A comparison of breast stimulation and intravenous oxytocin for the augmentation of labor.

BACKGROUND: Breast stimulation to augment labor has been used for centuries in tribal societies and by midwives. In recent years it has been shown to be effective in ripening the cervix, inducing labor, and as an alternative to oxytocin for the contraction stress test. This study compared the effectiveness of breast stimulation with oxytocin infusion in augmenting labor. METHODS: Women admitted to the labor ward were eligible for the study if they had inadequate labor with premature rupture of the membranes and met inclusion criteria. They were assigned to oxytocin augmentation or breast stimulation (manual or pump), and were switched to oxytocin in the event of method failure. Outcomes included time to delivery, intervention to delivery, proportion of spontaneous deliveries, and Apgar scores. One hundred participants were needed in each arm of the study to demonstrate a 2- to 3-hour difference in delivery time, with a power of 80 percent. RESULTS: Analysis was performed on 79 women, of whom 49 were in the breast stimulation group and 30 in the oxytocin group. Sixty-five percent of the participants failed breast stimulation and were switched to oxytocin infusion. Although augmentation start to delivery was shorter for the oxytocin group (p < 0.001), no differences in total labor time occurred between the groups. Nulliparas receiving breast stimulation had more spontaneous (relative risk 1.7, p = 0.04), and fewer instrumental deliveries than those receiving oxytocin (relative risk 0.2, p = 0.02). No significant differences in adverse fetal outcomes occurred between the study groups. CONCLUSIONS: The small number of participants and a variety of problems with the conduct of the study prevented the formulation of reliable conclusions from the results. However, the study provided important insights into the feasibility and problems of developing a high-quality randomized trial of augmentation by breast stimulation.

Patterns of uterine contractions and prolonged uterine activity using three methods of breast stimulation for contraction stress tests.

The contraction patterns in 378 breast-stimulated contraction stress tests administered to 213 women are described. The subjects were assigned sequentially to one of four intervention groups: bilateral manual breast massage, unilateral pump stimulation, heating pad stimulation, and placebo. There was a marked increase in the proportion of tests with three to four contractions in 5-minute intervals after the interventions occurred. Twenty-five percent of all tests showed prolonged uterine activity, occurring most frequently in women with postdate gestations using manual massage or breast pump stimulation. The duration of prolonged contractions ranged from 1.5-8 minutes, with 19% lasting from 4.5-8 minutes. There was no difference in the incidence of fetal heart rate abnormalities between tests with and without prolonged uterine activity, and no late decelerations occurred in tests with tachysystole.

Doctor-patient communication on the telephone.

Since its invention, the telephone has been an important tool in medical practice, particularly for primary care physicians. Approximately half the calls made to a physician's office during regular consulting hours are for clinical problems and most are handled effectively over the phone without an immediate office visit. Telephone encounters are generally very brief, and managing such calls requires a pragmatic approach that is often quite different from the approach taken in the office visit. The telephone encounter should be recognized and recorded as a specific medical interaction in the medical chart for both clinical and legal reasons. Effective telephone encounters depend on good communication skills; decision making regarding disposition is a major goal. The physician's perception of a medical problem may be different from the patient's; patients are frequently seeking advice and reassurance rather than diagnosis and treatment, and may call because of anxiety and psychological stress. For physicians and their families who are not prepared for after-hours telephone encounters, calls that interrupt more "legitimate" activities may result in anger or frustration for the physician and dissatisfaction for the patient.

Uterine hyperstimulation. The need for standard terminology.

The incidence of uterine hyperstimulation during oxytocin augmentation in labor and in breast-stimulated and oxytocin contraction stress tests showed a wide variation in a number of reported studies. One major reason is the lack of a standard definition of uterine hyperstimulation.

On certain Hecke rings.

We examine rings that embed into the smash product of the group algebra of the Weyl group with the field of meromorphic functions on the Cartan subalgebra and are generated by elements that satisfy braid relations. We prove that every such ring is isomorphic to either the Hecke algebra, the nil Hecke ring, or the group algebra of the Weyl group.

Prepartum and intrapartum breast stimulation in obstetrics. A review.

The publication of studies that describe the use of breast stimulation to produce or augment contractions before and during labor has grown rapidly over the last three years. Until recently, this physiologic phenomenon appears to have been little recognized in the medical literature, though references to the technique do appear in the medical literature from Hippocrates to the present.

Uterine responses to three techniques of breast stimulation.

Uterine contractions produced by three methods of breast stimulation and a placebo were compared in 202 high-risk women between 35 and 44 weeks' gestation during contraction stress tests. Manual stimulation produced significantly more successful responses of three or more contractions within ten minutes than did a heating pad or a placebo, but did not show significant differences when compared with a breast pump. The placebo group showed an increase in contractions over a resting state. Of the women with successful contraction stress tests, over 50% demonstrated exaggerated uterine activity (a hypertonic contraction of greater than 90 seconds, or five or more contractions in a ten-minute period).

Physician decision making over the telephone.

Physician decision-making behaviors were evaluated for 31 telephone encounters between trained patient simulators and 9 first-year residents, 11 third-year residents, and 8 practicing physicians on after-hours call. The following trends occur as physicians become more experienced: mean call length decreases, less time is spent on diagnosis, fewer diagnostic questions are asked, greater time is spent on management, and diagnostic reasoning becomes more intuitive. These findings suggest that previous models of good telephone decision making, which focused on empirical data collection, may not represent the process used by experienced physicians.

Characteristics and perceptions of after-hours callers.

After-hours care remains an important aspect of community practice although little is known about the views of either physicians or patients. This study presents an analysis of 12 499 after-hours calls made to a family practice centre over a five-year period, and 798 follow-up telephone interviews conducted with people who called for help after hours. Fifty per cent of the callers requested care for themselves while the remainder made the call for another family member, usually a child; most had discussed the problem with family or friends before calling. A majority stated that they would go to a hospital emergency room if they could not use the after-hours service. Physicians tended to perceive the calls as being due primarily to physical problems, while almost one-third of the callers stated that the motive for their call was anxiety or concern rather than physical discomfort. Although there was a lack of agreement between physician and caller on several aspects of the contact, most of the callers were satisfied with the contact.

Using patient-simulators to teach telephone communication skills to health professionals.

Using patient-simulators is an effective and inexpensive approach for teaching telephone communication skills to health professionals. An audiotaped simulation program has been carried out with the residents of the Family Practice Center at the University of North Carolina at Chapel Hill and has been implemented in several other areas, including pediatrics, psychiatry, nursing, and a third-year elective clerkship in family medicine.

Patient participation in a medical education environment.

Family practice residency programs are specifically directed toward training primary care physicians to serve the interests of communities. This paper describes two methods of developing a feedback mechanism to increase the awareness of physicians in training to patients' health needs and desires. One method involves the development of a patient advisory group in the Family Practice Center at The University of North Carolina, and the other an ongoing telephone survey of patients who call after hours.

The telephone survey in family practice.

Patient surveys can be useful methods of obtaining information for the purposes of improving health services, practice management, or research in family medicine. The telephone interview is an effective and economical method of undertaking such a survey. The advantages and disadvantages of the telephone survey method are briefly illustrated by a study conducted in the Family Practice Center at the University of North Carolina concerning patient perspectives on their after-hours medical encounters with physicians.