Vaginal birth after cesarean: a meta-analysis of indicators for success.

The cesarean birth rate has continued to climb despite efforts to counteract this trend. A major reason for this rise is the practice of doing an elective repeat cesarean. Our study used a statistical model of meta-analysis to analyze the findings of 29 individual studies that looked at the association between the success of a trial of labor and various preexisting conditions. We hypothesized that various preexisting factors, including cephalopelvic disproportion, previous breech, previous vaginal delivery, more than one previous cesarean, use of oxytocin, and the length of labor and extent of dilatation in the previous cesarean, would affect the prediction of the outcome of a trial of labor. After determining odds ratios for the individual preexisting factors from the individual studies, we calculated overall odds ratios which incorporated the findings from all of the studies. For previous cephalopelvic disproportion, the odds were 0.5 for a successful trial of labor; for prior breech, 2.1; for women with a previous vaginal delivery, 2.1; for women who had had more than one cesarean, 0.7; and for women receiving oxytocin, 0.3. We were unable to analyze other preexisting factors because the data were not available, but short discussions of some of these other factors are offered. Even though the success rates do vary with the different preexisting factors, the clinician may anticipate a greater than 50% chance for success in any individual labor.

Abnormal labor and infant brain damage.

OBJECTIVE: To determine whether arrest disorders result in increased neurologic abnormalities in infancy or childhood. METHODS: Four hundred thirteen infants with arrest disorders as defined by Friedman criteria were matched to a similar population without arrest disorders. The median length of follow-up was 6 years for the study infants and 5.07 years for the controls. The numbers of children with abnormalities in the groups with and without arrest disorders, as well as the specific abnormalities encountered, were stratified by method of delivery. RESULTS: Thirty neurologic abnormalities were found in the arrest group and 37 in the control group; thus, the null hypotheses could not be rejected. In addition, although the control group was not followed as long as the study population, the diagnosis of abnormalities was more frequent in the later years in the controls. This suggests that had the follow-ups been equal, there would have been stronger proof that arrest by itself was not associated with infant brain damage. CONCLUSION: Our study confirms that labor diagnoses of prolonged active phase, protractions or arrests, and failure to descend are not associated with increased neurologic abnormalities. Delivery by cesarean or vaginal birth and use of oxytocin are not factors in the etiology of major brain damage.

Vaginal birth after cesarean: a meta-analysis of morbidity and mortality.

The cesarean birth rate has continued to climb despite efforts to counteract it. A major reason for this rise is the practice of elective repeat cesarean. We conducted a meta-analysis that included 31 studies with a total of 11,417 trials of labor to evaluate the association between birth route after a cesarean and morbidity and mortality for the mother and infant. Summary odds ratios were calculated. Maternal febrile morbidity was significantly lower after a trial of labor than after an elective repeat cesarean. The intended birth route made no difference in the rates of uterine dehiscence or rupture. The use of oxytocin, presence of a recurrent indication for the previous cesarean, and presence of an unknown uterine scar were also unassociated with dehiscence or rupture. After excluding antepartum deaths, fetuses weighing less than 750 g, and congenital anomalies incompatible with life, we found no difference in perinatal death rates. The proportion of 5-minute Apgar scores of 6 or lower was higher after a trial of labor, but we were unable to exclude very low birth weight fetuses or those with congenital anomalies from this analysis. Our findings argue for trials of labor for more women after a cesarean birth.

Significance of atypical endometrial cells detected by cervical cytology.

A retrospective study was conducted to assess the histologic significance of atypical endometrial cells identified on routine cervical cytology. One hundred seventy-seven women had Papanicolaou smears demonstrating atypical endometrial cells. The histology of the endometrium was available from endometrial sampling and/or hysterectomy in 134 of the patients within 12 months of their abnormal cytologic evaluation. Fifty-six women (42%) had endometrial disease, including 14 cases (10%) of endometrial polyp, 15 cases (11%) of endometrial hyperplasia, and 27 cases (20%) of adenocarcinoma. The frequency and nature of the endometrial changes depended on the age of the patient (P less than .001) and the degree of cytologic atypia (P less than .05). In 21 women over 59 years who had atypical endometrial cells suspicious for adenocarcinoma, 12 (57%) had adenocarcinoma. Using this information, we have estimated the risk of adenocarcinoma in various groups of women with atypical endometrial cells.

Significance of normal endometrial cells detected by cervical cytology.

A retrospective study was conducted to assess and confirm the significance of normal-appearing endometrial cells detected in cervical cytologic smears in the second half of the menstrual cycle or in the postmenopausal period. Of 440 women with normal endometrial cells identified on routine Papanicolaou smears, 179 underwent further endometrial evaluation. Endometrial disease was identified in 64 (35.7%) of those patients having endometrial sampling and/or hysterectomy within 12 months of the cytologic evaluations. These lesions included 21 cases (11.7%) of endometrial polyps, 23 cases (12.9%) of endometrial hyperplasia, and 20 cases (11.2%) of adenocarcinoma. The frequency of endometrial cancer was positively associated with age (P less than .01). Five of 20 women with endometrial cancer were asymptomatic.

Fascio-cutaneous cross-arm flaps in hand reconstruction.

Experience is reported in the use of eight fascio-cutaneous cross-arm and forearm flaps in three patients. This has proved to be a reliable and satisfactory means of providing skin cover in reconstruction of the hand, giving flaps of a length to breadth ratio of at least two to one. The method was particularly useful where multiple defects were encountered, although in one case where a single defect required reconstruction, the ability to tube the pedicle of the flap allowed full mobility of the injured hand. Primary wound healing was achieved in all cases, and the patients have progressed to a satisfactory functional result. The advantages and disadvantages of this flap are discussed and compared with other established methods of reconstruction.

Forearm muscle herniae and their treatment.

Three cases of forearm muscle hernia are described. Their aetiology differed but, in all three, symptoms were sufficiently severe to interfere with the patient's work. Surgical repair of the myocoeles, by closure of the fascial defects using lata onlay grafts or an interweave of palmaris longus tendon, produced complete resolution of symptoms and enabled the patients to return to full employment.

Use of a flap of flexor retinaculum to cover bone after osteophyte removal within the carpal tunnel.

We describe three instances of ruptured flexor pollicis longus tendons due to bony spurs within the carpal tunnel. In each case, the bony spur was excised and the remaining exposed bone was covered with a flap of flexor retinaculum.

Process and outcome: lack of correlation in a primary care model.

Records of 87 hypertensive patients in a group family practice were reviewed to assess the validity of the process audit in determining medical care quality. Although a significant reduction in mean diastolic blood pressures was found at two follow-up intervals, physician performance scores showed no significant correlation with this outcome. Nor could an association between medical process and outcome be demonstrated when control of blood pressure to less than 95 mmHg was used as an outcome measure. The reliability between two chart auditors was poor, with complete agreement being achieved in only 29 percent of cases. Accurate quality assessment will require more practical methods of review which relate directly to patient outcomes.

Screening guidelines in a family medicine program: a five-year experience.

An audit of charts of 112 adult patients at the University of Rochester Family Medicine Program was conducted to determine the effect of screening guidelines introduced into the practice in 1975. Beyond the initial educational effort when the guidelines were introduced and a verbal explanation of the guidelines printed in each patient record given to new providers as they entered the program, no continuous encouragement was offered. Over the next five years, provider compliance fell short of the guideline recommendations for all 10 screening tests. Depending on the test, 10 to 100 percent of patients received no screening over that period. Tests performed by nursing personnel were completed more frequently than those performed by physicians (P=0.05). Frequency of screening by physicians correlated with the frequency of complete physical examination (P less than 0.0001) and sex (P less than 0.02), and screening by nurses correlated with complete physical examination frequency (P less than 0.0001), visit rate (P less than 0.0001), and patient age (P less than 0.0001). Awareness of screening recommendations was insufficient to result in provider compliance with them. Strategies for improving screening compliance are discussed.

Ten years of screening for cancer in a family practice.

The Cohocton office of Tri-County Family Medicine has maintained an active screening program for breast cancer, colorectal cancer, and cervical cancer since 1974. This article reports a retrospective study of all patients with a diagnosis of cancer during the ten-year period from July 1974 to June 1984. Particular attention was paid to the relationship of screening to the diagnosis of these cancers. Sixty-nine cancers were diagnosed during the study period. Screening detected 7 of 11 breast cancers, 2 of 11 colorectal cancers, and 2 of 3 cervical cancers. In addition, all cases of respiratory cancer occurred in cigarette smokers and were therefore theoretically preventable. The data suggest that a large population of inactive, unscreened patients is a major obstacle to cancer prevention.

From process to policy: a generic prescription for test over-utilization in the emergency department.

Patients presenting to a community hospital emergency department were studied retrospectively to assess the determinants of diagnostic test ordering, and prospectively following an intervention to reduce test utilization. Records of thirty patients were selected for detailed physician review. Consensus criteria for excessive testing were defined by four physician reviewers and applied to each record. One third of all tests were judged excessive. Of multiple demographic and clinical variables studied, only patient age and severity were related to test ordering behavior. Six months after an administrative change caused by review of these findings, a repeat audit of sixty patient records revealed significantly fewer tests ordered (p less than .05) and significantly fewer excessive tests (p less than .05). The projected annual savings in laboratory charges for these patients were $14,838. Simple distribution of the base-year findings, by assisting a change in policy, have effected substantial reductions in excessive laboratory testing.

Comparisons of family physicians and internists. Process and outcome in adult patients at a community hospital.

In view of the relatively high cost and mortality associated with hospitalization, 1,989 inpatients of family physicians and internists were compared with regard to length of stay, charges generated, charges generated per day, disposition (home, death, or other), number and type of diagnoses, and number of procedures. There were no interspecialty differences in mean length of stay (9 days), charges generated ($3,604), charges per day ($475), number of procedures done or disposition (79% went home, 9.5% died, and 11.5% had other placements). There were interspecialty differences in the type of diagnoses coded (chi-square = 52, P less than 0.0001); family physicians tended to assign fewer diagnoses than internists (mean 3.08 versus 3.43, P less than 0.0001). Review of a random sample of 50 charts of patients admitted to family physicians and a matched sample of charts of patients admitted to internists did not reveal any differences in either severity of illness on admission or rate of readmission. Multivariate adjustment for differences in case mix did not affect the direction or significance of the main findings. Similar findings were obtained whether using the hospital admission or the physician as the unit of analysis. The results are discussed in the context of related investigations in the ambulatory setting.

The incidence of cerebral palsy.

The clinician is often held responsible for obstetric events that are suspected of being related to cerebral palsy. To review the incidence of cerebral palsy and to aid the clinician in this situation, a search of published studies was conducted. Composite rates of cerebral palsy in different birth weight infants and cerebral palsy with and without serious mental retardation were calculated. The cumulative incidence rate at the age of 5 to 7 years was 2.7 cases of cerebral palsy for 1000 birth cohorts. Approximately 36% of all cerebral palsy occurred in the infant less than 2500 gm. Serious mental retardation (intelligence quotient less than 50) accompanied cerebral palsy approximately 30% of the time for the term infant and 18% of the time when the infant was less than 2500 gm. On the basis of a past estimation that 70% of cerebral palsy is of antepartum or unknown origin, the term infant at risk for intrapartum-attributed cerebral palsy may be about 1 in 2000 term births.

Island pedicled nerve grafts.

A technique of nerve grafting is described whereby a nerve "graft" is raised, maintaining its blood supply via a vascular pedicle. It is then transposed to reconstruct a defect in an adjacent nerve. Although there is little clinical evidence that this technique results in better nerve regeneration when compared with conventional nerve grafting, the method has advantages which are discussed.