Nurse-midwifery at Gundersen Clinic: a twenty year review

The twenty-year experience of the Certified Nurse-Midwife (CNM) Service at Gundersen Lutheran Medical Center is presented. The Service was started in September, 1975. From 1975 through 1995, the nurse-midwives have attended 9,120 women in labor (32.5% of all laboring women at Lutheran Hospital). During this time, the CNM service perinatal mortality rate was 6.8 per 1,000 births and the primary cesarean section rate was 5.8%. A close working relationship between nurse-midwives and obstetricians is thought to be one of the main factors in the growth, acceptance and safety of the service.

A quality improvement project to increase the use of postmenopausal hormonal replacement therapy (HRT)

Many medical institutions are initiating quality improvement and disease prevention programs. In this paper, we report the results of a program designed to increase the rate of hormonal replacement therapy (HRT) in a postmenopausal population. After initially assessing the rate of HRT use, we instituted an educational program directed at both physicians and patients. Reassessment two years later indicated the rate of HRT had increased from 31% to 48.4%. Further educational efforts were followed by a reassessment three years later that showed a further improvement in prescription rate to 64%. We conclude that our educational program directed at physicians and patients dramatically increased the rate of HRT prescription of postmenopausal women.

Is a twelve-percent cesarean section rate at a perinatal center safe?

OBJECTIVE

Our purpose was to examine the pregnancy and neonatal outcomes at a perinatal center with a consistent cesarean section rate approximately half the national average.

STUDY DESIGN

Ten years of vaginal delivery and cesarean section rates (1983 to 1992) and 5 years of mortality and morbidity outcomes (1988 to 1992) were compared with national health statistics and national health objectives.

RESULTS

The cesarean section rate during the 10-year period ranged from 10% to 15%, with an average of 12.5%. The cesarean section rate for the 5 years during which maternal and neonatal outcome data were obtained was 11.3%. The forceps and vacuum extraction rates during that time were consistently less than 5%. The nurse-midwifery service delivered approximately 36% of all babies during this period. In an examination of maternal mortality, we discovered only one death during the 5-year interval. The rate of maternal admission to the intensive care unit after delivery was 0.2%. The percent of women who received blood transfusions was 1%. The average length of stay for both vaginal and cesarean section deliveries declined steadily across the whole interval and was 2.5 days for a vaginal delivery and 5.5 days for a cesarean section. An examination of neonatal morbidity and mortality revealed an admission rate to the intensive care unit of less than 6%. The distribution of Apgar scores indicated less than 4% of neonates had scores < or = 3 at 1 minute; 0.5% had scores < or = 3 at 5 minutes. The neonatal death rate was 614 per 100,000 births, and fetal mortality was 729 per 100,000 births from 1988 to 1992.

CONCLUSIONS

The lowest safe cesarean section rate is not known; it will undoubtedly vary with location and patient mix. We believe that we have been able to establish a rate of cesarean section one half of the national average with good maternal and fetal outcomes. This has been accomplished through a vigorous prenatal care program, excellent perinatal and infertility services, a vigorous program of vaginal birth after cesarean section, and a competent nurse-midwifery service.

Peripheral joint laxity increases in pregnancy but does not correlate with serum relaxin levels

OBJECTIVE

Our purpose was to evaluate peripheral joint laxity during pregnancy and to determine whether serum relaxin levels are associated with increased joint laxity.

STUDY DESIGN

A prospective observational study was performed.

RESULTS

A significant increase in joint laxity was found in five of seven peripheral joints over the course of the pregnancy and post partum. There was no correlation with serum relaxin levels. There were no significant differences in joint laxity on the basis of parity, age, or prepregnancy exercise levels.

CONCLUSIONS

Peripheral joint laxity is noted to increase as pregnancy progresses. The cause of this change is undetermined.

Evaluating the thirty minute interval in emergency cesarean sections

BACKGROUND

This study was done to evaluate what percent of emergency cesarean sections are begun within the 30 minute interval between decision and incision time and to evaluate morbidity associated with this time interval.

STUDY DESIGN

A retrospective patient-control study of records from 75 patients undergoing emergency cesarean sections and two different control groups was undertaken.

RESULTS

Sixty-three percent of emergency cesarean sections were begun in less than 30 minutes. A significantly greater number of infants in the group that delivered in less than 30 minutes experienced five minute Apgar scores less than six. There was no significant differences in maternal morbidity associated with emergency cesarean sections.

CONCLUSIONS

The 30 minute interval is obtainable in a large number of patients but did not have a beneficial effect on neonatal morbidity. There was no significant morbidity seen in the patients who underwent emergency cesarean section. Other measurements of emergency preparedness should be considered other than the 30 minute rule.

Live birth after treatment of severe adenomyosis with a gonadotropin-releasing hormone agonist

A patient with a 10-year history of secondary infertility underwent GnRH-a therapy with LA for 5 months to control symptoms of severe adenomyosis and to avoid an unwanted hysterectomy. Shortly after cessation of treatment, the patient conceived. A healthy male was delivered at term by cesarean section, which makes this the first report of a live birth after treatment of severe adenomyosis with a GnRH-a.

Factors that influence weight loss in the puerperium

A study group of 795 women was followed with frequent weight measurements and questionnaires about their activities for 6 months postpartum. The mean (+/- SD) net weight gain from the first prenatal visit to 6 months postpartum was 1.4 +/- 4.8 kg. Weight gain during prenatal care was the variable most highly correlated to weight loss. Return to work outside the home, parity, and smoking also correlated significantly to weight loss. Breast-feeding, exercise, season of the year, age, and marital status were not correlated. Route of delivery was related to weight loss at 2 and 6 weeks, but not at 6 months. Counseling women about weight gain during pregnancy and weight loss requires an understanding of these variables with a long-term perspective of at least 6 months.

Evaluation of patients with atypical results of a Papanicolaou smear

One hundred women with atypical Papanicolaou smear results were examined in a protocol of colposcopy, cervicography, cervical cultures, and wet preparations of vaginal secretions. Infections of the vagina and cervix were rare and often found in patients with coexistent cervical dysplasia. Cervicography identified many of the patients who ultimately were found to have cervical dysplasia but had high false positive and false negative rates. Forty-seven percent of the patients had cervical dysplasia or cervical condyloma. Based on this high rate of dysplasia, treatment of vaginitis and repeated cervical cytology cannot be recommended. Colposcopy represents the most appropriate approach to the patient with atypical cytology.

Outpatient microsurgical reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy

A prospective study of 17 cases of microsurgical reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy was performed. Inclusion criteria included age less than 43; weight less than ideal body weight plus 20%; documentation of ovulation; 2 cm of proximal oviduct on hysterosalpingography; and a normal semen analysis or postcoital test. A comparison group of the 5 cases of sterilization reversal performed by a standard inpatient technique during the same period was analyzed. The study technique was performed on an outpatient basis in 15 of the 17 cases, 12 patients (71%) conceived 13 intrauterine pregnancies, one ectopic pregnancy occurred, and total patient costs and time until return to work were significantly less with the study versus standard technique.

Cervical screening with cervicography and the Papanicolaou smear in women with genital condylomata

Cervicography has been shown to be a very sensitive screening tool in the general population. Its value in screening a high-risk population was explored. One hundred five women seen with vulvar condylomata or a history thereof were offered a cervigram and Papanicolaou smear. Twelve patients had abnormal smears, whereas 53 had abnormal cervigrams. Colposcopically directed biopsies in the abnormal Papanicolaou group revealed cervical intraepithelial neoplasia (CIN) I in six patients and III in two. Cervicography-positive patients exhibited CIN I in 9 cases, II in 1 and III in 2. There was some overlap. Twelve patients had cervical condylomata without dysplasia. Cervicography, in addition to cervical cytology, should be considered for all women with vulvar condylomata.

Obstetric care of a Southeast Asian refugee population in a midwestern community

The obstetric records of 430 Hmong and other Southeast Asian refugee women were retrospectively reviewed from January 1, 1977 to July 1, 1988. All patients gave birth in two hospitals in a midwestern community, La Crosse, Wisconsin. Lack of medical care for early pregnancy complications, late onset of obstetric care, anemia, and high rates of parasites and hepatitis occurred frequently in pregnancy. Admission in advanced labor, a low operative delivery rate (6%), and a higher prematurity rate characterized intrapartum care. Birthweight data revealed statistically significantly smaller infants after 38 weeks' gestation. Postpartum febrile morbidity and neonatal complications were rare. Cultural differences and their effects on obstetric care are discussed.

Early crown-rump length. A good predictor of gestational age

With the increased resolution of newer transabdominal and transvaginal imaging equipment, ultrasound is being used more frequently for the diagnosis of early pregnancy complications. Extrapolation of gestational age from early crown-rump lengths (CRLs) has been difficult because previously established tables of CRL versus gestational age have contained few measurements at less than seven to eight weeks from the first day of the last menses. Accordingly, the relationship between early CRL (in millimeters) and calculated menstrual age (CMA) (in days) in 36 patients with a known date of conception was studied with transvaginal sonography and found to have a linear relationship, defined by the equation CMA = 0.99 x CRL + 40.0 (r = .95, P less than .001). The relationship can be used to date pregnancies as early as 26 days after conception.

Intrauterine insemination of cryopreserved donor semen

The use of cryopreserved specimens is becoming the standard of care for donor insemination. Commercial specimens often have low numbers of actively motile sperm. Intrauterine insemination may be of value in the wives of men with oligoasthenospermia. Accordingly, an intrauterine insemination protocol using one or two vials of commercial semen with a minimum of 24 million motile sperm per vial was used to determine if acceptable monthly conception rates could be obtained. During the study period, there were 82 insemination cycles, resulting in 20 pregnancies in 35 women. The monthly conception rate was 24% and monthly ongoing pregnancy rate was 18%. If confirmed by other investigators, intrauterine insemination may be a way to improve the pregnancy rate with cryopreserved semen.

The Papanicolaou smear and the cervigram. A preliminary report

We reviewed the results of Papanicolaou smears and cervigrams obtained at the same session from 250 patients. Seven Papanicolaou smears were abnormal, and 56 cervigrams were abnormal. Fourteen cases of cervical intraepithelial neoplasia I and two cases of cervical intraepithelial neoplasia III were missed by the Papanicolaou smear but identified by cervicography.

False labor

The nature of false labor and its influence on the subsequent course of true labor was examined by a retrospective case-controlled matched study of 83 patients admitted in false labor. Patients with a history of false labor had a significantly greater incidence of dysfunctional labor when true labor did commence. The frequency of cesarean section was also higher, though not statistically significantly so. The dilatation of the cervix and the station of the presenting part at admission were both significantly different in patients with false labor from those in true labor; however, the overlap of these two groups makes this of limited clinical use. Time of day and day of the week did not correlate with the likelihood of being admitted in false labor.

Heterogeneity of prenatal onset hydrocephalus: management and counseling implications

We have evaluated 30 cases of congenital hydrocephalus, most with a presumed early prenatal onset. The ten cases delivered in 1982 were studied prospectively. In 18 of the 25 nonsurvivors, no cause was apparent and many had multiple anomalies. The heterogeneity seen in this series is discussed in relation to intrauterine treatment.

Fetomaternal bleeding as a cause for "unexplained" fetal death

Among a series of 29 antepartum fetal deaths without apparent cause, 4 (13.8%) were apparently due to transplacental fetal exsanguination. This represents 3.4% of all fetal deaths and 0.04% of all births in a series of 9223 deliveries. The principal conclusion of this study is that massive fetal maternal hemorrhage occurring without apparent cause or predisposing factors represents a significant cause of fetal wastage, examination of which should be included in evaluation of these patients.

Primary squamous cell carcinoma of the endometrium

Primary squamous cell carcinoma of the endometrium is extremely rare. The 21st case of this lesion that meets Fluhmann's criteria is presented. The histogenesis of this lesion remains unclear. The etiology of squamous cell changes in the endometrium is presented, and the prognostic implication of malignant squamous cells in endometrial carcinoma is discussed.

Fetal calcitropic hormones and neonatal calcium homeostasis

Ionic calcium (Ca2+), total calcium, magnesium, phosphorus, albumin, immunoreactive parathyroid hormone (PTH), and immunoreactive calcitonin (CT) were measured in maternal and cord blood at term delivery of 96 women near term with predominantly normal pregnancies. Calcium, magnesium, phosphorus, and albumin were measured in the infants at 24 hours of age. Umbilical Ca2+ levels exceeded maternal values significantly (2.82 +/- 0.15 vs 2.23 +/- 0.09 mEq/liter, P < .001), as did calcium, magnesium, phosphorus, and albumin levels. The relative fetal hypercalcemia was associated with significantly higher CT levels in fetus than in mother (248 +/- 68 vs 209 +/- 54 pg/ml, P < .05) but PTH concentrations did not differ significantly between the two circulations. Within the fetal circulation, levels of each component did not differ except for PTH which was in higher concentration in venous than in arterial blood (5.50 +/- 1.81 vs 4.93 +/- 1.71 microliter-eq/ml, P < .05). Stepwise multiple regression analysis, utilizing neonatal Ca level as the dependent variable, identified one clinical feature (duration of pregnancy) and six laboratory data as significant independent variables, account in sum for 35% of the variation in neonatal calcium level. The significant laboratory variables, in order of entry into the model, were maternal PTH, umbilical venous PTH, maternal phosphorus, umbilical venous magnesium, neonatal albumin, and neonatal magnesium. These results indicate that the normal fetus responds to hypercalcemia in late intrauterine life by increasing CT secretion but not by suppressing PTH output. The umbilical PTH level is one of several factors at birth which correlates significantly with calcium concentration at 24 hours of age.

Maternal-perinatal calcium relationships

Serum concentrations of total and ionic calcium, magnesium, phosphorus, and albumin were measureed in maternal and cord blood of 115 near-term deliveries. The same measurements (except for ionic calcium) were made in blood obtained from corresponding newborns at 24 hours of age. Cord levels of all components exceeded maternal values, and maternal and cord levels correlated significantly with each other. In the case of calcium, the cord-maternal difference involved both ionic and protein-bound forms. Significant umbilical arterio-venous differences were found only in the case of total calcium, and this difference reflected variation in the protein-bound form only. During the first 24 hours postpartum, total calcium concentration fell (by an average of 0.75 mEq/liter), phosphorus levels rose (by an average of 0.63 mg/dl), and magnesium and albumin did not change significantly. Cord levels of all agents correlated significantly with corresponding neonatal values. In view of the significant positive relationships demonstrated between maternal and cord levels and between cord and neonatal levels, these results substantiate the importance of the maternal serum ionic calcium concentration in normal perinatal calcium homeostasis.

Mechanism of protection from alloxan diabetes provided by n-butanol

Pretreatment with n-butanol (10 mmol/kg i.p.) 30 minutes before alloxan (100 mg/kg) protects mice from the permanent hyperglycemic effects (measured at 72 hours) of the diabetogenic agent. This dose of n-butanol caused an elevation of serum glucose at 30 minutes, the time of alloxan administration. Since glucose administration can protect animals from alloxan, the possibility that alcohol-induced hyperglycemia protected mice from alloxan was investigated. Mannoheptulose, an antagonist of glucose action at the pancreatic beta-cell, when given 24 minutes after n-butanol and 6 minutes before alloxan, eliminated the alcohol-induced protection. Fasted mice did not exhibit n-butanol-induced hyperglycemia at 30 minutes and alloxan given at that time produced diabetes. No protection was observed in fed animals when n-butanol was given 5 minutes before alloxan. The high serum levels of butanol and normal serum glucose which were observed at 5 minutes after alcohol administration indicated that the lack of protection was not due to a lack of circulating alcohol but resulted from an absence of hyperglycemia. The results indicate that pretreatment with n-butanol protects mice from alloxan-induced diabetes by the indirect mechanism of producing hyperglycemia at the time of alloxan administration.

Synthesis of an active hydroxylated glutethimide metabolite and some related analogs with sedative-hypnotic and anticonvulsant properties

Two synthetic pathways are described for the preparation of 4-hydroxy-2-ethyl-2-phenylglutarimide (2), an active hydroxylated metabolite of glutethimide (1). Fourteen other glutethimide analogs were also synthesized and tested for biological activity. Most of the analogs exhibited sedative-hypnotic properties and compound 2 possessed the greatest activity compared to the parent drug. 4-Amino-2-ethyl-2-phenylglutarimide and 4-hydroxy-2-ethyl-2-phenylglutaconimide (13) exhibited the greatest potential as anticonvulsant agents. The structure-activity relationships of the series are discussed.