Perineal length: norms in gravid women in the first stage of labour

Introduction  

The purpose of this study was to generate normative data for perineal length for Caucasian and Asian women in labour.     

Perineal body length as a risk factor for ultrasound-diagnosed anal sphincter tear at first delivery

Introduction and hypothesis

Shortened perineal body (PB) is associated with an increased risk of ultrasound-detected obstetric anal sphincter tear. The objective was to determine if shortened perineal body length (<3 cm) is a risk factor for ultrasound-detected anal sphincter tear at first delivery.

Methods

Pregnant nulliparous women were recruited over 18 months. At 35–37 weeks’ gestation and 6 weeks’ postpartum perineal body length (PB) was measured and subjects completed quality of life questionnaires. Primary outcome was ultrasound-diagnosed anal sphincter tear at 6 weeks postpartum. Secondary outcomes were also assessed. A priori power analysis determined that 70 subjects were needed to detect a difference in anal sphincter tear based on a PB cut-off of 3 cm.

Results

Seventy-three subjects completed the study. Mode of delivery was 69.9 % spontaneous vaginal, 15.1 % operative vaginal, and 15.1 % labored cesarean. There were 25 anal sphincter abnormalities (34.2 %) seen on ultrasound: 11 (15.1 %) internal or external sphincter tears, 3 (4.1 %) internal sphincter atrophy, 6 (8.2 %) external sphincter thinning, and 7 (9.6 %) external sphincter scarring. Only the 11 sphincter tears qualified as abnormal for the primary outcome. In the vaginal delivery group 16.4 % (10 out of 61) had a sphincter tear, compared with 8.3 % (1 out of 12) in the labored cesarean group (p?=?0.68). Women with PB?<?3 had a significantly higher rate of ultrasound-diagnosed anal sphincter tear (40.0 % vs 11.1 %, p?=?0.038). When comparing women with and without sphincter tear, there was a significant difference in mean antepartum PB (3.1 vs 3.7 cm, p?=?0.043).

Conclusions

A shortened perineal body length in primiparous women is associated with an increased risk of anal sphincter tear at the time of first delivery.     

Preferred spoken language mediates differences in neuraxial labor analgesia utilization among racial and ethnic groups

IntroductionThe aims of this study were to assess racial/ethnic disparities for neuraxial labor analgesia utilization and to determine if preferred spoken language mediates the association between race/ethnicity and neuraxial labor analgesia utilization.MethodsWe performed a retrospective cohort study of 3129 obstetric patients who underwent vaginal delivery at a tertiary care obstetric center. Bivariate analyses and multivariate logistic regression models were used to assess the relationships between race/ethnicity, preferred spoken language and neuraxial labor analgesia.ResultsHispanic ethnicity (adjusted OR 0.77, 95% CI 0.61–0.98) and multiparity (adjusted OR 0.59, 95% CI 0.51–0.69) were independently associated with a reduced likelihood of neuraxial labor analgesia utilization. When preferred spoken language was controlled for, the effect of Hispanic ethnicity was no longer significant (adjusted OR 0.84, 95% CI 0.66–1.08) and only non-English preferred spoken language (adjusted OR 0.82, 95% CI 0.67–0.99) and multiparity (adjusted OR 0.59, 95% CI 0.51–0.69) were associated with a reduced likelihood of neuraxial labor analgesia utilization.ConclusionsThis study provides evidence that preferred spoken language mediates the relationship between Hispanic ethnicity and neuraxial labor analgesia utilization.     

Aesthetic proportions of the nasal aperture in 3 different racial groups of men

OBJECTIVE: To define baseline aesthetic dimensions of the nasal aperture in 3 different racial groups. METHODS: Healthy volunteers from 3 different racial groups (15 white, 15 Chinese, and 15 Indian men) were enrolled in the study at the Department of Otolaryngology, University of Dundee, Dundee, Scotland. Those with a history of nasal or facial surgery or trauma were excluded from the study. Images were obtained and stored in a digital format. The dimensions of nasal aperture were defined by the length of the columella at the narrowest point, the width of the columella at the narrowest point, the length of the nasal aperture at the maximum length, the width of the nasal aperture at the maximum width, and the width of the alar cartilage base. RESULTS: There was no significant difference in the length or the width of the columella for the 3 racial groups. There was no significant difference in the length of the nasal aperture between the Chinese and the white groups. The nasal aperture was longer in the Indian group compared with the other 2 groups (P<.002). The nasal aperture at the maximum width was narrower in the Chinese group compared with the other groups (P<.002); there was no significant difference between the white and Indian groups. The nasal alar width was slightly narrower at the alar base in the Chinese group compared with other racial groups (P<.001). CONCLUSIONS: The aesthetic dimensions of the nasal aperture differ between racial groups. The nasal aperture and the alar base were narrower in the Chinese group, and the nasal aperture was longer in the Indian group. The aesthetic surgeon should ideally have an understanding of these ethnic variations.     

产妇正常分娩第一产程护理最佳证据总结

目的 检索、评价、整合产妇正常分娩第一产程护理的最佳证据,为临床实践提供参考。 方法 计算机检索国内外循证资源数据库、指南网站、原始文献数据库等,获得与正常分娩第一产程护理相关的临床决策、证据总结、指南及专家共识。检索时限为2016年1月至2021年11月。 结果 共纳入临床决策2篇、证据总结9篇、指南5篇、专家意见2篇;整合形成人文关怀、舒适与安全、药物镇痛、助产技术、医疗干预措施5个方面的33条最佳证据。 结论 助产士可根据第一产程护理的最佳证据,根据临床情境及产妇偏好,针对性提供产时护理,改善产妇的分娩体验、促进母婴安全。     

Perioperative complications and oncological outcomes following radical cystectomy among different racial groups: A long-term,single-center study

IntroductionCurrent literature on perioperative and oncological outcomes following radical cystectomy among different racial groups is limited, especially among Hispanics and Asians. The objective of this study was to assess the impact of racial differences on perioperative and oncological outcomes in a large cohort of bladder cancer patients who underwent radical cystectomy.MethodsWe retrospectively reviewed the records of 3293 patients who underwent radical cystectomy with curative intent at our institution between 1971 and 2017. Based on race, patients were categorized as Hispanic (n=190), Asian (n=145), African American (n=67), and Caucasian (n=2891). Baseline characteristics, pericystectomy complications, and oncological outcomes, including recurrence-free and overall survival, were compared between the racial groups.ResultsMean patient age was 68±10.6 years. Median followup was 10.28 years. Body masss index and American Society of Anesthesiologists scores were significantly higher in Hispanic and African American population, and smoking incidence was lower in Asian patients. Hispanics presented with significantly higher clinical stage and longer time interval from diagnosis to treatment (mean 85.5 vs. 75.4 days in Caucasians, p<0.001). Overall 90-day complication and readmission rates were higher in Hispanics (41.06% and 18.95%, respectively). Oncological outcomes, however, were comparable between different race groups. In multivariate analysis, pathological nodal status and lymphovascular invasion were independent predictors of oncological outcomes, but race was not.ConclusionsIn this very large, ethnically diverse patient cohort who underwent radical cystectomy with curative intent, pericystectomy complications were more common in Hispanics; however, race was not an independent predictor of long-term oncological outcome.     

High volume of subarachnoid levobupivacaine decreases drug requirement in first stage labor analgesia

AIM: Using the statistic method of sequential allocation, we realized a prospective double-blind study in order to establish the minimum local anesthetic concentration (MLAC) of large intrathecal volume of levobupivacaine, during the first stage labour analgesia in spontaneous and induced laboring women. METHODS: Seventy-five nulliparous, at term, with cervical dilatation <5 cm parturients requesting combined spinal/epidural analgesia, were enrolled. The starting concentration was chosen according to recent literature. Total volume of study solution was 10 ml and efficacy was assessed with a visual analogue pain scale at the height of the uterine contraction. RESULTS: We established that MLAC of levobupivacaine, in 10 ml intrathecal volume, during the first stage of spontaneous and induced labour was 0.0134% and 0.0195%, respectively. No complications occurred during the study and the only side effect was shivering, which is common even in other anesthetic techniques. We produced a very selective sensitive block. Neither sympathetic nor motor block occurred. CONCLUSIONS: Low intrathecally concentration of local anesthetic allows the anesthetist to reduce the total amount of drug and improves not only the differential blockade between motor and sensitive but also between sympathetic and sensitive fibers.     

全产程分娩镇痛与第一产程分娩镇痛对妊娠高血压综合征产妇产程的影响

目的比较全产程分娩镇痛与第一产程分娩镇痛用于合并妊娠高血压综合征产妇的安全性及有效性。方法选择2015年3~11月于北京妇产医院分娩的产妇196例,年龄22~35岁,ASAⅠ或Ⅱ级。所有产妇均为初产、单胎和足月妊娠,诊断妊娠高血压综合征。随机将入选产妇分为全产程分娩镇痛组(T组)和第一产程活跃期分娩镇痛组(F组)。T组在出现子宫规律收缩后进行分娩镇痛,持续应用镇痛泵至第三产程结束;F组在出现子宫规律收缩且进入第一产程活跃期(子宫口开至3cm)后进行分娩镇痛,子宫口开全后,由生理盐水代替泵内麻醉药物至第三产程结束。记录镇痛前、镇痛后10、60min、宫口开全、第二产程屏气用力和胎头娩出时的MAP和VAS评分;记录应用缩宫素例数和第二产程屏气用力时Bromage评分;记录第一、第二、第三产程时间、分娩方式、子痫和产后出血情况。结果第二产程屏气用力时,T组MAP明显低于F组[(106.0±7.0)mm Hg vs.(115.4±7.3)mm Hg,P0.05],VAS评分明显低于F组[(2.0±1.1)分vs.(5.1±1.2)分,P0.05];胎头娩出时,T组MAP明显低于F组[(106.2±7.2)mm Hg vs.(116.0±7.6)mm Hg,P0.05],VAS评分明显低于F组[(1.9±1.2)分vs.(5.2±1.3)分,P0.05];T组应用缩宫素例数明显多于F组[50(51%)vs.35(35%),P0.05]。两组Bromage评分、产程时间、分娩方式和相关不良反应差异无统计学意义。结论全产程分娩镇痛可安全有效地应用于合并妊娠高血压综合征的产妇。     

Minimum analgesic doses of fentanyl and sufentanil for epidural analgesia in the first stage of labor

In this study, we sought to determine the minimum analgesic doses and relative potencies of fentanyl and sufentanil when they are used as the sole epidural analgesic during the first stage of labor. Nulliparous parturients (n = 66) in spontaneous labor at term gestation and requesting epidural analgesia were enrolled into this prospective, double-blinded, randomized, sequential-allocation study. Each woman received fentanyl or sufentanil diluted with 0.9% wt/vol saline to a volume of 10 mL. The initial dose was arbitrarily chosen to be 125 microg for fentanyl and 25 microg for sufentanil, with subsequent doses being determined by the response of the previous patient (testing interval, 5 microg for fentanyl and 1 microg for sufentanil). Efficacy was accepted if the visual analog score decreased to < or =10 mm on a 100-mm scale within 30 min. The minimum analgesic dose or median effective dose was 21.1 microg (95% confidence interval [CI], 20.2-21.9 microg) for sufentanil and 124.2 microg (95% CI, 118.1-130.6 microg) for fentanyl (P < 0.0001). The sufentanil/fentanyl potency ratio was 5.9 (95% CI, 5.6-6.3). In conclusion, we have established the equivalent doses and relative potencies of fentanyl and sufentanil for epidural analgesia in the first stage of labor. IMPLICATIONS: This study determined the minimum analgesic doses of fentanyl and sufentanil for epidural anesthesia in the first stage of labor. The sufentanil/fentanyl potency ratio was 5.9. This ratio may be used to establish the equivalent doses for fentanyl and sufentanil for epidural analgesia in labor.     

Clinical patterns of presentation of breast cancer in women of different racial groups in South Africa

The ages at presentation of white patients with breast cancer were found to be significantly higher than those of blacks, Indians and coloureds; 73% of white women fell into the postmenopausal group, in marked contrast to only 35% of Indians, while blacks and coloureds had similar proportions of pre- and post-menopausal patients. A significantly higher incidence of poorly differentiated tumours was seen in Indian and black patients. Blacks showed a significant tendency to present with more advanced disease, while whites were generally diagnosed at a much earlier stage.     

Changes in length of the first ray with two different first MTP fusion techniques: a cadaveric study

BACKGROUND: First metatarsophalangeal joint (MTP) fusions are performed as salvage procedures for a variety of conditions ranging from osteoarthritis, rheumatoid arthritis, hallux valgus, and failed first MTP arthroplasty. A number of bone preparation techniques have been described to fuse the first MTP joint, with varying degrees of success. The aim of this study was to characterize and compare the average shortening of the first ray with a conical reamer fusion technique versus flat bone cut technique. MATERIALS AND METHODS: Six paired cadaver feet were divided into two groups with one foot from each pair in each group. Preoperative first ray lengths were measured radiographically. Each group then underwent arthrodesis of first MTP joint with one of two different bone cut techniques: flat cuts or conical reaming. The postoperative lengths of the first rays were measured and the data analyzed using a two-tailed Student's t-tests. RESULTS: The average shortening that occurred in both groups after the procedure was 7.1 mm for the flat cut group (Group I) and 5.7 mm for the machined conical reaming group (Group II). Comparing both groups, there was no statistically significant difference in the shortening between the groups. CONCLUSION: Both flat bone cut and conically reamed techniques caused shortening of the first ray after first MTP fusion. However, there was no statistically significant difference in the postprocedure lengths of the first ray between the two groups. CLINICAL RELEVANCE: Neither technique is more likely to lead to transfer metatarsalgia since the shortening was similar.     

Effects of intrathecal sufentanil on plasma oxytocin and cortisol concentrations in women during the first stage of labor

BACKGROUND AND OBJECTIVES: Intrathecal sufentanil provides analgesia comparable to epidural bupivacaine for the first stage of labor. Both epidural local anesthetics and intrathecal opioid reduce some parameters of the neuroendocrine response to labor pain and the reflex release of oxytocin in animals. In humans, epidural local anesthetics only reduce the spurt release of oxytocin. This study compared the effect of intrathecal sufentanil and epidural bupivacaine administration on the plasma concentration of oxytocin and cortisol in women with labor pain during the first stage of labor. METHODS: Thirty healthy parturients requesting analgesia were enrolled in this randomized and open-label study. Each patient was in spontaneous labor at greater than 5 cm cervical dilatation. Using a combined spinal and epidural technique, patients received either intrathecal sufentanil 10 microg (SUF = intrathecal sufentanil group) or epidural plain bupivacaine 0.25%, 12 mL (BUPIV = epidural bupivacaine group). Analgesia was assessed using a visual analog scale, and blood samples for oxytocin and cortisol plasma concentration measurements were collected immediately before analgesia and 15, 30, 60, and 90 minutes after induction of the analgesia. Plasma cortisol and oxytocin concentrations were determined by specific radioimmunoassay. The values were expressed as mean +/- SEM. RESULTS: Intrathecal sufentanil provided faster and more complete analgesia within 15 and 30 minutes of its administration, compared with epidural bupivacaine. Plasma oxytocin concentrations were similar in the 2 groups before analgesia (7.24 +/- 2.1 and 6.6 +/- 3.1 pg/mL SUF and BUPIV, respectively). It decreased significantly in the SUF and increased in the BUPIV after analgesic administration. Cortisol concentrations were elevated in both groups before analgesia (51.6 +/- 5.3 and 54.2 +/- 4.8 microg/dL SUF and BUPIV, respectively). Both analgesic treatments significantly decreased the plasma cortisol levels. CONCLUSIONS: Intrathecal sufentanil analgesia decreases plasma concentrations of oxytocin and cortisol in women with labor pain during the first stage of labor, but epidural bupivacaine only reduced the cortisol concentration.     

Metabolic bone disease in the elderly. Biochemical studies in three different racial groups living in South Africa.

In an attempt to detect biochemical evidence of metabolic bone disease in the aged, we measured plasma parathyroid hormone (PTH) concentrations, in addition to plasma calcium, phosphorus, alkaline phosphatase and creatinine levels, in elderly White, Black and Indian women. All three ethnic groups demonstrated raised mean PTH concentrations. The Black patients, however, showed the greatest mean PTH elevation and the lowest plasma calcium level. Increased PTH secretion in elderly females may reflect either an age-related decline in renal function or subclinical osteomalacia. Elderly Black women seem particularly susceptible to the latter disorder, probably because of dietary and environmental factors.     

Measurements of the lumbar spinal canal in 2 racial groups.

Direct measurements of 1,340 lumbar vertebrae in 275 skeletons in two racial groups are reported. The average figure, and the upper and lower limits of normal are reported for the anteroposterior diameter of the canal and for Spinal Index. Radiological studies have established a technique for defining the posterior margin of the spinal canal on plain X-ray films. It is formed by a line joining the apex of the superior to the inverted apex of the inferior articular facet. The Spinal Index is not a reliable factor. The anteroposterior diameter alone is the essential parameter in assessing spinal stenosis. The negroid canal is marginally less spatial than that of the caucasoid.     

Treatment of third stage of labor

The safe delivery of the placenta is more important to the maternal health than the safe delivery of the fetus. Recognition of separation of the placenta is an outstanding item in the conduct of the third stage of labor. Mechanism of placental separation and signs of separation are described. Spontaneous delivery of the placenta, “indirect expulsion,” and simple expression are essentially physiological. Credé method and manual removal of the placenta represent pathology in the third stage of labor. The importance and technique of placental inspection are also given.