Outcome of pregnancy in a woman with an increased body mass index.

OBJECTIVE: To show the increased risk of adverse outcomes in labour and fetomaternal morbidity in obese women (BMI > 30). DESIGN: A population-based observational study. SETTING: University Hospital of Wales. The study sample was drawn from the Cardiff Births Survey, a population-based database comprising of a total of 60,167 deliveries in the South Glamorgan area between 1990 and 1999. Population Primigravid women with a singleton uncomplicated pregnancy with cephalic presentation of 37 or more weeks of gestation with accurate information regarding height and weight recorded at the booking visit (measured by the midwives) were included in the study. METHODS: Comparisons were made between women with a body mass index of 20-30 and those with more than 30. SPSS version 10 was used for statistical analysis. Student's t test, chi(2) and Fisher's exact tests were used wherever appropriate. MAIN OUTCOME MEASURES: Labour outcomes assessed were risk of postdates, induction of labour, mode of delivery, failed instrumental delivery, macrosomia and shoulder dystocia. Maternal adverse outcomes assessed were postpartum haemorrhage, blood transfusion, uterine and wound infection, urinary tract infection, evacuation of uterus, thromboembolism and third- or fourth-degree perineal tears. Fetal wellbeing was assessed using Apgar <7 at 5 minutes, trauma and asphyxia, cord pH < 7.2, babies requiring neonatal ward admissions, tube feeding and incubator. RESULTS: We report an increased risk [quoted as odds ratio (OR) and confidence intervals CI)] of postdates, 1.4 (1.2-1.7); induction of labour, 1.6 (1.3-1.9); caesarean section, 1.6 (1.4-2); macrosomia, 2.1 (1.6-2.6); shoulder dystocia, 2.9 (1.4-5.8); failed instrumental delivery, 1.75 (1.1-2.9); increased maternal complications such as blood loss of more than 500 mL, 1.5 (1.2-1.8); urinary tract infections, 1.9 (1.1-3.4); and increased neonatal admissions with complications such as neonatal trauma, feeding difficulties and incubator requirement. CONCLUSION: Obese women appear to be at risk of intrapartum and postpartum complications. Induction of labour appears to be the starting point in the cascade of events. They should be considered as high risk and counselled accordingly.

Computer skills among trainee doctors.

Computer skills are an essential part of every field, including medicine. However, training in computers is limited mainly to clerical and paramedical staff. We conducted this questionnaire survey to assess the extent of training and the opinion of trainee doctors in obstetrics and gynaecology in Wales. The results showed that the computer skills among these doctors was low and the majority of them agreed that there was a need for training in computer skills to assist them in their career progress. In view of the findings of this survey, we feel that incorporation of computer skills courses in the training curriculum must be of benefit.

The outcome of macrosomic fetuses in a low risk primigravid population.

OBJECTIVES: To ascertain whether fetal macrosomia is associated with increased maternal and neonatal morbidity in uncomplicated, singleton, vertex deliveries at term in primigravid women. METHODS: This was a retrospective population based survey of 8617 deliveries over an 11-year period. These were stratified into three birthweight categories: 2500-3999 g (n=7854), 4000-4499 g (n=666) and > or =4500 g (n=97). Outcome variables included maternal characteristics, delivery details, maternal and perinatal morbidity data. RESULTS: Increased BMI and incidence of Caucasian ethnicity and non-smoking were significantly greater in macrosomic compared with non-macrosomic infants (P<0.001). Increasing birthweight (especially > or =4.5 kg) was associated with significantly (P<0.001) lower rates of spontaneous onset of labor, spontaneous vertex deliveries and significantly higher rates (P<0.001) of maternal and neonatal morbidity. CONCLUSIONS: This study supports the notion of expectant management in suspected fetal macrosomia in low risk primigravid women until 40 weeks gestation. Thereafter, the safest mode of delivery is controversial, with some evidence pointing to elective cesarean section as a viable alternative in these women. A prospective RCT is needed to evaluate the best management option in terms of fetal and maternal outcome in cases of suspected macrosomia after 40 weeks' gestation.

Comparison of continuous infusion versus midwife administered top-ups of epidural bupivacaine for labour analgesia: effect on second stage of labour and mode of delivery.

Using a population-based study we retrospectively compared the effect of continuous versus intermittent top-up epidural analgesia on the outcome of labour at the University Hospital of Wales. We analysed the labour outcome of 410 primigravid deliveries over an 18-month period during a change in delivery suite protocol. Data were retrieved from the Cardiff Births Survey and the sample was analysed in two groups: group 1 (n = 201) received a continuous infusion of 0.1% bupivacaine plus fentanyl 2 microg/mL and group 2 (n = 209) received intermittent top-ups of the same solution. Outcome measures were the number of operative deliveries and the proportion of those deliveries that were due to prolongation of the second stage of labour. There were no significant differences in terms of group characteristics, women undergoing assisted vaginal delivery (group 1: 83 vs. group 2: 70, OR 0.8 CI 0.5-1.2), caesarean section (group 1: 59 vs. group 2: 61, OR 1.0 CI 0.6-1.5), and women with prolonged second stage (group 1: 50 vs. group 2: 47, OR 1.1 CI 0.6-1.8). The presumed reduction in motor blockade associated with intermittent top-up epidural regimes did not affect the outcome of labour.

Who are the women who default from colposcopy clinics?

Compliance at colposcopy clinics is an essential factor for effectiveness of a cervical screening programme. However, there is not enough research on women who default from the colposcopy clinic. In this study, we have looked at some of the factors which might influence non-attendance at colposcopy clinics. We found that women who were younger and nulliparous appeared to be at greater risk of non-attendance than older and parous women. Women tend to miss follow-up appointments rather than primary appoints and none of them missed treatment appointments. There was no relation between non-attendance and grade of the lesion. We were not able to assess other factors such as smoking, socio-economic status or marital status in this study due to inadequate documentation.

Who is responsible for the rising caesarean section rate?

In view of the rising trend in caesarean section rates all over the world and women requesting caesarean section without any medical indication, we conducted a questionnaire survey to assess the opinion of clinicians in the field of obstetrics to assess their views regarding this issue. We found that clinicians agree that the caesarean section rates are increasing and most of them hold the media and women responsible for this rising trend. However, in situations where no definite medical indication was evident, most of the clinicians favoured caesarean section. The findings of this study suggest that there is a need for change in the attitude of clinicians before attempting to educate women regarding the caesarean section for non-medical reasons.