maternity clinical report of the bromley hospital : 1949
TRANSCRIPT
BROMLEY HOSPITAL
(Incorporating the Bromley, Chislehurst and District
Maternity Hospital)
Maternity
Clinical
Report
1949
22501683522
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 1949
COMPILED BY
ALISTAIR L. GUNN, M.D., F.R.C.S.(Edin.), F.R.C.O.G.
(Visiting Obstetrician)
and
BRUCE ETON, M.B., Ch.B.
(Registrar)
General Wards at Cromwell Avenue
Widmore Maternity Unit at 118 Widmore Road
Masons Hill Maternity Unit at 20 Masons Hill
Bromley, Kent
SHREWSBURY:
WILDING & SON LTD.
33 CASTLE STREET
CONTENTS PAGE
Committees and Officers ... ... ... ... ... ... ... ... 3 Medical Staff ... ... ... ... ... ... ... ... ... ... 3 Midwifery Nursing Staff ... ... ... ... ... ... ... ... 5 Physiotherapy Staff ... ... ... ... ... ... ... ... ... 5 Survey ... ... ... ... ... ... ... ... ... ... ... 6 Abbreviations ... ... ... ... ... ... ... ... ... ... 9
I. THE OBSTETRIC SECTION
Statistical summary ... ... ... ... ... ... ... ... ... 10
Out-patient treatment—
Table A X-ray examinations ... ... ... ... ... ... 11 Table B Ante-natal breech presentation ... ... ... ... ... 11 Table C External version before labour ... ... ... ... ... 12
In-patient treatment—
Numerical summary of cases ... ... ... ... ... ... ... 15 Table 1 Associated diseases not detailed elsewhere ... ... ... 16 Table 2 Abortion ... ... ... ... ... ... ... ... 17 Table 3 Hyperemesis gravidarum ... ... ... ... ... ... 18 Table 4 Cardiac disease ... ... ... ... ... ... ... 19 Table 5 Pre-eclampsia, albuminuria ... ... ... ... ... 21 Table 5a Pre-eclampsia, hypertension without albuminuria ... ... 24 Table 6 Eclampsia ... ... ... ... ... ... ... ... 25 Table 7 Accidental ante-partum haemorrhage ... ... ... ... 26 Table 7a Ante-partum haemorrhage, unclassified ... ... ... ... 27 Table 8 Placenta praevia ... ... ... ... ... ... ... 28 Table 9 Hydramnios ... ... ... ... ... ... ... 29 Table 10 Tumours associated with pregnancy, labour or the puerperium 29 Table 11 Prolonged labour ... ... ... ... ... ... ... 30 Table 12 Persistent posterior position of the occiput and transverse arrest 32 Table 13 Uncomplicated breech delivery ... ... ... ... ... 34 Table 13a Breech presentation treated by Caesarean Section ... ... 35 Table 14 Complicated breech delivery ... ... ... ... ... 35 Table 15 Face and brow presentation ... ... ... ... ... 36 Table 16 Transverse and oblique lie ... ... ... ... ... 36 Table 17 Multiple pregnancy ... ... ... ... ... ... 37 Table 18 Labour following previous Caesarean Section ... ... ... 38 Table 19 Contracted pelvis and disproportion ... ... ... ... 39 Table 20 Failed forceps ... ... ... ... ... ... ... 42 Table 21 Prolapse and presentation of cord ... ... ... ... 42 Table 22 Post-partum haemorrhage ... ... ... ... ... 43 Table 23 Manual removal of placenta ... ... ... ... ... 47 Table 24 External version before labour (see p. 12) ... ... ... 48 Table 25 Surgical induction of labour ... ... ... ... ... 49 Table 26 Caesarean Section ... ... ... ... ... ... ... 52 Table 27 Forceps delivery ... ... ... ... ... ... ... 54 Table 28 Version in labour ... ... ... ... ... ... ... 56 Table 29 Embryotomy and craniotomy ... ... ... ... ... 56 Table 30 Puerperal pyrexia, genital infection ... ... ... ... 57 Table 31 Puerperal pyrexia, extra-genital infection ... ... ... 58
Maternal deaths ... ... ... ... ... ... ... ... ... 59 Anaesthesia and analgesia ... ... ... ... ... ... ... ... 60
II. PAEDIATRIC SECTION
Introduction and summary ... ... ... ... ... ... ... ... 61 Table 32 Stillbirths .62 Table 33 Neo-natal deaths ... ... ... ... ... ... ... 63 Table 34 Premature infants ... ... ... ... ... ... ... 64 Table 35 Congenital malformations ... ... ... ... ... ... 66 Table 36 Birth trauma ... ... ... ... ... ... ... 66 Table 37 Neo-natal infections ... ... ... ... ... ... 67 Table 38 Other neo-natal diseases ... ... ... ... ... ... 68
Post-natal supervision... ... ... ... ... ... ... ... ... 69 Bacteriology and pathology ... ... ... ... ... ... ... ... 69
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.DJLond.), F.R.C.SJEng.) A. TALBOT ROGERS, Esq., M.B., B.S.
C. DENISON STILWELL, 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.SJEd.), M.R.C.S., L.R.C.P.
HOUSE COMMITTEE (in office 1948 to 1949)
Chairman H. CREWDSON HOWARD, Esq., F.C.A.
Vice-Chairman DR. DENIS B. WHITLOCK
LADY ALEXANDER MISS KATHLEEN CLAY MRS. J. R. C. JORGENSEN mrs. j. w. Macdonald TOM BROWN, Esq. H. E. GROVES, Esq.
Members ALDERMAN F. W. ISARD E. K. JENKINS, Esq. J. W. NEIGHBOUR, Esq.
• ALDERMAN J. 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.DJLond.), F.R.C.P., 49 Harley 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.PJEd.), 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.DJLond.), 19 Oaklands Road, Bromley, Kent
CARDIOLOGIST C. G. BAKER, O.B.E., M.D., F.R.C.P., Guy’s Hospital, London, S.E.l
3
PAEDIATRICIAN T 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 Tweedy Road,
Bromley, Kent
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.C.S.,
L.R.C.P., 35 London Road, Bromley, Kent
SENIOR SURGEON C. JENNINGS MARSHALL, M.D., M.SJLond.), F.R.C.S., 121 Harley Street, London, W.l
ASSISTANT SURGEON W. P. GREENING, F.R.C.S., 62 Queen Anne Street, London, W.l Surgical Assistants :
CLAUD DYSART, M.R.C.S., L.R.C.P., 36 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.l Orthopaedic Surgical Assistant : D. B. WHITLOCK, F.R.C.S.(Ed-), M.R.C.S., L.R.C.P., Villa 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, F.R.C.S., F'.R.C.O.G., 28 Kidbrooke Grove, London, S.E.3 Gynaecological Assistant : R. B. COLEMAN, M.B., Ch.BJBirm.), 27 London Road, Bromley, Kent
OPHTHALMIC SURGEONS ERIC H. LYLE, M.A., M.D.(Cantab.), 1 Elmheld Road, Bromley, Kent R. H. RUSHTON, M.R.C.S., L.R.C.P., D.O.M.S., 1 Elmheld Road, Bromley, Kent
SENIOR EAR, NOSE AND THROAT SURGEON R. J. 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.ChJCantab.), M.R.C.S., L. R.C.P., 7 Elmheld Road, Bromley, Kent
DERMATOLOGIST F W PROSSER THOMAS, M.A., M.D., B.Ch.(Cantab.), 8 Harley Street, London, W.l Dermatological Assistant : C. W. F. McKEAN, M.A., M.B., B.Ch., M.R.C.S., L.R.C.P., 43 Wimpole
Street, London, W.l
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.ChirJCamb.),
M. R.C.S , L.R.C.P., 44 Albion Street, London, W.2
NEUROLOGIST S. BEHRMAN, B.ScJLond.), M.R.C.P., 33 Harley Street, London, W.l
. RADIOLOGIST A C GLENDINNING, 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, Pickhurst Lane, Hayes, Kent
^ q LAY, M.B., B.S., M.R.C.S., L.R.C.P., Woodbourne, Chislehurst, 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 T T HANCOCK, B.D.SJLond.), L.D.S. (R.C.S.Eng.), Dental Department, Guy’s Hospital, London,
S E 1 D GRAHAM WATT, L.D.S.(Edim), “ Thornburg,” Elmheld Road, Bromley.
EMERITUS PHYSICIAN F G FRANCE, M.B., B.SJLond.), 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,
Bickley, Kent.
EMERITUS ANAESTHETISTS «;TDNEY T ROWNTREE, M.R.C.S., L.R.C.P., 7 Elmheld Road, Bromley W HORSF’ALL CHESTERS, M.B., B.SJLond.), 126 Widmore Road, Bromley, Kent AGNES WESTWOOD, M.A., M.B., B.SJLond.), 115 Widmore Road, Bromley, Kent
4
RESIDENT STAFF
RESIDENT MEDICAL OFFICER J. F. CLEOBURY, M.B., B.S.
OBSTETRIC REGISTRAR J. L. WARREN, M.B., B.S., D.Obst. R.C.O.G.
SENIOR HOUSE SURGEON S. DROZDOWSKI, M.D.(Lwow)
OBSTETRIC HOUSE SURGEONS D. B. ALLBROOK, M.B., B.S., M.R.C.S., L.R.C.P.
BRUCE ELTON, M.B., B.S., D.Obst. R.C.O.G.
HOUSE PHYSICIAN D. S. BAILEY, M.B., B.S.
HOUSE SURGEON J. F. SHEEHAN, M.R.C.S., L.R.C.P.
CASUALTY OFFICER J. R. GODFREY, L.R.C.P.E., L.R.C.S.E., L.R.F.P. & S.G.
STAFF PARTICULARLY ENGAGED IN THE MATERNITY DEPARTMENT
Visiting Obstetrician A. L. GUNN, M.D., F.R.C.S., F.R.C.O.G.
Visiting Paediatrician J. N. O’REILLY, M.A., D.M., M.R.C.P.
Anaesthetists 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. Q. 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.
Radiologist A. C. GLENDINNING, M.B., D.M.R.D.
Pathologist J. H. H. KEALL, B.Pharm., M.D., M.R.C.S., L.R.C.P.
Medical Officer in Charge of Physical Medicine A. TALBOT ROGERS, M.B., B.S.(Lond.), M.R.C.S., L.R.C.P.
Dental Surgeon T. J. HANCOCK, B.D.S.(Lond.), L.D.S.(Eng.)
Obstetric Registrar J. L. WARREN, M.B., B.S., D.Obst. R.C.O.G.
Obstetric House Surgeons D. B. ALLBROOK, M.B., B.S., M.R.C.S., L.R.C.P.
BRUCE ELTON, M.B., B.S., D.Obst. R.C.O.G.
Matron M. BERKELEY, S.R.N., S.C.M.
Superintendent Midwives
R. HURRELL L. STICKNEY
Midwifery Teacher E. SNELLING, M.T.D.
Midwifery Sisters E. K. DICKSON B. M. WOOD R. M. WILD M. HOLDER M. A. WOODWARD M. FARLEY E. M. GREEN D. WEDGBURY F. LIESCHING J. MORTON
Physiotherapists B. K. TWEED H. M. PEARCE V. 0. KEITLEY J. ALLEN E. M. MILNER B. S. HOWARTH E. C. MAYNARD A. C. DANIELS
Almoner P. M. PERKINS
SURVEY
This clinical report for 1949 is for the first complete year’s working since the Hospital came into the National Health Service, under the South East Metropolitan Regional Hospital Board. It is the fourth report to be published in the standard form, and conforms with the recommendations of the Council of the Royal College of Obstetricians and Gynaecologists published in 1948.
THE HOSPITAL
Those who have not received previous reports may wish to know a few details of the Hospital and the patients it serves.
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 teachable. Apart from Non-Booked patients, who this year numbered 47, most of 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, the former Bromley, Chislehurst and District Maternity Hospital, has twenty-two beds, and is situated about half-a-mile from the other buildings. It is here that all the ante-natal out¬ patient work is done. 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 WORK
The Hospital has continued to deal largely with Booked cases, although no emergency case in which pregnancy has advanced beyond twenty-eight weeks is ever refused.
The Hospital is recognised by the Royal College of Obstetricians and Gynaecolo¬ gists in obstetrics for the M.R.C.O.G. examination and for the D. Obst. R.C.O.G. During the year the Obstetric Registrar, Dr. J. L. Warren, obtained the Diploma.
Last year the Hospital was approved by the Central Midwives Board to train pupils for Part I certificate, and this year our first twenty-eight candidates com¬ pleted the training and sat for the examination. Twenty-three of them passed, while five candidates from other Hospitals, who had entered this Hospital for further training, gave four more passes. In addition, one midwife completed a course of two months’ post-graduate training required by the Central Midwives Board prior to practising again after a lapse of several years.
The Hospital is also approved for training and examining pupils and midwives in Gas and Air Analgesia. During the year thirty-five pupil midwives attended the courses of instruction. Five midwives attended the post-graduate course of instruc¬ tion and obtained certificates of proficiency.
We are indebted to Mr. J. S. Hovell, M.B., F.R.C.S.(Edin.), F.R.C.O.G., late Obstetrician and Gynaecologist to the Sudan Medical Service, and now Consultant Obstetrician and Gynaecologist to S.W. Durham, Darlington and Northallerton, who took charge of the department for a week in June and a month in August and September. The year started with Dr. J. L. Warren as Registrar and Dr. D. B. Allbrook as Obstetric House Surgeon. In the summer Dr. Bruce Elton, M.B., B.S. (Sydney), succeeded Dr. Allbrook. Dr. Warren entered the R.A.M.C. in December, and his place as Registrar was taken by Dr. Bruce Eton, M.B., Ch.B.(Manchester), who resumed his appointment after a year’s gynaecological work at another hospital.
At the close of the year we very much regretted the departure of Miss R. Hurrell, Superintendent Midwife at Masons Hill Maternity Unit, who resigned to take up an appointment in the Mission Field in Northern Rhodesia. Her place was taken by Miss Dickinson.
Mr. T. J. Hancock, the dental surgeon, continued to give a regular service of dental examinations to all the patients at the time of booking. He was able to treat those who could not readily be treated by their own dental surgeons. The result was that all the Booked patients were rendered dentally fit during pregnancy.
The new ante-natal department has attracted a number of visitors who have shown their interest in the plan of the building, and in the way the patients are seen by appointment and quickly passed through the examining rooms. Professor H. Martius, of Gottingen, and Professor Ernst Held, of Zurich, were two distinguished visitors.
6
THE MONTHLY CLINICO-PATHOLOGICAL MEETINGS
Throughout the year we held monthly clinico-pathological meetings of the maternity department to review the work of the previous month. The attendance has been consistently good ; the pathologist, radiologist, paediatrician, anaesthetist, clinical assistants and obstetrical staff have come regularly. The senior midwifery sisters and two or three general practitioner obstetricians have been present, and an increasing number of medical officers of the Kent County Council, who refer abnormal patients to the Hospital and supervise the domiciliary midwifery. Welcome visitors have been Registrars from the maternity departments of the other Hospitals in the Group. At the meetings the work is scrutinised in similar form to the records in this report ; but stillbirths, neonatal deaths and serious cases are reviewed in detail, and the opinions of the different specialists are freely given for the benefit of all. The value of these meetings cannot be over-estimated both as a means of improving the standard of work and to promote smooth working, not only within the Hospital but also among all professional members of the health services concerned with maternity work in the locality. Visits have been received from obstetricians who wish to start similar meetings in their own Hospitals.
THIS REPORT
The primary importance of the preventive aspect of obstetrics is stressed by 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 Masons 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 out-patient treatment, 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 presenta¬ tion has been interpreted more strictly so as to include* all cases in 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.
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 has been given a letter in addition to the number.
THE RESULTS
Amongst the 1,169 Booked, 47 Non-booked and 136 Private cases there was one maternal death, a rate of 0.7 per 1,000. The stillbirth rate was 21 per 1,000 compared with 17 in 1948 and 28 in 1947. The infant death rate was 4 per 1,000 compared with 11 in 1948 and 13 in 1947. The combined rates per 1,000 for stillbirths and neo-natal deaths during the past four years are as follows :—
Year Stillbirths Infant Deaths Com 1946 . . 25 15 40 1947 . . 28 13 41 1948 ... . 17 11 28 1949 . . 21 4 25
Because breech labour carries with it a high foetal mortality, the aim of the Hospital has been to prevent breech labour, and only allow it to occur when a favourable result can be expected. Chief reliance is placed on external version at thirty-two weeks. Anaesthesia is hardly used at all. In the few cases in which version
7
cannot be performed, the choice of treatment is between surgical induction of premature labour at thirty-eight weeks or Caesarean Section at term. This year one baby was lost because of breech labour (W398). It was the first baby to be lost because of breech labour in 3,991 successive has died.
Total number of Booked deliveries
Number of patients with breech presenta¬ tion treated by external version
Number of anaesthetics administered
Number of uncomplicated breech deliveries
Number of Caesarean Sections for breech...
Number of babies stillborn or dying follow¬ ing breech labour or external version for breech
booked deliveries since 1945. No mother
1946 1947 1948 1949 Total
831 1,000 997 1,163 3,991
116 122 112 98 448
8 9 4 5 26
2 2 2 7 13
1 5 3 3 12
0 0 0 1 1
It has been a year of steady work with one or two grievous disappointments, from which lessons have been learnt. Dr. Warren, the Registrar, and the successive House Surgeons, Dr. Allbrook and Dr. Elton, have co-operated wholeheartedly. No praise can be too high for the skill and devotion to duty of our nursing staff. This report has been largely compiled by Dr. Bruce Eton, the present Registrar, who has used the careful records kept by the Midwifery Sisters, and abstracted by the Superintendent Sisters, Miss Hurrell and Miss Stickney. Miss Dean, the Secretary, has been tireless in carrying out her duties, and I feel personally grateful to each one of the staff.
A.G.
8
ABBREVIATIONS
Alb.
A.N.
A.N.C.
A.P.H.
A. R.M.
B. A.
B.B.A.
B. P.
C. S.
C. V.
D.
D. C.
E. B.M.
E.C.
Epis.
E. U.A.
F.
F.
F. D.
G. C.P.
Grav.
Hb.
Hr.Min.
I.D.I.
EM.
In.
I.V.
L.
M.
M.
Mat.
M.C.
M. D.
n2o
N. Y.
o2
P.M.
P.N.F.
P.F.
P.P.
P.P.H.
Preg.
Rh.
S.B.
S. F.
T.
T.B.
Tb.
Trans.
W.R.
- Albumen
= Ante-natal
= Ante-natal Clinic
= Ante-partum haemorrhage (Accidental)
= Artificial rupture of membranes
= Before admission
= Born before admission
= Blood pressure
= Caesarean Section
= Conjugata vera
=? Died
= Diagonal conjugate
= Expressed breast milk
= External conjugate
= Episiotomy
= Examination under anaesthesia
= Female
= Fresh
= Fully dilated
= Generally contracted pelvis
= Gravida
= Haemoglobin
= Hours, minutes
= Induction—delivery interval
= Intramuscular
= Inches
= Intravenous
= Living on discharge from Hospital
= Macerated (Stillborn)
= Male
= Maturity
= Mother, Child
= Maternal death
= Nitrous oxide
= New York Heart Assoc., 1939
= Oxygen
= Post-mortem examination
= Promontory not felt
= Promontory felt
= Post-partum
= Post-partum haemorrhage
= Pregnancy
= Rhesus
= Stillborn (fresh)
= Scarlet fever
= Transferred
= Tubercle bacilli
= Tuberculosis
= Transverse diameter of pelvic brim
= Wasserman reaction
9
SECTION I. THE OBSTETRIC SECTION
STATISTICAL SUMMARY
Patients delivered in hospital after 28th week Primiparae
Patients delivered in hospital after 28th week Multiparae
Patients admitted after delivery (B.B.A.) Primiparae ...
Patients admitted after delivery (B.B.A.) Multiparae
Total, patients delivered after 28th week
Abortions ...
Patients transferred
Maternal deaths ...
Maternal death rate per 1,000 ...
Infants born in hospital ...
Infants born before admission (B.B.A.)...
Total infants born
Infants transferred
Stillbirths ...
Stillbirth rate (stillbirth rate per 1,000 live and stillbirths) ...
Neonatal deaths ...
Neonatal death rate per 1,000 live births
Other infant deaths
deed Non-booked Private Total
522 19 45 586
641 26 90 757
1 1 0 2
6 1 1 8
,170 47 136 1,353
7 7 0 14
0 4 0 4
1 0 0 1
0.85 0 0 0.73
181 48 136 1,385
7 1 1 9
188 49 137 1,394
0 3 0 3
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4 2 0 6
3.4 44.4 0 4.4
0 0 0 0
10
OUT-PATIENT TREATMENT
Table A
X-RAY EXAMINATIONS
148 cases were referred to the X-Ray Department. Reasons for reference were :—
Booked Non-Booked Private Total
Maternal conditions (cardiac, pulmonary, renal, etc.) ...
For foetal parts ...
Breech
Presentation, attitude, etc.
Twins
Foetal death
Anencephaly
Hydrocephaly
Pelvimetry
For maturity
Table B
ANTE-NATAL TREATMENT OF BREECH PRESENTATION
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 contra-indication. With the technique adopted this procedure was largely successful, and out of 121 cases it was only necessary to administer an anaesthetic in 5.
The prevention of foetal mortality due to breech labour has been successful, because of 1,170 Booked deliveries, uncomplicated breech labour occurred in only 7 cases, without foetal loss. One intra-uterine death occurred six weeks after version. In one case in which version failed, a stillbirth was considered to be due to breech delivery (No. W398).
Breech presentation diagnosed, excluding twins ... ... ... ... ... 121
Spontaneous version ... ... ... ... ... ... ... ... ... 11
External version finally successful without anaesthesia ... ... ... ... 97
Version under anaesthesia successful ... ... ... ... ... ... 1
Version under anaesthesia unsuccessful ... ... ... ... ... ... 4
Caesarean Section for breech presentation ... ... ... ... ... 3
Uncomplicated breech deliveries ... ... ... ... ... ... ... 7
Complicated breech deliveries ... ... ... ... ... ... ... 7
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IN-PATIENT TREATMENT
A numerical summary of cases admitted for treatment, delivered in hospital or admitted after delivery. Some cases appear in more than one category in the summary.
Booked Non-Booked Private Total Conditions chiefly ante-natal—-
Hypertension only 10 4 3 17 Albuminuria 73 3 7 83 Eclampsia ... 1 0 0 1
Persistent vomiting of pregnancy... 13 1 0 14 Acute pyelitis 8 0 0 8 Malnutrition, debility, simple
anaemia, etc. ... 8 1 0 9
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Chronic rheumatic carditis 5
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Anterior positions of the vertex ... 1,037 60 106 1,203 Posterior positions of the vertex ... 59 9 7 75 Breech 23 0 4 27 Shoulder (not delivered as such) ... 0 0 0 0 Face and brow 2 1 1 4 Caesarean Section ... 29 6 o O 38 Twins and triplets ... 18 3 l 22 Accidental haemorrhage ... 3 3 l 7 Placenta praevia ... 2 1 0 3 Other ante-partum haemorrhage... 18 1 1 20 Hydramnios 14 1 0 15 Prolapse of cord 7 1 1 9 Primary uterine inertia 32 8 4 44 Retained placenta ... 18 1 2 21 Post-partum haemorrhage 96 8 12 116 B.B.A. 8 3 1 12 Lacerated perineum and episiotomy 577 35 87 699 Abortion 5 8 0 13 Ectopic gestation ... 0 0 0 0
Post-partum complications—
Notified puerperal pyrexia 28 9 2 32 Mastitis, not suppurative 24 4 2 30 Mastitis, suppurative (aspirated)... 0 0 0 0 Delayed involution of the uterus ... 15 3 2 20 Post-partum urinary infection 8 1 0 9 Post-partum superficial phlebitis... 2 0 0 2 Post-partum deep venous throm-
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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 four weeks until 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
Number of stillbirths and infant deaths
Foetal and infant mortality
Number of maternal deaths
Booked Non-
Booked Private Total
73 3 7 83
8 0 2 10
10.9% 0 28.5% 12%
0 0 0 0
Number of cases—
Responded to treatment and delivered spontaneously near term (after 38 weeks) ... 31
Spontaneous premature labour or abortion ... ... ... ... ... ... 1
Not responding to treatment, labour induced ... ... ... ... ... ... 32
Not responding to treatment, hysterectomy or hysterotomy performed ... ... 0
Not responding to treatment, abortion per vaginam induced... . ... 1
Not responding to treatment, Caesarean Section performed ... ... ... ... 8
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HYPERTENSION WITHOUT ALBUMINURIA
Number of cases ... ... ... ... ... ... ... ... ... ... 10
Number of stillbirths and infant deaths ... ... ... ... ... ... ... 0
Foetal and infant mortality ... ... ... ... ... ... . ... 0
Number of maternal deaths ... ... ... ... ... ... ... ... ... 0
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0 0
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Responding to treatment and delivered spontaneously at term
Spontaneous premature labour or abortion
Not responding to treatment, labour induced ...
Not responding to treatment, hysterectomy or hysterotomy performed
Not responding to treatment, abortion per vaginam induced...
Not responding to treatment, Caesarean Section performed ...
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Table 9
HYDRAMNIOS
15 Cases.
The diagnosis of hydramnios was made on clinical examination and not by measuring the amount of liquor. The cases therefore only include those with a notable excess of liquor.
Previous Maturity Case Reg. Pregnancies on at Result No. No. Age Before After diag- de¬ Treatment M. C. Remarks
28 wks. 28 wks. nosis livery BOOKED
1 W132 29 — 34 39 Admitted for rest . A. A. Albuminuria. 2 W176 32 — 2 38 40 Admitted for rest . A. A. Repeat C.S. 3 W234 31 — 1 32 40 — A. A. Normal delivery. 4 W237 22 — 1 37 40 — A. A. Normal delivery. 5 W355 38 1 1 38 40 — A. A. Normal delivery. Child 10 lb. 6 W373 21 — 38 41 — A. A. Normal delivery. 7 W392 34 1 36 41 Admitted for rest . A. S.B. Toxaemia, C.S., child 11 lb. 8 W469 19 — 32 34 — A. S.B. Breech labour, Wilm’s tumour. 9 W498 22 — 38 40 — A. A. Normal delivery.
10 W540 36 — 32 40 — A. A. P.P.H., blood transfusion. 11 M 16 42 — 2 32 39 — A. A. Persistent transverse lie, C.S. 12 M562 29 — 35 39 Admitted for rest, A.R.M. .. . A. A. Child weighed 9 lb. 13 oz. 13 M779 37 1 1 32 40 .— A. A. 14 M808 31 — 32 40 — A. A.
NON-BOOKED
15 M482 45 2 1 40 40 — A. A. Child weighed 8 lb. 14 oz.
Table 10
TUMOURS ASSOCIATED WITH PREGNANCY, LABOUR OR PUERPERIUM
13 Cases.
No mother died. No infant died.
Previous Case Reg. Pregnancies Nature of Result No. No. Age Before After
28 wks. 28 wks. Tumour Treatment M. C. Remarks
BOOKED
1 W147 33 - - Fibroid Conservative ... A. A. Retroverted uterus, corrected ondary P.P.H.
2 W218 21 — 1 Fibroid Trial labour, spon¬ A. A. Threatened abortion, P.P.H. taneous delivery
3 W345 45 1 Fibroid Conservative ... A. A. A.P.H. 4 M103 36 ■—- -—- Fibroid High head, trial labour A. A. 5 M300 33 1 Fibroid Conservative ... A. A. A.N. Breech. 6 M355 38 1 1 Fibroids Conservative ... A. A. Hydramnios. 7 M407 32 1 Fibroid Conservative ... A. A. 8 M504 26 — — Fibroid Conservative ... A. A. Retroverted uterus. 9 M608 31 — 1 Fibroid Conservative ... A. A. A.N. Breech.
10 M671 37 — 2 Fibroid Conservative ... A. A. Retroverted uterus.
NON-BOOKED
11 M376 34 — Fibroid C.S. myomectomy A. A. Contracted pelvis, inertia. 12 M643 34 — 1 Fibroid Conservative ... A. A. Delayed involution.
PRIVATE
13 W547 37 — — Degenerating Rest, analgesics A. A, Congenital heart disease, fibroid eclampsia, breech delivery.
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58
MATERNAL DEATH
Case No. 1. Reg. No, M125. Mrs. E. S., aged 28, booked early in pregnancy. She was a healthy looking woman 5 ft. 5 in. tall and weighing 9 st. 9 lb. There
was no rheumatic or nephritic history ; but she had been treated for pulmonary tuberculosis six years previously, spending six months in a sanatorium, and being treated by phrenic avulsion. The disease had healed, but, on the advice of her physicians, she had waited for the first three years of her married life before they had agreed that pregnancy was permissible.
When pregnancy was advanced to thirty weeks, the physicians were satisfied with the patient’s clinical and radiological condition. At booking, her haemoglobin was estimated to be 78 per cent, normal, the red blood cells were Rhesus negative, she belonged to group O (4), and the Kahn Test and Wasserman Reaction were negative. The patient showed no clinical signs of disease during pregnancy, her urine was always free from albumen, and the diastolic blood pressure never exceeded 70 mm.Hg. Three days before the onset of labour the blood pressure measured 120/68 mm.Hg., and there was no albumen in the urine.
The patient was admitted at term in labour two hours after the onset of pains. The head was well engaged in the pelvis, the cervix admitted one finger, and pains were not well established. The urine contained a trace of albumen, and blood pressure was 120/84 mm.Hg. The patient was given an enema and bath and settled off to sleep after a hypodermic injection of heroin gr. J. At the eighth hour of labour the pains were still not well established, but the patient vomited. Ten hours after the onset the pains became regular every three minutes. The patient was distressed, and was given 150 mgms. pethidine intramuscularly. At twelve hours the patient's pulse rate rose from 80 to 120 per minute, she became cyanosed, and the lungs became moist, although the pulse was strong and regular. The head was low, the cervix was now three fingers dilated, but the foetal heart could not be heard. The pains were strong. Because of the oedema of the lungs and cyanosis, the patient was given atropine gr. 1/50 and morphia. She was placed in an oxygen tent, and her condition improved considerably. Fifteen hours after the onset of labour, urine withdrawn by catheter was blood-stained, contained a heavy cloud of albumen, and microscopically there were a few red blood cells, much red cell debris, a moderate number of blood casts, and a few hyaline casts. There was no excess of leucocytes.
The patient held her own in the oxygen tent, and labour progressed. At eighteen hours the foetal scalp was visible, and episiotomy was performed under local anaesthesia. The patient’s condition improved, and her pulse rate fell from 136 to 120. The labour progressed slowly, but at twenty-four hours, local anaesthesia was produced by peri-vulval infiltration and pudendal block, and the macerated baby was delivered with forceps, the patient remaining in the oxygen tent. The baby weighed 8 lb. 15 oz. Bleeding totalled about 18 ounces. The perineum was rapidly repaired, and the patient was given morphia, gr. atropine gr. 1/100, and ergometrine 0.5 mgms. The patient’s condition thereafter improved. Twelve hours after delivery she was still in the oxygen tent, and her blood pressure measured 92/68. She was passing urine freely, and it still contained a little albumen and a few hyaline casts. Thirty-six hours after delivery her condition was better, and the oxygen tent was lifted for half-an-hour without ill effect. At forty-five hours the patient felt faint, cyanosis returned, and the lungs became moist, while there were severe bouts of coughing with expectoration of frothy mucus. The patient died forty-seven hours after delivery.
Post-mortem examination showed about 8 ounces of serous yellow fluid in each pleural cavity. The left lung showed healed fibro-caseous tuberculosis just below the left apex, and there were numerous adhesions of the left pleura. The right lung showed general emphysema, and both lungs were oedematous. Pericardial fluid was increased over the normal amount, the myocardium was flabby, and both the right and left heart were dilated. Liver and spleen were both considerably enlarged and grossly congested. Uterus and pelvis were normal. Death was due to cardiac failure following acute oedema of the lungs.
The patient had never been pyrexial, and the final picture was undoubtedly one of circulatory failure causing acute pulmonary oedema. At the onset spontaneous pneumothorax seemed likely, and it was very difficult to exclude this condition in a woman having frequent labour pains. It is regretted that venesection was not tried.
59
ANALGESIA
In the first stage of labour, drugs were freely used. Patients in whom labour was likely to last more than twelve hours were given morphia gr. \ or heroin gr. J, especially to give them sleep during the night hours. When the first stage appeared to have only a few hours to run, pethidine 150 mgms. was given by intramuscular injection.
Further injections of 100 mgms. were given if necessary in long labours.
In the second stage, gas and air mixture was given to all patients by means of the Minnitt or Queen Charlotte’s Hospital machine. In a few cases trichlorethylene was given with Friedman’s inhaler.
ANAESTHESIA
For episiotomy and perineal repair, local anaesthesia was used in all cases in which general anaesthesia had not already been needed for other procedures. One per cent, procaine with a few drops of adrenaline solution was used to infiltrate the tissues.
For forceps delivery, unless rotation of the head was required or other diffi¬ culty was expected, local anaesthesia was used. The vulval area was surrounded with the same anaesthetic solution, and each pudendal nerve was blocked in the region of the ischial spine. General anaesthesia, gas and oxygen with sometimes a little cyclopropane, trilene or ether, was administered in the remaining cases by the hospital anaesthetists. Anaesthesia was always very light so as not to abolish uterine contractions. As soon as the baby was delivered, the mother was given morphia gr. |. For manual removal of the placenta, gas and oxygen with a little cyclo¬ propane, trilene or ether were used. All these patients were given morphia and ergometrine and an intravenous infusion of saline or blood was usually set up before anaesthesia was induced. Many of the patients were given amyl nitrite 4-8 minims put into the anaesthetic inhaler to relax the contraction of the lower uterine seg¬ ment to allow the operator to introduce his hand. The choice of anaesthetic for Caesarean section has depended on the patient’s condition, both general and obstetric, and on the preference of the anaesthetist.
The 38 cases of Caesarean Section were anaesthetized as follows :—
30 cases
7 cases
1 case
Spinal anaesthesia
General anaesthesia
Local anaesthesia
For the spinal anaesthetic, all the instruments and materials were autoclaved, and 1.5 ccs. of heavy nupercaine were injected with the patient lying in the left lateral position. In some of these patients under spinal anaesthesia, amyl nitrite inhalation was needed to relax the uterus for the baby to be extracted.
60
II. THE P/EDIATRIC 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, and he does complete ward rounds twice a week. Normal infants are breast fed every four hours 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 e^ectant 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 glass shell during the last four weeks of pregnancy. The ante-natal expression of secretion employed so success¬ fully by Dr. H. Iv. 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 if the baby fails to gain weight after the initial loss. Glass shells are used for engorged breasts, and in some cases stilboestrol is administered during the painful stage.
INFANT FEEDING
Booked Non-Booked Private
No. % No. P/ /o No. 0/ /o
Number of infants discharged during the year 1949 1,165 45 135
Number breast fed 1,088 93.4 40 88.8 125 92.6
No. mixed feeding 60 5.1 1 2.2 7 5.2
Number artificial feeding 17 1.5 4 9.0 3 2.2
Booked and Non-Booked
No. % Number of children whose
mothers attended post-natal clinic ... 994
Breastfeeding 801 80.6
Mixed feeding 85 8.6
Artificial feeding ... 108 10.8
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Table 35
CONGENITAL MALFORMATIONS
22 Cases.
Case Reg. Nature of Malformation
No. No.
BOOKED
1 W 56 Spina bifida
2 W144 Bilateral talipes. 3 W253 Bilateral talipes ...
4 W269 Bilateral talipes ...
5 W549 Congenital heart disease ...
6 W554 Hypospadias and incomplete fusion of scrotum...
7 M218 Absence of urinary tract and adrenals ...
8 M307 Sublingual cyst
9 M456 Cleft palate
10 M467 Bilateral hare lip and cleft palate
11 M512 Pyloric stenosis .
12 M536 Congenital absence of in ter auricular septum, horseshoe kidney
13 M567 Volvulus of jejunum .
14 M589 Bilateral talipes ... 15 M639 Absence of index, second and third fingers both
hands ; absence of left foot, and big toe of right foot ; right talipes
16 M646 Cleft palate 17 M737 Hypospadias 18 M746 Absence of kidneys .
NON -BOOKED
19 W108 Absence of left half of diaphragm .
20 W451 Hydrocephaly
21 M514 Turner’s syndrome .
PRIVATE
22 M484 Syndactyly third and fourth fingers left hand ...
Intercurrent Birth Sex Result Maternal Remarks
Weight Diseases lb. oz.
4 8 M. M. —
8 8 F. A. —
7 14 M. A. — Hydramnios. 7 12 M. A. — 7 2 M. A. —
7 6 M. A. —
Intra-uterine death. Both 3 8 M. S.B. —
previous babies stillborn.
8 1 M. A. — Mixed feeding. 6 2 F. A. — Hydramnios. 5 13 M. A. — Elderly primigravida.
8 14 M. A. — Medical treatment failed. Rammstedt operation at 46 days.
5 6 F. S.B. —
7 11 F. D. — Died after coecostomy. Previous child died from
intestinal obstruction.
7 14 F. A. —
5 8 F. A. — Premature baby.
8 1 M. A. _ 5 3 M. A. —
Previous baby had con¬ 5 0 M. D. —
genital abnormalities and died.
7 0 M. D. — 5 10 F. S.B. — 5 12 M. A. — Second twin.
6 13 M. A. —
Table 36
BIRTH TRAUMA
2 Cases.
Case No.
Reg. No.
Matu¬ rity
Birth Weight lb. oz.
Sex Type of Injury Method of Delivery Cause of Injury Result Remarks
BOOKED Convulsions 24 hrs.
after birth. 1 W231 42 7 5 F. Cerebral irritation Spontaneous Rapid second stage A.
PRIVATE Head retraction.
2 W547 42 6 2 M. Cerebral irritation Breech — A.
66
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68
POST-NATAL SUPERVISION
It will be seen from the numerical summary of cases on page 15 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 78 per cent.
Number of sessions held ... ... 52
Number of patients attending ... ... 1,006
Total attendances ... ... ... 1,232
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 of 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 ... ... ... ... 96.6%
Result II ... ... ... ... 3.2%
Result III ... ... ... ... 0.2%
BACTERIOLOGY AND PATHOLOGY
Throughout the year certain haematological and bacteriological investigations were done for every patient who attended the ante-natal clinic or who was admitted to the maternity wards without previous ante-natal care. The blood tests comprised Wasserman Reaction, Kahn test, estimation of the haemoglobin, ABO grouping, and the examination of the red cells for the Rhesus factor and the serum for Rhesus antibodies. The following numbers give an indication of the volume of this work
Blood grouping and testing for Rh. factor ... ... 1,541
Wasserman Reaction and Kahn Test ... ... ... 1,609
All expectant mothers whose red blood corpuscles were Rhesus negative were tested for Rhesus antibodies when pregnancy reached 32 weeks and again at 36 weeks. When antibodies were discovered, frequent tests were done, and we received assist¬ ance from the National Blood Transfusion Laboratory at Sutton and the Lewisham Group Laboratory. We are grateful to the laboratories both for their help and for supplying Rhesus testing sera.
All patients admitted to the Maternity Department were bacteriologically investi¬ gated to find out when haemolytic streptococci and other pathogenic bacteria were being brought into the hospital. A swab of the throat, one from the nose, and a third from the vagina were taken from each patient. The staff, too, medical, nursing and domestic, had their noses and throats bacteriologically investigated every fortnight. The total number of swabs examined during the year was 7,076.
Apart from these systematic investigations designed to protect the patients from infection, the medical staff were given prompt service in the numerous pathological investigations for which they asked.
During the year 21 autopsies were carried out on foetuses and new-born babies. Many of these had died in utero, and were macerated, so that only a restricted examination could be made. There were three interesting congenital abnormalities. In one the left crus of the diaphragm was absent, and the stomach and intestines were found in the left pleural cavity, and in two cases the adrenals and the whole of the genito-urinary apparatus were absent.
JOHN KEALL,
Pathologist.
69
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