Oxytocin infusion in primiparous women using epidural analgesia SIR,-I congratulate Mr Nigel J St G Saunders and his colleagues on their paper': as one who has attempted a similar study, I can testifv to the difficulties of accumulating stufficient numbers of primigravid women undergoing epidural analgesia in whom full dilatation of the cervix is achieved without prior stimulation with oxytocin. I think, however, that they have left themselves open to criticism on a few aspects of their studyT design. Firstly, it is not clear why the duration of oxytocin infusion was limited to only one hour before organised pushing. The acid-base state of both mother and fetus at the start of the second stage is superior in epidural labours, and several studies have shown that the second stage can be prolonged beyond four hours with no adverse effects on the mother or fetus.' The oxytocin infusion could thus have been continued for a minimum of two hours before organised pushing: this might have made a difference to the incidence of rotational forceps deliveries. Secondly, they do not explain why the pushing phase was limited to one hour: in the absence of fetal distress and maternal exhaustion there is no need to stop the mother pushing. Owing to impaired expulsive efforts women undergoing epidural analgesia may need a slightly longer pushing phase to achieve a normal delivery. Besides, having had a restful labour thanks to the epidural they are usually able to push for longer episodes. Thirdly, the decision to increase the oxytocin infusion was taken by the midwife on the basis of abdominal palpation. This method is unreliable as a means of assessing the adequacy of uterine contractions, and my own experience of midwives' attitudes to oxytocin is that they are wary of its use, particularly in women who have reached the second stage without augmentation. It is therefore possible that some women did not receive adequate oxytocin. I do rnot believe that the use of intrauterine catheters would have biased the attendants as intrauterine pressures vary widely among patients. A case might be made for increasing oxvtocin infusion in all women until a predetermined intrauterine pressuLre is achieved. ISAAC T MANYONDA
Dcpartment of Cellular anid Miolecular Sciences, St George's Hospital Medical School, London SW 17 ORE Saunders NJStG, Spibv H, Gilbcrt L, et al. Oxvtocin intfusion during second stage of labour in primiparoLts women uIsilng cpidtiral analgesia: a randomised doublc blind placebo trial.
BrrfedJ7 1989;299:1423-6. (9 DeLereber.) JF, Davies P. *IThe effect of coritintiouLs lttmbar epidUral analgesia tipon fetal acid-base status dturing the second stagc ot labour. 7ournal of Obstetrics and Gsvnaecolocv of the British Commontwealth 1974;81:975-9. 3 Smith ARB, James DK, Faragher EB, Gilfillan S. Conitiniuous lttmbar epidural analgesia in labour-does delaying pushing in the second stage reduce the incidence of instrumental delivery? 7ournal of Obstetrics and Gvnaecology 1982;2: 170-2.
2 Pearson
AUTHOR'S REPLY, -Any study concerned with the management of the second stage of labour will require that arbitrary time limits are set concerning both the overall duration of the second stage and the duration of maternal pushing efforts. The criteria adopted are probably not critical provided that they are applied uniformly to both treatment groups. Dr Manyonda suggests that a longer second stage of labour with more prolonged use of oxytocin might have reduced the incidence of malposition of the occiput. This is possible but unlikely given that patients uitimately delivered by Kielland's rotational forceps were allowed a longer second stage and received more oxytocin than
262
patients who delivered spontaneously or by use of non-rotational forceps. Generally, with epidural analgesia the second stage mav be allowed to continue for several hours without apparent harm to mother and baby, provided that continuous fetal heart rate monitoring is undertaken, but in an analysis of the probability of spontaneous delivery in relation to the duration of the second stage Kadar et al concluded that for most patients little was to be gained bv extending the second stage beyond three hours.' rhey also noted that the rate of rotational forceps delivery was not influenced bv the time spent in the second stage of labour. In fact, Dr Manvonda quotes a studv in which attempts to prolong the second stage did not influence the operative delivery rate. Dr Mianvonda also suggests that measurement of intrauterine pressure would not have disclosed the nature of the infusion to the attendants at the births. In a small pilot study we did observe changes in intrauterine pressure apparently in response to oxytocin infusion and thought that the double blind nature of the trial could have been compromised by this information. In the treatment arm of the study the mean maximum dose rate of oxytocin was over 9 mU/minute, and therefore I do not accept that the attending midwives were too restrained in their control of the infusion rate. The results of our trial suggest that the current widespread practice of administering oxytocin in the second stage of labour to correct malposition of the occiput may not be effective. The use of a higher dose rate of oxytocin for a longer period of time certainly deserves further study, but from the available evidence it seems unlikely that this approach will fundamentally alter the oiutcome of labour in this group of women. NIGEL SAUNDERS
Departmenit of Obstetrics and (Gsnaecology,
St Mary's Hospital Mtedical School, London W2 lP(i
I Kadar N, Crtoddas 1\1, Campbell S. Estimating the probability of spontaneoois delivery conditional on time spent in the second stage. Br]7 Obsretrvnaccol 19X6;93:568-76. 2 Smith ARB, James DK, Faragher EB. Gillfillan S. Continuous lumbar epidural analgesia itt labour-does delivery "pushing" in the sccond stage reduce the incidence of iinstrumental deliserNs ?]ournal oflObstetnics and Gsnaecologs 1982;2:170-2.
Hearing problems of elderly people SIR,-Dr Gordon Hickish suggests using the resources available in general practice to tackle the problem of hearing difficulties in elderly people.' The provision of hearing aids by the NHS through an ear, nose, and throat consultant has largely been historical. It has long been argued that referral of patients needing hearing aids to an ear, nose, and throat consultant will help to identify any underlying problems unrecognised by (untrained) general practitioners. The fact that aids are widely available without the intervention of any doctor for people willing to pay is widely ignored, as is the fact that assessment of patients referred for hearing aids to ear, nose, and throat departments is often delegated to the most junior members of staff. To counter this argument I carried out a prospective study in a North Yorkshire general practice to determine whether a general practitioner using simple clinical methods can adequately assess the need for a hearing aid and the absence of serious remedial disease in patients aged over 65, as measured by the outcome of referral to an ear, nose, and throat clinic. The assessment consisted of questions concerning present and previous otological problems or symptoms, examination of the ear with an otoscope, Rinne tuning fork test, and a whispered voice test. The patients seen in the surgery setting were self
referrals to one of five partners or to me, the trainee. I assessed 30 patients over a 10 month period before referring them: 25 were referred after failing the whispered voice test, two were found to have symptoms and signs of chronic suppurative otitis media, and three declined referral after consultation. All 25 referred for hearing aids received these, and none was investigated other than by pure tone audiometry by the consultant at the local district general hospital. The whispered voice test will detect a loss of 30 dB or more, a level of impairment that is generally accepted as likely to benefit from amplification. Pure tone audiometers are not generally available in general practice and are time consuming and cumbersome as a screening tool, especially in a domiciliary setting. At present, audiometry by a general practitioner would in any case be repeated at the ear, nose, and throat clinic before an aid was dispensed. General practitioners should be able accurately to identify those elderly patients with hearing loss due to presbycusis, and in view of the often prolonged wait to see an ear, nose, and throat consultant a direct referral to an audiology technician would be a logical alternative. MARTIN VALLIS Lowestoft NR32 1 PA 1 Hickish G. Hearing problems of elderly people. Br Med .7 1989;299:1415. (9 December.) 2 Swan IRC, Browning GG. The whispered voice as a screening test for hearing impairment. J R Coll Gen Praci 1985;35:197.
SIR,-The British Association of Community Doctors in Audiology noted with interest Dr Gordon Hickish's editorial on hearing problems of elderly people. We welcome his suggestions for audiometric screening of the elderly within the practice premises, but we deplore the idea that a short period of training would enable practice nurses or even general practitioners to prescribe and fit hearing aids and carry out rehabilitation. Training in hearing aid prescription and fitting cannot be obtained without the background knowledge in audiology that is part of the hospital audiology technician's training. Surely it would be preferable to improve the salary structure and training of hospital audiology technicians and encourage their work in the community? This has already happened in some districts, but the national shortage of technicians has made their role in the community the exception rather than the rule. Dr Hickish presumably refers to children rather than the elderly in respect of using audiometry to monitor glue ear. As most children with glue ears are pre-school age, many under 3 years, it is unlikely that their hearing could be tested by pure tone audiometry. Unfortunately, testing young children with behavioural techniques is not easy and requires quiet conditions and skilled testers; moreover, the degree of hearing loss often bears little relation to the medical and developmental need for surgical intervention. The British Association of Community Doctors in Audiology recommends that testing of children should not be carried out by anyone-be they medical, nursing, or technical staff-who has not had considerable experience in child development in addition to training in audiological techniques. JUDITH HOI)GSON
Birkenhcad L43 SSQ Hickish G. Hcaring problcms of elderly peoplc. Br Mcd 7 1989;299:1415-6. 9 D)cemhcr.)
SIR,-Dr John R Hughes' criticises Dr Gordon Hickish- for suggesting that the elderly should be screened, on the grounds that Dr Hickish had not shown a beneficial outcome for his patients and also because the workload that might flow
BMJ VOLUME 300
27 JANUARY 1990
Dcpartment of Cellular anid Miolecular Sciences, St George's Hospital Medical School, London SW 17 ORE Saunders NJStG, Spibv H, Gilbcrt L, et al. Oxvtocin intfusion during second stage of labour in primiparoLts women uIsilng cpidtiral analgesia: a randomised doublc blind placebo trial.
BrrfedJ7 1989;299:1423-6. (9 DeLereber.) JF, Davies P. *IThe effect of coritintiouLs lttmbar epidUral analgesia tipon fetal acid-base status dturing the second stagc ot labour. 7ournal of Obstetrics and Gsvnaecolocv of the British Commontwealth 1974;81:975-9. 3 Smith ARB, James DK, Faragher EB, Gilfillan S. Conitiniuous lttmbar epidural analgesia in labour-does delaying pushing in the second stage reduce the incidence of instrumental delivery? 7ournal of Obstetrics and Gvnaecology 1982;2: 170-2.
2 Pearson
AUTHOR'S REPLY, -Any study concerned with the management of the second stage of labour will require that arbitrary time limits are set concerning both the overall duration of the second stage and the duration of maternal pushing efforts. The criteria adopted are probably not critical provided that they are applied uniformly to both treatment groups. Dr Manyonda suggests that a longer second stage of labour with more prolonged use of oxytocin might have reduced the incidence of malposition of the occiput. This is possible but unlikely given that patients uitimately delivered by Kielland's rotational forceps were allowed a longer second stage and received more oxytocin than
262
patients who delivered spontaneously or by use of non-rotational forceps. Generally, with epidural analgesia the second stage mav be allowed to continue for several hours without apparent harm to mother and baby, provided that continuous fetal heart rate monitoring is undertaken, but in an analysis of the probability of spontaneous delivery in relation to the duration of the second stage Kadar et al concluded that for most patients little was to be gained bv extending the second stage beyond three hours.' rhey also noted that the rate of rotational forceps delivery was not influenced bv the time spent in the second stage of labour. In fact, Dr Manvonda quotes a studv in which attempts to prolong the second stage did not influence the operative delivery rate. Dr Mianvonda also suggests that measurement of intrauterine pressure would not have disclosed the nature of the infusion to the attendants at the births. In a small pilot study we did observe changes in intrauterine pressure apparently in response to oxytocin infusion and thought that the double blind nature of the trial could have been compromised by this information. In the treatment arm of the study the mean maximum dose rate of oxytocin was over 9 mU/minute, and therefore I do not accept that the attending midwives were too restrained in their control of the infusion rate. The results of our trial suggest that the current widespread practice of administering oxytocin in the second stage of labour to correct malposition of the occiput may not be effective. The use of a higher dose rate of oxytocin for a longer period of time certainly deserves further study, but from the available evidence it seems unlikely that this approach will fundamentally alter the oiutcome of labour in this group of women. NIGEL SAUNDERS
Departmenit of Obstetrics and (Gsnaecology,
St Mary's Hospital Mtedical School, London W2 lP(i
I Kadar N, Crtoddas 1\1, Campbell S. Estimating the probability of spontaneoois delivery conditional on time spent in the second stage. Br]7 Obsretrvnaccol 19X6;93:568-76. 2 Smith ARB, James DK, Faragher EB. Gillfillan S. Continuous lumbar epidural analgesia itt labour-does delivery "pushing" in the sccond stage reduce the incidence of iinstrumental deliserNs ?]ournal oflObstetnics and Gsnaecologs 1982;2:170-2.
Hearing problems of elderly people SIR,-Dr Gordon Hickish suggests using the resources available in general practice to tackle the problem of hearing difficulties in elderly people.' The provision of hearing aids by the NHS through an ear, nose, and throat consultant has largely been historical. It has long been argued that referral of patients needing hearing aids to an ear, nose, and throat consultant will help to identify any underlying problems unrecognised by (untrained) general practitioners. The fact that aids are widely available without the intervention of any doctor for people willing to pay is widely ignored, as is the fact that assessment of patients referred for hearing aids to ear, nose, and throat departments is often delegated to the most junior members of staff. To counter this argument I carried out a prospective study in a North Yorkshire general practice to determine whether a general practitioner using simple clinical methods can adequately assess the need for a hearing aid and the absence of serious remedial disease in patients aged over 65, as measured by the outcome of referral to an ear, nose, and throat clinic. The assessment consisted of questions concerning present and previous otological problems or symptoms, examination of the ear with an otoscope, Rinne tuning fork test, and a whispered voice test. The patients seen in the surgery setting were self
referrals to one of five partners or to me, the trainee. I assessed 30 patients over a 10 month period before referring them: 25 were referred after failing the whispered voice test, two were found to have symptoms and signs of chronic suppurative otitis media, and three declined referral after consultation. All 25 referred for hearing aids received these, and none was investigated other than by pure tone audiometry by the consultant at the local district general hospital. The whispered voice test will detect a loss of 30 dB or more, a level of impairment that is generally accepted as likely to benefit from amplification. Pure tone audiometers are not generally available in general practice and are time consuming and cumbersome as a screening tool, especially in a domiciliary setting. At present, audiometry by a general practitioner would in any case be repeated at the ear, nose, and throat clinic before an aid was dispensed. General practitioners should be able accurately to identify those elderly patients with hearing loss due to presbycusis, and in view of the often prolonged wait to see an ear, nose, and throat consultant a direct referral to an audiology technician would be a logical alternative. MARTIN VALLIS Lowestoft NR32 1 PA 1 Hickish G. Hearing problems of elderly people. Br Med .7 1989;299:1415. (9 December.) 2 Swan IRC, Browning GG. The whispered voice as a screening test for hearing impairment. J R Coll Gen Praci 1985;35:197.
SIR,-The British Association of Community Doctors in Audiology noted with interest Dr Gordon Hickish's editorial on hearing problems of elderly people. We welcome his suggestions for audiometric screening of the elderly within the practice premises, but we deplore the idea that a short period of training would enable practice nurses or even general practitioners to prescribe and fit hearing aids and carry out rehabilitation. Training in hearing aid prescription and fitting cannot be obtained without the background knowledge in audiology that is part of the hospital audiology technician's training. Surely it would be preferable to improve the salary structure and training of hospital audiology technicians and encourage their work in the community? This has already happened in some districts, but the national shortage of technicians has made their role in the community the exception rather than the rule. Dr Hickish presumably refers to children rather than the elderly in respect of using audiometry to monitor glue ear. As most children with glue ears are pre-school age, many under 3 years, it is unlikely that their hearing could be tested by pure tone audiometry. Unfortunately, testing young children with behavioural techniques is not easy and requires quiet conditions and skilled testers; moreover, the degree of hearing loss often bears little relation to the medical and developmental need for surgical intervention. The British Association of Community Doctors in Audiology recommends that testing of children should not be carried out by anyone-be they medical, nursing, or technical staff-who has not had considerable experience in child development in addition to training in audiological techniques. JUDITH HOI)GSON
Birkenhcad L43 SSQ Hickish G. Hcaring problcms of elderly peoplc. Br Mcd 7 1989;299:1415-6. 9 D)cemhcr.)
SIR,-Dr John R Hughes' criticises Dr Gordon Hickish- for suggesting that the elderly should be screened, on the grounds that Dr Hickish had not shown a beneficial outcome for his patients and also because the workload that might flow
BMJ VOLUME 300
27 JANUARY 1990
