Impact of the severity of fetal distress on decision-to-delivery intervals for assisted vaginal delivery.

To correlate the severity of fetal distress assessed retrospectively using the Dublin intrapartum fetal monitoring classification, with decision-to-delivery intervals (DDI) and neonatal outcome, a prospective 3-month study of 78 consecutive instrumental deliveries was conducted. There were 66 cardiotocographs (CTGs) with an 83% majority agreement on classification: it was agreed 95% of deliveries should be expedited for the 58 interpretable CTGs. Although the more abnormal CTG patterns resulted in shorter DDIs and greater neonatal acidaemia, there were no significant correlations. Acidosis was present in 14% with a suspicious, or 22% an ominous CTG pattern. Delivery as a trial in theatre doubled the DDI at 41.5 +/- 22.7 (mean +/- SD) min, compared with 18.1 +/- 8.1 min in the labour room (p < 0.0001), with one case of severe acidosis in the former group. The prolonged DDI with a trial of delivery in theatre could adversely compromise the already 'distressed' fetus and should be used only when clearly indicated.

The impact of a trial of instrumental delivery in theatre on neonatal outcome.

OBJECTIVE: To observe the effect of a trial of instrumental delivery in theatre on outcome for mother and baby. DESIGN: A prospective observational study. METHODS: Relevant maternal and neonatal data were collected for all instrumental deliveries of singleton viable pregnancies delivered over a three month period. POPULATION: Two hundred and twenty nine consecutive deliveries conducted by ventouse or forceps because of fetal distress or dystocia. SETTING: The maternity unit of a teaching hospital delivering around 6000 women annually. MAIN OUTCOME MEASURES: The decision-to-delivery intervals (DDI), mode of delivery and neonatal condition at birth. RESULTS: Sixty (26%) deliveries were managed as a trial in theatre, 46 (77%) because of prolonged second stage, with malposition being a factor in 39, and 14 (23%) because of fetal distress. The mean +/- SD DDI for these 60 deliveries was 59.2 +/- 20.4 minutes (median 58 minutes) compared with 21.2 +/- 9.0 minutes (median 20 minutes) for 169 delivered in the labour room (P < 0.0001). Of these 169 deliveries, 168 were delivered within 46 minutes and 1 delivered by caesarean section at 60 minutes. Nine women (13%) ultimately delivered by caesarean section, eight following a trial in theatre; in seven, there was malposition. Deliveries following a trial had slightly less favourable cord blood gas results. CONCLUSIONS: Trial of instrumental delivery takes two to three times longer than delivery in the labour room; fetal malposition was the major indication for the trial of instrumental delivery and reason for failed delivery. Adopting the recent guidelines of the Royal College of Obstetricians and Gynaecologists, at least 107 (47%) should have been managed as a trial in theatre. The added delay in delivery could be damaging to an already hypoxic fetus, and the use of a trial should be individually assessed.

Prevalence of group B streptococcal colonization in pregnant third trimester women in Trinidad.

A study of colonization by group B streptococcus was conducted in 204 pregnant women in their third trimester. Positive cultures were obtained from vaginal and rectal swabs in 64 (31.4%) of these women. No significant differences in colonization rates were noted on the basis of ethnicity (race) and gravidity. However, there was a significant difference in the rate of colonization of vagina and rectum. Fifty-two (25.5%) women had positive isolates from vaginal swabs compared with 26 (12.7%) women with positive rectal isolates (P < 0.05). There was a significant trend of increasing prevalence with increasing age. Colonization was not significantly greater in multigravid than in primigravid women. There was no significant difference between colonization in Negro (black) women and colonization in East Indian women.

The value of gonadotrophin releasing hormone analogue in an intrauterine insemination (IUI) programme.

Gonadotrophin releasing hormone analogue (GnRHa) is widely used in in-vitro fertilisation programmes and has no doubt led to a significant improvement in the pregnancy rate as well as cycle planning. However, its use in intrauterine insemination (IUI) programmes remains controversial. This is a retrospective review of patients who received IUI treatment at our assisted conception unit, during a 12-month period from August 1997 to July 1998. Fifty-two patients underwent a total of 85 cycles. Six cycles were abandoned, five due to excessive response and one for continuous bleeding. They all received Nafarelin nasal spray from day 2 until ovulatory HCG was administered. Metrodin injection was given from day 3. There were 18 clinical pregnancies. Seventy-nine cycles were completed giving a pregnancy rate of 22.8% per completed cycle. There were five (27.8%) multiple pregnancies. The use of GnRHa in our programme enabled us to achieve a good cycle control as well as flexibility in the timing of insemination such that weekend work was avoided. We conclude that the use of GnRHa facilitates the efficiency of an IUI programme.

Laparoscopic surgical management of ectopic pregnancy: a district general hospital experience.

This is an audit of laparoscopic management of ectopic pregnancy in a District General Hospital (DGH), using a retrospective casenote review. The study was conducted at New Cross Hospital, Wolverhampton, a large DGH. We recorded the duration of operation, postoperative opiate requirement, length of hospital stay, operative and postoperative complications. Case notes of patients with surgically treated ectopic pregnancies between January 1996 and June 1998 (n=106) were reviewed and grouped into three categories: (1) immediate laparotomy, (2) laparoscopy followed by laparotomy, and (3) laparoscopic management. Comparisons were made between the three groups. The incidence of ectopic pregnancy was 1-91 live births. The mean age of the patients was 29.9 years (range 14-41). Seven (6.6%) patients were haemodynamically unstable and underwent immediate laparotomy, 66 (62%) patients had laparoscopic management while 33 (31%) patients had laparotomy following preliminary laparoscopy. Mean operative time in the laparoscopic management group was 61.9 minutes. The mean +/- 2 SD was 61.9+/-37.4 (range 27-107) with a mean length of hospital stay of 1.9 days (range 1-4), compared with 49.9 minutes (+/-SD 16.5 (range 35-98) and 3.9 days (range 2-8), respectively, in the laparotomy following preliminary laparoscopy group. Only one patient in the laparoscopic management group required opiate analgesia 24 hours postoperatively compared with all the patients in the immediate laparotomy group and seven patients (21%) in laparotomy following the preliminary laparoscopy group. Complications in the laparoscopic management group included wound infection and a persistent ectopic. One patient in the laparotomy group required subtotal hysterectomy for persistent bleeding from cornual ectopic, while complications in the laparotomy following the laparoscopy group consisted of minor wound infection and a case of deep venous thrombosis (DVT). Laparoscopic management of ectopic pregnancy is safe and can be carried out successfully in a DGH setting with clear advantages, including shorter hospital stay and reduced postoperative opiate requirement.

What is the normal heart rate of a term fetus?

There is controversy about the value of continuous versus intermittent auscultation of the fetal heart during labour, but there is no agreement on what constitutes normal heart rate of a term fetus. There are variations between the definitions adopted by different countries, and even within a single country. We propose 110-160 beats per minute for clinical use.