摘要:

ObjectiveTo assess a labor-management protocol that mandated at least 4 hours of oxytocin augmentation before cesarean delivery for active-phase labor arrest.MethodsWe prospectively evaluated term gravidas in spontaneous labor with active-phase labor arrest (cervix at least 4 cm dilated and 1 cm or less of cervical progress in 2 hours). Exclusion criteria included nonvertex presentation, previous cesarean, multiple gestation, and a nonreassuring fetal heart rate tracing or chorioamnionitis at the time of labor arrest. After the diagnosis of active-phase arrest, oxytocin was initiated with an intent to achieve a sustained uterine contraction pattern of greater than 200 Montevideo units. Cesarean delivery was not performed for labor arrest until at least 4 hours of a sustained uterine contraction pattern of greater than 200 Montevideo units, or a minimum of 6 hours of oxytocin augmentation if this contraction pattern could not be achieved.ResultsFive hundred forty-two women were managed by the protocol, and 92% delivered vaginally. The subsequent vaginal delivery rate for parous women who had not progressed (1 cm of cervical dilation or less) despite 2 hours of oxytocin augmentation was 91%, and it was 74% for nulliparas. With no labor progress after 4 hours of oxytocin augmentation, the subsequent vaginal delivery rates were 88% for parous women and 56% for nulliparas. There were no severe maternal complications. One neonate had persistent fetal circulation and one had a positive blood culture, but both did well.ConclusionExtending the minimum period of oxytocin augmentation for active-phase labor arrest from 2 to at least 4 hours was effective and safe.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo determine whether term nulliparas with an unengaged vertex presentation at onset of active labor have a higher risk for cesarean delivery.MethodsA retrospective cohort of 1250 randomly chosen nulliparous patients at 37–42 weeks' gestation who delivered between 1988 and 1989 were selected. Four hundred forty-seven patients were excluded because of nonvertex presentation, cesarean delivery before active phase of labor, multiple gestation, delivery at less than 37 weeks' or greater than 42 weeks' gestation, induction of labor, or missing charts. For the purpose of this study, active labor was defined as regular contractions with cervical dilatation of at least 3 cm. The station at onset of active labor was recorded. Engagement was considered to be at station 0 or below.ResultsOf the 803 patients in the study group, 567 presented unengaged and 236 patients presented engaged. The cesarean rates differed significantly between the two groups: 14% of those unengaged compared with 5% of those engaged (χ2= 11.9,P< .001). After adjusting for confounding variables, engagement at the time of onset of active labor was associated with lower risk of cesarean delivery (odds ratio .512, 95% confidence interval .285, .922).ConclusionEighty-six percent of nulliparas with an unengaged vertex at onset of active labor delivered vaginally. Engaged vertex at the onset of active labor was associated with a lower risk of cesarean delivery.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo examine the risks of vaginal delivery after previous cesarean and to find criteria to help decide whether a trial of labor or an elective repeat cesarean should be preferred.MethodsWe evaluated 29,046 deliveries after previous cesarean registered in a pooled database of 457,825 deliveries used to assess quality control in gynecology and obstetrics departments in Switzerland.ResultsAmong the 17,613 trial-of-labor cases logged (attempt rate 60.64%), the success rate was 73.73% (65.56% after inducing labor and 75.06% after the spontaneous onset of labor). The following complications were significantly more frequent in the previous-cesarean group: maternal febrile episodes (relative risk [RR] 2.77; 95% confidence interval [CI] 2.52, 3.05), thromboembolic events (RR 2.81; CI 2.23, 3.55), bleeding due to placenta previa during pregnancy (RR 2.06; CI 1.70, 2.49), uterine rupture (92 cases; RR 42.18; CI 31.09, 57.24), and perinatal mortality (118 cases, including six associated with uterine rupture; RR 1.33; CI 1.10, 1.62). The postcesarean group also showed a 0.28% rate of peripartum hysterectomy (81 cases; RR 6.07; CI 4.71, 7.83). There was one maternal death in the group, compared with 14 maternal deaths in the group without previous cesarean (no statistical significance). The risk of uterine rupture for patients with previous cesareans was elevated in the trial-of-labor group compared with the group without trial of labor (RR 2.07; CI 1.29, 3.30), but all other maternal risks, including peripartum hysterectomy (RR 0.36; CI 0.23, 0.56), were lower. When comparing the women having a trial of labor, the 70 with uterine rupture more often had induced labor (24.29% compared with 13.92% in the nonrupture group;P= .013), had epidural anesthesia (24.29% compared with 8.44%;P< .001), had an abnormal fetal heart rate tracing (32.86% compared with 8.53%;P< .001), and had failure to progress (21.43% compared with 7.98%;P= .001).ConclusionA history of cesarean delivery significantly elevates the risks for mother and child in future deliveries. Nonetheless, a trial of labor after previous cesarean is safe. Induction of labor, epidural anesthesia, failure to progress, and abnormal fetal heart rate pattern are all associated with failure of a trial of labor and uterine rupture.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo determine whether it is necessary for a pediatrician to attend all cesarean deliveries.MethodsWe analyzed a database of 17,867 consecutive deliveries to determine the rates of low Apgar scores in the following three groups of patients: those with vaginal delivery, cesarean delivery using regional anesthesia without fetal indication, and cesarean delivery for fetal indications or using general anesthesia.ResultsThere was a significantly higher rate of low Apgar scores in the fetal indications or general anesthesia group when compared with vaginal deliveries. Specifically, 35 (5.8%) of 596 cesareans for fetal heart rate abnormality or using general anesthesia had 1-minute Apgars under 4 in contrast to 115 of 10,270 (1.1%) of vaginal deliveries. There was no significantly increased risk for low Apgar scores in the group of cesareans using regional anesthesia for nonfetal indications (33 of 2057, 1.6%). Results were similar for Apgar scores under 7 at 5 minutes.ConclusionBecause there is no higher incidence of low Apgar scores in cesarean deliveries using regional anesthesia for nonfetal indications compared with vaginal deliveries, there is no convincing need for pediatrician attendance at such deliveries.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo assess whether epidural analgesia is associated with fever, independent of maternal infection, by evaluating the relationship between epidural analgesia and inflammation of the placenta.MethodsPlacentas collected prospectively from women with singleton gestations, who delivered 6 hours or more after membrane rupture, were evaluated systematically for histologic inflammation by an investigator blinded to all clinical information. Maternal and neonatal markers of infection were assessed in the cohorts who did and did not receive epidural analgesia.ResultsOne hundred forty-nine consecutive placentas were analyzed, and 80 (54%) of these women received epidural analgesia. On univariate analysis, significant differences between epidural and no epidural groups were found with respect to maternal fever 38C or greater (46% versus 26%,P= .01), placenta inflammation (61% versus 36%,P= .002), and length of labor (11.8 hours versus 9.6 hours,P= .03). The combination of maternal fever plus placental inflammation was significantly more common in the epidural group (35% versus 17%P= .02). However, maternal fever in the absence of supporting evidence of infection, in the form of placental inflammation, was not increased after epidural analgesia (11% versus 9%,P= .61).ConclusionEpidural analgesia is associated with intrapartum fever, but only in the presence of placental inflammation. This suggests that the fever reported with epidural analgesia is due to infection rather than the analgesia itself.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo identify the effect of spinal anesthesia on the success rate of external cephalic version after 36 weeks' gestation.MethodsWomen with singleton breech presentations after 36 weeks' gestation were offered enrollment. Those who agreed were randomized to receive spinal anesthesia or no anesthesia. Up to four attempts were made using ultrasound surveillance. External cephalic version was terminated with patient discomfort or fetal heart decelerations. Statistical analysis based on intent-to-treat was performed using χ2, Studentttests, and multivariate analysis. Sample size projection based on 20% difference in success rate from a baseline of 50% indicated a need for 50 women in each group.ResultsOne hundred two women were entered in the study from October 1993 to August 1997. There were no differences between groups in parity, maternal age, amniotic fluid index, gestational age, birth weight, placental location, type of breech presentation, maternal weight, or gestational age at delivery. Forty-four external cephalic versions were successful. Fifty (49%) women received spinal anesthesia, and 52 (51%) did not; there was no difference in the overall success rate between groups (44% spinal versus 42% no spinal). Spontaneous version occurred before external cephalic version was attempted in four patients in the spinal group (after the spinal was given) and one patient in the no-spinal group. These patients were included in the analysis.ConclusionSpinal anesthesia does not increase the external cephalic version success rate in singleton pregnancies with breech presentations after 36 weeks' gestation.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo determine if buffered lidocaine provided a more effective nerve block in a short time than plain lidocaine for neonatal circumcision.MethodsOne hundred ninety-four newborn males were studied in a randomized trial using two dorsal penile nerve block preparations for circumcision. Ninety-two received plain lidocaine, and 102 received buffered lidocaine. The infants were evaluated at timed intervals before the procedure, during anesthetic injection, and during circumcision. Objective measurements of heart rate and oxygen saturation, and subjective determinations of behavioral state were recorded. Using heart rate as the major outcome variable, it was determined that 65 subjects per group would be needed to achieve a power of .08. Complications also were noted.ResultsHeart rates and oxygen saturations were similar in the two groups at each timed interval. The behavioral characteristics and amount of crying also were comparable in both groups. The only complication was minor bleeding, seen in each group.ConclusionAdding a buffering agent to lidocaine did not provide a more effective level of anesthesia in a short time.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo compare the ability of combined cytology and cervicography with cytology alone to decrease the number of premalignant cervical lesions found in subsequent screening.MethodsFive thousand five hundred fifty women 18–91 years old were randomized to cytology plus cervicography or cytology alone. One year later, women were rescreened using both cytology and cervicography. All women with positive lesions were referred for colposcopically directed biopsies and treatment as indicated. We expected to decrease by half the number of cervical intraepithelial neoplasia (CIN) lesions at 1-year screening by adding cervicography to cytology at initial screening.ResultsCompared with cytology screening alone, screening with cytology plus cervicography showed a 30% reduction in CIN I-II-III cervical lesions at 1-year screening round (relative risk [RR] 0.70; 95% confidence interval [CI] 0.32, 1.55,P= .35) and a 43% reduction in CIN II-III cervical lesions (RR 0.57; CI 0.14, 2.16,P= .36). Most lesions detected by one test were not detected by the other. In a retrospective search, nine biopsies (one normal and eight revealing CIN I or more on histopathology) were found to be positive for the human papillomavirus; five of the nine biopsies were found by cytology, three by cervicography, and one by both tests.ConclusionThe addition of cervicography to cytology in initial screening did not significantly decrease the number of premalignant cervical lesions detected 1 year later, probably because of the transient nature of most of these lesions. Because cytology and cervicography seemed to detect different premalignant lesions, it is possible that cervicography could detect lesions that do not express the cellular abnormalities necessary for detection by cytology.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo study the histologic regression and progression rates of cervical intraepithelial neoplasia (CIN) II and III after delivery and the effect the route of delivery has on the regression rates of CIN.MethodsPregnant patients with satisfactory colposcopic examinations and biopsy-proven CIN II and III were identified. Delivery information and postpartum biopsy results were obtained by chart review.ResultsTwo hundred seventy-nine patients had antepartum biopsies of CIN II or CIN III. Of these, 126 women were excluded for the following reasons: lost to follow-up (75), human immunodeficiency virus positive (two), cesarean hysterectomy (four), and inadequate postpartum follow-up (45). This yielded a study group of 153 patients consisting of 82 with CIN II and 71 with CIN III. The regression rates were 68% and 70% among CIN II and CIN III patients (P= .78), respectively. Seven percent of patients with CIN II progressed to CIN III on postpartum evaluation. Twenty-five percent of those patients with CIN II and 30% of those with CIN III remained the same postpartum. No CIN lesions progressed to invasive carcinoma. There were no differences in regression rates or progression rates among the women who had vaginal deliveries (130), women who labored and then underwent cesarean (17), or women who proceeded to a cesarean without laboring (six).ConclusionWe found similar high postpartum regression rates despite the route of delivery. We recommend conservative antepartum management with postpartum colposcopic evaluation regardless of route of delivery because we are unable to predict which of these lesions are more likely to regress.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo evaluate sonographic measurements of endometrial thickness in postmenopausal women taking adjuvant tamoxifen therapy for breast cancer, and to correlate sonographic and pathologic findings to symptoms and duration of tamoxifen therapy.MethodsMedical records and sonograms of 80 postmeno-pausal women treated for breast cancer with adjuvant tamoxifen therapy were reviewed retrospectively. Endometrial thickness was recorded as a single-layer thickness and considered abnormal when greater than 2.5 mm for post-menopausal women. Sonographic endometrial thickness was correlated to histologic findings, symptoms, and duration of tamoxifen therapy.ResultsFifty-seven of 80 postmenopausal women (69%) had single-layer endometrial thicknesses of 2.5 mm or greater, measured by transvaginal sonography, and 55 of 57 had endometrial biopsies or dilatations and curettage. Biopsies detected 24 cases of abnormal endometria, including endometrial carcinoma (two), breast carcinoma metastatic to the endometrium (one), endometrial polyps (13), tubal metaplasia (three), and benign endometrial hyperplasia (five). Using a single-layer endometrial thickness greater than 2.5 mm by transvaginal ultrasound, 21 of 24 (87.5%) women with abnormal endometria were detected. Women with abnormal pathologic findings had a significantly thicker mean single-layer endometrial thickness than those with normal findings, 7 mm versus 4 mm (P< .01). Twelve women had postmenopausal bleeding, all of whom had a single-layer endometrial thickness greater than 2.5 mm on transvaginal sonography.ConclusionWith a sensitivity of detecting endometrial abnormalities of 84%, transvaginal sonography was useful for studying postmenopausal tamoxifen-treated women.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID