British Journal of Obstetrics and Gynaecology October 1992, Vol. 99. pp. 861-862

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CORRESPONDENCE

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Can out-of-hours work by junior doctors in obstetrics be reduced? and role of the senior house officer in the labour ward Dear Sir, The conclusion by McKee etal. (1992) that there is scope for reducing the workload of junior obstetricians at night through the adoption of an extended role by midwives is thoughtfully commented upon by Pogmore (1992) in the same issue. The findings by McKee about epi- durals in labour must, however, give rise to concern. He found that in one instance an obstetric SHO commenced epidural anaesthesia and that in two of the four hospitals studied the task of topping-up epi- durals was shared between the SHO, the anaesthetist and the mid- wife (in the other two hospitals no details about this task were available). The training of anaesthetists in obstetric analgesia and anaesthesia is often informal, despite guidelines having been pro- duced by the Royal College Anacsthetists (1991). In general no anaesthetist will be on-call for the labour ward with less than one year of anaesthetic training.

The training of midwives in the management of women with epi- durals and topping-up epidurals is also thorough. The acceptance by Mr Pogmore that the topping-up of epidurals is all part of the job of the SHO, who is often a general practitioner trainee wishing to gain predominantly antenatal and post-natal experience, is only exac- erbating the problem of inappropriate analgesia in labour and as chairman of the Hospital Recognition Committee perhaps he should have been denouncing this practice as out-dated and dangerous. The institution of epidural analgesia should be left solely with the anaes- thetist and the topping-up of epidurals should be shared between the midwife and the anaesthetist.

The work of the junior obstetrician is already recognized as inten- sive (Dowie 1989) and this small change will not only ease the work- load. but it will also improve patient safety.

Michael Cross Registrar

Barbara Morgan Senior LecturerConsultant Anaesthetist

Department of Anaesthetics Queen Charlottes and Chelsea Hospital

Goldhawk Road, London W6 OXG

References

McKee M., Priest l?, Ginzler M. & Black N. (1992) Can out-of-hours work by junior doctors in obstetrics be redued? B R J Obstet Gynaecol99,197-202.

Pogmore .I. R. (1992) Role of the senior house officer in the labour ward. Br J Obstet Gynaecol99,180-181.

Royal College of Anaesthetists (1991) Guidelinesfor Basic Specialist Training.

Dowie R. (1989) Patterns ofMedical Staffing, Interim Report, BPMF, London.

Role of prostaglandin in the management of prelabour rupture of the membranes at term Dear Sir, In the study by Mahmood et al. (1992) on the use of vaginal prosta-

glandins in the treatment of prelabour rupture of membranes at tcrm, they had two patients who were delivered by caesarean section for fetal distress. Both patients were in the group treated with vaginal prostaglandins and it is stated that uterine hyperstimulation occurred. They suggest that this may be caused by uncontrolled prostaglandin absorption into the amniotic cavity or the maternal circulation.

We have measured the level of prostaglandins in the maternal cir- culation in such circumstances. We found that the levels of prosta- glandin E metabolite prior to treatment was approximately 10 times higher than that which is normally achieved after vaginal PGE, treat- ment whcn the membranes are intact. The level of prostaglandin E metabolite within the maternal circulation did not significantly increase after trcatment (Fig. 1). The high level of prostaglandin E metabolite presumably reflects endogenous production of PGE, fol- lowing rupture of the membranes and any exogenous PGE2 which enters the circulation following treatment is insignificant in comparison.

Any effect which vaginal PGEL may have in the presence of rup- tured membranes must therefore be at a local level either directly into the amniotic fluid or into the uterus. Alternatively, in view of the high levels of prostaglandin E metabolite in the circulation, the hyperstimulation seen in Mahmood’s study may represent an idio- syncratic rather than a dose-related pehnomenon.

Peter Stewart Consultant Obstetrician and Gynaecologist

Helen Spiby Research Midwife

Department of Obstetrics and Gynaecology Northern General Hospital Shefield

Ian Greer Professor of Obstetrics and Gynaecology

Glasgow Royal Maternity Hospital, Rottenrow Glasgow G4 ONA.

01 I I I Before treatment 30 min 60 rnin

Fig. 1. Maternal serum levels of prostaglandin E metabolite following application of vaginal PGE, gel. 0 = Unfavourable cervix 2 m PGE,; 0 = Favourable cervix 1 mg PGE,.

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