The influence of intrathecal fentanyl on the characteristics of subarachnoid block for caesarean section

Forty healthy parturients scheduled for elective Caesarean section were randomly allocated to receive either 0.3 ml 0.9% saline (control group, n = 20), or 15 micrograms (0.3 ml) fentanyl (treatment group, n = 20) added to 2.5 ml 0.5% hyperbaric bupivacaine given intrathecally in the sitting position. A sensory block to T4 was achieved after 6.5 min in those who received fentanyl compared to 8.0 min in the control group; this was not significantly different. The highest level of sensory block achieved in both groups was similar. Ephedrine was required earlier (p < 0.05) in those who received fentanyl but the total requirement of ephedrine intra-operatively was similar. Fentanyl significantly improved the quality of intra-operative surgical anaesthesia as none of the patients in the treatment group complained of discomfort compared with seven in the control group (p < 0.05). Similarly those in the treatment group had better comfort scores as evaluated by visual analogue score (p < 0.01). Regression of anaesthesia to T12 took longer (184 vs 156 min, p < 0.05) in those who received fentanyl but this did not affect the total requirement of morphine in the first 24 h after operation. There was no difference in the incidence of side effects in the mother and no adverse effects were detected in the baby. The results indicate that adding 15 micrograms fentanyl to hyperbaric bupivacaine for spinal anaesthesia markedly improves intra-operative anaesthesia for Caesarean section.     

Epidural anaesthesia for elective caesarean section does not influence fetal umbilical artery blood flow indices

This prospective study was completed to determine the influence of epidural anaesthesia on the fetoplacental circulation of normal subjects. Thirty-seven normal pregnant patients at term, undergoing elective Caesarean section, had Doppler measurements of the fetal umbilical artery blood flow velocity before and after epidural anaesthesia using lidocaine 2% without epinephrine. There were no differences in systolic/diastolic, resistance or pulsality indices following epidural anaesthesia. These results suggest that this technique has no adverse effect on fetoplacental circulation in normal non-labouring subjects.     

Effect of age and parity on primary caesarean section rates

OBJECTIVE: To study the effect of maternal age and parity on the rates of primary caesarean section. METHOD: We reviewed all patients who delivered at the Princess Badeea Teaching Hospital between 1 January, 1995 and 26 November, 1995. RESULTS: There were 8,732 deliveries included in this study. The primary caesarean section rates in primiparous women less than 25, 25 to 34 and over 34 years of age were 6.1%, 11.1% and 22.2%, respectively. A similarly dramatic rise with advancing maternal age was seen in multiparous women with rates of 3.1%, 6.4% and 9.5%, respectively, in the three age groups. A strong association between maternal age and primary caesarean section exists (p < 0.05). Caesarean section rates in the primiparous women were higher in all age groups when compared with multiparous women (p < 0.0001). CONCLUSIONS: Increasing maternal age and parity are factors strongly associated with increased primary caesarean section rates.     

Dystocia: is it a major indication for caesarean section?

An unusual case of rhinocerebral zygomycosis with its clinical and histopathological features are presented. A good response was observed with oral itraconazole at a dose of 200 mg day-1 for a period of 3 months. To our knowledge, it is the first case report of this infection, involving the maxillary sinus, eye and the brain, from Madras, Tamilnadu, India.     

高温空气对燃烧回流区流动影响的数值模拟

通过建立圆管状燃烧室内甲烷气体燃烧的数学模型,对燃烧室回流区的温度场、速度场、流场以及甲烷、氧气、二氧化碳以及氮氧化合物的质量分数进行了数值模拟.通过改变入口高温空气的预热温度,数值模拟了以上变量的分布规律.研究结果表明:提高空气的预热温度,燃烧室内的反应进行越彻底,温度分布更均匀.研究结果对燃烧室的设计和燃烧室工况分析具有指导意义,所建立的数学模型为燃烧室几何及结构设计和燃烧过程操作中进行定量分析的有效手段.     

Prevention of hypotension during spinal anaesthesia for caesarean section: ephedrine infusion versus fluid preload

We compared the efficacy of prophylactic ephedrine infusion over fluid preloading in prevention of maternal hypotension during spinal anaesthesia for Caesarean section. Forty-six women undergoing elective Caesarean section at term were allocated randomly to receive either intravenous fluid preloading with Hartmann's solution 20 ml.kg-1 (fluid group) or prophylactic intravenous ephedrine 0.25 mg.kg-1 (ephedrine group). Moderate hypotension was defined as > or = 20% reduction in systolic blood pressure and severe hypotension as > or = 30% reduction in systolic blood pressure. Maternal uterine circulation was measured using Doppler ultrasound in 11 parturients before and after spinal anaesthesia. There was a lower incidence of severe hypotension in the ephedrine group compared with the fluid group (35% vs. 65%, p = 0.04), although the incidence of moderate hypotension was similar. Mean umbilical venous pH was higher in the ephedrine group than in the fluid group (7.33 vs. 7.29, p = 0.02) and the number of patients shivering was lower in the ephedrine group (2 vs. 9, p = 0.02). No difference was found between pre- and postspinal uterine artery pulsatility indices in either group. We conclude that prophylactic ephedrine infusion alone is at least as good as fluid preload alone in combating the hypotension associated with spinal anaesthesia for Caesarean section.     

Cardio-pulmonary-bypass time has important independent influence on mortality and morbidity

OBJECTIVE: To determine the influence of cardio-pulmonary-bypass-time on hospital mortality and ICU-morbidity in isolated CABG surgery. METHODS: Between 1985 and 1994 perioperative data of 8578 consecutive CABG operations were prospectively collected. Seven variables: gender, redo vs. primary operation, elective vs. urgent surgery, age in 4 categories, use of IMA, number of distal anastomoses (> 4 vs. < = 4), and cardio-pulmonary-bypass-time in four categories were entered in multivariate logistic regression analysis and odds ratios for respective cardio-pulmonary-bypass-time-categories with regard to mortality, length-of-stay in the ICU and 8 ICU-complications were calculated. Bypass-time up to 90 min was the reference category, the other categories were from 1.5 to 2.5 h, 2.5 to 3.5 h, and longer than 3.5 h. RESULTS: 8337 operations had complete data. Mortality and ICU-morbidity were low. The odds ratios for mortality were 2.3 (P = 0.0094), 7.4 (P < 0.0001) and 20.7 (P < 0.0001) for ascending bypass-time-categories. The odds ratios for prolonged ICU-stay were 1.8 (P = 0.0002), 3.3 (P < 0.0001) and 7.9 (P < 0.0001) for ascending bypass-time-categories. For postoperative complications the same pattern was found: consequently higher odds ratios for longer bypass-time-categories. CONCLUSION: The highly significant correlation between cardio-pulmonary-bypass-time-category and the occurrence of undesirable postoperative events is demonstrated by the consequent rise in odds ratios. This independent influence of cardio-pulmonary-bypass-time on outcome reflects both problems encountered during revascularisation and time-related influence of cardio-pulmonary-bypass on the human body. When a predictive model was created, CPBT proved to be a good predictor of undesirable postoperative events.     

Planned vaginal delivery versus elective caesarean section: a study of 705 singleton term breech presentations

To define the pathology of bronchopulmonary dysplasia (BPD) in surfactant-treated patients (S-BPD), we reviewed 22 BPD patients (14 S-BPD and eight non-surfactant-treated [NS-BPD]) and 15 age-matched controls, the lungs from which had been processed after formalin inflation. These were studied for surfactant therapy, postconceptional age, crown-rump length, weight at autopsy, radial alveolar count (RAC), mean linear intercept (MLI), RAC/MLI ratio, and amount and extent of fibrosis. On trichrome staining, there was no alveolar septal fibrosis in the control group, whereas there was mild to moderate alveolar septal fibrosis in 5 of 14 S-BPD patients, of which three had fibrosis in most or all of the acini. In contrast, seven of eight NS-BPD had moderate to severe alveolar septal fibrosis in scattered acini throughout the lung. The patients were divided into two groups, with the first group having a postconceptional age at the time of death of up to 40 weeks' gestation. In group 1, the RAC in S-BPD (nine patients) was significantly lower than that of the controls (seven patients); mean, 4.14 and 5.13, respectively (P = .016), whereas the RAC in the NS-BPD (four patients) and the MLI in both S-BPD and NS-BPD were not statistically significantly different. In group 2, those with adjusted age greater than term, the mean RAC, a measure of acinar complexity, was 3.89 in the S-BPD (five patients) and 3.90 in the NS-BPD (four patients), whereas in the control group (eight patients), it was 5.79 (P = .0007). The mean MLI, a measure of alveolar size, was 0.21 and 0.17 in the S-BPD and NS-BPD groups, respectively, each of which was significantly greater than the mean value of 0.12 in the control group (P = .0003). The comparison of RAC/MLI ratios showed similar statistically significant differences. Based on these results, we conclude that (1) the amount of alveolar septal fibrosis is substantially less and tends to be more diffuse in S-BPD than in NS-BPD; (2) during the period after birth, there is a partial to complete arrest in acinar development (alveolar saccular and alveolar) of similar severity for S-BPD and NS-BPD; and (3) even though on histological examination there are minimal changes, RAC, MLI, and their ratio may be used to support the diagnosis of BPD and help in assessing the amount of lung damage that occurs in S-BPD.     

Pre-eclampsia: the effect of intravenous fluid preload on atrial natriuretic peptide secretion during caesarean section under spinal anaesthesia

BACKGROUND: The haemodynamic effect of volume load at elective Caesarean delivery may be modulated by atrial natriuretic peptide (ANP) especially in pre-eclamptic women in whom basal ANP levels are increased. METHODS: We followed the haemodynamic parameters and determined the peripheral venous levels of ANP before and after an intravenous volume preload of 1000 ml of Ringer's acetate solution, followed by a further load of the same volume under spinal anaesthesia in 7 healthy and in 6 pre-eclamptic women. RESULTS: During the preload period the median ANP level increased more (from 14.8 to 22.1 pmol/l, P = 0.03) in pre-eclamptic than in healthy women (from 8.0 to 8.5 pmol/l, NS); while an increment in central venous pressure (CVP) was also greater in pre-eclamptic than in healthy women. The increase in the concentrations of ANP correlated significantly (P < 0.05) with the increase in CVP in the total study group. A significant increase in ANP levels in healthy pregnant women was not seen until during the second infusion period under spinal anaesthesia; in pre-eclamptic women the levels increased further during that period. CONCLUSION: These findings concur with the theory that atrial stretch is a stimulus for ANP release. An exaggerated release of ANP in response to volume loading may aid in the adaptation of maternal circulation to volume load at elective Caesarean delivery in pre-eclamptic women.     

A case report: cephalic replacement and emergency caesarean section for the resolution of shoulder dystocia

Shoulder dystocia is a serious complication of delivery. Various manoeuvres had been described, all aim at achieving shoulder descent and vaginal delivery. We report a case whereby shoulder dystocia was managed by a rather unique technique--the foetal head was replaced in the vagina and baby delivered by emergency Caesarean Section.     

The effect of internal fetal monitoring on maternal infection following cesarean section

A retrospective review of 300 cesarean sections was performed. Patients with internal fetal monitoring were at no greater risk for infection than were those patients with labor and rupture of membranes but without internal monitoring. However, the combination of rupture of membranes and labor was a major risk factor for both the frequency and severity of maternal infection after cesarean section. Once membranes are ruptured, we find no contraindication to the use of internal monitoring.     

Parent–child interaction: The influence of maternal employment.

Data were collected from 40 mother–father–preschool child triads, including 20 employed and 20 nonemployed mothers. Information from the Parent-Child Activity Questionnaire, in-home unstructured observations, play task observations, and observer ratings indicated that maternal employment did not significantly alter the role specialization observed in single earner families. Mothers exhibited more caretaking, quiet play, positive affect, and speaking, whereas fathers exhibited more active play. Parents from single earner families demonstrated more speaking and quiet play than parents from dual earner families. Sons received more attention in families with nonemployed mothers, whereas daughters received more attention in families with employed mothers. Parents from families with employed mothers had more favorable attitudes toward dual roles for women. There was increased negative affect in families experiencing incongruence between parents' attitudes and the mother's employment status. (24 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Vaginal delivery from the persistent occiput posterior position. Influence on maternal and neonatal morbidity

We performed a retrospective study of 564 vaginal occiput posterior (OP) deliveries to investigate the influence of this position on maternal and fetal morbidity. The cases were compared to 1,068 controls matched for race, parity and delivery method. The OP group had a higher incidence of severe perineal laceration and episiotomy than the occiput anterior (OA) group. Within the OP group, operative delivery was associated with a higher incidence of severe perineal laceration, vaginal laceration and episiotomy than was spontaneous delivery. Similarly, the OP group delivered by forceps had a higher incidence of severe perineal lacerations, vaginal lacerations and episiotomy than those delivered by vacuum extraction. Mediolateral episiotomy was associated with a lower incidence of severe perineal lacerations than median episiotomy during delivery from the OP position. The infants delivered from the OP position had a higher incidence of Erb's and facial nerve palsy than did those delivered from the OA position. All these injuries occurred following forceps delivery. Vaginal delivery from the persistent OP position is associated with increased maternal morbidity, and operative vaginal delivery from this position is associated with increased neonatal morbidity.     

Pharmacist influence on economic and morbidity outcomes in a tertiary care teaching hospital

The influence of pharmacist participation on economic and morbidity outcomes at a tertiary care teaching hospital was studied. Patients admitted to internal medicine wards during a nine-month period were assigned to either a treatment team or a control team. Each team consisted of an attending physician, senior and junior medical residents, and medical students; the treatment team included a pharmacist who reviewed all patient charts, made rounds with the team, and recommended modifications of drug therapy. Pharmacy interaction with the control team was limited to contacting physicians about potentially dangerous orders, answering questions from the medical team, and handling orders for items not on the formulary or otherwise unavailable. After discharge, data from patient records were analyzed for pharmacy costs and total hospital costs and length of stay (as markers of the pharmacist's effect on economics and morbidity, respectively). Analysis of baseline characteristics showed that the two groups of patients were statistically comparable. Treatment team patients who were included in the data analysis (414) had significantly shorter stays (by a mean of 1.3 days) and lower pharmacy and total hospital costs (by a mean of $301 and $1654, respectively) than those included in the control team analysis (453). The direct participation of a pharmacist on a patient care team significantly decreased pharmacy and hospital costs, as well as length of stay, compared with minimal participation of a pharmacist.     

Boulder at 50: Introduction to the section.

The Boulder conference was the first national meeting ever held in the United States to discuss standards for doctoral training in psychology, despite the fact that psychology doctoral programs in America had been around for more than 60 years by that time. On this, the 50th anniversary of the Boulder report, we offer this special section of articles beginning with a look back at professional psychology before Boulder, a history of the Boulder conference, and a set of commentaries on the aftermath of Boulder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The influence of maternal anxiety on the course and outcome of pregnancy: A review.

Reviews the evidence on the influence of maternal anxiety on the course and outcome of pregnancy. It is suggested that the impact of stress may be moderated by factors including trait anxiety, attitudes toward the pregnancy, appraisal of the stress, psychosocial support, and coping strategies. Heightened anxiety may have direct implications for uterine physiology and fetal health and development, as well as indirect effects through prompting behaviors that are contraindicated in pregnancy, such as smoking or alcohol consumption. The implications of this framework for prenatal care are considered in terms of reducing anxiety levels and promoting adherence to prenatal health care recommendations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)