Quantum mechanics and theory of relativity are the most important scientific achievements of the twentieth century. Unfortunately, in spite of the great technological progress in the production of medical instruments and means of communication, they have not been used to the full in gynecological procedures. 100 years ago the notion of quantum and later timespace were introduced but obstetrician still adhere to out-of-date ideas of absolute time and space. As I. Newton in the seventeenth century they tend to put their trust in deterministic causality rather than their statistical conditioning. To make matters worse, half of our colleagues - even if they know modern definitions of preterm and at term labor – continue to assess fetal maturity according to fetal weight or calendar duration of pregnancy and on that premise they act improperly. Pregnancy ends with reaching full fetal maturity, which can and has to be quantized like e.g. radiation and thermal or electric conduction. Likewise, mass is technically quantized in grams or kilograms, while gestational age is expressed in days, weeks or months. Maturity is neither mass nor time and cannot be assessed in grams or units of time. Therefore modern neonatologists and obstetricians successfully worked out maturity quantizing in points without taking into account mass, length or gestational age of fetuses and newborns! The fact that technologists install incorrect scales in ultrasonographic devices designed on the basis of the newest achievements of the twentieth century is reprehensible.
Everyone should be aware that on both sides of the mean value of the normal pregnancy duration (281st-283rd day) there are two populations of newborns very much alike in their characteristics. Only 2.5% of these newborns have values of mass, length and maturity higher and lower than the range of the norm of the entire population, which in humans is 6 weeks. It was proven on hundreds of thousands and even millions of observations of pregnancy duration in the whole world! In the meantime, the scales of modern ultrasonographic devices do not cover the whole range of the 95% birth occurrence from 370/7 to 432/7 weeks after the last menstrual period. To make things worse, as the pregnancy progresses in weeks, the mean values of observed ultrasonographic measurements are falsely extrapolated or concealed by providing the wide range of standard duration »3 weeks. These obvious arithmetic errors lead to iatrogenic and mediagenic diseases and deaths.
Technicians not only use the falsely interpreted calendar scale of pregnancy duration playing up the role of the beginning of pregnancy at the expense of its much more important end. They entirely overlook the auxological laws, which are so well known from a next human developmental period i.e. sexual maturation. No one predicts the date of menarche on the basis of the absolute body mass or height but rather of the rate of their increase.
One of the most frequent causes of instrumental deliveries, as well as the continuing 7-8% prematurity rate, is obstetricians ignorance of the achievements of auxology. Much better off are pediatricians, who observe auxological standards from the rate of birth of every human being. Every child up until the pubertal spurt generally develops in its own canal (range), whose change must be explained in every case. It is worthy of note that puberty is the next developmental stage following fetal maturation. Children which mature sooner have higher growth parameters than their peers, but the duration of their pubertal spurt is shorter and ultimately they grow to lower height. The same situation occurs before fetus reaches full maturity. The average values which determine weight and length of infants whose maturation is the fastest, i.e. those born in 37th week, are lower than in children born in 38th week, while it is only from 39th week that the characteristics of infants born in the following labor weeks are stabilized. Only newborns in 39th week have the distribution of their features closest to the normal. In fetuses which are born normally but earlier, the prevailing values are lower than the average, while in the most slowly maturating fetuses the situation is reverse.
Thus, the auxological rules must not be disregarded. After all it suffices that in the proper period of pregnancy the obstetrician examines twice the rate of fetal maturation. The data obtained from these examinations allow him to predict the birth-term with the accuracy of several days instead of weeks.
Everybody knows that he was born on a given one day, while every obstetrician is able to prove that the commencing delivery and its prodromes occur during just two or three days of profound transformation from pregnancy to labor. Therefore the delivery date has to be estimated with accuracy of ± 3 days. Unfortunately, obstetricians single out two days in the calendar pregnancy scale: the 259th day, starting from every fetus is magically considered “mature”, and then – somewhat contradictorily – the next day in question is 287th or 294th as the last one to determine maturity.
Extensive statistics show that from 287th day of the calendar scale to its 303rd day, there mature over ten percent of slowly developing fetuses. If the physician terminate these pregnancies by inducing labor, in at least several percent of cases he will deliver premature infants. If we consider 100 healthy women (100%) with the same beginning and normal course of pregnancy, 3 of them according to the Gauss curve will deliver in the first and 3 in the last week of the six-week range of the occurrence of births within 360/7 - 432/7 weeks after the last menstrual period, and 30 in each of the 2 middle weeks (390/7 - 406/7 ), while only 15 in 380/7 –386/7 and in 410/7 –416/7 week. (Fig.1)
Figure 1. Normal occurrence of human birth according to Gauss curve.
Pregnancy - just as every natural phenomenon (structure or process) - is an individual time-spatial event whose most important element is fetal maturation of a human being, first to the level of viability, and then to full maturity to self-dependent life (Fig.2).
Figure 2 Fetal maturation to the level of viability and self-dependent life.
Out of the any group of 100 pregnant women with calendar age 370/7 - 376/7 weeks, only in 3 the process of fetal maturation is completed. Out of the remaining 97, only 15 will have it completed in 38th week and about twice as many in 39th week (Fig. 3).
Figure 3 Full fetal maturity among 100 pregnant women at 370/7- 6/7 gestational week.
When examine 50 pregnant women in 40th week, we have to realize that only approximately 30 out of their fetuses are mature for labor and other ones will deliver - unless pregnancy is iatrogenically terminated - after 287th day of physiologic pregnancy => 410/7 week (Fig. 4).
Figure 4 Full fetal maturity among 51 pregnant women in 400/7 - 6/7 gestational week.
After the 42nd week still 3% of children can be physiologically delivered. (Fig.5)
Figure 5 Comparison of pre-and postnatal ages of babies at 37th , 40th and 43rd weeks after LMP.
How can one predict in the observed individual pregnant women, in which of the 6 weeks, than labor has to occur? It needs to be stressed that ultrasonographic measurements of selected fetal parameters by means of existing devices are exact and precise; it is only their interpretation that is false. When making physical measurement of one of 100 fetuses in 37th week of pregnancy even by means of the best and unfortunately common percentile scales one cannot conclude if the fetus has to be deliver in days (Fig.6) or weeks (Fig.7).
Figure 6 Comparison of fetal and postnatal ages of babies of 37th week after LMP.
Figure 7 Comparison of fetal and postnatal ages of babies of 43rd week after LMP.
Obstetricians cannot equally relate the same calendar week of very late pregnancy those fetuses, which will indeed be born during this period (e.g. 41st or 43rd). Thus, a preterm birth can occur even at 42nd week just as a postterm birth is possible even at 38th week owing to failed feto-maternal mechanism of labor initiation. Both fetus and mother in the last 3-4 days of pregnancy undergo rapid pre-labor changes necessary to delivery and sudden child's adaptation to extrauterine life. Labor which starts before its own individual term (preterm) as well as delayed due to disturbance of it's initiation (postponed pregnancy) is possible in the large six-week range.
At the beginning of the period of the norm, the increase in morbidity and mortality is caused not only by labors of multifetal pregnancies, but mainly by lack of help necessary for undiagnosed true preterm births. Reversibly, at the end of the period of the norm (»41st week) premature induction in over ten percent of labors causes iatrogenic prematurity because of statistical , not individual postdatism.
The six-week period of birth occurrence in a human being is too big for obstetrical management to be determined by statistical methods. An increase in instrumental deliveries and lack of progress in lowering the number of premature births associated with increased fetal morbidity and mortality are the consequence of this approach.
Maturity is not a phenomenon like three other measurable fetal dimensions, but it is a consequence of space-time distribution of mass and energy in fetus. At the atomic level each subsequent new indivisible unit (quantum) of fetal maturity appears at a particular time which is inseparable from maturing fetal structure. Delivery occurs when a full quanta of fetal maturity has been completed. Thus, accordingly to the quickness of appearance of the consecutive quanta some fetuses are already mature at 370/7 postmenstrual weeks of gestation while the other ones have to mature until 432/7 (95% of confidence limits).
Technical quantization differs from physical one by the fact the scale of examined parameters is set on macro level in such a way as to make them multiples of a selected measure (quantum) in our case - points. Physicians' error consist in fact that in spite of the proven simplicity of maturity quantization and its expression in point scale, doctors attempt to measure it on the scale of grams or centimeters or - even worse - of gestational days or weeks.
However, it is enough to understand the meaning of the three categories of pregnancy time to eliminate many iatrogenic actions. In figure 8 the calendar time is marked on the horizontal X-axis, where the starting points is the date of LMP or birth. The developmental time, is measured on the vertical Y–axis and in physics adopts the designation “imaginary time”. Every fetus during the period of maturation (developmental time) must acquire a specific amount of maturity quanta sufficient for self-dependent life. The rate of fetal maturation depends on the frequency of appearance of maturity quanta and therefore the biological time, which is the sum of developmental time and intraquantal intervals, is longer and is located on the diagonal line.
Figure 8. Distribution of maturity quanta from conception to the birth.
By means of an ultrasonographic device we take a measurement of biophysical event such as fetal maturation which is subject to be quantizied. Thus, we have to relate the results to the individual time of examined fetus; this is done on the Y axis together with the mass and height instead of calendar horizontal scale (X axis). It suffices to compare a measurement made in 37th or later week to any previous examination »28th week. Then even the same absolute increase in an examined parameter during 2-3 weeks enables to divide fetuses into fast (predicted labor in 37th-38th week), regular (predicted labor in 39th-40th week) and slowly (predicted labor in »41st week) maturating once.
Figure 9. Distribution of maturity quanta from conception to the birth.
The maturity level can be evaluated immediately after labor through obligatory assessment of just six of the many possible newborn features: position of the limbs, elbow angle, its mobility, breast nipple, plantar creases and lanugo (see Table I). For each of those features one can allocate from 0 to 2 points, which maximally gives 12 technical points of full maturity.
On the day of delivery newborns have the same number of maturity quanta (according to the above maturity scale (9 ± 1.5 points). It is only the same appearance of new quanta that occurs in shorter intervals in fast-maturing fetuses and longer in the slowly maturing ones. What is important is not the absolute increase, but its rate (The increase is tangent of a angle).
Iatrogenic consequences of induction of the labor in improper time
Modern medical means as ultrasonographic devices, cardiotocographs or neonatological incubators from the technical point of view stems from the greatest advances of quantum mechanics and theory of relativity. Unfortunately, their use in obstetrics paradoxically leads to iatrogenic morbidity and mortality due to lack of understanding of time-spatial fetal maturation and relativity of calendar pregnancy duration.
Labor occurred at an improper time is a common obstetrical error, which finds confirmation among others in higher perinatal mortality indexes both at the beginning (weeks 37th/38th) and the end (weeks 41st/42nd) of birth occurrence range in humans. The former is characterized by neglect of assistance in actual preterm labor one week before true individual term, and the latter by preterm labor induction or – even worse – attempts to bring belated assistance in postmature pregnancies, whose birth time has passed in the former weeks of the calendar SCALE of pregnancy duration.
By means of the same ultrasonographic devices but taking into account quantum mechanics and relativity of pregnancy duration one can made - on the basis of two measurements within
Table I. Scoring system for clinical assessment of Klimek’s maturation index in newborn infants
»2 weeks - not only assess the current maturity, mass, length and gestational age of the child but also predict those values in the perinatal period. It brings measurable medical, social and financial profits and - most importantly – discards the ethics of reticence on the dangerous dominance of technology over general knowledge. It also reminds the doctors that their first obligation remains the tenet “primum non nocere”. There was a time when improper use of cardiotocographs resulted in too much irreversible medical and social damage. The time has come to point one’s finger at manufacturers and users who bear the responsibility for similar effects in obstetrical ultrasonography. This is the best way to bring the percentage of prematurity down to the natural limit of 2.5% of all deliveries. Currently, 10-18% of labors are induced prematurely only because the calendar time of pregnancy duration has exceeded 287 or 294 days from the date of the last menstrual period, which additionally is given by the mothers accurate to several days, anyway.
The reduction of perinatal mortality – sometimes wrongly ascribed mainly to obstetricians – is primarily an effect of the amazing progress in neonatology. Low birth weight, perinatal mortality and prematurity rate have been even adopted as general social and economic indices of development of entire countries or at least selected territories. Therefore, to bring out the role of obstetricians there in, one should permanently introduce two other clinical criteria: distribution of birth in the range of six-week norm of occurrence in humans and ratio of premature infants to the mature ones at the gestational age <37 weeks counting from the last menstrual period.
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