Jennifer J. Henderson

Induction of labour in nulliparous women with an unfavourable cervix: a randomised controlled trial comparing double and single balloon catheters and PGE2 gel.

Objective  To compare the efficacy and patient satisfaction of three methods of labour induction (double balloon catheters, single balloon catheters and prostaglandin gel) in term nulliparous women with unfavourable cervices.

Postcesarean analgesia with spinal morphine, clonidine, or their combination.

In this randomized, double-blind trial in 240 women, we investigated the analgesic efficacy and duration of subarachnoid fentanyl 15 μg with morphine, clonidine, or both morphine and clonidine for cesarean delivery. A dose-finding analysis showed similar postoperative efficacy and side effects for groups receiving morphine 100 μg with clonidine 60, 90, or 150 μg. Data from these groups were combined (MC60–150, n = 113) and compared with groups receiving morphine 100 μg (n = 39), clonidine 150 μg (n = 39), or morphine 100 μg plus clonidine 30 μg (n = 41). The four groups differed in the time to patient-controlled morphine use and cumulative morphine consumption (P < 0.0001 and P < 0.001, respectively), with the longest duration and smallest dose in MC60–150. Pain scores were significantly different among groups. Onset of sensory block, ephedrine requirement and incidence of hypotension, patient satisfaction, and recovery were similar. Groups receiving clonidine had greater sedation, those receiving morphine had more severe pruritus, and group MC60–150 showed a trend to more vomiting intraoperatively. Compared with morphine 100 μg or clonidine 150 μg alone, the combination of subarachnoid morphine 100 μg and at least 60 μg of clonidine was found to increase the duration of postcesarean analgesia, reduce opioid requirement, and increase intraoperative sedation.

Preterm birth aetiology 2004–2008. Maternal factors associated with three phenotypes: spontaneous preterm labour, preterm pre-labour rupture of membranes and medically indicated preterm birth

Objectives: To (1) investigate the current distribution of PTB phenotypes; (2) identify factors associated with spontaneous preterm labour (SPTL), PPROM, and indicated PTB; (3) investigate the relationship of gestational age (ga) with each PTB phenotype. Methods: Retrospective review of all live, singleton births 23+0 to 36+6 weeks ga at an obstetric referral centre 2004–2008. Results: A total of 4,522 PTBs were included (SPTL 31.7%, PPROM 27.4%, indicated 40.8%). PTB phenotype distribution differed between ga groups (<27 weeks: SPTL 45%, PPROM 32%, indicated 23%; 27–33 weeks: SPTL 30%, PPROM 32%, indicated 39%; 34–36 weeks: SPTL 32%, PPROM 24%, indicated 44%, p < 0.001). Between 34–36 weeks’, demographic factors were significantly different between PTB phenotypes (age ≥35: SPTL 13.8%, PPROM 15.4%, indicated 21.6%; Caucasian ethnicity: SPTL 61.6%, PPROM 69.0%, indicated 70.2%; Assisted Reproductive Technology (ART): SPTL 2.8%, PPROM 1.9%, indicated 9.3%; all p < 0.001). Between 27–33 weeks’ PTB phenotype was associated with smoking (SPTL 24.9%, PPROM 29.3%, indicated 20.2%; p = 0.002) and ART (SPTL 2.3%, PPROM 1.6%, indicated 5.0%; p = 0.002). Demographic factors were not associated with PTB phenotype at 23–26 weeks. Conclusions: The increase in PTB rates may be explained by medical indications at late preterm gestations, primarily in older, Caucasian women requiring fertility assistance. Interventions to reduce the rate of PTB need to be targeted to this high-risk population.

Impact of intrapartum epidural analgesia on breast-feeding duration

Background:  Although the labour and delivery outcomes of epidural analgesia have been investigated extensively, the effects on breast‐feeding success are not clearly identified.

Effect of an extended midwifery postnatal support programme on the duration of breast feeding: A randomised controlled trial

OBJECTIVE to evaluate the effects of an extended midwifery support (EMS) programme on the proportion of women who breast feed fully to six months. DESIGN randomised controlled trial. SETTING large public teaching hospital in Australia. PARTICIPANTS 849 women who had given birth to a healthy, term, singleton baby and who wished to breast feed. INTERVENTION participants were allocated at random to EMS, in which they were offered a one-to-one postnatal educational session and weekly home visits with additional telephone contact by a midwife until their baby was six weeks old; or standard postnatal midwifery support (SMS). Participants were stratified for parity and tertiary education. MEASUREMENTS the main outcome measures were prevalence of full and any breast feeding at six months postpartum. FINDINGS there was no difference between the groups at six months postpartum for either full breast feeding [EMS 43.3% versus SMS 42.5%, relative risk (RR) 1.02, 95% confidence interval (CI) 0.87-1.19] or any breast feeding (EMS 63.9% versus SMS 67.9%, RR 0.94, 95%CI 0.85-1.04). CONCLUSIONS the EMS programme did not succeed in improving breast-feeding rates in a setting where there was high initiation of breast feeding. Breast-feeding rates were high but still fell short of national goals. IMPLICATIONS FOR PRACTICE continuing research of programmes designed to promote breast feeding is required in view of the advantages of breast feeding for all mothers and babies.

Benefits of introducing universal umbilical cord blood gas and lactate analysis into an obstetric unit

Background:  Current evidence suggests that umbilical arterial pH analysis provides the most sensitive reflection of birth asphyxia. However, there’s debate whether umbilical cord blood gas analysis (UC‐BGA) should be conducted on some or all deliveries.

Accurate prediction of hypoxic-ischaemic encephalopathy at delivery: a cohort study

Objective: Hypoxic-ischaemic encephalopathy (HIE) is a major acute neurologic manifestation of perinatal asphyxia associated with significant mortality and morbidity. The study aimed to develop a simple, accurate method of predicting HIE at delivery. Methods: Between January 2003 and December 2009, all HIE cases were identified from the 38,404 deliveries at a single tertiary centre. Receiver operating curve (ROC) analysis and multivariate logistic regression assessed the ability of clinical and biochemical assessments to predict HIE. Results: Sixty neonates met the HIE criteria: 39 were moderate-severe HIE. Univariate analyses identified clinical neonatal markers (Apgar scores and neonatal resuscitation level) to be better HIE predictors than biochemical markers (umbilical artery pH, base excess and lactate values). Multivariable models using two to four predictors had areas under ROC curves up to 0.98, sensitivities up to 93% and specificities up to 99%. For moderate-severe HIE, the most effective predictor was neonatal resuscitation level and arterial lactate (ROC 0.98, sensitivity 85%, specificity 99%). Conclusion: The combination of umbilical arterial lactate and neonatal resuscitation level provides a rapid and accurate method of predicting moderate-severe HIE that can identify neonates at birth that may benefit from tertiary care and neuroprotective therapies.

Early diet quality in a longitudinal study of Australian children: associations with nutrition and body mass index later in childhood and adolescence

Obesity has origins extending to antenatal and early postnatal periods; however, the relationship between early postnatal diet and subsequent obesity is not well defined. The aims of this study were to determine whether early childhood dietary quality was associated with (a) infant and adolescent nutrition and (b) body mass index (BMI) in childhood and adolescence. The degree to which early nutrition and growth factors determine BMI throughout childhood and adolescence was also explored. This research was conducted using the Raine Study, a longitudinal survey of Australian children assessed from mid-gestation to 17 years of age. A dietary quality index, the Raine Eating Assessment in Toddler score, was assigned to 2562 participants to assess early nutrition. Linear regression determined that breastfeeding was associated with dietary quality at 1-3 years. Dietary elements at 14 years of age were related to earlier dietary quality. There were no consistent associations between early diet and BMI at 3, 5, 8, 10, 14 or 17 years. In contrast, birth weight and infant weight gain were significantly associated with BMI at these ages. This study suggests that early dietary patterns are associated with aspects of diet in adolescence, likely reflecting the influence of maternal reporting. Birth weight and early growth appear to be more important determinants of adolescent BMI than early diet and nutrition. While optimizing early diet by maternal nutritional education has potential to influence later nutrition, interventions focussing on early weight gain may have a greater impact on the obesity epidemic.

The risk of placenta accreta following primary elective caesarean delivery: a case–control study

To evaluate the risk of placenta praevia accreta following primary (first) elective or primary emergency caesarean section in a pregnancy complicated by placenta praevia.

The effect of time, temperature and storage device on umbilical cord blood gas and lactate measurement: a randomized controlled trial.

Objective: Umbilical cord blood gas analysis has a significant and growing role in early neonatal assessment. Factors often delay analysis of cord blood allowing values to change. Consequently, this study evaluates the impact of time, temperature and method of storage on umbilical blood gas and lactate analyses. Methods: Umbilical cord segments from 80 singleton deliveries were randomized to: cords at room temperature (CR), cords stored on ice (CI), syringes at room temperature (SR) or syringes stored on ice (SI). Analysis occurred every 15 minutes for one-hour. Mixed model analysis of variance allowing for repeated measures was utilized. Results: Cord arterial pH deteriorated in CR, CI, and SI within 15 minutes (p ≤ 0.001), with SR stable until 60 minutes (p = 0.002). Arterial pCO2 remained stable in SR and CI, increased in SI (p = 0.002; 45 minutes) and decreased in CR (p < 0.001; 45 minutes). Arterial base excess deteriorated in CR and SI (p ≤ 0.009; 15 minutes), SR (p < 0.001; 30 minutes), and CI (p < 0.001; 45 minutes). Arterial lactate levels increased within 15 minutes in all groups (p < 0.001). Conclusions: Cord blood gas values change rapidly after delivery. Smallest changes were seen in SR group. Data suggest that analyses should be conducted as soon as possible after delivery.