Terbutaline (intravenous bolus) for the treatment of acute intrapartum fetal distress.

beta 2-Sympathomimetics have been used in acute intrapartum fetal distress to abolish uterine contractions and thus enable the fetal metabolism to recover before delivery. Because some serious complications were reported when a terbutaline intravenous bolus (0.25 mg) was used as a tocolytic, we assessed its safety and efficacy when used in patients not affected by cardiovascular disease, tachycardia greater than 100 beats/min, thyrotoxicosis, fluid overload, corticoids, atropine, or severe abruptio placentae. No maternal or fetal complications occurred in the 36 patients studied; a well-tolerated tachycardia developed in most patients. Fetal heart rate tracings and pH improved in 32 patients. Thirty-four neonates were delivered in good clinical and metabolic condition. We conclude that terbutaline intravenous bolus 0.25 mg is a safe and efficacious procedure when the proper indications and contraindications are followed.

A clinical test for diagnosing nuchal cords.

A simple, noninvasive clinical test for detecting nuchal cords late in pregnancy and during labor is based on recording the changes in the fetal heart rate produced by transabdominal manual compression of the fetal neck area. The test was applied in 88 women close to full term and to 67 women in labor. Overall, the sensitivity of the test was 82.3% and specificity, 89.1%. The results were statistically significant in both late pregnancy and labor. A positive test implies an impending risk of cord compression and is an indication for close electronic fetal monitoring, particularly during labor. Routine use of the nuchal cord test can contribute to decreasing perinatal morbidity and mortality by diminishing the impact of cord problems.

Treatment of acute intrapartum fetal distress by beta 2-sympathomimetics.

Patients with a diagnosis of severe intrapartum fetal distress by fetal heart rate and capillary blood pH monitoring received beta 2-sympathomimetics to inhibit uterine contractions (tocolysis) while the obstetric team was preparing to deliver the fetus. Fetal heart rate and acidosis significantly improved after tocolysis; these fetuses were subsequently delivered in very good metabolic and clinical condition. The favorable effect of tocolysis on fetal homeostasis is attributed to the suppression of the ischemic effect of contractions on the placental circulation. The few fetuses having an extremely compromised placental function showed no improvement in heart rate or acidosis with tocolysis and were immediately delivered. Considering the mild side effects observed, the lack of maternal complications, and the remarkable perinatal outcome obtained, we recommend using tocolysis before delivering distressed fetuses.

A descriptive analysis of involuntary bearing-down efforts during the expulsive phase of labor.

A series of descriptive studies was carried out to characterize maternal respiration, type of bearing-down efforts, vocalization, and behavior; describe the obstetric conditions and intrauterine pressure associated with the bearing-down reflex; and describe the duration of second stage, fetal heart rate, and neonatal outcomes when women bear down spontaneously. Thirty-one healthy nulliparous women who had received no formal childbirth education were neither directed nor instructed to bear down with contractions. The women were supported in their involuntary bearing-down efforts throughout the second stage of their labors while the above features of their labor were recorded. The findings suggest that labor progress is adequate and fetal outcome is good when the management of the expulsion phase of labor encourages maternal pushing that is complementary with the involuntary bearing-down reflex rather than sustained breath-holding. These findings support the necessity for further research regarding the bearing-down techniques used during labor.

Effects of lateral recumbency and sitting on the first stage of labor.

We compared uterine activity in lateral recumbency and the sitting position during the first stage of labor in a group of nulliparas. Lateral recumbency was accompanied by more intense, less frequent and more efficient uterine contractions than sitting. Patients preferred sitting for the first half of labor and lateral recumbency for the second. No adverse fetal reaction was noticed in either position, judging from the fetal heart rate. An increase in maternal pulse rate during sitting could have indirectly indicated some compression of the prevertebral vessels. Maternal position clearly affects several parameters of labor, and its selection should be based upon maternal comfort, uterine contractility and efficiency, and hemodynamic repercussions.

Maternal positions in labor: analysis in relation to comfort and efficiency.

The influence of maternal position during labor on comfort and uterine efficiency was studied by contrasting the influence of sitting in a chair with lying on the side during the first stage of labor. Nineteen primigravidas alternated between these two positions at 30 minute intervals for as long as this was possible during their labors. There was a significant difference in their preference to sit up during early labor (less than 6 cm dilation) and lie on their side during late labor (greater than 6 cm dilation). Uterine efficiency, however, was significantly less (p less than 0.05) in early labor in the sitting position than on the side. After labor was well established, ie after 6 cm dilation, the efficiency of uterine contractions to dilate the cervix was not significantly different between the 2 positions although it was less in the sitting position. The lateral recumbent position was accompanied by more efficient labor and was preferred by most women in late labor. Localization of pain and fetal position also seem to be associated with maternal position preference, and both factors require further investigation.

Transcutaneous PO2 measurements in seriously ill newborn infants.

Continuous monitoring of oxygen tension using the transcutaneous electrode developed by Huch and co-workers was studied in severely ill newborn infants. Acceptable results were obtained despite the theoretical possibility that vasoconstriction might interfere with the method when used in the very ill. The reliability and clinical usefulness of the method is illustrated in 4 cases of severely ill newborn infants.

The maintenance of a stable baseline in intra-uterine pressure with varying maternal position--a practical approach.

When measuring intra-uterine pressure, the tracing baseline varies according to maternal position because of changes in hydrostatic pressure. To compensate for this effect, the membrane of the transducer should always be kept close to the uterine fundus. An additional advantage of this method is that it enables the use of a short catheter, thus causing less tracing artifacts.

Effects of standing position on spontaneous uterine contractility and other aspects of labor.

The aim of this paper has been to compare the uterine contractility, pain produced by contractions and comfort of the patients between standing and supine position. The study has been performed in twenty normal nulliparae who were changed from supine to standing position and viceversa at intervals of approximately thirty minutes. Intrauterine pressure and fetal heart rate were continuously monitored. Cervial dilatation was evaluated every thirty minutes. No medication was given to the patients. They were asked to assess the pain produced by uterine contractions in each one of both positions and which was the more comfortable. It has been found: 1. That the intensity of contractions was significantly higher in fifteen out of the twenty patients in standing position. 2. Frequency of contractions diminished significantly in one third of the patients. 3. Uterine activity increased significantly in half of them. 4. Consistently, less pain accompanied uterine contractions in standing position. 5. Patients reported more comfort in this position. The average duration of labor was 3 hrs 55 min. This duration is short, compared with standard clinical experience and with published data. No complications occurred, by the use of standing position during labor, on the mother or fetus. The physiological mechanisms responsible for the above mentioned effects of standing position are unknown. It is condluced that there are no clear arguments against the use of standing position during labor and that this position should be used more frequently in clinical obstetrics, provided obstetrical conditions are similar to those reported in this paper.