Preparing obstetricians and gynecologists for capitation.

We are indeed facing a changing paradigm in the way medical services are delivered and reimbursed. Physicians are becoming entangled in the business world. Terms such as "medical loss ratio" must be integrated within the physician's existing language. According to Green and Barnett, "No group is so large or so small as to likely survive the next decade without being involved in a capitated contract." The change is not tomorrow, it is today. Do not be lost in the changing world of medicine without becoming involved, and see if it is for you and your practice. Progress of medicine may not be what you would like but do not be passed by without making an impact. Capitation offers an opportunity to regain control of the management of care, to develop innovative and cost-effective approaches to delivery, and to enhance income and revenue in the face of declining health care budgets.

Intrapartum fetal heart rate: correlation with scalp pH in the preterm fetus.

The relationship of FHR patterns and fetal scalp blood pH is well documented in the term fetus. Although FHR monitoring has been increasingly used to guide intrapartum management of the preterm fetus, little documentation of efficacy and the interrelationship of FHR patterns with pH is available. This report of 62 preterm fetuses documents the relationship of FHR findings and their correlation with fetal pH. The ominous connotation of late deceleration is emphasized. The evaluation of the presence or absence of FHR variability and acceleration patterns are proved as significant factors which are helpful in making management decisions.

The evaluation of uterine activity: a comparative analysis.

In this study a comparison is made between the most widely accepted method of expressing uterine activity, Montevideo units, and an automated on-line method expressed as uterine activity units. Although the actual numerical expression differs, the percentage of variation when the two values are compared is small at various phases of labor. The variation between the methods for uterine activity required to progress from 4 to 6 cm cervical dilatation and from 6 to 10 cm cervical dilatation is less than 5%. Both methods closely agree on the actual expression of uterine activity or uterine work.

Monitoring of uterine activity.

The aim of modern obstetrics is to deliver a healthy, undamaged infant to a healthy, happy mother. The ability to classify and treat abnormalities of uterine activity safely with the plotting of cervical progress against time and to quantitate uterine activity as adequate or inadequate allows for more specific and rapid treatment. Treatment may be instituted more rapidly with monitoring and thus avoid prolonged labours with maternal exhaustion and dehydration. With normal fetal heart rate and variability Schifrin (1974) has stated that the differences in fetal outcome associated with various patterns of abnormal labour essentially disappear if mid-forceps procedures are abandoned and only spontaneous vaginal delivery or caesarean section is used.

Fetal heart rate variability: an approach to automated assessment.

Three hundred seventy-five hours of fetal heart rate (FHR) data derived from the direct fetal electrocardiogram (ECG) were studied. This data had been stored on magnetic tape from 83 intrapartum patients. By means of a computerized technique, the FHR variability was assessed quantitatively. The degree of variability was then related to: (1) state of labor, (2) fetal scalp pH values, and (3) the 1-minute Apgar score. FHR variability was computed from differences between consecutive R-R intervals measured from the R wave of each fetal ECG. A trend of increasing variability was seen with advancing labor, defined by either time prior to delivery or cervical dilatation, but values were not statistically significant. Significantly less FHR variability was encountered when fetal scalp pH values below 7.20 were compared to higher values. FHR variability assessed during the 20 minutes immediately preceding delivery was significantly lower in infants with 1-minute Apgar scores less than 7. Machine assessment of FHR variability thus could be correlated with fetal condition as determined by scalp pH and neonatal outcome determined by Apgar score.

Uterine activity in the multiparous patient.

There were 149 parous patients with normal cervical dilatation patterns studied. The purpose was to quantitate and characterize uterine activity in a group of multiparous patients with normal labor using our present on-line method and to evaluate our method against pervious work done on uterine activity. A mean total of 5,299 uterine activity units (UAU) was required to progress from 4 cm. through delivery. In the patients receiving oxytocin 5,907 UAU were required and 4,498 UAU for those not receiving oxytocin. Of the total uterine work from 4 cm. to delivery, 49.4% was required to progress from 4 to 6 cm. 38.7% to progress from 6 to 10 cm., and 11.9% for the second stage. This study establishes in a quantitative way, using on-line methods, the patterns of uterine activity expended by the parous patient in normal labor and can be compared to previous off-line and manual evaluations. These data can be compared with the on-line observations previously made in a primiparous group, and will be fundamental to automated evaluations including definitions of abnormal labor.