Objective Review usage and outcome of cases where STAN fetal monitoring was used at University Hospital of Wales over 6 months (June–November 2009). Background STAN monitoring was introduced in our unit in 2006. Local guideline for its usage is available. Training in its usage is regularly conducted in the unit. Methods Paper files were hand searched for all cases where STAN monitoring was used during the study period. SPSS used for analysis. Results STAN monitoring used in 43 cases (2% of deliveries). 77% were primip. STAN monitoring was used in high risk cases as post date induction of labour (44% of cases), medical problem (14%), intrauterine growth restriction (2%), cardiotocograph abnormalities (44%). Other indications were prolonged rupture of membranes, previous Caesarean section (CS), thick meconeum. Outcome 33% had spontaneous vaginal delivery, 35% had instrumental delivery and 32% delivered by CS. 29% of these CS was for fetal distress and 71% for failure to progress. The background CS rate in the unit is 22%. There was one case of metabolic acidosis; delivery occurred within 30 min of significant STAN event. Three cases admitted to SCBU (special care baby unit): one for fetal academia and low Apgar score (discharged after 1 day), one for thick meconeum aspiration (discharged after 3 days) and last one for congenital anomaly. None required follow up. Conclusion STAN usage in the unit was appropriate. Larger cohort is required to assess reduction of intervention and fetal academia.

Objective Estimate the influence of maternal age, fertility treatment and period of delivery (temporal effect) on twin maternities Methods The authors performed an age period cohort analysis. A logistic regression model was used to assess the independent effect of each factor on twinning. Results The following table summaries the odds of twinning by maternity periods, maternal age and fertility treatment: Conclusion Our analysis confirms the importance of maternal age and fertility treatments on twin maternities. It also suggests a temporal effect, which may reflect recent changes in the environment surrounding pregnancy (nurture).

Background 41-year-old, Caucasian booked at 13 weeks of her seventh pregnancy. Patient has history of previous six spontaneous abortions followed by surgical removal of uterine septum. Antenatal patient had uneventful pregnancy up until 33 weeks when she was admitted with threatened preterm labour. Steroids given and patient discharged 24 h later when tightening settled. Labour patient admitted 3 days later with regular contractions (33 weeks + 5), presentation was breech and patient opted for vaginal delivery. First stage lasted 2 h and patient had assisted vaginal breech delivery under pudendal nerve block. Procedure Placenta was not delivered an hour following delivery and decision made for manual removal of placenta under spinal anaesthesia. Manual removal attempted by both registrar and consultant on call but was not successful. Possibility of placenta accereta especially in view of previous uterine surgery was main concern. Ultrasound confirmed that there is a line of cleavage. Removal of the placenta piece meal using sponge holders and guided by ultrasound was attempted. Two sponge holders were used one to fix lower part of placenta and the other to catch a higher portion of placenta. After removal of two cotyledons piece meal, the rest of placenta separated and subsequently delivered. Patient made uneventful recovery with average blood loss. Conclusion Ultrasound can be useful tool in such circumstances. It helped making it safer to use intrauterine metal instrument soon after delivery as well as visualizing the instruments, placenta and line of cleavage.

There is no universally agreed definition of quality of care (QoC). However, we assumed that the QoC in a London teaching hospital is high and could be used as a benchmark QoC with which to compare the practice in Cairo. We aim to highlight differences in the frequency of adverse outcomes attributable to differences in the QoC between two maternity teaching hospitals in Cairo and London, in low risk, standard primiparae (SP) delivered in 1999. In Ain Shams Maternity Hospital in Cairo and St Mary's Maternity Hospital in London, the caesarean section rate was 9.1% and 22.5%, respectively (OR = 0.34, p < 0.0001); the instrumental delivery rate was 4.1% and 26.8%, respectively (OR = 0.12, p < 0.0001), and the induction of labour (IOL) rate was 1.1% and 16.7%, respectively (OR = 0.06, p < 0.0001). Third degree perineal tears occurred in 0.3% and 8.2%, of the vaginal deliveries (OR = 0.14, p = 0.002) and the still birth rate was 0.78% and 0.1% (OR = 7.96, p < 0.01) in the Cairo and London hospitals, respectively. This is the first time the SP method has been used to compare similar institutions in developed and developing countries. Intervention rates were significantly higher at St Mary's and so was the improved fetal outcome. A trade-off of improved fetal outcomes for more interventions is difficult to establish. Residual differences in case mix and patient preferences may explain some of the results.

Objective: To assess trends in twinning over four decades using a population-based registry.Design: Ecological study to conduct trend analysis of twin pregnancies in a geographically defined area over 40 years.Setting: All pregnancies in the Cardiff and Vale of Glamorgan area Of South Wales from 1965 to 2004, as recorded in the Cardiff Birth Survey (CBS) database.Methods: Trends of the incidence of all twin pregnancies (>= 18 weeks of gestation) were calculated in 5-year increments, beginning with 1965-1969 and ending in 2000-2004. Natural twinning rates could only be calculated for the terminal five time periods (i.e., 1980-1984, 1985-1989, 1990-1994 1995-1999, and 2000-2004), when information regarding non-spontaneous (iatrogenic) twinning was first collected in the database. All results were adjusted for maternal age.Results: The total twinning rate was 13.1 per 1000 pregnancies in the 1st time period (1965-1969). Subsequently, there was a gradual reduction in twinning, reaching a nadir of 10.3 per 1000 for the time period 1980-1985 (Z = 3.15, P value < 0.00 1). This was followed by a gradual increase in twinning, reaching a maximum of 15.7 per 1000 for both 1995-1999 and 2000-2004 (Z = -5.18, P value < 0.000 1). After exclusion of the cases of iatrogenic pregnancies,, the natural twinning rate showed a continuous and gradual increase from 10 per 1000 spontaneous pregnancies in 1980-1984 to 13.3 per 1000 in 2000-2004 (Z= -5.08. P value < 0.0001).Conclusion: The data showed a gradual, continuous increase in natural twinning rates over the last two decades. Such an increase cannot be attributed to the rise in maternal age alone. (C) 2008 Elsevier Ireland Ltd. All rights reserved.

Objective: To review the association between major causes of maternal mortality and vitamin A, trying to determine if these associations are causal in nature, and to highlight possible biological pathways that may explain vitamin A effects.Design: Literature review, observational studies and clinical trials. The strength of association was determined by applying Bradford Hill criteria of causality.Results: In a vitamin A deficient population, vitamin A is essential for adequate treatment of anaemia. While vitamin A does not seem to be capable of preventing uterine atony, obstetric or surgical trauma, which are important causes of haemorrhage, it might be capable of preventing or decreasing coagulopathy. Possible effects on the placenta as regards implantation, site and size are not clear. As regards pregnancy-related infections, vitamin A supplementation can improve wound healing by decreasing fibrosis and increasing transforming growth factor-beta (TFG-beta). It can increase resistance to infection by increasing mucosal integrity, increasing surface immunoglobulin A (sIgA) and enhancing adequate neutrophil function. If infection occurs, vitamin A can act as an immune enhancer, increasing the adequacy of natural killer (NK) cells and increasing antibody production. beta-carotene in its provitamin form can act as an antioxidant by decreasing endothelial cell damage (the pathognomonic feature of pre-eclampsia) and promote the vasodilator effect of nitric oxide that might bring about a better outcome of toxaemia in pregnancy. It is unlikely that vitamin A or beta-carotene has an effect on obstructed labour.Conclusions: Plausible biomedical pathways can only be constructed for obstetric haemorrhage, anaemia in pregnancy, hypertension in pregnancy and pregnancy-related infections. A 40% reduction in the maternal mortality ratio, as observed in Nepal, is unlikely to be solely explained through the aforementioned pathways.