Submucous paracervical blockade compared with intramuscular meperidine as analgesia during labor: a double-blind study

A double-blind study was carried out to compare the effect of submucous paracervical blockade using 12 mL 0.25% bupivacaine (55 women) to the effect of intramuscular injection of 75 mg meperidine (62 women) during the first stage of labor. All 117 were normal primiparous pregnancies. Seventy-eight percent of the women in the paracervical blockade group achieved full or acceptable pain relief against 31% in the meperidine group (P less than .01). Transient fetal bradycardia occurred in two cases in the paracervical blockade group and one in the meperidine group; all infants were born in good condition. Fetal distress, defined as an umbilical artery pH of 7.15 or less and/or a one-minute Apgar score of 7 or less was more frequent in the meperidine group (16 infants) than in the paracervical blockade group (six infants) (P less than .05). Submucous paracervical blockade is superior to intramuscular meperidine as pain relief during labor. Furthermore, meperidine results in more infants with asphyxia as compared with paracervical blockade.     

Bupivacaine paracervical block. Effects on the fetus and neonate.

To evaluate effects on the fetus and neonate, 53 paracervical blocks were administered to 38 low-risk parturients using a controlled superficial injection of 0.25% bupivacaine. Continuous fetal heart rate monitoring revealed no instance of bradycardia or late deceleration pattern. Apgar scores, cord arterial and venous pH values, and neurobehavioral evaluations of the neonates were similar to those observed in other low-risk patients. The effectiveness of pain relief of the blocks was less than expected or reported by other authors. Although we observed no harmful effects on the fetus or neonate from the superficial paracervical injection of bupivacaine, we did not find this combination of drug and technique to give dependable, effective pain relief in labor.     

Prolonging paracervical block anesthesia: addition of dextran to 2-chloroprocaine.

Forty parturient women received paracervical block (PCB) anesthetics during labor with 2-chloroprocaine (2-CP) and epinephrine in either normal saline or dextran. Thirty-six patients were though to have adequate anesthesia. Nineteen patients who recived 2-CP in saline had a mean duration of anesthesia lasting 55.4 min; one fetus developed post-PCB bradycardia. Seventeen patients who received 2-CP in dextran had a mean duration of anesthesia lasting 72.7 min; no fetal bradycardia was observed following PCB. Neonatal depression, expressed by 1 and 5 min Apgar scores below seven, was not observed in either group. The addition of dextran to 2-CP significantly prolongs the duration of PCB anesthesia and does not appear to compromise the fetus. The pain relief provided by a single PCB with 2-CP in dextran is still relatively short and would not persist throughout the active phase of labor in most parturient women.     

Experience with mepivacaine paracervical block in an obstetric private practice.

OBJECTIVE: The objective of this study was to determine the efficacy and safety of mepivacaine paracervical block in term, low-risk obstetric patients. STUDY DESIGN: Over a 3-year period all term, low-risk obstetric patients in the author's private practice were offered mepivacaine paracervical block anesthesia. One hundred eighty-two patients received 200 mg mepivacaine with each block. The patients who declined paracervical block were used as a control group to compare Apgar scores, subject to chi 2 analysis. RESULTS: Initial injections were 97.3% successful. Average duration of anesthesia was 59.7 minutes with the first injection. Fetal bradycardia occurred in 13.2% with an average duration of 4.5 minutes. The slightly higher incidence of low Apgar scores at 1 and 5 minutes in the study group was not statistically significant. One neonatal death occurred secondary to group B streptococcal sepsis in the study group. CONCLUSION: Mepivacaine paracervical block remains an anesthetic option in low-risk patients. The high success rate is limited by its short duration of action and the incidence of fetal bradycardia.     

The effect of epidural analgesia upon fetal and neonatal status

The effect of epidural analgesia on the fetal and neonatal status was studied in 72 patients who received a standard epidural block during labor. Recordings were made of maternal blood pressure, fetal heart rate, and uterine contractions. Observations on the neonates continued to the day of discharge from the hospital. A control group of 100 patients who received either no analgesia during labor or a form of pain relief other than epidural block was also studied. The control patients were monitored for obstetric indications and therefore are not strictly comparable to the study group. The study group of patients was subdivided into 4 groups (SG1 to SG4). Twenty-four patients in SG2 received oxytocin and did not develop hypotension; 7 patients in SG3 did not receive oxytocin and developed hypotension; 20 patients in SG4 neither received oxytocin nor developed hypotension. Significant fetal heart rate (FHR) decelerations were seen in 55 per cent of the study patients; these occurred most frequently in those patients who developed hypotension (71 per cent) but also developed in 40 per cent of those patients whose blood pressure remained stable. The most common significant FHR pattern was that of late deceleration, occurring in 33.3 per cent of the study group of patients. Of the neonates from the study group of mothers, 9.7 per cent had low Apgar scores compared to 17 per cent of the control neonates. The majority recovered shortly after the 5 minute Apgar observation and continued normally until the day of discharge.     

Koilocytotic metaplasia and koilocytotic dysplasia

Four hundred seventy-one patients undergoing diagnostic ultrasonography were identified as having moderately decreased amniotic fluid or oligohydramnios, and 339 of these cases were reviewed. Ninety-two of the patients were excluded from further statistical analysis because their decreased fluid was attributed to rupture of the membranes only. Of the remaining patients there was a 7% neonatal malformation rate. Decreased amniotic fluid before 27 weeks of gestation was associated with a significantly poor outcome. Of all the live births, infants of patients with oligohydramnios had lower Apgar scores at 1 minute and 5 minutes than did infants of patients with moderately decreased amniotic fluid. Of cases of patients with decreased fluid, 10% involved fetal distress during labor and in 17% meconium was present. Decreased levels of fluid were associated with an increased rate of abdominal deliveries. Preeclampsia was present in 24.7% of patients with decreased fluid. There was no correlation between the quantitative fluid amounts and the severity of the disease. In view of normative data and clinical experience, these observations suggest that the diagnosis of decreased amniotic fluid on routine ultrasonography requires a fetal scan to rule out anomalies, close antepartum observation to detect complications that may arise in the pregnancy, and delivery under conditions that allow appropriate support and intervention on behalf of the fetus.     

Clinical significance of fetal heart rate patterns during labor. II. Late decelerations.

Among a population of high-risk patients in labor who had continuous "direct" electronic monitoring, 147 presented late decelerations and 598 had no decelerations at the time the first stage was completed, or a cesarean section decided upon. A variety of clinical aspects of mother and fetus were analyzed, considering some alterations observed in the FHR pattern. Apgar scores were lower among decelerations, and there was a negative correlation between these two. Maternal pathology, other than PRM, was higher among decelerations and these required enhancement more often. There was very high association with tachycardia, saltatory, and fixed baseline among decelerations, and these infants were very often distressed and born depressed. Within the group of decelerations, small fetuses had lower Apgar scores. There was a negative correlation between number of decelerations and Apgar score. The small fetuses had a high incidence of tachycardia and fixed baseline, saltatory being almost absent. Their neonatal outcome was poor. A comparison of fetal response to distress was done considering age of gestation (premature, term, and postmature) and found to be different. The mechanisms involved in late deceleration are discussed, reviewing the published experimental work. When interpreting FHR patterns, age of gestation should be one of the most important considerations.     

产时不同类型胎儿酸血症与胎心监护图形的关系

目的研究产时脐动脉血显示的不同类型酸血症与产时胎心监护图形变化的关系及产后４年随诊的结果。方法采用回顾性病例对照研究方法,选择对象为１９９１年单胎、足月分娩的２９８１例新生儿,产程中定时胎心监护,分娩时测定脐动脉血气。生后４年进行儿童随诊。结果纯代谢性酸血症４７例（代酸组）,混合性酸血症６７例（混酸组）,该两组在第一产程末,胎心率评分＜６和６～７分者发生率显著高于对照组。减速图形特点显示晚期减速与纯代谢性酸血症有关,而异常可变减速与混合性酸血症有关。两组产后１分钟Ａｐｇａｒ评分＜７分者也明显高于对照组。儿童４岁时随诊其发育、运动和语言能力显示：代酸组及混酸组和对照组比较差异无显著性,只在混酸组语言表达迟钝的例数略多。结论晚期减速可能是纯代谢性酸血症的一个表现,而异常可变减速可能是混合性酸血症的一个表现。两者均与１分钟Ａｐｇａｒ评分低分的发生有密切关系。产时酸血症和以后的语言发育缺陷间关系需进一步估价     

Fetal heart rate pattern before and after paracervical anesthesia. A prospective study

A prospective study of the fetal heart rate pattern during labor before and after paracervical blockade (PCB) was performed. The material comprised 469 women in labor, or 28% of 1673 women delivered during a 6-month period. The majority of the anesthesias (87%) were administered by specially trained midwives. Bupivacain (Marcain) was the anesthetic used. The injections were made at four different points at a cervical diameter of 3-9 cm. The concentration of the anesthetic was 0.25 or 1.25% generally in 10 ml of normal saline. A second PCB was administered in 54 patients at least one hour after the preceding one. Fetal heart rate (FHR) was recorded via a scalp electrode and the pattern studied 15 min before and 30 min after the injection of the anesthetic. Bradycardia was defined as a persistent deceleration exceeding 3 min and occurring within 30 min of the PCB. Variability and acceleration pattern persisted independently of the PCB. Following PCB, decelerations of all types increased, while the basal rhythm decreased by on average 1.5 beats/min. Following PCB fetal bradycardia occurred in 1.9%. The bradycardia persisted on average for 6.5 min with a lowest average FHR of 73 beats/min. Retrospectively, 6 out of 9 infants exhibited recognized risk factors for bradycardia. All infants with bradycardia scored 9-10/5 min, according to the Apgar rating scale and all had a normal development with regard to growth, motor and speech development at the age of 2 years. There were no significant differences in vaginal operative deliveries between the PCB and the non-PCB group.(ABSTRACT TRUNCATED AT 250 WORDS)     

The lambda fetal heart rate pattern: an assessment of its significance in the intrapartum period

The "lambda" fetal heart rate (FHR) pattern was first described in 1977 as a pattern involving an acceleration followed immediately by a deceleration. However, its clinical significance has not been elucidated. During 6 months, 56 patients with this pattern were identified, representing 4% of all deliveries during this period. These were compared with a control group of 500 consecutive low-risk term patients who had been monitored electronically. The lambda pattern generally appeared early in labor and lasted for a variable period of time, but rarely persisted throughout labor. The relative rates of low Apgar scores, cesarean sections, and associated nonreassuring FHR patterns were similar between the two groups. The timing or depth of the decelerative portion of the pattern did not appear to correlate with any adverse outcome. Therefore, it does not appear that the lambda pattern is associated with any adverse outcome, nor does it predict the development of other concerning FHR patterns.     

Apgar scores and umbilical arterial pH in preterm newborn infants

One- and five-minute Apgar scores and umbilical cord arterial pH values were compared in preterm newborn infants of various gestational ages. The more premature the infant, the more likely the Apgar score was low in the presence of a pH greater than or equal to 7.25. Conversely, the closer to term, the more frequently an infant with a pH of less than 7.25 had an Apgar score of greater than or equal to 7. Therefore, in preterm infants, there is little congruity between the Apgar score and umbilical cord pH. Based on these findings, it is not appropriate to label preterm newborn infants as asphyxiated based on a low Apgar score.     

Fetal heart rate variability: an approach to automated assessment.

Three hundred seventy-five hours of fetal heart rate (FHR) data derived from the direct fetal electrocardiogram (ECG) were studied. This data had been stored on magnetic tape from 83 intrapartum patients. By means of a computerized technique, the FHR variability was assessed quantitatively. The degree of variability was then related to: (1) state of labor, (2) fetal scalp pH values, and (3) the 1-minute Apgar score. FHR variability was computed from differences between consecutive R-R intervals measured from the R wave of each fetal ECG. A trend of increasing variability was seen with advancing labor, defined by either time prior to delivery or cervical dilatation, but values were not statistically significant. Significantly less FHR variability was encountered when fetal scalp pH values below 7.20 were compared to higher values. FHR variability assessed during the 20 minutes immediately preceding delivery was significantly lower in infants with 1-minute Apgar scores less than 7. Machine assessment of FHR variability thus could be correlated with fetal condition as determined by scalp pH and neonatal outcome determined by Apgar score.     

Epidural analgesia for obstetrics: a maternal, fetal, and neonatal study

The effect of lumbar epidural (LE) and caudal epidural (CE) analgesia on the fetal heart rate and fetal acid-base status (pH and base excess) of 41 patients was studied during first- and second-stage analgesia in a controlled research delivery room environment. All patients had baseline parameters which made it possible to observe the effects of the epidural technique upon the fetal heart rate, pH, and base excess. Certain neonatal parameters were recorded to evaluate the epidural effect upon the neonate's postdelivery period. These included Apgar scores at 1 and 5 minutes, umbilical cord arterial and venous blood gases, and neonatal blood gases from the umbilical artery in the first hour after birth. There was an increase in late deceleration after epidural block despite segmental analgesia with minimal lidocaine dosages and the absence of hypotension. However, unless second-stage embarrassment or hypotension occurred, no significant deterioration of the acid-base status was noted. The greatest incidence of late deceleration was noted when epidural analgesia was combined with oxytocin. For the few toxemia patients studied, the epidural technique did not prove hazardous. These intrapartum regional analgesic techniques (LE and CE) do not appear to present a hazard to the normal fetus or the fetus at mild risk. Nevertheless, discretion would dictate that these techniques be restricted with evidence of combined antepartum and intrapartum fetal compromise.     

Combined (stressed and non-stressed) antenatal fetal heart rate monitoring.

Acceleration patterns of the fetal heart rate, or a normal heart rate during spontaneous contractions, were used as a short weekly screening test to evaluate fetal well-being in 1102 high-risk pregnancies. When accelerations or contractions were absent during the initial screening, oxytocin was administered to stimulate uterine contractions. The mean duration of the antenatal monitoring was 18.5 min when the initial antenatal monitoring was normal, but 38.8 min when the initial results were uncertain. Oxytocin was administered to 38% of patients. This reduced the number of occasions where the diagnosis was uncertain from 46.6% to 12%. Patients with uncertain antenatal fetal monitoring had significantly more late decelerations during labor as well as newborns with low Apgar scores when compared to those with normal antenatal monitoring. Patients with abnormal antenatal monitoring (positive stress test) had significantly more low 5-min Apgar scores, late decelerations during labor and growth-retarded infants than the patients with normal antenatal fetal monitoring. Only 1 intrauterine death occurred within 7 days of a normal antenatal heart rate recording. No preventable fetal deaths occurred when antenatal monitoring demonstrated an acceleration pattern of the fetal heart rate.     

A study of variable decelerations in association with other heart rate patterns during monitored labor.

A review of 1,011 consecutive intrapartum heart rate tracings yielded 37.3% with some degree of variable deceleration pattern. No differences in Apgar score distribution were observed in the presence of uncomplicated variable deceleration pattern when compared to those tracings marked normal. However, the presence of variable decelerations in association with other heart rate patterns resulted in lower mean Apgar scores at 1 and 5 minutes, which were significantly different from those of the fetal heart rate (FHR) normal group. Mean Apgar scores at 1 and 5 minutes were significantly different from normal when variable decelerations were noted in the presence of tachycardia and loss of variability. Mean Apgar scores were lower when bradycardia (prolonged episodes of heart rate less than 120 bpm) was present in the record when compared to normal, but the presence of variable decelerations with bradycardia did not result in different mean scores. The presence of baseline changes with loss of variability and variable decelerations appeared to result in the lowest mean scores. When bradycardia or tachycardia occurred in exclusive association with variable decelerations, the percentage of depressed newborn infants was relatively high.     

Clinical significance of fetal heart rate patterns during labor. I. Baseline patterns.

From a population of 2,774 high-risk patients monitored during labor, 1,304 single pregnancies in cephalic presentation and with direct monitoring for at least 1 hour before completion or cesarean-section were studied. The maternal and fetal clinical data and the tracings were hand reviewed, coded, and programmed for computer analysis. In the record were studied baseline, its changes (tachycardia, fixed, saltatory), the accelerations, and the decelerations (early, variable, late). Fifty-four per cent had some type of FHR deceleration. Accelerations were recorded in over 12 per cent of all cases and were associated with cord problems in 41 per cent. Subgrouping the patients by age of gestation (less than or equal to 36 weeks, 37 to 41 weeks, and greater than or equal to 42 weeks) revealed a 10 per cent prolonged gestation rate and only 6.8 per cent premature; these had a lower 5 minute Apgar score. Fetal weight and age were positively correlated with Apgar score. Baseline changes were much frequent among pre- and postmature infants, particularly tachycardia in the latter (40 per cent). The premature infants had a 25 per cent incidence of fetal distress and the postmature infants had 20 per cent. Neonatal morbidity and mortality rates were very high among premature infants and a mortality rate of 2.3 per cent was found among postmature infants. Saltatory pattern and particularly fixed baseline seem characteristic of prolonged gestation and placental insufficiency. With tachycardia, they constitute subtle symptoms of fetal distress.     

The fetal and labor outcome of 102 positive contraction stress tests

A total of 5447 contraction stress tests (CST) were performed on 3246 high-risk patients during pregnancy. Positive tests occurred in 102 patients (3.1%), 59 of whom had primary cesarean sections. Labor was induced in 40 patients (39.2%), and 17 developed cardiotocographic evidence of fetal distress. In 2 patients labor was terminated due to prolapse of the umblilical cord, and the remaining 21 patients did not develop fetal distress. Fetal distress was more common in patients with proved intrauterine growth retardation (IUGR) and where the acceleration patterns were not noted during the CST. Only 23% of the patients delivered vaginally. The fetal loss was 100% in those infants weighing less than 1000 g, but no infant weighing greater than or equal to 2500 g died. The overall perinatal mortality was 8.7%. The incidence of late decelerations during labor, low 5-minute Apgar scores, and small-for-date infants was significantly higher in patients with positive stress tests than in a control group of 257 patients with negative stress tests done over the same period of time.     

Appropriateness of antenatal referrals to a regional perinatal center

In an ideal system, all women should receive perinatal care adequate to their needs. For specific high-risk groups, this can only be accomplished by antenatal referral to another source of care. The appropriateness of antenatal referrals for patients at risk for premature delivery (less than or equal to 34 weeks) was studied. Records of 122 women in preterm labor and/or with premature rupture of membranes (PROM) presenting to two level I rural hospitals located 60 miles from the regional perinatal center (RPC) were reviewed. Fifty-three patients were not referred and were delivered of 59 infants within 24 hours of admission. Cervical dilatation greater than or equal to 4 cm (34 patients), vaginal bleeding (6 patients), extreme prematurity (6 patients), and advanced labor (7 patients) precluded referrals. Realistically, two of these patients should have been referred. Twenty-two of the 59 infants weighed less than or equal to 1,500 g at birth, 17 weighed 1,501-2,000 g, and 20 weighed greater than or equal to 2,000 g. Five infants died in the hospital, two during the first month and three later. Twenty-two percent had Apgar scores of less than or equal to 3 at 5 minutes. Thirty-four infants were transported to a level III neonatal intensive care unit (NICU). Fourteen of the 69 antenatal referrals required hospitalization (average 11 days), were returned to their local hospital, and delivered at term. Forty-four patients were delivered within 24 hours and 11 between 1 day and 9 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)     

Neurodevelopmental outcome and electronic fetal heart rate monitoring in a neonatal intensive care population

In a one-year population, 1977, of newborn infants admitted to the Neonatal Intensive Care Unit (NICU) the incidence of persistent neurodevelopmental handicaps was 3%, i.e. 13 of 427 survivors at 2 years of age. Transient abnormalities during the first 6 months of life were found in 63 infants, but after 6 months of age they were all normal at follow-up examinations. Most mothers with infants showing transient abnormalities or persistent handicaps had a high-risk pregnancy but one-third (35.5%) had a low-risk pregnancy and in this group 4 out of 7 cases with persistent major neurodevelopmental handicaps were found. In the total one-year population, 6% showed ominous fetal heart rate patterns (FHR) in labor compared with 31% of infants with later abnormalities and handicaps. Furthermore, all 13 infants with persistent handicaps had a normal Apgar score at 5 min, indicating that Apgar scoring was less predictive than FHR for neurodevelopmental outcome. Altogether 54 infants born in 1977 were small for gestational age (SGA): 33 NICU-treated and 21 not NICU-treated. Seven (6 NICU-treated, 1 not NICU-treated) had transient abnormalities (12.9%). No SGA infant developed persistent handicaps. The results suggest an improved obstetric and neonatal care of these infants.     

Is end-stage deceleration of the fetal heart ominous?

Summary. End-stage deceleration (ESD) defined as deep and sustained fetal bradycardia during the second stage of labour was observed in 55 patients. Fetal well-being and neonatal outcome were assessed with fetal-scalp pH, umbilical-vein pH and l-min Apgar score values. Only six infants with pathological fetal heart-rate patterns before ESD had a l-min Apgar score of <7 and an acidotic umbilical-vein pH. The remaining 49 babies were born in excellent condition, although when ESD persisted for more than 15 min umbilical-vein pH decreased.