Thomas F. Baskett

Investigation of an increase in postpartum haemorrhage in Canada

Objective  To investigate the cause of a recent increase in hysterectomies for postpartum haemorrhage in Canada.

Perinatal implications of shoulder dystocia

Objective To assess the antecedents of shoulder dystocia, the risk of recurrence, and the perinatal morbidity associated with the different maneuvers used for its management. Methods We conducted a 10-year (1980–1989) retrospective case record review of all instances of shoulder dystocia in a teaching maternity hospital. Results There were 254 cases of shoulder dystocia in 40,518 vaginal cephalic deliveries (0.6%), with 33 cases (13.0%) of brachial plexus palsy and 13 fractures (5.1%). There were no perinatal deaths attributable to shoulder dystocia. The risk of shoulder dystocia was increased with prolonged pregnancy (threefold), prolonged second stage of labor (threefold), mid-forceps deliveries (tenfold), and increasing birth weight. Of the maneuvers used to deal with shoulder dystocia, strong downward traction on the head was significantly correlated with brachial plexus palsy compared with other individual methods of delivering the shoulders. There was only one case of recurrent shoulder dystocia in 80 women having 93 cephalic vaginal deliveries after their original delivery coded with shoulder dystocia. Conclusion Shoulder dystocia is not a reliably predictable event in labor. Although the risk of shoulder dystocia is increased with prolonged pregnancy, prolonged second stage of labor, increasing birth weight, and mid-forceps delivery, the majority of cases occur without these risk factors. Strong downward traction on the head is associated with the greatest degree of neonatal trauma, whereas McRoberts maneuver has the least. The risk of recurrent shoulder dystocia is low.

Maternal intensive care and near‐miss mortality in obstetrics

Objective To determine the level of near‐miss maternal mortality and morbidity due to severe obstetrical complications or maternal disease in a tertiary maternity hospital.

Amniotic-fluid embolism and medical induction of labour: a retrospective, population-based cohort study

BACKGROUND Amniotic-fluid embolism is a rare, but serious and often fatal maternal complication of delivery, of which the cause is unknown. We undertook an epidemiological study to investigate the association between amniotic-fluid embolism and medical induction of labour. METHODS We used a population-based cohort of 3 million hospital deliveries in Canada between 1991 and 2002 to assess the associations between overall and fatal rates of amniotic-fluid embolism and medical and surgical induction, maternal age, fetal presentation, mode of delivery, and pregnancy and labour complications. FINDINGS Total rate of amniotic-fluid embolism was 14.8 per 100,000 multiple-birth deliveries and 6.0 per 100,000 singleton deliveries (odds ratio 2.5 [95% CI 0.9-6.2]). Of the 180 cases of amniotic-fluid embolism in women with singleton deliveries during the study period, 24 (13%) were fatal. We saw no significant temporal increase in occurrence of amniotic-fluid embolism for total or fatal cases. Medical induction of labour nearly doubled the risk of overall cases of amniotic-fluid embolism (adjusted odds ratio 1.8 [1.3-2.7]), and the association was stronger for fatal cases (crude odds ratio 3.5 [1.5-8.4]). Maternal age of 35 years or older, caesarean or instrumental vaginal delivery, polyhydramnios, cervical laceration or uterine rupture, placenta previa or abruption, eclampsia, and fetal distress were also associated with an increased risk. INTERPRETATION Medical induction of labour seems to increase the risk of amniotic-fluid embolism. Although the absolute excess risk is low, women and physicians should be aware of this risk when making decisions about elective labour induction.

A Simplified Protocol for Pessary Management

Objective To evaluate a simplified protocol for pessary management. Methods Women with symptomatic pelvic organ prolapse who opted for pessaries were enrolled in a prospective simplified protocol for pessary management. After the initial pessary fitting, they were seen at 2 weeks for reexamination and thereafter at 3- to 6-month intervals. Results One hundred ten women (mean age 65 years) were enrolled, and 81 (74%) of them were fitted successfully with a pessary. Life-table analysis showed that 66% of those who used a pessary for more than 1 month were still users after 12 months and 53% were still users after 36 months. The severity of pelvic prolapse did not predict the likelihood of pessary failure except in cases of complete vaginal eversion. Patients complaining of stress incontinence were less likely to have a successful pessary fitting and more likely to opt for surgery. Current hormone use and substantial perineal support do not predict greater likelihood of pessary fitting success. No serious complications from using the pessary were observed n the study sample. Conclusion Stringent guidelines calling for frequent Pelvic examinations during pessary use can be relaxed safely. Pessaries can be offered as a safe long-term option for the mangement of pelvic prolapse.

Maternal and perinatal outcomes with increasing duration of the second stage of labor.

OBJECTIVE: To estimate maternal and perinatal outcomes among women with increasing duration of the second stage of labor. METHODS: A population-based cohort study was conducted among women with low-risk, singleton, vertex, nonanomalous deliveries at or after 37 weeks of gestation between 1988 and 2006. Individual maternal (hemorrhagic, infectious, and traumatic), perinatal (birth depression, infectious, and traumatic), and composite outcomes were evaluated with increasing duration of the second stage. Logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals for all outcomes and to account for confounding variables, including maternal age, prelabor rupture of membranes, augmentation of labor, antibiotics in labor, regional analgesia, gestational age, birth weight, and year of birth. Effect modification caused by method of delivery was considered. RESULTS: From a population of 193,823 women, 121,517 women met inclusion and exclusion criteria, of whom 63,404 (52%) were nulliparous. There was an increase in risk of maternal obstetric trauma, postpartum hemorrhage, puerperal febrile morbidity and composite maternal morbidity, and low 5-minute Apgar score, birth depression, admission to the neonatal intensive care unit, and composite perinatal morbidity among both nulliparous women and multiparous women, with increasing duration of the second stage of labor. Method of delivery only modified the effect of duration of second stage among nulliparous women. CONCLUSION: Risks of both maternal and perinatal adverse outcomes rise with increased duration of the second stage, particularly for duration longer than 3 hours in nulliparous women and longer than 2 hours in multiparous women. LEVEL OF EVIDENCE: II

Maternal and perinatal morbidity of caesarean delivery at full cervical dilatation compared with caesarean delivery in the first stage of labour

To estimate maternal and perinatal morbidity associated with caesarean delivery at full cervical dilatation, a population‐based cohort study from 1997 to 2002 was used, which included 1623 nullipara with singleton pregnancies at 37–42 weeks of gestation requiring caesarean delivery in labour. Compared to caesarean delivery at less than full dilatation, women undergoing caesarean delivery at full dilatation were more likely to have complications of intraoperative trauma (RR 2.6, P < 0.001) and infants with perinatal asphyxia (RR 1.5, P < 0.05). There was no difference in maternal or perinatal morbidity when duration of the second stage of labour or when failed assisted vaginal delivery was considered.

In the arms of Morpheus the development of morphine for postoperative pain relief.

Purpose: To analyse the historical development of morphine for postoperative analgesia and how this development was shaped by the evolution of anesthetic techniques.Methods: After a systematic review of the literature, information was gathered from primary sources.Principal Findings: In ancient medicine, some plant derivatives were used to alleviate pain including: alcohol, cannabis, mandrake, and opium. Over the past two centuries, opium and its derivatives have become the most widely used analgesics for severe pain. Before the development of general anesthesia, surgery was only performed out of extreme necessity. It is probable that an analgesic such as opium would have been given following surgery although its use may not have been recorded. The first description of postoperative opium was by James Moore in 1785. Morphine was isolated from opium by Friedrich Serturner in 1805. However, it was not until the development of the hypodermic needle and syringe nearly 50 yr later that the use of morphine became widespread. Over the last century, various delivery systems for morphine have been developed including subarachanoid and epidural injection, and more recently patient-controlled intravenous, epidural and intranasal analgesia. In addition, many new opioids have been synthesized.Conclusion: Since its isolation from opium almost 200 yr ago, morphine remains the most widely used analgesic and the standard against which all new opioids for postoperative pain relief are compared.RésuméObjectif: Décrire le développement historique de la morphine comme analgésique postopératoire et montrer comment il a été façonné par l’évolution des techniques anesthésiques.Méthode: On a d’abord passé systématiquement en revue la documentation pertinente, puis rassemblé les informations des principales sources.Constations principales: La médecine ancienne utilisait certains dérivés de plantes pour soulager la douleur: l’alcool, le cannabis, la mandragore et l’opium. Au cours de deux derniers siècles, l’opium et ses dérivés sont devenus les analgésiques les plus utilisés contre la douleur vive. Avant l’avènement de l’anesthésie générale, l’intervention chirurgicale n’était réalisée qu’en cas d’extrême nécessité. Il est probable qu’un analgésique comme l’opium ait été administré à la suite d’une opération sans qu’on en consigne l’emploi. La première description de l’utilisation postopératoire d’opium revient à James Moore en 1784. La morphine a été isolée de l’opium par Friedrich Serturner en 1805. Cependant, son usage ne s’est répandu qu’avec l’arrivée, 50 ans plus tard, de l’aiguille hypodermique et de la seringue. Pendant le siècle dernier, on a mis au point différents systèmes d’administration de la morphine, y compris l’injection sous-arachnoïdienne et péridurale et, plus récemment, l’analgésie intraveineuse, péridurale et intranasale contrôlée par le patient. De plus, nombre de nouveaux opioïdes ont été synthétisés.Conclusion: Depuis que la morphine a été isolée de l’opium, il y a près de 200 ans, elle demeure l’analgésique le plus utilisé et une norme de comparaison pour tout nouvel opioïde utilisé pour soulager la douleur postopératoire.

Uterine compression sutures for postpartum hemorrhage: efficacy, morbidity, and subsequent pregnancy.

OBJECTIVE: To review the efficacy, morbidity, and subsequent pregnancy outcome after uterine compression sutures for severe postpartum hemorrhage. METHODS: A 7-year review (2000–2006) of all uterine compression sutures for postpartum hemorrhage at one tertiary obstetric hospital. RESULTS: During the 7 years, 28 uterine compression sutures were performed in 31,519 deliveries (1 per 1,126). All were done at the time of cesarean delivery: 22 in 4,870 cesarean deliveries in labor (1 in 221) and 6 in 3,819 elective cesarean deliveries (1 in 637). The indications for suture were atonic postpartum hemorrhage in 25 of 28 (89%), placenta previa in 2 of 28 (7%), and partial placenta accreta in 1 of 28 (4%). Hysterectomy was avoided in 23 of 28 women (82%). Blood transfusion was needed in 13 of 28 (46%), and intensive care in 5 of 28 (18%). Seven women had subsequent uncomplicated term pregnancies, all delivered by elective repeat caesarean delivery. CONCLUSION: Uterine compression sutures for severe postpartum hemorrhage may obviate the need for hysterectomy and appear not to jeopardize subsequent pregnancy. LEVEL OF EVIDENCE: III

Maternal morbidity associated with cesarean delivery without labor compared with induction of labor at term

OBJECTIVE: To estimate the maternal morbidity associated with cesarean deliveries performed at term without labor compared with morbidity associated with induction of labor at term. METHODS: A 15-year population-based cohort study (1988–2002) using the Nova Scotia Atlee Perinatal Database compared maternal outcomes in nulliparous women delivering by cesarean delivery without labor and nulliparous women at term undergoing induction of labor for planned vaginal delivery with singleton, cephalic presentation. RESULTS: A total of 5,779 pregnancies satisfied inclusion and exclusion criteria, 879 of which were cesarean deliveries without labor. There were no maternal deaths. There was no difference in wound infection, puerperal febrile morbidity, blood transfusion or intraoperative trauma. After controlling for potential confounders, women undergoing cesarean delivery without labor were less likely to have complications of early postpartum hemorrhage (relative risk 0.61, 95% confidence interval 0.42–0.88, number needed to treat 32) and composite maternal morbidity (relative risk 0.71, 95% confidence interval 0.52–0.95, number needed to treat 34) compared with women undergoing induction of labor. Subgroup analyses of maternal outcomes after induction of labor in women by method of delivery were also performed and demonstrated additional risks of traumatic morbidity after induction of labor. The highest morbidity was found in the assisted vaginal delivery and cesarean delivery in labor groups. CONCLUSION: Early postpartum hemorrhage and composite maternal morbidity were decreased in cesarean delivery without labor compared with induction of labor. Hemorrhagic and traumatic morbidities with labor induction are increased after assisted vaginal delivery and cesarean delivery in labor compared with cesarean delivery without labor. LEVEL OF EVIDENCE: II-2