Managing difficult labor: avoiding common pitfalls.

The suggestions offered in this article represent an effort to reduce the incidence of cesarean delivery for dystocia while maintaining a safe course to vaginal birth. Avoiding difficult labor induction in which a compelling indication is lacking, providing prompt and effective oxytocin therapy of arrested first stage labor, and liberalizing the use of oxytocin therapy in selected cases of second-stage arrest are emphasized. With the widening use of conduction analgesia, indicated operative vaginal delivery has an increasingly important role in tempering cesarean birth rates. Operative vaginal delivery can play an effective role only when strict conditions to insure its safety are met.

Genitourinary prolapse and joint hypermobility in women.

OBJECTIVE: To determine whether joint hypermobility, a clinical marker for connective tissue abnormalities, is associated with genital prolapse. METHODS: One hundred seven women were recruited from a university gynecology clinic. Subjects were examined in the standing and nonstraining positions for cystocele, rectocele, and uterine or vault prolapse. The degree of prolapse was graded 0-3. A separate investigator, blinded to the results of the gynecologic examination and using accepted criteria, evaluated each subject for joint hypermobility. RESULTS: Clinical joint hypermobility was found in 39 of 107 (36%) study patients. Subjects with joint hypermobility had a significantly higher prevalence of cystocele (33 of 37 [89%] versus 40 of 69 [58%], P = .001), rectocele (32 of 38 [84%] versus 33 of 69 [48%], P = .0002), and uterine or vault prolapse (25 of 38 [66%] versus 20 of 69 [29%], P = .0002) compared to women with normal joint mobility, respectively. No differences in the prevalence of stress incontinence were found between the two groups. CONCLUSION: Women with joint hypermobility have a significantly higher prevalence of genital prolapse compared to women with normal mobility, which suggests an underlying connective tissue abnormality as one etiology of pelvic relaxation.

Intrapartum management of twin gestation.

The intrapartum management of the patient with a multiple gestation should begin in the antenatal period. With the present widespread use of ultrasound, the number of multiple gestations diagnosed early in pregnancy has now increased, permitting determination of placentation and monitoring of fetal growth. When a patient with a twin gestation presents in labor, ultrasound should be used to establish fetal presentation and size. The fetal well-being should be evaluated with fetal heart monitoring, and assessment of potential maternal complications, such as anemia, hypertension, and polyhydramnios, should be accomplished. With more than two fetuses, cesarean delivery is recommended. The principal controversy in intrapartum management of twin gestation relates to the planned route of delivery, particularly because this consideration is influenced by malpresentation and prematurity. There is general agreement favoring vaginal delivery for vertex-vertex twin pairs. With dual fetal heart rate monitoring and appropriate delivery room preparation for emergency cesarean section, recent evidence supports planned vaginal delivery of the mature nonvertex second twin. Elective cesarean section for the nonvertex second twin estimated as weighing less than 1800 gm is advised.

First-trimester maternal Listeria monocytogenes sepsis and chorioamnionitis with normal neonatal outcome.

A secundigravida developed culture-proved Listeria monocytogenes sepsis with signs and symptoms of chorioamnionitis at 13 weeks' gestation. Pregnancy termination was refused, and she was treated with intravenous ampicillin and gentamicin followed by oral trimethoprim/sulfamethoxazol. Fifteen days after initiation of therapy, an amniotic fluid culture was negative, although uterine tenderness persisted for 7 weeks. A healthy, culture-negative infant was delivered at term.

The relationship of fetal plasma protein concentration and hemoglobin level to the development of hydrops in rhesus isoimmunization.

Fetoscopic samples of pure fetal blood were obtained at 18 to 25 weeks' gestation from seven hydropic and 10 nonhydropic fetuses affected by rhesus isoimmunization, and the fetal plasma albumin, plasma total protein, and hemoglobin concentrations were determined. All fetuses with sonographic evidence of hydrops had a hemoglobin of 3.8 gm/dl or less, whereas all but one of those without hydrops had a hemoglobin greater than 4.0 gm/dl. The plasma total protein was less than 2 standard deviations below the mean of the normal range in all hydropic fetuses and in six of 10 of those without hydrops. Hypoalbuminemia was found in six of the seven hydropic fetuses and in two of the nonhydropic fetuses. Ascitic fluid total protein and albumin concentrations were also determined in four hydropic fetuses, and the values in three were found to be more than 50% of the corresponding plasma levels.

Obstetric forceps pad designed to reduce infant trauma.

The use of the standard obstetric forceps has been associated with varying degrees of maternal and fetal trauma. To reduce the degree of skin markings, a pliable polyurethane pad with selfadherent backing has been designed, which can be applied to each blade of the forceps. One hundred five neonates who required forceps-assisted deliveries were observed for evidence of skin trauma immediately after delivery and again at 24 hours. Padded forceps significantly reduced craniofacial visible skin markings when compared with the skin markings produced by the unpadded forceps. The addition of the pad to the forceps blade had no adverse effect on the mother, and obstetricians encountered no problems in the application and use of the pads.

Culture-proven herpes simplex type 2 meningitis associated with genital herpes. A case report.

Only 14 cases of culture-proven herpes simplex type 2 meningitis have been reported besides the one reported here. Although an uncommon complication of a common disease, herpes simplex type 2 meningitis should be recognized by gynecologists, for it has the potential for severe and chronic neurologic sequelae.

A technique to facilitate delivery of the high-floating head at cesarean section.

When cesarean section is performed before labor has lengthened and attenuated the lower uterine segment one may encounter considerable difficulty delivering the floating fetal head. The result is often either traumatic or deliberate extension of the uterine incision and undue delay in delivering the infant. This report describes a practical technique to facilitate delivery of the infant in this difficult circumstance.

Fetal platelet counts in the obstetric management of immunologic thrombocytopenic purpura.

The optimal method of infant delivery for gravida women with immunologic thrombocytopenic purpura (ITP) is controversial because of the unpredictability of the fetus developing thrombocytopenia and the uncertainty of the relation between vaginal birth and intracranial hemorrhage in thrombocytopenic infants. We have employed the technique of platelet counts on fetal scalp blood obtained prior to or early in the course of labor in 12 patients with ITP. A count of 50,000/cu mm, selected on the basis of literature review and retrospective analysis of our own experience, was used to define fetal thrombocytopenia. Three thrombocytopenic fetuses were delivered by cesarean section. Trial labor was permitted in the other nine cases in which fetal scalp platelet count exceeded 50,000/cu mm. The outcome was good in all instances. If cesarean section is to be employed in ITP patients to obviate the potential danger of fetal hemorrhage with vaginal delivery, the use of platelet counts of fetal scalp blood seems to provide the most rational basis for management at present.

Determination of regional manpower requirements in obstetrics and gynecology.

The number of trainees produced by a residency program must relate directly to manpower needs in a specialty, not to the service needs of the training institution. In order to avoid geographic maldistribution of specialists, it is preferable to determine correct trainee output on a regional basis and combine such information inductively to determine overall national needs. A model for determination of the number of residents appropriate to train in obstetrics and gynecology by 1985 in the University of Utah program has been constructed in the setting of regional requirements. Components of this model include detailed population growth forecasts at the county level, consideration of the impact of increased urbanization, age-specific data for attrition of regional specialists by death or retirement, and estimation of the proportion of regional requirements to be met by the University of Utah program on the basis of distribution data of previous graduates.

Teaching pelvic examination to second-year medical students using programmed patients.

A great deal of interest has been expressed in the use of the "programmed" patient during the past several years. This pilot study used programmed patients to teach medical students the techniques of pelvic examination. From the study, it was concluded that the experience with the programmed patient adds significantly to an undergraduate learning program, that this technique is well accepted by students and faculty, and that it adds realism to the study of obstetrics and gynecology early in a medical school curriculum.