Ginical Practice

neonatal aspects of perinatal wast-

age and morbidity.
Management of ANTEPARTUM
MANAGEMENT
High-Risk Pregnancy: An already existing area of 14
antepartum beds was selected to
care for high-risk complications of

Report of a Combined Obstetrical and pregnancy. This area is adjacent to

the labour unit and to the Obstet¬
Neonatal Intensive Care Unit rical and Neonatal Intensive Care
Unit (O.N.I.C.U.).
Patients are freely admitted to
SUMMARY..The methodology, equipment and personnel required this ward by their private or staff
to carry out an intensive-care program in the management of high-risk attending physician or obstetrician.
pregnancies have been outlined. The perinatal mortality rate has been de¬ A team of house staff, consisting of
termined and its etiology has been analyzed. a junior rotating intern, a resident
There appear to be three conditions in which the degree of high risk in a family practice course and an
is such as to warrant provision of the complete facilities of the service we obstetrical resident, see each patient
described, viz., (a) severe pre-eclampsia; (b) marked intrauterine growth every morning. They are assisted by
a team of specially trained nurses
retardation with placental insufficiency as determined from serial measure¬ who are conversant with the special
ments of uterine growth and estriol determinations; and (c) irreversible procedures used in assessing feto-
labour in premature pregnancies where a birth weight of 2200 g. or less placental status, as well as fetal
is anticipated. Numerous other conditions that we have monitored have cardiovascular and biochemical
perhaps had their good outcome because of monitoring facilities. A less monitoring procedures.
sophisticated and more easily applied method of monitoring should be In this group of high-risk preg¬
available within the context of routine labour and delivery rooms. nancies, investigations include sys¬
There is a pressing need to re-evaluate and change some of our tematic hematological and hormonal
methods of educating our undergraduate, postgraduate and practising (estriols) values, uterine growth
curves, nutritional and electrolyte
physicians and to provide continuing education in the realm of prenatal balance, placental transfer tests,
care and recognition of high-risk pregnancy. Regionalization and centrali- fetal electrocardiography and am¬
zation of this type of intensive care for high-risk pregnancies are required. niotic fluid studies.
Indispensable to the success of this type of project is the incorpora¬ In addition, a scoring system, re¬
tion, without physical, emotional or intellectual barriers, of both a pedia¬ cently described,1 was used to pre¬
tric and an obstetrical component within the intensive-care unit. dict perinatal mortality. Each pa¬
tient has a "prognostic risk score"
(PRS) assigned at the onset of
Any attempt to improve the the provision of the facilities to im¬ labour. This score includes pathol¬
quality of perinatal care must as¬ plement them must be weighed ogical factors, function tests, pa¬
sess and implement advances in against the cost on the one hand tient vital statisties, such as age,
diagnosis and management of con¬ and the possible improvement in height, weight, ethnic origin and
ditions hazardous to the ante- survival and health on the other. economic status, and a complete
partum, intrapartum and neonatal The ability to pre-select the popu¬ physical examination. After the
organism. Some of the newer tech¬ lation which can benefit from these current statistical evaluation of the
niques used to assess fetal reserve methods, and the willingness to al¬ validity of this system of scoring
and placental function must be ter our concepts of medical care in (Fig. 1), it is hoped to develop
standardized, and their risk assessed order that this service will be ac- further systems able to predict, at
and balanced against the benefits cessible to this population are pre- earlier stages of gestation, pregnan¬
that may accrue. The practicality of requisites to any serious attempt to cies needing further investigation.
application of these techniques and improve the quality of perinatal The resident team freely consults
care. with the Obstetrical Director of the
The program which we will out¬ O.N.I.C.U. and incorporates the ad¬
line is aimed at looking separately vice given in their discussions with
S. B. EFFER, at antepartum, intrapartum and the patient's attending doctor. This
This project was supported by the Ontario Hospital Services Commission Pilot Project and
M.D., F.R.C.S.[C],* the R. G. Ivey Foundation.
?Assistant Professor, Department of Obstetrics and Gynecology, University of Western Ontario,
London, Ont. St. Joseph's Hospital, London, Ontario. Present address: Associate Professor, Department of
Obstetrics and Gynecology, McMaster University, Hamilton, Ontario.
Reprint requests to: Dr. S. B. Effer, Department of Obstetrics and Gynecology, McMaster Uni¬
versity Clinic, Hamilton General Hospital, Hamilton, Ontario.
Canad. Med. Ass. J., Oct. 4, 1969, vol. 101.389 55
 IO
9 t
i:
A :
A .
JM
I
N,
K> X>
FIG. 1..Multiple weighting factors
plotted against one-minute Apgar score.
whole team then together arrives at
a decision regarding the ideal me¬
thod and time of terminating the
pregnancy.
INTRAPARTUM CARE
An area of 90 square metres ad¬
jacent to and within 50 metres of
the labour, antepartum, premature
and neonatal intensive-care areas
was remodelled. This core area con¬
sists of three rooms: a labour and
delivery room equipped to monitor
labour, and for the delivery of the
patient vaginally or by cesarean
section; a contiguous neonatal adap¬
tation and resuscitation room; and
between the first two rooms, a
laboratory equipped with electronic
polygraphs and biochemical blood
measuring systems. All three areas
intercommunicate by sound and
closed-circuit television to permit
continuous surveillance by all mem¬
bers of the intensive-care team. The
newborn, immediately upon birth, is
given to the neonatal resident and/
or his consultant, who within 60
seconds of birth has the newborn
in a heated environment, being
monitored and resuscitated. Time is
not wasted by the obstetrical staff
in applying suction to a baby who
can more safely and effectively be
looked after by the neonatalogist,
56
XX .. .. J : .* !. ! .
.?«:;.:.... .
.:
.
.::
. .
. .
SO
STK tISK
are added and correction factors applied to produce
provided his unit is within 10
seconds distance of, i.e. contiguous
with, the delivery room.
Delivery Room
The labour and delivery room is
staffed by a nurse specially trained
to render expert supportive care to
the patient and to the team of phy¬
sicians carrying out biophysical and
biochemical monitoring procedures.
The nurse in this unit is drawn from
the antepartum area, where each
shift has one nurse assigned to the
O.N.I.C.U. for patients in labour.
Laboratory
The technical staff required to
run the laboratory (serving the de¬
livery area in which approximately
10% of the hospital deliveries oc¬
cur) consists of two full-time elec¬
tronic technicians and two bio¬
chemistry technicians. It is possible
to manage with this reduced staff,
instead of around-the-clock shift
coverage, by allowing the
O.N.I.C.U. Director freedom to ar-
range versatility of working condi¬
tions, duties and employee selection.
The ideal technical staff for this
area, with interest in the program
and expert technical ability, is dif¬
ficult to find because of the unpre-
dictability of patient scheduling, the
#. r«o.7i
MO 400 soo
a "prognostic risk score" which is
great differences between fetal and
adult monitoring technological
problems, and the lack of pre-
cedents in this type of work.
Neonatal Room
The neonatalogists (Drs. N.
Jaco and M. Sutton) and their
team of residents and intensive-care
nurses take over the immediate
resuscitative care and further moni¬
toring procedures as dictated by the
clinical condition (Apgar scores),
the cardiovascular adaptation pat¬
terns and the blood gas status of
the newborn in the first half hour
of life.
MATERIALS AND
METHODS
This discussion will be confined
to intrapartum patients admitted to
the O.N.I.C.U. labour and delivery
area. Patients were referred to the
Unit by family physicians, private
obstetricians or resident house staff.
The reasons for referral fell into
three major categories: (a) clini¬
cally detected fetal distress in pa¬
tients already in labour in the rou¬
tine labour setting; (b) total
management of labour, of spon¬
taneous or induced origin, in pa¬
tients to whom had been assigned
the label "high-risk pregnancy"; (c)
Canad. Med. Ass. J.. Oct. 4, 1969, vol. 101.390
 TABLE I..SUMMARY OF INDICATIONS FOR ADMISSION TO O.N.I.C.U.
July /, 1967 to December 31, 1968
Maternal complications of pregnancy Fetal distress (clinically detected) 32
* * ***
Toxemia. 65 Fetal bradycardia. 11 5
Hypertension. 1 Fetal tachycardia. 9 0
Urinary tract infection. 0 Fetal heart irregularities. 9 0
Excess weight gain. 0 Meconium-stained liquor amnii . 3 4
Diabetes mellitus. 3 Occult cord prolapse. 0 0
Prediabetes. 7
Rhesus incompatibility. 10 Uterine factors 24
Rheumatic fever (valvular disease). 1 Prolonged labour. 17 6 1
Varicose veins. 0 Cephalopelvic disproportion. 5 14 1
Epilepsy. 0 Uterine inertia. 1 0 1
Chronic chest disease. 0 Uterine anomalies. 0 1
Anemia. 0 Previous uterine surgery. 1 0
Leiomyomata uteri. 0 0
Gestational duration pathology Incompetent cervix. 0 0
Failed induction of labour. 0 0
Prematurity. 7
Postmaturity. 5 History of 23
Premature rupture of membranes. 8
Poor obstetrical performance. 13 10 11
Placental pathology Infertility. 4 3 8
Elderly gravida. 5 9 8
Placenta praevia. 0 No prenatal care. 0 1 1
Abruptio placentae. 10 Grandmultiparity. 1 1 1
First-trimester bleeding. 1
Third-trimester bleeding (uncPd). 5 Fetal factors 3
Placental insufficiency. 4 Breech presentations. 2 0
Abnormal estriol excretions. 2 Twin pregnancies. 1 1
No. of cases. * Primary
**
Secondary
***Other

a history of perinatal loss(es), cre¬
ating either a high-risk or premium-
baby situation.
The reassurance afforded to the
attending staff by continuous ob¬
servation of fetal status soon cre¬
ated such a demand that more clear
delineation of the service available,
and the indications for it, was man-
datory. This information was dis¬
seminated to the medical staff of
the community and surrounding
region by three main methods: (a)
controlled analgesia and anesthesia, physician, private obstetrician or the
frequency of vaginal examinations, Unit Director when specifically re¬
blood pressure recordings, labour¬ ferred to his care. Owing to the
ing position of patient, indications nature of the pilot project no eco¬
for and timing of fetal scalp blood nomic structure has been estab¬
sampling and other routine pro- lished, and no charges additional to
JJnit No._Age Date
_E.D.C_ Gest'n
PRE-PREGNANT WT._KG. PRESENT Wt._KG. HEIGHT_ CMS.
Uterine Measurements_/._/_: FHR-High_Low_Mean_
DELIVERY Apgar-_1 min._5 min._Other/ Birth Time._
BPM.

a formal presentation by the author

at a quarterly staff meeting; (b)
posting of bulletins in key areas of
the hospital; (c) personal com¬
munications by (1) the O.N.I.C.U.
staff with practising physicians and
(2) the obstetrical resident, who
maintains a close surveillance on
all patients in labour.
Two hundred and eleven patients
were admitted and 215 babies were
delivered between July 1, 1967 and
December 31, 1968. The indica¬
tions for admission were coded as
primary, secondary and other
(Table I).
On admission to the O.N.I.C.U.
a standardized data form was com¬
pleted (Fig. 2). The management
of labour was standardized after
presenting a protocol to the attend¬
ing obstetrical staff for discussion
and approval. The protocol covered
Canad. Med. Ass. J., Oct. 4, 1969, vol. 101.391
Sex_Wt._gm. Length_cm.
PLACENTA Wt._gm. Volume_ml. Diams._cm.
cervix on admission t0 o.n.i.c.u.
length_cm. Thickness_mm.
consistency_positi on_
dilatation_cm. membranes_
station_cm. Above_Below_ SPS.
CORD
Knots_"YES ~"N0~ Around Neck_YES NO TIMES
Prolapse_Tightly_J_oosely_
Other Complications_
w- Done_Not Done_Positive_Negative..
FIG. 2..Data recording sheet.
cedures. The protocol was modi¬ those applied to other equivalent
fied only to conform to specific clinical situations were made to the
medically indicated situations. By patient.
standardizing the labour manage¬ PARAMETERS MONITORED
ment, certain statistical evaluations
can now be made regarding the ef¬ 1. Maternal heart rate (MHR)..
ficacy of the management. The pa¬ This was recorded on a beat-to-beat
tient was delivered by her attending basis with a threshold tachometer,
57
which used the R wave of the
maternal ECG. It was recorded on
one channel of an eight-channel
Grass Model 7 Polygraph.
2. Maternal blood pressure..In¬
direct brachial blood pressures
were recorded with the patient in a
lateral position at half-hourly inter-
?^ JBJ|||||1
laliftiiiil
FIG. 3..Modified spring loaded scalp clip applicator with
silver, silver-chloride scalp electrode.
vals up to 6 cm. of cervical dila¬
tation and every 10 minutes there¬
after. Femoral artery catheterization
and Statham transducer recording
of blood pressure continuously
were reserved for specific hyper¬
tensive problems.
3. Fetal heart rate (FHR)..
When the cervix was dilated 2 to
3 cm. or more, favourable, and with
adequate descent of the presenting
part, a scalp clip of silver, silver-
chloride was applied, using a spe-
cially modified long Kelly clamp
(Fig. 3). The clip itself was de¬
signed after the one described by
Hon.2 We found that we were able
to insert scalp clips earlier in labour
by a blind sterile examining hand
technique, keeping the Kelly clamp
tips and scalp clip between two ex¬
amining fingers, than by the use of
a cone. The insertion of a cone in
a posteriorly positioned cervix we
often found difficult, but this may
well be a matter of personal orien¬
tation. The well-applied clip usu¬
ally provided a signal with an R-
wave amplitude of 200 to 500 /*V.
which, when suitably filtered, was
quite adequate to trigger a thres¬
hold tachometer which could dif-
ferentiate accurately down to a 0.2
to 0.5 beat-per-minute variation. In
order to achieve this we used a
Grass EEG pre-amplifier. When
clinical conditions did not permit
the artificial rupture of membranes,
either cancellation of maternal ECG
58
on abdominally placed electrodes
was used or the signal from a Dop-
tone pulse detector used to trigger
our tachometer.
4. Fetal ECG..The fetal ECG
was sampled occasionally when ab¬
normal heart rate patterns became
obvious.
5. Intrauterine pressures..The
uterine contractions were monitored
with a Statham transducer attached
to a normal saline-filled disposable
Levin tube inserted transcervically
after amniotomy. When the latter
was contraindicated, either a trans-
abdominal amniocentesis was car¬
ried out and a p-90 catheter fed
through a thin-walled 16-gauge
needle, or a simple tokodynamo-
meter was used to identify at least
the frequency and timing of con¬
tractions.
6. Uterine work..A polygraph
integrator was used in some of our
records to determine the area under
the curve of the intrauterine pres¬
sure curves, and thus give more
ready assessment of efficacy of oxy-
tocin when this agent was necessary.
In addition to the above biophysi¬
cal parameters, written notes were
inserted on one empty channel of
the polygraph, accurately timing:
drug administrations, vaginal ex¬
aminations and findings, patient po¬
sition and any other manipulations
or variables, such as scalp blood
sampling.
7. Biochemical and hematological
studies on scalp blood were:
(a) pH; PcOjj?; Po2; 02 satura¬
tion; base deficit; bicarbonate.
(b) Microhematocrit.
(c) Micro blood sugar in pre-
or frank diabetics and in fetuses
with intrauterine growth retarda¬
tion.
Canad. Med. Ass. J., Oct. 4, 1969, vol. 101.392
(d) Direct Coombs' test, serum
bilirubin and hemoglobin in Rh-
sensitized patients who had received
intrauterine transfusions.
8. Cord artery and vein..All
the above biochemistry was studied,
and in addition, electrolytes, serum
proteins with electrophoresis, hemo¬
globin electrophoresis, calcium and
phosphorus were estimated.
9. Maternal blood samples..A
warmed finger-prick sample was
obtained in order that arterialized
capillary blood gases could be de¬
termined. Feto-maternal gradients
were studied.
10. Amniotic fluid cytology, bio¬
chemistry and spectrophotometry
were carried out.
DELIVERY
Vaginal delivery was selected un¬
less obstetrical indications for ce¬
sarean section became apparent.
Fetal distress, characterized by late
decelerations of the FHR or by
persistent fetal tachycardia, unex¬
plained by maternal tachycardia or
pyrexia, was considered an indica¬
tion for cesarean section if vaginal
delivery could not be anticipated
before a sum of amplitudes of de¬
celerations of 600 beats was at¬
tained.6 When these situations ex¬
isted, uterine contractility was in¬
hibited, by stopping oxytocin where
this was being used, and/or by the
use of high-dose isoxuprine hydro¬
chloride, until preparations for ce¬
sarean section were complete.
NEWBORN MANAGEMENT
By agreement with our neonatal
colleagues, the time of birth was
defined as the time when the entire
fetus was outside the maternal birth
tract. Precise one-minute and five-
minute Apgar scores were deter¬
mined and their components noted.
Resuscitation and monitoring of the
newborn heart rate was in progress
usually before 60 seconds had
elapsed. Umbilical artery catheteri¬
zation was limited to excessively
small newborns or to babies in
whom the fetal scalp blood or cord
blood showed significant acidosis.
All resuscitative and monitoring
procedures were carried out on a
table with an overhead radiant
heater; this table was 15 metres
from the delivery site, with no in-
terposing deterring doors.
 STAFF AND PERSONNEL
Medical Personnel
The obstetrical team consisted of
one obstetrician director, who is
oriented as a perinatal physiologist,
one full-time resident, the junior
house staff and the attending private
physician and/or obstetrician.
Nursing Personnel
The antepartum ward for high-
risk pregnancies was found to re¬
quire a ratio of one nurse to four
patients on each of the day and
evening shifts, and one to six on
the night shift; in addition to the
above, one extra nurse on each
shift was available for O.N.I.C.U.
patients in labour. These require¬
ments, after pro-rating for time off,
sickness and vacation time, place
the total staff requirements at ap¬
proximately one nurse per 100 an¬
nual deliveries.
Paramedical Personnel
Electronic ..The con¬
stantly available supervision of the
equipment by a technician was
found essential in view of the fre¬
quent electronic adjustments and
calibrations required. It was found
that one full-time technician would
be required to handle the load of
100 patients per year monitored
in labour. This technical help also
maintains the equipment and pro¬
vides scalp lead manufacture as
well as on-line repairs.
Biochemistry..The carrying out
of blood-gas and acid-base estima¬
tions of scalp blood at a moment's
notice, the calculation of the values
on line, and the following of blood
gases in the newborn were found to
require two full-time technicians in
a setting where 200 to 250 patients
are monitored annually.
Clerical..One full-time clerk is
required to carry out the scoring
procedures and the computer cod¬
ing of data being stored.
Computation..Computer coding
and analysis were not used in this
project, but would facilitate and
standardize findings when such fa¬
cilities as ours are offered on an
expanded regionalized basis to out-
iying communities.
RESULTS
The 211 patients who were
monitored have been classified ac¬
Canad. Med. Ass. J., Oct. 4, 1969, vol. 101.393
cording to the diagnostic criteria for
admission to the O.N.I.C.U. (Table
I). The results of this study will be
outlined in the main with regard to
perinatal mortality and degree of
infant depression. Detailed correla¬
tions of fetal cardiovascular activity
and blood-gas studies will be the
subject of a further study.
There were eight perinatal deaths
(rate: 37.2/1000 total births). Dur¬
ing the same period of study the
perinatal mortality in the remainder
of the population delivered in our
delivery suite was 28.8/1000. Com¬
parison of these two figures is not
valid for two main reasons: (a)
No patient who has a stillborn in¬
fant is admitted to the O.N.I.C.U.
This automatically decreases the
O.N.I.C.U. rate, and the factor by
which it is reduced has been as¬
certained by studying the percent¬
age of stillbirths which occur before
the onset of labour, in both the
mature and premature weight
groups. (b) The cases studied were
high-risk pregnancies exclusively,
with an expected poor outcome.
Prediction of risk by a scoring sys¬
tem may enable one to assess, at
least to some degree, the efficacy
of the management undertaken.
PROGNOSTIC MSK SCORES
An attempt was made to find
a quantitative expression of the
degree of risk of perinatal death
faced by any one patient. Statistical
information used to develop this
scoring system was taken from two
main studies: "Supplement to the
Second Report of the Perinatal
Mortality Study in Ten University
Teaching Hospitals, Ontario, Can¬
ada";3 and the first report of the
1958 British Perinatal Mortality
Survey.4
One hundred and fifty-five items
were listed, each with its respective
risk factor. These factors included
standard vital statisties, such as
weight, age and height, as well as
epidemiological data, including
place of birth and place and dura¬
tion of residence. Medical, surgical
and obstetrical past and present
complications are also included in
the scoring system.
The procedure of scanning the
questionnaireofanda searchingexamina¬
through
the findings physical
tion takes approximately 15 to 20
minutes when performed by a
medically non-skilled but trained
coding clerk. Each of our 211 pa¬
tients was coded with the data
available at the onset of labour. A
similar procedure was applied to a
random group of 350 patients ad¬
mitted to the standard labour and
delivery unit of our hospital during
two months of our study.
Two correction factors were
found necessary to validate the
scoring system as appliedwithto our
study patients. One dealt the
exclusion of antepartum stillbirths
from our study. This correction fac¬
tor was taken from the British
study,4 in which the percentages of
antepartum and intrapartum deaths
were ascertained both for premature
(under 2500 g.) and mature groups
separately. This correction factor
was applied after delivery in order
to take into account the birth
weight of the infant. The second
correction factorwas derived from
many factors we considered as hav¬
ing anadditive score, which ap¬
parently evaluatedproduce
did not additive
risk. We the raw scoring
of our random non-study group,
and found that the actual score ex¬
ceeded the perinatal mortality rate
after
by a factor of 4.3. Therefore,
first correction,
making the above the score ob¬
we further divided
tained by 4.3 and believe that this
should represent the perinatal mor¬
tality of our patients as accurately
as possible.theabove two correction
Using
factors, we would have expected a
total of 10 perinatal deaths in our
study (a rateactualof 47.8/1000 total
Our results showed
births).
eight perinatal deaths (37.2/1000
births) (Table III). By this method
of assessment we would assume
that a 20% reduction has been
achieved. We are fully aware of the
difficulties in any comparative statis¬
ties in this area, and have tried to
make as valid an approach as pos¬
sible by the method described.
A bar graph representation of a
frequency histogram of risk the distri¬
bution of the prognostic scores
showed that 89% of ran¬
(PRS) into labour had
dom patients going
a PRS of 50 less (Fig. 4). A
estimate
or
has frequently sug¬
generalthat 10% of all pregnancies
gested
have some increased risk. From the
above two statements we would
suggest that, using our scoring sys¬
tem, any score above 50 represents
high-risk pregnancies.
59
 In our group of patients moni¬
tored as high-risk pregnancies 46%
had a score over 50, as opposed to
the 11% in random patients.
Further appraisal of our scoring
system was made by correlating the
prognostic risk score (PRS) with
the outcome in terms of perinatal
mortality and infant depression
(Fig. 1). There was a good correla¬
tion between the one-minute Apgar
and the PRS (r = 0.71, P<0.01).
SO-** IOO-149 1SO-199 300-349
MOONOSTIC
317 HO 24
FIG. 4..Prognostic risk scores: comparison of frequency
distribution in high-risk group and random group of patients.
PERINATAL MORTALITY
Maturity and weight were crucial
factors in perinatal survival (Table
II). There was only one perinatal
death of an infant over 1900 g.; this
infant had congenital anomalies and
weighed 2198 g. With the weight of
the infant playing such an impor¬
tant role in survival, it became in¬
creasingly evident that a more ac¬
curate clinical or other method of
predicting the size of the infant in
60
utero is required. Our work in pro¬
gress in this area suggests that
simple measurement of the uterus
from the superior border of the
symphysis to the fundus uteri, while
by no means free of error, has im¬
proved random clinical guessing by
a large factor (Fig. 4).
Two of our perinatal deaths were
in patients referred from other cen¬
tres. We merely point out that this
factor must be considered when
ftANDOM PATIfNT*
control»
7SO ?
RISK SCOUt
comparing statisties, as it will be
the main cause of a rising perinatal
mortality rate in any project which
involves increasing regionalization
referral,as we feel it should.
One of these referrals from out of
town was a patient in whom pre¬
mature labour complicated a hys-
terotomy and fetal umbilical artery
transfusion. The fetus and mother
remained well for 72 hours follow¬
ing restoration of the former to the
intrauterine environment. The baby
Canad. Med. Ass. J., Oct. 4, 1969, vol. 101.394
was born vaginally after failure to
control premature labour with ex¬
isting uterine inhibitors, and died of
marked immaturity (744 g.) (Table
II).
PREMATURITY
Our high prematurity rate reflects
the high-risk nature of our study
group. Thirty-eight infants under
2500 g. were delivered (17.7%). A
graphic representation of the rela¬
tionship of gestation and birth
weight, with superimposition of
Lubchenco's percentile line, is
shown in Fig. 6.5
A large number of our patients
were transferred from our ante¬
partum area.patients in whom dif¬
ferent complications of pregnancy
all contributed to functional insuf¬
ficiency of the placenta, resulting in
intrauterine growth retardation. Our
results clearly reflect this situation
by the incidence of dysmaturity we
have shown. The careful selection
of time of delivery, with monitoring
throughout induction and active
labour, has contributed to a reduc¬
tion in stillbirths in this group of
patients; no perinatal deaths oc¬
curred in this group, though labour
was often induced with a predicted
small baby, on the basis of ab¬
normal estriols, uterine growth
curves, uterine measurements and
amniotic fluid studies.
The immediate and on-site avail¬
ability of expert pediatric neonatal
care, always present before delivery
in high-risk pregnancies, in order
that resuscitation may be prepared
for and staff and equipment ready,
is the only explanation for the
absence of neonatal deaths in these
very high-risk dysmature infants.
ETIOLOGICAL FACTORS
Toxemia of pregnancy was by
far the commonest pathological
condition qualifying for admission
to the O.N.I.C.U. The toxemias of
pregnancy were subdivided into the
severe (blood pressure over 160
systolic or 110 diastolic) and mild.
No perinatal deaths occurred in the
mild toxemias. Two perinatal deaths
were associated with severe tox¬
emia; both mothers had neglected
antepartum care. One patient was
referred from out of town 11 days
before term with a very marked in¬
trauterine growth retardation and
severe pre-eclampsia. The other

Days N.B.
Age gest. wt.
26 254 1729
perinatal death was in a case re¬
ferred by the attending physician
immediately at 295 days' gestation,
on the occasion of the first prenatal
visit. Both these babies weighed
under 1800 g.
Twenty of our 71 cases of tox¬
emia had severe pre-eclampsia.
Rh sensitization accounted for a
larger proportion than one would
have expected because of the par¬
ticular interest taken at this centre
and by the author in this condition.
In the present study eight patients
had severe Rh disease, with the
amniotic fluid presenting indications
for either early induction or intra¬
uterine transfusion. The latter pro-
. .
S-f
NfWBORN
FIG. 5..Height of uterine fundus measured from superior border of symphysis along
convex surface of abdomen, plotted against newborn weight.
Canad. Med. Ass. J., Oct. 4, 1969, vol, 101.395
TABLE IL.PERINATAL DEATHS
Wt. Apgar
gest. min. Prognostic
(%) 1 5 risk score High-risk factors Main causes of death
Toxemia; abruptio; age; Neonatal aspiration; severe
placental insufficiency; dysmaturity
previous intrauterine death
Severe pre-eclampsia; placental Delayed toxemia management;
insufficiency; previous intra¬ abruptio; cord prolapse;
uterine death; cord prolapse dysmaturity
Severe Rh disease; failed intra¬ Abruptio complicating failed
uterine transfusion; abruptio intrauterine transfusion;
placentae prematurity
Prolonged rupture of membranes Prematurity; breech
(100 days); breech; previous
intrauterine death
Abruptio; polyhydramnios; Neonatal pneumothorax;
congenital renal anomalies; renal anomalies
premature rupture of mem¬
branes
Abruptio; premature breech; Prematurity; subdural hematoma;
no prenatal care neonatal pneumothorax
Severe Rh sensitization; two Immaturity
previous intrauterine deaths;
premature labour after extra¬
uterine fetal transfusion
<10 121.8 Abruptio; placenta praevia; Neonatal cooling; respiratory
prematurity distress syndrome
cedure was resorted to in five, and to impose one of the greatest
there were three survivors. threats to the fetus, especially when
I have found a useful place for a severe degree is present in early
continuous monitoring of the fetal pregnancy. One of the most danger¬
heart rate during intrauterine trans¬ ous situations associated with this
fusion, by using a stainless-steel condition, we found, was the neces¬
electrode (3 6-gauge) inserted sity to induce labour in the face of
through the catheter used for in- unripe conditions. Oxytocin ad¬
fusing the packed cells into the ministration was found to be
peritoneal cavity. In several in¬ hazardous even in doses as low as
stances a warning tachycardia has 1.0 mU per min., and may well
developed, and the transfusion has have been causal in the develop¬
been interrupted, only to be re- ment of abruptio placentae in some
surried after the fetal heart resumed circumstances, even when patterns
a normal rate. of recorded uterine activity were
Placental insufficiency, associated within normal limits. Recourse to
with known pathological changes or cesarean section in these early and
idiopathic in nature, would appear dysmature pregnancies had even
worse results.
Clinically detected fetal distress
occasioned the transfer of 42 pa¬
tients from a routine labour setting
to our unit. In none of these did
perinatal death occur.
. . . Of 18 women on whom cesarean
.. . . . . .
sections were carried out for fetal
. .. . . ... .
distress, only four had been ad¬
. . . mitted to our unit with this as an
indication for admission. Of the 42
w.
* * patients admitted to the O.N.I.C.U.
... .. .
with clinically detected fetal
. .. .
distress, 36 gave birth to babies who
.
£.... .
were born with Apgar ratings at
. .. one minute over 6, and all 42 in¬
fants had five-minute Apgar scores
r-0.71 over 6. Thus it would appear that
clinically detected fetal distress cor¬
WEIGHT (grams)
relates very poorly with infant out¬
come from a perinatal morbidity or
mortality standpoint.
61
 *o-l
FIG. 6..Weight-gestation correlation of high-risk pregnancies and their distribution into Lubchenco's percentiles.
Forty-five cesarean sections were
carried out in our O.N.I.C.U., a
rate of 21.1%. Forty per cent of
these were performed because of
cephalopelvic disproportion. Many
patients with borderline pelvis were
admitted in order that a physiologi¬
cal approach to stimulation of
labour could be safely carried out.
With uterine pressures continuously
recorded, little danger of hyper-
tonus, hypersystole, or abnormal
frequency or rhythm of uterine con-
tractions was present. When any of
these developed, it was immediately
recognized and corrected.
A comparison was made between
the results of the cesarean sections
carried out for fetal distress and
those for CPD (Table IV). From
our results it would appear that
neither the surgical procedure itself
nor the concomitant anesthetic
TABLE IIL.PREDICTED AND ACTUAL PERINATAL MORTALITY
PROGNOSTIC RISK SCORE BASIS
* Rate per thousand live births.
t Rate corrected for exclusion of antepartum stillbirths.
** Correction factor
applied eliminating false additive risk (c.f.
62
WEEKS OF AMINORRHEA
played a significant role in
pression of the newborn.
Obstetrical history..It is of note
that three of our perinatal deaths
(37.5%) occurred in patients who
had had previous perinatal losses.
This high incidence is especially
noteworthy because this indication
for referral to our unit represents
only 10% of our admissions; fur¬
ther, only 5% of patients in our
hospital with such a history arrived
in our unit for care.
DISCUSSION
It became apparent during our
study that numerous patients who
might have benefited from referral
to our unit were not admitted. Simi¬
larly, many patients with lesser de¬
grees of high risk were being re¬
ferred who might well have been
4.3).
the de¬ cared for in less sophisticated at¬
a
mosphere.
Our entire efforts cannot solve
the problem of the preventable peri¬
natal losses; the mothers of some
infants of obviously viable size (well
over 2200 g.) may arrive in hospital
with the baby dead in utero and
with a history of slight, and some¬
times not so slight, toxemia or
TABLE IV..CESAREAN
SECTION
bleeding managed inadequately.
This leads to a conclusion that a
method of improved education of
the undergraduate, the postgradu¬
ate and the practising physicians
should be sought. In both outlying
communities and in university
centred programs an exchange of
residents in family-practice or spe-
cialty-training programs with prac¬
tising physicians and specialists
might prove useful. Mutual benefits
may accrue, on the one hand, from
Canad. Med. Ass. J., Oct. 4, 1969, vol. 101.396
a re-exposure to academic environ-
ment with newer methods of in-
vestigating and managing conditions
which lead to perinatal loss and
which are now preventable, and on
the other hand, by an awareness of
the actual problems of practices in
the outlying areas.
Another ancillary approach
would be the expanded use of
scoring methods for assessing preg-
nancies and providing, if necessary,
an itinerant scoring service with
carefully delineated and classified
indications that would warrant re-
ferral of the mother to a regional
centre for care.
The role of an antepartum ward
for the management and investiga-
tion of complicated pregnancies has
become quite apparent. The number
of beds that would be required for
management of pregnancies which
are in this way complicated would
appear to be in the range of one
antepartum bed per 150 annual deli-
veries. This ratio may be lowered
to one bed per 100 annual de-
liveries in a special referral area.
Intrapartum monitoring of the
patient in labour has made it pos-
sible that many deliveries which
previously would have been effected
by a cesarean section are managed
and watched conservatively, with
the delivery of perfectly healthy
babies who have never been de-
pressed. The commonest examples
of these are the bradycardias and
fetal heart irregularities which,
when seen on a beat-to-beat basis,
are discovered to be either head
compression patterns or just normal
vagally induced variations in the
basal heart rate patterns.
The second observation of im-
portance is that in patients with
true fetal distress this complication
is recognized immediately, and de-
livery is effected when necessary by
cesarean section at an earlier stage,
before more lasting and damaging
hypoxia can ensue.
In our study, numerous examples
of marked newborn bradycardia
responded immediately to accurate
suction and endotracheal aspiration.
When this is done, an immediate
return to normal heart rate and
colour clearly shows that adequate
pediatric resuscitative care must be
available, at least for every high-
risk delivery if not for all routine
deliveries.
The newborn area has also
demonstrated the need for a
warmed environment to carry out
the resuscitation of the newborn
and for it to be immediately avail-
able from the standpoints of both
time and space.
The obvious questions to be
asked in the final evaluation of this
type of project are: have any babies
actually been saved, has the pen-
natal mortality been reduced, and
has morbidity decreased? An at-
tempt has been made to answer
these questions, in part, by the use
of a predictive scoring system. We
have been disappointed in any at-
tempt to make comparisons regard-
ing the state of depression of in-
fants. This disappointment stems
mainly from the recognition that
Apgar scores which appear in cli-
nical records represent in fact
merely a retrospective guess. While
a five-minute Apgar score has been
said to correlate better with the
eventual neurological status and de-
velopment it would appear from
some of our graphs that a one-min-
ute Apgar score may have the
greater significance when this score
is actually assigned at one minute
and if every point is correctly
evaluated.
R.um.
Cet article expose la mc.thodo-
logie, l'appareillage et le personnel
n.cessaires pour la r.alisation d'un
projet de soins intensifs applicable
aux cas de grossesse . risque .lev..
Nous avons .tudi. le taux de
mortalit. p.rinatale et analys. son
A notre avis, ii y a trois types de
cas de grossesse dont les risques
sont assez .levc.s pour justifier le
recours au service complet que nous
d.crivons. Ce sont: a) un stat s.vc.re
de pr.-&lampsie, b) un net retard
dans la croissance intra-ut.rine, ac-
compagnc. d'une insuffisance pla-
centaire qui peut s'.valuer par des
mesures p.riodiques de la croissance
ut.rine et le dosage de l'estriol, et c)
le travail irr.versible des cas d'ac-
couchement pr.matur. oji on
s'attend t. la naissance d'un b.b.
pesant au plus 2200 g. II est
.videmment de nombreux autres
stats que nous avons trait.s dans
ce centre et dont l'heureux d.noue-
ment est peut-.tre di2 aux moyens
d'action dont nous disposions. On
devrait aussi songer c. installer un
syst.me de surveillance moms corn-
plet et d'application plus facile dans
le cadre des salles de travail et
d'accouchement existantes.
Nous estimons qu'il est urgent de
reviser et de changer certaines de
nos m.thodes d'enseignement aux
futurs me.decins, aux r.sidents et
aux m.decins pratiquants et de leur
fournir les moyens pour un perfec-
tionnement continu dans le domaine
des soins prc.natals et de la d&ou-
verte des cas de grossesse c. risque
.lev.. 11 faudrait . la fois centrali-
ser et r.gionaliser ce type de d.-
partement de soins intensifs.
Pour que pareil projet re.ussisse,
il faudrait inclure dans le cadre de
ce d.partement de soins intensifs,
les facteurs pe.diatrique et obst.-
trical indispensables.
I wish to acknowledge the able as-
sistance of the two residents who at-
tended all the patients in the intensive
care unit, Drs. H. N. Ramaprakash and
J. K. Milne, as well as of all the tech-
nical, nursing and secretarial staff, and
also the full support of the Chief of the
Department of Obstetrics, Dr. J. H.
Walters.

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1968. auspices of the National Birthday Trust Fund, E. & S. Living-
2. HON, E. H.: Amer. J. Obstet. Gynec., 86: 772, 1963 stone Ltd., Edinburgh, 1963.
3. Ontario Perinatal Mortality Study Committee: Second report of the 5. LUBCHENCO, L. 0. et al.: Pediatrics, 32: 793, 1963.
perinatal mortality study in ten university teaching hospitals, 6. CALDEYRO-BARCIA, R. et al.: In: The child, edited by A. Dorfman,
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Canad. Med. Ass. J., Oct. 4, 1969, vol. 101-397 63