June 2001 Digest ~ Abstracts or reports from 
10 journal articles on various clinical topics of interest

Interdelivery Time Affects Uterine Rupture Risk 
During Trial of Labor After
Prior Cesarean 

WESTPORT, CT (Reuters Health) Feb 16 - The risk of uterine rupture during a trial of labor after a prior cesarean delivery is threefold higher if the interval since the previous delivery is 18 months or shorter, rather than 19 months or longer. The finding, reported by Dr. Thomas D. Shipp, of Massachusetts General Hospital, in Boston, and colleagues, suggests that more time may be needed for complete healing of the uterine scar from a previous cesarean section. The team examined the effects of interdelivery interval on the risk of symptomatic uterine rupture in more than 2400 women who underwent a trial of labor after a previous cesarean delivery during a 12-year period. All of the women for whom the prior delivery date was known had delivered term singleton infants, had only one prior cesarean and had no prior vaginal deliveries, the investigators report in the February issue of Obstetrics and Gynecology. Of the women, 29 experienced symptomatic uterine ruptures. The rate of uterine rupture was higher in women with interdelivery intervals of 18 months or less than in those with longer interdelivery intervals, at 2.25% and 1.05%, respectively. After accounting for other risk factors, the odds ratio for uterine rupture was 3.0 for interdelivery intervals of 18 months or less. "The short interpregnancy intervals could have led to incomplete healing and therefore the higher rate of uterine rupture in subsequent pregnancies," Dr. Shipp and others surmise. They add that additional studies will be needed to determine the specific etiologic mechanisms involved.

Obstet Gynecol 2001;97:175-177.

Perineal Trauma at First Delivery Tied 
to Subsequent Tearing

(Reuters Health) May 28 - Women who experience perineal tears or episiotomy during their first delivery are more than three times more likely to sustain spontaneous perineal tears at the birth of their second child, Canadian researchers report in the April issue of the Journal of Family Practice. Dr. Michel Labrecque of Universite Laval in Quebec City and colleagues note that as many as 75% of women may experience perineal trauma while giving birth. However, "very few" studies have assessed whether such trauma "during a first delivery is a risk factor for spontaneous tears at the next delivery." To do so, the researchers examined data on 1895 women who had had their first and second deliveries at one hospital in Quebec City. All of the women had given birth vaginally to one child on both occasions and none had had an episiotomy at the second delivery. Having a perineal trauma at the first delivery increased the relative risk of spontaneous perineal tears of the second degree or higher at the second delivery to 3.3. Furthermore, the greater the degree of trauma at the first delivery, the greater was the risk. For example, 54.5% of women with severe lacerations at the first birth sustained tears at the second. The researchers conclude that these findings "support arguments for the prevention of perineal trauma at the first delivery and the selective use of episiotomy."  J Fam Pract 2001;50:333-337

Frequency of Eating in Second Trimester 
Helps Predict Risk of Premature

WESTPORT, CT (Reuters Health) Apr 12 - Skipping meals or snacks regularly during pregnancy can induce physiologic stress and lead to premature delivery, according to new findings published in the April 1st issue of the American Journal of Public Health. "Very little guidance, if any, on this topic is given to pregnant women by their physicians," lead author Dr. Anna Maria Siega-Riz explained to Reuters Health. "[Clinicians] should ask at the first prenatal visit if the woman is likely to skip any meals due to work schedule or preference. If the answer is yes, this practice should be discouraged. In addition, women should be advised to have at least two healthy nutritious snacks during the day to prevent long time periods without any food." Dr. Siega-Riz, of the University of North Carolina at Chapel Hill, and multicenter colleagues examined the association between frequency of eating and preterm delivery in more than 2000 women enrolled in the Pregnancy, Infection, and Nutrition Study from August 1995 to December 1998. All women were asked about their frequency of eating during the second trimester of pregnancy and were followed through delivery. The vast majority of women met current Institute of Medicine recommendations for eating three
meals plus two snacks each day during pregnancy. Women who fell short of these guidelines had a 30% increase in risk of delivering prematurely than the others. Women who ate less often than recommended were also slightly heavier prior to conception, were older and had lower total energy intakes than the other women in the cohort. Research in animals suggests that skipping meals could result in elevated levels of stress hormones that have been "implicated in the events leading to a preterm delivery," Dr. Siega-Riz told Reuters Health. Skipping meals becomes a "stressor" to the body and "stress during pregnancy has been postulated as antecedent of preterm birth," she explained. Some studies in humans also support this mechanism of action. The authors speculate that measuring the frequency of food intake during pregnancy could be a "simple and useful public health tool" for identifying women at increased risk of preterm delivery.    
Am J Epidemiol 2001;153:647-652.

Ginger Reduces Nausea and Vomiting of Pregnancy

WESTPORT, CT (Reuters Health) Apr 11 - Ginger 1 g per day significantly reduces the severity of the nausea and vomiting of pregnancy, report investigators in Thailand. Dr. Teraporn Vutyavanich and colleagues, of Chiang Mai University, randomly assigned 32 women attending an antenatal clinic to treatment with ginger, and 35 to placebo. The ginger, prepared by baking fresh ginger root and grinding it to a powder, was administered in 250-mg capsules q.i.d. Outcomes are reported in the April issue of Obstetrics and Gynecology. After 4 days of treatment, nausea scores based on a 10-cm visual analog scale decreased by a median of 3.4 in the ginger-treated group and 1.5 in the placebo-treated group, a significant difference. At the 1-week followup visit, 87.5% of those treated with ginger reported symptom improvement, compared with 28.6% of the control subjects. During the day before treatment began, 100% of those in the ginger group and 94.3% in the placebo group had vomited at least once. After 4 days, 37.5% in the treatment group had vomited, compared with 65.7% in the placebo group. Adverse effects one case each of abdominal discomfort, heartburn, and diarrhea in the ginger group were minor and did not prevent subjects from continuing the treatment regimen. No significant differences were observed in spontaneous abortions, term deliveries, or cesarean deliveries. There were no cases of congenital anomalies. Obstet Gynecol 2001;97:577-582.

Babies whose mothers had betadine used for peri prep have a higher rate of transient neonatal hyperthyrotropinemia and false positive test for hypothyroidism on their newborn screen. This can lead to healthy newborns being worked up for this.

Arena Ansotegui J, Emparanza Knorr JI, San Millan Vege MJ, Garrido Chercoles A, Eguileor Gurtubai 
Departamento de Pediatria, Hospital Nuestra Senora Aranzazu, San Sebastian.

The high incidence of transient thyroid dysfunction in newborns from our hospital (0.6%), led us to investigate whether povidone perineal prep. during delivery and daily postpartum antisepsis, induced  iodine overload in the newborn, and whether breast milk was the vehicle. In a controlled randomized trial we used either povidone-iodine or clorhexidine in 36 mothers, and we investigated in them and in their newborns iodine levels and thyroid function. Iodine levels in cord blood,  maternal urine and newborn urine were significantly higher in povidone treated group (p less than 0.001) up to the 4th postpartum day. These levels were also significantly higher in breast fed than in formula-fed babies within the group of povidone-iodine-treated mothers. Maternal prepartum urine iodine, and thyroid function in mothers and newborns were not significantly different in both groups

A new model of routine antenatal care emphasizes fewer prenatal visits, may achieve cost-savings without compromising maternal and perinatal care, according to the findings of two studies published in the The Lancet.

Dr. Jose Villar from the World Health Organization (WHO) in Geneva and colleagues performed a randomized trial of the new model and a review of several other trials to assess the value of an antenatal care model that had fewer clinic visits than standard care models. In the randomized trial, 53 clinics in Argentina, Cuba, Saudi Arabia, and Thailand were selected to provide the new or standard antenatal care model, the researchers note.

The new model emphasized only those interventions that have been shown to improve maternal and neonatal outcomes. Women who participated in the new model of care, but were deemed high-risk, received care for their conditions but were still included in the new model group for analysis. The median number of prenatal visits for the new model and standard model group was five and eight, respectively. While more women in the new model group were referred to higher levels of care, both groups had similar hospital admission rates, diagnoses and lengths of stay, the authors note. In addition, the rates of low birthweight, postpartum anemia, urinary-tract infection, and pre-eclampsia/eclampsia did not differ significantly.

In general, women and providers in both groups appeared satisfied with the care. Some women in the new model group, however, were concerned about the timing of visits, the investigators state. Costs of the new model were equivalent to and, in some cases, less than those of the standard model. In the second study, Dr. Villar's team reviewed seven randomized controlled trials of routine antenatal care. The investigators found that a reduced number of antenatal visits did not increase the risk of pre-eclampsia, urinary tract infection, postpartum anemia, maternal mortality or low birthweight. Perinatal deaths were too infrequent to allow statistical analysis. Cost findings were similar to those of the first study.

"Basically, the model contains all the interventions that are known to improve maternal/neonatal outcomes packaged into a minimum of four clinic visits," Dr. Villar told Reuters Health. "The model is for routine visits only," he emphasized. "If the woman has additional complaints, she needs appropriate follow-up for those problems." The model also needs to be adjusted for countries with specific disease concerns, he added.

"Before maternal interventions are implemented, it must be shown that they are effective through solid research," Dr. Villa said. "If the interventions don't stand up to scientific scrutiny then they shouldn't be included in routine antenatal care." Lancet 2001;357:1551-1570 (May 19, 2001).

A Female Friend At The Bedside Boosts The Chances Of A Natural Birth
Reviewed by Dr Michael Peters

Feb 19, 2001 -- Having the support of a female friend by your bedside during labour halves the risk of having a caesarean, says a new study. She will also reduce the potential for a forceps delivery by 40 per cent, the need for an epidural by 60 per cent and the length of labour by a quarter, compared to mothers who don't have a mother figure by their side. The extraordinary findings come as Britain finds itself in the midst of what has been dubbed a 'Caesarean epidemic'. Surgical delivery of babies is now at an all-time high -- representing 17 per cent of all births -- and a recent Royal College of Midwives report revealed 29 per cent of maternity wards are unable to offer one-to-one care during childbirth.

But the benefits of having a friend close by -- known as a doula -- are not confined to the mother. The baby too may be helped, says the study carried out by Dr John Kennell at Case Western Reserve University, in Cleveland. Mothers who use female companions for two months after the birth bond more quickly with their babies than women who do not have one. 'If the doula were a medication or electronic device it would be immediately provided in every hospital for every labouring women,' writes Dr Kennell.

While the US medical establishment is becomingly increasingly tolerant towards the idea of doulas, the latest research has received mixed reactions from British midwives and obstetricians. The honorary chairwoman of the Association for Improvements in Maternity Services (AIMS), Beverley Lawrence Beech, argues that British maternity wards would achieve exactly the same results as doulas if midwives were, 'allowed to do their job properly' 'Women can only get the right level of care if they have a home birth these days because they are nothing more than obstetric nurses in maternity wards. Resources and staffing numbers are so short that they don't have time to give mothers the one-to-one care they need. 'Instead of bringing doulas into the UK, which would be nothing more than a quick fix anyway, we should be thinking about rescuing our midwives. There are nearly 60,000 registered midwives who are not working at the moment -- that's how dreadful the situation is.'

However, the latest research was cautiously welcomed by Mr Rupert Fawdry, a consultant specialising in maternity care at Milton Keynes Hospital. 'The evidence does seem to suggest that doulas have an important effect. If women are more relaxed, we know they are more likely to deliver naturally. And the support of an independent figure, who is not a relation, seems to have beneficial effects on the mother.'When the point of being a midwife is to provide that continuity of care, and far too many women in labour today aren't getting that, then we have to consider the potential benefits doulas could bring into our maternity wards.'

The word 'doula' is Ancient Greek for a woman experienced in childbirth. In the US a doula is professionally trained to provide labour support, but she is not a midwife and she does not perform any clinical tasks. As well as providing support during labour, she can also give advice on issues on post-natal issues such as breastfeeding and can even provide child care, cooking and cleaning support. Most doulas are privately hired but there are some American hospitals now offering doulas as part of their maternity care. In Britain you can employ a doula at a cost of 10 an hour or around 200 for a delivery, through an agency called Top Notch Nannies.

Press officer Jasmine Birtles says they have more than 100 doulas aged between their 20s and 60s. Although she admits that the type of woman interested in hiring a doula is probably more likely to have a natural birth anyway, she says the need for doulas is very real. 'Our doulas are constantly in demand. Women are having children later in life today, so perhaps their mother is dead; sometimes there is such a gap between the generations that they don't necessarily want their mother and there also more single mothers today. 'But because of the fact we are an agency, we are only used by those who can afford us. We are unable to reach the women who really need us.' 

Warm tub bathing during labor: maternal and neonatal effects.

Ohlsson G, Buchhave P, Leandersson U, Nordstrom L, Rydhstrom H, Sjolin
Department of Obstetrics and Gynecology, Central Hospital, Karlskrona, Sweden.

AIM: To study possible detrimental maternal and neonatal effects of immersion in warm water during labor. DESIGN: Prospective randomized controlled bathing during first stage of labor vs no bathing. 
SETTING: Obstetrical departments at a university hospital and two central hospitals. 
PRIMARY END-POINT: Referral of newborns to NICU. 

MATERIAL AND METHODS: Randomization took place by means of sealed opaque envelopes at each delivery unit. Preconditions for participation in the study were: singleton parturient wishing to bathe, a gestational duration of at least 35 weeks+0 days, a planned vaginal delivery, normal admission test, regular contractions and cervix dilated to at least 3-4 cm. Parturients randomized to the 'no bath' control group were allowed to use a shower. Rupture of the membranes was not a contra-indication to participation. Those excluded from randomization were women with intra-uterine growth retardation, meconium-stained amniotic fluid, or in the event that the tub was occupied by another randomized parturient.

MAIN RESULTS: On average, parturients stayed in the tub for 50-60 min. No significant difference was seen regarding the referral rate to NICU among 612 cases vs 625 controls, OR 0.8; 95% CL 0.2, 3.1. The OR for epidural analgesia was 1.0; 95% CL 0.8, 1.3. Nor was any significant difference seen in the rate of perineal tear grade III-IV (OR 1.3), instrumental delivery (OR 1.1), cesarean section (OR 1.8), or maternal post partum stay on the ward. During the neonatal period, no significant difference was seen in the number of newborns with Apgar <7 at 5 min (4 vs 5), neonatal distress (OR 2.2) or tachypnea (OR 1.0). 

CONCLUSION: In the present study no negative effects of bathing during labor could be discerned. The results indicate that expectant mothers wishing to bathe during labor may do so without jeopardizing their own, or their newborns' wellbeing after birth.

Predicting incomplete uterine rupture with vaginal sonography during 
the late second trimester in women with prior cesarean.

AUTHORS:  Gotoh H; Masuzaki H; Yoshida A; Yoshimura S; Miyamura T; Ishimaru T
AUTHOR AFFILIATION:  Department of Obstetrics and Gynecology, 
Nagasaki University School of Medicine, Nagasaki, Japan.
SOURCE:  Obstet Gynecol 2000 Apr;95(4):596-600.
CITATION IDS:  PMID: 10725496 UI: 20192115

ABSTRACT:  OBJECTIVE: To evaluate the usefulness of serial transvaginal ultrasonographic measurement of the thickness of the lower uterine segment in the late second trimester for predicting the risk of intrapartum incomplete uterine rupture in women with previous cesarean delivery. METHODS: Serial transvaginal ultrasonography with full bladder was performed in 374 women without previous cesarean delivery (control group) and 348 women with previous cesarean delivery (cesarean group) from 19 to 39 weeks' gestation. The thickness of the lower uterine segment was measured in the longitudinal plane of the cervical canal.

RESULTS: The thickness of the lower uterine segment decreased from 6.7 +/- 2.4 mm (mean +/- standard deviation [SD]) at 19 weeks' gestation to 3.0 +/- 0.7 mm at 39 weeks' gestation in the control group, but the thickness was more than 2.0 mm throughout this period in each control subject. In the cesarean group, the thickness decreased from 6.8 +/- 2.3 mm at 19 weeks' to 2.1 +/- 0.7 mm at 39 weeks' gestation and was significantly thinner than that of the control group after 27 weeks' gestation (P <.05). Eleven of 12 women (91%) with lower uterine segment less than the mean control - 1 SD in the late second trimester had a very thin lower uterine segment at cesarean delivery with fetal hair being visible through the amniotic membrane, ie, incomplete uterine rupture. In 17 of 23 women (74%) with lower uterine segment less than 2.0 mm in thickness within 1 week (4 +/- 3 days) before repeat cesarean delivery, intrapartum incomplete uterine rupture developed. 

CONCLUSION: Transvaginal ultrasonography is useful for measurement of the uterine wall after previous cesarean delivery

ACDM editor Note: This is a tenitive conclusion and would depend on the skill and familiarity of the technician and may well produce a high false positive or false negative rate when widely employed.

Study Casts Doubt on Down Screening

By LINDSEY TANNER .c The Associated Press

CHICAGO (AP) - Several features on ultrasound scans that doctors thought were warning signs of Down syndrome are almost always harmless, leading many women with normal fetuses to undergo unnecessary amniocentesis, researchers say. The analysis of 56 previous studies casts doubt on the reliability of ultrasound in detecting Down syndrome in the womb.

Pregnant women routinely undergo blood tests and ultrasound scans to check for abnormalities in the fetus. When warning signs are spotted on the ultrasound image, women are often advised to undergo amniocentesis, in which a needle is used to draw fluid from the womb for analysis. Amniocentesis itself carries a small risk of causing a miscarriage.

In this latest research, doctors looked at seven markers sometimes spotted on ultrasound scans that are thought to increase the risk of Down's, a form of retardation caused by a certain chromosomal abnormality. Only one of those markers - a shaded area suggesting a thickening at the back of the neck - was found to be a reliable enough indicator to justify an amnio, said Dr. Rebecca Smith-Bindman, a radiologist at the University of California at San Francisco who led the study.``Even then, only 3 percent of fetuses will be affected by Down syndrome, but this risk is sufficiently high that a woman might consider invasive testing with amniocentesis,'' Smith-Bindman said.

The six other markers were certain brain cysts; shortened thigh and upper-arm bones; bright spots on the bowel or heart; and high fluid levels in the kidneys. About 10 percent to 14 percent of pregnant women have one of these markers, but fewer than 1 percent have Down's babies, Smith-Bindman said. For women whose blood tests are normal, ``if your baby is found to have any of these isolated markers, your baby is almost certainly normal and you shouldn't be concerned about it and undergo an amnio because of it,'' she said.

In 1998, the latest year for which figures are available, 112,778 amnios and 2.5 million ultrasounds were performed in the United States. Smith-Bindman would not estimate how many amnios are unnecessary, but it's ``clearly a lot.'' Ultrasounds that show an obvious structural abnormality, such as heart defects that are common in Down syndrome, should not be discounted, she said. One in 800 to 1,000 U.S. babies is born with Down syndrome. Women over 35 and those who have already had an affected baby face an increased risk.

Routine prenatal blood tests done in the second trimester are considered a more accurate diagnostic tool for Down's. Amniocentesis is the most definitive test, but it can trigger a miscarriage in about one in 200 to one in 400 cases. In fact, the risks of miscarriage from amniocentesis are greater than the risks that a woman with normal blood tests but one of the ultrasound markers will have a Down syndrome baby, according to the analysis. Smith-Bindman's analysis is based on studies published between 1980 and 1999 involving 132,295 fetuses, including 1,930 with Down syndrome. It appears in Wednesday's Journal of the American Medical Association.

Dr. Joe Leigh Simpson, a Down syndrome expert and chairman of obstetrics and gynecology at Baylor College of Medicine, said the findings are not surprising and underscore the weaknesses in using ultrasound to detect Down syndrome.Simpson said the older studies analyzed may have used outdated ultrasound machines, but he added that even when the most accurate scanners are operated by the most experienced technicians, second-trimester ultrasound is still not the best way to diagnose Down syndrome.

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Baby Girl Weibe and parents at
San Mateo County Birth Registration Office