35

S Y M P H Y S I OTOMY----c, ontinued.

C a s e N o .

60060

Age Gray. Par.

26 1 : 0

Delivery

Assisted breech. Head delivered by forceps.

Baby

Alive 6 lb. 8 oz.

Note

Primigravid breech case. Admit- ted at 38 weeks for urinary tract infection and pelvic assessment which was noted as being un- suitable for primip, breech delivery because of android shape with convergence of pubic r~rnl in forepart of brim and cavity. X-Ray pelvimetry did n o t support these findings. Further assessment made after medicinal induction had been given and outlet contraction considered to be present with general narrowing of forepelvis. Symphysiotomy performed. Rapid progress followed with easy assisted breech delivery 10 hours later.

C O M M E N T '

Case No. 59973 was disastrous due to ex t rac t ion of the head from b r i m level immedia te ly following symphysio tomy. This sequence of events ( symphys io tomy immedia te ly followed b y forceps) is reported b y experts on symphys io tomy to be the worst possible procedure and the one most l ikely to be followed by severe stress incont inence. Caesarean section should have been performed in this case, and the subsequent career of this pa t ien t has been quite disastrous.

The remain ing two cases were extremely successful with no ill effects subsequent ly . The main effect of symphys io tomy is to increase the t ransverse d iameters of the pelvis a n d l i t t le can be expected from the operat ion in causing improvement of the antero-posterior diameters. Appreciat ion of this fact will assist the proper selection of cases, a nd it would appear t ha t the procedure should be done early in labour and is then l ikely to be followed b y min ima l complications.

PROLAPSE AND PRESENTATION OF THE CORD (R.C.O.G. TABLE 24)

DR, ROSEMARY JORDAN

Summary :

~ [ Booked == 26 (a) Total number of cases . . . . . . . . . ~ Unbooked = 7

Incidence against total deliveries 28 weeks maturity and over (4,902) . . . . . . 0.67 per cent,

(b) Maternal mortality . . . . . . . . . Nil

(r Gross foetal loss . . . . . . . . . . . . Perinatal mortality rate . . . . . . . . .

2 (both deadborn) 60.6

PROLAPSED CORD :

Total cases . . . . . . . . . . . . . . .

Incidence against total cases in Table 24 ... Foetal loss Incidence agains 'iotal oi rola ;;d

2~ f Primipar~ = 3 u ~ Multipa~ --20

69.6 per cent. 2 (both deadborn) 8.9 per cent,

36

Management : Total D/B N N D

C a e s a r e a n sec t ion . . . . . . . . . 8 - - - - R e p l a c e m e n t a n d v a g i n a l d e l i v e r y . . . . . . . . . 1 - - - - V a g i n a l d e l i v e r y . . . . . . . . . . . . . . . 14 2 - -

,4nalysis of vaginal deliveries :

(1) F o r c e p s . . . . . . . . . . . . . . . . . . 6 (2) B r e e c h e x t r a c t i o n . . . . . . . . . . . . 4 (3) I n t e r n a l v e r s i o n ] b r e e c h e x t r a c t i o n . . . . . . 2 (1 D e a d b o r n ) (4) A s s i s t e d b r e e c h . . . . . . . . . . . . . . . 1 (5) V a c u u m e x t r a c t i o n . . . . . . . . . . . . 1 (6) S p o n t a n e o u s . . . . . . . . . . . . . . . 1 ( D e a d b o r n )

Causes or foetal loss associated with prolapsed cord :

DEADBORN ~ 2

A b r u p t i o p l a c e n t a . . . . . . . . . . . . . . . . . . . . . l P l a c e n t a p r a e v i a a s s o c i a t e d w i t h a c c i d e n t a l h a e m o r r h a g e .. . 1

P R E S E N T A T I O N OF THE CORD :

1 ̂ ( P r i m i p a r a = 3 T o t a l cases . . . . . . . . . . . . . . . u ~. M u l t i p a r a ---- 7

I n c i d e n c e a g a i n s t t o t a l cases in T a b l e 24 ... 30.3 p e r c en t . Foe4ml loss . . . . . . . . . . . . . . . Nil

Management : Total D/B N N D

C a e s a r e a n s e c t i o n 5 - - - - R e p l a c e m e n t a n d v a g i n a l d e l i v e r y . . . . . . . . . 2 - - - - ] V a g i n a l d e l i v e r y . . . . . . . . . . . . 9. - - - - I n c i d e n t a l f i nd ing a t L .S :S . . . . . . . . . . . . . 1 - - - -

.4 nalysis of vaginal deliveries :

(1) F o r c e p s . . . . . . . . . . . . . . . . . . . . . . . . 1 (2) V a c u u m e x t r a c t i o n . . . . . . . . . . . . . . . . . . 1 (3) B r e e c h e x t r a c t i o n . . . . . . . . . . . . . . . . . . . . . 1 (4) S p o n t a n e o u s . . . . . . . . . . . . . . . . . . . . . 1

COM M ENT

The incidence of prolapse/presentation of the cord has remained constant but this year the perinatal mortal i ty has dropped to 6.1 per cent. The perinatal mortali ty incidence was 33.3 per cent. in 1962 and 25 per cent. in 1961.

The 2 infants lost were both stillbirths, and each case was associated with antepartum haemorrhage. In the first case the patient was admitted with an antepartum haemorrhage from a grade 2 posterior placenta praevia and shoulder presentation. The cord was prolapsed and not pulsating. Delivery was completed by internal version and breech extraction. The second patient was admitted with an accidental haemorrhage. As the forewaters were punctured the cord prolapsed but since pulsation was absent, spontaneous delivery was awaited.

In the 14 cases delivered by Caesarean section the primary indication for the operation was not necessarily prolapse or presentation of the cord.