The rate of cesarean delivery has become an important health care issue, and has attracted the attention of governments, professional organizations, health care administrators, clinicians, and patients. This has resulted in the generation of guidelines, clinical recommendations, and other documents aimed at increasing the likelihood of vaginal delivery. Sometimes, these recommendations are formulated with limited input from clinicians. In some countries, such as the United Kingdom, external pressure exerted on clinicians to reduce the rate of cesarean delivery has been the subject of public debate, and has led to unintended consequences, including an increase in medicolegal tensions. In the United States and Australia, recent recommendations generated by professional bodies have advocated that clinicians should change practice to reduce the rate of cesarean delivery. We do not summarize the risks and benefits of cesarean birth in different clinical situations, which have been the subject of numerous reviews. Rather, we try to examine the potential implications of such policies in light of recent observations made in maternity units, judicial decisions, and clinical research. The emphasis is on maternal morbidity and patient autonomy. This may include the negative consequences of increasingly risky attempts at vaginal birth after cesarean delivery such as uterine rupture, higher rates of pelvic floor and anal sphincter trauma due to rising forceps rates, and a bias against elective cesarean delivery on maternal request.

UNLABELLED:Vasa previa is a rarely reported condition in which the fetal blood vessels, unsupported by either the umbilical cord or placental tissue, traverse the fetal membranes of the lower segment of the uterus below the presenting part. The condition has a high fetal mortality due to fetal exsanguination resulting from fetal vessels tearing when the membranes rupture. Despite improvements in medical technology, vasa previa often remains unsuspected until this fatal fetal vessel rupture occurs. Significant reduction in the fetal mortality from this condition depends on a high index of suspicion leading to antenatal diagnosis, and elective delivery by cesarean. We believe transvaginal ultrasound in combination with color Doppler is the most effective tool in the antenatal diagnosis of vasa previa and should be utilized in patients at risk, specifically those with bilobed, succenturiate-lobed, and low-lying placentas, pregnancies resulting from in vitro fertilization, and multiple pregnancy. Where there has been antepartum or intrapartum hemorrhage, especially when associated with fetal heart irregularities, we also recommend a test to exclude fetal blood in the vaginal blood. Similarly, amnioscopy before amniotomy may help to diagnose this condition. Cesarean delivery is the method of delivery of choice, and aggressive resuscitation of the affected neonate may be life saving. With a high index of suspicion, antenatal diagnosis using transvaginal sonography in combination with color Doppler, elective delivery by cesarean, and aggressive resuscitation of the neonate where fetal vessel rupture has occurred, the mortality from this complication may be considerably reduced.TARGET AUDIENCE:Obstetricians & Gynecologists, Family Physicians.LEARNING OBJECTIVES:After completion of this article, the reader will be able to identify the risk factors and associated conditions for vasa previa, to identify the various clinical presentations and management of vasa previa, and to be aware of the diagnostic tools available to make the antepartum diagnosis of vasa previa.

Objective: To assess whether Doppler indices of intraovarian blood flow are related to the subsequent follicular response in an in vitro fertilization (IVF) program.Methods: One hundred five women underwent ultrasonographic assessment of ovarian morphology, transvaginal color Doppler measurement of intraovarian blood flow and immunoassay of serum FSH during the early follicular phase of an IVF cycle. The subsequent follicular response was related to the Doppler data.Results: Mean ovarian stromal peak systolic blood flow velocity was significantly correlated with the follicular response (P = .001), even after adjusting for the age of patient, type of ovary (polycystic or normal), total number of human menopausal gonadotropin ampules used, and serum FSH. Mean ovarian stromal pulsatility index was not related to the follicular response. Mean ovarian stromal peak systolic blood flow velocity was significantly lower (P = .007) in the poor-response group. The adjusted odds of a poor response increased significantly by an estimated 22% per cm/second decrease in velocity (P = .02).Conclusion: Ovarian stromal blood flow at the baseline ultrasound scan is correlated with subsequent follicular response and may be a new indicator for predicting ovarian responsiveness in an IVF program.

Screening for fetal chromosomal abnormalities on the basis of maternal age has not resulted in a substantial fall in the proportion of infants born with an abnormal karyotype. Most fetuses with major chromosomal abnormalities have defects that can be recognised on detailed ultrasonographic examination. Therefore, provided the cardinal signs of each chromosomal syndrome are recognised, it is possible that screening by ultrasound examination could have a greater impact. We karyotyped 2086 fetuses after ultrasonographic examination had revealed fetal malformations, growth retardation, or both. Chromosomal abnormalities were detected in 301 (14%) cases and were more common among fetuses with multisystem malformations (29%) than among those with isolated defects (2%). The commonest chromosomal abnormality was trisomy 18, followed by trisomy 21, triploidy, Turner's syndrome, unbalanced chromosomal rearrangements, and trisomy 13. Trisomy 18 was associated with strawberry-shaped head, choroid plexus cysts, facial cleft, micrognathia, heart defects, exomphalos, malformations of hands and feet, and growth retardation. In trisomy 21, the associated defects were subtle and included nuchal oedema, macroglossia, atrioventricular septal defects, mild hydronephrosis, clinodactyly, and sandal gap. The frequency of autosomal abnormalities increased with maternal age, but if fetal karyotyping had been restricted to mothers older than 35 years, large proportions of chromosomally abnormal fetuses would not have been diagnosed prenatally (64-97%). Our findings provide guidelines as to which defects to search for in screening studies for the detection of chromosomal abnormalities.

Preeclampsia, intrauterine growth retardation, and abruptio placentae are associated with the failure of the placenta to create an adequate communication with the maternal vasculature and subsequently reduced placental perfusion, with secondary effects on villous maturation and placental function, thereby failing to meet the needs of the growing fetus. Also, primary failure of placental maturation has been linked with the chromosomally abnormal fetus. Doppler ultrasound allows examination of blood flow in maternal and fetal vessels and assists in our ability to understand, predict, and diagnose pregnancy complications. Over the last 10 years there has been a rapid development in the capacity and complexity of the equipment used for clinical Doppler examination, from simple continuous wave devices to duplex-color flow systems, and the advantages of these developments continue to be defined. As with all innovations there has been a period of extensive appraisal of this technology, and further applications of Doppler await clarification. This review puts the most recent publications in perspective, and points to the likely areas of interest in the future.

BJOG: An International Journal of Obstetrics & GynaecologyVolume 97, Issue 6 p. 543-544 Relation between maternal-to-fetal blood glucose gradient and uterine and umbilical Doppler blood flow measurements D. L. Economides, D. L. Economides S. Campbell Harris Birthright Research Centre for Fetal Medicine, King's College School of Medicine and Dentistry, Denmark Hill, London SE5 8RX, UKSearch for more papers by this authorK. H. Nicolaides, Corresponding Author K. H. Nicolaides S. Campbell Harris Birthright Research Centre for Fetal Medicine, King's College School of Medicine and Dentistry, Denmark Hill, London SE5 8RX, UKK. H. NicolaidesSearch for more papers by this authorS. Campbell, S. Campbell S. Campbell Harris Birthright Research Centre for Fetal Medicine, King's College School of Medicine and Dentistry, Denmark Hill, London SE5 8RX, UKSearch for more papers by this author D. L. Economides, D. L. Economides S. Campbell Harris Birthright Research Centre for Fetal Medicine, King's College School of Medicine and Dentistry, Denmark Hill, London SE5 8RX, UKSearch for more papers by this authorK. H. Nicolaides, Corresponding Author K. H. Nicolaides S. Campbell Harris Birthright Research Centre for Fetal Medicine, King's College School of Medicine and Dentistry, Denmark Hill, London SE5 8RX, UKK. H. NicolaidesSearch for more papers by this authorS. Campbell, S. Campbell S. Campbell Harris Birthright Research Centre for Fetal Medicine, King's College School of Medicine and Dentistry, Denmark Hill, London SE5 8RX, UKSearch for more papers by this author First published: June 1990 https://doi.org/10.1111/j.1471-0528.1990.tb02529.xCitations: 17AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume97, Issue6June 1990Pages 543-544 RelatedInformation

We have read with great interest the article by Keckstein et al. (1990), which describes three cases of umbilical cord hematoma after cordocentesis for fetal transfusion in utero. We observed recently a similar case. The mother had developed anti-C and anti-E antibodies during her first normal pregnancy, and subsequently had two pregnancies complicated by the intrauterine death of normalily formed hydropic fetuses. In the present pregnancy, six intravascular fetal blood transfusions were given. Cordocenteses were uneventful, except ,at 32 weeks' gestation, when, at the end of the procedure, fetal heart rate decelerations to 80 bpm were observed for 2 min. The umbilical cord at the placental insertion became hyperechogenic. However, the post-transfusiom umbilical vein blood gases (PO, = 30 mmHg, pC0, = 41.4, pH=7.36) were within the normal range for gestation. On account of premature labour and breech position, the patient was delivered by elective cesarean section at 34 weeks of a normal male infant weighing 2200 g. Pathologic examination of the cord revealed a 4cm organized fusiform hematoma near the placental insertion. Serial histologic sections of

Ultrasonographic features of a fetus at 18 weeks of gestation suggesting a body stalk anomaly are presented. These included a large abdominal anterior wall defect in apparent continuity with the placenta, severe kyphoscoliosis of the lower spine, the absence of one kidney, and a very short umbilical cord with only one umbilical artery. The amniotic fluid was reduced and the fetus was almost immobile at short‐interval ultrasound examinations. The pregnancy was terminated and autopsy of the fetus showed abnormalities compatible with maldevelopment of both cephalic and caudal embryonic folds.

EchocardiographyVolume 6, Issue 4 p. 353-362 Pulsed-Doppler as Applied to Maternal Circulation in Normal and Failed First Trimester Pregnancy ISABEL STABILE M.R.C.O.G., PH.D., Corresponding Author ISABEL STABILE M.R.C.O.G., PH.D. Academic Units of Obstetrics and Gynaecology, King's College Hospital Medical SchoolAddress for correspondence: Isabel Stabile, Terra, Inc., 325 John Knox Road, Atrium Building, Suite 201, Tallahassee, FL 32303.Search for more papers by this authorJURGIS GRUDZINSKAS M.D., JURGIS GRUDZINSKAS M.D. The London Hospital Medical College, London, United KingdomSearch for more papers by this authorSTUART CAMPBELL, STUART CAMPBELL Academic Units of Obstetrics and Gynaecology, King's College Hospital Medical SchoolSearch for more papers by this author ISABEL STABILE M.R.C.O.G., PH.D., Corresponding Author ISABEL STABILE M.R.C.O.G., PH.D. Academic Units of Obstetrics and Gynaecology, King's College Hospital Medical SchoolAddress for correspondence: Isabel Stabile, Terra, Inc., 325 John Knox Road, Atrium Building, Suite 201, Tallahassee, FL 32303.Search for more papers by this authorJURGIS GRUDZINSKAS M.D., JURGIS GRUDZINSKAS M.D. The London Hospital Medical College, London, United KingdomSearch for more papers by this authorSTUART CAMPBELL, STUART CAMPBELL Academic Units of Obstetrics and Gynaecology, King's College Hospital Medical SchoolSearch for more papers by this author First published: July 1989 https://doi.org/10.1111/j.1540-8175.1989.tb00315.xCitations: 1 This work was made possible by a grant from the North East Thames Regional Health Authority Locally Organized Research Scheme (UK). AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume6, Issue4July 1989Pages 353-362 RelatedInformation

Ultrasound-directed surgical ET is useful in patients with a history of difficult cervical (nonsurgical) transfer, and was performed without complications in the small group reported here. The technique is straightforward, and requires no greater expertise than that necessary for ultrasound-guided oocyte collection. However, further studies are necessary to assess its role in the routine transfer of embryos following IVF.

Fetal and maternal placental (intervillous) blood samples were obtained by means of an outpatient ultrasound-guided technique from a 33-week pregnancy with symmetrical intrauterine growth retardation. The baby was delivered by emergency caesarean section because blood gas, pH, and lactate measurements showed severe hypoxic acidosis, due to inadequate placental transfer.

The prenatal diagnosis by ultrasound examination of Joubert's syndrome of familial agenesis of the cerebellar vermis is described allowing termination of pregnancy at 26 weeks gestation. The diagnosis was made by a comparison of the prenatal ultrasound examination with computerized axial tomography obtained from the siblings with the same condition.

Episiotomy is one of the most commonly performed operative procedures and yet little information is available on the subjective reactions in the puerperium to this procedure. The present study was designed to furnish information on the attitudes of patients, levels of pain, and of course recovery by studying a consecutive series of 101 Caucasian primiparea who received episiotomies at delivery. Women were interviewed within 24 hours of delivery and then, at three months after delivery, completed a questionnaire. The high level of pain experienced was noteworthy. Labour pain and episiotomy pain were uncorrelated, indicating the importance of distinguishing between them. Several women were experiencing problems at the three-month follow-up, with some attributing these to the episiotomy repair. The data are presented in the framework of providing women in the postpartum period with systematic information on the nature of postepisiotomy pain and subsequent recovery to facilitate their adjustment.

The accuracy with which ovarian morphology and size can be determined by a real-time, ultrasound mechanical sector scanner was assessed. Both ovaries of 11 climacteric women appeared morphologically normal by ultrasonography and these findings were confirmed at laparotomy the following day. The correlation coefficient between ovarian volumes determined by sonar and those obtained by direct measurement at operation was 0.97. In a series of 31 postmenopausal women in whom clinical examination was unremarkable, both ovaries were identified by sonar in 26 subjects (84%) and a cystic ovary was diagnosed in 1 patient. Ovarian morphology in the other 25 subjects appeared normal and the range of volumes was from 1.47 to 10.43 cm3 with an arithmetic mean of 4.33 cm2 +/- 1.91 (SD). The mean difference between the volumes of the right and left ovaries was 1.48 cm3 +/- 1.19 and the percentage mean difference was 42.88% +/- 32.05. An ovary with a volume more than twice the size of its fellow should be regarded with some suspicion because ovarian volumes within individuals are clearly related (correlation coefficient = 0.82). The potential of the technique as a screening test for the early detection of ovarian cancer warrants further evaluation.

Primiparae were randomly assigned to two conditions of routine ultrasound examination at their first antenatal clinic visit: (a) high feedback ultrasound where the monitor screen was visible and the patient was shown the foetal size, shape and movement (N = 67); (b) low feedback ultrasound where the screen was not seen and specific verbal feedback was denied (N = 62). Women were interviewed at 16 weeks gestation. Those receiving high feedback were more likely to report that they had acted on health advice given at the first antenatal visit to reduce their smoking and drinking.

WHITEHEAD, M. I.; TOWNSEND, P. T.; GILL, D. K.; COLLINS, W. P.; CAMPBELL, S. Author Information

The incidence and frequency of fetal respiratory movements (FRM) and fetal trunk movements (FTM) were measured in 21 normal pregnancies between 28 and 39 weeks gestation. Fetal activity was assessed with a real-time ultrasound scanner and all observed movements were punched directly onto computer tape. Recordings were made for one hour in three over a 24 hour period, providing a total of 168 hours for analysis. The overall mean percentage incidence of FRM was 31 per cent at a mean breathing rate of 43 breaths/minute. The mean percentage incidence of FRM during the day (0800-1759 hours) was 37 per cent. The overall mean percentage incidence of FTM was 18 per cent with a mean of 29 moves per 30 minute observation period. The mean percentage incidence of FTM during the day (0800-1759 hours) was 16 per cent. There was a well-defined circadian variation in fetal activity with FRM peaking between 1900 and 2200 hours, and FTM between 2200 and 0100 hours. There was considerable variation in the amount of FRM and FTM recorded from hour to hour. Total fetal activity rarely fell below 10 per cent in any one recording period and this measurement may be a more useful clinical test of fetal well-being than FRM or FTM alone.