Have Kielland forceps reached their 'use by' date?

Kielland forceps have long been used in Australian hospitals for rotation and delivery from occipitolateral and occipitoposterior positions. We have studied the pattern and use of these forceps in our hospital, and conducted a statewide survey of obstetric trainees about their experience with Kielland forceps. We conclude that current obstetric training programmes are unlikely to provide registrars with sufficient skill in their safe use.

Uterine perforation during surgical abortion: a review of diagnosis, management and prevention.

We analysed results of 13,907 women who underwent termination of pregnancy over a 6-year period in a public day-surgery clinic in South Australia to determine possible risk factors and preventive measures for known perforation of the uterus in surgical abortion. The perforation rate in the first trimester was 6 in 12,040 (0.05%) and in the second trimester (13-20 weeks), 6 in 1,867 (0.32%). Previous gynaecological surgery had been performed in 11 of 12 (92%) women sustaining perforation and was the main risk factor identified. No second trimester perforations occurred in the 2 years following identification of the risk factor and the introduction of precautionary protocols, and there was only 1 first trimester perforation. The overall reduction in perforation rate was from 0.13% to 0.02% (p=0.022). We conclude that previous gynaecological surgery including termination of pregnancy, lower segment Caesarean section and the large loop excision of transformation zone of the cervix (LLETZ) procedure, which may have resulted in scarring of the internal cervical os is a previously unreported risk factor for tearing of the internal os leading to perforation of the uterus during subsequent surgical abortion procedures. Dilatation of the cervix particularly for these 'at risk' procedures should be predominantly passive by the use of oral prostaglandins such as misoprostol and osmotic dilators.

Calcium supplementation in nulliparous women for the prevention of pregnancy-induced hypertension, preeclampsia and preterm birth: an Australian randomized trial. FRACOG and the ACT Study Group.

A multicentre, randomized controlled double-blind trial in 5 maternity hospitals in Australia assessed the effect of a daily supplement of calcium (1.8g oral calcium or an oral placebo) taken daily until delivery, from less than 24 weeks' gestation, on the frequency of pregnancy-induced hypertension, preeclampsia and preterm birth (< 37 weeks' gestation) in 456 nulliparas with a singleton pregnancy. Treatment with calcium reduced the risk of preeclampsia (relative risk 0.44 [95% CI, 0.21-0.90], p = 0.02) and the risk of preterm birth (relative risk 0.44 [95% CI, 0.21-0.90], p = 0.02). No significant differences were seen between the 2 groups in the frequency of pregnancy-induced hypertension, although the study only had statistical power to detect large differences in this outcome. An updated systematic review of the 9 randomized trials of calcium supplementation in pregnancy shows a significant reduction in the risk of hypertension and preeclampsia although no effect on preterm birth. Calcium supplementation during pregnancy reduced the risk of preeclampsia and preterm birth in this nulliparous population. The available evidence for systematic review of all the randomized trials of calcium supplementation shows benefit in reducing the risk of hypertension and preeclampsia.

Knee-chest postural management for breech at term: a randomized controlled trial.

BACKGROUND: In 3 to 4 percent of all term births, the fetus presents as a breech. The objectives of this trial were to assess if assuming the knee-chest position reduced the frequency of breech presentation at delivery, increased the success of the subsequent external cephalic version, or both, and to determine if this management plan reduced the need for cesarean delivery. METHODS: A randomized clinical trial recruited 100 women from two hospitals in Adelaide, South Australia, with a singleton breech presentation and a gestational age equal to or more than 36 weeks. Women in the treatment group were advised to assume the knee-chest position for 15 minutes three times a day for one week. Women in the control group did not perform postural management. All participants were reviewed one week later, and women whose baby remained as a breech presentation were offered an external cephalic version. RESULTS: Postural management did not increase the success of the external cephalic version, reduce the frequency of breech presentation at delivery, or reduce the need for cesarean delivery in women with a breech presentation at term. CONCLUSIONS: Findings from this trial included in a meta-analysis of postural management for breech presentation at term suggested that this is not an effective form of care to be offered routinely to women with a breech presentation at term.

Outcomes of induced labour.

We report a review of maternal and neonatal outcomes of labour in 1,405 pregnancies managed during a 12-month period. This included all singleton pregnancies of greater than 20 weeks' gestation, excluding women antenatally assigned for Caesarean delivery. Labour was induced in 313 cases (22.3%), and records were available for review in 311 of these. We classified the indications for induction according to the Australian Council of Healthcare Standards (ACHS)/RACOG list of 'defined' indications in Obstetric Clinical Indicator number 1. In 165 cases (53.7%) labour was induced for defined indications. There was no significant difference in the rates of instrumental vaginal delivery, Caesarean delivery or adverse neonatal outcome (admission to neonatal nursery in the first 24 hours of life; 5 minute Apgar score of < 7) between women who laboured spontaneously and those induced for 'nondefined' indications. However, labours induced for 'defined' indications had a significantly increased rate of these outcomes.

Ultrasound placental cysts associated with massive placental stem villous hydrops, diploid DNA content, and exomphalos.

A pregnancy associated with antenatally detected placental cysts and an anterior abdominal wall defect is described. The anterior abdominal wall defect proved to be an exomphalos in which a short segment of normal cord intervened between the herniated sac and the cord insertion. The placental cysts detected antenatally by ultrasound were shown subsequently to be massive main stem villous hydrops with cisternal formation but no evidence of trophoblastic hyperplasia. Antenatal placental biopsy and amniocentesis revealed a normal male karyotype. Confined placental mosaicism for triploidy was excluded by DNA flow cytometry. This case was not associated with Beckwith-Wiedemann syndrome.

Eclampsia in association with partial molar pregnancy and congenital abnormalities.

A case of eclampsia in association with partial molar pregnancy is described. Cytogenetic analysis confirmed a 69,XXX karyotype, and pathologic examination of the fetus showed a meningomyelocele, exomphalos, incomplete intestinal rotation, and cerebral ventricular dilatation.

Vietnamese refugees in Adelaide: an obstetric analysis.

An analysis is made of the pregnancies of all Vietnamese refugees who presented to the antenatal clinic at the Queen Elizabeth Hospital, Adelaide, during the period from June, 1977, to January, 1980. This comprised 78 pregnancies in 76 women. Previous medical history, social status, antenatal and delivery complications and neonatal outcome are assessed, and differences between the study group and the non-Asian public patients, Which are discussed in detail, are demonstrated.

The ultrasonic diagnosis of cervical ectopic pregnancy.

Two patients with cervical pregnancy who had ultrasonic scans performed before operation are reported. The ultrasonic features of this condition are presented.

The management of anticoagulant therapy during and after pregnancy.

Fifteen patients were treated with oral anticoagulants during pregnancy. At 37 weeks they were changed to heparin and were given 5 mg of Vitamin K1 by intravenous injection. Labour was induced seven to ten days later. All infants were normal and healthy and in the 12 tested the cord prothrombin times were within the normal range.

Liquor bilirubin levels and false prediction of severity in rhesus haemolytic disease.

Liquor bilirubin levels gave a false prediction of outcome for the fetus in 80 out of 716 rhesus-sensitized women referred for treatment during 1965-9. Trauma caused by amniocentesis seemed to be responsible for an increase in the severity of immunization in a significant proportion of cases. In addition, contamination of liquor samples by plasma, particularly fetal plasma, completely invalidated liquor bilirubin estimations. Errors in estimation of gestational length were also found to be associated with misleading results and a poor fetal prognosis.