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A prize infant in an elderly primigravida
Volume 87 Number 7
Clinical problems 975
far better than attempting to treat a metastatic lesion. The latter is often a debatable and uncertain problem. Since it is so infrequent for a metastasis to develop in the midportion of the vagina, I am inclined to believe the lesion in this patient is the result of direct implantation and that it is a single isolated lesion. On this basis in this particular patient local excision is preferable. At the time of operation and during the histologic examination of the tissue an attempt should be made to determine whether the rectal musculature has been invaded. If it has not, I would consider the
surgical procedure completed but I would add deep external radiation to the pelvis because the disease is known to have spread beyond the uterus. If the rectum has been invaded, a temporary colostomy would be performed and, '\vhen it vvas functioning properly, a good-sized segment of the rectal wall, including mucosa, would be excised followed by deep external radiation.
REFERENCE
I. Roberts, S., Long, L., Jonasson, 0., McGrath, R., McGrew, E., and Cole, W. H.: Surg. Gynec. & Obst. lll; 3, 1960.
A orize infant in an elderlv orimigravida I
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-J
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Case presentation
Mrs. B. S., 38 years old, gravida ii, para 0, had an obstetric history of a missed abortion at 4 months treated by dilatation and curettage in 1960. Her present pregnancy was uncomplicated. She was admitted to the hospital at 41 weeks' gestation on April 2, 1962, for x-ray pelvimetry and possible induction of labor. The patient was extremely anxious and concerned over the outcome of this pregnancy. At the time of admission the cervix was 1 em. dilated and partly effaced. The presentation was cephalic and the presenting part was at minus-3 station. X-ray pelvimetry (Colcher-Sussmann technique) revealed: inlet, anteroposterior 10 em., transverse 13 em.; midpelvis, anteroposterior 10.5 em., transverse 11 em.; outlet, anteroposterior 7 em., transverse 10 em. The following day intravenous oxytocin resuited in uterine contractions occurring every 5 to 8 minutes of 20 to 30 seconds' duration. However, after 12 hours of such stimulation, the cervix was only. 2 em. di-
lated and the station was still minus-3. Fetal heart tones remained normal. Problem: Discuss your management of this patient. Consultation
Luke Gillespie, M.D. Boston, Massachusetts Instructor, Department of Obstetrics and Gynecology, Harvard Medical School This patient is a primigravida as far as labor and pelvic delivery are concerned. Her cervix has been dilated some once, but this dilatation vvas produced by artificial n1eans, and not by the natural force of physiologic contractions. Even though she is 38 years old, I do not consider her an elderly primigravida. She has been pregnant twice in 2 years, so she has no sterility problem. Her pregnancy has been uneventfui; her past history is negative for complicating medical, surgical, or gynecologic disease that might make this infant a so-called "premium baby."
976
Clinical problems
I presume that an attempt to induce labor was made because of "postmaturity." The main objection to this course of action is that most infants exhibiting the postmature syndrome do not come from patients who are overdue by dates. The pelvis is adequate by x-ray examination, but the cervix is not ripe for induction. The vertex is floating ( minus-3 station). There is no real indication for induction, and none of the basic requirements for safe induction are present. Twelve hours of intravenous oxytocin stimulation produced very, very little change in the condition of the cervix, and produced no descent of this still floating head. Fortunately, it produced no evidence of fetal distress. This patient is still unfavorable for induction. I would discharge her from the hospital to be followed prenatally, as before admission, either in the office or the clinic. I would await the spontaneous onset of labor. .\ floating head in a primigravida at term is supposed to mean cephalopelvic disproportion. It may be that this floating vertex will never descend into the pelvis and engage, but I see no harm in waiting to see what spontaneous labor can accomplish in this respect. Was it the patient who was extremely anxious and concerned over the outcome of this pregnancy, or was it an impatient obstetrician? Sprague H. Gardiner~ M.D. Indianapolis, Indiana Professor of Obstetrics and Gynecology Indiana University School of Medicine From the above information, it is obvious that the physician has permitted the patient's anxieties to become his anxieties and, under pressure from the patient and family, has felt forced to "do something." There is no other indication for the induction of labor. The patient is at term, not past term, and there is a 90 per cent chance that she wiil fall into spontaneous labor within the next
Dt~C<'mlwr I. 19fd Am . .). Ob,t. & Cyncc.
7 to 10 days if the menstrual history is accurate. The head is at station negative 3, and the cervix 1 em. dilated. Although the x-ray measurements reveal slightly small anteroposterior diameters of the inlet and midpelvis, the areas of the inlet, lT1idpelvis, and outlet are normal. The pelvic evaluation is such that, given average uterine contractions with an average-sized baby, a safe vaginal delivery would be anticipated. Should evidence of cephalopelvic disproportion or uterine inertia develop during labor, a cesarean section should be performed earlier than in the average case because of the patient's age (38 years old with her first term pregnancy). The persisting poor uterine contractions and the failure of progressive cervical effacement and dilatation after prolonged oxytocin administration indicate that either the uterus is not ready "to go into labor" or insufficient concentrations of oxytocin have been employed. An "unripe" uterus is the n1ost likely cause, for, in most instances, 3 to 4 hours of oxytocin infusion, in even moderate doses, will "nudge" a "ripe and ready" uterus into active labor. This patient has had uterine contractions induced by oxytocin, but has shown no signs of having been in labor. Early in the antepartum course, the morbid anxieties expressed by the patient regarding the outcome of the pregnancy should have received more therapeutic attention by the physician. Although the curettage removed the products of conception of the missed abortion of the first pregnancy and, obstetrically speaking, the patient was cured, obviously the feelings of guilt, selfrecrimination, inadequacy, and insecurity, associated with the loss of the pregnancy in the mind of the patient, vvcre not alleviated. These disturbed attitudes and feelings have become intensified during the current pregnancy, reaching a climax at term as demonstrated by the statement, "the patient was extremely concerned and anxious over the outcome of this pregnancy." The physician's management of the current pregnancy should have been directed toward two goals:
Volume 87 Number 7
l. By a sympathetic, understanding attitude, he should have made the patient aware of his appreciation of the reality of her disturbed, emotional reactions to the lo~s of the first pregnancy, permitting her to discuss and ventilate these attitudes and feelings. Such discussions would not only have been therapeutically beneficial to the patient, but would have offered the physician the opportunity to educate and strongly reassure the patient regarding the favorable prognosis for this current pregnancy based upon well-recognized obstetric facts. 2. By words and action, the physician could have instilled into the patient suffi= cient confidence that he, by virtue of his professional ability and judgment and understanding of her attitudes and feelings, would be able to conduct her pregnancy and labor with a maximum of safety for her and her child. Had these goals been accomplished during the anterpartum period, much of the patient's anxiety and fear could have been modified to a significant degree. My recommendations for the current management of the patient are as follows: 1. Discontinue the oxytocin stimulation and give the uterus 'a deserved rest. The induced uterine contractions will most likely taper off and subside.
Clinical problems 977
2. Give the patient fluid and food to replenish her nutritional requirements. 3. Mild sedation may help her achieve the much needed rest after the fatiguing and frustrating ordeal of the prolonged induction attempt. 4. In confident and reassuring terms, explain the current situation to the patient and her husband along the following lines: A. The failure of labor to have been induced means only that the uterus just is not ready to go into labor. It does not mean that anything is wrong with the uterus. To persist in attempting to drive the uterus into labor vvould be potentially dangerous. The attempt at induction has been safe for the mother and baby and they have suffered no ill effects. B. The x-ray studies have revealed the pelvic measurements to be normal. 5. Keep the patient in the hospital overnight, but not in the labor room. If, the next morning, there are no uterine contractions, I would dismiss the patient. 6. I would have the patient report by phone to my office each day regarding her progress and I would see her every 3 days to evaluate her status and to give reassurance of the normalcy of the situation. 7. I would await spontaneous onset of labor.
Clinical problems 975
far better than attempting to treat a metastatic lesion. The latter is often a debatable and uncertain problem. Since it is so infrequent for a metastasis to develop in the midportion of the vagina, I am inclined to believe the lesion in this patient is the result of direct implantation and that it is a single isolated lesion. On this basis in this particular patient local excision is preferable. At the time of operation and during the histologic examination of the tissue an attempt should be made to determine whether the rectal musculature has been invaded. If it has not, I would consider the
surgical procedure completed but I would add deep external radiation to the pelvis because the disease is known to have spread beyond the uterus. If the rectum has been invaded, a temporary colostomy would be performed and, '\vhen it vvas functioning properly, a good-sized segment of the rectal wall, including mucosa, would be excised followed by deep external radiation.
REFERENCE
I. Roberts, S., Long, L., Jonasson, 0., McGrath, R., McGrew, E., and Cole, W. H.: Surg. Gynec. & Obst. lll; 3, 1960.
A orize infant in an elderlv orimigravida I
-
-
-
-
-
- -
--
-J
.- -
-- - - -\,;J- -
-
- ----
Case presentation
Mrs. B. S., 38 years old, gravida ii, para 0, had an obstetric history of a missed abortion at 4 months treated by dilatation and curettage in 1960. Her present pregnancy was uncomplicated. She was admitted to the hospital at 41 weeks' gestation on April 2, 1962, for x-ray pelvimetry and possible induction of labor. The patient was extremely anxious and concerned over the outcome of this pregnancy. At the time of admission the cervix was 1 em. dilated and partly effaced. The presentation was cephalic and the presenting part was at minus-3 station. X-ray pelvimetry (Colcher-Sussmann technique) revealed: inlet, anteroposterior 10 em., transverse 13 em.; midpelvis, anteroposterior 10.5 em., transverse 11 em.; outlet, anteroposterior 7 em., transverse 10 em. The following day intravenous oxytocin resuited in uterine contractions occurring every 5 to 8 minutes of 20 to 30 seconds' duration. However, after 12 hours of such stimulation, the cervix was only. 2 em. di-
lated and the station was still minus-3. Fetal heart tones remained normal. Problem: Discuss your management of this patient. Consultation
Luke Gillespie, M.D. Boston, Massachusetts Instructor, Department of Obstetrics and Gynecology, Harvard Medical School This patient is a primigravida as far as labor and pelvic delivery are concerned. Her cervix has been dilated some once, but this dilatation vvas produced by artificial n1eans, and not by the natural force of physiologic contractions. Even though she is 38 years old, I do not consider her an elderly primigravida. She has been pregnant twice in 2 years, so she has no sterility problem. Her pregnancy has been uneventfui; her past history is negative for complicating medical, surgical, or gynecologic disease that might make this infant a so-called "premium baby."
976
Clinical problems
I presume that an attempt to induce labor was made because of "postmaturity." The main objection to this course of action is that most infants exhibiting the postmature syndrome do not come from patients who are overdue by dates. The pelvis is adequate by x-ray examination, but the cervix is not ripe for induction. The vertex is floating ( minus-3 station). There is no real indication for induction, and none of the basic requirements for safe induction are present. Twelve hours of intravenous oxytocin stimulation produced very, very little change in the condition of the cervix, and produced no descent of this still floating head. Fortunately, it produced no evidence of fetal distress. This patient is still unfavorable for induction. I would discharge her from the hospital to be followed prenatally, as before admission, either in the office or the clinic. I would await the spontaneous onset of labor. .\ floating head in a primigravida at term is supposed to mean cephalopelvic disproportion. It may be that this floating vertex will never descend into the pelvis and engage, but I see no harm in waiting to see what spontaneous labor can accomplish in this respect. Was it the patient who was extremely anxious and concerned over the outcome of this pregnancy, or was it an impatient obstetrician? Sprague H. Gardiner~ M.D. Indianapolis, Indiana Professor of Obstetrics and Gynecology Indiana University School of Medicine From the above information, it is obvious that the physician has permitted the patient's anxieties to become his anxieties and, under pressure from the patient and family, has felt forced to "do something." There is no other indication for the induction of labor. The patient is at term, not past term, and there is a 90 per cent chance that she wiil fall into spontaneous labor within the next
Dt~C<'mlwr I. 19fd Am . .). Ob,t. & Cyncc.
7 to 10 days if the menstrual history is accurate. The head is at station negative 3, and the cervix 1 em. dilated. Although the x-ray measurements reveal slightly small anteroposterior diameters of the inlet and midpelvis, the areas of the inlet, lT1idpelvis, and outlet are normal. The pelvic evaluation is such that, given average uterine contractions with an average-sized baby, a safe vaginal delivery would be anticipated. Should evidence of cephalopelvic disproportion or uterine inertia develop during labor, a cesarean section should be performed earlier than in the average case because of the patient's age (38 years old with her first term pregnancy). The persisting poor uterine contractions and the failure of progressive cervical effacement and dilatation after prolonged oxytocin administration indicate that either the uterus is not ready "to go into labor" or insufficient concentrations of oxytocin have been employed. An "unripe" uterus is the n1ost likely cause, for, in most instances, 3 to 4 hours of oxytocin infusion, in even moderate doses, will "nudge" a "ripe and ready" uterus into active labor. This patient has had uterine contractions induced by oxytocin, but has shown no signs of having been in labor. Early in the antepartum course, the morbid anxieties expressed by the patient regarding the outcome of the pregnancy should have received more therapeutic attention by the physician. Although the curettage removed the products of conception of the missed abortion of the first pregnancy and, obstetrically speaking, the patient was cured, obviously the feelings of guilt, selfrecrimination, inadequacy, and insecurity, associated with the loss of the pregnancy in the mind of the patient, vvcre not alleviated. These disturbed attitudes and feelings have become intensified during the current pregnancy, reaching a climax at term as demonstrated by the statement, "the patient was extremely concerned and anxious over the outcome of this pregnancy." The physician's management of the current pregnancy should have been directed toward two goals:
Volume 87 Number 7
l. By a sympathetic, understanding attitude, he should have made the patient aware of his appreciation of the reality of her disturbed, emotional reactions to the lo~s of the first pregnancy, permitting her to discuss and ventilate these attitudes and feelings. Such discussions would not only have been therapeutically beneficial to the patient, but would have offered the physician the opportunity to educate and strongly reassure the patient regarding the favorable prognosis for this current pregnancy based upon well-recognized obstetric facts. 2. By words and action, the physician could have instilled into the patient suffi= cient confidence that he, by virtue of his professional ability and judgment and understanding of her attitudes and feelings, would be able to conduct her pregnancy and labor with a maximum of safety for her and her child. Had these goals been accomplished during the anterpartum period, much of the patient's anxiety and fear could have been modified to a significant degree. My recommendations for the current management of the patient are as follows: 1. Discontinue the oxytocin stimulation and give the uterus 'a deserved rest. The induced uterine contractions will most likely taper off and subside.
Clinical problems 977
2. Give the patient fluid and food to replenish her nutritional requirements. 3. Mild sedation may help her achieve the much needed rest after the fatiguing and frustrating ordeal of the prolonged induction attempt. 4. In confident and reassuring terms, explain the current situation to the patient and her husband along the following lines: A. The failure of labor to have been induced means only that the uterus just is not ready to go into labor. It does not mean that anything is wrong with the uterus. To persist in attempting to drive the uterus into labor vvould be potentially dangerous. The attempt at induction has been safe for the mother and baby and they have suffered no ill effects. B. The x-ray studies have revealed the pelvic measurements to be normal. 5. Keep the patient in the hospital overnight, but not in the labor room. If, the next morning, there are no uterine contractions, I would dismiss the patient. 6. I would have the patient report by phone to my office each day regarding her progress and I would see her every 3 days to evaluate her status and to give reassurance of the normalcy of the situation. 7. I would await spontaneous onset of labor.