CMAJ 1997;156:749
© 1997 Canadian Medical Association
Physicians often find that theirs is a sad profession, one more occupied by the ravages of disease than by the prospect of health. Those who provide care for pregnant women encounter many happy exceptions to this rule. Here the challenge is to maintain the dyad of mother and fetus in health and to do no harm. In this issue we look at 4 aspects of pregnancy and childbirth.
First is the potential for the fetus to be affected by a chromosomal anomaly or neural tube defect. In a typical population of 10 000 pregnant women one may expect 16 cases of Down syndrome, 10 cases of open neural tube defect and 1 case of trisomy 18. June Carroll and associates (page 775) show that health care providers in Ontario continue to have doubts about maternal serum screening (MSS) for these disorders. Do high rates of false-positive results give rise to too much needless anxiety? Is this disadvantage outweighed by the benefits of avoiding "routine" amniocentesis for many women over age 35? Jane Evans (page 805) counsels physicians to learn more about MSS and its appropriate use and to take the time to provide adequate patient counselling.
In utero exposure to alcohol poses serious risks; binge drinking -- the consumption of 5 or more standard drinks on a single occasion -- appears to be particularly teratogenic. Jonathan Gladstone and colleagues (page 789) found that pregnant women who reported binge drinking to a pregnancy counselling service in Toronto were more likely to be young, single, white and users of illicit drugs than controls. Josephine Nanson (page 807) discusses the need for more attention to the socioeconomic risk factors for binge drinking during pregnancy.
Third, a question about delivery. Which women should be given an episiotomy? In reviewing over 6500 consecutive vaginal deliveries Michel Labrecque and associates (page 797) found that the risk of severe perineal laceration was almost 5 times higher among women who underwent median episiotomy than among women who did not. Michael Helewa (page 811) reviews the ever-accumulating evidence that the many benefits claimed for episiotomy have no basis in fact. It seems that median episiotomy may go the way of other surgical practices such as routine tonsillectomy and radical mastectomy.
Lastly, Laurence Reynolds (page 831) suggests that the psychologic distress that some women experience after a difficult labour may be a variant of post-traumatic stress disorder. Extreme pain, fear, feelings of depersonalization and of loss of control can precipitate psychiatric illness after childbirth. -- JH
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