Management of labor in the patient with cardiac disease

750

THE

AMERICAN

JOURNAL

Oli

OBSTETRICS

AND

GYNECOLOGY

The first stage of labor does not put a se\-ere strain on the heart, even with Because of the drop in exhaustion, but the second stage is the important phase. the blood pressure, the patient may collapse or may have a severe hemorrhage immediately after delivery. With auricular fibrillation the author does not induce labor until specific treatGenerally, induction of labor is advisable over ment with digitalis has failed. eesarean section in any of the cardiac complications. Rest and sedatives are valuable in the first stage, and instrumental help early in the second stage. During pregnancy rest with “specific treatment” is recommended. The writer is not strictly opposed to pregnancies in cardiac patients, although The heart usually responds very well there is an increased danger to the mother. to treatment during gestation. Ii.

Sachs, E.: Management med. Wehnschr. 54:

of Labor 45, 1928.

in the Patient

with

Cardiac

CT. ~~ESSELTINE.

Disease.

Dcutsche

The most important problem is the treatment of the diseased heart. Interruption of pregnancy is the last thin g to be considered, even in early pregnancies. If rest and proper medication does not restore the disturbed compensation then termination of pregnancy certainly will not prove beneficial. The situation is different in advanced pregnancy because there are mechanical conditions and special demands on heart action, etc., which might add to the existing difficulties, but even under these conditions the restoration of compensation is the prime task of all therapy. The value of proper psyyehie intlucnre should not be uudcrvalued. The patient must be assured that her physician will be with her during labor, that all unnecessary pain and physical effort will be avoided as far as possible. Inability to combat decompensation and extracardial complications (nephritis) render prognosis bad. It is necessary to avoid all sudden fluctuations in blood pressure, incident to emotions, bearing down efforts, escape of blood into abdominal viscera after expulsion of the fetus, etc. Earlier in labor, the quinine-rthcr-oil enema works satisfactorily, later to be supplanted with twilight. The labor is terminated quicker by use of a pituitary preparation, forceps, or extraction in breech presentation. Prompt administration of ergot and application of a heavy sandbag on the abdomen, immediately after expulsion of baby, prevents sudden fall in blood pressure and “empty pumping” of heart as result of large quantities of blood passing into the visceral blood vessels. Puerperium itself, if normal, holds no further dangers. These patients always should be managed in hospitals. Cesarean section the writer reserves only for eases with added complications such as narrow pelvis, placenta preria or prolapsed cord because in the cesarean operation the sudden fall in blood pressure can be combated solely with ergot. The operation is preferably done under lumbar anesthesia, but it is his belief, that delivery through the vagina is safer than cesarean for all cardiac patients. CX~TENFELD.

Zinsstag, G.: Pregnancy 75: 498, 1927.

and

Mitral

Stenosis.

Monatschr.

f. Geburtsh.

u. Gyngk.

The author reports three fatal eases of mitral stenosis which oecurrcd in pregnant women. He is convinced that contrary to some opinions, mitral stenosis can be a very serious complication in pregnanry. In these eases, signs of decompensation which are usually present with other forms of heart trouble, are frequently