Fetal mortality in contracted pelvis with prolonged labor and delivery through the birth canal

Fetal mortality in contracted pelvis with prolonged labor and delivery through the birth canal

FETAL MORTALlTY IN CONTRACTED LONGED LABOR AND DELIVERY THE BIRTH CANAL PELVIS WITH THROIJGH PRO- C. H. Pmxmnc, M.D., AND Ei. RUDER, M.D., BALTIMO...

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FETAL

MORTALlTY IN CONTRACTED LONGED LABOR AND DELIVERY THE BIRTH CANAL

PELVIS WITH THROIJGH

PRO-

C. H. Pmxmnc, M.D., AND Ei. RUDER, M.D., BALTIMORE, &ID. (Prom the Departtm.ent of Obstetric, the Joh.ns Hopkkas Uaivwsity mnd Hospital)

T

HE decision as to the course to be pursued in the management of casesof so-c.alled“ borderline’ ’ contracted pelvis is a particularly difficult one. No clinical judgment is required to predict delivery through t,he birt,h canal in a woman whose pelvic measurements are normal and whose child is not excessive in size. Likewise, it is simple to elect cesarean section for a term pregnancy in a case of marked pelvic contraction. However, a decision as to elective section or trial of labor in a patient whose pelvis is slightly contracted, when the child does not seem overly large, and when disproportion is slight, calls for the nicest clinical judgment,. In an effort to avoid unnecessary cesarean sections the custom has developed in doubtful casesof allowing the patient a “test of labor!’ which may terminate in normal delivery or delivery through the abdomen by the low cervical route. This test, of labor has received many interpretations, varying from a certain number of hours of first stage pains to a duration of two hours in the second stage of labor. It was the definite feeling of the late Dr. Williams that in order for a test of labor to be significant, the patient should go through a two-hour second stage, with the membranes ruptured, and with the aid of her o,wn expulsive efforts. Obviously, following this procedure, many women with slight degrees of pelvic contraction have been delivered spanl.aneously OP by operative means t,hrough the birth canal, in whom a, shortcxl*test of labor would have terminated in cc1sarea.n section. It has been 0111’impression for some time, howcvcr, that many of thcsc woInc~, 11a,vchad prolonged labors (over t.hirt,y hours) aud that their delivery, othrr than by cesarcan section, has been attended with ;1 high fetal mar1alit.y. Accordingly, it seemedproper to invest,igate the outcome to the child in casesof prolonged labor, contracted pelvis, and delivery through the birth canal. The results of this investigation are presented in the following paragraphs. A search through the records of all the patients delivered on the Ohst,etrical Service of the Johns Hopkins Hospital from its inception in 1896 to the end of 1931, revealed 422 cases satisfying the abovementioned criteria. It should be stated that all pelves a,re classified as (Aoutracted when the diagonal conjugate mcasur(bs 11.5 cm. or less, rcg~rdl~ss of other mensnrcments. This scrics dots not. include pelrcs with Olltl~~l ~Oilt~l~iWtiO~~S alone, but dOCS includ(~ I hose CiISc’swith liar537

TOTAr, 1) I?I >TVERIE::

White, para 0 White, para X Black, para 0 Black, para X Total, pars 0 Total, para X Total White Total Black ‘l’ata,l Both Races

l:ROSS MORT . Y L T T Y 95

‘ii) “9 246 97 310 126 !J!l :+4:: 44”

CORRECTED MORTALITY

10.4.5 17.24 12.29 18.Fi2 11.88 18.18 1 Y.A!

s

CLIS IC POPULATIOS GROSS MOX‘TA LITY C,h

4.6!1

Taltl~ I indicat,rs tlu* nlnrt:rlit~ Y:lttV, gross amd rY)rrcYttVl, in terms of czolor 2nd l,n.ritp of the patient. That, mart dent,hs occnrred among the lblaczks than the whit,cs of the series was an expected finding and one that pertains to the clinic population as a whole. It secmcd noteworthy t.hat, for both races higher rates obtained ia multiparous than in primiparons womcm. These differences are probably largely explained by the fact that the average baby horn to a muit,ipnra. weighs several ounces more than that of a primipara. i8 ounces in the white and 3 ounces in the black Such observations inclicatp the hazard of disregarding cvcn minor degrees racej. of pelvic eontraction solely bccnusc the patient gives :t history of previous norm:11 deliveries. It should be, particularly noted timt thcl mort:llit\rates given for tI,cL series are eonsist,ently about thriar: times as glent ns those lx~rt.aining to the genrr:rl clinic population. In other words, our eq.riexcc indicates that t,he risk to the ~:l~iltl is markedly increased in ln-olonqed l:\l,or tllrrmgh :I contracted pelvis. For

The effect of the type of pelvic contract,ion this purpose, the cases in the series

on fetal mortality have been divided

is show11 in Tnblc TT. into the three main

PECKHAM

TABLE II. ___----~

AKD

KUDER:

PETAL

IvfORTAIdTY

IN

COSTR.ACTED

539

PELVIS

FETAL MORTALITY (GROSS SD CORRECTED) ACCORDINGTO TYPX m hX,VIC CCINTRACTION -.-__ ~-~. ___-.--____~-. -___ CORRECTED !NYP-kL GROSS DELIVERIES

____--

Flat Generally contracted lthaehitic Other types

MORTALITT

29 248 159 Ii

___~.________.._________ --____

flat, generally ?ont,ractcYl, and the 11:rl)y occurs with flat pelves will 11c shown subsequently that the :Ivcr:rge wright of the babies

--

TOTAL

Forceps Breech extraction Version and extraction Destructive operations Other operations

‘F

00 r)n *u.uu 10.7:: 17.01 Il.00

CASES

~.___.

INCIDENCE

PER ___--

('ENT

54.52 39.86 3.17 5.66 5.43 1.36

241 132 14 2’s 24 G

sL pontamous

hlORTALIm

27.59 16.1:; 23.“7i 0.00

varieties of pelvic abnormality observed: namely, rllachitic. It will bc noted that the greatest risk to and the least in the gencrxlly contra&d type. It these mortality rates may be dirtctly correlated with born through the three types of contracted pelvis.

--___-

c/o

-

Table 111 is inserted merely to indicate the type of delivery following the prolonged labor. Almost Mf of the tots1 cases were terminated 1.1~ operative means and in 24 instances, or about 5.5 per cent of the total, delivery could only be effected by craniotomy. It might bc noted that spontaneous termination occurred more frequently in the black than in the white race despite the higher fetal mortality in the former group. Also, it is of interest tllat some form of operative delivery was necessary much oftener in the rnultiparas than in the primiparas of the series.

__-

Spontaneous Operative Forceps Breech extraction Version and extraction Destructive operations Other operations

TOTAL D'ELIVERIES

GROSS MORl'ALI'l'Y

211 !?(I1 13” .a 1-L 25 34 0

7.47 .33.33 19.70 42.86 36.00 -_-33.33

70

CORRM'TED MORTALITY

L ob,

3.6” 27.17 17.1!1 38.463 “7 .“7 . n 3 . .33 -~-

From a study of Table IV, it seems evident that when spontaneous &~livc!ry follows prolonged labor in contra&cd pelvis the results to the child are quite satisfactory, and indeed, a corrected mortality of 2.62 per cent could be considered as good in a series of normal patients with labors of average duration. However, if the labor had to be terminated by operative means the fetal mortality rose to an appalling figure, with a corrected death rate of 27.17 per rent. Of the various operative ma.neuvers used forceps were attended with the fewest fetal deaths. The exceedingly high mortality risk to the child when breech extraction or version and extraction were employed serves as additional warning of the dangers attendant on these procedures when any degree of pelvic contraction oxists.

Table VI offers n comparison between fetal mortality and the weight of the at birth. The mortality i s high in babies weighing less than 3,500 gm. at a fact most readily explained on the grounds that the diminutive size of the renders it more susceptible to danlage from the strainx of labor. With this tion, there was found a progressive mortality rate with increasing hirth weight serves to emphasize the importance of careful Mimntion of the. size of thr in :+ny ease of mild pelvic contraction.

___~.-. Not,

correctable Asphyxia Intracranial injury Prolapse of cord Broken neck Fracture of skull (‘raniotorny, living Unknown

~--

~_____.--56 28 16 5 I 1

rhild

child birth, child excepwhich fetus

1

4

(‘orrectable Dead on admission Syphilis Hemorrhagic disease Malformation Premature separation l
39 IF, 5 3 I 1 1 1 1

1

Finally, the raosc of death to the rhild is portrayed in Table’ VII. We believe that, in 29 instances the outcome was not dependent on the contracted pelvis of tile patient or the treatment she received, and hence, designated these deaths as correctable. However, there remain 56 cases of fetal death (13.56, corrected mortality per cent) in which it is reasonable to assume that protracted labor, contracted pelvis, and delivery through the birth canal were directly responsible for the fatal outcome; and this figure would seem to offer a true, estimate of the risk involved in such cases. It might be stated that in addition to the 16 deaths listed as intracranial hemorrhage it seems probable that more careful study would have increased the number somewhat at the expense of the larger number clinically attributed to asphyxia. DISCXJSSION

LMivery through the birth canal following labors of more than thirty in 442 women with some degree of pelvic contraction occasioned a gross fetal mort,alit,y of 19.23 per cent and a corrected mortality of 13.56 per cent. Thcsc X&S arc about three t,imts as great as those obtaining for the gcncrnl rlinic population. on the Obstctrica.1 Service of the *Johns Hopkins Hospital. The mortality was greater among black than white women and was higher in the mult,iparous than in the primiparous division in t,he scrics. The highest death rate was found in cases of flat pelvis, was somewhat less with the rhachitic variety, and was lowest in the generally contracted group. Almost half t,ht: labors wcrc terminated by some sort of operative means and in 24 instances craniot,omy had to bc cmploycd. The correct>rd fetal mortality when the labor was spontaneous was only 2.62 per cent, but. when an opera.tive procedure was necessary, the deat.11 rate even after corrcet.ion POW t.o 27.li per cent, and was highe.r wit,h breech txt.ract.ion and podalir. version than followins forceps delivery. The mean wright of a child born to a woman with a simple flat. pelvis was about that of the arerage clinic baby-, while with rhachitic Flours

and unless the cranial bones, not the caput succcdaneum, are at the level of the spines such an operation seems open to question. Tt, is realized that the above policy would result in an increased numl)cJr of c’CsarWi1 sclctioiis alId fcwcr tests of li1bOr terminating in d(‘livery thwugh t.hc birth cat~l. Furtl~tmivre, it must bc rcctognizcd that the operation, evc!l though done by skilled hands and under fayora,blc conditions, carries with it a. definite risk to the mother and one which increases with the advance of labor. Statistical reports of seI*ies of low ccrsica.1 cesarean section (the operation ol’ choice following tclst o-f labor) would indicate a mortality risk of bctwclnl 1 and 3 1)~ c*cnt ~ossly, aud it secamsfair to state that this type of optrat,ion properly tlone after a, well-regulated test of labor should not result in ii dtaatIi I’iLtL’ Of OVer ll,/r, per CCllt flYJIll rClat,cd causes. On the other hand, iii our scrics of 442 cases, there w(bre 6 matctx;11 dea,ths (1.36 ~)er cent) and 4 of thcsc8were directly attributable t,o obstetric procedures involved, b Giving a corrected mortality rate of 0.91 per ce’nt. Thus it would seem that prolonged labor, particularly if termina.ted by operative procedures from below, tnt.ails an appreciable risk to the mother, a.nd although this risk is somewhat less than if cesarean section is employed, the increased number of live births resulting from the latter operation and contrasted with a fetal mortalit,y rate of 19.23 per cent from the former would seem to count.crbalancc it considerably. CONCLUSIONS

1. The gross fetal mortality attendant on delivery through the birth canal following prolonged labor in cases of contracted pelvis was 19.23 per cent in a series of 442 casesand even after correction for unrclatrd causes was 13.56 per cent. 2. An increased death rate was observed among the black women of the group and was definitely higher in the multiparous than in the primiparous portion of the series. 3. The highest mortality was seen in casesof flat pelvis, and the lowest in the generally contracted variety with the rhachitic group falling between the two. 4. Almost hadf the labors had to be terminated by some sort of operative means, and there were 24 instances of craniotomy. 5. The mortality rate was satisfactory if spontaneous delivery occurred but with operative procedures was 27.17 per cent even after correction. Breech extraction and podalic version were extremely lethal to the child. 6. Children born to women with flat pelves were about average in size but were several ounces below normal if the pelvis was generally contracted or rhachitic. The fetal mortality varied directly with the size of the child.

T

HE

physiologic dilatation of the abdominal lx&ioll of t.ht: urinar:. is a well-recognized 1)ltenomcnou in thra during pregnanq~ unhuman being.l% ii The right side of the urinar). system invariably dergoes a. gesta.tional enlargcmcnt 2 to 3 times its diameter in the nonpregnant, while the left, sitlc Ilyl)tLrt rol)hies to a similar degree in onI> 70 to 80 per cent of pregnant womc’n. tract

Investigation of t,his phenomt~~o~l 1)~ rnktans of intravenous urography, using the rabbit as esperimcntal atlimal, disclosed the fact that- no changes were observahlc inI its m-illayv t met driving pxgnancy (SW h?tion I). This ObSeIwlion prompkcl a study of the urct,crs of otlic~~ common animals with spr&tl ~*cfcrcn~c to gross ant1 microscopic cha.r~g,rt!s during pregna.ncy. Nothing was found ill the. Jjteratur(l dealing with such clmngc~s in t IIC. ureters of pregnant animals. IIowcvcr, FIofbaucr3 studied them in (consequent !y, 14 pregnant women from ~I;II trial obtained at autopsy. the present study was undcrta.ken ill order to ascertain what changes, if any, occur in the ureters of pl*egnaiit; animals. It deals with : (1) measurement of rocntg~~noprarns. oh1 aincd by intravenous urography, of the ureter of pregnani and nonpregnant, rabbits; (2 j measurement of the whole ureter and of it-l conq)on(~nt. l,arls in histologic sections of X different species 01’ 1~W~~la ttt atId nollpl*egllant animals. including thcz rabbit. RABBITS ,

Ten Lbregnaneies, o~cm2%lg in $1 rabbits, w(‘rv investigated by means of intraumous orography. Rkiodan was used as the contrast, medium, and the technic of injection and exposure wm identical with thxt drrrloped 1)~ Mengrrt.” Antepartum roentgenowere made during the svc~ond half of pregnajl<‘y. A second set of grams roentgenogrsms of the same rnhhit was made between three and sixty-five days after delivery. Ureteral diameters of identiral points of the upper and middle thirds of