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Objective: To explore the association between midline episiotomy and the risk of third- and fourth-degree lacerations during operative vaginal delivery with either vacuum extractor or forceps., Methods: This retrospective cohort study analyzed all operative vaginal deliveries at a university hospital in 1989 and 1990. Univariate analysis of the relationships between perineal lacerations and obstetric variables was performed. Stratified analysis using the relevant variables was used to calculate relative risk (RR) estimates., Results: Episiotomy, birth weight, and whether the index birth was the first vaginal birth were associated with third- and fourth-degree perineal lacerations. Stratified analysis demonstrated an RR of 2.4 with a 95% confidence interval of 1.7-3.5 for rectal injury with episiotomy, adjusting for parity and birth weight., Conclusion: Midline episiotomy is associated with an increased risk of third- and fourth-degree perineal lacerations in operative vaginal deliveries.

Objective: To assess the efficacy of external cephalic version, including safety, cost-benefit analysis, and impact on the cesarean delivery rate., Data Sources: A MEDLINE search was conducted to identify all articles published in English between 1980-1991 on external cephalic version. References were also cross-checked for all reports., Methods of Study Selection: We reviewed only those articles providing sufficiently detailed data to determine actual numbers of subjects. In cases of duplicate results, only the latest publication was used. Rates of successful version, cesarean delivery, and fetal and maternal complications were presented., Data Extraction and Synthesis: Among the United States trials, the success rate was approximately 65% (range 48-77%), and once version succeeded, almost all the fetuses stayed in the vertex position until birth. Among those in whom external version was performed, the mean cesarean delivery rate was 37%, compared with 83% in controls (P < .001). External version would also save 12.3% of the costs of delivering breech patients overall., Conclusion: External cephalic version is safe and cost-effective. It substantially reduces the cesarean delivery rate among breech presentations, decreases the risk related to breech delivery, and avoids cesarean delivery in subsequent pregnancies. However, external version will not have a major impact on the high overall cesarean birth rate.

This report describes 40 consecutive emergency cerclages on dilated and effaced cervices prior to 26 weeks' gestation. These "emergency" cerclages were associated with a mean extension of gestational age of 12 weeks (range, 3 days to 20.5 weeks). Thirty-one of 40 pregnancies were carried to 28 weeks' gestation and 23 were carried to 34 weeks' gestation or greater. Twelve of 19 women with amniotic membranes bulging into the vagina carried pregnancies to 28 weeks' gestation, with seven of these 19 women carrying the gestation to 34 weeks' or beyond. There was no maternal morbidity. Thirty-four of 41 infants survived (83%). Two pregnancies delivered within 8 days of the procedure. Emergency cerclages should be considered as a management option in women with painless dilation of the cervix and previable gestation.

Thrombocytopenia, associated with microangiopathic disease, is one characteristic of severe preeclampsia. Thrombocytopenia and intravascular hemolysis usually resolve by postpartum days 4 to 5. When thrombocytopenia secondary to microangiopathic disease persists, plasmapheresis may be used to arrest and reverse the process. Three patients over a 24-month period were successfully treated with plasma exchange with fresh frozen plasma. Several investigators who have cared for patients with persistent thrombocytopenia associated with preeclampsia have concluded that early plasmapheresis may be useful therapy. Plasma exchange should also be considered as a therapeutic option when clinical deterioration occurs due to microangiopathic disease.

Meconium-stained amniotic fluid occurs in approximately 12% of live births. In approximately one third of these infants meconium is present below the vocal cords. However, meconium aspiration syndrome develops in only 2 of every 1000 live-born infants. Ninety-five percent of infants with inhaled meconium clear the lungs spontaneously. Recent investigations have suggested that a reexamination of our assumptions about the etiology of meconium aspiration syndrome is in order. Several authors have provided evidence that support the hypothesis that it is not the inhaled meconium which produces the primary pathologic condition of meconium aspiration syndrome but rather it is fetal asphyxia that is the etiologic agent. Asphyxia in utero produces pulmonary vasospasm and hyperreactivity of the pulmonary vessels. With severe asphyxia the fetal lungs undergo pulmonary vascular damage with pulmonary hypertension. The damaged lungs are then unable to clear the meconium. In the most severe cases there is right-to-left shunting and persistent fetal circulation with subsequent fetal death. The incidence of meconium aspiration may thus be essentially unaffected by current obstetric and pediatric interventions at birth. For the asphyxiated or distressed infant we recommend suctioning at birth and tracheal intubation. In the healthy fetus observation may be sufficient.

A new technique using acrylic plug surface electrodes was employed to record electromyographic activity in the musculature surrounding the rectum and vagina. Forty-one asymptomatic nulliparous women were tested. The group had a wide range of normal values. When eight women were chosen at random for a second testing session, intra-class correlation coefficients to compare readings between the two sessions ranged from 0.76-0.97, indicating adequate reliability. No demographic factor correlated with the voltage generated in these women.

We reviewed twin deliveries during a five year period at North Carolina Memorial Hospital and Wake County Medical Center in which Twin B presented as nonvertex. We compared three delivery routes: primary abdominal delivery, breech extraction of the second twin and external version of the second twin. There was no difference in neonatal outcome between the delivery routes. Mothers in the external version group were more likely than those in the breech extraction group to undergo abdominal delivery of the second twin. These women also required more emergency anesthesia, had a higher blood loss and stayed in the hospital longer after delivery.

Of 1280 consecutive fetuses monitored internally with a scalp electrode for at least 10 minutes during labor, 54 (4.2%) demonstrated the sinusoidal heart rate (SHR) pattern. Seven of these demonstrated the SHR pattern for more than 90 minutes. In six of these seven cases, the SHR pattern occurred during oxytocin administration. The SHR group did not differ from the 1226 fetuses not demonstrating the SHR pattern (NSHR group) in Apgar scores, incidence of other fetal heart rate abnormalities, or passage of meconium. The scalp pH was obtained from three fetuses in the SHR group and was above 7.30 in each. Alphaprodine administration during labor was associated with development of the SHR pattern, whereas other narcotic administration was not. The significance of "atypical" SHR pattern with increased amplitude is discussed, along with the need to adhere to strict definition of the SHR pattern.

Presented are three cases of fetal death, all of which occurred within 3 days of a normal biophysical profile. Despite the excellent record of this antepartum test in predicting fetal well-being, there is a low incidence of false-negative tests; increasing the frequency of testing will not prevent all false-negative tests.

As a pilot study of occupational stress and pregnancy, we measured urinary catecholamine excretion in ten pregnant physicians and three intensive care nurses between 26-37 weeks' gestation, once during a work day and again during a non-work day. Urinary catecholamines were increased by 58% (P less than .03) during work periods compared with non-work periods. Catecholamine levels were also increased by 64% (P less than .025) over those of a working non-physician control group of similar gestational age. Urinary catecholamine levels are a direct reflection of plasma catecholamine levels. Catecholamine levels are known to increase with physical stress, such as standing, and with mental stress, such as difficult problem-solving. Catecholamines are also known to decrease uterine blood flow. Measurement of catecholamines may be a helpful marker in investigating the relationship between occupation and pregnancy outcome.

Using a retrospective cohort design, we analyzed the effects of intrauterine diethylstilbestrol (DES) exposure on various antepartum and intrapartum events. Gravidas exposed to DES had a higher likelihood of being delivered abdominally, undergoing manual removal of the placenta, and hemorrhaging in the postpartum period. The increased risk for these events remained after controlling for age, race, and parity. We also constructed labor curves in DES-exposed women by plotting cervical dilation against time. The curves were similar for nulliparous DES-exposed women and nulliparous controls, but DES-exposed parous women experienced prolonged labors. These findings suggest that, in addition to the well-known adverse effects of intrauterine DES exposure, the interaction between the uterus and placenta is altered in some DES-exposed patients.

Sixty-one of 375 women with hypertension and preeclampsia in a 48-month period had thrombocytopenia. By postpartum day 3, 90% of these women had rising platelet counts, and by day 4, 59 of 61 women had counts greater than 100,000/mm3. The two exceptions had other pathologic conditions in addition to preeclampsia. Thrombocytopenia associated with preeclampsia should resolve by postpartum day 4.

Plasmapheresis, a process in which blood is withdrawn, the plasma removed, and the red cells reinfused after resuspension in a replacement solution, has been used for a variety of conditions during pregnancy, but is most useful in the treatment of pregnancy complicated by thrombotic thrombocytopenic purpura or persistent postpartum microangiopathic hemolytic disorders. A low risk of morbidity and fatalities associated with plasmapheresis has been reported, but the incidence of these complications does not seem to be affected by pregnancy.

The clinical manifestations of severe preeclampsia and thrombotic thrombocytopenic purpura are similar. Patients with thrombotic thrombocytopenic purpura have been demonstrated to have larger than usual von Willebrand factor multimers. Serial serum samples were taken from patients with severe preeclampsia, all with platelet counts less than 50,000. Von Willebrand factor multimeric patterns were normal in all the patients except one, who later proved to have chronic relapsing thrombotic thrombocytopenic purpura. All patients had elevated levels of von Willebrand factor. Although the clinical presentations of thrombotic thrombocytopenic purpura and severe preeclampsia with thrombocytopenia have many similarities, the underlying pathophysiology of each disorder appears to be different.

Triamcinolone acetonide, a fluorinated glucocorticoid, when given in large parenteral doses has produced structural anomalies and severe growth retardation in nonhuman primates. We present a case report of a gravid patient who applied 40 mg/day of triamcinolone cream because of atopic dermatitis from 12 to 29 weeks' gestation. The infant was symmetrically growth retarded, possibly from exposure to triamcinolone acetonide. There was no evidence of hypoxic, chromosomal, or infectious cause of the growth delay.

A prospective, nonrandomized controlled study was performed to determine the effect of using midline episiotomy only for mothers who experienced fetal distress and/or operative vaginal delivery. Such a policy resulted in a significant decline in third- and fourth-degree lacerations in nulliparous women. This reduction was most pronounced in nulliparous women delivering infants larger than 3400 g. No third- or fourth-degree laceration occurred without antecedent episiotomy in any woman. A policy of using episiotomy selectively appears to lower the incidence of perineal trauma.

A technique of fetal transfusion using sonographic guidance for needle placement is described. Sixteen patients underwent a total of 43 transfusions. The fetal mortality risk appears to be lower than that encountered in fluoroscopy-directed transfusions. Fetal irradiation has been dramatically reduced from an average of 2.2 rads per transfusion to 0.29 rads per transfusion. The technique allows very precise placement of a needle within the uterus or fetus. We have used it in difficult cases for amniocentesis. The technique could also be adapted to other problems requiring accurate placement of a needle within the body, such as biopsy of masses or aspiration of cysts.

This report describes and illustrates a case of a fetal death 2 hours after an ultrasonically guided intravascular intrauterine transfusion. The apparent cause of fetal death was a cord hematoma at the site of puncture, with umbilical vein thrombosis. The hematoma appears to have been related to injection of pancuronium before confirmation of needle placement, resulting in creation of a dead space in the cord adjacent to the puncture site. A total of 68 such procedures performed on 23 fetuses with three fetal deaths (4%) have been reported. This case is the first documented procedure-related death in a consecutive experience of 35 transfusions in 15 fetuses at this institution.

Routine intrapartum pharyngeal suctioning with a DeLee catheter of infants with meconium staining has significantly reduced the incidence and severity of meconium aspiration syndrome (MAS). There have been no adverse sequelae to this procedure, which is carried out while the infant's head is on the perineum, prior to the onset of respirations. Routine suctioning of the trachea under direct vision after delivery is rarely necessary but should be done if meconium is visualized at the vocal cords. Tracheobronchial lavage with saline may add to the respiratory morbidity. No deaths or severe cases of MAS have occurred since institution of the obstetric suctioning procedure.

All physicians responsible for the care of gravidae at high risk for preterm labor and delivery must be expert in the management of these pregnancies. Only a fraction of women who present in labor remote from term are candidates for long-term tocolysis. Whatever treatment regimen is utilized, the clinician must be familiar with their risks as well as their benefits. The majority of women who present with preterm labor will require delivery or will deliver despite efforts to the contrary. If delivery is imminent or indicated, intensive intrapartum monitoring of these fetuses, especially those weighing less than 1500 gm, is mandatory. The mother should be transferred to a facility that contains both expert obstetric care and a neonatal intensive care unit staffed with individuals experienced in the management of these very low birth weight infants. Attempts at pharmacologic induction of lung maturation should be reserved for those situations in which: (1) the fetal membranes are intact, (2) the fetal lungs are likely to be immature, (3) delivery of the infant may be delayed without undue risk for 48 hours following initiation of therapy, and finally, (4) the informed consent of the parents has been obtained. (By the same token, the probable efficacy of glucocorticoids should not serve as license to deliver the preterm infant.) Preterm infants are viable, even at 25 to 26 weeks of gestation, provided that labor and delivery are managed expertly. When vaginal delivery is contemplated, labor, if induced, should not be forceful. Fetal heart rate and uterine contractions should be monitored continuously. Evidence of fetal jeopardy must be dealt with expeditiously. Nontraumatic delivery, including the liberal use of cesarean section, into the hands of an experienced neonatologist will reduce the number of asphyxiated premature infants and, therefore, the risk of hyaline membrane disease. For the very low birth weight infant presenting as a breech, abdominal delivery is recommended. It is important that the uterine incision, regardless of type, be large enough to allow for nontraumatic delivery of the infant. If greater improvements in the survival and outcome of low birth weight infants are to continue, it is mandatory that there be close collaboration not only between obstetrician and pediatrician, but also between all physicians and nursing staff who care for this group of high-risk patients.

Vital records data (1971 to 1978) were used to assess the change in neonatal and fetal mortality in Colorado in relationship to the regionalization of perinatal health care within the state. There has been a decrease in neonatal mortality rate from 13.4 to 6.9 during a period of time when there was a minimal decrease in the incidence of low-birth weight infants. The improved neonatal mortality has been associated with a shift in the frequency of birth of very low-birth weight (VLBW) infants to hospitals with level II and III perinatal services and relatively greater survival rates of VLBW infants born in these hospitals as compared to those born in level I hospitals. There was no decrease in fetal mortality in the same period of time. These date suggest that outreach education in perinatal medicine should now emphasize current knowledge and methods for reducing antepartum deaths.

This report deals with a patient's refusal to undergo cesarean section, which was recommended when fetal distress occurred in labor. Faced with this conflict of maternal and fetal rights, the physicians, administrators, and attorneys of the hospital requested a hearing and decision on the issue by the juvenile court. As a result cesarean section was performed as ordered by the court to safeguard the life of the unborn infant in spite of the objections of the mother. This case, in part, illustrates the need for the administrative capability to deal with such a situation even on an emergency basis, and a possible solution when this situation arises.

Most drugs have been found to be excreted in human breast milk. Usually when the drug is taken in therapeutic amounts for short periods of time by the mother, the levels of the drug in breast milk are sufficiently low to be of little hazard to the infant. However, is a breast-feeding infant should become ill or fail to thrive and the morbidity cannot be explained, one of the following should be done: 1. Discontinue the drug. 2. Discontinue breast feeding. Frequently this can be accomplished on a temporary basis with the mother pumping her breasts to maintain lactation while the response of the infant is monitored. 3. Collect maternal plasma, breast milk, and infant plasma samples for drug assay. In situations in which this can be accomplished, it may be possible to incriminate (or exonerate) a drug or one of its metabolites as the source of the morbidity on the basis of the amounts of drug found in the milk or the infant's plasma. As tedious and impractical as this approach may seem, it would eventually lead to the accumulation of a reasonable amount of data from which could be drawn sensible conclusions about the effect of drugs on the breast-fed infant.

We reviewed the perinatal mortality due to group B streptococcal infection over a three-year period at a tertiary center. In 6 of 16 perinatal deaths due to group B Streptococcus, representing a range of gestational ages, infection occurred with the membranes intact. A review of reports from the obstetric and pediatric literature revealed that 10-50% of group B streptococcal infections occur in this manner. Several investigators of both animals and humans have demonstrated the pathophysiology of an ascending transamniotic infection. The current series emphasized this mode of infection in group B streptococcal disease.

Studies indicate an increased risk of adverse late pregnancy events, such as preterm labor and preterm delivery, for practicing physicians. These adverse pregnancy outcomes also occur among pregnant women who work long hours with high levels of psychological stress, a mechanism most likely related to catecholamine and posturally mediated alterations in uterine blood flow. Further evaluation and research into the epidemiology of physicians' pregnancies are needed because of the increasing number of women physicians in their childbearing years.

Neonatal mortality in Colorado in the 3-year period 1977-1979 has been analyzed by means of standardized neonatal mortality ratios derived from birth weight-specific mortality for every obstetric facility. The standardized neonatal mortality ratios adjusted for the percentage of neonatal deaths due to untreatable disorders are presented as one possible method for comparing the neonatal outcome in obstetric populations of dissimilar risk. We have suggested that facilities with adjusted standardized neonatal mortality ratios significantly above 1 are those that might benefit from an in-depth review of perinatal services.

Late during the fifth intravascular intrauterine transfusion of a fetus with severe Rh isoimmunization, the loss of visible echogenic turbulence within the umbilical vein during injection preceded the development of unresolving fetal bradycardia. An umbilical cord hematoma was found at the time of emergency cesarean delivery. Although seldom described, echogenic turbulence is an important feature of the successful intravascular intrauterine transfusion, and deserves close surveillance. Disappearance of this visible turbulence suggests loss of proper needle location. Possible sources of needle tip displacement are discussed and preventive measures described.

Umbilical cord length may be a function of fetal movement. Agents that cause decreased fetal movement may cause short umbilical cords. This investigation examined the effect of the beta-blocker atenolol on umbilical cord length in rabbits. Fetuses of rabbits treated with atenolol had significantly shorter cords than control animals (p less than or equal to 0.0005). Since short cords are associated with problems in labor, low Apgar scores, and abruption, we recommend careful surveillance of mothers and fetuses who are given beta-blocking agents in the first 30 weeks of pregnancy.

The successful use of ultrasound-guided fetal umbilical venipuncture and direct intravascular transfusion in a case of severe hydrops fetalis at 28 weeks' gestational age is described. Complete reversal of the hydropic changes was observed in utero. The use of this new technique in fetal treatment of Rh disease is discussed.

Eighteen cases of acute and subacute puerperal inversion were studied to identify important predisposing factors and to assess management and postpartum morbidity. The study patients did not differ from case-matched controls in age, parity, duration of labor, type of delivery, or management of the third stage. The most common signs noted were hemorrhage (94%) and shock (39%). All inversions were recognized immediately and manually replaced within 60 minutes. Shock was treated prior to repositioning in all cases. Calculated blood loss averaged 1775 ml. There was no mortality nor febrile morbidity. The average hospital stay of the study patients and their case-matched controls was 3 days. Immediate recognition of uterine inversion and prompt initiation of therapy will ensure a normal postpartum course.

One hundred thirty women were randomly assigned to treatment with one of three triphasic oral contraceptives and 43 women using nonhormonal methods served as controls for a 6-month study of the metabolic effects of these formulations. One of the oral contraceptives contained ethinyl estradiol and levonorgestrel, and the other two contained ethinyl estradiol and norethindrone. Compared with pretreatment assessment, all three triphasic oral contraceptives produced small increases in the mean plasma glucose levels that were statistically significant but clinically unimportant. No subjects had abnormal glucose response curves in glucose tolerance test results. Compared with pretreatment assessment, all of the oral contraceptive preparations produced small increases in the mean insulin levels at 3 months but not at 6 months. Overall there were no statistically significant differences among the three formulations in their effects on carbohydrate metabolism as measured by glucose or insulin levels after 6 months of treatment.

Maternal floor infarction is a recurring placental disease of ubiquitous perivillous fibrin deposition with obliteration of normal placental architecture. In this case, elevated levels of maternal serum alpha-fetoprotein (AFP) were found as well as a small fetal-maternal bleed. The association between placental disease and elevated maternal serum AFP is discussed.

Continuous monitoring tracings of fetal heart rate in 61 infants with birth weights of 1,500 grams or less were analyzed and related to newborn outcome. Reassuring heart rate patterns or good baseline variability correlated well with a normal unbilical artery pH. Fetal heart rate patterns and baseline variability were not related in a predictive way to central nervous system hemorrhage, respiratory distress syndrome, or neonatal death. Early intervention and operative delivery in cases demonstrating abnormal fetal heart rate patterns may have influenced the outcome in these infants. Fetal heart rate patterns can play an important role in the intrapartum assessment of the condition of the very-low-birth-weight infant and may be used to select those infants requiring prompt operative intervention and vigorous neonatal resuscitation.

Records on 16,458 consecutive births were examined to determine associations between the respiratory-distress syndrome of the newborn and cesarean section, maternal diabetes, ante-partum hemorrhage, toxemia of pregnancy, low one-minute Apgar scores and prolonged rupture of fetal membranes. Groups of infants were compared by four-week gestational age blocks. One-minute Apgar scores of less than 5 and of less than 8 were associated with a significant ( less than 0.05) increase in the incidence of respiratory-distress syndrome at gestational ages beyond 30 weeks. Cesarean section was associated with a significant increase after 34 weeks of gestation. There was no association between the syndrome and toxemia of pregnancy, ante-partum hemorrhage or prolonged rupture of fetal membranes. These data do not support the hypothesis that there is a lower incidence of the respiratory-distress syndrome in infants born after prolonged rupture of fetal membranes.

Unusual antenatal treatment of a case of severe fetal hydrothorax with secondary polyhydramnios and preterm labor is presented and illustrated. Bilateral pleural drainage catheters were placed antenatally to decompress the fetal chest in an effort to prolong pregnancy because of immature pulmonary studies and poor prognosis. Catheter migration occurred and effective drainage ceased after three days, but with tocolysis and bilateral thoracentesis, delivery was delayed another 48 hours to allow steroid therapy. With ventilatory therapy and chest drainage the infant survived and is doing well at one year of age.

A unique approach in utilization of nursing personnel was instituted at the University of Colorado Medical Center to alleviate the following patient care problems: 1) lack of continuity of care of obstetric patients, 2) inadequate prenatal instruction, and 3) the unpredictability of patient census in the labor and delivery area. Half the nurses from the labor and delivery area were organized into four teams of two nurses each who acquired a case load of patients for antepartum care. When a patient was admitted to the hostpial in labor, the nurse from her team who was on call came in and provided all nursing care during the intrapartum period. The problems and benefits of this new approach to nursing care are discussed.