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Stillbirth and ways to reduce it
Stillbirth and ways to reduce it
‘I’ H E aim of tlic present
~vork is to stud? the causes of stillbirth and the possibility of eliminating ihem by means of improving the quality of the work of ohstetrical-gynecological units. \\rt* made ~1 stud). of 8 10 pregnancirs which terminated in stillbirths and which occurred o\.er the course of a number of years in the obstetrical institutions of Stalinskaya Oblast. This was accomplished by means of an analysis of birth management through planned visits to various localities and by the study of annual reports and data obtained from a questionnaire which was worked out especially for this purposci. AI1 the pregnancies which terminated in stillbirth were discussed with the local physicians. As a result of these analyses we were able to note a subsequent improvement in all the figures for obstetrical work in thcx obstetrical-gynecological units. Thus, the, stillbirth rate was reduced hv 2.5 per cen( anron,q those born of full-trrrn pregnancicks and by almost twice as much among the prematurely born. Of the 810 stillbirths, antenatal death of the fetus occurred in 30.6 per cent; intranatal, in 69.4 per cent. Antenatal death of the fetus attests the need for intensification of the work of obstetrical consultations for thr detection of the toxemias of pre,gnancy as
~vcll as (‘xt ragcGta1 and other clisc*ascssl~~clin? to the death of the fetus hcforc: the onit of labor. Measures for the elimination of intranatal death of the fetlts rcprrsc’nt out of the complrs problems of obstetrics, the, solution of which rcxquircs adcquatc, training of obstetrician-gynecologists ant -I midwives. Among the stillborn infants, 68.7 per WIII wcw full term and 31.3 per cent were premature. In the survey by Porembskiy,” these iigurcs were 57 per cent and 43 pi cclnt. rc:spectivelJ,. Causes
of
stilfbirth
According to the existing classification. WY’ divided the causes of stillbirth into forlr “roups: 31.5 per cent were due to maternal ,7 causes (Group I) : 25.5 per cent to fetal causes i(Group rq : 17 per cent to placental causes [Group 111) ; and 26 per cent to indeterminate causes (Group IV), 1. Indeterminate causes. The number of’ stillbirths from indeterminate causes ‘26 per cent) should be considered very high 1 k.1 per cent are indeterminate according to Keylin’ and 4.39 per cent according to Ii. S. Kozina). Careful documentation of thch management of Iabor (recording of labor acti\Gtv and of changes in the fetal and Iwart rat?. uotf5 of all examinations operations madrb) and pathological examination of all stillborn babies should play an important part in the determination of the trur cause of stillbirth: however, WC’ had at o111 disposal tilt. r-cults of autopsies in onI>, 61 per cent 01’ ~~ascs. No autopsy was pcrformed in the remainder.
From the Obstetrical-Gynecological Hospital (Hend. Profrssor. P. P. Sidorozaj of the Stalin Medical Institutr (Director, Docent A. M. Ganichkin). Original Rus.rian article published in Sovetskaia Meditsina (Soviet Medicine) 21 (2) : 35-41, 1957: ‘translation bl National Institutes of Health.
244
Stillbirth
After analyzing the causes of stillbirth and taking into consideration the deficiencies in the work of the obstetrical institutions, we shall, in our further discussion, t.a.ke the liberty of making a number of practical suggestions in the matter of the proper management of labor, which should, in our opinion, contribute somewhat to reducing the stillbirth rate. 2. Maternal causes. The maternal causes oi‘ stillbirth are presented in Table I. From the point of view of the study of the causes of stillbirth and its reduction, prolonged dry labor, which occurred in 15.4 per cent of all the cases of stillbirth, is of great interest. Long duration of labor likewise exerts a significant effect in increasing the stillbirth rate, which coincides with data published by P. A. Beloshapko, M. MM. G-inzburg, and S. L. Keylin. Long, dry labors are often the result of poor work in the obstetrical institutions where physicians have not familiarized themselves sufficiently with modern methods oi‘ controlling labor. An individual approach IQ the management of labor should be incorporated into the practice of obstetrical institutions on a broad scale. This will include the application of anesthesia in some cases and the simultaneous acceIeration or intensification of labor (methods of Khmelevskiy, Shub, and Kurdinovskiy-Shteyn) and, in other cases, giving the mother rest, building up her stren,yth, and thus contribut-
Table
I
Causes
of
stillbirth
Protracted dry labor, primary and secondary uterine inertia Toxemias of pregnancy Acute, chronic, and febrile diseases Cardiac disease Cephalopelvic disproportion Rupture of the uterus Other trauma to the mother --Total
1 groufi
1 births
48.7 8.8
15.4 2.7
19.5 0.4 18.0 3.1 1.5 100.0
3.6 0.1. 5.6 1.0 0.5 28.9
and
ways
to
reduce
it
245
ing to the restoration of normal labor. One of the measures used in protracted labor during the second stage, particularly in cases where there are defects in the abdominal wall, is the application of the Verbov binder which contributes to analgesia (Petchenko) and to shortening of this stage. Along with this, attention should also be directed to the problem of prophylaxis of intrauterine asphyxia of the fetus in cases of protracted labor, by means of the timely application of the A. P. Nikolayev method. This involves a systematic, frequent (every 10 to 15 minutes during the first stage and every 3 to 5 minutes during the second stage of labor) auscultation of the fetal heartbeat. Changes in the heartbeat urgently dictate the application of measures for combating asphyxia and, where necessary, for terminating labor. A number of authors (S. I,. Keylin, A. V. Lankovits, A. B. Sigalov) mention the high percentage of stillbirths in deliveries complicated by maternal disease and particularly by influenza and its complications. The instructions of the Ministry of Health, U.S. S.R., for combating influenza in the obstetrical institutions--timely and obligatory hospitalization of pregnant women who are ill and a high degree of aseptic precaution in the obstetrical institutions-should be carried out in these cases as measures directed at reducing the stillbirth rate. The use of antibiotics and sulfonamides should be considered obligatory in cases of infection in pregnant women. As far as the toxemias of pregnancy are concerned (nephropathy of pregnancy, preeclampsia), the detection of the early forms of toxemias and the hospitalization of these patients contribute to reducing the number of stillbirths. Stillbirth associated with a narrow pelvis can be prevented in many cases through the proper use of obstetrical consultations. The degree of constriction of the pelvis with consideration of the indications for operative delivery should be determined at the time of the obstetrical consultation, and pregnant women with this type of pathological condition should be sent to the hos-
246
Kuznetsov
and Sigalov
pita1 for delivery. With ;I detailed study of the pelvis and application of methods of functional diagnosis (mt~asurcment ol’ Ihc fetal head and study of the relations of th(% head to the pelvic diameters, Rastin’s sign,” the determination of progress of thcb head by txternal methods. s-ray ~xaniination, etc. !. the proper rnanagrment of iabor in such an event should rcducf, the stillbirth 3. Fetal causes. The fetal causes of stillbirths are presented in Table II. The data SIKW that 7.5 per cent ol all stillbirths ark associated with breech prc,srntations, 6 per cent with a transverse position of the f‘etlls. and 4.5 pel. ccmt with rnultipl(* pregnancy. Adeyuatc qualiiication of the obstetricalqnccolo+xl personnel plays a particularl)inlportant part in redltcinl: the incidence 01 stillbirths in this group.
ccruscs of stillbirths Breech presentations Trnnsvek positions of tht, ItaIs Multiple pregnancy Monstrosities and drvelopmrntal defects Faulty
engagemrnts
of rhc
fetal head Birth trauma ‘l‘o:al
Death of the fetus in breech presentations occurs for the most part at the time of cstraction by the bret&. \.ery often ina,dviscdly, as well as through untimely or improper manipulation. The proper managcxmcnt of labor, with the application of thcx Tsov’yanov method in frank breech and footling presentations as well as the USC of spasmolytic agents f 1 c.c, of atropine solution 1: 1,000 subcutaneously), should reduce the stillbirth rate, Transverse presentations of the fetus rc“.I>
given
in
the
Russian:
Va~trn’~
Volume Number
79 ?
tion are sometimes hospitalized late, and therefore some of them are admitted with considerable anemia from hemorrhage and frequently with a dead fetus. The operation of version with the cervix incompletely dilated, which for a number of reasons is still bein,g used in certain obstetrical institutions for placenta previa, leads inevitably to the death of the fetus. In patients with marginal placenta previa Ivanov’s method (scalp forceps) considerably reduces the stillbirth rate and is often effective as a means of stopping hemorrhage. In a whole series of patients with central placenta previa or with premature separation of a normally situated placenta, cesarean section performed in time saves both the mother and the fetus. Coiling of the umbilical cord leads to stillbirth in a considerable number of cases. The difficulty of diagnosis does not permit the rendering of timely aid when needed. Careful and frequent auscultation of the fetal heartbeat aids in the detection of incipient asphyxia, and the administration of agents counteracting asphyxia (Nikolayev’s triad) and the use of suitable operative procedures should reduce the incidence of stillbirth. Vaginal examination, which contributes so much to the early diagnosis of complicati:ons of labor, including umbilical cord presentation and prolapse, is still not being used extensively in all the obstetrical institutions. This may explain the high percentage of stillbirths in the presence of complications. Where prolapse of the umbilical cord is diagnosed, operative delivery (version with extraction of the fetus, forceps, episiotomy ) should be performed in time. Incorrect management of labor in the case of hydramnios also contributes to stillbirth. Instead of watchful waiting in the first stage with cautious release of excessive quantities of amniotic fluid by puncture of the fetal sac after 3 to 3y’ fingerbreadths’ dilatation of the cervix, with the fingers introduced into the cervical canal, certain physicians use primarily oxytocics, which are not indicated in the given case. These incorrect tactics frequently lead to a precipitate discharge of amniotic fluid with pro-
Stillbirth
and
ways to reduce
it
247
lapse of the umbilical cord or of small parts of the fetus, which can result in stillbirth. Comment
In analyzing the procedures undertaken in complicated and pathological labors, we noted that in a number of institutions low forceps, the Ivanov method, the Tsov’yanov method, and the Verbov binder are not being used sufficiently at definite stages of labor in the presence of appropriate indications. Timely and correct application of the procedures mentioned would contribute to reducing the stillbirth rate. In certain cases (transverse positions of the fetus with early escape of the amniotic fluid, marginal presentation of the placenta), the operation of metreurysis is indicated. Familiarization of physicians with the proper management of labor is of great significance in the fight against stillbirth. Correct obstetrical tactics, should, when indicated, be combined with timely, cautious methods of operative delivery. In individual cases (incorrect position of the fetus and early escape of amniotic fluid, abnormality of labor in “elderly” parturients, unfavorable obstetrical history) where there is an insistent request by the parturient for a live fetus and in the absence of contraindications, recourse may be had to cesarean section. As a result of our investigation we observed that the proper management of delivery (stimulation of labor, combating intrauterine asphyxia, timely, cautious, and correctly performed operative intervention) can prevent intrauterine death of the fetus in a number of cases. It should be noted that the number of stillbirths which are preventable decreases from year to year, which is evidence for the increase in qualified aid for delivery. Nevcrtheless, the work of improving the qualifications of obstetrician-gynecologists and midwives should be continued on an even greater scale. Conclusions
1. Reduction in the rate problem of great, state-wide
of stillbirth significance.
is a
248
Kuznetsov
and
Sigalov
,&. Improvingthth quality. oi ohxtctrical consultations is important in reducing tht, stillbirth rate. 5. Drlaycd diagnosis of birth complications. improprr management of delivery. and appropriate, obstetrical intrrvention lmdcrtaken latr or incorrwtly pcrforrnrd incrtxw the stillbirth rate. To topcx with this situat ion, the qualifications of obstctrician,:,r\.npcologists sllould hr raised. and tlw\
REFERENCES
1. 2.
1’. A.: Akush. i gin. (Obstetrics and Gynrcoloqyi, 1950, Ko. ti. Beloshapko.
Krylin, S. L.: Causes and Prophylaxis of Stillbirth ( Prirhiny i profilaktika mertvorozhdaemosti i ( Moscow, 1948. Yi. Porembskiy, V. K.: ‘l’hr Stillbirth Ratts .\c.cording to Data of thrl Obstrtrical Hospital
Jlould hc writ prl~iodically to study [lit. c‘attscs of stillbirth in the lying-in hospitals. ‘l’hc raising of the qualifications of mid\vi\w is also ohligator\“. 6. ‘1‘1~: main diffirulty in ti-1~ stud>. of ~IIC stillbirth ~111 is th(’ high pt~rrcrita~~~ of ho-callrd indctcrrtrinatt~ cat1ws, for tilt. t~iimOf which ination careful documentation 01 t hf. managtwt~nt of labor and autopsv of all stillborn infants should hc rnade routine. T’he public l~~altll organizations should tqaniw llic pathology senicc3 of all largt~ rayon centers and impose on them as a clut\ ttlc drtailrd ,ymss and microscopic pathological txatnination of the placenta, urnhilical cord. hmill. liwt~, cw.. of the stilltxwr.
imeni Professor Snegirtv for it Period of ‘I’crl Yc*ars ( 1905-1915). A collection dedicated to thv 175th anniversary of the Obstetrical Hospital imeni Snegirw, 1949. (Mertvorozhtlzw most’ po dannym roddoma im. Prof. Snrgiwva za 10 let [1935-19151, Sborn., posviashchvn. 1 7%lctiiu roddoma itrt. Snegirwa, I9-f9. 1
‘I’ H E aim of tlic present
~vork is to stud? the causes of stillbirth and the possibility of eliminating ihem by means of improving the quality of the work of ohstetrical-gynecological units. \\rt* made ~1 stud). of 8 10 pregnancirs which terminated in stillbirths and which occurred o\.er the course of a number of years in the obstetrical institutions of Stalinskaya Oblast. This was accomplished by means of an analysis of birth management through planned visits to various localities and by the study of annual reports and data obtained from a questionnaire which was worked out especially for this purposci. AI1 the pregnancies which terminated in stillbirth were discussed with the local physicians. As a result of these analyses we were able to note a subsequent improvement in all the figures for obstetrical work in thcx obstetrical-gynecological units. Thus, the, stillbirth rate was reduced hv 2.5 per cen( anron,q those born of full-trrrn pregnancicks and by almost twice as much among the prematurely born. Of the 810 stillbirths, antenatal death of the fetus occurred in 30.6 per cent; intranatal, in 69.4 per cent. Antenatal death of the fetus attests the need for intensification of the work of obstetrical consultations for thr detection of the toxemias of pre,gnancy as
~vcll as (‘xt ragcGta1 and other clisc*ascssl~~clin? to the death of the fetus hcforc: the onit of labor. Measures for the elimination of intranatal death of the fetlts rcprrsc’nt out of the complrs problems of obstetrics, the, solution of which rcxquircs adcquatc, training of obstetrician-gynecologists ant -I midwives. Among the stillborn infants, 68.7 per WIII wcw full term and 31.3 per cent were premature. In the survey by Porembskiy,” these iigurcs were 57 per cent and 43 pi cclnt. rc:spectivelJ,. Causes
of
stilfbirth
According to the existing classification. WY’ divided the causes of stillbirth into forlr “roups: 31.5 per cent were due to maternal ,7 causes (Group I) : 25.5 per cent to fetal causes i(Group rq : 17 per cent to placental causes [Group 111) ; and 26 per cent to indeterminate causes (Group IV), 1. Indeterminate causes. The number of’ stillbirths from indeterminate causes ‘26 per cent) should be considered very high 1 k.1 per cent are indeterminate according to Keylin’ and 4.39 per cent according to Ii. S. Kozina). Careful documentation of thch management of Iabor (recording of labor acti\Gtv and of changes in the fetal and Iwart rat?. uotf5 of all examinations operations madrb) and pathological examination of all stillborn babies should play an important part in the determination of the trur cause of stillbirth: however, WC’ had at o111 disposal tilt. r-cults of autopsies in onI>, 61 per cent 01’ ~~ascs. No autopsy was pcrformed in the remainder.
From the Obstetrical-Gynecological Hospital (Hend. Profrssor. P. P. Sidorozaj of the Stalin Medical Institutr (Director, Docent A. M. Ganichkin). Original Rus.rian article published in Sovetskaia Meditsina (Soviet Medicine) 21 (2) : 35-41, 1957: ‘translation bl National Institutes of Health.
244
Stillbirth
After analyzing the causes of stillbirth and taking into consideration the deficiencies in the work of the obstetrical institutions, we shall, in our further discussion, t.a.ke the liberty of making a number of practical suggestions in the matter of the proper management of labor, which should, in our opinion, contribute somewhat to reducing the stillbirth rate. 2. Maternal causes. The maternal causes oi‘ stillbirth are presented in Table I. From the point of view of the study of the causes of stillbirth and its reduction, prolonged dry labor, which occurred in 15.4 per cent of all the cases of stillbirth, is of great interest. Long duration of labor likewise exerts a significant effect in increasing the stillbirth rate, which coincides with data published by P. A. Beloshapko, M. MM. G-inzburg, and S. L. Keylin. Long, dry labors are often the result of poor work in the obstetrical institutions where physicians have not familiarized themselves sufficiently with modern methods oi‘ controlling labor. An individual approach IQ the management of labor should be incorporated into the practice of obstetrical institutions on a broad scale. This will include the application of anesthesia in some cases and the simultaneous acceIeration or intensification of labor (methods of Khmelevskiy, Shub, and Kurdinovskiy-Shteyn) and, in other cases, giving the mother rest, building up her stren,yth, and thus contribut-
Table
I
Causes
of
stillbirth
Protracted dry labor, primary and secondary uterine inertia Toxemias of pregnancy Acute, chronic, and febrile diseases Cardiac disease Cephalopelvic disproportion Rupture of the uterus Other trauma to the mother --Total
1 groufi
1 births
48.7 8.8
15.4 2.7
19.5 0.4 18.0 3.1 1.5 100.0
3.6 0.1. 5.6 1.0 0.5 28.9
and
ways
to
reduce
it
245
ing to the restoration of normal labor. One of the measures used in protracted labor during the second stage, particularly in cases where there are defects in the abdominal wall, is the application of the Verbov binder which contributes to analgesia (Petchenko) and to shortening of this stage. Along with this, attention should also be directed to the problem of prophylaxis of intrauterine asphyxia of the fetus in cases of protracted labor, by means of the timely application of the A. P. Nikolayev method. This involves a systematic, frequent (every 10 to 15 minutes during the first stage and every 3 to 5 minutes during the second stage of labor) auscultation of the fetal heartbeat. Changes in the heartbeat urgently dictate the application of measures for combating asphyxia and, where necessary, for terminating labor. A number of authors (S. I,. Keylin, A. V. Lankovits, A. B. Sigalov) mention the high percentage of stillbirths in deliveries complicated by maternal disease and particularly by influenza and its complications. The instructions of the Ministry of Health, U.S. S.R., for combating influenza in the obstetrical institutions--timely and obligatory hospitalization of pregnant women who are ill and a high degree of aseptic precaution in the obstetrical institutions-should be carried out in these cases as measures directed at reducing the stillbirth rate. The use of antibiotics and sulfonamides should be considered obligatory in cases of infection in pregnant women. As far as the toxemias of pregnancy are concerned (nephropathy of pregnancy, preeclampsia), the detection of the early forms of toxemias and the hospitalization of these patients contribute to reducing the number of stillbirths. Stillbirth associated with a narrow pelvis can be prevented in many cases through the proper use of obstetrical consultations. The degree of constriction of the pelvis with consideration of the indications for operative delivery should be determined at the time of the obstetrical consultation, and pregnant women with this type of pathological condition should be sent to the hos-
246
Kuznetsov
and Sigalov
pita1 for delivery. With ;I detailed study of the pelvis and application of methods of functional diagnosis (mt~asurcment ol’ Ihc fetal head and study of the relations of th(% head to the pelvic diameters, Rastin’s sign,” the determination of progress of thcb head by txternal methods. s-ray ~xaniination, etc. !. the proper rnanagrment of iabor in such an event should rcducf, the stillbirth 3. Fetal causes. The fetal causes of stillbirths are presented in Table II. The data SIKW that 7.5 per cent ol all stillbirths ark associated with breech prc,srntations, 6 per cent with a transverse position of the f‘etlls. and 4.5 pel. ccmt with rnultipl(* pregnancy. Adeyuatc qualiiication of the obstetricalqnccolo+xl personnel plays a particularl)inlportant part in redltcinl: the incidence 01 stillbirths in this group.
ccruscs of stillbirths Breech presentations Trnnsvek positions of tht, ItaIs Multiple pregnancy Monstrosities and drvelopmrntal defects Faulty
engagemrnts
of rhc
fetal head Birth trauma ‘l‘o:al
Death of the fetus in breech presentations occurs for the most part at the time of cstraction by the bret&. \.ery often ina,dviscdly, as well as through untimely or improper manipulation. The proper managcxmcnt of labor, with the application of thcx Tsov’yanov method in frank breech and footling presentations as well as the USC of spasmolytic agents f 1 c.c, of atropine solution 1: 1,000 subcutaneously), should reduce the stillbirth rate, Transverse presentations of the fetus rc“.I>
given
in
the
Russian:
Va~trn’~
Volume Number
79 ?
tion are sometimes hospitalized late, and therefore some of them are admitted with considerable anemia from hemorrhage and frequently with a dead fetus. The operation of version with the cervix incompletely dilated, which for a number of reasons is still bein,g used in certain obstetrical institutions for placenta previa, leads inevitably to the death of the fetus. In patients with marginal placenta previa Ivanov’s method (scalp forceps) considerably reduces the stillbirth rate and is often effective as a means of stopping hemorrhage. In a whole series of patients with central placenta previa or with premature separation of a normally situated placenta, cesarean section performed in time saves both the mother and the fetus. Coiling of the umbilical cord leads to stillbirth in a considerable number of cases. The difficulty of diagnosis does not permit the rendering of timely aid when needed. Careful and frequent auscultation of the fetal heartbeat aids in the detection of incipient asphyxia, and the administration of agents counteracting asphyxia (Nikolayev’s triad) and the use of suitable operative procedures should reduce the incidence of stillbirth. Vaginal examination, which contributes so much to the early diagnosis of complicati:ons of labor, including umbilical cord presentation and prolapse, is still not being used extensively in all the obstetrical institutions. This may explain the high percentage of stillbirths in the presence of complications. Where prolapse of the umbilical cord is diagnosed, operative delivery (version with extraction of the fetus, forceps, episiotomy ) should be performed in time. Incorrect management of labor in the case of hydramnios also contributes to stillbirth. Instead of watchful waiting in the first stage with cautious release of excessive quantities of amniotic fluid by puncture of the fetal sac after 3 to 3y’ fingerbreadths’ dilatation of the cervix, with the fingers introduced into the cervical canal, certain physicians use primarily oxytocics, which are not indicated in the given case. These incorrect tactics frequently lead to a precipitate discharge of amniotic fluid with pro-
Stillbirth
and
ways to reduce
it
247
lapse of the umbilical cord or of small parts of the fetus, which can result in stillbirth. Comment
In analyzing the procedures undertaken in complicated and pathological labors, we noted that in a number of institutions low forceps, the Ivanov method, the Tsov’yanov method, and the Verbov binder are not being used sufficiently at definite stages of labor in the presence of appropriate indications. Timely and correct application of the procedures mentioned would contribute to reducing the stillbirth rate. In certain cases (transverse positions of the fetus with early escape of the amniotic fluid, marginal presentation of the placenta), the operation of metreurysis is indicated. Familiarization of physicians with the proper management of labor is of great significance in the fight against stillbirth. Correct obstetrical tactics, should, when indicated, be combined with timely, cautious methods of operative delivery. In individual cases (incorrect position of the fetus and early escape of amniotic fluid, abnormality of labor in “elderly” parturients, unfavorable obstetrical history) where there is an insistent request by the parturient for a live fetus and in the absence of contraindications, recourse may be had to cesarean section. As a result of our investigation we observed that the proper management of delivery (stimulation of labor, combating intrauterine asphyxia, timely, cautious, and correctly performed operative intervention) can prevent intrauterine death of the fetus in a number of cases. It should be noted that the number of stillbirths which are preventable decreases from year to year, which is evidence for the increase in qualified aid for delivery. Nevcrtheless, the work of improving the qualifications of obstetrician-gynecologists and midwives should be continued on an even greater scale. Conclusions
1. Reduction in the rate problem of great, state-wide
of stillbirth significance.
is a
248
Kuznetsov
and
Sigalov
,&. Improvingthth quality. oi ohxtctrical consultations is important in reducing tht, stillbirth rate. 5. Drlaycd diagnosis of birth complications. improprr management of delivery. and appropriate, obstetrical intrrvention lmdcrtaken latr or incorrwtly pcrforrnrd incrtxw the stillbirth rate. To topcx with this situat ion, the qualifications of obstctrician,:,r\.npcologists sllould hr raised. and tlw\
REFERENCES
1. 2.
1’. A.: Akush. i gin. (Obstetrics and Gynrcoloqyi, 1950, Ko. ti. Beloshapko.
Krylin, S. L.: Causes and Prophylaxis of Stillbirth ( Prirhiny i profilaktika mertvorozhdaemosti i ( Moscow, 1948. Yi. Porembskiy, V. K.: ‘l’hr Stillbirth Ratts .\c.cording to Data of thrl Obstrtrical Hospital
Jlould hc writ prl~iodically to study [lit. c‘attscs of stillbirth in the lying-in hospitals. ‘l’hc raising of the qualifications of mid\vi\w is also ohligator\“. 6. ‘1‘1~: main diffirulty in ti-1~ stud>. of ~IIC stillbirth ~111 is th(’ high pt~rrcrita~~~ of ho-callrd indctcrrtrinatt~ cat1ws, for tilt. t~iimOf which ination careful documentation 01 t hf. managtwt~nt of labor and autopsv of all stillborn infants should hc rnade routine. T’he public l~~altll organizations should tqaniw llic pathology senicc3 of all largt~ rayon centers and impose on them as a clut\ ttlc drtailrd ,ymss and microscopic pathological txatnination of the placenta, urnhilical cord. hmill. liwt~, cw.. of the stilltxwr.
imeni Professor Snegirtv for it Period of ‘I’crl Yc*ars ( 1905-1915). A collection dedicated to thv 175th anniversary of the Obstetrical Hospital imeni Snegirw, 1949. (Mertvorozhtlzw most’ po dannym roddoma im. Prof. Snrgiwva za 10 let [1935-19151, Sborn., posviashchvn. 1 7%lctiiu roddoma itrt. Snegirwa, I9-f9. 1