Rupture of the foetal heart during labour.

Obstetical Hiwstory. The mother, aged 28 years, gave a history of two miscarriages about the eighth and tenth weeks of pregnancy in 1947 and 1951. During the present pregnancy she had been attending the ante-natal clinic and her general condition was considered satisfactory but, on June 12, 1952, about the thirty-ninth week of prenancy, she was admitted to hospital on account of pitting oedema of the ankles, legs and abdominal wall. On admission, her blood pressure was 134 90 mm. Hg and the urine was fiee from protein. History of laboe. The presentation was a vertex and clinically there was no cephalo-pelvic disproportion. Pelvimtry also showed the pelvis to be adequate. On June 12, 1952, a quinine induction (four doses of quinine hydrochloride, gr. 5, at four hourly intervals) was given, followed by 'pitocin' (six doses of 2 i.u. at half-hourly intervals) to induce labour. (The expected date of confinement was June 18, 1952.) On June 13, the membranes were ruptured surgically as labour had not begun. After this, labour proceeded normally; a bilateral sympathetic block was performed with good relief during the first stage. The first stage lasted 11 hours and 40 miutes. A local pudendal block was performed at the start of the second stage. The head advanced slowly and, beause of delay in delivery of the head, an episotomy was performed. Following delivery of the head, difliclty in delering the shoulders was experinced: this was easily overcome by placing fingers in the axillae and exerting traction. No difficulty was encountered thereafter. The second stage lasted for one hour and 50 minutes. A stillborn male infant weighing 8 lb. 6 oz. (3 8 kg.) was born. The foetal heart sounds had been regular during labour, the last recording being made 10 minutes before delivery. Although the baby was stillborn it was considered advisable, at the time, to attempt to establish respiration; this was done by intubation and oxygen insufflation. An intracardiac injection was not given. Ncropsy. The infant was well nourished and there were no external physical malformations. Oedema, jaundice and cyanosis were absent. A prominent caput was present over the vertex. On opening the thorax the pericardial sac was seen to be distended with blood. The sac was opened: fresh blood escaped and a blood clot, approximately 15 nmn. in diameter, lay along the left border of the left ventricle. Careflly turnmg the apex of the heart upwards, the diaphragmatic surface and base of the heart were examined. A small hole, through which a clot of blood protruded, was observed in the lower and posterior part of the right atrium just anterior to the point of insertion of the inferior vena cava. This tear, approximately 6 mm. long x 1-2 mm. broad, involved mainly the membranous portion of the atrial wall but extended into the muscular part, and extravasation of blood within the wall could be seen over an area adjacent to the site of rupture (Fig. 1). The other cardiac chambers, valve orifices and cusps, and the myocardium presented no abnormal features. The lungs showed evidence of very slight aeration. In the abdomen, apart from moderate congestion of the liver, no abnormality was seen. The brain was normal.