the Hospital Consultation The Role of Program in the Prevention of Prematurity and the Deaths of Prematures JERE B. FAISON, M.D. Obstetric Consultant, Maternity and Newborn Division, New York City Department of Health, New York, N. Y. FEW people will doubt that the pur- woman who is not in the best physical poses of good obstetric care are to and mental condition. In other words, maintain the mother in good health the first step in the prevention of a pre- throughout pregnancy, to make child- mature birth should be taken before birth as satisfactory an experience as pregnancv begins. The premarital ex- possible, and to deliver a normal live amination is an excellent opportunity for baby. Fortunately, these purposes are finding and evaluating pathological con- realized in most cases. Where they are ditions in the pelvis. The exact treat- not realized, this responsibility may lie ment of each case, as, for example, a with the physician, with the patient, retroverted uterus, is a matter of debate, with extraneous factors, or, more likely, but the mere recognition of the condition with various combinations of responsi- will enable us to deal more intelligently bility. Prematurity is an outstanding with its relation to a supervening preg- example of our failure to attain our pur- nancy. In the case of general or sys- poses in the sense that premature babies temic diseases, notably heart disease, are often stillborn, or, even when born efforts can be made to stabilize this and alive, constitute the major problems of to treat a secondary anemia. The pa- neonatal mortality. In this paper we tient's eating habits should be ascer- intend to review briefly the role of the tained at this time and should be cor- obstetrician in preventing prematurity rected to conform with a diet based upon or in handling most effectively the de- the recommendations of the National livery of a premature baby, and to indi- Research Council. These recommenda- cate how our Hospital Consultation tions are basically the same for preg- Program stresses the importance of this nancy, with the addition of protein, role. To implement further this aspect minerals, and vitamins. It has been of the program, the Maternity and New- found that patients are inclined to carry born Division, in collaboration with the over their normal eating habits into Advisory Obstetric Council to the New pregnancy, and if these habits exhibit York City Department of Health, has marked deficiencies, the efforts to correct prepared a guide for hospitals called The such deficiencies during pregnancy con- Prevention of Prematurity and Deaths stitute a major problem for the patient from Prematurity from the Obstetric and her doctor. The premarital inter- Viewpoint. view and examination may be used to It is a simple truism that a healthy give a woman an insight into the physi- woman is more likely to have a normal ology of pregnancy. An informed pregnancy and a healthy baby than a patient is more likely to cooperate with 76] Vol. 41 PREVENTION OF PREMATURITY 77 her physician to take such measures as other important type of hemorrhage as- will maintain the best of health through- sociated with prematurity is abruptio out pregnancy. placenta, the premature separation of Once conception has taken place, we the normally implanted placenta, for- move on to the next phase of supervi- merly known as accidental hemorrhage. sion, which is antepartum or prenatal The underlying cause of this accident is care. Antepartum care, as it applies to unknown. It is possibly due to vascular the prevention of prematurity, is essen- lesions in the decidua basalis and these tially the same care which should be lesions may be due to a state of toxemia. carried out for all patients. With the Although manifestations of toxemia such exception of syphilis and severe heart as albuminuria, hypertension, or other disease and the pelvic pathological le- evidence of renal damage are not con- sions mentioned, we seldom find in early stant findings in abruptio, they are pregnancy any conditions which imme- associated frequently enough to empha- diately suggest the possibility of a pre- size further the importance of prevent- mature birth. Syphilis is today much ing toxemia. less important a factor because of in- Of all the conditions associated with creased case finding and efficient treat- premature labor, toxemia is probably ment. Heart disease is still important the most important. We do not know and requires early diagnosis and treat- the cause of toxemia any more than we ment, preferably in consultation with a know the cause of the onset of labor. competent cardiologist. The pelvic Inevitably, all these unknowns lead to a lesions, if found only after conception, great deal of speculation and a resulting must be dealt with according to the best lack of rational approach. Furthermore, obstetrical judgment. the association of toxemia and prema- Later in pregnancy we encounter three turity is not entirely a causal relation- conditions which are so frequently asso- ship. Very often premature labor is ciated with premature birth, namely, artificially induced as part of the treat- placenta previa, premature separation ment of a toxemic patient. But our of the placenta, and toxemia. Of these, conclusion is the same-in order effec- the simplest to deal with is placenta tively to reduce the incidence of prema- previa, simplest because as its former turity, we must prevent the development name-unavoidable hemorrhage-indi- of toxemia. cates, it is purely a matter of treatment. The many theories on the etiology Nevertheless, even though it cannot be of pregnancy toxemias have different prevented, the termination of a preg- points of departure and suggest the nancy complicated by placenta previa presence of many operative factors. can be delayed by complete bed rest for Probably the most basic consideration the patient. It may be said here that is the importance of nutrition. Tompkins objections on economic grounds to en- of Philadelphia goes so far as to state forced bed rest for some weeks should be flatly that toxemia is a nutritional de- considered in the light of the heavy ex- ficiency state and that this deficiency is pense of good care for a premature baby. due partly to emotional instability. He Obviously, in any case of threat- claims that he and his associates at the ened or actual bleeding, provisions must Nutrition Research Clinic have been be made for the prompt replacement of able, by controlling diet and other blood loss. This is necessary not only aspects of nutrition, to reduce the inci- to safeguard the life of the mother but dence of prematurity in treated patients also to maintain adequate oxvgen in the by 70 per cent over a group of control maternal and fetal circulation. The patients. The work of Ebbs, Tisdale, 78 AMERICAN JOURNAL OF PUBLIC HEALTH Nov., 1951 and Scott in Canada and that of Burke patient who did not keep her appoint- and her associates in Boston suggests ments because she had to wait so long that dietary supplements such as pro- in a crowded clinic, who was not fol- teins, vitamins, and minerals have re- lowed up because there was inefficient duced the incidence of toxemia and pre- organization of records and no liasion maturity. The reports of really large with other agencies, who did not follow groups come from England and Wales. sensible eating habits because her die- The Peoples League of Health surveyed tary instruction was perfunctory and about 5,000 women in the London area, time was not available to answer her half of whom were given vitamins and questions and to explain how she could minerals, the other half serving as con- achieve such a diet, who was finally trols. The incidence of prematurity admitted as an emergency with a severe was lower in the treated group. Balfour preeclampsia and had to have her preg- reported on 20,000 women in the dis- nancy terminated to get a live but pre- tressed areas of England and Wales. The mature baby-when this chain of events effect of dietary supplements upon the can be demonstrated, steps to remedy incidence of prematurity was not sepa- the multiple deficiencies will suggest rately recorded but was included in themselves. Cause and effect will not figures on stillbirths and neonatal mor- always be shown so readily, but it is tality. The decreased incidences in the the importance to the well-being of the treated patients were statistically sig- patient of all these and other related nificant, probably even more so when it factors that we try to convey in our is remembered that the patients were program. treated according to apparent need and When it comes to the delivery of a were a less favored economic group than premature baby, we can point to the the controls. Though all this testimony well recognized fact that the smaller may not prove that toxemia is caused baby is more susceptible to anoxia. On by a lack of vitamins or minerals or this basis, the use of analgesia must be protein or all three, it is too strongly reduced to the absolute minimum be- suggestive of the significance of diet to cause these drugs pass into the fetal be ignored. circulation, tending to cause delay in In the course of the Hospital Consul- establishing respiration at birth. Anes- tation Program, we feel quite justified thesia should be limited to local infiltra- on the basis of the evidence at hand in tion or pudendal block. It is known stressing the need for supervising diet. that inhalation anesthesia in effective This is an integral part of antepartum concentration causes diminution of oxy- care in general, as well as a preventive gen supply to the fetus, but it is not measure against toxemia and prematu- always appreciated that conduction rity. In presenting these facts to hospital anesthesia may achieve the same effect medical personnel, the approach is upon because of varying falls in blood pres- a clinical basis. Some aspects of ante- sure following administration. The baby partum care lend themselves more to should preferably be delivered by low dramatic presentation. The case history forceps with a wide episiotomy to de- of a patient who died from hemorrhage crease the possibility of damage to the due to placenta previa is a vivid re- soft fetal skull from prolonged pressure minder to the hospital of the importance on a resistant pelvic floor. It is probably of having adequate blood on hand. The helpful to delay the tying of the umbili- number of premature births does not cal cord until it has ceased pulsating, carry the same impact. But when the and more oxygen-carrying blood cells chain of events is demonstrated-the may be added to the fetal circulation by Vol. 41 PREVENTION OF PREMATURITY 79 gentle stripping of the cord. During this suscitator; a suction apparatus; and an procedure an assistant can gently aspi- infant laryngoscope and tracheal cathe- rate mucus from the baby's mouth with ter for the intubation of an anoxic a soft rubber catheter. A pediatrician baby. should be present at the delivery of Needless to say, all this equipment is every premature baby, ready to take valueless unless it can be intelligently over from the obstetrician and assure used. And it is part of the aim of our the maintenance of a clear airway, oxy- program to work with hospitals toward gen, and warmth. This implies the pro- implementing all these recommendations vision in the delivery room of an incu- for preventing premature births and bator or heated crib, depending upon handling these births as well as possible the estimated weight of the baby; a re- when they occur.