General practitioner obstetrics in Bradford.

The standard of obstetrics care by general practitioners in Bradford was assessed by reviewing the case records of all women who in 1988 were booked for delivery under their general practitioner but subsequently required transfer to consultant care. A total of 5885 women were delivered in Bradford during 1988. Of 1289 booked under their general practitioner, 637 required transfer to consultant care. In 259 cases transfer occurred during labour; only 37 of these women were visited by their general practitioner. Many of the problems that precipitated transfer were predictable and some were considered preventable: 263 of the women transferred were considered unsuitable for booking by general practitioners. The perinatal mortality among women booked under their general practitioner was 10.1/1000 and the stillbirth rate 7.8/1000. These figures are high and suggest a need for tighter controls over the qualifications and experience of doctors participating in a fully integrated system of obstetric care.     

Changing pattern in a general practitioner obstetric unit.

Over the past nine years in Watford the proportion of hospital confinements has increased and domiciliary confinements have almost ceased. The proportion of patients originally booked into the general practitioner obstetric unit and subsequently transferred to the consultant unit has increased. Most patients are transferred during pregnancy, and the numbers transferred in labour are decreasing. The proportion of GPs attending their patients for delivery is low: local practitioners appear to be prepared for the consultant unit to supervise delivery with the practitioner co-operating in antenatal and postnatal care and family planning. There seems little doubt that the success of GP units depends on the enthusiasm and interest of individual practitioners.     

Audit of 26 years of obstetrics in general practice.

To assess the feasibility and quality of general practitioner obstetrics an audit of 1223 consecutive obstetric deliveries over 26 years was carried out with standard clinical records. The perinatal mortality of 9.0 per 1000 births was significantly better than the national average of about 19.0 per 1000 for the overall period. During the audit home deliveries virtually stopped. The proportion of consultant bookings and deliveries more than doubled because of more stringent booking arrangements despite relocation of the previously isolated general practitioner unit to beneath the consultant unit. Abnormal deliveries also rose significantly. A "steady state" was achieved during the final 11 years in which 73% of women booked to be delivered by their general practitioner, 64% were admitted to the general practitioner unit, and 54% were delivered by their general practitioner. Though this is enough to sustain obstetric experience, the proportion might safely be increased.     

Home births in England and Wales, 1979: perinatal mortality according to intended place of delivery.

A survey was carried out of all 8856 births occurring at home in England and Wales in 1979. Of these births, 67% had been booked for delivery at home, 21% had been booked for delivery in hospital, 3% had not been booked, and for 9% the intended place of delivery was unknown. The perinatal mortality varied almost 50-fold according to the intended place of delivery, ranging from 4.1/1000 births in those booked for delivery at home to 196.6/1000 unbooked births. Deliveries that occurred at home but had been booked for a hospital consultant unit were associated with a perinatal mortality of 67.5/1000. Births that had been booked for delivery at home included the smallest proportion of babies of low birth weight: 2.5% weighed 2500 g or less compared with 18% of those booked for consultant units and 29% of those not booked. Within these low birthweight groups there were noticeable differences in perinatal mortality; births booked to occur at home had the lowest mortality and unbooked births had the highest. Perinatal mortality among babies who weighed more than 2500 g was generally low irrespective of the intended place of delivery; the only exception was in babies whose delivery had not been booked. In all groups perinatal mortality was considerably higher in nulliparous than parous women. Women booking a delivery at home are clearly a selected group, and some may have been transferred to hospital during labour and were thus not included in the survey. Nevertheless, these data suggest that the perinatal mortality among births booked to occur at home is low, especially for parous women.     

Perinatal mortality rates in isolated general practitioner maternity units.

OBJECTIVE--To determine the perinatal mortality rate among normally formed, singleton babies with birth weights greater than or equal to 2500 g in Bath health district based on the intended place of delivery at the time of onset of labour or at the time of diagnosis of intrauterine death. DESIGN--The numbers of live births and stillbirths were collected monthly returns from the maternity units concerned. Deaths of infants aged less than or equal to 1 week were collected in the same returns. The intended place of delivery was confirmed at the monthly perinatal mortality meeting, during which maternal and fetal factors were discussed. SETTING--A rural health district of 400,000 population where one third of all deliveries occurred in seven isolated general practitioner maternity units, 8% in the integrated general practitioner unit, and the remainder in the consultant unit. SUBJECTS--All babies of women whose deliveries were booked in the district before the onset of labour or the diagnosis of intrauterine death, excluding twins, babies with lethal congenital malformations, and those less than 2500 g. MAIN OUTCOME MEASURES--Outcome of all deliveries and parity of mothers. RESULTS--14,415 Deliveries were analysed. The perinatal mortality rate was 2.8/1000 births in the consultant unit (7950 deliveries), 4.8 in the isolated general practitioner units (5237 deliveries), and zero in the integrated general practitioner unit (1228 deliveries). Perinatal deaths attributable to asphyxia were more common in the isolated general practitioner units (1.5 per 1000) than the consultant unit (0.6 per 1000). The perinatal mortality rate among babies born to nulliparous women was 3.2/1000 births in the consultant unit and 5.7 in the isolated general practitioner units; for those born to multigravid women it was 2.4 and 4.2 respectively. CONCLUSIONS--The outcome of delivery was not influenced by parity. Both antenatal and intrapartum care were responsible for the higher perinatal mortality rate in the isolated general practitioner units. The integrated unit, which shared midwifery staff with the consultant unit, seemed to work well. Analysis by intended place of delivery at the time of onset of labour or diagnosis of intrauterine death suggested that the care given in isolated units needs to be improved, perhaps by better training of general practitioners and consultant supervision of antenatal care.     

Management of labour in an isolated rural maternity hospital.

OBJECTIVES--To evaluate the use of a maternity unit run by general practitioners and midwives, describing the outcome of labour in an unselected group of women and quantifying the contribution made by general practitioners. DESIGN--Retrospective population based review of obstetric patients who had access to an isolated rural maternity unit. SETTING--Rural area 120 km from a consultant maternity unit. SUBJECTS--997 consecutive women delivered between January 1987 and May 1991. MAIN OUTCOME MEASURES--Mode of delivery and complications by place of booking and place of delivery; need for medical intervention and transfer. RESULTS--530 women (53%) were booked for delivery in the rural unit; this group had a caesarean section rate of 3.8% and an unplanned transfer rate of 12.8% to the consultant unit in labour. Of the 462 who delivered in the low risk unit, 25 (5%) required a forceps delivery; postnatal complications requiring emergency medical support occurred in a further 33 (7%). CONCLUSIONS--Risk characterisation is possible, but medical support from general practitioners and obstetricians is required in almost a third of women at low risk for complications of delivery. Results of this study support the team approach to obstetric management but not the move towards isolated units without organised medical support.     

Evaluating perinatal mortality rates: effects of referral and case mix.

OBJECTIVE--To evaluate perinatal mortality rates as a method of auditing obstetric and neonatal care after account had been taken of transfer between hospitals during pregnancy and case mix. DESIGN--Case-control study of perinatal deaths. SETTING--Leicestershire health district. SUBJECTS--1179 singleton perinatal deaths and their selected live born controls among 114,362 singleton births to women whose place of residence was Leicestershire during 1978-87. MAIN OUTCOME MEASURE--Crude perinatal mortality rates and rates adjusted for case mix. RESULTS--An estimated 11,701 of the 28,750 women booked for delivery in general practitioner maternity units were transferred to consultant units during their pregnancy. These 11,701 women had a high perinatal mortality rate (16.8/1000 deliveries). Perinatal mortality rates by place of booking showed little difference between general practitioner units (8.8/1000) and consultant units (9.3-11.7/1000). Perinatal mortality rates by place of delivery, however, showed substantial differences between general practitioner units (3.3/1000) and consultant units (9.4-12.6/1000) because of the selective referral of high risk women from general practitioner units to consultant units. Adjustment for risk factors made little difference to the rates except when the subset of deaths due to immaturity was adjusted for birth weight. CONCLUSION--Perinatal mortality rates should be adjusted for case mix and referral patterns to get a meaningful result. Even when this is done it is difficult to compare the effectiveness of hospital units with perinatal mortality rates because of the increasingly small subset of perinatal deaths that are amenable to medical intervention.     

Outcome of pregnancies referred to a general practitioner maternity unit in a district hospital.

OBJECTIVE--To audit the outcome of pregnancies booked for confinement in a general practitioner maternity unit in a district general hospital. DESIGN--Retrospective review of case records. SETTING--General practitioner maternity unit in a district general hospital. PATIENTS--685 Women referred to a general practitioner unit in 1987. RESULTS--315 Nulliparous women and 330 multiparous women were booked for confinement; 202 women transferred to consultant care before delivery and a further 104 during labour or after delivery. Recognised risk factors, other than nulliparity, rarely predicted the need for transfer. Confinement in the general practitioner unit was associated with low intervention and good fetal outcomes. CONCLUSIONS--The general practitioner maternity unit provides a safe alternative for confinement in low risk pregnancies. High rates of transfer deny this facility to many women who desire confinement in a low technology environment.     

Induction of labour and scheduled cesarean deliveries in twin pregnancies at the Port-Royal Maternity Hospital in Paris France.

The study is a critical analysis of the decisions to induce labour or schedule cesareans in the practice of a third level referral centre, with as outcome criterion the reduction of fetal death. 783 women pregnant with twins were included from 1.1.1993 to 31.12.1998, in three groups: originally booked, referred for care during pregnancy, or transferred from another institution. The results show that an important proportion of preterm deliveries result from a medical decision to induce labour or from a scheduled cesarean in the originally booked group with even higher proportions in groups of referred and transferred women. These results are discussed in relation to fetal death rates and causes. Deaths related to fetal growth restriction were not observed in women originally booked for care. The hospital bias has been discussed. The conclusion is that decisions to minimize fetal deaths in twin pregnancies increased preterm deliveries by medical decision.     

Intended place of delivery and perinatal outcome.

Data from the "1958 Perinatal Mortality Survey" have been analysed to assess differences in stillbirth and neonatal death rates according to the arrangements made for delivery. Only women aged 20-34 delivering at term, with no pregnancy abnormalities, were selected from three groups of women (normotensive primiparae, hypertensive primiparae, and normotensive women of parity 1, 2, or 3). Despite the fact that within each group the women booked for NHS consultant units were heavily weighted with adverse factors, the death rate of their infants was no more than 70% of that found among the women booked for either domiciliary, general practitioner unit, or private consultant delivery. Care and delivery in a NHS consultant unit carries least risk of death for the infant.     

Use by general practitioners of obstetric beds in a consultant unit: a further report.

Of 1,700 women booked for delivery by general practitioner obstetricians in a consultant unit, 1,399 had uncomplicated deliveries and the co-operation between practitioner and consultant was an obvious advantage for the 257 who were transferred completely to consultant care during pregnancy, labour, or puerperium. The scheme, which started in 1964, has enabled general practitioners to continue to give complete obstetric care to their patients. The number of participating practitioners has, however, declined from 80 to 16 indicating that many preferred to concentrate on antenatal work.     

Preparation,purification, and properties of E. coli virus T2

1. A method for the preparation of 8 to 10 liter quantities of T₂ virus lysates, titering 2 to 5 x 10¹¹ infectious units per ml. has been described. 2. Procedures have been developed for the concentration and purification of virus to a high specific infectivity. No fractionation procedure of the several used succeeded in further raising the specific infectivity of these purified preparations. 3. Some of the general properties of the better preparations have been determined. They exhibited titers of 2 x 10¹⁵ infective units per gm. of material or 1.2 x 10¹⁶ per gm. of nitrogen. 4. A study of the distribution of nitrogen among the various fractions of the virus showed that about 6 per cent of the total nitrogen is soluble in 4 per cent trichloracetic acid; that the protein nitrogen is about 40 per cent of the total and the nucleic acid nitrogen is 53 per cent. At least 96 per cent of the total phosphorus is in the nucleic acid fraction. Less than 0.5 per cent quantities of lipid and PNA were found.     

General practitioner obstetrics in the Northern region in 1983.

In late 1983 a four page questionnaire on general practitioner obstetrics was sent to a 50% random sample of general practitioners in the Northern region of England; 84% responded. Half of them said that they had access to general practitioner facilities for delivery, and half of these used them. A quarter of all respondents had provided intranatal care previously but had given it up, most of them during the late 1970s. Younger general practitioners were more highly qualified in obstetrics than older ones but did not do more intranatal work. Isolated general practitioner maternity units were much more likely to be used than those that were alongside consultant units or integrated with them. Ninety per cent of respondents provided antenatal care, 77% of these at special clinics and 88% with midwives in attendance. Teamwork, however, was not well developed. Increasing general practitioner participation in obstetric care seems feasible but depends heavily on more appropriate training and intranatal facilities being provided for general practitioners in association with specialist units.     

Early age reproduction in female savanna elephants (Loxodonta africana) after severe poaching

A 10-year study revealed that after severe poaching (>93% killed) of elephants ( Loxodonta africana ) in Zambia's North Luangwa National Park (NLNP) during the 1970s and 1980s, the age of reproduction in females was greatly reduced. Fifty-eight per cent of births were delivered by females aged 8.5–14 years, an age at which elephants were reported to be sexually immature in nearby South Luangwa National Park (SLNP) before poaching. The mean age of females at first birth (AFB) (1993, 1994) was 11.3 years. Prior to poaching, the mean age AFB in SLNP was 16 years. The NLNP age structure and sex ratio were skewed, mean family unit size was reduced, and 37% of family units contained no females older than 15 years. Twenty-eight per cent of family units were comprised entirely of a single mother and her calf, and 8% of units consisted only of orphans who would have been considered sexually immature prior to poaching. Only 6% of survivors were older than 20 years, the age at which females in little-poached populations generally become most reproductively active. After a community-based conservation programme and the UN-CITES ban on the ivory trade were introduced, no elephants were recorded killed. In spite of a high reproductive rate, 6 years after poaching decreased, the density of the NLNP population had not increased, supporting predictions that the removal of older matriarchs from family units will have serious consequences on the recovery of this species.     

Prospective regional study of planned home births. Home Birth Study Steering Group.

OBJECTIVE: To collect data from a cohort of women requesting a home birth and examine the experience and outcome of pregnancy, the indications for hospital transfer, and the attitudes of mothers, midwives, and general practitioners. DESIGN: Follow up study with anonymised postal questionnaires. SETTING: Northern Regional Health Authority area. SUBJECTS: The 256 women resident in the Northern region who expected to deliver in 1993 and whose request for a home birth became known to one of the local supervisors of midwives. Limited cross validating information was also collected retrospectively on all other women delivering a baby outside hospital in 1993. MAIN OUTCOME MEASURES: Rate of and reason for transferred care; maternal, midwifery, and general practitioner views; perinatal outcome. RESULTS: Five women miscarried, leaving 251 in the study. Of these, 142 (57%) delivered at home. There were 17 (7%) caesarean sections but no perinatal deaths. General practitioners had reservations about half of the booking requests. Two thirds of the women thought they had not been offered any option about place of birth, 74 (29%) were referred to hospital for delivery before the onset of labour, and 35 (14%) were referred to hospital during labour. Intrapartum transfers were uneventful, and half the mothers commented spontaneously that they valued having spent even part of their labour at home. CONCLUSIONS: Home birth is valued for its family setting. General practitioners'' support is sought and influential but uncommon, possibly because of a lack of understanding of the responsibilities of the midwife and general practitioner.     

The results and characteristics of the mupirocin (Bactroban) sanative treatment of intranasal Staphylococcus carriers in a large hospital]

The action of mupirocin as a nasal ointment (Bactroban) was studied on intranasal carriers of the hospital staphylococcal strains. The study included 37 medical workers from different and mainly problem units of the large general hospital. The tolerability of the ointment was good. After the Bactroban use no complications of the patients were recorded. The efficacy of Bacroban by the microbiological criteria in total amounted to 100 per cent. The eradication of methicillin resistant Staphylococcus aureus (MRSA) was observed in 93 per cent of the cases. A decrease of the level of the nasal passages dissemination by MRSA and methicillin resistant coagulase-negative staphylococci (MRSC) up to such low titers as 100 and 90 per cent was stated. No difference in the action of Bactroban on MRSA, MSSA and MRSC was noted. The bacteriological monitoring for 3 to 4 months revealed a change of the staphylococcal strains in 94 per cent of the cases, recolonization by the same staphylococcal strain in 19 per cent, recolonization by some another staphylococcal strains in 33 per cent and no recolonization in 14 per cent. A stable decrease of staphylococcal strains was possible with simultaneous Bactroban sanitation of all the bacterial carriers of the hospital or its isolated unit.     

Midwife managed delivery unit: a randomised controlled comparison with consultant led care.

OBJECTIVE--To examine whether intrapartum care and delivery of low risk women in a midwife managed delivery unit differs from that in a consultant led labour ward. DESIGN--Pragmatic randomised controlled trial. Subjects were randomised in a 2:1 ratio between the midwives unit and the labour ward. SETTING--Aberdeen Maternity Hospital, Grampian. SUBJECTS--2844 low risk women, as defined by existing booking criteria for general practitioner units in Grampian. 1900 women were randomised to the midwives unit and 944 to the labour ward. MAIN OUTCOME MEASURES--Maternal and perinatal morbidity. RESULTS--Of the women randomised to the midwives unit, 647 (34%) were transferred to the labour ward antepartum, 303 (16%) were transferred intrapartum, and 80 (4%) were lost to follow up. 870 women (46%) were delivered in the midwives unit. Primigravid women (255/596, 43%) were significantly more likely to be transferred intrapartum than multi-gravid women (48/577, 8%). Significant differences between the midwives unit and labour ward were found in monitoring, fetal distress, analgesia, mobility, and use of episiotomy. There were no significant differences in mode of delivery or fetal outcome. CONCLUSIONS--Midwife managed intrapartum care for low risk women results in more mobility and less intervention with no increase in neonatal morbidity. However, the high rate of transfer shows that antenatal criteria are unable to determine who will remain at low risk throughout pregnancy and labour.     

Distribution of Coliphages in Hong Kong Sewage

Coliphage content of sewage collected from 11 different localities in Hong Kong was determined. The number of plaque-forming units (PFU) ranged from 0.036 x 10(3) to 15.9 x 10(3) per ml. In general, urban sewage tended to be richer than rural sewage both in PFU count as well as plaque morphological variation. Seventy-seven isolates were subjected to a host range study. Fifty per cent of these were able to grow on Escherichia coli K-12 as well as E. coli B. Approximately 32% were found to be male specific, and the remaining 18% were K-12 specific although sex-indifferent.     

INFLUENZA VACCINE,ASIAN STRAIN—Reactions Following Its Use in Adults

A study of reactions following influenza vaccine inoculation of 327 employees of Peralta Hospital, 55 men and 272 women, showed a very low value for significant or severe reactions. The reaction rate as observed with the present monovalent vaccine containing 200 CCA units of Asian strain, Type A influenza virus, was considerably lower than that reported with previous polyvalent vaccines containing up to 1,400 or 1,500 CCA units of total virus content.The absenteeism rate was 1.1 per cent for women, nil for men.The incidence of reactions was much greater in women than in men. Local reactions such as pain, swelling, or redness at the site of injection occurred in 29.1 per cent of men and 35.7 per cent of women. The incidence of systemic reactions—fever, aching, chilliness, headache, nausea and vomiting—was 3.6 per cent in men and 8.8 per cent in women. About 9 per cent of men and 30 per cent of women had both local and systemic reaction. Some 58 per cent of men and 25 per cent of women had no reaction.The greater majority of reactions appeared within five hours after inoculation with influenza vaccine.In adults the prevention of anaphylactic reactions due to the small amount of egg protein in influenza vaccine, can be accomplished by screening for history of hypersensitivity to egg, chicken or chicken feather. In questionable cases, intradermal testing can be done.The reaction rate observed in this study for the present influenza vaccine was so low that it ought not deter immunization.     

Pollination intensity and potential seed set in Passiflora vitifolia

Summary Initial seed set and fruit set were pollen-limited in a Costa Rican population of Passiflora vitifolia, a self-incompatible species with 200–350 ovules per flower. Pollination intensity was measured by counting the number of allogamous pollen grains on stigmas of the large one-day flowers. Hand-pollinations demonstrated that 25–50 pollen grains are required for fruit set, and >450 are needed for maximum seed set, with a pollen:seed ratio of about 1.6:1.0. Hummingbirds (Phaethornis superciliosus) delivered sufficient allogamous pollen for maximum seed set to only 28% of the flowers examined. Naturally pollinated flowers yielded fewer fruits and fewer seeds per fruit than those pollinated by hand. Most pollen transferred by humming-birds was self-incompatible; emasculated flowers yielded higher seed set than flowers with intact anthers. Visitation rates did not provide a good index of effective pollination.There were significant differences in ovule number, maximum seed set, and maximum per cent seed set among individual vines. More than half of an individual's flowers failed to set fruit, whether pollinated by birds or by hand. In this population, maximum reproductive potential may be limited by maternal resources for fruit development, but seed set varies with pollination intensity. Pollen-limited seed set may be a disadvantage of self-incompatibility, especially in species with many-seeded fruits.