A study of fetal distress, its interpretation and significance

A STUDY

OF FETAL DISTRESS, ITS INTERPRETATION AND SIGNIFICANCE’z (Prom

d.

~PHE

&≪

JR.,

mj.,

the AND

Ewmauei liospitnl/ BEMY

Iv.

&JLSHII:R,

>m.,

mTL.lh’b),

IKE.

HE prognostic importance of variations in fetal heart rate go back as early as 1833. Since then, fetal distress has been alluded to in many articles scattered throughout the obstetrical literature. However, despite the frequent reference to this condit,ion, its interpretation, significance, and evaluation have never been satisfactorily investigated. Obstetric texts3: 6 j, 6 have for many years stressed the importance of fetai heart auscultation. This importance increases as the first stage of labor nears its termination and the second st,age is entered. Fetal heart auseultation thereafter is urged at very close intervals, stated as often as every five minutes or oftener if clinica. factors deem it a,dvisable. The findings which are used most frequently to diagnose fetal distress pertain to changes in the behavior of the fetal heart3, 5, Ii! These changes are specified as disturbances in rhybhm, rate, or in the quality of the heart sounds themselves. A second sign leading to the diagnosis of fetal distress has been the passage of ineconium5~ s, I2 in other than sacral present,ations. A third criterion has been an increase in fetal activity.“, I2 There are approximately four obstetric condit.ions wherein the development of fetal distress should reasonably be anticipated. These are the abruption of the placenta, placenta presia, prolapsed cord, a,nd tumultuous labor and descent. All four alter fetal physiology in a detrimental or even fatal manner as is well recognized. When confronted with the probable or certain diagnosis of one of these four conditions, every obstetrician should be instantly aware that the fetus is in jeopardy. It is not within the scope of this paper to set, forth the diagnostic findings present in these conditions. The occurrence of a palpable or visible prolapsed cord has set agile minds to work envisioning an “occult” or a trapped cord in the lower uterine segment. As the cord is literally the “life line” of the fetus, other worrisome placements or conditions have become legendary in producing fetal distress. These are loops of cord around the neck, under the arm, between the legs, or around a foot; a knot in the cord; a rupture of a marginal sinus; or a pathologically short cord. With the exception of occult cord entanglement, all these conditions can he strongly suspected or diagnosed with certainty from the clinical picture. *Presented Association at

at the Annual Glacier National

Meeting Park,

of the Pacific June 28, 1952. 1006

Northwest

Obstetrical

and

Gynecological

Volume Number

65 5

FETAL

DIRTREStS

1007

It is with the exclusion of these clinically recognizable entities that we interpret the allusion to fetal distress in the literature. ‘The entity of fetal distress with no demonstrable cause is an intriguing diagnosis and as interpreted above was the reason for this investigation. A review of the recent literature disclosed that American investigators have given little time to this subject in the past few years and not much has been added since the basic observations of the founders of obstetrics in this icountry. Foreign investigators have been more active in attempting to analyze the fetal heart tones as a criterion of fetal distress. The types of rates and/or rhythms commonly taken to indicate fetal distress are as follows : (1) rapid rate, over 160; (2) slow rate, under 100 ; (3) fluctuating rate ; and (4) irregular rate. The predomina,nt opinions concerning these types of rhythm disturbances have been reviewed by Abraham and Dye? in 1949. They are set forth below. 1. Rapid Rate.-KinglO believes that rates up to 170 to 180 are an infallible sign of fetal distress; Richardson l5 feels that such increase in rate may be the earliest evidence of abruptio placentae. X. Slow Rate.-This is given more grave significa.nce than rapid rate, especialI,y when persistent, and tnay indicate true knot in the cord, coil around the neck with tension, or a prolapse of the cord. 3. Fluctuating Rate.-From slow to fast or vice versa. The importance of this finding is stressed in the foreign literature especially. It is believed to be associated with marked vagal stimulation and accompanied by efforts to breathe. 4. Irregdar Rate.-This is not significant during a contraction according to King but serious when present between contractions. Recently, however, articles have appeared in the foreign literature which seriously question the validity of these observations. One article*O which a,ppeared in the Zentralblatt fur Gyntikologie (Leipzig) by Thiele and Braun of the [GiessenUniversity Woman’s Clinic offers statistics which show that the fetal heart tones are a very vague and inaccurate means of diagnosing fetal distress and have practically no value in establishing a prognosis for the fetus, The authors show that in a series of 89 cases, I-wo-thirds of the newborn who had shown fetal distress of various nature cried immediately at birth and presented no sign of embarrassment. The conclusions drawn by these German authors from their statistics are as follows : 1. The common belief t,hat fetal heart tone disturbances have more significance during the second stage than durin g the first stage is not substantiated statistically. 2. Slow heart tones during the second stage are not a more serious sign than other types of rate anomalies. 3. One is not justified in attemptin g to make a prognosis about the fetus from the behavior of the fetal heart tones. 4. There is no correlation between the duration of the fetal distress and the amount of asphyxia shown by the infants at birth, which casts some doubt on the advisability of hurried and sometimes traumatic intervention to deliver the infant on the basis of fetal heart tone findings. 5. Premature infants do not appear to be more prone to fetal heart tone disturba,nces than mature fetuses. 6. Fetal heart tone disturbances are just as frequent in cephalic as in breech presentations.

In another paper I3 from the Spanishspeakin, U. countries, Mercado states that he “no longer believes what the authors state about fetal heart tones.” XIe relates some of his cases where infants who had been given up for dead on the basis of absent fetal heart tones, made a noisy entry into the world, causing some commotion among their parents and relatives who had resigned themselves to a stillbirth. Many eases have been reported of infants being born in excellent condition after many hours of fetal heart disturbances. In some of these cases a section which had been thought indicated in the interest of the fetus was not done for various reasons. As the above-ment,ioned German authors conclude in their study, “a revision of the ideas which have been handed down to us on the significance of the fetal heart tones and their interpretation in case management appears in order at this time.” In another recent study,l Abolins of the Pro Patria lying-in hospital in Stockholm reviewed 10,000 deliveries during the years 1940 to 1950. There were 115 cases of slow fetal heart tones, 22 cases of rapid fetal heart tones, and 36 cases of irregular heart tones. There were 23 cases of deep asphyxia or stillbirth in which there had been no change in the fetal heart rhythm. The statistics are quite similar to those from the Giessen Clinic previously mentioned. In Abolins’ conclusion, he wishes to introduce a new class of fetal heart tones showing qualitative changes which are deemed more significant prognostically than the classification of rhythm disturbances. The fetal heart tones fall into this new class when they change from a strong to a weak “‘monotone-embryonal” type of beat. It is hoped that current? and future observations of fetal heart physiology as gleaned from antepartum and intrapartum fetal cardiography will shed valuable light on this unexplored phase of fetal physiology. The incidence of fetal distress varies considerably; most statistical surveys are available only from the foreign clinics. The Giessen Clinic had a.n incidence of 5.9 per cent; Zurich, 6.5 per cent; Koenigsberg, 13.6 per cent; Wuertzburg, 22.8 per cent ; Stockholm, 3 per cent. The importance of obtaining an infant in a healthy, robust condition makes the approach to this subject a difficult one. Unfortunately our coding system does not permit reviewing those cases in which a cesarean section was abandoned for some reason and the baby born in good condition. All cases that presented the above-mentioned criteria of distress were not so labeled because some of our staff do not place such importance on them. In reviewing the stillbirths and neonatal deaths, if any had shown distress and were not coded, they were included in our series. Actually, the only criterion that we are left with as valid evidence of fet.ai distress is the immediate postnatal condition of the baby. This in itself may be misleading because we have no way of accurately assessing the baby’s condition if not,hing has been done in the presence of fetal distress, i.e., if there has been no hasty accouchement for&. On this premise, we have graded the amount of resuscitation each baby The required in the cases diagnosed as having fetal distress prior to delivery. amount of resuscitation is classified as follows: 0, none needed; I+, oxygen and mild physical stimulation ; 2+, oxygen with artificial respiration and occasionally tracheal catheter; 3+, oxygen and warm tube bath imnlersion; 3+,

Volunlc 65 Number

FETAL DISTRESS

j

1009

oxygen plus drugs for respiratory and/or cardiac stimulation. The changes in fet,al heart rate and rhythm were classified exactly as previously stated, namely : rapid (over 160 per minute) ; slow (under 100 per minute) ; fluctuating (from rapid to slow and slow to rapid) ; irregular (no specific rate). This has been enlarged in our series to include the combinations of irregular rhythm with the rapid, fluctuating, and slow rate. All these classifications deal with the predominant change or variations observed. The appearance of meconium in all but sacral presentations was also tabulated. Increased fetal activity as a crit.erion for fetal distress was not encountered in the charts reviewed. Our series of feta1 distress embraces 173 cases diagnosed during the years 1950-1951. During this period there were 8,785 deliveries, giving an incidence of 1.97 per cent. Table I shows these cases tabulated as to division between primiparous and multiparous patients, amount of resuscitation needed, and the fetal outcome. The code letters refer to case-history summaries which are to be found at the end of the paper. It will be noted that 7 of the 10 infants who died postnatally required more thaa minimal supportive help in maintaining vital functions. However, it is worth while noting that these same 7 are in a group The other 16 survived. The total of 23 requiring 2+, 3+, and 4-t resuscitation.’ fetal loss in the series is 14, or 8 per cent. TABLE None

I.

TOTAL (

P 43

EG 18

LMultiparas 101

65 108

173

Letters

refer

to case

OF CASES 0~ FETAL

RESUSCITATION 1+ 1 2+

Primiparas 72

Total

NUMBER

NEEDED / 3+

It

;

20

6

?

38

9

1

DISTRESS

4t

1 ST;T;-

R 3 HLMN 6

(

EGPR 4 FHKLMN 6 10

BCD 3 A 1 4

9

N;;;;;;J,

summaries.

Table II similarly set up, lists those infants showing only fetal heart disturbances. I’t is thus shown that the same 7 infants mentioned above remain in this group. They are now included in a group of 14 requiring 2+, 3+ and 4-t resuscitation. TABLE

II.

NUMBER

OF CASES OF FETAL~DISTRESS ALOXE

None Primiparas

53

Multiparas

77

Total 130 Letters

TABLE

III.

Primioaras Multiparas Total 17

refer

7 10

RESUSCITATION li/ 2+

E

NEEDED ( .?+

3:

11

Ji

i

51

15

86

26

4 4

2 4

to case

NU~~BER

/

I~ASED ON FETAL

1

4+

5 6

TONE FINDINGS

STILL1 ;O:

NEONATAL

‘R 2 HLMN 4 6

DEATHS

EPR 3 FHKLMN 6 9

3 A 1

4

summaries.

OF CASES OF FETAL DISTRESS DIAGNOSED ALONE (CEPHALIC PRESENTATIONS)

None 1

HEART

1

RESUSCITATION It 1 2t 4 2

2 6

0 2

NEEDED 1 3+

0 1 1

1

4+

cl 2 2

FBOM

EXCESSIVE

STILLBORN

0 0 0

MECONIUM

WXONATAL DEATHS

0 0 0

Table III depicts fetal distress based on the passage of meconium En cephalic presentations. The group is small but it would appear that this as a, solitary criterion of distress is not borne out by the fet,al outcome. Table IV shows the cases of feta,l distress in which fetal heart disturbance plus the presence of meeonium was used as a criterion. Here again the group is small with only one fetal loss. This infant required no resuscitation to spea,k of, Therefore, this combination of factors seemsto have no significance for prognosticating fetal outcome. TABLE

IV.

NUMBEE

OF CASES

OF FETAL HEART

DISTRESS UIAGKOSED Tom CHANGES

FROM

MECOKIL'IJ

PLUS

FETAL -

I

RESUSCITATIOX

! None Primiparas Multiparas Total 26 Letters

12 14

1

l+ G 3

7 9 16

refer

to

case

j

NEEDED

2+

/

3+

I

NEONATAL DEATHS

STILLBORP;

4+

G 1

0

0

3

2

0

i

0

:!

6

3

0

1

0

1

summaries.

Table V shows the relationship between the type of fetal heart disturbance present with the resuscitation required. It will be noted that the heart rates slow, slow and irregular, and irregular comprise 79 per cent of all the types of fetal heart disturbance. The fetal loss in this group is 8.8 per cent. If computed for the individual rates, we see that the percentage feta,l loss is 10 per cent, 0 per cent, 8.2 per cent, 0 per cent, 25 per cent, 0 per cent, and 20 per cent, respectively. TABLE

V.

I/ NO. I

IRapid Rapid

Row

OF

TYPE

Blow and Fluctuating Fluctuating irregular Irregular Total

NONE

1

8 4 44 18

/

1

8

16 10%

5 32

4

‘75 156

I+

1: 5 3 3.

25 8 9

and

DISTURBAKCE I

6 73

irregular

TOXE

RESUSCITATION

CASES

irregular

HEART

I

10 and

OF FETAL

I

NEEDED 2+

/

3+

0 1 3 0 i

/

4+

0

0 7

STILLBORN

-NkO-_ XATAL DEATHS

ii 0 0 0

1 0 x

0 0 :

1

0 0

0 0

0 4

2 7

D

3

4

10

s 0 2 0

The preceding five tables include a.11cases of fetal distress. Table VI sets forth just the easesof fet.al distress in which no clinically demonstrable cause was present. Our corrected incidence of fet,al distress therefore is 1.56 per cent (137 cases). It is noted that there were 2 stillbirths and 4 neonatal deaths. Three of the latter required 4-t resuscitation. The fetal loss in this TABLE

VI.

CAKES

OF FETAL

DISTRESS AND

EYCLUIXNG PROLAPSED

ilBKUPTI0 CORD

PLACENTBE,

PLACENTA

PREV~,

--

Primiparas

61

3s

RESUSCITATION 1+ / 2+ G 15 3

Nultiparas Total

76

50

16

5

31

8

NONE

L.

Letters

refer

137 to ease

88 summaries.

I

SEEDED j 3t

/ j

4+

STILLBORN

2

B 3 HM

C 1 A

0 2

4 6

1 2

/ aZer D1EATHS GR 2

H&I 2 4

--

FETAL

1011

I~ISTRI~:SS

group was 6, or 4.3 per cent. Our uncorrected fetal mortality for the 8,785 deliveries for this period (1950-1951) was 2.43 per cent. Table VII compares the cephalic presentation fetal distress cases to the breech cases. It will be seen here as well as in Table I that there were 7 fetal deaths among the primiparas and 7 among th.e multiparas. However, although these fetal deaths are almost evenly distributed among primiparas and multiparas .within each category of cephalic and breech cases, the incidence of fetal loss is more than six times greater in the latter. The fetal death rates, respeetively, are 5.7 per cent and 35.7 per cent. Six of the deaths in these two groups occurred with the finding of slow fetal heart tones. Five deaths were associated with irregular rates. Fetal distress was diagnosed twice as often in the second stage of labor in tile cephalic presentations and was about equally distributed between the first There were only a few cases noted and second stages in breech presentations. befor’e labor. Significant resuscitation for cephalic presentation was required in 21 cases, The ratio is almost twice as high for and in 3 cases for breech presentation. the cephalic cases which is paradoxical considering the higher breech fetal death rate. It will be noted too that 3 of the 4 stillbirths for the entire series were in the cephalic group. Theoretically, t,herefore, we should expect more neonatal deaths in the cephalic group if we are to use the degree of asphyxia requking resuscitation as an index of the degree of fetal distress thought to TABLE

VII.

COMPARISON

OF FETAL

DISTRESS

IP; CEPHALIC

AND

; pR;lyiLEro;;

Bigns

of

Fetal

Dis-

Rapid Rapid

and

irregular

tress.--

slow Slow and Fluctuating Fluctuating irregular

Meconium changes

anal FIIT

1 pR;~:,yl~Fi/~T~*,

n

i

0

AM 39

58

14

19

1 E 2

2 2

7 6

0 1

0 0

HK 8 10

IS 17

ii

L 3 0

3 0

i 12

14

5%

0

0

0

p” 5 4 BD 10

Irregular Meconium

PRESENTATIONS

5 3

2 1 R 19

irregular and

BREECH

;

1 0 FN 4

1 1

1

3

5

-

0 1

When Fetal Distress Occurred.-

Before labor First stage Second stage

2 24 41

5 26 67

7 50 108"

1 2 5

2 5

TYPO I)elivery.-

Cesarean Vaginal

18 47

21 73

39 120

1 7

G s

Resuscitation Needed.-

None

35

(j

100

4

8

l+ 2+ 3+ 4+

17 3 2 4

36 9

1 0 1 2

2 0 1 2

3

-- 4

section delivery

BD Fetal O&come.--

Stillborn

Neonatal death *#Six cases with distress present betters refer to case summaries.

G:R

2

0

in first

9 d

19

6 2 4 A 1 IIKM 3 and second

4 s

6 stages.

1

7

MC TABLE

VIII.

CESAREAN

CALL

SECTIONS OTHER

Signs of Fetal DisWess.-

TOTAL

Rapid Rapid and irregular Slow Slow and irregular

FULSHER PERFORMED

INDICATION

FOR FETAL

PLUS

FETAL

DISTRESS

DISTRESS

12 t

4 0 1

3 0 0

1 0 0

4 E 3

0

0

0

0

I

0

P 1 0

0 0

0 t!

0 1

1 0

2 0 0

KL 2 1 0

2 0 0

0 0 0

0 0 0

None

P a

1

2

I

1

1;

E 5

3

1

0

0

2+ 3+

0 3

0 0

I 3

i

4+

0

,” L 2

0

0

0

EP 2

KL -0

0

0

0

0

0

-0

0

0

Fluctuating Fluctuating and irregular Irregular Meconium Meconium plus FHT changes Resuscitation Feeded.-

AXD

I(

Neon&d Deaths.Stillborn.Letters

refer

to

case

summaries.

be present during labor. However, t.he breech series is too small to permit this conclusion. Table VIII lists the 45 eesarean sections performed in this series of 173. AS is shown, 17 cases were performed solely for fetal distress with no demonstrable pathology to account for the fetal disturbance. It will be noted that only one infant succumbed in these 17 cases. That infant had multiple congenital anomalies which were incompatible with neonatal life. The other 4 neonatal deaths were associated with two conditions previously cited as jeopardizing the fetus’ vital physiologic processes, namely, abruptio placentae and placenta previa. There were no stillbirths in this group. As previously pointed out, the preponderance of cases (27 in this group of 45) presented slow, slow and irregular, and irregular fetal heart disturbances. If our premise of distress related to resuscitation required is valid, the question is raised as to the necessity of any of these 17 sections. Table IX shows all cases of abruptio placentae, placenta previa, and prola,psed cord during the two years under study. The figures point out those cases presenting distress and those which did not. The highest ratio was in

FETAL TABLE

IX.

ALL

CASES

OF ABRUPTIO

DISTRESS

PLACENTAE,

1013

PLACENTA

ABRUPT10

PLACENTA

164 CASES PRIMIP.IMuLTIP.I

~-

Fetal Fetal Sians

distress distress o;F

Fetal .

absent present Raaid FHT Rapid and irregular

_.T dS 7

0”

AND

PREVIA

45 CASES TOTAL

104 20 2 0

PREVIA

PBIMIP.~MuLTIP.I

TOTAL

137 27

13 0

29 3

i

i

Fi

42 i 0

PROLAPSED

PROLAPSED CORD 20 CASES PRIMIP.)MULTIP.I TOTAL

4 4

11

14

0

0

0

0

irregular

1” P

4

5

0

0

0

0

0

0

and

0’

0 1

1 1

0 0

El

i

0 0

0 0

0 0

KL 2

2

A

:,

BD 4 0 0

Fl 0

i

: 1

1 1 1

0 0 2

1 1 4

i

23 9

30 15

1 11

2 18

15 9 2 2 0

23 12 4

4

4

0”

:

:

ii 2 1 1 3

Irregular Meconium alone Meconium with FHT changes

0 1 1

1

When Fetal Distress OCcwred.-

Before labor First stage Second stage

1 1 5

2

Qipe of Delivery.-

Cesarean Vaginal

Resuscitotion Weeded

None

section delivery

1+

2+ 3+ 4+

; 1

i 0 0

ii

3 10 14

2 38

11 113

13 151

20 5 0 2 2

72 15 1

92 20 1

Neonatal Deaths Excluding Distress Cases.-

Mature Premature

0 5

Stillbirths Exchdifng Distress Cases.-

Mature Premature

1 3

True

:

3

Fluctuating Fluctuating irregular

ExclGl~ng Distress Cases.-

:

14 6

F; 2

Slow and

10

E!

Distress.Slow

CORD

:,

8 3

i

:

: 0

1;

3 16

0 1

0 4

0 1

i

4 9

5 12

0 0

0 2”

0 2

0 4

-

-

-

6 2

10 3

prolapse

7, 7 uccult prolapse *One was second twin. Letters refer to case summaries.

the cases of prolapsed cord (1:2) ; abruptio placentae wa,s next with a ratio of 1:5, and placenta previa with 1:14. This is in accord with the suddenness and/or severity with which the fetus is separated from the maternal lifeline. It should be noted here that the 4 cases of occult prolapse of the cord showed no distress, all delivered vaginally, and there were no deaths. Resuscitation for the distress cases is included in our other tables and we thought it interesting to compare the amount of resuscitation required for those infants not showing distress. We see that 2+, 3+ or 4+ resuscitation was required in 17 cases. These 17 are found in a total of 193 cases. Referring back to Table VI, there were 16 requiring similar resuscitation out of 137 cases. The respective ratios are 1:11.3 and 1:8.5. The over-all fetal loss in those cases not showing distress (193) was 52, or 26.8 per cent. The mortality in this same group showing distress (36) was

0

16 4

xc

1014

CALL

SND

FULSHER

8, or 22.2 per cent. It would certainly seem more reasonable to find the mortality higher instead of lower in the babies showing distress if the eriteria for fetal disturbance have any validity. Table X tabulates the 214 cases of fetal loss for the two-year period, 19502351.

Only 4 of the 90 stillborn babies shelved distress. This is reasonably significant. Seventy mothers entered the hospital with absent fetal heart tones; the other 20 cases were intrapartum deaths. Sixteen infants succumbing before delivery and not showing some evidence of distress is a high figure! if we hope that fetal heart auscultation will be of prognostic value. TABLE

X.

TOTAL

FETAL

Loss (1950-1951)

-.--

STILLBIRTHS 90 CASES DISTRESS PRESENT

&gws of Fetal D,istyess.-

Rapid Rapid

and

NEOWATAL

124 1

DISTRESS PRESENT

DEATHS CASES 1 1

DISTRESS ABSEPiT

irregular

Slow Slow

and

irregular

Fluctuating Fluctuating

and

irregular

Irregular Meconium Meconium changes

When

Distress

Before

and

E‘IIT

labor

Ooourred.First

stage

Second ‘I’ype

of

Delivery-~

Cesarean Vaginal

Eemscitntion

iVeedecl.-

stage section delivery

None

Premature Letters

refer

to case

sumnxwies.

There were 124 neonatal deaths in these two years, 10 inf’ants showkg distress. The remaining 114 fetal deaths in the postnstal peyiocl are tabulated as to resuscitation needed. Thus 35 required 2+, 3+, and 4+ resusci-

Ietal

Volume 65 Number 5

FETAL

1015

DISTRESS

tation. Instead of drawing conclusions from the infants requiring a considerable amount of resuscitation, it is more significant to note the large number requiring minimal stimulation who regardless of the la& of depression subsequently died. We have purposely contradicted our tenets here because we feel that a critical analysis of the distressed infants that died must be the deciding factor. CASE A.-(F-16239) This 2%year-old multipara was admitted in active labor at 40 weeks’ gestation. She was taken to the delivery room with cervix completely dilated. After a saddle block was given with no drop in blood pressure, t,he fetal heart tones were reported slow, between 58 and 100. The patient was given oxygen. A 7 pound, 2’&~ ounce, stillborn female infant was delivered immediately by manual rotation and low forceps ex: traction. Death was attributed to cord entanglement. Autopsy was performed and did not reveal any abnormalities. I:t is hard to conceive of doing more than was done in order to obtain a live baby. NO explicit descriptjon of the position of the cord is recorded, or the rapidity of descent of the head. CASE B.-(F-16865) This was a 25-year-old primipara admitted in early labor. The head was unengaged. She was given a knee-chest enema which was shortly followed by The fetal heart tones cea.sed to be heard when the spontaneous rupture of the membranes. cervix was almost fully dilated. A palpable cord was found. A seven pound, seven ounce, stillborn female infant was delivered by low forceps. This case might clearly have been avoided if a knee-chest enema had not been given and if the danger of a prolapsed cord with an unengaged head had been given more consideration. CASE C.-(F-12326) A 19.year-old primipara was admitted at 40 weeks’ gestation in established labor. The patient was Rh negative and had mild p-re-eelampsia. The infant was in breech presentation. Distress was diagnosed by slow fetal heart tones in the second stage. Breech decomposition (complicated by nuchal arm) and extraction were performed under nitrous oxide-ether-oxygen anesthesia.. The infant, a male weighing 8 pounds, 15 ounces, was stillborn. Death was attributed to compression of the cord. Autopsy revealed erythroblastosis fetalis and marked patent duetus arteriosus. This was clearly an unpreventable death from our fetal distress point of view. CASE D.-(F-33311) A 41-year-old primipara was admitted in rapid and tumultuous labor at 34 weeks’ gestation. The cervix was fully dilated in about 1% hours. The presenting vertex had not descended into the true pelvis during the process of dilatation and At this time, the membranes the pa.tient was prepared for sterile vaginal examination. The fetal heart tones became irregular, She was examined imruptured spontaneously. mediately and the right arm, vertex, and prolapsed cord were found to be presenting in the vagina. A stillborn male infant, whose birth weight was estimated between 3% and 5% Autopsy revealed the cause of death to be subarachpounds, was delivered immediately. noid hemorrhage. There was aspiration of amniotic fluid. This is the usual unfortunate outcome in a case of true prolapse of the cord. This death a few before

was felt to be avoidable minutes or more prior fetal distress had been

if controlled rupture of the membranes to their explosive rupture. However, diagnosed.

had been this would

performed have been

CASE E.-(F-32895) A 25.year-old primipara was admitted to the hospital at 33 meeks’ gestation. She was a juvenile diabetic, difficult to control. She was, however, progressing uneventfully in her pregnancy until the present admission when she had a sudden The heart tones were found to splash of bleeding followed by rupture of the membranes. be slow and irregular. Abruptio placentae was diagnosed and an emergency Cesarean seeHis weight was five pounds, 5 ounces. The baby required I+ resuscitation. tion was done. Autopsy was performed and rev’ealed: (1) alveolar dysThe infant died 9 hours later. plasia; (2) hemorrhage in the left leptomeninges. Anesthesia was spina!.

elinieal

This was a case of a premature a,bruptio placentae-a known

infant showing baby-killer.

signs

of distress

in the presence

of a

CASE F.-(F-19907) A 36-year-old multipara was admitted with a tumultuous clinicai abruptio placentae at 30 weeks. The fetal heart tones were slow. She delivered, spontaneously a living 1 pound, 14l/l2 ounce, immature male by breech, who lived 7.5 minutes. This was another irreversible circumstance leading to the infant's demise. CAKE G.-(F-19771) A 90.year-old primipara was admitted at 39 weeks’ gestation in established labor with a brow (anterior) presentation. Progress of labor was satisfactory until the cervix was about 3 cm. dilated at whieh time the fetal heart tones became rapid, going up to 168 or 170. About an hour later the cervix was completely dilated and ahe was taken to the delivery room. The head was flexed manually and the occiput rotated to a right occipitoanterior. Low forceps were applied for extraction of the head with general anesthesia. The infant, who weighed 7 pounds, 7$!! ounces, required 1-b resuscitation. The nurses’ notes show that immediately prior to delivery there was passage of considerabie thick, yellow meconium. The infant, at birth, presented a large liver and edematous face, and erythroblastosis was diagnosed. The hemoglobin was 40 per cent. A replacement transfusion was given. However, the baby’s condition deteriorated and he died about 24 hours later. Autopsy was performed and confirmed the diagnosis of erythroblastosis fetalis. This case was interesting because the mother was a primipara and gave no history of having had a transfusion of Rh-positive blood in the past. This case presented passage of meconium or possibly the typically yellow-gold amniotic fluid so often seen with an erythroblastotic infant was mistaken for meconium. At any rate the fetal heart rate did rise rapidly. It has been observed that fetal heart changes are occasionally encountered in pathologically diseased or maldeveloped infaats.G-1% 17 CAKE H.-(F-19008) A 41.year-old multipara was admitted in active labor at 40 weeks ’ gestation with a cephalic. presentation. The cervix was a finger tip dilated. The blood pressure was 144/100. There was It ankle edema and albumin 10 mg. per cent. The diagnosis of mild pre-eclampsia was made. On admission at 1:30 P.M. the fetal heart tones were distant and completely absent for one or two seconds at frequent interGals. The dila.. tation was then 1 cm. At 3:lO P.M. the cervix was 5 cm. dilated, station minus 2. The fetal heart tones were between 120 and 140, with occasional skipping of several beats. Oxygen was given at this point with no improvement. The patient was taken to delivery room and delivered under general anesthesia shortly thereafter. A male infant weighing 6 pounds, 10 ounces, was delivered and required 4+ resuseitation. He was born with three loops of cord around the neck and a tight knot. There were four attempts at respiration. The infant died 4 minutes later. Diagnosis shown by autopsy was aspiration pneumonitis and bilateral diffuse atelectasis. This infant probably could have been saved by eesarean section. However, how many times are the same findings present with the baby delivered in good condition? We are sure the answer is many. CASE K.-(F-18790) A 25-year-old multipara was admitted at 32 weeks’ gestation for bleeding due to placenta previa. After admission there was a sudden episode of severe bleeding (300 CC.) with a drop in blood pressure from 104/64 to 90/55. The fetal heart tones became irregular during this episode. Section was performed immediately under general anesthesia. The infant, a male weighing 4 pounds, 9 ounces, cried immediately. He died 7 hours later. Autopsy revealed the cause of death as “prematurity.” This is a case of fetal distress due to one of the known causes that alter fetal phgsiology. Despite this the baby required no resuscitation. Death followed, however. CASE L.-(F-12250) A 34-year-old multipara was admitted at 28 weeks’ gestation for The fetal heart tones were reported to be irregular. A bleeding due to placenta previa. The baby (a male, weighing 2 pounds, cesarean section was done under general anesthesia. 24/s ounces) required 4+ resuscitation. He died 2 hours after delivery. Autopsy was not performed. The suspected cause of death was prematurity.

\‘olume 6s Number

5

This the rigors

FETAL was a repetition of the situation of placenta previa and premature

1017

DISTRESS of an immature entrance into

infant who the world.

was unable

to survive

CASE M.-(F-7661) A Wyear-old multipara was admitted to the hospital in active labor at 32 to 33 weeks’ gestation with a cephalic presentation. Labor was precipitous. The fetal heart tones dropped to about 100 after a spinal anesthetic was administered. There was no drop in blood pressure. A male infant weighing 3 pounds, 12 ounces, was easily delivered with low forceps and required 4+ resuscitation. He lived 36 hours. Autopsy was performed and the diagnosis was atelectasis and prematurity. It is hard to conceive of handling this case differently or expecting a more favorable out. come. CASE N.-(F-644) A 26.year-old multipara was admitted at 42 weeks’ gestation in established labor with a breech presentation (double footling). The membranes ruptured The patient was at 6 cm. dilatation and the fetal heart tones became slow (84 per minute). The cerplaced on the delivery table immediately and the cord was found to be prolapsed. vix was manually dilated and a female infant extracted under general anesthesia. Four plus resuscitation was given. The infant died shortly thereafter. The birth weight was 6 pounds, 14 ounces. Autopsy was performed and revealed asphyxia as the cause of death. This infant might have been salvaged if the cord compression could have been relieved by holding the breech up long enough to prepare for a section. Possibly the manual dilatation of the cervix (advisability questioned) took too long. Prolapse and the resultant compression of the cord caused death in a very short space of time. CASE P.-(F-27390) A 30.year-old primipara was admitted at 37 weeks’ gestation following passage of blood. She also gave the history of a few irregular contractions. Fetal heart tones were found to be fluctuating between 60 and 160. Sterile vaginal examination was done and the diagnosis of abruptio placentae was made. Cesarean section was performed immediately under general anesthesia. The infant, a female weighing 4 pounds, 4 ounces, cried spontaneously at birth. She was placed in an incubator with continuous oxygen. Three days later slight icterus was noted and a systolic murmur was heard at the apex. Following this the baby’s condition deteriorated and she died 18 days following delivery. The clinical diagnosis was cardiovascular anomaly. Autopsy revealed: (1) engorgement of both lungs; (2) bronchial secretions positive for Streptococcus viridans. The cause of death was terminal bronchial pneumonia. This case represents more than an abruption as the cause of deat)h, although this probably caused the change in the fetal heart rate. So asphyxia was encountered at birth. This death can hardly be attributed to either the fetal distress or the abruption. CASE R.-(F-31491) A 35year-old primipara was sectioned under general anesthesia after 7 to 8 hours in labor at 2.5 cm. cervical dilatation because the fetal heart tones slowed down to 60 and became irregular with pains. A premature 4 pound, 11 ounce, female infant .was given 4+ resuscitation and was pronounced dead after taking a few breaths. The infant had multiple congenital anomalies-dwarfism, congenital absence of anus, clubfeet, congenital absence of vertebral bodies. Autopsy was not performed. This case was briefly reviewed in the comments concerning Table VIII. The comto diseased or malment concerning Case G pertains here, as well as for Case C, relative developed fetuses. In analyzing the 4 cases of stillborn infants who gave evidence of fetal distress, we feel that at the time of the occurrence of distress and the associated findings fetal disturbance was predictable in 2. The other 2 cases could not have been hand.led differently with the belated appearance of signs of fetal distress. One (Case C) would have had no other outcome regardless of management. Therefore, they should not be used to invalidate our conclusions. Of the 10 cases of fetal distress which ended in neonatal death, we feel that only Case H might have had a more salutary outcome if more importance had been placed on the fetal heart disturbance early in labor. However, a

word of caution. Must we section 137 patients to salvage one infant with a condition which many many times is not lethal to the baby? Snalysis of the 6 deaths in the 137 cases (Table VI) allows us to correct our mortality rate from 4.3 per cent (6 cases) to 1.46 per cent (2 cases, A and H). In the 137 eases, there were 2 deaths (Cases G and H) in which there were signs of disturbance in the first stage of labor and in which no recognizable reason for distress could be found. In the over-all series (173), distress OCcurred before labor and in the first stage in 64 cases. Subtracting those eases of abruptio placentae, placenta previa, and prolapsed cord in which distress was evidenced before labor and in the first stage (17), we are left with 47 cases. Seventeen of these patients were sectioned. Only one baby in this group died (Case R). This case is reviewed elsewhere. In the other 16, no such convincing cord entaglement as was present in Case H was discovered. There were no deaths in the remaining 30 cases of vaginal delivery. Summary 1. A survey is presented of 173 cases of fetal distress, encountered among 8,785 deliveries during the period 1950-1951, an incidence of 1.97 per cent. 2. Of these, 137 cases offered no clinical findings other than one or more signs commonly accepted as evidence of fetal distress, i.e., fetal heart changes, or meconium, or both. The corrected incidence is 1.56 per cent. 3. Analysis of these ca,ses is presented in the accompanying text and tables.

Conclusions 1. Excluding those conditions which are known to jeopardize the survival of the fetus and which can be diagnosed from the clinical findings, fetal distress is a nebulous condition. Our figures show how unpredictable the infant’s condition at birth will be. Infants that require major degrees of resuscitation often survive, and those requiring no support subsequently die. 2. This presentation is not a plea to discard fetal heart auscultation. That would be most foolhardy. Fetal disturbance is a very tangible condition, but only when it is preceded or accompanied by a recognizable clinical entit.y known to affect deleteriously the fetal organism. 3. Without the clinical picture of one of these entities, caution and deliberation are urged in the individual case management.12 We wish to thank the attending staff of Emanuel Hospital be reviewed; the house staff and nurses of Emanual Hospital formation on the charts without which this paper would have W., A. E. S., and H. CT. R. for translating foreign monographs.

for allowing xheir cases to for recording valuable inbeen impossible; and A. R.

References 1. Abolius, J. S.: Nod. Med. &?I: 881, 2. Abraham, L. A., and Dyer, I.: New 3. Adair, F. L., editor: Obstetrics and 194. 4. Beck, A. C.: Obstetrical Practice, pany, p. 304. 5. Beck, A. C.: Obstetrical Practice, pany, pp. 105, 854.

1951. Orleans 31. & S. J. 102: 245, 1949. Gynecology, Philadelphia, 1940, Lea

& E’ebiger,

ed. 2, Baltimore,

1939,

Williams

and

Wilkins

Com-

ed. 5, Baltimore,

1951,

Williams

and

Wilkins

Corn.

pg.

‘Volume

FETAL

65

Number 5

DISTRESS

6. Davis,

W. F. Prior

7.

ed. 8, Phila-

8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

C. H., editor: Gynecology and Obstetrics, Hagerstown, &Id., 1951, Company, vol. 2, pp. 2-3, 5. DeLee, J. B., and Greenhill, J. P.: Principles and Practice of Obstetrics, delphia, 1944, W. B. Saunders Company, p. 257. Hunt, A. B.: M. Clin. North America 23: 1061, 1939. Jordan, F. C., and Randolph, H.: Am. Heart J. 33: 109,1947. King, E. L.: An{. J. OBST. & GYNEC. 39: 529, 1940. Lund, C. J.: Am. J. Obst. & Gynec. 40: 946,194O. McCorriston, C. C.: Hawaii M. J. 7: 474, 1948. Mercado. L. Laverde: Rev. obst. v einec.. Caracas 10: 261. 1950. Plant, R: K., and Steven, R. A.: ig Heait J. 30: 615, 1945. Richardson, G. C.: AM. J. OBST. & GYNEC. 32: 429,1936. Riley, I. D.: Arch. Dis. Childhood 24: 309, 1949. Sankey, A. 0.: Brit. M. J. 2: 676, 1948. Stadler, H. E., Reid, C. A., and Friedman, H. P.: J. Pediat. 36: 370, 1950. Stadler, H. E.: J. Pediat. 33: 624, 1948. Theile, W. H., and Braun, H.: Zentralbl. f. GynHk. 73: 194, 1951. 812 S. W. WASHINGTON

STREET