Continuous fetal monitoring in the ambulant patient in labour.

Fetal heart rate was monitored continuously in 30 ambulant women in labour by radiotelemetry. The procedure was practicable and, since contractions were less uncomfortable with the patient standing or walking about, reduced the need for analgesia. It also resulted in a more natural labour. Use of the procedure may lessen the risk of thromboembolism.     

Effects of naloxone on pethidine-induced neonatal depression. Part I--Intravenous naloxone.

Infants whose mothers had had pethidine during labour were given either naloxone 40 microgram or isotonic saline administered intravenously double-blind within one minute of birth. Peak alveolar carbon dioxide tension, carbon dioxide excretion, alveolar ventilation, feeding behaviour, and habituation to a specific sound stimulus were measured regularly up to 48 hours after birth. Alveolar carbon dioxide tension was significantly lower and alveolar ventilation significantly higher half an hour after birth in the naloxone-treated group than in the saline-treated group, but these differences between the groups were not significant at any other time, and there were no significant differences in sucking frequency or pressure, milk consumption, or habituation to the auditory stimulus.     

Comparison of the antiemetics metoclopramide and promethazine in labour.

A double blind trial was conducted in 477 mothers in labour to compare the antiemetics metoclopramide 10 mg and promethazine 25 mg and placebo when added to the first dose of pethidine. Metoclopramide and promethazine were equally effective, and both better than placebo, in reducing the incidence of nausea and vomiting after the administration of pethidine. Seventy seven per cent of mothers were drowsy, and 8% slept in the hour after the pethidine injection, with no difference between the groups. The sedative effect was more persistent in the promethazine group, 66% of whom were still drowsy after delivery. One third of the mothers in each group needed further analgesia, with 77% of these ultimately requesting an epidural. The reduction in pain half an hour and one hour after pethidine, assessed by a visual analogue scale, were, respectively, 22% and 22% for placebo; 26% and 23% for metoclopramide; 13% and 9% for promethazine. Analgesia after metoclopramide was significantly better than that after promethazine in terms of pain score, duration of first injection, and need for Entonox. Metoclopramide is therefore to be preferred to promethazine as an antiemetic in labour.     

COOK双球囊导管在足月妊娠引产中的临床研究

目的:探讨宫颈双球囊导管在足月妊娠促宫颈成熟及引产中的有效性和安全性。方法:回顾性选择符合有引产指征、单胎头位、宫颈评分6分的100例足月妊娠孕妇进行分析,其中51例采用COOK双球囊导管引产者为COOK组,49例采用小剂量缩宫素引产者为对照组,比较分析两组宫颈成熟度、引产效果、分娩方式、分娩结局、产后出血、新生儿窒息等情况。结果:100例孕妇引产指征主要是延期(过期)妊娠、羊水过少、妊娠期高血压、妊娠期糖尿病、妊娠合并甲减等。COOK组51例促宫颈成熟有效49例(96.08%),对照组有效16例(32.65%),COOK组促宫颈成熟有效率显著高于对照组,差异有统计学意义(P0.05)。COOK组诱发临产时间明显少于对照组,两组差异有统计学意义(P0.05)。COOK组阴道分娩41例(80.39%),剖宫产10例(19.61%);对照组阴道分娩20例(40.82%),剖宫产29例(59.18%),COOK组阴道分娩率明显高于对照组,剖宫产率明显低于对照组,两组差异均有统计学意义(P0.05)。两组之间的总产程、羊水污染率、新生儿窒息率、产后出血率等围产结局无显著差异(P0.05);COOK组引产过程中出现不良反应6例(11.76%),对照组5例(10.20%),两组无显著差异(P0.05)。结论:COOK双球囊导管促宫颈成熟及引产效果明显优于缩宫素,且不增加不良反应的发生,由于操作简单,有效性和安全性高,值得国内临床推广。     

Effectiveness of pain relief in labour: survey of 1000 mothers

The amount of pain that had been experienced by 1000 women during vaginal delivery of a live child was determined by interview within 48 hours of delivery. Patients had been offered a choice of analgesia, and 536 had received epidural analgesia: pain relief was greatest in this group, just over half having had a painless labour. The duration of pain was also reduced by a third in this group even though patients who had received an epidural block had tended to have longer labour and an incidence of assisted delivery of 51% compared with 6% in the remainder. Seventy-two per cent of the patients receiving an epidural had had as much pain as they had expected. A similar proportion (70%) was reported with simpler analgesic methods, suggesting that women may expect a certain amount of pain in labour and request further analgesic treatment when this is exceeded.     

Prolonged pregnancy: the management debate.

A prospective trial was conducted to compare the effects of conservative management of prolonged pregnancy (conservative group) with routine induction of labour at 42 weeks'' gestation (active group) in otherwise uncomplicated pregnancies. Of the 402 pregnancies studied, 207 (51%) were allocated to conservative management and 195 (49%) were allocated to have labour induced. The groups were well matched for age, parity, and smoking habits. One hundred and sixty six (80%) of the patients in the conservative group went into spontaneous labour. Of the remainder, two underwent elective caesarean section, 19 had labour induced because of clinical concern, and the remaining 20 had labour induced at the patient''s own request. One hundred and twenty five (64%) of the patients in the planned active group underwent induction of labour. Of the remaining 70, 49 went into spontaneous labour and 21 (11%) asked that they should not have labour induced. Comparison of the two groups showed no difference in the length of the first stage of labour but a trend towards an increased need for intervention for fetal distress (p less than 0.06) in the active group. There were no differences in the length of the second stage, the need for intervention, or the mode of delivery. In terms of Apgar scores the neonatal outcome was not significantly different between the two groups, but a greater proportion of the babies (15% v 8%) in the active group required intubation. Umbilical cord venous pH estimated in the last 183 consecutive deliveries in the study showed a significantly lower mean value in the active group (p less than 0.05). There was no difference in birth weight between the two groups. Two deaths occurred in the study. There was a stillbirth in the conservative group at 292 days after massive abruption, and one neonatal death in the active group owing to multiple congenital abnormalities. The outcome for mother and baby in patients from both groups who went into spontaneous labour was generally good. The outcome for patients for whom conservative management was planned but induction became necessary was no different from that of patients who underwent planned induction at term. Thus from our results we can find no evidence to support the view that women with normal prolonged pregnancy should undergo routine induction of labour at 42 weeks'' gestation.     

Daytime rest behavior of the Welsh pony (Equus caballus) mare and foal

Upright and recumbent rest of 15 Welsh pony foals and their mothers was studied over a 2 year period. During their first week of life, the foals spent 32% of the time in recumbent rest. Subsequently, the percentage of time spent in recumbent rest decreased, but was still greater than for the foal's mother by Week 21, when the foals spent 6.5% of their time in recumbent rest. Adults spent little time in recumbent rest. Foals rested upright only 3.5% of the time during their first week of life. Mares rested upright more than foals did to Week 13, at which time peak values for time spent in upright rest occurred for both mares (32.5%) and foals (23%). Subsequently, mares and foals spent equal, but decreasing, amounts of time resting upright. The total time spent resting by the foals decreased gradually, and was characterized by a transition from recumbent rest to upright rest. Foals were more likely to be resting, either recumbent or upright, if their mother was resting upright. During the late spring, summer, and early autumn, mares and foals were most likely to be resting upright between 09:00 and 17:00 h.     

Comparative study of a two dose schedule of PGE2 3 mg pessary and 1700 micrograms film for induction of labour in nulliparae with poor cervical score

Efficacy of a two dose schedule of 3 mg pessary or 1700 micrograms film of PGE2 for induction of labour was compared in nulliparae with poor cervical score. Patient characteristics in the two groups (43 in 3 mg and 40 in 1700 micrograms group) were comparable in age, period of gestation, indications for induction of labour and in their initial cervical score. The number of patients who started labour with a two dose schedule 4 hours apart were similar in each group. The improvement of cervical score, length of labour, mode of delivery and the neonatal outcome were not different in the two groups. There was no advantage of using a film preparation over that in the form of a pessary and the use of 3 mg dose did not give significantly better results compared with the 1700 micrograms dose, in terms of obstetric or neonatal outcome.     

Progesterone and oestradiol levels and cytoplasmic receptor concentrations in the human myometrium at term, before labour and during labour

Progesterone (P) and oestradiol (E2) cytoplasmic receptor levels in the myometrium of 12 women, who underwent cesarean section at term were determined by means of an exchange assay. Six of the women had an elective cesarean section, and the other six were in active labour when the operation was performed. Both the P and the E2 receptor concentrations were significantly higher in the myometrium of those women who were in labour. The plasma P and E2 levels did not change before labour and during labour. The myometrial E2 concentrations were also similar in both groups. The myometrial P concentration was lower in the labour group, but the difference was not statistically significant. This study is the first which compares the steroid receptor levels at term before labour and during labour in human myometrium, although only the unbound and the cytosol receptor levels were determined. The change of levels in receptor concentrations could be a sign of the decrease of the P dominance in the myometrium during labour.     

Generation of recombinant Orf virus using an enhanced green fluorescent protein reporter gene as a selectable marker

Background

The purpose of this study was to compare the effects of 0.5 fraction of inspired oxygen (FiO₂) and >0.95 FiO₂ on pulmonary gas exchange, shunt fraction and oxygen delivery (DO₂) in dorsally recumbent horses during inhalant anesthesia. The use of 0.5 FiO₂ has the potential to reduce absorption atelectasis (compared to maximal FiO₂) and augment alveolar oxygen (O₂) tensions (compared to ambient air) thereby improving gas exchange and DO₂. Our hypothesis was that 0.5 FiO₂ would reduce ventilation-perfusion mismatching and increase the fraction of pulmonary blood flow that is oxygenated, thus improving arterial oxygen content and DO₂.

Results

Arterial partial pressures of O₂ were significantly higher than preanesthetic levels at all times during anesthesia in the >0.95 FiO₂ group. Arterial partial pressures of O₂ did not change from preanesthetic levels in the 0.5 FiO₂ group but were significantly lower than in the >0.95 FiO₂ group from 15 to 90 min of anesthesia. Alveolar to arterial O₂ tension difference was increased significantly in both groups during anesthesia compared to preanesthetic values. The alveolar to arterial O₂ tension difference was significantly higher at all times in the >0.95 FiO₂ group compared to the 0.5 FiO₂ group. Oxygen delivery did not change from preanesthetic values in either group during anesthesia but was significantly lower than preanesthetic values 10 min after anesthesia in the 0.5 FiO₂ group. Shunt fraction increased in both groups during anesthesia attaining statistical significance at varying times. Shunt fraction was significantly increased in both groups 10 min after anesthesia but was not different between groups. Alveolar dead space ventilation increased after 3 hr of anesthesia in both groups.

Conclusions

Reducing FiO₂ did not change alveolar dead space ventilation or shunt fraction in dorsally recumbent, mechanically ventilated horses during 3 hr of isoflurane anesthesia. Reducing FiO₂ in dorsally recumbent isoflurane anesthetized horses does not improve oxygenation or oxygen delivery.     

The influence of women’s attachment style on the chronobiology of labour pain,analgesic consumption and pharmacological effect

Circadian variation in biological rhythms has been identified as affecting both labour pain and the pharmacological properties of analgesics. In the context of pain, there is also a growing body of evidence suggesting the importance of adult attachment. The purpose of this study was to examine whether labour pain, analgesic consumption and pharmacological effect are significantly affected by the time of day and to analyse whether this circadian variation is influenced by women’s attachment style. This prospective observational study included a sample of 81 pregnant women receiving patient-controlled epidural analgesia (PCEA). Attachment was assessed with the Adult Attachment Scale – Revised. The perceived intensity of labour pain in the early stage of labour (3?cm of cervical dilatation and before the administration of PCEA) was measured using a visual analogue scale (VAS). Pain was also indirectly assessed by measuring the consumption of anaesthetics. The latency period and the duration of effect were recorded for a chronopharmacology characterisation. Pain, as assessed with the VAS, was significantly higher in the night-time group than in the daytime group. An insecure attachment style was significantly associated with greater labour pain at 3?cm of cervical dilatation (p?<?0.001) and before the beginning of analgesia (p?<?0.001) as well as with higher analgesic consumption and lower pharmacological efficacy (p?<?0.05). The time of day was significantly associated with the pharmacological effect: the latency period was longer at night, and the duration of the pharmacological effect was longer during the daytime. The interaction between time of day and attachment style was not significant for any of the study variables. Our results provide evidence of the importance of circadian variation in studying labour pain and the pharmacological effect of labour analgesia involving epidural blockage with a PCEA regimen. Moreover, although there was no evidence that attachment style influenced the circadian variation, these data emphasise that insecure attachment patterns are a risk factor for greater labour pain and analgesic consumption, which should be considered in pain management approaches.     

Influence of Digitalis on Time of Onset and Duration of Labour in Women with Cardiac Disease

A comparison was made of the time of onset and duration of labour in 22 women taking digitalis and in 64 women who were not. Spontaneous labour occurred more than one week earlier and lasted about half as long in the patients taking digitalis. The likely explanation for this difference is that digitalis has a direct action on the myometrium.     

Neonatal Jaundice and Maternal Oxytocin Infusion

A prospective study of 78 neonates provides evidence for an association between maternal oxytocin infusion and neonatal jaundice. On the second and fifth days infants of mothers whose labour had been induced by amniotomy followed immediately by intravenous oxytocin (group C) had mean total bilirubin levels significantly higher (P <0·05) than did infants whose mothers had had a spontaneous onset of labour and did not require oxytocin (group A). Bilirubin levels in infants of mothers whose onset of labour was spontaneous but required oxytocin to accelerate progress (group B) did not differ significantly from group A.Though these findings suggest a dose dependent effect of oxytocin, other possible explanations are suggested which take into account other drugs administered to the mother and also differences in the corticosteroid status of the groups of infants.     

Effect of nifedipine and propranolol on blood flow,venous compliance and blood pressure in essential hypertension

To determine the efficacy of nifedipine combined with propranolol in the treatment of hypertension, 23 patients with essential hypertension uncontrolled while they were receiving propranolol, 120 mg/d, entered a dose response trial of four 8-week periods while continuing propranolol therapy. Therapy during the four periods consisted respectively of a placebo, 30 mg/d of nifedipine, 30 or 60 mg/d of nifedipine, and 30 or 60 mg/d of nifedipine along with only 60 mg/d of propranolol. Studies of forearm blood flow and venous compliance were carried out in nine of the patients. Ten patients dropped out after the first period. The mean blood pressures while the patients were recumbent after the first, second and third periods were 163 ± 17/100 ± 6, 147 ± 13/89 ± 10 and 141 ± 19/84 ± 10 mm Hg respectively. There was no evidence of tolerance in the four patients who received 30 mg/d of nifedipine during the third period. There was a significant dose-diastolic pressure response (p < 0.0006) without a change in heart rate in the eight who received 60 mg/d of nifedipine during this period. After 16 weeks of therapy with nifedipine 11 patients had a diastolic pressure less than 90 mm Hg while recumbent. While mean blood pressure and heart rate for the group were not significantly increased at the end of the fourth period, in three of the patients the diastolic pressure while recumbent increased to over 90 mm Hg. This suggests that 120 mg/d of propranolol is the minimum dose required for concomitant therapy. Adverse symptoms were mild and transient. Forearm plethysmography showed that nifedipine induced arteriolar but not venous dilation and that propranolol attenuated the vasodilator effect of nifedipine. The author concludes that nifedipine was safe and effective in combination with propranolol in this group of patients with essential hypertension.     

Attitude and preferences of nigerian antenatal women to social support during labour

SummaryThis was a hospital-based cross-sectional study of 224 randomly selected antenatal women receiving care at the University College Hospital, Ibadan, Nigeria. The study aimed to seek the attitude and preferences of respondents about social support during childbirth and also identify variables that may influence their decisions. Seventy-five per cent of respondents desired companionship in labour. Approximately 86% preferred their husband as companion while 7% and 5% wanted their mother and siblings as support person respectively. Reasons for their desire for social support were emotional (80.2%), spiritual (17.9%), errands (8.6%) and physical activity (6.8%). Socio-demographic variables found to be statistically significant on logistic regression analysis for the desire of a companion in labour were nulliparity (OR 3.57, 95% CI 1.49-8.52), professionals (OR 3.11, 95% CI 1.22-7.94) and women of other ethnic groups besides Yoruba (OR 2.90, 95% CI 1.02-8.26), which is the predominant ethnic group in the study area. Only those with post-secondary education were found to want their husbands as doula (OR 2.96, 95% CI 1.08-8.11). More than half of the respondents wanted information about labour prior to their experience. It is important that Nigerian women are allowed the benefit of social support during childbirth, particularly as there is a lack of one-to-one nursing care and other critical services, including epidural analgesia in labour, at many of the health care facilities in Nigeria. Men could play a pivotal role in the process of introducing support in labour so as to improve the outcome for both the mother and her newborn.     

The Bristol third stage trial: active versus physiological management of third stage of labour.

OBJECTIVE--To compare the effects on fetal and maternal morbidity of routine active management of third stage of labour and expectant (physiological) management, in particular to determine whether active management reduced incidence of postpartum haemorrhage. DESIGN--Randomised trial of active versus physiological management. Women entered trial on admission to labour ward with allocation revealed just before vaginal delivery. Five months into trial high rate of postpartum haemorrhage in physiological group (16.5% v 3.8%) prompted modification of protocol to exclude more women and allow those allocated to physiological group who needed some active management to be switched to fully active management. Sample size of 3900 was planned, but even after protocol modification a planned interim analysis after first 1500 deliveries showed continuing high postpartum haemorrhage rate in physiological group and study was stopped. SETTING--Maternity hospital. PARTICIPANTS--Of 4709 women delivered from 1 January 1986 to 31 January 1987, 1695 were admitted to trial and allocated randomly to physiological (849) or active (846) management. Reasons for exclusion were: refusal, antepartum haemorrhage, cardiac disease, breech presentation, multiple pregnancy, intrauterine death, and, after May 1986, ritodrine given two hours before delivery, anticoagulant treatment, and any condition needing a particular management of third stage. INTERVENTIONS--All but six women allocated to active management actually received it, having prophylactic oxytocic, cord clamping before placental delivery, and cord traction; whereas just under half those allocated to physiological management achieved it. A fifth of physiological group received prophylactic oxytocic, two fifths underwent cord traction and just over half clamping of the cord before placental delivery. ENDPOINT--Reduction in incidence of postpartum haemorrhage from 7.5% under physiological management to 5.0% under active management. MEASUREMENTS AND MAIN RESULTS--Incidence of postpartum haemorrhage was 5.9% in active management group and 17.9% in physiological group (odds ratio 3.13; 95% confidence interval 2.3 to 4.2), a contrast reflected in other indices of blood loss. In physiological group third stage was longer (median 15 min v 5 min) and more women needed therapeutic oxytocics (29.7% v 6.4%). Apgar scores at one and five minutes and incidence of neonatal respiratory problems were not significantly different between groups. Babies in physiological group weighed mean of 85 g more than those in active group. When women allocated to and receiving active management (840) were compared with those who actually received physiological management (403) active management still produced lower rate of postpartum haemorrhage (odds ratio 2.4;95% CI1.6 to 3.7). CONCLUSIONS--Policy of active management practised in this trial reduces incidence of postpartum haemorrhage, shortens third stage, and results in reduced neonatal packed cell volume.     

Molecular genetic evidence of clinical heterogeneity in Fukuyama-type congenital muscular dystrophy

Fukuyama-type congenital muscular dystrophy (FCMD) is an autosomal recessive severe muscular dystrophy associated with brain malformation. The gene responsible for FCMD was mapped to chromosome 9q31, a region in which convincing evidence of strong linkage disequilibrium between FCMD and mfd220 (D9S306) was recently found. FCMD is also characterized clinically by a peak motor function which, at best, allows patients to sit unassisted or slide on the buttocks. However, a small fraction of patients acquire the capacity to walk unassisted. Whether such ambulant cases belong to the FCMD spectrum or to a different disease entity has been a topic of considerable debate. We performed linkage analysis for ten families with ambulant cases using DNA markers flanking the FCMD locus. The mfd220 locus yielded a significant lod score of 3.09 for ambulant FCMD. We also found evidence for linkage disequilibrium between ambulant FCMD and mfd220. We further conducted haplotype analysis in FCMD siblings with different phenotypes, one of whom was ambulant while the other was not. The results indicate that the FCMD siblings share exactly the same haplotype at nine marker loci spanning 23.3 cM surrounding the FCMD locus. On the basis of these results, we conclude that, genetically, ambulant cases are, in fact, part of the FCMD spectrum. Received: 28 June 1996     

Respiratory, circulatory and neuropsychological responses to acute hypoxia in acclimatized and non-acclimatized subjects

Respiratory, circulatory and neuropsychological responses to stepwise, acute exposure at rest to simulated altitude (6,000 m) were compared in ten acclimatized recumbent mountaineers 24 days, SD 11 after descending from Himalayan altitudes of at least 4,000 m with those found in ten non-acclimatized recumbent volunteers. The results showed that hypoxic hyperpnoea and O2 consumption at high altitudes were significantly lower in the mountaineers, their alveolar gases being, however, similar to those of the control group. In the acclimatized subjects the activation of the cardiovascular system was less marked, systolic blood pressure, pulse pressure, heart rate and thus (calculated) cardiac output being always lower than in the controls; diastolic blood pressure and peripheral vascular resistance, however, were maintained throughout in contrast to the vasomotor depression induced by central hypoxia which occurred in the non-acclimatized subjects at and above 4,000 m [alveolar partial pressure of O2 less than 55-50 mmHg (7.3-6.6 kPa)]. It was concluded that in the acclimatized subjects at high altitude arterial vasodilatation and neurobehavioural impairment, which in the non-acclimatized subjects reflect hypoxia of the central nervous system, were prevented; that acclimatization to high altitude resulted in a significant improvement of respiratory efficiency and cardiac economy, and that maintaining diastolic blood pressure (arterial resistance) at and above 4,000 m may represent a useful criterion for assessing hypoxia acclimatization.     

Cervical ripening with intravaginal prostaglandin E2 gel.

We describe a technique of administering prostaglandin E2 (PGE2) in a viscous cellulose gel into the vagina to ripen the unfavourable cervix in patients requiring induction of labour. A total of 168 primigravidae were studied, of whom 102 received 2 mg PGE2 in 2% gel and 66 received 5 mg PGE2 in 4% gel. In the latter group, the state of the cervix was significantly improved in 58 patients (87.9%), while 32 (48.5%) had started labour before planned induction. There were no maternal or fetal side effects or complications.     

Functional roles of the leg muscles when pedaling in the recumbent versus the upright position

An understanding of the coordination of the leg muscles in recumbent pedaling would be useful to the design of rehabilitative pedaling exercises. The objectives of this work were to (i) determine whether patterns of muscle activity while pedaling in the recumbent and upright positions are similar when the different orientation in the gravity field is considered, (ii) compare the functional roles of the leg muscles while pedaling in the recumbent position to the upright position to the upright position and (iii) determine whether leg muscle onset and offset timing for recumbent and upright pedaling respond similarly to changes in pedaling rate. To fulfill these objectives, surface electromyograms were recorded from 10 muscles of 15 subjects who pedaled in both the recumbent and upright positions at 75, 90, and 105 rpm and at a constant workrate of 250 W. Patterns of muscle activation were compared over the crank cycle. Functional roles of muscles in recumbent and upright pedaling were compared using the percent of integrated activation in crank cycle regions determined previously for upright pedaling. Muscle onset and offset timing were also compared. When the crank cycle was adjusted for orientation in the gravity field, the activation patterns for the two positions were similar. Functional roles of the muscles in the two positions were similar as well. In recumbent pedaling, the uniarticular hip and knee extensors functioned primarily to produce power during the extension region of the crank cycle, whereas the biarticular muscles crossing the hip and knee functioned to propel the leg through the transition regions of the crank cycle. The adaptations of the muscles to changes in pedaling rate were also similar for the two body positions with the uniarticular power producing muscles of the hip and knee advancing their activity to earlier in the crank cycle as the pedaling rate increased. This information on the functional roles of the leg muscles provides a basis by which to form functional groups, such as power-producing muscles and transition muscles, to aid in the development of rehabilitative pedaling exercises and recumbent pedaling simulations to further our understanding of task-dependent muscle coordination.