Nicholas Johnson

The role of the father

Abstract Only the mother-to-be is admitted to a maternity unit, but the midwife is admitting to the care not one but three persons—mother, father and baby—each dependent on the other for a safe and memorable birth. At no time during the childbearing experience should any person in the three-sided unit be lost, for exclusion of one member of the family can have serious consequences for all.

Fetal monitoring with pulse oximetry

Summary. Continuous fetal monitoring was achieved with a fetal scalp pulse oximetry sensor in 86 labours. The average recorded fetal oxygen saturation in early labour (cervical dilatation < 5 cm) was 68% (SD 13%). At the end of labour (cervical dilatation ≥ 9 cm) the recorded mean oxygen saturation was 58% (SD 17%). The largest range of readings during a single labour was 81%‐11% but this drop was associated with cord compression. The average SD during 1 h of normal labour was 10%. A second group of 40 fetuses was monitored during induction of labour before and after elective amniotomy. Oxygen saturation did not appear to change after amniotomy (mean change −0.4%, SD 1.2%) and there was no difference between mean antenatal or early intrapartum readings. We excluded the amniochorionic membranes as a possible source of data corruption by measuring their in vitro absorption spectra and confirming that they do not preferentially absorb light of either 660 or 940 nm wavelength. Non‐invasive pulse oximetry can be used to monitor the fetus before and during labour.

The efficacy and tolerance of mifepristone and prostaglandin in termination of pregnancy of less than 63 days gestation; UK multicentre study—Final results

This paper summarizes the final results of an open multicenter study in 13 hospital gynecological units in Scotland and England. In the study, 1018 pregnant women with up to 9 week amenorrhoea received 600 mg oral mifepristone followed 48 h later by vaginal gemeprost 1 mg for the induction of first trimester abortion. Outcome was measured by assessment of the frequency of complete abortion or the need for subsequent surgical evacuation. Tolerance was assessed in terms of pain, requirement for analgesia, bleeding, and other adverse effects. There was complete abortion in 94.8% (95%CI 93.4-96.2); surgical evacuation was performed in 5.2% of patients. There was no relationship between outcome and age of gestation on the day mifepristone was given. Seven women were given a transfusion. Narcotic analgesia was administered after gemeprost to 38.1% of nullipara and 10.7% of multipara. Mifepristone and prostaglandin is an effective and acceptable alternative to surgical termination of pregnancy in the early first trimester.

SIMULATION OF CERVICAL CHANGES IN LABOUR: REPRODUCIBILITY OF EXPERT ASSESSMENT

A carefully designed set of simulators showing cervical effacement and dilatation was used to assess the error within and between observers in a group of 36 midwives and 24 obstetricians. No observer was correct in every case. There was no significant difference between the obstetricians and the midwives in assessment of effacement or overall assessment of dilatation. However, midwives were significantly more likely than obstetricians to assess dilatation inaccurately by more than 1 cm. Inaccuracy was greatest in the simulators 5-7 cm dilated. These findings have implications for labour management and teaching.

A new method for measuring menstrual blood loss and its use in screening women before endometrial ablation

Objective 1. To develop and validate a method for measuring menstrual blood loss in a routine setting, and 2. To assess the value of measuring menstrual blood loss before endometrial ablation.

Effect of mifepristone on dilatation of the pregnant and non-pregnant cervix

The effect of the progesterone antagonist mifepristone on the cervix was investigated in two randomised double-blind placebo-controlled trials, the first in 30 women undergoing first trimester surgical termination of pregnancy and the second in 30 non-pregnant premenopausal women. 600 mg mifepristone, given orally 48 h before surgery, increased the mean preoperative cervical dilatation in both pregnant and non-pregnant treatment groups and also reduced the force required to dilate the pregnant and non-pregnant cervix.

The effect of oxytocin-induced hyperstimulation on fetal oxygen

considering that there is a natural decline in uterine activity of about 30 % of the initial value over a 90-minute period in the third stage of labour (when no drug is administered) (Ingemarsson et al. 1989). This study demonstrates a significant increase in uterine activity with breastfeeding or nipple stimulation. The differences between individual women in the absolute baseline uterine activity and the percentage increase after breastfeeding or nipple stimulation can be attributed to biological variation. The study supports the proposal of WHO (1993) that if oxytocics are not available, breastfeeding or nipple stimulation may be a safe, effective and economical means of reducing postpartum blood loss, especially blood loss resulting from a significant haemorrhage in the third stage. This needs further study in a clinical setting comparing postpartum blood loss and the incidence of postpartum haemorrhage with and without post-delivery breastfeeding. References Chua S., Arulkumaran S., Adaikan G. & Ratnam S. S. (1993) The effect of oxytocics stored at high temperatures on postpartum uterine activity. Br J Obster Gynaecol 100, 874-875. Ingemarsson I., Arulkumaran S., Wide-Swensson D., Forma A,, Andersson K.-E. & Ratnam S. S. (1989) Effects of isradipine, a new calcium antagonist on postpartum uterine activity. Acta Obstet Gynecol Scand 68, 725-730. Prendeville W., Elbourne D. & Chalmers I. (1988) The effect of routine oxytocic administration in the management of the third stage of labour: an overview of the evidence from controlled trials. Br J Obstet Gynaecol95, 3 16. Ratnam S. S., Viegas 0. A. C. & Singh K. (1989) Magnitude and causes of maternal mortality as a basis for its prevention. In Maternal and Child Care in Developing Countries (E. Kassel & A. K. Awan, ed.), Ott Publishers, Switzerland, pp. 80-90. World Health Organisation Regional Office for the Western Pacific (1993) World Breastfeeding Week 1993. Press Release.

Randomised trial comparing a policy of early with selective amniotomy in uncomplicated labour at term

Objective To compare two management policies: rupture of the fetal membranes when women are in normal labour or leave them intact as long as feasible.

Intracervical tents: usage and mode of action.

n Topical prostaglandins and intracervical tents at present comprise the most widely used methods for priming of the cervix before surgery. While tents and prostaglandins are comparable in terms of shortening the time interval between labor induction and delivery, tents do not initiate powerful myometrial contractions and thus are not associated with the complication of uterine hypertonus. In early abortion, tents are regarded as superior to prostaglandins, estrogen, and relaxin. In the midtrimester abortion, however, best results are achieved through the combined use of tents and prostaglandins. This approach facilitates a shorter abortion time, a lesser risk of sepsis, and use of a lower dose of prostaglandin. The effect of the particular type of tent selected--Clamicel, Dilapan, or Laminaria--is related to the initial state of the cervix, with the best results achieved in the soft patulous cervix of young pregnant women. Laminaria tents are declining in popularity as a result of their lengthy duration of action, unreliability, pain, or insertion and as the tent expands, and need for several insertions of multiple tents. The synthetic Dilapan tent does not share the disadvantages of inconsistency, long duration of action, and risk of sepsis, but tends to fragment and fracture so that the distal portion remains within the uterus. Lamicel, a polyvinyl alcohol sponge impregnated with magnesium sulfate, has a less impressive speed of action than Dilapan (3 hours and 2 hours, respectively), yet its softness makes it easy to withdraw without fragmentation or fracture. Lamicel has been used successfully in 1st-trimester abortion, before induction of labor or IUD insertion, for hysteroscopy and removal of lost IUDs, and in formal diagnostic curettage.n

Continuous fetal monitoring with a pulse oximeter: A case of cord compression

We have adapted a pulse oximeter to monitor fetal oxygen saturation during labor. In a case of acute cord compression the pulse oximetry reading dropped below 20% and this change in fetal oxygen saturation preempted changes in the cardiotocograph.