Baillière's clinical obstetrics and gynaecology
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Baillieres Clin Obstet Gynaecol · Sep 1998
ReviewTraditional analgesic agents: are parenteral narcotics passé and do inhalational agents still have a place in labour?
Systemic labour pain treatment with opioids and inhaled nitrous oxide has for many decades frequently been used in medically developed countries. Self-administered nitrous oxide (50% in oxygen) has never gained the same popularity in the USA as in the UK or Scandinavia but the use of opioids, mainly pethidine, has generally been widespread in spite of well-known negative effects on the postnatal adaptation of the newborn. Since the often very intense labour pain seems to respond very poorly even to highly sedating doses of parenteral opioids, their frequent use during delivery and parturition has to be questioned. Self-administered inhalation of nitrous oxide 50% in oxygen also has a limited efficacy for relieving labour pain but because it is mainly devoid of adverse effects on the baby or on the parturient its future use in obstetrics can be defended more easily, either as a sole agent in women with low labour pain scores or in early labour preceding epidural analgesia.
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The delivery of twins presents considerable challenges to the obstetric team, particularly in terms of decision-making, technical skills required and the need to respond quickly to changing circumstances. There is a serious lack of sound evidence upon which to base decisions concerning the method of delivery of twins. The trend towards the routine use of caesarean section is not supported by evidence of improved outcome for the infants, while maternal outcome is compromised. ⋯ Caesarean section does not eliminate the chance of fetal trauma during delivery, particularly for premature twins. The techniques of twin delivery, whether vaginal or by caesarean section, require thorough preparation for all possible eventualities, and skilled teamwork. Particular attention should be paid to emotional needs during labour, birth and afterwards, of the parents of twins.
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Baillieres Clin Obstet Gynaecol · Sep 1997
Future research needs for venous thrombo-embolic disease in obstetrics and gynaecology.
The clinical management of thrombo-embolic disease in obstetrics and gynaecology is hampered by the paucity of firm evidence on which to base clinical decisions. This is particularly so in obstetrics where there have been no randomized controlled trials of thromboprophylaxis in pregnancy or the puerperium of sufficient size to detect differences in the incidence of clinical thrombo-embolic events. ⋯ The small randomized comparisons that have been performed suggest that relatively non-invasive procedures may be just as effective as heparin in preventing thrombo-embolism without the associated complications. Recent controversies concerning the effect of the OCP and HRT on the risk of thrombo-embolic disease indicate that the present methods we use to evaluate these interventions needs to be urgently addressed so that safety rather than efficacy becomes the principle outcome.
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The terminology of laparoscopically-assisted hysterectomies needs to be simplified and clarified. Laparoscopic hysterectomy should be used as a general term, whereas operative laparoscopy before hysterectomy, laparovaginal, laparoscopic total and subtotal hysterectomy should be used to describe the types of laparoscopic hysterectomy. The complication rates from laparoscopic hysterectomy, abdominal hysterectomy and vaginal hysterectomy are similar. ⋯ Controlled trials show that laparoscopic hysterectomy has advantages over abdominal hysterectomy which include reduced pain, reduced hospitalization time and earlier return to work. Most abdominal hysterectomies can be replaced by laparoscopic or vaginal hysterectomies. Whether this happens will depend upon adequate training facilities.
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Lactate is a metabolite that can safely and easily can be determined in fetal scalp blood using new microvolume (5-20 microliters) lactate meters. However, new lactate analysing methods need their own reference values. ⋯ Prospective randomized studies are needed before the method can be introduced into clinical practice. As a predictor of neonatal outcome, lactate can substitute pH in routine assessment of cord artery blood at delivery.