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The aim of the study is to identify factors associated with a second stage of labour greater than 2 hours in nulliparous women delivering at term. It a retrospective case-control study of 182 women with a second stage less than 2 hours' duration, matched with 182 women with a second stage greater than 2 hours. Women with a short second stage of labour were significantly younger (mean age 23.2 vs. 24.9 years) and had significantly smaller babies (mean weight 3315 g vs. 3463 g) than women with a long second stage. Long duration of the second stage of labour was significantly associated with oxytocin and epidural use. The intervention rate did not rise above 50% until the second stage exceeded 5 hours duration. The fetal outcome was good in both groups of patients.

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BACKGROUND: Cyclic GMP (cGMP) has been implicated in modulating the effects of general anaesthesia. Changes in cGMP in humans undergoing anaesthesia have not been reported previously. METHODS: In this pilot study we measured cGMP in the saliva of six healthy volunteers and eight patients undergoing general anaesthesia for minor gynaecological procedures. Samples were obtained using a commercially available sampling device and cGMP was determined with an enzyme immunoassay and results expressed as a cGMP per mg protein. RESULTS: There was no statistically significant variation in salivary cGMP either day-to-day or between time points in healthy volunteers. Analysis of variance of salivary cGMP of patients undergoing general anaesthesia showed that cGMP increased significantly intraoperatively and returned to preoperative levels after surgery (P=0.03). CONCLUSIONS: This is the first time that real time in vivo changes in salivary cGMP levels during general anaesthesia in humans have been demonstrated and may allow an alternative technique for measuring depth of anaesthesia in the future.

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To compare the efficacy and acceptability of conventional intravenous sedation with patient-controlled inhalational isodesox, 57 women undergoing outpatient oocyte recovery were randomly allocated to receive isodesox by face mask, while 55 women were given intravenous fentanyl and midazolam. Women's satisfaction with pain relief, peroperative pain, clouding of memory and the surgeons' assessment of operating conditions were evaluated. Thirty-eight women in the inhalation group (67%) and 41 (75%) women in the intravenous group were 'very satisfied' with their analgesia (p = 0. 41). The mean (SD) pain score in women given isodesox was 46.8 (34. 7), while in the intravenous group it was 34.1 (21.3) (p = 0.02). Oxygen saturation levels < 94% were recorded in one woman using isodesox and in 16 (29%) women given intravenous analgesia. Despite higher pain scores, in comparison with the conventional analgesia, patient-controlled isodesox offers a safer method of pain relief with comparable satisfaction rates.

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We review the evidence base for fluid management in pre-eclampsia. Current understanding of the relevant pathophysiology and the possible impact of styles of fluid management on maternal and fetal outcome are presented. There is little evidence upon which to base the management of fluid balance in pre-eclampsia. Reports are conflicting and no large prospective outcome studies of fluid management have been performed. Volume expansion does not appear to reduce the incidence of fetal distress. Pulmonary oedema and oliguria receive particular attention. There is no evidence of long-term renal damage in pre-eclampsia, but there are strong suggestions that pulmonary oedema is linked to fluid administration. Monitoring is discussed and some principles of management are suggested

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Although the conventional method of pain relief during outpatient oocyte recovery involves physician-administered drugs, patient-controlled analgesia (PCA) offers an alternative technique with the potential to give women more control over peroperative analgesia. We conducted a prospective randomized study to compare the effect of fentanyl administered either through a PCA delivery system or by a physician. Thirty-nine women were randomized to PCA during egg collection while 42 were allocated to receive intermittent doses administered by a physician. Pain was evaluated by means of a 100 mm linear analogue scale. The mean (SD) pain score in the PCA group was 38.5 (19.8) while in the other group it was 46.1 (21.3) (P = 0.1). In the PCA group, 64% of women felt very satisfied with their analgesia as compared with 57% in the non-PCA group (P = 0.6). Among the PCA users, 39% of demands were successful. Significantly more fentanyl (97.5 microg) was used in the PCA group than in the other group (84.6 microg) (P = 0.03). Though intraoperative PCA with fentanyl is an effective alternative to physician-administered techniques, many women still feel the need for more analgesia during the procedure.

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Measurement of cardiac output by means of Doppler ultrasound is based on the velocity of aortic blood flow and therefore requires that aortic diameter should not change between measurements. Work has been published which suggests that, in pregnancy, aortic diameter varies significantly with systemic blood pressure. The implication of this is that aortic diameter must be remeasured for each determination of cardiac output in pregnant patients. This study investigated the changes in aortic diameter with blood pressure in patients having spinal anaesthesia for caesarean section. Aortic diameter did appear to vary with blood pressure but this variation was within the error of the measurement and did not significantly affect the accuracy of the technique.

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An alteration in pulmonary water balance might be expected during pregnancy and the puerperium, as a result of the physiological adaptations to pregnancy. A preliminary investigation of this hypothesis was conducted using a radiological method of lung water measurement in 20 normal primigravidae during the early puerperium. Evidence of interstitial lung water was found in seven of the 20 mothers. There was a significant correlation with plasma volume (p less than 0.05) and fluid turnover (p less than 0.05) in the group with excess lung water. The implications of increased interstitial lung water and its possible causes during pregnancy are discussed.

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An accurate, non-invasive means of measuring pulmonary water is desirable, for both clinical and research use. Nuclear magnetic resonance imaging is theoretically very suitable for this purpose. Nuclear magnetic resonance (NMR) spectroscopy was used to show that the water content of lung tissue could be predicted accurately from the intensity of signal resulting from a 90 degree saturation recovery sequence. The water contained in an image section may, therefore, be calculated by reference to a 100% water standard. Lung water was obtained by imaging the lung in continuous sections and summing the water contents of the component sections. The method performed well when applied to a sponge phantom, but underestimated by up to 30% in excised sheep lung. The total (vascular and extravascular) pulmonary water measured by NMR in six healthy volunteers was 292 g (SD 58 g) or 4.6 g/kg body weight, less than predicted by some other indirect methods and post-mortem values. A briefer examination comprising two axial sections at standardised levels was also devised. In 15 healthy volunteers the mean water content of a 1.6 cm-thick axial section through the right lung was 17.8 g at the sternal angle, and 23.3 g 5 cm caudally. In the left lung, the values were 16.4 g and 16.3 g, respectively.

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There have been major changes in obstetric and anaesthetic practice since 1946, including the introduction of intravenous infusions, oxytocics, tocolytic drugs, and endotracheal intubation. Some of these may adversely affect pulmonary water balance, which is probably already altered by pregnancy. These changes may have contributed to the increased severity of Mendelson's syndrome in pregnancy and to some extent explain the failure of prophylaxis to reduce maternal deaths.

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No significant difference has been found in either stroke volume or cardiac output between twin pregnancies and singleton pregnancies. Cardiac output is less in preeclamptic twin pregnancies.

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In an effort to demonstrate the potential of nuclear magnetic resonance imaging (NMR) in the management of pregnancy, 15 patients in the first trimester and one in the third trimester of pregnancy have been investigated in the Aberdeen University NMR imager. Simple measurements of biparietal diameter and crown-rump length were made from both the NMR images and the ultrasound images on the same day, with good correlation between the two. The NMR data was displayed as inversion recovery, calculated T1, proton density and S1-S2 images. The proton density and S1-S2 images were found to be the most useful for the demonstration of the fetus and for discriminating between placenta and uterus. The calculated T1 data provided accurate quantification of the proton-spin lattice relaxation times of the different tissues, indicating that this measurement may be of use in the study of fetal brain development and placental function. The inversion recovery images showed poor tissue discrimination and were found to be of limited value. The unique information available using NMR and the non-invasive nature of the technique indicated that it should provide a useful method for the investigation of both fetal development and placental function in addition to making basic measurements of fetal size.

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