FACTORS IN PREVENTION OF PERINATAL LOSS

BY Schuyler G. Kohl1

May I express my thanks and appreciation for the opportunity to speak with you about perinatal mortality. I wish to offer the College my congratulations on the occasion of your fourth annual meeting. It seems so short a time since you were first organized. Also, I am so happy that you are making such satisfactory progress and that you are attaining the measure of recognition which you and your work merit.

Our subject, perinatal mortality, is the fourth major cause of death, in the United States. The 140,000 deaths per year which are associated with the period before, during, and after birth are ex- ceeded numerically only by heart disease, cancer, and vascular dis- eases of the central nervous system as causes of death. If we also consider the severe neurologic deficits present in newborns who survive, there is a combined perinatal mortality and morbidity of about 200,000 individuals per year. Such a large loss cannot be afforded by any community, even one with the resources of the United States of America. Therefore, it seems to me, that all medical, paramedical, and lay individuals must take an active part in pre- vention. We are currently engaged in becoming educated in the etiology and the magnitude of our problem so that we may attack it with purpose and direction.

You and I are equipped, by our training and experience, to mount an attack on certain aspects of this problem-the clinical factors; and we can indicate areas of basic research to those ca- pable of making contributions in that area.

There are certain maternal diseases which have a considerable influence upon pregnancy outcome in a deleterious fashion. The first of these that I would bring before you is heart disease. Between one and two per cent of all mothers have heart disease of slight to severe degree. About ten per cent of women with heart disease during pregnancy will have Class 111 or Class IV heart disease. If these women are not identified early in pregnancy and treated as well as our medical knowledge permits, heart failure will be common during pregnancy. Heart failure, in pregnancy, puts two lives at stake. Neither mother nor infant need be unduly jeopardized, if proper treatment is employed. For example, in our own clinic, in a five-

1Schuyler G. Kohl, M. D., is from the Department of Obstetrics and Gynecology of the State University of New York, College of Medicine at New York and the Kines Countv Hosuital. Brooklyn. New York. This uauer was read before the Annual Convention of The American College of Nuke-Mid; wifery, Philadelphia, Pa., May 11, 1959.

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year period, we cared for over 400 women with heart disease, Only one of these women died, and that was the fault of the New York Giants beating the Brooklyn Dodgers in a play-off game for the league title. You will remember that Bobby Thomson hit a home run. The patient was an ardent Dodger fan. In this same period, these women, with heart disease, suffered a perinatal loss only slightly above that for the clinic as a whole.

Diabetes is a disease which has an unfavorable effect upon pregnancy and is affected adversely by pregnancy, if the mother is a diabetic. Also, unexplained fetal deaths are more frequent. Further, the infants of such pregnancies tend to be large and less able to withstand the possible difficulties of labor. Periods of acidosis are especially unfavorable to the fetus in utero and many a fetus dies following such an attack. However, when the patient is known to have diabetes and is properly treated and controlled, during preg- nancy, the previously mentioned unfavorable episodes can be markedly diminished and fetal salvage improved considerably. Too often this disease is diagnosed after a fetal death. With more diabetic patients reaching child bearing age and becoming pregnant and with our ability to improve results by proper treatment during pregnancy, it is essential that we carry on an active program of case finding in the pqrinatal period. The results which may be achieved by such a program are truly amazing. In 1951 the perinatal mortality as- sociated with maternal diabetes was 31.6 per c-ent in our clinic. By a program of active case finding, in our prenatal clinic, we have increased the number of cases identified by one third and decreased the perinatal mortality by two thirds to 11.8 per‘ cent in 1957. There is nothing magic about our ability to do this, anyone can accom- plish the same results if he takes the time and trouble.

I shall mention virus diseases merely to state that one should make every effort to protect the pregnant woman from those known to be associated with perinatal mortality or morbidity. The difficul- ty here is in relation to germ plasm damage and liftle can be done after infection has resulted in a susceptible individual.

There are certain experiences surrounding the birth process which may contribute considerably to perinatal mortality and we must be informed and observant if we are to keep perinatal loss at a minimum.

Induction of Labor: Elective induction of labor is .ascommon practice in many areas and with many obstetricians.‘Is it a “per- fectly safe” procedure? Certainly it is in most instances and for most patients. There have been many reports about the degree to which this procedure is innocuous. Recently, we recorded, in detail, the results of over 600 patients who were submitted to “elective induction of labor.” As far as could be determined, by two com-

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petent obstetricians, these patients and their pregnancies were normal in all respects. Here are some of the “surprisks” we found:

1.

2.

3.

4.

5. 6.

7. 8.

9.

There were seven unrecognized breech presentations, 2 face presentations, and 1 tranverse lie. Thirteen patients required “indicated mid-forceps” oper- ations for delivery. Eleven patients, 1.8 per cent, had to be delivered by cesarean section. Almost four per cent of the patients received blood trans- fusions. Almost six per cent of the patients had postpartum fever. Seven patients had placenta previa or premature separation of the placenta. Four patients suffered prolapse of the umbilical cord. . There were 11 infants whose birth weight was less than 2500 grams. There were four perinatal mortalities. Two infants weighed less than 2500 grams.

Stimulation of Labor: In some hospitals as many as 50% of patients in labor receive “elective” stimulation of labor. Examination of the perinatal deaths discloses occasional remarks like the follow- ing: “Fetal distress noted following tetanic contraction after third dose of pitocin.” “Maternal diabetes-infant weighed 4989 grams.” “Tranverse Lie.” “Fetal distress during first stage of labor-de- livered by cesarean section.’’ In addition to a perinatal loss rate which is rarely less than otherwise handled normal patients, we have no information about long term results in surviving infants.

The Repeat Cesarean Section : About one half of all cesarean sections performed today are upon patients who have had a previous abdominal delivery. The perinatal loss rates should be very low. That is one of the reasons for employing this method of delivery in subsequent pregnancies. Yet perinatal loss rates as high as 2%% are seen with frequency. This is mainly due to the fact that an appreciable number of infants so delivered weigh less than 2500 grams. It is not a fortuitous observation that, in some clinics, atelectasis with hyaline membranes is most frequently noted in perinatal deaths associated with repeat cesarean section. In those clinics where the incidence of prematurity is low, the incidence of prematurity in repeat cesarean sections may equal or exceed the overall clinic rate. Care must be exercised to prevent the delivery of a premature infant in these situations.

Obstetrical Trauma : The formerly frequent cause of perinatal mortality and morbidity, obstetrical trauma, is becoming less fre- quent every year. This is related to the better training of the physicians and nurses who are responsible for the care of the partu-

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rient. The marked decrease in the use of the mid-forceps operation and other traumatic procedures along with an intelligent increase in the use and safety of cesarean section is largely responsible for this improvement. The cesarean section rate is a less revealing indicator of the level of obstetric practice than is an investigation of the in- dications for which the operation is performed.

Breech Presentation : Breech presentation is seen in slightly more than four per cent of all deliveries but is associated with 25% of all perinatal deaths and with 17% of all perinatal deaths in in- fants over lo00 grams birth weight. A situation which is present four per cent of the time, has a perinatal mortality four times that for all infants of similar birth weight. To put it another way, a con- dition which occurs 1/25th of the time is associated with 1/5 of the perinatal deaths. Reduction of the incidence is difficult to obtain because it is so closely associated with prematurity, and premature labor has long awaited a preventive therapeutic solution. However, very careful handling of breech delivery by experienced attendants and avoidance of trauma will reduce the high loss. Sometimes it is as simple as remembering that the head of the infant is the largest part which must negotiate the pelvis and that there must be sufficient time allowed for adequate cervical dilatation to take place.

Toxemias of Pregnancy: Toxemias of pregnancy occur in six to ten per cent of all deliveries, depending upon the population being serviced. The perinatal mortality associated with the toxemias of pregnancy is at least double that of the patients without toxemia. The best way to treat this complication is to prevent it or at least to identify its presence early and submit the patient to adequate care and treatment. Adequate prenatal care should certainly eliminate eclampsia with its high maternal and perinatal death rates. The perinatal mortality is at least 10%-15% in the presence of eclampsia. The toxemias have a tendency to repeat and to be more prevalent in certain patients; the patient with hypertensive disease, the diabetic, the elderly and young primigravida, the patient whose non-pregnant weight is over 180 pounds. Such patients require special and extra prenatal care.

The Pelvis: The influence of the pelvis upon fetal outcome is apparent and accepted. The pre-occupation with the dangers of ionizing radiation may well decrease the use of x-ray pelvimetry possibly to the detriment of the fetus. This must not be permitted to happen. Careful evaluation of the pelvis by clinical and/or x-ray techniques is of utmost importance. The obstetrical attendant must be certain of pelvic capacity before induction or stimulation of labor is embarked upon. Likewise, obstetrical procedures should be done with knowledge and consideration of the size and configuration of the pelvis and its relationship to the size and presentation of the. fetus.

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Anteparturn Hemorrhage : The modern management of placenta previa has made possible a considerable reduction in the perinatal mortality associated with this complication of pregnancy. When I was a medical student and a house officer, a perinatal loss rate of thirty per cent was acceptable and expected. With modern management the loss rate in the Kings County Hospital has decreased to about fifteen per cent. However, there are many institutions in which the loss rate remains between 25% and 30%. The modern treatment may require prolonged hospitalization and bed rest. If the fault is in the economic problem, then we must discover a way to handle this problem other than at the expense of the fetus. With premature separation of the placenta (abruptio), the fetus is com- promised to such a degree, that I believe that the obstetricians’ efforts should be directed towards the mother, primarily. It has been pleasant to observe that such an orientation may be associated with a more favorable fetal outcome also, in many instances.

Prenatal Care: All that is good and desirable in obstetric practice is associated with good prenatal care. I, like all of you, am against sin; and inadequate prenatal care is the great obstetric sin. There is no question, though, that those patients who receive the best prenatal care enjoy the more favorable perinatal mortality rates. This may only mean that a routine of good prenatal care indicates a high level of obstetric care and ability. I think that the discipline of good prenatal care is associated with good obstetric practice. The value of preventive medical care has long been recognized as a very important factor in good health. I know of no area in which ex- ploitation of its principles may produce greater dividends than in the practice of obstetrics. I have pointed out above several areas in which a preventive medicine and epidemiologic approach will pay large dividends in decreasing loss of life and decrease of morbidity. Time does not permit the pursuance of this self evident benefit.

Premature Care: Proper and adequate care of the premature infant is an activity which must be of great and continuing interest to every person involved in obstetric and newborn care. This usually means the establishment of the facilities, equipment, and personnel needed to give premature infants the care they require. It seems to me that economics should never prevent the establishment of such units. If the patient cannot afford to purchase them, if the hos- pital cannot -afford to establish them, if the personnel is not avail- able to staff them, it is incumbent upon public or other agencies to assume responsibility. That which may be accomplished by the es- tablishment and maintenance of such an ideal premature unit is evident when a comparison is made between neonatal death rates in an eastern city and the Kings County Hospital:

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NEONATAL LOSS RATES (%)

BIRTH WEIGHT City “X” Kings County Hospital

1001 - 1500 grams 61.3 33.3

2001 - 2500 grams 5.4 2.1

1501 - 200 grams 15.5 13.0

In order to obtain the best results, properly trained nursing, medical, and ancillary personnel are required for continued observation and treatment of these infants. The occasional practitioner will not suf- fice. The establishment and observation of well-planned “routines” is essential.

Placental Function: The ability to determine the state of placental function, at any given time, would be the greatest of aids in reducing perinatal mortality. We would then know when an in- fant was in jeopardy and could practically eliminate fetal deaths. While many investigators are currently working on this problem, we currently have no such test of function and must depend upon such gross observations as the fetal heart rate and rhythm and fetal movements.

There have been numerous studies of perinatal mortality in re- cent years. Some have been oriented towards pathologic deterrni- nation of causes of death and some towards clinical considerations. I have participated in one which attempted to evaluate both. Perhaps a brief consideration of some of our findings may help to point up our discussion. The following are some of our observations from the New York City Perinatal Mortality Study:

1. Thirty-five per cent of the perinatal deaths were judged to have been preventable. That is, the mother and/or infant did not receive optimal care at all times.

2. The preventability rates was 1% times greater for mature infants than for premature infants.

3. The factors contributing to preventable losses were:

A. Errors in medical judgment

B. Errors in medical technique

C. Unsatisfactory pediatric care

D. Inadequate prenatal care

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4. Untrained individuals made a greater contribution to pre- ventable deaths than did properly tralned individuals.

5. The preventability rates were lower in teaching hospitals than in non-teaching institutions.

6. The toxemias of pregnancy and medical complications of pregnancy were less well treated than our level of medical knowledge permitted.

7. There is a pattern of a “continuum of pregnancy wastage” which was not always appreciated by the obstetric attendant and those patients who merited special care and surveillance did not always receive it.

8. Only 35% of thedeaths were submitted to pathologic study.

What can and what should we do about this situation in an effort to reduce perinatal mortality and increase our knowledge and understanding of the problem?

1. Establishment of perinatal study committees in each institu- tion which cares for maternity patients. These sessions should be joint efforts on the part of obstetricians, pedia- tricians, pathologists, and nursing personnel. Records and classifications should be kept and analyzed from time to time. Thus areas of weakness and potential improvement may be identified. Also, areas of potentially profitable clin- ical investigation may be set forth.

2. Cooperation on the part of physicians responsible for patient care, public health agencies, and the nursing profession for the purpose of education and the providing of needed facil- ities as well as the establishment of standards of care and facilities.

3. Participation in special studies such as the anterospective Cerebral Palsy Study being conducted by the National In- stitute for Neurological Diseases and Blindness.

4. Periodic evaluations of local performance, which is pos- sible if proper records are maintained.

5. Provisions for proper anesthesia coverage of the delivery area. At present, all too frequently the best anesthesia is available in the general operating rooms where but one life is at stake, while a much lower brand of care is pro-

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vided in the delivery room when two lives are at stake. I do not suggest that the general surgical anesthesia care be reduced to that present in the delivery suite, but rather that the delivery room coverage be improved.

6. Every person responsible for obstetric care become pro- ficient in infant resuscitation. This care of the newborn infant with respiratory difficulty should be in an approved and proper manner. We should be familiar with the recent publication by the American Academy of Pediatrics, on this subject.

7. Take the steps necessary to see that our premature infants are properly cared for by trained personnel in adequate fa- cilities.

8. Intelligent use of analgesic and anesthetic techniques.

9. Encourage patients to accept full and adequate prenatal care, and do what we can to see that such facilities are es- tablished and available to our patients.

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