Improving the standards of care for women having caesarean sections

Improvement in the uptake of prophylactic antibiotics at caesarean section was chosen as a priority at the 1994 ASQUAM (Achieving Sustainable Quality in Maternity) meeting. The interventions used were guidelines, cyclical audit of cases and a patient-specific reminder stamp in the notes. A more detailed qualitative assessment of standards of communication and outcome was undertaken on a smaller cohort of women. Data on antibiotic prophylaxis were obtained from an audit record completed for every caesarean section undertaken at North Staffordshire Hospital from 1996 to 1998. Information on morbidity following caesarean section and on counselling was obtained from a review of the case records of a consecutive series of 75 caesarean sections and from a telephone call. In the baseline audit, 75% of women had received antibiotics; this increased to 92% in the remainder of 1996, 95% in 1997 and 98% in 1998. Fifty-eight of the 75 women were contactable by telephone (77%); of these 16 (28%) had a 'wound infection', 12 of which developed after discharge from hospital. Only 25 women (43%) remembered being counselled about the caesarean section. It is possible to achieve significant improvements in the quality of care for women having caesarean sections through the use of local guidelines, cyclical audit and reminder stamps. However, this audit, with community follow-up, raises questions about the adequacy of single dose prophylaxis. It also suggests the need for improved compliance with RCOG communication following caesarean section guidelines.

Operative vaginal delivery rates in the United Kingdom

Operative vaginal delivery with the vacuum extractor or forceps is integral to the practice of obstetrics worldwide. The rates at which obstetricians in different countries intervene vary enormously. The wide range of operative vaginal delivery rates reported in the United Kingdom has been noted as a cause for concern. At a Royal College of Obstetricians and Gynaecologists consultants' conference, the participants of a discussion group were surveyed regarding their 'actual' and perceived 'optimal' operative vaginal delivery rate. The 'actual' operative vaginal delivery rate was 10.5% and the perceived 'optimal' was 8.7%. Given that there are approximately 600 000 births per annum in the UK, if the optimal delivery rate was achieved over 10 000 operative vaginal deliveries could be avoided, with significant reductions in maternal morbidity. Reductions could be achieved by examining practice at a number of points in the care pathway. Individual units should examine their practice to establish whether their guidelines and continuing education programmes reflect current knowledge of best practice.

Critical appraisal workshops to promote evidence-based healthcare

We evaluated the effect of literature appraisal workshops on participants views, attitudes and knowledge about evidence-based medicine in the West Midlands region in 1998. The performance of 55 practitioners was evaluated, before and after attending the workshop. After attending the workshop, participants paid more attention to the study design (81% vs. 98%, P=0.02), they did not find research evidence confusing (35% vs. 52%, P=0.05), and they felt more confident in assessing research evidence (26% vs. 59%, P=0.0001). Their mean knowledge scores improved from 47.3 (SD12.2) to 57.9 (SD 9.0) ( P=0.0001). Our critical appraisal skills workshops improved attitudes and knowledge needed for the provision of evidence-supported healthcare. Such workshops should be incorporated in postgraduate obstetrics and gynaecology training programmes.

Suggestions in maternal and child health for the National Technology Assessment Programme: a consideration of consumer and professional priorities

In North Staffordshire, the Achieving Sustainable Quality in Maternity (ASQUAM) meetings provide the programme for clinical guidelines and audit over the following year. The ASQUAM clinical effectiveness programme has attempted to address a number of the issues identified as obstacles to informed democratic prioritization. For example, it became clear that a number of topics raised were actually research questions. The organizers therefore decided to split the fourth ASQUAM day into an 'audit' morning and a 'research' afternoon. The meeting organized by RJ, CR and PJ in partnership with the Midwives Information and Resource Service and the National Childbirth Trust, was timed to allow the research ideas to feed into the national Health Technology Assessment (HTA) programme. This meeting was designed to increase the profile of ASQUAM amongst consumers and to increase their representation at the meeting. Objectives were to choose a new set of research priorities for the year 2000, and to ascertain the voting pattern of comparison to health professionals. There was overall agreement in terms of priorities, with the consumer group prioritizing 8 of the 10 topics chosen by the professionals (or 10 of the 11). No significant differences between the proportions of voted cast for each topic by professionals and consumers were found apart from topic 20. The numbers of consumers were small which does limit the number the validity of statistical comparisons. Nevertheless, it is clear that voting patterns were similar. Overall the process suggests that democratic prioritization is a viable option and one that may become essential within the framework of clinical and research governance.

A randomised trial of an intervention package designed to promote external cephalic version at term

OBJECTIVE

To evaluate the effectiveness of an intervention package to promote external cephalic version (ECV).

STUDY DESIGN

(1) Design and Setting--A randomised-controlled trial of 20 consultant-based maternity units in the West Midlands NHS Region. (2) Intervention Units--One consultant obstetrician from each unit was encouraged to promote changes in clinical practice within their unit. A multifaceted package including a workshop, written material, guidelines and videos was delivered to these consultants. (3) Control Units--No intervention. (4) Main Outcome Measure--The percentage of women with breech presentation at term who were offered ECV in the antenatal clinic, before and after the intervention.

RESULTS

Pre-intervention, there was no difference between the intervention and control units in the proportion of women offered ECV (20 and 19%, respectively). Post-intervention, the proportions were 15% in the control group and 36% in the intervention group (P=0.016).

CONCLUSION

This type of intervention package can alter clinical practice and increase the proportion of women with breech presentation at term being offered ECV after the intervention.

Surface expression of the conserved C repeat region of streptococcal M6 protein within the Pip bacteriophage receptor of Lactococcus lactis

The C repeat region of the M6 protein (M6c) from Streptococcus pyogenes was expressed within the Pip bacteriophage receptor on the surface of Lactococcus lactis. M6c was also detected in the culture medium. The pip-emm6c allele was integrated into the chromosome and stably expressed without antibiotic selection. The level of cell-associated surface expression of PipM6c was 0.015% of total cellular protein. The amount of PipM6c on the cell surface was increased about 17-fold by expressing pip-emm6c from a high-copy-number plasmid. Replacing the native pip promoter with stronger promoters isolated previously from Lactobacillus acidophilus increased surface expression of PipM6c from the high-copy-number plasmid up to 27-fold. Concomitantly, the amount of PipM6c in the medium increased 113-fold. The amount of PipM6c did not vary greatly between exponential- and stationary-phase cultures. Western blots indicated that the full-length PipM6c protein and most of the numerous proteolytic products were found only on the cell surface, whereas only one proteolytic fragment was found in the culture medium.

A low dose ("Dhaka") magnesium sulphate regime for eclampsia

BACKGROUND

Eclampsia remains a common cause of maternal death in Bangladesh. Early experience of magnesium sulphate use for eclampsia in Bangladesh was based on a lower dose regime, tailored for use in the smaller woman.

OBJECTIVES

a) To determine the recurrent convulsion rate with the low dose "Dhaka" magnesium sulphate regime (recognizing the limitations of sample size). b) To identify whether toxicity occurs with this regime. c) To measure serum level of magnesium with this regime.

METHODS

This prospective study included 65 eclamptic patients receiving lower dose magnesium sulphate therapy at Dhaka Medical College Hospital from 25 March 1998-15 June 1998. The loading dose of magnesium sulphate was 10 gm. Following this 2.5 gm was given intramuscularly 4 hourly, for 24 hours after administration of the first dose. Four blood samples were collected for serum magnesium levels. Patients were monitored hourly by observing their respiratory rate, knee jerks and urinary output. Findings were matched with serum magnesium levels.

RESULTS

The range of serum magnesium levels was 1.74 to 6 mg/dl with mean (s.d.) values of 3.87 (0.78). Only five (9%) patients had diminished knee jerks 6, 10, 12, 12 and 15 hours after administration of the loading dose. But at those times the serum magnesium levels were 3.2 mg/dl, 3.8/dl, 3.4 mg/dl and 3.3 mg/dl respectively. Of the 65 patients, only one developed recurrent convulsions. This was 3 hours after the loading dose and was controlled by diazepam treatment and maintenance magnesium sulphate.

CONCLUSION

Half of the standard dose of magnesium sulphate appeared to be sufficient to control convulsions effectively and serum levels of magnesium remained lower than levels which produce toxicity.

Pre-eclampsia, diagnosis and treatment

Pre-eclampsia is a multisystem disorder of pregnancy usually associated with raised blood pressure (BP) and proteinuria. The pathogenesis is not understood despite decades of research. Abnormal placentation related to immune mechanisms and maladaptation of the placenta may be the first step in the development of the disease. Although there are a number of risk factors and new innovatory tests (e.g., uterine artery Doppler) which can be used to predict pre-eclampsia, none fulfils standard diagnostic criteria. Of possible prophylactic value are antiplatelet agents, calcium supplementation and vitamins C and E. Prevention of eclampsia with magnesium sulfate is the subject of a current international randomised controlled trial (RCT), known as MAGPIE. Therapeutic strategies include avoidance of hypertensive injury and delivery of the baby and placenta. Further research into specific antihypertensive agents and conservative management strategies is required.

Haemodynamic, invasive and echocardiographic monitoring in the hypertensive parturient

AIM

To determine the clinical usefulness of invasive and non-invasive haemodynamic assessment in pre-eclampsia.

METHOD

A systematic review of the literature was undertaken, using a MEDLINE electronic search using a combination of MESH headings and textwords. Over 1500 abstracts were perused; we obtained 156 full papers that were related to the subject matter. Of the full papers, 55 yielded relevant information. Hand-searching the reference lists of the retrieved papers completed the search.

RESULTS

There are no data from randomized controlled clinical trials illustrating the clinical usefulness of pulmonary artery catheters or echocardiographic techniques in hypertensive pregnancy. There are a wealth of data illustrating the haemodynamic profiles of both untreated and treated pre-eclamptic women. Data are also available comparing right heart and left heart filling pressures, demonstrating a relatively poor correlation between the two values. The clinical impact of either measurement is unclear. Data are available illustrating the correlation between echocardiographic techniques and pulmonary artery catheterization.

Reducing risk by improving standards of intrapartum fetal care

Confidential Enquiries into Stillbirths and Deaths in Infancy (CESDI) have pointed to a high frequency of suboptimal intrapartum fetal care of a kind that, in the event of an adverse outcome, is hard to defend in court. In an effort to minimize liability, various strategies were applied in a district hospital labour ward--guidelines, cyclical audit, monthly feedback meetings and training sessions in cardiotocography (CTG). The effects of these interventions on quality of care was assessed by use of the CESDI system in all babies born with an Apgar score of 4 or less at 1 min and/or 7 or less at 5 min. 540 babies (4.3%) had low Apgar scores, and neither the percentage nor gestational age differed significantly between audit periods. In the baseline audit, care was judged suboptimal (grade II/III) in 14 (74%) of 19 cases, and in the next four periods it was 23%, 27%, 27% and 32%. In the latest audit period, after further educational interventions, it was 9%. Many of the failures to recognize or act on abnormal events were related to CTG interpretation. After the interventions there was a significant increase in cord blood pH measurement. There were no differences between audit periods in the proportion of babies with cord pH < 7.2. These results indicate that substantial improvements in quality of intrapartum care can be achieved by a programme of clinical risk management.

Management of massive postpartum haemorrhage: use of a hydrostatic balloon catheter to avoid laparotomy

Postpartum haemorrhage remains a significant complication of childbirth in the UK and worldwide. The most common cause of postpartum haemorrhage is uterine atony, but placent accreta is becoming more frequent. In these situations tamponade may be required. The successful use of the inflated stomach balloon (300ml) of a Sengstaken-Blakemore tube has been reported previously. We describe an innovative method of 'tamponade' which is simple and effective, using the Rüsch urological hydrostatic balloon catheter. In two cases of failed medical therapy for PPH, where the catheter has been tried, further surgical interventions have been avoided.

Management of obstetric emergencies and trauma (MOET): regional questionnaire survey of obstetric practice among career obstetricians in the United Kingdom

Across specialties in the UK concern exists that the shortened training time, combined with the restriction on hours of work, will result in trainees being short of the necessary depth and breadth of experience for independent practice at the end of their defined training period. In terms of risk management, it is recognised that high reliability organisations anticipate the worst and equip themselves to deal with it at all levels in the organisation. Alternative methods of assessment and training need to be utilised, including models and scenario teaching. While it is important for clinicians to learn common skills well before practising on the labour ward, it is correspondingly more important that rare complications be rehearsed with models. In the UK, the MOET (Managing Obstetric Emergencies and Trauma) course has been developed to allow specialist obstetricians to learn, or revise, how to undertake procedures on models, and then to have their skills tested in scenarios. This survey aimed to ascertain the views of career obstetricians in terms of their ability to respond to some of the course scenarios and how frequently the rarest procedures have been undertaken. A one-page questionnaire with 15 questions, based on clinical scenarios taught on the MOET (Managing Obstetric Emergencies and Trauma), course was sent to all career obstetricians in the West Midlands region. Participants were asked to indicate whether they thought a particular management was 'good practice', 'bad practice' or 'good practice but would prefer a caesarean section' and to indicate the number of such procedures they had undertaken in their obstetric career. The response rate was 40% (97/243). There was a broad spectrum in obstetric views about 'good' and 'bad' practice. Overall the respondents agreed with the literature in terms of practices that are regarded as 'good' and 'bad'. A large proportion of respondents, however, would rather undertake a caesarean section than carry out a 'good' practice. Twenty-six obstetricians had experience in the rare obstetric procedures. Of these, 16 (66%) had worked outside the UK, either in the Middle East, South East Asia, Africa or the Caribbean. This survey highlights the need for training courses to teach and revise operative procedures.

Techniques for performing caesarean section

In many countries caesarean section has become the mode of delivery in over a quarter of all births. Safety of the mother and cost are the two main areas of concern. Various studies on the techniques of performing a caesarean section have focused on reducing the operating time, blood loss, wound infection and cost. Given the fact that caesarean section is the most commonly performed operation in obstetrics, it is important that trainers and trainees are familiar with the basic surgical techniques and that best practice is followed. At the same time surgeons should take necessary precautions to reduce their risk of exposure to Hepatitis B and HIV. The skin incision and entry into abdominal cavity is best achieved by the modified Cohen's incision. The lower segment transverse uterine incision has stood the test of time over a period of 75 years and remains the best way to enter the uterus. Closure of the uterus in single layer appears to be acceptable, whenever technically possible. Placental delivery should be by controlled cord traction after spontaneous expulsion. Closure of the visceral and parietal layers of the peritoneum no longer seems to be necessary. Obliteration of space in the subcutaneous layer, either by suture or by suction, seems to reduce wound disruption. These issues are being considered in the CAESAR randomized controlled trial of surgical techniques currently underway in England.Prophylactic antibiotics are mandatory in preventing post-operative morbidity. Many of the above mentioned steps have been tested in randomized trials. Further studies are needed to examine a wide range of questions arising from this review, e.g. best position of the patient, the value of exteriorization of the uterus whilst repairing the uterus, and the use of agents to relax the uterus in difficult deliveries.

Evidence-based medicine in obstetrics

OBJECTIVES

The main objectives of this study were to determine: (a) the most popular sources of educational material for use in obstetrics, and the relative values assigned to these; (b) the relative importance of current evidence-based medicine (EBM) activities including use of guidelines and audits; and (c) worldwide practice in respect of 4 RCOG audit recommendations.

METHODS

A postal questionnaire was distributed to 2472 obstetricians/gynecologists worldwide.

RESULTS

A total of 1090 questionnaires were returned. The results found broad support for the principles of EBM, with most clinicians having access to electronic databases, and using guidelines and audits. There was wide interest in further research in suggested key areas.

CONCLUSION

The traditional reliance on meetings, reviews and colleagues' opinion continues, indicating that further research must be undertaken to optimize these educational opportunities.

Democratic prioritization of maternity care: a rational basis for planning a clinical effectiveness programme

BACKGROUND

The aim of the study was to evaluate the use of a democratic process for prioritizing the ASQUAM (Achieving Sustainable Quality in Maternity) clinical effectiveness programme.

METHODS

Twenty-two improvements in the standards of maternity care were chosen as top-topic priorities at the 1996 and 1997 ASQUAM meetings. We wished to assess the relative priorities of local and national delegates, by comparing their voting patterns at the two meetings. The setting was North Staffordshire ASQUAM prioritization days, and the subjects were all the delegates at the 1996 and 1997 ASQUAM meetings. Main outcome measures were comparison of numbers of votes cast by local and national delegates for each of the 20 topics presented at the two ASQUAM meetings, and proportions of the 11 top-topics decided at each meeting that were chosen by local and national delegates.

RESULTS

In 1996, significantly more local than national delegates voted for two topics related to maternal mortality or morbidity (incontinence and hypertensive diseases of pregnancy), but there were no statistically significant differences between the proportions of votes cast for any of the other 18 topics presented on the day. Indeed, local delegates had prioritized 11/11 of the final top-topics, and only one was omitted by the national delegates (10/11). In 1997, significantly more national than local delegates voted for three topics relating to professional stress levels, user involvement in working groups and antibiotic prophylaxis, but there were no statistically significant differences between the proportions of votes cast for any of the other 17 topics presented on the day. Again, local delegates had prioritized 11/11 of the final topics, with only one being omitted by the national delegates (10/11).

CONCLUSION

There appeared to be a remarkable concordance between local and national delegates at both meetings, suggesting an underlying rationality to decision making. We believe this to be a reflection of the process of careful evaluation of outcome and intervention supported by the protection of a secret ballot, allowing free expression of individual's values.

The North Staffordshire Maternity Hospital prospective study of pregnancy-associated depression

The objective of the study was to establish the frequency of depression during pregnancy and the puerperium, and its relationship to marital disharmony and sociodemographic variables. A prospective longitudinal study was carried out in a district general hospital in the West Midlands, UK. The cohort consisted of 417 women booked for confinement at the hospital. Depression was measured as a proportion of high scores (> 14) on the Edinburgh Postnatal Depression Scale (EPDS) and marital disharmony was determined by the Spanier Dyadic Adjustment Scale. Using recommended cut-offs, 41/417 (9.8%) of the women were depressed during pregnancy and 31/417 (7.4%) were depressed at 3 months postpartum. There was a significant association between antenatal and postnatal depression, seven of the 31 women who were depressed postpartum had also been depressed in the antenatal period. Only five of the 41 women with antenatal depression and eight of the 31 women with postnatal depression were identified by their general practitioners as depressed. Marital disharmony was sequentially associated with depression before and after delivery. We conclude that antenatal depression is more common than generally thought, and that both antenatal and postnatal depression are frequently missed during routine consultation. Pregnancy-associated depression is more common where marital disharmony exists. More widespread use of the EPDS during pregnancy may help to highlight these often unidentified mental health problems.

Double-blind randomised controlled trial of glyceryl trinitrate spray for external cephalic version

A placebo controlled trial of glyceryl trinitrate was carried out in women whose first attempt at external cephalic version without tocolysis had been unsuccessful. No significant differences between groups were found and no side effects were noted. It is recommended that a larger, possibly multicentre study, should be undertaken.

Soft versus rigid vacuum extractor cups for assisted vaginal delivery

BACKGROUND

The original cups used for vacuum extraction delivery of the fetus were rigid metal cups. Subsequently, soft cups of flexible materials such as silicone rubber or plastic were introduced. Soft cups are thought to have a poorer success rate than metal cups. However they are also thought to be less likely to be associated with scalp trauma and less likely to injure the mother.

OBJECTIVES

The objective of this review was to assess the effects of soft versus rigid vacuum extractor cups on perineal injury, fetal scalp injury and success rate.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Date of last search: February 2000.

SELECTION CRITERIA

Acceptably controlled comparisons of soft versus rigid vacuum extractor cups.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Nine trials involving 1375 women were included. The trials were of average quality. Soft cups are significantly more likely to fail to achieve vaginal delivery (odds ratio 1.65, 95% confidence interval 1.19 to 2.29). However, they were associated with less scalp injury (odds ratio 0.45, 95% confidence interval 0.15 to 0.60). There was no difference between the two groups in terms of maternal injury.

REVIEWER'S CONCLUSIONS

Metal cups appear to be more suitable for 'occipito-posterior', transverse and difficult 'occipito-anterior' position deliveries. The soft cups seem to be appropriate for straightforward deliveries.

Randomised trial of educational visits to enhance use of systematic reviews in 25 obstetric units

OBJECTIVE

To evaluate the effectiveness of an educational visit to help obstetricians and midwives select and use evidence from a Cochrane database containing 600 systematic reviews.

DESIGN

Randomised single blind controlled trial with obstetric units allocated to an educational visit or control group.

SETTING

25 of the 26 district general obstetric units in two former NHS regions.

SUBJECTS

The senior obstetrician and midwife from each intervention unit participated in educational visits. Clinical practices of all staff were assessed in 4508 pregnancies.

INTERVENTION

Single informal educational visit by a respected obstetrician including discussion of evidence based obstetrics, guidance on implementation, and donation of Cochrane database and other materials.

MAIN OUTCOME MEASURES

Rates of perineal suturing with polyglycolic acid, ventouse delivery, prophylactic antibiotics in caesarean section, and steroids in preterm delivery, before and 9 months after visits, and concordance of guidelines with review evidence for same marker practices before and after visits.

RESULTS

Rates varied greatly, but the overall baseline mean of 43% (986/2312) increased to 54% (1189/2196) 9 months later. Rates of ventouse delivery increased significantly in intervention units but not in control units; there was no difference between the two types of units in uptake of other practices. Pooling rates from all 25 units, use of antibiotics in caesarean section and use of polyglycolic acid sutures increased significantly over the period, but use of steroids in preterm delivery was unchanged. Labour ward guidelines seldom agreed with evidence at baseline; this hardly improved after visits. Educational visits cost pound860 each (at 1995 prices).

CONCLUSIONS

There was considerable uptake of evidence into practice in both control and intervention units between 1994 and 1995. Our educational visits added little to this, despite the informal setting, targeting of senior staff from two disciplines, and donation of educational materials. Further work is needed to define cost effective methods to enhance the uptake of evidence from systematic reviews and to clarify leadership and roles of senior obstetric staff in implementing the evidence.

Choice of instrument for vaginal delivery

This review covers a selection of the important recently published papers that show enormous variations in obstetric intervention rates. It includes references to the forceps versus vacuum extractor controversy, discussing the controlled trial data as well as selected observational studies. Papers on new equipment and techniques of delivery are reviewed, although in the recent literature these are principally related to the vacuum extractor and not to forceps. Final discussion is made of methods of ensuring adequate training.

The haemodynamic and respiratory effects of intravenous nimodipine used in the treatment of eclampsia

OBJECTIVE

To establish the antihypertensive properties of intravenous nimodipine used to treat eclamptic patients. To assess the effects of intravenous nimodipine on oxygen delivery and consumption.

DESIGN

A prospective observational study.

SETTING

The Maternity Centre Obstetric Intensive Care Unit, Groote Schuur Hospital.

PARTICIPANTS

Four unselected patients presenting with proteinuric hypertension and seizures.

METHODS

Haemodynamic observations were obtained by a radial artery catheter and right heart catheterisation with a pulmonary artery flow directed thermodilution catheter. Observations were obtained prior to and after the administration of nimodipine.

RESULTS

A significant reduction in mean arterial pressure occurred in all patients after administration of nimodipine. This was due to a significant reduction in systemic vascular resistance. Neither oxygen delivery to the tissues nor peripheral oxygen consumption changed significantly during nimodipine infusion. No adverse effects related to the use of nimodipine were documented.

CONCLUSIONS

Nimodipine is an effective vasodilator. There may be a role for nimodipine as a single agent for the management of eclampsia.

The oxygen consumption/oxygen delivery curve in severe preeclampsia: evidence for a fixed oxygen extraction state

OBJECTIVE

Increased total body oxygen consumption requirements are usually met by increased oxygen delivery and increased oxygen extraction. In certain conditions (e.g., adult respiratory distress syndrome) the ability to increase oxygen extraction is lost, and any increase in oxygen consumption depends on increased oxygen delivery. The objective of this study was to investigate the oxygen delivery/oxygen consumption relationship in severe preeclampsia.

STUDY DESIGN

Thirty-two patients with severe preeclampsia (blood pressure > 160/110 mm Hg; 3 to 4+ proteinuria) were monitored with a pulmonary artery catheter. Baseline oxygen consumption and delivery in a group without volume expansion or pharmacologic vasodilatation were compared with those in a group who had received a magnesium sulfate infusion.

RESULTS

Oxygen consumption, oxygen delivery, arterial-venous-oxygen difference, and the oxygen extraction ratio were low when compared to that for normal 32 to 38 week pregnancy. The oxygen extraction ratio, defined as the ratio of oxygen consumption to oxygen delivery, was abnormally low for pregnancy, especially considering the low oxygen delivery levels in these patients. Oxygen consumption was dependent on oxygen delivery over the entire range of values seen.

CONCLUSIONS

Severe preeclampsia is associated with an abnormality of tissue oxygen extraction, as evidenced by a low and unresponsive oxygen extraction ratio. Oxygen consumption increases proportionately with increases in oxygen delivery without reaching an oxygen delivery-independent state. Even at high oxygen delivery levels the oxygen consumption in preeclamptic patients is still abnormally low for pregnancy.

Health after childbirth: a comparison of normal and assisted vaginal delivery

413 women were included in the study: 100 who had had a normal delivery and 313 who had participated in a randomised controlled comparison of forceps or ventouse delivery. The study comprised a questionnaire and assessment at 24-48 hours after delivery and a questionnaire in the second year after delivery. There was significantly more morbidity in the women in the instrumental delivery group compared to women in the normal delivery group at both the early assessment and long-term follow-up.

Temperature changes during the first day of life in the North Staffordshire Maternity Hospital

A prospective study of post-delivery temperature changes from birth to 24 h, carried out in a busy District General Hospital is reported. The temperature fall after delivery was less than expected and reflected a high level of awareness of the dangers of hypothermia. On the basis of the findings of the survey, hypothermia in the first 24 h can be defined as a rectal temperature of less than 36.4 degrees C. Those babies who did become hypothermic were significantly more likely to be of low birth weight or preterm gestation.

A randomized prospective study comparing delivery with metal and silicone rubber vacuum extractor cups

OBJECTIVE

To determine the relative benefits and complications of assisted vaginal delivery with metal and silicone rubber vacuum extractor cups.

DESIGN

Prospective randomized controlled study.

SETTING

A busy referral maternity hospital in Kathmandu, Nepal.

SUBJECTS

101 women were assigned to delivery with the Silc-cup and 98 to delivery with the metal cup.

MAIN OUTCOME MEASURES

Success rate at achieving delivery with the assigned instrument and incidence of neonatal trauma. Analysis was by 'intention to deliver' with women remaining in their original group regardless of the eventual mode of delivery.

RESULTS

Randomization resulted in two groups of women similar in respect of age, parity, gestation and indication for delivery. The overall success rate was similar for the two instruments (Silc-cup 85% and metal cup 87%). The Silc-cup was more likely to fail if there was excessive caput (seven failures compared with one in the metal cup group). The frequency of clinically significant maternal trauma was low in both groups. There were fewer babies with clinically significant scalp trauma in the Silc-cup group (22%), compared with the metal cup group (37%).

CONCLUSIONS

The data indicate a greater tendency for the Silc-cup to fail when excessive caput is present but that metal cups are associated with increased scalp injuries.