H.-31

46

The Future op Obstetrical Practice. In my report of last year I made certain suggestions regarding the direction in which the practice of obstetrics was likely gradually to trend. I subsequently repeated them in an extended form in my address as President of the Obstetrical Section of the recent Medical Congress at Sydney. It is unnecessary again to emphasize them here, as they will be found in extenso in my recent book on " The Causes and Prevention of Maternal Mortality." There is, however, one point to which I wish to refer. The British Medical Association has adopted in Great Britain a scheme for obstetrical practice which very closely resembles that suggested by me. There is, however, one essential difference. In the scheme of the Association it is proposed to hand over the care of the pregnant woman to the midwife both during pregnancy and normal labour, and it is left to her to refer the patient to the medical practitioner during pregnancy, should she consider it advisable. My proposal, on the contrary, was that the entire responsibility for the care of the patient during pregnancy and labour should rest on the medical practitioner ; that his special duties should be ante-natal care and diagnosis, assistance at abnormal labour, and post-natal care ; and that he should be free to delegate such part of ante-natal care and of the management of normal labour to the midwife as he considered well. Ido not think it is advisable to relieve medical practitioners of ante-natal care and diagnosis. These matters are essentially medical, and depend on many other things than a technical knowledge of midwifery. I believe that marked reduction in maternal mortality will not result until some such scheme as I have outlined comes into effect, but, when it does, I trust it will not imitate that part of the British scheme which hands over antenatal care to the midwife. Dr. Hector's Investigations. Dr. Hector has, during the year, continued his investigation into still-births and neo-natal deaths. He has examined a considerable amount of material, and has drawn up a report which appears elsewhere. Naturally, in the short time at his disposal, the material examined is insufficient to enable him to arrive at definite conclusions. I should be very glad to see him given the opportunity of continuing his work, if it was possible to arrange for him to do so. Post-natal Clinics. The establishment of post-natal clinics in maternity training hospitals has not, so far, become effective, although the fact that such clinics are working satisfactorily in similar institutions shows that it is feasible. The importance of these clinics is recognized, and it is quite time that they were generally established. Even if they did not, for the present, go further than the routine examination of patients before they left hospital, and the treatment of those who needed treatment, much good would be done. The difficulty of initiating even this examination is, however, considerable in large hospitals such as the Wellington and Auckland St. Helens, because of the increased work it throws on the medical officers. I think the difficulty would be removed by the appointment of clinical assistants, who would relieve the medical officers of this and possibly other routine work. Such appointments should be honorary, and would, I fancy, be acceptable to many practitioners who desired to increase their knowledge of obstetrical and gynaecological practice. The appointment of a resident medical officer to these hospitals is urgently wanted, but, as there is at present a lack of the necessary accommodation, it is impossible. The appointment of clinical assistants would be the most effective means of providing the necessary additional assistance until this accommodation was available. As things are at present there is a danger that, in consequence of the increased demands on the time of the medical officer for the teaching of midwives and medical students, the purely clinical work of the hospital may be hampered. I think, further, that the time has come to place on a definite footing the status and duties of the medical officers of the St. Helens Hospitals, in order that these hospitals may more nearly conform to the modern idea of an obstetrical teaching hospital. There are no difficulties that I know in the way of so doing, and a readjustment would, I think, add both to the efficiency and the status of the hospitals. Eclampsia. The analysis of the eclamptic returns for the past year are somewhat similar to those of the previous year. The statistics of the last three years are as follows : —

Table "A."—Eclampsia.

Death rate, 1927, 22-9 per cent.; 1928, 17-2 per cent.; 1929, 17-9 per cent.

Lived. Died. Total. 1927. 1928. 1929. 1927. 1928. 1929. 1927. I 1928. 1929. I Ante-partum eclampsia— (a) Conservative treatment 27 42 44 1 7 14 28 49 58 (b) Accouchement force.. .. 1 .. 3 2 .. 1 3 .. 4 (c) Caesarean section .. ..5 3 4 2 3.. 7 6 4 (d) Induction of labour ..5 5 8 4 2.. 9 7 8 Post-partum eclampsia . . 10 21 10 5 3 .. 15 24 10 Total notifications .. .. .. .. .. .. | 62 86 84 I