Maternal mortality in Europe.

Maternal mortality rates (or ratios) are widely used as one indicator of the quality of medical care. There has been concern that conclusions may be drawn from unreliable data. A survey of practices in European countries confirms that there are differences in interpretation of definitions and evidence of significant under-reporting in official returns of vital statistics. Actual and potential sources of error are identified and a need for greater precision and uniformity of data collection is established.

A paramedic based emergency domiciliary obstetric service: the South Glamorgan experience.

OBJECTIVE: To assess the potential benefits of using extended trained ambulance personnel (paramedics) as primary responders for domiciliary obstetric and gynecological emergencies. DESIGN: An observational study of performance and analysis of operational data in a newly established service. SETTING: A mixed urban and rural population served by South Glamorgan Health Authority. MAIN OUTCOME MEASURES: Work load, response times, management and transfer of patients, efficiency of communications and appropriateness of training. RESULTS: There was an initial increase in requests above that when a hospital-based service operated. Targets for response times were met. The mean response time for providing appropriate skilled help was halved compared with the previous arrangements and a safe and efficient service was provided. Prompt transport and advance notice and preparation for reception in the delivery unit contributed to optimal management. Medical staff depletion in the delivery unit was minimised. CONCLUSION: An Emergency Domiciliary Obstetric Service based on primary response by specially trained ambulance service paramedics can beneficially replace traditional hospital-based Obstetric Flying Squads.

The obstetric forceps--are we using the appropriate tools?

A total of 166 pairs of obstetric forceps of three different types in regular use in two major obstetric units was measured and compared with manufacturers' master instruments and drawings. As well as linear measurements of blade, shank and handle the distances between the tips and maximum distance between the blades, and the mean radius of the cephalic curve were determined. The purpose of the study was to assess the suitability of instruments in common use for present day practice. It was found that the measurements differed significantly from the original descriptions and there were wide variations between instruments of the same type, even when supplied by the same manufacturer. In some cases the blades had not been packed in matching pairs in the Central Sterile Supplies Department. It is suggested that critical reappraisal of the forceps in current use in many obstetric units is overdue. As well as a need for reconsidering the type of forceps used the dimensions of individual pairs should be checked.

The availability of epidural anaesthesia and analgesia in obstetrics.

This survey analyses the provision of obstetric epidural services on national and regional bases and also by size of obstetric unit. Epidural anaesthesia and analgesia in obstetrics is not readily available to all women who wish for it, or in whom it is recommended on medical grounds, in spite of the recommendations of the Social Services Committee and other advisory bodies. Deficiencies in the provision of facilities are obvious but further analysis at a local level is required to determine the reasons and the remedies.

Serious non-fatal complications associated with extradural block in obstetric practice.

A retrospective study of serious non-fatal complications of extradural block in obstetric practice was carried out using a postal questionnaire. Two hundred and three obstetric units in the United Kingdom (responsible for 2,580,000 deliveries from 1982 to 1986 inclusive) responded. A total of 505,000 extradural blocks were performed, 84% for relief of pain in labour and 16% for Caesarean section. Of 108 events reported, five were associated with permanent disability. Neuropathy involving a single spinal nerve, acute toxicity from the local anaesthetic, and problems associated with accidental dural puncture were the commonest complications. This investigation indicates the need for a prospective study. Although rare, serious complications could be reduced further by meticulous technique, while early diagnosis and treatment of untoward events would reduce the incidence of permanent disability.

A device for measurement of radius of curvature of obstetric forceps.

Details of the design of obstetric forceps are important to ensure that they can be used safely for mother and baby. One of the most important measurements is the radius of the cephalic curve of the blades since if this is inappropriate there will be a poor grip on the baby's head and risk of slippage, superficial injury or even intracranial haemorrhage and brain damage because of undue compression. Because of the complex design of the forceps blades, which have a pelvic curve as well as a cephalic curve and a fenestra, the radius of the cephalic curve is difficult to measure. A device was designed to facilitate this measurement and was found to be accurate and reliable in use. This was the first stage in the study to assess the suitability for modern practice of instruments designed many years ago.

Seminal acid phosphatase in relation to fertility.

In a study involving 176 males attending an infertility clinic and 88 controls awaiting elective vasectomy, the semen acid phosphatase activity was found to be significantly higher in the former group (p less than 0.001). However, no definite relationship of semen acid phosphatase level to ejaculate volume, sperm motility, viability, morphology, seminal zinc, magnesium or fructose was observed in either group. The distribution of acid phosphatase in the males attending the infertility clinic, unlike that of the controls, was found to be bimodal. 32 presumably infertile males had acid phosphatase values exceeding the control mean +/- 2 SD. These 32 nevertheless did not have a significantly different mean ejaculate volume, sperm motility, morphology or viability, when compared with the group with normal acid phosphatase levels. Causes of the bimodal distribution of concentrations of acid phosphatase are discussed.

Placental transfer of naloxone.

Maternal and umbilical venous serum naloxone concentrations were measured after the i.v. (30 mothers) or i.m. (seven mothers) injection of naloxone 400 micrograms. Following i.v. naloxone there was rapid transfer to the fetus and therapeutic plasma concentrations could be expected in 1 or 2 min. However, following i.m. administration, neonatal concentrations were variable. In five non-pregnant volunteers naloxone 400 micrograms i.v. resulted in concentrations greater than 2.5 micrograms ml-1 for up to 30 min. After naloxone 2 mg i.m., a peak was reached at 10 min, followed by slow clearance over several hours.

Should women at high risk of neural tube defect have an amniocentesis?

As part of an investigation into the practical problems of a maternal serum alphafetoprotein (AFP) neural tube defect (NTD) screening programme carried out in Mid Glamorgan, South Wales, between 1977 and 1979, obstetricians were recommended to refer women with high risk pregnancies directly for counselling, high resolution ultrasonography, and amniocentesis without first carrying out serum screening. Out of 15 687 pregnant women one-third attended too late to be screened. A total of 637 was classed as high risk, mostly at greater risk than 1 in 50 because of a previously affected pregnancy or an affected close relative. Compliance with recommended procedure was relatively low as many were screened. There were 10 pregnancies with a recurrence of NTD, of which one was not tested at all, two were not detected (one closed meningocele and one closed iniencephalic), and seven were detected and the pregnancies terminated. All the latter, as well as the iniencephalic, would have been detected from a serum AFP determination and a high resolution ultrasound scan alone. It is concluded that these investigations are sufficient for high risk pregnancies and that amniocentesis is not really cost effective or necessary unless either of these investigations is abnormal. As numbers in this study were small it is suggested that these conclusions should be tested in a larger study.

Linked tutorial teaching by teleconference and videocassette.

A system for linked tutorial teaching involving several groups of students at different locations has been introduced successfully into the teaching resources of the University of Wales College of Medicine. It utilizes standard telephone equipment supplemented by specially prepared videocassette material. The results of an evaluation questionnaire given to students indicate that the format as currently used is very acceptable and interesting. Students feel more involved than in larger group teaching sessions and value the discussion periods. This teaching method has the potential to overcome several weaknesses in existing formal teaching programmes, especially when students are based at several sites. In particular, it minimizes travelling, allows more time for clinical experience and makes optimal use of teaching expertise. The system is being developed further to encompass postgraduate centres in Wales.

Can we afford screening for neural tube defects? The South Wales experience.

Clinical and financial gains and losses accruing from five different options for screening for open neural tube defects were estimated, based principally on the results of detailed monitoring of inputs and outcomes and of process costs in the South Wales Anencephaly and Spina Bifida Study. As well as estimating the overall clinical costs of a screening service it was shown that if the prevalence, including terminations, of open neural tube defects is between 1.25 and five per 1000 births the financial cost of avoiding the birth of a seriously handicapped child who would survive for more than 24 hours is in the range 9000 pounds- 54000 pounds depending on the option adopted and the prevalence of the condition in the target population. Prevalence is the biggest determinant of cost. The data should provide a basis for assessment and discussion of resource priorities in the National Health Service.

Antisperm antibodies and male infertility.

Two hundred males attending a fertility clinic and 65 men who had fathered one or more children were screened for sperm antibodies using sperm agglutination and immobilisation tests. The incidence of sperm antibodies was significantly higher in the former group. Agglutinin and immobilisin were not related to sperm concentration, morphology, ejaculate volume, seminal plasma zinc, magnesium, acid phosphatase and fructose. However, sperm motility and viability were significantly reduced in the presence of sperm antibodies. There appeared to be no relationship between the presence of antisperm antibodies and Mycoplasma, aerobic or anaerobic organisms. There was a positive correlation between agglutinating and immobilising antibodies in serum and seminal plasma. This study suggests that sperm antibodies at a significant titre may lower male fertility.

The effect of Ureaplasma urealyticum on semen characteristics.

Semen samples from 280 men were cultured for Ureaplasma. The presence of Ureaplasma in the male genital tract did not affect ejaculate volume, motility, viability, or morphology. Sperm concentration was significantly lower in the presence than in the absence of Ureaplasma. The longevity of sperm as evaluated by sperm motility and viability at different intervals of time was also not influenced by the presence of Ureaplasma. Biochemical parameters, namely zinc, magnesium, acid phosphatase, and fructose were not affected by the presence of Ureaplasma. No relationship of Ureaplasma with sperm antibodies, aerobic infection, or anaerobic infection was observed.