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Objective: To identify potential risk or mishap in the system of intrapartum care, relating to the deployment of midwives., Design: Prospective semistructured observational study., Setting: Labour wards of seven maternity units in the north west of England., Participants: All midwives working on the labour ward during the observation period in 2000., Main Outcome Measure: "Latent failures" within the system relating to midwifery staffing levels, deployment, and training or updating opportunities., Results: Despite the exemplary dedication of midwives, potential risk of mishap due to their deployment occurred within the system of care. A shortfall of midwives existed in all seven maternity units and was most acute in the largest units. Six units relied on bank midwives to maintain minimum staffing levels. High risk practices (oxytocin administration and epidural blockades) continued during midwifery shortfalls in all units. Some adverse events and "near misses" were attributable to midwifery shortages in all units, and near misses remained unreported in all units. Uptake of opportunities for training or updating in interpretation of cardiotocographs and obstetric emergency management remained low owing to midwifery shortages in all units. A poor skill mix of midwives occurred at times in all units. In six units midwives spent time away from clinical areas performing clerical duties. In three units team midwifery systems were reported to erode labour ward skills and confidence., Conclusion: Midwives are fundamental components in the system of intrapartum care, and the system cannot operate safely and effectively when the number of midwives is inadequate, midwives are poorly deployed, and they are unable to engage in opportunities for training and updating.

For an unprepared sexually active teenager the 1990s present a minefield of potential problems in addition to the most obvious problems of unplanned pregnancy and sexually transmitted disease. Promoting the importance of a healthy sexual and reproductive life to young people requires openness, better sex education, realistic discussion of related issues, and provision of contraception, as well as support if things go wrong. The Woodhouse Park Clinic in south Manchester opened in October 1988 with the aim of providing weekly advice sessions to young people up to the age of 18. Advice is given on topics such as substance misuse and smoking as well as on family planning. Attendance has steadily increased over the years; from April to June 1993 the average number of attenders per session was 39, one third of whom were young men.

Objective: To compare the effectiveness and acceptability of three regimens of postcoital contraception., Design: Randomised group comparison of ethinyloestradiol 100 micrograms plus levonorgestrel 500 micrograms repeated after 12 hours (Yuzpe method); danazol 600 mg repeated after 12 hours; and mifepristone 600 mg single dose., Setting: Community family planning clinic., Subjects: 616 consecutive women with regular cycles aged 16 to 45 years., Main Outcome Measures: Number of pregnancies, incidence of side effects, and timing of next period., Results: The raw pregnancy rates (with 95% confidence intervals) for the Yuzpe, danazol, and mifepristone groups were 2.62% (0.86% to 6.00%), 4.66% (2.15% to 8.67%), and 0% (0% to 1.87%) respectively. Overall, these rates differed significantly (chi 2 = 8.988, df = 2; p = 0.011). The differences between the mifepristone and Yuzpe groups and between the mifepristone and danazol groups were also significant. Side effects were more common and more severe in the Yuzpe group (133 women (70%)) than in either the danazol group (58 (30%)) or the mifepristone group (72 (37%)). The Yuzpe regimen tended to induce bleeding early but mifepristone prolonged the cycle. Three women bled more than seven days late in the Yuzpe group compared with 49 in the mifepristone group., Conclusions: Mifepristone was effective in reducing expected pregnancy rates and the Yuzpe method also had a clinical effect. Danazol had little or no effect. A further multicentre trial is needed.

The results of fitting Dalkon Shield I.U.D.s in Southampton and Dublin were compared. At 12 months the continuation rates were 77.4% and 93.4% respectively. There were also differences between the two cities in the major complication rates associated with the use of the device. At 12 months these rates for Southampton and Dublin were: pregnancy 5.6% and 1.4%, expulsion 4.0% and 0.9%, and removal for pain and/or bleeding 12.1% and 3.0%, respectively. Possible reasons for the difference in performance may include the older average age of the users in Dublin, and the greater number and more varied experience of the medical staff responsible for fitting in Southampton. We recommend that population factors be taken into account when comparing data relating to fertility regulation.

Intrauterine contraceptive devices (IUCDs) are thought to cause pelvic inflammatory disease by allowing vaginal bacteria to pass into the uterus along the tail of the device. In this study the uterine cavities of 22 women using an IUCD were examined by a multiple biopsy technique. All five uteruses with a tailless IUCD were sterile but 15 out of 17 with a tailed device contained bacteria. The bacteria had not reached the fundus and most were commensals. The bacteria were not introduced by insertion of the IUCD as bacteria were present in several cases long after insertion. No differences in bacterial count were found between monofilamentous and multifilamentous devices. Bacteria were cultured from only four devices, which suggested that the bacteria adhere to the endometrium and not to the device. The bacteria in the cavity represent interference by the tail with the protective mechanisms of the uterus, which explains the increase in pelvic inflammatory disease in IUCD users.

We measured the rate of release from copper-bearing intrauterine contraceptive devices (IUDs) with varying copper surface areas. Over 135 days of observation the release rate decreased exponentially. This decrease in the release rate was associated with the deposition of a protein layer on the surface of the metal. The bioavailability of copper on IUDs was not related to the volume of copper remaining on the device. Consequently any increase in the copper surface area of an IUD is unlikely to affect the duration of its copper-dependent contraceptive action.

A prospective study was carried out to see whether a small fixed dose of warfarin (1 mg daily) given before operation (mean 20 days) would prevent deep vein thrombosis in patients having major gynaecological surgery. One hundred and four patients were randomised into three groups: fixed minidose warfarin; full dose oral anticoagulation; and no treatment (controls). There was a significantly lower incidence of deep vein thrombosis in the minidose warfarin and full dose anticoagulant treatment groups (9% (3/32) and 3% (1/35) respectively) than in the controls (30%; 11/37) but no significant difference between the two anticoagulant treatment groups. Prothrombin time and the activated partial thromboplastin time were normal on the day of surgery in the warfarin treatment group, whereas times were prolonged in the group given full dose anticoagulation. Mean haemoglobin concentrations fell in all three groups after operation but the fall was significantly less in the minidose warfarin treatment group than after full dose anticoagulation. The benefit from full dose oral anticoagulant prophylaxis, based on a preoperative international normalised ratio of 1.5-2.5 with rabbit brain Manchester reagent, was similar to the protection achieved in an oral anticoagulant treatment group controlled with human brain Manchester comparative reagent at a similar level of anticoagulation. The lack of disturbance of normal haemostasis at the time of operation together with a significant reduction in deep vein thrombosis may encourage surgeons to introduce minidose prophylaxis with warfarin.

Stimulation of uterine activity after amniotomy has been carried out with prostaglandin E2 (PGE2) tablets in two dosage regimens and with intravenous oxytocin. Oxytocin stimulation was the most successful. The difference in success rate was most marked in nulliparous patients and those with low Bishop score.

The urinary gonadotrophin and ovarian steroid excretion pattern was studied in five women taking an oral contraceptive formulation consisting of mestranol 50 mug and norethisterone 1 mg. Both the pretreatment and post-treatment cycles were normal. The ovulatory peak of luteinizing hormone (LH) during the treatment cycles was uniformly suppressed, but LH continued to be excreted within the normal range. In one fifth of the treatment cycles there was a pronounced and sustained rise of oestrogen output in the absence of ovulation, and in many of the other treatment cycles oestrogen levels suggested that active ovarian steroidogenesis was taking place.

A survey of the sexual attitudes and knowledge of general practitioners in Wessex found that GP trainees and those in practice for less than 10 years were less conservative and better informed than doctors in practice for 20 years or more, The results suggest that the attitudes of the doctors are determined by their early environmental influences rather than their clinical experience.

Intrauterine devices containing copper were introduced into cultures of adult and fetal cells. The Dalkon shield had no apparent effect on cell growth. The Gravigard device caused inhibition of growth and an increase in copper concentration in the supranatant medium. When the latter device was transferred through a series of subcultures the rate of release of copper decreased and growth was no longer inhibited.

Three of the wives of 25 men undergoing maintenance haemodialysis for terminal renal failure became pregnant. This suggests that fertility is not necessarily impaired in these patients and that contraceptive methods should be used by women patients at risk.

Preliminary acceptability and reliability tests of the Dalkon Shield were done in 377 women over 17 months, amounting to 3,028 months of use. There was a 98% follow-up. The pregnancy rate of 4.7 and expulsion rate of 6.3 do not meet the claims described in initial trials by the developers of the device. Nevertheless, the Dalkon Shield seems to be an advance in intrauterine contraception since it has the advantages of a lower expulsion rate than the "first generation" inert intrauterine devices.