Miriam Orleans

A controlled trial of the differential effects of intrapartum fetal monitoring

A controlled prospective study of the differential effects of intrapartum fetal monitoring on mothers and infants has been conducted at Denver General Hospital, Denver, Colorado. A total of 690 high-risk obstetric patients in labor were randomly assigned to one of three monitoring groups--auscultation, electronic fetal monitoring alone, or electronic monitoring with the option to scalp sample. There were no differences in immediate infant outcomes in any measured category (Apgar scores, cord blood gases, neonatal death, neonatal morbidity, nursery course) among the three groups. There were no differences in rates of infant or maternal infections. The cesarean section rate was markedly increased in the electronically monitored groups, especially in the electronically monitored alone (18%) as compared with the auscultated (6%) (P less than 0.005). In this controlled trial electronic monitoring did not improve neonatal outcomes and the mothers were at increased risk of cesarean section.

Obstetric anesthesia work force survey, 1981 versus 1992.

Background: In 1981, with support from the American Society of Anesthesiologists and the American College of Obstetricians and Gynecologists, anesthesia and obstetric providers were surveyed to identify the personnel and methods used to provide obstetric anesthesia in the United States. The survey was expanded and repeated in 1992 with support from the same organizations. Methods: Comments and questions from the American Society of Anesthesiologists Committee on Obstetrical Anesthesia and the American College of Obstetricians and Gynecologists Committee on Obstetric Practice were added to the original survey instrument to include newer issues while allowing comparison with data from 1981. Using the American Hospital Association registry of hospitals, hospitals were differentiated by number of births per year (stratum I, >or= to 1,500 births; stratum II, 500–1,499 births; stratum III, < 500 births) and by U.S. census region. A stratified random sample of hospitals was selected. Two copies of the survey were sent to the administrator of each hospital, one for the chief of obstetrics and one for the chief of anesthesiology. Results: Compared with 1981 data, there was an overall reduction in the number of hospitals providing obstetric care (from 4,163 to 3,545), with the decrease occurring in the smallest units (56% of stratum III hospitals in 1981 compared with 45% in 1992). More women received some type of labor analgesia, and there was a 100% increase in the use of epidural analgesia. However, regional analgesia was unavailable in 20% of the smallest hospitals. Spinal analgesia for labor was used in 4% of parturients. In 1981, obstetricians provided 30% of epidural analgesia for labor; they provided only 2% in 1992. Regional anesthesia was used for 78–85% (depending on strata) of patients undergoing cesarean section, resulting in a marked decrease in the use of general anesthesia. Anesthesia for cesarean section was provided by nurse anesthetists without the medical direction of an anesthesiologist in only 4% of stratum I hospitals but in 59% of stratum III hospitals. Anesthesia personnel provided neonatal resuscitation in 10% of cesarean deliveries compared with 23% in 1981. Conclusions: Compared with 1981, analgesia is more often used by parturients during labor, and general anesthesia is used less often in patients having cesarean section deliveries. In the smallest hospitals, regional analgesia for labor is still unavailable to many parturients, and more than one half of anesthetics for cesarean section are provided by nurse anesthetists without medical direction by an anesthesiologist. Obstetricians are less likely to personally provide epidural analgesia for their patients. Anesthesia personnel are less involved in newborn resuscitation.

Complications and recovery from laparoscopy-assisted vaginal hysterectomy compared with abdominal and vaginal hysterectomy

Objective To complete a systematic review of the published literature comparing complications, postoperative recovery time, and costs following laparoscopy-assisted vaginal hysterectomy, total abdominal hysterectomy(TAH), and vaginal hysterectomy. Data Sources We searched MEDLINE and several bibiliographies, identifying all reports using the term “laparoscopy-assisted hysterectomy” published from 1989 to september 1995. Methods of study selection We excluded case reports, letters, and reports of laparoscopy-assisted vaginal hysterectomy procedures used for radical cancer surgery, sex-change operations, total laparoscopic hysterectomy, or supracervical hysterectomy. Tabulation, Integration, and Results Cases identified included 3112 laparoscopy-assisted vaginal hysterectomies, 1618 TAHs, and 690 vaginal hysterectomies. Laparoscopy-assisted vaginal hysterectomy cases compared with TAH cases demonstrated significantly greater incidence of blader injury (1.8% for laporoscopy-assisted vaginal hysterectomy versus 0.4% for TAH; P = .01), significantly longer operating room time (115 minutes, standard deviation [SD] 37 minutes, for laparoscopy-assisted vaginal hysterectomy versus 87 minutes, SD 18 minutes, for TAH; P < .001), and significantly shorter hospitalization (49 hours, SD 16 hours, for laparoscopy-assisted vaginal hysterectomy versus 79 hours, SD 20 hours, for TAH; P < .001). Use of analysis was consistenly less for laparoscopy-assisted vaginal hysterectomy and return to full activity was always sooner when compared to TAH. Cost for the new procedure was higher in seven out of 11 studies, but when disposable instruments and hospital length of stay are considered, the remaining vaginal hysterectomy. Conclusion Although laparoscopy-assisted vaginal hysterectomy involves a shorter hospital stay, speedier postoperative recovery, and less analgesia use, there is also a higher rate of bladder injury and lenghier surgery. These outcomes must be weighed when choosing an intervention.

Preeclampsia in multiple gestation: the role of assisted reproductive technologies.

OBJECTIVE To estimate the relationship of assisted reproductive technologies and ovulation‐inducing drugs with preeclampsia in multiple gestations. METHODS This historical cohort study was conducted on 528 multiple gestations from a Colorado health maintenance organization. Using univariate and logistic regression analysis, we determined if women who conceived a multiple gestation as a result of assisted conception were at a greater risk of preeclampsia than those who conceived spontaneously. RESULTS Between January 1994 and November 2000, there were 330 unassisted and 198 assisted multiple gestations. Sixty‐nine multiple gestations followed assisted reproductive technologies (in vitro fertilization and gamete intrafallopian transfer). Human menopausal gonadotropins and clomiphene citrate were associated with 38 and 91 of the multiple gestations, respectively. Compared with unassisted multiple gestations, the relative risk of mild or severe preeclampsia among mothers who received assisted reproductive technologies was 2.7 (95% confidence interval [CI] 1.7, 4.7) and 4.8 (CI 1.9, 11.6), respectively. Adjusted for maternal age and parity, women who received assisted reproductive technologies were two times more likely to develop preeclampsia (odds ratio 2.1, CI 1.1, 4.1) compared with those who conceived spontaneously. The adjusted odds ratios of nulliparity and maternal age for preeclampsia were 2.1 (CI 1.3, 3.4) and 1.1 (CI 1, 1.1), respectively. Although the incidence of preeclampsia was greater in mothers who received clomiphene citrate and human menopausal gonadotropins, this association did not reach statistical significance at the P < .05 level. CONCLUSION Women who conceive multiple gestations through assisted reproductive technologies have a 2.1‐fold higher risk of preeclampsia than those who conceive spontaneously.

Rehospitalizations and outpatient contacts of mothers and neonates after hospital discharge after vaginal delivery

OBJECTIVE Our purpose was to determine whether length of hospital stay after vaginal delivery as determined by the discharging physician is associated with rehospitalizations or increased outpatient contacts by mothers and neonates and to assess the impact of home health care visits. STUDY DESIGN An inception cohort study of all rehospitalizations and outpatient contacts of mothers and neonates after vaginal delivery at St. Joseph Hospital, Denver, Colorado, was done from January 1, 1994, to September 30, 1995. All Kaiser Permanente mother-neonate pairs in which the delivery was vaginal (excluding those with multiple gestations or birth weight < 2500 g) were included. Length of initial hospital stay was divided into three time periods: < or = 24 hours, 25 to 48 hours, and > 48 hours. The Colorado Kaiser Permanente Perinatal Database was used to identify perinatal and demographic factors that might have increased health care use. Additional information was sought in administrative databases, bill records, and inpatient charts. Mothers were followed up for 6 weeks and neonates for 28 days after delivery. Home care visits were provided to more than half the mothers and neonates by means of a standardized protocol. The main outcome measures were rehospitalizations and outpatient visits for mothers and neonate, controlling for home care visits. RESULTS A total of 4323 mother-neonate pairs were identified. For the mothers, a longer initial hospital stay (> 48 hours) was significantly associated with both readmission (P < .01) and increased outpatient care use (P = .01) in the 6-week postpartum period. Thirty-five mothers (.81%) were rehospitalized by 6 weeks. Maternal factors associated with increased outpatient contacts were preeclampsia, preterm delivery, and instrument delivery. Sixty-seven neonates (1.55%) were readmitted to the hospital. Home care visits reduced the need for both readmissions and outpatient visits. CONCLUSIONS For mothers in this cohort a longer initial hospital stay was significantly associated with hospital readmission and increased outpatient care in the postpartum period. Further analysis revealed that mothers with recognized potential and observed problems were rarely discharged in < or = 24 hours. We did not find statistically significant problems among neonates that were related to the length of their initial hospital stay. Those neonates receiving home care were less likely to require hospital readmission and less likely to seek outpatient care. It is unlikely that a single discharge policy will be appropriate for all mothers and neonates.

Nifedipine for treatment of preterm labor : a historic prospective study

OBJECTIVES The purpose of this study was to ascertain whether adverse fetal and/or neonatal effects occurred during nifedipine treatment of preterm labor and to assess maternal tolerance of nifedipine therapy in patients intolerant of a beta-sympathomimetic agent. STUDY DESIGN We undertook historic prospective review of medical records of 102 women admitted to an antepartum ward for treatment of preterm labor who received nifedipine. Data were collected regarding maternal side effects, fetal surveillance, and neonatal outcome. RESULTS The number and severity of reported maternal side effects were significantly reduced when patients were switched from terbutaline to nifedipine. No discontinuance of nifedipine occurred because of maternal side effects. Fetal surveillance testing and neonatal outcome data failed to reveal deleterious in utero effects of nifedipine. CONCLUSIONS Nifedipine was a well-tolerated and safe tocolytic in this population and warrants further investigation.

The contribution of assisted conception, chorionicity and other risk factors to very low birthweight in a twin cohort

Objectives To investigate the contribution of assisted conception (assisted reproductive technology and ovulation induction), chorionicity and selected maternal risk factors for very low birthweight.

Oral intake policies on labor and delivery: a national survey

STUDY OBJECTIVE To examine current policies on oral intake during labor among hospitals throughout the United States. DESIGN AND SETTING Anonymous questionnaire survey distributed to the directors of anesthesia and obstetrics departments of 740 hospitals. Completed surveys were then grouped by number of deliveries performed each year. MEASUREMENTS AND MAIN RESULTS A total of 2,265 surveys were distributed. Of that number, 902 (33% response rate) surveys, representing 740 U.S. hospitals, were returned. Of the surveys returned, 419 surveys were received from obstetricians and 401 surveys were received from anesthesiologists. Oral intake during labor is limited primarily to clear liquids, although hospitals with fewer deliveries allow significantly more oral intake during latent phase than do hospitals with larger services. Allowing nonclear liquids or solid foods is uncommon in either phase of labor, regardless of hospital size. CONCLUSIONS The results give an indication of oral intake policies used by labor and delivery units in the United States, and they may be helpful for obstetric services that are in the process of developing their own policies.

High and Low Technology

In 1971, Victor Papanek published Design for the Real World (1), a book which attacked the lack of problem-oriented and population-based reasoning in industrial design. The lack of congruence between need and production, from Papaneks perspective, had resulted in exotic, costly, and idiosyncratic responses to a gadget-oriented market (2).

Assessing reproductive technology.

The cultural and emotional importance of having and raising healthy children is undisputed. Cross-cultural solutions to problems resulting from involuntary childlessness have included such strategies as adoption, finding new partners, and dissolving marriages that do not produce offspring. While both males and female infertility may result from heritable factors, environmental exposures, and disease, it is usually the result of functional incapacity in youth and in old age. The high value attached to reproduction is not puzzling. Human reproduction is protected by strong basic instincts. Childlessness is seldom met with stoicism by those who wish to have children. The happiness that follows the successful birth of a wanted child must not be discounted. Traditional definitions of “family” imply “offspring” before the acknowledgment of other memberships.