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The management of labour used to be largely expectant—“wait and see” or “never let the sun set twice on a labouring woman,” implying that a labour taking up to 48 hours was acceptable. Labours of this length are often emotionally traumatic for women, may hide hazards to the fetus, and are very demanding on staff resources. In the 1960s, '70s, and '80s O'Driscoll and colleagues promoted “active management” of labour for women in their first labour. This management emphasised: #### Rates of oxytocin augmentation in primiparous women and incidence of caesarean section during labour View this table: Results of meta-analysis of effect of having partners present in labour (with odds ratios and 95% confidence intervals for various outcomes) Subsequent studies showed that, although thisapproach reduces the length of labour bya small amount, the onlycomponent with a clear benefit in promoting spontaneous vaginal birth is the continuous presence of the birth attendant. Women have declared their intolerance of long labours, however, by increasingly requesting delivery by caesarean section. In many major maternity units in the developed world, the rate of caesarean sections is now 16% or higher. In the United Kingdom this process has been accelerated by the ChangingChildbirth initiative, which emphasises the importance of maternal preferences. Currently, the most common recommendations for monitoring progress in labour are measuring the descent of the fetal head and a vaginal examination of cervical dilatation every four hours. The rate of dilatation below which augmentation by Syntocinon infusion is recommended varies from 1 cm/h (the original O'Driscoll recommendation, resulting in augmentation rates in first labours of 40-50%) to 0.5 cm/h (leading to augmentation rates of about 15%). The mother's …

Twin pregnancies are becoming more common because of the increasing use of assisted reproduction technologies.1 They are associated with an eight to tenfold increase in the perinatal mortality rate,2 mainly because 40-70% of twins are born preterm.3 However, the safety of term vaginal delivery for twins has long been of concern; some large epidemiological studies have suggested that the second twin is at especially high risk of death.4 Complications associated with the second twin include the longer second stage, compound presentation leading to trauma during delivery, cord prolapse, and premature separation of the placenta.5 However, the only randomised controlled trial identified by a Cochrane review6 of caesarean section compared with vaginal delivery in twins7 and other small retrospective studies8 have not confirmed clinicians' subjective impressions of poor outcome in the second twin. The study by Smith and colleagues in this week's BMJ is welcome for the light it sheds on this topic.9 They studied twin pregnancies in the United Kingdom from 1994 to 2003 in which one of the twins died during or after labour for reasons other than congenital abnormality (1377 pregnancies). Before 37 weeks' of gestation, the two babies were at equal risk, but at term the risk of death was higher in second twins (odds ratio 2.3, 95% confidence interval 1.7 to 3.2, P

Neonatal respiratory morbidity is halved, but they may be harmful in the long term I n recent years the caesarean section rate in developed countries has been rising. This may be because improved techniques to control haemorrhage, infection, and thromboembolism have increased the safety of the procedure. As a result obstetricians and pregnant women have a reduced threshold for choosing it. However, although maternal risks have decreased, the effects on the baby of surgical delivery before the due date continue to be debated.' In this issue (p 662), Stutchfield et al confirm previous reports that elective caesarean section before 40 weeks' gestation increases neonatal admissions to the special care unit for respiratory distress (mainly for transient tachypnoea of the newborn).12 In the control group of the randomised controlled trial, 11.4% were admitted at 37 weeks, 6.2% at 38 weeks, and 1.5% at 39 weeks. If women were given two intramuscular injections of 12 mg of betamethasone in the …

It seems odd that Krafft’s associated editorial adopts such a celebratory tone. He says that many years have been spent “looking for better evidence favouring iron supplementation in pregnancy”1 but does not consider the possibility that the failure of so many studies to find a significant advantage might mean that the value is marginal. Despite the large number …

Objective To determine the optimum mode of delivery for women in preterm breech labour at a gestational age of 26 to 32 weeks. Design A multicentre randomised controlled trial. Setting Twenty-six hospitals in England, UK. Participants Women with a singleton breech fetus in spontaneous preterm labour between 26 and 32 completed weeks of gestation, with no clear indication for a caesarean section or vaginal breech delivery. Intervention Random allocation to either ‘intention to delivery vaginally’ or ‘intention to deliver by caesarean section’. Main outcome measures Perinatal mortality, neonatal morbidity, maternal morbidity and gestation at delivery. Results The trial was closed after 17 months because of low recruitment, by which time substantial numbers of women had been in the eligible gestation period. Thirteen women from six hospitals were recruited. One infant, randomised to and delivered vaginally, was stillborn. Three fetal presentations were cephalic at delivery despite a diagnosis of breech presentation at trial entry. No formal statistical analysis was performed due to the small numbers. Conclusions No conclusions about the optimum mode of delivery for women in preterm labour with a fetus presenting by the breech can be drawn from this trial. The low accrual rate was due to clinicians’ reluctance to randomise eligible women, reflecting the circumstances and nature of the trial.

Recent data suggest that the ovarian peptide relaxin is responsible for the pregnancy-associated fall in plasma osmolality in the rat. In order to test whether relaxin has the same role during human pregnancy, plasma osmolality, electrolytes, urea and creatinine were measured in samples obtained at 10, 20 and 30 weeks gestation from singleton pregnancies conceived following ovum donation (OD, n = 12), spontaneously (N, n = 12) and following in-vitro fertilization and embryo transfer (IVF, n = 14). These groups were chosen, as relaxin concentrations throughout pregnancy are undetectable (OD), elevated (IVF) or normal (N). Thus, if relaxin alone is responsible for the fall in plasma osmolality associated with pregnancy in the human, then plasma osmolality would be expected not to fall during pregnancy in the OD group and to show a consistent decline from OD to N to IVF throughout pregnancy. Plasma osmolality fell significantly during pregnancy in both the OD and N groups, but not the IVF group. In addition, plasma osmolality was only significantly greater in OD when compared with IVF group at 10 weeks gestation; thereafter there were no significant differences between the groups with regard to plasma osmolality. Similarly, at 10 weeks the plasma concentrations of sodium and potassium were significantly higher in the OD than in either the N or IVF groups. Thus, although relaxin may be important in the initial control of plasma osmolality, other factors, probably derived from or regulated by the feto-placental unit, supersede it as pregnancy advances.

The percentage of UK graduates considering a career in obstetrics and gynaecology is falling.1 In 1974, for example, 3.9% of men (55) and 4.3% of women (23) specified the specialty as their first preference for a career2; by 2000, this was only 0.9% (12) and 3.2% (54).1 An increasing proportion of women in the workforce exacerbates the shortage, as overall women contribute fewer working hours than men to the specialty.3 Experiences during undergraduate training are likely to influence graduates' perceptions of identifying with and thriving within a given specialty. Differences in experience and performance in examinations may explain, at least in part, the current reluctance of male students to consider a career in obstetrics and gynaecology. All undergraduates …

Changing Childbirth, the report of the expert committee chaired by Lady Cumberlege,1 followed the recommendations of the Winterton committee2 in emphasising choice: freedom for women to choose a home confinement, pool birth, or elective caesarean section. Choice means shifting much decision making from professionals to women, which many find challenging; it also has cost implications. The flexibility, skill, and knowledge required to give women choice demands higher standards of professional training, particularly for midwives, whose enhanced role has forced obstetricians and general practitioners to rethink their own. Screening for fetal abnormality is a growth industry. Amniocentesis with karyotyping of fetal cells obtained from amniotic fluid at around 16 weeks' gestation was introduced widely in the mid-1970s and is now universal. The association of Down's syndrome with low concentrations of (alpha) fetoprotein and high concentrations of s human chorionic gonadotrophin in maternal serum led in June 1993 to a call for providing screening for all who wanted it.3 Soon, however, concern was expressed about inadequate counselling of pregnant women,4 5 who commonly find it difficult to understand the statistical concepts of risk without a great deal of help (many professionals find it difficult, too). Since there is currently no national policy on screening, and no additional funding to pay for the extra counselling or for the scans during the first trimester that are essential to confirm gestational age, it is not surprising that nearly half of all obstetricians in Britain feel that the current service is inadequate.6 This concern is corroborated by objective surveys of the women themselves.7 The introduction of biochemical screening is sometimes accompanied by disillusion at the relatively low sensitivity of the methods, due not just to technical problems but also to the often surprisingly high proportion of women who decline screening …

We of Group B Strep Support (GBSS) were disappointed that Margaret McCartney reiterated some myths about screening for group B streptococcus during pregnancy.1 We challenge four of her statements. (1) “The risks of antibiotic use include anaphylaxis, which is thought to be fatal in one in 10 000 women treated.” This is an unreferenced statement from the UK National Screening Committee’s 2008 review of antenatal screening for streptococcus B. Fatal anaphylaxis is extremely rare. Law et al reported that 1.8 million women in the US were given benzylpenicillin (or ampicillin) between 1997 and 2001 with no deaths from anaphylaxis reported.2 Their review of UK data showed no adverse drug reactions attributable to benzylpenicillin in a population of 630 000 over six months. They conclude that the risk of death is negligible. (2) “Broad spectrum antibiotics lead to resistant organisms . . . The potential for long-term persistence of early-colonising bacteria suggests that much more thought should …

We have developed a continuous in vivo meconium monitor for intrapartum use in order to provide new insight in the study of the pathophysiology of meconium passage. Meconium is measured using an optical sensor placed at the tip of an intrauterine probe. Measurements of meconium are made at intervals of one minute and plotted on a cardiotocograph-like chart. The accuracy is of ±33% and the linearity better than 95%. The amount of blood in the amniotic fluid is also monitored.

The importance of soft tissue resistance to the progress of labour has been known for some time. The means to quantify and compare this property between different labours has however not been available. We have developed a system to produce a real-time recording of fetal head-to-cervix force (HCF) and intrauterine pressure (IUP). A study involving 31 patients demonstrated a good correlation between 50th percentile of active force (AF) and mode of delivery. A further study of 18 patients of differing parities confirmed this relationship, and analysis of the data by parity and cervical dilatation rate also suggested that a ratio of) mean active force to mean active pressure gives a quantitative indication of cervical compliance. HCF and IUP are displayed in real-time and calculations are performed "off-line". A new system is being developed which will display mean AF, mean active pressure (AP), mean AF / mean AP ratio and the linear relationship between AF and AP. This information obtained should allow evaluation and improvement of treatments for slow labour.

The human fetus is normally warmer than its mother. The principal route of fetal heat dissipation is through the placental circulation. We developed a technique that is noninvasive to the fetus to record the fetal skin and maternal uterine wall temperatures, from which we derived the temperature difference. We have established a range of normal values (mean temperature difference 0.24C) and present some preliminary data. The results show a correlation between changing temperature and baseline fetal heart rate (r = 0.628, P less than .001) and the influence of contractions and epidural analgesia on these measurements. Measurement of the fetal-maternal temperature difference during labor may help detect abnormal umbilical-placental blood flow, resulting in fetal distress, and may help distinguish sinister from iatrogenic fetal tachycardias. Our technique provides the first simple means of recording this basic fetal variable.

The adequacy or otherwise of fetal growth in human pregnancy is of great concern to the obstetrician because of its link not only with stillbirth but also with subsequent development of the baby into adult life. Indeed, in the last 20 years, the work of the Southampton group led by David Barker (supplemented by researchers in many other centres) has led to a fuller understanding of fetal origins of adult disease. At present, we are unable to significantly modify fetal growth but we can intervene to deliver the baby from a deteriorating intrauterine environment. Without knowing more about the mechanisms of fetal growth, we will never be able to develop effective therapies to normalize it. Accordingly, it is timely that the editors Kiess, Chernausek and Hokken-Koelega have brought together 12 chapters over 167 pages to review this topic. Their book was published in hardback in early 2009 by Karger at the fairly hefty cost of £95.41. The format and cost mean that this is likely to be a book acquired for the departmental library and it is certainly not a light read. Part of the problem with this topic is that the terminology is far from standardized or used consistently. Probably the most useful definition of fetal growth restriction (we used to call it fetal growth retardation but this led to parents thinking that the baby would be brain damaged and so the terminology was changed) is failure to reach the genetic growth potential of the fetus. Even this definition is problematic because it seems likely that fetuses can develop normally within a range of growth velocities to suit the prevailing environmental conditions. Moreover, genetically abnormal babies are often small and function poorly but this is because their genetic potential is abnormal. In any case, we cannot at present assess accurately the genetic growth potential of an individual baby. Accordingly, it is more usual to classify babies according to their centile position of weight for gestational age at birth. However, even the centiles used to define smallness vary (from the 10th centile to as low as the third centile) and sometimes two standard deviations below the mean is used (the 2.7th percentile). A more dynamic way of assessing fetal growth is to monitor fetal size sequentially through pregnancy using ultrasound. A baby that is ‘falling down the centiles’ is likely to function poorly and to exhibit the signs of intrauterine ‘starvation’ after birth, i.e. reduced subcutaneous fat, small liver size, large head to body ratio (known as brain sparing), etc. One of the problems with this book is that the chapters are not consistent in the way that they define growth restriction and it is acknowledged in the introduction that the expression ‘intrauterine growth restriction is frequently used synonymously with small for gestational age’, although we know that it should not be. Thus, some of the chapters refer primarily to babies that are small for gestational age below the 10th centile (the majority of whom will be small normals), whereas others refer more appropriately to babies whose growth profiles in utero are below normal. The book is as a result more useful to those who are already familiar with such confusion of definitions and wish to use it as a valuable compendium of data and references. It will be particularly useful for students starting out in this area of research, with experienced supervisors who can guide them through the various points of view and explain the inconsistencies within the book. There is a particularly useful introduction to the molecular control of fetal growth by Steven Chernausek, as this is a topic that can be baffling in its complexity. Most of the research described relates to the developed world as in most parts of the developing world gestational age at birth is unknown and only birthweight can be measured accurately. Accordingly, the chapter describing the global perspective of the problem of poor fetal growth is restricted to describing problems associated with low birthweight (defined as less than 2.5 kg), of which the major determinant is in fact preterm birth rather than fetal growth restriction. It might have been useful if the editors had drawn together the discussions on the definition of poor fetal growth in their introductory chapter and then deleted the repeated descriptions at the beginning of each chapter, not all of which are of the same high standard and a few of which show a significant lack of insight. In summary, this will be a useful book for academic departments of obstetrics and paediatrics but cannot be recommended as a suitable introductory text for the general reader.

A questionnaire regarding the route of birth for the preterm fetus with particular reference to the management of the preterm breech was sent to 180 consultants in England and Wales. Only 23% of respondents use electronic fetal monitoring below 26 weeks gestation and only 12% use caesarean section routinely for fetal indications at less than 26 weeks. Only 12% will use caesarean section for the preterm fetus presenting by the vertex in uncomplicated labour. Only 35% of all respondents consider that there is sufficient evidence to support the use of caesarean section for the uncomplicated preterm breech, but 76% will actually use caesarean section for this indication. Overall 71% reported that they are affected by medicolegal considerations in their management of the preterm breech. Overall, 83% said that they might change their practice regarding the mode of delivery of the preterm breech in the light of the findings of a randomized prospective controlled trial.

Petr Skrabanek, a Czech, was in Ireland when the Soviets invaded his country, so he stayed, publishing many criticisms of medical humbug while working with James McCormick in the Department of Community Health at Trinity College, Dublin, until his premature death in 1994. The book has been translated into six languages and is on the reading list of medical schools around the world, to encourage an appropriate scepticism about medical dogma. For example, could strict adherence to evidence based practice be harmful to patients? This is the intriguing hypothesis suggested in the first section of this subversive book. It points out that although the placebo effect is very powerful, to work best it requires both the patient and the doctor to believe in it. As …

T he current political agenda for choice in medical care is being presented as something new. However, choice has always existed. Not everyone who is ill chooses to seek medical care. For example, 50% of women with heavy periods (blood loss of > 80 ml in each period) do not complain, whereas 50% of those who seek treatment have bleeding that objectively is in the normal range. There has long been a choice about whom to consult. Many people with acute symptoms prefer to visit the hospital's emergency department rather than seeing their family doctor. Many seek second, or even several, opinions. This option—long available to the wealthy—has been encouraged by medical specialisation. For example, many women lose babies because of going intolabour before term. They are desperate to avoid are petition. They often consult widely and may be seen by a haematologist looking for a thrombophilia, an infertility specialist to help …

Objective To investigate the relation of diastolic blood pressure in pregnancy with birth weight and perinatal mortality. Design Prospective study. Setting 15 maternity units in one London health region, 1988-2000. Participants 210 814 first singleton births of babies weighing more than 200 g among mothers with no hypertension before 20 weeks' gestation and without proteinuria, delivering between 24 and 43 weeks' gestation. Main outcome measures Birth weight and perinatal mortality. Results The mean (SD) birth weight of babies born to mothers with no hypertension before 20 weeks' gestation or proteinuria was 3282 g (545 g) and there were 1335 perinatal deaths, compared with 94 perinatal deaths among women with proteinuria or a history of hypertension. Diastolic blood pressure at booking for antenatal checks was progressively higher from weeks 34 to 40 of gestation. The birth weight of babies being delivered after 34 weeks was highest for highest recorded maternal diastolic blood pressures of between 70 and 80 mm Hg and lower for blood pressures outside this range. Both low and high diastolic blood pressures were associated with statistically significantly higher perinatal mortality. Using a linear quadratic model, 94 of 825 (11.4%) perinatal deaths could be attributed to mothers having blood pressure differing from the optimal blood pressure (82.7 mm Hg) predicted by the fitted model. Most of these excess deaths occurred with blood pressures below the optimal value. Conclusions Both low and high diastolic blood pressures in women during pregnancy are associated with small babies and high perinatal mortality.

EDITOR,--Fiona Alderdice and colleagues reported on the safety of labour and birth in water and recommended that information about such practices should be collected routinely as part of local audit.1 We have audited 112 case records selected by hospital number sequence from those of the 353 women who either laboured or delivered in a birthing pool in our unit between January 1990 and December 1993. The mean cervical dilatation on entry to the pool was 4.8 (SD 2.0) cm (range 1-10). The time spent in the pool ranged from 10 minutes to a total of 13 hours 25 minutes (mean 2 hours 28 minutes). Fifty one (46%) women delivered in the pool while …

Discussing the management of coarctation of the aorta in pregnancy, Dr Venning and her colleagues (May 2003 JRSM1) emphasize the importance of close monitoring, control of hypertension and a multidisciplinary approach. We agree absolutely; but we disagree with their recommendation that 'elective caesarean section be performed in such cases to avoid the second stage and to reduce the need for Valsalva manoeuvres...'. We have cared jointly for many parturients with cardiac disease, including coarctation and Marfan's syndrome, and unless the mother or fetus is in imminent danger we recommend vaginal delivery with low-dose epidural analgesia, and elective instrumental delivery without maternal pushing in the second stage, to avoid Valsalva manoeuvres. This avoids the risks associated with caesarean section—namely, bleeding, deep vein thrombosis, infection, the need for intravenous Syntocinon (oxytocin) with its potential for adverse cardiovascular effects, and an increased requirement for caesarean section in subsequent pregnancies. Furthermore, both regional anaesthesia (which we prefer) and general anaesthesia for caesarean section are more likely to induce cardiovascular instability than low-dose epidural analgesia in labour. If caesarean section is required, the epidural can be readily extended in most cases. In the past, elective caesarean section (usually under general anaesthesia) was the mode of delivery for many women with cardiac disease, but there is increasing evidence that vaginal delivery with regional analgesia can produce a good outcome.2 Elective caesarean section may be desirable in the occasional patient with coarctation and uncontrollable systemic hypertension, marked aortic root dilatation and/or severe residual or native coarctation,3 although supportive data for this approach are clearly required.

OBJECTIVE To assess the effect of epidural analgesia on fetal temperature in labor, contrasting intrauterine with oral thermometry. METHODS Fetal skin and maternal uterine wall temperatures were measured with an intrauterine probe in 57 laboring women at term. Maternal oral temperatures were measured in the normal way by birth attendants unaware that their measurements would be examined. Maximum recorded fetal, uterine, and oral temperatures were compared. RESULTS Epidural analgesia resulted in a significant fetal temperature rise compared with other methods of analgesia. Duration of epidural analgesia correlated with the fetal temperature (R = 0.44, P = .012). Oral thermometry underestimated fetal temperature in 95% of the studies. CONCLUSIONS We estimate that 5% of fetuses reached a core temperature in excess of 40C in this study, all in association with epidural analgesia. We suggest that antipyretic measures be considered after 5 hours of epidural analgesia in ambient temperatures above 24C.

Vasopressin and oxytocin both stimulated inositol phosphate accumulation in isolated uterine decidua cells. Pretreatment of cells with the phorbol ester 12-O-tetradecanoylphorbol 13-acetate (TPA) prevented this agonist-induced phosphoinositide hydrolysis. TPA (0.1 microM) alone had no effect on basal inositol phosphate accumulation, but stimulated phosphoinositide deacylation, as indicated by a 2-fold increase in lysophosphatidylinositol and glycerophosphoinositol. TPA also stimulated a dose-related release of arachidonic acid from decidua-cell phospholipid [phosphatidylcholine (PC) much greater than phosphatidylinositol (PI) greater than phosphatidylethanolamine]. The phorbol ester 4 beta-phorbol 12,13-diacetate (PDA) at 0.1 microM had no effect on arachidonic acid mobilization. The TPA-stimulated increase in arachidonic acid release was apparent by 2 1/2 min (116% of control), maximal after 20 min (283% of control), and remained around this value (306% of control) after 120 min incubation. TPA also stimulated significant increases in 1,2-diacylglycerol and monoacylglycerol production at 20 and 120 min. Although the temporal increases in arachidonic acid and monoacylglycerol accumulation in the presence of TPA continued up to 120 min, that of 1,2-diacylglycerol declined after 20 min. In decidua cells prelabelled with [3H]choline, TPA also stimulated a significant decrease in radiolabelled PC after 20 min, which was accompanied by an increased release of water-soluble metabolites into the medium. Most of the radioactivity in the extracellular pool was associated with choline, whereas the main cellular water-soluble metabolite was phosphorylcholine. TPA stimulated extracellular choline accumulation to 183% and 351% of basal release after 5 and 20 min respectively and cellular phosphorylcholine production to 136% of basal values after 20 min. These results are consistent with a model in which protein kinase C activation by TPA leads to arachidonic acid mobilization from decidua-cell phospholipid by a mechanism involving phospholipase A-mediated PI hydrolysis and phospholipase C-mediated PC hydrolysis, coupled with further hydrolysis of the 1,2-diacylglycerol product.

The involvement of phosphoinositide hydrolysis in the action of oxytocin and vasopressin on the uterus was investigated in gestational myometrium and decidua cells by measuring the production of inositol phosphates. Both peptides stimulated a dose related increase in all three inositol phosphates in myometrium. This may be related to the control of sarcoplasmic Ca++ levels in the myometrium. Oxytocin and vasopressin also stimulated inositol 1-phosphate (IP) production in decidua cells. The hydrolysis of phosphatidylinositol by decidua homogenates exhibited a precursor-product relationship for diacylglycerol and arachidonic acid accumulation. Hence both peptides may mobilise free arachidonic acid, for prostaglandin biosynthesis, from decidua cell phosphoinositides by the sequential action of phospholipase C and diacylglycerol lipase.

Phosphoinositide hydrolysis is thought to be important in regulating a variety of intracellular signals, including Ca ++ and prostaglandins, both of which have been implicated in the action of oxytocin during uterine smooth muscle contraction. We investigated the in vitro effect of oxytocin and various other uterotonic agents on phosphoinositide hydrolysis in gestational myometrium by measuring the production of inositol phosphates in tissue explants prelabeled with 3 H-inositol. Oxytocin caused significant increases in all three inositol phosphates in myometrium at 3 minutes. Stimulation of inositol monophosphate production was sustained for 30 minutes and was dose dependent, with a half-maximal effect around 2 x 10 -8 mol/L. Platelet activating factor and α-adrenergic agonists also stimulated myometrial phosphoinositide hydrolysis, but carbachol prostaglandins E 2 and F 2α had no effect. Vasopressin had greater efficacy than oxytocin for stimulating hydrolysis in gestational myometrium. Furthermore, in contrast to vasopressin, oxytocin had no effect on inositol phosphate production in nongestational myometrium. Oxytocin also stimulated arachidonic acid release and prostaglandin E 2 and F 2α . production in gestational myometrium. The hydrolysis of phosphatidylinositol by myometrium homogenates showed a precursor-product relationship for the production of diacylglycerol, monoacylglycerol, and arachidonic acid, indicative of a sequential action of phospholipase C and diacylglycerol lipase. These data demonstrate the potential for certain uterotonic agonists to use inositol lipid signaling to mobilize free arachidonic acid for prostaglandin production and to release intracellular Ca ++ during excitation-contraction coupling.