A survey of 325 stillbirths from 27,072 babies delivered at University College Hospital Galway from April 1, 1972 to March 31, 1982, gave a stillbirth rate of 12 per thousand, which, when corrected for 66 lethal congenital abnormalities, became 9.6 per thousand. The cause of death in each stillbirth was determined clinically and pathologically where possible and was classified according to a modified Aberdeen classification of perinatal death. Consideration of the birth weights of the babies who died showed that 223 (68.6%) weighed over 1,500 g, and excluding those with abnormalities, they must be considered salvageable with the application of intensive neonatal care. There were 54 (16.6%) intrapartum deaths, which must also be considered preventable. The application of ultrasonic surveillance should complement clinical acumen, by allowing easier detection of the fetus at risk, thereby facilitating earlier intervention which in turn should reduce antenatal stillbirths.

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A study of perinatal mortality in multiple pregnancy over a period of 12 years, 1972 to 1984, showed prematurity and low birthweight as the major causes of fetal loss. The highest risk was found at 28 to 30 weeks gestation (306/1,000). There was a significantly greater risk to babies delivered by the breech (136/1,000), and likewise in the second twin when compared with the first, ratio 1:14. A significant drop in the perinatal mortality rate, from 98/1,000 to 39/1,000, was observed between 1972-1978 and 1979-1984. Ultrasound has facilitated the earlier diagnosis of twins and provides more accurate serial fetal assessment. Bedrest, more vigilant antenatal care, intrapartum surveillance and improved neonatal care, are required to maintain and further reduce the perinatal mortality rate. When regional analgesia was employed in labour, the number of babies lost was 41/1,000, vs 93/1,000 in patients not receiving regional analgesia. External cephalic version and vertex delivery of the second twin is preferable to internal version and breech extraction. It should also be contemplated, as an alternative to elective cesarean section for a transverse lie or breech presentation of the second fetus.

Fear of uterine rupture has led to the widespread practice of 'Once a section, always a section'. Between 1972 and 1982, 1498 patients with one or more previous cesarean sections were delivered at University College Hospital, Galway. Trial of labor was undertaken in 844 patients, while the remaining 654 patients underwent repeat elective section because they had two or more prior sections. Eight true ruptures and 22 scar dehiscences were found. Regional analgesia and oxytocin did not significantly affect the rate of true rupture. The mean parity with uterine rupture was five, and it occurred most frequently in the initial trial of labor. There were four perinatal deaths associated with true rupture. Failure to detect the already compromised fetus before labor and delivery, rather than the method of delivery, was responsible for fetal demise in some instances. Five true ruptures were found in the trial of labor group (i.e. a ratio of 1:169), with the loss of three babies. A further baby was stillborn in a mother who ruptured a classical scar before labor. There were no maternal deaths in trial-of-labor patients and one in the elective section group. Two patients with true rupture had their uterus repaired, and were subsequently delivered by section. Another two patients with bloodless dehiscence and no repair, had two subsequent elective repeat sections each, and the unrepaired scar dehiscence was not evident.

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