Effect of epidural analgesia on the primary cesarean section and forceps delivery rates.

OBJECTIVE: To determine the impact of introducing epidural analgesia for labor pain relief on the primary cesarean and forceps delivery rates. STUDY DESIGN: The control group consisted of 1,720 women who delivered on a charity hospital service between September 1, 1992, and August 31, 1993; epidural analgesia was not available for this cohort of patients. The study group consisted of 1,442 patients who delivered on the same service between September 1, 1993, and August 31, 1994; elective epidural analgesia for labor pain relief was available for this cohort of patients. A computerized obstetric database was analyzed to compare the two groups regarding demographics, parity, pregnancy complications, labor characteristics, type of delivery, low birth weight incidence and five-minute Apgar scores. RESULTS: The two groups were similar with respect to demographics and pregnancy complications. No control group patient received epidural analgesia for labor pain relief; 734 of 1,285 (57%) laboring patients in the study group elected epidural analgesia for pain relief. The primary cesarean delivery rate for the control group was 9.6% and for the study group 11.0% (not statistically significant). The control group had 34 (2.0%) forceps deliveries and the study group, 88 (6.1%), for a statistically significant difference. There were significantly more vaginal births after cesarean in the study group (42 vs. 26). CONCLUSION: Epidural analgesia was not associated with an increase in the primary cesarean delivery rate but was associated with an increase in the operative vaginal delivery rate.

Detection of sentinel lymph nodes with lymphazurin in cervical, uterine, and vulvar malignancies.

BACKGROUND: Identification of sentinel lymph nodes may allow prediction of metastatic disease in cancer patients. We did a prospective study to determine whether lymphazurin dye could identify sentinel lymph nodes in patients with cervical, uterine, and vulvar cancer. METHODS: In 33 patients having surgery for either uterine, cervical, or vulvar carcinoma, lymphazurin dye was injected into the respective organs before the tumor and node dissection began. Sentinel lymph nodes were identified and dissected in situ. RESULTS: The identification rate of sentinel lymph nodes was 0/8 (0%) for uterine cancer patients, 2/13 (15.4%) for cervical cancer patients, and 9/12 for vulvar cancer patients (75%). CONCLUSIONS: In a limited number of patients, lymphazurin day may be useful in identifying or assessing the sentinel nodes draining vulvar and cervical cancers. The role of this procedure in treatment planning for patients with gynecologic malignancies is yet to be determined.

Zero-flow pressures and pressure-flow relationships during single long diastoles in the canine coronary bed before and during maximum vasodilation. Limited influence of capacitive effects.

The proposal that diastolic coronary flow is regulated by an intramyocardial "back-pressure" that substantially exceeds coronary venous and ventricular diastolic pressures has been examined in an open-chest canine preparation in which instantaneous left circumflex pressure and flow could be followed to cessation of inflow during prolonged diastoles. Despite correlation coefficients consistently >0.90, pressure-flow data during individual diastoles were concave to the flow axis before and during pharmacologically induced maximum coronary vasodilation. Data were better fitted (P < 0.01) by second-order equations than by linear equations in >90% of cases. Second-order pressure-axis intercepts (P(f=0))(1) averaged 29+/-7 (SD) mm Hg before vasodilation and 15+/-2 mm Hg during vasodilation; left and right atrial pressures were always substantially lower (8+/-3 and 5+/-2 mm Hg before vasodilation and 8+/-2 and 4+/-1 mm Hg during dilation). Values of P(f=0) before vasodilation varied directly with levels of coronary inflow pressure. A modification of the experimental preparation in which diastolic circumflex pressure could be kept constant was used to evaluate the suggestion that P(f=0) measured during long diastoles are misleadingly high because of capacitive effects within the coronary circulation as inflow pressure decreases. Decreases in P(f=0) attributable to capacitive effects averaged only 5.9+/-3.0 mm Hg before vasodilation and were smaller during dilation. We conclude that P(f=0) is a quantitatively important determinant of coronary driving pressure and flow, resulting from both factors related to, and independent of, vasomotor tone. Adjustments of flow during changing physiological situations may involve significant changes in P(f=0) as well as in coronary resistance.