Posterior occiput presentation

POSTERIOR

OCCIPUT

PRESENTATION”

ANALYTICAL REVIEW OF POSTERIOR OC‘CIPUT PRESENTATIONS OCXXJRRIN IN 1,000 CONSECUTIVE DELIVERIES AT THE EVANSTON HOSPITAL

BY R. g. S;COTT, M.D., F.A.C.S., (From

the

Department

of

Obstetrics

and

EVANSTOS,

Gynwology

of

the

ILL. Ernnston

Hospital)

I

T HAS been customary from time to time in the obstetric department of the Evanston Hospital to review the histories covering certain types of delivery. Such analytical reviews have been instructive and beneficial, for in retrospect our method of t,reatment is often an improvement over the actual methods used. The number of occipitopostrrior presentations occurring in the 1,000 consecutive cases in the period from November. 1928 to January, 1930 inclusive was 144, an incidence of 14.04 per cent. These we have placed in three groups: Group

1.

Group 2. Group

3.

Posterior oceipitoprescntation, position. Posterior occipitopresentation, anterior position. Posterior oceipitopresentation, anterior position.

delirered rotating

in t,he poskrior spontaneously

rotated

manually

to to an

Group I.--Fifty (50) or 34.7 per cent of the total number of cases were delivered in the posterior position. As might be expected there were only 10 primiparae, the remaining 40 being multiparae. All patients were at term. The duration of labor varied from one hour and fifty-two minutes to thirty-three hours and fifty minutes; the average length of labor being seven hours and thirty-seven minutes. The length of the first stage varied from one hour and forty minutes to thirty-three hours and forty minutes, with an average length of seven hours and twenty-four minutes. The second stage had a variation of ten minutes to four hours and fifteen minutes with an average duration of forty-one minutes. Thirty-six delivered spontaneously, 11 with low forceps and 3 with mid forceps. Only a small percentage of this group received any sedative during the first stage. There was no maternal or fetal mortality. Group 2.-Posterior occiput presentations rotating spontaneously to an anterior position, numbered 43, or 29.9 per cent of the total number of cases. All of these pat’ients were at term. There were 20 primiparae, about double the number in group one, and 23 multiparae. *Read Springs,

before the Central October 10, 1930.

Association

of Obstetricians 400

and

Gynecologists,

Excelsior

SCOTT

:

POSTERIOR

OCCIPUT

401

PRESENTATION

The hours of labor varied from two hours and forty-eight minutes to twenty-seven hours and thirty-three minutes, an average duration of eleven hours and thirty-six minutes. The first stage varied from two hours and ten minutes to twentyseven hours and twenty-five minutes, an average first stage of ten hours and fifty minutes, an increased average of about three hours over that of group one. The second stage varied from ten minutes to three hours and three minutes, giving an average second stage of fifty-two minutes as compared with forty-one minutes in group one. In this group an estimate was made of the time the head remained in the posterior position, before the spontaneous anterior rotation. The time varied from two hours and ten minutes to twenty-seven hours and fifty minutes; with an average time of eleven hours and twentyfour minutes. This is a reasonably accurate estimate because the interns are instructed to see the patient every half hour or oftener if necessary and rectal examinations are made if there is an increased frequency or any change in the character of the pains. Although to some it may appear too long a period to allow the head to remain in a posterior position, the resulting absence of either maternal or fetal mortality in this group rewarded our conservatism. Thirty-two delivered spontaneously. Ten with low forceps and one with mid forceps. Group 3.-Posterior presentations which were rotated manually to an anterior position (one exception being a Seanzonian maneuver) numbered 51, or 35.4 per cent of the total number of cases, 37 primiparae and 14 multiparae. In this group we thought it unnecessary to note the length of time in the first and second stage of labor because the time the head was allowed to remain in the posterior occiput position before interference is the important point to consider. The elapsed time in each instance was just a few minutes less than the total hours of labor. The shortest time elapsed was fifty minutes and the longest thirty-seven and one-half hours, or an average time of twelve hours and twenty-eight minutes. Full dilatation was completed normally in all but 3 instances. In one of these three Duehrssen incisions were made, and in two, complete dilatation was produced manually. Period of complete dilatation before attempted delivery was also noted. In 23 instances, delivery was made immediately after complete dilatation. In 28 cases, the time ranged from fifteen minutes to three hours and five minutes, an average time of forty-seven minutes before any interference was instituted. The indications for immediate delivery or delay, were: In

the case of the mother 1. Amount of exhaustion 2. Type and frequency dilatation

of labor

pains

and

degree

of

effacement

and

402 In

AMERICAK .JOLJRNAL OF OBSTETRICS AND GTNEC’OLOGX the 1. 2. 3.

cme of the baby Rate and strength of fetal heart Degree and rapidity of descent of head Ratio between head and pelvis

In all instances except one, a Scanzoni operation, the head was rotated to an anterior position manually. In every instance forceps were applied and delivery attempted. Thirty-five in this group were forceps deliveries; 26 low forceps, 8 mid forceps and 1 high forceps, the remaining 16 were delivered by version and extraction. No mothers were lost, but three babies died as a. result of the version and extraction manipulation. One lived a few minutes and the other two were stillborn. The fetal heart was audible until the delivery started. The postmortem examination on these babies revealed brain hemorrhage, traumatic in origin. In 13 cases cervical lacerations were found, and in 1 case Duehrssen incisions had been made. The remaining 3’7 had no cervical tears. DISCUSSIOiV The discussion of these cases must necessarily be the author’s personal opinion and he therefore craves your kind indulgence. Group 1 in which the patients delivered in the posterior position rhow a surprisingly short average labor ot’ seven hours and thirtythree minutes. It being the general impression that such a type of delivery is accomplished only after long hours of labor, this low average, in part is due, I am sure to our routine use of nitrous oxide and ethylene gas for analgesia in the second stage of labor. A specific instance showing the importance of hospitalization in obstetric cases. Group 2 in which anterior rotation was spontaneous, numbered 43, or 29.9 per cent of the total number of eases. This is a very satisfactory percentage for it is this type of case that demands sound obstetric judgment, and requires experience and training for its proper management. In group 3, where interference is indicated there are in most cases definite symptoms relating to mother or fetus that aid one’s judgment. The importa.nt, consideration is, with what type of interference to proceed in a given case. The infant mortality rat,e of 5.88 per cent (3 out of 51 cases) is a little high, showing either an error in judgment, or lack of skill in the delivery. A. Concerning a possible error ila judgment in thas procedure.-Perhaps the labor was allowed to proceed to the detriment of the fetal heart strength, or a disproportion between fetal head and pelvic outlet escaped notice. B. Concerning la’& of skill at this point.-Perhaps the head was not rotated to the anterior position, or there was a possible faulty application of forceps, or there was too much traction with the forceps, or in the case of version and extraction, a brain injury to the child was

XURZROCK

:

PROLAPSED

UMBILICAL

CORD

403

inflicted because the operator was in too much of a hurry in delivering the after-coming head. The author has occasionally, in the case of a small fetus delivered a persistent occipitoposterior by version and extraction without any attempt at manual rotation. When the head is small and the bone plates in the baby’s skull are widely separated, I think it a little safer procedure than the use of forceps. If we all had the skill of a Potter sot)ze of our version and extractions might be more successful. Although many obstetricians apply forceps to the after-coming head as a routine measure, the staff at the Evanston Hospital delivers more cases without than with the aid of forceps. We have had good results with the Piper forceps. Cesarean section is correctly indicated in persistent posterior occiput presentation when the trial of labor has been sufficient and dilatation has not progressed to the point where its completion can be executed. This is particularly the case in the so-called borderline type of contracted pelves. The author would like to state that he found Keielland’s forceps, because of their shape and length, very satisfactory if applied in like manner to other forceps to the anteriorly rotated head. We have not had much success with these forceps when using them in the manner prescribed by their inventor.

PROLAPSED AN BY

(From

JULIUS

the

ANALYSIS

UMBILICAL OF

ONE

HUNDRED

CASES

M.D., NEW

KURZROCK,

Obstetricul

CORD*

Srrvice

of

the

YORK,

Harlem

N. Y. Hoipital)

E MAY consider prolapsed cord a condition in which that, structure has left its normal site and has taken a position compromisAccording to its position we may classify ing the life of t.he fetus. this entity as follows: (1) occult or concealed, (2) presenting, and (3) prolapsed. The statistics of prolapsed cord herewith presented are based on the records of 100 consecutive cases treated at Harlem Hospital in New York during the years 1915 to 1927 on the services of George L. Brodhead and Fred A. Kassebohm, and represent the combined work of ten members of the visiting staff and a number of interns. lhquency of Prolapsed Cord-In 16,942 consecutive deliveries there occurred 100 cases of prolapsed cord giving a frequency of one in 169 deliveries. This figure tallies with the ratios reported in several of the recent series, as noted in Table I. The average frequency is about *Read Medicine,

before the Section of Obstetrics New York City, November. 1930.

and

Gynecology,

New

York

Academy

of