Vaginal birth after cesarean section in twin gestation

OBJECTIVE: We report a 10-year experience with vaginal birth after cesarean section in women with twins. STUDY DESIGN: Data were gathered from labor and delivery records and maternal and neonatal hospital charts. Women with a vertical uterine scar, a previous uterine rupture, an unrepaired dehiscence, or obstetric contraindications to labor were excluded from a trial of labor. Full-thickness uterine defects requiring intervention were classified as ruptures; all others were classified as dehiscences. RESULTS: Between Jan. 1, 1985, and Dec. 31, 1994, at Los Angeles County/University of Southern California Women's Hospital, 210 women with previous cesarean births were delivered of twins. One hundred eighteen (56%) underwent repeat cesarean delivery without a trial of labor. Ninety-two (44%) undertook a trial of labor with no uterine ruptures and no increase in maternal or perinatal morbidity or mortality. CONCLUSIONS: In women with twins a trial of labor after a previous cesarean section is a safe and effective alternative to routine repeat cesarean delivery.     

Isotopic ventriculography in healthy young volunteers. Their response to different types of stress

BACKGROUND AND OBJECTIVES: This study determined the perceived characteristics of family practice residency training programs that produce a high percentage of graduates who provide maternity care. METHODS: We surveyed a Delphi panel of 28 family practice maternity care experts. RESULTS: Consensus was reached after the third survey. The characteristics of the family medicine faculty and teaching service were rated as most important. Other essential characteristics were an adequate obstetrical training volume; mutual respect between obstetric and family medicine faculty and residents; support for family practice maternity care from obstetricians, administration, and nursing staff; and family physicians being accepted in the community as maternity care providers. CONCLUSIONS: Family practice residency programs that produce a high percentage of graduates who provide maternity care have a unique, family practice maternity care-friendly environment. Residency programs wishing to increase the percentage of their graduates who provide maternity care should ensure that their faculty support family practice maternity care, are competent in maternity care, and model maternity care in their own practices. They should strive to ensure an adequate volume of obstetrical cases for resident education and work toward educating patients and local obstetricians, nursing staff, and hospital administration regarding family practice maternity care.     

Delivery of the overweight woman. Analysis of 115 patients

OBJECTIVE: Our purpose was to assess the effect of weight gain during pregnancy on labor and delivery. Abnormal pregnancies were excluded from the study to avoid interaction with the management of labor. POPULATION AND METHODS: A retrospective monocentric case-control study was carried out. We analysed 115 pregnancies delivered in our institution between June 1994 and November 1994. The course of labor was studied in 2 groups of patients: a group of overweight patients and a control group. RESULTS: In the overweight patients, the frequency of induction of labor (25%) and of obstetrical analgesia (82%) was significantly higher than in the control group (respectively 7% and 64%), as well as the average duration of labour and the average duration of the rupture of the membranes. The rate of cesarean section was higher in the overweight patient group (16.7%) than in the control group (3.7%). The difference was not significant because of the small number of patients. CONCLUSION: These results show a more frequent requirement of induction of labour, analgesia, and cesarean section in overweight patients. This led us to propose a multidisciplinary management of overweight patients to minimize these different obstetrical risks during labor.     

Institutional influences on the primary cesarean section rate in Utah, 1992 to 1995

OBJECTIVES: Our purpose was to evaluate institutional and organizational influences on cesarean section rates in Utah and to adjust such rates for differences in patient acuity. STUDY DESIGN: Data on cesarean section rates were derived from the Utah Hospital Discharge Database and adjusted for patient acuity by correcting raw cesarean rates for those patients undergoing cesarean section meeting regional gestational age transport criteria. RESULTS: When analyzed by means of 1-way analysis of variance, the following factors had a significant negative correlation (P < .05) with cesarean section rate: presence of a newborn intensive care unit and maternal-fetal medicine subspecialists, presence on the medical staff of obstetrician-gynecologist(s) as opposed to family physicians only, delivery volume >1500/y, urban location, and 24-hour in-house anesthesiology. When cesarean rates were corrected for acuity, facilities with maternal-fetal medicine specialists and a newborn intensive care unit had significantly lower rates (P < .001) and more uniform rates than otherwise similar institutions. CONCLUSIONS: More medically sophisticated physicians and institutions have lower cesarean rates when patient acuity is taken into account.     

Pregnancy and delivery in the patients with spina bifida--report of 5 cases

BACKGROUND: Because of improvement in the management for life-threatening complications of spina bifida, quality of life in the patient has become better and pregnancy is becoming more common problem in adolescent and adult female patients. In this paper, we reported patients with spina bifida who became pregnant and delivered a baby. METHODS: There were 6 deliveries from 5 patients. Mean patient age at the first pregnancy was 27.6 years (ranged from 26 to 32 years). Four patients had undergone surgical managements before pregnancy, of whom 1 had augmentation cystoplasty. Urological and obstetrical conditions during the pregnancy were analyzed. RESULTS: Upper urinary tract deterioration which was transient, was observed in 3 pregnancies. Serum BUN and creatinine levels remained stable throughout pregnancy in 4 patients. Pyelonephritis complicated 3 of 6 pregnancies. Delivery was vaginal in 4 and by cesarean section in 2. There were 7 obstetrical complications, which consisted of premature labor (2), uterine inertia (2), cephalo pelvic disproportion (2) and hydramnios (1). There were no significant anomalies in the newborns of these patients. CONCLUSION: To achieve successful pregnancy and delivery in the patient with spina bifida, careful urological and obstetrical observation for the potential complications is needed.     

Newborn Country USA

"Newborn Country USA" describes a concept for a regionwide, integrated perinatal care system that serves a population of more than four million. How the four sectors of the Denver Regional Perinatal Center - The Children's Hospital, Denver, Denver General Hospital, Fitzsimons Army Medical Center, and the University of Colorado Army Medical Center - interact as a regional resource, relate to 223 hospitals in portions of 10 states, and assist in serving a portion of 70,000 live births in 1976 are reported.     

Family medicine in Minnesota: office costs and productivity

Clinics representing more than half of Minnesota's family physicians participated in a statewide study on the practice of family medicine conducted by the Minnesota Academy of Family Physicians. The survey was designed to provide direction for individual physicians, administrators, and the Minnesota Academy of Family Physicians as an organization. The survey identified some concerns regarding access to care. In the central portion of the state, 71% of the full-time equivalent family physicians were in practices with Medicaid patient restrictions. In the most sparsely populated towns, 35% of the reporting family physicians who provided obstetrical care three years ago discontinued that service due to the cost or availability of professional liability coverage. Statewide in 1989, 57% of the family physician positions recruited for by the practices studies were unfilled at year's end, with 82% unfilled in the most sparsely populated areas.     

Fair hearing testimony

Realizing the competitive environment of medicine, the gold standard for credentials must remain training, experience, ability, and/or competence. These two doctors have met this standard. Family physicians have cesarean privileges in Memphis, Tenn.; Wichita, Kan.; Kansas City, Mo.; Rochester, Minn.; and numerous other cities across our state and nation. With access to perinatal care of critical importance, all physicians must practice medicine to their fullest capabilities. This hospital will greatly benefit from its support of fair privileging for family physicians. And the AAFP will vigorously defend each family physician's right to practice obstetrics on both a state and national level.     

Comparison of two low-molecular-weight heparins for the prevention of postoperative venous thromboembolism after elective hip surgery. Reviparin Study Group

BACKGROUND: Many physicians today are employed by another physician, group, hospital, HMO, or other organization. However, the differences in the characteristics, practice patterns, and patient outcomes of self-employed and employed physicians are not well understood. METHODS: The practices of 108 community family physicians in northeast Ohio were assessed using a multimethod cross-sectional design. Physician characteristics were assessed by questionnaire. Direct observation of 3536 consecutive patient visits was used to measure time use and the delivery of preventive services recommended by the US Preventive Services Task Force. Patient satisfaction was assessed with the Medical Outcomes Study (MOS) 9-item Visit Rating Form. RESULTS: Employed physicians were more likely to be female, in group practice, work fewer hours, and see fewer patients. Job satisfaction was similar between the two groups, but employed physicians reported greater satisfaction with leisure and family time. Employed physicians spent more time per patient visit, scheduled a larger percentage of well-care visits, and were more likely to refer to specialists. Employed physicians also spent a greater proportion of their patients' visit time performing history-taking and eliciting family information, and a lesser proportion of time on physical examination, planning treatment, providing health education, and chatting. Recommended screening and health habits counseling preventive services were more likely to be delivered by employed physicians. Patient satisfaction was similar for the two groups. CONCLUSIONS: Primary care physician characteristics and practice patterns differ by employment status. The consequences of the trend toward a largely employed physician workforce as reported in this study should be carefully considered.     

Hospital integrated lanes training: brigade-directed implementation of a medical lanes training program during annual training

The "lanes" concept of training was integrated into a medical site support mission of the 804th Medical Brigade, U.S. Army Reserve, during Annual Training, 1993 at Fort Drum, New York. This training, termed Hospital Integrated Lanes Training (HILT), included STX, FTX, patient play, and full use of Deployable Medical Systems equipment. The medical care of over 33,000 personnel participating in tactical annual training exercises was not interrupted during any concurrent phase of lanes training. Brigade operations planners developed an array of medical exercises that involved both moulaged and paper patient play. These exercises began prior to hospital set-up and continued for 24 hours a day throughout the tactical exercise. Injuries likely to be encountered during combat operations were inserted into the play singly and under a mass-casualty scenario. The standard of care for all injuries was determined with the Army Medical Department Center and School guidance. Prior coordination of brigade medical assets with external air and ground ambulance organizations broadened the scope of the training and facilitated effective use of command and control, communications, and equipment over a wide geographic area. Medical records were collected and evaluated at the conclusion of all exercises. After-action reviews were conducted by all medical units to assist in the planning of future HILT exercises. The HILT concept is a valuable tool for the complex training requirements of field medical units organized under medical Force 2000. The concept of integrated lanes training allows for the development and continuous improvement of individual and sectional skills for medical personnel and should be applied within all echelons of care.     

Epidural analgesia in labor and cesarean delivery for dystocia

Published studies assessing the effect of epidural analgesia in nulliparous labor on the frequency of cesarean delivery for dystocia are reviewed. There are at least four retrospective studies and two prospective studies that suggest that epidural analgesia may increase the risk of cesarean delivery for dystocia in first labors. The potential for epidural to increase the frequency of cesarean delivery for dystocia is likely influenced by multiple variables including parity, cervical dilatation at epidural placement, technique of epidural placement, management of epidural during labor, and the obstetrical management of labor after placement of epidural analgesia. Two studies suggest that delaying placement of the epidural until 5 cm of cervical dilatation or greater may reduce the risk of cesarean birth. Epidural is safe and may be a superior labor analgesic when compared with narcotics. However, patients should be informed that epidural analgesia may increase the risk of cesarean birth in first labors.     

Histologic distribution of hepatitis A, B, C, D, E, and G with concomitant cytokine response in liver tissue

BACKGROUND: Studies focusing on the economic impact of cancer on families have emphasized that costs of chronic disease are substantial for patients and their families. However, little effort has been devoted to measuring the costs of care for families of patients hospitalized with stroke. METHODS: A total of 215 stroke patients and their families from four teaching hospitals in the Taipei metropolitan area were monitored from the date of the patient's admission to hospital until the date of discharge. The value of labor contributed by families was estimated by assigning the current monetary market rate of providing health aide to the time families spent caring for patients in hospital. Lost earnings of patients and families, expenditure for medical care, and expenses for food, clothes, adult diapers, transportation and other miscellaneous items were determined and summed to arrive at the total family cost of providing care. RESULTS: The average cost of care for one family per inpatient day was NT$4,358.20. A total of 98.6% of the families incurred labor costs, which accounted for about half of family costs for providing care. Hospital bills accounted for almost 19% of total family costs. The income loss for families and patients accounted for about 25% of total family costs. Expenses for food, clothes, transportation, diapers and other illness-related miscellaneous items accounted for about 12% of total family costs. Multiple regression analyses demonstrated that the number of family members involved in giving care and the length of stay are important predictors for the total cost of care. Average total family costs per day increased by 24.3% when an additional family member was involved in providing care. Total family costs increased 2.5% for each hospital day. CONCLUSIONS: If direct and indirect nonmedical costs are not included in the total cost calculation for providing hospital care to stroke patients, the economic impact of care on families is likely to be underestimated.     

Perioperative nursing in Israel

Perioperative nursing in Israel's Hadassah Medical Organization hospitals-Ein Kerem and Mt Scopus-reflects quality patient care practices paralleling those in US hospitals. Although these two hospitals, both located in Jerusalem, represent only 5% of the hospital beds in Israel, they receive more than 60% of referrals made to all Israel hospitals. Throughout Israel's tumultuous history, the Hadassah Medical Organization has served the country during both war and peace. In 1991, Mt Scopus was designated as the hospital on duty in case of a chemical attack during the Gulf War. The authors provide an overview of perioperative nursing at the Eln Kerem and Mt Scopus Medical Centers of the Hadassah Medical Organization and describe one American nurse's experience as a volunteer in the Mt Scopus Medical Center OR during the Gulf War.     

History of the public health policy in Chad 1900-1995

Public health policy in Chad began after colonization in 1899 and remained under the control of French Army Medical Corps for a long time. Military doctors shared their time between treating service personnel and indigenous people entitled Medical Assistance and making rounds in their sector. Since independence public health in the country has been based on a two-pronged association including fixed facilities (hospitals and dispensaries) and mobile services such as the Endemic Disease Unit whose most notable success was control of sleeping sickness in the southern part of the country. Over the years Chad has built up a national medical staff comprising 150 physicians. A medical school was opened in N'Djamena in 1990 and paramedical personnel are now trained at the National School for Public Health. War and lack of funds interrupted mobile services and there is presently a recrudescence of sleeping sickness. Since 1990 the World Health Organization has imposed its views and primary care is now available for all. However, it is now too early to judge the efficacity of this program in Chad.     

The primary care network--a new type of HMO for private practice physicians

A new type of health maintenance organization has been developed to encourage primary care physicians in private practice to become coordinators and financial managers for all medical care. Each patient chooses one internist, family or general physician, or pediatrician and must be referred by that physician for all hospital admissions and care by specialists. The primary care physician authorizes all payments from his own account for care provided to his patients. He shares any deficit or surplus remaining at the end of the year. Hospital admission rates and length of stay are lower than those of Blue Cross, with only one of three dollars paid to hospitals. The plan is providing care to 38,000 persons with 750 participating physicians in Northern California, Washington and Utah. This plan represents an attempt by physicians to control costs without government regulation.     

Evaluation of copper(II)-pyruvaldehyde bis (N-4-methylthiosemicarbazone) for tissue blood flow measurement using a trapped tracer model

PURPOSE: Adolescent childbearing is twice as common among Native Americans as among all US races combined. Despite this, little is written about the psychosocial context or prenatal care of pregnant Native American adolescents. The objective of this study was to explore the reactions and prenatal care of Navajo and Apache adolescents delivering infants at Shiprock Indian Hospital, New Mexico, between January and March 1991, and Whiteriver Indian Hospital, Arizona, between May and June 1991. METHODS: Of the 25 eligible adolescents aged 19 years and younger, 15 Navajo and 5 Apache participants were interviewed within 24 hours of delivery. The interview consisted of 121 questions divided into 5 areas: sociodemographics, personal and family reactions to the pregnancy, knowledge and attitudes toward prenatal care, barriers to care, and ways to improve access to care. RESULTS: The mean age was 17.4 +/- 1.1, 6 were married, and 13 were primiparous. According to the Maternal Health Services Index, 5 adolescents received adequate, 13 intermediate, and 2 inadequate prenatal care. During the pregnancy, 3 adolescents used tobacco, 3 used alcohol, and none admitted to other drugs. Although only 1 adolescent planned the pregnancy, 15 were not using contraception when they became pregnant. In exploring reactions to the pregnancy, 13 adolescents were afraid to tell their families and 4 concealed the pregnancy until confronted. During the pregnancy, 7 adolescents described loneliness and 6 expressed suicidal ideation. Although over half reported no barriers to obtaining prenatal care, barriers that were noted by the remainder included transportation, family problems, and missing school. CONCLUSION: We conclude that pregnancy among many American Indian adolescents is unplanned and characterized by uncertainty and fear of disclosure, resembling the reactions to pregnancy of other adolescent populations. Furthermore, despite universal access to health services, many American Indian adolescents continue to experience barriers to care and receive intermediate or inadequate prenatal care. These preliminary findings suggest further research may help clarify how adolescent reactions to pregnancy and knowledge of prenatal care affect health care utilization.     

Impact of risk-adjusting cesarean delivery rates when reporting hospital performance

CONTEXT: Hospitals and health plans are often ranked on rates of cesarean delivery, under the assumption that lower rates reflect more appropriate, more efficient care. However, most rankings do not account for patient factors that affect the likelihood of cesarean delivery. OBJECTIVE: To compare hospital cesarean delivery rates before and after adjusting for clinical risk factors that increase the likelihood of cesarean delivery. DESIGN: Retrospective cohort study. SETTING: Twenty-one hospitals in northeast Ohio. PATIENTS: A total of 26127 women without prior cesarean deliveries admitted for labor and delivery from January 1993 through June 1995. MAIN OUTCOME MEASURES: Hospital rankings based on observed and risk-adjusted cesarean delivery rates. RESULTS: The overall cesarean delivery rate was 15.9% and varied (P<.001) from 6.3% to 26.5% in individual hospitals. Adjusted rates varied from 8.4% to 22.0%. The correlation between unadjusted and adjusted hospital rankings (ie, 1-21) was only modest (R=0.35, P=.12). Whereas 7 hospitals were classified as outliers (ie, had rates higher or lower [P<.05] than overall rate) on the basis of both unadjusted and adjusted rates, outlier status changed for 5 hospitals (24%), including 2 that changed from outliers to nonoutliers, 2 that changed from nonoutliers to outliers, and 1 that changed from a high outlier to a low outlier. CONCLUSIONS: Cesarean delivery rates varied across hospitals in a single metropolitan region. However, rankings that fail to account for clinical factors that increase the risk of cesarean delivery may be methodologically biased and misleading to the public.     

Postoperative suture manipulation for control of corneal graft astigmatism

Placenta percreta is a rare complication of pregnancy. Rupture of the uterus due to placenta percreta is one of the most urgent obstetrical catastrophes. Recently, we observed a patient who developed placenta percreta accompanied by spontaneous uterine rupture at 28 weeks of gestation. A 29-year old gravida 3, para 1, who had a history of one cesarean section and one miscarriage with dilatation and curetage, was seen at 28 weeks of gestation. An acute abdomen and shock were diagnosed. Immediate laparotomy revealed a transverse rupture on the fundus of the uterus. A hysterectomy was performed. Pathological examination of the uterus showed placenta percreta. Rupture of the uterus due to placenta percreta before the onset of labor is extremely rare.