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Prolonged labor: A study of 211 cases
T
HIS paper is a review of t,htl recorcls of p~olongetl l;tl)or in the [Ynivcrsity of Maryland Hospital from .July I. 1945, through .June 30, J949. F’or the purposes of this stutly prolonged labor is tlefined as any labor i.hat la&s longer than twenty-five hours excluding the thirtl stage. The onset of labt)r is defined as the progressive dilatation and eff’ac(~r~lcllt,of t.he cervix to 3 or 1 em. withrtut regard to t,he frequency, intensity, or dllt.iltioll of eonI-l.:tctiolls. 811 the periorl from the time labor is established utltii delivery is caoillplet,etl is regarded as la.bor regardless of \\rhether or not uteritlc c~ontractic~ns occur in the int,erint.
Material The records of 10,042 deliveries were reviewed. !)f the 850 cases in which the original diagnosis was prolonged labor, only 211 fulfilled the criteria outlined above. Of 211 patients, 114 were Negroes, 27 were white ward patients, and 70 were white private patients. The ratio of cases of prolonged labor to t,he total number of paGents seen during the period covered by this review was approximately the same for the three groups. The incidence of prolonged labor was found to be 2.1 per cent which compares with 2.7 per cent reported by Odell, Randall a.nd Scott,5 4 per cent by I)onnelly.2 and 4 per cent hy Bradford, Woltz and Bradford.’ One maternal death occurred in the series. The patient was a :51-year-old primigravida who was admitted in severe I,rc-edampsia and in labor, and who She was deliverned of a livhad not received antepartum metlieal supervision. ing 4,423 gram child by low forceps a I’tcr forty-five hours of labor ant1 died suddenly eight, hours post partum in toscmic shock.
Etiology The clistributiolr of the eases according to t,he causes of prolonged labor is given in Table I. As has been found I,y most. other investigat,ors, primary uterine inertia was the most common (pause. The incidetlce of primary ut,erint‘ inert,ia based on all deliveries was 0.N per* cent, which is somewha,t lower than that usually reportetl.“. i Tt is felt, that in 24 of these cases the use of ht:av), sedation very early in labor probably upset the normal rhythmic uterine COIIJncluded under positional dystocia tractions, thereby causing uterine inertia. were cases of transverse arrest, persistent occiput posterior pasjtion, and breech presentation in which no definite cephllopelvic disproportion existed and labor was not of the inertial type. l’rimary uterine inertia, cephalopelvic disproportion, and positional dystocia acacounted for 93.3 per cent of the cases of prolonged labor in this series. In the vases listed under “early spinal anesthesia” the diagnosis of cervical dilat:~tio~l or of the station of the presenting part, or both, was in error and satl(lle l~lock anesthesia was given very early in labor. The patient with the dermoicl cyst was admitted in labor and was treated by cesarean section and extirpati
Resident
in
Obstetrics,
thus
T:niv
of
Marylan~l
Hospital.
PROLONGED
Volume 61 Number 3 TABLE -___ --Primary
_-____
I.
623
LABOR
CAL?SES OF PROLONGED
CAUSES uterine inertia (24 probably caused by sedation) Positional dystocia Cephalopelvic disproportion Cervical dystocia Early spinal anesthesia Dermoid cyst blocking birth canal Contraction ring Multiple uterine fibroids
Length
LABOR NO. CASES 76
PER CENT 36.0
60 61 8 3 I 1 7
28.4 28.9 3.8 1.4 0.5 0.5 0.5
of Labor
In 15.2 per cent of the cases labor lasted longer than fifty hours (Fig. 1). The second stage was longer than two hours in X cases and longer than six hours in 9 cases. One fetal death occurred in this group, that being due to intracranial hemorrhage. If the fetal mortality rate in these 37 cases (2.7 per cent) is compared with the over-all rate of 10 per cent for the 211 cases, it appears that prolongation of the second stage did not increase fetal mortality. LENGTH
OF LABOR
iitS% looBO60s
272%
40,
1-m-1I 25-35
35-50
50-i7l
over70
HOURS Fig.
I.--length
of labor
in 211 caged
of
wwlonged
labor.
The babies of mothers with prolonged labor were not excessively large (Fig. 2) ; only 8 weighed more than 4,500 grams. However, 4 of these were born to rnultiparas who had previously been delivered of smaller babies in normal labors, and 3 of the 4 died of intracranial hemorrhage. It would seem then, that while excessive size of infants was not a constant factor, yet when pI*olonged labor was due to this fact, fetal mortality was excessively high ant1 the risks l-o the mother were increased.
Roentgen-ray
Pelvimetry
It is felt that roentgen-ray pelvimetry has been used too infrequently and that its increasing use, particularly in conjunction with pelvic examinations, will be reflected in lower maternal and fetal morbidity and mortality rates. This type of pelvimetry should never be neglected in multiparas whose labor fails to progress. It was used in only 41 of the 61 cases in which the final diagnosis was cephalopelvic disproportion.
Method
of Delivery
An analysis of the cases aC%(Jl’dill, v lo the trtt&od (Jf delivery is given ill Table III. Five fetal deaths occurred in the 41 midforceps deliveries. sane The cesarean section rate of the 20 hysterostomatomy incisions extentled. for the series was 12.2 per cent while the rate for the entire clinic during t,he same period was 2.5 per cent. Thirteen of the eesarean sections were of the extraperitoneal type, 12 were low cervical, and 1, because of the extrem(J obesity of the patient, was a classical cesarean section. When abdominal drlivery is indicated, it is t,he policy of this hospit,al to do this by the estraperitoneal route in some of the cases. Of the 1.3 here reported, 5 were indicated on the basis of infection in patients admitted late in labor. Bectal estensions occurred in 16 of the 141 central episiotomies and in 2 of the .I:: mrdictlateral episiotomies. Cervical lacerations occurred in 21.2 per cent and Vil.$Gnal lacerations in 16.3 per cent of all deli\rcbrics from below.
_____
__.---.-
.-.-
..-.
-.~--
-~-
S 0.
*In posterior
LOW f oreeps Midforceps (20 with hysterostomatomy inrisions1 Cesarean section 9k pontaneous Breech I)estructive ~______._ 41.6 per cent of ail deliveries to anterior was done. Scalp
CASES
----lll.--
PEE CENT
110
_.....
-.
.i 2 .I
~ 41 “6 18 1“ _ ._ . .___---.----._-~. 4 ~~-~ ~~--~-~_from below rotation from ocdWt clamp used 14 times without fetal death.
19.4 I”.:1 x.5 5.; 1.9 --.. - ..~~ .~ ~~~transverse i)r
use of Eklgs All Pitocin used was given intramuscularly in doses not greater than 1 minim each twenty minutes. There was no case of uterine rupture. Table [V shows that the use of I’itocin apparently did not increase fetal mortality and that reduction in the use of midforceps and the length of labor was effected. This is essentially in agreement with the findings of Eastman” and Beid.” Pitocin was wrongly used in 18 cases in which cephalopelvic and positional dystocia were later found to exist ; ‘1 ,. f&al cleaths. all dne to int,racr:lninl hrmota-
PROLONGED LABOR
Volunle 61 Number
3
625
Hysterostomatomy incisions were necessary rhage, occurred in this subgroup. in 8 cases after Pitocin had been used, possibly indicating its failure. It is felt that Pitocin should not be used (1) if mechanical obstruction to delivery exists, (2) in doses greater than 1 minim each twenty minutes, or (3) in patients whose parity is greater than 4. More recent experience indicates that the administration of Pitocin by intravenous drip, as outlined by Hellman is the most efficacious method in primary uterine inertia. FETAL
Fig.
2:-Fetal
weights
WEIGHTS
in
211
cases
of
prolonged
labor.
The dire results of greatly prolonged labor, also found by Eradford, Woltz and Bradford,l are illustrated in Fig. 3. Operative delivery is defined as one accomplished by midforceps, cesarean section, or destructive procedures. It is felt that, because of the extremely poor results in labors that last longer than fifty hours, labor should be interrupted at least by that time. Of the 49 patients who received penicillin or sulfadiazine or both prophylactically, 10.2 per cent became febrile. Of the 162 who did not receive prophylactic drugs 23.2 per cent became febrile. The total maternal morbidity rate was 118.9 per cent. Fifty-five per cent of the 211 patients received fluids intravenously, and 35 per cent received morphine to promote rest. Prophylactic antibiotic therapy is felt to be indicated when it is suspected that label may be prolonged. This is especially true in cases in which the membranes are ruptured early. Morphine is the drug of choice for giving patients much needed rest after twelve hours or more of labor. The resulting period of quiet may be used to advantage for giving glucose or saline, or bot,h, intravenously. IV.
TABLE
USE
OF PITOCIN PITOCIN -’
Fetal
death
Patients hours, Patients uterine
rate,
per
cent
in labor less than per cent having midforceps inertia, per cent
35 for
GIVEN (45 CASES) 8.9 (4 deaths) 66.8 22.7
NOT
(166
GIVEN CASES)
10.2 (17
Ef5Yhs) 37.0
EFFECT
OF PROLONGED
LABOR
100_percent 8060.. 4030, 20.:
I
10 5 1 ,
25-35
I
I
3350
I
over70
50-70
HOIJRSOF LABOR MATERNAL MOWBIRITY FETAL MORTALITY . . . . . . . . . OPERATIVE Fig.
:{.-1:nfavorable
DELWEFtlES effects
of
--we--
prolonged
labor.
Table V shows the causes of the 17 stillbirths. Of the 8 stillborn Petuses that showed intracranial hemorrhage, 3 of these were proved at, necropsy ant! destructive procedures were carried out. on the other 5 after fetal death was diagnosed. One of these was delivered by extraperitoneal cesarean section and embryotomy at a dilatation of 6 cm. after fift,y hours of labor. It, is felt TABLE
V.
>‘)i:‘l’AI.
CAT-S&S
~~I~IWALIT
P
~. j
~__~~No._~~~~--
~. .~
Stillbirths.---
___--~-
Intracranial hemorrhage Shoulder dystoeia Atelectasis Prolapsed cord Infection Hydrocephalus IJnknown Neonatal Deaths.--Intracranial hemorrhage Tatal Fetal mortality rate, per
I /
-~ cent,
_~ .I -.- ~.. __._ .._._._ / --- ..-.
: 2 1 1 1
L 4 --_-_-~~_-~ 21 ~-._-~~.~ 10-..~
.~ _ -~ ~. _ - ..~
that the handling of this ease is open to considerable criticism in that the destructive procedure undoubtedly should have been done from below. The stillbirth due to infection occurred in a patient who was referred and admitted In 1 of the 3 cases included late in labor with a severe intrapartum infection. under shoulder dystocia the umbilical cord was found to be tight around the baby’s neck. There were 4 neonatal deaths all resulting from intracranial hemorrhage. One of the patients was delivered by cesarean section at a dilatation of 5 cm. after sixty-three hours of labor. The other 3 all underwent difficult deliveries from below, axis traction being used in all 3 and midforceps in 2. The total fetal mortality rate was 10 per cent. This compares with 10.4 per cent reported Woltz, and by Odell, Randall, and Scott,5 and 4.7 per cent by Bradford, 1:radford.l TABIJ:
VI.
FETAL
MORTALITY
ASSOCIATED
WITH
27 1 CASES
ZZZZCAUSE
OF FETAL
DEATH
ASSOCIATED
PROLONGED
LABOR
DEATHS
WITH
Primary uterine inertia (76 cases) Intr&ranial hemorrhage Prolapsed cord Infection Cephalopelvic disproportion (61 cases1 Intracranial hemorrhage Shoulder dystocia Atelectasis Hydrocephalus Positional dystocia (60 cases) Intracranial hemorrhage Shoulder dystocia Atelectasis Cervical dystocia (8 cases) Unknown Other conditions (6 cases)
OF
-~-
3 1 1 1 13 9 2 I 1 ‘,
1 0
i 1 1
Table VI breaks down the fetal deaths according to the cauee of prolonged labor. While cephalopelvic disproportion was the cause of prolonged labor in only 28.9 per cent of the cases, 61.9 per cent of all fetal deaths were in this group. The cause of 9 of the 13 fetal deaths in this group was intracranial hemorrhage. It is apparent that early abdominal delivery in these cases would have reduced fetal mortality.
Summary
and Conclusions
1. An analysis of 211 cases of prolonged labor, an incidence of 2.1 per cent in 10,042 deliveries, has been presented. One maternal death occurred; this was secondary to severe pre-eclampsia. 2. The three principal causes of prolonged labor were found to be primary uterine inertia, cepha.lopelvic disproport,ion, and positional dystocia. 3. The highest incidence of prolonged labor was in primigravidas. It is noted that in prolonged labor in multigravidas excessive size of the fetus may be the cause of cephalopelvic disproportion. 4. Rupture of the membranes seemed to hasten labor in some cases. 5. Prolongation of the second stage did not seem to affect the fet,al mor-
tality inertia
rate. 6. The use of Pitocin, with proper precautions, in cases of primary uterine was found to hasten labor and to reduce the number of midforceps
I.
Bradford,
51’. Z.,
ll’oltz,
.I. 11. E.,
iLlId
Bradford.
\V. B.:
.khl.
.J. OHST.
Lt (:TNxC.
58:
109:s,
1949. 2. :j. 2. 5. 6. i.
Donnelly, J. Eastman, N. Hellman, I,. Odell, L. D., Reid, D. E.: Schmitz, R. GYNEC.
F.: Sorth Carolina &I. .J. 9: 19RT 1949. .I.: AM. -7. OBST. & OYNEC. 53: 432, 194i. M.: AM. J. OBST. & GYMW. 57: 364, 1949. Randall, 3. H., and Scott,, G. W.: ,J. A. &I. A. 133: 735. 19-l;. New York State J. Med. 48: ‘?GUl, 1918 E., Bremner, J. X., Towar!, .lanet I<., and Baba, G. It.: 54: 64.7. 1947.
AN.
J. 088~.
&
HIS paper is a review of t,htl recorcls of p~olongetl l;tl)or in the [Ynivcrsity of Maryland Hospital from .July I. 1945, through .June 30, J949. F’or the purposes of this stutly prolonged labor is tlefined as any labor i.hat la&s longer than twenty-five hours excluding the thirtl stage. The onset of labt)r is defined as the progressive dilatation and eff’ac(~r~lcllt,of t.he cervix to 3 or 1 em. withrtut regard to t,he frequency, intensity, or dllt.iltioll of eonI-l.:tctiolls. 811 the periorl from the time labor is established utltii delivery is caoillplet,etl is regarded as la.bor regardless of \\rhether or not uteritlc c~ontractic~ns occur in the int,erint.
Material The records of 10,042 deliveries were reviewed. !)f the 850 cases in which the original diagnosis was prolonged labor, only 211 fulfilled the criteria outlined above. Of 211 patients, 114 were Negroes, 27 were white ward patients, and 70 were white private patients. The ratio of cases of prolonged labor to t,he total number of paGents seen during the period covered by this review was approximately the same for the three groups. The incidence of prolonged labor was found to be 2.1 per cent which compares with 2.7 per cent reported by Odell, Randall a.nd Scott,5 4 per cent by I)onnelly.2 and 4 per cent hy Bradford, Woltz and Bradford.’ One maternal death occurred in the series. The patient was a :51-year-old primigravida who was admitted in severe I,rc-edampsia and in labor, and who She was deliverned of a livhad not received antepartum metlieal supervision. ing 4,423 gram child by low forceps a I’tcr forty-five hours of labor ant1 died suddenly eight, hours post partum in toscmic shock.
Etiology The clistributiolr of the eases according to t,he causes of prolonged labor is given in Table I. As has been found I,y most. other investigat,ors, primary uterine inertia was the most common (pause. The incidetlce of primary ut,erint‘ inert,ia based on all deliveries was 0.N per* cent, which is somewha,t lower than that usually reportetl.“. i Tt is felt, that in 24 of these cases the use of ht:av), sedation very early in labor probably upset the normal rhythmic uterine COIIJncluded under positional dystocia tractions, thereby causing uterine inertia. were cases of transverse arrest, persistent occiput posterior pasjtion, and breech presentation in which no definite cephllopelvic disproportion existed and labor was not of the inertial type. l’rimary uterine inertia, cephalopelvic disproportion, and positional dystocia acacounted for 93.3 per cent of the cases of prolonged labor in this series. In the vases listed under “early spinal anesthesia” the diagnosis of cervical dilat:~tio~l or of the station of the presenting part, or both, was in error and satl(lle l~lock anesthesia was given very early in labor. The patient with the dermoicl cyst was admitted in labor and was treated by cesarean section and extirpati
Resident
in
Obstetrics,
thus
T:niv
of
Marylan~l
Hospital.
PROLONGED
Volume 61 Number 3 TABLE -___ --Primary
_-____
I.
623
LABOR
CAL?SES OF PROLONGED
CAUSES uterine inertia (24 probably caused by sedation) Positional dystocia Cephalopelvic disproportion Cervical dystocia Early spinal anesthesia Dermoid cyst blocking birth canal Contraction ring Multiple uterine fibroids
Length
LABOR NO. CASES 76
PER CENT 36.0
60 61 8 3 I 1 7
28.4 28.9 3.8 1.4 0.5 0.5 0.5
of Labor
In 15.2 per cent of the cases labor lasted longer than fifty hours (Fig. 1). The second stage was longer than two hours in X cases and longer than six hours in 9 cases. One fetal death occurred in this group, that being due to intracranial hemorrhage. If the fetal mortality rate in these 37 cases (2.7 per cent) is compared with the over-all rate of 10 per cent for the 211 cases, it appears that prolongation of the second stage did not increase fetal mortality. LENGTH
OF LABOR
iitS% looBO60s
272%
40,
1-m-1I 25-35
35-50
50-i7l
over70
HOURS Fig.
I.--length
of labor
in 211 caged
of
wwlonged
labor.
The babies of mothers with prolonged labor were not excessively large (Fig. 2) ; only 8 weighed more than 4,500 grams. However, 4 of these were born to rnultiparas who had previously been delivered of smaller babies in normal labors, and 3 of the 4 died of intracranial hemorrhage. It would seem then, that while excessive size of infants was not a constant factor, yet when pI*olonged labor was due to this fact, fetal mortality was excessively high ant1 the risks l-o the mother were increased.
Roentgen-ray
Pelvimetry
It is felt that roentgen-ray pelvimetry has been used too infrequently and that its increasing use, particularly in conjunction with pelvic examinations, will be reflected in lower maternal and fetal morbidity and mortality rates. This type of pelvimetry should never be neglected in multiparas whose labor fails to progress. It was used in only 41 of the 61 cases in which the final diagnosis was cephalopelvic disproportion.
Method
of Delivery
An analysis of the cases aC%(Jl’dill, v lo the trtt&od (Jf delivery is given ill Table III. Five fetal deaths occurred in the 41 midforceps deliveries. sane The cesarean section rate of the 20 hysterostomatomy incisions extentled. for the series was 12.2 per cent while the rate for the entire clinic during t,he same period was 2.5 per cent. Thirteen of the eesarean sections were of the extraperitoneal type, 12 were low cervical, and 1, because of the extrem(J obesity of the patient, was a classical cesarean section. When abdominal drlivery is indicated, it is t,he policy of this hospit,al to do this by the estraperitoneal route in some of the cases. Of the 1.3 here reported, 5 were indicated on the basis of infection in patients admitted late in labor. Bectal estensions occurred in 16 of the 141 central episiotomies and in 2 of the .I:: mrdictlateral episiotomies. Cervical lacerations occurred in 21.2 per cent and Vil.$Gnal lacerations in 16.3 per cent of all deli\rcbrics from below.
_____
__.---.-
.-.-
..-.
-.~--
-~-
S 0.
*In posterior
LOW f oreeps Midforceps (20 with hysterostomatomy inrisions1 Cesarean section 9k pontaneous Breech I)estructive ~______._ 41.6 per cent of ail deliveries to anterior was done. Scalp
CASES
----lll.--
PEE CENT
110
_.....
-.
.i 2 .I
~ 41 “6 18 1“ _ ._ . .___---.----._-~. 4 ~~-~ ~~--~-~_from below rotation from ocdWt clamp used 14 times without fetal death.
19.4 I”.:1 x.5 5.; 1.9 --.. - ..~~ .~ ~~~transverse i)r
use of Eklgs All Pitocin used was given intramuscularly in doses not greater than 1 minim each twenty minutes. There was no case of uterine rupture. Table [V shows that the use of I’itocin apparently did not increase fetal mortality and that reduction in the use of midforceps and the length of labor was effected. This is essentially in agreement with the findings of Eastman” and Beid.” Pitocin was wrongly used in 18 cases in which cephalopelvic and positional dystocia were later found to exist ; ‘1 ,. f&al cleaths. all dne to int,racr:lninl hrmota-
PROLONGED LABOR
Volunle 61 Number
3
625
Hysterostomatomy incisions were necessary rhage, occurred in this subgroup. in 8 cases after Pitocin had been used, possibly indicating its failure. It is felt that Pitocin should not be used (1) if mechanical obstruction to delivery exists, (2) in doses greater than 1 minim each twenty minutes, or (3) in patients whose parity is greater than 4. More recent experience indicates that the administration of Pitocin by intravenous drip, as outlined by Hellman is the most efficacious method in primary uterine inertia. FETAL
Fig.
2:-Fetal
weights
WEIGHTS
in
211
cases
of
prolonged
labor.
The dire results of greatly prolonged labor, also found by Eradford, Woltz and Bradford,l are illustrated in Fig. 3. Operative delivery is defined as one accomplished by midforceps, cesarean section, or destructive procedures. It is felt that, because of the extremely poor results in labors that last longer than fifty hours, labor should be interrupted at least by that time. Of the 49 patients who received penicillin or sulfadiazine or both prophylactically, 10.2 per cent became febrile. Of the 162 who did not receive prophylactic drugs 23.2 per cent became febrile. The total maternal morbidity rate was 118.9 per cent. Fifty-five per cent of the 211 patients received fluids intravenously, and 35 per cent received morphine to promote rest. Prophylactic antibiotic therapy is felt to be indicated when it is suspected that label may be prolonged. This is especially true in cases in which the membranes are ruptured early. Morphine is the drug of choice for giving patients much needed rest after twelve hours or more of labor. The resulting period of quiet may be used to advantage for giving glucose or saline, or bot,h, intravenously. IV.
TABLE
USE
OF PITOCIN PITOCIN -’
Fetal
death
Patients hours, Patients uterine
rate,
per
cent
in labor less than per cent having midforceps inertia, per cent
35 for
GIVEN (45 CASES) 8.9 (4 deaths) 66.8 22.7
NOT
(166
GIVEN CASES)
10.2 (17
Ef5Yhs) 37.0
EFFECT
OF PROLONGED
LABOR
100_percent 8060.. 4030, 20.:
I
10 5 1 ,
25-35
I
I
3350
I
over70
50-70
HOIJRSOF LABOR MATERNAL MOWBIRITY FETAL MORTALITY . . . . . . . . . OPERATIVE Fig.
:{.-1:nfavorable
DELWEFtlES effects
of
--we--
prolonged
labor.
Table V shows the causes of the 17 stillbirths. Of the 8 stillborn Petuses that showed intracranial hemorrhage, 3 of these were proved at, necropsy ant! destructive procedures were carried out. on the other 5 after fetal death was diagnosed. One of these was delivered by extraperitoneal cesarean section and embryotomy at a dilatation of 6 cm. after fift,y hours of labor. It, is felt TABLE
V.
>‘)i:‘l’AI.
CAT-S&S
~~I~IWALIT
P
~. j
~__~~No._~~~~--
~. .~
Stillbirths.---
___--~-
Intracranial hemorrhage Shoulder dystoeia Atelectasis Prolapsed cord Infection Hydrocephalus IJnknown Neonatal Deaths.--Intracranial hemorrhage Tatal Fetal mortality rate, per
I /
-~ cent,
_~ .I -.- ~.. __._ .._._._ / --- ..-.
: 2 1 1 1
L 4 --_-_-~~_-~ 21 ~-._-~~.~ 10-..~
.~ _ -~ ~. _ - ..~
that the handling of this ease is open to considerable criticism in that the destructive procedure undoubtedly should have been done from below. The stillbirth due to infection occurred in a patient who was referred and admitted In 1 of the 3 cases included late in labor with a severe intrapartum infection. under shoulder dystocia the umbilical cord was found to be tight around the baby’s neck. There were 4 neonatal deaths all resulting from intracranial hemorrhage. One of the patients was delivered by cesarean section at a dilatation of 5 cm. after sixty-three hours of labor. The other 3 all underwent difficult deliveries from below, axis traction being used in all 3 and midforceps in 2. The total fetal mortality rate was 10 per cent. This compares with 10.4 per cent reported Woltz, and by Odell, Randall, and Scott,5 and 4.7 per cent by Bradford, 1:radford.l TABIJ:
VI.
FETAL
MORTALITY
ASSOCIATED
WITH
27 1 CASES
ZZZZCAUSE
OF FETAL
DEATH
ASSOCIATED
PROLONGED
LABOR
DEATHS
WITH
Primary uterine inertia (76 cases) Intr&ranial hemorrhage Prolapsed cord Infection Cephalopelvic disproportion (61 cases1 Intracranial hemorrhage Shoulder dystocia Atelectasis Hydrocephalus Positional dystocia (60 cases) Intracranial hemorrhage Shoulder dystocia Atelectasis Cervical dystocia (8 cases) Unknown Other conditions (6 cases)
OF
-~-
3 1 1 1 13 9 2 I 1 ‘,
1 0
i 1 1
Table VI breaks down the fetal deaths according to the cauee of prolonged labor. While cephalopelvic disproportion was the cause of prolonged labor in only 28.9 per cent of the cases, 61.9 per cent of all fetal deaths were in this group. The cause of 9 of the 13 fetal deaths in this group was intracranial hemorrhage. It is apparent that early abdominal delivery in these cases would have reduced fetal mortality.
Summary
and Conclusions
1. An analysis of 211 cases of prolonged labor, an incidence of 2.1 per cent in 10,042 deliveries, has been presented. One maternal death occurred; this was secondary to severe pre-eclampsia. 2. The three principal causes of prolonged labor were found to be primary uterine inertia, cepha.lopelvic disproport,ion, and positional dystocia. 3. The highest incidence of prolonged labor was in primigravidas. It is noted that in prolonged labor in multigravidas excessive size of the fetus may be the cause of cephalopelvic disproportion. 4. Rupture of the membranes seemed to hasten labor in some cases. 5. Prolongation of the second stage did not seem to affect the fet,al mor-
tality inertia
rate. 6. The use of Pitocin, with proper precautions, in cases of primary uterine was found to hasten labor and to reduce the number of midforceps
I.
Bradford,
51’. Z.,
ll’oltz,
.I. 11. E.,
iLlId
Bradford.
\V. B.:
.khl.
.J. OHST.
Lt (:TNxC.
58:
109:s,
1949. 2. :j. 2. 5. 6. i.
Donnelly, J. Eastman, N. Hellman, I,. Odell, L. D., Reid, D. E.: Schmitz, R. GYNEC.
F.: Sorth Carolina &I. .J. 9: 19RT 1949. .I.: AM. -7. OBST. & OYNEC. 53: 432, 194i. M.: AM. J. OBST. & GYMW. 57: 364, 1949. Randall, 3. H., and Scott,, G. W.: ,J. A. &I. A. 133: 735. 19-l;. New York State J. Med. 48: ‘?GUl, 1918 E., Bremner, J. X., Towar!, .lanet I<., and Baba, G. It.: 54: 64.7. 1947.
AN.
J. 088~.
&