A case report of uterine rupture in labor with epidural anesthesia is presented. The woman had good analgesia on the left side, but complained of severe labor pais on her right side. Uterine rupture occurred which was manifested by sudden vaginal bleeding, fainting, low blood pressure and fetal distress. She did not feel any pains typical of uterine rupture. Rupture of the left uterine wall, with a large hematoma in the left parametrium was seen at surgery. It seems the unilateral anesthesia of the left side concealed the early signs of rupture.

Assessment of fetal movements by the pregnant woman is a useful screening test in high and low risk pregnancies. Decreased fetal movements to less than 10 during 12 hours is an expression of fetal distress, and may be the first alert of impending fetal death. Pregnancies with decreased fetal activity comprise a very high risk group, however some normal pregnancies are still included. With the object of excluding false positive observations, fetal heart rate monitoring was added as a secondary screening procedure. There were seventy patients with diminished fetal movements, 28 had two or more fetal heart rate accelerations in twenty minutes, while 42 had one or no accelerations in twenty minutes. In the former group there was no perinatal mortality, while in the latter, 18 (42.8%) succumbed either pre- (16.6%) or post-natally (26.2%). It is suggested that daily fetal movement recording should be the primary screening test for pregnant women. Whenever reduced fetal activity to less than 10 in 12 hours is perceived, fetal heart rate should be monitored. The existence of at least two accelerations in 20 minutes excludes all the fetuses prone to disaster. One or no accelerations in 20 minutes when coexisting with decreased fetal movements, have a very grave prognosis, and interruption of pregnancy should be considered.

Abstract. Maternal hyperventilation can cause transient reduction in fetal oxygen tension. Fifty women with normal and high‐risk pregnancies, between the 32nd and 43rd week, were voluntarily hyperventilated; in 33, fetal heart rate (FHR) acceleration or transient tachycardia were observed (reactive FHR). Of the 33 pregnancies the outcome was good in 30 (91%) as judged by the absence of perinatal death, no fetal distress in labor and no intrauterine growth retardation (IUGR). In 14 patients in whom there was no FHR response to maternal hyperventilation (non‐reactive FHR), the outcome of pregnancy was significantly worse; one infant died neonatally, 10 were either chronically (IUGR), or acutely distressed. Only in 3 was the outcome good (21%). The study showed that there is good correlation between a “reactiv” FHR and favorable neonatal outcome, and between a “non‐reactive” FHR and an unfavorable neonatal outcome.

Various fetal scalp lesions are related to the use of the vacuum extractor. Blood sequestered in these lesions could result in an increased bilirubin load on the functionally limited neonatal liver, leading to the development of hyperbilirubinemia. In the present study bilirubin levels of vacuum extracted neonates were compared with those of non-instrumentally delivered babies during the first 72 hours of life. Sixty-nine vacuum extracted neonates had higher bilirubin levels than 56 non-instrumentally delivered babies at 24 (114 mumol/l vs. 96 mumol/l), 48 (163 vs. 141) and 72 (194 vs. 144) hours of age. The p values were 0.05, less than 0.025 and less than 0.001 respectively. This trend was apparent in both oxytocin induced and non-induced deliveries and whether or not phototherapy cases were included in the analysis. The incidence of hyperbilirubinemia requiring phototherapy was higher after vacuum extraction than after non instrumental delivery (27.5% vs. 12.5%; p less than 0.04). Analysis of our results unexpectedly indicated that oxytocin induction was generally associated with an attenuation of bilirubin levels after both vacuum extraction and spontaneous delivery. The clinician attending newborn babies should be aware of the higher incidence of neonatal hyperbilirubinemia associated with vacuum extraction.

Fetal movements (FM) in utero are an expression of fetal well-being, and the importance of assessing these movements has been shown in cases of chronic fetal distress. The diurnal variations were studied in 2 groups of high-risk pregnant women who assessed FM by subjective perception. The patients in the first group assessed FM before and after meals. The majority (86%) reported no significant difference in fetal activity before and after meals; the remaining 14% noted a constant decrease after meals. Of the second group, which assessed FM 3 times daily 82% discerned no significant differences and 18% showed significant diurnal variations. It is concluded that assessment of FM is not necessarily dependent on a strict timetable.

A sinusoidal fetal heart rate pattern, associated with Kell incompatibility, severe fetal anaemia, maternal hypertension and intrauterine fetal growth retardation, is described. The mechanism and management are discussed.

In high risk pregnancies with severe fetal distress, a reduction of fetal movements may take place before fetal death occurs. This decrease is accompanied by a weakening of the fetal movements. One hundred and twenty pregnant women (310 recordings) between 20 and 41 weeks gestation recorded fetal movements and classified them into weak, strong, and rolling. The movements noted by the woman were correlated to those recorded by a fetal movements recorder. The rate of weak movements gradually decreased until the 36 to 37th week, while the strong and rolling movements increased. From the 36 to 37th week till term weak movements increased again with a decline in strong and rolling movements. Before fetal death, or in severe fetal distress with decreased total movements, the relative rate of weak movements increased. Reduction in daily total movements without a change in the distribution of the type of movement may not indicate fetal distress.

Two cases of severe Rh-immunization are presented. The obstetric history, maternal serum anti-D titre, amniotic fluid spectrophotometric evaluation, amniography and ultrasound placentography suggest the diagnosis of hydrops fetalis. The reduction of fetal movements until cessation in the presence of an audible fetal heart point to a severely distressed fetus and impending death, thus providing additional data confirming the diagnosis of hydrops fetalis. The importance of diagnosed hydrops fetalis lies in the fact that most authors agree that in these cases treatment of the fetus should not be attempted.

Fetal movements in utero are an expression of fetal well-being. However, a sudden increase of fetal movements is a sign of acute fetal distress, such as in cases of cord complications or abruptio placentae. Decreased fetal movements are seen in cases of chronic fetal distress such as preeclampsia, hypertension in pregnancy, etc. It was shown that in these cases a pronounced decrease up to cessation of fetal movements occurred before fetal death in utero while fetal heart beats were still audible for at least 12 hours. This situation was called "movements alarm signal" (MAS). This sign points to a severely disturbed fetus and indicates impending intrauterine fetal death. Such a development is an indication for immediate delivery of the fetus, provided it is viable. High-risk pregnant women are instructed to assess and record fetal movements daily as a monitor of fetal condition. A special device which records fetal movements is used to confirm the women's assessment of fetal movement. It was shown that fetal movement monitoring was found to be more reliable than the urinary estriol determination in predicting impending fetal death in utero. It was also shown that in cases of MAS, fetal heart rate (FHR) changes will appear 1 to 4 days after the MAS has appeared. Meconium was found in only 50% of these cases. Increased fetal movements are manifested as a response to various stimuli such as sound, light, touch, and ultrasound. Classification of high-risk pregnancies into 3 groups according to the hormone assays, enzyme assays, ultrasonic cephalometry, fetal movements, and FHR is suggested.

A fetus spontaneously aborted in the 4th month of gestation is described. The fetus displayed nonsymmetrical syndactyly of both hands and partial amputation of fingers in one hand caused by a dense tissue microscopically found to be composed of multiple folds of amnion. The placenta was examined, and showed severe pathology: multiple hematomas, infarctions, and fibrosis. The possible mode of formation of amniogenic bands is discussed and correlated with the clinical history and pathology of the placenta and membranes.

Departments of Ophthalmology and Obstetrics and Gynecology, Rothschild Hadassah University Hospital, Jerusalem, Israel Obst. & Gynec., 15: 231, 1960