Library

Notes: Objective Guidelines in some European countries and the United States suggest that pregnant women should avoid prolonged standing and heavy lifting in the workplace during the second and third trimester of pregnancy. However, results from epidemiological studies on this topic are ambiguous. The aim of this study was to evaluate the influence of standing and walking at work in the second trimester on preterm delivery in a population with a low frequency of other workplace hazards.Subjects and design A prospective cohort of 8711 women with singleton pregnancies was established during 1989 through 1991. Information was collected during the 16th week of pregnancy about medical and obstetrical history, general lifestyle factors and exposures at work. The analyses were restricted to 4259 respondents who worked at the 16th week. Potential confounders and effect modifiers were evaluated by stratification and multivariate analyses.Results After adjustment for confounders, women standing more than five hours per work day had an odds ratio (OR) for preterm delivery of 1.2 (95% CI 0.6 to 2.4) compared with women standing two hours or less. For walking, the OR was 1.4 (95% CI 0.7 to 2.5). Many women were unable to separate periods of standing from periods of walking; a combined measure of these two exposures was created to reflect exposure intensity. Women who reported more than five hours of both standing and walking had an adjusted OR of 3.3 (95% CI 1.4 to 8.0) compared with women who reported two hours or less on either of the exposures. No adverse effects were seen for lifting or other types of physical exertion.Conclusions Our findings suggest that standing and walking at work during the second trimester may present a particular risk for preterm delivery, and workplace guidelines are justified. Further research is needed to address the specific mechanisms by which physical exertion, including standing and walking, might cause preterm delivery.

Notes: Objective To describe the relation of employment status during pregnancy to potential demographic, behavioural and obstetrical risk factors for adverse late pregnancy outcome, as well as the risks of having a preterm delivery and a small for gestational age infant.Design Cohort study.Setting A university hospital.Subject Of 8711 women with singleton pregnancies (1989–91), 5875 returned questionnaires about risk factors and employment status at 16 and 30 weeks gestation. Of the respondents 5552 were analysed in five groups: (1) women working throughout pregnancy, (2) women working in the first, but unemployed during the second trimester, (3) women on sick leave in the first and second trimester, (4) women unemployed throughout pregnancy, and (5) students. The association between employment status and having a small for gestational age infant and preterm delivery was evaluated, accounting for other risk factors.Results Working women and students had the most and unemployed women the least favourable demographic risk factors. Women on sick leave had the least favourable obstetrical and medical history, followed by unemployed women. No clear pattern of the behavioural risk factors was found. Differences in risk of having a small for gestational age infant were a function of parity, smoking and maternal height. Adjustment for these factors plus education yielded a lower risk of preterm delivery in partially unemployed women and higher risk among women on sick leave compared to working women, accounted for by different risks of bleeding in the second and third trimester.Conclusions Comparison of pregnancy outcome among women with different work status should consider the differences in risk factor profile. Adjusting for such risk factors, we found no evidence that work per se had any detrimental or beneficial effects on the risk of having a small for gestational age infant or preterm delivery.

Notes: The objectives of the study were to identify factors associated with utilisation of antenatal care facilities in a rural population in South India. A community-based, cross-sectional questionnaire study of 30 randomly selected areas was used. A total of 1254 women (95%) had at least one antenatal care visit. The median number of visits was four. High utilisation of antenatal care facilities was associated with low parity and adverse obstetrical history, short distance to healthcare facilities and literacy. It was concluded that antenatal care coverage was high. Information about the above few aspects can be used to target women who are at risk of getting inadequate antenatal care.

Notes: Objective To evaluate the influence of mediolateral episiotomy on the perineal state after spontaneous, singleton vaginal deliveries with fetus in the occiput anterior position.Design The study was a population based, observational study. Two approaches were used in the analyses. Initially, we considered the parturients as quasi-randomised to one of three equally sized groups of midwives with different attitudes towards episiotomy. Secondly, we studied the effect of episiotomy on the state of the anal sphincter, controlling for birthweight, parity, and duration of second stage of labour.Subjects 2188 pregnant women delivering consecutively.Main outcome measures Perineal lacerations and tear of the anal sphincter.Results Women allocated to the group of midwives with the lowest rate of episiotomy were more likely to have intact perineum after delivery (OR = l.8 (l.4–2.2)), had a slight tendency towards more perineal lacerations (OR = 1.3 (1.0–1.5)), but no increase risk of having tear of the anal sphincter, compared with the women allocated to the two groups of midwives with higher frequencies of episiotomy. The second approach showed that episiotomy was related to an increased risk of tear of the anal sphincter (OR = 2.3 (1.2–4.6)). However, this relation was not found among the group of parturients delivered by the midwives with the lowest rate of episiotomy (22%).Conclusions Our results encourage a conservative approach to the use of mediolateral episiotomy, and in the light of previous findings, it seems reasonable to suggest that episiotomy should ideally be used in about one in five spontaneous vaginal deliveries.

Notes: Summary. The course of pregnancy and labour, neonatal outcome and social circumstances, were compared between 87 women with placental abruption and a control group of 5697 women. First and second trimester haemorrhage, amniocentesis, congenital malformations, maternal smoking and a job involving much standing or walking were associated with placental abruption.

Notes: Objective To study the association between attendance to antenatal care and postpartum health behaviour among women in rural Tamil Nadu, South India.Design Community based, cross-sectional questionnaire study of 30 randomly selected areas served by health subcentres.Setting Rural parts of Salem District, Tamil Nadu, South India.Population 1321 women who were delivered in the six months before the questionnaire-based interview.Main outcome measures Feeding of colostrum, time of initiation of breastfeeding and maternal dietary habits during the first month postpartum.Results The median number of antenatal visits was four (range 0-51; lower quartile 3, upper quartile 7)., The fifth month of pregnancy was the median time for the initiation of antenatal care. Pregnant women 1. who had a large number of antenatal care visits, 2. who initiated antenatal care in the first trimester or 3. who reported having received information about breastfeeding were more likely to feed colostrum (odds ratio 1.48; 95% CI 1.06 to 2.07), (odds ratio 1.40; 95% CI 1.06 to 1.85), (odds ratio 1.66; 95% CI 1.29 to 2.14, respectively). Only women who reported having received information about breastfeeding were more likely to initiate early breastfeeding (odds ratio 1.81; 95% CI 1.34 to 2.43). Use of antenatal care facilities was not associated with maternal postpartum dietary habits.Conclusions A large number of women attended antenatal care in the study area, but antenatal care had a limited effect on postpartum health behaviour. As antenatal care is considered an essential part of primary health care and takes up considerable resources, we recommend further research to explain the gap between the intentions of antenatal care and the actual outcome of such care.

Notes: Objective To evaluate the association between smoking during pregnancy and preterm birth.Design A follow up study.Setting Department of Gynaecology and Obstetrics, Aarhus University Hospital, Denmark.Participants Four thousand one hundred and eleven nulliparous women with singleton pregnancies who returned questionnaires about smoking habits at 16 weeks of gestation.Results The overall rate of preterm delivery was 4.3 %. Smokers had a 40 % higher risk of preterm birth compared with nonsmokers. A dose response relationship was found between smoking and risk of preterm birth. Adjustment for women's height, prepregnancy weight, age of the mother, marital status, education, occupational status, and alcohol intake did not change the results. Among women with an intake of less than 400 mg of caffeine per day no difference in the risk of preterm birth between smokers and nonsmokers was found. However, among women with an intake of more than 400 mg of caffeine per day, the risk of preterm birth was increased almost threefold among smokers compared with nonsmokers. Furthermore, among women with a high intake of caffeine a dose-response relationship was found; women smoking one to five cigarettes per day had no increased risk of preterm birth compared with nonsmokers with the same intake of caffeine, women smoking six to ten cigarettes per day had almost three times higher risk of preterm birth, and women smoking more than 10 cigarettes per day had almost five times higher risk of preterm birth compared with nonsmokers with the same intake of caffeine.Conclusions Smoking increases the risk of preterm birth. The association between smoking and preterm birth was only present among women with a high intake of caffeine. However, whether smoking alone influences the risk of preterm birth among heavy consumers of caffeine needs further investigation.

Notes: Abstract A total of 132 consecutive patients underwent centralized treatment of acute symptomatic pulmonary embolism during the period 1975–1987. The spectrum ranged from patients with minor peripheral emboli to those with massive central emboli causing cardiocirculatory collapse. The patients were treated with full-dose heparin (N=41), streptokinase (N=52), or embolectomy during extracorporeal circulation (N=39). The duration of symptoms (zero to sixty days), number of embolic episodes before the diagnosis, degree of circulatory affection, abnormalities on chest radiography, arterial blood gases, and electrocardiographic (ECG) findings were analyzed in relation to underlying diseases as well as to degree of pulmonary vascular obstruction (scintigraphic/angiographic embolic score). Systolic pulmonary artery pressure (SPAP) correlated directly with duration of symptoms; the highest SPAP (〉70 mmHg) was found in patients with symptoms lasting more than one week, which, irrespective of embolic score and choice of treatment, involved a definite risk of later development of chronic cor pulmonale. SPAP correlated directly with embolic score only after exclusion of patients with symptoms lasting more than a week and with preexisting cardiopulmonary disease. The majority of patients with circulatory collapse had had a reversible shock hours to days previously, which further underlines the necessity of an aggressive diagnostic and therapeutic attitude. ECG signs of acute right ventricular strain and sinus tachycardia reflected both massive and short-lasting embolization and are now used routinely to indicate emergency pulmonary arteriography (rather than ventilation-perfusion scintigraphy) in the diagnostic approach. Based on previous results, the authors' indications for embolectomy were in 1984 broadened to include all patients with central emboli (less than one week old), including those who were cardiocirculatorily stable. In the present evaluation, multivariate risk analysis in total patient series as well as in patients with central emboli showed that medical treatment (heparin and streptokinase as opposed to embolectomy) independently increased the mortality rate. This was confirmed by a matched analysis of embolectomy versus streptokinase treatment in patients with central fresh emboli and no circulatory collapse. A diagnostic strategy and indications for treatment representing an aggressive approach are advocated.