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The problem of foetal weight estimation has not been satisfactorily solved to date. We studied quantitatively the influence of the mathematical approach and the number of distance measurements of different parts of the foetal body, on the accuracy of prospective calculation of the actual foetal weight. Of 230 foetuses of known gestational age we measured via ultrasound 13 lengths of head, rump and extremities during the last three days before delivery. 22 types of formulas were analysed. To decide on the best mathematical way of calculation we recalculated all coefficients in all formulas for each study group. In this way each formula can yield best possible results for the presented group. Three formulas yield very good results--a logarithmic type using 7 measured distances, and 2 linear types of formulas using 10 and 11 measured distances. The standard deviations of the differences (calculated weight minus actual weight) range from 216 g to 219 g. The frequency of differences greater than +/- 15% of the calculated weight ranges between 3.0% and 4.3% of the cases. Miscalculations of more than 700 g (absolutely) have not been noted. In addition, five other formulas (logarithmic and linear types with 5 to 8 measurements) have yielded good results. Using 5 to 8 measurements, the logarithmic types of formulas are better than the linear ones. The mathematical types of formulas cannot achieve the improvements resulting from a greater number of measurements.

In a synoptic schema are presented the percentiles curves of the biparietal diameter, the sum of the sagittal and transversal thoracic diameter and the fetal weight (Lubchenco modif.). To attain the percentiles curves of the ultrasonic parameters we applied 5400 mensurations of the biparietal diameter and 1300 mensurations of the thorax. In the diagram are published the percentiles P 10, P 25, P 50, P 75, P 90. It is possible to diagnose a divergence between the cephalic and thoracic growth (dystrophia, hypertrophia) and estimate the gestation weeks.

In the University-Clinic of Obstetrics and Gynecology (Charite) of Berlin we carried out about 20,000 examinations with the method of ultrasound. In the presented paper we want to put a declaration about the survey of this method in the system of diagnosis during pregnancy. Our experiences led to the same conclusions like published in international journals. The following parameters have been successful in clinical practice: biparietal diameter, position of the fetus, localisation of placenta, diagnosis of heart-beat and other. We concentrated our investigations to the calculation of actual fetal weight in utero. For this aim we established formulas; thus we are able to calculate the weight with the aid of 4 parameters of ultrasound. The evaluation of 621 cases has shown the deviation of the calculated weight compared with the real birth weight is without problems in the group of big babies. For the group of premature deliveries it is nessecery to carry out tocolysis until a calculated weight of 2500 g. In all the babies, calculated in this largeness everyways the real birth weight has been more than 2000 g.

The validity of the modern methods of fetal monitoring to decide for the indication of urgent obstetric operations. The reliability of the modern supervision of the fetus is studied in cases of doubtful fetal heart action. Up to the present day we have no method for the exact estimation of the degree of a damage to the fetus. In such a precarious situation we should use all available methods for the diagnosis of the fetal condition, because the results of only one of the methods offer insufficient evidence. By means of the literature the alterations in the ECG of the dying fetus are interpreted in comparison to artefacts. In cases of doubtful fetal heart action we recommend in addition to the clinical findings to record the fetal ECG, to controll the actual fetal pH and attempt an investigation by ultrasonic.

The concentration of hypoxanthine in plasma was suggested as an indicator of hypoxic conditions in newborns. We examined the concentration of hypoxanthine in maternal venous as well as in umbilical cord blood during pregnancy and during and after labor. The concentration of hypoxanthine in the cubital venous blood of nonpregnant healthy women and in healthy pregnant women and in women with complicated pregnancies was the similar. During birth there is an increase of the hypoxanthine concentration in maternal blood. This could be caused by the muscular work involved in giving birth (contraction, pushing, breathing). The values increased from 2.0-4.1 mumol/l in normal and abnormal pregnancy up to values of 9.4-11.8 mumol/l immediately after delivery. At the end of delivery the level of hypoxanthine is higher in the venous blood of the mother than in the umbilical blood. The concentration of hypoxanthine in umbilical venous blood and umbilical arterial blood did not show any significant differences. When clinical symptoms of hypoxia (depressed state of the neonate, high Thiringer asphyxia score, low Apgar score) were observed in the neonate, the hypoxanthine concentration in the umbilical vessels was increased (normal 4.7 mumol(l; slightly depressed 7.6 mumol/l, severely depressed 10 mumol/l).

At first the allround etiology of premature birth is explained in the paper. There are to distinguish three groups: 1. Causes with known etiologic mechanism. 2. Causes with partly known etiologic mechanism. 3. Dispositions for premature birth. These are concluded from statistically investigations. In the last group are collected the patients from which are established some known scores for diagnosis of the risk of premature birth. All the scores but have a detriment. If they want to detect about 90% from premature births one must carry out examination and observation about 40% from all pregnant women. For this the scores are not suitable for selection of patients to observe in a special consultation. The organised care for pregnant women must be in such a way that all the criterias of imminent prematurity will be detected. This way has been successfull in our hospital.

Parameters which have influence on the accuracy of the calculation of fetal weight. We estimated about 1500 cases in which we within three days before birth carried out an ultrasonic measurement. Most of the differences between the calculated prenatal and the scaled postnatal weight are caused by errors of measurement and abnormalities of the fetal development in pathologic pregnancy. In severe intrauterine retardation the actual fetal weight will be calculated about 600 g to heavy. In fetopathia diabetica with fetal hypertrophy the weight will be calculated about 400 g to small. Opposite to these sources of error the biologic variation and the inaccuracy involved by the mathematical regression model are small. The regression formula should be adapted by 1000 cases.

The during labor removed head of the newborn (configuration) regular within the following 4 days will become again his normal figure. This procedure we call "refiguration". By means of X-ray and hydrocephalometric investigations during the refiguration we conclude on the morphologic alterations during preceded configuration. Though we got the opinion, that by the force of labor the procedure of the configuration leads to a diminution of the volume of the head and to displacements of the cerebral substance. We think, that this are parts of the normal compensatory mechanism of the fetus against pressure under birth.

Evaluation of multidimensional screenings within the prematurity-dysmaturity-preventive-programmes. We estimated the PDP-programmes recommended in literature. The result is discussed together with the analysis of our 6000 investigated cases. We found, that, the published scores, using many factors and basing on multidimensional regression or discriminant analysis, give not a satisfactory result in predicting birth of a newborn with low weight. If you wish predict right 90% of all low birth weight infants, your risk group contains about 50% of all pregnant women. If you wish to have only a trifling risk group of 10% of all pregnant women, you can predict right only about 50% of all infants with low birth weight. We recommend for practice to go an other way. We find it is better for prophylaxis and therapy of the threatened premature labour to diagnose and treat special risks as placenta praevia, multiple pregnancies, hemorrhage during pregnancy, smoking and anamnestic previous prematurity. The summarizing of risk points is to our opinion of minor importance. Only pregnant women with risks, which need expansive apparatus and specialists, should be sended for a perinatal center (Rh-incompatibility, hydramnious, suspicious malformation, severe intern diseases). Especially the diagnosis and therapy of genetic defects must be carried out in a center. About the possibility with genetic diagnostic to diminute the birth of impaired children of low weight is given a particular explanation.

In face of the simplified performance of the mechanical course of birth in the manuals of obstetrics, in reality the conformations of the mechanical course are immense. This we found also in our investigations. But mere an alteration from the classical form of the course of birth is not an indication of intervention. The mechanical course of birth is, however, of much interest for determination of a possible localisation of an injuring mechanism in a brain damaged infant. It should be noticed exactly in the obstetrical journal.

We recommend to define the "birth trauma" as all influences, which injure the fetus under birth in any pattern. These birth traumatical agents we divide in the group of predominant mechanical agents and in the group of predominant metabolic components (hypoxia). This definition is explained and justified in a matter-of-fact way. We discuss the advantages of its application in practice.

We have studied the propotions of displacements from fetal cerebral parts during simulated intrauterine pressure. Stillborn children from the death to the experiments last only some hours, were put in cephalic position in our birth model. The cavum uteri was simulated by a metal cylinder, in which we gave compressed air for simulating the labor. The pressure was held about 100 mm Hg. A rubber cuff was fixed on the metal cylinder and let an opening of 8 cm, simulating the cervix uteri. The model with the death infant in it was frozen and than the fetal head sectioned in slides of 1,5 cm in the right of the birth pressure axis. We found, that the gyri occipital were widened, opposite the gyri frontal were compressed. Parieto-occipital we found a venous blood congestion. The brain stem was kinked and displaced dorsal. In one case we carried out in the meantime an aniogram. The cerebral vessels became under the pressure elongated. This was reversible by decrease of the pressure. The limitation of such model studies are give in some facts. We do not know, how much the loosening of the skull, following the fetal death, leads to a more than normal shifting. We further do not know, which proportions of the displacements of the cerebral substance during labor from the fetus could be compensated. Our findings suggest, that it is possible, that cerebral blood flow will be altered by displacements of the cerebral masses during intrauterine pressure. But we have not exact informations about it.

Recommendation of recording influence of birth mechanics on the head of the newborn. The birth mechanical influence, visible on the head of the neonate, by a single manner can be recorded. Two presented figures give an example for a possible registration of configuration and injuries. Visible configuration of the neonatal head is the extern finding of related dislocations of cerebral substance. Latters are most followed by a slight neurological symptomatology of the newborn, which most is reversible. The topical location of an irreversible brain damage in some cases, diagnosed in childhood, can be related to the mechanical course of birth.

In this paper is investigated, in what a quantity the caesarean section can improve the prognosis for the infant. Two groups (1968 to 1972 and 1973 to 1975) are opposed. The decrease of the neonatal mortality from 8,2% on 5,0% can be subsequently of the widening for caesarean indication during the second time (1973-1975). In spite of other minds we have found, that the birth traumatical loading of the newborn during vaginal delivery of breech presentation is more severe in nullipara than in multipara. Hypothetical estimations show, that if we had carried out in all breech positions in nullipara the caesarean section, we had 7 infants (2,7%) which not had died. But this way had lead to a rise of the section frequence from 24,5% to 72,3% of all breech presentations. Because of the high mortality and morbidity of the caesarean operation most of the authors recommend the expanded indication for caesarean section and not the general indication. Our own screening for expanded indication has been presented.

From 1971 to 1974 in the Department of Gynecology and Obstetrics of the Humboldt-University of Berlin we monitored 1132 fetuses. The extent of the analysed groups runs to 306 to 632 cases, according to the completeness of the investigations and documentation. We have compared our CTG-findings with those of other authors. We found relationships between the risk factors and the CTG findings: for low weight fetuses more frequent Dip I, for maternal vitium cordis more frequent fetal tachycardia, for meconium stained liquor more frequent smooth baseline (silent) for EPH-gestosis (toxemia) more frequent Dip II (late deceleration) and variable deceleration. The relationships between the risk factors and the CTG findings are loose and not suitable to verify the great differences in frequency of the CTG pattern, published in the literature. We believe, that these differences are caused by different definitions and subjective interpretation of the CTG.

The acute syndroms of the brainstem of cerebral injuried newborns by the birth trauma (casuistry). The neurologic clinical symptomatology of the acute syndroms of the brainstem are described in brief. Three cases of damaged newborn with this syndroms are particular published. Especially performed are: the possibility of repair, the changing of the symptoms, the danger of manual transformation of abnormous cephalic positions and the need of topological diagnosis in follow-up of special care.

The therapy of imminent prematurity needs specific treatment of the respective illness. Moreover there are three fundamental measures: 1. To appease the patients and to applicate sedatives. 2. To carry out tokolysis with medicamentes. 3. To carry out cerclage operation in order to close the uterine mouth. These possibilities must be combined in various ways dependent from the success in every individual case. These measures also are suit in prophylaxis, for example in disorders of former pregnancies. All schemes of therapy adapted to the individual case. The dosis must be determined from the effect of therapy. A particular view point must be the hospitalisation between 28. and 32. week of pregnancy in cases of twins or placenta previa. Also in cases of early rupture of amnion prolongation of pregnancy must be aspired.

Evaluation of more than 1500 cases has shown that real foetal weight can be calculated on the basis of mean thorax diameter, if linear ultrasonic measures are used. Addition of more parameters will render calculation more sophisticated and complex, though gain in accuracy will be unimportant. Accuracy depends not only on biological variation but even more on precise measurement by the examiner. An aid for more convenient calculation is described.

In a prospective study process curves of fetal development were done for 1618 patients using humerus and femur with at least 5 ultrasound investigations per patient. These prenatal ultrasound values were divided in 7 groups and compared with the postnatal values of newborns to get a reliable statement. Typical curve processes have been demonstrated for low-profile development, mild and severe intrauterine growth-retardation, a macrosomy, and for a diabetic fetopathy. The following results have been gained from ultrasound values of prospective staging of fetal development. From 1618 cases 1263 cases (78.0%) have been staged exactly. 333 cases (20.6%) were not total exact. 22 cases (1.4%) have been evaluated wrong. From 121 cases of IUGR 95 cases (78.5%) have been staged correctly. Humerus and femur values are below the normal range in for IUGR group. 77 cases (62.1%) from the 124 macrosomal newborns have been detected right. Only 2 cases (4.9%) from the 41 cases of diabetic fetopathy have been evaluated lower. Humerus and femur values in severe macrosomia were over the normal range in contrast to the diabetic fetopathy. Our scheme for control of fetal development which use humerus and femur as additional parameters shows higher precision.

Ultrasonic findings in a women's clinic are very heterogeneous. In their totality they will be unmethodical very quick. Therefore we decided to organize four separate card indexes: 1. gynaecologic findings; 2. breast diagnostics; 3. supervision of pregnancy and look for fetal malformations; 4. single findings in pregnancy.--Each card index does not exceed 2000 to 3000 patients by appropriate actualization. A filing card for supervision of pregnancy and systemic detection of fetal malformations is created.

We analyzed 5 cases of uterine rupture observed in our clinic in the last 8 years (= 0.36 per 1000 deliveries) because spontaneously appearing ruptures of a normal uterus often have symptoms which may mislead our efforts like amniotic fluid infusion or clotting defects. All our 5 cases were multiparous women, in 4 cases oxytocic drugs were applied and only in one case there was a histologic damage of the myometrium. In no case classic sharp pain and cessation of contractions could be observed, only in one case painful abdomen and tenderness of the uterus. On the other hand shock could be seen in every case, vaginal bleeding in 4 cases and alteration of fetal heart frequency in 3 of 4 cases with primary living fetus. The different symptoms may occur as to time in a variable sequence. Therefore the right diagnosis is made often very late. In accordance with the literature a digital control of the uterine cavity is proposed in every case of an acute event during childbirth, especially evidence of shock, also if another diagnosis than rupture of the uterus is more probable.

By means of a casuistic about successful course of pregnancy and labour by a patient with methaemoglobinemia (HbM Leipzig II) is reported.

By means of schematic illustrations we demonstrate the working point of the power of labour, obstetrical forceps and vacuum extractor, The bones of the fetal skull are by sutures movable fastened together. Every extraction so will rise the intracranial pressure of the fetus, because the resistance of the birth canal tissues must be overcome. This for the extraction needed power and rising of the intracranial pressure is independent from the instrument with which the extraction is carried out. It is impossible to make a "cage" around the fetal head with the Shute forceps during extraction, to protect the fetal head from the extraction power. Another question is, that some instruments (included vacuum extractor) can limit the used power. By using forcipes with crossed lock without fixation the forces for extraction are not limited and there is a need of better operative technic. By the comparison of the forcipes from Shute, Naegele and Zweifel we can summarize, that for success is decided the indication and good operative technic and not the instrument. Every instrument for vaginal extraction has advantages and disadvantages in different obstetrical situations.

Three cases were detailed pointed out. They demonstrate the opinion of the author about the relations between mechanical cerebral pressure on the fetus, fetal CTG, fetal pH and neurological findings during neonatal period. It is possible, that a cerebral damadge resulting from mechanical birth trauma occours without the findings of variable decelerations and Dip II in the fetal CTG or without fetal acidosis. Our conclusions are: terminate the delivery after 2 hours severe Dip I under normal fetal pH or after 12 hours of efficient labour.

Evaluation of ultrasonic fetometry in diabetic pregnancy. In 51 cases we have carried out 134 ultrasonic investigations. The diabetes we classified to the score of White A--F. To evaluate the increase in fetal weight and the maturity in a qualified sense, we measured the biparietal diameter, the transversal and the sagital diameter of the thorax and the trunk length. The findings were registered into diagrams of our percentiles of development.--The fetopathia diabetica will be diagnosed right, if it is joint with fetal hypertrophy. The beginning of the macrosomia of the fetus is possible to recognize from the 32th week of gestation.

The parameters of the intrapartal fetal CTG and the actual pH are related to each other and to the Apgar score of the newborn. The interpretation was carried out by means of groups of 300 to 600 cases. The actual fetal pH has the most compact relation to the Apgar score of the newborn (C equals 0,31). But also this contingence is unsatisfactory. At fetal acidosis most of the Apgar scores are pathological, in that manner the pH is the most important test for indication of operative delivery. The rare CTG pattern as dip II and variable decelerations combined with tachycardia of bradycardia, the bradycardia with 80 bpm or less, are likewise indications of urgent delivery.

Extrauterine pregnancies scarcely achieve an advanced developmental stage and were rarely diagnosed preoperatively. Even the ultrasonic B scanning don't eliminate the difficulties in recognising the ectopic pregnancy. We can demonstrate this by means of 3 case. In one of them, a case of full term abdominal pregnancy with healthy fetus, we could diagnose this preoperatively.

The possibility to diagnose slight masked malformations increased in the last years both by improving technical ultrasonic equipment and progressive personal experience of the examiners. With regard to time and technique it is impossible to treat fully all possibilities of ultrasonics, because the time-patient-ratio would be to enormous, the malformation rate would be to low and not any malformation is followed by an obstetric consequence. Additionally most of the malformations can be diagnosed or excluded only in determined gestational weeks. Therefore we present as a compromise a checklist which guarantees as well as examination of 8-10 patients per hour as a detection of the most important malformations. Abnormalities like double monsters, hydrocephalus, anencephaly, microcephalus, posterior and anterior tumors, thoracal and abdominal cysts, micromely and amely should not escape. Smaller abdominal cysts caused by filled intestines are very frequent. Controlling these findings, like looking for defects of extremities e.g. dub-feet is impossible, but not necessary, too, because of the lacking antenatal consequences.

Selection of birth-traumatical injured newborns for follow-up with special care.--Premature newborns most will be in a special care during infancy and childhood. For all the mature infants this way is to expensive. We publish a compilation of abnormal neurological findings suitable for selecting with high risk of birth traumatical induced brain damage. The risk-group contains about 5% of all mature newborns. This number is small enough for a high expense within the bounds of the common care for mother and child.

It can be suggested that a NSE concentration in body fluids above the normal range may indicate brain damage, because NSE is found in neurons and neuroendocrine cells only. In this paper the concentration of the neuron specific enolase (NSE) in the amniotic fluid of normal and high risk pregnancies was investigated. Sixty-three samples of amniotic fluid were collected from 55 pregnant women and women in labor between the 19th and the 42nd gestational week. In 24 normal pregnancies 1.02 +/- 0.31 microgram NSE/L (mean +/- SD) were found. A relationship of NSE concentration was not found for gestational age, uterine contractions, age and parity of the mother, infant's birth weight or 1 min Apgar score. Maternal diseases such as diabetes mellitus, hypertension and others do not result in any increase of NSE concentration in the amniotic fluid (N = 20; 1.06 +/- 0.24 microgram NSE/L). Fetal and birth related high risk factors such as meconium stained amniotic fluid, cord around the neck, severe decelerations of the fetal heart rate or combinations of these factors caused the NSE concentration to exceed significantly normal values (N = 17; 2.22 +/- 0.87 microgram NSE/L). Due to its high organ and cell specificity, NSE may be a possible parameter for brain damage due to hypoxia in the fetus and newborn; however, only subsequent neurological and psychological examinations of these children can indicate the prognostic value of an elevation of NSE concentration in amniotic fluid.

Within systematic fetal supervision by CTG of the risk pregnancies sometimes single decelerations of variable type are observed. Most they didn't repeat. In the majority of the cases in follow up pregnancy the child will be born spontaneously without complications. In a lot of other cases, however, there appears fetal distress. For prognostic statistical evaluation of antenatal decelerations we watched prospectively the following groups: 1.43 cases with severe antenatal variable decelerations, 2.39 cases with mild antenatal variable decelerations, 3.88 cases without antenatal decelerations. - The appearance of severe decelerations was followed by fetal distress in 42%, by perinatal death in 12%, and by caesarean delivery in 40%. Fetal prognosis in this group is significantly more unfavourable than in the two other groups with mild decelerations (fetal distress 15%, caesarean section 23%, no fetal loss) or without decelerations (fetal distress 13%, caesarean section 10%, no fetal loss). - Single severe decelerations in antenatal CTG must be evaluated as a symptom of high fetal risk.

Analyses were applied by the authors to 278 samples of maternal serum, 106 amniotic fluid samples, and 81 samples of umbilical vein serum, since no complex study into alpha-amylase activity in the context of pregnancy and labour had been found in the literature. Rise in amylase activity in amniotic fluid, depending on length of gestation, had been one of the points made elsewhere in a publication and was confirmed by the authors' experiments (17th to 22nd weeks of pregnancy: means = 1,8 +/- 0,8 AU/1; 37th to 41st weeks of pregnancy: means = 10,3 +/- 6,0 AU/1). Somewhat relaxed relationships between amylase activity in maternal serum, on the one hand, and age of the pregnant woman as well as activity in amniotic fluid, on the other, were found to be without any clinical relevance. Additional correlations were not detected, not even those with complications in the course of pregnancy and in labour. Global measurement of amylase activity is of no importance to obstetric diagnosis.

Experiences by continuous ultrasonic measurements during pregnancy. The authors have published earlier a diagram for use to evaluate the fetal development. The aptitude in practice has been proved.--To evaluate normal fetal growth the percentiles curves of Lubchenco are less suitable than of the GDR. But also the last show the normal weight 100 to 150 g to small during the 30th to 36th gestation week in comparison to the calculated fetal weight of normal pregnancies. The intrauterine retardation and hypertrophy can well be diagnosed if the beginning of the measures occurs at the end of the first trimenon of the pregnancy. But it is necessary to know the possibilities of apparent "abnormalities" in normal pregnancy, as ceccation of the fetal growth for 3 or 4 weeks, the late flattening of the biparietal diameter in breech presentation etc.--Our effort to simulatae the fetal growth in intrauterine retardation by using beta-stimulating sympathicomimetics, was without of success.

6780 mothers postpartaly were asked how they assess their occupational employment. We made following groups: the work is physically very strain, middle strain or not strain, the work is mentally very exert, middle exert or not exert. We selected 2/3 or all cases to have high risk in pregnancy or neonatal period. We found statistical coherences between the subjective judgement and the social status. The correlations between the subjective judgement of the occupational employment and the risk factors of the perinatal period were loose. The correlations between the perinatal risk factors and the objective social dates (trade, number of children, age of the mother etc.) are better than between perinatal dates and subjective assessment of their occupational employment by the mother.