Fetal hypothalamic-pituitary-adrenal axis.
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Delivery, Obstetric↗
Biomedical subjects
R A Chez
Publications and source records attributed to R A Chez.
The no-show rate in a high-risk obstetric clinic.
We wished to determine the reasons for an average missed appointment rate of 28% in a high-risk pregnancy clinic. Only 41% of the 261 women in the study group could be reached by telephone. The reasons included not having a phone, the phone had been disconnected, incorrect phone number on the chart, the patient had moved, and the patient did not respond to the answering machine message. The reasons for missing the appointment included lack of transportation, scheduling problems, overslept or forgot, presence of a sick child or relative, and lack of child care. The response of patients to assessing prenatal care may reflect their priority of medical care relative to other priorities associated with day-to-day existence. There may be a baseline missed appointment rate for prenatal care in lower socioeconomic populations of women. The commitment of personnel time and energy to attempt to modify the no-show rate should be reexamined.
Appointments and Schedules↗
Cervimetry: a review of methods for measuring cervical dilatation during labor.
Several different methods of measuring cervical dilatation have been described. In this article, we review those methods and examine findings from studies using them. Although many instruments have been developed to measure cervical dilatation during labor and their use as a research tool has been established, no device has yet been successfully used for clinical obstetrics. The ideal device has not yet been developed; however, because repeated digital cervical examinations are time consuming for the clinician, are poorly reproducible, and are uncomfortable for the patient, continued efforts to develop a cervimeter suitable for clinical use is a worthwhile endeavor.
Cervix Uteri↗
Uterine rupture and dehiscence associated with intravaginal misoprostol cervical ripening.
OBJECTIVE: To evaluate if the prostaglandin E1 analogue misoprostol, when used as an agent for cervical ripening, is associated with uterine rupture. STUDY DESIGN: We performed a two-year retrospective chart review to determine the incidence of uterine rupture in patients with a previous cesarean delivery undergoing cervical ripening or the induction of labor. RESULTS: Uterine dehiscence occurred in 1 and uterine rupture occurred in 3 of 48 women with a prior cesarean delivery treated with 50 micrograms doses of intravaginal misoprostol for cervical ripening. Uterine rupture was found in 1 of 89 women who had an oxytocin infusion for induction of labor and none of the 24 patients who received intravaginal prostaglandin E2 placed for cervical ripening. CONCLUSION: Intravaginal misoprostol appears to be associated with an increased incidence of uterine rupture when used in patients undergoing a trial of labor after cesarean.
Administration, Intravaginal↗
Response of obstetrics and gynecology program directors to a domestic violence lecture module.
OBJECTIVE: Our goal was to determine the use by obstetrics and gynecology residency program directors of The American College of Obstetricians and Gynecologists' domestic violence slide lecture module and the opinions of the directors regarding its efficacy. STUDY DESIGN: A 6-question survey was mailed to 289 directors of accredited obstetrics and gynecology programs in the United States and Canada 9 and 13 months after a learning module on domestic violence was mailed to these same persons. The questions related to receipt and use of the module in the curriculum, target audiences, future plans for integration of the module into curricula, and recommendations for future supplemental topics in the same format. RESULTS: The return rate for the survey was 57% (164/289). The responses represented university-affiliated, community- and military-based programs with representation from all geographic areas of the country. Fourteen directors who had no recollection of receiving the package were sent a second set. The lecture had been presented by 72% of the respondents' departments to audiences of residents (89%), medical students (55%), practicing physicians (41%), and the lay public (11%). Two thirds of the nonusers and 87% of the users intended to use the module as a formal lecture in the curriculum of both residents and medical students in the coming school year. Recommendations for future supplemental lecture packages included abuse during pregnancy, screening women with different cultural backgrounds, and how to ask tough questions. CONCLUSION: The majority of obstetrics and gynecology resident program directors who responded to the survey integrated or will integrate an American College of Obstetricians and Gynecologists-created learning module on domestic violence into their residents' and medical students' formal curricula.
Community Health Services↗
Traumatic liver rupture in pregnancy.
Two pregnant women, 1 in the second trimester and 1 in the third trimester, sustained blunt liver trauma as unrestrained drivers in motor vehicle accidents. One patient had an overt injury that was apparent on computerized tomography and underwent surgical exploration when nonreassuring fetal monitoring occurred. The second patient, discharged after 23 hours of normal observation, returned a day later with overt intra-abdominal hemorrhage from an obvious liver laceration.
Accidents, Traffic↗
Magnesium sulfate, maternal hypothermia, and fetal bradycardia with loss of heart rate variability.
BACKGROUND: Fetal bradycardia and decreased heart rate variability can indicate a nonreassuring fetal status. However, there can be iatrogenic, physiologic, or pathologic causes. CASE: A patient in premature labor received toxic levels of magnesium sulfate for tocolysis. Elevated maternal serum magnesium levels correlated inversely with maternal temperature and both fetal heart rate and fetal heart rate variability. There was also a relative decrease of the maternal heart rate from baseline. When the magnesium levels returned to normal, these vital signs returned to normal. CONCLUSION: Magnesium sulfate therapy can result in maternal hypothermia and a decrease in fetal heart rate and heart rate variability. Maternal hypothermia might be the cause of fetal bradycardia. A direct action of magnesium on the fetal heart might be the cause of heart rate variability.
Adult↗
Personal health among midlife women hospital employees.
We hypothesized that women employees working in a hospital environment would be particularly attuned to aspects of personal health, well-being, and disease prevention. We performed an observational study at a local hospital, offering free assessments in its outpatient women's wellness screening program to women employees aged 39-60 years. Data from the first 60 women to enroll in the program are presented as a test of our hypothesis. Undiagnosed hypertension, abnormal lipid profiles, glucose intolerance, alcohol abuse, abnormal cervical cytology, breast masses, depression, or combinations of these were found in 49 of the 60 women. Twenty-one women were obese. Most women with abnormal findings did not follow specific personalized recommendations for remedial follow-up, including referral to a specialist. An important percentage of midlife women employees at this hospital exhibited unhealthful personal behaviors, had unrecognized disease, and did not use recommended health screening practices. The data emphasize the benefit for employees who participate in medical facility worksite health promotion programs.
Adult↗
Cervical ripening.
In conclusion, no pharmacologic method presently used in the hospital to ripen the cervix has attained the level of standard of care for application in most office or clinic outpatient settings. Published data are accumulating that support the safety of the prostaglandin preparations for this purpose. Sweeping the membranes in the office and clinic does have sufficient data to support its continued use for this purpose.
Ambulatory Care↗
Charting progress.
Logbooks can be considered aggregate databases that registered nurses (RNs) have the primary responsibility of completing in most health care settings. However, RNs may be unaware of the many uses for the information contained in logbooks and the importance of these entries (Paine et al., 1988). Labor and delivery (L&D) logs provide an essential source of vital statistics birth data for the medical records staff. These data bits are used for reporting statistics, projecting trends, and planning future care for pregnant women.
Delivery Rooms↗
Urine protein dipstick measurements. A screen for a standard, 24-hour urine collection.
OBJECTIVE: To determine if the sum of urine protein dipstick values recorded during every void can be used to screen for patients who need a standard, 24-hour urine collection for determination of protein excretion. STUDY DESIGN: Thirty inpatient and 17 outpatient pregnant women undergoing 24-hour urine collection for protein concentration were enrolled. The volume, dipstick protein values and time of void were recorded. The 24-hour quantitative analysis of protein excretion performed by the laboratory was compared to the 24-hour sum of the products of each voided volume and dipstick value (dipstick factor). RESULTS: The dipstick factor significantly correlated with the total 24-hour protein excretion (correlation coefficient 0.84, P < 1 x 10(-7)). A dipstick factor of > or = 300 mg, indicated proteinuria with a sensitivity of 96%, specificity of 90%, positive predictive value of 92% and negative predictive value of 95%. Separately, we found differences in the amount of protein excretion when the 24-hour period was divided into six 4-hour periods, using analysis of variance. Paired t test analysis of the mean protein excretion from 16:00 to 04:00 showed significantly higher results than did the protein excretion from 04:01 to 16:00 (1,197 +/- 356 mg vs. 674 +/- 158 mg, P < .0001). CONCLUSION: The sum of dipstick factors in a 24-hour period is a reliable screening test for identifying patients who need the standard laboratory test for proteinuria.
Adult↗
The challenge of complementary and alternative medicine.
Complementary and alternative medicine can be defined as those medical systems, practices, interventions, and applications that currently are not part of the dominant or conventional medical system. There are more than 300 different topics under the term complementary and alternative medicine that can be divided into seven major categories on the basis of philosophy, approach to the patient, and orientation. Most patients seeking care from complementary and alternative medicine providers do so for the relief of signs and symptoms related to chronic illness while they are under the care of a physician. Clinical data derived from appropriately conducted clinical trials support the use and value of complementary and alternative medicine for selected indications. The challenge for both conventional medicine and complementary and alternative medicine is to fulfill the role of patient advocate by engaging in reciprocal open communication, facilitating the patient's informed choice, avoiding harmful or useless practices, and implementing an integrated evidence-based care plan.
Complementary Therapies↗
Three student manuals for obstetric and gynecologic outpatient care.
We have written three pocket manuals to facilitate the interaction between obstetric and gynecology patients and medical students, junior residents, and advanced practice nurses in an ambulatory care setting. The purposes of the manuals include the organization of the content of outpatient care into a consistent framework for interaction with the patient at each outpatient visit and the provision of a practical memory jogger to facilitate effective clinician-patient communication. Each visit contains specific and suggested content under the same five categories: questions to be asked of the patient, focused aspects of the physical examination, laboratory tests to order, topics for purposeful discussion, and sentences to close the visit. These learning tools were designed to be integrated by local faculty into the department's formal curriculum. They are intended to support training in ambulatory care. They now need to be evaluated prospectively at individual sites.
Ambulatory Care↗
The effect of a resident night team on cesarean delivery.
We tested the hypothesis that the implementation of a resident night team would change the rate of, the indications for, and the time of day of cesarean delivery. A retrospective chart review was performed on patients who underwent cesarean birth during two time periods. Charts of 1722 patients who had a cesarean delivery between January 1, 1990 through June 30, 1991 (control group) and January 1, 1992 through June 30, 1993 (study group after implementation of a resident night team) were abstracted. All patients were cared for only by resident physicians and all patients delivered during a workweek defined as Sunday 1700 through Friday 0700. Each workday was divided into three shifts (0001-0700; 0701-1700; and 1701-2400) for analysis. After implementation of the night team, the cesarean rate increased (p < 0.002), the proportion of planned repeat cesarean deliveries decreased, the proportion of cesareans for malpresentation decreased (p < 0.005), and the proportion of cesareans for arrest of labor increased (p < 0.0001). These changes were not associated with a change in the temporal distribution for any indication among the three shifts. The implementation of a resident night team did not change the time of day distribution of cesarean delivery for any of six indications.
Adult↗
Complementary and alternative medicine. Part I: Clinical studies in obstetrics.
Studies in which complementary and alternative medicine (CAM) interventions were used in the care of obstetric patients were identified by searching The National Library of Medicine's electronic database. This paper is a selected review of both randomized and nonrandomized clinical trials. There are a number of CAM therapeutic practices that may have potential benefit for patients. Additional clinical research with appropriate scientific methodology is warranted to determine the merit and value of integrating some CAM modalities into conventional medical obstetric care.
Analgesia, Obstetrical↗
Complementary and alternative medicine. Part II: Clinical studies in gynecology.
This review describes randomized and nonrandomized clinical studies in which complementary and alternative interventions were used to treat gynecologic illness and disease. The articles were identified through the use of The National Library of Medicine's electronic database. Statistically significant clinical benefit could not be identified for most practices. However, additional scientific investigation with appropriate research methods would help clarify a number of provocative insights and suggestions of potential clinical effectiveness.
Complementary Therapies↗
Emergency contraception. The pill's little-known secret goes public.
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Administration, Oral↗
Logbook data as a source of birth information. Are they valid?
OBJECTIVE: To determine if the data recorded in the labor and delivery logbook in two hospitals are complete and consistent with the information in the patient's medical record. STUDY DESIGN: We performed a retrospective comparison of the information in the labor and delivery logbook to the content of 110 patients' hospital charts in each of two hospitals. RESULTS: The logbooks of both hospitals had erroneous entries and missing data as compared to the antepartum complications, intrapartum events and immediate newborn care recorded in the patients' medical records. The range of error in these three categories was 61%, 31% and 60% in one hospital and 37%, 29% and 30% in the other hospital. CONCLUSION: The results of this study do not support the use of logbooks as a source of data for individual or collated departmental, hospital or agency reports containing antepartum, intrapartum and newborn information.
Delivery, Obstetric↗