maternity clinical report of the bromley hospital : 1948

BROMLEY HOSPITAL (Incorporating the Bromley, Chislehurst and District

Maternity Hospital)

Maternity

Clinical

Report

for

1948

Bromley Group Hospital Management Committee

SOUTH-EAST METROPOLITAN REGIONAL HOSPITAL BOARD

Maternity Clinical Report OF THE

Bromley Hospital (Incorporating the Bromley, Chislehurst and District Maternity Hospital)

for 1948

Compiled by

ALISTAIR L. GUNN, M.D., F.R.C.S., F.R.C.O.G.,

Visiting Obstetrician and

J L. WARREN, M.B., B.S., D.Obst.R.C.O.G.,

Resident Obstetric Officer

General Wards at Cromwell Avenue,

Widmore Maternity Unit at 118 Widmore Road,

Masons Hill Maternity Unit at 20 Masons Hill,

BROMLEY, KENT

BRITISH LEGION PRESS

MAIDSTONE

KENT

CONTENTS

Committees and Officers

Medical Staff

Midwifery Nursing Staff

Physiotherapy Staff

Survey

Abbreviations

I. THE OBSTETRIC SECTION

1 2 2a

3 4 5 5a 6 7 7a 8 9

puerperium

Statistical summary

Out-patient treatment .

Table A. Conditions treated

Table B. Ante-natal breech presentation .

Table C. X-Ray examinations . .

In-patient treatment

Numerical summary of cases Associated diseases not detailed elsewhere ...

Abortion Ectopic pregnancy

Hyperemesis gravidarum

Cardiac disease ...

Pre-eclampsia, albuminuria

Pre-eclampsia, hypertension without albuminuria

Eclampsia

Accidental ante-partum haemorrhage

Ante-partum haemorrhage, unclassified

Placenta praevia

Hydramnios Tumours associated with pregnancy, labour or the

Prolonged labour Persistent posterior position of the occiput and transverse arrest

Uncomplicated breech delivery

Breech presentation treated by Caesarean Section

Complicated breech delivery ...

Face and brow presentation ...

Transverse and oblique lies

Multiple pregnancy

Labour following previous Caesarean section

Contracted pelvis and disproportion

Failed forceps

Prolapse and presentation of cord

Post-partum haemorrhage

Manual removal of placenta ...

External version before labour—see p. 19 ...

Surgical induction of labour ...

Caesarean section

Forceps delivery ...

Version in labour

Embryotomy and craniotomy

Puerperal pyrexia, genital infection ...

Puerperal pyrexia, extra-genital infection ...

Table Table Table

Table

Table

T able

Table

Table

Table

Table

Table

Table

Table 10

Table 11

Table 12

Table 13

Table 13a Table 14

Table 15

Table 16

Table 17

Table 18

Table 19

Table 20

Table 21

Table 22

Table 23

Table 24

Table 25

Table 26

Table 27

Table 28

Table 29

Table 30

Table 31

Maternal deaths

Anaesthesia and analgesia

II. PAEDIATRIC SECTION

Introduction Table 32 Table 33 Table 34 Table 35 Table 36 Table 37 Table 38

and summary Stillbirths Neo-natal deaths Premature infants Congenital malformations Birth trauma Neo-natal infections Other neo-natal diseases

Post-natal supervision Bacteriology and pathology

PAGE

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5 5 6 8

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10 10

11 12 13 13

14

14

15

20 21 21 22 22 23

23

24

26 28

28

29

30

30

31

31

32

33

34

35

38

38

39

42

44

47

47

47

48

48

49

49 50 51 52 54 54 55 55

56 56

/

3

BROMLEY GROUP HOSPITAL MANAGEMENT COMMITTEE CHAIRMAN

ALDERMAN ARTHUR COLLINS.

VICE-CHAIRMAN

FRANK HEALEY, Esq., J.P.

MEMBERS

MRS. E. M. BARLAS, J.P. COUNCILLOR MRS. I. BROOK, S.R.N., S.C.M. MISS G. H. WARRACK, B.Sc. COUNCILLOR G. R. D. BRADFIELD, L.D.S., R.C.S.(Eng.). TOM BROWN, Esq., M.Com., F.C.W.A., F.I.I.A., F.S.S. COUNCILLOR A. OWEN CARTER. BRIGADIER A. D. CURTIS. C. E. W. DULEY, Esq. STANLEY HOOKER, Esq. H. CREWDSON HOWARD, Esq., F.C.A. D. G. MADIGAN, Esq., B.A., M.B., B.Ch. C. JENNINGS MARSHALL, Esq., M.S., M.D.(Lond.), F.R.C.S.(Eng.). A. TALBOT ROGERS, Esq., M.B., D.S. C. DENISON STIEWELL, Esq., M.R.C.S., L.R.C.P. RUFUS C. THOMAS, Esq., F.R.C.S.E., F.R.C-O.G. DENIS B. WHITLOCK, Esq., F.R.C.S.(Ed.), M.R.C.S., L.R.C.P.

HOUSE COMMITTEE (In office 1948 to 1949)

CHAIRMAN

H. CREWDSON HOWARDS, Esq., F.C.A.

VICE-CHAIRMAN

DR. DENIS B. WHITLOCK.

\

LADY ALEXANDER. MISS KATHLEEN CLAY. MRS. I. R. C. TORGENSEN MRS. 1. W. MacDONALD. TOM BROWN, Esq. H. E. GROVES, Esq.

MEMBERS

ALDERMAN F. W. ISARD. E. K. 1ENKINS, Esq. L W. NEIGHBOUR, Esq. ALDERMAN L S. MARRIOTT. L. F. SCHOOLING, Esq. COUNCILLOR F. G. HAMILTON SPRATT.

SECRETARY OF THE MANAGEMENT COMMITTEE

R. C. MILLWARD

FINANCE OFFICER

W. S. LEA.

SUPPLIES OFFICER

J. W. LIS.

GROUP ENGINEER

COLONEL O. STURT, M.A.

BROMLEY HOSPITAL

ADMINISTRATIVE OFFICER

S. W. COLLETT.

MATRON

MISS M. M. BERKELEY.

ASSISTANT ADMINISTRATIVE OFFICER

S. H. DUNMALL.

CLERK TO MATERNITY DEPARTMENT

MISS D. A. DEAN.

HEAD ALMONER

MISS N. E. KING.

CATERING OFFICER

MISS D. SMYTH.

VISITING MEDICAL AND SURGICAL STAFF

CONSULTING PHYSICIANS

ARTHUR H. DOUTHWAITE, M.D.(Lond.), F.R.C.P., 49 Harlev Street. London W 1 ARTHUR C. HAMPSON, M.C., M.A., M.D.(Cantab.), F.R.C.P., 101 Harley Street, London, W.l.

PHYSICIAN

N. S. PLUMMER, M.D., F.R.C.P., 49, Harley Street, London, W.l. Medical Assistant: D. N. DOBBIE, M.B, F.R.C.P.(Ed.l, 31 Westmoreland Road., Bromley, Kent.

CHEST PHYSICIAN

D. G. MADIGAN, B.A., M.B,, B.Ch., B.A.O., 2 Park Road, Bromley. Chest Medical Assistant: MURIEL F. PROUT, M.D.(Lond.), 19 Oaklands Road, Bromley, Kent.

4

CARDIOLOGIST

C. G. BAKER, O.B.E., M.D., F.R.C.P., Guy’s Hospital, London, S.E.I.

PAEDIATRICIAN

I. N O’REILLY, M.A., D.M., B.Ch.(Oxon.), M.R.C.P., 114 Harley Street London W.l Paediatric Assistant: LAWRENCE WALKER, M.D., B.Ch., B.A.O.(Belf), 45 I weedy Road, Bromley,

kCnt’ CONSULTANT IN PHYSICAL MEDICINE

ARTHUR H. DOUTHWAITE, M.D.(Lond.), F.R.C.P., 49 Harley Street, London, W.l. Medical Officer in Charge of Physical Medicine: A. TALBOT ROGERS, M.B., B.S.(Lond ), M.R. .

L.R.C.P., 35 London Road, Bromley, Kent.

SENIOR SURGEON

C. JENNINGS MARSHALL, M.D., M.S.(Lond.), F.R.C.S., 121 Harley Street, London, W.L

ASSISTANT SURGEON

W. P. GREENING, F.R.C.S., 02 Queen Anne Street, London, W.L Surgical Assistants: CLAUD DYSART, M.R.C.S., L.R.C.P., 26 High Street, Bromley, Kent. A. E. O’DONNELL, M.B.E., M.D., B.Ch., B.A.O., Aldborough, Chislehurst, Kent.

ORTHOPAEDIC SURGEON

T T STAMM M.B., B.S., F.R.C.S., Keats House, Guy’s Hospital, S.E.I. Orthopaedic Surgical Assistant: I). B. WHITLOCK, F.R.C.S.(Ed-), M.R.C.S., L.R. . .,

Vil'.a Vita, Scotts Lane, Shortlands, Kent.

VISITING OBSTETRICIAN

A. L. GUNN, M.D., F.R.C.S., F.R.C.O.G., 51 Harley Street, London, W.L

OBSTETRICIANS AND GYNAECOLOGISTS

ALISTAIR L. GUNN, M.D., F.R.C.S., F.R.C.O.G., 51 Harley Street, London W.l. C. KEITH VARTAN, E.R.C.S., E.R.C.O.G., 28 Kidbrooke Grove, London, S.E.3. Gynaecological Assistant : R. Il’cOl'eMAN,’ M.B., Ch.B.(Birm.), 27 London Road, Bromley, Kent.

OPHTHALMIC SURGEONS

ERIC H LYLE, M.A., M.D.(Cantab.), 1 Elmfield Road, Bromley, Kent. R. II. RUSHTON, M.R.C.S., L.R.C.P., D.O.M.S., 1 Elmfield Road, Bromley, Kent.

SENIOR EAR, NOSE AND THROAT SURGEON

R 1 CANN M.B., M.S.(Lond.), 101 Harley Street, London, W.l. ASSISTANT EAR, NOSE AND THROAT SURGEON

J. V. BROAD, M.A., M.B., B.Ch,(Cantab.), M.R.C.S., L.R.C.I’., 7 Elmfield Road, Bromley, kenr.

DERMATOLOGIST

F W PROSSER THOMAS, M.A., M.D., B.Ch.(Cantab.), 8 Harley Street, London, W.l. Dermatological Assistant: D. W. BURGESS, M.R.C.S., L.R.C.P., Berlaymount, Susan Wood,

Chislehurst, Kent. PHYSICIAN IN PSYCHIATRIC MEDICINE

G. D. MORGAN, M.A.(Cantab.), M.R.C.P., 44 Albion Street, London, W.2.

ASSISTANT PHYSICIAN IN PSYCHIATRIC MEDICINE ELIZABETH TYLDEN, M.A., M.B., B.ChirRCamb.), M.R.C.S., L.R.C.P., 44 Albion Street,

London, W.2. NEUROLOGIST

S. BEHRMAN, B.Sc.(Lond-), M.R.C.P., 33 Harley Street, London, W.l.

RADIOLOGIST

A. C. GLEN DINNING, M.B., D.M.R.D., Bromley Hospital, Cromwell Avenue, Bromley, Kent.

PATHOLOGIST JOHN H. H. KEALL, B.Pharm.. M.D., M.R.C.S., L.R.C.P., Bromley Hospital, Cromwell Avenue,

Bromley, Kent. ANAESTHETISTS

KEVIN McCAUL, M.B.E., L.R.C.P.I,, L.R.C.S.I., L.M., D.A. 10 Blyth Road, Bromley, Kent. C R G BARRINGTON, M.R.C.S., L.R.C.P., D.A., Husseywell, Pickburst Lane, Hayes, Kent. R. A. O. LAY, M.B., B.S., M.R.C.S., L.R.C.P., Woodbourne, Cbisllehurst, Kent. A. DANIN, M.R.C.S., L.R.C.P., D.A., 24a Lewisham Way, London, S.E.14.

CONSULTING DENTAL SURGEON

G. RUSSELL EDEY, L.D.S. (R.C.S.Eng.), 83 High Street, Bromley, Kent.

DENTAL SURGEONS

IAN C. WILSON, L.D.S. (R.C.S.Eng.), 83 High Street, Bromlev, Kent. T. J. HANCOCK, B.D.SRLond.), L.D.S. (R.C.S.Eng.), Dental Department, buys Hospital,

London, S.E.I. EMERITUS PHYSICIAN

F. G. FRANCE, M.B., B.S.(Lond.), M.R.C.S., L.R.C.P., 8, Bromley Common, Bromley, Kent W. S. HUNT, M.A., M.D., B.Chir.(Cantab.), 57 Bromley Common, Bromley, Kent.

EMERITUS SURGEON

P R. BOSWELL, M.C., M.A., M.B., B.Ch.(Cantab.), M.R.C.S., L.R.C.P., 32 Southborough Road, Bicklley, Kent.

EMERITUS ANAESTHETISTS

SIDNEY 1 ROWNTREE, M.R.C.S., L.R.C.P., 7 Elmfield Road, Bromley. \V HORSFALL CHESTERS, M.B., B.S.(Lond.), 126 Widmore Road, Bromley, Kent. AGNES WESTWOOD, M.A., M.B., B.S.(Lond.), 115 Widmore Road, Bromley, Kent

5

RESIDENT STAFF

RESIDENT MEDICAL OFFICER

J. F. CLEOBURY, M.B., B.S.

RESIDENT OBSTETRIC OFFICER

BRUCE ETON, M.B., Ch.B.

SENIOR HOUSE SURGEON

J. E. HURMAN, M.B., B.S.

OBSTETRIC HOUSE SURGEON

J. L. WARREN, M.B., B.S., D.Obst., R.C.O.G

HOUSE PHYSICIAN

R. A. KERSHAW, M.B., Ch.B.

HOUSE SURGEON

J. F. SHEEHAN, M.R.C.S., L.R.C.P.

CASUALTY OFFICER

R. SOUTHWELL, M.B., B.S.

STAFF PARTICULARLY ENGAGED IN THE MATERNITY DEPARTMENT

Visiting Obstetrician

Visiting Paediatrician

Anaesthetists.

Radiologist .

Pathologist

Medical Officer in Charge Medicine.

Resident Obstetric Officer ..

Obstetric House Surgeon ..

Matron .

of Physical

A. L. GUNN, M.D., F.R.C.S., F.R.C.O.G.

J. N. O’REILLY, M.A., D.M., M.R.C.P.

KEVIN McCAUL, M.B.E., L.R.C.P.I., L.R.C.S.I., L.M., D.A.

C. R. G. BARRINGTON, M.R.C.S., L.R.C.P., D.A. R. A. O. LAY, M.B., B.S., M.R.C.S., L.R.C.P. A. DANIN, M.R.C.S., L.R.C.P., D.A.

A. C. GLENDINNING, M.B., D.M.R.D.

J. H. H. KEALL, B.Pharm., M.D., M.R.C.S., L.R.C.P.

A. TALBOT ROGERS, M.B., B.S.(LoncL), M.R.C.S., L.R.C.P.

B. ETON, M.B., Ch.B.

J. L. WARREN, m’.B,, B.S., D.Obst., R.C.O.G.

M. BERKELEY, S.R.N., S.C.M.

Superintendent Midwives

Midwifery Teacher ...

Midwifery Sisters

Physiotherapists

Almoner

R. HURRELL. L. STICKNEY.

E. SNELLING, M.T.D.

E. K. DICKSON. R. M. WILD. M. A. WOODWARD. E. M. GREEN. F. LEISCHING. B. M. WOOD. M. HOLDER.

B. K. TWEED. V. O. KEITLEY. E. M. MILNER. E. C. MAYNARD. H. M. PEARCE. J. ALLEN. P. BURKETT.

P. M. PERKINS.

6

SURVEY

THIS, the report for 1948, is the first to be published since the hospital came into the National Health Scheme under the South East Metropolitan Regional Hospital Board. It is the third report to be published in the standard form

but the first since the publication of the recommendations of the Council of the Royal College of Obstetricians and Gynaecologists on maternity hospital reports. This says, “The Council of the College is firmly of the opinion that the publication of a medical report is of extreme value in maintaining a high standard of practice, and would go so far as to urge all maternity hospitals and departments to publish an annual report. The standard form now recommended closely follows the form used in the past and if it can be widely adopted the value of the information obtained will be enhanced by

the possibility of comparisons over a number of years.”

The Hospital

Bromley is a Kentish market town which has become enveloped by the dormitory suburbs of London but which has maintained its own civic character. The patients are drawn mainly from the middle class, some in more favourable circumstances than others but very few really poor people, and few who are not intelligent and eminently teachable. Apart from Non-booked patients, who this year numbered 57, the patients book for their confinements a full six months before the expected date so that ante-natal supervision can have a strong influence on the course of pregnancy.

The maternity department is in two units. The Widmore Unit of twenty-two beds is situated about half a mile from the other buildings, and it is here that all the ante-natal out-patient work is carried on. It is the former Bromley, Chislehurst and District Maternity Hospital. There are four single-bedded rooms, one two-bed ward, and the remaining beds are in wards of three, four and five beds.

The Masons Hill Unit of thirty-eight beds is also self-contained and its grounds are a stone’s throw from the grounds of the main Hospital. It has fourteen single rooms and the largest ward accommodates six patients.

The facilities provided for all expectant mothers include comprehensive blood investigations, instruction in dietetics, exercise classes in the Physiotherapy Depart¬ ment, and the systematic obstetric supervision which can be assessed in the pages of

this report.

The year’s progress

Early in the year we began holding monthly clinico-pathological meetings to review the work of the previous month. These meetings have been well attended by the pathologist, radiologist, paediatrician, anaesthetist, clinical assistants and the obstetrical staff together with the medical officers of those Kent County Council ante-natal clinics which refer patients to the hospital. The senior midwifery sisters are present and also several general practitioner obstetricians who work in the patients’ homes. There is no doubt that these meetings have kept our work under constant scrutiny so that we have been quick to effect improvements. They have also made for smoother and more efficient relations between the three divisions which Parliament has made in maternity work. The value of the meetings has been so evident that the idea is being copied in other centres.

The first pupil midwives to enter the Hospital for training for Part I of the Central Midwives Board examination began their training during the year. The hospital was also recognised for training midwives and pupils in the administration of analgesia and Dr. Kevin McCaul has visited the hospital to lecture and supervise this work.

The new ante-natal clinic at Widmore Road was opened during the year. It is made from a prefabricated hut and includes three consulting rooms, each with two changing cubicles, urine testing room, offices and sanitary equipment together with a lecture room and a dental surgery. The facilities enabled Mr. T. J. Hancock to begin a regular service of dental examination of all out-patients at the time of booking, and to begin treatment of those who could not readily obtain it from their own dental surgeons.

We are indebted to Mr. Lewis Graham, M.S., F.R.C.S., Consulting Surgeon to the Maternity Hospital, Birmingham and the Birmingham and Midland Hospital for Women, Consulting Obstetrician to the Queen’s Hospital, Birmingham, and Con¬ sulting Gynaecologist to the Birmingham General Hospital, who again took charge of the department for a month in August and September.

In July Dr. Bruce Eton was appointed Resident Obstetric Officer and Dr. J. L. Warren took up the duties of Obstetric House Surgeon.

The Emergency Obstetric Service (Flying Squad) has been in readiness throughout the year but it only needed to go out on one occasion to a very serious case of post-partum haemorrhage at Beckenham.

7

This Report

These reports are intended to enable the clinical work to be examined and compared with that of previous years and w'ith the work of other hospitals so that methods and results can be evaluated for the benefit of our future patients.

The primary importance of the preventive ^aspect of obstetrics is stressed b} classifying the patients with abnormal conditions treated in the hospitals into “Booked” and “Non-Booked.” A “Booked” case is one that attended the ante-natal clinic on more than one occasion. “Non-booked” patients had not been to the hospital for ante-natal supervision more than once, and were either admitted seriously ill or at the last moment after little or no ante-natal care. This report differs from similar ones in that it includes a third category of cases, “Private.” These women were cared for during their pregnancies and confinements by private practitioners; but some of the “Private” cases were similar to the hospital “Non-booked” group in that they had neglected to place themselves in their doctors’ hands until late in pregnancy.

Throughout the report, patients treated in the Widmore Unit have a registered number prefixed by “W,” while the Mason’s Hill cases are marked “M.”

The report includes all the data required in the recommended form of the College and adheres to its plan except in the following details.

The College recommends that a “Booked” case is one for which the hospital has accepted responsibility for the ante-natal care, but our definition is stricter as already defined.

A preliminary sub-section of the Obstetric section has been created to deal with ante-natal care and in this has been included the Table 47, External Version of Breech Presentation, because it appears to be out of place amongst the tables devoted to In-patient treatment. The definition of uncomplicated breech presentation has been interpreted more strictly so as to include all cases irt which there was no other risk to the life of the foetus than breech presentation. Extended legs, extended arms and prolapse of the cord are considered to be risks arising from breech presentation and so are included. This table is important because all the cases are ones in which breech presentation could have been prevented by version and it thus includes all the foetal losses due to breech labour which could have been prevented.

The other variations from the College model are the inclusion of a third unclassified group of cases of ante-partum haemorrhage and the division of the “Toxaemia” table into two groups, “Albuminuria” and “Hypertension without albuminuria.” The table numbers have been kept the same, and where an additional table has been inserted it ha.s been given a letter in addition to the number.

\

The Results

There has been continuous improvement. Amongst the 1,039 Booked, 57 Non- booked and 241 Private Cases there was not any maternal death. The stillbirth rate was 17 per 1,000, compared with 28 irt 1947 and 25 in 1946. The infant death rate was 11 per 1,000 compared with 13 in 1947 and 15 in 1946. Combined, stillbirth and infant death rate was 28 compared with 41 in 1947 and 40 in 1946.

I he prevention of breech labour has been successful and for the third successive year there has not been any stillbirth or infant death due to breech delivery in “Booked” cases nor any infant losses among patients on whom version has been performed.

The year has been one of solid work and steady progress in which every member of the staff has contributed to the full. The midwifery sisters have helped by keeping careful records throughout the year. The completion of the report has only been made possible by the tireless efforts of Dr. Warren, the Superintending Sisters Miss Hurrell and Miss Stickney and the secretary Miss Dean, to whom I am very grateful. J

A. G.

8

ABBREVIATIONS

Alb. = Albumen.

A.N. = Ante-natal.

A.N.C. = Ante-natal Glinic.

A.P.H. = Ante-partum haemorrhage (Accidental).

A.R.M. = Artificial rupture of membranes.

B.A. = Before admission.

B.B.A. = Born before admission.

B.P. = Blood pressure.

C.S. = Caesarean Section.

D. = Died.

D.C. = Diagonal conjugate.

E.B.M. = Expressed breast milk.

E.C. = External conjugate.

Epis. = Episiotomy.

E.U.A. = Examination under anaesthesia.

F. = Female.

F. = Fresh.

F.D. = Fully dilated.

G.C.P. = Generally contracted pelvis.

Grav. = Gravida.

Hb. = Haemoglobin.

Hr. Min. = Hours, minutes.

I.M. = Intramuscular.

In. = Inches.

I.V. = Intravenous.

L. = Living on discharge from Hospital.

M. = Macerated (Stillborn).

M. = Male.

Mat. — Maturity.

M.C. = Mother, Child.

M.D. = Maternal death.

n2o. = Nitrous oxide.

N.Y. = New York Heart Assoc., 1939.

o2 Oxygen.

P.M. = Post-mortem examination.

P.N.F. = Promontory not felt.

P.F. = Promontory felt.

P.P.H. = Post-partum haemorrhage.

Preg. = Pregnancy.

Rh. = Rhesus.

S.B. = Stillborn (fresh).

S.F. = Scarlet fever.

T.B. = Tubercle bacilli.

Tb. Tuberculosis.

W.R. = Wasserman reaction.

9

SECTION I. THE OBSTETRIC SECTION

STATISTICAL SUMMARY Booked Non-booked Private Total

Adult patients admitted after 28th week ... 1039 57 241 1337

Patients delivered in hospital after 28th week Primiparae 481 31 101 613

Patients delivered in hospital after 28th week Multiparae 516 25 135 676

Patients admitted after delivery (B.B.A.) Primiparae 1 0 1 2

Patients admitted after delivery (B.B.A.) Multiparae 2 0 2 4

Total patients delivered after 28th week ... 1000 56 239 1295

Abortions 10 9 1 20

Patients transferred ... 2 0 0 2

Maternal deaths 0 0 0 0

Maternal death rate per !,000 0 0 0 0

Infants born in hospital 993 54 240 1287

Infants born before admission (B.B.A.) ... 3 0 3 6

Total infants born 996 54 243 1293

Infants transferred 2 0 0 2

Stillbirths 18 3 1 22

Stillbirth rate (stillbirth rate per 1,000 live and still births) ... 17.8 52.6 4.1 16.8

Neo-natal deaths 9 2 3 14

Neo-natal death rate per 1,000 live births 9.1 37.0 12.5 10.9

Other infant deaths ... 0 0 0 0

OUT=PATIENT TREATMENT

TABLE A.

Conditions treated in the Ante-Natal Department ip patients not admitted to hospital for treatment of these

Abortion, threatened

conditions.

4 Retroversion of gravid uterus ... 51

Acroparaesthesia ... 4 Scabies 2

Anaemia (Hb. 65% or less) 27 Syphilis 4

Breech presentation ... 133 Threadworms 2

Cervical polypus ... 4 Tuberculosis, pulmonary 5

Epilepsy and petit mal ... . 2 Tuberculosis, non-pulmonary ... 1

Erythema nodosum ... 1 Urinary infection 4

Herpes Zoster ... 1 Urticaria 1

Hyperemesis ... 32 Vaginitis, trichomonas ... 6

Hypertension ... 6 ,, Monilia 21

Migraine ... 1 ,, other ... 3

Phlebitis, superficial ... ... 3

10

ANTE NATAL TREATMENT OF BREECH PRESENTATION

TABLE B.

Breech presentation was particularly looked for at the thirty-second week of pregnancy, and external version was performed as soon as possible unless there was some contraindication. With the technique adopted this procedure was largely successful and out of 167 cases it was only necessary to administer an anaesthetic in 4.

The prevention of foetal mortality due to breech labour has been entirely success¬ ful, because of 997 Booked deliveries uncomplicated breech labour occurred in only two cases. Moreover there were not any stillbirths or infant deaths in these cases or in cases in which external version was performed or attempted. In 2 other uncomplicated Booked cases, breech presentation was treated by Caesarean section.

i ■

Breech presentation diagnosed, including 34 recurrences but excluding twins 167

Spontaneous version ... ... ... ... ... ... ... ... ... 10

External version, finally successful without anaesthesia ... ... ... 110

Version under anaesthesia successful ... ... ... ... ... ... 2

Version under anaesthesia unsuccessful ... ... ... ... ... ... 2

Caesarean Section for breech presentation ... ... ... ... ... ... 2

Uncomplicated breech deliveries ... ... ... ... ... ... ... 2

Complicated breech deliveries ... ... ... ... ... ... ... 4

X=RAY EXAMINATIONS TABLE C.

111 cases were referred to the X-Ray Department. Reasons for reference were :—

Booked Private Total

Maternal conditions (cardiac, pulmonary, renal, etc ) 15 1 16

For foetal parts 1 0 1

Breech 19 3 22

Presentation, attitude, etc. 41 2 43

Twins 14 0 14

Foetal death 0 0 0

Anencephaly 2 0 2

Hydrocephaly 0 0 0

Pelvimetry 11 0 11

For maturity 2 0 2

\

11

IN PATIENT TREATMENT A NUMERICAL SUMMARY OF CASES admitted for treatment, delivered in

hospital or admitted after delivery. Some

in the summary.

1. Conditions chiefly ante-natal—

Hypertension only

Albuminuria

Eclampsia

Persistent vomiting of pregnancy

Acute pyelitis

Malnutrition, debility, simple anaemia, etc.

2. Intercurrent disease—

Chronic rheumatic carditis

3. Conditions chiefly natal—

Anterior positions of the vertex

Posterior positions of the vertex

Breech

Shoulder (not delivered as such)

Face and brow

Caesarean section

Twins and triplets

Accidental haemorrhage

Placenta praevia

Other ante-partum haemorrhage

Trial labour

Hydramnios

Prolapse of cord

Primary uterine inertia

Retained placenta

Post-partum haemorrhage

B.B.A.

Lacerated perineum and episiotomy ...

Obstructed labour

Premature labour

Abortion ...

Ectopic gestation

4. Post-partum complications—

Notified puerperal pyrexia

Mastitis, not suppurative

Mastitis, suppurative (aspirated)

Delayed involution of the uterus

Post-partum urinary infection

Post-partum superficial phlebitis

Post-partum deep venous thrombosis

cases appear in more than one category

Booked Non-booked Private Total

12 0 1 13

• 58 4 7 69

3 0 0 3

8 1 1 10

7 0 1 8

5 0 0 5

3 0 0 3

863 58 199 1120

110 5 21 136

14 1 8 23

2 0 0 2

4 0 2 6

12 4 12 28

14 1 4 19

3 1 1 5

4 0 2 6

10 0 0 10

31 1 2 34

10 1 i 12

1 0 1 2

27 4 2 33

13 2 2 17

63 4 15 82

3 0 3 6

476 19 128 623

0 0 0 0

36 2 9 47

10 9 1 20

0 4 0 4

14 0 3 17

19 1 5 25

1 0 0 1

31 2 0 33

15 0 1 16

7 1 0 8

1 0 0 1

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15

ALBUMINURIA AND HYPERTENSION Every patient attending the Ante-Natal clinic has the urine tested and the blood pressure recorded at each visit.

Normal patients attend every 4 weeks untill the 28th week of pregnancy, then fortnightly until 36 weeks, after which they make weekly visits until delivery. All cases of albuminuria are admitted to hospital. The routine treatment adopted in hospital was rest, and a mixed diet containing as much fresh natural foods as possible, excluding red meat. Copious fluids and alkalies were given, and aperients if necessary. If the signs did not lessen in about seven days, or if they became worse, labour was induced.

ALBUMINURIA AND HYPERTENSION.


Number of cases 58 4 7 6!)

Number of stillbirths and infant deaths . . 5 1 2 8

Foetal and infant mortality . ... . . 8.6% 25% 29% 11.6%

Number of maternal deaths . . 0 0 0 0

Number of cases—

Responded to treatment and delivered spontaneously near term (after 38 weeks) 23 1 1 25

Spontaneous premature labour or abortion 3 1 0 4

Not responding to treatment, labour induced . . 28 2 5 35

Not responding to treatment, hysterectomy or hysterotomy performed 0 0 0 0

Not responding to treatment, abortion per vaginam induced 1 0 0 1

Not responding to treatment, Caesarean Section performed 3 0 1 4

HYPERTENSION WITHOUT ALBUMINURIA

Number of cases . 12 0 1 13

Number of stillbirths and infant deaths. . 1 0 0 1

Foetal and infant mortality 8.3% 0 0 7.7%

Number of maternal deaths 0 0 0 0

Number of cases—

Responding to treatment and delivered spontaneously at term 5 0 1 6

Spontaneous premature labour or abortion 0 0 0 0

Not responding to treatment, labour induced ... 5 0 0 0

Not responding to treatment, hysterectomy or hysterotomy performed 0 0 0 0

Nor responding to treatment, abortion per vaginam induced 0 0 0 0

Not responding to treatment, Caesarean Section performed 2 0 0 2

16

TABLE 5

ALBUMINUKIA

Previous Weight History Albuminuria

Case Reg. Age pregnancies Maturity of of Maxi¬ On Oedema Headache Eye

No. No. before after On At Child Renal mum discharge Signs

28 28 ad¬ de¬ lbs. ozs. Disease BOOKED weeks weeks mission livery

No No No 1 W 18 37 — 1 41 41 8 0 * No Moderate None

2 W 32 29 _ _ 44 44 7 14 No Slight None No No No

3 W 44 22 — — 40 40 7 11 No 2 None Moderate No No

4 W 77 34 1 1 40 42 5 12 No Slight None No No No 6 15

5 W 82 32 — — 40 42 7 3 No Slight None No No No 6 W 95 21 — — 40 40 7 8 No 2.5 Trace Slight Yes No 7 W121 34 — — 40 40 8 13 No 3 None Moderate No No 8 W133 22 — — 37 39 5 10 No 2 None No Yes No

9 W153 22 _ _ 38 38 6 14i No Slight None No Yes No

10 W206 23 — — 40 40 6 10 No 0.25 None No No No

11 W234 24 — — 32 35 4 11 No 2.0 None Severe Yes No 5 11

12 W238 26 _ _ 39| 40 6 9 No 0.25 None Moderate No No

13 W252 31 — — 40 40 7 0 No Slight None No No No

14 W277 28 — — 40 40 5 12 No Slight None Yes No No

15 W287 25 2 , 37 40+ 8 2 No 0.25 None No No No 10 W300 37 _ — 27 27 1 13 No Severe None Severe Yes Yes

17 W345 23 — — 35 38 5 14 No 2 None No No No

18 W380 33 — i 40 40 6 14 No 0.25 None No No No

19 W405 27 _ _ 38 40 6 4 No 0.5 None No No No 20 M 13 19 — — 41 44 7 6 No Trace None No No No 21 M 80 35 — — 39 39 4 2 No Moderate None No No No

22 M 94- 23 2 38 38 7 7 No Slight None No No No 23 M 97 35 — 2 39 39 7 3 S.F., Slight None No No No

Neph. Alb. of preg.

24 M119 21 — — 38 40 6 0 No 0.5 None No No No 25 M144 17 — — 41 41 6 11 No 0.4 None Moderate Yes No 26 M145 23 — — 37 37 5 1 No 4 parts None Slight No No 27 M164 31 — — 39 40 7 14 No 0.5 None No No No

28 Ml 88 30 __ __ 38 38 7 12 No 0.175 None Slight Yes No 29 M190 26 — — 37 37 5 7 No 0.7 None Moderate No Yes 30 M195 22 — — 37 38 7 4 No 0.5 Moderate No No No

31 M196 22 — — 38 40 7 8 Neph., Slight None No No No 1944

32 M205 40 1 36 38 6 11 No 0.25 None No No No

33 M210 43 — — 39 39 7 11 No 1.5 None Moderate No No

34 M222 35 — 1 37 41 10 9 No Slight None No No No

35 M256 25 — — 35 41 7 11| No Slight None Slight No No

36 M260 30 _ 39 40 6 Hi No 0.5 None No No No 37 M289 32 - ' — 39 39 8 0 No 1 None No No No

38 M358 26 _ _ 40 40+ 7 5 No 0.5 None No No No 39 M371 34 _ — 37 39 7 6 S.F. 0.5 None Moderate Yes Yes 40 M381 22 — — 40 + 40+ 6 1 No 0.5 None No No No 41 M395 21 — — 41 42 7 11 No 0.25 None No No No

42 M416 36 40 40 8 5 No Slight None No No No 43 M439 33 — — 38 39 6 15 No 2 pts Slight Slight No No

6 6

44 M482 26 38 40 5 10 No 2 pts None No No No 45 M490 25 — — 35 39 7 10 No 0.25 None No No No 46 M494 21 — — 40 41 7 1 No 1 None Slight No No 47 M503 30 — — 38 39 6 7 No 2 None Slight No No

48 M514 30 1 39 39 8 3 No Slight None No No No 49 M567 40 — — 35 38 4 12 S.F. at li J part Slight No No

6 yrs. 50 M570 32 — — 40 40 9 8 No l

4 None Slight No No

17

69 Cases.

No. of days Highest in hosp. Method Method Post Natal Exam.

Blood before of term¬ of Result 6 weeks after delivery Remarks

Pressure labour inating delivery M. C. Blood or pregnancy Pressure Albumen

discharg e 158/116 2 A.R.M. Normal L. D. 136/80 None Post-partum haemorrhage. Blood trans¬

fusion. Long labour.

140/90 4 A.R.M. Normal L. L. 122/70 None Post maturity.

164/110 4 A.R.M. Normal L. L. 134/88 None

128/98 9 Spontaneous Normal 1 L. 2nd twin shoulder presentation: Int ver¬ Breech L. 2 SB 128/80 None sion to breech presentation. Second twin

S.B. Hydramnios post-parturn haemorr¬ hage.

150 j 90 4 Spontaneous Normal L. L. 88/54 None Albumen present on day of admission only. 158/94 2 Spontaneous Normal L. L. 132/80 Slight Persistent albuminuria. 180/118 1 Spontaneous Normal L. L. 132/78 None 144/108 15 A.R.M. Normal L. E. 128/72 None

160/110 5 Spontaneous Normal L. L. 136/74 None Infant bullous impetigo. 153/98 2 Spontaneous Normal L. L. 138/82 None

160/90 26 Spontaneous 1 Breech L. L. 132/82 None Twin pregnancy. 2 Vertex L.

154/108 3 Spontaneous Normal L. L. Did not attend

130/80 1 Spontaneous Norm ail L. L. 128/74 None Albumen present on admission. No hypertension.

134/110 6 Spontaneous Normal L. L. 134/70 None

136/104 10 Spontaneous Normal L. L. Did not attend 208/110 3 A.R.M. Normal L. — 164/100 None Therapeutic Abortion. 170/130 21 A.R.M. Normal L. L. 150/90 Slight

170/110 1 Spontaneous Normal L. L. 110/68 None Post-partum haemorrhage.

154/108 15 Spontaneous Normal L. L. 120/70 None Post-partum haemorrhage. 138/98 18 Spontaneous Normal E. L. 128/70 None Post mature. 170/116 3 Spontaneous Normal L. L. Did not attend Ante-natal anaemia (Hb. 34%) and trans¬

fusion.


140/100 24+3 A.R.M. Normal L. L. 130/76 Slight Renal function impaired.

158/110 15 A.R.M. Normal L. L. 126/72 None 200 /HO O A.R.M. Forceps L. L. 128/72 None Forceps delivery—rigid soft parts. 146/110 1 A.R.M. Normal L. L. 132/80 None 180/120 8 A.R.M. Normal L. L. 134/60 None

200/110 180/120

4 A.R.M. Normal L. L. 128/76 None 3 A.R.M. Normal L. L. 130/80 None

180/132 10 A.R.M. Normal L. L. 134/82 Slight Self discharge 10th day. 130/94 5 Spontaneous Normal L. L. 132/76 None Re-admitted in labour.


200/140 1 Caesarean Section

Caesarean Section

L. L. 142/90 None


145/95 10, 5, 8 Ol Ric Normal L. L. 138/88 Slight Discharged albumen free twice during pregnancy.


150/98 3 A.R.M. Normal E. L. 136/98 None Hymenectomy at 13th week.

148/96 5 Spontaneous Normal L. L. 120/74 None 160/104 16 A.R.M. Normal L. L. 140/88 None P.P.H.

168/108 1 Spontaneous Normal L. L. 140/90 None Trial! labour.

140/100 6 Spontaneous Normal L. L. 120/60 None Manual removal of placenta. Blood trans fusion 2 pints.

160/114 — Spontaneous Normal L. L. Did not attend Hydramnios primary inertia. Forceps delivery.

160/128 7 Caesarean Section

Caesarean Section

L. L. 120/70 None Twin Pregnancy.



158/110 9 Spontaneous Normal E. L. 120/70 None

176/116 7 A.R.M. Normal L. L. 120/60 None Forceps delivery. Post-partum anaemia. Blood transfusion. Notifiable pyrexia.

160/92 6 hrs A.R.M. Normal L. L. Did not attend Previous large baby.


160/118 Admitted Spontaneous Normal L. L. 120/80 None Hydramnios. Primary inertia. in labour

18

ALBUMINURIA.- -continued

Previous Weight History Albuminuria Case Reg. Age pregnancies Maturity of of Maxi¬ On Oedema Headache Eye No. No. before after On At Child Renal mum discharge Signs

28 28 ad¬ de¬ lbs. ozs. Disease weeks weeks mission livery

51 M583 25 — 2 35 35 4 3 No 2 None None None None 52 M613 31 2 1 41 42 8 3 No Slight None Slight No No

53 M645 28 — — 36 37 4 11 No 6.0 None Slight No No

3 12

54 M662 30 — — 40 40 8 3 No Slight None Slight No No 55 M668 25 — — 35 37 5 14 Pyelitis 14 None Moderate Yes No 56 M671 25 — 1 33 33 2 8 No 3.5 None Slight No No 57 M684 39 32 35 3 3 No 1.5 Slight No Yes No

58 M751 34 — — 39 41 7 11 No Slight None No No No

NON -BOOKED 59 W311 43 — 5 34 34 5 0 No Moderate None No No No

60 W486 35 _ 2 42 43 7 15 No 3.0 None No No No 61 M712 26 — — 42 42 9 4 No Moderate None No No No

62 M717 26 —* — 42 42 7 2 No 1.5 None Slight No No

PRIVATE 63 W308 40 1 — 36 36 5 4 No 3.5 None No Yes Yes

4 4 64 M193 34 •— 34 34 4 10 No Severe Moderate Slight Yes No

65 M364 37 __ 3 40 40 8 7 No Slight None No No No 66 M450 39 — 1 32 36 4 1 Toxaemia 0.5 None No No No

1st preg¬ nancy

67 M634 31 — — 39 40 6 15 No Slight None No No No 68 M729 35 2 1 35 35 3 10 No 3.75 Slight Moderate No No 69 M732 28 — 40 40 7 8 No Slight None No No No

19

No. of days Highest in hosp. Method Method Blood before of term- of

Post Natal Exam. Result 6 weeks after delivery Remarks

Pressure labour inating delivery M. C. Blood or pregnancy Pressure Albumen

discharge 150/100 0 A.R.M. Normal L. SB Did not attend Accidental A.P.H. 118/70 4 Pitocin induc¬

tion (47 hrs.) Normal ' L. L. 120/78 None

160/100 10 Spontaneous Normal Vertex

L. 118/70 None Internal version second twin.

Breech L. L.

150/110 2 A.R.M. Forceps L. L. 118/68 None Forceps delivery for rigid soft parts. 180/110 13 A.R.M. Normal L. L. 120/76 None 174/122 4 Spontaneous Normal L. SB 118/80 None Previous stillborn child. 190/120 20 A.R.M. Spontane¬

ous Breech L. SB 120/70 None

170/120 16 * Caesarean Caesarean L. L. 120/80 None Contracted pelvis. Section Section

132/92 Admitted Spontaneous Breech L. SB 110/70 None Accidental A.P.H. in labour

150/108 5 A.R.M. Normal L. L. Did not attend 148/100 Admitted A.R.M. before Forceps L. L. Did not attend Uterine inertia. Forceps delivery. Manua

in labour admission delivery removal of placenta, P.P.H. 160/114 Admitted Spontaneous Normal L. L. Did not attend

in labour

170/100 2 A.R.M. Normal L. L. L. D.

Did not attend Twin labour.

168/116 1 Caesarean Caesarean L. Did not attend Myomectomy. Section Section

164/124 2 A.R.M. Normal L. L. Did not attend 154/112 28 A.R.M. Normal L. L. Did not attend Previous Toxaemia.

176/110 6 A.R.M. Normal L. L. Did not attend Induction with pitodirt failed. 158/120 3 A.R.M. Normal L. D. Did not attend 140 100 Admitted Spontaneous Normal L. L. Did not attend P.P.H,

in labour

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23

TABLE 9. HYDRAMNIOS

12 Cases

The diagnosis of hydramnios was made on dinical therefore only include

Previous Pregnancies Maturity

examination and not by measuring the : those with a notable excess of liquor.

amount of liquor. The cases

Case Reg. No. No.

BOOKED

Age before 28

weeks

after 28

weeks

on diag- at de- nosis livery

Treatmeut Result M. C.

Remarks

1 W 53 21 _ _ 32 43 None L. SB Intra-uterine death.

2 W 77 34 1 1 32 42 Podalic version 2nd twin L L. SB

Twins, pre-eclampsia P.P.H.

3 W109 22 32 40 None ... . . L. L. Twin labour.

4 M 23 40 2 3 24 34 None . L. L. L.

5 M 25 31 o 32 39 Surgical induction L. SB' Anencephaly.

6 M 66 40 — — 32 36 Caesarean section L. L. Unstable presentation, pre-eclampsia.

7 M416 36 — — 32 40 None . L. L. Pre-eclampsia, primary inertia, forceps delivery.

Anencephaly. 8 M531 22 — 1 32 33 Surgical induction L. SB

9 M570 32 — — 32 40 None L. L. Albuminuria, primary- inertia.

10 M804 32

NON-BOOKED

’— 1 36 38 None L. L. P.P.H.

11 M327 39 — — 44 Caesarean section L. L. Disproportion.

PRIVATE

12 W338 31 1 —- • 40 None

No mother died. Of 14 foetuses, 4 were stillborn, a foetal

L. L.

mortality

Primary inertia, forceps delivery.

of 29%.

TABLE 10.

TUMOURS ASSOCIATED WITH PREGNANCY, LABOUR OR

PUERPERIUM 9 Cases

No mother died. One infant died, a foetal mortality of 11%.

Previous Pregnancies

Remarks Case Reg. No. No.

BOOKED

Age before after 28 28

weeks weeks

Nature of tumour

Treatment Result M. C.

1 W 12 33 — — Fibroids Conservative L. L. P.P.H.

2 W216 30 — — Ovarian cyst C.S and left oophorectomy L. L.

3 M235 28 — 1 Ovarian cyst Right oocystectomy 18 weeks ... L. L.

4 M687 32 — — Ovarian cyst Left oocystectomy 10 weeks ... L. T ,

6 M748 36 _ — Fibroids Conservative L. L.

6 M752

PRIVATE

40 Fibroids Conservative L. L.

Caesarean section for disproportion.

7 W391 38 — — Fibroids L. L.

8 M 4 35 _ 1 Ovarian cyst Caesarean section L. L. Rt. oocystectomy.

(5 M193 34 — Fibroids Myomectomy & Caesarean Section L. D. Severe pre¬ eclampsia at 34 weeks.

24

TABLE 11.

Case Reg. No. No.

Age Mat¬ urity

Previous Pregnancies

before after 28 28

Position of Foetus at onset at

of labour delivery Other

obstetric abnormality

PROLONGED (Arbitrary definition being

33 Cases. No mother died.

Time of Cause of rupture Duration delay as of 1st

diagnosed Membranes stage (hours before

BOOKED 1 W 35 26 40

weeks

2

weeks

1 R.O.A. L.O.L. Contracted pelvis Disproportion

delivery)

12 50 52 20 2 W125 25 43 — — L.O.L. L.O.L. Contracted pelvis Inertia 72 30 69 30 3 W322 33 42 — ■— R.O.A. R.O.A. None None 1 30 51 50 4 W352 34 40 — — L.O.A. L.O.A. None I nertia 52 10 49 55

5 W383 26 40 _ 1 L.O.A. L.O.A. None Inertia 63 30 63 30 6 W390 22 40 — 1 L.O.A. L.O.A. Contracted pelvis Disproportion 10 0 58 25 7 W490 32 40 2 2 R.O.P. L.O.A. None Inertia 0 25 52 15

8 M 54 19 40 — —- L.O.A. L.O.A. Mild disproportion Inertia 1 20 68 30

9 MHO 32 41 _ _ R.O.L. L.O.A. Foetal distress Inertia 82 0 83 0 10 M112 23 41 — — R.O.P. L.O.A. None Inertia 52 30 53 15 11 M134 33 40 — — L.O.A. L.O.A. Foetal distress I nertia 46 45 48 15 12 M178 30 41 — — L.O.P. L.O.A. None Inertia 81 0 81 0

13 M179 25 42 _ _ L.O.A. L.O.A. None Disproportion 111 10 111 0 14 M214 25 36 — — L.O.A. L.O.A. A.P.H. . Inertia 42 5 49 0 15 M240 27 42 — — R.O.P. R.O.A. None Inertia 76 25 78 45 16 M304 22 42 — — L.O.L. L.O.A. None Inertia 45 45 60 50

17 M305 * 25 40 _ _ L.O.A. L.O.A. None Inertia 74 30 74 30 18 M373 30 40 — — L.O.A. L.O.A. None Inertia 5 0 74 45 19 M405 31 40 1 — R.O.P. L.O.A. None Inertia 20 15 59 0 20 M408 19 41 — — R.O.A. R.O.A. Contracted pelvis Disproportion 20 45 62 10

21 M545 35 39 — — R.O.P. R.O.A. None Inertia 3 0 62 50

22 M570 32 40 L.O.A. L.O.A. Hvdramnios AObuminaria Inertia 11 45 111 15

23 M644 37 38 — — R.O.A. R.O.A. Rigid soft parts Inertia 12 30 68 15

24 M681 24 41 — — R.O.A. R.O.A. None Inertia 79 10 79 10

25 M770 33 36 J

— \ R.O.A. L.O.A.

R.O.A. 1 L.O.A. j Twin labour ... I nertia

f 18 '1 46

25 55 21 45

26 M777 24 40 — — L.O.A. L.O.A. None Inertia 39 50 64 0

27 M811 22 43 — — R.O.A. R.O.A. Albuminaria Inertia 45 ’30 65 5

NON-BOOKED 28 W446 32 42 1 L.O.A. L.O.A. None Inertia 8 55 62 25 29 M 93 36 42 — — L.O.A. L.O.A. Contracted outlet Inertia 54 5

30 M617 34 41 — 4 L.O.L. L.O.A. None Inertia 59 0 104 20 31 M712 26 42 — — R.O.P. R.O.A. Pre-eclampsia Inertia 169 20 123 20

PRIVATE 32 W165 25 44 L.O.P. L.O.A. None Inertia 10 40 52 0 33 W338 31 40 1 — L.O.P. R.O.A. Hydramnios ... Inertia 60 0 57 0

25

LABOUR labour lasting 48 hours or more).

One infant died, a foetal mortality of 3%.

of labour 2nd 3rd Treatment P.P.H. Morbidity Method of delivery Weight

of Result

M. C. stage St8.£ e

Sedatives and feeding No Nil Lower segment C.S.

child

8 3 L. L.

L.

4 0 6 40 Sedatives and feeding Yes Genital infection High forceps 8 u D. T

1 35 0 25 Sedatives and feeding No Nii] Normal 8 5 L. L. L. 2 25 0 12 Sedatives and feeding Yes Nil Normal . 8 9 L,

0 15 0 15 Sedatives and feeding No Nil Normal 8 0 L. L.

2 55 0 15 Sedatives and feeding No Mild genital infection Forceps 8 4 L. L.

0 30 4 0 Sedatives and feeding Yes Nil Normal 7 2 L. L.



1 55 0 15 Sedatives and feeding No Puerperal mastitis Normal 6 10 L. L. L. 1 5 0 30 Sedatives and feeding No Nil Normal 7 1 L.

0 50 0 10 Sedatives and feeding No Nil Normal . 7 15 L. L.



L. L. 2 20 1 15 Sedatives and feeding No Nil Forceps 7 15



4 20 1 25 Sedatives I.V. Glucose No Nil Forceps 8 6 L. L.

0 15 1 15 Sedatives and feeding No Nil Forceps 7 5 L. L.

3 5 0 15 Sedatives and feeding No Niil Normal 6 12 L. L.

3 0 0 25 Sedatives and feeding No Nil Forceps 7 1 L. L.


14 25 0 40 Sedatives and feeding No Puerperal anaemia Forceps 5 9 L. L.

0 35 0 10 Sedatives and feeding No Mastitis Normal 8 J6 (6

8 3

L. L. L.

30 25 1 15 Sedatives,, A.R.M. No Puerperal anaemia Nil

Normal 8 L. L.’

0 40 0 40 Sedatives and feeding No Normal 6 8 L. L.

2 35 0 20 Sedatives and feeding No Nil Forceps ... 9 10 L. L.

1 10 0 30 Sedatives and feeding Yes Mastitis Forceps 8 9 L. L.

Sedatives and feeding No Nil Lower segment C.S. ... 8 5i L. L.

0 15 0 20 Sedatives and feeding No Nil Normal 4 4 4 5 3 L. L.

0 5 1 45 Sedatives Yes Nil Forceps .44 9 4 L. L.

1 0 0 15 Sedatives No Nil Forceps 8 9 L. L.

0 45 0 30 Sedatives No Nil Forceps 44. 9 14 L. L.

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28

TABLE 13.

UNCOMPLICATED BREECH DELIVERY 6 Cases

An uncomplicated breech delivery is one where an additional risk to the lifq of the foetus is not present—such as ante-partum haemorrhage, prematurity, monstrosity, pre-eclampsia, twins, etc. Extended limbs and prolapse of the cord are due to the breech presentation itself and so are included in this table.

One object of ante-natal care is to reduce the number of breech deliveries to a minimum. Infant? losses in the uncomplicated breech delivery table may be regarded as preventable by ante-natal treatment.

In the 997 Booked cases delivered during the year only 2 uncomplicated breech deliveries occurred, and the maternal and foetal mortality due to breech labour was nil.

Previous Pregnancies Mat¬ Legs Method Result Weight Episiot-

Case Reg. No. No.


weeks weeks

urity flexed or extended

of delivery

M. C. of child

omy or tear

Remarks

BOOKED 1 YV319 21 - - 42 Extended Legs brought down L. L. 6 12 Epis 2 M 48 26 1 38 Elexed Spontaneous L. L. 7 4 — Two A.N.

versions. PRIVATE 3 M 42 29 — 1 40 Flexed Spontaneous L. L. 8 2 Tear 4 M323 31 — — 41 Flexed Spontaneous L. L. 7 8 Epis 5 M483 25 — — 38 Flexed Spontaneous L. L. 6 1 Epis Extended arms. 6 M727 32 1 39 Extended Spontaneous L. L. 7 7 —

TABLE 13A.

BREECH PRESENTATION TREATED BY CAESAREAN SECTION 5 Cases

Case Reg. Age

Previous Pregnancies before after Mat¬

No mother and no infant died.

Indication Result

M. C.

Weight of

child Remarks No. No.

BOOKED i M273 38

28 28 weeks Weeks

1 —

urity

39 Elderly primigravida ... L. L.

lb. ozs.

7 11 2 M280 39 — 1 40 Elderly. Previous child 12 yrs ago ... L. L. 7 8

3 M439 33 — — 39 Pre-eclampsia L. i L. 1 L.

6 15 6 6 Twins.

NON-BOOKED 4 M756 30 40 Contracted pelvis L. L. 7 15 Recurrent

PRIVATE 5 M809 26 - 1 37 Placenta praevia L. L. 7 4

malpresentation

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30

/

I ABLE 15. FACE AND BROW PRESENTATION

6 Cases.

No mother died. One foetus Was stillborn, a foetal mortality of 17%.

Previous Pregnancies Mat-

Case Keg. No. No.


weeks weeks

urity Position Treatment

BOOKED 1 W191 32 — -—- 40 R.M.A. None

2 W372 18 — 1 39 L.M.A. None

3 M531 22 -* 1 33 ? None

4 M616 27 -• — 40 L.M.A. None

PRIVATE 5 M369 23 — -- 40 R.M.A. Caesarean

section

6 M543 39 1 1 40 R.M.A. None

Method of Result

Weight of Remarks

delivery M. C. child

Normal L. L. 6 6

Normal L. L. 8 3 Normal L. SB 5 0 Anencephalic: A R fv

Normal L. L. 8 1

Caesarean L. L. 8 4

section Normal L. L. 7 8

TABLE 16

TRANSVERSE AND OBLIQUE LIE 2 Cases.

No mother died. One foetus was stillborn, a mortality of 50%.

Previous Pregnancies Mat- Size of Weight


BOOKED

Age before after urity 28 28

weeks weeks

Obstetric complication

os when diagnosed

Treatment Result M. C.

of child

1 W 77 34 _ _ 42 2nd twin, shoulder presentation

F.D. Internal version

L. SB 6 15 Pre-eclampsia

2 M 645 28 -- — 37 2nd twin, shoulder presentation

F.D. Internal version

L. L. 3 12 Pre-eclampsia

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TABLE 21. PROLAPSE AND PRESENTATION OF CORD

2 Cases.

No mother died. One foetus was stillborn, a mortality of 50%.

Previous pregnancies Mat-

Case Reg. Age before after urity

No. No. 28 28 weeks weeks

BOOKED 41 1 W 43 26 — 1

PRIVATE 40 2 W209 37 — o

Size of Cause of prolapse pos when or presentation diagnosed

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FORCEPS DELIVERY

Forceps were applied 74 times (55 Booked, 5 Non-booked, 14 Private cases).

There was not any maternal death. In 55 Booked cases there were two stillbirths and one infant died, an infant

mortality of 5.5%. In Non-booked and Private cases there was no infant mortality. The total foetal and infant

mortality in forceps cases was 4%.


Disproportion 1 0 0 1 Rigid soft parts .

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arrest 21 2 3 26

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Weak pains and delay 5 0 2 7

Maternal distress 9 0 3 12

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VERSION IN LABOUR 3 Cases.

No maternal death, no foetal death.

Previous pregnancies Weight


BOOKED


weeks weeks

Mat¬ urity

Indication Bipolar, external or internal

of Child

Result M. C.

1 W 77 34 - - 42 2nd twin, shoulder presentation

Internal . 6 15 L. L. Pre-eclampsia

2 W188 34 — 1 38 2nd twin, R.S.A. Bipolar cephalic ... . 6 6 L. L. Pre-eclampsia 3 M645 28 - - 37 2nd twin, shoulder

presentation Internal ... 3 12 L. L.

TABLE 29.

EMBRYOTOMY AND CRANIOTOMY No Cases.

PUERPURAL PYREXIA All cases of pyrexia and maternal deaths are included as morbid. In 997 Booked deliveries there were 14 cases

of pyrexia. The morbidity rate for Booked cases was therefore 1.4%. In 56 Non-booked cases there was no maternal morbidity. In 236 Private cases there were 3 cases of pyrexia. The morbidity rate for Private cases was 1.3%. The morbidity rate for all cases was 1.3%.

As in previous years the standard of pyrexia has been a temperature of 100.4° F or more on two occasions after 24 hours and within 21 days of delivery. Should one such reading occur, or the pulse rate be raised, the patient’s temperature and pulse are recorded four-hourly.

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ANALGESIA

In the first stage of labour drugs have been freely used. Patients in whom labour is likely to last more than twelve 'hours are given morphia gr. £ or heroin gr. 1/0 especially to give them sleep during the night hours. When the first stage appears to have only a few hours to run, pethidine 150 mgms. is given by intramuscular injection.

Further injections of 100 mgms. are given if necessary in long labours. In the second stage, gas and air mixture is given to all patients, by means of the Minnitt or Queen Charlotte’s

machine. In a few cases trichlorethylene has been given with Friedman’s inhaler.

ANAESTHESIA

For episiotomy and perineal repair, local anaesthesia has been used in alt cases in which general anaesthesia had not already been needed for other procedures. One per cent, procain with a! few drops of adrenaline solution was used to infiltrate the tissues.

For forceps delivery, in all except 2 cases, gas and oxygen with sometimes a little cyclopropane, trilene or ether were administered by the hospital anaesthetists. Anaesthesia is always very light so as not to abolish uterine contractions. As soon as the baby has been delivered the mother is given morphia gr.

In the other two cases of forceps delivery, local anaesthesia was employed. For manual removal of the placenta gas and oxygen with a little cyclopropane, trilene or ether were used. All

these patients have been given morphia and ergometrine; and an intravenous infusion of saline or blood has usually been set up before anaesthesia is induced.

Many of the patients have been given amyl nitrite 4-8 minims put into the anaesthetic inhaler to relax the contraction of the lower uterine segment to allow the operator to introduce his hand.

The choice of anaesthetic for Caesarean section depended on the patient’s condition both general and obstetric and on the preference of the anaesthetist. The 28 cases of Caesarean section were anaesthetised as follows:

Spinal anaesthesia ... ... ... ... ... ... ... ... ... 15 cases. Nitrous oxide, oxygen, ether Pentothal 0.5 gm. followed by nitrous oxide, oxygen, ether . Pentothal 0.5 gm. followed by nitrous oxide, oxygen, trilene . Pentothal 0.5 gm. followed by nitrous oxide, oxygen . Pentothal 0.5 gm. followed by nitrous oxide, oxygen, and cyclopropane

For the spinal anaesthetic all! the instruments and materials were antoc'laved, and were injected with the patient lying in the left lateral position. In some o$ these patients under spinal anaesthesia amyl nitrite inhalation was needed to relax the uterus for the baby to be extracted.

7 cases. 3 cases. 1 case1. 1 case. 1 case.

1.5 ccs. of? heavy nupercain

II. THE PAEDIATRIC SECTION Introduction.

The babies all occupy cots in nurseries apart from the mothers. The Paediatrician is responsible for the medical care of all the babies andf he does complete ward rounds twice a week. Normal infants are breast fed every four hoursi from birth, omitting the night feed. There is not a permanent premature nursery because of the small number of premature babies; but when it is needed a small ward is adapted for* the purpose. Oxygen tents are freely used/ for premature and ill babies.

The preparation of the expectant mother’s breasts for lactation consists in simple hygiene during the last two months of pregnancy by merely washing, drying and anointing the nipples with lanoline or olive oil. If the nipples are flat they are gently moulded. If a nipple is inverted the mother wears a glasd shell during the last 4 weeks of pregnancy. The ante-natal expression of secretion employed so successfully by Dr. H. K. Waller is only advised for women who have previously failed to breast feed and who are willing to carry it out.

Test-weighing is done until breast feeding is well established. Glass shells are used for engorged breast^, and in some cases stilboestrol is administered during the painful stage. Lugol’s iodine has been prescribed to encourage the flow of milk in those with insufficient, and it has appeared to have been of help.

INFANT FEEDING

No. of infants discharged during the year'1948 No. breast fed . No. mixed feeding No. artificial feeding.

No. of children whose mothers attended Post-Natal Clinic

Breast feeding . Mixed feeding Artificial feeding .

Booked N on-Booked Private Number 0/

/o Number % Number % 987 52 240 877 89 45 86.5 195 81

99 10 3 6 31 13 11 1 4 7.5 14 6

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CONGENITAL MALFORMATIONS 21 Cases.

Case Reg. No. No.

Nature of Malformation Birth weight

Sex Result Intercurrent maternal disease

Remarks

ROOKED 1 W 98 Congenital atresia of gut 7 1 M L. None Colostomy performed

2 W132 Left talipes equino-varus 7 13 F L. None

3 W190 Hydrocephaly 7 0 M D None

4 W402 Mongolism 7 8 M L. None

5 W436 Bilateral hare lip and cleft palate 6 12 M L. None . 1st twin 6 W498 Bilateral talipes calcaneo-varus 7 7 E L. None

7 M 25 Anencephaly 3 14 F SB Hydramnios

8 M196 Umbilical hernia ... 7 8 F L. None

9 M200 Hypospadias . 7 13 M L. None

10 M388 Talipes calcaneo-valgus, right 5 5 F L. None

11 M484 Talipes equino-valgus, right Talipes calcaneo-valgus, right

6 7 F L. None Forceps delivery

12 M489 7 10 F L. None

13 M520 Bilateral hare lip, cleft palate, Umbilical hernia, supernumary digit

6 0 M D None

11 M531 Anencephaly 5 0 M SB Hydramnios

15 M572 Wasserman and Kahn tests positive ... Soina bifida

7 6 F L. Congenital syphilis

1 fi M589 8 5 M SB None Intestinal anasto¬

mosis performed 17 M635 .Atresia of small gut .

NON-BOOKED

8 2 F D None

18 M554

PRIVATE

Bilateral hare lip and cleft palate Hypospodias

9 2 M L. None

19 W152 Paralysis of left leg 7 14 M L. None

20 M242 Haemangioma of forehead . 7 10 M L. None 2nd triplet

•

21 M312

TABLE 36.

Haemangioma of scalp. 3

BIRTH

15 E L.

TRAUMA

None

3 Cases.

Case Reg. No. No.

BOOKED

Mat¬ urity

Birth weight

Sex Type of injury Method of delivery

Cause of injury Result Remarks

1 M 23 38 6 14 F Fracture right humerus . Breech Delivery of extended arm L. 2nd twin

2 M754 38

NON-BOOKED

6 12 F Cephalhaematoma Normal L.

3 M712 42 9 4 M Left Erb’s palsy .. Forceps —— E.

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56

POST-NATAL SUPERVISION

It will be seen from the numerical summary of cases on page 11 that numbers' of patients were treated during the lying-in period for abnormal conditions which necessitated a prolongation of their stay in hospital. Every Booked patient, on discharge from hospital, was given an appointment for attendance at the Post-natal Clinic. The proportion of mothers who attended for examination six weeks after delivery was 76%.

Number of sessions held ... ... ... ... ... ... 49 Number of patients attending ... ... ... ... ... 806 Total attendances ... ... ... ... ... ... ... 991

All cases treated to their termination during the year were classified into the following groups—

Result I : Health unimpaired as a result of recent confinement (i.e., no symptoms and no anatomical or functional disability).

Result II : Health slightly impaired as a result ol recent confinement (i.e., no symptoms or disability, but anatomical damage, likely to lead to disability in the future, particularly if increased by further pregnancies. This group includes cases impaired by previous confinements, and further damaged by the recent confinements so as to make the total impairment due to all previous confinements equal to that described in Result III).

Result III : Health seriously impaired as a result of recent confinement (i.e., symptoms or disability present due to trauma, infection, etc., or damage to vital organs as in chronic nephritis).

Result I Result II Result III

93.0% 7.0% 0.1%

BACTERIOLOGY AND PATHOLOGY

In 1948 we continued the same systematic bacteriological investigations carried out in the previous year. The object of the routine examinations was to try to discover when pathogenic organisms were introduced into the maternity department. All patients on admission had throat, nose and vaginal swabs taken. Each fortnight nasal and throat swabs were taken from all nursing, domestic and ambulance staff.

Any patients showing pyrexia, however mild, during the puerperium, had urine, breast milk and vaginal swabs examined bacteriologically and the nose and throat examinations were repeated.

In 1948 no fewer than 6,909 swabs were examined from the Maternity Units.

The Pathology facilities were largely used by the maternity department. Throughout the year all patients booking for delivery as hospital cases have had their blood examined in early pregnancy. The tests undertaken at the time of book¬ ing were the group, Rhesus factor, haemoglobin estimation, Wassermann reaction and Kahn test. Further blood tests in those requiring them were quite numerous, and patients with Rhesus negative red cells were all tested for antibodies at the 32nd and 36th weeks of pregnancy and some of them more often.

No. of specimens of blood tested for Rhesus factor 1,353

y y yy y y y y y y tested for Rhesus antibodies 308

yy yy y y y y y y grouped 1,296

yy yy y y y y y y for Wassermann Reaction 1,157

y y yy y y y y y y for Kahn Tests 1,157

yy y y y y y y y y for Haemoglobin estimation 1,164

The department has undertaken the examination of numerous specimens, including the physical, chemical and microscopic examinations of some 418 samples of urine, several histological sections, and 18 post-mortem examinations of the bodies of foetuses and new-born babies.

JOHN KEALL,

Pathologist.

maternity clinical report of the bromley hospital : 1948

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