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Fetal and Neonatal Results in Breech Presentation in the Primiparous Patient at Term
PETAL AND NJIONATAL BIIWL..a IN UBOH PB:UDTATION IN THE PIU!4IPABOUS PATIENT AT TllltM \VILLIAM PoMERANCE, M.D., F.A.C.S., AND IsiDORE DAICHMAN, M.D., F.A.C.S., BROOKLYN,
N. Y.
(From the Jewish Hospital of Brooklyn)
HII. E the fetal mortality for breech delivery has been variously given as ranging from 3.8 to 52 per cent, it is quite clear that the corrected fetal mortality for term fetuses is somewhat less than 5 per cent (Dieckmann, Cox). What part of this fetal loss is directly attributable to the abnormal presentation is, as yet, not as clear. Also what readily discernible clinical characteristics are associated with the high fetal losses are likewise not clear. This report is an attempt to reach some conclusion in regard to these last two considerations.
W
Material This study is concerned with 716 breech presentations occurring in primiparous patients during the years 1939 through 1948 at the Jewish Hospital of Brooklyn. All of these cases were primary breech presentations and in each case only a single fetus was present, and in each case the fetus weighed 5 pounds or over. Multiparas were not studied because it was felt that a separate review of these should be made. Multiple births also were omitted because these included other complications besides the one of presentation. Likewise, fetuses under 5 pounds were excluded because they represented an additional complicating factor of prematurity that seemed to be beyond the scope of this paper. These 716 cases included 621 (86.7 per cent) patients delivered vaginally and 95 (13.3 per cent) patients delivered by cesarean section. The former group was analyzed as to the influence of age of the patient, weight of the fetus, method of delivery, duration of labor, duration of second stage, type of breech presentation, and duration of ruptured membranes. lncidence.-There were 41,135 deliveries at the Jewish Hospital during the years studied. ·Of these, 19,498 were primiparous patients; and of these 18,387 infants weighed 5 pounds or over. Therefore, our incidence of breech presentation in primiparous patients with fetuses weighing 5 pounds or over was 3.9 per cent (Table I). Petal and Neonatal Loss.-There were 32 stillbirths and neonatal deaths, or an uncorrected fetal loss of 4.5 per cent. However, since all of our fetal and neonatal loss occurred in vaginal deliveries, we have related this :figure to the 621 vaginal deliveries, or a loss of 5.1 per cent. 'fhis figure should becompared with our figure of 1.4 per cent fetal and neonatal loss occurring at our hospital in all fetuses 5 pounds or over, indicating an approximate loss of 3.7 per cent due to the vaginal delivery of such fetuses in primiparous patients. An approximation is likev.rise obtained by correcting the fetal and neonatal loss for antepartum deaths (3 cases) and for fetal abnormality inconsistent 110
Volume64 Number I
111
FE'l'AL AND NEONATAL RESULTS IN BREECH PRESENTATION
with life (2 cases) and for neonatal infection (1 case), which resulted in a fetal loss figure of 4.2 per cent (Table II). It seems, therefore, that it can be safely said that vaginal delivery of a fetus weighing over 5 pounds increases the fetal loss approximately 4 per cent. TABL};
I.
BREECH PRESENTATION IN PRIMIPAROUS DELIVERIES
Total number of primiparous deliveries Total number of primiparous deliveries, infants 5 pounds or over Total number of primiparous breech deliveries
The 26 fetal and neonatal deaths occurring in the 615 vaginal deliveries are analyzed with respect to certain clinical variations as noted above. These are presented in table and chart form and are herewith summarized. TABLE
II.
CORRECTED FETAL AND NEONATAL LOSS FOR VAGINAL DELIVERIES
cases Corrected for antepartum fetal deaths Corrected for fetal abnormality and neonatal infection
618 615
29 26
4.7
4.2
Fetal results in relation to the weight of the fetus: An analysis of Table III and Fig. 1 shows that when the fetus weighs 9 pounds or over there is a marked increase in the fetal and neonatal loss and only a moderate variation below that weight level. · Fetal results in relation to age of patient: Table IV shows that there is no relationship between the age of the patient and fetal and neonatal loss. TABI,E
III.
FETAL A~D NEONATAL LOSS I~ RELATION TO WEIGHT OF FETUS
ounces 6 pounds to 6 pounds, 15 ounces 7 pounds to 7 pounds, 15 ounces R pounds to 8 pounds, 15 ounces 9 and over
232
5
20i
10
68
.,
2.1 4-.i\ 2.9
20
5
25.0
Fetal results in relation to method of delivery: When breech extraction is necessary the fetal loss increases moderately (from 1.7 per cent to 4.0 per cent) and when breech extraction and forceps on the after-coming head (which are not used routinely at our hospital) are necessary, the fetal and neonatal losses ure increased very considerably (from 4.0 per cent to 14.5 per cent). TABLE
IV.
FETAL AND NEONATAL Loss IN RELATION TO AGE OF PATIENT
20 to 29
30 to 39 40 and over
450 140
5
18 i 0
4.0 5.0 0.0
112
POMERANCE AND DAlCHMAN
Am . .J OlH.
&
lu!y.
. • Fig. 1.·-Fetal and neonatal loss in relation to weight of fetus.
-.
18'
£
lS
.._
fl2
fiJ
a
j M ~
12
""'"' t(
9
~
t!
fi
~
6
i4
.3
DURATION
OF
LA.&:lR
(HOURS)
Fig. 2.~Fetal and neonatal Joss in relation to duration of labor.
Volume 64
Number l
FETAL AND NEONATAL RESULTS IN BREECH PRESENTATION
lt:l
Fetal result in relation to total duration of labor: Table V and Fig. 2 show that the fetal and neonatal loss increases considerably when the labor is over 24 hours and quite markedly when the labor is over 48 hours. TAJli,E V.
FETAL AND NEONATAl, LOSS IN R~;LATION TO DURATION OF LABOR
12 to 24 24 to 48
215 75 21
Over 4.8
6 7 4
Fetal result in relation to duration of second stage: Table VI and "B'ig. 8 show a slight increase in fetal and neonatal loss when the second stage is under a half-hour and a considerable increase in such loss when the second stage i;.; over two hours. · TABLR
VI.
FETAL AND NEONATAL LOSS IN HE!u\TION To DntAT!O:.i OF RECoNJ> i-l'I'.\HE
One-half to one One to two Over two Unknown
186
6
3.:.!
200
6
H.O
85
7 0
H.:!
7
0.0
Fetal result in relation to duration of ruptured meml>ranes: Table VIJ and Fig. 4 indicate a considerable increase in fetal Joss when the membranes are ruptured over 48 hours. TABLE VJT.
FETAL AND NEONATAL LOSS IN RELATION 'l'O DURATION
m' RUPTI'REli
MF:~IBRANI:~
DURATION OF RUPTURED MEMBRANES
12 to 24 24 to 48 48 and over
100
3
64 31
2
:~.l
5 4
lti.1 12.5
32
Unknown --··----
il.O
~-~--~---~--
Fetal result in relation to type of breech: Analysis of Table VIII shows that complete or footling breech results in a definitely increased fetal loss over frank breech. TABI,E
VIII.
Undetermined
FETAL AND NEONATAl, LOSS IN RELATIOX TO TYPE OF BREECH
lJA
:\m
DURATION
OF
SECOND
STAGE
f.
Ol»t. & Gynec J"ly. l9S:.:
(HOURS)
Fig. 3.-Fetal and neonatal loss in relation to duration of second stage.
16
....
12 10
8 6
4 2
UNDER
l2
DURATION
12-:lk
OF RUPfURED MEii!BRANES
(HOURS)
Fig. 4.-Fetal and neonatal loss in relation to duration of ruptured membranes.
""
Volume64 Number I
FETAL AND NEONATAL RESULTS IN BREECH PRES:RNTATlON
llfi
Petal Morbidity.-The fetal morbidity associated with breech presentation is probably as important as the fetal mortality, in so far as many of the injuries (3.7 per cent) are of a permanent and serious nature. In our series there were 11 cases of Erb 's palsy, 4 cerebral injuries, 6 fractured long bones, 2 spinal injuries, 1 skull fracture. There were also 5 cases of torticollis and hematoma of sternocleidomastoid muscle and 12 fetal abnormalities ( 5 had clubfeet others were cardiacs, spina bifida) (Table lXJ. TABLE
IX.
NEONATAL MORBIDITY IN ~URYIVIKG BABIES SECTION
injuries Fracture of long hones Spinal injuries Skull fracture Torticollis and hematomas of sternocleidomastoid Fetal abnormalities
3 6 2 1 5 12
Cerebral injury
Fetal abnormalities
:l
l)
Prolapsed Cord.-There were 12 prolapsed cords in our entire series. Nine of the 12 cases were associated with footling presentation. There were 3 stillbirths (25 per cent fetal mortality) among these 12-one ante partum and two intra partum. Nine of the 12 infants were delivered vaginally; all of the stillborn infants were delivered vaginally. Stillbirths and Neonatal Deatks.-As noted above, of the total of 32 fetal and neonatal deaths, 3 were antepartum deaths. Of the others, 5 fetal deaths occurred during labor, 14 infants were lost during the delivery, and 10 deaths were neonatal (Table X). All 3 antepartum deaths were of infants in footling presentation and one had a prolapsed cord-no other causes for these deaths were ascertainable. Of the 10 neonatal deaths, 7 were due to cerebral injuries, one infant was an anencephalic monster, one died of infection, and one died following surgery for correction of an omphalocele. TABLE
X.
STILLBIRTHS AND NEONATAL DEA'riiS
NEONATAL DEATHS
Cause::;: 7 cerebral injury 1 anencephaly 1 infection 1
Cesarean Section.-Of the 716 cases studied, 95, or 13.3 per cent, were delivered by cesarean section (Table XI). Two mothers died (2.1 per cent); the fetal mortality was zero. A brief abstract of the two maternal deaths wiH he 'l'ABLE
XI.
FETAL AND NEONATAL Loss IN PRIMIPAROUS BREEC'H DF:I,IVERY (lm'ANTS 5 POUNDS AND OVER)
116
PO~fERANCJ<~
Ai-!D JJAICHMAN
Am.
J.
Obst. & .f
given later. The indications for cesarean section were usually several in number. Blderly primiparity (33 years or over) was an important factor iH 27 eases ( 28.4 per cent). Additional indications were toxemia ( 6 eases), eolttracted pelvis (41 cases), sterility (13 cases), uterine inertia (7 cases), large baby, fibroids, double vagina, and prolapsed cord ( 3 cases). The breech presentation plus some of the above-mentioned indications were the common reasons for doing the section. Cesarean section has been advocated by some observers in breech presentation when the baby weighs 9 pounds or over (Potter). 'l'he reason given for this is the high fetal mortality associated with these very large babies. This particular fact is well brought out in our group of 621 vaginal deliveries. In this group there were 20 babies that weighed 9 or more pounds, and of these, 5, or 25 per cent,·were stillborn. In our section group of 95 cases, the large size of the baby, when suspected, was occasionally an additional factor in the decision to do a section, hut it was rarely the only factor. Almost every patient with a large breech that was delivered by section had one or more additional indications present which influenced the decision in favor· of abdominal delivery. A study of the duration of labor, duration of r·uptured membranes, and type of breech presentation did not yield any particularly worth-while information. Maternal Jlortality.-Two mothers died. CASE 1.--A 34-year-old primipara, 38 weeks pregnant, with footling presentation and android pelvis, had ruptured membranes for six hours, but no labor. Low ilap section and subserous myomectomy were done under general anesthesia. The baby weighed 7 pounds, 2 ounce~, and is alive. and well. The mother had a temperature elevation for five days. She died suddenly on the sixteenth day. No autopsy was obtained. CASE 2.-'l'he patient was a 26-year-old primipara at term with ruptured membranes for eight hours, in mild labor with a footling breech and prolapsed cord and a small gynecoid pelvis. Cesarean section was done under local and Pentothal Sodium anesthesia with delivery of a markedly asphyxiated infant that survived with definite cerebral injury. 'fhe mother went into shock six hours afte.r operation and died within one hour. There was no autopsy.
Fetal1tlortality.-There was no fetal mortality. Fetal Morbidity.-Of the 95 section babies there was one case of cerebral injury, three fetal deformities, and one clubfoot. Discussion of Use of Section.-From the above review of our 95 sections, three facts stand out prominently: The fetal mortality of zero, the decreased fetal morbidity, and two maternal deaths. ·while the absence of any fetal mortality is a worth-while achievement, the loss of two mothers is certainly serious enough to make us realize that there is a definitely increased risk to the mothers. Our average maternal mortality in cesarean section is less than 0.5 per cent; even this figure represents a considerable increase over the maternal mortality by vaginal delivery. We do not believe that one balances the other by any means, and would therefore suggest that the decision to deliver a given case of breech presentation by the abdominal route should be given very serious consideration. The fetal morbidity is definitely lower by section than by vaginal delivery as is to be expected. This, like the fetal mortality of zero, is very desirable, but, to emphasize again, it is bought at a price of increased maternal mortality.
...
Summary
1. Seven hundred sixteen eases of single, full-term, primiparous breech presentations were reviewed.
...,_.--
Volume64 Number I
FETAL AND NEONATAL RESULTS IN BREECH PRESENTATION
117
2. An attempt was made to determine the percentage of fetal mortality due to the presentation per se-in this report approximately 3.7 per cent. a. Cesarean section resulted in an increased fetal salvage, but at an increased maternal cost. 4. Vaginal delivery of babies weighing over 9 pounds resulted in very high fetal loss. G. Breech extraction with forceps for after-coming head resulted in an incr·eased fetal mortality. G. Vaginal delivery after 48 hours of labor and/or ruptur·ed memhranPs Lot· the same period of time resulted in considerably increased fetal loss. 7. Fetal morbidity in the vaginal deliveries was considerable, and in many instances of a serious nature. 8. Prolapsed cord, usually associated with footling pr·esentation, is also associated with a high fetal loss.
References Cox, Lloyd Woodrow: J. Obst. & Gynaee. Brit. }Jmp. 57: 197, Hl50. Dieckmann, William J.: AM. J. OssT. & GYNEC. 52: 3411, Ul41i. Potter, Milton G., Erving, Henry W., and Brown, .f. Hn":e: AM ..T. OnsT. & Gv!'mc. 49: 567, 1945. \) PROSPECT PARK, WEST
N. Y.
(From the Jewish Hospital of Brooklyn)
HII. E the fetal mortality for breech delivery has been variously given as ranging from 3.8 to 52 per cent, it is quite clear that the corrected fetal mortality for term fetuses is somewhat less than 5 per cent (Dieckmann, Cox). What part of this fetal loss is directly attributable to the abnormal presentation is, as yet, not as clear. Also what readily discernible clinical characteristics are associated with the high fetal losses are likewise not clear. This report is an attempt to reach some conclusion in regard to these last two considerations.
W
Material This study is concerned with 716 breech presentations occurring in primiparous patients during the years 1939 through 1948 at the Jewish Hospital of Brooklyn. All of these cases were primary breech presentations and in each case only a single fetus was present, and in each case the fetus weighed 5 pounds or over. Multiparas were not studied because it was felt that a separate review of these should be made. Multiple births also were omitted because these included other complications besides the one of presentation. Likewise, fetuses under 5 pounds were excluded because they represented an additional complicating factor of prematurity that seemed to be beyond the scope of this paper. These 716 cases included 621 (86.7 per cent) patients delivered vaginally and 95 (13.3 per cent) patients delivered by cesarean section. The former group was analyzed as to the influence of age of the patient, weight of the fetus, method of delivery, duration of labor, duration of second stage, type of breech presentation, and duration of ruptured membranes. lncidence.-There were 41,135 deliveries at the Jewish Hospital during the years studied. ·Of these, 19,498 were primiparous patients; and of these 18,387 infants weighed 5 pounds or over. Therefore, our incidence of breech presentation in primiparous patients with fetuses weighing 5 pounds or over was 3.9 per cent (Table I). Petal and Neonatal Loss.-There were 32 stillbirths and neonatal deaths, or an uncorrected fetal loss of 4.5 per cent. However, since all of our fetal and neonatal loss occurred in vaginal deliveries, we have related this :figure to the 621 vaginal deliveries, or a loss of 5.1 per cent. 'fhis figure should becompared with our figure of 1.4 per cent fetal and neonatal loss occurring at our hospital in all fetuses 5 pounds or over, indicating an approximate loss of 3.7 per cent due to the vaginal delivery of such fetuses in primiparous patients. An approximation is likev.rise obtained by correcting the fetal and neonatal loss for antepartum deaths (3 cases) and for fetal abnormality inconsistent 110
Volume64 Number I
111
FE'l'AL AND NEONATAL RESULTS IN BREECH PRESENTATION
with life (2 cases) and for neonatal infection (1 case), which resulted in a fetal loss figure of 4.2 per cent (Table II). It seems, therefore, that it can be safely said that vaginal delivery of a fetus weighing over 5 pounds increases the fetal loss approximately 4 per cent. TABL};
I.
BREECH PRESENTATION IN PRIMIPAROUS DELIVERIES
Total number of primiparous deliveries Total number of primiparous deliveries, infants 5 pounds or over Total number of primiparous breech deliveries
The 26 fetal and neonatal deaths occurring in the 615 vaginal deliveries are analyzed with respect to certain clinical variations as noted above. These are presented in table and chart form and are herewith summarized. TABLE
II.
CORRECTED FETAL AND NEONATAL LOSS FOR VAGINAL DELIVERIES
cases Corrected for antepartum fetal deaths Corrected for fetal abnormality and neonatal infection
618 615
29 26
4.7
4.2
Fetal results in relation to the weight of the fetus: An analysis of Table III and Fig. 1 shows that when the fetus weighs 9 pounds or over there is a marked increase in the fetal and neonatal loss and only a moderate variation below that weight level. · Fetal results in relation to age of patient: Table IV shows that there is no relationship between the age of the patient and fetal and neonatal loss. TABI,E
III.
FETAL A~D NEONATAL LOSS I~ RELATION TO WEIGHT OF FETUS
ounces 6 pounds to 6 pounds, 15 ounces 7 pounds to 7 pounds, 15 ounces R pounds to 8 pounds, 15 ounces 9 and over
232
5
20i
10
68
.,
2.1 4-.i\ 2.9
20
5
25.0
Fetal results in relation to method of delivery: When breech extraction is necessary the fetal loss increases moderately (from 1.7 per cent to 4.0 per cent) and when breech extraction and forceps on the after-coming head (which are not used routinely at our hospital) are necessary, the fetal and neonatal losses ure increased very considerably (from 4.0 per cent to 14.5 per cent). TABLE
IV.
FETAL AND NEONATAL Loss IN RELATION TO AGE OF PATIENT
20 to 29
30 to 39 40 and over
450 140
5
18 i 0
4.0 5.0 0.0
112
POMERANCE AND DAlCHMAN
Am . .J OlH.
&
lu!y.
. • Fig. 1.·-Fetal and neonatal loss in relation to weight of fetus.
-.
18'
£
lS
.._
fl2
fiJ
a
j M ~
12
""'"' t(
9
~
t!
fi
~
6
i4
.3
DURATION
OF
LA.&:lR
(HOURS)
Fig. 2.~Fetal and neonatal Joss in relation to duration of labor.
Volume 64
Number l
FETAL AND NEONATAL RESULTS IN BREECH PRESENTATION
lt:l
Fetal result in relation to total duration of labor: Table V and Fig. 2 show that the fetal and neonatal loss increases considerably when the labor is over 24 hours and quite markedly when the labor is over 48 hours. TAJli,E V.
FETAL AND NEONATAl, LOSS IN R~;LATION TO DURATION OF LABOR
12 to 24 24 to 48
215 75 21
Over 4.8
6 7 4
Fetal result in relation to duration of second stage: Table VI and "B'ig. 8 show a slight increase in fetal and neonatal loss when the second stage is under a half-hour and a considerable increase in such loss when the second stage i;.; over two hours. · TABLR
VI.
FETAL AND NEONATAL LOSS IN HE!u\TION To DntAT!O:.i OF RECoNJ> i-l'I'.\HE
One-half to one One to two Over two Unknown
186
6
3.:.!
200
6
H.O
85
7 0
H.:!
7
0.0
Fetal result in relation to duration of ruptured meml>ranes: Table VIJ and Fig. 4 indicate a considerable increase in fetal Joss when the membranes are ruptured over 48 hours. TABLE VJT.
FETAL AND NEONATAL LOSS IN RELATION 'l'O DURATION
m' RUPTI'REli
MF:~IBRANI:~
DURATION OF RUPTURED MEMBRANES
12 to 24 24 to 48 48 and over
100
3
64 31
2
:~.l
5 4
lti.1 12.5
32
Unknown --··----
il.O
~-~--~---~--
Fetal result in relation to type of breech: Analysis of Table VIII shows that complete or footling breech results in a definitely increased fetal loss over frank breech. TABI,E
VIII.
Undetermined
FETAL AND NEONATAl, LOSS IN RELATIOX TO TYPE OF BREECH
lJA
:\m
DURATION
OF
SECOND
STAGE
f.
Ol»t. & Gynec J"ly. l9S:.:
(HOURS)
Fig. 3.-Fetal and neonatal loss in relation to duration of second stage.
16
....
12 10
8 6
4 2
UNDER
l2
DURATION
12-:lk
OF RUPfURED MEii!BRANES
(HOURS)
Fig. 4.-Fetal and neonatal loss in relation to duration of ruptured membranes.
""
Volume64 Number I
FETAL AND NEONATAL RESULTS IN BREECH PRES:RNTATlON
llfi
Petal Morbidity.-The fetal morbidity associated with breech presentation is probably as important as the fetal mortality, in so far as many of the injuries (3.7 per cent) are of a permanent and serious nature. In our series there were 11 cases of Erb 's palsy, 4 cerebral injuries, 6 fractured long bones, 2 spinal injuries, 1 skull fracture. There were also 5 cases of torticollis and hematoma of sternocleidomastoid muscle and 12 fetal abnormalities ( 5 had clubfeet others were cardiacs, spina bifida) (Table lXJ. TABLE
IX.
NEONATAL MORBIDITY IN ~URYIVIKG BABIES SECTION
injuries Fracture of long hones Spinal injuries Skull fracture Torticollis and hematomas of sternocleidomastoid Fetal abnormalities
3 6 2 1 5 12
Cerebral injury
Fetal abnormalities
:l
l)
Prolapsed Cord.-There were 12 prolapsed cords in our entire series. Nine of the 12 cases were associated with footling presentation. There were 3 stillbirths (25 per cent fetal mortality) among these 12-one ante partum and two intra partum. Nine of the 12 infants were delivered vaginally; all of the stillborn infants were delivered vaginally. Stillbirths and Neonatal Deatks.-As noted above, of the total of 32 fetal and neonatal deaths, 3 were antepartum deaths. Of the others, 5 fetal deaths occurred during labor, 14 infants were lost during the delivery, and 10 deaths were neonatal (Table X). All 3 antepartum deaths were of infants in footling presentation and one had a prolapsed cord-no other causes for these deaths were ascertainable. Of the 10 neonatal deaths, 7 were due to cerebral injuries, one infant was an anencephalic monster, one died of infection, and one died following surgery for correction of an omphalocele. TABLE
X.
STILLBIRTHS AND NEONATAL DEA'riiS
NEONATAL DEATHS
Cause::;: 7 cerebral injury 1 anencephaly 1 infection 1
Cesarean Section.-Of the 716 cases studied, 95, or 13.3 per cent, were delivered by cesarean section (Table XI). Two mothers died (2.1 per cent); the fetal mortality was zero. A brief abstract of the two maternal deaths wiH he 'l'ABLE
XI.
FETAL AND NEONATAL Loss IN PRIMIPAROUS BREEC'H DF:I,IVERY (lm'ANTS 5 POUNDS AND OVER)
116
PO~fERANCJ<~
Ai-!D JJAICHMAN
Am.
J.
Obst. & .f
given later. The indications for cesarean section were usually several in number. Blderly primiparity (33 years or over) was an important factor iH 27 eases ( 28.4 per cent). Additional indications were toxemia ( 6 eases), eolttracted pelvis (41 cases), sterility (13 cases), uterine inertia (7 cases), large baby, fibroids, double vagina, and prolapsed cord ( 3 cases). The breech presentation plus some of the above-mentioned indications were the common reasons for doing the section. Cesarean section has been advocated by some observers in breech presentation when the baby weighs 9 pounds or over (Potter). 'l'he reason given for this is the high fetal mortality associated with these very large babies. This particular fact is well brought out in our group of 621 vaginal deliveries. In this group there were 20 babies that weighed 9 or more pounds, and of these, 5, or 25 per cent,·were stillborn. In our section group of 95 cases, the large size of the baby, when suspected, was occasionally an additional factor in the decision to do a section, hut it was rarely the only factor. Almost every patient with a large breech that was delivered by section had one or more additional indications present which influenced the decision in favor· of abdominal delivery. A study of the duration of labor, duration of r·uptured membranes, and type of breech presentation did not yield any particularly worth-while information. Maternal Jlortality.-Two mothers died. CASE 1.--A 34-year-old primipara, 38 weeks pregnant, with footling presentation and android pelvis, had ruptured membranes for six hours, but no labor. Low ilap section and subserous myomectomy were done under general anesthesia. The baby weighed 7 pounds, 2 ounce~, and is alive. and well. The mother had a temperature elevation for five days. She died suddenly on the sixteenth day. No autopsy was obtained. CASE 2.-'l'he patient was a 26-year-old primipara at term with ruptured membranes for eight hours, in mild labor with a footling breech and prolapsed cord and a small gynecoid pelvis. Cesarean section was done under local and Pentothal Sodium anesthesia with delivery of a markedly asphyxiated infant that survived with definite cerebral injury. 'fhe mother went into shock six hours afte.r operation and died within one hour. There was no autopsy.
Fetal1tlortality.-There was no fetal mortality. Fetal Morbidity.-Of the 95 section babies there was one case of cerebral injury, three fetal deformities, and one clubfoot. Discussion of Use of Section.-From the above review of our 95 sections, three facts stand out prominently: The fetal mortality of zero, the decreased fetal morbidity, and two maternal deaths. ·while the absence of any fetal mortality is a worth-while achievement, the loss of two mothers is certainly serious enough to make us realize that there is a definitely increased risk to the mothers. Our average maternal mortality in cesarean section is less than 0.5 per cent; even this figure represents a considerable increase over the maternal mortality by vaginal delivery. We do not believe that one balances the other by any means, and would therefore suggest that the decision to deliver a given case of breech presentation by the abdominal route should be given very serious consideration. The fetal morbidity is definitely lower by section than by vaginal delivery as is to be expected. This, like the fetal mortality of zero, is very desirable, but, to emphasize again, it is bought at a price of increased maternal mortality.
...
Summary
1. Seven hundred sixteen eases of single, full-term, primiparous breech presentations were reviewed.
...,_.--
Volume64 Number I
FETAL AND NEONATAL RESULTS IN BREECH PRESENTATION
117
2. An attempt was made to determine the percentage of fetal mortality due to the presentation per se-in this report approximately 3.7 per cent. a. Cesarean section resulted in an increased fetal salvage, but at an increased maternal cost. 4. Vaginal delivery of babies weighing over 9 pounds resulted in very high fetal loss. G. Breech extraction with forceps for after-coming head resulted in an incr·eased fetal mortality. G. Vaginal delivery after 48 hours of labor and/or ruptur·ed memhranPs Lot· the same period of time resulted in considerably increased fetal loss. 7. Fetal morbidity in the vaginal deliveries was considerable, and in many instances of a serious nature. 8. Prolapsed cord, usually associated with footling pr·esentation, is also associated with a high fetal loss.
References Cox, Lloyd Woodrow: J. Obst. & Gynaee. Brit. }Jmp. 57: 197, Hl50. Dieckmann, William J.: AM. J. OssT. & GYNEC. 52: 3411, Ul41i. Potter, Milton G., Erving, Henry W., and Brown, .f. Hn":e: AM ..T. OnsT. & Gv!'mc. 49: 567, 1945. \) PROSPECT PARK, WEST