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The most frequent cause of perinatal death following intrauterine transfusion in cases of severe rhesus hemolytic disease remains premature onset of labor and the resulting newborn so delivered. In the present study, 70% of all perinatal deaths were directly related to immaturity. A factor of decisive importance as an initiator of labor before the intended time is the leakage of blood into the amniotic fluid at the time of the procedure. (Mostly, this blood seems to originate from the fetal abdomen into which it was injected for therapeutic reasons.) The effect of blood-contaminated amniotic fluid on uterine activity is demonstrated on the material from Lewisham Hospital of London, where between 1 and 5 intrauterine transfusions were performed on 517 patients during a period between November 1963 and the end of March 1973. The presence of blood in the amniotic fluid was proved either by means of amniocentesis performed 2 days after intrauterine transfusion, or at the time of membrane rupture in labor. Patients who received a self-retaining catheter for any length of time were excluded from the material since the additive influence of the catheter on labor could not be assessed. Out of a total of 452 cases receiving single-use catheters, there were 208 cases (46%) with premature onset of labor. In 2-thirds of the cases this happened within the first week after the last intrauterinetransfusion. Further investigation of 332 case-histories with complete records was carried out. In 61.6% of the patients with labor before the intended time within 21 days after the last intrauterine transfusion, blood contaminated amniotic fluid was found, whereas this occurred in only 34.8% of the cases without premature onset of labor (p less than 0.001). From the same material, corresponding percentages for livebirths and stillbirths were calculated. As a consequence of these results, it is recommended that patients be kept under intensive hospital care following intrauterine transfusion whenever blood can be proved to be present in the amniotic fluid. Prophylactic measures to prevent premature onset of labor should also be considered.

An investigation into several selected biosocial factors affecting perinatal mortality was made based on all single (live and still) births, 42,279, and related singleton perinatal deaths, 1468, occurring to women resident in Belfast, Northern Ireland, during a 5-yr period of observation—1962–1966. The data were examined by unifactor and multifactor analyses. The relative contributions to perinatal mortality risk and the confounding effects between several biosocial factors were studied in detail using a binary multiple regression model. A multi-factor model containing seventeen factors explained 46.5 per cent of the total variation in perinatal mortality risk while a model containing one factor only, birthweight, explained 42.7 per cent. It was concluded that birthweight is the most important single factor determining fatal or nonfatal outcome during the perinatal period. The relative contributions of such factors as maternal age, parity and social class, although significant, were small in comparison. The findings were discussed in relation to previous studies and with respect to the use of risk evaluation models in determining obstetric care.

Summary The necropsy findings on 2,000 infants dying in the serinatal period and examined in the pathology department of the Royal Women's Hospital, Melbourne, are described. The over-all findings are similar to those of Butler and Bonham (1963) in the Perinatal Mortality Survey in Britain. In the study of such perinatal deaths it is essential that a careful anatomical dissection be carried out and the need for bacteriological and virological study is emphasised. The lungs in particular must always be examined histologically, but a full histological survey is also desirable since this will bring to light many unsuspected features. Iso-immunisation and premature labour appear fertile fields for the improvement of perinated wastage figures.

Summary A 10-year survey of perinatal mortality in a circumscribed population of a quarter of a million is described. It was based on necropsy findings in 93% of all perinatal deaths irrespective of place of birth. Between 1957 and 1966 the trend of perinatal mortality in Blackpool has been similar to that in England and Wales. Our necropsy findings show that all major lesions, except intraventricular haemorrhage, have become less frequent. Factors which have played a part in lowering the mortality include an increasing proportion of young mothers, improved booking practice, a decline in severe toxaemia, better results in breech presentation, delayed cord ligation at premature deliveries, fewer babies of low birth weight, more successful prophylaxis of pneumonia and a decline in major central nervous system malformations.

Cord serum immunoglobulin G and M levels and their relationship to race, sex, birth weight, and clinical status are examined. The levels of both immunoglobulins are not related to sex. Negro infants have higher IgG and lower IgM levels than Caucasians. IgG levels and birth weight are associated, smaller infants having lower levels. The previously reported relationship between high levels of IgM and congenital infection is confirmed. In addition, a significant relationship between very low levels and adverse fetal outcome is demonstrated by neurologic abnormalities, severe congenital malformations, and perinatal deaths.

Summary: In a randomised study of 207 patients, labour was induced with oral prostaglandin E2in 107 and intravenous oxytocin (Syntocinon) in the remainder, half in each group with medication alone, the other half with fore-water amniotomy as well. Prostaglandin and oxytocin were found to be more effective when preceded by amniotomy. Once labour was established, the time taken to achieve vaginal delivery was the same with either drug, as also the number of successful vaginal deliveries. There were 6 failed inductions, but no statistical significance in the percentage differences between PGE2 and oxytocin could be found. The two perinatal deaths which occurred could not be attributed to either drug. Oral PGE2is therefore as effective as intravenous oxytocin with no observed hypertonus and little side-effects.

Fetal assessment and subsequent management of 137 patients with meconium or fetal heart rate abnormalities in the first stage of labor was determined by the fetal blood pH. In the majority of patients the fetal blood pH was 7.25 or more, and the fetus was considered to be adequately oxygenated. Twenty-three per cent of the fetuses were initially observed to have a pH of less than 7.25. Repeat pH estimations, both when the pH was between 7.15 and 7.25 and toward the end of labor, improved the diagnosis of intrauterine asphyxia. Fetal heart rate abnormalities as detected by auscultation were not commonly present in those patients with meconium in whom the fetal pH was less than 7.15. Seven cesarean sections were performed for fetal acidosis. There were 4 perinatal deaths, one of which was due to intrapartum anoxia. A significantly increased incidence of infants with low Apgar scores occurred among patients with a predelivery fetal blood pH of less than 7.25. The results suggest that a progressive deterioration of pH below 7.25 is an indication for intervention in labor and delivery of the fetus.

The results of 24 hour urinary estriol determinations in 47 prolonged gestations, 25 pre-eclamptic or chronically hypertensive gravidas, and 9 diabetic pregnancies are presented. The use of urinary estriol levels in determining the method and timing of delivery in these 81 complicated pregnancies is discussed. The fetal outcome, including case reports of 4 perinatal deaths, is provided. A brief critical evaluation of the usefulness of urinary estriols is included. "Serial urinary estriol determinations … offer promise of a useful laboratory aid and the only objective method thus far available to supplement clinical judgment." 1

Summary A survey of the pattern of growth, as revealed by the structure of the costo-chondral junction, suggests that the great majority of infants dying in the neonatal period had intrauterine disease antedating labour. This involves approximately 60% of premature birth deaths and around 75 % of perinatal deaths at term.

SUMMARYAn analysis has been made of still-births and difficulties at parturition in a dairy herd in which purebreds and crossbreds of Friesian, Ayrshire and Jersey origin were kept. There were 2,049 calvings including 28 involving twins.Purebred heifer dams produced 14·7% dead purebred calves (mostly Friesian and Jersey) and 6·4% dead crossbred calves (P < 0·05). For older dams the corresponding values were 2·4% and 3·6% (P > 0·05). Losses were smaller with crossbred dams. Crossbred heifer dams (two-breed crosses) with 6·5% dead calves exceeded older crossbreds with 1·9% dead calves. Three-breed crossbred dams gave similar results (8·2% and 1·2%). An intermediate size of cow of second or later parity was associated with the lowest mortality.Friesian and Hereford sires, the calves by which were heavier than those by Ayrshire and Jersey sires, were associated with greater losses than were the latter but this applies to heifer dams and not to the same extent if at all, to older dams.Of 52 parturitions described as difficult, 31 resulted in dead calves. Malpresentation accounted for 32 cases; the majority of these were ‘hindfeet first’. Friesian and Hereford bulls sired a higher proportion of the calves involved in difficult cases than Ayrshire and Jersey sires.

Urinary estriol levels were obtained from 31 normal pregnant women and from 186 women attending the prenatal/diabetic clinic. The latter included 137 Class A (studied in three groups according to the degree of carbohydrate intolerance present), 32 Class B, 7 Class C, and 10 Class D patients. The results were not used to influence the clinical management. Mean values for the entire abnormal group were calculated weekly from 28 weeks until term. These values were used as the basis for comparison of the different classes studied. Only Classes C and D demonstrated depressed levels of excretion. Sixteen perinatal deaths occurred and 9 were considered avoidable had the estriol results been taken into consideration. The “estriol-preventable deaths” are described in detail. It is concluded that the assay presents a potentially valuable adjunct to the clinical management of the pregnant patient with disordered carbohydrate metabolism.

Among 16,046 births in Saginaw hospitals from July 1, 1956, to July 1, 1959, there occurred 520 perinatal deaths. The mortality rate for A.M.A. perinatal period II averaged 32.4 per 1,000 births. Prematurity was a factor in 69 per cent of perinatal deaths. The premature salvage of liveborn infants weighing 1,000 grams or over was 90.7 per cent. One hundred forty-six cases of perinatal death (28.1 per cent) were judged to have been preventable. Although it is probable that not all of these babies could have been salvaged, it was felt that in none of these cases was an optimum level of physician and hospital care or of patient cooperation achieved. In addition to the collection of statistical information, this study has focused the attention of physicians in Saginaw County on the perinatal problem. Each of the Saginaw hospitals has established regular Perinatal Mortality Conferences in its teaching program. Marked improvements have appeared in the recording of data on obstetrical and newborn charts. Growing interest in the causes of perinatal deaths is reflected in the increasing number of autopsies and placental examinations.

An assessment of paracervical nerve block anaesthesia was made in 118 women during labour using 0·5% bupivacaine with 1:200,000 parts of adrenaline added. The 82 multiparae were each given a single block and the 36 primigravidae a continuous block to try to provide the sole means of analgesia throughout the first stage of labour. Only 48% of the primigravidae required no other form of analgesia, as against 72% of the multiparae. Complications included a 17% incidence of maternal haemorrhage during insertion of the continuous needle, an overall fetal bradycardia rate of 11%, and two perinatal deaths following single paracervical block. It is concluded that the use of continuous paracervical block should be discontinued, and that amide-type local anaesthetic agents should not be used for single paracervical block.

A survey of 8½ years of perinatal mortality records from the Methodist Hospital of Dallas is presented. The presentation is motivated by the slow decline of perinatal mortality in the United States since 1950 and the lag of this decline behind that of western Europe. The survey encompasses 28,313 births and 689 perinatal deaths. Immaturity is found to be the largest single category and also to be associated with all other categories in 66 per cent of the deaths. The question is raised of a relationship between the increasing number of deaths from respiratory distress in the immature neonate and the amount of sedation and type of anesthesia used during premature labor and delivery.

Human chorionic somatomammotrophin (HCS) in plasma and oestriol excretion in urine were serially determined in 45 diabetic and 15 normal pregnancies. In the diabetic group there were three perinatal deaths. Mean HCS and oestriol values were not significantly influenced by factors such as maternal age, age at onset of diabetes, duration of diabetes or presence of retinopathy. Group mean HCS and oestriol values were not significantly different between diabetics and controls. Six diabetics had one or more HCS values below 4 μg/ml. Four of them delivered small for date infants with one intra-uterine and one neonatal death. In the former case death was preceded by a pronounced drop in oestriol and in the latter case oestriol values were low and fluctuating. Among Ihe remaining women with low HCS values, three had normal and one had increasing oestriol values within the lower normal range. All women with HCS values above 4 μg/ml had normal oestriol values and normal outcomes with one exception; this woman had l...

Summary 1 Transcervical amnioscopy has been used to view the amniotic fluid of 540 patients where there was an increased risk of meconium appearing. 2 The technique, indications, contraindications and difficulties have been outlined. 3 Using the criteria described, amnioscopy detected nearly a half of those who developed meconium in the amniotic fluid. 4 Three types of meconium could be distinguished — light green, dark green and yellow. Some aspects of the type and duration of meconium in the amniotic fluid were considered in relationship to the foetal outcome. 5 When a marked reduction of liquor was detected in the otherwise clear forewaters 1 in 3 were later found to have meconium. 6 There were 4 perinatal deaths, 2 during labour and 2 within 24 hours of delivery. In 3 of these meconium had been detected by amnioscopy. Clear liquor throughout carried a good foetal prognosis. 7 The procedure provides the clinician with worthwhile information at little risk to mother or foetus.

1. 1. A review of 6,860 cases of electively induced labors has been presented. 2. 2. The most effective method of inducing labor is simple amniotomy. 3. 3. Eighty-two and three-tenths per cent of the patients were in labor within 4 hours, and only 2.3 per cent had a latent period of over 24 hours. 4. 4. Pitocin stimulation was used in patients with prolonged latent periods or desultory labors with intrapartum fever. 5. 5. Serious though must be given to performance of cesarean section when the latent period is prolonged and infection is present, if labor cannot be stimulated within 24 to 36 hours. 6. 6. There was one maternal death related to induction. 7. 7. The principal fetal hazards were (a) prematurity, 3.1 per cent; (b) prolonged latent period, 5.0 per cent; (c) malpresentation, 0.9 per cent; (d) prolapsed cord, 0.3 per cent. 8. 8. There were 6,889 babies born. Of these, 37, or 0.6 per cent, were 9. stillborn, and 55, or 0.8 per cent, died neonatally. The perinatal mortality was 1.4 per cent. 10. 9. Thirty-nine of the perinatal deaths (0.6 per cent of the babies delivered) were directly related to the elective induction. 11. 10. A conservative attitude should be maintained by the specialist toward the elective induction of labor. The average general physician should allow labor to start spontaneously.

Objective: To determine the causes of perinatal death using Wigglesworth classification and to assess the feasibility of using Wigglesworth classification in a tertiary care hospital setting. Methods: All live and stillborn babies delivered at BIRDEM over a 5 yr period(from January 2000 to December 2004) were recorded. Perinatal deaths of that period were analysed according to Wigglesworth classification Results: According to Wigglesworth classification, majority of deaths were in the group "macerated stillbirths" (63.5%). Perinatal asphyxia was responsible for 13.6% of deaths, lethal congenital malformation was found in 11.2% and immaturity and "others" each accounted for 6.1%. Conclusion: Macerated stillbirth and asphyxia were the two leading causes of death at BIRDEM and Wigglesworth classification has been found to be feasible in BIRDEM for categorising perinatal deaths retrospectively. Key words: Perinatal death; Wigglesworth classification DOI: 10.3329/bjch.v31i1.6072 Bangladesh Journal of Child Health 2007; Vol.31(1-3): 32-39

The risk of perinatal mortality is the resultant of a large number of biological and social influences. Age, parity, social class, height, and past obstetric history are only some of the factors that should be taken into account in assessing the risk for any particular woman. This raises a difficult problem. In several factors she may be below average in risk while in others she is above average. She may, for example, be in Social Class I, but be 38 years old and having her fourth child. How should her risk be compared with that of another woman who is in Social Class V but is 23 years old and having her third child? Assessing the risk for any case requires estimating the specific effect of each factor and weighing these together to arrive at an overall value. This paper reports the development of a multiple regression method for evaluating perinatal mortality risks and identifying cases most likely to benefit from intensive antenatal care or hospital delivery. The data used for this study was collected by the Perinatal Mortality Survey (Butler and Bonham, 1963). During one week in March, 1958, the Survey directed by Dr Neville Butler obtained information on 16,994 single births, some 98 per cent, of all births during the week. Perinatal deaths (defined to include the entire 4-week neonatal period) of babies born during March, April, and May were also recorded. The 7,117 survey deaths represent an estimated 94 per cent, of all deaths at risk.

Summary: Urinary oestriol measurements were performed in 239 rhesus immunized patients with rhesus positive infants. Oestriol excretion was low in 31 of the 55 pregnancies (56%) resulting in perinatal deaths, including 17 of the 26 in which the fetus was hydropic at birth. When oestriol excretion was low the perinatal mortality rate was 65% (31 of 48). When the fetus had severe erythroblastosis, oestriol assays sometimes provided useful extra information when amniotic fluid bilirubin was unexpectedly low. The important conclusion from this study was that low oestriol excretion was an accurate index for selection of the fetus in jeopardy in rhesus immunized patients, although normal oestriol values did not guarantee that the fetus was in good condition.

Summary Out of 180 patients who had a myomectomy at the Chelsea Hospital for Women between 1954 and 1962, 116 were followed for more than one year. One in four of these patients had a subsequent hysterectomy and about one in three conceived after surgery. Of the patients known to have conceived only three out of four carried pregnancies beyond 28 weeks. Myomectomy did not seem to alter the high incidence of abortions and perinatal deaths in patients found to have fibromyomata. Pregnancies occurring after myomectomy required close specialist supervision and often ended in Caesarean section.

A 10 year analysis of 450 consecutive perinatal deaths in Perinatal Period I among 24,097 births at The Jewish Hospital of St. Louis (1958 to 1968) revealed an over-all perinatal mortality rate of 18.8 per 1,000 live births. This analysis confirmed the national observation of increased perinatal mortality in Negro births with a Negro perinatal mortality rate of 28.6 per 1,000 live births in contrast to a white perinatal mortality rate of 16.9 per 1,000 live births. The difference in perinatal mortality rates could not be related entirely to differences in prenatal care, incidence of prematurity, specific causes of death, or preventable factors. It is suggested that other determinants, perhaps nonmedical, are yet to be identified. Highest research priority should be given to the three major groups which comprised 51 per cent of all perinatal deaths in the study: abnormal pulmonary function, congenital malformations, and “no demonstrable cause.” Present achievement falls short of what can be accomplished, as evidenced by an 11.3 per cent incidence of preventable perinatal deaths.

In a prospective study of 1000 consecutive primigravidae labour was induced on 95 occasions. None of 16 perinatal deaths and none of 4 cases of suspected brain damage occurred after prolonged pregnancy or pre-eclampsia. It is concluded that a low incidence of induction is compatible with good results and that enthusiasm for the statistical concept of high risk in obstetric practice should be reviewed in the interest of mothers and children as individuals.

The primary necropsy finding are presented for 726 perinatal deaths; the classification of the 1958 British Perinatal Mortality Survey is used, and results of the two surveys are compared. Lethan malformation has replaced intrapartum hypoxia as the most common cause of perinatal death. There has been substantial reduction in intracranial trauma but an increase in intraventricular haemorrhage and, possible, extrapulmonary infection. Chromosome abnormalities occurred in 28 of 500 karyotyped infants (5-6 per cent). Indications for genetic counselling, and antenatal diagnosis in any subsequent pregnancy, were apparent in 10 per cent of cases.

Evidence that maternal undernutrition contributes to the problem of low birth weight in industrial societies will be discussed in the following categories: (1) epidemiological associations, (2) clinical studies of growth-retarded babies, (3) maternal dietary studies, and (4) pathologic findings in perinatal deaths. Epidemiological Associations Mean Birth Weight. —As summarized by Rosa and Turshen, 1 quite large differences between populations occur with respect to mean birth weight. In contrast, differences in mean length of gestation are minor. Thus, between-population variance in mean birth weight reflects principally differences in rate of fetal growth. It is a central problem of perinatal medicine to know the relative contributions of heredity and environment to the variance in fetal growth rate, and, among the environmental factors, to know the effect of maternal undernutrition. Within industrial societies, similar though less obvious differences are seen in the mean birth weight. For example, mean weight at term for male

In a series of 5,001 pregnant patients, 4 perinatal deaths and 2 cases of severe neonatal morbidity were explained by counting fetal erythrocytes in the maternal circulation. The omission of this simple test would have left these 6 cases unexplained. This paper outlines the necessity of counting fetal erythrocytes in the maternal circulation after every delivery, in vaginal blood loss during the third trimester of pregnancy, and when blood is aspirated at amniocentesis. Fetal erythrocyte counting is a valuable aid in fetal care and in perinatal mortality and neonatal morbidity studies. The indications for fetal erythrocyte counting are described.

Any physician who corrects a significant medical disorder in a female prior to or during her childbearing years and thereby improves her general health is practicing preventive medicine in obstetrics; he is also laying the groundwork for a continuum of care and supervision throughout the reproductive years that is a prerequisite to effective obstetric management. The general physician is the key figure in providing this care, and it is every physician's responsibility to take the lead in establishing an effective program which will combat perinatal deaths.

Evaluation of numbers of perinatal deaths in a population rather than death rates shows that neither preterm infants nor those of low birth weight constitute as great a majority as is usually believed. Original data from the British Perinatal Mortality Survey and from hospitals in Baltimore were supplemented by 16 reported series and 4 made available by colleagues. About 40 to 60 per cent of all deaths occurred in infants weighing more than 2,500 grams or having a gestational age of more than 37 weeks. The problems inherent in the deaths of full-term and full-sized infants must not be overlooked because death in these groups is more readily preventable at the present state of our knowledge than that of small or immature infants.

Despite great progress in the control of infectious diseases, infections still rank among the commonest causes of perinatal death. It is difficult to estimate the relative frequency with which infections are responsible for wastage of human lives prior to so-called viability. The morphological characteristics of the abortus are often unrevealing, although decidual necrosis and inflammation are almost invariably found. Appropriate bacteriological studies are rarely made. The majority of septic abortions follow instrumentation of the uterus, although the victims of these infections claim to have aborted spontaneously. However, similar phenomena occasionally evolve without external intervention, especially when the abortion takes place during the second trimester of pregnancy. Both the clinical course and the laboratory data in these bona fide “natural” intrauterine infections recapitulate those associated with many premature births, occurring weeks later in gestation. Review of the case histories and pertinent laboratory data indicates that intrauterine infections, notably bacterial infections, are important causes of recurrent obstetrical catastrophes, such as habitual abortions, repetitive premature labors, and consecutive perinatal deaths (Driscoll, 1965; Benirschke and Driscoll, 1967).

Summary By the use of birth registers the clinico-pathological cause of perinatal mortality has been examined for 1333 perinatal deaths out of 48 582 infants delivered in two hospitals in Makassar, Indonesia between 1951 and 1969. When compared with the cause of mortality in the British Perinatal Mortality Survey, the Makassar hospitals had a lower incidence of congenital abnormality and rhesus isoimmunization but a high incidence of “premature unknown” and “mechanical” causes. A separate study of birthweight was carried out on 1060 consecutive maternities during 1969 and this demonstrated that Chinese Indonesian infants had a higher mean birthweight than non-Chinese Indonesian infants and that the difference could not be accounted for by differences of social class, maternal stature or birth rank.

A causeofdeathisthemorbidcondition orother disease process, abnormality, orinjury leading directly or indirectly todeath...Fromthestandpoint ofthe prevention ofdeaths itisimportant tocutthechain of events orinstitute thecureatsomepoint. Themost effective public health objective, ofcourse, istoprevent theprecipitating cause fromoperating. Forthis purpose themostuseful single statistic isthatrelating tothe underlying cause ofdeath which maybedefined as(a) the disease orinjury whichinitiated thetrain ofmorbid events leading directly todeath, or(b) thecircumstances oftheaccident orviolence whichproduced thefatal injury ...Symptoms ormodesofdying suchasheart failure, asthenia etc., arenotconsidered tobecauses of death forstatistical purposes. (W.H.O., 1948). Inthevastmajority ofcasesthese elementary rules ofprocedure present little difficulty tothe doctor whohastosign adeath certificate. Mistakes aresometimes made, buteachcertificate iscarefully scrutinized attheGeneral Register Office andif there isanyreason tosuppose that thestated cause of deathmerely describes themodeofdying itis promptly returned foramendment. Inthecaseof stillbirths andneonatal deaths, however, therules cannot bestrictly enforced. Theabsence ofdefinite signs ofdisease (ortheco-existence ofseveral equally lethal conditions), combined withthe difficulty offollowing intra-uterine events, frequently makesitimpossible toexpress areasoned opinion astothecauseofdeath. Itisobvious, forexample, that prematurity cannot possibly have"initiated the trainof eventsleading directly to death". Nevertheless everyyearthousands ofcertificates giving this asthecauseofdeath areaccepted bythe General Register Office, and"prematurity" regularly takes itsplace asacauseofdeath bothinofficial vital statistics andintheinternational list ofdiseases. Atfirst sight certificates whichnamesomething moreprecise, like acongenital defect, asthecause of deathseemmoreinformative thanthosewhich attribute deathtoprematurity. Buta moment's thought will showthat itisthesecondary nature of * Inreceipt ofagrant fromtheMedical Research Council. prematurity andnotanyvagueness intheterm(or anydoubtwhether ababyshould besodescribed) thatmakesitsounrevealing asacauseofdeath. Since maldevelopment, likeunder-development, is theend-result ofanunknownprocess, evencertificateswithsuchprecise diagnostic termsas anencephalus andexomphalos donomorethan describe amodeofdying. Therealization thata medical classification of stillbirths andneonatal deaths isunsatisfactory has ledworkers tostress theimportance ofnon-medical conditions, andtostudy social andgenetic factors which(though theywill never gainadmission tothe International list) arenevertheless ona parwith somecategories nowaccepted ascauses ofdeath (Baird andIllsley, 1953; Douglas, 1950; Karnand Penrose, 1952;Sutherland, 1949; Woolf,1947). Theresults ofsuchinvestigations mayeventually provide uswithamoresatisfactory nomenclature. Meanwhile there issomuchconfusion aboutwhat areproximate andremote causes ofdeath ininfancy, andwhataremerely modesofdying, that itmaybe ofvalue totake agroup oflive anddeadbabies and, without prejudice to thequestion ofcausation, compare thefrequency ofvarious observations made before, during, andimmediately after delivery. Withthis endinviewwehaveexamined theantenatal andobstetrical records ofjust overathousand stillbirths andneonatal deaths, andhavecompared themwiththerecords ofanequal numberofbabies whosurvived beyond theageof4weeks.

1. 1. A review of 6,860 cases of electively induced labors has been presented. 2. 2. The most effective method of inducing labor is simple amniotomy. 3. 3. Eighty-two and three-tenths per cent of the patients were in labor within 4 hours, and only 2.3 per cent had a latent period of over 24 hours. 4. 4. Pitocin stimulation was used in patients with prolonged latent periods or desultory labors with intrapartum fever. 5. 5. Serious though must be given to performance of cesarean section when the latent period is prolonged and infection is present, if labor cannot be stimulated within 24 to 36 hours. 6. 6. There was one maternal death related to induction. 7. 7. The principal fetal hazards were (a) prematurity, 3.1 per cent; (b) prolonged latent period, 5.0 per cent; (c) malpresentation, 0.9 per cent; (d) prolapsed cord, 0.3 per cent. 8. 8. There were 6,889 babies born. Of these, 37, or 0.6 per cent, were 9. stillborn, and 55, or 0.8 per cent, died neonatally. The perinatal mortality was 1.4 per cent. 10. 9. Thirty-nine of the perinatal deaths (0.6 per cent of the babies delivered) were directly related to the elective induction. 11. 10. A conservative attitude should be maintained by the specialist toward the elective induction of labor. The average general physician should allow labor to start spontaneously.

Extract Perinatal deaths are common among piglets in New Zealand. They tend to occur in epidemics, they are independent of the type of soil or of feeding practices, and are most common in the litters of young sows and of those recently introduced into the piggery. Affected sows may show signs of sickness and inappetence before farrowing, and the piglets are usually born dead (delivered in intact foctal membranes) or they may be weak and die within 24 hours of birth. A sow that has once delivered dead piglets rarely, if ever, does so at later farrows.

This 308 page hardcover summary of a conference costs $8.50. At 2¾¢ per page (typewritten print!) it is at best a poor buy. The book presents current as well as potential techniques for monitoring mutagenesis and teratogenesis, topics of particular interest in this era of environmental, ecologic disaster. Unfortunately, in the words of one of the contributors, the volume is "heavy on theory and light on accomplishment" (page 246). The following general methods are discussed in an exhausting, tedious, and inarticulate manner. Prenatal methods, employing detailed anatomic examination of all fetal deaths as well as amniotic fluid analyses are not logistically practical in an era when viable perinatal deaths are seldom autopsied or carefully examined. Monitoring for major and minor malformations using both retrospective (death certificate) and prospective techniques also appears to be logistically impractical and unrewarding. Again, the most telling criticism comes from one of the contributors (page 103)

The purpose of this communication is to record the occurrence of hyaline membrane disease of the lung in Thailand. A review of the autopsy records for 1959 at the Chulalongkorn Medical School in Bangkok disclosed 9 cases of hyaline membrane disease among 58 postmortem examinations conducted on infants who died during the perinatal period. The most recent year, 1959, for which autopsy records were available was selected for study. A total of 65 perinatal deaths was tabulated in the autopsy records of this year. Each of these cases was reviewed, and lung sections were restudied. Material from 7 cases was not available for review, and they were therefore excluded from consideration. Of the remaining 58 cases, 9, or about 15%, showed the classical changes of hyaline membrane disease. All of these 9 infants were alive at birth, succumbing in from 7 to 37 hours after delivery. The birth weight ranged