Operational Obstetrics and Gynecology: the medical care of women assigned to sea duty and other remote duty stations

It presents information on therapy and chemotherapy related to routine care, Pap smears, human papilloma virus, vulvar lesions, vaginal discharge, birth control pill problems, problems with subdermal implants and long-acting injectable progestagens, abdominal pain, abnormal bleeding, normal and abnormal pregnancy, sexual assault, problems with urination, and itching.

Surgical emergencies in Obstetrics and Gynecology: the surgical care of women in operational settings

It presents information on care, therapy and chemotherapy related to obstetric illnesses with surgical significance, and gynecologic problems of surgical significance, and surgical procedures.

Changes in women's health care aboard one ship.

UNLABELLED: Health care needs of women assigned to sea duty may change over time. OBJECTIVE: Determine changes in the obstetrical/gynecological needs of U.S. Navy women assigned to a submarine tender. METHODS: Retrospective record review of personnel aboard one U.S. Navy ship in 1990 and in 1995. RESULTS: The demographic character of the female crew members changed. Compared with 1990, the women in 1995 were older, more experienced, of higher rank, more likely to use contraception, and more likely to have children. The pregnancy rate dropped from 2.7 to 1.5 per 100 women per month. Sexually transmitted diseases were less frequent, and the "satisfactory Papanicolaou smear" rate increased from 52 to 93%. Both in 1990 and 1995, women utilized Sick Call more often than men. CONCLUSION: Measurable changes occurred in the obstetrical/gynecological health care needs of women assigned to one ship in 1990 and 1995.

Field-expedient gynecologic examination table.

In field operational environments, the gynecologic health needs of women may be difficult to provide because of the lack of a small, lightweight, durable, inexpensive gynecologic examination table. Such a table already exists, in pieces, in the inventory of most field-deploying units of battalion aid station size or larger. Because the table's existence is not commonly known, we describe the assembly and use of this field-expedient gynecologic examination table.

Routine prenatal and gynecologic care in prepaid group practice.

A survey of routine prenatal and gynecologic care provided by 26 prepaid medical groups to 1 673 895 members and 25 724 obstetrical deliveries per year showed that, in actual clinical practice, there is considerable disagreement over what should constitute routine care. The fact that many providers of care do not adhere to routines recommended by textbooks, professional groups, or legal precedent leads to diversity of routine care.

Fetal position during pregnancy.

In this study of a normal, undelivered population the incidence of each fetal position was reported. Fetal position at 20 weeks' gestation did not correlate with delivery position. Fetal position at 36 weeks was very predictive of fetal position at delivery. Malposition was not associated with premature delivery per se.

Routine ultrasound scanning for the detection and management of twin pregnancies.

One thousand five hundred fifty-one private patients underwent routine ultrasound scanning in part to detect twins. Five thousand nine hundred fifty private patients acted as controls and underwent ultrasound scanning only when indicated by conventional obstetric standards. When diagnosed, twin pregnancy was treated with increased bed rest, nutritional counseling and careful monitoring, with delivery in a tertiary-level center. No significant differences between the two groups could be demonstrated in maternal age, parity or incidence of twin pregnancy. A significant difference could be shown, however, in the early detection of twin pregnancy. By the end of the 24th week, 94% of the twins in the routinely scanned group had been diagnosed as compared to only 68% in the controls (p = 0.03). A significant improvement in perinatal outcome was also demonstrated in the routinely scanned patients as compared to the controls. The incidence of any unfavorable outcome in any infant was reduced from 60% in the controls to 25% in the routinely scanned patients (p = 0.0007). This reduction was due to a reduced incidence of low birth weight, smallness for gestational age, prematurity, depressed Apgar scores and stillbirths. When all twins diagnosed prior to the 25th week of pregnancy were compared with those diagnosed after that week, similar findings were demonstrated.

Myotonic muscular dystrophy associated with ritodrine tocolysis.

A patient thought to be normal was admitted with premature labor at 29+ weeks' gestation. Treatment with the beta-mimetic ritodrine hydrochloride appeared to provoke symptoms of myotonic muscular dystrophy. Neurological history and examination confirmed the presence of previously unsuspected myotonic dystrophy in the patient, her father, and paternal grandfather. Discontinuation of the drug led to improvement in myotonia symptoms but worsening premature labor. Magnesium sulfate did not provoke the same symptoms but was unsuccessful in controlling premature contractions. Long-term management with bed rest, phenytoin, and isoxsuprine hydrochloride resulted in term delivery. Subsequently, maternal symptoms of myotonia disappeared. Congenital myotonia was suspected in the fetus because of the ultrasonic demonstration of polyhydramnios and reduced fetal movements. This was confirmed at delivery. The mechanism by which ritodrine unmasked the myotonia is unclear but may be related to changes in the cell membrane (chloride conductance, the sodium-potassium pump, or membrane polarization).

Routine ultrasound for detection and management of the small-for-gestational-age fetus.

Serial ultrasound scanning was used routinely in 1687 private patients to detect small-for-gestational-age infants, twins, congenital anomalies, placenta previa, and errors in gestational age estimates. A control population of 8350 private patients was scanned only when indicated. Twenty-three percent of the small-for-gestational-age infants were detected in the control subjects, while routine scanning increased the detection rate to 57% (P = .0007). A high rate of false positive results were found. Seventeen percent of the routinely scanned population were found to be at risk for small-for-gestational age, but only 6% of those actually were small. Despite the increased detection of small-for-gestational-age infants in the routinely scanned population, no significant difference between the routinely scanned and the selectively scanned small-for-gestational-age patients could be shown in the areas of stillborns (6%), neonatal deaths (4%), perinatal mortality (10%), low one-minute (27%) or five-minute (7%) Apgar scores, cesarean section rate (22%), mean gestational age at birth (38.8 weeks), or weight (257 g below the tenth percentile). This occurred despite the aggressive use of maternal bedrest, correction of risk factors, serial scans, nonstress testing, and early delivery when indicated.

Forceps operations in perspective. II. Failed operations.

Eighteen recent cases of failed forceps operations are reviewed. Although no maternal or fetal deaths occurred, low Apgar scores were found in more than half of those patients considered at significant risk with the use of the Perinatal Morbidity Index (PMI) and Maternal Morbidity Index (MMI) developed at our institution. Among low-risk patients more favorable results were found. Whenever difficulty in a forceps delivery is encountered because of misjudgement of pelvic capacity or fetal size, further attempts at vaginal delivery should cease and a cesarean section should be performed. This procedure will most likely lead to a favorable outcome for mother and child. A patient already at significant risk should, under ordinary circumstances, not be considered a candidate for a forceps trial. If the trial is successful, the infant has a nearly 50% chance of unfavorable outcome; if it is unsuccessful, the chance of an unfavorable outcome is 64%.

Maternal and fetal outcome of Lamaze-prepared patients.

To determine whether Lamaze childbirth preparation is harmless, harmful, or beneficial, 500 consecutive Lamaze-prepared patients were compared to 500 hand-picked controls, matched for age, race, parity, and educational level. Lamaze preparation was found to have a significant beneficial effect in almost every obstetric preformance category. The Lamaze-oriented patients had one-fourth the number of cesarean sections and one-fifth the amount of fetal distress (P less than .005). Postpartum infection, measured both by maternal febrile morbidity and by the incidence of antibiotic use, was one-third that of the controls (P less than .005). Similarly, the "prepared" patients had fewer perineal lacerations and those that occurred were not as serious as those in the control patients (P less than .005). The control patients had three times as many cases of toxemia of pregnancy (P less than .005) and twice as many of prematurity (P less than .05).

Forceps operations in perspective. I. Midforceps rotation operations.

Four hundred fifty-eight consecutive midforceps rotation operations were evaluated with a specially designed Perinatal Morbidity Index (PMI) and Maternal Morbidity Index (MMI). An unfavorable fetal outcome occurred in 30.8% of the midforceps rotation operations, and an unfavorable maternal outcome occurred in 13.5% of the cases. Twelve risk factors were found to be associated with suboptimal results. Among patients with no risk factors, an unfavorable fetal outcome occurred in 11% of the cases. Of the patients with three or more risk factors, in contrast, an unfavorable fetal outcome was found in 47% of the cases. A uniformly good fetal outcome was noted among patients selected as controls. Under ordinary circumstances, midforceps rotation operations should not be attempted in a patient already at significant risk. "Significant risk" is defined in the article.

Experience with modern inert IUDs to date: a review and comments.

A review of data from various large-scale studies reveals as much variation between studies as between devices. Many factors clearly unrelated to the IUD design undoubtedly influence their efficacy and continued use. Thus, the conclusions of the 1968 FDA report on effectiveness and utility still appear valid at this time. They are: A. "The Committee finds adequate scientific data attesting to the effectiveness and utility of the intrauterine devices." B. "The intrauterine devices are highly effective in preventing pregnancy, although they are not quite as reliable as the hormonal contraceptives if the latter are taken according to instructions." C. "The rate of continuation of use is similar to that of the oral contraceptives and is far higher than that of traditional methods, at least among the socially and economically deprived."

The effect of fetal monitoring on the incidence of cesarean section.

To determine whether routine fetal monitoring inevitably increases the cesarean section rate, we studied the pertinent literature and analyzed the cesarean sections performed at Evanston Hospital during the last 8 years. Many authors have found a slight to moderate increase in cesarean section rates, whereas others have found no change or a decrease. At Evanston Hospital, the primary cesarean section rate has increased from 2.6% in 1968-1969 to 6.9% in 1974-1975. Only 19.2% of this increase is due to increased fetal distress; the magnitude of the increase is due to changes in other factors, notably, breech deliveries (29.5% of the increase) and "dystocia" (60.2% of the increase). The incidence of cesarean section is controlled by several complex variables, only one of which is fetal monitoring. To describe the fetal monitors as the cause of the increased cesarean section rate is to ignore these other equally profound changes in obstetric technic and philosophy.

An evaluation of preinduction scoring systems.

A double-blind clinical study of five preinduction scoring systems was undertaken to determine the accuracy of clinical usefulness of each system as applied to a diverse group of patients. When strictly applied, all five systems were found to be as accurate and useful as it was originally claimed they were. However, when applied without regard to each author's prerequisites, none of the five scoring systems was found to be reliable. A series of preinduction score modifiers is presented which, when applied to any of the preinduction scoring systems, will reliably predict the outcome of induction of labor, with a 50% induction failure rate in patients with lower third scores, a 10% failure for middle third scores, and essentially a 0% failure in the upper third scores.