A randomized study of combined spinal-epidural analgesia versus intravenous meperidine during labor: impact on cesarean delivery rate.

Background: Combined spinal-epidural (CSE) analgesia produces rapid-onset pain relief and allows ambulation in early labor. Epidural local anesthetics may contribute to an increase in operative deliveries by decreasing perineal sensation and causing motor weakness. Operative delivery rates might be reduced with CSE, by avoiding or delaying administration of local anesthetics.

Lack of effect of walking on labor and delivery.

Background And Methods: Walking during labor may reduce patients' discomfort and improve outcomes. We conducted a randomized trial of walking during active labor to determine whether it altered the duration of labor or other maternal or fetal outcomes. Women with uncomplicated pregnancies between 36 and 41 weeks' gestation and in active labor were randomly assigned either to walking or to no walking (usual care).

Does magnesium sulfate given for prevention of eclampsia affect the outcome of labor?

Objective: The purpose of this study was to determine whether magnesium sulfate given for prevention of eclampsia affected labor outcomes compared with phenytoin, which is not known to impede uterine activity when given in anticonvulsant doses.

Study Design: Secondary analysis was performed of a study of women with pregnancy-induced hypertension who were admitted for delivery and randomly assigned to receive either magnesium sulfate or phenytoin for eclampsia prophylaxis. Nulliparous women with a singleton pregnancy in cephalic presentation at term were selected for analysis in an effort to limit the influence of confounding variables such as preterm birth and malpresentations on labor management and outcomes.

Clinical chorioamnionitis and the prognosis for very low birth weight infants.

Objective: To determine the effects of clinical chorioamnionitis on neonatal morbidity and mortality in very low birth weight infants.

Methods: This was an observational cohort analysis of all singleton live-born infants weighing 500-1500 g at 24 weeks' or greater gestational age and born between 1988 and 1996 at Parkland Memorial Hospital, Dallas, Texas. Chorioamnionitis was diagnosed on the basis of maternal fever of 38C with supporting clinical evidence, which included fetal tachycardia, uterine tenderness, and/or malodorous infant, and the absence of another source of infection.

The course of labor with and without epidural analgesia.

Objective: Our purpose was to measure effects of epidural analgesia on labor compared with boluses of meperidine in a cohort of women with similar clinical circumstances.

Study Design: One hundred ninety-nine nulliparous women who were delivered spontaneously at term and who received oxytocin for labor augmentation before the initiation of analgesia were identified for analysis. All these women were managed in a low-risk labor unit according to a standardized protocol.

Pregnancy outcomes in women with gestational diabetes compared with the general obstetric population.

Objective: To compare pregnancy outcome in a homogeneous group of women with glucose intolerance with that of women without this disorder.

Methods: This was a retrospective cohort study of all women with singleton cephalic-presenting pregnancies delivered at University of Texas Southwestern Medical Center during the period January 1, 1991, through December 31, 1995. During this period, women were screened selectively for glucose intolerance and National Diabetes Data Group thresholds were used to diagnose gestational diabetes.

Cesarean delivery: a randomized trial of epidural versus patient-controlled meperidine analgesia during labor.

Background: Reports indicate that the administration of epidural analgesia for pain relief during labor interferes with labor and increases cesarean deliveries. However, only a few controlled trials have assessed the effect of epidural analgesia on the incidence of cesarean delivery. The authors' primary purpose in this randomized study was to evaluate the effects of epidural analgesia on the rate of cesarean deliveries by providing a suitable alternative: patient-controlled intravenous analgesia.

Intraventricular hemorrhage and fetal heart rate in very low birth weight infants.

Objective: This study was designed to investigate the relationship between fetal heart rate patterns before delivery and periventricular-intraventricular hemorrhage in the very low birth weight infant.

Study Design: The last 30 minutes of electronic fetal heart rate data preceding delivery were analyzed for 84 singleton infants weighing between 700 and 1500 gm. All these infants received serial cranial ultrasonographic examinations commencing within 24 to 48 hours of birth.

Amniotic fluid meconium: a fetal environmental hazard.

Objective: To investigate the hypothesis that meconium aspiration syndrome, the major hazard of meconium during labor, may be associated with superimposed fetal acute acidemia.

Methods: Umbilical artery blood gases were measured in 7816 term pregnancies with meconium in the amniotic fluid (AF) and the results were correlated with intrapartum and neonatal outcomes.

Results: Sixty-nine (1%) infants developed meconium aspiration syndrome and 31 (45%) of these were in association with fetal acidemia at birth.

Randomized investigation of antimicrobials for the prevention of preterm birth.

Objective: Occult amniotic fluid infection has emerged as a possible cause of many heretofore unexplained preterm births. We sought to determine whether antimicrobial therapy is effective in preventing preterm delivery.

Study Design: A double-blind, placebo-controlled, randomized trial was conducted to study the efficacy of ampicillin-sulbactam and amoxicillin-clavulanic acid in women hospitalized for preterm labor between 24 and 34 weeks' gestation.

Obstetric clavicular fracture: the enigma of normal birth.

Objective: To determine the main risk factors involved in neonatal clavicular fracture, the most common injury to the neonate.

Methods: Two hundred fifteen cases of clavicular fracture of 65,091 vaginal deliveries (0.4%) occurring between January 1983 and December 1988 were pair-matched with controls based on mode and date of delivery, race, and maternal age.

Intentional delivery versus expectant management with preterm ruptured membranes at 30-34 weeks' gestation.

Objective: To determine maternal and neonatal outcomes in pregnancies complicated by preterm rupture of membranes (PROM) at 30-34 weeks' gestation.

Methods: A randomized controlled trial was conducted to study the benefits of expectant management in women hospitalized for PROM at 30-34 weeks' gestation. During this investigation, no tocolytics, corticosteroids, or prophylactic antibiotics were used.

Randomized trial of epidural versus intravenous analgesia during labor.

Objective: To compare the effects of epidural analgesia with intravenous (IV) analgesia on the outcome of labor.

Methods: Thirteen hundred thirty women with uncomplicated term pregnancies and in spontaneous labor were randomized to be offered epidural bupivacaine-fentanyl or IV meperidine analgesia during labor.

Results: Comparison of the allocation groups by intent to treat revealed a significant association between epidural allocation and operative delivery for dystocia.

The pregnant patient with an intracranial arteriovenous malformation. Cesarean or vaginal delivery using regional or general anesthesia?

Background And Objectives: A parturient with large intracranial arteriovenous malformation presented for elective cesarean delivery.

Methods: The anesthetic technique included acute hydration with intravenous crystalloid followed by continuous epidural anesthesia with bupivacaine and fentanyl and oxygen by face mask. Intraoperative monitoring consisted of electrocardiography, pulse oximetry, invasive arterial blood pressure, and analysis of arterial blood gases.

Randomized comparison of general and regional anesthesia for cesarean delivery in pregnancies complicated by severe preeclampsia.

Objective: To evaluate the maternal and fetal effects of three anesthetic methods used randomly in women with severe preeclampsia who required cesarean delivery.

Methods: Eighty women with severe preeclampsia, who were to be delivered by cesarean, were randomized to general (26 women), epidural (27), or combined spinal-epidural (27) anesthesia. The mean preoperative blood pressure (BP) was approximately 170/110 mmHg, and all women had proteinuria.

A comparison of magnesium sulfate with phenytoin for the prevention of eclampsia.

Background: Magnesium sulfate is used widely to prevent eclamptic seizures in pregnant women with hypertension, but few studies have compared the efficacy of magnesium sulfate with that of other drugs. Anticonvulsant prophylaxis with phenytoin for eclampsia has been recommended, but there are virtually no data to support its efficacy. Our objective was to compare magnesium sulfate with phenytoin in preventing seizures in hypertensive women during labor.

Genital herpes during pregnancy: no lesions, no cesarean.

Objective: To determine the effects at our hospital of adoption of the 1988 guidelines recommended by ACOG for management of genital herpes infections during pregnancy.

Methods: Between 1984-1986, 96 pregnancies complicated by active genital herpes were delivered at Parkland Hospital. The outcome of these pregnancies were compared with 217 similar pregnancies managed after implementation of the 1988 ACOG herpes guidelines.

Fetal acidemia associated with regional anesthesia for elective cesarean delivery.

Objective: To determine the prevalence, magnitude, and type of fetal acidemia associated with contemporary obstetric anesthetic techniques.

Methods: Umbilical artery blood gases were obtained in 1601 singleton pregnancies delivered by elective cesarean.

Results: General anesthesia was used in 371 (23%) women, epidural in 286 (18%), combined spinal-epidural in 659 (41%), and spinal in 231 (14%).

The economic advantages of measured change in health care: an example from obstetrics.

To evaluate the economic effects of an increased oxytocin dosage for labor stimulation at a large urban hospital, a cost analysis of a before and after cohort, analytic clinical trial was performed. Delivery outcomes for two different oxytocin dosages were evaluated from the perspective of provider and consumer costs attributable to the oxytocin regimen. The high-dose oxytocin regimen resulted in an estimated provider and consumer cost savings of approximately $350,000 per year.

Maternal youth and pregnancy outcomes: middle school versus high school age groups compared with women beyond the teen years.

Objective: We sought to measure and compare pregnancy complications in middle school versus high school versus older maternal age groups.

Study Design: From January 1988 through December 31, 1991, maternal and infant data from 16,512 consecutive nulliparous women were collected and electronically stored. These women were divided into three study groups: middle school (11 to 15 years old), high school (16 to 19 years old), and women 20 to 22 years old at delivery.

Correlation of measured amniotic fluid volume and sonographic predictions of oligohydramnios.

Objective: To compare the measured volume of amniotic fluid (AF) in term gestations to the volume predicted sonographically.

Methods: One hour before elective cesarean delivery, 40 women had sonographic measurement of the AF index and largest vertical pocket diameter. At surgery, a suction catheter was placed into a 1-cm uterine incision and a second catheter was used to aspirate AF from the operative field.

A simplified phenytoin regimen for preeclampsia.

The objective of this study was to assess the feasibility of giving phenytoin to a group of mild preeclamptic women in a universal dosing scheme comparable to that typical of magnesium sulfate administration. Serum phenytoin levels were measured at regular intervals for 32 hours following a 1 g intravenous loading dose in 14 patients. A second group of 14 women received 500 mg orally to supplement the 1 g initial dose and had serum levels similarly measured.

Meconium: a 1990s perspective on an old obstetric hazard.

Objective: To quantify the current perinatal consequences associated with intrapartum detection of meconium in the amniotic fluid (AF).

Methods: We compared retrospectively the outcomes in 8136 term singleton cephalic pregnancies with meconium and 34,573 similar pregnancies with clear AF.

Results: Virtually all measures of adverse fetal-neonatal outcomes were significantly increased with meconium.