Relationship between prenatal anxiety and perinatal outcome in nulliparous women: a prospective study.

Nulliparous women with singleton gestation were assessed prospectively for anxiety levels with the State-Trait Anxiety Inventory, which measured state (situational and transitional) and trait (dispositional and stable) anxiety, with high scores indicating high anxiety. Bivariate and multivariate methods were used for data analysis. Anxiety assessments (n = 239) were obtained in 88 women at different stages of gestation. Mean anxiety scores were lowest at 22 to 26 weeks. A woman's successive scores were highly correlated. The trait anxiety (A-T) scores were higher for married women. A positive correlation was present between anxiety scores and gestational age at delivery. Low A-T scores correlated with low birthweight, preterm delivery, and chorioamnionitis. High state anxiety (A-S) levels correlated with the presence of meconium in the amniotic fluid and neonatal congenital abnormalities. Postdate delivery also was associated with higher although statistically insignificant anxiety scores. Women who presented to the labor and delivery room for various complaints had higher A-S and A-T levels. Maternal anxiety level was associated with adverse perinatal outcome; specifically, prematurity and low birthweight correlated with low A-T levels.

Births to teenagers: trends and obstetric outcomes.

OBJECTIVE: To compare the trends and obstetric outcomes of pregnancy in teenage women with those of adult women. METHODS: We analyzed a 19-year (1975-1993) computerized perinatal data base with data on 69,096 births collected prospectively from a single inner-city tertiary medical center. RESULTS: Of all the births, 1875, (2.7%) were to teenagers 12-15 years old and 17,359 (25.3%) were to teenagers 16-19 years old. Over the study period, the number and proportion of births to teenagers of both age groups declined (P < .001 in both cases). The proportions of teenagers 12-15 and 16-19 years old were highest among blacks (4.1% and 28.1%, respectively), followed by Hispanics (2.4%, 24.7%) and whites (1.6%, 23.1%). More than 95% of teenagers had no private health insurance coverage (staff), significantly higher than the 81.6% of mothers aged 20 years or older (P < .001). More than 8.1% of teenagers 12-15 years old had two or fewer prenatal care visits, significantly higher than 6.8% for teenagers 16-19 years old and 7.1% for adults (P < .001). The average gestational age and birth weight were significantly lower for teenagers 12-15 years old compared with those 16-19 years old and adults. Patients 16-19 years of age had longer gestational age and higher birth weight than the adults. The proportion of primary cesarean deliveries among teenagers 12-15 years old was 11.6%, significantly higher than 9.4% for those 16-19 years old and 10.2% for adults (P < .001). CONCLUSION: On average, females 16-19 years old had better obstetric outcomes than adults, whereas obstetric outcomes for those 12-15 years old were worse than for adults. Therefore, all teenagers should not be grouped together when their obstetric outcomes are compared with those of adults.

Safety and efficacy of early postoperative solid food consumption after cesarean section.

Traditionally patients have received a physician-dictated regimen of gradual expansion of their diets following cesarean section. This has been based upon concern about the possibility of ileus from expanding the diet too rapidly. Given the economic necessity of earlier postoperative discharge following abdominal delivery, many patients have solid food reintroduced in their diets around the time they leave the hospital. This prospective, randomized, controlled study compared a traditional, gradual dietary expansion scheme with patient-determined reintroduction of solid food, which was offered within eight hours of surgery. The hypotheses were that women would eat more rapidly after cesarean section when given the opportunity and that early solid food consumption would reduce the need for analgesia. The results indicated that both hypotheses were correct. Given the opportunity, women will eat solid food very soon after cesarean section (mean +/- SD 10.2 +/- 5.2 hours from surgery to onset of solid food consumption) as compared to women on a traditional dietary expansion regimen (mean +/- SD 41.5 +/- 16.0 hours, P < .001). Women offered food within hours of cesarean section required less patient-requested injectable narcotic postoperatively than did women on gradual dietary expansion (median, 75 mg versus 225 mg meperidine, P < .05). There was no evidence of compromise of safety or comfort from introducing solid food early and allowing the patient to decide when to eat postoperatively. The conclusion from these data is that early postoperative feeding after cesarean section is a safe and effective alternative for most women, who now face early hospital discharge.

Warming fluid for amnioinfusion during labor.

While it has never been shown that warming fluid to body temperature prior to using it for amnioinfusion in labor is necessary, the practice is generally accepted. Ideally it is done with a blood warmer. Since blood warmers are expensive and not always available, fluid bags are often warmed in "constant temperature" devices used to heat blankets and fluid used in surgery. These units are ubiquitous, create no extra expense with their use and are a reasonable alternative to blood warmers. A study was designed to determine whether warming ovens actually did heat the fluids used for amnioinfusion to around 37 degrees C. Fluid bags were placed in the warming oven for 48 hours or more, and opening temperatures of the contained fluids were recorded. The temperatures were extremely variable, ranging from 21 degrees C to > 50 degrees C. The variability in opening temperatures was a result of wide temperature fluctuations in the warming oven itself and the condition of the fluid bags on removal. Blanket and surgical fluid warming ovens are not appropriate for heating fluids used in amnioinfusion during labor.

Trends in an obstetric patient population: an eighteen-year study.

OBJECTIVE: Our goal was to evaluate various trends including gestational age, birth weight, and mode of delivery in an inner-city obstetric patient population delivered at a tertiary medical center. STUDY DESIGN: We used an 18-year computerized perinatal database collected prospectively since 1975 in an inner-city tertiary medical center. More than 63,500 deliveries from 1975 through 1992 were evaluated. Trends in gestational age, birth weight, and mode of delivery were investigated with Cox-Stuart, regression, and other trend analysis methods. RESULTS: The number of deliveries increased from 2682 in 1975 to 4740 in 1991, an increase of 77%. The median maternal age has increased from 20 years in 1975 to 23 years in 1992 (p < 0.001). Overall, the mean gestational age has declined monotonically from 39.2 +/- 2.84 weeks in 1975 to 38.3 +/- 3.17 weeks in 1992 (p = 0.057). While the median and lower percentiles of birth weight for singleton births have declined, the 75th and higher percentiles of birth weight have increased during 18 years. Overall, the proportion of preterm births (< 37 completed weeks gestational age) has increased from 3.3% in 1975 to 7.8% in 1991 (p < 0.001). During this period the proportion of low-birth-weight infants (< 2,500 gm) increased significantly from 12.7% to 17.3% (p < 0.001). The proportion of cesarean section deliveries for private patients has declined from 37% in 1975 to 25% in 1992 (p = 0.025), while this proportion has increased monotonically for staff patients from 10% to 17% during this period (p < 0.001). CONCLUSIONS: Considering the large size of the database and diverse background of the study population, we believe that these trends can provide a realistic characterization of an obstetric patient population for a large inner-city urban population.

The development of cyclic motility in fetuses of diabetic mothers.

The cyclic organization of spontaneous movement was studied longitudinally in 22 fetuses of diabetic mothers (FDMs) during the third trimester of gestation and quantified with spectral analysis. Cyclic motility at frequencies between .08 and 1.22 cycles/min was found in all fetuses, although it was temporarily absent in 12 of the 22 fetuses at some time between 25 and 38 weeks. While some parameters of cyclic motility changed little, the frequency of the dominant motility cycle doubled from .24 to .48 cycle/min between 28 and 36 weeks, and the relative strength of motility cycles in the band between .18 and 1.02 cycles/min decreased temporarily at 36 weeks. These developmental changes and the common absence of cyclic motility contrast sharply with previous findings in normal fetuses, and (except for its absence) are accounted for by a subgroup of FDMs whose mothers' blood glucose levels were least well controlled during the third trimester of gestation. The presence of cyclic motility in all FDMs provides further evidence that cyclic activation is a basic property of the developing central nervous system in the human, as it appears to be in other vertebrates. However, the differences between FDMs and normal fetuses suggest that the development of cyclic motility is sensitive to disturbances in the fetal metabolic environment.

Midforceps deliveries: long-term outcome of infants.

Infants delivered by midforceps between 1976 and 1982 were evaluated for evidence of developmental delay or neurological deficit by chart review. The 110 infants who were followed for at least 2 years were compared to a matched group of infants delivered by cesarean section. The cesarean section group was matched for the immediate indication for delivery (dystocia or fetal distress), birth weight, gestational age, sex, and race. There was no significant difference in abnormal outcomes in the two groups.

Intrauterine atrial fibrillation associated with fetomaternal hemorrhage.

Atrial fibrillation is an arrhythmia that is rarely diagnosed in utero. We report a case of fetal atrial fibrillation documented by antepartum echocardiography associated with a fetomaternal hemorrhage.

The midforceps: maternal and neonatal outcomes.

A retrospective review of midforceps deliveries occurring between 1976 and 1982 at a county teaching hospital is presented. Midforceps deliveries were performed in 0.8% of deliveries (176 of 21,414) during this period, a rate reflecting the general admonition against potentially traumatic injury to the infant. Under these conditions, midforceps deliveries were associated with active and second-stage labor abnormalities, abnormal fetal heart rate patterns, maternal perineal lacerations, low 1-minute Apgar scores, and neonatal cephalohematomas more frequently than were deliveries of the remainder of the patients. Epidural anesthesia was significantly associated with midforceps deliveries. Midforceps patients were matched to similar groups who were delivered by cesarean section or low forceps or who had spontaneous births. The findings do not document an increase in short-term neonatal morbidity in the midforceps group under the conditions described.

Elevated maternal alpha-fetoprotein levels with subsequent fetal exsanguination.

Presented is a case with persistently elevated maternal serum alpha-fetoprotein and normal amniotic fluid alpha-fetoprotein values associated with subsequent fetal-maternal bleeding and fetal death. Fetal-maternal bleeding, with potential for rhesus sensitization and fetal death, should be considered in the presence of elevated serum alpha-fetoprotein levels.

Human fetal movement: spontaneous oscillations near one cycle per minute.

Spectral analysis of spontaneous fluctuations in human fetal movement revealed strong oscillations at frequencies between 0.24 and 0.90 cycle per minute, which are much higher than those of the cyclic alternation of quiet and active states in the fetus and neonate. Oscillations at frequencies up to 2.88 cycles per minute were also detected, but they were usually much weaker. The prominent peaks in the fetal movement spectra are in the frequency range of recently reported neonatal motor rhythms, and indicate the existence of a cyclic process controlling spontaneous motor output that oscillates near one cycle per minute and begins to function in utero.

The clustering of fetal heart rate changes and fetal movements in pregnancies between 20 and 30 weeks of gestation.

The temporal organization (nonrandomness) of fetal heart rate (FHR), fetal movement, and their association was evaluated in 20 normal pregnancies at 20 to 22 or 28 to 30 weeks of gestation with the use of external electronic fetal monitoring and statistical analysis with the runs test. At 20 to 22 weeks, significant clustering was found in one of 10 pregnancies for FHR change, two of 10 pregnancies for fetal movement, and one of 10 pregnancies for FHR changes associated with fetal movement. At 28 to 30 weeks, significant clustering was found in eight of 10 pregnancies for FHR change, eight of 10 pregnancies for fetal movement, and all 10 pregnancies of FHR change associated with fetal movement. There was significantly more clustering of FHR change, fetal movement, and FHR change associated with fetal movement at 28 to 30 weeks of gestation than at 20 to 22 weeks of gestation. Clustering of FHR changes was highly correlated with clustering of fetal movement.

Active and quiet periods in the preterm and term fetus.

Heart rate variability and fetal movement were used to classify active and quiet fetal periods. Fetuses at 28 to 30 weeks and at 38 to 40 weeks' gestation were compared. A period of fetal movement with increased variability of heart beat was classified as active and one with the absence of movement and diminished fetal heart beat was classified as quiet. The results demonstrated significant differences both in the number of active-quiet cycles per hour and in the length of the active periods. These findings suggest that analogs of fetal behavioral states may be present before birth and have cyclic patterns, and that the time spent in each fetal period is longer in older fetuses.

The association between fetal heart rate patterns and fetal movements in pregnancies between 20 and 30 weeks' gestation.

The relationships between fetal heart rate (FHR) patterns and fetal movements (FM) were evaluated in 20 normal fetuses between 20 and 20 weeks' gestation. In 10 fetuses at 20 to 22 weeks' gestational age, 602 of the 620 observed FHR changes (97.1%) were decelerations. In this same group, most of the FHR changes (62.4%) were associated with FM. Similarly, 387 of 569 (68%) recorded FM between 20 and 22 weeks' gestation were associated with FHR changes. In a second group of fetuses between 28 and 30 weeks' gestation, in contrast to the less mature group, 227 of 670 FHR changes (33.9%) were decelerations. Among the remainder of the FHR changes, 240 (35.8%) were accelerations and 203 (30.3%) were accelerations with decelerations. As in the less mature group of fetuses, most of the FHR changes in these older fetuses were associated with FM (81.8%) and 548 of 611 (89.7%) recorded FM were associated with FHR changes. In summary, in normal pregnancy, FHR decelerations are common between 20 and 30 weeks' gestation. With advancing gestation, FHR decelerations are less commonly seen, and the frequency of acceleration and acceleration/deceleration patterns increases. The association between FHR and FM becomes stronger with advancing gestational age between 20 and 30 weeks. These findings suggest that the criteria for evaluating the health of the fetus before 30 weeks may be different from the criteria used later in pregnancy. Consequently, in the evaluation of low-birth weight fetuses between 20 and 30 weeks' gestation, new criteria for normal and abnormal nonstress monitoring tests must be developed.

The change in fetal activity periods in diabetic and nondiabetic pregnancies.

Fetal active and quiet periods of behavioral activity were determined at 28 and 32 weeks' and 36 to 40 weeks' gestational age in insulin-dependent diabetic pregnancies and in normal pregnancies resulting in infants with weights appropriate for gestational age. Fetal active and quiet periods were based on observations of fetal movements and long-term fetal heart rate variability. The number of fetal active-quiet periods, the average duration of fetal quiet periods, and the average duration of fetal active periods were the three parameters evaluated. In the normal pregnancy groups, with increasing fetal gestational age from 28 to 32 weeks to 36 to 40 weeks there was an increase in the length of the active and quiet periods with fewer active-quiet cycles per hour. The fetuses of the diabetic women had findings similar to those of the normal group at 28 to 32 weeks; these findings were essentially unchanged at 36 to 40 weeks. These findings suggest delayed development of the active-quiet cycles in these diabetic pregnancies.

Correlation between gestational age and fetal activity periods.

Cyclic patterns of active and quiet fetal activity were evaluated in 36 clinically normal gravidas between 27 and 42 weeks of gestation. All infants were subsequently delivered between 37 and 42 weeks of gestation, were clinically normal and of appropriate weight for gestational age. Active-quiet cycles occurred less frequently and were of longer duration with increasing gestational age. Regression analysis of the number of active-quiet cycles with gestational age yielded a correlation coefficient of 0.52 (p less than 0.01). The similarity of fetal active-quiet cycles and active and quiet sleep cycles observed after birth is noted.

A comparison between maternal, tocodynamometric, and real-time ultrasonographic assessments of fetal movement.

Fetal movements were simultaneously studied with maternal perception, tocodynamometry, and real-time ultrasonography. A comparison between these three modalities demonstrated good agreement. The percentage of agreement improved with increasing duration of fetal movements. For fetal movements lasting longer than 3 seconds, the agreement between ultrasonography and tocodynamometry was 95.6%. These findings suggest that tocodynamometry is a sensitive method for studying fetal movements.