Women's antenatal knowledge and plans regarding intrapartum pain management at the Royal Hospital for Women

AIMS: To examine women's knowledge and antenatal plans regarding intrapartum pain management options at Royal Hospital for Women (RHW), Sydney, Australia. METHODS: From October 2002 to January 2003 women aged over 16 who had been in labour were given a questionnaire to complete in the first week post-partum regarding intrapartum pain management. This included questions regarding their antenatal knowledge and predetermined plans. RESULTS: There were 496 participating women (69% response rate). Antenatal pain management information was accessed by 98% of women. Sources most accessed were antenatal classes (55%), multimedia (53%), and friends/relatives (46%). Sixty percent of women felt 'very well informed' antenatally. Women felt better informed antenatally if married/defacto, university educated, privately insured, or receiving birth centre care. Antenatally, 80% planned to use intrapartum pain management: 'natural' methods were most popular (62% planned to use), and pethidine least (49% planned against). The most common determinant against using medical methods was possible maternal side-effects. Intrapartum, 19% used 'unwanted' pain management, mostly (67%) due to increased labour pain. Increased information access was associated with significantly higher use of both 'natural' methods and epidural analgesia, as well as significantly higher satisfaction scores. CONCLUSIONS: Almost all women at RHW access information antenatally about intrapartum pain management, often from informal sources. Demographic factors affected type of information accessed and women's plans. Adequate access to information affected use of, and satisfaction with, pain management.     

Intrauterine restriction (IUGR)

Perinatal mortality and morbidity is markedly increased in intrauterine growth restricted (IUGR) fetuses. Prenatal identification of IUGR is the first step in clinical management. For that purpose a uniform definition and criteria are required. The etiology of IUGR is multifactorial and whenever possible it should be assessed. When the cause is of placental origin, it is possible to identify the affected fetuses. The major complication is chronic fetal hypoxemia. By monitoring the changes of fetal vital functions it is thus possible to improve both management and outcome. The timing of delivery is crucial but the optimal management scheme has not yet been identified. When IUGR is identified at very early gestational ages, serial assessments of the risk of continuing the in utero fetal life under adverse conditions versus the risks of the prematurity should be performed. Delivery of IUGR fetuses should take place in centers where appropriate neonatal assistance can be provided. Careful monitoring of the IUGR fetus during labor is crucial as the IUGR fetus can quickly decompensate once uterine contractions have started.     

Immunoglobulin concentrations in newborn infants associated with intrauterine growth retardation

Immunoglobulin G, A, and M (IgG, IgA and IgM) levels were measured in paired maternal and cord serum samples from 18 pregnancies with intrauterine growth retardation (IUGR) and 55 with normal growth (adequate-for-gestational-age pregnancies) delivered vaginally at 36 weeks' gestation or later. Cord blood levels of IgG, IgA, and IgM in IUGR infants were found significantly lower than those in infants with adequate-for-gestational-age growth. Lower Lower levels of cord IgG in IUGR may be due to a defect in the active transport of IgG across the placenta. Lower levels of cord IgM and IgA suggest an impairment of synthesis of immunoglobulins in the IUGR infants. There was no difference in cord immunoglobulin concentrations between infants with intrapartum fetal heart rate (FHR) decelerations and those without FHR decelerations in either the IUGR or the adequate-for-gestational-age group. No difference was observed in maternal immunoglobulin concentrations among the study groups.     

Intrauterine growth restriction from screening to diagnosis: the role of ultrasound

Intrauterine growth restriction (IUGR) is a condition observable, according to the modern criteria, in about 15% of pregnancies. This situation can be associated with many adverse fetal factors of which the most important is represented by hypoxemia, which occurs in about 30% of IUGR cases. For a long time, IUGR has been defined on the basis of the birth weight, but, after the introduction of obstetric ultrasound in clinical practice, it has become possible to observe the growth restriction in utero and, as a consequence, it has been recognized that being small for date is not synonymous of IUGR In fact, fetuses undergoing restriction of growth when also having a birth weight over the 10th centile are affected by hypoxemia and undergo intrauterine demise with increased frequency. By using fetal biometry, it is possible to monitor accurately the characteristics of the growth which must not be confused with weight or size. Doppler technology has also been shown to provide the possibility of evaluating fetoplacental hemodynamics, distinguishing between fetuses affected by hypoxemia and those who are unaffected, allowing improvements in management and outcome. Since the crucial point is therefore represented by early recognition of IUGR, the controversial problem of screening is discussed.     

An intrapartum intervention scoring system for the comparison of maternity units' intrapartum care of nulliparous women suitable for midwifery-led care

OBJECTIVE: To develop an intrapartum intervention scoring tool which could be used to define maternity units as either 'lower intrapartum intervention' or 'higher intrapartum intervention' units. This scoring tool was designed to form the basis of a comparison of the perception of risk by midwives working in either 'lower intrapartum intervention' or 'higher intrapartum intervention' units. DESIGN: Three aspects were included: (1) the systematic data reduction of the St. Mary's Maternity Information System database used by 11 maternity units to include Caucasian nulliparous women suitable for midwifery-led care; (2) the calculation and the ranking of frequency distributions for the following interventions/management: (a) the management of breech presentation and of one previous caesarean section, the choice of home birth; and (b) augmentation of labour, use of electronic fetal monitoring, use of epidural, method of delivery; (3) the sum of the individual intrapartum ranking marks made up the final intrapartum score for each unit. RESULTS: Intrapartum interventions varied considerably between units. The scoring system enabled units to be described as either 'Lower intrapartum intervention' or 'Higher intrapartum intervention' units. CONCLUSIONS: Routinely collected computerised data can be used to identify the outcomes of intrapartum care. This study suggests that the analysis of computerised data could provide a suitable basis for the audit and the comparison of intrapartum interventions for the care of women suitable for midwifery-led care.     

Isolated intrauterine growth restriction: a survey of Central Association of Obstetricians Gynecologists (CAOG) members

Objective: The objective was to ascertain clinicians’ opinions and current management with isolated (no concomitant morbidity) intrauterine growth restriction (IUGR). Methods: Members of the Central Association of Obstetricians and Gynecologists (CAOG) were surveyed. We considered consensus to be agreement among 90% of the respondents. Results: The response rate was 36% (137/385). Among the 21 questions on the topic, the only consensus was that none of the respondents informed women of the recurrence rate of IUGR. There was variance in what constitutes IUGR as well as practice patterns for detection and management of suboptimal growth. Ten (7%) of the respondents had at least one litigation involving management of IUGR. Responses from 87 general obstetrician-gynecologists varied significantly from that of 33 maternal-fetal medicine (MFM) subspecialists for 48% (10/21) of the survey questions (p < 0.05). Conclusions: There is large practice variation in detection and management of isolated IUGR. This stresses the need for additional studies and a national guideline on its management.     

Impaired fetal growth: definition and clinical diagnosis

Intrauterine growth retardation (IUGR) may affect up to 10% of pregnancies and results in substantially increased perinatal morbidity and mortality. Although many infants are small on a constitutional basis and not as a result of disease, many others suffer malnutrition from chronic progressive uteroplacental insufficiency. Genetic disease, embryonic infection, and various drug exposures may also result in IUGR. Inconsistency of diagnostic criteria has seriously hampered clinical research aimed at clarification of both the short- and long-term implications of IUGR. This part of the report examines both the significance and clinical definition of IUGR and reviews the diagnostic tests used for the detection of the problem of impaired fetal growth. The clinical approach to the management of IUGR is presented in the subsequent part of the report, which includes the ultrasonic evaluation and management of this entity.     

Obstetric conduct in IUGR

Purpose of the study is to identify the correct attitude that the obstetrician must engage in the management of pregnancy and birth in case of IUGR. Different methods of diagnosis and therapy of IUGR and the formalities of assistance to the birth have been examined and compared. Accurate clinical examinations of the mother, the study of fetal kariotype and ultrasonography, are essential for the diagnosis of IUGR. The genetic study could be performed by collecting chorionic villi, amniocentesis, cordocentesis or placenta biopsy. Ultrasonography identifies the cases of IUGR, and distinguishes early IUGR from late IUGR. Color Doppler identifies the pathology of the flow in the umbilical artery, in the abdominal aorta and in the middle cerebral artery. After the 26th week, the follow-up of the fetus with IUGR is done with cardiotocography with or without acoustic stimulation or oxytocin. The amelioration of maternal conditions is obtained by avoiding the cigarette smoking, preferring to rest in bed and a balanced feeding; the hyperoxygenation doesn't find unanimous consent. The treatment off IUGR can consist of abdominal decompression, intra-abdominal infusion of amniotic liquid, or use of aspirin. The birth is carried out in the hospital, when the fetus has reached a sufficient maturity. The management of IUGR requires an accurate follow-up and an adequate antepartum therapy. The goal is a birth with less risk.     

Role of attempted vaginal delivery in the management of placenta previa

Sixty-nine documented cases of placenta previa were managed at The Mount Sinai Medical Center during a five-year period. Vaginal delivery was attempted in six instances of partial placenta previa and was successful in five (83%). For these six cases, intrapartum bleeding was not excessive, blood transfusions were not necessary during or after labor, and all Apgar scores were greater than or equal to 7 at one and five minutes. Anemia in a neonate delivered at 32 weeks of gestation was the only neonatal complication that may have been due to intrapartum fetal hemorrhage. This series suggests that routine cesarean section is not necessary for all cases of partial placenta previa. A protocol is proposed for the intrapartum management of suspected placenta previa at term. Further clinical studies are necessary to evaluate the safety and clinical use of this mode of management.     

Antepartal assessment of IUGR fetuses.

Intrauterine growth restriction (IUGR) should be defined on the basis of a prenatally recognized defective growth compared to that expected for this fetus. This condition is encountered in 10-15% of the pregnancies and the perinatal outcome is impaired mainly as a consequence of fetal hypoxemia that is present in 30% of IUGR fetuses. In order to allow for proper management, the IUGR should be recognized prenatally and the method of choice for this purpose is ultrasound fetal biometry. After the identification of IUGR, 2nd level tests should be performed in order to assess the fetal oxygenation conditions. The validity of Doppler investigation on fetal and umbilical vessels is discussed, and the importance of using computer assisted cardiotocography instead of traditional eye ball evaluation of the non-stress test is emphasized.     

Intrapartum pain management at the Royal Hospital for Women

AIMS: To explore use of, and women's satisfaction with, intrapartum pain management at Royal Hospital for Women (RHW), Sydney, Australia. METHODS: From October 2002 to January 2003 women aged over 16 who had been in labour at RHW were given a questionnaire to complete in the first week post-partum regarding their intrapartum pain management. Supplementary information was obtained from patient records. RESULTS: A total of 496 women participated (69% response rate), including 95 birth centre clients. The mean age was 32 years and 73% percent had a normal vaginal delivery. At least one form of pain management ('natural', nitrous oxide, pethidine, epidural, local infiltration of the perineum) was used by 463 (93%) women, with 74% using two or more methods. Labour pain was 'worse' or 'much worse' than expected for 55%. Seventy-two percent were 'very' or 'quite' satisfied with overall pain management. Epidural analgesia had the highest utility scores (89%'very useful') and likelihood of use in subsequent labours (67%), and pethidine the lowest. Factors affecting analgesic use included cervical dilation on admission, labour length, English-speaking background, delivery suite versus birth centre care, parity, and syntocinon use. CONCLUSIONS: Women at RHW use a variety of pain management methods in labour and most use multiple methods. Labour was rated more painful than expected by a majority; however, most were satisfied with their pain management. Labour length and cervical dilation on admission were most predictive of pain management use.     

Colour Doppler in IUGR- Where are we and where do we go?

Intra-uterine growth restriction (IUGR) is an important perinatal problem giving rise to increased morbidity and mortality in the growth restricted fetus. The aim of fetal medicine today, is to prevent the mere occurrence of IUGR in high risk pregnancies and to deliver the fetuses already afflicted with growth restriction, before they have suffered from the effects of hypoxia. The use of Doppler provides this information, which is not readily obtained from the other conventional tests of fetal well being. The Doppler patterns follow a longitudinal trend in the arterial and venous circulation of the fetus as well as the placental vasculature guiding management decisions regarding the appropriate time of delivery. Progressive knowledge of the fetal circulation and its adaptation when the fetus is subjected to hypoxia, has helped us recognize the early signs of IUGR thereby improving the prognosis of these complicated pregnancies. It has therefore become the gold standard in the management of the growth-restricted fetus.     

Intrauterine growth retardation and fetal cardiac function

Intrauterine growth retardation is a pathology which is found in 3-10% of all pregnancies and it is associated with around 20-25% of all fetal intrauterine deaths and with long-term neurologic sequelae. It presents an increased risk of distress during labor and delivery and a greater risk of perinatal mortality. The causes of IUGR and the cardiac and venous Doppler in normal fetuses are analyzed, and the hemodynamic cardiac modifications in IUGR fetus are discussed. The fetal cardiac function in intrauterine growth retardation shows a redistribution of the fetal cardiac output, which tends to favor the left ventricle as the mechanism to compensate for the uteroplacental insufficiency. The Doppler velocity indices are modified as the fetal condition progressively deteriorates and they represent an important tool for the management of the complicated pregnancy.     

Obstetric management of women with a history of recurrent genital herpes

Genital herpes simplex is a common sexually transmitted disease in our society. A genital infection complicating pregnancy can result in the vertical transmission of a devastating neonatal illness. The appropriate obstetric management of women with a history of genital herpes remains controversial. Past management protocols have stressed frequent third trimester viral cultures in an attempt to identify those at risk for asymptomatic viral shedding at delivery. Cesarean section was recommended if asymptomatic shedding was suspected. Subsequent research has shown that surveillance schema aimed at identifying asymptomatic shedding in term gestations will fail to identify antepartum the majority of cases of neonatal herpes. Furthermore, weekly surveillance cultures have failed to predict intrapartum viral shedding accurately. The current literature supports mode of delivery decisions based on clinical history and careful intrapartum examination. The development of rapid diagnostic tests for intrapartum diagnoses of viral shedding as well as the prophylactic use of antiviral agents will influence future recommendations.     

Use of fetal heart rate scoring system in intrapartum fetal monitoring

A scoring system of intermittent 5-second successive fetal heart rate auscultation was devised for intrapartum fetal monitoring. Its use among 150 cases in two hospitals, yielded a negative predictive rate of 93.8% and a positive rate of 71.4%, higher than that of the routine auscultation method. The scoring system was also well correlated with the umbilical blood gases values. Hence, it is recommended for intrapartum fetal monitoring, especially, where electronic monitoring is not available.     

Advanced maternal age is an independent risk factor for intrauterine growth restriction

Reports on the association between advanced maternal age (AMA) and intrauterine growth restriction (IUGR) are conflicting. Our objective was to determine if AMA is an independent risk factor for IUGR. Our case-control study compared cases with IUGR (birthweight<10th percentile for gestational age) and a control group without IUGR. Gestational ages were all confirmed by ultrasound. The study included only singletons and fetal anomalies were excluded. Both groups were evaluated for maternal demographics and clinical risk factors. AMA was defined as maternal age>35 years. Univariate and multivariate analyses were used to examine associations. During the study period, there were 824 cases with IUGR meeting the inclusion criteria; these were compared with 1648 controls (no IUGR) randomly selected from the same population during the same study period. The significant factors associated with IUGR multivariate analyses were black race (odds ratio [OR], 22.4; 95% confidence interval [CI], 17.8 to 28); chronic hypertension (OR, 2.2; 95% CI, 1.5 to 3.2); pregestational diabetes (OR, 3.3; 95% CI, 1.6 to 7) illicit drug use (OR, 3.3; 95% CI, 2.2 to 5.2), and AMA (OR, 1.4; 95% CI, 1.1 to 1.8). There was a positive dose-response association between increasing maternal age and increasing risk for IUGR. At maternal age of 40 years or older, the OR and 95% CI for IUGR was 3.2 and 1.9 to 5.4, respectively. AMA is an independent risk factor for IUGR. Our findings suggest that screening for IUGR is indicated in women age 35 years or older.     

胎盘绒毛滋养层细胞MMP-9表达与胎儿宫内发育迟缓的关系

目的:研究胎盘绒毛滋养层细胞基质金属蛋白酶-9(MMP-9)的表达,探讨MMP-9在胎儿宫内发育迟缓(IUGR)发病中的作用。方法:用免疫组化两步法测定30例妊高征合并IUGR患者和28例非妊高征IUGR及30例正常妊娠患者胎盘组织中滋养层细胞MMP-9的表达。结果:正常妊娠组滋养细胞MMP-9表达阳性率为73.3％,明显高于妊高征合并IUGR组及非妊高征IUGR组(分别为23.3％和21.4％,P<0.001),而后两者差异无显著性(P>0.05)。随妊高征病情的加重,MMP-9的表达有减少的趋势。结论:在妊高征合并IUGR及非妊高征IUGR患者胎盘中,滋养细胞基质金属蛋白酶表达均减少,与IUGR发生有密切关系。     

System errors in intrapartum electronic fetal monitoring: a case review

Intrapartum electronic fetal monitoring (EFM) interpretation and management continue to be a common issue in litigation involving adverse outcomes in term pregnancies. This article uses a case study approach to illustrate system errors related to intrapartum EFM. Common system errors related to use of intrapartum EFM include knowledge deficits, communication failures, and fear of conflict. Strategies for reducing error and the promotion of a patient safety approach to risk management in EFM are discussed, with an emphasis on the importance of a true team approach to EFM education, interpretation, and management.     

Update on intrapartum fetal pulse oximetry

This article examines the current status of fetal pulse oximetry (FPO) as a means of intrapartum assessment of fetal wellbeing. FPO has been developed to a stage where it is a safe and accurate indicator of intrapartum fetal oxygenation. In general, sliding the FPO sensor along the examiner's fingers and through the cervix, to lie alongside the fetal cheek or temple is easy The recent publication of a randomised controlled trial (RCT) of FPO versus conventional intrapartum monitoring has validated its use to reduce caesarean section rates for nonreassuring fetal status. An Australian multicentre RCT is currently underway. Maternal satisfaction rates with FPO are high. FPO may be used during labour when the electronic fetal heart rate trace is nonreassuring or when conventional monitoring is unreliable, such as with fetal arrhythmias. If the fetal oxygen saturation (FSpO2) values are < 30%, prompt obstetric intervention is indicated, such as fetal scalp blood sampling or delivery FSpO2 monitoring should not form the sole basis of intrapartum fetal welfare assessment. Rather, the whole clinical picture should be considered.     

Validity of umbilical artery blood velocimetry in the prediction of intrauterine growth retardation and fetal compromise

In a prospective longitudinal investigation, the validity of umbilical artery velocimetry in the detection of IUGR and fetal compromise was calculated in a group of 105 patients. With the help of pulsed Doppler ultrasound, measurements were performed from a menstrual age of 15 weeks onwards till term. The pulsatility index was calculated. The sensitivity, specificity, likelihood ratio and post test probability were determined with regard to the ability to predict IUGR and fetal compromise. The sensitivity in the detection of IUGR was 44.4%, the post test probability was 32.4%. For the prediction of fetal distress a sensitivity of 77.8% and a post test probability of 40.1% was calculated. In a selected group of high-risk patients (IUGR or PIH) the post-test probability was 77.6%. It seems clear that umbilical artery velocimetry is not useful as a screening tool for IUGR, but it has some potential to predict fetal distress.