Fatal perineal cellulitis from an episiotomy site.

Perineal cellulitis originating from an episiotomy incision resulted in 20% of the maternal mortality in King County, Washington, between 1969 and 1977. Necrotizing fasciitis was present in 2 of the cases, and clostridial myonecrosis was present in 1. These fatalities occurred because the practitioners were not aware that necrotizing fasciitis can occur in the fatty superficial fascia of the perineum and that resection of the necrotic tissue is necessary for successful therapy.

Alternative birth rooms and birth options.

The hospital-based alternative birth room has become a popular alternative to the conventional labor and delivery room setting. Responses to a mailed questionnaire from 78 of 82 (95%) Washington State hospitals with obstetric services were used to relate available birth options to alternative birth room status and obstetric volume. Alternative birth rooms were in existence, or planned, in 63% of responding hospitals. The presence of an alternative birth room was directly related to obstetric volume (P less than .05) and perceived local incidence of home deliveries (P less than .025). Hospitals with an alternative birth room had more postpartum options regardless of obstetric volume. Hospitals with an alternative birth room and less than 1000 annual deliveries had more delivery and bonding options. The results of this analysis, plus the fact that 47 of 78 (60%) responding hospitals offered more than half of the options surveyed, suggest that Washington State hospitals have responded to new consumer desires more than previously appreciated.

Chronic fetal stress and the risk of infant respiratory distress syndrome.

The relationship between five conditions of chronic fetal stress and the incidence of infant respiratory distress syndrome (RDS) was investigated among 614 premature (less than or equal to 36 weeks) infants delivered at the University of Washington Hospital from 1977 to 1980. The strongest association found was a protective effect of abnormal antepartum testing (nonreactive nonstress test, positive contraction stress test, or low or falling maternal urinary estriols). Among the 45 infants with abnormal antepartum testing, the probability of RDS was 15.0 versus 33.8% for the infants without the complication (odds ratio = 0.35, P less than or equal to .01, adjusted for gestational age and mode of delivery). Rupture of the membranes for greater than 24 hours (N = 151), amnionitis (N = 63), and vaginal bleeding beginning more than 24 hours before delivery (N = 108) were each associated with a reduced risk of RDS (adjusted odds ratios = 0.63, 0.51, and 0.58, respectively, P less than or equal to .05). Hypertensive disease of pregnancy was not associated with a decreased risk of RDS; in fact, the opposite trend occurred (N = 96, odds ratio = 1.67, P = .07). The associations with RDS were not explained by differences between births with and without each complication in terms of gestational age, mode of delivery, absence of labor, administration of antenatal steroids, and other complications of pregnancy. This study adds support to the hypothesis that certain conditions associated with chronic fetal stress lead to an acceleration in pulmonary maturity.

Sperm penetration assay and subsequent pregnancy: a prospective study of 74 infertile men.

Seventy-four men of infertile couples, for whom a female infertility factor had been excluded, were followed for up to three years after semen analyses that included the sperm penetration assay, an in vitro test of sperm function. At 156 weeks after a normal sperm penetration assay, the cumulative pregnancy rate was 68%, versus only 27% when an abnormal assay was noted. Cumulative pregnancy percents at one year varied significantly (P less than .02) according to the magnitude of the assay result (0%, 1-10%, 11-15%, 16% or greater). However, differences between 0% versus 1-10%, and 11-15% versus 16% or greater, were not statistically significant. Only one of 14 men effected conception after an assay result of 0%. These findings were little altered when analysis of the sperm penetration assay was restricted to men with normal sperm concentration (20 X 10(6) sperm mL-1 or greater) and motility (60% or greater). The presence of pyospermia (six or more white blood cells per 100 spermatozoa) was associated with continued infertility, but neither abnormal sperm concentration nor motility were associated significantly with lower cumulative pregnancy percents. When performed for infertile men according to standard protocol, the sperm penetration assay enhances prediction of future pregnancy.

An out-of-hospital birth center using university referral.

Out-of-hospital birth centers are controversial. A retrospective chart review was performed for 150 consecutive patients who had their prenatal care at The Birthplace, a Seattle birth center with certified nurse-midwives licensed by the state of Washington. Seventy-two percent of the women were nulliparous. Antepartum or intrapartum hospital referral was necessary for 28% of the patients. An additional 17% of the patients would have been transferred if specific written criteria for transfer had been precisely followed. The cesarean section rate was 6% (9 of 150). Nonoptimal 1-minute Apgar scores of 6 or less were more common in nulliparas (20%) than in multiparas (3%) who delivered at The Birthplace (P less than .05). All 5-minute Apgar scores were 7 or more. Three infants had birth weights less than 2500 g. Noncompliance with the transfer criteria was associated with untoward outcome. Patients considering out-of-hospital delivery should be counseled that a high rate of hospital transfer is necessary to minimize risk.

Maternal smoking and infant respiratory distress syndrome.

The relationship between maternal smoking and infant respiratory distress syndrome (RDS) was investigated among 550 premature (36 weeks or less) births delivered at the University of Washington Hospital from 1977 to 1980. Forty-five percent of the mothers were smokers. To avoid bias due to the reduced birth weight of infants of smokers, infants of smokers and nonsmokers were compared within small gestational age categories (two-week intervals) and not by birth weight categories. Infants of mothers who smoked had a reduced incidence of RDS for their gestation compared with infants of nonsmokers. The probability of RDS (adjusted for gestational age and method of delivery) was 25% for the infants of smokers versus 38% for the infants of nonsmokers (odds ratio = 0.55, P = .005), equivalent to approximately a 1.5-week acceleration in lung maturity for infants of smokers. The smoking effect was not explained by demographic differences between smokers and nonsmokers, nor by differences in the incidence of pregnancy complications between the two groups. This study adds support to the theory that adverse pregnancy conditions may lead to an acceleration in pulmonary maturity to allow earlier extrauterine adaptation.

Supraumbilical upper abdominal midline incision for pelvic surgery in the morbidly obese patient.

An upper abdominal midline incision was used for pelvic surgery in 16 morbidly obese patients (229-401 lb). When this approach is used, a Bookwalter retractor displaces the incision inferiorly and compresses the abdominal wall over the pelvis, and is then secured to the operating-room table. This approach provides adequate exposure of the pelvic organs and avoids an incision in the panniculus with its associated complications. No wound infections, postoperative dehiscences, or other serious postoperative morbidity occurred in these patients.

Cesarean birth and neonatal mortality in very low birth weight infants.

The authors attempted to relate neonatal mortality to method of delivery in a series of 345 infants, weighing 700 to 1500 g, who were born in King County, Washington, from 1977 to 1979. Overall, 38% of infants delivered vaginally died as opposed to 32% of those with cesarean births. However, after adjustment for birth weight, presentation, and place of delivery, cesarean birth was not associated with reduction in mortality. Even among those infants with a breech presentation, a group believed (on the basis of previous studies) to particularly benefit from cesarean birth, the data failed to show any mortality reduction. Based on the results of this study of very low birth weight singleton infants, it appears that the reduced neonatal mortality associated with cesarean birth, if present at all, is small in magnitude.

Fetal monitoring and predictions by clinicians: observations during a randomized clinical trial in very low birth weight infants.

Predictions about perinatal outcome in very low birth weight infants were studied in a randomized clinical trial of electronic fetal monitoring and periodic auscultation to assess the effect of diagnostic monitoring information on clinicians' ability to predict perinatal outcomes. The only predictions consistently correct before monitoring information was available were those regarding infant survival (88% correct, kappa [kappa] = 0.40, P less than .001 for the electronic fetal monitoring group; 80% correct, kappa = 0.35, P less than .01 for the periodic auscultation group). After monitoring, predictions of 5-minute Apgar scores and arterial cord pH were significantly more accurate, and clinicians' confidence in their predictions increased significantly in both the electronic fetal monitoring and the auscultation groups. Predictions of 5-minute Apgar scores were significantly more accurate in the electronic fetal monitoring group (92% correct, kappa = 0.80) than in the periodic auscultation group (61% correct, kappa = 0.28) (Z difference = 3.04; P less than .01). We conclude that clinicians gain information during intrapartum monitoring that generally leads to improved predictions and increased confidence in predictions. In this study, they made more accurate predictions about 5-minute Apgar scores with electronic fetal monitoring, suggesting that electronic fetal monitoring may provide better information about neonatal well-being than does periodic auscultation. Improved information, as measured by clinical predictions, is probably highly valued by patients and clinicians and may be an important determinant of acceptance of this diagnostic technology.

Sperm penetration assay: useful test in evaluation of male fertility.

The recently developed sperm penetration assay (SPA) tests the functional capacity of sperm. It is based upon the ability of in vitro capacitated human spermatozoa to penetrate zona-free hamster eggs in vitro. The SPA was superior to seminal fluid analysis in predicting both fertility and infertility; in the prediction of infertility, the difference was highly significant. Data further indicated that fertility in the male may not remain constant with the passage of time. The SPA would appear to have wide application both clinically and experimentally.

A randomized trial of electronic fetal monitoring in preterm labor.

Intrapartum electronic fetal heart rate (FHR) monitoring and fetal blood gas sampling were compared with periodic auscultation of FHR in a multicentered randomized trial of preterm singleton pregnancies with fetal weights of 700-1750 g. Two hundred forty-six pregnancies were studied (electronic FHR monitoring N = 122, auscultation N = 124). Perinatal or infant death was associated with 14% of pregnancies with electronic FHR monitoring and 15% with auscultation. No significant differences were noted in the prevalence of low five-minute Apgar scores, intrapartum acidosis, intracranial hemorrhage, or frequency of cesarean section (P greater than .10). Compared with electronic FHR monitoring, intrapartum auscultation as done in this study is unlikely to be associated with detectable differences in perinatal outcomes within the high-risk setting of preterm labor.

Genital tract examinations and zona-free hamster egg penetration tests from men exposed in utero to diethylstilbestrol.

Because most men with prenatal exposure to diethylstilbestrol (DES) are still young and have not attempted to father children, its reproductive effects are uncertain. In a previous pilot study, we had noted an association between in utero DES exposure and reduced penetration of zona-free hamster eggs by sperm. To test these findings in a controlled manner, we performed physical examinations on 51 men with in utero DES exposure and 29 unexposed men and evaluated the penetration of zona-free hamster eggs by their sperm. Epididymal cysts or abnormalities of the prostate, testicle, or penile meatus were present in 37% of men with in utero DES exposure, versus 4% of nonexposed men (P less than 0.001). The mean proportions of penetrated eggs were 25% after in utero DES exposure and 29% in the nonexposed group (P greater than 0.57). The genital abnormalities related to DES exposure were not related to reduced egg penetration. We conclude that in utero exposure to DES is not related to a significant change in the penetration of zona-free hamster eggs by sperm.

Maternal and fetal well-being.

Pregnancy outcomes can be improved by following modern recommendations for personal health maintenance. Adequate caloric intake, reflected by a weight gain of about 10 to 12.3 kg (22 to 27 lb) for women of average build, is associated with the lowest rate of perinatal mortality. Maternal dietary protein supplementation should generally be avoided because it may be associated with low-birth-weight pregnancies. Abstinence from social drugs offers the greatest positive opportunity to modify the health of a fetus. Serious perinatal infection can be prevented by preconception immunization (rubella), food hygiene (toxoplasmosis) and attention to the expression of virus in the mother (herpes simplex). Available data do not correlate exercise programs begun before pregnancy and continued during pregnancy with adverse fetal effects. Athletic capacity need not diminish postpartum. Most employment may safely continue until delivery. Routine recommendations for prolonged maternal disability leaves are not medically warranted.

Racial differences between linked birth and infant death records in Washington State.

The race of infants who died in Washington State 1968-1977 was ascertained by two different methods: 1) race on the death record, and 2) race on the corresponding linked birth record. The second method resulted in substantial increases in the numbers of infant deaths for the nonwhite races: Indian 39 per cent (n = 114/293), Filipino 56 per cent (n = 19/34), Japanese 121 per cent (n = 23/19), and Chinese 117 per cent (n = 14/12). For Indians, the discrepancy between birth and death records was greatest when the age at death was less than seven days (p < 0.01).

An investigation of the relationship between cesarean section birth and respiratory distress syndrome of the newborn.

To clarify the nature of the association between respiratory distress syndrome and Cesarean section birth, a study was conducted which compared 273 premature (36 weeks or less) Cesarean-delivered infants with 341 premature vaginally delivered infants who were born at the University of Washington Hospital from January 1, 1977 through March 31, 1980. The gestational age-adjusted probability of respiratory distress syndrome was higher among the Cesarean cohort compared with the vaginal cohort (38.2% vs. 27.6%, odds ratio = 1.63, 95% confidence interval = 1.11-2.39). Three alternative explanations for the association of Cesarean section with respiratory distress syndrome other than causation were tested, and each was rejected. The association was not explained by 1) improper timing of elective Cesarean deliveries; 2) misclassification of cases of mild, transient respiratory distress (which may be more common after Cesarean birth) as respiratory distress syndrome; or 3) the differences in the occurrence of pregnancy complications preceding Cesarean births compared with vaginal births. Lack of labor appears to account for part of the increased risk of respiratory distress syndrome among infants delivered by Cesarean section. The gestational age-adjusted probabilities of respiratory distress syndrome were 47.0% for Cesarean birth without labor, 35.4% for Cesarean birth preceded by labor, and 27.6% for vaginal birth.

Evaluation of elective repeat cesarean section as a standard of care: an application of decision analysis.

The rationale for routine repeat cesarean section (RCS) is avoidance of uterine rupture during labor. However, the incidence of uterine rupture following modern cesarean section is low, and the charge for cesarean section is greater than that for a trial of labor (TOL). The technique of decision analysis was used to investigate strategies of elective RCS and TOL with precautionary monitoring. Hypothetical cohorts of 10,000 pregnant women with previous low-transverse cesarean incisions were assumed. Probability data were obtained from the literature. In the TOL cohort, 6,623 patients were delivered vaginally. Uterine rupture occurred in 73 patients. In spite of this, TOL resulted in 37 fewer perinatal deaths and 0.7 fewer maternal deaths than elective RCS. The excessive perinatal mortality in the RCS cohort was related to iatrogenic prematurity that is now avoidable with the lecithin/sphingomyelin test. Direct costs were $5 million greater in the RCS cohort. We concluded that in contemporary practice mortality rates are essentially equal for both delivery practices. However, substantial cost savings are available with TOL.

Out-of-hospital delivery in Washington State, 1975 to 1977.

The annual rate of out-of-hospital deliveries in Washington State increased from 1.6% in 1975, to 2.4% in 1977. Birth certificates, linked birth and death certificates files, and log books from tertiary referral hospitals were used to investigate this trend. As parity increased, rates of home delivery (HD) also increased (p less than 0.001). However, alternative birth center delivery (BCD) rates did not change with parity (p greater than 0.1). HD rates and BCD rates increased with birth weight (p less than 0.001). Obstetric professionals attended 91% of BCD as compared to 65% of HD. Fifty-four percent of the women in the BCD group had 10 or more prenatal visits compared to 40% in the HD group. Infant mortality rates were lower with BCD than with HD. However, our analysis of mortality was limited by countervailing biases inherent in the data. We concluded that out-of-hospital deliveries were a heterogeneous group that in future studies should be stratified into groups of birth center deliveries and home deliveries.

Oral contraceptive use and the occurrence of pituitary prolactinoma.

To determine whether prior oral contraceptive (OC) use is a risk factor for pituitary prolactinoma, we attempted to identify all women (n = 72) with a prolactinoma diagnosed between 1976 and 1980 in three counties in western Washington. A control group of 303 women was selected by dialing random telephone numbers from the same counties. Prior OC use, according to OC indication, was ascertained during a standardized telephone interview. Relative to the risk for women who had never used an OC, the risk of prolactinoma for women who had used OCs for birth control was 1.3 (95% confidence interval, 0.7 to 2.6). This risk was 7.7 for women who used OCs for menstrual regulation (95% confidence interval, 3.7 to 17.0). Previous findings of an association between OC use and prolactinoma may have resulted from OC treatment of menstrual irregularity in women with an undiagnosed prolactinoma.

Identification of neurodevelopmental abnormality at four and eight months by the movement assessment of infants.

The predictive validity of infant neuromotor evaluation by the Movement Assessment of Infants (MAI) was investigated in low-birthweight infants. Motor performance at four and eight months was examined in relation to neurodevelopmental outcome at 18 months of age. Correlations were equally strong between total MAI risk scores at four and eight months and performance on the Bayley Scales. Muscle tone observations were more discriminating at four months, and automatic reactions and volitional movement were most predictive at eight months. The MAI was highly sensitive to neurodevelopmental abnormality at four and eight months and more sensitive than the Bayley Motor Scale; both assessment tools had lower specificity at eight months. The high false-positive rate is attributed to transient neuromotor abnormalities and immaturity of motor function in low-birthweight infants with normal outcome.

Relationship of hamster ovum sperm penetration assay to seminal fluid analyses in the evaluation of infertile couples.

The males of 279 infertile couples were evaluated with hamster ovum sperm penetration assay (SPA) and seminal fluid analysis. The mean SPA score for the total population was 23.0% penetration with a range of 0-97%. Twenty five percent of the patients demonstrated scores within the abnormal range (0-10%), and 15% were in the "equivocal" range (11-14%). Comparing each individual with the total population using linear regression analysis, it was noted that sperm concentration, percent motility, and percent oval forms varied directly with the SPA, and the slopes of the relationships are positive and statistically significant (p less than 0.0001, 0.002, and 0.0001, respectively). The relationship between SPA and volume is not statistically significant (p greater than or equal to 0.354). To determine whether the SPA could be utilized to establish appropriate normal parameters for various components of SFA, these were analyzed in 169 men who had SPAs of greater than or equal to 15%. Although most SFA values fell within the normal range for this group, there were several exceptions, particularly with respect to percent motility and the presence of leukocytes in the semen. Comparing the percentage of males with abnormal SPA in groups of couples with or without a demonstrable abnormality affecting fertility in the wife, no statistically significant differences could be found. The value of the SPA and SFA in investigating males of infertile couples is discussed.