Autologous Fascial Slings for Stress Urinary Incontinence: a 17-year Follow-up of a Randomised Controlled Study.

INTRODUCTION AND HYPOTHESIS: Safety concerns with the use of mesh in vaginal surgery have been ongoing. Autologous fascial slings (AFS) avoid foreign body complications. We compared the long-term (17-year) outcomes of two AFS repair methods-the standard sling and short sling (sling-on-string), and assessed durability and patient satisfaction of these for the treatment of stress urinary incontinence (SUI). METHODS: A total of 107 patients from three urogynaecology units who had participated in a randomised controlled trial assessing standard (n = 52) and short (n = 55) slings were followed up for a median period of 17 years. Primary outcomes were Incontinence Impact Questionnaire (IIQ-7) and Urogenital Distress Inventory (UDI-6) scores to assess the impact on the quality of life and symptom distress. Logistic quantile regression was employed to compare the two methods. Secondary outcomes included long-term complications and patient satisfaction. RESULTS: Mean scores showed no statistically significant difference between the standard and short slings at the 17-year follow-up relating to IIQ and UDI scores, leakage or urgency (p > 0.05). Improved bladder function was observed at 17 years compared with baseline (standard sling-IIQ scores mean difference [MD] 1.22 [CI: 0.69, 1.74], UDI scores MD 0.83 [CI: 0.70, 0.97]; short sling-IIQ score MD 1.14 [CI: 0.73, 1.54], UDI scores MD 0.54 [CI: 0.40, 0.67]) with age-related deterioration over time. Re-operation rates were low and patient satisfaction rates were high (67.2%) at follow-up. CONCLUSIONS: Autologous fascial slings are an effective and durable option for management of SUI and the short sling procedure can be recommended owing to plausible surgical advantages.

Modified autologous fascial sling technique ('sling on a string') for stress incontinence.

INTRODUCTION AND HYPOTHESIS: Describe the modified autologous fascial sling procedure that has been employed in the largest randomized controlled trial comparing autologous slings, mesh slings and xenografts. METHODS: The video aims to demonstrate the modified Aldridge technique. The surgical procedure is demonstrated. A 6-cm suprapubic incision is made to harvest the rectus sheath fascia. Loop-0-PDS sutures are attached on either end of the sling. A marking suture is placed in the middle of the graft to facilitate tension-free adjustment. A vaginal incision is made at the mid-urethra. Paraurethral dissection is performed to create a tunnel for the fascial graft to be passed through (in the same manner as with transvaginal mesh slings). The ends of the graft PDS sutures are passed through the paraurethral tunnel. One hand is placed abdominally below the rectus muscles to palpate the pelvic floor from above. The graft sutures are passed through the pelvic floor with control on either side. A cystoscopy is performed to check the bladder integrity. The graft placement is adjusted to be tenson-free. The incisions are closed. The short- and long-term outcomes of this technique have been investigated and published. RESULTS: The cure rates and complication rates were no different in the mesh and autologous slings. The xenograft had inferior outcomes. CONCLUSION: Autologous fascial slings can be used in the surgical management of urodynamic stress incontinence. The technique demonstrated in this video is the technique employed in the largest randomized controlled trial investigating the efficacy of autologous fascial slings to xenografts and tapes.

Cluster randomised control trial of the effect on attendance and outcomes of multi-disciplinary teams involving psychologists during pelvic floor muscle training for pelvic floor dysfunction.

Pelvic floor muscle training (PFMT) is effective, acceptable to patients, and cost efficient as a treatment for Pelvic Floor Dysfunction (PFD). However, PFMT outcomes are mediated by patient variables, such as depression, anxiety, motivation, and health values. The current study examined whether multi-disciplinary provision of PFMT involving a psychologist would improve attendance and outcomes (Clinical Trial Registration: NCT02549157). 88 consecutively referred patients (age 28 - 85 years), with a variety of PFD, were randomised into two groups: PFMT treatment as usual (n = 47), and PFMT with a psychologist involved (n = 41). Patients received 6-month out-patient physiotherapy. More patients with the psychologist completed the course, and there were significantly greater improvements in subjective symptoms (Queensland scale), quality of life (EQ-5D), and anxiety (HADS), although not in objective measures (Oxford Grading) or depression (HADS). These results suggest that an MDT including a psychologist during PFMT intervention treatment may help some patients.IMPACT STATEMENTWhat is already known on this subject? Pelvic floor muscle training (PFMT) is effective, acceptable to patients, and cost efficient as a treatment for Pelvic Floor Dysfunction (PFD). However, PFMT outcomes are mediated by patient variables, such as depression, anxiety, motivation, and health values. The effectiveness of a multi-disciplinary team delivering both PFMT and psychological support simultaneously to women undergoing PFMT for PFD is unknown.What do the results of this study add? Psychological support delivered alongside PFMT increased patient attendance, improved subjective ratings of pelvic floor functioning, health-related quality of life, and reduced anxiety. This is one of the first demonstrations that this can be achieved through a multi-disciplinary team delivering their support simultaneously to the patients.What are the implications of these findings for clinical practice and/or further research? Improving subjective functioning and reducing attrition rates in PFD patients has cost implications in terms of reduced need for surgery, and making future surgery more effective. The inclusion of brief, easily delivered psychological support, integrated into the PFMT sessions in a multidisciplinary way may represent an extremely cost effective method of improving the service for these patients.

Acceptability and effectiveness of a multidisciplinary team approach involving counselling for mesh-removal patients.

Patients with complications following mesh removal risk a variety of symptoms, and can view medical intervention negatively. This study explored the patient-acceptability of a Multidisciplinary Team (MDT), and whether the presence of a Counsellor would be accepted and effective. Twenty consecutively referred women, who had undergone mesh-removal but experienced complications were interviewed about their experiences, and completed the Queensland scale for pelvic floor symptoms, McGill Pain Questionnaire, and Hospital Anxiety and Depression Scales, before and after treatment. Patients had high levels of pelvic-floor symptoms, sensory and affective pain, anxiety, and depression. 70% reported a positive MDT experience; predicted by higher anxiety, and lower depression. 60% elected to receive Counselling, which commenced within one week of referral, typically lasted 1-4 sessions, and reduced pelvic-floor symptoms, affective pain, anxiety, and depression. Results suggest that the MDT approach is generally acceptable for this patient group, and that mesh-removal patients accept and benefit from input by a Counsellor.Impact statementWhat is already known on this subject? Concerns have been raised regarding the safety of mesh insertion. Multidisciplinary Teams (MDTs) are suggested to offer a strong approach to managing many women's health conditions, but no studies have examined mesh-removal patients, making generalisation difficult to the current patient group. Furthermore, it is unknown whether an MDT approach, including a Counsellor, would be acceptable to mesh-removal patients.What do the results of this study add? Patients had high levels of pelvic-floor symptoms, pain, anxiety, and depression. 70% reported the MDT experience as positive, predicted by higher anxiety, and lower depression. 60% elected to receive Counselling, which reduced pelvic-floor symptoms, affective pain, anxiety, and depression.What are the implications of these findings for clinical practice and/or further research? The Counselling provided as part of the MDT approach was able to commence quickly, did not require many sessions, and reduced reported pelvic-floor symptoms, affective pain, anxiety, and depression. These findings suggest that an MDT approach involving Counselling is generally acceptable, and that mesh-removal patients accept and benefit from the input of a Counsellor, as part of their treatment.

Randomized Controlled Trial of the Effect of a Brief Telephone Support Intervention on Initial Attendance at Physiotherapy Group Sessions for Pelvic Floor Problems.

OBJECTIVE: To assess the efficacy of a brief telephone call to patients on a waiting list for physiotherapy treatment of pelvic floor dysfunction on initial attendance. DESIGN: Three-armed randomized controlled trial. SETTING: Outpatient physiotherapy clinic at a hospital. PARTICIPANTS: Female patients (N=130; mean age, 51.47±13.33y; range, 26-84y) with various pelvic floor dysfunction problems. INTERVENTIONS: Telephone support call (2-10min) 3 days before or 3 days after receiving an invitation letter to physiotherapy sessions. MAIN OUTCOME MEASURES: Attendance at the initial physiotherapy group session. RESULTS: Groups receiving a telephone call demonstrated 80% attendance at the session, with no significant difference between these groups. The group receiving no call had significantly lower attendance rates (50%) than did the call groups. The telephone support was more effective in those people who were older, came from less economically deprived areas, and had been on the waiting list for less time. CONCLUSIONS: A brief telephone support call may be an effective method to enhance patient attendance at treatment, but it may work best when targeted at certain groups of individuals.

Alkalinized lidocaine versus lidocaine gel as local anesthesia prior to intra-vesical botulinum toxin (BoNTA) injections: A prospective, single center, randomized, double-blind, parallel group trial of efficacy and morbidity.

AIMS: To assess the efficacy and morbidity of alkalinized lidocaine solution compared to lidocaine gel for intra-vesical anesthesia during botulinum toxin (BoNTA) injections in a statistically powered, prospective, parallel group, double-blind randomized controlled trial. METHODS: Fifty-four patients of either sex were randomized to receive either alkalinized lidocaine (AL) solution (10 ml 8.4% sodium bicarbonate + 20 ml 2% lidocaine solution + 22 ml sterile Aquagel®) or lidocaine gel (LG) (22 ml standard 2% lidocaine gel Instillagel® + 30 ml 0.9% normal saline solution). Primary outcome was average pain (assessed by 100 mm visual analog score) felt during intra-vesical BoNTA injections performed at least 20 min after instillation. Secondary outcome was the rate of adverse events. RESULTS: Of 60 randomized patients 54 received the allocated intervention and were analyzed. Mean pain score in the AL group was 17.11 mm (95%CI 8.65-25.57 mm) and in the LG group was 19.53 mm (95%CI 13.03-26.03mm) with no significant difference between the groups. Cost of interventional medication in the AL group was almost double that of the LG group. No adverse events were attributable to local anesthetic instillation in either group. CONCLUSIONS: Alkalinized lidocaine solution is not superior to lidocaine gel for anesthesia during intra-vesical BoNTA injections, and the higher cost precludes its use over lidocaine gel at our centre. We have used the results of this study to adapt our local protocol for BoNTA injections and continue to use lidocaine gel as the local anesthetic of choice. Neurourol. Urodynam. 35:522-527, 2016. © 2015 Wiley Periodicals, Inc.

Long-term follow-up of a multicentre randomised controlled trial comparing tension-free vaginal tape, xenograft and autologous fascial slings for the treatment of stress urinary incontinence in women.

OBJECTIVE: To compare the long-term outcomes of a tension-free vaginal tape (TVT; Gynecare™, Somerville, NJ, USA), autologous fascial sling (AFS) and xenograft sling (porcine dermis, Pelvicol™; Bard, Murray Hill, NJ, USA) in the management of female stress urinary incontinence (SUI). PATIENTS AND METHODS: A multicentre randomised controlled trial carried out in four UK centres from 2001 to 2006 involving 201 women requiring primary surgery for SUI. The women were randomly assigned to receive TVT, AFS or Pelvicol. The primary outcome was surgical success defined as 'women reporting being completely 'dry' or 'improved' at the time of follow-up'. The secondary outcomes included 'completely dry' rates, changes in the Bristol Female Lower Urinary Tract Symptoms (BFLUTS) and EuroQoL EQ-5D questionnaire scores. RESULTS: In all, 162 (80.6%) women were available for follow-up with a median (range) duration of 10 (6.6-12.6) years. 'Success' rates for TVT, AFS and Pelvicol were 73%, 75.4% and 58%, respectively. Comparing the 1- and 10-year 'success' rates, there was deterioration from 93% to 73% (P < 0.05) in the TVT arm and 90% to 75.4% (P < 0.05) in the AFS arm; 'dry' rates were 31.7%, 50.8% and 15.7%, respectively. Overall, the 'dry' rates favoured AFS when compared with Pelvicol (P < 0.001) and TVT (P = 0.036). The re-operation rate for persistent SUI was 3.2% (two patients) in the TVT arm, 13.1% (five) in the Pelvicol arm, while none of the patients in the AFS arm required further intervention. CONCLUSIONS: Our study indicates there is not enough evidence to suggest a difference in long-term success rates between AFS and TVT. However, there is some evidence that 'dry' rates for AFS may be more durable than TVT.

Influence of antenatal physical exercise on haemodynamics in pregnant women: a flexible randomisation approach.

BACKGROUND: Normal pregnancy is associated with marked changes in haemodynamic function, however the influence and potential benefits of antenatal physical exercise at different stages of pregnancy and postpartum remain unclear. The aim of this study was therefore to characterise the influence of regular physical exercise on haemodynamic variables at different stages of pregnancy and also in the postpartum period. METHODS: Fifty healthy pregnant women were recruited and randomly assigned (2 × 2 × 2 design) to a land or water-based exercise group or a control group. Exercising groups attended weekly classes from the 20th week of pregnancy onwards. Haemodynamic assessments (heart rate, cardiac output, stroke volume, total peripheral resistance, systolic and diastolic blood pressure and end diastolic index) were performed using the Task Force haemodynamic monitor at 12-16, 26-28, 34-36 and 12 weeks following birth, during a protocol including postural manoeurvres (supine and standing) and light exercise. RESULTS: In response to an acute bout of exercise in the postpartum period, stroke volume and end diastolic index were greater in the exercise group than the non-exercising control group (p = 0.041 and p = 0.028 respectively). Total peripheral resistance and diastolic blood pressure were also lower (p = 0.015 and p = 0.007, respectively) in the exercise group. Diastolic blood pressure was lower in the exercise group during the second trimester (p = 0.030). CONCLUSIONS: Antenatal exercise does not appear to substantially alter maternal physiology with advancing gestation, speculating that the already vast changes in maternal physiology mask the influences of antenatal exercise, however it does appear to result in an improvement in a woman's haemodynamic function (enhanced ventricular ejection performance and reduced blood pressure) following the end of pregnancy. TRIAL REGISTRATION: ClinicalTrials.gov NCT02503995. Registered 20 July 2015.

Outcomes and complications of trans-vaginal mesh repair using the Prolift™ kit for pelvic organ prolapse at 4 years median follow-up in a tertiary referral centre.

PURPOSE: To evaluate the anatomical, functional and post-operative outcomes of polypropylene mesh (Prolift™) in the surgical management of pelvic organ prolapse (POP). METHODS: A single-centre observational study of 106 successive patients, who underwent Prolift™ mesh repair (POP ≥ 2) with a median follow-up of 4 years, was performed. Outcomes of interest measured included patient demographics, intra and post-operative complications, concomitant procedures for POP or urinary incontinence. Using the Baden-Walker classification, grade ≥2 prolapses in the operated compartment were deemed as surgical failure. Validated questionnaires including ICIQ-VS and ICIQ-UI were used to assess functional outcome. RESULTS: Of the 106 patients, 56 had an anterior, 36 a posterior and 14 a total Prolift™. 101 patients were available for follow-up (median 4 years). 82 women underwent a clinical follow-up whilst 19 underwent a telephonic follow-up. Peri-operative bladder injury was noted in 2 (1.9 %) cases. Six (5.6 %) patients developed mesh exposure post-operatively. Re-operation rates for recurrent prolapse in the operated compartment were 2.8 % (n = 3). At follow-up, prolapse recurrence in the operated compartment was noted in another 7.3 % (n = 6) patients. Combining re-operations for POP and recurrences noted during follow-up, the revised failure rate was 10.1 % (n = 9). De novo prolapse in the non-operated compartment occurred in 19.5 % (n = 16) women. CONCLUSION: Our study demonstrates that Prolift™ vaginal mesh surgery offers anatomical cure rates of 89.9 %. A higher rate of de novo recurrence in the non-operated compartment was noted suggesting that surgical correction in one compartment may exacerbate recurrence in other compartments.

Relationship between depression, anxiety, and attendance at pelvic-floor muscle training sessions.

OBJECTIVES: Psychological comorbidities are associated with non-attendance for pelvic-floor muscle training (PFMT) appointments and non-engagement with ongoing treatment. However, little direct work has examined the precise relationship between these variables. DESIGN: A prospective observational study of consecutively referred women patients with Pelvic-floor Dysfunction. Patients were assessed at intake for age, BMI, pelvic symptoms (measured by the Queensland Pelvic Symptom Scale), and anxiety and depression (measured by the Hospital Anxiety and Depression Scales). SETTING: A women's health physiotherapy outpatient unit of a metropolitan hospital. PARTICIPANTS: 433 consecutively-referred women with pelvic-floor dysfunction (PFD). INTERVENTIONS: Six sessions of PFMT, lasting over a period of 6 months. MAIN OUTCOME MEASURES: Attendance at PFMT sessions was the outcome, and was related to intake patient age, BMI, pelvic symptoms, as well as anxiety and depression. RESULTS: Psychological symptoms of depression and anxiety predicted attendance at PFMT sessions, over and above physical symptoms. Depression was the key predictor of non-attendance, with anxiety having a more complex relationship with attendance. There were few differences between these psychological variables and the different types of PFD, or between type of PFD and PFMT attendance. CONCLUSIONS: The findings add to the literature suggesting that consideration of patients' psychological state is important when designing treatment-regimes. CONTRIBUTION OF THE PAPER.

Change in depression predicts change in bladder symptoms for women with urinary incontinence undergoing pelvic-floor muscle training.

INTRODUCTION: To examine the relationship between depression and bladder symptoms, especially the impact of change in depression on changes in bladder symptoms, for women with urge and stress urinary incontinence undergoing a course of PFMT. METHOD: 106 adult females with pelvic-floor dysfunction (PFD), consecutively referred to an outpatient pelvic-floor muscle training (PFMT) programme for either urge, stress, or mixed incontinence, participated in a prospective observational study. Participants reported subjective views of their pelvic floor problems (Queensland), and their levels of depression (HADS_D), and data relating to age and BMI were collected. The trial was registered on clinicaltrials.gov (NCT02549157). RESULTS: There was a positive relationship between depression and bladder symptoms at intake. Levels of initial depression significantly predicted levels of bladder symptoms at completion of PFMT, and ability to complete the PFMT programme. Change in depression significantly predicted change in bladder symptoms, over and above intake patient characteristics and symptoms. DISCUSSION: These data imply a multidisciplinary focus, including psychological input, for PFD may be a highly effective strategy for its management.

Patient and economic benefits of psychological support for noncompliant patients.

The current paper provides an overview of treatment noncompliance at various points in the treatment pathway, especially with respect to treatment for Pelvic-floor Dysfunction (PFD). The effects of noncompliance on healthcare are considered, and examples of supporting patients psychologically to increase compliance are discussed. An outline of a method to identify costs of non-compliance, and where such costs most intensely impact the healthcare system, is provided. It is suggested that psychological support is effective in terms of increased compliance and improved healthcare economics. The model is presented for PFD, but the principles developed can be generalised to many aspects of healthcare.

Chronic Urinary Infection in Overactive Bladder Syndrome: A Prospective, Blinded Case Control Study.

Objectives: To investigate whether women with overactive bladder (OAB) symptoms and no evidence of clinical infection by conventional clean-catch midstream urine cultures have alternative indicators of sub-clinical infection. Patients/Subjects Materials & Methods: The study was a prospective, blinded case-control study with 147 participants recruited, including 73 OAB patients and 74 controls. The OAB group comprised female patients of at least 18 years of age who presented with OAB symptoms for more than 3 months. Clean-catch midstream urine samples were examined for pyuria by microscopy; subjected to routine and enhanced microbiological cultures and examined for the presence of 10 different cytokines, chemokines, and prostaglandins by ELISA. Results: The mean age and BMI of participants in both groups were similar. No significant difference in the number of women with pyuria was observed between OAB and control groups (p = 0.651). Routine laboratory cultures were positive in three (4%) of women in the OAB group, whereas the enhanced cultures isolated bacteria in 17 (23.2%) of the OAB patients. In the control group, no positive cultures were observed using routine laboratory cultures, whereas enhanced culture isolated bacteria in 8 (10.8%) patients. No significant differences were observed in the concentrations of PGE2, PGF2α, MCP-1, sCD40L, MIP-1ß, IL12p70/p40, IL12/IL-23p40, IL-5, EGF and GRO-α between the OAB and control groups. Conclusions: Patients with OAB symptoms have significant bacterial growth on enhanced culture of the urine, which is often not detectable through routine culture, suggesting a subclinical infection. Enhanced culture techniques should therefore be used routinely for the effective diagnosis and management of OAB.

Impact of Strength and Nature of Patient Health Values on Compliance and Outcomes for Physiotherapy Treatment for Pelvic Floor Dysfunction.

OBJECTIVE: To determine whether patient values impact on compliance and outcome for physiotherapy treatment for pelvic floor dysfunction. Although studies have related "health values" to behaviors in the laboratory, or to behaviors such as exercise, there have been no studies of the impact of patient values on actual medical treatments. METHODS: A prospective observational study of the impact of patient values on compliance and outcomes for physiotherapy treatment for pelvic floor dysfunction was conducted in a physiotherapy clinic in the urogynaecological outpatients unit of a hospital. Two hundred eighteen patients were approached and agreed to participate. Prior to treatment, pelvic floor functioning was assessed using the Oxford Grading System, and Queensland Pelvic Floor Questionnaire, and values were assessed using the Personal Values Questionnaire (PVQ-II). Following a 6-month physiotherapy treatment programme, pelvic floor function was reassessed. RESULTS: The strength of patient health-related values measured by the PVQ-II significantly predicted compliance with the intervention, but the nature of health value (intrinsically-valued, as opposed to externally-controlled) predicted objective outcome. CONCLUSION: Patient values impact on physiotherapy adherence and outcomes, and could be considered as part of future assessment/screening procedures.

Dynamic analysis of beat-to-beat fetal heart rate variability recorded by SQUID magnetometer: quantification of sympatho-vagal balance.

BACKGROUND: Quantitative analysis of fetal heart rate variability (HRV) can be used to investigate the neural control mechanisms of fetal cardiac activity. However, conventional power spectrum methods do not reveal the full complexity of the time-varying sympatho-vagal balance in the fetus. AIM: This study was carried out to explore alternative digital signal processing methods of analysing fetal HRV in time domain (rather than frequency domain), in line with most types of physiological monitoring. METHODS: The beat-to-beat fetal heart rate was obtained by Superconducting Quantum Interference Device (SQUID) magnetocardiographic recording. These data were filtered within appropriately selected frequency bands: high frequency (HF) f>0.2 Hz, low frequency (LF) 0.05

Influence of somatic state on cardiovascular measurements in pregnancy.

Normal pregnancy causes marked changes in cardiac and haemodynamic function but there is continuing debate about the patterns of 'normal' change. We believe that this lack of consensus is in large part caused by inappropriate assessment conditions. This study aimed to assess physiological data obtained from pregnant women during multiple steady-states and during between-state changes. The study was a longitudinal characterization of apparently healthy pregnant women aged >18 years with assessments at three antenatal stages (12-16, 26-28 and 34-36 weeks) and at 12 weeks following birth. Cardiovascular and heart rate variability (HRV) measures were quantified non-invasively during a range of states including postural manoeuvre, exercise and respiratory regulation. Cardiovascular and HRV variables were influenced by pregnancy in specific ways: (1) steady-state values were influenced differently to state-change responses; (2) cardiac output (CO) increased progressively throughout pregnancy in all states except supine rest; (3) the ΔCO response to the supine-standing manoeuvre was particularly sensitive to pregnancy stage; (4) blood pressure was unaffected by pregnancy; (6) ΔCO and ΔSBP (systolic blood pressure) were enhanced from mid-pregnancy onwards; (7) ΔHRV responses to state changes were markedly and progressively influenced by pregnancy. This study indicates that cardiovascular function in pregnant women is best quantified during at least one physical state change (in particular during the supine-to-standing manoeuvre) and that assessment during supine rest is inadequate for quantifying antenatal physiological function.

Rapidly developing myomatous erythrocytosis syndrome: a case report.

Myomatous erythrocytosis syndrome is polycythaemia associated with uterine leiomyoma, a rare condition known for over five decades with unclear aetiology. The present case is a 51-year-old Caucasian woman who presented with urinary retention and anaemia secondary to multiple uterine fibroids and menorrhagia 5 years following uterine artery embolisation. She opted for abdominal hysterectomy but preoperatively was found to be polycythaemic with haemoglobin of 23 g% and raised serum erythropoietin requiring serial venesections. At a year postoperatively she maintains normal haemoglobin and serum erythropoietin levels. Ectopic production of erythropoietin by fibroids is the most favoured aetiopathogenesis in this case. However, the rapid transition from anaemia to polycythaemia in 5 months is a striking feature as fibroid-linked polycythaemia has so far been reported on presentation. Vigilance is crucial in excluding polycythaemia while such patients are on waiting list as there is a risk of thromboembolism, which is further increased by surgery.

The impact of intrapartum analgesia on infant feeding.

OBJECTIVE: To investigate the impact of intrapartum analgesia on infant feeding at hospital discharge. DESIGN: Retrospective cohort. SETTING: Maternity unit of a UK district general hospital. POPULATION: A random sample of 425 healthy primiparae delivering healthy singleton babies at term in 2000. METHODS: A random sample of primiparae delivering term neonates was identified from the birth register. We retrieved and analysed the corresponding joint midwifery/obstetric case notes. MAIN OUTCOME MEASURE: Infant feeding method at discharge from hospital. RESULTS: Women [190/424 (45%)] were exclusively bottle feeding their babies at discharge from hospital. No one commenced breastfeeding after hospital discharge. Regression analysis revealed that the main determinants of bottle feeding were as follows: maternal age [odds ratio (OR) 0.90, 95% confidence interval [CI] 0.85-0.95 per year]; occupation (OR 0.63, 95% CI 0.40-0.99 for each category, unemployed, manual, non-manual); antenatal feeding intentions (OR 0.12, 95% CI 0.080-0.19 for each category, bottle feeding, undecided, breastfeeding); caesarean section (OR 0.25, 95% CI 0.13-0.47, caesarean or vaginal delivery); and dose of fentanyl administered intrapartum (OR 1.004, 95% CI 1.000-1.008, 90% CI 1.001-1.007 for each microgram administered, range 8-500 mug). CONCLUSIONS: A dose-response relationship between fentanyl and artificial feeding has not been reported elsewhere. When well-established determinants of infant feeding are accounted for, intrapartum fentanyl may impede establishment of breastfeeding, particularly at higher doses.