Beneficial effects of postnatal skin-to-skin contact.

UNLABELLED: In a randomized trial, Bystrova et al. examined the traditional neonatal practice of swaddling. They demonstrated that extended skin-to-skin contact with the mother is the most effective way to maintain the infant's temperature and decrease the "stress of being born". CONCLUSION: Only through research such as that reported by Bystrova et al. can the advantages or disadvantages of routinely accepted perinatal practices be evaluated.

Authoritative knowledge, evidence-based medicine, and behavioral pediatrics.

Evidence-based medicine is the conscientious and judicious use of current best knowledge in making decisions about the care of individual patients, often from well-designed, randomized, controlled trials. Authoritative medicine is the traditional approach to learning and practicing medicine, but no one authority has comprehensive scientific knowledge. Archie Cochrane proposed that every medical specialty should compile a list of all of the randomized, controlled trials within its field to be available for those who wish to know what treatments are effective. This was done first for obstetrics by a group collecting and critically analyzing all of the randomized trials and then indicating procedures every mother should have and those that no mother should have. Support during labor was used as an example. Similar groups are now active in almost all specialties, with information available on the Internet in the Cochrane Database of Systematic Reviews. Developmental-behavioral pediatrics should be part of this movement to evidence-based medicine.

The doula: an essential ingredient of childbirth rediscovered.

Eleven randomized control trials examined whether additional support by a trained lay person (called a doula), student midwife or midwife, who provides continuous support consisting of praise, encouragement, reassurance, comfort measures, physical contact and explanations about progress during labor, will affect obstetrical and neonatal outcomes. The women were healthy primigravidas at term. Meta-analysis of these studies showed a reduction in the duration of labor, the use of medications for pain relief, operative vaginal delivery, and in many studies a reduction in caesarian deliveries. At 6 weeks after delivery in one study a greater proportion of doula-supported women were breastfeeding, reported greater self-esteem, less depression, a higher regard for their babies and their ability to care for them compared to the control mothers. Observations during labor showed that fathers remained farther away from mothers than doulas, talked and touched less. When the doula was present with the couple during labor the father offered more personal support. The father-to-be' s presence during labor and delivery is important to the mother and father, but it is the presence of the doula that results in significant benefits in outcome.

Congenital absence of the corticospinal fibers: pathologic and clinical observations.

We describe 2 patients with primary absence of corticospinal tracts. Both presented with delayed motor development, head lag, and spasticity of the limbs. We could not identify precentral cortex, and there were no corticospinal fibers below the internal capsules. We postulate that the fibers were displaced or interrupted early in their development.

The perinatal paradigm: is it time for a change?

Two different care procedures are presented to raise the difficult question of whether we should completely reevaluate our paradigms of care in the perinatal period. In this thorough review, should we continue to use the same framework of beliefs in deciding on the benefits and risks of any care procedure?

Effects of social support during parturition on maternal and infant morbidity.

Because continuous social support during labour is a component of care in many societies but inconsistent in our own, the clinical effect of support during labour on maternal and neonatal morbidity were studied. Social support was provided by female companions. Four hundred and sixty five healthy primigravidous women were enrolled using a randomised design. Compared with 249 women undergoing labour alone 168 women who had supportive female companions throughout labour had significantly fewer perinatal complications (p less than 0.001), including caesarean sections (7% v 17%, p less than 0.01) and oxytocin augmentation (2% v 13%, p less than 0.001), and fewer infants admitted to neonatal intensive care (p less than 0.10). Of the women who had an uncomplicated labour and delivery requiring no interventions, those with a companion had a significantly shorter duration of labour (7.7 hours v 15.5 hours, p less than 0.001). This study suggests that constant human support may be of great benefit to women during labour.

Prevalence of maternal and neonatal infections in a developing country: possible low-cost preventive measures.

The frequency and duration of infectious illnesses in 408 pregnant rural women and 417 poor urban infants in Guatemala have been investigated, together with morbidity and mortality among the offspring of the rural women. Rural women suffered high rates of infection during the gestation period. Symptomatic illnesses, mainly acute respiratory infection and diarrhoeal disease, usually showed a higher incidence during the last months of pregnancy. Significant bacteriuria was identified in 21% of the women, though symptoms of urinary tract infection were found in about 25%. Vaginal infection was found in 38% of women at the beginning of pregnancy and in 79% at its end. Twelve per cent of women showed evidence of reactivated infections with cytomegalovirus, herpes simplex virus and Toxoplasma gondii. The neonatal mortality rate in the rural population was 37.7 per 1000 liveborn infants. Most deaths were among preterm babies. Significant bacteriuria was related to low birth weight. Morbidity in rural neonates was also high, but the illnesses were not severe and had a short duration. Neonatal morbidity in poor urban infants was also high. Breast-feeding had a protective effect: breast-fed rural and poor urban infants had a lower incidence of illness than urban babies who were not breast-fed. The influence of infection during pregnancy on the conceptus and some low-cost measures for reducing it are discussed. Measures for decreasing neonatal morbidity in rural and poor urban ureas are proposed.