Eisenmenger's syndrome in pregnancy: Use of epidural anesthesia and analgesia for elective cesarean section

We describe a case of a pregnant patient with a large ventricular septal defect (VSD) and pulmonary artery hypertension, presented to the hospital and underwent elective cesarean section under epidural anesthesia and postoperative analgesia. The procedure was uneventful till the patient was discharged on 10^th day.

Neuraxial analgesia effects on labour progression: facts, fallacies, uncertainties and the future

Approximately 60% of women who labour in the USA receive some form of neuraxial analgesia, but concerns have been raised regarding whether it negatively impacts the labour and delivery process. In this review, we attempt to clarify what has been established as truths, falsities and uncertainties regarding the effects of this form of pain relief on labour progression, negative and/or positive. Additionally, although the term 'epidural' has become synonymous with neuraxial analgesia, we discuss two other techniques, combined spinal-epidural and continuous spinal analgesia, that are gaining popularity, as well as their effects on labour progression.

Introduction of Inhaled Nitrous Oxide and Oxygen for Pain Management during Labour - Evaluation of Patients' and Midwives' Satisfaction

Aim: Effective pain management during labour is important because pain affects the birth experience. Epidural analgesia is effective but often it may not be possible; however, inhaled analgesia offers another option. Use of inhaled nitrous oxide and oxygen for pain management in labour is well established in obstetrics but is still not used much in Germany. This study aimed to investigate the acceptance of the inhaled analgesia of inhaled nitrous oxide and oxygen by midwives and pregnant women during labour. Material and Methods: In this observational study carried out between April and September 2013, a total of 66 pregnant women received inhaled nitrous oxide and oxygen during labour on request and after prior assessment of suitability. After the birth, all of the women and the responsible midwives were interviewed about their experience and satisfaction with the inhaled analgesia. Results: A statistically significant reduction of pain was achieved with nitrous oxide and oxygen. The inhaled analgesia was mostly used by women who refused epidural analgesia. The likelihood of using inhaled nitrous oxide and oxygen again was reported as higher for patients who tolerated it well (p = 0.0129) and used it in the second stage of labour (p = 0.0003) and when bearing down (p = 0.0008). Conclusion: Inhaled nitrous oxide and oxygen is an effective method for pain management during labour and is accepted well by women in labour and by midwives.

Effect of the presence of support person and routine intervention for women during childbirth in Isfahan, Iran: A randomized controlled trial

Background:

The aim of this study was to examine the effects of the presence of continuous support person and routine interventions during labor and delivery in Isfahan, Iran.

Materials and Methods:

One hundred pregnant women in spontaneous labor were assessed in four groups: Group 1; received routine intervention with a support person, Group 2; received routine intervention without support person, Group 3; received support person without routine intervention, Group 4; did not receive routine intervention or a support person. Sociodemographic, antenatal characteristics, length of stage of labor, instrumental delivery, the cervical laceration, perineal tear, labor pain, satisfaction and Apgar score collected and analyzed.

Results:

Based on the results there was no significant difference in regard to maternal age, BMI, maternal education and working statutes among the studied groups (P-value >0.05). Also, 1 and 5-min Apgar <7, cervical lacerations and instrumental delivery among studied groups were similar (P-value >0.05). Length of first and second stage of labor, perineal tear, satisfaction score and pain before and after labor were significant among studied groups (P-value <0.05).

Conclusions:

Presence of a support person and routine intervention during labor did not effect on incidence of cervical lacerations, instrumental delivery and Apgar <7. Labor pain and women's dissatisfaction, and number women with third and fourth degree of perineal tear among women who received routine intervention were increased compare to others. Interventions makes decreased the length of first and second stage of labor. In totally, the presence of a support person during labor in Iranian women decrease length of labor and improved labor outcomes.

Outcomes of asymptomatic malaria parasitaemia in neonates in a tertiary hospital, southeast Nigeria

Background:

Malaria infestation during pregnancy is mostly asymptomatic and untreated especially in unbooked pregnancies. It presents with almost all the fetal complications of overt malaria in pregnancy. The aim of this study was to determine the effect of asymptomatic malaria parasitaemia on the neonates of unbooked parturients delivered at term at the Federal Teaching Hospital, Abakaliki.

Materials and Methods:

This study was conducted in the labour ward complex of the Federal Teaching Hospital, Abakaliki from March to May 2012. Unbooked pregnant women who fulfilled the inclusion criteria and gave consent were consecutively recruited. Cord blood and placenta tissue were collected for haemoglobin concentration determination and histology, respectively. Birth weights were determined with an electronic weighing machine. Statistical Analysis was done with 2008 Epi Info™ software and level of significant was set at P-value <0.05.

Results:

A total of 250 unbooked parturients were recruited, of which 194 (77.6%) had asymptomatic malaria parasitaemia while 227 (90.8%) had placental parasitisation. The prevalence of low birth weight in the study was 16.4%. There was significant relationship between asymptomatic malaria parasitemia and birth weight (X² = 43.70, P-value < 0.001). There were no low-birth-weight deliveries among paturients without placental parasitemia. No neonate, however, had anaemia in the study.

Conclusion:

Asymptomatic malaria parasitemia and placental parasitisation by malaria parasites contribute to the outcome of the foetal birth weight. Asymptomatic malaria parasitaemia and placental parasitaemia did not result in a corresponding foetal anaemia on babies delivered.

Rates and Indicators for Episiotomy in Modern Obstetrics - a study from Saudi Arabia

BACKGROUND

This observational study aimed to describe the rates and indicators for practice of episiotomy during normal labour and to compare them between women who have had one pregnancy (PG) and women who have already delivered two or more children (G2 and above).

METHODS

The study was conducted at Mother and Child Hospital, Buraidah from October- December 2013 as a descriptive cross sectional study.

RESULTS

Overall rate of Episiotomy was 51.20%. Amongst the Primigravidas all went through episiotomies however in G2 and above only 7 patients (4.69%) delivered with episiotomy. Proportions tests revealed that there were significant differences between gravidity groups on two indications of episiotomy (vaginal breech p <0.001 and previous history of perineal tear p < 0.001). G2 and above had episiotomy for breech delivery (1 of 7 = 14.29%) significantly more often than PG participants (0 of 142 = 0.0%). And G2 and above participants experienced episiotomy for previous perineal tear (2 of 7 = 28.5% as compared to none in PG No other significant differences were found on indications of episiotomy.

CONCLUSION

Episiotomy is a very common obstetric intervention (51.20%). The PG experience episiotomy significantly more often than G2 and above women. Efforts should be made to reduce its rates. This can be done by reviewing the indications and rates at repeated intervals and setting guidelines for these indications.

Oxytocin: its mechanism of action and receptor signalling in the myometrium

Oxytocin is a nonapeptide hormone that has a central role in the regulation of parturition and lactation. In this review, we address oxytocin receptor (OTR) signalling and its role in the myometrium during pregnancy and in labour. The OTR belongs to the rhodopsin-type (Class 1) of the G-protein coupled receptor superfamily and is regulated by changes in receptor expression, receptor desensitisation and local changes in oxytocin concentration. Receptor activation triggers a number of signalling events to stimulate contraction, primarily by elevating intracellular calcium (Ca(2+) ). This includes inositol-tris-phosphate-mediated store calcium release, store-operated Ca(2+) entry and voltage-operated Ca(2+) entry. We discuss each mechanism in turn and also discuss Ca(2+) -independent mechanisms such as Ca(2+) sensitisation. Because oxytocin induces contraction in the myometrium, both the activation and the inhibition of its receptor have long been targets in the management of dysfunctional and preterm labours, respectively. We discuss current and novel OTR agonists and antagonists and their use and potential benefit in obstetric practice. In this regard, we highlight three clinical scenarios: dysfunctional labour, postpartum haemorrhage and preterm birth.

Perspectives of expectant women and health care providers on birth plans

OBJECTIVE

A birth plan is a document detailing a woman's preferences and expectations related to labour and delivery. Empirical research exploring the value of birth plans has shown conflicting findings about whether birth plans have a positive or negative effect on labour and delivery, suggesting a need for further study. This study aimed to understand the perspectives of women, health care providers, and support persons regarding the use of birth plans.

METHODS

A cross-sectional questionnaire was distributed to a convenience sample of expectant or postpartum women, health care providers, and support persons from January 2012 to March 2012 in British Columbia.

RESULTS

In total, 122 women and 110 health care providers and support persons completed the questionnaire. Both women and their attendants viewed the birth plan as being valuable for acting as both a communication and education tool. However, the respondents noted that women may be disappointed or dissatisfied if a birth plan cannot be implemented. The most important elements of a birth plan identified included pain management, comfort measures (e.g., mobility during labour), postpartum preferences (e.g., breastfeeding), atmosphere (e.g., privacy), and birthing beliefs (e.g., cultural views).

CONCLUSION

This is the first study to identify advantages and disadvantages of using a birth plan as well as the most important aspects of a birth plan from the perspectives of both women and their attendants in Canada. The findings could be applied to optimize the efficacy of birth plans in Canada and potentially internationally as well.

Rate of spontaneous onset of labour before planned repeat caesarean section at term

BACKGROUND

Guidelines recommend that, in the absence of compelling medical indications (low risk) elective caesarean section should occur after 38 completed weeks gestation. However, implementation of these guidelines will mean some women go into labour before the planned date resulting in an intrapartum caesarean section. The aim of this study was to determine the rate at which low-risk women planned for repeat caesarean section go into spontaneous labour before 39 weeks.

METHODS

We conducted a population-based cohort study of women who were planned to have an elective repeat caesarean section (ERCS) at 39-41 weeks gestation in New South Wales Australia, 2007-2010. Labour, delivery and health outcome information was obtained from linked birth and hospital records for the entire population. Women with no pre-existing medical or pregnancy complications were categorized as 'low risk'. The rate of spontaneous labour before 39 weeks was determined and variation in the rate for subgroups of women was examined using univariate and multivariate analysis.

RESULTS

Of 32,934 women who had ERCS as the reported indication for caesarean section, 17,314 (52.6%) were categorised as 'low-risk'. Of these women, 1,473 (8.5% or 1 in 12) had spontaneous labour or prelabour rupture of the membranes before 39 weeks resulting in an intrapartum caesarean section. However the risk of labour <39 weeks varied depending on previous delivery history: 25% (1 in 4) for those with spontaneous preterm labour in a prior pregnancy; 15% (1 in 7) for women with a prior planned preterm birth (by labour induction or prelabour caesarean) and 6% (1 in 17) among those who had only previously had a planned caesarean section at term. Smoking in pregnancy was also associated with spontaneous labour. Women with spontaneous labour prior to a planned CS in the index pregnancy were at increased risk of out-of-hours delivery, and maternal and neonatal morbidity.

CONCLUSIONS

These findings allow clinicians to more accurately determine the likelihood that a planned caesarean section may become an intrapartum caesarean section, and to advise their patients accordingly.

Androgens in pregnancy: roles in parturition

BACKGROUND

Understanding the physiology of pregnancy enables effective management of pregnancy complications that could otherwise be life threatening for both mother and fetus. A functional uterus (i) retains the fetus in utero during pregnancy without initiating stretch-induced contractions and (ii) is able to dilate the cervix and contract the myometrium at term to deliver the fetus. The onset of labour is associated with successful cervical remodelling and contraction of myometrium, arising from concomitant activation of uterine immune and endocrine systems. A large body of evidence suggests that actions of local steroid hormones may drive changes occurring in the uterine microenvironment at term. Although there have been a number of studies considering the potential role(s) played by progesterone and estrogen at the time of parturition, the bio-availability and effects of androgens during pregnancy have received less scrutiny. The aim of this review is to highlight potential roles of androgens in the biology of pregnancy and parturition.

METHODS

A review of published literature was performed to address (i) androgen concentrations, including biosynthesis and clearance, in maternal and fetal compartments throughout gestation, (ii) associations of androgen concentrations with adverse pregnancy outcomes, (iii) the role of androgens in the physiology of cervical remodelling and finally (iv) the role of androgens in the physiology of myometrial function including any impact on contractility.

RESULTS

Some, but not all, androgens increase throughout gestation in maternal circulation. The effects of this increase are not fully understood; however, evidence suggests that increased androgens might regulate key processes during pregnancy and parturition. For example, androgens are believed to be critical for cervical remodelling at term, in particular cervical ripening, via regulation of cervical collagen fibril organization. Additionally, a number of studies highlight potential roles for androgens in myometrial relaxation via non-genomic, AR-independent pathways critical for the pregnancy reaching term. Understanding of the molecular events leading to myometrial relaxation is an important step towards development of novel targeted tocolytic drugs.

CONCLUSIONS

The increase in androgen levels throughout gestation is likely to be important for establishment and maintenance of pregnancy and initiation of parturition. Further investigation of the underlying mechanisms of androgen action on cervical remodelling and myometrial contractility is needed. The insights gained may facilitate the development of new therapeutic approaches to manage pregnancy complications such as preterm birth.

Values beyond value? Is anything beyond the logic of capital?

We are living in a time when it is frequently assumed that the logic of capital has subsumed every single aspect of our lives, intervening in the organization of our intimate relations as well as the control of our time, including investments in the future (e.g. via debt). The theories that document the incursion of this logic (often through the terms of neoliberalism and/or governmentality) assume that this logic is internalized, works and organizes everything including our subjectivity. These theories performatively reproduce the very conditions they describe, shrinking the domain of values and making it subject to capital's logic. All values are reduced to value. Yet values and value are always dialogic, dependent and co-constituting. In this paper I chart the history by which value eclipses values and how this shrinks our sociological imagination. By outlining the historical processes that institutionalized different organizations of the population through political economy and the social contract, producing ideas of proper personhood premised on propriety, I detail how forms of raced, gendered and classed personhood was formed. The gaps between the proper and improper generate significant contradictions that offer both opportunities to and limits on capitals' lines of flight. It is the lacks, the residues, and the excess that cannot be captured by capital's mechanisms of valuation that will be explored in order to think beyond the logic of capital and show how values will always haunt value.

Induction of labour

OBJECTIVE

To review the most current literature in order to provide evidence-based recommendations to obstetrical care providers on induction of labour.

OPTIONS

Intervention in a pregnancy with induction of labour.

OUTCOMES

Appropriate timing and method of induction, appropriate mode of delivery, and optimal maternal and perinatal outcomes.

EVIDENCE

Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library in 2010 using appropriate controlled vocabulary (e.g., labour, induced, labour induction, cervical ripening) and key words (e.g., induce, induction, augmentation). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to the end of 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The evidence in this document was rated using criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1). SUMMARY STATEMENTS: 1. Prostaglandins E(2) (cervical and vaginal) are effective agents of cervical ripening and induction of labour for an unfavourable cervix. (I) 2. Intravaginal prostaglandins E(2) are preferred to intracervical prostaglandins E(2) because they results in more timely vaginal deliveries. (I).

To compare the effect of camylofin dihydrochloride (anafortin) with combination of valethamate bromide (epidosin) and hyoscine butyl-N-bormide (buscopan) on cervical dilation

BACKGROUND

Various drugs have been tried to hasten cervical dilatation so that problems and hazards of prolonged labour both for the mother and fetus are minimised without increasing maternal or perinatal mortality and morbidity.

AIMS AND OBJECTIVES

To compare the effect of camylofin dihydrochloride with combination of valethemate bromide (epidosin) & hyoscine N butyl bromide (buscopan) on cervical dilatation, evaluate the incidence of side effects and to look for neonatal outcome.

MATERIAL AND METHODS

Two hundred cases were included of primigravidae or multigravidae with gestational age of 37 to 40 weeks with full term with single foetus,vertex presentation and no major antenatal complication of women in labour, admitted to labour room of gynaecology Department, Government Medical College, Patiala, India, was studied and divided into 2 groups Group A-100 Cases - labour accelerated by camylofin dihydro chloride and Group B-100 Cases-labour accelerated by valethemate bromide (epidosin) and hyoscine N butyl bromide.

OBSERVATIONS

The mean age, parity and period of gestation in Anafortan group was 24.13 ± 3.60 years, 49% primigravidae and 51% multigravidae and 38.81 ± 1.09 weeks, while that in Epidosin + Buscopan group was 24.43 ± 3.42 years, 45% primigravidae and 51% multigravidae and 38.94 ± 1.09 weeks respectively. The difference was insignificant and both the groups were comparable.

RESULTS

Mean duration of Active phase of 1st stage of labor was 141.40 ± 55.41 minutes in Anafortan group and 181.46 ± 75.58 minutes in Epidosin + Buscopan group. Mean rate of cervical dilatation according to active phase of first stage was 3.33 ± 1.03 cm/hours in Anafortan group and 2.69 ± 1.03 cm/hr in Epidosin + Buscopan group. The difference between the two groups is highly significant (p < 0.01) thus it is concluded that Anafortan hastened the rate of cervical dilatation.

Placental blood transfusion in newborn babies reaches a plateau after 140 s: Further analysis of longitudinal survey of weight change

Objective:

With the introduction of active management of the third stage of labour in the 1960s, it became usual practice to clamp and cut the umbilical cord immediately following birth. The timing of this cord clamping is controversial, as blood may beneficially be transferred to the baby if clamping of the cord is delayed slightly. There is no agreement, however, on how long the delay should be before clamping the cord. This study aimed to establish when blood ceased to flow in the umbilical cord to determine how long to delay clamping of the umbilical cord following delivery of the term newborn to maximise placental transfusion.

Methods:

This observational study collected longitudinal weight measurements set in a hospital labour ward. A total of 26 mothers at term and their singleton babies participated in the study. In this reanalysis, the velocity of weight change over the first minutes of life determined by functional data analysis was estimated.

Results:

We found that the flow velocity in the umbilical cord was on average 0 at 125 s after placing the baby on the scales, which was typically 140 s after birth.

Conclusions:

To maximise placental transfusion, cord clamping should be delayed for at least 140 s following birth of the baby.

Measuring the quality and quantity of professional intrapartum support: testing a computerised systematic observation tool in the clinical setting

BACKGROUND

Continuous support in labour has a significant impact on a range of clinical outcomes, though whether the quality and quantity of support behaviours affects the strength of this impact has not yet been established. To identify the quality and quantity of support, a reliable means of measurement is needed. To this end, a new computerised systematic observation tool, the 'SMILI' (Supportive Midwifery in Labour Instrument) was developed.The aim of the study was to test the validity and usability of the 'Supportive Midwifery in Labour Instrument' (SMILI) and to test the feasibility and acceptability of the systematic observation approach in the clinical intrapartum setting.

METHODS

Systematic observation was combined with a postnatal questionnaire and the collection of data about clinical processes and outcomes for each observed labour.The setting for the study was four National Health Service maternity units in Scotland, UK. Participants in this study were forty five midwives and forty four women.The SMILI was used by trained midwife observers to record labour care provided by midwives. Observations were undertaken for an average of two hours and seventeen minutes during the active first stage of labour and, in 18 cases, the observation included the second stage of labour. Content validity of the instrument was tested by the observers, noting the extent to which the SMILI facilitated the recording of all key aspects of labour care and interactions. Construct validity was tested through exploration of correlations between the data recorded and women's feelings about the support they received. Feasibility and usability data were recorded following each observation by the observer. Internal reliability and construct validity were tested through statistical analysis of the data.

RESULTS

One hundred and four hours of labour care were observed and recorded using the SMILI during forty nine labour episodes.

CONCLUSION

The SMILI was found to be a valid and reliable instrument in the intrapartum setting in which it was tested. The study identified that the SMILI could be used to test correlations between the quantity and quality of support and outcomes. The systematic observational approach was found to be an acceptable and feasible method of enquiry.

Hypnosis antenatal training for childbirth: a randomised controlled trial

OBJECTIVE

To determine the use of pharmacologic analgesia during childbirth when antenatal hypnosis is added to standard care.

DESIGN

Randomised controlled clinical trial, conducted from December 2005 to December 2010.

SETTING

The largest tertiary referral centre for maternity care in South Australia.

POPULATION

A cohort of 448 women at >34 weeks of gestation, with a singleton pregnancy and cephalic presentation, planning a vaginal birth. Exclusions were: the need for an interpreter; pre-existing pain; psychiatric illness; younger than 18 years; and previous experience of hypnosis for childbirth.

METHODS

All participants received usual care. The group of women termed Hypnosis + CD (hypnotherapist guided) were offered three antenatal live hypnosis sessions plus each session's corresponding audio CD for further practise, as well as a final fourth CD to listen to during labour. The group of women termed CD only (nurse administered) were played the same antenatal hypnosis CDs as group 1, but did not receive live hypnosis training. The control group participants were given no additional intervention or CDs.

MAIN OUTCOME MEASURE

Use of pharmacological analgesia during labour and childbirth.

RESULTS

No difference in the use of pharmacological analgesia during labour and childbirth was found comparing hypnosis + CD with control (81.2 versus 76.2%; relative risk, RR 1.07; 95% confidence interval, 95% CI 0.95-1.20), or comparing CD only with control (76.9 versus 76.2%, RR 1.01, 95% CI 0.89-1.15).

CONCLUSIONS

Antenatal group hypnosis using the Hypnosis Antenatal Training for Childbirth (HATCh) intervention in late pregnancy does not reduce the use of pharmacological analgesia during labour and childbirth.

Epidural abscess after multiple lumbar punctures for labour epidural catheter placement

Epidural catheterization is routinely used by anaesthesiologists to provide labour and post-operative analgesia. In most cases, catheter placement is without serious side effects and uneventful. However, epidural abscess is a rare complication that may result in severe morbidity. We present a case of epidural abscess after labour epidural catheter placement in a healthy 36-year-old female who presented on post-partum d 10 with complaints of fever and back pain. She was treated with intravenous antibiotics and fully recovered.

Endocrinology of parturition

The myometrium must remain relatively quiescent during pregnancy to accommodate growth and development of the feto-placental unit, and then must transform into a highly coordinated, strongly contracting organ at the time of labour for successful expulsion of the new born. The control of timing of labour is complex involving interactions between mother, fetus and the placenta. The timely onset of labour and delivery is an important determinant of perinatal outcome. Both preterm birth (delivery before 37 week of gestation) and post term pregnancy (pregnancy continuing beyond 42 weeks) are both associated with a significant increase in perinatal morbidity and mortality. There are multiple paracrine/autocrine events, fetal hormonal changes and overlapping maternal/fetal control mechanisms for the triggering of parturition in women. Our current article reviews the mechanisms for uterine distension and reduced contractions during pregnancy and the parturition cascade responsible for the timely and spontaneous onset of labour at term. It also discusses the mechanisms of preterm labour and post term pregnancy and the clinical implications thereof.

A multicentre randomized controlled trial

BACKGROUND

Pain relief during labour is a topic of major interest in the Netherlands. Epidural analgesia is considered to be the most effective method of pain relief and recommended as first choice. However its uptake by pregnant women is limited compared to other western countries, partly as a result of non-availability due to logistic problems. Remifentanil, a synthetic opioid, is very suitable for patient controlled analgesia. Recent studies show that epidural analgesia is superior to remifentanil patient controlled analgesia in terms of pain intensity score; however there was no difference in satisfaction with pain relief between both treatments.

METHODS/DESIGN

The proposed study is a multicentre randomized controlled study that assesses the cost-effectiveness of remifentanil patient controlled analgesia compared to epidural analgesia. We hypothesize that remifentanil patient controlled analgesia is as effective in improving pain appreciation scores as epidural analgesia, with lower costs and easier achievement of 24 hours availability of pain relief for women in labour and efficient pain relief for those with a contraindication for epidural analgesia.Eligible women will be informed about the study and randomized before active labour has started. Women will be randomly allocated to a strategy based on epidural analgesia or on remifentanil patient controlled analgesia when they request pain relief during labour. Primary outcome is the pain appreciation score, i.e. satisfaction with pain relief.Secondary outcome parameters are costs, patient satisfaction, pain scores (pain-intensity), mode of delivery and maternal and neonatal side effects.The economic analysis will be performed from a short-term healthcare perspective. For both strategies the cost of perinatal care for mother and child, starting at the onset of labour and ending ten days after delivery, will be registered and compared.

DISCUSSION

This study, considering cost effectiveness of remifentanil as first choice analgesia versus epidural analgesia, could strongly improve the care for 180.000 women, giving birth in the Netherlands yearly by giving them access to pain relief during labour, 24 hours a day.

TRIAL REGISTRATION NUMBER

Dutch Trial Register NTR2551, http://www.trialregister.nl.

Acceptability of counselling and testing for HIV infection in women in labour at the University College Hospital, Ibadan, Nigeria

BACKGROUND

Many patients are referred to labour ward as emergencies, and therefore do not benefit from the antenatal HIV counselling and testing and treatment offered to registered patients.

OBJECTIVE

To assess the acceptability and suitability of offering HIV counselling and testing to women of unknown HIV status presenting in labour.

METHODS

A cross-sectional study comprising counselling and obtaining consent for HIV testing among 104 unregistered patients who presented in labour over a 3-month period. Rapid and enzyme-linked immunosorbent assay screening was performed for 90 consenting respondents. Reactive results were confirmed by Western blot. Appropriate therapy was instituted.

RESULTS

Acceptance rate for HIV testing was 86.5%, prevalence of HIV was 6.7%. Women of lower educational status were more likely to accept testing in labour (OR: 0.3; 95% CI: 0.1-0.7; p=0.01); age, parity, occupation and knowledge of HIV had no influence. Most women (66.3%) had satisfactory knowledge of HIV. No one admitted to feeling coerced to test in fear of being denied care. Most refusals for screening were to avoid needle pricks (28.6%). Compared to ELISA screening test, specificity of the rapid test was 100%, sensitivity 85.7%, positive predictive value 100% and negative predictive value 98.8%. Attitude to testing was maintained on post-partum re-evaluation.

CONCLUSION

The prevalence of HIV amongst unregistered parturients showed the importance of offering point-of-care HIV testing and intervention, especially in an environment where antenatal clinic attendance is poor. Rapid testing appeared to be acceptable and feasible in labour to prevent the mother-to-child transmission of HIV.

Uterotonic plants and their bioactive constituents

Abnormalities in the process of uterine muscle contractility during pregnancy and birth can have major clinical implications, including preterm labour, which is the single largest cause of maternal and prenatal mortality in the Western world and a major contributor to childhood developmental problems. In contrast, induction of labour may be necessary in certain conditions. Currently used interventional therapies to suppress (tocolytic agents) or to induce (uterotonic agents) uterine contractions lack potency and/or selectivity and can have harmful side effects for mother and baby. Nature's diversity has always been, and still is, one of the biggest resources of therapeutic lead compounds. Many natural products exhibit biological activity against unrelated targets, thus providing researchers with starting points for drug development. In this review we will provide an overview of uterine muscle physiology, describe currently available biological screening procedures for testing of uterotonic plant compounds and will summarise traditionally-used uterotonic plants, their active components and their mechanisms, primarily focusing on uterotonic active circular plant peptides called cyclotides. Finally we will comment on the discovery of novel cyclotide-producing plant species and the possibility for the development of novel plant-derived uterotonic and tocolytic drugs.

How often is a low Apgar score the result of substandard care during labour?

Please cite this paper as: Berglund S, Pettersson H, Cnattingius S, Grunewald C. How often is a low Apgar score the result of substandard care during labour? BJOG 2010;117:968-978. Objective To increase our knowledge of the occurrence of substandard care during labour. Design A population-based case-control study. Setting Stockholm County. Population Infants born in the period 2004-2006 in Stockholm County. Methods Cases and controls were identified from the Swedish Medical Birth Register, had a gestational age of >/=33 complete weeks, had planned for a vaginal delivery, and had a normal cardiotocographic (CTG) recording on admission. We compared 313 infants with an Apgar score of <7 at 5 minutes of age with 313 randomly selected controls with a full Apgar score, matched for year of birth. Main outcome measure Substandard care during labour. Results We found that 62% of cases and 36% of controls were subject to some form of substandard care during labour. In half of the cases and in 12% of the controls, CTG was abnormal for >/=45 minutes before birth. Fetal blood sampling was not performed in 79% of both cases and controls, when indicated. Oxytocin was provided without signs of uterine inertia in 20% of both cases and controls. Uterine contractions were hyperstimulated by oxytocin in 29% of cases and in 9% of controls, and the dose of oxytocin was increased despite abnormal CTG in 19% and 6% of cases and controls, respectively. Assuming that substandard care is a risk factor for low Apgar score, we estimate that up to 42% of the cases could be prevented by avoiding substandard care. Conclusions There was substandard care during labour of two-thirds of infants with a low Apgar score. The main reasons for substandard care were related to misinterpretation of CTG, not acting on an abnormal CTG in a timely fashion and incautious use of oxytocin.

Postpartum period: three distinct but continuous phases

Postpartum period is distinct in three phases. The third phase is the delayed postpartum period, which can last up to 6 months. Some changes to the genitourinary system are much longer in resolving, and some may never fully revert to the prepregnant state. A burgeoning volume of literature on pelvic floor support implicates childbirth as the initiation of a whole host of conditions including stress urinary incontinence, incontinence of flatus or feces, uterine prolapse, cystocele, and rectocele. The duration and severity of these conditions affect many variables, including the patient's intrinsic collagen support, the size of the infant, the route of delivery, and the degree of perineal trauma occurring either naturally (lacerations) or iatrogenically (episiotomy).

Comparison of domiciliary and institutional delivery-care practices in rural Rajasthan, India

A retrospective cross-sectional survey was conducted to assess key practices and costs relating to home- and institutional delivery care in rural Rajasthan, India. One block from each of two sample districts was covered (estimated population--279,132). Field investigators listed women who had delivered in the past three months and contacted them for structured case interview. In total, 1947 (96%) of 2031 listed women were successfully interviewed. An average of 2.4 and 1.7 care providers attended each home- and institutional delivery respectively. While 34% of the women delivered in health facilities, modem care providers attended half of all the deliveries. Intramuscular injections, intravenous drips, and abdominal fundal pressure were widely used for hastening delivery in both homes and facilities while post-delivery injections for active management of the third stage were administered to a minority of women in both the venues. Most women were discharged prematurely after institutional delivery, especially by smaller health facilities. The cost of accessing home-delivery care was Rs 379 (US$ 8) while the mean costs in facilities for elective, difficult vaginal deliveries and for caesarean sections were Rs 1336 (US$ 30), Rs 2419 (US$ 54), and Rs 11,146 (US$ 248) respectively. Most families took loans at high interest rates to meet these costs. It is concluded that widespread irrational practices by a range of care providers in both homes and facilities can adversely affect women and newborns while inadequate observance of beneficial practices and high costs are likely to reduce the benefits of institutional delivery, especially for the poor. Government health agencies need to strengthen regulation of delivery care and, especially, monitor perinatal outcomes. Family preference for hastening delivery and early discharge also require educational efforts.

Expression of scaffolding, signalling and contractile-filament proteins in human myometria: effects of pregnancy and labour

Successful parturition requires the co-ordination of numerous myometrial signalling events to allow for timely and efficient uterine contractions. Late pregnancy and labour onset in humans may be associated with changes in the expression of myometrial proteins implicated in such uterine contractile signal integration. Accordingly, in myometria from non-pregnant women and pregnant women, not in labour or in labour, we examined the content of putative plasmalemmal scaffolding proteins (caveolin-1 and -2) and compared these to the proportions of signal transducing rho-associated kinases (ROKalpha and beta) and contractile filament-associated proteins alpha-actin, myosin regulatory light chain (MLC(20)) and h-caldesmon. There was no effect of pregnancy or labour on the proportion of caveolin, ROK betaor alpha-actin. However, pregnancy was associated with a decrease in ROKalpha and MLC(20) such that ROK alpha: alpha-actin and MLC(20): alpha-actin ratios were reduced compared to myometria of non-pregnant women. In contrast, h-caldesmon was up-regulated in pregnancy resulting in an elevated h-caldesmon: alpha-actin ratio. There were, however, no further significant changes in ROK alpha, MLC(20) or h-caldesmon expression with spontaneous or oxytocin-induced labour. These data suggest that the mechanism(s) integrating myometrial signalling events with the onset of human labour does not involve differential alterations of the cellular expressions of caveolins, ROK, alpha-actin, MLC(20) or h-caldesmon.

Spontaneous labour at term is associated with fetal monocyte activation

The aetiology of both term and preterm labour remains incompletely understood. Maternal infectious diseases as well as intra-uterine infections were shown to be a well established cause of uncontrollable preterm delivery, indicating that inflammatory reactions, regulated by maternal immunecompetent cells, are implicated in labour-promoting mechanisms. To investigate the possibility that the activation of the fetal immune system may be involved in labour induction, we examined cytokine production patterns of different cord blood cell populations obtained from neonates after spontaneous onset of normal term labour and vaginal delivery (n = 25), vaginal delivery but induced term labour (n = 17), and preterm delivery because of uncontrollable labour (n = 27, 20 patients received corticoid treatment for fetal lung maturation), in comparison with cells obtained from neonates after elective term caesarean delivery in the absence of labour (n = 15). Our results demonstrate that spontaneous term labour, but not induced term labour, was associated with significantly increased IL-6 production by myelomonocytic cell populations. Preterm delivery due to uncontrollable labour with resistance to tocolysis was not associated with increased IL-6 production by fetal myelomonocytic cells. Two-colour flow cytometry combined with intracellular cytokine staining was used to identify fetal monocytes as sources of labour-associated IL-6 release at term. We did not find any activation of cord blood T cells in association with spontaneous term or uncontrollable preterm labour. Therefore, fetal T cell responses may not cause monocyte activation. Our results suggest that increased release of IL-6 from fetal monocytes is involved in mechanisms promoting normal term, but not preterm labour, and that mechanisms inducing term and preterm labour are completely different.

Calcium antagonistic properties of the cyclooxygenase-2 inhibitor nimesulide in human myometrial myocytes

The non-steroidal anti-inflammatory drug nimesulide is a selective inhibitor of cyclooxygenase-2 which relaxes spontaneously contracting human myometrium in vivo and is potentially a useful tocolytic drug. Part of the relaxant action of nimesulide may be via block of myometrial Ca2+ channels. Here, we describe the Ca2+ channel blocking properties of nimesulide in freshly dispersed human term-pregnant myometrial smooth muscle cells (HMSMCs). Both L- and T-components of the whole cell Ca2+ channel current were inhibited by 100 microM nimesulide (38+/-3 and 35+/-1% block, respectively). At physiological pH inside and outside the cell (pHo/pHi = 7.4/7.2), this block did not depend on the holding or test potential, although a degree of use-dependence was observed during high frequency stimulation at a higher concentration of drug (300 microM). At pHo/pHi = 6.8, under which condition the concentration of the non-ionized form of the drug is increased 3 fold compared to pH 7.4, nimesulide blocked the L-type current more potently (58+/-3% inhibition at 100 microM, P<0.01) compared to physiological pH. Nimesulide caused a 7 mV leftward shift in the availability curve of the current at pH 6.8, suggesting that the affinity of the drug for the inactivated channel is approximately 4 fold higher than its affinity for the closed channel. We speculate that acidification and depolarization of the myometrium during the intense and prolonged contractions of labour might increase the potency of nimesulide as a Ca2+ channel antagonist, promoting its action as a tocolytic agent.

Episiotomy and the second stage of labour

The use of episiotomy emerged with the advent of "modern obstetrics". Few of the benefits attributed to it have been sustained by scientific study. The author of this article explores the interrelationship between episiotomy and other interventions in the second stage of labour and makes a plea for a reassessment of our management of this stage of labour. In particular, he questions the place of episiotomy in the prevention of pelvic floor relaxation.

Birth observed: a photographic essay

The author presents 17 photographs taken during labour and delivery in a large urban teaching hospital. The text describes a family doctor's experience of normal birth. Shown are birth with the parturient in a squatting position, on hands and knees, and in the lithotomy position, using the squatting bar for high foot support.

Intrapartum obstetrical consultation in a rural hospital

This study reviews the reasons why family physicians consult an obstetrician during their patient's labour and delivery in a small rural hospital.