Kirkwood K. Shy

Effects of Electronic Fetal-Heart-Rate Monitoring, as Compared with Periodic Auscultation, on the Neurologic Development of Premature Infants

In a multicenter, randomized clinical trial, we assessed the early neurologic development of 93 children born prematurely whose heart rates were monitored electronically during delivery and compared it with that of 96 children born prematurely whose heart rates were periodically monitored by auscultation. All the children were singletons with cephalic presentation, and all weighed less than or equal to 1750 g at birth. The mental and psychomotor indexes of the Bayley Scales of Infant Development (standardized mean score +/- SD, 100 +/- 16) and a formal neurologic examination were administered at three follow-up visits (at 4, 8, and 18 months of age, corrected for gestational age). At 18 months, the mean mental-development scores in the groups receiving electronic fetal monitoring and periodic auscultation were 100.5 +/- 2.4 and 104.9 +/- 1.8, respectively (P greater than 0.1). The mean psychomotor-development scores in the two groups at 18 months were 94.0 +/- 2.4 and 98.3 +/- 1.8, respectively (P greater than 0.1). The incidence of cerebral palsy was higher in the electronically monitored group--20 percent as compared with 8 percent in the group that was monitored by auscultation (P less than 0.03). In the electronic-fetal-monitoring group (but not in the periodic-auscultation group), the risk of cerebral palsy increased with the duration of abnormal fetal-heart-rate patterns, as assessed by retrospective review (chi 2 trend = 12.71, P less than 0.001). The median time to delivery after the diagnosis of abnormal fetal-heart-rate patterns was 104 minutes with electronic fetal monitoring, as compared with 60 minutes with periodic auscultation. We conclude that as compared with a structured program of periodic auscultation, electronic fetal monitoring does not result in improved neurologic development in children born prematurely.

Possible relationship between in utero diethylstilbestrol exposure and male fertility

Seventeen men who were exposed in utero to diethylstilbestrol (DES), 12 non-DES-exposed volunteers, and 11 fertile control subjects were evaluated by physical examination, seminal fluid analysis, and sperm penetration assay (SPA). Fourteen of the 17 male subjects exposed to DES in utero and two of the 12 non-DES-exposed volunteers had SPAs of less than 14% and qualified as infertile by the criteria of this test. All 11 fertile control subjects had demonstrated SPA values in the fertile range. Thirteen of the 17 DES-exposed male subjects, four of the 12 non-DES-exposed volunteers, and four of the 11 fertile control subjects demonstrated at least one abnormality of the reproductive organs.

Evaluation of elective repeat cesarean section as a standard of care: An application of decision analysis

The rationale for routine repeat cesarean section (RCS) is avoidance of uterine rupture during labor. However, the incidence of uterine rupture following modern cesarean section is low, and the charge for cesarean section is greater than that for a trial of labor (TOL). The technique of decision analysis was used to investigate strategies of elective RCS and TOL with precautionary monitoring. Hypothetical cohorts of 10,000 pregnant women with previous low-transverse cesarean incisions were assumed. Probability data were obtained from the literature. In the TOL cohort, 6,623 patients were delivered vaginally. Uterine rupture occurred in 73 patients. In spite of this, TOL resulted in 37 fewer perinatal deaths and 0.7 fewer maternal deaths than elective RCS. The excessive perinatal mortality in the RCS cohort was related to iatrogenic prematurity that is now avoidable with the lecithin/sphingomyelin test. Direct costs were

IDENTIFICATION OF NEURODEVELOPMENTAL ABNORMALITY AT FOUR AND EIGHT MONTHS BY THE MOVEMENT ASSESSMENT OF INFANTS

5 million greater in the RCS cohort. We concluded that in contemporary practice mortality rates are essentially equal for both delivery practices. However, substantial cost savings are available with TOL.

Benefits of the sperm (hamster ova) penetration assay in the evaluation of the infertile couple

The predictive validity of infant neuromotor evaluation by the Movement Assessment of Infants (MAI) was investigated in low‐birthweight infants. Motor performance at four and eight months was examined in relation to neurodevelopmental outcome at 18 months of age. Correlations were equally strong between total MAI risk scores at four and eight months and performance on the Bayley Scales. Muscle tone observations were more discriminating at four months, and automatic reactions and volitional movement were most predictive at eight months. The MAI was highly sensitive to neurodevelopmental abnormality at four and eight months and more sensitive than the Bayley Motor Scale; both assessment tools had lower specificity at eight months. The high false‐positive rate is attributed to transient neuromotor abnormalities and immaturity of motor function in low‐birthweight infants with normal outcome.

Status of infants at birth and risk for adverse neonatal events and long-term sequelae: A study in low birth weight infants

The males of 310 infertile couples and 30 control couples (current pregnancy) were evaluated with the sperm (hamster ova) penetration assay (SPA) and seminal fluid analysis (SFA). The SPA was found to have a sensitivity of 100% and a specificity of 97% compared to 41% and 90%, respectively, for the SFA. The highest degree of concordance of the two tests existed when both tests were abnormal and no female factor was identified. The poorest concordance occurred when the SFA was normal and no female infertility factor was identified. In almost all cases of unexplained infertility where no female infertility factor was present, the problem could be assigned to the man, as evidenced by an abnormal SPA. The SFA seemed to have some predictive value with respect to the outcome following treatment of the man.

Out-of-hospital delivery in Washington State, 1975 to 1977

We evaluated the relationship of infant status at birth to neonatal morbidity and long-term development in 246 low birth weight infants (600 to 1750 gm). Nineteen percent of infants had 1-minute Apgar scores of less than or equal to 3, and 8% had an umbilical artery pH of less than or equal to 7.2. Acidosis was associated with an increased risk of grade 3 to 4 intracranial hemorrhage (odds ratio = 3.3). Low 1-minute Apgar score was associated with an increased risk of death (odds ratio = 4.8). Grade 3 to 4 intracranial hemorrhage was a strong risk factor for cerebral palsy among survivors (odds ratio = 16.1), as was low 1-minute Apgar score (odds ratio = 2.9). Only 15% of cases of cerebral palsy in this study were associated with acidosis at birth.

Evaluation of a public-private certified nurse-midwife maternity program for indigent women.

The annual rate of out-of-hospital deliveries in Washington State increased from 1.6% in 1975, to 2.4% in 1977. Birth certificates, linked birth and death certificates files, and log books from tertiary referral hospitals were used to investigate this trend. As parity increased, rates of home delivery (HD) also increased (p less than 0.001). However, alternative birth center delivery (BCD) rates did not change with parity (p greater than 0.1). HD rates and BCD rates increased with birth weight (p less than 0.001). Obstetric professionals attended 91% of BCD as compared to 65% of HD. Fifty-four percent of the women in the BCD group had 10 or more prenatal visits compared to 40% in the HD group. Infant mortality rates were lower with BCD than with HD. However, our analysis of mortality was limited by countervailing biases inherent in the data. We concluded that out-of-hospital deliveries were a heterogeneous group that in future studies should be stratified into groups of birth center deliveries and home deliveries.

Supraumbilical Upper Abdominal Midline Incision for Pelvic Surgery in the Morbidly Obese Patient

OBJECTIVES This study assessed the impact of a public-private certified nurse-midwife program on prenatal and delivery outcomes among medically indigent women. METHODS A population-based quasi-experimental design was used to compare 1 intervention county with 2 nonintervention counties. RESULTS The program significantly reduced the number of women who received no prenatal care and the risk of acquiring less than adequate prenatal care. Reductions in the proportion of infants born premature or with low birth-weights were of borderline significance. The use of induction and/or stimulation of labor was statistically elevated. CONCLUSIONS These results suggest that the intervention program was instrumental in reducing some, but not all, negative prenatal and delivery outcomes.

A randomized trial of electronic fetal monitoring in preterm labor

An upper abdominal midline incision was used for pelvic surgery in 16 morbidly obese patients (229-401 lb). When this approach is used, a Bookwalter retractor displaces the incision inferiorly and compresses the abdominal wall over the pelvis, and is then secured to the operating-room table. This approach provides adequate exposure of the pelvic organs and avoids an incision in the panniculus with its associated complications. No wound infections, postoperative dehiscences, or other serious postoperative morbidity occurred in these patients.