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Background: There are two approaches to care during the third stage of labour: Active management includes three components: administration of a prophylactic uterotonic drug, cord clamping and controlled cord traction. For physiological care, intervention occurs only if there is clinical need. Evidence to guide care during the third stage is limited and there is variation in recommendations which may contribute to differences in practice. This paper describes current UK practice during the third stage of labour., Methods: A postal survey of 2230 fellows and members of the Royal College of Obstetricians and Gynaecologists (RCOG) and 2400 members of the Royal College of Midwives was undertaken. Respondents were asked about care during the third stage of labour, for vaginal and caesarean births and their views on the need for more evidence to guide care in the third stage. The data were analysed in Excel and presented as descriptive statistics., Results: 1189 (53%) fellows and members of the RCOG and 1702 (71%) midwives responded, of whom 926 (78%) and 1297 (76%) respectively had conducted or supervised births in the last year. 93% (863/926) of obstetricians and 73% (942/1297) of midwives report 'always or usually' using active management. 66% (611/926) of obstetricians and 33% (430/1297) of midwives give the uterotonic drug with delivery of the anterior shoulder; this was intramuscular Syntometrine(R) for 79% (728/926) and 86% (1118/1293) respectively. For term births, 74% (682/926) of obstetricians and 41% (526/1297) of midwives clamp the cord within 20 seconds, as do 57% (523/926) and 55% (707/1297) for preterm births. Controlled cord traction was used by 94% of both obstetricians and midwives. For caesarean births, intravenous oxytocin was the uterotonic used by 90% (837/926) of obstetricians; 79% (726/926) clamp the cord within 20 seconds for term births as do 63% (576/926) for preterm births.Physiological management was used 'always or usually' by 2% (21/926) of obstetricians and 9% (121/1297) of midwives. 81% (747/926) of obstetricians and 89% (1151/1297) of midwives thought more evidence from randomised trials was needed; the most popular question was when is best to clamp the cord., Conclusions: Active management of the third stage of labour is widely used by both obstetricians and midwives in the UK. Syntometrine(R) is usually used for vaginal births and oxytocin for caesarean births; when this is given and when the cord is clamped varies.

Pregnancy and childbirth should be a safe and memorable experience for both women and their partners. This article discusses the current position of maternity services, their strengths and limitations, and suggests future directions required to improve these services further.

Background: Diabetes causes a rise in blood glucose above normal physiological levels causing damage to many systems including the cardiovascular and renal systems. Pregnancy causes a physiological reduction in insulin action; for those women who have pre-gestational diabetes, this results in an increasing insulin requirement. There are several methods of administering insulin. Conventionally, insulin has been administered subcutaneously, formally referred to as intensive conventional treatment, but now more usually referred to as multiple daily injections (MDI). An alternative insulin administration method is the continuous subcutaneous insulin infusion pump (CSII)., Objectives: To compare continuous subcutaneous insulin infusion with MDI of insulin for pregnant women with diabetes., Search Strategy: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2006)., Selection Criteria: Randomised controlled trials comparing CSII with MDI for pregnant women with diabetes., Data Collection and Analysis: Three authors independently assessed studies and extracted data., Main Results: Two studies (60 women with 61 pregnancies) were included. There was a significant increase in mean birthweight associated with CSII as opposed to MDI (weighted mean difference 220.56, 95% confidence interval (CI) -2.09 to 443.20; two trials, 61 participants). However, taking into consideration the lack of significant difference in rate of macrosomia (birthweight greater than 4000 g) (relative risk (RR) 3.20, 95% CI 0.14 to 72.62; two trials, 61 participants), this is not viewed by the authors as clinically significant. No significant differences were found in any other outcomes measured, which may reflect the small number of trials suitable for meta-analysis and the small number of participants in the included studies. No significant differences were found in perinatal mortality (RR 2.00, 95% CI 0.20 to 19.91), fetal anomaly (RR 1.07, 95% CI 0.07 to 15.54), maternal hypoglycaemia (RR 3.00, 95% CI 0.35 to 25.87) or maternal hyperglycaemia (RR 7.00, 95% CI 0.39 to 125.44)., Authors' Conclusions: There is a dearth of robust evidence to support the use of one particular form of insulin administration over another for pregnant women with diabetes. The data are limited because of the small number of trials appropriate for meta-analysis, small study sample size and questionable generalisability of the trial population. Conclusions cannot be made from the data available and therefore a robust randomised trial is needed. The trial should be adequately powered to assess the efficacy of continuous subcutaneous insulin infusion versus multiple daily injections in terms of appropriate outcomes for women with diabetes.

The study aim was to identify the time from a decision to perform a fetal blood sample to the result of the test being available. A total of 100 consecutive fetal scalp blood samples taken on women in labour were identified from the blood gas analysers on the delivery suite. Eighty-nine percent of attempts yielded a result. The median time taken was 18 minutes (interquartile range 12-25 minutes). In 9% of women, the result took longer than 30 minutes. This is important clinically when repeated testing is required or in the second stage when operative vaginal delivery is achievable. Furthermore, when retrospectively analysing cases with a poor outcome, the time to obtain a result needs to be taken into account when determining the time at which a baby could have been delivered.

Objective: The United Kingdom Amniotic Fluid Embolism Register was established to identify the incidence of the condition and examine any differences or common factors between survivors and fatalities., Design: An anonymous voluntary register., Setting: The United Kingdom from 1997 to 2004., Population: Any woman with a clinical diagnosis of amniotic fluid embolism. The entry criteria were as follows: acute hypotension or cardiac arrest, acute hypoxia and coagulopathy with onset during labour, caesarean section or within 30 minutes of delivery with no other clinical condition or potential explanation for the symptoms and signs., Methods: A data collection form was completed after reporting., Main Outcome Measures: Mortality and morbidity rates in women and their babies., Results: Of 66 cases, 44 had sufficient information to be included. Thirteen (29.5%; 95% CI 17-45%) women died. If the five extra deaths in the Confidential Enquiry into Maternal Death were included, the mortality would be 37% (95% CI 23-52%). Of the 31 survivors, 12 women had a cardiac arrest, 7 had a hysterectomy, 2 had further laparotomies, 1 had subglottic stenosis and 2 had persisting neurological impairment. Twenty-four of the 31 survivors were admitted to intensive care units. Of the 13 women who died, 7 of their babies survived. Four were acidotic at birth, of whom two developed hypoxic ischaemic encephalopathy (HIE) and one of these is known to have developed cerebral palsy. In 18 cases, the woman survived and the baby was alive and in utero at the time of the maternal collapse. Four of these died, four had HIE with one known to have developed cerebral palsy and one other was acidotic at birth., Conclusion: The mortality of amniotic fluid embolism is high but the majority of women will survive. There is significant maternal and neonatal morbidity even when the woman survives. Continuing assessment of cases of amniotic fluid embolism is important to identify ways of improving outcome.

Objective: To establish the risk of serious complications from severe pre-eclampsia and eclampsia in a region using a common guideline for the management of these conditions., Design: A five-year prospective study., Setting: Sixteen maternity units in Yorkshire., Population: All women managed with severe pre-eclampsia and eclampsia., Methods: A common guideline was developed for the management of women with these conditions. A network of midwives prospectively collected outcome data., Main Outcome Measure: Incidence of the conditions and serious complication rates., Results: A total of 210,631 women delivered in the 16 units between 1 January 1999 and 31 December 2003. One thousand eighty-seven women were diagnosed with severe pre-eclampsia or eclampsia (5.2/1000). One hundred and fifty-one women had serious complications including 82 women (39/10,000) having eclamptic seizures and 49 women (23/10,000) requiring ICU admission. There were no maternal deaths but 54 out of 1145 babies died before discharge, giving a mortality rate of 47.2/1000. Of the 82 cases of eclampsia, 45 occurred antenatally (55%), 18 before admission to the maternity unit. Eleven cases occurred in labour (13%), including 1 during a caesarean section, and 26 cases occurred following delivery (32%). Twenty-five women developed pulmonary oedema (2.3% of cases) and six women required renal dialysis (0.55% of cases). One hundred and sixty-five (15%) required no antihypertensive therapy and 489 (53%) of the remainder required only oral therapy. Two hundred and one (18.5%) required more than one drug., Conclusion: A regional guideline for severe pre-eclampsia and eclampsia can be developed and implemented. Its use may contribute to a low rate of serious complications.

Background: Gestational diabetes and impaired glucose tolerance (IGT) in pregnancy affects between 3 and 6% of all pregnancies and both have been associated with pregnancy complications. A lack of conclusive evidence has led clinicians to equate the risk of adverse perinatal outcome with pre-existing diabetes. Consequently, women are often intensively managed with increased obstetric monitoring, dietary regulation, and in some cases insulin therapy. However, there has been no sound evidence base to support intensive treatment. The key issue for clinicians and consumers is whether treatment of gestational diabetes and IGT will improve perinatal outcome., Objectives: The objective of this review was to compare alternative policies of care for women with gestational diabetes and IGT in pregnancy., Search Strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register (12 September 2002) and the bibliographies of relevant papers. The Cochrane Central Register of Controlled Trials was also searched (The Cochrane Library, Issue 3, 2002)., Selection Criteria: Randomised controlled trials comparing alternative management strategies for women with gestational diabetes and IGT in pregnancy., Data Collection and Analysis: Quality was assessed according to the criteria defined by the Cochrane Reviewers' Handbook. Data were extracted and checked independently by two reviewers. Any disagreements were resolved through discussion with the third reviewer., Main Results: Three studies with a total of 223 women were included. All three included studies involved women with IGT. No trials reporting treatments for gestational diabetes met the criteria. There are insufficient data for any reliable conclusions about the effect of treatments for IGT on perinatal outcome. The difference in abdominal operative delivery rates is not statistically significant (relative risk (RR) 0.86, 95% confidence interval 0.51 to 1.45) and the effect on special care baby unit admission is also not significant (RR 0.49, 95% confidence interval (CI) 0.19 to 1.24). Reduction in birthweight greater than 90th centile (RR 0.55, 95% CI 0.19 to 1.61) was not found to be significant. This review suggests that an interventionist policy of treatment may be associated with a reduced risk of neonatal hypoglycaemia (RR 0.25, 95% CI 0.07 to 0.86). No other statistically significant differences were detected. A number of outcomes are only reported by one study resulting in a small sample and wide confidence intervals., Reviewer's Conclusions: There are insufficient data for any reliable conclusions about the effects of treatments for impaired glucose tolerance on perinatal outcome.

Objective: To determine whether a study of a less intensive form of management for impaired glucose tolerance in pregnancy is feasible and whether women would accept randomisation., Design: Prospective randomised controlled study., Setting: A large district general hospital and a large teaching hospital in West Yorkshire., Sample: Seventy women with impaired glucose tolerance in pregnancy., Methods: One group monitored plasma glucose up to four times daily. The other group did not monitor plasma glucose at all., Main Outcome Measures: The number of women recruited of those approached and neonatal admissions to special care baby units in each group., Results: Sixty-eight of 70 women approached entered the study. There were no statistically significant differences between the groups in neonatal outcome measures. The median number of plasma glucose measurements in the monitored group was 118 (range 0-500), and 19% of women in the monitored group were treated with insulin., Conclusions: This study fails to demonstrate any benefit from intensive management of impaired glucose tolerance in pregnancy with additional maternal inconvenience. This pilot study has shown that a large randomised controlled study of the management of impaired glucose tolerance in pregnancy is not only feasible but necessary.

Amniotic fluid embolism is rare but is a significant cause of maternal death. No clear risk factors seem to be identifiable from previous cases. A register has been established in the UK to look at possible therapies.

A woman with a very poor obstetric history with a cervical pregnancy was managed without hysterectomy. Diagnosis was made by the transvaginal ultrasound. Haemorrhage was controlled by suction evacuation and balloon tamponade. Although cervical perforation occurred, the tamponade was able to control haemorrhage after repair of the perforation.

Objective: To compare the impact on use of resources in the management of small for gestational age babies using Doppler ultrasound versus cardiotocography., Design: A randomised controlled trial., Setting: A large district general hospital delivering 5500 to 6000 infants each year, 30% to 35% of which are to women of Pakistani origin., Population: One hundred and fifty women delivered of small for gestational age infants., Main Outcome Measures: Primary outcome measures were length of hospital inpatient stay and induction of labour rates. Secondary outcome measures included caesarean section rates and length of stay on neonatal unit., Results: The use of Doppler reduced average hospital inpatient stay from 2.5 days to 1.1 days, compared with cardiotocography (P = 0.036). There was no effect on induction of labour rates or caesarean section rates. There was no significant difference in length of stay on the neonatal unit (P = 0.33). There was a reduction in monitoring frequency and fewer hospital antenatal clinic visits., Conclusion: The use of Doppler ultrasound to manage small for gestational age infants reduces the use of resources, compared with cardiotocography.

Objective: To determine the usefulness of platelet count, mean platelet volume and serum uric acid levels in the prediction of pre-eclampsia in women with mild hypertension in pregnancy, and to see if it is appropriate to base the management of such patients on these tests., Subjects: Three hundred and thirty-six women attending the antenatal day unit with a diagnosis of non-proteinuric hypertension in pregnancy (diastolic blood pressure > or = 90 mmHg on two separate recordings) from whom at least one blood sample was taken., Main Outcomes Measured: The development of proteinuria (1+ or greater on urine Albustix); the need for oral antihypertensive medication, the need for the 'pre-eclampsia regime' intra- or post-partum; the need for induction of labour because of hypertension., Results: No test, at any cut-off level, was found to be of any use in predicting the outcomes studied. Nor was a weekly change in any of the tests found to be of any use., Conclusion: Basing the management of patients with mild non-proteinuric hypertension on the results of platelet count, mean platelet volume or urate level is unwise as none of these tests was able to predict outcome in such patients.

Objective: To determine whether n-3 fatty acid (EPA/DCHA) prophylaxis is beneficial in high risk pregnancies., Design: A randomised, double blind, placebo controlled trial., Setting: Antenatal clinic of St James's University Hospital, Leeds., Subjects: Two hundred and thirty-three pregnant women at high risk of developing proteinuric or nonproteinuric pregnancy induced hypertension or asymmetrical intrauterine growth retardation., Intervention: Active treatment was 2.7 g of MaxEpa daily (1.62 g of eicosapentaenoic acid and 1.08 g of docosahexaenoic acid). Placebo were matching air-filled capsules., Main Outcome Measures: Occurrence of proteinuric, nonproteinuric pregnancy induced hypertension or birthweight < 3rd centile., Results: There was no difference in an intention to treat analysis between the placebo and active treatment groups for occurrence of proteinuric pregnancy induced hypertension (relative risk (RR) = 0.88; 95% CI 0.47-1.66), nonproteinuric pregnancy induced hypertension (RR = 0.89; 95% CI 0.48-1.64), birthweight < 3rd centile (RR = 0.89; 95% CI 0.48-1.64), or the duration of pregnancy (difference of mean durations = 0.1 days; 95% CI -4.8 to 4.9 days). Analyses stratified by use of tobacco, and analyses excluding known major protocol violators gave essentially identical results., Conclusion: There is no evidence from this study for any useful effect of fish oil supplementation for women at high risk of adverse outcomes from a pregnancy, but a small protective effect remains a possibility.

Our objective was to determine if local anesthesia reduces pain after a laparoscopy. Eighty women were assigned randomly 10 ml of 0.5% bupivacaine or 0.9% saline flushed over the peritoneal folds and into the abdominal wall after laparoscopy under general anesthesia. Pain scores from the deep abdomen, skin, shoulder, and back were collected 30 min, 2 h, 4 h, and the day following laparoscopy. Pain scores also were correlated with patients' height, weight, operative findings, surgical technique and procedure, and volume of gas insufflated into the abdomen. Bupivacaine has a small effect on abdominal and skin pain 2 h after surgery (p = 0.01) but has no effect on shoulder or back discomfort. Women who have been sterilized, have not had previous abdominal surgery, or have evidence of old pelvic inflammation report more postoperative backache and deep abdominal pain but no greater skin or shoulder discomfort. Weight, height, whether the abdominal wall was picked up, and the volume of gas used to insufflate the abdomen are independent of all postoperative pain scores. Local anaesthetic instilled down the laparoscopy trocar reduces skin discomfort 2 h after surgery, but this beneficial effect is small compared with other factors influencing pain after laparoscopy.

Objective: to determine the reliability of conservative management of cone biopsies showing apparently incomplete excision of cervical intraepithelial neoplasia (CIN) by comparing surgical and conservative management., Design: a retrospective study., Subjects: 74 consecutive cone biopsies with a histology report of apparently incomplete excision of CIN 2 or CIN 3 from a series of 738 cone biopsies., Main Outcome Measures: the presence of CIN at hysterectomy against the pick up rate in conservatively managed patients., Results: where excision appeared incomplete at the ectocervix this was confirmed in 1 of 6 (16.7%) of patients managed surgically and 2 of 17 (11.8%) of patients managed conservatively (P = 0.40). Where excision appeared incomplete at both endo- and ectocervix, 5 of 6 (83.3%) were confirmed to have incomplete excision in the surgical group, and 3 of 5 (60%) had further proven CIN in the conservative group (P = 0.34). Where excision appeared incomplete at the endocervix only, this was confirmed in 7 of 22 (32%) of cases managed surgically, but only 2 of 18 (11.1%) of cases managed conservatively had further proven CIN (P = 0.14). Combining all patients with incomplete excision at the endocervix irrespective of the ectocervix status revealed confirmation of residual CIN in 12 of 28 (42.9%) patients managed surgically and in 5 of 23 (21.7%) patients managed conservatively (P = 0.097)., Conclusions: management should depend on the site of the apparent incomplete excision. Where excision appears incomplete at the ectocervix only, cytological follow up should be employed. If the endocervix is involved, further excisional surgery may be more appropriate.

Our aim was to assess the effect of the introduction of a day-care unit on the care of women with non-proteinuric hypertension in pregnancy. A randomised controlled trial was carried out on 54 women who presented at 26 weeks of pregnancy or later with non-proteinuric hypertension (systolic blood pressure 150-170 mm Hg and/or diastolic pressure 90-105 mm Hg on two occasions at least 15 min apart). 30 women were allocated to care by the day unit and 24 were managed according to the established practice of their clinicians without access to the day unit (control group). Women in the control group spent on average 4.6 times longer as inpatients (difference in mean stay 4.0 days [95% confidence interval 2.1-5.9 days]) than the day-unit group and were 8.8 times (95% CI 3.0-25.8) more likely to be admitted to hospital. Induction of labour was 4.9 times (95% CI 1.6-13.8) more likely in the control than in the day-unit group and the development of proteinuria 11.4 times (95% CI 1.8-71.4) more likely. The control group had a mean of 1.5 fewer hospital outpatient visits (95% CI 0.36-2.64). The groups did not differ in their use of antihypertensive drugs. Day-unit care for hypertension in pregnancy significantly reduced the need for and the length of antenatal inpatient admissions and the number of medical interventions, at the cost of an increase in outpatient attendances. Our results are further evidence that inpatient care does not improve outcomes or prevent the development of proteinuria in this disorder.

A case of vulval Crohn's disease in childhood is presented. The presentation of this disease as a vulval lesion is well recognised, either as the initial complaint, or as a metastatic lesion. Crohn's disease in childhood is well recognised and up to 49% of sufferers may have perianal disease. Vulval Crohn's disease in children, however, is uncommon, especially when it is the presenting symptom.

We prospectively recorded placental site, maternal weight and parity in 182 patients reporting decreased fetal movements and compared these with controls. Reports of decreased fetal movements were 2.10 times (95% CI 1.51-2.92) as likely in association with an anterior placenta and 1.81 times (95% CI 1.20-2.93) and 2.61 times (95% CI 1.26-5.40) as likely in mothers weighing over 80 and 90 kg, respectively, but there was no association with parity. Decreased perception of fetal movements is more likely to have serious implications in thin women with a posterior placenta. Our findings also suggest that the sensation of fetal movements arises from pressure against body wall structures rather than the uterus or peritoneum.

Between February 1983 and September 1985, an outbreak of methicillin-resistant Staphylococcus aureus involving 151 patients and staff occurred in a district general hospital. At its peak, 43 cases occurred in 3 months. Sixty-two patients suffered morbidity and two died. Conventional isolation techniques and once-daily whole body washing of affected patients with triclosan successfully controlled the outbreak.

We have evaluated a new agglutination test for serum immunoreactive lipase in 24 patients with abdominal pain and hyperamylasaemia. On admission all 20 patients with acute pancreatitis had a positive lipase test, 3 of the 4 patients who did not have pancreatitis had a negative lipase test. The sensitivity of the lipase test on day 1 is 100%, the specificity 96% and predictive value of a positive test is 95.2% compared to 83% for amylase. A negative test excludes pancreatitis. In addition, the test stays positive longer than hyperamylasaemia.