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Breech presentations, report of 170 cases
MOHLER:
which are prevalent mal progression.
BREECH
61
PRESENTATIONS
and which have added confusion
to a simple, nor-
CONCLUSIONS
1. The cells surrounding the ovum in the graafian follicles are undifferentiated cells that are capable of developing in more than one way. 2. Under what may be called normal stimuli they develop into connective tissue. 3. Under other stimuli they develop into true epithelium. 4. The transition from normal cells into epithelial cells can be definitely traced. 1025
NORTH
CALVERT
STREET. (For
BREECH
PRESENTATIONS, BY
ROY W.
MOHLER,
REPORT M.D.,
discussion,
see page
148.)
OF 170 CASES”
PHILADELPHIA
I
NFANT mortality is very high for babies presenting by the breech. Every group of obstetricians should know of the mortality in their service and try in every possible way to lower it. In order to accomplish this, they should analyze their series of cases and determine what has been accomplished or neglected, and then aim to carry out those procedures which have proved advantageous. It is with this idea in mind that this report is given. At the Philadelphia Lying-In Hospital there have been 170 breech deliveries in the period extending from April 1, 192’7, to October 31, 1930. No breech presentations which were delivered by cesarean sect,ion have been included. At the Philadelphia Lying-In Hospital the following methods of delivery have been carried out over the period of time represented by this report. During this time there were 65 spontaneous breech deliveries, all were small babies or very rapid deliveries. There were 38 extractions, which means that the baby was guided through the pelvis and the normal mechanism of labor was facilitated. There were 40 extractions with t.he application of forceps to the after-coming head. There were 23 babies decomposed and extracted and forceps were applied to the after-coming head, and there were 4 in which the method of delivery was not stated. The series of 170 cases which we are reporting is not large as compared with many that have been reported. The infant mortality of the various reports varies greatly depending upon the exclusion of the premature infants and macerated infants above a certain weight, de*From Read
the before
Philadelphia the Obstetrical
Lying-In Society
Hospital, Philadelphia, of Philadelphia, March
Pa. 5, 1931.
62
AMERICAN
JOURNAL
OF’
OBSTETRICS
AND
GYNECOLOGY
formed babies, etc. Until there is some standard met.hod of classification adopted we cannot compare statistics w;cll. I have, therefore, included all cases which presented by the breech and were delivered by vagina. The 170 patients which form the basis of this report wore
No. of eases No. of live babies Gross mortality Group l-Babies under 3 pounds Group l-Macerated fetus weight not given Group l-Total No. of babies Group 2-No. of babies dead which weighed over 3 pounds. Table TI
170
1111 60 33
64.6 G.4 19.3
6”
x.4
40 22 12
G-L..5 35.G
10X 70 3x
65.8
lCJ.3
“1
19.3
.i
7
35 9
22.3 .i .3
I...,
13 5
40.!! S.Oi-
63.6 35.2
.I
3.8
,r) ‘> 4
23.1
4.0
classified as 62 primiparae and 108 moltiparae. There mere 40 live healthy babies discharged from the hospital which were delivered of the primiparae and 70 live healthy babies discharged from the hospital which were delivered by multiparae. There were 60 babies delivered by the breech which were lost, this represents a gross mortality of 35.4 per cent. I have arranged these cases in three groups. In Group 1 there mere 33 babies weighing three pounds or less and could not be expected to survive. There were 5 more which weighed over three pounds but were premature ant1 macerated. This would indicate that breech pregnancy has a very great chance of ending prematurely. In clinic cases, patients are difllcult to control., and it seems quite impossible to lower t.his mortality from prematurity. In ----__ CA :
P n na
4560
i
7 pounds
5150
i
4 pounds
2670
i
3 pounds
3812
WEIGHT
OF CHILD
4 ounces
12 ounces
i
6 pounds
-I ounces
i
3 pounds 5 pounds
8 ounces 5 ounces
18427 1477
iv
1158
iv
2908 19618
six
___...
.~~. _ FETUS
TIME
Yaeerated Body torlr head Born alive Cord about No pulsation cord Macerated Hemorrhage newborn Syphilis Small
from neck in o f
ii
Not given; months 3 pounds
9 ounces
Premature
ii
4 pounds
8 ounces
Macerated ; premature separation of olacenta
OF I1EATII
AUTOPSY
One week before birth Before admission to hospital Few hours after delivery Before birth after labor began Before labor Seventh day postpartum
No
After
NII
delivery
After delivery No injury Seven days before delivery
No NO No NO
Yes
No
MOHLER
:
BREECH
PRESENTATIONS
63
Group 2 there were 9 babies that weighed over three pounds which died or were stillborn, their cause of death is noted in Table II and was not due to any accident of delivery, which could have been controlled in the hospital. In Group 3 there were 13 babies which we feel were lost because of birth trauma and I shall give briefly their history. CUE 3966.-Primipara, frank breech, cervix fully with labor, decomposition of child 8 pounds 6 ounces. because of size of child’s showed subdural hemorrhage
aged sixteen, colored, diagnosis not made until in labor, dilated and effaced, descent to mid pelvis. No progress and extraction with forceps to after-coming head, weight Pelvic measurements were normal, difficult extraction head, child lived ten minutes after delivery. Autopsy and tentorial tear.
CASE 4692.-Primipara, aged thirty-one, membranes ruptured, contracted pelvis Weight recognized under anesthesia, prolapsed cord, did not pulsate during pains. of child 5 pounds 4 ounces, cervix dilated manually, breech decomposed and exAutopsy showed no gross lesions, death tracted with forceps to after-coming head. possibly from asphyxia due to prolapsed cord.
CASE 4139.-Primipara, aged twenty-eight, foot presenting at vulva, hard labor pains, cervix fully dilated and effaced, difficulty with nuchal arms and extended head. Extraction with forceps to after-coming head, baby born alive, lived twentyAutopsy showed a subdural hemorrhage four hours, weighed 7 pounds 131/3 ounces. with clots.
CASE 3894.-Primipara, aged thirty-four, cervix completely dilated and effaced, Measurements were normal, easy extraction with no progress in second stage. forceps to after-coming head. Baby weighed 6 pounds Y$ ounce. Born dead. Autopsy showed a fracture of the seventh cervical vertebra with spinal cord completely severed. CASE 5193.-Para ii, aged twenty-eight. First. labor was spontaneous and short, Pelvic measurements were normal, cervix completely baby presented by vertex. dilated and effaced, breech was decomposed and fetus extracted with forceps to after-coming head. Baby weighed 8 pounds 6 ounces and died twenty-four hours after delivery. Autopsy showed a bilateral tentorial tear. CASE 6227.-Para vi, aged thirty-three. All previous labors spontaneous except one easy forceps, emergency case sent into hospital with breech impacted for twentyfour hours. Breech was decomposed, baby extracted with forceps to after-coming head. Baby weighed 8 pounds with large‘head, died fifteen minutes after delivery. No autopsy was done but history suggested intracranial injury. CASE 165S.-Para iv, aged twenty-seven. All previous labors were spontaneous. Breech was decomposed and extracted after full dilatation, and effacement of cervix. Baby weighed 8 pounds 6 ounces, died during labor. Autopsy was not performed but history suggested asphyxia or fracture of the skull. CASE 3341.-Para v, aged twenty-six. Emergency case. Babies were lost in two previous labors. Breech had been impacted for forty-eight hours, large postmature baby which weighed over 8 pounds. Baby was decomposed and extracted, craniotomy performed to remove after-coming head. Uterus was ruptured and hysterectomy was performed soon after delivery. Patient recovered from the delivery and operation and died on the thirteenth day after operation of a hemorrhage from bowel, the source of which could not be determined by autopsy. This is the only maternal death of the series.
64
AMERICAN
JOURNAL
OF
OBSTETRI(‘S
AND
GYWE.COT~OGY
colored, ~nc livilrg child, two dead CASE 3123.-Para iv, aged twenty-eight, children, none stillborn, previous labors were spontaneous with vertex presenting. Long first stage of labor, cervix fully dilated and effaced, no progress in second stage of labor. l)ecomposition of breech and extraction of t; pnund fetus, both Aut0psy 0f fetus showed a arms became uuchal, head extracted with forcq~s. compression of r,ord and subdllral fracture of fifth and sixth cervical vertrbrac, hemorrhage caused hp laceration of dwa rowring t.he coron;d suture. The patient had a contracted pelvis which was rccogniz~4 in prqnancy but hwanse of other spontaneous labors was not considered seriously as a cause for d?stocia. CASE
ficulty
811.-M., in operation.
yarn vi, breech estraction Bxi)~ died on fifth da:-
of uf
baby weighing $1 pounds, intracranial hcmorrlmge.
no
dif.
CASk: 360-l--Para ii, aged thirty. E’ird labor was qwntaricous easy vertex. Admitted to hospital without prenatal care. 1)i:ignosis made in labor, cervix was not completely dilated or cffsccd. Had hwn in labor six hours. Rrcech decomposed and extrartcrl after-comiq head, deliwred with forceps. Baby weighed 6 pounds 1 ounce. Autopsy showctl a tentorial tear. This patient was delivered by house officer, and it seems from history that better reault,s r-o&l h:rro been secuwd by waiting until the first stage of labor was completed. CXX 4TSti.-Para iii, aged twenty-nine:. 1’w1n previous spontanrous labors at home. Patient had a 1:rrge pelvis. Left foot of baby was presenting; cervix ful1.v dilated and effaced after ten hours’ labor. F&p extraction without traction. Head was delivered easily without forceps. Baby weighed 12 pounds. Bahp died soou after birth. Autopsy showed a complete tentrlrinl tcsar. hICKICE
CASE .X04.-l’ara
ii, aged
tllirty.
I’wvious
In1 wr was normal,
forceps
had
been applied to vertex when head was on perineum. Pelvic measurements were normal. Long first stage labor. no progress in sceond stage after complete dilatation and effacement of cervix. Breech was decomposed and a 7 pound 3 ounce baby est.rncted. Cord was edematous, no pulsation noted during labor. Baby was dead at birth. %usc of death was pressure on cord dwing swond stage of labor. No autopsy.
It is the analysis of the acciclent,s occurring in Group 3 whose histories I have just. reviewed from which we wish to draw our conclusions. These deaths represent about a 10 per cent fetal mortality OI 15 of the 123 viable babies or 13 babies from l’i0 brrech pregnancies were lost from some accident of delivery. Eleven of these received intracranial injuries sufficient to prove fatal. Three of these were delivered of primiparae and 8 of multiparae. Eight of the 11 babies dead of cranial injury weighed approximately 8 pouncls or over. The other two deaths were due to prolapsrct cords, one was, a primipara whose baby weighed 5 pouuds 14 ounces: the other a multipara whose baby weighed 7 pouncls 3 ounces. It is generally agreed that prola,psecl cord is a frequent, cause of death in babies presenting by the breech. A certain number of such cases can be controlled by carefull) watching the patient throughout labor. 1%‘~do not feel that these accidents require any apology or cxplanat,ion. The incidence of deaths from this cause wou1.d have been about the same in cases presenting by the vertex.
MOHLER
:
BREECH
PRESENTATIONS
65
66
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
In the whole series of the 170 patients there were 23 multiparae and 4 primiparae who delivered babies weighing about. S pounds or over. This confirms the impression that, usually mult,iparae deliver larger babies than primiparae. Six of the 23 multiparae and 2 of the 4 primiparae with babies mcighing near 9 pounds or over lost their babies because of intracranial injuries directly due to delivery. This reprcsents a mortality of approximately 30 per cent which is three times greater than the mortality of all via.ble babies in the entire series. If a deduction can be drawn from this small number of cases, we may say that a baby weighing 8 pounds or over has only a 70 per cent chance of being born alive if prescnt,ing by breech, and delivered vaginally. How shall these cases be managed! The man who has had a large experience in the management of breech presentations could have managed successfully the vaginal delivery of some of these cases; in a large hospital service thcrc are times when the breech will not have been recognized during pregnancy, thr resident, staff or a man with limited experience in handling breech labors will at, times be forcetl to manage them. It would seem that rccoguitiou CJC the brcecli is imperative, in all doubtful cases x-ray shonltl be usctl for diagnosis. The size of the child should be dctcrmincd, it is usually possible to judge fairly accurately as to whether it is large or not. If in doubt t,he method of Thorns, which adapts the perforated lcad plate to a plant which corresponds to the plane of the inlet of the pelvis ma? be adopted. If the baby is then considered large, the expediency of doing a cesarean section must be considered. There are some n-ho believe that all primiparae thirty-five years of age or older shonltl be dcliveretl of il breech by a cesarcan section. Instead of this dictum we should accept the one t.hat all breech babies which weigh over S pounds should be delivered by cesarean section, if the assurance of a living child warrants the additional risk to the mother. It should always be planned to do an elective section when possible. This dictum sl~o~~ld be a.ccepted only by trained obstetricians. In drawing conclusions from this series of cases, we should first recommend that all cases of breech present,ation should be studied very carefully during the prenatal period. Each obstetrician should aim to be present. at as many breech cleliveries as possible so as to constantly keep himself in practice by managing breech labors frequently. Finally the size of the child should be considered more in the management of the breech presentation, thaTi the age and parity of the patient.
which are prevalent mal progression.
BREECH
61
PRESENTATIONS
and which have added confusion
to a simple, nor-
CONCLUSIONS
1. The cells surrounding the ovum in the graafian follicles are undifferentiated cells that are capable of developing in more than one way. 2. Under what may be called normal stimuli they develop into connective tissue. 3. Under other stimuli they develop into true epithelium. 4. The transition from normal cells into epithelial cells can be definitely traced. 1025
NORTH
CALVERT
STREET. (For
BREECH
PRESENTATIONS, BY
ROY W.
MOHLER,
REPORT M.D.,
discussion,
see page
148.)
OF 170 CASES”
PHILADELPHIA
I
NFANT mortality is very high for babies presenting by the breech. Every group of obstetricians should know of the mortality in their service and try in every possible way to lower it. In order to accomplish this, they should analyze their series of cases and determine what has been accomplished or neglected, and then aim to carry out those procedures which have proved advantageous. It is with this idea in mind that this report is given. At the Philadelphia Lying-In Hospital there have been 170 breech deliveries in the period extending from April 1, 192’7, to October 31, 1930. No breech presentations which were delivered by cesarean sect,ion have been included. At the Philadelphia Lying-In Hospital the following methods of delivery have been carried out over the period of time represented by this report. During this time there were 65 spontaneous breech deliveries, all were small babies or very rapid deliveries. There were 38 extractions, which means that the baby was guided through the pelvis and the normal mechanism of labor was facilitated. There were 40 extractions with t.he application of forceps to the after-coming head. There were 23 babies decomposed and extracted and forceps were applied to the after-coming head, and there were 4 in which the method of delivery was not stated. The series of 170 cases which we are reporting is not large as compared with many that have been reported. The infant mortality of the various reports varies greatly depending upon the exclusion of the premature infants and macerated infants above a certain weight, de*From Read
the before
Philadelphia the Obstetrical
Lying-In Society
Hospital, Philadelphia, of Philadelphia, March
Pa. 5, 1931.
62
AMERICAN
JOURNAL
OF’
OBSTETRICS
AND
GYNECOLOGY
formed babies, etc. Until there is some standard met.hod of classification adopted we cannot compare statistics w;cll. I have, therefore, included all cases which presented by the breech and were delivered by vagina. The 170 patients which form the basis of this report wore
No. of eases No. of live babies Gross mortality Group l-Babies under 3 pounds Group l-Macerated fetus weight not given Group l-Total No. of babies Group 2-No. of babies dead which weighed over 3 pounds. Table TI
170
1111 60 33
64.6 G.4 19.3
6”
x.4
40 22 12
G-L..5 35.G
10X 70 3x
65.8
lCJ.3
“1
19.3
.i
7
35 9
22.3 .i .3
I...,
13 5
40.!! S.Oi-
63.6 35.2
.I
3.8
,r) ‘> 4
23.1
4.0
classified as 62 primiparae and 108 moltiparae. There mere 40 live healthy babies discharged from the hospital which were delivered of the primiparae and 70 live healthy babies discharged from the hospital which were delivered by multiparae. There were 60 babies delivered by the breech which were lost, this represents a gross mortality of 35.4 per cent. I have arranged these cases in three groups. In Group 1 there mere 33 babies weighing three pounds or less and could not be expected to survive. There were 5 more which weighed over three pounds but were premature ant1 macerated. This would indicate that breech pregnancy has a very great chance of ending prematurely. In clinic cases, patients are difllcult to control., and it seems quite impossible to lower t.his mortality from prematurity. In ----__ CA :
P n na
4560
i
7 pounds
5150
i
4 pounds
2670
i
3 pounds
3812
WEIGHT
OF CHILD
4 ounces
12 ounces
i
6 pounds
-I ounces
i
3 pounds 5 pounds
8 ounces 5 ounces
18427 1477
iv
1158
iv
2908 19618
six
___...
.~~. _ FETUS
TIME
Yaeerated Body torlr head Born alive Cord about No pulsation cord Macerated Hemorrhage newborn Syphilis Small
from neck in o f
ii
Not given; months 3 pounds
9 ounces
Premature
ii
4 pounds
8 ounces
Macerated ; premature separation of olacenta
OF I1EATII
AUTOPSY
One week before birth Before admission to hospital Few hours after delivery Before birth after labor began Before labor Seventh day postpartum
No
After
NII
delivery
After delivery No injury Seven days before delivery
No NO No NO
Yes
No
MOHLER
:
BREECH
PRESENTATIONS
63
Group 2 there were 9 babies that weighed over three pounds which died or were stillborn, their cause of death is noted in Table II and was not due to any accident of delivery, which could have been controlled in the hospital. In Group 3 there were 13 babies which we feel were lost because of birth trauma and I shall give briefly their history. CUE 3966.-Primipara, frank breech, cervix fully with labor, decomposition of child 8 pounds 6 ounces. because of size of child’s showed subdural hemorrhage
aged sixteen, colored, diagnosis not made until in labor, dilated and effaced, descent to mid pelvis. No progress and extraction with forceps to after-coming head, weight Pelvic measurements were normal, difficult extraction head, child lived ten minutes after delivery. Autopsy and tentorial tear.
CASE 4692.-Primipara, aged thirty-one, membranes ruptured, contracted pelvis Weight recognized under anesthesia, prolapsed cord, did not pulsate during pains. of child 5 pounds 4 ounces, cervix dilated manually, breech decomposed and exAutopsy showed no gross lesions, death tracted with forceps to after-coming head. possibly from asphyxia due to prolapsed cord.
CASE 4139.-Primipara, aged twenty-eight, foot presenting at vulva, hard labor pains, cervix fully dilated and effaced, difficulty with nuchal arms and extended head. Extraction with forceps to after-coming head, baby born alive, lived twentyAutopsy showed a subdural hemorrhage four hours, weighed 7 pounds 131/3 ounces. with clots.
CASE 3894.-Primipara, aged thirty-four, cervix completely dilated and effaced, Measurements were normal, easy extraction with no progress in second stage. forceps to after-coming head. Baby weighed 6 pounds Y$ ounce. Born dead. Autopsy showed a fracture of the seventh cervical vertebra with spinal cord completely severed. CASE 5193.-Para ii, aged twenty-eight. First. labor was spontaneous and short, Pelvic measurements were normal, cervix completely baby presented by vertex. dilated and effaced, breech was decomposed and fetus extracted with forceps to after-coming head. Baby weighed 8 pounds 6 ounces and died twenty-four hours after delivery. Autopsy showed a bilateral tentorial tear. CASE 6227.-Para vi, aged thirty-three. All previous labors spontaneous except one easy forceps, emergency case sent into hospital with breech impacted for twentyfour hours. Breech was decomposed, baby extracted with forceps to after-coming head. Baby weighed 8 pounds with large‘head, died fifteen minutes after delivery. No autopsy was done but history suggested intracranial injury. CASE 165S.-Para iv, aged twenty-seven. All previous labors were spontaneous. Breech was decomposed and extracted after full dilatation, and effacement of cervix. Baby weighed 8 pounds 6 ounces, died during labor. Autopsy was not performed but history suggested asphyxia or fracture of the skull. CASE 3341.-Para v, aged twenty-six. Emergency case. Babies were lost in two previous labors. Breech had been impacted for forty-eight hours, large postmature baby which weighed over 8 pounds. Baby was decomposed and extracted, craniotomy performed to remove after-coming head. Uterus was ruptured and hysterectomy was performed soon after delivery. Patient recovered from the delivery and operation and died on the thirteenth day after operation of a hemorrhage from bowel, the source of which could not be determined by autopsy. This is the only maternal death of the series.
64
AMERICAN
JOURNAL
OF
OBSTETRI(‘S
AND
GYWE.COT~OGY
colored, ~nc livilrg child, two dead CASE 3123.-Para iv, aged twenty-eight, children, none stillborn, previous labors were spontaneous with vertex presenting. Long first stage of labor, cervix fully dilated and effaced, no progress in second stage of labor. l)ecomposition of breech and extraction of t; pnund fetus, both Aut0psy 0f fetus showed a arms became uuchal, head extracted with forcq~s. compression of r,ord and subdllral fracture of fifth and sixth cervical vertrbrac, hemorrhage caused hp laceration of dwa rowring t.he coron;d suture. The patient had a contracted pelvis which was rccogniz~4 in prqnancy but hwanse of other spontaneous labors was not considered seriously as a cause for d?stocia. CASE
ficulty
811.-M., in operation.
yarn vi, breech estraction Bxi)~ died on fifth da:-
of uf
baby weighing $1 pounds, intracranial hcmorrlmge.
no
dif.
CASk: 360-l--Para ii, aged thirty. E’ird labor was qwntaricous easy vertex. Admitted to hospital without prenatal care. 1)i:ignosis made in labor, cervix was not completely dilated or cffsccd. Had hwn in labor six hours. Rrcech decomposed and extrartcrl after-comiq head, deliwred with forceps. Baby weighed 6 pounds 1 ounce. Autopsy showctl a tentorial tear. This patient was delivered by house officer, and it seems from history that better reault,s r-o&l h:rro been secuwd by waiting until the first stage of labor was completed. CXX 4TSti.-Para iii, aged twenty-nine:. 1’w1n previous spontanrous labors at home. Patient had a 1:rrge pelvis. Left foot of baby was presenting; cervix ful1.v dilated and effaced after ten hours’ labor. F&p extraction without traction. Head was delivered easily without forceps. Baby weighed 12 pounds. Bahp died soou after birth. Autopsy showed a complete tentrlrinl tcsar. hICKICE
CASE .X04.-l’ara
ii, aged
tllirty.
I’wvious
In1 wr was normal,
forceps
had
been applied to vertex when head was on perineum. Pelvic measurements were normal. Long first stage labor. no progress in sceond stage after complete dilatation and effacement of cervix. Breech was decomposed and a 7 pound 3 ounce baby est.rncted. Cord was edematous, no pulsation noted during labor. Baby was dead at birth. %usc of death was pressure on cord dwing swond stage of labor. No autopsy.
It is the analysis of the acciclent,s occurring in Group 3 whose histories I have just. reviewed from which we wish to draw our conclusions. These deaths represent about a 10 per cent fetal mortality OI 15 of the 123 viable babies or 13 babies from l’i0 brrech pregnancies were lost from some accident of delivery. Eleven of these received intracranial injuries sufficient to prove fatal. Three of these were delivered of primiparae and 8 of multiparae. Eight of the 11 babies dead of cranial injury weighed approximately 8 pouncls or over. The other two deaths were due to prolapsrct cords, one was, a primipara whose baby weighed 5 pouuds 14 ounces: the other a multipara whose baby weighed 7 pouncls 3 ounces. It is generally agreed that prola,psecl cord is a frequent, cause of death in babies presenting by the breech. A certain number of such cases can be controlled by carefull) watching the patient throughout labor. 1%‘~do not feel that these accidents require any apology or cxplanat,ion. The incidence of deaths from this cause wou1.d have been about the same in cases presenting by the vertex.
MOHLER
:
BREECH
PRESENTATIONS
65
66
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
In the whole series of the 170 patients there were 23 multiparae and 4 primiparae who delivered babies weighing about. S pounds or over. This confirms the impression that, usually mult,iparae deliver larger babies than primiparae. Six of the 23 multiparae and 2 of the 4 primiparae with babies mcighing near 9 pounds or over lost their babies because of intracranial injuries directly due to delivery. This reprcsents a mortality of approximately 30 per cent which is three times greater than the mortality of all via.ble babies in the entire series. If a deduction can be drawn from this small number of cases, we may say that a baby weighing 8 pounds or over has only a 70 per cent chance of being born alive if prescnt,ing by breech, and delivered vaginally. How shall these cases be managed! The man who has had a large experience in the management of breech presentations could have managed successfully the vaginal delivery of some of these cases; in a large hospital service thcrc are times when the breech will not have been recognized during pregnancy, thr resident, staff or a man with limited experience in handling breech labors will at, times be forcetl to manage them. It would seem that rccoguitiou CJC the brcecli is imperative, in all doubtful cases x-ray shonltl be usctl for diagnosis. The size of the child should be dctcrmincd, it is usually possible to judge fairly accurately as to whether it is large or not. If in doubt t,he method of Thorns, which adapts the perforated lcad plate to a plant which corresponds to the plane of the inlet of the pelvis ma? be adopted. If the baby is then considered large, the expediency of doing a cesarean section must be considered. There are some n-ho believe that all primiparae thirty-five years of age or older shonltl be dcliveretl of il breech by a cesarcan section. Instead of this dictum we should accept the one t.hat all breech babies which weigh over S pounds should be delivered by cesarean section, if the assurance of a living child warrants the additional risk to the mother. It should always be planned to do an elective section when possible. This dictum sl~o~~ld be a.ccepted only by trained obstetricians. In drawing conclusions from this series of cases, we should first recommend that all cases of breech present,ation should be studied very carefully during the prenatal period. Each obstetrician should aim to be present. at as many breech cleliveries as possible so as to constantly keep himself in practice by managing breech labors frequently. Finally the size of the child should be considered more in the management of the breech presentation, thaTi the age and parity of the patient.