Experience with fetal monitoring in a university teaching hospital.

Fetal monitoring during labour may be expected to decrease perinatal losses and the number of infants born with brain damage. In a prospective study of intrapartum fetal monitoring in selected high-risk pregnancies in a Winnipeg hospital the monitoring rate was 26.5% and the cesarean section rate in the monitored group was 22.0%. The fetal outcome in the monitored group was better than in the unmonitored group. The establishment of a fetal intensive care unit is believed to be strongly desirable in improving fetal surveillance during labour. Fetal monitors should be stationed in the delivery room as well as in the first-stage room.     

Referral of mothers and infants for intensive care.

During 1975-7, 96 mothers were referred to University College Hospital for delivery from 39 other hospitals because their pregnancies were considered to be at very high risk. One hundred of the 111 infants born to the 96 mothers weighed 2500 g or less and 60 weighed 1500 g or less. A high proportion of the infants developed serious illnesses necessitating intensive care. The birth-weight-specific neonatal mortality rates of the infants were much lower than those of infants born in England and Wales as a whole and were also lower than those of the 370 infants transported to this hospital for intensive care after delivery elsewhere. Whenever possible mothers with very high-risk pregnancies should be referred for delivery to centres with full facilities for the intensive care of the mother, fetus, and newborn infant.     

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.     

Antepartum fetal heart rate recording and subsequent fast transmission by a distributed microprocessor-based dedicated system

Fetal heart rate monitoring in high-risk pregnancies can require admission to hospital over prolonged periods, or the even less satisfactory alternative of routine weekly or sporadic outpatient monitoring. We have developed a digital system for distant fetal heart rate recording with the facility of later rapid transmission by telephone in the hospital. A completed half-hour recording is transmitted to the central computer and permanently stored in less than 30 s, then immediately displayed for verbal reporting. One hundred and seventeen recordings have been made in 27 patients' home and of these 111 (95%) were easy to interpret. This expandable system meets the major functional requirements for practical and ecomonical antental fetal heart rate monitoring at a distance.     

The Effects of Food Limitation on Life History Tradeoffs in Pregnant Male Gulf Pipefish

Syngnathid fishes (pipefishes, seahorses and seadragons) are characterized by a unique mode of paternal care in which embryos develop on or in the male’s body, often within a structure known as a brood pouch. Evidence suggests that this pouch plays a role in mediating postcopulatory sexual selection and that males have some control over the events occurring within the pouch during the pregnancy. These observations lead to the prediction that males should invest differently in broods depending on the availability of food. Here, we use the Gulf pipefish to test this prediction by monitoring growth rate and offspring survivorship during the pregnancies of males under low- or high-food conditions. Our results show that pregnant males grow less rapidly on average than non-pregnant males, and pregnant males under low-food conditions grow less than pregnant males under high-food conditions. Offspring survivorship, on the other hand, does not differ between food treatments, suggesting that male Gulf pipefish sacrifice investment in somatic growth, and thus indirectly sacrifice future reproduction, in favor of current reproduction. However, a positive relationship between number of failed eggs and male growth rate in our low-food treatments suggests that undeveloped eggs reduce the pregnancy’s overall cost to the male compared to broods containing only viable offspring.     

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.     

Birth rights and rituals in rural south India: care seeking in the intrapartum period

Maternal morbidity and mortality are high in the Indian context, but the majority of maternal deaths could be avoided by prompt and effective access to intrapartum care (WHO, 1999). Understanding the care seeking responses to intrapartum morbidities is crucial if maternal health is to be effectively improved, and maternal mortality reduced. This paper presents the results of a prospective study of 388 women followed through delivery and traditional postpartum in rural Karnataka in southern India. In this setting, few women use the existing health facilities and most deliveries occur at home. The analysis uses quantitative data, collected via questionnaires administered to women both during pregnancy and immediately after delivery. By virtue of its prospective design, the study gives a unique insight into intentions for intrapartum care during pregnancy as well as events following morbidities during labour. Routine care in the intrapartum period, both within institutions and at home, and impediments to appropriate care are also examined. The study was designed to collect information about health seeking decisions made by women and their families as pregnancies unfolded, rather than trying to capture women's experience from a retrospective instrument. The data set is therefore a rich source of quantitative information, which incorporates details of event sequences and health service utilization not previously collected in a Safe Motherhood study. Additional qualitative information was also available from concurrent in-depth interviews with pregnant women, their families, health care providers and other key informants in the area. The level of unplanned institutional care seeking during the intrapartum period within the study area was very high, increasing from 11% planning deliveries at a facility to an eventual 35% actually delivering in hospitals. In addition there was a significant move away from planned deliveries with the auxiliary nurse midwive (ANM), to births with a lay attendant or dai. The proportion of women who planned for an ANM to assist was 49%, as compared with the actual occurrence, which was less than half of this proportion. Perceived quality of care was found to be an important factor in health seeking behaviour, as was wealth, caste, education and experience of previous problems in pregnancy. Actual care given by a range of practitioners was found to contain both beneficial and undesirable elements. As a response to serious morbidities experienced within the study period, many women were able to seek care although sometimes after a long delay. Those women who experienced inadequate progression of labour pains were most likely to proceed unexpectedly to a hospital delivery.     

Understanding users' perspectives of barriers to maternal health care use in Maharashtra, India.

This paper uses data collected using in-depth, semi-structured interviews to examine utilization of maternal health care services among two rural and urban populations of Pune and Mumbai in Maharashtra, India. The study aims to identify key social, economic and cultural factors influencing women's decisions to use maternal health care and the places used for child delivery, whilst considering the accessibility of facilities available in the local area. Socioeconomic status was not found to be a barrier to service use when women perceived the benefits of the service to outweigh the cost, and when the service was within reasonable distance of the respondent's place of residence. A large number of women perceived private services to be superior to those provided by the government, although cost often meant they were unable to use them. The provision of services did not ensure that women used them; they had to first perceive them to be beneficial to their health and that of their unborn child. Respondents identified the poor quality of services offered at government institutions to be a motivating factor for delivering at home. Thus further investigation is needed into the quality of services provided by government facilities in the area. A number of respondents who had received antenatal care went on to deliver in the home environment without a trained birth attendant. Further research is needed to establish the types of care provided during an antenatal consultation to establish the feasibility of using these visits to encourage women, particularly those with high-risk pregnancies, to be linked to a trained attendant for delivery.     

Maternal morbidity associated with in utero transfer.

OBJECTIVE--To determine the extent of maternal morbidity associated with in utero transfer. DESIGN--Retrospective study of 190 consecutive cases over two years. SETTING--Liverpool Maternity Hospital. PATIENTS--190 Pregnant women were transferred to the hospital under the in utero transfer arrangements from district general hospitals both within and outside the Mersey region. The women admitted were divided into two categories: those in threatened or established uncomplicated preterm labour and those who may or may not have been in threatened or established preterm labour but who had coexisting complicating factors affecting the mother or fetus, or both. INTERVENTIONS--Planned delivery of the fetus if indicated and arrangements for appropriate postpartum care of the mother. MAIN OUTCOME MEASURE--Assessment of the progress of labour and, if appropriate, resuscitation of the mother. RESULTS--Women who were transferred with no coexisting disease (124) had relatively uncomplicated deliveries whereas those transferred with coexisting diseases (66) exhibited considerable morbidity and 17 of these required prolonged intensive monitoring after delivery. CONCLUSIONS--In utero transfer in healthy mothers may have benefits for babies born very prematurely. If mothers have coexisting disease, however, the desirability of transfer should be reviewed urgently in the light of the considerable maternal morbidity associated with these problems. In these cases transfer may introduce an additional hazard.     

Effects of social support during parturition on maternal and infant morbidity.

Because continuous social support during labour is a component of care in many societies but inconsistent in our own, the clinical effect of support during labour on maternal and neonatal morbidity were studied. Social support was provided by female companions. Four hundred and sixty five healthy primigravidous women were enrolled using a randomised design. Compared with 249 women undergoing labour alone 168 women who had supportive female companions throughout labour had significantly fewer perinatal complications (p less than 0.001), including caesarean sections (7% v 17%, p less than 0.01) and oxytocin augmentation (2% v 13%, p less than 0.001), and fewer infants admitted to neonatal intensive care (p less than 0.10). Of the women who had an uncomplicated labour and delivery requiring no interventions, those with a companion had a significantly shorter duration of labour (7.7 hours v 15.5 hours, p less than 0.001). This study suggests that constant human support may be of great benefit to women during labour.     

Estimates of time and propensity for dental treatment among institutionalised elders

The oral health and concerns of elderly residents were surveyed in a stratified random selection of 41 long-term care facilities in Vancouver. The residents who could participate were examined and interviewed to determine their oral health and concerns about dental treatment. The need and time required for treatment were estimated in six groups to reflect the propensity for treatment in dentate and edentate subjects. The propensity for treatment was high in about one-third of the participants whereas it was unlikely that one-tenth of those examined would ever use a dental service. In general, there was a widespread need for a diagnostic service because so few had been examined by a dentist in the previous year. Prosthodontics accounted for most of the treatment in all of the propensity groups, with substantially more time required by the dentate residents. There was also a substantial need for management of mucosal pathoses and oral hygiene and, to a lesser extent, for dental restorations and endodontics. Overall, our estimates indicate a substantial need for dental treatment among residents of long-term care facilities, although the need is reduced by half if the propensity for treatment is considered.     

Epidemiology of spontaneous premature rupture of membranes: factors in pre-term births

The frequency of spontaneous premature rupture of membranes (PROM) was determined in the pregnancies of 1,848 white mothers and their singleton infants, born at the University of Kansas Medical Center between April 1975 and April 1978. The frequency of PROM increased significantly from a low of 34/707 (4.8 percent) among low-risk mothers, to 40/444 (9.0 percent) among mothers smoking one to 60 cigarettes a day, to 21/204 (10.3 percent) among mothers with multiple adverse maternal practices, and to 12/46 (26 percent) among mothers with selected complications of their pregnancies. The proportion of low birth weight (LBW) (less than 2,500 g) pre-term infants born to PROM mothers increased among the risk factor groups in a similar manner, from a low of 2/34 (6 percent) in low-risk pregnancies to 8/40 (20 percent) among mothers smoking one to 60 cigarettes a day, to 7/21 (33 percent) among mothers with multiple adverse practices, and to 7/12 (58 percent) among mothers with selected complications of pregnancy. The increased incidence of low birth weight pre-term infants born to mothers with PROM was associated with evidence of growth retardation among full-term infants in the high-risk groups. This finding was manifested by reductions in mean birth weights of full-term infants born to high-risk mothers but not observed in full-term infants born to low-risk mothers. The attained growth at birth of low birth weight pre-term infants could not be determined, because appropriate birth weight standards for pre-term infants born to mothers with low-risk pregnancies are not available. These results suggest that growth retardation in fetuses increased the probability of the mothers having PROM prior to the onset of labor, and, if PROM did occur, of having a premature delivery. We hypothesize that the tensile strength of the amnion and chorion is diminished by the same conditions that retard fetal growth, and that this reduction in strength of the fetal membranes contributes to premature rupture of membranes and pre-term delivery.     

Prostaglandin-induced abortion and outcome of subsequent pregnancies: a prospective controlled study

We analysed a prospective series of 204 pregnancies occurring in 168 women after a prostaglandin-induced abortion. The mean (±standard error of mean) interval between abortion and first subsequent conception was 10·4 ± 0·6 months; no patient reported secondary subfertility.Fifty-five of the subsequent pregnancies were terminated, 23 during the second trimester, again using prostaglandins. Of the 149 pregnancies not terminated, 127 were delivered at term, and 19 spontaneously aborted, seven during the second trimester; there was one missed abortion and two ectopic pregnancies. Morbidity in the 127 term pregnancies was infrequent; spontaneous preterm labour occurred in three patients, and four singleton infants weighed less than 2500 g at birth. There was no apparent association between morbidity in the subsequent pregnancies and the period of gestation at the time of the previous abortion, route of prostaglandin administration, or need for post-abortion curettage.The results obtained overall were very similar to a control group of 612 women consecutively admitted for delivery or abortion to the Oxford obstetrical and gynaecological units. There was, however, an increased incidence of spontaneous abortion and placenta praevia after prostaglandin-induced abortion, and the multigravidae in that group had a longer average duration of labour than the control group. Sixty-five per cent of the post-abortion pregnancies were unplanned compared with 36% of the control group.     

Cardiac Monitoring in a Community Hospital—Analysis of 18 Months' Experience

Cardiac monitoring facilities have been present in teaching hospital centers for over five years. A substantial decrease in mortality has been observed in monitored patients with acute myocardial infarction. The community hospital system offers a challenge to effective monitoring since many physicians care for patients and often many kinds of therapy are used.After 18 months of operation mortality from myocardial infarction was only 16.6 percent in a community hospital monitoring unit where the majority of the emergency care and resuscitation was carried out by nurses. Vital to this success was the use of standing orders for nurses, requirement of privilege to practice within the monitoring facility and acceptance of the nurse as a therapist in emergency situations.Fourteen patients were successfully resuscitated and were later discharged from the hospital. Four of them had ventricular fibrillation from digitalis intoxication.Patients with shock and severe congestive heart failure continue to be a major unsolved clinical problem. The results indicate that the potentially viable patient with serious electrical disturbances can almost invariably be salvaged.     

The rate of preterm twin births (22-27 weeks) as a criterion for measuring the quality of prenatal care.

While the true figures are not well established, outcomes of twin pregnancies are directly dependent on a small number of preterm births between 22 and 27 weeks. Observation of perinatal outcomes in twin pregnancies yields two contradictory results. Firstly, it shows an improvement in perinatal mortality figures. Secondly, it reveals an increase in the rates of preterm deliveries. These findings result from the observation of 783 twin pregnancies followed and delivered in a level 3 perinatal centre in Paris between 1993 and 1998. Women followed since the beginning of pregnancy through the outpatient clinic of the institution are included in this number, as are women who were referred or transferred to the centre at a later date due to complications, This analysis reflects the influence of two contrasting policies. The first, and less recent policy is devoted to the prevention of preterm births, and is reflected by the low number of extremely preterm deliveries at 22-32 weeks. The second is the effect of our new approach to the prevention of foetal deaths in relation to foetal growth retardation in twins which has resulted in increased medical intervention such as the induction of labour or scheduled Caesarean birth. This has resulted in an increase in twin preterm births from 33 to 36 weeks, with the expected result of fewer foetal deaths.     

The epidemiology of white full-term infants with short crown-heel lengths for gestational ages at birth

Fetal growth retardation was diagnosed in 137 (7.8 percent) of 1,757 white full-term infants who had crown-heel lengths below the fifth percentiles for their gestational ages. The incidence of short infants was 121 (11.1 percent) among 1,093 mothers with high-risk pregnancies compared to 16 (2.4 percent) in 664 low-risk mothers (p less than 0.0001). There were four high-risk categories: spontaneous premature rupture of membranes (PROM), fetal conditions, complications of pregnancy, and adverse maternal practices. The incidence of short infants was significantly higher in each of the four high-risk categories than in the low-risk group. There were three other conditions that were present in all pregnancies that were associated with the frequency of short infants: maternal height, socioeconomic status of head of household, and sex of infant. A short maternal height (under 157.7 cm = 62 inches) was significantly associated with an increase in short infants among mothers who smoked cigarettes at any level during pregnancy and among mothers with PROM in combination with other risks, but not in the group of 664 low-risk mothers. Significantly more short girls than short boys were born to mothers who smoked ten or more cigarettes a day throughout pregnancy or who had multiple adverse maternal practices, but no statistically significant differences were noted among mothers who smoked fewer than ten cigarettes per day, among those with PROM as the only risk factor, or among those with medical or obstetrical complications. Moreover, those mothers who were in socioeconomic groups III and IV and had other risk factors had a significantly higher incidence of short infants than did similar mothers in socioeconomic groups I and II.     

Conservative management of pregnancy in diabetic women.

In 1979 the obstetric management of pregnancies in diabetic women in Cardiff was changed from elective delivery at 37-38 weeks to delivery at term. This change was facilitated by home monitoring of blood glucose concentrations and improved techniques for assessing fetal wellbeing. There were 35 pregnancies in insulin dependent diabetics in 1972-8 and 45 in 1979-82. The quality of diabetic control during pregnancy was equally good in both periods. The average gestation at final admission to hospital increased from 30 to 37 weeks. Amniocentesis to assess fetal pulmonary maturity was necessary in 26 patients (74%) in the first period of study and in only four (9%) in the second. Gestational age at delivery increased from 37.4 to 39.4 weeks after the change in policy. The proportion of mothers entering spontaneous term labour and delivering vaginally increased from 14.3% to 37.8%. The mean birth weight of live born, singleton infants increased from 3090 g to 3650 g, the feeding pattern improved, and respiratory problems were less common. Morbidity was reduced and perinatal mortality was not increased with conservative management of pregnancy in diabetic women.     

Rapid-prenatal diagnosis through fluorescence in situ hybridization for preventing aneuploidy related birth defects

BACKGROUND AND OBJECTIVE:

Women with high-risk pregnancies are offered prenatal diagnosis through amniocentesis for cytogenetic analysis of fetal cells. The aim of this study was to evaluate the effectiveness of the rapid fluorescence in situ hybridization (FISH) technique for detecting numerical aberrations of chromosomes 13, 21, 18, X and Y in high-risk pregnancies in an Indian scenario.

MATERIALS AND METHODS:

A total of 163 samples were received for a FISH and/or a full karyotype for prenatal diagnosis from high-risk pregnancies. In 116 samples both conventional culture techniques for getting karyotype through G-banding techniques were applied in conjunction to FISH test using the AneuVysion kit (Abbott Molecular, Inc.), following standard recommended protocol to compare the both the techniques in our setup.

RESULTS:

Out of 116 patients, we got 96 normal for the five major chromosome abnormality and seven patients were found to be abnormal (04 trisomy 21, 02 monosomy X, and 01 trisomy 13) and all the FISH results correlated with conventional cytogenetics. To summarize the results of total 163 patients for the major chromosomal abnormalities analyzed by both/or cytogenetics and FISH there were 140 (86%) normal, 9 (6%) cases were abnormal and another 4 (2.5%) cases were suspicious mosaic and 10 (6%) cases of culture failure. The diagnostic detection rate with FISH in 116 patients was 97.5%. There were no false-positive and false-negative autosomal or sex chromosomal results, within our established criteria for reporting FISH signals.

CONCLUSION:

Rapid FISH is a reliable and prompt method for detecting numerical chromosomal aberrations and has now been implemented as a routine diagnostic procedure for detection of fetal aneuploidy in India.     

Women's views on the impact of operative delivery in the second stage of labour: qualitative interview study

Objective To obtain the views of women on the impact of operative delivery in the second stage of labour.Design Qualitative interview study.Setting Two urban teaching hospitals in the United Kingdom.Participants Purposive sample of 27 women who had undergone operative delivery in the second stage of labour between January 2000 and January 2002.Key themes Preparation for birth, understandings of the indications for operative delivery, and explanation or debriefing after birth.Results The women felt unprepared for operative delivery and thought that their birth plan or antenatal classes had not catered adequately for this event. They emphasised the importance of maintaining an open mind about the management of labour. They had difficulty understanding the need for operative delivery despite a review by medical and midwifery staff before discharge. Operative delivery had a noticeable impact on women''s views about future pregnancy and delivery.Conclusions Women consider postnatal debriefing and medical review important deficiencies in current care. Those who experienced operative delivery in the second stage of labour would welcome the opportunity to have a later review of their intrapartum care, physical recovery, and management of future pregnancies.     

Copying out our ABCs: the role of gene redundancy in interpreting genetic hierarchies.

The complete sequence of the Arabidopsis genome is scheduled to be determined by the end of the year 2000. While this goal could prove to be something of a moving target (the estimated size of the genome has grown from 120 Mb to 130 Mb over the last year1), it is clear that the majority of genes required for higher plant growth, reproduction and development will have been described within this time frame. Some of the implications of this landmark achievement are already becoming clear, even though less than a half of the genome has been sequenced.