Document Sample
76 Powered By Docstoc
					                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
 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.