Peter C. Boylan

The Dublin randomized controlled trial of intrapartum fetal heart rate monitoring

In a randomized controlled trial involving 12,964 women, a policy of continuous electronic intrapartum fetal heart monitoring was compared with an alternative policy of intermittent auscultation, both policies including an option to measure fetal scalp blood pH. Women allocated to electronic fetal heart monitoring had shorter labors and received less analgesia. The caesarean delivery rates were 2.4% for electronic fetal heart monitoring and 2.2% for intermittent auscultation but this small difference arose from the identification of nearly twice as many fetuses with low scalp pH (less than 7.20) in the electronic fetal heart monitoring group. The forceps delivery rate was 8.2% in the electronic fetal heart monitoring group compared with 6.3% in the intermittent auscultation group, and this excess was explained by more instrumental deliveries prompted by fetal heart rate abnormalities. There were 14 stillbirths and neonatal deaths in each group, with a similar distribution of causes. There were no apparent differences in the rates of low Apgar scores, need for resuscitation, or transfer to the special care nursery. Cases of neonatal seizures and persistent abnormal neurological signs followed by survival were twice as frequent in the intermittent auscultation group, and this differential effect was related to duration of labor. Follow-up at 1 year of babies who survived neonatal seizures revealed three clearly abnormal infants in each group. The implications of these findings for both theory and practice are discussed.

The effect of continuous epidural analgesia on cesarean section for dystocia in nulliparous women

Epidural analgesia in labor is generally accepted as safe and effective and therefore has become increasingly popular. However, little is known regarding the effect of epidural analgesia on the incidence of cesarean section for dystocia in nulliparous women. During the first 6 months of 1987 we studied 711 consecutive nulliparous women at term, with cephalic fetal presentations and spontaneous onset of labor. Comparison of 447 patients who received epidural analgesia in labor with 264 patients who received either narcotics or no analgesia was performed. The incidence of cesarean section for dystocia was significantly greater (p less than 0.005) in the epidural group (10.3%) than in the nonepidural group (3.8%). There remained a significantly increased incidence (p less than 0.005) of cesarean section for dystocia in the epidural group after selection bias was corrected and the following confounding variables were controlled by multivariate analysis: maternal age, race, gestational age, cervical dilatation on admission, use of oxytocin, duration of oxytocin use, maximum infusion rate of oxytocin, duration of labor, presence of meconium, and birth weight. The incidence of cesarean section for fetal distress was similar (p greater than 0.20) in both groups. There were no clinically significant differences in frequency of low Apgar scores at 5 minutes or cord arterial and venous blood gas parameters between the two groups. This study suggests that epidural analgesia in labor may increase the incidence of cesarean section for dystocia in nulliparous women.

Maternal satisfaction with management in labour and preference for mode of delivery.

The aim of this study was to assess womens level of satisfaction with management during labour and to ascertain their preference for mode of delivery. The basis for the findings was the cross-sectional anonymous questionnaire survey of 520 women at a Dublin obstetric hospital. Visual analogue scales were used to assess degree of satisfaction. The response rate was 63% (520 of 830). 98.5% of women had hoped for a vaginal delivery and 1.5% for a Cesarean section. All primiparas had wanted a vaginal delivery. The majority of women were satisfied with their care in labour (65% had a score of > or = 7). Factors significantly associated with high levels of satisfaction were good analgesia during labour (particularly epidural), vaginal delivery, adequate preparation for labour and if personal wishes were listened to by staff. Almost all women have a preference for vaginal delivery. Satisfaction with care in labour is significantly influenced by vaginal delivery, empathetic communication by staff and good analgesia in labour.

Prolonged labor in nulliparas: lessons from the active management of labor.

Objective To define factors causing prolonged labor in nulliparous women undergoing active management of labor. Methods We included all nulliparas delivered during 1990–1994 with spontaneous onset of labor lasting more than 12 hours, singleton gestation, cephalic presentation, and labor at greater than 37 weeks. Each patient was matched with the next nulliparous woman who delivered with a labor lasting less than 12 hours and who fulfilled the same inclusion criteria. Subjects were managed according to the previously described active management of labor protocol from The National Maternity Hospital, Dublin. Results In the 5-year period, 9018 nulliparas met inclusion criteria, with 147 (1.6%) having prolonged labor. Prolonged labor was due to inefficient uterine action in 65%, persistent occipitoposterior position in 24%, and cephalopelvic disproportion in 11% of cases. Univariate analysis showed statistically significant (P <.05) differences in maternal body mass index, cervical dilation on admission, oxytocin use, epidural use, placement of epidural at less than 2 cm of dilation, and birth weight between these study groups. On multivariate conditional logistic regression analysis, the following were significant independent predictors for having a prolonged labor (odds ratios with 95% confidence intervals presented): 3.1 (1.3–7.3) for cervical dilation less than 2 cm on admission, 42.7 (7.5–242.0) for early epidural placement, 5.1 (1.9–13.7) for epidural placement at greater than or equal to 2 cm, and 10.2 (3.6–29.4) for birth weight greater than 4000 g. Conclusion Less-advanced cervical dilation on admission and epidural use, especially when placed early, are strongly associated with prolonged labor.

Changes in vaginal breech delivery rates in a single large metropolitan area

OBJECTIVE Vaginal breech delivery rates have been accepted widely to be in decline and the Term Breech Trial (TBT) has recommended delivery of a breech-presenting infant by elective cesarean section delivery. Our aim was to examine the rate of vaginal delivery of term breech pregnancies in the 8 years before and after the publication of the TBT. STUDY DESIGN We retrospectively examined vaginal delivery rates of breech presentations over a 16-year period in 3 large tertiary maternity hospitals that serve a single large metropolitan population. All 3 hospitals are of similar size and serve a population with similar risk profile. We also examined rates of perinatal mortality in the 3 hospitals over the study period. RESULTS During the 16-year study period, there were 344,259 deliveries among the 3 hospitals; 11,913 of which were breech deliveries. There were 5655 breech deliveries in the 8 years before the publication of the TBT, with a cesarean delivery rate of 76.9%. There were 6258 breech deliveries in the 8 years since publication of the TBT, and the cesarean delivery rate increased to 89.7% (P < .0001). During the 8 years since publication, the rate of vaginal delivery in nulliparous women decreased from 15.3-7.2% (P < .0001). The vaginal breech delivery rate in multiparous women decreased from 32.6-14.8% (P < .0001). The rates of corrected perinatal mortality showed a significant decrease in the last 4 years of the study. CONCLUSION Our study demonstrates that the results and recommendations of the TBT have contributed to decreasing vaginal breech delivery rates, which were already in decline before its publication.

Does oxytocin augmentation increase perinatal risk in primigravid labor

To assess the influence of high-dose oxytocin augmentation of spontaneous labor, a consecutive series of 30,874 primigravid term deliveries were analyzed for adverse perinatal outcome. In spite of a longer mean duration of labor, the frequencies of asphyxial perinatal death, neonatal seizures, and abnormal neonatal neurologic behavior were not significantly increased in 14,119 (45%) oxytocin-treated patients. There was no case of uterine rupture in any primigravid labor during the study. These results from 13 years of clinical practice provide reassurance about maternal and fetal safety if oxytocin is used as part of a protocol of active management to correct dystocia when spontaneous primigravid labor with vertex presentation fails to progress.

Acute intermittent porphyria in pregnancy — a case report

SummaryAcute intermittent porphyria diagnosed in the course of a first pregnancy is described. Despite severe neuro-psychiatric complications, the outcome was satisfactory for both mother and child. The patient and the literature are discussed.

Fetal acidosis in labour: a prospective study on the effect of parity.

The effect of parity on intrapartum fetal scalp pH was investigated in 6466 patients in labour with a live fetus who were delivered in 1987. 350 (5.4%) required fetal scalp blood sampling for pH (FBS), 236 primigravidae (10.4%) and 114 multigravidae (2.7%) (P less than 0.001). Fetal acidosis (pH less than 7.20) was detected in 35 patients, 27 primigravidae (11.4%) and 8 multigravidae (7.0%) (P less than 0.001). The incidence of intrapartum acidosis in the 2275 primigravidae and the 4191 multigravidae was 1.2 and 0.2% respectively (P less than 0.001). The two deaths from birth asphyxia and three cases of neonatal seizures occurred in primigravidae. In primigravidae requiring FBS, fetal acidosis was not associated with the use of oxytocin or with increased duration of labour. Neonatal seizures were more common overall in primigravidae than in multigravidae and more common in patients requiring FBS than in those not requiring FBS (P less than 0.05). The higher incidence of FBS, fetal scalp acidosis and neonatal seizures in primigravidae has important implications for intrapartum fetal monitoring.

HOW ACTIVELY SHOULD DYSTOCIA BE TREATED

osteosclerosis. By February, 1987, her spleen had virtually doubled in size (11 cm), and in view of her relatively young age and the likelihood of transfusion dependence we decided on a trial of IFN, with the patient’s consent. Before therapy with IFN-x on Feb 16,1987, the patient’s Hb was 9-8 g/dl, white cell count 18-4 x 109/1, and platelet count 73 x 109/1. Treatment began with 2-2 megaunits daily subcutaneously, but after 3 weeks of therapy Hb had fallen to 81 g/dl (platelets 38 x 109/1, white cells 10-0 x 109/1), and the dose was reduced to 2-2