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The management of early labor
Correspondence 765
Volume 160 Number 3
letters to the editors, and occasionally a supplement. The latter, with its collection of papers on one subject, provides reports of studies, opinions, or reviews by multiple authors or a group of authors on various aspects of the subject of the symposium, which are informative for readers. We recognize that some readers will have a different opinion than ours of an article that is published, just as our consultants (peer reviewers) will, on occasion, differ in their opinion of the same manuscript sent to them for review. Dr. Goodlin expressed in his letter his opinion of two other matters about which we have different opinions. He stated, "It is not necessarily progress to develop and test new antibiotics particularly when present drugs and regimens do so well." We agree antibiotics are presently doing well. However, since their introduction fifty years ago as a major breakthrough, more has been learned of both bacteria and antibiotics and progress has been made. We should not be content with the present. We should continue attempts to increase knowledge and the development of all aspects of medicine, including antibiotics. The pharmaceutical industry has consistently supported medicine in education, research, and service to patients; this support has been helpful and is appreciated. The Editors
Isolation of acquired immunodeficiency syndrome virus from the placenta To the Edztors:
We read with great interest the article of Hill et al. "Isolation of acquired immunodeficiency syndrome virus from the placenta" (AM J OBSTET GVNECOL 1987;157:lO-l) and would like to make the following comments. We doubt whether the described method is sufficient to demonstrate that human immunodeficiency virus (HIV) could be isolated from the placenta, and no definitive evidence is supported by Fig. I. So we agreed with the authors when they admitted that "positive viral culture of the placenta was probably a result of the patient'S positive blood culture." To investigate the role of the placenta in maternal transmission of HIV, we conducted a prospective study for immunodetection of HIV proteins in the placenta. At this time 20 placentas (13 induced abortion and 7 deliveries) of pregnant women HIV 1 positive (Centers for Disease Control grades II and III) were collected and tissue samples were immediately snap-frozen in liquid nitrogen. The detection of HIV proteins and the phenotype of inflammatory cells was achieved by an immunoperoxidase technique on cryostat sections with antibody directed against HIV proteins (PI8, P24, PlIO), cellular antigens [Leu4(CD3), Leu2a(CD8), Leu3a(CD4), LeuM5] and anti-early cytomegalovirus proteins. We could not detect any HIV viral protein,
but mononuclear cells LeuM5 positive CD4 positive were found in the chorion and in the villi. Such negative results have to be confirmed with additional cases, but suggest that in the placenta there were noninfected cells and that HIV replication did not occur; transplacental transmission could have happened during a viremic episode at various gestational ages. However, we could not formally rule out the hypothesis that HIV ribonucleic acid was present but without translation detected by immunohistochemical techniques. In this respect it will be of interest to perform in situ hybridization with HIV probe. Finally, the precise role of the placenta in maternofetal transmission of HIV is not fully determined. M. Peuchmaur, MD Department of Pathology
J. C. Pons, MD E. Papiernik, MD
Department of Gynecology and Obstetrics Department of Internal Medicine
J.
F. Delfraissy, MD
Hopital A. Beclere 157 rue de la Porte de Trivaux 92140 Clamart, France
Reply To the Editors:
We appreciate the interest of the authors of the preceding letter regarding our article, "Isolation of acquired immunodeficiency syndrome virus from the placenta." We have indicated that the positive viral culture of the placenta was probably a result of the patient's positive blood human immunodeficiency virus (HIV) status. These authors, and others, are investigating further the role of the placenta in the maternal transmission of HIV by carrying out a prospective study. Their study is an attempt to detect HIV proteins in placental tissue. Although they have not been successful to date, further results of their work will be interesting. We also agree that the precise role of the placenta in maternal-fetal transmission of HIV requires further study. Washington C. Hill, MD James R. Carlson, PhD Veronica Bolton Department of Obstetrics and Gynecology Creighton University School of Medicine 601 North 30th Street, Suite 4810 Omaha, NE 68131
The management of early labor To the Editors:
In their study (A prospective randomized study of the aggressive management of early labor. AM J OBSTET GVNECOL 1987;157:1174-7) Cohen et al. conclude that
766 Correspondence
"The active management of labor did not alter the mode of delivery" despite emphasizing that" the study was not designed to replicate the active management protocol." It is not scientifically valid to reach the conclusion that a method of managing labor does not work without first testing the method. In five continents, including North America, application of active management of labor' resulted in a significant reduction in operative delivery rates with excellent perinatal results.2-6 We suggest that widespread introduction of active management in the United States should be given careful consideration. We can find no evidence in the study of Cohen et al. to suggest that its introduction would not be beneficial. Finally, the use of the word "aggressive" in an article dealing with childbirth is regrettable. Michael J. Turner, MRCOG Peter Boylan, MRCOG Ruth Connolly, MRCOG John M. Stronge, FRCOG National Maternity Hospital Holles Street Dublin 2, Ireland REFERENCES 1. O'Driscoll K, Foley M, MacDonald D. Active management of labor as an alternative to cesarean section for dystocia. Obstet Gynecol 1984;63 :485-90. 2. Ward A. Introducing active management of labour to Nigeria. In: Proceedings of an International Conference organized by the Society of Gynaecology and Obstetrics of Nigeria. Ibadan, Nigeria, October 16-23, 1977. 3. Vengadasalam D. Active management of labour: an approach to reduce the rising caesarean section rate; Singapore experience. Singapore J Obstet Gynaecol 1986; 17: 33-6. 4. Masoli de la Cerda P, Pico VC, Pellerano IB. Manejo activo del parto. Experiencia en el hospital Gustavo Fricke. Rev Chile Obstet Ginecol 1986;51 :223-30. 5. Boylan P, Frankowski R, Rountree R, Selwyn B, Parrish K. Active management of labor as a method of reducing the incidence of cesarean section for dystocia in nulliparas. In: Proceedings of the fifth annual meeting of the American Gynecological and Obstetrical Society, Hot Springs, Virginia, September 4-6, 1986. 6. Turner MJ, Brassil M, Gordon H. Active management of labor associated with a decrease in the cesarean section rate in nulliparas. Obstet Gynecol 1988;150-4.
To the Editors: Having spent 2 years working in the National Maternity Hospital, Dublin, I feel that a number of issues raised by Cohen et al. in their article (Cohen GR, O'Brien WF, Lewis L, Knuppel RA. A prospective randomized study of the aggressive management of early labor. AM] OBSTET GYNECOL 1987;157:1174-7) need clarification. Although the authors state that it was never their intention to replicate the active management protocol outlined by O'Driscoll, this did not prevent them from cautioning against the more widespread use of these methods. The Dublin management protocol, which is quite different from their own, has proved very successful over a long number of years and
March 1989 Am J Obstet Gynecol
it seems unreasonable to caution against an active approach to the management of labor on the basis of their own findings. The success of the active management of labor as practiced in Dublin depends on the early diagnosis and treatment of inefficient uterine action (not incoordinate uterine action, which in some cases may be associated with normal progress in labor). This diagnosis is made only on the basis of slow progress measured by the rate of cervical dilatation and descent of the presenting part. A positive diagnosis oflabor is made when painful uterine contractions accompany full effacement of the cervix. Since a cervical dilatation of 3 cm was one of the criteria for admission to this trial, dysfunctional labor may already have been present for some time. This delay would have been compounded by the small and infrequent increments in the dosage of oxytocin used (1 mU every 30 minutes compared with 6 mU every 15 minutes in the National Maternity Hospital, Dublin). Therefore the failure of this trial to show any benefit from the use of "active management" is, in my opinion, largely a reflection of late and inadequate treatment in the study group. Karl Murphy Nuffield Department of Obstetrics and Gynaecology John Radcliffe Hospital Headington, Oxford, England OX3 9DU
Reply To the Editors: We are pleased to find that our article has been received with interest if not enthusiasm by our colleagues across the Atlantic. The purpose of our study, as clearly stated in the introduction, was to "assess an aggressive approach to early labor in a prospective, randomized fashion." At the time of the study, and to our knowledge at present, no other study has addressed this issue in a prospective, randomized fashion. We clearly stated that this study did not replicate the active management protocol as practiced at the National Maternity Hospital in Dublin. What was addressed, however, is a major difference in the indication and timing of oxytocin administration and amniotomy between the Dublin and American stan,dards. Adoption of a standard of labor diagnosis and management very different from one's own requires a "leap of faith." Study of the individual components of such a system is more readily amenable to scientific study. With regard to the comments of Dr. Murphy, it is not our experience that patients achieve complete effacement before cervical dilation and these patients were considered to be in early labor. The dosage of oxytocin suggested by Dr. Murphy far exceeds that commonly used in the United States and our regimen was based upon the carefully performed studies of Seitchek and Castillo.' In summary, we do not disagree that the management of labor does warrant further careful consider-
Volume 160 Number 3
letters to the editors, and occasionally a supplement. The latter, with its collection of papers on one subject, provides reports of studies, opinions, or reviews by multiple authors or a group of authors on various aspects of the subject of the symposium, which are informative for readers. We recognize that some readers will have a different opinion than ours of an article that is published, just as our consultants (peer reviewers) will, on occasion, differ in their opinion of the same manuscript sent to them for review. Dr. Goodlin expressed in his letter his opinion of two other matters about which we have different opinions. He stated, "It is not necessarily progress to develop and test new antibiotics particularly when present drugs and regimens do so well." We agree antibiotics are presently doing well. However, since their introduction fifty years ago as a major breakthrough, more has been learned of both bacteria and antibiotics and progress has been made. We should not be content with the present. We should continue attempts to increase knowledge and the development of all aspects of medicine, including antibiotics. The pharmaceutical industry has consistently supported medicine in education, research, and service to patients; this support has been helpful and is appreciated. The Editors
Isolation of acquired immunodeficiency syndrome virus from the placenta To the Edztors:
We read with great interest the article of Hill et al. "Isolation of acquired immunodeficiency syndrome virus from the placenta" (AM J OBSTET GVNECOL 1987;157:lO-l) and would like to make the following comments. We doubt whether the described method is sufficient to demonstrate that human immunodeficiency virus (HIV) could be isolated from the placenta, and no definitive evidence is supported by Fig. I. So we agreed with the authors when they admitted that "positive viral culture of the placenta was probably a result of the patient'S positive blood culture." To investigate the role of the placenta in maternal transmission of HIV, we conducted a prospective study for immunodetection of HIV proteins in the placenta. At this time 20 placentas (13 induced abortion and 7 deliveries) of pregnant women HIV 1 positive (Centers for Disease Control grades II and III) were collected and tissue samples were immediately snap-frozen in liquid nitrogen. The detection of HIV proteins and the phenotype of inflammatory cells was achieved by an immunoperoxidase technique on cryostat sections with antibody directed against HIV proteins (PI8, P24, PlIO), cellular antigens [Leu4(CD3), Leu2a(CD8), Leu3a(CD4), LeuM5] and anti-early cytomegalovirus proteins. We could not detect any HIV viral protein,
but mononuclear cells LeuM5 positive CD4 positive were found in the chorion and in the villi. Such negative results have to be confirmed with additional cases, but suggest that in the placenta there were noninfected cells and that HIV replication did not occur; transplacental transmission could have happened during a viremic episode at various gestational ages. However, we could not formally rule out the hypothesis that HIV ribonucleic acid was present but without translation detected by immunohistochemical techniques. In this respect it will be of interest to perform in situ hybridization with HIV probe. Finally, the precise role of the placenta in maternofetal transmission of HIV is not fully determined. M. Peuchmaur, MD Department of Pathology
J. C. Pons, MD E. Papiernik, MD
Department of Gynecology and Obstetrics Department of Internal Medicine
J.
F. Delfraissy, MD
Hopital A. Beclere 157 rue de la Porte de Trivaux 92140 Clamart, France
Reply To the Editors:
We appreciate the interest of the authors of the preceding letter regarding our article, "Isolation of acquired immunodeficiency syndrome virus from the placenta." We have indicated that the positive viral culture of the placenta was probably a result of the patient's positive blood human immunodeficiency virus (HIV) status. These authors, and others, are investigating further the role of the placenta in the maternal transmission of HIV by carrying out a prospective study. Their study is an attempt to detect HIV proteins in placental tissue. Although they have not been successful to date, further results of their work will be interesting. We also agree that the precise role of the placenta in maternal-fetal transmission of HIV requires further study. Washington C. Hill, MD James R. Carlson, PhD Veronica Bolton Department of Obstetrics and Gynecology Creighton University School of Medicine 601 North 30th Street, Suite 4810 Omaha, NE 68131
The management of early labor To the Editors:
In their study (A prospective randomized study of the aggressive management of early labor. AM J OBSTET GVNECOL 1987;157:1174-7) Cohen et al. conclude that
766 Correspondence
"The active management of labor did not alter the mode of delivery" despite emphasizing that" the study was not designed to replicate the active management protocol." It is not scientifically valid to reach the conclusion that a method of managing labor does not work without first testing the method. In five continents, including North America, application of active management of labor' resulted in a significant reduction in operative delivery rates with excellent perinatal results.2-6 We suggest that widespread introduction of active management in the United States should be given careful consideration. We can find no evidence in the study of Cohen et al. to suggest that its introduction would not be beneficial. Finally, the use of the word "aggressive" in an article dealing with childbirth is regrettable. Michael J. Turner, MRCOG Peter Boylan, MRCOG Ruth Connolly, MRCOG John M. Stronge, FRCOG National Maternity Hospital Holles Street Dublin 2, Ireland REFERENCES 1. O'Driscoll K, Foley M, MacDonald D. Active management of labor as an alternative to cesarean section for dystocia. Obstet Gynecol 1984;63 :485-90. 2. Ward A. Introducing active management of labour to Nigeria. In: Proceedings of an International Conference organized by the Society of Gynaecology and Obstetrics of Nigeria. Ibadan, Nigeria, October 16-23, 1977. 3. Vengadasalam D. Active management of labour: an approach to reduce the rising caesarean section rate; Singapore experience. Singapore J Obstet Gynaecol 1986; 17: 33-6. 4. Masoli de la Cerda P, Pico VC, Pellerano IB. Manejo activo del parto. Experiencia en el hospital Gustavo Fricke. Rev Chile Obstet Ginecol 1986;51 :223-30. 5. Boylan P, Frankowski R, Rountree R, Selwyn B, Parrish K. Active management of labor as a method of reducing the incidence of cesarean section for dystocia in nulliparas. In: Proceedings of the fifth annual meeting of the American Gynecological and Obstetrical Society, Hot Springs, Virginia, September 4-6, 1986. 6. Turner MJ, Brassil M, Gordon H. Active management of labor associated with a decrease in the cesarean section rate in nulliparas. Obstet Gynecol 1988;150-4.
To the Editors: Having spent 2 years working in the National Maternity Hospital, Dublin, I feel that a number of issues raised by Cohen et al. in their article (Cohen GR, O'Brien WF, Lewis L, Knuppel RA. A prospective randomized study of the aggressive management of early labor. AM] OBSTET GYNECOL 1987;157:1174-7) need clarification. Although the authors state that it was never their intention to replicate the active management protocol outlined by O'Driscoll, this did not prevent them from cautioning against the more widespread use of these methods. The Dublin management protocol, which is quite different from their own, has proved very successful over a long number of years and
March 1989 Am J Obstet Gynecol
it seems unreasonable to caution against an active approach to the management of labor on the basis of their own findings. The success of the active management of labor as practiced in Dublin depends on the early diagnosis and treatment of inefficient uterine action (not incoordinate uterine action, which in some cases may be associated with normal progress in labor). This diagnosis is made only on the basis of slow progress measured by the rate of cervical dilatation and descent of the presenting part. A positive diagnosis oflabor is made when painful uterine contractions accompany full effacement of the cervix. Since a cervical dilatation of 3 cm was one of the criteria for admission to this trial, dysfunctional labor may already have been present for some time. This delay would have been compounded by the small and infrequent increments in the dosage of oxytocin used (1 mU every 30 minutes compared with 6 mU every 15 minutes in the National Maternity Hospital, Dublin). Therefore the failure of this trial to show any benefit from the use of "active management" is, in my opinion, largely a reflection of late and inadequate treatment in the study group. Karl Murphy Nuffield Department of Obstetrics and Gynaecology John Radcliffe Hospital Headington, Oxford, England OX3 9DU
Reply To the Editors: We are pleased to find that our article has been received with interest if not enthusiasm by our colleagues across the Atlantic. The purpose of our study, as clearly stated in the introduction, was to "assess an aggressive approach to early labor in a prospective, randomized fashion." At the time of the study, and to our knowledge at present, no other study has addressed this issue in a prospective, randomized fashion. We clearly stated that this study did not replicate the active management protocol as practiced at the National Maternity Hospital in Dublin. What was addressed, however, is a major difference in the indication and timing of oxytocin administration and amniotomy between the Dublin and American stan,dards. Adoption of a standard of labor diagnosis and management very different from one's own requires a "leap of faith." Study of the individual components of such a system is more readily amenable to scientific study. With regard to the comments of Dr. Murphy, it is not our experience that patients achieve complete effacement before cervical dilation and these patients were considered to be in early labor. The dosage of oxytocin suggested by Dr. Murphy far exceeds that commonly used in the United States and our regimen was based upon the carefully performed studies of Seitchek and Castillo.' In summary, we do not disagree that the management of labor does warrant further careful consider-