Use of breast stimulation for antepartum stress testing.

Bilateral breast stimulation was used to evoke a spontaneous contraction stress test. The success rate and incidence of abnormal uterine activity using the stimulus was compared with patients tested by the authors' standard oxytocin stress test protocol. Bilateral breast stimulation was initially used for 346 tests between 32 and 43 weeks of gestational age. A satisfactory test, or three contractions within ten minutes, was obtained in 239 (69%) patients. The testing time was reduced with successful breast stimulation. The incidence of abnormal uterine activity after breast stimulation was not statistically different from that observed with oxytocin administration alone. However, when oxytocin was administered after breast stimulation, there was a significant increase in the incidence of prolonged contractions.

Antenatal diagnosis and management of the small-for-gestational-age fetus.

The small-for-gestational-age fetus continues to account for a large proportion of fetal demise in late pregnancy. Delivery at 37 to 38 weeks' gestation to preempt this is our recommended mode of management. Prenatal diagnosis was made in only 33% of cases in this study. The course of 101 growth-retarded pregnancies has been critically evaluated towards improving the rate of prenatal diagnosis.

Correlation of fetal heart rate patterns and fetal pH with neonatal outcome.

Fetal monitoring data in 200 consecutive cases was evaluated in the second hour prior to delivery to determine how neonatal outcome could be most accurately predicted. It was found that the correlation between ominous fetal heart rate-uterine contraction (FHR-UC) patterns and a depressed Apgar score at 1 minute was, at best, 37%. However, where the last fetal scalp blood pH (FSB-pH) was less than or equal to 7.2, neonatal depression occurred in 88% of cases. FSB-pH, therefore, provided a more reliable means of diagnosing fetal distress.

Correlation of the oxytocin challenge test with perinatal outcome.

A total of 234 oxytocin challenge tests (OCT) were performed on 100 high-risk patients. The results were negative (N) in 68 of these 100 patients, suspicious (S) in 22, and positive (P) in 10. The incidence of late decelerations during labor was N, 5%; S, 40%; P, 86%; and meconium staining of the amniotic fluid was N, 4%; S, 5%; and P, 30%. The cesarean section rate was N, 16%; S, 36%; and P, 60%; and of these the cesarean section rate for fetal indications was N, 9%; S, 25%; and P, 67%. The overall perinatal mortality in the study group was 2% (N, 1.5%; S, 0%; P, 10%). The results confirm the negative OCT as innocuous and positive OCT as the most ominous. They also indicate that the majority of patients with positive OCT can be delivered vaginally without endangering the fetus if fetal scalp blood pH determinations can be performed.

An analysis of birth weight by gestational age using a computerized perinatal data base, 1975-1992.

OBJECTIVE: To develop birth weight-for-gestational age nomograms based on a computerized perinatal data base collected prospectively from 1975-1992. METHODS: Using information from over 60,000 singleton deliveries (January 1975 through October 1992) at the MetroHealth Medical Center in Cleveland, Ohio, standard curves for normal birth weights were computed. Nomograms were developed for the overall population and for subgroups determined by factors known to affect fetal growth, including sex, race, smoking status, and gestational diabetes. The nomograms included the tenth, 50th, and 90th percentiles of birth weights for 24-44 weeks' gestation. Gestational age was based on clinical obstetric estimates confirmed by Dubowitz assessment of the neonate. In addition, third-order regression models were developed to predict median birth weight using gestational age. These models were validated using delivery data for the months of November and December, 1992, which were not included in model development. RESULTS: The most significant predictors of median birth weight were the first-, second-, and third-order gestational ages, which explained over 80% of the total variation in birth weight. Other significant factors influencing birth weight included infant gender, maternal race, parity, smoking, and diabetes status. Among the marginally significant factors influencing birth weight were pay status and maternal age. In general, before 33 weeks' gestation, there were few differences in the birth weight percentiles of various groups except for those with diabetes; infants of diabetic women exhibited greater birth weights as early as 26 weeks' gestation. CONCLUSIONS: Considering the large size of the data base and the diverse background of the study population, we believe that these nomograms provide useful norms of birth weight for an indigent urban population. These norms enhance the obstetrician's and neonatologist's ability to identify true cases of retardation or acceleration of intrauterine growth. Simple mathematical models provide easy calculation of the median birth weights for 24-44 weeks while adjusting for many confounding factors.

Correlation of fetal heart rate-uterine contraction patterns with fetal scalp blood pH.

The significance of fetal heart rate-uterine contraction (FHR-UC) monitoring as a means of predicting the condition of the fetus during labor was studied by correlating 460 fetal pH determinations obtained from 216 patients with the analysis of the 20-minute FHR-UC record preceding the fetal scalp blood sample. Both qualitative and quantitative analyses of the FHR-UC record were performed. The results indicate a less than 10% chance of fetal pH less than or equal to 7.250 with an normal baseline FHR and no periodic changes or with periodic accelerations, early decelerations, and uncomplicated baseline bradycardia or tachycardia. Variable or delayed decelerations with a total surface area (TSA) of 1-100 for the 20-min period were associated with a fetal pH less than or equal to 7.250 in 23 and 34% of cases, respectively. Variable or delayed decelerations with a TSA greater than 100 had a 35 or 47% chance of fetal pH less than or equall to 7.250. It is concluded that FHR-UC monitoring can be used to screen the innocuous from the ominous periodic change but that fetal scalp blood pH must be obtained to identify accurately the true from the false-positive ominous pattern.

Vaginal delivery after cesarean section: a five-year study.

All pregnancies that were complicated by a previous cesarean section were reviewed for a five-year period from 1978 to 1982. Of 799 such pregnancies, 216 underwent a trial of labor, and 66% experienced successful vaginal delivery. When the primary cesarean section was for cephalopelvic disproportion, 54% delivered vaginally, 75% breech, and 70% for fetal distress or other nonrepeating indications. There was no evidence of uterine scar disruption in the vaginally delivered group. Vaginal delivery after previous cesarean section can be a safe alternative for carefully selected patients cared for in the proper environment.

Clinical associations of variable decelerations during reactive nonstress tests.

Six hundred ninety-three patients at or beyond 30 weeks' gestation with reactive nonstress tests (NSTs) were divided into groups based on the occurrence of variable decelerations of 15 seconds or more in duration and of 20 or more beats per minute in severity. Ultrasound examination within a month of testing showed no increases in nuchal cord localization or decreased amniotic fluid volumes in a subgroup of 181 patients. Fetuses with antepartum variable decelerations were more likely to demonstrate similar decelerations in labor (P less than .001), to undergo operative delivery for a diagnosis of "distress" (P less than .05), to require intensive care nursery admission (P less than .01), and to be small for gestational age (P less than .01). No significant differences were noted in frequency of nuchal or other cord entanglements, overall cesarean section rate, or low pH or Apgar score values. We conclude that variable decelerations in the absence of other alarming NST findings may aid in identifying patients at risk for adverse perinatal occurrences, although factors other than nuchal cord placement or oligohydramnios may be responsible.

Colposcopic evaluation of patients with abnormal cytologic smears during pregnancy.

One-hundred thirty-two patients with abnormal Papanicolaou smears of the cervix uteri during pregnancy underwent colposcopic evaluation. Seventy-five patients had biopsies during pregnancy, and 34 patients had colposcopic evaluation without performing any biopsy. Postpartum colposcopic evaluation was performed on 95 patients. In 93 patients of this group, the postpartum cytologic and histologic information obtained was the same or less than that obtained in antepartum evaluation. In only 1 case, antepartum colposcopically guided biopsy at 38 weeks' gestation revealed moderate dysplasia, and postpartum cold conization showed carcinoma in situ. In another case, colposcopic evaluation and biopsy during pregnancy showed mild dysplasia while colposcopic biopsy as well as examination of a hysterectomy specimen taken at 16 months after delivery revealed severe dysplasia. No case of invasive carcinoma was missed during pregnancy. The results of this study, in support of previous reports, show that colposcopic evaluation is a simple, safe, and accurate method of investigating abnormal Papanicolaou smears during pregnancy.

Saline instillation with oxytocin administration in midtrimester abortion.

PIP: Oxytocin was infused at 10 units per hour in 100 ml Ringers lactate after instilling saline for 108 midtrimester abortions in 107 patients. Amniocentesis was performed in the treatment room with drapes, cap, mask, gloves, local anesthetic, but without pelvic examination. Strict care was taken that clear amniotic fluid flowed before 20% saline was injected. The patients averaged 23 years old, 2.05 parity and 17.6 weeks since their last menstral period, but the 41 multiparas were significantly older than the 66 primiparas. In 7 amniocenteses more than one puncture was needed. The mean volume of saline instilled was 185 ml over a 10 minute interval. Although time before oxytocin and labor did not differ significantly, the mean length of labor was significantly shorter in multiparas (6.7 hours) than in primiparas (10.5). Thus the total mean time to abortion was 19 hours for multiparas compared with 26 hours for primiparas (p less than .0005). Frequency of incomplete abortion (34%) needing curettage (4.6%) rather than manual or sponge stick manipulation was high. Complications included 1 failure to abort, 20 instances of tachycardia during amniocentesis, 1 fever, and 1 grand mal seizure probably due to water intoxication.^ieng

Births to teenagers: trends and obstetric outcomes.

OBJECTIVE: To compare the trends and obstetric outcomes of pregnancy in teenage women with those of adult women. METHODS: We analyzed a 19-year (1975-1993) computerized perinatal data base with data on 69,096 births collected prospectively from a single inner-city tertiary medical center. RESULTS: Of all the births, 1875, (2.7%) were to teenagers 12-15 years old and 17,359 (25.3%) were to teenagers 16-19 years old. Over the study period, the number and proportion of births to teenagers of both age groups declined (P < .001 in both cases). The proportions of teenagers 12-15 and 16-19 years old were highest among blacks (4.1% and 28.1%, respectively), followed by Hispanics (2.4%, 24.7%) and whites (1.6%, 23.1%). More than 95% of teenagers had no private health insurance coverage (staff), significantly higher than the 81.6% of mothers aged 20 years or older (P < .001). More than 8.1% of teenagers 12-15 years old had two or fewer prenatal care visits, significantly higher than 6.8% for teenagers 16-19 years old and 7.1% for adults (P < .001). The average gestational age and birth weight were significantly lower for teenagers 12-15 years old compared with those 16-19 years old and adults. Patients 16-19 years of age had longer gestational age and higher birth weight than the adults. The proportion of primary cesarean deliveries among teenagers 12-15 years old was 11.6%, significantly higher than 9.4% for those 16-19 years old and 10.2% for adults (P < .001). CONCLUSION: On average, females 16-19 years old had better obstetric outcomes than adults, whereas obstetric outcomes for those 12-15 years old were worse than for adults. Therefore, all teenagers should not be grouped together when their obstetric outcomes are compared with those of adults.

Priming of the uterine cervix with oral prostaglandin E2 in the term multigravida.

A double-blind study evaluating two dose schedules of oral prostaglandin E2 (PGE2) was conducted in 56 normal "unripe" multiparas at term. The effect of PGE2 was evaluated by comparing the change in Bishop score of the cervix and patient's response to oxytocin induction of labor after the prostaglandin priming. In the two study groups (one group on a fixed PGE2 dosage and the other on a variable drug regimen) an average change of more than three points in the Bishop score was observed. In control group no significant change in cervical ripeness was observed. Nine of the 32 patients (28%) receiving prostaglandin delivered during the priming phase of the study, whereas only 1 control patient (4.2%) delivered during priming. Six of 24 control patients (25%) failed to deliver, wheras only 3 of 32 study patients (9%) failed. In the successfully induced patients, the response to oxytocin, as expressed by the time to active phase, total time of labor, and mean dose of oxytocin required, did not vary significantly when control and study groups were compared. It is concluded that PGE2 at either dosage schedule is effective in changing the Bishop score of the cervix and that it is not feasible to titrate the PGE2 dose in order to effectively ripen the cervix without a very high incidence of induction of labor. In those cases where priming was completed, without accidental delivery, the induction phase was successful more than 90% of the time. No adverse effect to mother or baby was observed during this study.

Interlocking twins. Experience with four cases and suggested management.

Experience with the management of 4 pairs of locked twins is described and analyzed. In view of the high morbidity figures a proposed preemptive management is suggested.

Modern management of hypertensive disorders of pregnancy.

Hypertensive disorders of pregnancy contribute significantly to perinatal mortality. Successful application of modern tests of antepartum fetal status and appropriately timed delivery, with monitored labor and liberal use of cesarean section led to significantly improved fetal and neonatal salvage in 242 patients with hypertensive disorders of pregnancy between 1973 and 1975. The reduction in perinatal mortality to a corrected rate of 12/1000 in the years 1973-1975, compared to a previous rate of 75/1000 between 1970 and 1972, justifies the modern aggressive management of hypertensive disorders in pregnancy.

Modern management of the diabetic pregnancy.

The effect of modern antepartum and intrapartum fetal monitoring technics on the outcome of the pregnancy complicated with diabetes was studied by comparing the perinatal mortality of 2 groups of patients whose management differed primarily by the use of these tests. The perinatal death rate was halved to 9.2%, and when corrected for major congenital defects and referred fetal deaths it was 5.3%. Modern fetal diagnostic tests clearly add a degree of objectivity in the management of the diabetic pregnancy not previously available.

Colposcopic evaluation of patients with abnormal cervical cytology.

A total of 1580 new patients underwent colposcopic evalution in the Dysplasia Clinic at Nassau County Medical Center. Of these patients, 186 had abnormal Papanicolaou smears associated with pregnancy, 150 were referred because of in utero exposure to diethylstilbestrol, and 1244 were referred because of abnormal cervical cytologic smear or suspicious cervical or vaginal lesion. Further analysis of this latter group revealed that 1184 (95%) patients had satisfactory colposcopic evaluation, and directed biopsy showed the following: 10 cases of invasive cervical carcinoma, 9 of carcinoma in situ with microinvasion, 118 of cervical carcinoma in situ, 110 of severe dysplasia, and 424 cases of mild to moderate cervical dysplasia. All of these patients subsequently were treated accordingly. Evaluation of final histologic specimen revealed a very high correlation with colposcopically guided biopsies. In 54 patients, where colposcopic evaluation was unsatisfactory, diagnostic cold knife conization was performed. Final histologic diagnosis disclosed a more advanced lesion in 30 patients (or 56%) of this group. The result of this study shows that satisfactory colposcopic evaluation is a highly accurate method of evaluation of abnormal cervical and vaginal cytologic smear.

The association of umbilical cord complications and variable decelerations with acid-base findings.

Variable decelerations during the last 2 hours of labor were associated with an abnormally positioned umbilical cord at delivery in 52% of cases. In cases where an abnormally positioned umbilical cord was seen at delivery, 89% had been preceded by variable decelerations. Cord compression resulted in an A-V difference in pH that was significantly increased when compared to a control group. This was mainly due to a decrease in the pH of the umbilical artery. The pathophysiology of cord compression is discussed.

"Second generation" prostaglandins: midtrimester pregnancy termination by intramuscular injection of a 15-methyl analog of prostaglandin F2alpha.

Eighty midtrimester gravid patients were treated with prostaglandin 15(S)-15-methyl Fa alpha by repeated intramuscular injections of 250 mug at 2-hour intervals for the elective termination of pregnancy. A success rate of 97.5% was achieved, with a mean initiation-to-abortion time of 17.2 +/- 1.0 hours. Gastrointestinal side effects were prominent but no serious complications occurred. Serial serum progesterone determinations and continuous intra-amniotic pressure recording were carried out in selected cases and correlated with abortifacient activity. This method of pregnancy termination appears particularly suitable for use in the early midtrimester of gestation.

Births to unmarried mothers: trends and obstetric outcomes.

PIP: This study examines trends in nonmarital childbearing among women who represent an inner-city urban population that includes high-risk privately insured mothers and a large number of indigent mothers. The study population includes data collected from a computerized database at the MetroHealth Medical Center in Cleveland, Ohio, during 1974-93, on 73,544 births. The subsample for the clinical analysis is based on 29,865 deliveries that occurred during 1987-93. Findings indicate that the proportion of deliveries to unmarried mothers increased by at least 20% over a 19-year period. The proportion of privately insured unmarried mothers increased from 6.7% to 27.3% during 1975-93. The proportion of staff-funded mothers increased from 63.5% to 77.5%. The proportion increased for all races, funding groups, and age groups. In the subsample of births during 1987-93, there were 51% Whites, 38% Blacks, 8% Hispanics, and 3% other. Only 15% had private medical insurance. 34.2% of births were to married mothers. 38% of births were to women who were smokers, 3.2% were alcohol users, and 15.4% were narcotic users. 15.4% were cesarean births. The infant mortality rate was 13/1000 live births. Unmarried mothers tended to be about four years younger than married mothers. Over 30% of unmarried mothers and only 10% of married mothers were teenagers. 48% of White mothers, 14% of Black mothers, 35% of Hispanic mothers, and 70% of mothers of other race were married at the time of delivery. The mean birth weight for unmarried mothers was 100 g less than for married mothers. Significant predictors of mothers' marital status were insurance status, race, age, and their interaction. The odds of unmarried status increased with younger age, delivery later in the study period, race, insurance pay status, and parity, which, when controlled for, showed Black and Hispanic mothers with increased odds of an unmarried status. Significantly more unmarried mothers had infants with thick meconium, premature delivery, and fetal distress among neonates.^ieng

A vaginal delivery protocol for the term breech infant utilizing ball pelvimetry.

Ball pelvimetry has been utilized at the Medical Center Hospital of Vermont to evaluate infants with breech presentation for vaginal delivery. That technique provided measurements of both the fetal head volume and maternal pelvic capacity so that relative fetomaternal relationships could be established. Between January 1979 and December 1981, 107 patients in spontaneous labor with term pregnancy were evaluated with the protocol. Inadequate pelvimetry and hyperextension of the fetal head occurred in 21 patients (20%). Of the 86 patients who were allowed to labor, 51 (59%) had a vaginal delivery. The total cesarean section rate was 52%. Vaginal delivery in our highly selected patient population did not increase neonatal morbidity. There were no neonatal deaths.