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Poor nutrient intake during pregnancy can adversely affect both infant and maternal health. The aim was to investigate the efficacy of multiple-micronutrient supplementation during pregnancy in a socially deprived population in the developed world. We conducted a randomised, double-blind, placebo-controlled trial of multiple-micronutrient supplementation including 20 mg Fe and 400 microg folic acid, from the first trimester of pregnancy in 402 mothers, in East London, UK. Nutrient status was measured at recruitment, and at 26 and 34 weeks of gestation. Infants were weighed at birth. At recruitment the prevalence of anaemia was 13%, vitamin D insufficiency 72%, thiamin deficiency 12% and folate deficiency 5%, with no differences between groups. Only 39% of women completed the study; rates of non-compliance were similar in both groups. Intention-to-treat analysis showed that participants receiving treatment had higher mean Hb at 26 weeks of gestation (110 (sd 10) v.108 (sd 10) g/l; P = 0.041) and 34 weeks of gestation (113 (sd 12) v.109 (sd 10) g/l; P = 0.003) and packed cell volume concentrations at 26 weeks of gestation (0.330 (sd 0.025) v. 0.323 (sd 0.026) l/l; P = 0.011) and 34 weeks of gestation (0.338 (sd 0.029) v. 0.330 (sd 0.028) l/l; P = 0.014) compared with controls. Analysis of compliant women showed supplemented women had higher median concentrations of serum ferritin, erythrocyte folate and 25-hydroxyvitamin D later in gestation than controls. In the compliant subset (n 149), placebo mothers had more small-for-gestational age (SGA) infants (eight SGA v. thirteen; P = 0.042) than treatment mothers. Baseline micronutrient deficiencies were common; the multiple-micronutrient supplement was well-tolerated and improved nutrient status. Multiple-micronutrient supplements from early pregnancy may be beneficial and larger studies are required to assess impact on birth outcomes and infant development. [ABSTRACT FROM AUTHOR]

Background: The role of folate supplementation in preventing neural tube defects is well known; however, preconception supplement use continues to be low, especially amongst the socially disadvantaged. The present study explored periconception folic acid supplement use in a socially deprived, ethnically diverse population. Methods: Pregnant women (n = 402) in the first trimester of pregnancy were recruited in East London. Using a researcher led questionnaire, details were obtained regarding social class, ethnicity and folic acid use. Red cell folate levels were determined for 367 participants during the first trimester. Results: Although 76% of participants reported using folic acid supplements during the first trimester, only 12% started preconception and a further 17% started before neural tube closure. Mothers from higher social groups or with higher levels of education were more likely to use folic acid and started taking it earlier. Ethnic differences were also seen in preconception usage (Africans, 5%; West Indians, 8%; Asians, 12%; Caucasians, 19%; P = 0.038). Participants who took folic acid supplements had significantly higher mean (SD) red cell folate concentrations than those who took none [936 (*\1.6) and 579 (*\1.6) nmol L)1, respectively; P < 0.001]. Conclusions: Folic acid supplement use preconception and prior to neural tube closure continues to be low, exhibiting both social and ethnic disparities. [ABSTRACT FROM AUTHOR]

BACKGROUND: New school meal standards are currently being phased in by the government in an attempt to improve the nutritional composition of school food. However, no standards are applied to packed lunches. The present study aimed to compare the food and nutrient intakes of primary school children eating a school meal with those taking a packed lunch. METHODS: A sample of 120 children, aged 6-11 years, was observed once at a lunch time and all items consumed were recorded. Nutrient analysis was performed, and differences in nutrient intake between those children consuming packed lunches and school meals were determined. RESULTS: Mean energy and protein intakes were similar. The amount of energy provided by starchy carbohydrate was also similar but, compared with school meals, packed lunches provided twice as much energy from sugar (P < 0.001). School meals on average provided more energy from fat (P < 0.001), but intakes of saturated fat were lower in the school meals group (P = 0.021). Packed lunches provided more sodium (P < 0.001), calcium (P < 0.001) and iron (P = 0.016) than the school meals. Very few packed lunches contained vegetables, and fruit intake was particularly low for those having a school meal. CONCLUSIONS: Children taking a packed lunch to school were consuming approximately double the amount of sugar and 50% more sodium and saturated fat in their midday meal compared with those having a school lunch. However packed lunches were providing children with more calcium, iron and fruit. [ABSTRACT FROM AUTHOR]

Folate, vitamin D and iodine are key micronutrients in pregnancy, with deficiency associated with poor maternal and infant outcomes. For folate and vitamin D especially, deficiency is more common amongst women with obesity and recommended intakes and guidance on supplementation varies worldwide. The present study aims to investigate dietary and supplementary intakes of these micronutrients amongst a population of pregnant women with obesity in the United Kingdom, alongside key maternal demographic characteristics. Expectant women ( n = 75) with a body mass index ≥ 30 kg/m 2 at first antenatal appointment were recruited at 12 weeks gestation. Participants were asked about their supplement use preconception and during trimester one in a baseline questionnaire which also asked about demographic characteristics. Women also completed a four day diet diary from which dietary and supplemental intakes of micronutrients intakes were estimated. Folic acid was taken by 96% of women at any point in trimester 1, whilst only 26% of women took the higher 5 mg dose recommended for women with obesity in the UK. For vitamin D and iodine, 56% and 44% of women met the UK RNI, respectively. Maternal age was positively associated with taking supplements of any kind and the 5 mg folic acid supplement, whilst parity was inversely associated with both outcomes. This study strengthens the rationale for further work to be done raising awareness of the need for women with obesity to supplement both with a higher dose of folic acid and vitamin D and to be aware of the role of iodine during pregnancy.

Background: It is widely acknowledged that maternal obesity and excessive gestational weight gain (GWG) are associated with increased risk of fetal macrosomia and recent studies have suggested a role for the timing and composition of GWG., Aims: To examine the effect of the rate of change in GWG and maternal upper-body subcutaneous fat on neonatal anthropometric outcomes in a pilot observational study amongst women with obesity., Study Design: Expectant women with a body mass index (BMI) > 30 kg/m 2 at first antenatal appointment were recruited at 12 weeks gestation. Maternal height, weight and skinfold thickness (SFT) measurements were collected at baseline and repeated at 28 and 36 weeks gestation. Following delivery, World Health Organisation (WHO)-UK infant birthweight z-scores were calculated, and infant anthropometric measurements were obtained., Results: The sum of upper body SFT measurements increased in mid-pregnancy (0.08 ± 0.71 mm/week) and decreased in late pregnancy (-0.04 ± 1.17 mm/week). After adjustment for maternal age, BMI and parity, mid- but not late- pregnancy GWG was positively associated with infant birthweight z-score (p<0.05), while mid- but not late-pregnancy changes in the sum of SFT were inversely associated with infant birthweight z-score (p<0.01)., Conclusions: The present study suggests that mid- rather than late-pregnancy changes in weight and upper-body subcutaneous fat are associated with infant birthweight. Further research is required in larger, more diverse populations to explore whether pregnancy interventions aiming to improve maternal and offspring health can be personalised beyond BMI and GWG., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Substituting sugar-sweetened for artificially sweetened beverages may reduce energy intakes. This study aims to ascertain the acute glycaemic effects of the NNS aspartame and acesulfame-K in UK diet-cola (DC). Ten healthy participants attended the laboratory fasted on three occasions. Individuals drank (1) 25 g glucose in 125 mL water + 236 mL water, (2) 25 g glucose in 125 mL water with 236 mL DC and (3) 236 mL sucrose-sweetened cola with 125 mL water. Blood (glucose) was measured pre-test and every 15 minutes over a 120-minute period using portable glucometers. The glucose-control and glucose + DC elicited similar blood glucose rises above pre-prandial levels. Sucrose-sweetened cola showed a non-significant lower rise in postprandial glycaemia, exhibiting the lowest glycaemic index (GI) (77.0 ± 9.1). GI of glucose (100.0 ± 15.2) and glucose + DC (104.3 ± 8.5) was similar and a one-way repeated-measures ANOVA showed no significant differences in glycaemic response between test drinks ( F (2,29) = 1.68, p  > .05). Results demonstrate the glycaemic inactivity of non-nutritive sweeteners.

Background/objectives: Short sleep duration has been linked to maternal hyperglycaemia following a 1-h 50 g oral glucose tolerance test (OGTT) in observational studies conducted primarily in the USA. Our objective was to examine the relationship between objectively measured sleep duration and plasma glucose values following the 2-h 75 g OGTT routinely used in the UK amongst women with obesity., Methods: Sleep and OGTT data were available for 49 pregnant women who wore wrist actigraphs for at least two nights, and took a 2-h 75 g OGTT at the end of their second trimester. Multivariable regression was used to evaluate associations between sleep duration and OGTT results., Results: Higher 2-h plasma glucose values were significantly associated with shorter sleep duration and higher maternal age and BMI, with no association observed between wake after sleep onset (WASO) and 2-h plasma glucose values. No associations were observed between fasting plasma glucose values and any sleep parameters., Conclusions: We found that shorter sleep duration, as measured using actigraphy, is associated with higher 2-h plasma glucose values following a 2-h 75 g OGTT in the UK. These findings are in keeping with those observed elsewhere in the world, employing alternative OGTT protocols. Future studies should investigate sleep extension as a potential candidate for inclusion in future RCTs aiming to improve glucose tolerance and prevent GDM amongst those at risk., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Although whole-fruit consumption is regarded as protective against type 2 diabetes (T2DM), conventionally prepared fruit juice is associated with increased T2DM risk, and current public health advice recommends its restriction. 'Nutrient extractor' style blenders are increasing in popularity worldwide as an alternative means of juicing fruit, but little is known about their effect on postprandial glucose levels. The current study investigated the effect of nutrient extraction on postprandial blood glucose response and glycemic index (GI) compared with a glucose control for both mixed fruit and a high GI fruit (mango). Remarkably, consumption of nutrient-extracted mixed fruit resulted in a significant lowering of the GI (32.7±8.5) compared with whole mixed fruit (66.2±8.2, P<0.05). For the high GI mango, there were no differences between nutrient-extracted and whole fruit, indicating that even for a high GI fruit the effect of nutrient extraction does not increase GI compared with the whole fruit. These findings suggest that, in contrast to conventionally prepared fruit juice, fruit juice prepared by nutrient extraction in some cases elicits a more favorable postprandial glycemic response than whole fruit and even for high GI fruits do not worsen the response. The mechanism responsible for this effect is currently unclear. However, these results suggest that fruit homogenized by nutrient extraction should be considered as a potential dietetic strategy for glycemic control.

Background: Obesity rates in Saudi Arabia are amongst the highest in the world. It is known that teenage girls are less active than teenage boys, but less is known about the diet and activity patterns in younger girls. Therefore this study sought to investigate dietary intake and daily physical activity in girls aged 8-11 years old in Saudi Arabia., Methods: This was a cross- sectional observational study conducted in seven schools across the city of Makkah. A total of 266 girls had anthropometric measurements taken including height, weight, waist circumference and body fat estimations. Dietary assessment using a 4 day unweighed diet diary was undertaken in 136 of these participants, and 134 agreed to monitor their physical activity for the 4 days using an accelerometer. After exclusion for under-reporting, 109 remained in the dietary analysis and 78 in the physical activity analyses. Differences in means between BMI groups were determined using one-way ANOVA with post hoc Tukey test. Multivariable linear regression analysis was performed to look at the effect of multiple variables on body weight., Results: A total of 30% of participants were classified obese or overweight. There was a significant difference in the mean daily energy intake between the BMI groups with the obese group having the highest energy, fat, carbohydrate and protein intake (obese group: 2677 ± 804 kcal/d; healthy weight group: 1806 ± 403 kcal/d, p < 0.001), but the percentage contribution of the macronutrients to energy intake remained the same across the BMI groups. There were no differences in number of steps taken per day or time spent in moderate to vigorous intensity exercise according to BMI category. Most of the girls did not meet daily physical activity guidelines (5969 to 6773 steps per day and 18.5 - 22.5 mins per day of moderate to vigorous activity). Multiple linear regression showed that energy intake positively predicted body weight (Beta = 0.279, p =0 .001), whereas, total energy expenditure per kg of body weight and family income had a significant negative influence on body weight (Beta = -0.661, p < 0.001; -0.131, p = 0.028 respectively)., Conclusions: The results of this cross sectional analysis suggest that obesity in girls aged 8-11 years is linked to excessive energy intake from all macronutrients and the majority of girls in all weight categories are inactive. Research should be conducted to further investigate causal relationships in longitudinal studies and develop interventions to promote dietary change and activity that is culturally acceptable for girls in Saudi Arabia.

Good nutrition in the early years of life is essential, yet the diets of many pre-school children in the UK are known to be poor. Understanding the decisions parents make when feeding young children is very important in determining what type and nature of interventional support may be developed to promote good nutrition. The aim of this study was to explore using qualitative methods, parental perceptions of feeding their children in order to inform the development of a nutrition intervention. Focus groups (n = 33) and individual interviews (n = 6) were undertaken with parents, most of whom were attending children's centres in two deprived populations from one urban (Islington, north London) and one rural (Cornwall) location in England. Accounts of feeding pre-school children were primarily concerned with dealing with the practicalities of modern life, in particular the cost of food and the need to manage on a restricted household budget. Time pressures, a lack of perceived knowledge and confidence in preparing food and managing conflict over food choices between family members were also strong themes. Parents commonly reported differences between how they would like to feed their children and the reality of what they were able to do in their circumstances. These findings suggest that the poor eating habits of many pre-school children may be less a case of parental ignorance but rather the product of a range of coping strategies. Designing an intervention, which helps parents to build their confidence and self-efficacy, may enable them to make positive changes to their children's diets., (© 2013 Blackwell Publishing Ltd.)

5α-Reductase type 1 (5αR1) catalyses A-ring reduction of androgens and glucocorticoids in liver, potentially influencing hepatic manifestations of the metabolic syndrome. Male mice, homozygous for a disrupted 5αR1 allele (5αR1 knockout [KO] mice), were studied after metabolic (high-fat diet) and fibrotic (carbon tetrachloride [CCl4]) challenge. The effect of the 5α-reductase inhibitor finasteride on metabolism was investigated in male obese Zucker rats. While eating a high-fat diet, male 5αR1-KO mice demonstrated greater mean weight gain (21.6 ± 1.4 vs 16.2 ± 2.4 g), hyperinsulinemia (insulin area under the curve during glucose tolerance test 609 ± 103 vs. 313 ± 66 ng ⋅ mL(-1) ⋅ min), and hepatic steatosis (liver triglycerides 136.1 ± 17.0 vs. 89.3 ± 12.1 μmol ⋅ g(-1)). mRNA transcript profiles in liver were consistent with decreased fatty acid β-oxidation and increased triglyceride storage. 5αR1-KO male mice were more susceptible to fibrosis after CCl4 administration (37% increase in collagen staining). The nonselective 5α-reductase inhibitor finasteride induced hyperinsulinemia and hepatic steatosis (10.6 ± 1.2 vs. 7.0 ± 1.0 μmol ⋅ g(-1)) in obese male Zucker rats, both intact and castrated. 5αR1 deficiency induces insulin resistance and hepatic steatosis, consistent with the intrahepatic accumulation of glucocorticoids, and predisposes to hepatic fibrosis. Hepatic steatosis is independent of androgens in rats. Variations in 5αR1 activity in obesity and with nonselective 5α-reductase inhibition in men with prostate disease may have important consequences for the onset and progression of metabolic liver disease., (© 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.)

Objective: The present study explored parents’ requirements for healthy eating support prior to the development of a tailored intervention., Design: A cross-sectional study of parents attending children’s centres., Setting: Children’s centres in Cornwall (rural south-west England) and Islington (urban London borough)., Subjects: A total of 261 parents (94.2% female) of pre-school children (aged 2–5 years) completed a questionnaire on factors influencing food choice, and preferences for and views on healthy eating support., Results: Parents reported that health, taste, freshness and quality were the most important factors influencing their food choices for their pre-school children. The importance of individual factors varied according to level of educational attainment. Over a third (38 %) of parents said they wanted more advice on healthy eating for children. Less educated parents showed the greatest interest in learning more about several aspects: what a ‘healthy diet’ means, how to prepare and cook healthy food, how to understand food labels, budgeting for food, examples of healthy food and snacks for children, appropriate portion sizes for children and ways to encourage children to eat well., Conclusions: There was demand for healthy eating support among parents of pre-school children, especially those who are less educated, in one rural and one urban area of England

A questionnaire was designed to obtain information about factors affecting vitamin D status in Middle Eastern people living in the UK. A total of 242 questionnaires were returned out of 350 distributed. A total of 85% of the sample was estimated to have a low vitamin D intake (< 5 μg/d). Other risk factors for vitamin D insufficiency included covering skin from sunlight (62% men and 84% women); low use of vitamin D containing supplements (18.5%) and being overweight or obese (49% men and 44% women). Vitamin D intake was lowest in the Kurdish ethnic group (2.18 μg/d) and in those with primary (1.83 μg/d) and secondary school (2.14 μg/d) level education compared to higher education (3.0-3.59 μg/d). Vitamin D intake was highest in those aged 40-49 years (4.0 μg/d), those born in the Levant (4.29 μg/d), and in those who were obese (3.60 μg/d).

Background: Obesity is increasing in the UK and this is having an impact on the health of pregnant women and their infants. It is recommended that all pregnant women have their height and weight measured and their body mass index (BMI, kg m(-) ²) calculated and recorded in the midwifery notes. The aim of the present audit was to determine the extent of compliance with this recommendation., Methods: An audit was undertaken in a large district general hospital in the South West of England. A convenience sample of the midwifery notes was accessed retrospectively on the post-natal wards. Data collected from the notes included weight, height, BMI and gestational age when first recorded., Results: A total of 486 maternal notes were audited; of these, 9% did not have the BMI recorded. In total, 53.8% of the sample had either height or weight not recorded; however, 90.9% of the sample had a BMI recorded. In addition, 39.7% (n = 126) of heights and 16.0% (n = 63) of weights were recorded in imperial format. There was a high prevalence overweight (26.2%) and obesity (21.3%) amongst the sample., Conclusions: Recommendations for measurement of height, weight and calculation of BMI were not always followed. Where BMI was recorded, many notes had either height or weight missing or had measurements recorded in imperial units. This raises the question of how BMI was calculated and its accuracy. Inaccuracies in BMI could lead to individuals being overlooked as high risk and may not be referred for appropriate care including dietetic care. Accurate anthropometric measurements are important for dietary management and monitoring of weight gain., (© 2011 The Authors. Journal of Human Nutrition and Dietetics © 2011 The British Dietetic Association Ltd.)

The objective of this paper was to compare the nutrient intakes of mothers of different ethnic origins after they had given birth to a low birth weight (LBW) baby (< 2.5 kg). A total of 165 participants from East London, UK completed a prospective 7-day diet diary using household measures, between 8 and 12 weeks post-partum. The data were originally collected as baseline data prior to two separate nutrition intervention studies and were combined and re-interrogated for the purpose of this paper. Folate and iron intakes were low in all ethnic groups compared to the Reference Nutrient Intakes (RNI). Half did not meet the RNI for folate and 88% did not meet the RNI for iron. Nearly a quarter of the group did not achieve the Lower Reference Nutrient Intake (LRNI) for iron. The mean vitamin D and calcium intakes were significantly different between the ethnic groups (P = 0.007, P = 0.001, respectively). African women had the highest vitamin D intakes (4.72 microg d(-1)) and Caucasians and Asians the lowest (2.4 microg d(-1)). Caucasians had the highest calcium intakes (780 mg d(-1)) and Africans the lowest (565 mg d(-1)). Over two-thirds of African, Asian and African-Caribbean women did not meet the RNI for calcium. Thirty-one per cent of Africans did not meet the LRNI for calcium. Our data show a high prevalence of inadequate nutrition among women who deliver LBW babies with differences in nutrient intake between ethnic groups. This information can be used to target specific appropriate dietary advice to ethnic minorities for the prevention or repetition of LBW.

Biomass from an SBR running with no enhanced biological phosphorus removal (EBPR) but which exhibited anaerobic assimilation of glucose and acetate, was dominated by "G-bacteria", cocci in tetrads and clusters. Extracted 16S rDNA was amplified by PCR and then analysed using Denaturing Gradient Gel Electrophoresis (DGGE). Major bands were extracted and their sequences determined. Clone libraries were also prepared, the 16S rDNA extracted, PCR performed and the resultant fragments run by DGGE to aid in identifying the DGGE bands and provide fuller sequences than available by DGGE alone. The two approaches together allowed several bands to be identified. Probes for FISH analyses were designed for some of these in attempts to see to which phylogenetic group "G-bacteria" belonged, and whether they represented the dominant bands detected by DGGE. Then FISH/Microautoradiography (MAR) was used in attempts to see which bacteria there were assimilating substrates anaerobically. Results indicated that the "G-bacteria" were phylogenetically diverse, but mainly alpha-proteobacteria and members of the high G+C% gram-positive bacteria. Not all of these could assimilate glucose and/or acetate anaerobically, and Amaricoccus, the original "G-bacteria" of Cech and Hartman, was not detected.

A self-administered questionnaire was completed by 103 members of a self-help group for irritable bowel syndrome (IBS) and 130 controls, to compare the presence of IBS symptoms. Dietary fibre prescription, compliance and efficacy were documented in the IBS group. There were significant differences in the frequency of defaecation and number of symptoms present between the two groups. Most of the IBS subjects had been prescribed a high fibre diet but adherence to the diet and symptomatic improvement were poor. In contrast many IBS sufferers were following a range of diets not prescribed by their doctor. The seriousness of the IBS condition was highlighted by the fact that 8% of the IBS group had retired early due to their condition.

Surveys have been undertaken of the clinical dependency of surgical patients in eight United Kingdom acute general hospitals. The findings indicate that patients' needs are not always matched by appropriate levels of clinical care. In particular, it appears that a significant number of surgical patients need high-dependency care. Currently most of these patients are admitted to ITU beds, or are at risk on surgical wards.

Objective: To observe the effects of introducing an acute pain service to the general surgical wards of a large teaching hospital., Design: A study in seven stages: (1) an audit of current hospital practice succeeded by the sequential introduction to the general surgical wards of (2) pain assessment charts; (3) an algorithm to allow more frequent use of intramuscular analgesia; (4) increased use of local anaesthetic techniques of wound infiltration and nerve blocks; (5) an information sheet for patients about postoperative pain; (6) the introduction of patient controlled analgesia; (7) a repeat audit of hospital practice. Data were collected on each patient 24 hours after operation., Setting: University Hospital of Wales, which has both district general and tertiary referral functions., Patients: 2035 patients over nine months from all surgical specialties (excluding cardiac) at the hospital. General surgical operations were studied in detail and separated into major, intermediate, and minor for data collection., Main Outcome Measures: A change in the median visual analogue pain scores 24 hours after surgery for pain during relaxation, pain on movement, and pain on deep inspiration at each stage of the study., Results: There was a reduction in median visual analogue scores during the study. The median (95% confidence interval) scores for pain during relaxation decreased from 45 (34 to 53) in stage 1 to 16 (10 to 20) in stage 7 for major surgical procedures. Pain on movement decreased from 78 (66 to 80) to 46 (38 to 48), and pain on deep inspiration decreased from 64 (48 to 78) to 36 (31 to 38). The reductions in median scores for intermediate and minor operative procedures showed similar patterns., Conclusions: The introduction of an acute pain service to the general surgical wards led to considerable improvement in the level of postoperative pain as assessed by visual analogue scores. Simple techniques of regular pain assessment and the more frequent use of intramuscular analgesia as a result of using an algorithm were particularly effective.

The current experience of a high dependency unit established 5 years ago for the postoperative care of high-risk patients undergoing surgery is reported. The resource implications and contributions to the safety and quality of post-operative care, particularly pain relief, are described.

Two hundred mothers undergoing general anaesthesia for Caesarean section were allocated randomly to receive either 100% oxygen (group 100) or 50% nitrous oxide in oxygen (group 50), both supplemented with isoflurane. In each group the concentrations of isoflurane were chosen to deliver 1.5 MAC for the first 5 min after induction and 1.0 MAC thereafter. The mean umbilical venous PO2 was greater in group 100 for emergency sections (P = 0.001). Babies born to mothers in group 100 required less resuscitation than those in group 50 (P = 0.04) and there was a tendency to higher Apgar scores at 1 min in group 100, although this was not statistically significant. There were no instances of awareness, although two patients in group 100 and three in group 50 reported dreaming. This study confirms earlier findings that the use of 100% oxygen can significantly improve fetal oxygenation during Caesarean section, with particular benefit in emergency cases. This is associated with a lower incidence of neonatal resuscitation.

One hundred primigravidae were allocated randomly to receive either an extradural infusion of 0.125% bupivacaine (Marcain) 10 ml (12.5 mg) per hour during labour, or no infusion. Both groups had intermittent "top-ups" of 0.5% bupivacaine when indicated. The mean interval between top-ups was significantly longer in the infusion group (218 min v. 152 min). Seventy-six percent of the mothers in the infusion group required no or only one top-up. Although the infusion patients received a higher mean dose of bupivacaine (178 mg v. 130 mg), there was no difference between the groups with respect to mode of delivery, need for urinary catheterization, adverse cardiovascular effects on mother or fetus, or the time taken after delivery to recover sensation and motor power. The only real disadvantage was that the infusion group had an increased incidence of lower limb weakness (64% v. 44%). The neonates had similar Apgar scores, times to sustained respiration and requirements for resuscitation. The technique, therefore, should be safe if coupled with testing of sensory level, as no block extended higher than T6.

The efficacy of an extradural infusion of 0.0625% or 0.125% bupivacaine was studied in 98 primigravid mothers in active labour. No special measures were taken to posture the mother (except to avoid aorto-caval compression). The study regimen included a control group (no infusion) receiving intermittent top-ups (0.25%. bupivacaine 8-10 ml), two groups receiving bupivacaine 6.25 mg h-1 infusion in different concentrations (0.0625% and 0.125%), a fourth group receiving 0.125% bupivacaine 12.5 mg h-1 infusion, and a fifth group receiving 0.125% bupivacaine 18.75 mg h-1 infusion. The optimum infusion rate was 0.125% bupivacaine 10 ml h-1, at which 69% of primigravid mothers required none or only one "top-up" of 0.25% bupivacaine 8-10 ml during a mean duration of 7.1 h labour. In the group who had no extradural infusion, only 32% of mothers managed with one or no top-up. The median interval between top-ups was increased from 145 min in the no infusion group to 245 min in those mothers receiving 0.125% bupivacaine 10 ml h-1 by infusion. Increasing the rate of infusion to 15 ml h-1 did not improve the results. Spread of local anaesthetic to higher levels was limited (less than T5) so that testing sensory loss at the T5-6 level at 2-hourly intervals should detect accidental spinal blockade resulting from inadvertent intrathecal infusion.

The ability of midwives to assess accurately the level of epidural blockade after a short period of instruction was examined. Seventy-two midwives estimated the upper level bilaterally in 100 patients, by detection of the loss of sensation to a cold stimulus. The midwife and anaesthetist were in complete agreement over the level of block in 71.5% of cases; the midwife overestimated the height of the block in 9.5% of cases, and underestimated in 19%. The midwife underestimated by three spinal segments in 1.5% of cases, and never by more. The technique was acceptable to patients and midwives alike. This procedure should enable safe management of obstetric analgesia, whoever administers top-ups; accurate detection of a block that recedes below therapeutic levels should facilitate earlier top-ups and thus reduce pain for the patient in labour.

In a randomised controlled trial epidural analgesia with bupivacaine 0.5% (mean dose 112.8 mg) was compared with pethidine (mean dose 200 mg) and inhalational analgesia in primipara (28 and 30 mothers) and multipara (17 and 18 mothers). Mothers who had an uneventful pregnancy and labour and agreed to have either treatment were studied during labour and followed-up at interviews for 5 months after delivery. Epidural block was rated significantly superior in respect of pain relief and comfort, there were no differences between the groups in reports of perineal discomfort. Twice as many primipara required forceps delivery after epidural block. Very few mothers, in each group, reported something missing in their experience of childbirth. Two thirds of each group would use the same method again. Epidural block can therefore be recommended to uncommitted mothers as a satisfying and effective method of pain relief for labour.

In a randomised controlled trial of mothers in labour intramuscular pethidine 150 mg, repeated if necessary, was compared with self-administered intravenous pethidine (0.25 mg/kg available at 10-min-intervals). Each mother agreed to have either method of pain relief and could opt for epidural block. The intramuscular group had significantly more pethidine than the intravenous group (mean differences, primipara 29 mg; multipara 16 mg). Ratings by mothers of the pain of 1st, 2nd stage and overall (analogue scores and gradings) were consistently better for the intravenous group although not significantly different. There were no differences in mean Apgar scores between the babies in the groups. In mothers who do not choose epidural block, similar pain relief is afforded by adequate intramuscular pethidine or self-demand intravenous pethidine; however, intravenous self-administration is more efficient since the pain relief is achieved with a lower dose of pethidine.

The development of a High Dependency Unit (HDU) which caters for the early postoperative care of patients undergoing major surgery, and for the seriously ill, is described. During its first six months, 320 patients have been treated in the unit, and its initial objectives have been successfully achieved.

This study examines the changing pattern of maternal analgesia administration during the decade 1970-1979. In addition, the relationship between analgesia, anaesthesia and the infant's Apgar score was documented. Approximately 40000 deliveries to South Glamorgan residents were included in the study. Over the two quinquennia 1970-1974 and 1975-1979 the administration of epidural block increased from 5.6% to 17.5%. The Apgar score of babies in the epidural block group was significantly better in the latter period. Respiratory depression following Caesarean section remains a problem. The group delivered by elective Caesarean section contained a substantial proportion of infants with a low Apgar score; 30% had an Apgar score less than 8 and 10% had a score of less than 4. Likely causative factors include undue sensitivity of the infants' respiratory centre and aortocaval compression during surgery.

This paper considers cardiopulmonary resuscitation in obstetric patients at term and the influence of aortocaval compression on the outcome. The maximum chest compression force produced by eight physicians was measured as a function of angle of inclination using an inclined plane. The compression force at an angle of 27 degrees is 80% of that in the supine position and the Cardiff resuscitation wedge, designed to prevent aortocaval compression, is described with this inclination. Midwives' expertise in basic life support 6 months after instruction was assessed using a manikin simulator. The majority had acquired errors in external chest compression and mouth to mouth ventilation. These were corrected by additional tuition. Resuscitation of the manikin on the Cardiff wedge was found to be as efficient as in the supine position.

A patient aspirated soup 36 h after delivery, developed Mendelson's syndrome but survived. She was small and fat and was immobilized in bed for longer than usual because of inadvertent dural puncture; these factors are thought to have predisposed to the accident.

Forty patients undergoing elective and emergency Caesarean section (excluding severe fetal distress) were divided into four groups to receive 50% oxygen, 50% nitrous oxide, and 0.5% halothane (group 1, controls) or 100% oxygen supplemented by 1.5 x MAC of halothane, enflurane or isoflurane (groups 2,3,4, respectively) reducing to 1.0 x MAC 5 min after induction. The umbilical venous PO2 in the oxygen-only groups was higher than in the oxygen-nitrous oxide groups, this difference reaching statistical significance when the patients in the oxygen-only groups were combined. Blood loss and uterine contractility were unaffected by the increased concentrations of volatile agents, and awareness did not occur. Improved cardiovascular stability was demonstrated in the elective high-oxygen groups. The technique is safe and warrants further study, since there are no important ethical objections.

The administration of general anaesthesia for Caesarean section is described in a patient with an established biochemical diagnosis of acute intermittent porphyria. The technique used did not precipitate an acute exacerbation of the disease. Drugs associated with obstetric care are considered in the context of their use in porphyria.

The feasibility of patient-controlled on-demand analgesia by the intramuscular route during labour was tested on 10 primigravid mothers. Pethidine 50 mg or meptazinol 75 mg was available double-blind at minimum intervals of 20 min. The mean dose demanded was 190 (SD 96.2) mg of pethidine and 285 (SD 97.8) mg of meptazinol. The dose of pethidine is similar to that demanded by the intravenous route. Pain evaluations were not significantly different, but one mother who had meptazinol opted for epidural analgesia, and 2 wished they had done so. The system could be easily managed by all the mothers and there were not technical difficulties. Self-administered intramuscular analgesia could be instituted by a midwife with a dosage scheme similar to current practice. A field trial by midwives of self-administered intramuscular analgesia with pethidine is indicated.