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whole team then together arrives at provided his unit is within 10 great differences between fetal and
a decision regarding the ideal me¬ seconds distance of, i.e. contiguous adult monitoring technological
thod and time of terminating the with, the delivery room. problems, and the lack of pre-
pregnancy. cedents in this type of work.
Delivery Room
INTRAPARTUM CARE The labour and delivery room is Neonatal Room
An area of 90 square metres ad¬ staffed by a nurse specially trained The neonatalogists (Drs. N.
jacent to and within 50 metres of to render expert supportive care to Jaco and M. Sutton) and their
the labour, antepartum, premature the patient and to the team of phy¬ team of residents and intensive-care
and neonatal intensive-care areas sicians carrying out biophysical and nurses take over the immediate
was remodelled. This core area con¬ biochemical monitoring procedures. resuscitative care and further moni¬
sists of three rooms: a labour and The nurse in this unit is drawn from toring procedures as dictated by the
delivery room equipped to monitor the antepartum area, where each clinical condition (Apgar scores),
labour, and for the delivery of the shift has one nurse assigned to the the cardiovascular adaptation pat¬
patient vaginally or by cesarean O.N.I.C.U. for patients in labour. terns and the blood gas status of
section; a contiguous neonatal adap¬ the newborn in the first half hour
tation and resuscitation room; and Laboratory of life.
between the first two rooms, a The technical staff required to
laboratory equipped with electronic run the laboratory (serving the de¬ MATERIALS AND
polygraphs and biochemical blood livery area in which approximately METHODS
measuring systems. All three areas 10% of the hospital deliveries oc¬ This discussion will be confined
intercommunicate by sound and cur) consists of two full-time elec¬ to intrapartum patients admitted to
closed-circuit television to permit tronic technicians and two bio¬ the O.N.I.C.U. labour and delivery
continuous surveillance by all mem¬ chemistry technicians. It is possible area. Patients were referred to the
bers of the intensive-care team. The to manage with this reduced staff, Unit by family physicians, private
newborn, immediately upon birth, is instead of around-the-clock shift obstetricians or resident house staff.
given to the neonatal resident and/ coverage, by allowing the The reasons for referral fell into
or his consultant, who within 60 O.N.I.C.U. Director freedom to ar- three major categories: (a) clini¬
seconds of birth has the newborn range versatility of working condi¬ cally detected fetal distress in pa¬
in a heated environment, being tions, duties and employee selection. tients already in labour in the rou¬
monitored and resuscitated. Time is The ideal technical staff for this tine labour setting; (b) total
not wasted by the obstetrical staff area, with interest in the program management of labour, of spon¬
in applying suction to a baby who and expert technical ability, is dif¬ taneous or induced origin, in pa¬
can more safely and effectively be ficult to find because of the unpre- tients to whom had been assigned
looked after by the neonatalogist, dictability of patient scheduling, the the label "high-risk pregnancy"; (c)
56 Canad. Med. Ass. J.. Oct. 4, 1969, vol. 101.390
TABLE I..SUMMARY OF INDICATIONS FOR ADMISSION TO O.N.I.C.U.
July /, 1967 to December 31, 1968
Maternal complications of pregnancy Fetal distress (clinically detected) 32
* * ***
Toxemia. 65 Fetal bradycardia. 11 5
Hypertension. 1 Fetal tachycardia. 9 0
Urinary tract infection. 0 Fetal heart irregularities. 9 0
Excess weight gain. 0 Meconium-stained liquor amnii . 3 4
Diabetes mellitus. 3 Occult cord prolapse. 0 0
Prediabetes. 7
Rhesus incompatibility. 10 Uterine factors 24
Rheumatic fever (valvular disease). 1 Prolonged labour. 17 6 1
Varicose veins. 0 Cephalopelvic disproportion. 5 14 1
Epilepsy. 0 Uterine inertia. 1 0 1
Chronic chest disease. 0 Uterine anomalies. 0 1
Anemia. 0 Previous uterine surgery. 1 0
Leiomyomata uteri. 0 0
Gestational duration pathology Incompetent cervix. 0 0
Failed induction of labour. 0 0
Prematurity. 7
Postmaturity. 5 History of 23
Premature rupture of membranes. 8
Poor obstetrical performance. 13 10 11
Placental pathology Infertility. 4 3 8
Elderly gravida. 5 9 8
Placenta praevia. 0 No prenatal care. 0 1 1
Abruptio placentae. 10 Grandmultiparity. 1 1 1
First-trimester bleeding. 1
Third-trimester bleeding (uncPd). 5 Fetal factors 3
Placental insufficiency. 4 Breech presentations. 2 0
Abnormal estriol excretions. 2 Twin pregnancies. 1 1
No. of cases. * Primary
**
Secondary
***Other
a history of perinatal loss(es), cre¬ controlled analgesia and anesthesia, physician, private obstetrician or the
ating either a high-risk or premium- frequency of vaginal examinations, Unit Director when specifically re¬
baby situation. blood pressure recordings, labour¬ ferred to his care. Owing to the
The reassurance afforded to the ing position of patient, indications nature of the pilot project no eco¬
attending staff by continuous ob¬ for and timing of fetal scalp blood nomic structure has been estab¬
servation of fetal status soon cre¬ sampling and other routine pro- lished, and no charges additional to
ated such a demand that more clear
delineation of the service available,
and the indications for it, was man- JJnit No._Age Date
datory. This information was dis¬ _E.D.C_ Gest'n
seminated to the medical staff of
the community and surrounding PRE-PREGNANT WT._KG. PRESENT Wt._KG. HEIGHT_ CMS.
Uterine Measurements_/._/_: FHR-High_Low_Mean_
region by three main methods: (a) DELIVERY Apgar-_1 min._5 min._Other/ Birth Time._
BPM.
laliftiiiil
FIG. 3..Modified spring loaded scalp clip applicator with
silver, silver-chloride scalp electrode.
DELIVERY
Vaginal delivery was selected un¬
less obstetrical indications for ce¬
sarean section became apparent.
vals up to 6 cm. of cervical dila¬ 5. Intrauterine pressures..The Fetal distress, characterized by late
tation and every 10 minutes there¬ uterine contractions were monitored decelerations of the FHR or by
after. Femoral artery catheterization with a Statham transducer attached persistent fetal tachycardia, unex¬
and Statham transducer recording to a normal saline-filled disposable plained by maternal tachycardia or
of blood pressure continuously Levin tube inserted transcervically pyrexia, was considered an indica¬
were reserved for specific hyper¬ after amniotomy. When the latter tion for cesarean section if vaginal
tensive problems. was contraindicated, either a trans- delivery could not be anticipated
3. Fetal heart rate (FHR).. abdominal amniocentesis was car¬ before a sum of amplitudes of de¬
When the cervix was dilated 2 to ried out and a p-90 catheter fed celerations of 600 beats was at¬
3 cm. or more, favourable, and with through a thin-walled 16-gauge tained.6 When these situations ex¬
adequate descent of the presenting needle, or a simple tokodynamo- isted, uterine contractility was in¬
part, a scalp clip of silver, silver- meter was used to identify at least hibited, by stopping oxytocin where
chloride was applied, using a spe- the frequency and timing of con¬ this was being used, and/or by the
tractions. use of high-dose isoxuprine hydro¬
cially modified long Kelly clamp chloride, until preparations for ce¬
(Fig. 3). The clip itself was de¬ 6. Uterine work..A polygraph sarean section were complete.
signed after the one described by integrator was used in some of our
Hon.2 We found that we were able records to determine the area under
to insert scalp clips earlier in labour the curve of the intrauterine pres¬ NEWBORN MANAGEMENT
by a blind sterile examining hand sure curves, and thus give more By agreement with our neonatal
technique, keeping the Kelly clamp ready assessment of efficacy of oxy- colleagues, the time of birth was
tips and scalp clip between two ex¬ tocin when this agent was necessary. defined as the time when the entire
amining fingers, than by the use of In addition to the above biophysi¬ fetus was outside the maternal birth
a cone. The insertion of a cone in cal parameters, written notes were tract. Precise one-minute and five-
a posteriorly positioned cervix we inserted on one empty channel of minute Apgar scores were deter¬
often found difficult, but this may the polygraph, accurately timing: mined and their components noted.
well be a matter of personal orien¬ drug administrations, vaginal ex¬ Resuscitation and monitoring of the
tation. The well-applied clip usu¬ aminations and findings, patient po¬ newborn heart rate was in progress
ally provided a signal with an R- sition and any other manipulations usually before 60 seconds had
wave amplitude of 200 to 500 /*V. or variables, such as scalp blood elapsed. Umbilical artery catheteri¬
which, when suitably filtered, was sampling. zation was limited to excessively
quite adequate to trigger a thres¬ 7. Biochemical and hematological small newborns or to babies in
hold tachometer which could dif- studies on scalp blood were: whom the fetal scalp blood or cord
ferentiate accurately down to a 0.2 (a) pH; PcOjj?; Po2; 02 satura¬ blood showed significant acidosis.
to 0.5 beat-per-minute variation. In tion; base deficit; bicarbonate. All resuscitative and monitoring
order to achieve this we used a (b) Microhematocrit. procedures were carried out on a
Grass EEG pre-amplifier. When (c) Micro blood sugar in pre- table with an overhead radiant
clinical conditions did not permit or frank diabetics and in fetuses heater; this table was 15 metres
the artificial rupture of membranes, with intrauterine growth retarda¬ from the delivery site, with no in-
either cancellation of maternal ECG tion. terposing deterring doors.
58 Canad. Med. Ass. J., Oct. 4, 1969, vol. 101.392
STAFF AND PERSONNEL cording to the diagnostic criteria for coding clerk. Each of our 211 pa¬
Medical Personnel admission to the O.N.I.C.U. (Table tients was coded with the data
I). The results of this study will be available at the onset of labour. A
The obstetrical team consisted of outlined in the main with regard to similar procedure was applied to a
one obstetrician director, who is random group of 350 patients ad¬
oriented as a perinatal physiologist, perinatal mortality and degree of
infant depression. Detailed correla¬ mitted to the standard labour and
one full-time resident, the junior
house staff and the attending private
tions of fetal cardiovascular activity delivery unit of our hospital during
and blood-gas studies will be the two months of our study.
physician and/or obstetrician. subject of a further study. Two correction factors were
There were eight perinatal deaths found necessary to validate the
Nursing Personnel (rate: 37.2/1000 total births). Dur¬ scoring system as appliedwithto our
The antepartum ward for high- ing the same period of study the study patients. One dealt the
risk pregnancies was found to re¬ perinatal mortality in the remainder exclusion of antepartum stillbirths
quire a ratio of one nurse to four of the population delivered in our from our study. This correction fac¬
patients on each of the day and delivery suite was 28.8/1000. Com¬ tor was taken from the British
evening shifts, and one to six on parison of these two figures is not study,4 in which the percentages of
the night shift; in addition to the valid for two main reasons: (a) antepartum and intrapartum deaths
above, one extra nurse on each No patient who has a stillborn in¬ were ascertained both for premature
shift was available for O.N.I.C.U. fant is admitted to the O.N.I.C.U. (under 2500 g.) and mature groups
patients in labour. These require¬ This automatically decreases the separately. This correction factor
ments, after pro-rating for time off, O.N.I.C.U. rate, and the factor by was applied after delivery in order
sickness and vacation time, place which it is reduced has been as¬ to take into account the birth
the total staff requirements at ap¬ certained by studying the percent¬ weight of the infant. The second
proximately one nurse per 100 an¬ age of stillbirths which occur before correction factorwas derived from
nual deliveries. the onset of labour, in both the many factors we considered as hav¬
mature and premature weight ing anadditive score, which ap¬
Paramedical Personnel groups. (b) The cases studied were parently evaluatedproduce
did not additive
high-risk pregnancies exclusively, risk. We the raw scoring
Electronic ..The con¬ with an expected poor outcome. of our random non-study group,
stantly available supervision of the Prediction of risk by a scoring sys¬ and found that the actual score ex¬
equipment by a technician was tem may enable one to assess, at ceeded the perinatal mortality rate
found essential in view of the fre¬ after
quent electronic adjustments and
least to some degree, the efficacy by a factor of 4.3. Therefore,
first correction,
calibrations required. It was found of the management undertaken. making the above the score ob¬
we further divided
that one full-time technician would
be required to handle the load of
PROGNOSTIC MSK SCORES tained by 4.3 and believe that this
100 patients per year monitored An attempt was made to find should represent the perinatal mor¬
in labour. This technical help also a quantitative expression of the tality of our patients as accurately
maintains the equipment and pro¬ degree of risk of perinatal death as possible.theabove two correction
vides scalp lead manufacture as faced by any one patient. Statistical Using
well as on-line repairs. information used to develop this factors, we would have expected a
scoring system was taken from two total of 10 perinatal deaths in our
Biochemistry..The carrying out main studies: "Supplement to the study (a rateactualof 47.8/1000 total
of blood-gas and acid-base estima¬ Our results showed
tions of scalp blood at a moment's Second Report of the Perinatal births).
notice, the calculation of the values Mortality Study in Ten University eight perinatal deaths (37.2/1000
on line, and the following of blood Teaching Hospitals, Ontario, Can¬ births) (Table III). By this method
ada";3 and the first report of the of assessment we would assume
gases in the newborn were found to 1958 British Perinatal Mortality that a 20% reduction has been
require two full-time technicians in Survey.4 achieved. We are fully aware of the
a setting where 200 to 250 patients
are monitored annually. One hundred and fifty-five items difficulties in any comparative statis¬
Clerical..One full-time clerk is were listed, each with its respective ties in this area, and have tried to
risk factor. These factors included make as valid an approach as pos¬
required to carry out the scoring standard vital statisties, such as sible by the method described.
procedures and the computer cod¬ weight, age and height, as well as A bar graph representation of a
ing of data being stored. epidemiological data, including frequency histogram of risk the distri¬
Computation..Computer coding place of birth and place and dura¬ bution of the prognostic scores
and analysis were not used in this showed that 89% of ran¬
project, but would facilitate and tion of residence. Medical, surgical (PRS) into labour had
and obstetrical past and present dom patients going
standardize findings when such fa¬ a PRS of 50 less (Fig. 4). A
cilities as ours are offered on an complications are also included in estimate
or
has frequently sug¬
expanded regionalized basis to out- the scoring system. generalthat 10% of all pregnancies
iying communities.
The procedure of scanning the gested
questionnaireofanda searchingexamina¬
through have some increased risk. From the
the findings physical above two statements we would
RESULTS tion takes approximately 15 to 20 suggest that, using our scoring sys¬
The 211 patients who were minutes when performed by a tem, any score above 50 represents
monitored have been classified ac¬ medically non-skilled but trained high-risk pregnancies.
Canad. Med. Ass. J., Oct. 4, 1969, vol. 101.393 59
In our group of patients moni¬ utero is required. Our work in pro¬ was born vaginally after failure to
tored as high-risk pregnancies 46% gress in this area suggests that control premature labour with ex¬
had a score over 50, as opposed to simple measurement of the uterus isting uterine inhibitors, and died of
the 11% in random patients. from the superior border of the marked immaturity (744 g.) (Table
Further appraisal of our scoring symphysis to the fundus uteri, while II).
system was made by correlating the by no means free of error, has im¬
prognostic risk score (PRS) with proved random clinical guessing by PREMATURITY
the outcome in terms of perinatal a large factor (Fig. 4).
Our high prematurity rate reflects
mortality and infant depression Two of our perinatal deaths were the high-risk nature of our study
(Fig. 1). There was a good correla¬ in patients referred from other cen¬
tion between the one-minute Apgar tres. We merely point out that this group. Thirty-eight infants under
2500 g. were delivered (17.7%). A
and the PRS (r = 0.71, P<0.01). factor must be considered when
graphic representation of the rela¬
tionship of gestation and birth
weight, with superimposition of
ftANDOM PATIfNT*
control»
Lubchenco's percentile line, is
shown in Fig. 6.5
A large number of our patients
were transferred from our ante¬
partum area.patients in whom dif¬
ferent complications of pregnancy
all contributed to functional insuf¬
ficiency of the placenta, resulting in
intrauterine growth retardation. Our
results clearly reflect this situation
by the incidence of dysmaturity we
have shown. The careful selection
of time of delivery, with monitoring
throughout induction and active
labour, has contributed to a reduc¬
tion in stillbirths in this group of
patients; no perinatal deaths oc¬
curred in this group, though labour
was often induced with a predicted
small baby, on the basis of ab¬
normal estriols, uterine growth
curves, uterine measurements and
amniotic fluid studies.
The immediate and on-site avail¬
ability of expert pediatric neonatal
care, always present before delivery
in high-risk pregnancies, in order
that resuscitation may be prepared
for and staff and equipment ready,
is the only explanation for the
absence of neonatal deaths in these
SO-** IOO-149 1SO-199 300-349 7SO ? very high-risk dysmature infants.
MOONOSTIC RISK SCOUt
317 HO 24 ETIOLOGICAL FACTORS
FIG. 4..Prognostic risk scores: comparison of frequency
distribution in high-risk group and random group of patients.
Toxemia of pregnancy was by
far the commonest pathological
condition qualifying for admission
PERINATAL MORTALITY comparing statisties, as it will be to the O.N.I.C.U. The toxemias of
the main cause of a rising perinatal pregnancy were subdivided into the
Maturity and weight were crucial mortality rate in any project which severe (blood pressure over 160
factors in perinatal survival (Table involves increasing regionalization
II). There was only one perinatal systolic or 110 diastolic) and mild.
death of an infant over 1900 g.; this referral,as we feel it should. No perinatal deaths occurred in the
One of these referrals from out of mild toxemias. Two perinatal deaths
infant had congenital anomalies and town was a patient in whom pre¬ were associated with severe tox¬
weighed 2198 g. With the weight of mature labour complicated a hys- emia; both mothers had neglected
the infant playing such an impor¬ terotomy and fetal umbilical artery antepartum care. One patient was
tant role in survival, it became in¬ transfusion. The fetus and mother referred from out of town 11 days
creasingly evident that a more ac¬ remained well for 72 hours follow¬ before term with a very marked in¬
curate clinical or other method of ing restoration of the former to the trauterine growth retardation and
predicting the size of the infant in intrauterine environment. The baby severe pre-eclampsia. The other
perinatal death was in a case re¬ cedure was resorted to in five, and to impose one of the greatest
ferred by the attending physician there were three survivors. threats to the fetus, especially when
immediately at 295 days' gestation, I have found a useful place for a severe degree is present in early
on the occasion of the first prenatal continuous monitoring of the fetal pregnancy. One of the most danger¬
visit. Both these babies weighed heart rate during intrauterine trans¬ ous situations associated with this
under 1800 g. fusion, by using a stainless-steel condition, we found, was the neces¬
Twenty of our 71 cases of tox¬ electrode (3 6-gauge) inserted sity to induce labour in the face of
emia had severe pre-eclampsia. through the catheter used for in- unripe conditions. Oxytocin ad¬
Rh sensitization accounted for a fusing the packed cells into the ministration was found to be
larger proportion than one would peritoneal cavity. In several in¬ hazardous even in doses as low as
have expected because of the par¬ stances a warning tachycardia has 1.0 mU per min., and may well
ticular interest taken at this centre developed, and the transfusion has have been causal in the develop¬
and by the author in this condition. been interrupted, only to be re- ment of abruptio placentae in some
In the present study eight patients surried after the fetal heart resumed circumstances, even when patterns
had severe Rh disease, with the a normal rate. of recorded uterine activity were
amniotic fluid presenting indications Placental insufficiency, associated within normal limits. Recourse to
for either early induction or intra¬ with known pathological changes or cesarean section in these early and
uterine transfusion. The latter pro- idiopathic in nature, would appear dysmature pregnancies had even
worse results.
Clinically detected fetal distress
occasioned the transfer of 42 pa¬
tients from a routine labour setting
to our unit. In none of these did
perinatal death occur.
. . . Of 18 women on whom cesarean
.. . . . . .
sections were carried out for fetal
. .. . . ... .
distress, only four had been ad¬
. . . mitted to our unit with this as an
. . indication for admission. Of the 42
w.
* * patients admitted to the O.N.I.C.U.
... .. .
with clinically detected fetal
. .. .
distress, 36 gave birth to babies who
S-f .
£.... .
were born with Apgar ratings at
. .. one minute over 6, and all 42 in¬
fants had five-minute Apgar scores
r-0.71 over 6. Thus it would appear that
clinically detected fetal distress cor¬
NfWBORN WEIGHT (grams)
relates very poorly with infant out¬
come from a perinatal morbidity or
FIG. 5..Height of uterine fundus measured from superior border of symphysis along
convex surface of abdomen, plotted against newborn weight. mortality standpoint.
Canad. Med. Ass. J., Oct. 4, 1969, vol, 101.395 61
*o-l
WEEKS OF AMINORRHEA
FIG. 6..Weight-gestation correlation of high-risk pregnancies and their distribution into Lubchenco's percentiles.
Forty-five cesarean sections were played a significant role in the de¬ cared for in less sophisticated at¬
a
carried out in our O.N.I.C.U., a pression of the newborn. mosphere.
rate of 21.1%. Forty per cent of Obstetrical history..It is of note Our entire efforts cannot solve
these were performed because of that three of our perinatal deaths the problem of the preventable peri¬
cephalopelvic disproportion. Many (37.5%) occurred in patients who natal losses; the mothers of some
patients with borderline pelvis were had had previous perinatal losses. infants of obviously viable size (well
admitted in order that a physiologi¬ This high incidence is especially over 2200 g.) may arrive in hospital
cal approach to stimulation of noteworthy because this indication with the baby dead in utero and
labour could be safely carried out. for referral to our unit represents with a history of slight, and some¬
With uterine pressures continuously only 10% of our admissions; fur¬ times not so slight, toxemia or
recorded, little danger of hyper- ther, only 5% of patients in our
tonus, hypersystole, or abnormal hospital with such a history arrived TABLE IV..CESAREAN
frequency or rhythm of uterine con- in our unit for care. SECTION
tractions was present. When any of
these developed, it was immediately
DISCUSSION
recognized and corrected.
A comparison was made between It became apparent during our
the results of the cesarean sections study that numerous patients who
carried out for fetal distress and might have benefited from referral
those for CPD (Table IV). From to our unit were not admitted. Simi¬
our results it would appear that larly, many patients with lesser de¬
neither the surgical procedure itself grees of high risk were being re¬
nor the concomitant anesthetic ferred who might well have been
REFERENCES
1 EFFER, S. B.: High risk pregnancy. Paper presented at the annual 4. BUTLER, N. R. AND BONHAM, D. G.: Perinatal mortality. The first
meeting of the Ontario Medical Association, Toronto, May 6-10, report of the 1958 British Perinatal Mortality Survey under the
1968. auspices of the National Birthday Trust Fund, E. & S. Living-
2. HON, E. H.: Amer. J. Obstet. Gynec., 86: 772, 1963 stone Ltd., Edinburgh, 1963.
3. Ontario Perinatal Mortality Study Committee: Second report of the 5. LUBCHENCO, L. 0. et al.: Pediatrics, 32: 793, 1963.
perinatal mortality study in ten university teaching hospitals, 6. CALDEYRO-BARCIA, R. et al.: In: The child, edited by A. Dorfman,
Ontario, Canada; supplement, Department of Health, Toronto, The Year Book Publishers, Chicago, p. 8. in press.
1967.