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Examination of data base in midforceps delivery study
CORRESPONDENCE
Examination of data base in midforceps delivery study To the Editors: We would once again like to call the attention of your readers to the review article by Richardson et al. (Midforceps delivery: a critical review. AM .J 0BSTET GYNECOL 1983; 145:621). We believe that their review thoroughly presented the problem with mid forceps definitions, potential neonatal mortality and morbidity, as well as an objective evaluation of the data (or lack of data) in regard to continued judicious use of midforceps deliveries in the 1980s. They discussed the design deficiencies in the collaborative perinatal project as a whole, as well as in reports in which a small subgroup of project patients were analyzed for specific aspects of neonatal outcome in relation to only a few of the many potential variables, that is, arrest and descent disorders, and spontaneous versus low- or midforceps delivery. Perhaps more importantly, even if all of the potential variables listed by Richardson et al. were controlled for, the collaborative pn~ject patients did not have continuous electronic fetal monitoring. We would clearly anticipate a worse immediate neonatal outcome in terms of Apgar scores, neonatal acidosis, etc., when the indication for either midforceps or cesarean delivery is fetal distress as compared to an arrest of descent. Indeed, we reported significantly lower Apgar scores and umbilical cord pH's (less than 7.2) in both midforcep and cesarean deliveries performed for fetal distress versus arrest of labor disorders. 1 The recent condemnation of midforceps deliveries of Friedman et al." must be carefully reconsidered before acceptance inasmuch as they presented no data regarding the predelivery status of these neonates as reAeCled by the intrapartum fetal heart rate, presence or absence of late or severe variable decelerations, and/ or variability. This is by far the most commonly used method for ascertaining intrapartum fetal well-being in the 1980s, a technology not used during the collection of the collaborative perinatal project data. Thus Friedman et al. provided us with no information regarding the status of these neonates before their delivery by either cesarean section or low- or midforceps. The analysis of neonatal outcome in regard to arrest or protraction disorders and type of operative delivery has many variables, as Richardson et al. reported. In our opinion one must ensure that all fetuses began the actual delivery process in a reasonably similar state of well-being before condemning a particular method of delivery. Today this is routinely and best accomplished by continuous electronic fetal heart rate and pattern monitoring. The data of the collaborative project did not address this most important variable and, in our opinion, their ability to be used for such purposes has been exhausted. One must seriously question whether 814
the data base of the perinatal collaborative group, rather than the midforceps delivery, is not the real obstetric anachronism. john C. Hauth, M.D. Lany C. Gil1trap Ill, M.D. Gary D. V. Hankins, M.D. Department of Obstetrics and Gynecology Wilford Hall USAF Medical Center/SGHPG Lackland Air Force Base, Texas 78236-5300 REFERENCES I. (;iJstrap LC, Hauth .JC, Schiano S, Connor KD. Neonatal
acidosis and method of delivery. Obstet c;ynecol 1984;63:68 I. 2. Friedman EA, Sachtleben-Murray MS, Dahrouge D, Neff RK. Long-term effects of labor and delivery on offspring: a matched-pair analysis. A~!J OBSTET Gna:cm. 1984; 150: 941. The influence of fetal sex on rupture of the membranes and preterm labor To the Editors: It has been observed bv Hall and Carr-Hill 1 that labor starts earlier in pregnancies with male fetuses as compared to those with female fetuses. The reason for this is obscure, but it is possible that in the case of male fetuses there is production of androgens, which cause an imbalance in the estrogen/progesterone ratio and thus earlier inducement of uterine activity. The other possible reason is that in pregnancies with male fetuses premature rupture of the membranes may occur more often than in those with female fetuses. In order to investigate this, the records of Cape Colored women admitted to the Peninsula Maternity Service with preterm delivery in 1984 were studied. There were 237 women delivered before 37 weeks' gestation, and they were divided into those with boy babies and those with girl babies. The distribution of births by sex and the overall ratios of boy deliveries to girl deliveries by gestational age are shown in Table I. The cases were further divided into those with the onset of preterm labor with contractions and those with the onset with
Table I. Spontaneous preterm labor in singleton Cape Colored women from Groote Schuur Hospital records in 1984 Gestation
No. of boys
No. of
All
(wk)
girL1
(11)
Boylgirl ratio
24-27 28-30 31-33 34-36 Total
20 18 17 70 125
12 8 25 67 112
32 26 42 137 237
1.67: 2.25: 0.68: 1.04: 1.12:
I I I I I
Examination of data base in midforceps delivery study To the Editors: We would once again like to call the attention of your readers to the review article by Richardson et al. (Midforceps delivery: a critical review. AM .J 0BSTET GYNECOL 1983; 145:621). We believe that their review thoroughly presented the problem with mid forceps definitions, potential neonatal mortality and morbidity, as well as an objective evaluation of the data (or lack of data) in regard to continued judicious use of midforceps deliveries in the 1980s. They discussed the design deficiencies in the collaborative perinatal project as a whole, as well as in reports in which a small subgroup of project patients were analyzed for specific aspects of neonatal outcome in relation to only a few of the many potential variables, that is, arrest and descent disorders, and spontaneous versus low- or midforceps delivery. Perhaps more importantly, even if all of the potential variables listed by Richardson et al. were controlled for, the collaborative pn~ject patients did not have continuous electronic fetal monitoring. We would clearly anticipate a worse immediate neonatal outcome in terms of Apgar scores, neonatal acidosis, etc., when the indication for either midforceps or cesarean delivery is fetal distress as compared to an arrest of descent. Indeed, we reported significantly lower Apgar scores and umbilical cord pH's (less than 7.2) in both midforcep and cesarean deliveries performed for fetal distress versus arrest of labor disorders. 1 The recent condemnation of midforceps deliveries of Friedman et al." must be carefully reconsidered before acceptance inasmuch as they presented no data regarding the predelivery status of these neonates as reAeCled by the intrapartum fetal heart rate, presence or absence of late or severe variable decelerations, and/ or variability. This is by far the most commonly used method for ascertaining intrapartum fetal well-being in the 1980s, a technology not used during the collection of the collaborative perinatal project data. Thus Friedman et al. provided us with no information regarding the status of these neonates before their delivery by either cesarean section or low- or midforceps. The analysis of neonatal outcome in regard to arrest or protraction disorders and type of operative delivery has many variables, as Richardson et al. reported. In our opinion one must ensure that all fetuses began the actual delivery process in a reasonably similar state of well-being before condemning a particular method of delivery. Today this is routinely and best accomplished by continuous electronic fetal heart rate and pattern monitoring. The data of the collaborative project did not address this most important variable and, in our opinion, their ability to be used for such purposes has been exhausted. One must seriously question whether 814
the data base of the perinatal collaborative group, rather than the midforceps delivery, is not the real obstetric anachronism. john C. Hauth, M.D. Lany C. Gil1trap Ill, M.D. Gary D. V. Hankins, M.D. Department of Obstetrics and Gynecology Wilford Hall USAF Medical Center/SGHPG Lackland Air Force Base, Texas 78236-5300 REFERENCES I. (;iJstrap LC, Hauth .JC, Schiano S, Connor KD. Neonatal
acidosis and method of delivery. Obstet c;ynecol 1984;63:68 I. 2. Friedman EA, Sachtleben-Murray MS, Dahrouge D, Neff RK. Long-term effects of labor and delivery on offspring: a matched-pair analysis. A~!J OBSTET Gna:cm. 1984; 150: 941. The influence of fetal sex on rupture of the membranes and preterm labor To the Editors: It has been observed bv Hall and Carr-Hill 1 that labor starts earlier in pregnancies with male fetuses as compared to those with female fetuses. The reason for this is obscure, but it is possible that in the case of male fetuses there is production of androgens, which cause an imbalance in the estrogen/progesterone ratio and thus earlier inducement of uterine activity. The other possible reason is that in pregnancies with male fetuses premature rupture of the membranes may occur more often than in those with female fetuses. In order to investigate this, the records of Cape Colored women admitted to the Peninsula Maternity Service with preterm delivery in 1984 were studied. There were 237 women delivered before 37 weeks' gestation, and they were divided into those with boy babies and those with girl babies. The distribution of births by sex and the overall ratios of boy deliveries to girl deliveries by gestational age are shown in Table I. The cases were further divided into those with the onset of preterm labor with contractions and those with the onset with
Table I. Spontaneous preterm labor in singleton Cape Colored women from Groote Schuur Hospital records in 1984 Gestation
No. of boys
No. of
All
(wk)
girL1
(11)
Boylgirl ratio
24-27 28-30 31-33 34-36 Total
20 18 17 70 125
12 8 25 67 112
32 26 42 137 237
1.67: 2.25: 0.68: 1.04: 1.12:
I I I I I