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3,200 gram infant with an umbilical artery pH of 7.25. Despite this, the infant was markedly depressed, with a one-minute Apgar score of 1 (heart rate < 100 beats per minute) and a five-minute Apgar score of 5. Despite immediate intubation and vigorous resuscitation, the infant's condition did not improve. The infant remained flaccid, never breathed spontaneously, and was maintained with a respirator. On the fifth day after birth, after two electroencephalograms revealed no electrical activity, the infant was pronounced dead. Permission for postmortem examination was not granted. Throughout the entire labor the fetal heart pattern was as shown in Fig. l. There was a repetitive pattern of acceleration to 140 beats per minute, followed by a deceleration to 115 beats per minute, followed by a return to a "base line" of approximately 130 beats per minute. This pattern was repeated 10 to 16 times every I 0 minutes. These cyclic accelerations and decelerations showed no relationship to uterine contractions, and the "base-line" value of 130 beats per minute was maintained up until delivery. Beat-to-beat variation remained present throughout labor. None of the usual types of deceleration-earlv, variable. or late---was noted.

An unusual fetal heart rate pattern DWIGHT P. CRUIKSHANK, M.D.

Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa

rate monitoring during labor is now a common practice, and much is known about various heart rate patterns-base-line variability, beat-to-beat variation, accelerations, and early, late, and variable decelerations-as they relate to the fetal condition and the presence or absence of hypoxia and acidosis. Reported here is an unusual heart rate pattern associated with marked depression of the neonate, in the absence of acidosis, and ultimate neonatal death. We have not seen such a pattern previously reported. CONTINUOUS FETAL HEART

The patient was a 28-year-old white woman, gravida 5, para 3, abortus 1, at 41 weeks' gestation. She was transferred to our hospital after four eclamptic seizures and a cardiorespiratory arrest during the previous six hours. Upon admission, she was lethargic and had a blood pressure of 170/ 100 and 3 + proteinuria. The fetal heart rate was 135 beats per minute. She had pulmonary edema, and the arterial Po 2 while she was breathing room air was 50 mm. Hg. She was given 50 per cent oxygen via an endotracheal tube, which maintained the Po 2 above 100 mm. Hg until after delivery. Shortly after admission, therapy with magnesium sulfate ( 10 Gm. intramuscularly, followed by 1 Gm. per hour by intravenous infusion) was begun. No other drugs were given until after delivery. An amniotomy was performed, and internal monitoring* was instituted. Oxytocin augmentation resulted in excellent labor, and five hours after amniotomy the patient was delivered of a

Baskett and Koh 1 reported a "sinusoidal" fetal heart pattern which they ascribed to fetal hypoxia. That pattern differs from the one herein described in that the cycle frequency was twice as great and there was no return to a "base-line" value between cycles. However, the significance of the two may be similar, for the outcome-marked depression of the neonate and eventual neonatal death-was the same. The finding of a normal umbilical arterial pH, plus the absence of late or variable heart rate decelerations and the presence of beat-to-beat variation, leads one to conclude that the fetus probably was not hypoxic or acidotic during labor. More likely, the fetus suffered severe hypoxia during the maternal seizures and cardiorespiratory arrest, which resulted in central nervous system damage incompatible with extrauterine life. This may have disorganized vagal and sympathetic centers, and the heart rate pattern may represent the function of a fetal heart with disorganized neural regu-

Reprint requests: Dr. Dwight P. Cruikshank, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242. *Model 101B, Corometrics Medical Systems, Inc., North Haven, Connecticut.


102 Communications in brief

January I , 1978 Am. J. Obstet. Gynecol.

Fig. I. Representative sample of internal monitor tracing.

lation. However, such a hypothesis is difficult to prove. Observation of a fetal heart rate pattern with these unusual characteristics should provoke concern, for clinical management becomes difficult if one suspects that irreparable fetal damage has already occurred. One is faced with the dilemma of whether to perform operative delivery of a fetus possibly too severely damaged to survive or to allow labor to continue and perhaps lose a potentially salvageable fetus. I would be interested to learn if others have had experience with cyclic heart rate patterns such as this, for only with further clinical observation will the ultimate significance and proper management of such problems become know.

REFERENCE I. Baskett, T. F., and Koh, K. S.: Sinusoidal fetal heart pattern, a sign of fetal hypoxia, Obstet. Gynecol. 44: 379, 1974.

Revival of the extraperitoneal cesarean section H . HANSON

Anchorage, Alaska

THE EXTRAPERITONEAL cesarean section was used to prevent contamination of the peritoneal cavity. With the advent of the antibiotic era, this procedure has been relegated to history. However, Reid,t in 1973, reviewed 18 cases of fatal puerperal sepsis following transperitoneal cesarean section and concluded that Reprint requests: Dr. H. Hanson, Providence Professional Bldg., Suite 212, 3300 Providence Dr., Anchorage, Alaska 99504 .

the fatal peritonitis might have been avoided by the extraperitoneal approach or cesarean hysterectomy. The transperitoneal cesarean section was "not safe enough." Sporadic articles stressing the virtue of the extraperitoneal cesarean section continue to appear. During my residency, the extraperitoneal approach was used in obviously infected cases where the patient had been transferred to the medical center. One could not help but note that the patients who had extraperitoneal cesarean section had a remarkably benign postoperative course; invariably these patients did very well. Slowly the obvious question evolved: Why was the extraperitoneal cesarean section not performed on all patients? Thus, in private practice, I broadened my indications to include purely elective cases. The articles coupled with personal experience have made three points apparent: (I) The extraperitoneal cesarean section is a sound surgical procedure; (2) the extraperitoneal cesarean section could be applied to the majority of cesarean sections; (3) the patient will benefit from the extraperitoneal approach. To support these points, 45 consecutive extraperitoneal cesarean sections were reviewed. I performed these cesarean sections in Anchorage, Alaska, between july 1, 1972, and February I, 1977. The data relate only to extraperitoneal cesarean sections; there are no control data from transperitoneal cesarean sections performed during this same period of time. . Preoperative data are summarized in Table I. Prophylactic antibiotics were not utilized . Preoperative antibiotics were administered to three patients-"'with premature rupture of the membranes, fever, and positive cultures of the amniotic fluid. The operative technique, a lateral approach to the bladder through the paravesical space, pioneered by Latzko in 1909, was used throughout this series. Op· erative data are summarized in Table II. Prolonged operative time and prolonged incision-to-delivery times have been cited as major disadvantages of this

An unusual fetal heart rate pattern.

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