Kieran O'Driscoll

TRAUMATIC INTRACRANIAL HAEMORRHAGE IN FIRSTBORN INFANTS AND DELIVERY WITH OBSTETRIC FORCEPS

Exclusive of breech presentation, traumatic intracranial haemorrhage was demonstrated at necropsy on 27 occasions in 36 420 consecutive firstborn infants. All 27 were forceps deliveries. The main conclusion is that serious injury to the forecoming head at birth is almost invariably a direct effect of forceps. The relevance of this conclusion to some aspects of contemporary obstetric practice is discussed briefly.

Cesarean section and perinatal outcome: Response from the House of Horne

A direct comparison between Parkland Memorial Hospital in Dallas, Texas, and the National Maternity Hospital in Dublin, Ireland, on the basis of limited numbers taken from one year only (1983) led to the conclusion that the liberal use of cesarean section in Dallas was associated with a sevenfold decrease in intrapartum fetal deaths and a twofold decrease in neonatal seizures. However, when the scope of the survey is extended to include the year before (1982) and the year after (1984), a different picture emerges. During this extended period there were almost four times as many cesarean sections performed in Dallas with no significant difference in overall perinatal mortality, while for two of three years the incidence of neonatal seizures was twice as high in Dallas when compared with Dublin. The fact that high cesarean rates continue to rely on evidence of such a tenuous nature must remain a matter of concern.

Improvement in perinatal mortality rate attributed to spontaneous preterm labor without use of tocolytic agents

A retrospective study of the influence of spontaneous preterm labor on perinatal mortality rate over a period of 15 years was conducted at the National Maternity Hospital, Dublin. As the perinatal mortality rate from all causes declined from 48 to 16 per 1,000 births, the rate attributed to spontaneous preterm labor declined in the same proportion, from 10 to three per 1,000 births. Review of the circumstances of death attributed to spontaneous preterm labor in each case indicates that improvement in this area was due mainly to a natural reduction in incidence and, to a lesser degree, to better care of the neonate. Pharmacologic agents recommended for the purpose of averting spontaneous preterm labor made no contribution, because none was used. Natural improvement in the evolution of a disease may lead to exaggerated claims for the benefits of treatment; experience with perinatal death attributed to spontaneous preterm labor in this large unit suggests that current enthusiasm for tocolytic agents may well be misplaced.

Active Management of Labour and Occipito‐Posterior Position

Summary: A reappraisal of the clinical significance of the occipito‐posterior position is needed in the altered circumstances which derive from a policy of active management of labour. In a series of 1,000 consecutive primigravidae, the occiput was posterior at the time of delivery on 38 occasions. This had an adverse effect on the conduct of labour in approximately 3 cases (0.3%). It is concluded that the occipito‐posterior position has been reduced to a low level of clinical significance in current practice.