In Journal of Obstetrics & Gynecolgy Britanic Empire. 29 : 572.
The expenses of this investigation have been defrayed by a grant from the Medical Research Council.
DURING recent years numerous observers have studied the pathological lesions that may occur within the foetal head during labour. Special attention has been directed to lacerations of the dura mater and to the occurrence of hemorrhage ; and the importance of various obstetrical factors in the causation of these traumata has been emphasized. Further, these investigations possess a practical interest in so far as the infant is concerned, for they suggest methods of treatment which are certainly worthy of further trial.
In this paper is included a study of 80 neonatal deaths and stillbirths ; but since I was unacquainted with the method of treatment by lumbar puncture until a late stage in the examination of this series, the cases so treated are not yet numerous enough to justify definite conclusions. Only a brief outline of the treatment recommended will therefore be given in the present communication.
ANATOMY AND PHYSIOLOGY.
During a normal labour the following three factors are important in safeguarding the life of the foetus :
- The mobility of the bones of the cranial vault. This permits a gradual moulding of the foetal head, and protects the brain from sudden and severe damage. The degree of moulding is restrained by the intracranial dural septa, the action of which as controlling ligaments has been described and demonstrated by Eardley Holland1.
- The presence of membranous fontanelles and sutures allows an increase in cranial volume to occur, for example, during cerebral and meningeal congestion, without a dangerous rise in intracranial tension.
- The Iow excitability of the foetal respiratory centre, still further reduced during the normal asphyxia of birth, prevents premature respiration.
In dystocia, head-moulding is frequently excessive, and cerebral contusion results ; if the dural septa be torn, greater damage to the brain may occur. Further, lacerations of the dura mater may cause rupture of blood-vessels with haemorrhage.
When the intracranial volume is greatly increased by intense congestion and oedema, or by bleeding, the distensibility of the foetal skull is not great enough to prevent a dangerous increase in intracranial tension. In such circumstances foetal asphyxia is pronounced, the excitability of the respiratory centre being so reduced that even artificial stimuli may fail to call forth a response, and the infant then dies of atelectasis.
It is not necessary to describe the anatomy of the dura mater, of which a full account is given by Eardley Holland1. But it is interesting to note how closely the radiating fibrous bands resemble the spokes of a bicycle-wheel. This arrangement is obviously well-suited to resist excessive stress during cranial distortion of labour.
References will be made in the next section to the must frequent sources of haemorrhage.
Thomas Radford2 reported that he found intracranial haemorrhage in two infants born after difficult labours. Among recent observers, Warwick3 found that in a series of 36 stillbirths and neonatal deaths, 50 per cent. showed intracranial haemorrhage;
Schafer4 found this percentage to be 20 in a series of 680 autopsies upon newly-born infants; and of his cases of haemorrhage, 71.4 per cent. showed lacerations of the dural septa. Ehrenfest5 claims that tentorial ruptures occur in 30 to 40 per cent. of foetal and neonatal deaths occurring during or soon after delivery.
Eardley Holland1 found these ruptures to be present in 81 of 168 fresh foetus, that is, in 48 per cent. Subdural cerebral haemorrhage had occurred in all but six of the foetus showing dural lacerations.
This evidence demonstrates the frequency of grave intracranial trauma with haemorrhages. It is probable, however, that the lesser degrees of damage to the cranial contents have not received the attention which they deserve because at autopsy the macroscopical lesion is not striking.
Venous congestion of the foetal brain and meninges occurs during a normal labour. When it is developed to an excessive degree it may be no less dangerous to the foetus than a large subdural haemorrhage. It is a type of birth-trauma which must be fully considered not only because of its serious effects, but because it appears to be more easily and satisfactorily treated than are the grave intracranial injuries.
Intracranial birth-lesions may be divided into two groups : those associated with intracranial haemorrhage, and those in which intracranial haemorrhage has not occurred.
Cases Associated with lntracranial Haemorrhage.
In a majority of examples included in this subdivision ruptures of the dural septa are found. These tears are usually tentorial, but lacerations of the falx cerebri may be seen occasionally in cases delivered in persistent occipito-posterior positions.
The tentorium may be torn on one or on both sides ; the half which corresponds with the leading parietal bone is usually the more liable to injury.
Tentorial ruptures may be complete, that is to say, they may involve the whole thickness of the septum ; or they may be incomplete, in which case only one of the tentorial layers, commonly the superior, is torn.
Haemorrhages may take place from the following sources :
(1) Small tentorial vessels, coursing among the fibres of the tentorium cerebelli, may be torn ; the blood then collects in a film upon the upper surface of the cerebellum or upon the upper tentorial surface, draining posteriorly around the occipital lobes. The small venous effusions, amounting only to purple stains, which are not infrequently seen amidst the fibres of the dural septa, are of no clinical significance.
(2) Vena magna Galeni, which is frequently distorted during moulding of the head, may rupture at the point where the straight sinus is formed. The blood collects posteriorly to the mesencephalon, and drains downwards around the cerebellum, pons and medulla.
(3) Cerebral veins, near their terminations in the superior longitudinal sinus, may be injured. Cushing6 has pointed out that these veins are inadequately supported as they traverse the subdural space, and are frequently distorted, sometimes with rupture, during parietal overriding. The effused blood flows downwards in the subdural space. Usually the haemorrhage is unilateral, but sometimes it is bilateral.
(4) Superior longitudinal sinus, transverse sinus and straight sinus. It is only in the most severe types of birth-injury that such examples are found. The infant is almost invariably stillborn.
(5) The internal cerebral veins, for instance the choroidal veins, may be damaged. These examples are rare, and are found almost exclusively in stillborn premature infants. The blood-collection may occupy the lateral, the third and the fourth ventricles ; blood is also frequently found in these cases within the spinal membranes.
Instances of intracranial haemorrhage without injury to dural septa are infrequent. In these cases bleeding is caused by the rupture of vessels while in a state of congestion.
Lesions characteristic of asphyxia are found in the thorax and abdomen ; that is to say, the lungs are atelectatic ; the cardiac auricles and large veins are congested ,with dark-coloured fluid blood, and small ecchymoses may be seen scattered about the heart, pericardium, lungs and pleurae. The viscera are congested, and may be the seat of haemorrhages. This lesion is seen most frequently in the suprarenal glands of premature babies, and is said to be especially frequent when the infant has presented by the breech.
Cases in which lntracranial Haemorrhage has not Occurred.
ln these examples, in which death probably results from compression and asphyxial poisoning of the vital nerve-centres in the medulla, it is usual to find general congestion of the intracranial venous sinus and their tributary veins and of the choroid plexus.
The meninges present a watery appearance, and the brain appears to fit the cranial cavity more closely than usual ; its substance is congested and slightly oedematous. The cerebrospinal fluid is usually increased in volume. There may be slight lacerations of the dural septa, especially of the tentorium cerebelli.
In a majority of cases asphyxial lesions are found in the thorax and abdomen of the infant.
The production of intracranial trauma may be due to predisposing and determining causes.
Prematurity is undoubtedly of great importance. The softness and mobility of the cranial bones, as ,vell as the immaturity of the vessel-walls render premature foetus peculiarly susceptible to the effects of moulding and of asphyxia ; not only intracranial, but also subpleural, subepicardial, visceral and retinal haemorrhages occur with unusual frequency when the vessel-walls are weak.
If the foetus is also the subject of congenital disease, such as syphilis, it is probable that the vessel-walls are still more fragile, and more liable to suffer damage during labour.
The haemorrhagic diathesis, as a predisposing factor in the causation of intracranial haemorrhage, has been especially emphasized by American investigators. The average blood coagulation time in the newborn infant is five to nine minutes.
Rodda7 has shown that this interval normally becomes prolonged up to the fifth day of life, and returns again to its previous figure by the tenth day. It is reasonable to assume that in certain infants the coagulation time may be considerably longer than normal, and that in such cases grave danger may arise. But it is unlikely that the bleeding tendency is common. If it were, the mortality-rate of newborn babies would be very high, for even a very minute vascular rupture – possibly a frequent occurrence even in normal deliveries – would then give rise to dangerous and perhaps fatal haemorrhage.
These are numerous, and do not admit of satisfactory classification. A useful practical subdivision is as follows :
(1) Causes of excessive head-moulding.
(2) Causes of too-rapid head-moulding.
(3) Causes of foetal asphyxia.
In a majority of cases those factors which produce either excessive moulding or too-rapid moulding give rise at the same time to foetal asphyxia.
Causes of excessive head-moulding. The most important cause is disproportion in size between the maternal! bony pelvis and the foetal head ; for example, pelvic contraction and oversize of the foetus. Deficient cephalic flexion, the rigid cervix and outlet of the primigravida, and pelvic growths are less frequent causes. Some writers (Holland1, Ehrenfest5) have called attention to the fact that measures undertaken to support the perineum may be so vigorously carried out that intracranial trauma is caused by compression of the squamous occipital bone against the maternal pubic arch.
Causes of too-rapid head-moulding. Delivery which takes place very rapidl y, even when spontaneous, is dangerous to the foetus, especially in breech presentations. In these circumstances dilatation of the maternal passages is inadequate and gradual head moulding cannot occur. On these grounds Ehrenfest5 and others pointed out the possible dangers of pituitary extract.
Causes of foetal asphyxia. As previously mentioned, extreme intracranial congestion occurs in most cases of difficult labour. As a result the distended vessels are more liable to rupture during cranial distortion, and occasionally the distension itself is sufficient to break the vessel-wall. Certain other conditions, for example, prolapse of the umbilical cord, accidental haemorrhage, placenta praevia, and torsion of the umbilical cord around the foetal neck, may produce foetal asphyxia without excessive moulding.
Moreover, in a slow but otherwise normal labour, a dangerous degree of intracranial congestion may develop.
Attention must also be drawn to the possible influence of forceps, and of the methods of resuscitation in producing intracranial trauma. Forceps have been unjustly blamed. Abt8 states that it has been estimated that 30 to 40 per cent. of infants delivered by instruments suffer intracranial haemorrhage. Except when forceps are applied too early in the labour, or when the premature infant is delivered too rapidly, it is probable that the conditions which are the indications for the use of forceps are also mainly responsible for any foetal lesion which may occur.
The various methods of resuscitation have been suggested by Ehrenfest5 as causes of intracranial damage. Though it is unlikely that treatment would be so vigorously performed as to cause intracranial trauma, aggravation of damage suffered during labour and the re-starting of haemorrhage when clotting has just begun may follow certain of the more nocible methods. The « swinging » method, and the holding of the infant head downwards, would appear to be especially dangerous.
In a few cases none of the above determining causes can be traced. The infant born at the end of a normal pregnancy may suffer intracranial trauma during a labour which is apparently perfectly normal. It is in these cases, which are certainly uncommon, that the idea of the presence of the haemorrhagic diathesis finds its strongest support.
DIAGNOSIS AND PROGNOSIS.
In the diagnosis of intracranial trauma in the living newborn baby, the obstetrical history of the mother, and accurate details of the labour should be ascertained. External evidence of cranial stress may be present in the form of scalp injuries, extensive formation of caput succedaneum, cephalhematoma, excessive moulding, bone fracture or depressions ; but these signs may be absent even in the most severe forms of intracranial trauma.
Clinical signs are usually present at birth, or develop shortly after ; occasionally they are absent until the fourth or fifth day of postnatal life.
The most frequent sign of cranial stress is an abnormal colour of the foetal skin. lnstead of the rosy pink of the healthy newborn baby, a bluish asphyxial colouration is seen ; it is most prominent upon the face and feet. The lips may he surrounded by a pallid zone ; in more severe cases, white rather than blue is the prevailing colour. Frequently the early asphyxia appears to be satisfactorily overcome by treatment. ln a majority of cases the respirations are shallow, irregular and slow, and the pulse is infrequent and full.
Disinclination to suck is a very important feature ; the swallowing reflex may be lost in the more severe examples.
Epistaxis and pharyngeal bleeding often occur. If the intracranial haemorrhage be progressive there may be slight pyrexia.
When there has been diffuse bleeding into the cranial cavity, for instance in the subdural or subarachnoid space there may be no localizing sign ; but if a circumscribed haematoma has formed, a study of the nervous manifestations may provide information as to its probable site. If the blood is collected chiefly above the tentorium cerebelli the nervous signs are cortical in nature. The child is quiet and restless by turns ; be resents handling and occasionally gives a sharp scream reminiscent of the « hydrocephalic cry ». Spasms of the facial and limb muscles, which are not infrequently unilateral, may occur, and are of great diagnostic significance.
There may be nystagmus and ocular palsies ; the pupils, which react only feebly to light, may be unequal. Myosis and ptosis, when present, are usually found on the same side as the haemorrhage.
The anterior fontanelle is tense; generally it is not pulsatile. If the intracranial haemorrhage be copious, the anterior fontanelle and the eyes may protrude. Yawning and sighing frequently occur.
Convulsions may develop in any case of intracranial haemorrhage, but are more frequent when the bleeding is cortical : they are usually bilateral and arc of special significance when observed soon after birth.
Automatic muscular movements, for instance alternate closing and opening of the eyelids, may occur.
Medullary signs, such as irregular respiration and cyanosis, when present, develop later in the course of the illness. When the bleeding is mostly below the tentorium cerebelli, surrounding the cerebellum and medulla, bulbar signs supervene early. The infant is lethargic and quiet, but may take the breast at first. The muscular system is in a state of hypertonus characterized by rigidity of the neck and limbs, with occasional clonic contractions.
These spasms are especially frequent with bleeding in the posterior fossa.
The muscular excitability is exaggerated and the reflexes are brisk ; there may be erection of the penis and wrinkling of the scrotal skin.
Bulging of the anterior fontanelle may be seen as a late manifestation. Paralysis is not usually a prominent feature.
Cyanosis develops, and respiration may be irregular or of the Cheyne-Stokes type. Reflexes disappear and general convulsions usher in the termination of life, generally before the third day.
Haemorrhage into the lateral ventricles causes symptoms and signs resembling those found in infratentorial bleeding ; if convulsions develop they may be confined to the face. Medullary symptoms are speedily produced by haemorrhage into the fourth ventricle and spinal canal.
In most cases of intracranial haemorrhage the third or fourth day is the turning-point. Deaths directly due to haemorrhage usually occur before the fourth day ; atelectasis or aspiration pneumonia may produce a fatal termination between the fourth and tenth days.
ln cases which recover, paralysis is not usually noticed until several months have elapsed.
The importance of lumbar puncture in the diagnosis oi intracranial haemorrhage is very great ; and in view of its probable value as a therapeutic measure it is a procedure which be undertaken without delay in suspected cases. The technique of this operation does not differ from that employed for adult patients, and the ordinary lumbar puncture needle is quite serviceable.
There appears to be no danger in withdrawing cerebrospinal fluid so long as the rate of flow is faster than normal. The greatest volume removed at one puncture in this series of cases was 15 c.cms.
The colour and opacity of the fluid varies with the proportion of admixed blood and with the time which has elapsed since haemorrhage took place. At the first puncture the fluid may closely resemble whole blood ; while at a later puncture performed after the interval of a few days, it is found to be bright yellow in colour, almost transparent, and to contain but few erythrocytes ,which settle to the bottom of the test-tube as a small red deposit. The albumen content is considerably greater than normal.
Abt8 and other writers have claimed the diagnostic value of subdural puncture through the external angIe of the anterior fontanelle in cases of suspected supratentorial haemorrhages.
If physical signs point to a progressive haemorrhage, and the temperature is above normal. it may be of value to test the blood coagulation time in order to ascertain whether the haemorrhagic diathesis is causing continued bleeding.
While it is usually easy to recognize all but the slightest cases of birth-trauma, it is extremely difficult to diagnose accurately the nature of the lesion ; especially when the infant is premature, of poor colour, with shallow respirations and partial atelectasis.
Premature and full-time infants suffering with intracranial congestion produced during delivery may develop many signs noticed also in the subjects of intracranial haemorrhage : a bulging fontanelle, cyanosis and pallor, shallow whining respirations, twitchings and convulsions, and failure to suck may all occur in the absence of free bleeding. When general congestion has been severe enough to cause haemorrhage into viscera, such as the suprarenal glands and kidneys, shock is profound, and the infant may appear to be the subject of severe intracranial haemorrhage. Recognition of these facts emphasizes the importance of early lumbar puncture.
The immediate prognosis of intracranial trauma is favourable if the infant survives the fifth day, maintains a normal temperature and takes feeds satisfactorily. Abt8 states that the degree of asphyxia at birth is a guide in prognosis. Danger is constant so long as the colour of the infant’s skin does not return to the normal rosy-pink. Twitchings and convulsions are always of grave significance ; and protrusion of the anterior fontanelle, with a sensation of tenseness on palpation, should be regarded with misgiving.
COMPLICATIONS AND SEQUELAE
Brief reference only will be made to the complications and sequalae of intracranial trauma.
- Other injuries to the head, for instance, scalp wounds and fractures of the cranial bones.
- Injuries to other parts of the foetus, such as fracture of the clavicle or humerus and separation of the vertebral epiphyses.
- Prematurity of the foetus, frequently with atelectasis and broncho-pneumonia.
- Septic infection of an intracranial haematoma, with suppurative meningitis.
- Visceral haemorrhages.
- Permanent paralysis.
- Pathological mental and moral conditions, including weakmindedness, idiocy and epilepsy.
It is unnecessary to emphasize the fact that treatment is a poor substitute for prevention. The general principles of prophylaxis are well known, and in this paper they have already been enunciated, though indirectly, in regard to aetiology.
The treatment of intracranial traumata may be briefly summarized as follows :
- The infant should be handled as little as possible. If resuscitation is necessary, the less vigorous methods are advisable.
- The body-temperature must be maintained by means of hot bottles.
- Early lumbar puncture appears to relieve cerebral congestion and to assist respiration. The operation should be repeated so long as the anterior fontanelle protrudes. Convulsions are invariably an indication for immediate lumbar puncture.
- Since the sucking reflex is so frequently diminished or lost, feeding must in many cases be carried out with the pipette. If the swallowing reflex be impaired, sterile water should be given in preference to dilute milk.
- Continued bleeding may be checked in some cases by an intramuscular injection of 10 c.cms. of human or horse serum, repeated four times if necessary at intervals of three or four hours.
- Major operation appears to be contra-indicated except in those rare cases in which clinical signs and symptoms point definitely to a local cortical effusion of blood.
REPORT OF 80 NEONATAL DEATHS AND STILLBIRTHS.
It must be pointed out that the cases here reviewed were not specially selected as probable examples of intracranial birth-trauma. They formed an almost consecutive series of autopsies.
For the purpose of this study, blood-effusions occurring into the substance of the dural septa have not been regarded as intracranial haemorrhage, since it is probable that these bleedings are not in themselves dangerous to the newborn infant.
NEONATAL DEATHS (28 CASES).
(1) lntracranial haemorrhage occurred in 6 cases (21.4 percent.).
(2) Intracranial haemorrhage did not occur in 22 cases (78.6 percent.).
Cases in which intracranial haemorrhage occurred. Four of these cases (i.e., 66.6 percent.) showed lacerations of the dural septa. The tentorium cerebelli was ruptured on both sides in one case, on the left side in two cases, and on the right side in one case.
In all these examples the haemorrhage was subdural and occurred especially in the region of the tentorium cerebelli. ln one case there was also a blood-clot in the right lateral ventricle and its descending cornu. Dural injuries did not occur in two instances.
One of these showed small cortical blood-effusions ; in the other there was a blood-clot upon the dorsal surface of the mesencephalon in the region of the vein of Galen, and bleeding had also occurred into the left lateral ventricle, the fourth ventricle and slightly into the right lateral ventricle. In the spinal canal of this infant peridural and intrathecal haemorrhages were found. Signs of general tissue asphyxia were invariably present in these cases of intracranial haemorrhage. Atelectasis was frequent ; acute oedema had developed in expanded portions of lung. The viscera showed vascular congestion ; in one case haemorrhage had occurred into the right suprarenal gland, and in another case into the thymus. Three of the infants were premature, and three were probably full-time. The average weight was 5 lbs. 9½ ozs. Two of the mothers were primigravida, three had given birth to two children and one to four.
Delivery took place by the vertex four times (two right occipito anterior and two left occipito-anterior), by the breech once (internal version for shoulder presentation and placenta praevia), and by Caesarean section once (for shoulder presentation and placenta praevia). In the last-mentioned case the patient bad been in labour for six and a half hours ,when the operation was performed. There was a slight superficial laceration of the right half of the tentorium cerebelli ; haemorrhage had probably originated from congestive ruptures of cerebral veins.
Forceps were used on two occasions ; one, a difficult mid-forceps delivery of a large infant (9 lbs. 15 ozs.) ; the other, a low-forceps delivery of a premature infant after induction of labour on account of maternal cardiac disease. In another of the vertex cases tight coiling of the umbilical cord around the neck of the infant probably caused congestive ruptures of cerebral veins; the dural septa were uninjured in this case.
The average duration of neonatal life was almost 15 hours, four of the infants were born in a condition of white asphyxia, and one showed blue asphyxia. The sixth infant appeared normal at birth, but later became cyanosed. Convulsions occurred in only one case.
Cases in which intracranial haemorrhage did not occur. These cases may be further sub-divided as follows :
(a) Intracranial congestion with dural lacerations : 3
(b) Intracranial congestion without dural lacerations : 15
(c) No pathological intracranial vascular lesion : 4
Cases of intracranial congestion with dural lacerations.
The first example was an infant weighting 6 lbs. 3 ozs. ; it was born in the right sacro-posterior position and was the first of twins. The mother was a primigravida ; her pelvic measurements were : interspinous 10 ins. ; intercristal 11 ¼ ins. ; external conjugate 7 5/8 ins. White asphyxia was present at birth; the infant’s condition improved with resuscitation, but it died at the age of 49 hours. The cause of death was pleuro-pneumonia, probably contracted during or immediately after delivery. The presence of this disease complicated the interpretation of the intracranial :findings. There were slight superficial lacerations of both halves of the tentorium cerebelli and slight blood-effusion had taken place into the substance of this dural septum; there was slight general intracranial congestion. It is very probable that the condition of asphyxia pallida noted at birth was attributable to intracranial congestion caused by trauma during delivery. The twin infant survived.
The second example was an infant weighing 7 lbs. 9 ozs, born after induction of premature labour on account of pelvic contraction, the mother having previously given birth to seven children. The measurements were : interspinous 9 ¼ ins. ; intercristal 10 1/8 ins. ; external conjugate 7 3/8 ins. ; diagonal conjugal : 3 ¾ ins.
Delivery took place rapidly in the left occipito-anterior position ; hydramnios was present and the infant was horn in a state of blue asphyxia ; liquor amnii flowed away freely from the mouth. In spite of treatment life lasted only 40 minutes. The left half of the tentorium cerebelli was found to be very slightly torn ; blood-effusion had occurred amidst the ruptured fibres and also into the falx cerebri and falx cerebelli.
There was general intracranial and visceral congestion and atelectasis.
The third example, an infant weighing only 4 lbs. ¼ oz., was born at the 34th week after podalic version on account of placenta praevia, the mother having previously given birth to five children. The infant was in a state of asphyxia livida and survived 59 hours. The left half of the tentorium cerebelli showed a slight superficial laceration and was stained with blood. There were meningeal oedema and slight intracranial congestion. The lungs were partially atelectatic.
Cases of intracranial congestion without dural lacerations.
In eight of the fifteen cases placed in this category, intracranial congestion must be ascribed to causes other than trauma of labour. Deaths were due in these examples to the following causes :
(1) Prematurity and atelectasis (accidental! haemorrhage). Weight of infant = 2 lbs. 12 ozs.
(2) Syphilitic cachexia. Infant lived 10 days 15 hours.
(3) Prematurity and atelectasis (accidental haemorrhage). Weight of infant =3 lbs. 11 ozs.
(4) Congenital cardiac disease.
(5) Prematurity and marasmus (maternal cardiac disease). Infant lived 21 days.
(6) Prematurity and atelectasis (unknown cause). Weight of infant= 3 lbs. 3 ozs.
(7) Prematurity and atelectasis (accidental haemorrhage). Weight of infant = 3 lbs. 1 oz.
(8) Multiple deformities of the foetus.
In reviewing the remaining seven cases of this subsection-cases in which intracranial congestion was attributable to damage during labour is found that four of the mothers were primigravidae, two had given birth to two children, and one to three. The duration of pregnancy was full-time in three cases ; of the other four cases, two were about 38 weeks, one was 37 weeks, and one was 35 weeks.
In six cases delivery occurred by the vertex (three left occipito-anterior ; two right occipito-anterior ; one position not stated), and in one case by the breech (right sacro-anterior).
Induction of premature labour was performed in three cases ; in two of these on account of pelvic contraction and in one for maternal cardiac discase. Of the other cases, the pelvis was fiat in one, small round in one and slightly smaller than normal in two.
Forceps were used in two cases ; one was a difficult delivery, the other a low operation.
The average weight of the infants was 5 lbs. 13 ½ ozs., and the average duration of life 30½ hours.
The clinical signs were as follows : white asphyxia, three cases ; blue asphyxia, two cases ; poor general condition, two cases. Convulsions occurred in one instance ; rhythmic and tetanic muscular spasms, and irregular muscular twitchings were each noted in one case.
In a majority of cases general visceral congestion and partial atelectasis were found.
Cases in which no pathological intracranial vascular lesion was found.
Four cases did not show any vascular lesion attributable to the process of birth, and the dural septa were uninjured. The causes of death in these cases were respectively icterus neonatorum and omphalorrhagia ; meconium suffocation ; prematurity and broncho-pneumonia ; and ileo-colitis with melaena.
These cases need not be further considered in this paper.
STILLBIRTHS (52 CASES).
(1) lntracranial haemorrhage occurred in 24 cases (46.1 percent.).
(2) Intracranial haemorrhage did not occur in 28 cases (53.9 percent.).
Cases in which intracranial haemorrhage occurred. Twenty-three of these cases (96 per cent.) showed lacerations of dural septa. The tentorium cerebelli was ruptured on both sides in eighteen cases, on the left side in two cases, and on the right side in two cases. The falx cerebri was ruptured in two cases; in one it was the only dural injury found, and in the other it occurred together with a laceration of the right half of the tentorium cerebelli.
ln a majority of cases diffuse haemorrhage into the subdural space was found ; in two cases in which the collection of blood was more localized in the vault region, it appeared to have originated from ruptured cerebral veins rather than from lacerations of the dura mater.
One of these cases (Fig. 1) was the single instance of intracranial haemorrhage without dural laceration ; the etiology of this bleeding is complicated by the fact that the mother had six eclamptic convulsions before the birth of the foetus.
Figure 1 : (Approximately normal size). Intracranial dural septa are uninjured. Subdural hemorrhage was mainly over the vertex of the brain, and therefore is not seen in the figure. A. Falx cerebri. B. Tentorium cerebelli. C. Incisura tentorii.
In four instances haemorrhage had taken place into the iter of Sylvius ; and in two instances blood-clot was found in the latera] ventricle. Only in one case was a rupture of the straight sinus demonstrated.
The following associated injuries were encountered. In three cases there was separation of an epiphysis from the body of a spinal vertebra ; these were the sixth cervical, seventh cervical and third thoracic vertebrae respectively. In each instance there was much bleeding, both extradural and intradural, within the spinal canal.
Delivery had taken place in each case by the breech.
Two other foetus showed the presence of intraspinal haemorrhage, but without bone injury ; one of these was delivered by the breech and the other by the vertex -the last a difficult mid-forceps delivery.
In four cases there were fractures of the cranial vault bones ; in one case both parietal bones were fractured ; in two cases, the right parietal ; and in one case, in addition to a fracture of the right parietal bone, there was a gutter depression of the right frontal bone. Delivery took place by forceps in all these cases of fracture.
In one of them the large size of the foetus (9 lbs. 1 oz.) was the cause of the obstruction ; in another, multiple small uterine fibroids were present, and the foetus was large (8 lbs. 12 ozs.). The other two cases were examples of pelvic contraction ; in one the pelvis was very fiat, and induction of premature labour had been employed ; in the other the pelvis was generally contracted with a little flattening.
Signs of general tissue asphyxia were almost invariably found ; the lungs were atelectatic, and the viscera were congested with venous blood. Subcapsular hepatic haematomata were found in three cases ; the blond-collection had ruptured into the peritoneal cavity in one of these foetus. Also in three cases were noted small haemorrhages into the connective-tissue surrounding the pelvis of the ureter within the kidney sinus.
The average weight of the twenty-four foetus was just under 7 lbs. Only eight were premature.
More than one-half of the mothers (13 out of 24) were primigravidae or had given birth previously to only one child. The modes of delivery were as follows :
Left occipito-anterior : 8
Right occipito-anterior : 2
Left mento-anterior : 1
Right occipito-posterior : 1
Position not stated : 1
Total = 13
(i) Primary Breech.
Right sacro-anterior : 1
Left sacro-posterior : 1
Position not stated : 1
(ii) Breech by Version.
Left sacro-anterior : 2
Position not stated : 3
(iii) Breech (History unknown) : 2
Total = 10
Unknown – born before arrival of midwife : 1
Total : 24
Forceps were employed in nine of the twenty-four deliveries. Reference has been made above to four of the forceps cases. Of the remaining five, two were delivered in the left occipito-anterior position, and one each in the right occipito-anterior, left mento-anterior, and right occipito-posterior (persistent) (Fig. 2) positions.
Figure 2 : Slight superficial lacerations of the tentorium cerebelli are concealed by blood-clot. A large rupture of the falx cerebri is shown. A. Rupture of the falx cerebri. B. Blood-clot lying upon falx cerebri, tentorium cerebelli and floor of middle fossa. C. Blood-clot at origin of straight sinus.
The two left occipito-anterior cases were both born to primigravidae, whose pelvic measurements were : interspinous, 9 ins. ; intercristal, 10 ins. ; external conjugate, 7 1/8 ins and interspinous, 9 3/4 ins. ; intercristal, 10 ½ ins.; external conjugate, 6 3/4 ins. The foetus weighed 7 lbs. 7 ozs. and 816s. 8 ozs. (Fig. 3) respectively.
Figure 3 : Very extensive ruptures of the tentorium cerebelli, and lacerations of the falx cerebri are shown. Subdural and intraventricular blood-clots are present. A. Rupture of falx cerebri. B.B. Rupture of tentorium cerebelli on each side. C. Blood-clot in Ieft middle fossa. D. Blood-clot in 4th ventricle. E. Slight effusion of blood into falx cerebri.
The right occipito-anterior case was an instance of obstructed labour, probably due to pelvic contraction, but measurements were not obtained.
The foetus weighed 7 lbs. 2 ozs. The only previous pregnancy terminated in abortion at the third month.
In the cases of breech delivery by version the indications for this treatment were :
Placenta praevia : 2
Transverse lie : 2
Placenta praevia and transverse lie : 1
Cases in which intracranial haemorrhage did not occur. These cases may be subdivided, as were the corresponding neonatal cases :
(a) lntracranial congestion with dural lacérations : 8
(b) lntracranial congestion without dural lacerations : 16
(c) No pathological intracranial vascular lesion : 4
Cases of lntracranial Congestion with Dural Laceration.
In seven cases both halves of the tentorium cerebelli were lacerated, though it ,was usual to find more severe rupture of one side than of the other. In one case, only the left half of the tentorium was torn. On the whole the lacerations were of slighter degree than those noted in cases of intracranial haemorrhage.
ln no case was the falx cerebri found to be torn. General visceral congestion was noted in all these foetus. There were no instances of visceral haemorrhage. Three of the foetus were premature, the average weight being 4 lbs. 12 ozs. The average weight of the remaining five foetus was 7 lbs. 6 ozs.
Delivery in these cases took place respectively as follows : Vertex, three cases (two right occipito-anterior and one left occipito-posterior) ; primary breech, four cases (one left sacro-anterior; three position not stated) ; breech by version, one case (left shoulder presentation turned to right sacro-anterior). Both foetus delivered in the right occipito-anterior position were born spontaneously.
In one case the maternal pelvic measurements were : interspinous, 8 1/2 ins. ; intercristal, 10 ¼ ins.; external conjugate, 7 ½ ins. ; and the foetal head showed prominent head-moulding of the “small round pelvis” type.
In the other case the foetus, weighing 7 lbs. 10 ½ ozs., was born at a labour only 25 minutes in duration. The mother had previously given birth to eight children. The foetus born in the left occipito-posterior position was delivered in hospital with forceps, after failure with these instruments in the patient’s home.
The weight of the foetus was 7 lbs. 4¼ ozs. The maternal! Pelvic measurements were : interspinous, 10 ins.; intercristal, 10 ¾ ins. ; external conjugate 6 ¾ ins. There had been three previous labours, all instrumental.
Cases of Intracranial Congestion without Dural Laceration.
(I) In five of the sixteen cases placed in this subsection intracranial congestion must be ascribed to causes other than trauma of labour. Deaths were due to the following causes :
(1) Prematurity and atelectasis ( cause unknown ). Weight of foetus = 2 lbs. 14 ozs.
(2) Prematurity (eclampsia). Weight of foetus = 5 lbs. 10 ozs.
(3) Prematurity and atelectasis (placenta praevia). Weight of foetus = 5 lbs.
(4) Foetal asphyxia (accidental haemorrhage).
(5) General oedema of the foetus.
(II) In two cases the foetus, which weighed 7 lbs. 1 oz. and 7 lbs. 4 ozs. respectively, were born by normal delivery, and no cause can be given for these stillbirths. It is uncertain, therefore, whether the condition of intracranial congestion noted in these two examples can be ascribed to birth-trauma.
(III) The state of intracranial congestion noted in the nine remaining cases in this subsection may justifiably be ascribed to birth trauma.
In the autopsies general intracranial congestion was the most prominent feature ; the dural septa showed purple-coloured patches of blood-effusion among their fibres in three cases.
Pulmonary atelectasis, with subpleural petechiae, and general visceral congestion proved that death had been asphyxial. One case showed a subcapsular hepatic haematoma; and in another example there were small pulmonary haemorrhages, left suprarenal haemorrhage and a subcapsular hepatic haematoma, which had ruptured into the peritoneal cavity.
One foetus was born at the 38th week of pregnancy ; it was under-developed and weighed only 4 lbs. 10 ozs. The remaining eight foetus were apparently full-time ; the average weight was 7 lbs. 9½ ozs. Four of the mothers were primigravidae; one had given birth to two children, and the remaining four mothers to four or more children.
ln five cases pelvic deformity existed. Delivery took place by the vertex in seven cases (six left occipito-anterior ; one, position unstated), and by the breech after podalic version in two cases.
In the vertex cases, forceps were employed on four occasions ; one of these was a difficult mid-forceps delivery of a foetus weighing 7 lbs. 15 ozs., after induction of premature labour on account of general pelvic contraction. In this case the maternal pelvic measurements were : interspinous, 8 ¼ ins. ; intercristal, 10 ¼ ins. ; external conjugate, 7 ½ ins. ; diagonal conjugate, 4 ¼ ins.
Prolapse of the umbilical cord occurred in three cases. Coiling of the cord around the foetal neck probably aggravated the intracranial congestion noted in one instance. In each of the two cases delivered by the breech podalic version was performed on account of pelvic flattening. One foetus had presented by the brow and the other by the vertex.
Cases in which no pathological Intracranial Vascular Lesion was found.
Four foetus, to which brief reference will now be made, did not show any vascular lesion attributable to the process of birth, and the dural septa were uninjured.
(1) A foetus weighing 6 lbs. 4 ozs. presented by the shoulder and was delivered by podalic version. The scalp tissues contained a uniform haemorrhagic area over the right temporal fascia ; the cerebral meninges were oedematous ; the right atlanto-axial articulation contained effused blood, and haemorrhage had occurred into the left suprarenal gland. These pathological conditions which pointed to the probability of birth-trauma were not, however, supported by the presence of intracranial congestion, haemorrhage or dural injury. No explanation can be offered for these anomalous findings.
(2) A foetus, weighing only 3 lbs. 7 ozs., was delivered in the 33rd week of pregnancy by podalic version performed on account of placenta praevia. The brain appeared to be very white, and was surrounded by slightly turbid fluid enclosed in the subarachnoid space. Two subcapsular hepatic haematomata were present. It is surprising that no intracranial vascular injury had occurred.
(3) A premature foetus, the subject of general oedema, was delivered without difficulty in the 32nd week of pregnancy.
(4) A foetus, weighing 5 lbs. 14 ozs., was delivered by Cesarean section on account of placenta praevia. No uterine pains had occurred before the operation was undertaken.
SUMMARY AND CONCLUSIONS.
1. TWENTY-EIGHT NEONATAL DEATHS.
a. Signs and symptoms of intracranial birth-trauma occurred in 16 cases, that is, in 57.1 percent.
b. Intracranial haemorrhage occurred in 6 cases, that is, in 21.4 percent.
c. Lacerations of the dura mater occurred in 7 cases, that is, in 25.0 per cent.
d. It is considered important to recognize that in seven of the sixteen cases of birth-trauma, intracranial congestion was the only pathological condition found within the foetal skull ; also that in these cases there were no visceral haemorrhages. That is to say, in 43.7 per cent. of new-born living infants showing the effects of birth-trauma, the pathological lesion is one which is unlikely to cause the appearance of late signs and symptoms, for example, paralysis and mental changes, if satisfactory treatment were available to overcome its immediate and dangerous effects. lt is possible that further observations will prove the value of early lumbar puncture in the treatment of these cases.
e. Of sixteen infants showing signs and symptoms of birth trauma, eight were prematurely born.
2. FIFTY-TWO STILLBIRTHS.
a. Signs of intracranial birth-trauma occurred in 41 cases, that is, in 78.8 per cent.
b. Intracranial haemorrhage occurred in 24 cases, that is, in 46.1 per cent.
c. Lacerations of the dura mater occurred in 31 cases, that is, in 59.6 per cent.
d. Of 41 stillborn foetus showing evidence of intracranial trauma, 12 (that is, 29.3 per cent.) were prematurely born.
3. ln this series of 80 neonatal deaths and stillbirths the relative, frequency of the different foetal presentations in cases showing signs of birth-trauma differs very little from that obtaining in the uninjured specimens.
4. Intracranial haemorrhage occurring during labour is more frequently diffuse than localized. This fact would appear to contra-indicate surgical interference except in rare and special rases.
In carrying out this work I have been guided, stimulated and encouraged by Emeritus Professor H. Briggs, to whom I owe a great debt of gratitude.
Professor W. Blair Bell has very kindly assisted me with his excellent advice in preparing this paper for publication.
The Honorary Staff of the Liverpool Maternity Hospital have permitted me to study the cases under their charge, and have invariably helped me in every way. I am indebted to them and also to the Matron and Nursing Staff, who have given me every possible assistance.