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The purpose of this study was to assess whether the treatment of deliveries at the traditional threshold of viability has become more interventional since the publication of higher survival rates.State vital statistic data from 1995 to 2000 were reviewed to identify deliveries at 22 to 25 weeks of gestation with a birth weight of1 kg. Demographic data and frequency of cesarean delivery, antepartum bleeding, breech presentation, fetal distress, and cord prolapse were recorded. The cesarean delivery rate and the neonatal mortality rate were calculated for each year. Linear regression for cesarean delivery rate versus year and for neonatal mortality rate versus year were performed at each gestational age.Of 2924 births that met the study criteria, 1005 births (34.4%) were by cesarean delivery. The cesarean delivery rate at 23 weeks rose from 15.9% in 1995 to 28.2% in 2000 (P =.023). Demographic/obstetric factors did not vary with year of delivery. The neonatal mortality rate remained unchanged.These data suggest an increasingly aggressive approach to deliveries at the threshold of viability, beginning at 23 weeks of gestation.

The neonatal mortality rate has dramatically improved in recent years. Occurrence of these losses is concentrated in low-birth-weight infants. At Los Angeles County-University of Southern California Medical Center, the infants weighing less than 1,500 grams contribute two thirds of neonatal deaths, although they may represent only 1.5 per cent of total births. Such observations have led to the evaluation of obstetric factors as they relate to the outcome in the low-birth-weight infants weighing from 1,001 to 1,500 grams. Retrospective evaluation of 201 low-birth-weight infants' charts demonstrated a tendency by the obstetrician to clinically underestimate fetal weight. In cases where fetal estimated weight and measured birth weight correlated, the mortality rate was 20 per cent; in cases of underestimation, the mortality rate rose to 50 per cent. Other obstetric factors evaluated were the use of FHR monitoring, the method of delivery, and the significance of the Apgar score.

Vital records data (1971 to 1978) were used to assess the change in neonatal and fetal mortality in Colorado in relationship to the regionalization of perinatal health care within the state. There has been a decrease in neonatal mortality rate from 13.4 to 6.9 during a period of time when there was a minimal decrease in the incidence of low-birth weight infants. The improved neonatal mortality has been associated with a shift in the frequency of birth of very low-birth weight (VLBW) infants to hospitals with level II and III perinatal services and relatively greater survival rates of VLBW infants born in these hospitals as compared to those born in level I hospitals. There was no decrease in fetal mortality in the same period of time. These date suggest that outreach education in perinatal medicine should now emphasize current knowledge and methods for reducing antepartum deaths.

Accomplishing reduction of the neonatal mortality rate in the infant weighing less than 1,500 grams accounts for one of the major areas of potential impact in obstetrics today. Of the 8,169 live births occurring in the Perinatal Unit, Women's College Hospital, between January 1, 1976, and December 31, 1978, 79 infants weighed between 1,000 and 1,500 grams and 135 were between 1,501 and 2,000 grams. Analysis of approach and outcome shows that with immediate neonatal intensive care, morbidity in the larger group can be managed to prevent death. The mortality rate in the infant weighing less than 1,500 grams, as well as morbidity in the larger group, is improved by a more active obstetric approach for the sake of the neonate. In this study, such an approach resulted in a corrected survival rate of 100% in both groups during 1978.

The relationship between low birth weight, intrauterine growth retardation, and preterm delivery in infants born at a perinatal center is described. Between 20% and 30% of infants born weighing 500 to 2000 gm and nearly 50% of infants born weighing 2001 to 2750 gm had intrauterine growth retardation. For infants within the same low-birth weight group, infants with intrauterine growth retardation had one half to one sixth of the neonatal mortality rate of non-growth-retarded infants. However, only in the 501 to 1000 gm group did the difference in mortality between infants with and without intrauterine growth retardation substantially influence the composition of the group of survivors.

1. Five hundred and ten patients in whom caudal analgesia was attempted were studied. 2. Eighty per cent of patients in labor were found to be suitable for caudal analgesia with 97.5 per cent complete success. 3. An increased incidence in the use of oxytocic agents and operative obstetrics was found. 4. The advantages of caudal analgesia with elective induction of labor are stressed. 5. Three babies were lost, of whom 2 had congenital abnormalities incompatible with life. This gives a corrected neonatal mortality rate of 0.2 per cent.

Chronic shortage of physicians in a rural county hospital in California resulted in many deliveries in the county hospital being medically unattended. This led to the development in July, 1960, of a demonstration project calling for qualified nurse-midwives to provide maternity care services for all normal deliveries. Initially, the physicians were skeptical about the quality of care that could be provided by nurse-midwives. Their skepticism soon changed and they became staunch supporters of the program. Maternity patients also became enthusiastic about nurse-midwife services. Although there were only about 360 deliveries per year at the county hospital (60 per cent of all deliveries in the county), the neonatal mortality rate fell from 23.9 per 1,000 live births to 10.3 per 1,000 live births. Prematurity dropped from 11 per cent of all live births to 6.4 per cent.

Newborn health indices were measured before, during, and after a demonstration nurse-midwife program introduced to relieve a health manpower shortage at a county hospital in rural California. During the program, prenatal care increased, and prematurity and neonatal mortality rate decreased at the county hospital. After the 3 year program, prenatal care decreased while prematurity rose from 6.6 to 9.8 per cent (p

The neonatal outcome and follow-up over the first two years of life in a group of 124 infants with birth weights between 1,000 and 2,000 grams were studied. The overall neonatal mortality rate (first month of life) was 9% with a further five infants dying in the first year. Seventy-three infants have been seen for at least 1 year and three infants show evidence of neurological damage. Catch-up growth is slower in the 1,000 to 1,500 gram infant than in the 1,501 to 2,000 gram infant, the latter achieving normal head size at 2 years. However, mean Bayley Mental Development Scores are normal in both the 1,000 to 1,500 gram and 1,501 to 2,000 gram groups at both 1 and 2 years from expected date of confinement.

In an attempt to elucidate the effect of electronic fetal monitoring on cesarean section rates, a review was made of the experience before and that during the 7 years after the initiation of fetal monitoring at Vanderbilt University Hospital. When a comparison was made of the cesarean section rates in the 3 years prior to fetal monitoring with those over the subsequent 2 years, no change was observed, thus indicating that, in experienced hands, a liberal use of fetal monitoring in low-risk and high-risk patients does not necessarily cause a rise in the overall incidence of cesarean sections. During this time, the neonatal mortality rate fell approximately fourfold. On the basis of this study, the belief is that a liberal attitude toward delivery by cesarean section for patients with breech presentations and other high-risk conditions contributed more to the rise in cesarean sections at Vanderbilt University Hospital than did electronic fetal monitoring. With proper education of the clinician and correct interpretation of the findings, electronic fetal monitoring need not increase cesarean section rates, but rather should allow for a more accurate description of intrapartum life.

A stillborn infant was born to a drug-addicted mother who had withdrawal symptoms shortly before delivery. Mechanisms are presented to help explain the possible relationship between the maternal withdrawal and the fetal death. Statistics are also presented to show an increased stillborn and neonatal mortality rate in the over-all pregnant drug-addicted population.

A study of 277 elderly primiparas delivered at the Methodist Hospital of Brooklyn in the years 1943 to 1947, inclusive, has been presented. A comparison has been made of our findings with those reported in recent similar studies. Our incidence of these patients, 2.46 per cent, was higher than the 1.2 per cent reported by Hawkins and by Waters, and lower than the 2.75 per cent reported by Thompson, the 3.6 per cent reported by Arnot, and the 4.2 per cent reported by Dennen. Our cesarean section rate was practically the same as that reported by Thompson, Hawkins, and Waters, higher than that reported by Arnot, and less than half that reported by Dennen. The similarity in the incidence of elderly primiparas in the City of New York and at the Methodist Hospital has been demonstrated, so that the hospital experience in regard to the number of these patients and their problems may be considered as typical for the city as a whole. As compared with other hospital obstetric patients, elderly primiparas more often seek private care, and they have a cesarean section rate over four times as great, a premature rate half again as great, double the neonatal mortality rate, eight times the incidence of Mongolism, and twice the incidence of toxemia.