Erich Saling

External cephalic version under tocolysis

We currently consider the external version of the fetus from a breech to a vertex presentation near term the best solution to the disadvantages of a breech delivery for mother and child. Version at such a late time in gestation is only possible with the aid of the tocolytic relaxation of the uterus as recommended by us. This method offers two important advantages over the conventional method of external version, the performance of which after the 34th week of gestation has been discouraged because of the poor chance for success: 1. Because of the relatively decreased intrauterine space during the last month of pregnancy the fetus will revert less readily to a breech. 2. In the event of a complication during external version the immediate operative delivery of the mature infant near term is possible. After the presentation of the fetus has been diagnosed by ultrasound the mother is given 20-50 micrograms Fenoterol (Partusisten) intravenously simultaneously with an inhalation analgesia. The version itself is effected by positioning the hands of the operator against the fetal forehead and by turning the infant as in a backwards roll. If this fails, the dose of the tocolytic agent may be increased. In cases with extended legs the chances for success appear to be decreased. The completed version should be confirmed with an ultrasound examination and the undisturbed status of the fetus should be documented with a cardiotocogram immediately after the version. The following results were achieved: The external version was successful in 43 of 57 pregnant women (75%). If the material is selected more critically, over 80% of the attempted versions should be successful. We have now delivered 40 infants as vertex presentations after a previously diagnosed breech presentation. The frequency of breech deliveries in our hospital has decreased by 2.6% from 5.4% to 2.9% since the introduction of version. The decrease is statistically significant. Convincing evidence that version has decreased fetal risk from breech delivery is found in a comparison of the newborn status. The decrease in the percentages of clinically depressed and acidotic newborns is also statistically significant. The failure rate does not appear to increase with increasing gestational age. There is no correlation between parity and failure or between maternal age and failure. So far we have seen no serious complications. In 5 of 24 cardiotocograms recorded a transient fetal bradycardia occurred immediately after the version which disappeared after a few minutes of maternal lateral position.

The significance of the time interval in twin delivery

In order to evaluate the influence of the time interval on the second twin in twin deliveries, we have used more precise criteria than have been used in the literature to date. In the period from July 1, 1970 to December 31, 1974, 35 twin deliveries in our hospital were analyzed, in which both twins fulfilled the following criteria: 1. vertex presentation 2. vaginal deliveries 3. birth weight above 2000 g. We analyzed various parameters in the clinical and acidity score of the second twin alone as well as in comparison to the first twin. The following points of view were considered: 1. The more sensitive aspect of morbidity was utilized by including the assessment of the state of the newborn rather than just mortality. 2. Since Caesarean sections in twins are often performed for a fetal indication, short time intervals between the birth of both infants correlate intrinsically with a higher risk for the second twin. Therefore we considered only vaginal deliveries in order to exclude this intrinsic correlation. 3. By excluding infants below a birth weight of 2000 g, the influence of the low birth weight of the second twin was eliminated. 4. The frequently occurring positional anomalies of the second twin will deteriorate the conditions independent of the time interval. therefore we have considered only births from vertex presentations. A comparison of the acidity state demonstrated that the actual pH values in the umbilical artery blood of these second twins (Fig. 1) decrease statistically significantly with increasing time intervals. this is also true for metabolic acidity (pHqu40). The differences of the actual pH values (Fig. 2) and the pHqu40 values between the first and second twin decreases significantly also with an increasing time interval. Our results indicate that obstetricians, according to the clinical conditions, should accomplish the birth of the second twin as soon as possible after the birth of the first twin.

Analyses of tractive forces during the application of vacuum extraction

Numerous articles have been published concerning technique and clinical application of vacuum extraction. To date, however, there has been no direct research, äs far äs wc know, about the extent of the effective tractive forces and the length of application during the extraction. Because of this lack criteria based upon subjective judgments were used to characterize a vacuum extraction. Such criteria are insufficient for objective analysis of tractive forces.

First results and experiences with our prematurity and dysmaturity prevention program (PDP-Program)

The mortality and morbidity of newborns with low birth-weight are considerably higher than in newborns with normal body-weight. The incidence of perinatal death and injury is highest in the low birth-weight group. In countries with low prematurity rates perinatal mortality is in most cases correspondingly low, e. g. Sweden and the Netherlands. Hence the most pressing task of obstetrical and perinatal medicine is to lower the number of newborns with low birth-weight to the minimum. PAPIERNIK [10] and our staflf [12] have developed independently programs which can be used for evaluating in advance the risk of low birth-weight, so that appropriate measures can be taken in time.

Rapid specific determination of amniotic fluid lecithins as a test of fetal lung maturity

Normal respiratory function in the newborn depends on the development of adequate amounts of surf actant substances in the alveoli. The changes in the phospholipid content of the fetal lung during gestation correspond to those in the amniotic fluid. Therefore several methods have been developed to determine the amount of amniotic fluid lecithins, which are major constituents of surfactant substances and which, in contrast to the other main phospholipids, are greatly increased in the last trimester of gestation, especially near term. GLUCK et al. [3] have described a method for estimating the liquor lecithin/sphingomyelin ratio (L/S ratio). Some authors corroborated their results [1,5,7,11]; others came to different conclusions [4, 8,12]. GUSDON and WAITE [4] proposed a colorimetric method for the determination of phospholipids in amniotic fluid, 70 % of which are thought to consist of lecithins. There is no doubt that analysis, based on such measurements, is both unsatisfying and unreliable. In addition, determination of phosphorus is unspecific. Therefore, complete Separation of lecithins before determination is necessary. Some authors have achieved this objective by separating lecithins from other phospholipids using thin-layer chromatography and measurement of phosphorus in the eluate from silica gel scraped from the plate. The disadvantages of this method are the long-time periods involved, recovery problems (recovery: 86—92% [1]) and high liquor volumes (8 to 18 ml [l, 8, 9]). These facts give an idea of what is needed: A method for direct determination of lecithins Curriculum vitae

A combined clinical-biochemical scoring of the newborn. Results of the past four years

In 1953 VIRGINIA APGAR was the first to introduce clinical scoring of the newborn [1]. >The scoring System she introduced is now being used in almost every country. As with other similar clinical classification methods her System has the disadvantage of providing no exact measurable value and thus is prone to subjective influences. The co-author of this article introduced fetal blood analysis [2]; he recommended as early as 1965 that — supplementary to this biochemical assessment of the fetus — in addition to the clinical scoring, the pH-value in the umbilical artery blood be measured as a further parameter for the condition of the newborn [3]. To obtain a better over-all view of the judgement of the newborn we split together with WULF [4] the clinical and the acidity score into groups (Fig. 2). Since 1960 this acidity scoring has been employed at our clinic in all cases at risk in which fetal blood analysis (FBA) has been carried out; thus we have today a large number of newborn which have been observed in this manner (Tab. I). The percentage of fetuses observed by FBA in 1961 was only 5.1%, rising to about 50% in the last years (Tab. I). The reason for this increase was that the indication for FBA was broadened from year to year by increasingly intensive methods of diagnosis, cardiotocography in particular. At first we evaluated this large group of cases, to determine how many of the infants, supervised by using FBA, were born in an unsatisfactory Curriculum vitae

A new method to decrease the risk of intrapartum infection.

Ascending infections, especially those following the rupturing of membranes, have occupied the obstetricians for generations because of the increased risk to mother and infants. With the development of perinatal medicine during the last 15 years this risk has increased because of the introduction of intensive monitoring during labor. Several studies have shown that the colonization of the amniotic fluid increases rapidly within a few hours after the rupturing öf membranes [4,11,19]. The use of intensive monitoring techniques (cardiotocography, fetal bloodsampling, more internal examinations) adds to the introduction of organisms [8, 9, 12, 15]. This is demonstrated in Fig. l. While prophylactic use of antibiotics will decrease the immediate risk to mother and infant [17] this is not considered an appropriate solution because of the selection of resistant organisms [19]. Therefore, we have sought a new approach which would allow to combat the ascension of organisms without increasing hospital infections. With initiation of intrapartum monitoring we introduce together with the scalp electrode for fetal heart monitoring a thin plastic catheter attached to the electrode (Fig. 2) through which a suitable disinfectant solution is slowly pumped throughout the subsequent period of delivery. Thus the birth canal is being constantly rinsed with the solution from the presenting part to the vulva. We use äs the disinfectant an organic complex of polyvinylpyrrolidone with iodine (Trade Names: Betadine, Betaisodona).

Routine diagnosis of fetal lung maturity

The respiratory distress syndrome (RDS) is the most frequent postnatal complication of prematurity having a 25% lethal outcome even today (KEUTH [6]). The same author reports that RDS affects 8% of an unselected population of premature infants and 20% of a negatively selected population found in clinical departments for premature babies. Hence avoidance of prematurity is one of the most important tasks of modern perinatal medicine [12], In those cases in which prematurity is unavoidable, the methods of assessing the maturity of the lungs are becoming more and more numerous [5], e. g. by determining the lecithins content of the amniotic fluid. Our recent investigations show that there is a positive correlation between the lecithins content of tracheal secretion and that of the amniotic fluid [4], Different authors have put forward methods for determining lung maturity that are of variable effectiveness (for review see [7]). The work presented here suggests practical procedures for the routine diagnosis of lung maturity which can be used to evaluate a decrease in lecithins content in amniotic fluid and relate it to respiratory disturbances.