by Shona Levingston and Kevin Barham
About one third of Australian women will have their baby surgically removed, says Marsden Wagner, a perinatal epidemiologist. This figure places Australia as having the second highest total operative (including forceps, vacuum and caesarean section) birth rate in the world.
An underlying cause of excessive obstetrical interventions, says Wagner, is that early interventions such as induction and routine electronic foetal monitoring (CTG) during labour can initiate a cascade of interventions. A high false positive rate using CTG contributed to unnecessary caesarean sections.
Yet these disturbing figures, which are above the WHO recommended rate, needn't be so high.
A Melbourne obstetrician and gynaecologist has developed a technique which has succeeded in lowering caesarean sections and reduced the need for drug induced labour.
It seems to be rather a contradiction, using technology to prevent technological intervention, but Kevin Barham, a senior obstetrician and gynaecologist at the Mercy Hospital for Women (MHW) in Melbourne, has developed a way of video recording movie insights from the womb and, in doing so, has made some interesting discoveries.
When the amniotic fluid darkness is illuminated in late pregnancy, a healthy foetus usually responds by moving actively. This may stimulate the release of prostaglandins, known to be central to the initiation of labour.
'Using this technique, the chance of a woman coming into natural labour within 48 hours can be increased,' said Mr Barham.
'We have cut the incidence of surgical induction by half since we have adopted the policy of only carrying out surgical induction if the foetus is visually compromised, that is, the amniotic fluid is stained green from meconium bio-pollution, there is marked reduction of the amniotic fluid volume, or the foetal heart rate responses are abnormal.'
'Where we have compared the incidence of caesarean sections, there has been a significant reduction in those women whose foetuses were exposed to light and multi sourced imaging. After an initial light test of some 10-15 minutes, 40 per cent of women are into labour within 48 hours. After a second test, 40 per cent of the remaining women would go into labour.'
Mr Barham said the technique was pioneered in Melbourne on a research and development budget of $150,000 provided by private benefactors.
Mr Barham developed the Lite Help Video, as the procedure is called, with the help of N. Stenning & Co, and biomedical engineers from the Royal Children's Hospital in Melbourne.
In contrast to surgery and diagnostic medicine, there has been little application of endoscopic techniques to obstetrics apart from amnioscopy devised to detect antepartum meconium stained amniotic fluid.
In the past, amnioscopy has been used to illuminate the intrauterine darkness during late pregnancy followed by inspection of the amniotic fluid in the region of the lower uterine polar zone, using a simple tubed endoscope passed through the cervix as far as the transparent membranes. This is made possible in late pregnancy because usually the cervix softens, opens and can then be instrumented.
The Lite (Low Intrauterine Transcervical Endoscopy) Help (Honed Examinations of Late Pregnancy) Video eliminates observer error in visualising the colour of the amniotic fluid. In particular, it allows the detection of the green staining of meconium bio-pollution and, in doing so, a far better appreciation of the significance of antepartum meconium stained amniotic fluid can be obtained.
Lite also makes it possible to visually strip the membranes from the decidua with more precision, thereby activating the chorio-decidua to release endogenous prostanoids, ripen the cervix and activate labour where digital methods would be difficult, impossible or inadequate.
The omnioscope consists of a tapering endoscope and obturator and includes a special inner tube which locks into the endoscopic tube after removal of the obturator. This inner tube contains two channels, one for a fibre optic telescope for video endoscopy and the other for procedural access to the amniosphere.
A foetal surveillance data-video encoder was specially developed at the Royal Children's Hospital, Melbourne to video integrate transcervical endoscopic, cardiocographic and realtime ultrasonographic information as required.
The obstetrician now has the ability to combine transcervical and multisourced information with voice commentary signals and sound into a composite signal which can be recorded on a standard video cassette.
LHV can be used to furnish specific data about foetal position, morphometrics and Lite stimulated barophotonic foetal heart rate and gross body movement responses; amniotic fluid ecology and fluid movements with specific information in living dynamic colour about the amniotic fluid and decidua in the region of the lower uterine polar zone, the 'trigger' zone of the uterus; and uterine activity, particularly Lite stimulated barophotonic uterine activity.
LHV is usually offered to patients at increased clinical risk of foetal hypoxia and for patients attempting vaginal birth after caesarean section as a method of activating labour.
MHW studies also suggest that LHV may offer advantages in the area of child-birth preparation and planning for primidgravid patients.
An analysis of more than 3000 patients, who have had Lite, Lite Help or Lite Help Video has revealed that there were no perinatal deaths associated with hypoxia, meconium aspiration or infection. The procedure has been found to be safe for mother and baby. In particular, there has been no significant incidence of neonatal neurotoxicity.
Another advantage of LHV is the positive biofeedback that is generated when parents view the baby on screen. Also, any problems can be more easily explained by showing the parents the cause for concern.
LHV can be relayed to a nearby viewing room for teaching purposes. Such data could be relayed to a referring doctor in surgery or to a referring satellite hospital.
Mr Barham presented his technology at last year's World Congress for Obstetricuans and Gynaecologists in Montreal, where it generated considerable interest.
'It is a whole new world of imaging and monitoring', said Mr Barham. 'It is pre-birth obstetrics for the 21st century.'
This is an edited version of a May 1995 article, reprinted with permission from LAB NEWS