An inflatable birth canal dilator. A randomised pilot study

An inflatable device designed to achieve controlled dilatation of the pelvic floor soft tissues before the second stage of labour in women with epidural analgesia was tested in a randomised pilot study. Assisted vaginal delivery was required in 4/14 primiparous women (29%) after use of the dilator, and 8/16 controls (50%). The concept of improving the efficiency of pelvic floor dilatation and reducing the trauma associated with childbirth was found to be worth pursuing, and potential improvements in the design of the dilator were identified.     

Evaluation of positive expiratory pressure as an adjunct to chest physiotherapy in the treatment of cystic fibrosis.

It has been suggested that positive expiratory pressure may assist the clearance of bronchial secretions in the treatment of cystic fibrosis. It has been compared with currently used postural drainage techniques. Three treatment regimens were compared in 18 patients with cystic fibrosis. Treatment A consisted of breathing exercises emphasising inspiration, interspersed with the forced expiration technique in gravity assisted positions; treatment B comprised breathing exercises with positive expiratory pressure alternating with the forced expiration technique in the same gravity assisted positions; and treatment C comprised breathing exercises with positive expiratory pressure and the forced expiration technique in the sitting position. During treatment A a significantly greater quantity of sputum was produced than during treatments B and C (p less than 0.025 and p less than 0.001 respectively). Treatment B produced more sputum than treatment C (p less than 0.005). There were no significant differences in arterial oxygen saturation, FEV1 or forced vital capacity. Most adolescent and adult patients are able to carry out their treatment independently using gravity assisted positions, breathing exercises emphasising inspiration, and the forced expiration technique. Sputum clearance was less effective when positive expiratory pressure was included in the treatment regimen.     

Domperidone: secretion in breast milk and effect on puerperal prolactin levels

The possible effect on the infant of dopamine antagonists used to promote lactation is cause for concern. Domperidone (Motilium) may be safer than other drugs in this group as it does not cross the blood-brain barrier. The mean serum level of prolactin 2 h after treatment with 20 mg of domperidone in the puerperium was 255 ng/ml compared with 150 ng/ml after a placebo. The mean domperidone level in all breast milk samples during treatment with 10 mg, three times daily, was 2.6 ng/ml. This was significantly more than levels after a single 20 mg dose sampled at 2 h (0.24 ng/ml) and at 4 h (1.1 ng/ml), and considerably less than values available for metoclopramide and sulpiride, relative to the therapeutic dosage. The effectiveness of domperidone to augment lactation requires further study.     

Pulmonary oedema after hexoprenaline administration in preterm labour. A report of 4 cases

Despite the widespread use of beta-sympathomimetic agents for preterm labour there appears to be a limited appreciation of the need for cardiovascular monitoring in the mother. Four patients in whom pulmonary oedema developed during tocolysis with hexoprenaline are described and the aetiological factors and pathogenesis of this potentially lethal complication discussed. Guidelines for the safe use of hexoprenaline in preterm labour are suggested.     

A double-blind randomised placebo controlled trial of postnatal norethisterone enanthate: the effect on postnatal depression and serum hormones

Objectives To determine the effect of postnatal administration of the long-acting progestogen contraceptive, norethisterone enanthate, on postnatal depression and on serum hormone concentrations, and their association with depression.
Design Double-blind randomised placebo-controlled trial.
Setting A tertiary care hospital in Johannesburg, South Africa.
Population Postnatal women using a non-hormonal method of contraception (   n = 180  ).
Methods Random allocation within 48 hours of delivery to norethisterone enanthate by injection, or placebo.
Main outcome measures 1. Depression scores in the three months postpartum as rated by the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Edinburgh Postnatal Depression Scale (EPDS); 2. serum 17β-oestradiol, progesterone, testosterone and the 17β-oestradiol: progesterone ratio at six weeks postpartum.
Results There was a chance excess of caesarean section deliveries in the progestogen group. Mean depression scores were significantly higher in the progestogen group than in the placebo group at six weeks postpartum (mean MADRS score 8.3 vs 4.9; P = 0.01 11; mean EPDS score 10.6 vs 7.5; P = 0.0022). Mean serum 17β-oestradiol and progesterone concentrations were significantly lower in the progestogen group compared with the placebo group at six weeks postpartum. There were no correlations between any of the hormone parameters and depression at six weeks except in the formula feeding subgroup of the placebo group, where formula feeding and 17β-oestradiol concentrations were positively associated with depression.
Conclusions Long-acting norethisterone enanthate given within 48 hours of delivery is associated with an increased risk of developing postnatal depression and causes suppression of endogenous ovarian hormone secretion.     

Companionship to modify the clinical birth environment: effects on progress and perceptions of labour, and breastfeeding

OBJECTIVE--To measure the effects of supportive companionship on labour and various aspects of adaptation to parenthood, and thus by inference the adverse effects of a clinically orientated labour environment on these processes. DESIGN--Randomized controlled trial. SETTING--A community hospital familiar to most of the participants, with a conventional, clinically-orientated labour ward. SUBJECTS--Nulliparous women in uncomplicated labour. INTERVENTION--Supportive companionship from volunteers from the community with no medical nor nursing experience, concentrating on comfort, reassurance and praise. MAIN OUTCOME MEASURES--Duration of labour, use of analgesia, perceptions of labour and breastfeeding success. RESULTS--Companionship had no measurable effect on the progress of labour. Diastolic blood pressure and use of analgesia were modestly but significantly reduced. The support group were more likely to report that they felt that they had coped well during labour (60 vs 24%, P less than 0.00001). Their mean labour pain scores (26.0 vs 44.2, P less than 0.00001) and state anxiety scores (28.2 vs 37.8, P less than 0.00001) were lower than those of the control group. Compared with the control group (n = 75), at 6 weeks women in the support group (n = 74) were more likely to be breastfeeding exclusively (51 vs 29%, P less than 0.01); and to be feeding at flexible intervals (81 vs 47%, P less than 0.0001). CONCLUSIONS--Labour in a clinical environment may undermine women's feelings of competence, perceptions of labour, confidence in adapting to parenthood and initiation of successful breastfeeding. These effects may be reduced by the provision of additional companionship during labour aimed to promote self-esteem.     

Misoprostol dose-related shivering and pyrexia in the third stage of labour

Objective To select the misoprostol dose to be used in a large multicentre randomised trial comparing misoprostol with oxytocin in the routine management of the third stage of labour.
Design Randomised pilot trial, double-blinded with the use of double placebos.
Setting Two of the nine hospitals that will participate in the main multicentre trial. The hospitals were
Population Women during second stage of labour about to be delivered vaginally.
Methods located in Johannesburg, South Africa and Khon Kaen, Thailand. The trial had three arms: misoprostol 400 μg versus misoprostol 600 μg versus intramuscular oxytocin 10 IU. Each group received an injection and three tablets immediately after the birth of the baby.
Main outcome measures Shivering and pyrexia rates were the main outcome measures. Data on other side effects and characteristics of the third stage of labour were also collected. Side effects were noted as none, mild, moderate or severe.
Results Both shivering and pyrexia (temperature > 38°C) were most common in the 600 μg misoprostol group (28% and 7.5% for shivering and pyrexia, respectively) compared with 400 μg misoprostol (19% and 2%), and the oxytocin group (12.5% and 3%). The increase in shivering in the misoprostol 600 pg group was due primarily to a higher rate of moderate shivering. None of the women had a temperature > 40°C. There were no increases in severe side effects and other adverse events in the misoprostol 600 μg group.
Conclusions When used in the management of the third stage of labour oral misoprostol is associated with an increase in the rate of moderate shivering and pyrexia which seems to be dose-related. Based on the results of this pilot trial, the Steering Committee has decided to use 600 μg misoprostol in the main trial, comparing it with oxytocin, in order to achieve higher effectiveness.     

Effective Care in Pregnancy and Childbirth: A Synopsis

This article is the text and six tables from the final chapter (Chapter 50) of the new third edition of A Guide to Effective Care in Pregnancy and Childbirth. It summarizes the authors' conclusions and recommendations, based on the information they have compiled in the book about the beneficial or harmful effects of the various elements of care used during pregnancy and childbirth. The chapter numbers refer the reader to the relevant chapter of the book.     

Mycobacterium tuberculosis infection in patients with cancer, the role of 18-fluorodeoxyglucose positron emission tomography for diagnosis and monitoring treatment response

Active tuberculosis (TB) infection including asymptomatic and extrapulmonary disease may be detected with 18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT). This report highlights the promising role of FDG-PET/CT for evaluation of TB in high-risk, immunocompromised patients with cancer. PET/CT performed for cancer evaluation may detect asymptomatic infection and guide definitive diagnosis. It may also be a useful tool in the assessment of latent TB, to exclude active disease prior to treatment. PET/CT has potential for monitoring response to anti-tuberculosis treatment. Metabolic response may indicate clinical response and guide duration of anti-microbial therapy.