour. Agents commonly employed for cervical ripening include prostaglandin analogues, although these are associated with several adverse effects such as abdominal pain, gastrointestinal upset and vaginal bleeding. This study examines Isosorbide mononitrate (IMN) as a cervical ripening agent, administered on an outpatient basis, in women prior to induction of labour. There is no evidence of its cost-effectiveness although it is hypothesised that, compared with placebo treatment, the use of IMN will result in a shorter inpatient stay before delivery, hence decreased costs to the health service, as well as greater maternal satisfaction. There is also evidence that IMN may eliminate fetal heart rate abnormalities compared to the placebo. Preliminary findings will be reported on in relation to a prospective economic evaluation conducted alongside a randomised controlled trial estimating the cost-effectiveness of IMN. Three hundred women scheduled for induction of labour at Princess Royal Maternity Hospital, Glasgow, will be recruited to the study. The cost differences between the two groups, the IMN and placebo groups, will be measured, valued and combined with the clinical effectiveness data from the trial. Data will be collected on the health service resources used in the treatment of each woman and infant during the period between randomisation and hospital discharge. Data will be obtained from the trial data collection forms as well as observational research to provide details of the resources and staff inputs required for the induction of labour, as well as staff time, tests, procedures, drugs and equipment entailed by complications. Current UK unit costs will be applied to each resource item to value total resource use in each arm of the trial. The economic evaluation will be conducted from a health service perspective and will take two forms; (i) an overall cost analysis and (ii) an incremental cost-effectiveness analysis, which will be expressed in several forms, for example, incremental cost per operative delivery prevented. In the absence of stochastic data for all variables, a series of multi-way sensitivity analyses will be undertaken to explore the implications of uncertainty on the base-case incremental cost-effectiveness ratios. In addition, cost-effectiveness acceptability curves will be constructed using the net benefits approach. All analyses will be performed with a microcomputer using Statistical Package for the Social Sciences (SPSS) software.

Does intrauterine growth restriction affect quality of life in adulthood?

Objective: To compare health-related quality of life in 50-year-old adults who were born at term (⩾37 to 42 weeks’ gestation) with intrauterine growth restriction (IUGR; birth weight <10th centile) and...

Food as Social Markers : A Copenhagen Hospital 1800

Food and drink service is filled with social markers. Several of these social signals for Copenhagen society are interpreted through a close analysis of extant food regulations from 1806, for employees and birthing women at the Royal Maternity Hospital in Copenhagen (Den kgl. Fodsels- og Plejestiftelse). There are many strands here, not just the times of meals, the number of warm meals, the number of dishes at each meal, the types of dishes, the variation in food and drink, but also to a high degree, the differences in the most simple of dishes, namely bread. Except for the group lowest on the social scale, the indigent women giving birth, who received the same cheap hospital food as charity recipients in the city’s hospitals, the other adults at the hospital would seem to have represented a microcosm of the city’s social groups. Wetnurses and midwifery students received a better sort of urban common food ; those who paid 3-8 rdl a week were given food similar to that eaten by the city’s middle class, whi...

Passive Trust or Active Application: Changes in the Management of Difficult Childbirth and the Edinburgh Royal Maternity Hospital, 1850–1890

The history of the medical and nursing care given to parturient women has been approached in a number of ways. Early studies largely equated it with the development of obstetric technology that occurred from the early eighteenth century onwards, focusing on its potential to save maternal and foetal life, but without examining closely the frequency and significance of its actual use. Thereafter, feminist historians re-interpreted similar evidence to stress what they regarded as the degrading and invasive aspects of such technology, especially as it related to the increasing use of chloroform anaesthesia in the latter half of the nineteenth century. Interest then moved from the technology itself, to its effects on other aspects of care in childbirth, particularly on the eighteenth-century decline of the traditional midwife and the concomitant rise of the man-midwife.

Outcomes of pregnancy complicated by thyroid disease

To perform a case note review of pregnancies complicated by thyroid dysfunction to determine management and therapeutic intervention in relation to pregnancy outcome. A retrospective case note analysis of 81 ongoing pregnancies in 70 pregnant women with a history of thyroid dysfunction over a period of 5 years at the Glasgow Royal Maternity Hospital (GRMH), Glasgow, Scotland, United Kingdom. The results of thyroid function tests and whether a change in treatment was instituted were recorded. Thyroid function was assessed by standard laboratory reference ranges for free thyroxine (FT4) and thyroid stimulating hormone (TSH) in all trimesters. Other parameters were also noted. Medication levels needed to be increased in the hypothyroid group (45%), and decreased (38%) in the hyperthyroid group. Pregnancy outcome was good in majority of cases given appropriate replacement therapy for stated reference values.

First trimester maternal blood rheology and pregnancy induced hypertension

SummaryThis study evaluates the relationship between the first trimester assessment of maternal rheology and the subsequent development of pregnancy induced hypertension. This is a prospective observational study based in the Glasgow Royal Maternity Hospital, Scotland. From an original population of 744 consecutive antenatal attendees a total of 579 women were booked at less than 14 weeks' gestation. The main study group is a further subset comprising 251 primigravid women booking with a singleton pregnancy without essential hypertension. Previously published data from a group of non-pregnant women of similar age drawn from the same local community was used for external comparison. Blood samples were collected at the booking visit, from which fibrinogen, red cell aggregation, haematocrit and plasma, whole blood, relative and corrected viscosities were recorded. Information was obtained from the case notes in retrospect starting approximately 1 year after the first patients had first been recruited into the trial. The overall outcome of the pregnancies was noted with particular reference to pregnancy induced hypertension (PIH), birth weight, antepartum haemorrhage, pre-term labour, perinatal death, condition at delivery and neonatal complication. Our results show PIH is associated with a significantly raised mean blood viscosity and fibrinogen at time of booking. All significance disappears after adjustment for smoking, diastolic blood pressure and age. Viscosity is, however, only marginally non-significant (p = 0.07). In conclusion, blood rheology, in particular blood viscosity and fibrinogen, may play a predictive role in the development of pregnancy-induced hypertension. When combined with measurement of smoking and diastolic blood pressure at booking, these measurements could be used to calculate a risk score for the development of PIH, allowing targeting of antenatal care. Further data is required.

A randomised controlled trial of morphine versus phenobarbitone for neonatal abstinence syndrome

Background: The incidence of neonatal abstinence syndrome (NAS) has increased 10-fold over the last decade in Glasgow. In the Princess Royal Maternity Hospital, it now accounts for 17% of special...

Incidence of Fas positivity and deoxyribonucleic acid double-stranded breaks in human ejaculated sperm

Objective To determine the incidence of Fas positivity and DNA double-strand breaks (DSB) as indicators of early- and late-stage apoptosis in ejaculated sperm. Design Fas positivity was assessed by flow cytometry and DSB by the neutral Comet assay. Setting Andrology Laboratory, Royal Maternity Hospital, Belfast, Northern Ireland, United Kingdom. Patient(s) and intervention(s) Forty-five infertile men undergoing infertility investigations and 10 fertile men undergoing vasectomies. Main outcome measure(s) Percentage Fas-positive cells, percentage DNA fragmentation, olive tail moment. Result(s) The apoptotic marker Fas was detected in ejaculated sperm, with a higher incidence of Fas positivity in teratozoospermic and asthenozoospermic than in normozospermic semen. No Fas positivity was observed in fertile mens' sperm. Deoxyribonucleic acid fragmentation (DSB) was greater in infertile than in fertile men's sperm and also greater in sperm in semen than in sperm prepared for assisted conception. There was an inverse relationship between DSB and both sperm concentration and motility. There was no relationship between Fas positivity and DNA damage. Conclusion(s) Fas was expressed in sperm of infertile men. In contrast, DNA fragmentation was observed in all sperm of fertile and infertile men and correlated with inadequate concentration and motility, which suggests that sperm DSB are ubiquitous and are not solely associated with apoptosis.

An audit of neonatal respiratory morbidity following elective caesarean section at term.

Studies have suggested that a reduction in neonatal respiratory morbidity may be achieved by delaying elective caesarean section until 39 weeks gestation. In 1997 staff at the Glasgow Royal Maternity Hospital were concerned at the level of neonatal respiratory morbidity following elective caesarean section. To determine the extent of neonatal respiratory morbidity following elective caesarean section at term. Then to present the findings, make recommendations and perform a repeat analysis. A retrospective analysis of all elective caesarean sections at term between October 1996 and October 1997 was performed. Labour ward, operating theatre and SCBU records were examined, followed by maternal and infant case note review. The gestational age at the time of caesarean section and any neonatal respiratory morbidity was recorded. The results were subsequently presented at a perinatal morbidity meeting and a recommendation made to delay elective sections until 39 weeks gestation. The audit was repeated between June 1999 and June 2000. The first cycle of the audit showed significantly lower rates of neonatal admissions with advancing gestation (p < 0.001). There was also a reduction in the number of infants requiring oxygen (p = 0.001), the number of infants requiring intensive care admission (p = 0.001) and ventilation (p = 0.003) with advancing gestation. In the second cycle of the audit there was a significant decrease in the number of elective caesarean sections performed prior to 39 weeks gestation (51% vs. 26%) (p < 0.0001). There were fewer neonatal admissions with respiratory morbidity between the two phases of the audit (26/292 vs. 18/327) (RR = 0.62, 95% CI 0.34-1.1). There was also a reduction in the number of infants requiring oxygen (RR = 0.5, 95% CI 0.23-1.06) the number of infants requiring intensive care admission (RR = 0.45, 95% CI 0.15-1.29) and the number of infants requiring ventilation (RR = 0.38, 95% CI 0.1-1.47). A reduction in neonatal respiratory morbidity can be achieved by delaying elective caesarean section until 39 weeks gestation.

A randomised controlled trial of admission electronic fetal monitoring in normal labour

Aim: to test the hypothesis that the use of admission Electronic Fetal Monitoring (EFM) for healthy pregnant women in spontaneous labour would result in an increase in continuous EFM when compared to women who have had no admission EFM. Design: a randomised controlled trial. Setting: the Midwives Birth Unit in Glasgow Royal Maternity Hospital, a major urban teaching hospital with approximately 5000 births per year. Participants: healthy pregnant women admitted in normal labour, deemed low risk based on the midwives’ birth unit admission criteria. Intervention: women were randomly allocated either to receive a routine 20-minute period of EFM at the time of admission (control group), or to receive no routine admission EFM (study group). Outcome measures: primary study outcomes, use of continuous EFM; and use of EFM additional to the admission test. Secondary outcomes: artificial rupture of membranes, use of fetal scalp electrode, fetal blood sample, syntocinon, epidural analgesia, number of vaginal examinations, rate of transfer to labour ward, and reason for transfer. Key findings: there was no statistically significant difference between the groups for use of continuous monitoring, but significantly more women in the control group did receive additional EFM. There was no statistically significant difference between groups for any of the interventions studied. Conclusion: the use of admission EFM did not in itself lead to a cascade of intervention. Other factors including setting of care and philosophy of caregivers may have an effect on the rate of intervention in labour.

Experience of reversal of sterilisation at Glasgow Royal Infirmary.

To review experience at the Glasgow Royal Infirmary with regard to women who underwent reversal of sterilisation, to obtain a profile of these women and to evaluate the procedure itself in terms of safety and restoration of fertility. A retrospective study based on case records from the Glasgow Royal Infirmary and from the Glasgow Royal Maternity Hospital, both of which share the same catchment area. Eighty-five women underwent reversal of sterilisation between 1 January 1994 and 31 December 1998 at the Glasgow Royal Infirmary. Follow-up at the Glasgow Royal Maternity identified 43/85 women. Patients were identified from relevant theatre log books and from records at the maternity hospital until December 2000 and their case notes reviewed. Having a new partner was responsible for 90% of requests. Median age at request for reversal was 34 years and most had been sterilised before the age of 30 years. There were few postoperative complications. Pregnancy occurred in at least 43% of women. Reversal of sterilisation is a safe and effective method of restoring fertility. The actual incidence of pregnancy after reversal is likely to be higher than the 43.5% recorded due to difficulties in achieving 100% follow-up.

Prevalence of Chlamydia trachomatis and acceptability of screening in asymptomatic women attending antenatal clinics

Antenatal genital tract infection with Chlamydia trachomatis (CT) is associated with a two to threefold risk of preterm birth. The prevalence of CT in women attending antenatal clinics is unknown. The aim of this study was to determine the prevalence of infection and acceptability of screening for CT in an asymptomatic antenatal population. Women attending antenatal clinics in Glasgow (Princess Royal Maternity Hospital) and Aberdeen (Aberdeen Royal Infirmary) were asked to provide a first void urine sample for screening for CT using the ligase chain reaction. Women were also sent a postal questionnaire which asked for their views of screening. The prevalence of CT was highest in the under-20 age group, with a percentage prevalence (95% CI) of 12.1% (8.6 – 16.7) (see Table). Neither the presence of symptoms or signs of infection nor parity were correlated significantly with the risk of CT carriage. 77% of women thought that antenatal clinics were appropriate settings for screening for CT.

Readmission with respiratory syncytial virus (RSV) infection among graduates from a neonatal intensive care unit.

We evaluated the incidence of readmission with respiratory syncytial virus (RSV) infection among the graduates of a regional Neonatal Intensive Care Unit (NICU), and characterized those who were rehospitalized. These data were used as a predictive tool to estimate the number of babies likely to suffer readmission with RSV for the year 2000 cohort. Using the published efficacies of palivizumab, the costs and benefits of protecting this cohort were assessed. Retrospective analysis of 2,507 NICU inpatient records from January 1, 1994-December 31, 1999 from the Royal Maternity Hospital, Belfast, were compared with data on positive RSV samples from 1,790 patients between January 1, 1995-December 31, 1999 from the Northern Ireland Regional Virus Laboratory. The analysis yielded 136 (7.6%) ex-NICU patients among the positive RSV samples over this 5-year period. Characteristic seasonal peaks of RSV infection with interseasonal variability were observed. Of those readmitted, 86.9% were hospitalized with RSV before their first birthday. A calculated readmission rate of 5.4% for all NICU graduates, and 6.4% for those <or=35 weeks, was found, leading to an expectation of 36 readmissions from the 668 NICU graduates in the year 2000 over the next 1-2 years, 20 of whom would be <or=35 weeks and 12 would be <or=32 weeks. A cost of pound 1.3 million would be required to protect the <or=35-week year 2000 cohort and prevent 11 readmissions. This equals pound 120,000 per admission prevented, or 28.2 patients treated to prevent 1 readmission. A readmission rate of 6.4% may differ from other studies, as it represents analysis of a greater number of RSV seasons. Using economic arguments alone, the cost of routine administration of Palivizumab to ex-NICU <or=35-week infants is prohibitive. A selective practice of immunizing those with chronic lung disease with a background of extreme prematurity over the November to March RSV season may be more cost-effective.

Breech presentation at term: morbidity and mortality according to the type of delivery at Port Royal Maternity hospital from 1993 through 1999

Objective: To compare neonatal morbidity and mortality at Port Royal Maternity between 1993 and 1999 for infants with a singleton breech presentation born after 37 weeks, according to planned mode of delivery. Study design: Retrospective study of 501 patients of whom vaginal delivery was planned in 322 (64%) or/and cesarean in 179 (36%). Results: Severe neonatal morbidity was similar in the two groups (13/322, 4.0% versus 8/179, 4.5%; P=0.82); severe trauma morbidity was not significantly higher in the “planned vaginal delivery” group (3/322, 0.9% versus 1/179, 0.06%; P=0.16); there were no long-term sequelae. Mortality was not higher when vaginal delivery was planned. Conclusion: We have not found in this series any excess of morbidity or mortality attributable to vaginal delivery of breech presentations. This work does not indicate that we should change our obstetrical practice in the light of other recently-published studies.

Competencies of midwives with single or dual qualifications at the point of registration in Scotland

Objective: to compare and contrast competencies of midwives with single or dual qualifications at the point of registration in Scotland.Design: self-completing survey using the Glasgow Royal Maternity Hospital’s Skills’ Inventory by midwives at the point of registration and by Supervisors of Midwives analysed using non-parametric statistical tests. Content analysis of semi-structured interviews with experienced midwives and Supervisors of Midwives.Setting: midwifery education and practice settings throughout Scotland.Participants: 157 midwives at the point of registration, 166 Supervisors of Midwives.Measurements: Mann–Whitney and Kruskal Wallis analysis of skills of midwives at the point of registration in prenatal, labour, post-natal, neonatal areas and extended skills areas.Findings/implications for practice: all newly qualified midwives in Scotland, regardless of their educational preparation, are capable of providing care for women and babies in normal midwifery situations. While support for the direct entry programmes has been clearly demonstrated, this is not unanimous, although as more direct entry midwives take up positions, attitudes are becoming more positive.

Birth weight and cognitive function at age 11 years: the Scottish Mental Survey 1932

AIMSTo examine the relation between birth weight and cognitive function at age 11 years, and to examine whether this relation is independent of social class.METHODSRetrospective cohort study based on birth...

An outbreak of Serratia marcescens in two neonatal intensive care units

Outbreaks of infection in neonatal intensive care units (NICUs) due to Serratia marcescens are well recognized. In some outbreaks no point source has been found, whereas in others cross-infection has been associated with contaminated ventilator equipment, disinfectants, hands and breast pumps. We report an outbreak due to S. marcescens that involved two geographically distinct NICUs. The outbreak occurred over a six week period; 17 babies were colonized, 12 at Glasgow Royal Maternity Hospital (GRMH) and five at the Queen Mothers Hospital (QMH). At GRMH three babies developed septicaemia, of whom two died. The outbreak isolates were of the same serotype and phage type and were indistinguishable on the basis of restriction fragment length polymorphism analysis. During the outbreak, two babies shown consistently to be negative on screening, were transferred between the two units. In addition, two members of medical staff attended both units. In QMH no means of cross infection was identified. However, in GRMH the outbreak strain of S. marcescens was isolated from a laryngoscope blade and a sample of expressed breast milk.

Antenatal use of enoxaparin for prevention and treatment of thromboembolism in pregnancy.

To assess the safety and efficacy of enoxaparin use for thromboprophylaxis or treatment of venous thromboembolism during pregnancy. Retrospective review of casenotes of women who received enoxaparin during pregnancy. Obstetric Medicine Unit at Glasgow Royal Maternity Hospital. Data were obtained on 57 pregnancies in 50 women over six years. Information was obtained from case records in relation to outcome measures, the presence of underlying thrombophilia and indication for anticoagulation. Incidences of venous thromboembolism, haemorrhage, thrombocytopenia, peak plasma anti-factor Xa levels and symptomatic osteoporosis. There were no thromboembolic events in the thromboprophylaxis group. There were no incidences of heparin-induced thrombocytopenia. Twenty-two women had spinal or epidural anaesthesia and no complications were encountered. There was one instance of antepartum haemorrhage following attempted amniotomy in a woman with previously unknown vasa praevia. Two women sustained postpartum haemorrhage, both secondary to vaginal lacerations, resulting in blood loss > 1,000 mL. Blood loss following caesarean section was not excessive. No instances of vertebral or hip fracture were encountered. The median peak plasma anti-factor Xa level on a dose of 40 mg once daily was 0.235 U/mL; peak plasma anti-factor Xa levels were not affected by gestational age. The use of enoxaparin in pregnancy is associated with a low incidence of complications and a dose of 40 mg once daily throughout pregnancy provides satisfactory anti-factor Xa levels and appears effective in preventing venous thromboembolism.

Comparison of the effects of two methods of cryopreservation on testicular sperm DNA

Objective: To assess the effects of two methods of freezing on testicular sperm DNA from subjects with obstructive azoospermia and to compare these with samples of fresh and freeze-thawed testicular sperm from fertile men. Design: The Comet assay was used to determine the percentage of undamaged DNA in fresh testicular sperm, testicular sperm freeze-thawed in suspension and in a biopsy sample (men with obstructive azoospermia), and in fresh and freeze-thawed testicular sperm (fertile men). Setting: The Regional Fertility Center, Royal Maternity Hospital, Belfast, Northern Ireland, United Kingdom. Patient(s): Twelve males with obstructive azoospermia (normal testicular volume and hormone profiles) and nine fertile control subjects. Intervention(s): Trucut needle testicular biopsy under local anesthetic. Main Outcome Measure(s): Measurement of the percentage of undamaged DNA in fresh and freeze-thawed testicular sperm using the Comet assay. Result(s): No significant difference was found between the percentage of undamaged DNA of fresh testicular sperm and of both types of freeze-thawed testicular sperm. There was also no significant difference between the percentage of undamaged DNA in fresh or freeze-thawed testicular sperm from controls. Control ejaculated sperm DNA was significantly more damaged than testicular sperm DNA from control men. Conclusion(s): Cryopreservation of testicular sperm does not increase baseline levels of DNA damage.