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A survey population of 104 drug-dependent patients admitted to the obstetric service of Cook County Hospital was found to be similar to other groups of drug-dependent parturients. However, certain differences are reported: Among the 64 patients who delivered live infants, a low birthweight rate of 52% and a 50% rate of premature rupture of the membranes were noted. Therapy depends on whether the patient requests withdrawal during pregnancy. If withdrawal is accomplished during the antepartum period, the patient can be given the prenatal care that otherwise is often lacking. Abrupt withdrawal during the antepartum period is not recommended. Intrapartum medication should not be withheld from the patient experiencing withdrawal on the grounds that the medication depresses the fetus. Delivery room personnel can treat fetal depression.

Thirty-seven healthy term infants were subjected to three differing environments immediately after delivery. Infants who were exposed to delivery room conditions and then bathed on arrival at the nursery had a mean drop of deep body (core) temperature of 2.3° C. Infants similarly treated, but not bathed, had a mean fall of 1.8° C., whereas the mean drop for infants who were placed in an incubator (32.6 to 34.4° C. air temperature) was only 1.0° C. These were significant differences. The recovery of body temperature was also significantly shortened in the infants who were placed in the incubator. It is recommended that attempts be made to prevent excessive heat loss after birth. Methods of doing so are suggested.

The pathologic and physiologic factors involved in the prevention of neonatal asphyxia establish Eve's principle of nontraumatic “rocking resuscitation” as the only one that aids both important components, circulation and ventilation, and stimulates both phases of the latter, inspiration and expiration. Statistical results of 4,000 consecutive deliveries prove the efficacy of equipping every delivery room with an electrically operated bassinet and oxygen so that it may be immediately converted to a rocking resuscitator. While the usefulness is primarily for delivery rooms, rocking bassinets have a place in the nursery equipment. The need for them there, however, will be minimal, particularly by premature infants, if they are adequately rocked at delivery in spite of apparently satisfactory ventilation.

Fifty clinic patients, in the third trimester of pregnancy, were administered a comprehensive battery of psychological tests. Following childbirth, the women were classified by experienced obstetricians into a “normal” subgroup and an “abnormal” subgroup on the basis of signs of delivery room compli

A brief review of some of the problems of infection in the newborn has been presented. Emphasis is placed on a high level of suspicion of sepsis and an aggressive effort to identify the infecting organism. These efforts should start in the delivery room, or even before, in order to initiate timely and rational therapy. Selection of the most appropriate antibiotic is made difficult by the frequent necessity of prescribing therapy before the identity of the infecting organism is established. Possible toxic effects of the drugs used in therapy must be kept in mind. Colonization of the newborn occurs early and the spread is probably from the older infants in the nursery to the new arrivals. When infectious strains become established in the newborn, his entire family may later be plagued with unpleasant staphylococcal infections which stubbornly resist eradication. The possibility of viral infections in the newborn must be borne in mind. Knowledge in this field is just developing, but several definite clinical entities have been recognized.

The transition period from intra-uterine to extra-uterine life is complex and influenced by many factors.Rapidity of physiologic change; history of pregnancy, labor and delivery; gestational age; and the infant's course since birth must be considered in an adequate evaluation of the newborn.Optimum evaluation of the newborn would include serial examinations (1) in the delivery room, using the Apgar scoring system, (2) during the day of delivery, and (3) after the infant is 24 hours old.

During the past four years halothane has been used for obstetrical anaesthesia in the great majority of cases. It was cur choice for 3657 deliveries and 138 Caesarean sections, approximately 65 per cent of our confinements and 44 per cent of our Caesareans. The use of this anaesthetic agent began in the early part of 1959 With the advent of the Fluotec vaporizer, mounted on the Boyle apparatus as standard equipment, halothane began to occupy a definite sphere of usefulness in our delivery room. This device was effective in giving us accurate percentages of N2O, O2, and halothane, thus making the administration of this gas easy for the trained anaesthetist, and for the residents as well. The hazards of uterine haemorrhage, and resuscitation difficulties in the newborn, which were sounded as a warning note m earlier publications, did not occur in the course of our numerous anaesthetics with this agent, and we have no untoward incidents to report with halothane in the course of our present series of cases. In conclusion, we are still of the opinion that halothane is a potent and serviceable agent for obstetrical anaesthesia. It is recommended that care be taken never to exceed the optimal level of vapour concentration, in order to avoid cardiovascular collapse or atonia uteri. Undesirable side-effects both for the mother and the foetus were minimal, and compared very favourably with those of the other anaesthetic agents.

Newborn infants lose heat rapidly at birth and during the first half hour of life. This investigation was undertaken to determine whether the initial heat loss was due principally to evaporation, and whether or not establishment of breathing would be irregular or delayed if the initial cold stress was reduced. Five groups, each of 10 infants, were studied during the first half hour of life. Infants in Groups I and IV remained wet and were exposed to either room air or placed under a radiant heater. Those in Groups II, III, and V were dried promptly and exposed to room air, wrapped in a blanket or warmed by means of a radiant heater. Heat loss due to radiation and convection together was twice that from evaporation. Reduction of cold stress by placing the infant under a radiant heater as soon as he is born does not impede or delay the onset of breathing. Wet infants exposed to room air lost nearly five times more heat than those who were dried and warmed. In vigorous infants, the simple maneuver of drying and wrapping in a warm blanket is almost as effective in diminishing heat loss as placing them under a radiant heater. However, in depressed or immature infants who may be more asphyxiated or have reduced energy stores, radiant heat maintains body temperature while allowing access to the patient.

The state at birth of 1594 infants delivered at the Hammersmith Hospital is reported. Of 91 babies who were apnœic at one minute, 23 had cried before the onset of apnœa. On resuscitation, all but 1 left the delivery room with regular respiration. An attempt has been made to distinguish between primary and terminal apnœa in these babies. Adequate data was available in 60 cases; 42 of these were clearly in primary apnœa; the other 18 may or may not have been in terminal apnœa. The Apgar rating did not clearly distinguish between the two groups. Attention is drawn to the importance of three factors: (a) changes in heart-rate before resuscitation, (b) the sequence of events on recovery, whether gasping precedes an improvement in colour or vice versa; and (c) whether or not apnœa supervenes in a baby who has initially gasped or cried.

SINCE Steiner and Lushbaugh1 reported the first series of cases of amniotic-fluid embolism in 1941, there has been increasing interest in the subject. The following study of 14 placentas is offered because these placentas show the presence of amniotic squamous cells in abnormal locations. Hence, these observations may throw some light on the manner in which amniotic fluid enters the maternal circulation. The placenta that first roused interest was sent to the Boston Lying-in Hospital from the delivery room at St. Margaret's Hospital by Dr. Edmund L. Carey because of its singular appearance. The membranes were intact except for a . . .

gical nurses, delivery room nurses? Those in the emergency room? These were some of the questions we asked ourselves about a year ago when we were faced with some perplexing problems of nurse turnover and staffing. Like most hospitals, we were paying staff nurses the same basic salary range regardless of assignment, on the assumption that the jobs were basically similar in skills and responsibilities. But in a 12month period, our turnover in hospital inpatient nursing was 72 percent compared to 35.9 percent in the clinic and 17.3 percent in the operating room. Also, we were swamped with requests for transfer to the clinic.

A vacuum aspirator was used to remove retained fragments of placenta, membranes and hyperplastic decidua after delivery. No post-partum endometritis occurred in the group of 60 patients so treated, whereas five infections were found in a control group of 50 patients. The difference is almost significant. Moreover, favourable experience has led to the use of the vacuum aspirator in the treatment of atonic uterine haemorrhage. No complications have been observed, and the risk seems to be less than that in conventional curettage, particularly as anaesthesia is unnecessary.

THE incidence of infection with Pseudomonas aeruginosa, ordinarily an indifferent pathogen, is apparently rising in adult and pediatric patients1 , 2 in this country and in England.3 Premature infants are particularly susceptible to such infections,4 , 5 and, in them, disease is marked by a high case-fatality ratio. Therefore, prevention of infections in the nursery is of prime importance. It is hoped that this will be accomplished when the epidemiology of pseudomonas infections in nurseries is more clearly delineated. The epidemic described in this report occurred in a premature nursery in which Ps. aeruginosa was initially isolated from several environmental sites, none of . . .

ous bacteriologic agents have been in criminated in specific outbreaks, whil4 viral etiology has been postulated ii others.3 Recent studies have indicate( that organisms of the Escherichia groul may be of significance in infectiow. diarrhea of the newborn.4 Unfortunately, laboratory methods foi the identification of the Escherichia group are less well advanced than th( Kauffmann-White schema for typing ol Salmonella organisms.5' 6 The accurac3 of the latter method is of distinct value

T HE effectiveness of penicillin in combating postpartum infections has suggested its use prophylactically during labor. The drug has already been used by Ode11 andPlassl in the control of intrapartum infections with considerable benefit to both mother and child. On the basis of these casual observations, it, seemed advisable to learn more accurately if penicillin administration during labor and the early puerperium would produce a significant reduction in the number of puerperal fevers. This study was directed at ascertaining this information by means of controlled experimental use of the drug. The patients were delivered in the Department of Obstetrics and Gynecology of the State University of Iowa.Hospitals between Feb. 3,1947, and Feb. 1,1948. So far as was practicable, alternate patients as determined by the delivery room nurse received prophylactic penicillin” according to a predetermined schedule. The only patients excluded were those delivered by the abdominal route and those receiving penicillin therapeutically prior to the onset of labor. All patients were delivered under similar delivery room technique by medical students, residents, or the senior staff. Postpartum temperatures were taken by mouth every four hours (excluding 2:00 A.M.) during labor and the postpartum stay, which averaged from six to nine days.

l)e cent (If the wet weight of the organs. In a study of 143 German women, I\’Iischel4 found that the total iron ill the blood and tissue of the placentas averaged 1 l . 1 amid 4.2 mug., respectively, Tier 100 gin. of wet saniple. \Iore inforniation on the iron content of placelltas is needed in the evaluation of the iron requirement during pregnancy. The Inajority of investigations of this problem have been completed outside the United States, and few details of such factors as diet, prenatal medications and delivery procedures are ineluded, all of which mnay influence placental iroli losses. It appeared worthwhile, therefore, to collect intact placentas and their cords froni the delivery room of the State Uiiiversity of Iowa Hospitals in order to evaluate this iiiaterial ili niaternal iron loss.

A case of postpartum uterine inversion is presented as a possible complication of prolonged methoxyflurane-oxygen anaesthesia.

The management of the Rh-negative patient during pregnancy has been discussed. A classification has been suggested to determine the minimal laboratory requirements necessary for individual patients, thereby aiding in the possible prediction of erythroblastosis fetalis. A work sheet has been presented to aid the physician in deciding the amount of laboratory work necessary for individual patients. A method in the form of an index card has been suggested to warn the delivery room staff of Rh-negative patients to be admitted to the hospital. The immediate management of the newborn to determine the presence of erythroblastosis has been outlined and a choice of treatment suggested. Until specific treatment of the Rh-negative mother has been developed for the control of erythroblastosis in infants, it would be advisable to examine all Rh-negative patients systematically and to provide laboratory and hospital facilities in order to improve the survival rate of their infants.

POSITIVE pressure pulmonary inflation has been used by the anesthetist for many decades. More recently, with the advent of the respirator the principle has been commonly used on the wards and in the recovery room. It is also an essential part of modern, aggressive methods of resuscitation, both in the delivery room in asphyxic newborn infants and on the general wards following cardiac arrest. Positive pressure respiration is not without hazards. This has been emphasized by a number of case reports in the literature of the past 50 years, and several investigative studies are at hand to elucidate the pathogenesis involved. It is the purpose of this communication not only to call renewed attention to the possibility of iatrogenic alveolar or pleural rupture with their frequently disastrous consequences but also to point out that these complications are likely to go unrecognized because they are masked by the very circumstances bringing

Bilateral congenital choanal atresia carries a high risk of brain damage due to hypoxia. Proper management requires early diagnosis, preferably in the delivery room, where temporary measures such as inserting an oral airway or a gavage tube are usually sufficient to establish satisfactory respiration. Careful observation is essential in the nursery during the period of local and general diagnostic evaluation to prevent repeated, even brief, spells of apnea. If satisfactory ventilation cannot be maintained, and particularly if there are associated serious anomalies, tracheotomy is indicated, rather than an immediate attempt to establish choanal patency. Definitive transnasal surgical correction can be accomplished during the neonatal period. Relatively non-traumatic perforation of the obstruction with a probe or trocar, as reported by Hough in 1955, is followed by dilatation with appropriate metal sounds, and emplacement of non-reactive plastic tubing. Excessive cicatrization, which is responsible for many failures of transnasal surgical methods, is further discouraged by the use of anti-microbial agents to control infection in the choanal area. This can be expected to succeed in most cases if the tubing is maintained until healing is accomplished.

The obstetrician-gynecologist has a new interest in operating and delivery room fatalities, particularly the increasing deaths due to cardiac arrest and aspiration of stomach contents. The inability to prepare some patients adequately for obstetric anesthesia is a frequent handicap. Hasty induction of anesthesia, incomplete preanesthetic medication, and a full stomach are common in delivery rooms. Inexperienced personnel and inadequate equipment add to the anesthetic risk. Fetal death can also occur or begin with accidents of anesthesia. Improvement in resuscitation of the newborn infant is being realized. The anesthesiologist and physiologist are contributors to this advance. The pathologist can aid by helping us to understand better our failures.

SINCE THE REPORT by one of us on the use of open-chest cardiac massage in the stillborn, several other reports on this subject have been published. Recently, there appeared the first report of successful closed-chest resuscitation of a stillborn. The method used in that case was patterned after the description by Kouwenhoven et al. We wish to describe another case in which the same technique was successfully used. Report of a Case A 34-year-old woman, gravida 3, para 2, was admitted to the Long Island Jewish Hospital at 2:30A.M.on Sept. 13, 1961, at term and in labor. At 10A.M.the cervix was fully dilated and the baby at a plus 3 station. At this time the fetal heart tones were noted to be of good quality and regular rhythm. No vaginal bleeding was observed and the patient was taken to the delivery room with 3 cm. of

Infants needing resuscitation in the delivery room frequently become chilled. For resuscitation the infant must be covered and on a flat surface. Heated surfaces are available with circulating-water mattresses and resuscitation tables. These only heat the dependent area of the infant and are usually insufficient to prevent heat loss. The combination of such a unit with an overhead radiant heater or the overhead radiant heater alone is adequate. However, the overhead radiant heater must allow free access to the infant, which is not the case with all radiant heaters now being marketed.

This instrument embodies an improvement in structure over the stethoscope now in use by obstetricians. It is especially of greater advantage in the delivery room because it is arranged so that there is no obstruction to view, and because of the absence of tubing hanging down in front of the face and adventitious sound, usually caused by the contact of the tubing with the sheets or drapes of the patient. This also eliminates the risk of contamination of the sterile drapes by stethoscope tubing. The shaft of the stethoscope has been lengthened to 5½ inches in order to make its use more comfortable to the obstetrician and to lessen the risk of contamination. The bell of the stethoscope has a detachable end, which is of the usual screw type and made of metal so that it can be sterilized and attached by the obstetrician with his sterile gloved hand, if

Shortly after the introduction of ethylene-oxygen for anesthesia in the Presbyterian Hospital, March 14, 1923, two minor explosions occurred in the delivery room. The first one took place when the breathing tube and cone were placed on the head of the machine; the other one occurred while the anesthetist was holding the cone preparatory to its application to the patient's face. In the first instance, a spark was produced when the metal on the tube came in contact with the metal on the head of the machine. In the second case, the anesthetist thought it probable that he had struck the metal table with the cone, causing a spark. No further trouble was experienced for nearly a year, when two explosions occurred within two hours in different operating rooms. The first of these two explosions occurred when an assistant's gown brushed against the breathing tube in passing, and the other

Most would agree that the ultimate aim of cleft surgery is that the patient look well, feed well, and speak well. To achieve these goals much attention has been paid in the literature to individual techniques of lip repair, to the clinical results of palatal surgery, to the speech end-product, and occasionally to problems associated with cleft palate surgery. However , little, if any, attention has been paid to the study of mortality and morbidity accompanying cleft lip operations. The present report attempts to determine the incidence of, and the apparent causative factors in, the complications of cleft lip surgery. The review covers some 585 cleft lip repairs (Figure 1) performed over a 15—year period, from 1950 through 1964 inclusive, at the Children's Hospital of the University of Pittsburgh. The procedures were all done by qualified plastic surgeons of the University's faculty or by residents under their direct supervision. The immediate operative results have been examined to form a baseline for comparison in the future, not only for ourselves but for others subjecting their cases to critical analysis. In addition, a search was made for factors whereby the operative results may be further improved. The various types of cleft lip pathology are shown in Figure 2. The morbidity and mortality figures to be presented obviously represent children who have survived to an operative age of at least 10 to 12 weeks, for in this particular medical center the cleft child is not rushed from the delivery room to the operating table. Such practice would seem to have a definite bearing on both the operative mortality and morbidity. Admittedly, tissues heal well in the newborn, but the child of but 24 hours of age has not yet gone through a 'shake—down cruise' and there has not been sufficient time for the pediatrician to determine accurately what other defects might be present. There is a quite definite incidence of death of the infant (admittedly the more severely involved ones) in the first few weeks of life. Fogh-Andersen (3) reported a mortality rate of these patients during early life (before operation) at about 15%. In

A radiant heater provides a suitably warm microenvironment for a baby in an air-conditioned delivery room. With this heater, temperature loss is minimized (if the baby is dried soon after birth), and at the same time, the infant remains exposed for close observation and therapy.

French, German and Italian are all official languages in various parts of the country. But in Geneva, which is something of an international city, many people speak English. Many years ago the government of Switzerland delegated to the National Red Cross responsibility for developing schools of nursing. Not until 1944 did the nursing profession take a hand in its own destiny. Now the nurses have a state organization and work closely with the advisory committee of the Red Cross, comprised of both nurses and non-nurses, in developing and setting standards for nursing schools. The approved schools have a threeyear course in medical, surgical, and obstetric nursing. The latter includes prenatal and postnatal but no delivery room experience. Midwives who attend nearly all mothers in labor and delivery have a three-year course of training. Graduates of the schools which meet

In modern obstetrics, the midforceps operation has become the chief delivery room problem. This operation is usually selected for completion of deliveries in cases of midpelvic arrest caused by malposition or poor uterine or abdominal contractions. The definition of a type of forceps operation must include reference to fetal and pelvic planes that are ascertainable and constant. For the fetal point of reference, the use of the biparietal diameter is not wise, because in the average obstetrical forceps operation, the obstetrician contents himself with the station of the most dependent portion of the presenting part and the location of the sutures and fontanels for determining position and station. The location of the biparietal diameter is easily determined by a lateral roentgenogram, but determination of its level in the pelvic axis by manual examination is difficult. I, therefore, use and urge the adaptation of the most dependent portion of the presenting

THE APGAR SCORE1is designed to determine the physical condition or viability of the newborn 60 seconds after birth, and it has been established that there is a strong association between low scores and neonatal mortality.1-4Two of the five segments comprising the score involve crying, and the response sought to one of them (respiratory effort) is a "strong cry" (Table 1). The second sign(reflex irritability) lists "cry" in response to a tangential foot slap. The diagnostic value of the cry alone, reported in previous studies,5,6Msuggested the potential importance of its role within the Apgar score; thus, it seemed feasible to isolate for study the two segments, respiratory and reflex, in order to determine their relative contribution to the total score. Since Apgar2has already mentioned that some of the signs of her test may be more discriminative than others, it was decided to compare each of the signs with the other and with the total score. The cry segments and the total score were also compared with an independent measure of the newborn's crying activity taken from magnetic tape recordings made in the delivery room. In this manner, the "on-the-spot" Apgar evaluation of the cry

To the Editor.— I am a member of the family of the patient whose case is case 2 in "Surgical Disconnection of the Cerebral Hemispheres for Intractable Seizures," by Luessenhop et al. Unfortunately, the article (213:1630,1970) contains a number of inaccuracies in regard to this case. First, the article describes delivery as "normal." To be more accurate, delivery was accomplished by cesarean section some 15 hours after the onset of labor. Second, the article states that "two days after birth [the patient] began having frequent generalized seizures." In fact, these began within minutes of birth, while the baby still was in the delivery room. Third, the article described surgical operation" at the age of 36 months." It also says, "He was able to walk unassisted at 3 years of age and talk in simple phrases with a small vocabulary." The boy did walk unassisted at about 41 months of

NE of our many perplexing prob\ J lems has been how to provide adequate and safe care for mothers, especially immediately following delivery. The hospital ruling had always required each mother, immediately postpartum, to be observed constantly by a nurse for one hour, with pulse and respirations taken and recorded every ten minutes, With around 30Q babies delivcred each month, this number of hours of nursing care was not available. Through the concerted efforts, thinking, and planning of the obstetric staff and the hospital director, the idea of the obstetric recovery room was conceived. Although there were some fears that "we were not set up for it," we achieved our goal in a remarkably short time. We looked around at the facilities available with the thought in mind that the recovery room must be close to the delivery room. Perhaps we were fortunate in having had four delivery rooms two on either side of a corridor. We decided to equip two of the ad

To the Editor:— In the October 19 issue ofThe Journalan editorial comment stressed the value of blood tests for identification, especially in relation to blood samples and stains obtainable at postmortem examination. The article urged that "provision should be made to collect and save samples of blood at necropsies for eventual blood group tests much more regularly than is now the usual practice." I should like to suggest another important place for complete blood grouping as a means of identification where mistaken identity has often caused much anguish and has even made history, namely in the delivery room. Nowadays most hospitals take prints of the mother's thumb and of the newborn infant's foot as a means of identification. Usually either or both prints are smudged beyond recognition and are worthless. Even if the prints are taken carefully, they soon become useless because the baby's foot pattern, unlike that

The birth of a premature baby is most often an unexpected event and one for which the family is emotionally unprepared. The shock of this unanticipated event, coupled with the apprehension and concern surrounding premature labor and delivery, can precipitate feelings of disorganization, isolation, and inadequacy. The mother does not know how to cope with the problem. The mother of a premature often has not seen her baby in the delivery room, nor heard the baby cry-the sign of life to a mother. If the mother was anesthetized, she has not even felt the baby being born. If she was aware at all, she may only remember a "lifeless, limp, blue body draped over the doctor's arm." Such an experience followed by the "horrible silence in the delivery room," when no one yet knows the expectations for the baby, can only increase the mother's fears and fantasies.