[Development and fate of premature infants--then and now]

New scientific results and progress in technology allow even premature infants with very low birth weight to survive today. A vehement discussion arouse about effectiveness and efficiency of intensive care programs for these infants. However, an appreciation of the results at present should not be made without taking note of those achieved in former decades. A. Ylppö was the first pediatrician in Germany at the beginning of the 20th century, who was working systematically for the survival of low birth weight infants. He achieved remarkable results even at that time. After World War II the chances for survival of low birth weight infants became worse because of dangerous therapeutic innovations. In the 60's the frequency of serious sequelae could be reduced by improved therapeutic approaches. Since then the mortality rate is decreasing, whereas the frequency of serious sequelae remains nearly stable during the last 15 years. We hope that clinical research and new technologies may also reduce the morbidity of surviving premature babies in the future.

Birth injury to the cervical spine and spinal cord

Mechanical trauma to the cervical spine still occurs at birth. In 2 of 48 perinatal postmortems traumatic damage to the cervical spinal cord was found. Also in this series at least 12% of cases from one hospital showed some degree of trauma to the cervical spine but this was of a lesser degree in individual cases than 20 years ago.

Has an increased cesarean section rate for term breech delivery reduced in incidence of birth asphyxia, trauma, and death?

To evaluate whether the dramatic rise in the cesarean section rate for breech presentation (from 22% in the decade 1963 to 1973 to 94% in 1978 and 1979) has been justified, 770 term breech deliveries at the Royal Victoria Hospital during the period 1963 to 1973 and during 1978 and 1979 have been reviewed. Neonatal outcome, as determined by one neonatologist during the entire period of this study, was analyzed according to vaginal or cesarean section breech deliveries of primiparous and multiparous women. For each method of delivery and state of parity the occurrence of asphyxia neonatorum, abnormal cerebral signs, postasphyctic congenital heart failure or renal failure, and intrapartum and neonatal deaths was studied. The most severe cases were individually reviewed. While breech presentation has become a virtual indication for cesarean section in many centers, to date , there has not been an evaluation of how effective this procedure is in reducing birth asphyxia and trauma. In this study we assessed whether the trend to perform cesarean section in all term breech presentations is justified and whether neonatal morbidity and mortality rates have actually improved as a result.

[Labor in the older primipara]

In the Gynecology Department Split's General Medical hospital, during the period of 5 years (1975-1979) examinations were carried out on primiparas (10775 up to the age of 29, then 504 between the ages of 30-34, and 250 older then 35). These patients had pregnancy complications (EPH-gestosis and diabetes mellitus), premature delivery, birth of children with less then 2500 grams, overcarriage, obstetrical intervention (forceps, vacuum extraction, caesarian) section and perinal mortality and morbidity. Premature delivery and the birth of children lighter then 2500 grams is significantly increased between the ages of 30-34, and still increasing after the age of 35. The frequency of EPH--gestosis is increased between the ages of 30 and 34 and still increasing after the age of 35. The significant increase of diabetes in pregnancy becomes evident after the age of 35. Deliveries ended by an operation become very frequent between the ages of 30-34, significantly increasing after the age of 35 (vacuum extraction and caesarean). Perinal morbidity and mortality are significantly increased after the age of 35. The Author's conclusion is that older primiparas are those women who are expecting their first child after the age of 35. Primiparas between the ages of 30-34, because of the higher rate of fetal injury, should be shown more attention in the perinal period.

[Studies on the incidence of intracranial haemorrhages and their relation to the delivery by using the cranial computer-tomography (CT) in full-term newborns]

The cranial computer-tomography is a new non-invasive method for the diagnosis of perinatal intracranial haemorrhage. Among 80 neonates, who were examined by CT after delivery at term between the 3rd and 5th day of life, there were 43 newborns without any neurological symptom. These were examined voluntarily with the permission of their parents. A significant correlation between the CT-finding of an intracranial haemorrhage and the neurological observations was found, whereas there was no relation to the mode of delivery. Parity, birth weight, Apgar-score, cord blood-pH did not correspond to the CT-findings. An extremely short duration of the second stage of labor in spontaneous delivery seems to increase the risk of perinatal intracranial haemorrhage.

Management of low birth weight breech delivery: should cesarean section be routine?

A total of 434 low birth weight deliveries between 1967 and 1976 were studied retrospectively. Of these, 217 were breech deliveries, and the other 217 constituted a control series of vertex deliveries. In the breech deliveries the perinatal mortality was 1.8 times that of the cephalic cases, and the neonatal mortality was 2.9 times greater. During the last 5 years of the study, the cesarean section rate increased for the group of infants weighing between 1500 and 2499 g; this policy did not improve the prognosis in breech presentations. Malformations and respiratory distress syndrome were more frequent in breech presentations. Conditions associated with the corrected perinatal mortality (cerebral hemorrhage, fetal asphyxia, prolapsed cord) were also more common in breech presentations, but especially in the group of infants weighing less than 1500 g. This weight group, for which the cesarean section rate did not rise, emerged in the study as a special area of concern. Conclusions and recommendations for management are presented.

Birth injuries of the brachial plexus: incidence and prognosis

Between March 1969 and May 1978, 36 babies sustained birth injuries of the brachial plexus at the National Women's Hospital, Auckland, New Zealand. This gives an incidence of 0.87 per 1000 live births. Nearly 80 per cent of these children had made a complete recovery by the age of 13 months, while none of those with significant residual defects has severe sensory or motor deficit of the hand.

Obstetric clavicular fractures. A three-year analysis

A three-year retrospective study of al deliveries in a military residency program revealed 24 cases of fractured clavicles. Fifteen of these 24 cases were thoroughly reviewed. The incidence of clavicular fractures was 7.2 per 1,000 term deliveries. Fractured clavicle seemed to be best correlated with birth weight, level of obstetric experience of the delivering physician and midforceps deliveries. It was not well correlated with type of anesthesia, length of labor, length of second stage, Apgar scores, parity and judged difficulty of delivery. Only 1 infant of 15 suffered neurologic injury. A review of the literature and suggestions for possible prevention are presented.

[Incidence of birth injury in full term newborns in the last 5 years at Port Royal Maternity Hospital (author's transl)]

The incidence of birth injury in full term neonates during the last 5 years at Port Royal Maternity Hospital has been determined. Cerebral symptoms were classified in three grades; mild, moderate and severe. The study was concerned with gestational and obstetric causes of cerebral damage. Babies with malformations, metabolic disorders and infections were excluded. During the study the incidence of intra-partum deaths and still births was low, 2 to 2.5 per thousand births, and did not alter but there was a statistically significant reduction in the number of babies in the moderate and mildly affected groups. This may be due to improved obstetric practice. From 1974 to 1978 the incidence of fetal heart monitoring increased from 20 to 60 percent and since early 1977 amnioscopy has been performed in every woman admitted. The incidence of cerebral symptoms may be an important method of assessing the quality of obstetric care. Serious accidents are becoming rare and therefore the incidence of mild or moderate cerebral symptoms is likely to be a better indicator of good obstetric care. In full term infants perinatal factors are infrequently the cause of brain damage.

Delivery of twin pregnancy

Preliminary observations fail to indicate a higher risk to the twin babies as a result of labor induction or Cesarian section, so that a systematic clinical trial will now be possible.

The development of children born by vaginal or abdominal breech delivery (author's transl)

The early and late development of children born by the breech either by vaginal breech delivery or by caesarean Section is compared. The early and late morbidity of the two groups is discussed in detail. Considering the recently published data by Hagberg (6) theinterpretation of findings classified as secondary morbidity is very dificult. There are numerous especially antenatal factors which interfere with the interpretation. The conclusion is presented that it is a present not possible to make a definite statement on the value of vaginal or Caesarean Section delivery in breech presentation. It is still considered to be safe to do Caesarean Section delivery in breech presentation. It is still considered to be safe to do Caesarean Sections in breech presentations on an individualized basis.

[Breech presentation and its significance (author's transl)]

From 1959 to 1975, 1060 (3.6%) breech presentations were found among 29,463 infants. The breech deliveries from May 1, 1959 to December 31, 1965 were compared with those from January 1, 1966 to December 31, 1975. Among the 3.6% breech deliveries there were 47% male and 53% female. There were more primigravida breech deliveries in both groups. The mean age of the mothers was 25.4 years for primigravidas and 29.4 years for multiparas. There was a maternal mortality of 0.2% (2 cases) in breech delivery. 29% of the breech deliveries were premature deliveries. There was a strickingly high incidence of frank and full breech deliveries among all patients. Knee presentations were rare. Delivery was primarily accomplished with the Bracht manoeuver in over 80% of the cases. Complete breech extractions decreased and the incidence of Caesarean Sections rose from 6% in the first group to 21% in the second group of patients. During the past 3 years the Caesarean Section rate was approximately 30%. Perinatal complications in the breech deliveries compare well to those reported in the literature. Of 750 mature infants (70.8%), 12 died (1.6%). Discounting children with congenital malformations and intrauterine stillbirth there remained 5 deaths from breech deliveries (0.7%). Of 1032 breech deliveries with a birth weight of 1000 grams or over, 74 infants (over all perinatal mortality 7.2%) died. 110 infants of all breech deliveries had a birth weight of less than 2500 grams (prematurity rate 29.2%). Of 102 cases of perinatal mortality in breech deliveries including those below 1000 grams 90 (88.2%) were premature. Of those 90 premature deaths, 28 infants were less than 1000 grams. 25 infants showed fetal congenital abnormalities. The corrected perinatal mortality of the premature deliveries was therefore 11.9%. The rate of birth trauma was 6.3% in the first group and 2.7% in the second group.