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Breech delivery
BREECH ELMER M. HANSEN,
DELIVERY* M.D., LINCOLN, NEB.
T
HE subject of breech presentation has been discussed in the literature frequently during the past decade. Articles have appeared upholding both the conservative and active management of this presentation, but to date there has been no significant change in the fetal mortality. One is impressed with the fact that the results depend to a great extent upon the ability of the operators to perfect their particular method of treatment. Most of the communications on this subject have come from large obstetric centers representing, to a great extent, clinic material. The material used as a basis for the presentation of this communication represents the cases of breech deliveries occurring in the associated practice of Dr. Harold S. Morgan and myself over a period of twelve years. It is not a large series of cases, but it represents, we believe, an experience which is comparable to that of the average obstetrician in private practice, and for this reason, we are presenting this series of cases. During the past twelve years, 1,882 patients were delivered. One hundred and twenty-six babies were presented by the breech, the incidence being 6.7 per cent. This is higher than that usually reported. The incidence of breech presentation during the past twelve years at the Lincoln General Hospital in which 90 per cent of our patients were delivered was 4.2 per cent. Our increased incidence is explained by the fact that a large number of complicated deliveries are referred to us by general practitioners doing obstetrics. The parents of these babies are all white, coming from all social levels, chiefly middle-class American, the foreign element being negligible. The 126 babies were delivered of 120 mothers; four mothers had twin pregnancies in which both babies were presented as a breech, and 2 mothers had breech presentations in two succeeding pregnancies. There were 73 primiparas and 53 multiparas. SOGRCE
OF CASES
Hospital
Deliveries
Breech
Lincoln General Bryan Memorial St. Elizabeth Total
1,719 118 45 1,882
114 9 3 126
Incidence
No. of mothers 73 53
120
6.7% Primiparas Multiparas
*Presented before the Twelfth Annual stetricians and Gynecologists, Indianapolis,
Meeting of the Central Ind., October 12, 1940.
575
Association
of Ob-
576
AMERICAN
JOURNAL
OF DURATIOX
OBSTETRICS
AXD
GYNECOLOGY
OF LABOR
1st stage 2nd stage
(Variation) Primiparas 2W to 57 hours 5 min. to 7% hours
Multiparas 1 to 31 hours 5 min. to 2 hours
1st stage 2nd stage
(Average) 12.6 hours 1.2 hours
6.3 hours 35.1 min.
13 primiparas 1 multipara
had 2nd stage over 100 minutes. had 2nd stage over 100 minutes. FETAL
ATTITUDE
Ninety-six of the breech presentations were frank breech, 25 were single footlings, and 13 were double footlings. Sixteen of the single and 4 of the double footlings occurred in premature deliveries. Duration of Labor in Primipara.-The f&t stage averaged twelve and six-tenths hours, varying from two and one-half hours to fifty-seven hours. The second stage averaged seventy-one minutes, varying from five minutes to seven hours and seventeen minutes. There were 13 patients who had a second stage of over two hours’ duration. Duration of Labor in. M&tipara.-The first stage averaged six and three-tenths hours, varying from one hour to thirty-one hours. The second stage averaged thirtyfive minutes, varying from five minutes to two hours. Only one multipara had a second stage over one hour and forty minutes. TYPE
Manual Aid 109 5 decomposed (1 forcep) 7 forceps
OF DELIVERY
Extraction 13 2 forceps
Xeotion 4
The type of delivery is divided into three groups: manual aid, the procedure to be described, extraction, and cesarean section. One hundred nine patients were delivered with manual aid. In 5 of these, the breech was decomposed and then the patient delivered with manual aid. Forceps were applied to the aftercoming head in 7 patients. Extraction was the treatment in 13 patients. In 3 instances the patient failed to make progress in the second stage and extraction was the procedure then indicated. In 2 of these patients, forceps were applied to the aftercoming head. Two patients had late toxemia of pregnancy, and it was deemed best to termiTwo patients, both of whom were nate the delivery when the cervix was dilated. multiparas with placenta previa, one with a dead baby, were delivered through the placenta. Six premature twin babies were footling presentations, 2 being the first baby and 4 being the second baby of twins. Two patients had section for plaCesarean section was done on 4 patients. centa previa, and the breech presentation was incidental. Two patients, both elderly primiparas, were delivered by elective section because they had large babies and it was thought that delivery from below was questionable. Prolapse of the cord did not occur in the entire series. FETAL
MORTALITY
126 deliveries 15 babies died 5 multiparas 10 primiparas
Rate R,ate Rate
11.9% 9.4% 13.7%
HANSEN
Period of Gestation Term Term 34 weeks 27 weeks 27 weeks 26 weeks 25 weeks 24 weeks 28 weeks 28 weeks 33 weeks 28 28 27 27
weeks weeks weeks weeks
:
BREECH
577
DELIVERY
Abnor?nality None Spina bifida, hydrocephalus Anencephalia Premature Premature Premature Premature (toxemia) Premature (eecond of twins) Premature Twins Premature Twins Premature (No fetal heart tones) Placenta previa Premature -Twins Premature Twins Premature Twins Premature Twins
8 7 5 1 2 2 2 1 1 1 4
Weight lb. 4 oz. lb. 14 oz. lb. 4 oz. lb. 14 oz. lb. 10 oz. lb. 12 oz. lb. 5 oz. lb. 7 oz. lb. 9 oz. lb. 10 oz. lb. 15 oz.
2 1 1 1
lb. lb. 10 oz. lb. 7 oz. lb. 8 oz.
Summary of Fetal Mortality Term : 1 Intracranial hemorrhage 2 Monsters Premature : 1 33-week placenta previa. Stillborn. No fetal heart tones on admission. 11 period of gestation, 24 to 28 weeks. Weight varying from 1 lb. 7 oz. to 2 lb. I2 oz. Corrected mortality 0.8 per cent Fifteen babies were stillborn or died neonatally. This gives a gross mortality of 11.9 per cent. Five deaths occurred in multiparas (9.4 per cent), and IO in primiparas (13.7 per cent). Eleven babies were definitely premature, the period of gestation ranging from twenty-four to twenty-eight weeks, and the weights varying from 1 pound 7 ounces to 2 pounds 12 ounces. Several were one or both of twins. One baby was of thirty-three weeks’ gestation, and the mother, a multipara, had central placenta previa and no fetal heart tones on admission. Three patients were at term. One normal baby, weighing 8 pounds, 4 ounces, was delivered by manual aid after a second stage of five hours, The baby lived eight hours and fifteen minutes, and died suddenly. Post-mortem examination revealed intracranial hemorrhage ana a large cephalohematoma. One baby was hydrocephalic with a large spina bifida; it did not cry and lived only a few minutes. The third full-term baby was an anencephahc monster. Excluding the premature and abnormal babies, there remains only one fetal death or a corrected incidence of 0.8 per cent. FETAL MORBIDITY One baby who presented a frank breech was delivered by extraction after spontaneous delivery of the umbilicus because both arms were extended. The baby required resuscitation. Inspection reveaIed marked asymmetry of the face, with a depression of the vault into which the forearms fitted. This baby had The right arm recovered in seven days and bilateral Erb’s palsy when delivered. the left arm in three weeks. The left clavicle was fractured during delivery. One Three babies developed cephalohematomas, other baby had a fractured clavicle. and several babies developed hematomas of the sternocleidomastoid muscle. They all developed after the patient left the hospital. No known serious Sequelae followed. TWINS
In our series of breech presentation, 8 babies Twin incidence was interesting. were one of a set of twins; one of these died of prematurity. Eight babies represented both babies in 4 sets of twins. Six of these babies died. In the twelve years
578
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
Sixteen babies we have delivered 17 sets of twins, or 34 babies. Eighteen presentations; seven of the 16 died, all of prematurity. cephalic; two of these died of prematurity. MATERNAL
MORTALITY None
MATERNAL
MORBIDITY
Twelve Cases
were breech babies were
Incidence
CASES
CAIJSE
: 1 1 I 1 1
Phlebitis Pyelitis Otitis media Cystitis Parametritis Unknown Unknown
1 1 1 1 I
Unknown Unknown Unknown Unknown Unknown
METHOD OF DELIVERY Section Manual aid Manual aid Section Extraction Manual aid Bag induction Manual aid Section Manual aid Manual aid Section Manual aid
MATERNAL COMPLICATIONS Previous
cystitis
Placenta
previa
Toxemia Placenta
previa
DURATION 6 4 -I 2 5 2 2 3 2 2 3
weeks days days days days days days
days days days days 2 davs
9.5S%
SEVERITY Severe Mild Mild Mild Mild Mild Mild Mild Mild Mild Mild Mild
There was no maternal mortality. There were 12 mothers who had a temperature of 100” F. on two succeeding days, excluding the first twenty-four hours post partum. There were 122 confinements, which gives an incidence of 9.8 per cent. Causes of morbidity could not be determined in 7 patients. These were all mild and lasted only two to three days. In 5 patients the cause was known. One patient had phlebitis of the left lower extremity. She had had an elective section. She was in the hospital six weeks and recovered. One patient, with a previous history of pyelitis had a flare-up lasting four days. One patient had acute otitis media lasting four days. One patient with cystitis of two days’ duration was delivered by section because of placenta previa, and one patient with a parametritis (tender uterus) had mild symptoms for five days. All 4 patients delivered by section were morbid, but the morbidities were mild, with the exception of the case of phlebitis. DISCUSSION
The diagnosis of breech presentation was made prenatally in practieally every patient coming for prenatal care. Routinely, we carefully check our measurements and estimate the size of the baby. If there is a question of fetopelvic relationship, we use the x-ray as an aid to our decision. E,xternal version was not attempted in any patient. Our method of treatment is conservative. By conservative treatment, we mean giving supportive treatment to the mother with no interference unless labor is obstructed, progress ceases, or complieations arise endangering the life of mother, baby, or both. We were trained in the watchful expectancy method, and from experience we are convinced that meddlesome interference is a definite factor in the difficulties encountered in obstetrics. I am sure that if we all agree that conservatism is good procedure in cephalic presentntions it should be rational in the breech. From personal observation and experience, we have formulated t,he following points to guide us in breech delivery : 1. Dilatation of the cervix does not become complete in many cases until the buttocks are presenting deeply at the introitus.
HANSEN
:
BREECH
DELIVERY
579
2. Attempted delivery before complete dilatation is almost certain to result in extension of arms and head with difficulty in delivery. 3. It is natural for the force to be applied from above. Application of force from below by traction is not the normal force. Extension of the arms, nuchal arms, and extended head are the result of force applied from below rather than from above. 4. Manipulation from below, especially if the patient is not deeply anesthetized, will reflexly stimulate tetanic contraction of the cervix or lower uterine segment ; this contraction imprisons the shoulders and cephalic pole in the uterus and delays delivery ; it also necessitates increased force which traumatizes both mother a.nd baby. 5. Gentleness in all maneuvers is of the greatest importance. CONCLUSION
We have reported a series of 126 breech deliveries occurring during twelve years of private practice, with a corrected fetal mortality of 0.8 per cent. Conservative treatment in our hands has produced satisfactory results. Teamwork is an important feature of our treatment, and we believe it has had a definite influence on our results. Prematurity, especially prematurity in twin pregnancy, accounted Efforts toward preventing prefor 80 per cent of our fetal deaths. mature labor in twin pregnancies should lower the gross fetal mortality of breech presentation. This communication deals with private practice only. The reporting of many similar analyses and comparing them with reports from the clinic groups, we believe, would be worth while. 128 NORTH
13~~1 STREET DISCUSSION
DR. DAVID L. SMITH, Indianapolis, Ind.-The staff of the University Hospital at Indianapolis is essentially a closed one, made up of members of the teaching staff. There are two and one-half ward patients to one private patient. There Of the 31 stillbirths 4 were were 190 breech presentations in 1,264 deliveries. monsters, 6 were macerated fetuses and 6 were premature. There were 11 deaths attributable to the breech presentation, so the corrected mortality was 5.78 per cent, which is a great deal higher than Dr. Hansen’s. I have no way of accounting for that difference, except possibly on the basis that our service is somewhat of an emergency service, being a state hospital which admits patients from all over this portion of the state who have received no prenatal care and who sometimes are desperately ill. Review of the charts sometimes leads to conclusions as to what not to do. Two of the deaths occurred in labors which had been induced, both of which were definitely past term by history. In both the babies weighed a little over 5 pounds. One of the cardinal principles in breech management is to avoid induction of labor. We believe in external version as long as it is done with gentleness and without anesthesia. We personally have been successful in external version in about 60 per cent of the trials. Cesarean section should probably play a greater part in the management of breech delivery. We use intermittent nitrous oxide and oxygen anesthesia, and then change to We are using forceps on the afterdrop ether at the time the umbilicus is born. coming head more and more because we believe it is less traumatic to the baby than any other method of delivery.
580
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
DR. IRVING F. STEIN, Chicago, 111.-A complete breech is one with the fetus in the attitude of complete flexion, and the incomplete breech is one of deflexion I do not believe that this has been emphasized in obstetric literature. attitude. In incomplete breech one frequently observes the fetus in a military attitude with the head erect or sometimes turned to the side or even tilted back? like an inverse brow presentation. A greater amount of mobility of the fetus is evident with breech than with cephalic presentation. Even with complete breech you ma! occasionally find a displaced arm and the head a little deflexed; this can be discovered only by x-ray examination. The practical application of this procedure enables you to be forewarned and prepare for manual aid or extraction. The points I wish to emphasize are first, that incomplete breech is an example of a deflexion attitude; second, in cases of breech particularly, you can obtain much practical information by taking roentgenograms before delivery which would otherwise be missed by ordinary methods of examination. DR. RUDOLPH W. HOLMES, University, Va.-Some 75 years ago Carl Draun reported in his textbook on 67 cases of face presentation which were seen in his clinic. He stated as a result of that great experience that a face presentation iu a primiparous labor was prima facie evidence of a pelvic deformity. In our more mature knowledge of pelvic abnormalities we now know that pure pelvic asymmetry is as potent a cause as is definite contraction. We may further state that the flat pelvis and the obliquely contracted types are more prone to produce malpositions and presentations than the symmetrical generally contracted pelvis. Not only is a face presentation produced by these fac.tors, but we may broaden that statement to the rule that all deviations of presentation are sequential to aberrant contours of the pelvic brim. In my own experience a breech delivery with a normal pelvis is as physiologic and as safe as the normal vertex positions. On the other hand, when there is any disproportion, the breech delivery is fraught with the greatest difficulty and danger. I still believe that it is the exceptional case of breech which demands a cesarean section. Contributing factors which are of etiologic importance may more often indicate cesarean operation than similar conditions in a vertex position. DR. R. 8. SIDDALL, Detroit, Mieh-I want to make a few remarks on the basis of a recent monograph which Dr. Seeley and I have published. We found in going over a considerable number of papers in the literature that there were several series of 100 or 150 cases in which the results were comparable with those of Dr. Hansen. We did not find, however, any series of 200 or over which did not have a very considerable increase of fetal, not maternal, deaths associated with breech. In our series from the Herman Kiefer and Harper Hospitals in Detroit it was noticeable, however, that we would often have 125 or 150 cases in a series with Although one may have a relatively small series with only one or two deaths. good results, one eventually encounters difficulty. External version is associated with very little danger. It is very reasonable to employ an easy and safe procedure to convert a dangerous presentation associated wrth from 5 to 20 per cent mortality into one with only 1 or 2 per cent mortality. We found that there were three things which contributed very largely to excessive fetal mortality in breech: (1) The mortality increases with babies weighing from 8 pounds to 9 pounds and over until it reaches 20 to 25 per cent. (2) fetal mortality, as someone expressed Elderly primiparas have a “lamentable” it in the literature. It may be around 25 to 30 per cent. (3) Contracted pelvis also has a high mortality, even in the minor grades of pelvic contraction. DR. A. F. LASH, Chicago, Ill.-As a result of an extensive experience at the Cook County Hospital in Chicago, where we deliver over 5,000 babies a year, there are certain points which are crystallized in our minds regarding breech delivery.
HANSEN
:
BREECH
DELIVERY
581
First, breech presentations can deliver spontaneously as well as cephalic. This point requires special emphasis because when we get into discussions with the doctors in the surrounding rural communities, they say, “How can we deliver these babies without getting a 90 per cent fetal mortality?” Too often the conception is that as soon as the presenting part is visible, immediate extraction is started and it is associated with complications. Second, with regards to analgesia, we feel that we want the cooperation of the patient throughout labor. We never use the barbiturates during the first stage. If the patient is in strong labor and requires some rest, we feel morphine and scopolamine fulfill that requirement. Pudendal block and local infiltration of the perineum and pelvic floor will allow complete cooperation of the patient which helps in the delivery of the baby. We do not feel that eight minutes between the appearance of the cord and the delivery of the head is so important. We have found that as much as fifteen minutes can be taken in the delivery of the head as long as air reaches the mouth by retracting the perineum. It is at this point that the greatest harm is done to the baby by undue traction. When we feel that the head seems to meet with a good bit of obstruction, instead of continuing the extraction we usually release our pull on the baby’s head; we push the baby up, which allows increased flexion of the head, bringing the head down in the transverse diameter, thereby facilitating delivery of the head. With this in mind, I think we avoid damage to the baby and lower our fetal mortality. DR. FREDERICK H. FALLS, Chicago, Ill.-Breech is more common in the areuate type of bicornate uterus, which is seen relatively frequently. When breech is present in such a uterus, it is very difficult or impossible to do external version, and I think it is often dangerous even to try. We feel that not infrequently a combination of arcuate type of bicornate uterus and breech is a relaSince adopting this policy, we have tively strong indication for cesarean section. had very much better results in this type of case. In placenta previa we frequently have an associated breech presentation, because under this circumstance the breech will fit the lower uterine segment better than the head. The combination of breech and placenta previa is also a relative indication for cesarean section. The importance of the fact that the premature baby frequently presents by the breech cannot be overemphasized. The more premature the baby is, the more reason there is for thoroughly dilating the birth canal. In these cases we thoroughly dilate the birth canal and do an episiotomy to avoid cerebral damage to the premature baby during delivery. DR. J. C. LITZENBERG, Minneapolis, Minn.-If you will change the term external version” you will avoid a lot of ‘ ‘ external version ’ ’ to “attempted arguments. I have always taught that external version should be attempted but I have never persisted in it if it offers any difficulties whatsoever. There are certain conditions in which it should never be attempted. It is a shame in a case where external version could be done with the greatest of ease not to do it, but it is also a shame, and a greater one, to persist in its use when one has difficulty. DR. E. M. HANSEN (closing).-Dr. Morgan and myself have always tried to be conservative in our estimation of our ability to do a good job delivering a breech, and I am very frank with you when I say there has been a question in my mind As time has gone on each as to just how much luck we have had in our series. breech presentation has been a very definite challenge to us, and I think in that respect this challenge has had a very definite influence on our work, because we have tried every time to get a live baby. With regard to external version, not once was it attempted. The reason for this is that in my period of training I saw many external versions attempted and but very few of them successful. On two occasions babies were lost, one with pre-
AMERICAN
582
JOURNAL
OF OBSTETRICS AND GYNECOLOGY
mature separation of the placenta and another with rupture of the membranes, and prolapse of the cord. Before the situation could he analyzed, the baby died. Also, we have had unusually good results in t,he series without doing external version. In answer to Dr. Stein: pressure so as to control, if
~VTP do not maintain f~lrciblc but possible, thr flexion of the nftrrcoming
a steady head.
fundal
Four patients had cesarean se&on, two with placenta previa and the breech presentation was incidental. The other two were elderly primiparaa. One was 42 years old, having her first baby, whicah weighed over 9 pounds. The other primipara was 38 years old and delivered a baby whirh weighed 9 pounds, 15% ounces. 1 As it is, our incidenc~e of cesarean Fection believe that these are real indications. is very low. I would like to say a littIc something a.bout the general practitioner and his treatment of breech presentation. X few years ago we investigated the fetal mortality in our hospitals, and there was one hospital in our state that had a fetal mortality rate of 33 per cent in breech presentation over a period of three years. ilt the Lincoln General Hospital where we have done mo& of our work, we have a set of rules regarding our obstetric department. No man, and it makes no difference whether he is a member of the obstrtric staff or a visiting man who brings in a patient for delivery, can do an operative delivery and that includes breech extraction, without consultation. It is his privilege to call in a member of t,he obstetric department for ronsultation, which service must be rendered free of charge. Under the influence of that rule our fetal morta,lity was lowered to one-third of what it had been for the previous fiv! rears. It has now been in effect. for approximately five years. The general practltionrr usually interferes. It would be preferable for him to be more conservative.
ARE
THE
ANTEBIOR PITUITARY-LIKE GONADOTROPIC 1” A CLINICAL
WILLIS
EVALUATION
E. BROWN, &HI.,
SUBSTANCES
IN THE WOMAN
JAMES T. BRADBURY, D.Sc.,
ANN ARBOR, MICH., AND ID,A METZGER, M.D., YPSILANTI, (From the Dewrtment of 0bstettic.s and Gynecology, lJni,versity I’psilnnti Statr Hosphl J
MICH. Hospital
and
T
HE anterior pituitary-like substance from human pregnancy urine has been available for clinical use during the past decade. However, the medical literature is not unanimous in its opinion regarding the physiologic effects of this material. The well-known gonadotropic response obtained in the mouse and rabbit is not found consistently throughout laboratory animals, nor has it been duplicated in the human female in any manner that will stand critical evaluation. The clinical reports in the literature are based on patients who were treated for some menstrual abnormality of uncertain etiology and unpredictable course. On the basis of such observations, many authors enthusiastically recommend its use, but here and there are reports of dissenting opinion.
Geistl antuitrin-S. its use.
described Rock2 Hamblens
*Presented Obstetricians
atretic follicles with hemorrhage in women treat,ed with described probable degeneration of follicles in women following called attention to premature and increased involutional changes
before the Twelfth Annual and Gynecologists, Indianapolis,
Meeting Ind.,
of the Central October 12, 1940.
Association
of
DELIVERY* M.D., LINCOLN, NEB.
T
HE subject of breech presentation has been discussed in the literature frequently during the past decade. Articles have appeared upholding both the conservative and active management of this presentation, but to date there has been no significant change in the fetal mortality. One is impressed with the fact that the results depend to a great extent upon the ability of the operators to perfect their particular method of treatment. Most of the communications on this subject have come from large obstetric centers representing, to a great extent, clinic material. The material used as a basis for the presentation of this communication represents the cases of breech deliveries occurring in the associated practice of Dr. Harold S. Morgan and myself over a period of twelve years. It is not a large series of cases, but it represents, we believe, an experience which is comparable to that of the average obstetrician in private practice, and for this reason, we are presenting this series of cases. During the past twelve years, 1,882 patients were delivered. One hundred and twenty-six babies were presented by the breech, the incidence being 6.7 per cent. This is higher than that usually reported. The incidence of breech presentation during the past twelve years at the Lincoln General Hospital in which 90 per cent of our patients were delivered was 4.2 per cent. Our increased incidence is explained by the fact that a large number of complicated deliveries are referred to us by general practitioners doing obstetrics. The parents of these babies are all white, coming from all social levels, chiefly middle-class American, the foreign element being negligible. The 126 babies were delivered of 120 mothers; four mothers had twin pregnancies in which both babies were presented as a breech, and 2 mothers had breech presentations in two succeeding pregnancies. There were 73 primiparas and 53 multiparas. SOGRCE
OF CASES
Hospital
Deliveries
Breech
Lincoln General Bryan Memorial St. Elizabeth Total
1,719 118 45 1,882
114 9 3 126
Incidence
No. of mothers 73 53
120
6.7% Primiparas Multiparas
*Presented before the Twelfth Annual stetricians and Gynecologists, Indianapolis,
Meeting of the Central Ind., October 12, 1940.
575
Association
of Ob-
576
AMERICAN
JOURNAL
OF DURATIOX
OBSTETRICS
AXD
GYNECOLOGY
OF LABOR
1st stage 2nd stage
(Variation) Primiparas 2W to 57 hours 5 min. to 7% hours
Multiparas 1 to 31 hours 5 min. to 2 hours
1st stage 2nd stage
(Average) 12.6 hours 1.2 hours
6.3 hours 35.1 min.
13 primiparas 1 multipara
had 2nd stage over 100 minutes. had 2nd stage over 100 minutes. FETAL
ATTITUDE
Ninety-six of the breech presentations were frank breech, 25 were single footlings, and 13 were double footlings. Sixteen of the single and 4 of the double footlings occurred in premature deliveries. Duration of Labor in Primipara.-The f&t stage averaged twelve and six-tenths hours, varying from two and one-half hours to fifty-seven hours. The second stage averaged seventy-one minutes, varying from five minutes to seven hours and seventeen minutes. There were 13 patients who had a second stage of over two hours’ duration. Duration of Labor in. M&tipara.-The first stage averaged six and three-tenths hours, varying from one hour to thirty-one hours. The second stage averaged thirtyfive minutes, varying from five minutes to two hours. Only one multipara had a second stage over one hour and forty minutes. TYPE
Manual Aid 109 5 decomposed (1 forcep) 7 forceps
OF DELIVERY
Extraction 13 2 forceps
Xeotion 4
The type of delivery is divided into three groups: manual aid, the procedure to be described, extraction, and cesarean section. One hundred nine patients were delivered with manual aid. In 5 of these, the breech was decomposed and then the patient delivered with manual aid. Forceps were applied to the aftercoming head in 7 patients. Extraction was the treatment in 13 patients. In 3 instances the patient failed to make progress in the second stage and extraction was the procedure then indicated. In 2 of these patients, forceps were applied to the aftercoming head. Two patients had late toxemia of pregnancy, and it was deemed best to termiTwo patients, both of whom were nate the delivery when the cervix was dilated. multiparas with placenta previa, one with a dead baby, were delivered through the placenta. Six premature twin babies were footling presentations, 2 being the first baby and 4 being the second baby of twins. Two patients had section for plaCesarean section was done on 4 patients. centa previa, and the breech presentation was incidental. Two patients, both elderly primiparas, were delivered by elective section because they had large babies and it was thought that delivery from below was questionable. Prolapse of the cord did not occur in the entire series. FETAL
MORTALITY
126 deliveries 15 babies died 5 multiparas 10 primiparas
Rate R,ate Rate
11.9% 9.4% 13.7%
HANSEN
Period of Gestation Term Term 34 weeks 27 weeks 27 weeks 26 weeks 25 weeks 24 weeks 28 weeks 28 weeks 33 weeks 28 28 27 27
weeks weeks weeks weeks
:
BREECH
577
DELIVERY
Abnor?nality None Spina bifida, hydrocephalus Anencephalia Premature Premature Premature Premature (toxemia) Premature (eecond of twins) Premature Twins Premature Twins Premature (No fetal heart tones) Placenta previa Premature -Twins Premature Twins Premature Twins Premature Twins
8 7 5 1 2 2 2 1 1 1 4
Weight lb. 4 oz. lb. 14 oz. lb. 4 oz. lb. 14 oz. lb. 10 oz. lb. 12 oz. lb. 5 oz. lb. 7 oz. lb. 9 oz. lb. 10 oz. lb. 15 oz.
2 1 1 1
lb. lb. 10 oz. lb. 7 oz. lb. 8 oz.
Summary of Fetal Mortality Term : 1 Intracranial hemorrhage 2 Monsters Premature : 1 33-week placenta previa. Stillborn. No fetal heart tones on admission. 11 period of gestation, 24 to 28 weeks. Weight varying from 1 lb. 7 oz. to 2 lb. I2 oz. Corrected mortality 0.8 per cent Fifteen babies were stillborn or died neonatally. This gives a gross mortality of 11.9 per cent. Five deaths occurred in multiparas (9.4 per cent), and IO in primiparas (13.7 per cent). Eleven babies were definitely premature, the period of gestation ranging from twenty-four to twenty-eight weeks, and the weights varying from 1 pound 7 ounces to 2 pounds 12 ounces. Several were one or both of twins. One baby was of thirty-three weeks’ gestation, and the mother, a multipara, had central placenta previa and no fetal heart tones on admission. Three patients were at term. One normal baby, weighing 8 pounds, 4 ounces, was delivered by manual aid after a second stage of five hours, The baby lived eight hours and fifteen minutes, and died suddenly. Post-mortem examination revealed intracranial hemorrhage ana a large cephalohematoma. One baby was hydrocephalic with a large spina bifida; it did not cry and lived only a few minutes. The third full-term baby was an anencephahc monster. Excluding the premature and abnormal babies, there remains only one fetal death or a corrected incidence of 0.8 per cent. FETAL MORBIDITY One baby who presented a frank breech was delivered by extraction after spontaneous delivery of the umbilicus because both arms were extended. The baby required resuscitation. Inspection reveaIed marked asymmetry of the face, with a depression of the vault into which the forearms fitted. This baby had The right arm recovered in seven days and bilateral Erb’s palsy when delivered. the left arm in three weeks. The left clavicle was fractured during delivery. One Three babies developed cephalohematomas, other baby had a fractured clavicle. and several babies developed hematomas of the sternocleidomastoid muscle. They all developed after the patient left the hospital. No known serious Sequelae followed. TWINS
In our series of breech presentation, 8 babies Twin incidence was interesting. were one of a set of twins; one of these died of prematurity. Eight babies represented both babies in 4 sets of twins. Six of these babies died. In the twelve years
578
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Sixteen babies we have delivered 17 sets of twins, or 34 babies. Eighteen presentations; seven of the 16 died, all of prematurity. cephalic; two of these died of prematurity. MATERNAL
MORTALITY None
MATERNAL
MORBIDITY
Twelve Cases
were breech babies were
Incidence
CASES
CAIJSE
: 1 1 I 1 1
Phlebitis Pyelitis Otitis media Cystitis Parametritis Unknown Unknown
1 1 1 1 I
Unknown Unknown Unknown Unknown Unknown
METHOD OF DELIVERY Section Manual aid Manual aid Section Extraction Manual aid Bag induction Manual aid Section Manual aid Manual aid Section Manual aid
MATERNAL COMPLICATIONS Previous
cystitis
Placenta
previa
Toxemia Placenta
previa
DURATION 6 4 -I 2 5 2 2 3 2 2 3
weeks days days days days days days
days days days days 2 davs
9.5S%
SEVERITY Severe Mild Mild Mild Mild Mild Mild Mild Mild Mild Mild Mild
There was no maternal mortality. There were 12 mothers who had a temperature of 100” F. on two succeeding days, excluding the first twenty-four hours post partum. There were 122 confinements, which gives an incidence of 9.8 per cent. Causes of morbidity could not be determined in 7 patients. These were all mild and lasted only two to three days. In 5 patients the cause was known. One patient had phlebitis of the left lower extremity. She had had an elective section. She was in the hospital six weeks and recovered. One patient, with a previous history of pyelitis had a flare-up lasting four days. One patient had acute otitis media lasting four days. One patient with cystitis of two days’ duration was delivered by section because of placenta previa, and one patient with a parametritis (tender uterus) had mild symptoms for five days. All 4 patients delivered by section were morbid, but the morbidities were mild, with the exception of the case of phlebitis. DISCUSSION
The diagnosis of breech presentation was made prenatally in practieally every patient coming for prenatal care. Routinely, we carefully check our measurements and estimate the size of the baby. If there is a question of fetopelvic relationship, we use the x-ray as an aid to our decision. E,xternal version was not attempted in any patient. Our method of treatment is conservative. By conservative treatment, we mean giving supportive treatment to the mother with no interference unless labor is obstructed, progress ceases, or complieations arise endangering the life of mother, baby, or both. We were trained in the watchful expectancy method, and from experience we are convinced that meddlesome interference is a definite factor in the difficulties encountered in obstetrics. I am sure that if we all agree that conservatism is good procedure in cephalic presentntions it should be rational in the breech. From personal observation and experience, we have formulated t,he following points to guide us in breech delivery : 1. Dilatation of the cervix does not become complete in many cases until the buttocks are presenting deeply at the introitus.
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2. Attempted delivery before complete dilatation is almost certain to result in extension of arms and head with difficulty in delivery. 3. It is natural for the force to be applied from above. Application of force from below by traction is not the normal force. Extension of the arms, nuchal arms, and extended head are the result of force applied from below rather than from above. 4. Manipulation from below, especially if the patient is not deeply anesthetized, will reflexly stimulate tetanic contraction of the cervix or lower uterine segment ; this contraction imprisons the shoulders and cephalic pole in the uterus and delays delivery ; it also necessitates increased force which traumatizes both mother a.nd baby. 5. Gentleness in all maneuvers is of the greatest importance. CONCLUSION
We have reported a series of 126 breech deliveries occurring during twelve years of private practice, with a corrected fetal mortality of 0.8 per cent. Conservative treatment in our hands has produced satisfactory results. Teamwork is an important feature of our treatment, and we believe it has had a definite influence on our results. Prematurity, especially prematurity in twin pregnancy, accounted Efforts toward preventing prefor 80 per cent of our fetal deaths. mature labor in twin pregnancies should lower the gross fetal mortality of breech presentation. This communication deals with private practice only. The reporting of many similar analyses and comparing them with reports from the clinic groups, we believe, would be worth while. 128 NORTH
13~~1 STREET DISCUSSION
DR. DAVID L. SMITH, Indianapolis, Ind.-The staff of the University Hospital at Indianapolis is essentially a closed one, made up of members of the teaching staff. There are two and one-half ward patients to one private patient. There Of the 31 stillbirths 4 were were 190 breech presentations in 1,264 deliveries. monsters, 6 were macerated fetuses and 6 were premature. There were 11 deaths attributable to the breech presentation, so the corrected mortality was 5.78 per cent, which is a great deal higher than Dr. Hansen’s. I have no way of accounting for that difference, except possibly on the basis that our service is somewhat of an emergency service, being a state hospital which admits patients from all over this portion of the state who have received no prenatal care and who sometimes are desperately ill. Review of the charts sometimes leads to conclusions as to what not to do. Two of the deaths occurred in labors which had been induced, both of which were definitely past term by history. In both the babies weighed a little over 5 pounds. One of the cardinal principles in breech management is to avoid induction of labor. We believe in external version as long as it is done with gentleness and without anesthesia. We personally have been successful in external version in about 60 per cent of the trials. Cesarean section should probably play a greater part in the management of breech delivery. We use intermittent nitrous oxide and oxygen anesthesia, and then change to We are using forceps on the afterdrop ether at the time the umbilicus is born. coming head more and more because we believe it is less traumatic to the baby than any other method of delivery.
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DR. IRVING F. STEIN, Chicago, 111.-A complete breech is one with the fetus in the attitude of complete flexion, and the incomplete breech is one of deflexion I do not believe that this has been emphasized in obstetric literature. attitude. In incomplete breech one frequently observes the fetus in a military attitude with the head erect or sometimes turned to the side or even tilted back? like an inverse brow presentation. A greater amount of mobility of the fetus is evident with breech than with cephalic presentation. Even with complete breech you ma! occasionally find a displaced arm and the head a little deflexed; this can be discovered only by x-ray examination. The practical application of this procedure enables you to be forewarned and prepare for manual aid or extraction. The points I wish to emphasize are first, that incomplete breech is an example of a deflexion attitude; second, in cases of breech particularly, you can obtain much practical information by taking roentgenograms before delivery which would otherwise be missed by ordinary methods of examination. DR. RUDOLPH W. HOLMES, University, Va.-Some 75 years ago Carl Draun reported in his textbook on 67 cases of face presentation which were seen in his clinic. He stated as a result of that great experience that a face presentation iu a primiparous labor was prima facie evidence of a pelvic deformity. In our more mature knowledge of pelvic abnormalities we now know that pure pelvic asymmetry is as potent a cause as is definite contraction. We may further state that the flat pelvis and the obliquely contracted types are more prone to produce malpositions and presentations than the symmetrical generally contracted pelvis. Not only is a face presentation produced by these fac.tors, but we may broaden that statement to the rule that all deviations of presentation are sequential to aberrant contours of the pelvic brim. In my own experience a breech delivery with a normal pelvis is as physiologic and as safe as the normal vertex positions. On the other hand, when there is any disproportion, the breech delivery is fraught with the greatest difficulty and danger. I still believe that it is the exceptional case of breech which demands a cesarean section. Contributing factors which are of etiologic importance may more often indicate cesarean operation than similar conditions in a vertex position. DR. R. 8. SIDDALL, Detroit, Mieh-I want to make a few remarks on the basis of a recent monograph which Dr. Seeley and I have published. We found in going over a considerable number of papers in the literature that there were several series of 100 or 150 cases in which the results were comparable with those of Dr. Hansen. We did not find, however, any series of 200 or over which did not have a very considerable increase of fetal, not maternal, deaths associated with breech. In our series from the Herman Kiefer and Harper Hospitals in Detroit it was noticeable, however, that we would often have 125 or 150 cases in a series with Although one may have a relatively small series with only one or two deaths. good results, one eventually encounters difficulty. External version is associated with very little danger. It is very reasonable to employ an easy and safe procedure to convert a dangerous presentation associated wrth from 5 to 20 per cent mortality into one with only 1 or 2 per cent mortality. We found that there were three things which contributed very largely to excessive fetal mortality in breech: (1) The mortality increases with babies weighing from 8 pounds to 9 pounds and over until it reaches 20 to 25 per cent. (2) fetal mortality, as someone expressed Elderly primiparas have a “lamentable” it in the literature. It may be around 25 to 30 per cent. (3) Contracted pelvis also has a high mortality, even in the minor grades of pelvic contraction. DR. A. F. LASH, Chicago, Ill.-As a result of an extensive experience at the Cook County Hospital in Chicago, where we deliver over 5,000 babies a year, there are certain points which are crystallized in our minds regarding breech delivery.
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:
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DELIVERY
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First, breech presentations can deliver spontaneously as well as cephalic. This point requires special emphasis because when we get into discussions with the doctors in the surrounding rural communities, they say, “How can we deliver these babies without getting a 90 per cent fetal mortality?” Too often the conception is that as soon as the presenting part is visible, immediate extraction is started and it is associated with complications. Second, with regards to analgesia, we feel that we want the cooperation of the patient throughout labor. We never use the barbiturates during the first stage. If the patient is in strong labor and requires some rest, we feel morphine and scopolamine fulfill that requirement. Pudendal block and local infiltration of the perineum and pelvic floor will allow complete cooperation of the patient which helps in the delivery of the baby. We do not feel that eight minutes between the appearance of the cord and the delivery of the head is so important. We have found that as much as fifteen minutes can be taken in the delivery of the head as long as air reaches the mouth by retracting the perineum. It is at this point that the greatest harm is done to the baby by undue traction. When we feel that the head seems to meet with a good bit of obstruction, instead of continuing the extraction we usually release our pull on the baby’s head; we push the baby up, which allows increased flexion of the head, bringing the head down in the transverse diameter, thereby facilitating delivery of the head. With this in mind, I think we avoid damage to the baby and lower our fetal mortality. DR. FREDERICK H. FALLS, Chicago, Ill.-Breech is more common in the areuate type of bicornate uterus, which is seen relatively frequently. When breech is present in such a uterus, it is very difficult or impossible to do external version, and I think it is often dangerous even to try. We feel that not infrequently a combination of arcuate type of bicornate uterus and breech is a relaSince adopting this policy, we have tively strong indication for cesarean section. had very much better results in this type of case. In placenta previa we frequently have an associated breech presentation, because under this circumstance the breech will fit the lower uterine segment better than the head. The combination of breech and placenta previa is also a relative indication for cesarean section. The importance of the fact that the premature baby frequently presents by the breech cannot be overemphasized. The more premature the baby is, the more reason there is for thoroughly dilating the birth canal. In these cases we thoroughly dilate the birth canal and do an episiotomy to avoid cerebral damage to the premature baby during delivery. DR. J. C. LITZENBERG, Minneapolis, Minn.-If you will change the term external version” you will avoid a lot of ‘ ‘ external version ’ ’ to “attempted arguments. I have always taught that external version should be attempted but I have never persisted in it if it offers any difficulties whatsoever. There are certain conditions in which it should never be attempted. It is a shame in a case where external version could be done with the greatest of ease not to do it, but it is also a shame, and a greater one, to persist in its use when one has difficulty. DR. E. M. HANSEN (closing).-Dr. Morgan and myself have always tried to be conservative in our estimation of our ability to do a good job delivering a breech, and I am very frank with you when I say there has been a question in my mind As time has gone on each as to just how much luck we have had in our series. breech presentation has been a very definite challenge to us, and I think in that respect this challenge has had a very definite influence on our work, because we have tried every time to get a live baby. With regard to external version, not once was it attempted. The reason for this is that in my period of training I saw many external versions attempted and but very few of them successful. On two occasions babies were lost, one with pre-
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OF OBSTETRICS AND GYNECOLOGY
mature separation of the placenta and another with rupture of the membranes, and prolapse of the cord. Before the situation could he analyzed, the baby died. Also, we have had unusually good results in t,he series without doing external version. In answer to Dr. Stein: pressure so as to control, if
~VTP do not maintain f~lrciblc but possible, thr flexion of the nftrrcoming
a steady head.
fundal
Four patients had cesarean se&on, two with placenta previa and the breech presentation was incidental. The other two were elderly primiparaa. One was 42 years old, having her first baby, whicah weighed over 9 pounds. The other primipara was 38 years old and delivered a baby whirh weighed 9 pounds, 15% ounces. 1 As it is, our incidenc~e of cesarean Fection believe that these are real indications. is very low. I would like to say a littIc something a.bout the general practitioner and his treatment of breech presentation. X few years ago we investigated the fetal mortality in our hospitals, and there was one hospital in our state that had a fetal mortality rate of 33 per cent in breech presentation over a period of three years. ilt the Lincoln General Hospital where we have done mo& of our work, we have a set of rules regarding our obstetric department. No man, and it makes no difference whether he is a member of the obstrtric staff or a visiting man who brings in a patient for delivery, can do an operative delivery and that includes breech extraction, without consultation. It is his privilege to call in a member of t,he obstetric department for ronsultation, which service must be rendered free of charge. Under the influence of that rule our fetal morta,lity was lowered to one-third of what it had been for the previous fiv! rears. It has now been in effect. for approximately five years. The general practltionrr usually interferes. It would be preferable for him to be more conservative.
ARE
THE
ANTEBIOR PITUITARY-LIKE GONADOTROPIC 1” A CLINICAL
WILLIS
EVALUATION
E. BROWN, &HI.,
SUBSTANCES
IN THE WOMAN
JAMES T. BRADBURY, D.Sc.,
ANN ARBOR, MICH., AND ID,A METZGER, M.D., YPSILANTI, (From the Dewrtment of 0bstettic.s and Gynecology, lJni,versity I’psilnnti Statr Hosphl J
MICH. Hospital
and
T
HE anterior pituitary-like substance from human pregnancy urine has been available for clinical use during the past decade. However, the medical literature is not unanimous in its opinion regarding the physiologic effects of this material. The well-known gonadotropic response obtained in the mouse and rabbit is not found consistently throughout laboratory animals, nor has it been duplicated in the human female in any manner that will stand critical evaluation. The clinical reports in the literature are based on patients who were treated for some menstrual abnormality of uncertain etiology and unpredictable course. On the basis of such observations, many authors enthusiastically recommend its use, but here and there are reports of dissenting opinion.
Geistl antuitrin-S. its use.
described Rock2 Hamblens
*Presented Obstetricians
atretic follicles with hemorrhage in women treat,ed with described probable degeneration of follicles in women following called attention to premature and increased involutional changes
before the Twelfth Annual and Gynecologists, Indianapolis,
Meeting Ind.,
of the Central October 12, 1940.
Association
of