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Notizen: Summary. In a double blind trial, 60 nulliparae with a modified Bishop score of 〈inlineGraphic alt="leqslant R: less-than-or-eq, slant" extraInfo="nonStandardEntity" href="urn:x-wiley:14700328:BJO827:les" location="les.gif"/〉5 requiring induction of labour, received either 8 mg of salbutamol or an identical placebo orally, 30 min before vaginal administration of 2 mg prostaglandin E2 gel. Women in the salbutamol group experienced less uterine activity over the subsequent 12 h compared with those given placebo, and fewer (35%) commenced labour compared with the placebo group (62%). However, the change in cervical score was significantly less in the salbutamol group (mean 3.0, SD 3.1) than that in the placebo group (mean 5.8, SD 3.2), and the prostaglandin treatment to delivery time in the salbutamol group (mean 26.1 h, SD 6.49) was significantly longer than that in the placebo group (mean 19.3 h, SD 7.95). The first stage of labour lasted 〉10h in 11 women in the salbutamol group compared with five in the placebo group. Side effects attributable to salbutamol occurred in 10% 〉 of the treated women but in none of their fetuses and fetal outcome was satisfactory and similar in both groups. Our findings show that salbutamol can suppress prostaglandin-induced uterine activity during cervical ripening, which could be an advantage in induction of labour where a planned delivery is preferred. However, the poorer outcome of labour in salbutamol-treated women mitigates against this approach.

Notizen: Objective To determine whether a single ultrasound scan at or beyond 40 weeks of gestation to detect a single deepest pool of amniotic fluid 〈2 cm and amniotic fluid index (AFI) 〈5 cm is clinically useful in the prediction of subsequent adverse pregnancy outcome.Design A prospective double blind cohort study.Setting A university teaching hospital delivering approximately 6000 women annually.Population One thousand and five hundred and eighty-four pregnant women at or beyond 40 weeks of gestation.Methods Ultrasound assessment of liquor to detect the single deepest pool of amniotic fluid and derive the AFI at or after 40 weeks of gestation.Main outcome measures Perinatal death, meconium aspiration, birth asphyxia, intervention in labour for fetal distress, a cord arterial pH 〈7 and admission to the neonatal unit.Results An AFI 〈5 cm but not a single deepest pool 〈2 cm was significantly associated with birth asphyxia or meconium aspiration. An AFI 〈5 cm was also significantly associated with caesarean section for fetal distress in labour, a cord arterial pH 〈7 at delivery and low Apgar scores. Despite there being a statistically significant association with adverse outcomes the sensitivity of AFI was low at 28.6%, 12% and 11.5% for major adverse outcome, fetal distress in labour or admission to the neonatal unit, respectively.Conclusions The AFI is superior to a measure of the single deepest pool as an assessment of the fetus at or after 40 weeks but has a poor sensitivity for adverse pregnancy outcome. Routine use is likely to lead to increased obstetric intervention without improvement in perinatal outcomes.

Notizen: Objective To determine how long it takes from the decision to achieve delivery by non-elective caesarean section (DDI), the influence on this interval, and the impact on neonatal condition at birth.Design Twelve months prospective data collection on all non-elective caesarean sections.Methods Prospective collection of data relating to all caesarean sections in 1996 in a major teaching hospital obstetric unit was conducted, without the knowledge of the other clinicians providing clinical care. Details of the indication for section, the day and time of the decision and the interval till delivery were recorded as well as the seniority of the surgeon, and condition of the baby at birth.Results The mean time from decision-to-delivery for 100 emergency intrapartum caesarean sections was 42.9 minutes for fetal distress and 71.1 minutes for 230 without fetal distress (P 〈 0.0001). For 22 ‘crash’ sections the mean time from decision-to-delivery was 27.4 minutes; for 13 urgent antepartum deliveries for fetal reasons it was 124.7 minutes and for 21 with maternal reasons it was 97.4 minutes. The seniority of the surgeon managing the patient did not appear to influence the interval, nor did the time of day or day of the week when the delivery occurred. Intrapartum sections were quicker the more advanced the labour, and general anaesthesia was associated with shorter intervals than regional anaesthesia for emergency caesarean section for fetal distress (P 〈 0.001). Babies born within one hour of the decision tended to be more acidaemic than those born later, irrespective of the indication for delivery. Babies tended to be in better condition when a time from decision-to-delivery was not recorded than those for whom the information had been recorded.Conclusion Fewer than 40% intrapartum deliveries by caesarean section for fetal distress were achieved within 30 minutes of the decision, despite that being the unit standard. There was, however, no evidence to indicate that overall an interval up to 120 minutes was detrimental to the neonate unless the delivery was a ‘crash’ caesarean section. These data thus do not provide evidence to sustain the recommendation of a standard of 30 minutes for intrapartum delivery by caesarean section.

Notizen: Objective To determine the incidence, risk factors, presentation, treatment and morbidity associated with secondary postpartum haemorrhage.Design Analysis of 132 consecutive women presenting with secondary postpartum haemorrhage occurring over a three-year period.Setting The maternity unit in a district general teaching hospital serving an annual delivery rate of around 6500 women.Main outcome measures Factors associated with the cause of the haemorrhage and the resulting morbidity.Results Most women presented during the second week after delivery. A history of primary postpartum haemorrhage (OR 9.3; 95% CI 6.2-14.0) and manual removal of placenta (OR 3.5; 95% CI 1.6-7.5) were the only significant risk factors identified. There was a high associated morbidity, with 84% requiring hospital admission, 63% surgical evacuation, 17% blood transfusion, with three women suffering a uterine perforation, one managed by hysterectomy. In women undergoing evacuation only, 37% had retained placental tissue confirmed after surgery; pre-operative ultrasound examination did not provide a better discrimination over clinical assessment for this finding.Conclusions Secondary postpartum haemorrhage occurs in just under 1% of women, is associated with primary postpartum haemorrhage and retained placenta, and may result in significant maternal morbidity. This problem deserves more attention than it has received in recent years.