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SESSION 3-LABOUR AND DELIVERY Published online: 09 Jun 2015.
To cite this article: (1997) SESSION 3-LABOUR AND DELIVERY, Journal of Obstetrics and Gynaecology, 17:1, S38-S42 To link to this article: http://dx.doi.org/10.1080/714892002
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British Maternal and Fetal Medicine Society Abstracts
the extent of the problem and that it can and should be addresse d; (2) convinci ng others, particul arly those w ith funds, that the problem is im portant and should be addressed and; (3) plannin g, im plem enting and evaluati ng activitie s to solve the problem which involve (a) the adaptation to ® nite resource s, (b) the introduc tion of qualityim provem ent procedur es, (c) the practice of evidenc ebased m edicine, and (d) the provisio n of consum er-orien ted m edical services . Since British obstetri cians also have the need to plan, im plem ent and evaluate , they should be capable of giving the relevant training.
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33. Safe motherhoodÐ a perinatal priority in the developing world R. PITTROF London School of Hygiene and Tropical Medicine M any exam ples show that w hat is good for the mother is also good for her baby and that poor maternal health can have severe consequ ences for her baby and older children . The data presente d w ill provide an overview of the effect of m aternal m alnutritio n, trace elem ent de® ciency, sexually transm itted diseases , malaria, safe and clean delivery , m aternal m orbidity and m ortality on perinata l health. It w ill also describe successf ul projects from develop ing countrie s w hich have im proved both m aternal and child health. It w ill be show n that maternal health interven tions can be highly cost effectiv e particul arly in countrie s w ith very lim ited resource s.
34. Assessing the quality of obstetric care in Egypt R. PITTROF, O. CAMPBELL, S. HUTTLY and T. VOS London School of Hygiene and Tropical Medicine H. KASSAS, H. ABDUL HALIM and H. SULTAN Child Survival Project, Cairo, Egypt M ore than 98% of the w orld’ s 585 000 annual m aternal deaths occur in develop ing countrie s. To change this, governm ents and donors usually aim to improve the medical infrastru cture w hile paying only lip service to issues of quality of care. The national con® dential enquiry into m aternal deaths, E gypt 1992±93, identi® ed low quality of care as a major cause of avoidab le maternal deaths. Conventio nal assessm ent of the quality of care relies on good m edical inform ation system s and record keeping . This is not the case in Egypt. B y m eans of observat ion, intervie ws and self-com pletion question naires we therefor e assessed the conditio n w hich are necessar y to practice high quality of care and investig ated infrastru cture, supplies , m edical know ledge of care provider s, m edical skills of care provide rs, attitudes , percepti ons and expecta tions of care provide rs, availabi lity of care provide rs and organisa tion of
SESSION 3Ð DELIVERY
LABOUR AND
35. The epidemic of caesarean sections in Brazil: using qualitative and quantitative methods and designing a framework for potential interventions P. F. FREITAS London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Sciences, Maternal and Child Epidemiology Unit, London Rates of caesarea n sections in Brazil have been reported as the highest in the w orld; even in the public sector alone they approac h 40% . B esides de® nite health risks, the diversion and excessiv e use of health services resource s and a tendenc y to over-m edicalisa tion of birth, with adverse social persona l and cultural im plication s, can justify efforts to reverse the onw ard increase . A study in tw o stages w as directed to these issues. The ® rst stage consiste d of literatur e review and analysis of three existing sets of data. The second stage, ® eld w ork using qualitati ve and quantita tive m ethods, was conduct ed in Florianop olis, southern Brazil. Results point to the fact that many obstetric ians in Brazil are increasi ngly predisposed to delivery by caesarea n section but also that wom en’ s requests are com m on events and are taken into account by obstetric ians. A particula r feature of excess caesarea n section in Brazil is its link w ith tubal ligation although this has been over-stre ssed in som e reports. Interventions to reduce the excessiv e rate should be therefor e directed tow ards health service personn el and obstetri c practice and also tow ards w om en approac hing delivery . The ultim ate goal of this study is to develop a com prehensive understa nding w ithin w hich potentia l interven tions to reduce the excessiv e rates can be develop ed and evaluate d.
36. Extensive thrombo-embolic disease in pregnancy treated by a novel temporary vena caval ® lter M. GEARY and R. F. LAMONT Department of Obstetrics and Gynaecology, Northwick Park Hospital, Watford Road, Harrow, Middlesex HA1 3UJ A 33-year- old w om an expectin g tw ins, presente d at 34 weeks w ith left thigh pain. Ilio-fem oral venous throm bosis was suspecte d and she was anticoag ulated. D oppler ultrasound revealed a large unstable m obile throm bus in the left com mon fem oral vein. U ltrasoun d show ed both twins had oligohyd ram nios and reduced umbilical artery end diastolic ¯ ow, dictating the need for delivery . Insertion of a caval ® lter w as necessa ry before caesarea n section. Under radiological guidanc e, a tem porary ® lter w as inserted unevent fully via the right internal jugular vein and deployed in the distal inferior vena cava. Two m ale babies were delivered in good conditio n by an uncom plicated caesarea n section. The postpart um course was unevent ful, the ® lter was re-
Poster Presentations: Labour and Delivery
m orbidity . This ® rst-tim e use of a tem porary ® lter in pregnan cy was uncom plicated . Conclusio n. U se of a tem porary caval ® lter in pregnan cy is safe. In view of its tem porary nature w e recom m end that other clinician s give consider ation to its use.
37. Interface evaluation of an intelligent knowledge-based computer system for intrapartum management
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M. HARRIS, R. D. KEITH and K. R. GREENE Perinatal Research Group, Department of Obstetrics and Gynaecology, Derriford Maternity Unit, Plymouth; and Postgraduate Medical School, University of Plymouth Clinician s are increasin gly concern ed w ith the am ount of com plex inform ation they are required to process. Intelligent know ledge-ba sed com puter system s offer an attractiv e m eans of support but few have been accepted into m ainstream m edicine due to poor user interface design. For this reason we evaluate d the prototyp e user interface of an intellige nt know ledge-ba sed inform ation system to support decision m aking during labour. T he system is personal com puter based with interface to an electron ic fetal m onitor. C ardiotoc ograph inform ation, patient history and labour events are passed to the expert system module w hich interpre ts this com bined data to provide recom mended actions. In this random allocatio n cross-ov er study 22 m idw ives and six doctors entered data (medical and obstetric history, vaginal exam ination details, birth outcom e) using one of three input devices: touchscr een, keyboar d and mouse. The procedu re w as repeated after 7 days with subjects crossing over to the next allocate d input device. U ser interact ions w ere autom atically logged to the com puter data base. Input device, screen display and usability of the system were evaluate d using a sem antic differen tial and Likert scale question naire. The study w ill be com plete in January 1997 and statistica l tests w ill include K ruskal-W allis and factor analysis . This evaluati on w ill provide a fram ew ork for develop m ent and validatio n of the user interface before evaluati on of the intellige nt decision support system in a multi-cen tre study.
38. Improved outcome following a change in the management of eclampsia in a tertiary referral centre in southern India B. S. R. KALE Queen Elizabeth Hospital, Gateshead The objectiv e was to assess the bene® ts of changin g the m anagem ent of eclam psia from a lytic cocktail to m agnesium sulphate treatm ent. This prospec tive observat ional study was conduct ed at the Tertiary Referral C entre, Governm ent General Hospital, G untur, Southern India. Eighty eclam ptic w omen were treated with m agnesium sulphate during 2 years from D e-
S39
system depressi on with m agnesium (95% ) com pared w ith the lytic cocktail (14% ). Convulsio ns w ere w ell controll ed with m agnesium sulphate and there was no recurren ce of convuls ions after the loading dose whilst with lytic cocktail there was 30% recurren ce rate. Fourteen per cent w om en were delivere d by caesarea n section. Side effects and toxicity were m inim al w ith the reduced dose of m agnesium (6-hourl y injectio ns instead of every 4 hours) w ith a overall m orbidity of 16% com pared with lytic cocktail 38% . There was one case of m aternal death due to viral hepatitis and hepatic failure; m aternal m ortality rates 1% and 8% w ith m agnesium and the lytic cocktail respectiv ely. The perinatal mortality was 38% (lytic cocktail 45% ) out of which 37% were stillbirth s and 64% were neonata l deaths. C onclusio ns. Eclam psia rem ains a major obstetric problem in India even today and maternal m ortality varies from 2% to 8% . M agnesium sulphate in this setting im proved m aternal outcom e w ith the added bene® t of being easier to adm inister and m onitor. This is acceptab le and a routine procedu re in our institutio n.
39. Augmentation of labour and routine umbilical cord blood gas analysis at delivery C. LOGHIS, E. SALAMALEKIS, N. VITORATOS, G. CHRISTODOULACOS, N. PANAYOTOPOULOS and P. BETTAS 2nd Department of Obstetrics and Gynecology, Athens University, Areteion Hospital, Athens, Greece In obstetri c units w here labour augm entation with oxytocin is a com mon procedu re, there is need for fetal status evaluati on for fetal distress associat ed w ith uterine contractions. This is achieved by several methods for intrapar tum surveilla nce and is com pared and veri® ed through Apgar scoring. A better fetal evaluati on is achieve d w ith routine umbilical cord blood sam pling and pH, P CO 2 and base de® cit determ ination. In our study we present our results of fetal status in cases of augm ented labour. A part from fetal m onitoring through cardioto cography , umbilical cord blood was obtained from both artery and vein im m ediately after delivery and pH and P CO 2 are determ ined. The results are com pared to cardioto cograph ic data and Apgar score. U p to now we have collected data from 235 cases out of 523 deliverie s from July 1995 to June 1996. The num ber of reliable arterial and venous cord sam ples w ere 213. Our results indicate that with continuo us monitorin g using cardioto cograph y the increase d m yom etrial activity caused by controll ed oxytocin adm inistratio n has no adverse effects on neonata l status.
40. Intrapartum intervention: what are we doing and why? H. LYALL, C. WILLOCKS, P. YONG, M. M CKENZIE, K. HALSTEDT, S. LEWIS, A. MATHERS, E. STENHOUSE and H. CHEYNE Glasgow Royal Maternity Hospital,
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British Maternal and Fetal Medicine Society Abstracts
nity H ospital w ith current research evidenc e; (iv) to optim ise intrapart um care by minim ising interven tion in norm al labour and targetin g appropri ate interven tions to the high risk situation . A consecu tive sam ple of all w om en delivere d in the hospital betw een M ay and October 1996 was studied prospective ly. Clinical interven tion and outcom e details for intrapar tum care were collected at the tim e of delivery using a case record extractio n proform a. An extensiv e data base has been establish ed containi ng details of all aspects of current labour w ard practice . This paper describe s the ® rst 500 m aternitie s review ed and reports the incidenc e and effects of speci® ed interven tions, for exam ple, patterns of interven tion in spontan eous labour includin g augm entation and m onitorin g, plannin g and implem entation of prim ing and inductio n of labour and the roles played by m idw ives and the obstetric medical team w ithin labour w ard. W ith this inform ation we will be able to evaluate critically intrapar tum interven tion in the high risk situation while m inim ising its use with low risk w om en.
41. A new de® nition of discordancy in twin pregnancy? N. MANASSIEV Northamptonshire Fertility Services, Three Shires Hospital, The Avenue, Northampton The objectiv e was to ® nd an objectiv e de® nition of discordancy. W hile investig ating the relations hip betw een chorioni city an the outcom e of twin pregnan cies in our cohort of twins, w e noticed that there is no universa l agreem ent of what represen ts discorda ncy. Figures of 15% , 20% and 25% are being used in scienti® c journals and obstetric textbook s. M oreover , there is no mention of whether the ® rst tw in should be com pared with the second or the second with the ® rst. For exam ple, if w e take a 15% de® nition, a tw in pair of 2140 g and 1820 g w ould be discorda nt if the smaller tw in’ s w eight w ere taken as the basis for calculat ion but not discorda nt if the heavier tw in’ s weight were taken as the basis for calculati on. This prom pted us to search for a form ula which (i) w ill not be depende nt on which twin’ s w eight is taken as the basis for calculat ion, (ii) w ould not depend on the birth order, and (iii) would be easy for use. The follow ing expressi on seem s to ® t the above objectives: A BS 2(x 2 y)/x 1 y, where x and y are the twins’ w eights. U sing our ow n twin cohort, w e have calculate d a m ean 6 s.d. 15 6 14% . This may not represen t the true populati on m ean 6 s.d. because of the large num ber of tw ins conside red to be high risk being referred to our unit. A graphic chart has been construc ted. Conclusio n. T he form ula w e are suggesti ng will resolve the controve rsy surroun ding the de® nition of discorda ncy in twin pregnan cies and provide s a ® rm m athem atical basis for calculat ion. It will need to be tested on a w ider populational basis so that its clinical signi® cance can be de® ned.
42. Outcome of a second pregnancy after a previous caesarean section in a large district hospital
ted in their second ongoing pregnan cy. Overall, 69 w om en (41% ) had a repeat elective caesarea n section with patient request being the sole indicatio n in 19 cases (27´5% ). Ninety-ni ne w omen (59% ) had a trial of scar with 45 (45% ) resulting in an emergency caesarea n section. Failure to progress in the ® rst stage w as the most com m on indicatio n, seen in 21 cases (47% ). Oxytocin was not used in any of these cases. Vaginal delivery was achieved in 54 cases (55% ) w ho had a trial of scar. T he study highligh ts (1) a reluctan ce to m anage patients with one previou s low er segm ent caesarea n scar with either prostagl andin or oxytoci n; (2) a high patient request rate for repeat elective caesarea n section.
43. Active management of labour: a ® ve years experience from a university hospital in a developing country A. A. E. ORHUE Human Reproduction Research Programme Unit, Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital, Benin City, Nigeria Active m anagem ent of labour was conceiv ed as a procedure applicab le only for parturien ts in spontan eous active phase labour. For such parturie nts, the cervical dilatatio n on adm ission was used to constru ct an individu alised ` alert line’ with a slope of 1 cm/hour and an individu alised ` action line’ at 2 hours to the right and parallel to it on the W orld H ealth O rganizat ion partogra m . N orm al progress were with dilatatio n plotted on the left of the alert line through out. W hen plotted dilatatio n crossed the action line, oxytocin augm entation w as begun and maintaine d for 8 hours m axim um , during which vaginal exam ination was perform ed at 2-hourl y interval s and a persona l nurse was assigned . Junior resident s only perform ed tw o vaginal examinations on the sam e parturien ts, 2 to 4 hours apart; the third or subsequ ent vaginal exam ination w as by a m ore senior resident or consulta nt who took over further m anagem ent. All deliverie s were review ed w eekly to assess com pliance to the protoco l. O f the 8700 total deliverie s there were 2420 prim igravidae, 1700 of whom w ere adm itted in spontan eous active phase labour and had active managem ent as outlined above. The vaginal delivery rate was 94´2% includin g 67´1% (1140 cases) who did not require augm entation . The augm entation rate was 24´7% (420 cases) from which 18´8% (320 cases) achieved vaginal delivery and the caesarea n section rate of 5´9% (100 cases) occurred in this group. Labour duration of 12 hours occurred in 99´1% (1684 cases) and 0´9% delivere d at 14 hours. C onclusio n. Active m anagem ent entails the anticipa tion of labour progress at the rate of 1 cm /hour which is best accom plished using the W orld Health Organizat ion partogram w ith individu alised alert and action lines against which plotted dilatatio n progress can be assessed visually . W ith vaginal exam ination 4-hourly intervals for norm ally progress ing parturie nts and 2-hourly for those w ith poor progress , the w orkload w ith active m anagem ent was reduced w ithout loss in capacity to pick up poor progress . The strategy of pinpoint ing the need for augm entation only to instance s of plotted dilatatio n crossing the action line
Poster Presentations: Labour and Delivery
44. Measurement of uterine activity in obstetric units with a high rate of labour induction or augmentation
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N. PANAYOTOPOULOS, E. SALAMALEKIS, N. VITORATOS, C. LOGHIS, G. CHRISTODOULACOS and C. SALABASIS 2nd Department of Obstetrics and Gynaecology, Athens University; and Areteion Hospital, Athens, Greece In Greece, m any obstetric units use oxytocin to augm ent labour. A lthough in a num ber of cases labour is induced w ith prostagl andins, the m ajority are induced w ith oxytocin. In our clinic the rate of labour augm entation is 60% , w hile the labour inductio n rate is 20% . Uterine response to oxytocin is monitored m ainly by external tocograp hy, w hile in cases characte rised as ` dif® cult’ the response is m onitored by internal tocograp hy. Intra-ute rine pressure is assessed using an intra-ute rine tip transduc er (Sensor Tip, Corom etrics). Oxytocin is given by intraven ous infusion , using an autom atic infusion pum p, giving pulsed doses for labour inductio n. In cases of labour augm entation the doses of oxytocin do not exceed 12 m u/m in. In all cases w here oxytocin is used uterine activity is previous ly m onitored by external tocograp hy. A retrospe ctive evaluati on of our patients during the decade 1986±95 lead us to the follow ing conclusi ons: (1) the rate of labour inductio n and augm entation is high; (2) the use of oxytocin is a com m on procedu re in everyda y obstetric practice ; (3) uterine activity is monitored by external tocograp hy in m ost cases and in dif® cult cases by internal tocograp hy; (4) uterine response to oxytocin is depende nt on pre-exis ting myom etrial activity rather to the dose of oxytocin ; (5) internal tocograp hy does not seem to have clear advantag es over external tocograp hy in augm ented labour.
45. A study on late cord clamping in preterm babies born at , 32 gestational weeks H. RABE, A. WACKER, E. A. SCHULZE, ÈRNIG-FRANZ, G. JOCH and R. I. HO WITTELER Departments of Paediatrics and Obstetrics, University Hospital, MuÈnster, Germany The aim of the study was to investiga te the effect of late cord clam ping in preterm babies w ith regard to postpart um adaptati on, cardiova scular circulati on during the ® rst 24 hours after birth and requirem ents for packed red cell transfus ion during the ® rst days of life. This w as a random allocatio n trial at a tertiary perinata l centre. Single preterm babies , 32 weeks gestatio nal age w ere studied. Exclusion criteria were m ultiple pregnan cies, m ajor congenit al m alform ations, R hesus incom patibilit y, fetal hydrops , A pgar score , 3 at 0 min. Delayed cord clam ping w as perform ed after 20 seconds (group I) or after 45 seconds (group II) while the baby w as placed at or below the level of the placenta if this w as possible . O xytocin was given to the mother w hen the ® rst shoulde r was delivere d. So far ten babies have been included in group I (six m ale, four fem ale, m edian gestatio nal age 28 6 6/7 weeks,
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m l/kg in group II. C onclusio n. Late cord clam ping can be used in preterm babies in order to reduce the needs for volum e therapy in the ® rst 24 hours of life and for the reductio n of packed red cells transfus ed during the ® rst days of life.
46. The vacuum extractor is the instrument of ® rst choice for operative vaginal delivery in Greece E. SALAMALEKIS, N. VITORATOS, C. LOGHIS, N. PANAYOTOPOULOS and G. CHRISTODOULACOS 2nd Department of Obstetrics and Gynaecology, Athens University, Areteion Hospital, Athens, Greece In Greece, operativ e vaginal delivery is alm ost alw ays accom plished by vacuum extractio n. The preferen ce of Greek obstetri cians for the vacuum extracto r over forceps is based on the belief, after three decades of use, that this m ethod presents less danger of com plicatio ns to the mother and fetus. In addition , the extracto r is easier to apply and needs no adjuncti ve analgesi a. In this study w e evaluate the data on operativ e delivery during 20 years (1976±95). The rate of forceps delivery w as 0´38±4´24% , while the rate for vacuum extractio n w as 15´78±21´16% . T he rate of operative deliveri es per year varied betw een 16´70% and 22´83% during this time. The rate of forceps deliverie s was 4´24% in 1976 and 1´09% in 1995, w hile the rates of vacuum extractio n were 17´20% and 19´51% respecti vely. The M alm strom Ð and recently the Silc cupÐ vacuum extracto r becam e popular since it w as ® rst introduc ed in Greece. It is still applied not only as an instrum ent for obstetric em ergencies but also in assisting in cases of a prolong ed second stage of labour. On the contrary , forceps have been applied at a low er rate from the beginnin g and today they are used only for training .
47. Does the attending obstetrician in¯ uence the mode of delivery in the uncomplicated primipara? N. Y. VARAWALLA, A. TONKS, T. GRAY and R. S. SETTATREE Birmingham Heartlands and Solihull Hospitals NHS Trust (teaching); and West Midlands Perinatal Audit Unit W e have addresse d the above question by studying the m ode of delivery in prim iparous w om en with a singleto n, cephalic and term fetus. T he registrar on call at the time of every spontan eous delivery and the senior-m ost obstetri cian present at every assisted delivery am ongst uncom plicated prim iparous wom en at Solihull M aternity U nit betw een 1 January 1992 and 31 D ecem ber 1994 was recorded . The proport ion of wom en delivere d by each mode of delivery for each of the 13 registrar s w ho w orked at the unit during the study period was com pared with that of all the other registrar s using a c 2 2 3 2 continge ncy analysis . D uring the study the total num ber of deliveri es am ongst uncom plicated prim iparous women w ere 3459; 2049 (59´2% ) were spontane ous deliveri es, 939 (27´2% ) were
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British Maternal and Fetal Medicine Society Abstracts
delivery , particula rly, caesarea n section after an unsucce ssful attem pt at operativ e vaginal delivery . Conclusio ns. Individu al registrar s have sim ilar interven tion rates but differ in the proporti on of wom en they deliver by the various modes of assisted delivery .
SESSION 4Ð OUTCOME
PREGNANCY
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48. Value of repeated transvaginal sonographic examination in assessment of placenta praevia during the third trimester S. GHOURAB and A. AL-JABARI King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia The objectiv e w as to evaluate the value of repeated vaginal sonogra phic exam ination in 46 pregnan t w om en w ho were diagnos ed to have placenta praevia early in the third trim ester. Vaginal sonogra phic exam inations w ere repeated every 2 w eeks until delivery or until the low er m argin of the placenta migrated to a distance of m ore than 3 cm from the internal cervical os. A ll patients were follow ed up until delivery and accurate localisat ion of the placenta w as docum ented at delivery Placental migration to a distance of more than 2 cm from the internal cervical os was observed up to 34±35 weeks gestatio nal age in 22 patients (48% ) but no signi® cant m igration had occurred after 35 weeks. Seventee n patients (37% ) had achieved vaginal delivery ; in all of them the last sonogra phic exam ination show ed that the low er placenta l m argin w as thin and had a tapered edge and the distance from the internal cervical os w as either m ore than 2 cm in the case of an anterior placenta praevia or more than 2´7 cm in the case of a posterio r placenta praevia. Placenta praevia had persiste d alm ost in all patients w ho either had a posterio r placenta praevia w ithin one cm from internal cervical os (six patients ) or a total placenta praevia at the initial sonogra phic exam ination. Conclusio n. Repeated vaginal sonogra phic exam ination for assessm ent of placenta praevia seem s to be unneces sary if early third trim ester exam ination show a posterio r placenta praevia within 1 cm of the internal os or a placenta praevia covering the internal os and in all other patients after 34±35 weeks gestation al age. M ode of delivery does not depend only on the distance betw een the low er edge of placenta and the internal cervical os but also on the shape of low er placenta l m argin and placenta l position .
49. Antenatal diagnosis and outcome in sacrococcygeal teratoma: a review S. R. GRANT, K. J. BRACKLEY, M. D. KILBY and M. J. WHITTLE Division of Fetal Medicine, Academic Department of Obstetrics and Gynaecology,
A retrospec tive review was made of cases listed on the regional abnorm ality register and referred to the Birm ingham W omen’ s Hospital. W e studied nine of 10 consecu tive cases of sacrococ cygeal teratom a betw een A pril 1992 and October 1996. T he decision to deliver based on ultrasou nd criteria, ultrasou nd signs of prognos tic signi® cance and neonatal survival was studied. In one case no ultrasou nd abnorm ality was seen. One pregnan cy w as term inated at 21 weeks after con® rmation of a large sacroco ccygeal teratom a. T here were six live births, includin g one of a pair of tw ins, w ith one stillbirth and three neonata l deaths. D elivery w as twice precipita ted by scan ® ndings, with one caesarea n section because of tum our size. A spiration of a cystic teratom a was perform ed in another labour. Signs of poor prognos is in the early neonatal period were: (i) solid, large and rapidly grow ing tum ours; (ii) hydram nios. Three neonates successf ully underw ent surgery; one died after a dif® cult vaginal delivery , one from exsangu ination into the tum our after caesarea n section, and the last from com plication s of prem aturity. C onclusio n. A ntenatal diagnosi s of sacroco ccygeal teratom a allow ed planning of appropri ate m anagem ent and the detectio n of im portant prognos tic signs. Perinatal mortality was 55% .
50. Risk of caesarean section in nulliparous women in post-dates pregnancy, management of post-dates pregnancies and role of a day assessment unit N. KAMETAS, R-U. KHAN, F. EBEN and J. KINGDOM Whittington Hospital; and University College Hospital, London The purpose of this ongoing tw o-site study betw een University College and the W hittingto n Hospitals is to evaluate the effective ness of day care for post-term pregnan cies. So far, 70 w om en with a gestation al age . 41 1 0 weeks attendin g the day assessm ent unit over six months were review ed. The wom en all had a singleto n pregnan cy and no m edical or obstetric problem s. Am niotic ¯ uid volum e antenatal cardioto cograph y; um bilical artery D oppler velocim etry, and B ishop’ s score or cervical score (length and dilatatio n) w ere recorded and notes were review ed for outcom e of labour and indicatio ns for caesarea n section. T hirty-thr ee wom en (47% ) had a cervical score before the decision to undertak e inductio n of labour. T ests of fetal health were typically norm al with only one non-rea ctive cardioto cogram , one abnorm al um bilical D oppler (pulsatil ity index . 1´2) and one reduced am niotic ¯ uid volum e (one or m ore pools . 2 cm depth was consider ed norm al). T he m ajority of the caesarea n sections were in nulliparous w om en having labour induced with an unfavou rable cervix and carried a 67% risk for caesarea n section, the m ajority (8/10) for failure to establish in labour follow ing inductio n. Seven of those cases were know n to be unfavourab le in the antenata l clinic, yet despite norm al antenatal tests, routine inductio n was perform ed. T he alternati ve option of prolongi ng post-ter m pregnan cies with norm al tests of fetal well being using addition al
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SESSION 3-LABOUR AND DELIVERY Published online: 09 Jun 2015.
To cite this article: (1997) SESSION 3-LABOUR AND DELIVERY, Journal of Obstetrics and Gynaecology, 17:1, S38-S42 To link to this article: http://dx.doi.org/10.1080/714892002
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British Maternal and Fetal Medicine Society Abstracts
the extent of the problem and that it can and should be addresse d; (2) convinci ng others, particul arly those w ith funds, that the problem is im portant and should be addressed and; (3) plannin g, im plem enting and evaluati ng activitie s to solve the problem which involve (a) the adaptation to ® nite resource s, (b) the introduc tion of qualityim provem ent procedur es, (c) the practice of evidenc ebased m edicine, and (d) the provisio n of consum er-orien ted m edical services . Since British obstetri cians also have the need to plan, im plem ent and evaluate , they should be capable of giving the relevant training.
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33. Safe motherhoodÐ a perinatal priority in the developing world R. PITTROF London School of Hygiene and Tropical Medicine M any exam ples show that w hat is good for the mother is also good for her baby and that poor maternal health can have severe consequ ences for her baby and older children . The data presente d w ill provide an overview of the effect of m aternal m alnutritio n, trace elem ent de® ciency, sexually transm itted diseases , malaria, safe and clean delivery , m aternal m orbidity and m ortality on perinata l health. It w ill also describe successf ul projects from develop ing countrie s w hich have im proved both m aternal and child health. It w ill be show n that maternal health interven tions can be highly cost effectiv e particul arly in countrie s w ith very lim ited resource s.
34. Assessing the quality of obstetric care in Egypt R. PITTROF, O. CAMPBELL, S. HUTTLY and T. VOS London School of Hygiene and Tropical Medicine H. KASSAS, H. ABDUL HALIM and H. SULTAN Child Survival Project, Cairo, Egypt M ore than 98% of the w orld’ s 585 000 annual m aternal deaths occur in develop ing countrie s. To change this, governm ents and donors usually aim to improve the medical infrastru cture w hile paying only lip service to issues of quality of care. The national con® dential enquiry into m aternal deaths, E gypt 1992±93, identi® ed low quality of care as a major cause of avoidab le maternal deaths. Conventio nal assessm ent of the quality of care relies on good m edical inform ation system s and record keeping . This is not the case in Egypt. B y m eans of observat ion, intervie ws and self-com pletion question naires we therefor e assessed the conditio n w hich are necessar y to practice high quality of care and investig ated infrastru cture, supplies , m edical know ledge of care provider s, m edical skills of care provide rs, attitudes , percepti ons and expecta tions of care provide rs, availabi lity of care provide rs and organisa tion of
SESSION 3Ð DELIVERY
LABOUR AND
35. The epidemic of caesarean sections in Brazil: using qualitative and quantitative methods and designing a framework for potential interventions P. F. FREITAS London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Sciences, Maternal and Child Epidemiology Unit, London Rates of caesarea n sections in Brazil have been reported as the highest in the w orld; even in the public sector alone they approac h 40% . B esides de® nite health risks, the diversion and excessiv e use of health services resource s and a tendenc y to over-m edicalisa tion of birth, with adverse social persona l and cultural im plication s, can justify efforts to reverse the onw ard increase . A study in tw o stages w as directed to these issues. The ® rst stage consiste d of literatur e review and analysis of three existing sets of data. The second stage, ® eld w ork using qualitati ve and quantita tive m ethods, was conduct ed in Florianop olis, southern Brazil. Results point to the fact that many obstetric ians in Brazil are increasi ngly predisposed to delivery by caesarea n section but also that wom en’ s requests are com m on events and are taken into account by obstetric ians. A particula r feature of excess caesarea n section in Brazil is its link w ith tubal ligation although this has been over-stre ssed in som e reports. Interventions to reduce the excessiv e rate should be therefor e directed tow ards health service personn el and obstetri c practice and also tow ards w om en approac hing delivery . The ultim ate goal of this study is to develop a com prehensive understa nding w ithin w hich potentia l interven tions to reduce the excessiv e rates can be develop ed and evaluate d.
36. Extensive thrombo-embolic disease in pregnancy treated by a novel temporary vena caval ® lter M. GEARY and R. F. LAMONT Department of Obstetrics and Gynaecology, Northwick Park Hospital, Watford Road, Harrow, Middlesex HA1 3UJ A 33-year- old w om an expectin g tw ins, presente d at 34 weeks w ith left thigh pain. Ilio-fem oral venous throm bosis was suspecte d and she was anticoag ulated. D oppler ultrasound revealed a large unstable m obile throm bus in the left com mon fem oral vein. U ltrasoun d show ed both twins had oligohyd ram nios and reduced umbilical artery end diastolic ¯ ow, dictating the need for delivery . Insertion of a caval ® lter w as necessa ry before caesarea n section. Under radiological guidanc e, a tem porary ® lter w as inserted unevent fully via the right internal jugular vein and deployed in the distal inferior vena cava. Two m ale babies were delivered in good conditio n by an uncom plicated caesarea n section. The postpart um course was unevent ful, the ® lter was re-
Poster Presentations: Labour and Delivery
m orbidity . This ® rst-tim e use of a tem porary ® lter in pregnan cy was uncom plicated . Conclusio n. U se of a tem porary caval ® lter in pregnan cy is safe. In view of its tem porary nature w e recom m end that other clinician s give consider ation to its use.
37. Interface evaluation of an intelligent knowledge-based computer system for intrapartum management
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M. HARRIS, R. D. KEITH and K. R. GREENE Perinatal Research Group, Department of Obstetrics and Gynaecology, Derriford Maternity Unit, Plymouth; and Postgraduate Medical School, University of Plymouth Clinician s are increasin gly concern ed w ith the am ount of com plex inform ation they are required to process. Intelligent know ledge-ba sed com puter system s offer an attractiv e m eans of support but few have been accepted into m ainstream m edicine due to poor user interface design. For this reason we evaluate d the prototyp e user interface of an intellige nt know ledge-ba sed inform ation system to support decision m aking during labour. T he system is personal com puter based with interface to an electron ic fetal m onitor. C ardiotoc ograph inform ation, patient history and labour events are passed to the expert system module w hich interpre ts this com bined data to provide recom mended actions. In this random allocatio n cross-ov er study 22 m idw ives and six doctors entered data (medical and obstetric history, vaginal exam ination details, birth outcom e) using one of three input devices: touchscr een, keyboar d and mouse. The procedu re w as repeated after 7 days with subjects crossing over to the next allocate d input device. U ser interact ions w ere autom atically logged to the com puter data base. Input device, screen display and usability of the system were evaluate d using a sem antic differen tial and Likert scale question naire. The study w ill be com plete in January 1997 and statistica l tests w ill include K ruskal-W allis and factor analysis . This evaluati on w ill provide a fram ew ork for develop m ent and validatio n of the user interface before evaluati on of the intellige nt decision support system in a multi-cen tre study.
38. Improved outcome following a change in the management of eclampsia in a tertiary referral centre in southern India B. S. R. KALE Queen Elizabeth Hospital, Gateshead The objectiv e was to assess the bene® ts of changin g the m anagem ent of eclam psia from a lytic cocktail to m agnesium sulphate treatm ent. This prospec tive observat ional study was conduct ed at the Tertiary Referral C entre, Governm ent General Hospital, G untur, Southern India. Eighty eclam ptic w omen were treated with m agnesium sulphate during 2 years from D e-
S39
system depressi on with m agnesium (95% ) com pared w ith the lytic cocktail (14% ). Convulsio ns w ere w ell controll ed with m agnesium sulphate and there was no recurren ce of convuls ions after the loading dose whilst with lytic cocktail there was 30% recurren ce rate. Fourteen per cent w om en were delivere d by caesarea n section. Side effects and toxicity were m inim al w ith the reduced dose of m agnesium (6-hourl y injectio ns instead of every 4 hours) w ith a overall m orbidity of 16% com pared with lytic cocktail 38% . There was one case of m aternal death due to viral hepatitis and hepatic failure; m aternal m ortality rates 1% and 8% w ith m agnesium and the lytic cocktail respectiv ely. The perinatal mortality was 38% (lytic cocktail 45% ) out of which 37% were stillbirth s and 64% were neonata l deaths. C onclusio ns. Eclam psia rem ains a major obstetric problem in India even today and maternal m ortality varies from 2% to 8% . M agnesium sulphate in this setting im proved m aternal outcom e w ith the added bene® t of being easier to adm inister and m onitor. This is acceptab le and a routine procedu re in our institutio n.
39. Augmentation of labour and routine umbilical cord blood gas analysis at delivery C. LOGHIS, E. SALAMALEKIS, N. VITORATOS, G. CHRISTODOULACOS, N. PANAYOTOPOULOS and P. BETTAS 2nd Department of Obstetrics and Gynecology, Athens University, Areteion Hospital, Athens, Greece In obstetri c units w here labour augm entation with oxytocin is a com mon procedu re, there is need for fetal status evaluati on for fetal distress associat ed w ith uterine contractions. This is achieved by several methods for intrapar tum surveilla nce and is com pared and veri® ed through Apgar scoring. A better fetal evaluati on is achieve d w ith routine umbilical cord blood sam pling and pH, P CO 2 and base de® cit determ ination. In our study we present our results of fetal status in cases of augm ented labour. A part from fetal m onitoring through cardioto cography , umbilical cord blood was obtained from both artery and vein im m ediately after delivery and pH and P CO 2 are determ ined. The results are com pared to cardioto cograph ic data and Apgar score. U p to now we have collected data from 235 cases out of 523 deliverie s from July 1995 to June 1996. The num ber of reliable arterial and venous cord sam ples w ere 213. Our results indicate that with continuo us monitorin g using cardioto cograph y the increase d m yom etrial activity caused by controll ed oxytocin adm inistratio n has no adverse effects on neonata l status.
40. Intrapartum intervention: what are we doing and why? H. LYALL, C. WILLOCKS, P. YONG, M. M CKENZIE, K. HALSTEDT, S. LEWIS, A. MATHERS, E. STENHOUSE and H. CHEYNE Glasgow Royal Maternity Hospital,
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British Maternal and Fetal Medicine Society Abstracts
nity H ospital w ith current research evidenc e; (iv) to optim ise intrapart um care by minim ising interven tion in norm al labour and targetin g appropri ate interven tions to the high risk situation . A consecu tive sam ple of all w om en delivere d in the hospital betw een M ay and October 1996 was studied prospective ly. Clinical interven tion and outcom e details for intrapar tum care were collected at the tim e of delivery using a case record extractio n proform a. An extensiv e data base has been establish ed containi ng details of all aspects of current labour w ard practice . This paper describe s the ® rst 500 m aternitie s review ed and reports the incidenc e and effects of speci® ed interven tions, for exam ple, patterns of interven tion in spontan eous labour includin g augm entation and m onitorin g, plannin g and implem entation of prim ing and inductio n of labour and the roles played by m idw ives and the obstetric medical team w ithin labour w ard. W ith this inform ation we will be able to evaluate critically intrapar tum interven tion in the high risk situation while m inim ising its use with low risk w om en.
41. A new de® nition of discordancy in twin pregnancy? N. MANASSIEV Northamptonshire Fertility Services, Three Shires Hospital, The Avenue, Northampton The objectiv e was to ® nd an objectiv e de® nition of discordancy. W hile investig ating the relations hip betw een chorioni city an the outcom e of twin pregnan cies in our cohort of twins, w e noticed that there is no universa l agreem ent of what represen ts discorda ncy. Figures of 15% , 20% and 25% are being used in scienti® c journals and obstetric textbook s. M oreover , there is no mention of whether the ® rst tw in should be com pared with the second or the second with the ® rst. For exam ple, if w e take a 15% de® nition, a tw in pair of 2140 g and 1820 g w ould be discorda nt if the smaller tw in’ s w eight w ere taken as the basis for calculat ion but not discorda nt if the heavier tw in’ s weight were taken as the basis for calculati on. This prom pted us to search for a form ula which (i) w ill not be depende nt on which twin’ s w eight is taken as the basis for calculat ion, (ii) w ould not depend on the birth order, and (iii) would be easy for use. The follow ing expressi on seem s to ® t the above objectives: A BS 2(x 2 y)/x 1 y, where x and y are the twins’ w eights. U sing our ow n twin cohort, w e have calculate d a m ean 6 s.d. 15 6 14% . This may not represen t the true populati on m ean 6 s.d. because of the large num ber of tw ins conside red to be high risk being referred to our unit. A graphic chart has been construc ted. Conclusio n. T he form ula w e are suggesti ng will resolve the controve rsy surroun ding the de® nition of discorda ncy in twin pregnan cies and provide s a ® rm m athem atical basis for calculat ion. It will need to be tested on a w ider populational basis so that its clinical signi® cance can be de® ned.
42. Outcome of a second pregnancy after a previous caesarean section in a large district hospital
ted in their second ongoing pregnan cy. Overall, 69 w om en (41% ) had a repeat elective caesarea n section with patient request being the sole indicatio n in 19 cases (27´5% ). Ninety-ni ne w omen (59% ) had a trial of scar with 45 (45% ) resulting in an emergency caesarea n section. Failure to progress in the ® rst stage w as the most com m on indicatio n, seen in 21 cases (47% ). Oxytocin was not used in any of these cases. Vaginal delivery was achieved in 54 cases (55% ) w ho had a trial of scar. T he study highligh ts (1) a reluctan ce to m anage patients with one previou s low er segm ent caesarea n scar with either prostagl andin or oxytoci n; (2) a high patient request rate for repeat elective caesarea n section.
43. Active management of labour: a ® ve years experience from a university hospital in a developing country A. A. E. ORHUE Human Reproduction Research Programme Unit, Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital, Benin City, Nigeria Active m anagem ent of labour was conceiv ed as a procedure applicab le only for parturien ts in spontan eous active phase labour. For such parturie nts, the cervical dilatatio n on adm ission was used to constru ct an individu alised ` alert line’ with a slope of 1 cm/hour and an individu alised ` action line’ at 2 hours to the right and parallel to it on the W orld H ealth O rganizat ion partogra m . N orm al progress were with dilatatio n plotted on the left of the alert line through out. W hen plotted dilatatio n crossed the action line, oxytocin augm entation w as begun and maintaine d for 8 hours m axim um , during which vaginal exam ination was perform ed at 2-hourl y interval s and a persona l nurse was assigned . Junior resident s only perform ed tw o vaginal examinations on the sam e parturien ts, 2 to 4 hours apart; the third or subsequ ent vaginal exam ination w as by a m ore senior resident or consulta nt who took over further m anagem ent. All deliverie s were review ed w eekly to assess com pliance to the protoco l. O f the 8700 total deliverie s there were 2420 prim igravidae, 1700 of whom w ere adm itted in spontan eous active phase labour and had active managem ent as outlined above. The vaginal delivery rate was 94´2% includin g 67´1% (1140 cases) who did not require augm entation . The augm entation rate was 24´7% (420 cases) from which 18´8% (320 cases) achieved vaginal delivery and the caesarea n section rate of 5´9% (100 cases) occurred in this group. Labour duration of 12 hours occurred in 99´1% (1684 cases) and 0´9% delivere d at 14 hours. C onclusio n. Active m anagem ent entails the anticipa tion of labour progress at the rate of 1 cm /hour which is best accom plished using the W orld Health Organizat ion partogram w ith individu alised alert and action lines against which plotted dilatatio n progress can be assessed visually . W ith vaginal exam ination 4-hourly intervals for norm ally progress ing parturie nts and 2-hourly for those w ith poor progress , the w orkload w ith active m anagem ent was reduced w ithout loss in capacity to pick up poor progress . The strategy of pinpoint ing the need for augm entation only to instance s of plotted dilatatio n crossing the action line
Poster Presentations: Labour and Delivery
44. Measurement of uterine activity in obstetric units with a high rate of labour induction or augmentation
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N. PANAYOTOPOULOS, E. SALAMALEKIS, N. VITORATOS, C. LOGHIS, G. CHRISTODOULACOS and C. SALABASIS 2nd Department of Obstetrics and Gynaecology, Athens University; and Areteion Hospital, Athens, Greece In Greece, m any obstetric units use oxytocin to augm ent labour. A lthough in a num ber of cases labour is induced w ith prostagl andins, the m ajority are induced w ith oxytocin. In our clinic the rate of labour augm entation is 60% , w hile the labour inductio n rate is 20% . Uterine response to oxytocin is monitored m ainly by external tocograp hy, w hile in cases characte rised as ` dif® cult’ the response is m onitored by internal tocograp hy. Intra-ute rine pressure is assessed using an intra-ute rine tip transduc er (Sensor Tip, Corom etrics). Oxytocin is given by intraven ous infusion , using an autom atic infusion pum p, giving pulsed doses for labour inductio n. In cases of labour augm entation the doses of oxytocin do not exceed 12 m u/m in. In all cases w here oxytocin is used uterine activity is previous ly m onitored by external tocograp hy. A retrospe ctive evaluati on of our patients during the decade 1986±95 lead us to the follow ing conclusi ons: (1) the rate of labour inductio n and augm entation is high; (2) the use of oxytocin is a com m on procedu re in everyda y obstetric practice ; (3) uterine activity is monitored by external tocograp hy in m ost cases and in dif® cult cases by internal tocograp hy; (4) uterine response to oxytocin is depende nt on pre-exis ting myom etrial activity rather to the dose of oxytocin ; (5) internal tocograp hy does not seem to have clear advantag es over external tocograp hy in augm ented labour.
45. A study on late cord clamping in preterm babies born at , 32 gestational weeks H. RABE, A. WACKER, E. A. SCHULZE, ÈRNIG-FRANZ, G. JOCH and R. I. HO WITTELER Departments of Paediatrics and Obstetrics, University Hospital, MuÈnster, Germany The aim of the study was to investiga te the effect of late cord clam ping in preterm babies w ith regard to postpart um adaptati on, cardiova scular circulati on during the ® rst 24 hours after birth and requirem ents for packed red cell transfus ion during the ® rst days of life. This w as a random allocatio n trial at a tertiary perinata l centre. Single preterm babies , 32 weeks gestatio nal age w ere studied. Exclusion criteria were m ultiple pregnan cies, m ajor congenit al m alform ations, R hesus incom patibilit y, fetal hydrops , A pgar score , 3 at 0 min. Delayed cord clam ping w as perform ed after 20 seconds (group I) or after 45 seconds (group II) while the baby w as placed at or below the level of the placenta if this w as possible . O xytocin was given to the mother w hen the ® rst shoulde r was delivere d. So far ten babies have been included in group I (six m ale, four fem ale, m edian gestatio nal age 28 6 6/7 weeks,
S41
m l/kg in group II. C onclusio n. Late cord clam ping can be used in preterm babies in order to reduce the needs for volum e therapy in the ® rst 24 hours of life and for the reductio n of packed red cells transfus ed during the ® rst days of life.
46. The vacuum extractor is the instrument of ® rst choice for operative vaginal delivery in Greece E. SALAMALEKIS, N. VITORATOS, C. LOGHIS, N. PANAYOTOPOULOS and G. CHRISTODOULACOS 2nd Department of Obstetrics and Gynaecology, Athens University, Areteion Hospital, Athens, Greece In Greece, operativ e vaginal delivery is alm ost alw ays accom plished by vacuum extractio n. The preferen ce of Greek obstetri cians for the vacuum extracto r over forceps is based on the belief, after three decades of use, that this m ethod presents less danger of com plicatio ns to the mother and fetus. In addition , the extracto r is easier to apply and needs no adjuncti ve analgesi a. In this study w e evaluate the data on operativ e delivery during 20 years (1976±95). The rate of forceps delivery w as 0´38±4´24% , while the rate for vacuum extractio n w as 15´78±21´16% . T he rate of operative deliveri es per year varied betw een 16´70% and 22´83% during this time. The rate of forceps deliverie s was 4´24% in 1976 and 1´09% in 1995, w hile the rates of vacuum extractio n were 17´20% and 19´51% respecti vely. The M alm strom Ð and recently the Silc cupÐ vacuum extracto r becam e popular since it w as ® rst introduc ed in Greece. It is still applied not only as an instrum ent for obstetric em ergencies but also in assisting in cases of a prolong ed second stage of labour. On the contrary , forceps have been applied at a low er rate from the beginnin g and today they are used only for training .
47. Does the attending obstetrician in¯ uence the mode of delivery in the uncomplicated primipara? N. Y. VARAWALLA, A. TONKS, T. GRAY and R. S. SETTATREE Birmingham Heartlands and Solihull Hospitals NHS Trust (teaching); and West Midlands Perinatal Audit Unit W e have addresse d the above question by studying the m ode of delivery in prim iparous w om en with a singleto n, cephalic and term fetus. T he registrar on call at the time of every spontan eous delivery and the senior-m ost obstetri cian present at every assisted delivery am ongst uncom plicated prim iparous wom en at Solihull M aternity U nit betw een 1 January 1992 and 31 D ecem ber 1994 was recorded . The proport ion of wom en delivere d by each mode of delivery for each of the 13 registrar s w ho w orked at the unit during the study period was com pared with that of all the other registrar s using a c 2 2 3 2 continge ncy analysis . D uring the study the total num ber of deliveri es am ongst uncom plicated prim iparous women w ere 3459; 2049 (59´2% ) were spontane ous deliveri es, 939 (27´2% ) were
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British Maternal and Fetal Medicine Society Abstracts
delivery , particula rly, caesarea n section after an unsucce ssful attem pt at operativ e vaginal delivery . Conclusio ns. Individu al registrar s have sim ilar interven tion rates but differ in the proporti on of wom en they deliver by the various modes of assisted delivery .
SESSION 4Ð OUTCOME
PREGNANCY
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48. Value of repeated transvaginal sonographic examination in assessment of placenta praevia during the third trimester S. GHOURAB and A. AL-JABARI King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia The objectiv e w as to evaluate the value of repeated vaginal sonogra phic exam ination in 46 pregnan t w om en w ho were diagnos ed to have placenta praevia early in the third trim ester. Vaginal sonogra phic exam inations w ere repeated every 2 w eeks until delivery or until the low er m argin of the placenta migrated to a distance of m ore than 3 cm from the internal cervical os. A ll patients were follow ed up until delivery and accurate localisat ion of the placenta w as docum ented at delivery Placental migration to a distance of more than 2 cm from the internal cervical os was observed up to 34±35 weeks gestatio nal age in 22 patients (48% ) but no signi® cant m igration had occurred after 35 weeks. Seventee n patients (37% ) had achieved vaginal delivery ; in all of them the last sonogra phic exam ination show ed that the low er placenta l m argin w as thin and had a tapered edge and the distance from the internal cervical os w as either m ore than 2 cm in the case of an anterior placenta praevia or more than 2´7 cm in the case of a posterio r placenta praevia. Placenta praevia had persiste d alm ost in all patients w ho either had a posterio r placenta praevia w ithin one cm from internal cervical os (six patients ) or a total placenta praevia at the initial sonogra phic exam ination. Conclusio n. Repeated vaginal sonogra phic exam ination for assessm ent of placenta praevia seem s to be unneces sary if early third trim ester exam ination show a posterio r placenta praevia within 1 cm of the internal os or a placenta praevia covering the internal os and in all other patients after 34±35 weeks gestation al age. M ode of delivery does not depend only on the distance betw een the low er edge of placenta and the internal cervical os but also on the shape of low er placenta l m argin and placenta l position .
49. Antenatal diagnosis and outcome in sacrococcygeal teratoma: a review S. R. GRANT, K. J. BRACKLEY, M. D. KILBY and M. J. WHITTLE Division of Fetal Medicine, Academic Department of Obstetrics and Gynaecology,
A retrospec tive review was made of cases listed on the regional abnorm ality register and referred to the Birm ingham W omen’ s Hospital. W e studied nine of 10 consecu tive cases of sacrococ cygeal teratom a betw een A pril 1992 and October 1996. T he decision to deliver based on ultrasou nd criteria, ultrasou nd signs of prognos tic signi® cance and neonatal survival was studied. In one case no ultrasou nd abnorm ality was seen. One pregnan cy w as term inated at 21 weeks after con® rmation of a large sacroco ccygeal teratom a. T here were six live births, includin g one of a pair of tw ins, w ith one stillbirth and three neonata l deaths. D elivery w as twice precipita ted by scan ® ndings, with one caesarea n section because of tum our size. A spiration of a cystic teratom a was perform ed in another labour. Signs of poor prognos is in the early neonatal period were: (i) solid, large and rapidly grow ing tum ours; (ii) hydram nios. Three neonates successf ully underw ent surgery; one died after a dif® cult vaginal delivery , one from exsangu ination into the tum our after caesarea n section, and the last from com plication s of prem aturity. C onclusio n. A ntenatal diagnosi s of sacroco ccygeal teratom a allow ed planning of appropri ate m anagem ent and the detectio n of im portant prognos tic signs. Perinatal mortality was 55% .
50. Risk of caesarean section in nulliparous women in post-dates pregnancy, management of post-dates pregnancies and role of a day assessment unit N. KAMETAS, R-U. KHAN, F. EBEN and J. KINGDOM Whittington Hospital; and University College Hospital, London The purpose of this ongoing tw o-site study betw een University College and the W hittingto n Hospitals is to evaluate the effective ness of day care for post-term pregnan cies. So far, 70 w om en with a gestation al age . 41 1 0 weeks attendin g the day assessm ent unit over six months were review ed. The wom en all had a singleto n pregnan cy and no m edical or obstetric problem s. Am niotic ¯ uid volum e antenatal cardioto cograph y; um bilical artery D oppler velocim etry, and B ishop’ s score or cervical score (length and dilatatio n) w ere recorded and notes were review ed for outcom e of labour and indicatio ns for caesarea n section. T hirty-thr ee wom en (47% ) had a cervical score before the decision to undertak e inductio n of labour. T ests of fetal health were typically norm al with only one non-rea ctive cardioto cogram , one abnorm al um bilical D oppler (pulsatil ity index . 1´2) and one reduced am niotic ¯ uid volum e (one or m ore pools . 2 cm depth was consider ed norm al). T he m ajority of the caesarea n sections were in nulliparous w om en having labour induced with an unfavou rable cervix and carried a 67% risk for caesarea n section, the m ajority (8/10) for failure to establish in labour follow ing inductio n. Seven of those cases were know n to be unfavourab le in the antenata l clinic, yet despite norm al antenatal tests, routine inductio n was perform ed. T he alternati ve option of prolongi ng post-ter m pregnan cies with norm al tests of fetal well being using addition al
