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Multiple repeat cesarean sections
Multiple repeat cesarean sections WALTER DANIEL Boston,
THEIN, J.
M.D.
McSWEENEY,
M.D.
Massachusetts
C E S A R E A N section, although many times lifesaving and health-preserving to mother, baby, or both, is much maligned and criticized and accused of making a woman an ‘iobstetrical cripple.” Complications following both primary and repeat cesarean section are considered to be so much greater than those from vaginal delivery that ultraconservatism, which is often detrimental to both mother and baby, is considered the accepted method of management. Yet, it is sure, we can all reiterate the sage observation of Eastman who has said, in effect, that he regretted more instances in which he had not done a cesarean section than those in which he had done so unnecessarily. If it were shown that repeat cesareans do not offer too great a risk and that multiple cesareans may be done with relative impunity, then primary sections may be performed with broader indications, thus resulting in increased fetal salvage and prevention of birth trauma which may handicap the baby for life and also make a “vaginal cripple” of a woman because of pelvic relaxation, vaginal and cervical lacerations with sensitive scars, and consequent dyspareunia and pelvic discomfort. This report considers the question as to whether as many as 4 or more, even 8, repeat cesareans may be performed without undue risk to the mother or the fetus, provided the cases are done by qualified and
well-trained surgeons with good judgment and technical skill in a hospital with adequate facilities for covering every type of complication and with anesthesiologists particularly trained in obstetrical anesthesia. In 1956 McNally and Fitzpatrick1 published an excellent analysis of 130 patients and in 1961 2 of 7 10 patients who had 4 or more cesareans in several different hospitals. There were no maternal deaths in either series. They concluded that “the capabilities and integrity of the childbearing uterus in the patient with cesarean sections and relatively high parity have been underestimated.” Bremner and Dillon3 in 1955 reported upon 105 women who had three or more cesareans from two hospitals. There were no maternal deaths. They believe that ‘
material
From 1956 through 1962 at St. Margaret’s Hospital, there were 282 casts of four or more repeat cesarean sections on 196 different patients. During the 7 years of this study there were 32.543 deliveries of which 813 were primary cesarean sections and 1,23 I repeat sections, with an incidence of 2.5 per cent primary sections, 3.7 per cent repeat sections, and a total incidence of cesareans of 6.2 per cent. These data would indicate an
From the Departments of Gynecology and Obstetrics, St. Margaret’s Hosfiital and Tufts Uniuersity Medical School.
913
914
Thein
and
Table I. Surgical repeat
cesarean
McSweeney
difficulties section
at time
of
/ No. / 96 Bladder adhesions (high bladder) Weakness of previous uterine scar Beginning dehiscence of previous scar
Injury
to bladder
Adhesions of omentum to abdominal wall .4dhesions of bowel to parietal peritoneum Extension of incision into broad
ligament Hemorrhage
average not
13.82 9.92
12
4.25
3
1.06
(severe)
degree be
39 28 9 4
criticized
of
conservatism by
the
most
4
1.41
8
2 83
and staunch
3.91 1.41
could sup-
porters of vaginal delivery. The rules of the hospital demand that cesarean sections be done only by board qualified or certified specialists and consultations are required on all primary sections no matter who the surgeon may be. Repeat sections are done on all patients who have been delivered of their first baby by section and on all other patients who had previous section and started in labor spontaneously, but who showed a poorly effaced, undilated, or firm cervix cn examination. We are not heroic in our attempts to deliver a patient vaginally after a previous section. We elect vaginal delivery only if the apparent risk involved is practically nil as in the case of efficient labor, soft dilatable cervix, and small baby. In this 7 years’ study there were only 34 patients who were delivered vaginally after section, although the incidence of vaginal delivery postcesarean is increasing. In the first 5 years of the study there were only 11 patients delivered vaginally, while in the last 2 years there were 23, with the number of repeat sections remaining fairly constant. Statistical data The average age of the patients was 33. with the majority being in the favorable age group under 35. The younaest was 22 and the oldest was 44. There were 169 instances of 4 cesareans, 78 of 5 sections, 25 of 6 sections, 8 of 7 sections, and 2 of 8 cesarean sections.
Most of our repeat cesareans are donf, after the thirty-seventh week of gestation. We do not, as a rule, await labor before WC’ perform the operation, but prefer elective operation when careful appraisal of fetal size in utero suggests a fetal weight of 6 pounds or over. Eight per cent of the repeat sections were done at 37 weeks; 45 per cent at 38 weeks: 31 per cent at 39 weeks; and 9 per cent at 40 weeks. The remaining 7 per cent, which were done before the thirty-seventh week. were associated with some complication which required premature intervention. We found no evidence that waiting until the thirty-eighth week of gestation or later increased the danger of dehiscence or weakening of the lower segment scar. We would not recommend waiting so long if the scars were all in the corpus of the uterus, although one of us has reported 9 cesareans on 1 patient, all, with the exception of the eighth, being classical incisions.” Cephalopelvic disproportion (C.P.D.) was the original indication in 50 per cent of the cases. Placenta previa in 19 per cent, toxemia in 7 per cent, and abruptio placentae in 7 per cent were next in order of frequency. There were numerous other indications too rare to be significant. We give all patients with possible C.P.D. a test of labor, usually at least 8 hours from beginning dilatation and active labor, before resorting to cesarean section. We treat a11 cases of placenta previas by cesarean section: after the thirty-seventh week if possible, except marginal previas in which the bleeding is checked by rupture of membranes. Severe toxemia is treated by cesarean section if the cervix is unfavorable and the toxemia does not respond to treatment within 12 hours. Induction is attempted if the cervix is 50 per cent effaced, 2 cm. dilated, and response to intravenous oxytoxin assures delivery within 24 hours. Two hundred and fifty cases, 89 per cent of the total, were done electively on an appointed date. Twenty-two cases, 8 per cent, were done because labor had started and progress was not satisfactory enough to as-
Volume IVumbrr
90 7: part
Multiple
I
sure prompt delivery vaginally or the membranes had ruptured without labor. Ten cases, 3 per cent, presented indications which, per se, would have warranted cesarean section. These included 5 cases of placenta previa, 2 cases of abruptio placentae, and 1 case each of toxemia, Rh incompatibility with rising titer, and erythroblastosis with intrauterine fetal death. Ninety-five per cent of the cases were done by the low transverse cervical technique which permits more repeat sections than the low vertical or classical methods. Only 1 per cent were performed with a vertical incision in the lower segment. There were 4 per cent in which the incision was made vertically in the corpus and because the lower segment was inaccessible caused by adhesions, a transverse lie, or because of a placenta previa which precluded the low segment operation. There were two most common difficulties found at time of operation (Table I) . There were bladder adhesions in 39 cases (13.82 per cent). In 9 of these cases the adhesions were so severe that a classical incision was necessary because of the impossibility of separating the bladder from the lower segment. Weakness of the previous scar was found in 37 cases ( 13.12 per cent). In 28 cases (9.92 per cent) the previous scar was very thin and in 9 cases (3.91 per cent) there was dehiscence with membranes protruding through. There were no actual ruptures.
Table II. Complications
in relation
Adhesions
Weakness of scar Injury to bladder Hemorrhage during Others Placenta previa Abruptio placenta Placenta Placenta Hysterectomy
accreta located
(169
to the number
bladder
operation
on previous
at cesarean
scar section
4 cases) 23
cesarean
sections
915
Of the 28 patients in whom the thin scar was found, 2 underwent hysterectomy following unsuccessful attempt to resutllre. Of the 9 patients with dehiscence, 2 had hysterectomies without attempt to ~VSIIture. In one case the placenta had implanted in this area and was attached to the po$terior wall of the bladder. Other difficulties at time of cesarcan XVtion were 4 cases in which the bladder was injured {lacerated) and resutured. None 01 these patients had any postoperative complications in relation to this trauma. This proves that a bladder injury at time ~jf operation should not cause any further c~omplications if properly managed. Omentat and bowel adhesions to the parietal perit.ont:um were found in 15 cases (5.31 per ct%nt ‘i These adhesions were only cut 01. Iysrtl if they were in the field of operation anti intcrfered with the procedure. In 4 cases there were lacerations d the broad ligament by extension and in 1 of these was salpingo-oophorectom;< a unilateral necessary. Severe hemorrhage from tht* literine incision or extension into the broad ligament was present in 8 cases (2.83 per writ) An incisional hernia was repaired in 8 cases (2.83 per cent) and an umbilical hernia was repaired in 3 cases ( 1.06 per cent’;, Adhesions of the bladder to the 1owe1 uterine segment increased with thr numbex of cesareans as did weakness of thrx scar (Table II). Other complications did not increase any more than with increased p:srity.
of cesarean NO.
Complications including high
repeat
5 (78 cases) 19
of cezarean //
’ (25 cases) 8
22 3 4 3 10 2
10 3 6 8 2
2 11
2 8
1 2
3
3
3
sections ~-
...^. .~..
sectioflf /
(8 ,7,Ses) / .i
4
1 1
I 3 1
.-
1
’ (2 cases) 1
--
i .__--
916
Table
Thein
III.
and
McSweeney
Abnormal
-. Placenta
previa
<
Abruptio
placenta
Placenta
accreta
<
Plarenta
located
over
Table IV. morbidity.
but only 2 were diagnosed before and required immediate intervention.
placentas / No.
Complete Partia, Fzz?Jte previous
Postoperative
1%
7 14
2.48 4.96
t
y.77
jiii:l
-%J-~-
21
scar
5
1.77
5
1.77
21
7.44
complications
and
INo. Postpartum hemorrhage Wound dehiscence and Hematoma of abdominal Cecum dilatation Intestinal obstruction Paralytic ileus Postoperative infection Cystitis Pyelonephritis Acute bronchitis Bronchopneumonia Thrombophlebitis Wound infection
%
2 3 1 1 1 6 28 6
evisceration wound
(total)
a 3 3 5 3
Total
7.44
42
0.7 1.06 0.35 0.35 0.35 2.12 9.92 2.12 2.83 1.06 1.06 1.77 1.06 15
Abnormalities of the placenta were found in 31 cases. Placenta previa was found in 21 cases (7.44 per cent). This is considerably higher than the normal incidence of placenta previa which at St. Margaret’s Hospital is 0.6 per cent of all deliveries. Seven of these were complete and 14 were partial. As mentioned before, only 5 of these 21 patients showed any bleeding before operation and were operated upon before the scheduled date. The remainder were incidental findings during elective operation (Table III). There is a definite tendency for a placenta previa
at
the
site
of
an
old
scar
to
also
be-
come placenta accreta. Of the 21 cases of placenta previa, there were 15 in which implantation occurred partially or completely on the previous scar. There were 5 cases of placenta accreta, all of which were implanted on the previous scar. All of these were partial accretas and the area of abnormality involved the fibrous tissue of the scar in all instances. There were 5 cases of abruptio placenta,
of
the
abruptio
2 In 11 cesarean dence of previas,
partial,
placentas and
were 1 central
also
operation Thrrt* placenla previa.
cases hysterectomy at time of section was necessary--~-an inci3.9 per cent. Five were panhysterectomies and 6 supracervical hysterecFour were performed because of tomies. placenta accreta; 4 because the tissue was too friable for suturing as there was dehiscence of the scar; 2 were done because of hemorrhage; and 1 because of dehiscence with placenta attached to the posterior wall of bladder. Only 30 patients, 10 per cent of the 282 in the series, required blood transfusions. Only 5 patients, less than 2 per cent, needed more than two units. We require two units of blood cross-matched and ready before operation, and transfusions are given only if required because of blood loss or shock. Complications were no greater than with any major abdominal procedure (Table IV). The intestinal tract seemed particularly vuInerable to adynamic ileus, and abdominal wound dehiscence occurred on three occasions possibly caused by the repeated use of the same site for the abdominal incision. Complications did not increase with the number of cesarean sections. The most prevalent infection site was in the bladder and kidneys. Infection of the uterus, parametrium, or peritoneum was not mentioned in the records. Whether these areas were not involved in infection, mistakenly diagnosed as infection of the bladder or kidneys, or were aborted by antibiotics before a definitive diagnosis could be made is controversial. The general average baby weight was 6% pounds. Seventy-five per cent weighed 7 pounds or more. Only 20 babies, 7 per cent, were under 5% pounds and these included 8 twins. Th e gross permatal mortality rate was 3% per cent, which included 3 stillbirths, 1 case of erythroblastosis, 3 premature babies, 2 cases of hyaline membrane disease, and 1 case of pneumonitis.
Volume Number
90 7,
part
1
All
of our anesthesias are administered certified anesthesiologists. Ninety-five t)Y per cent were spinal anesthesias, solely or in combination with inhalation agents, usually nitrous oxide, given after the birth of the baby. Primary inhalation anesthesia, usually nitrous oxide and cyclopropane, was used in 4 per cent. Local anesthesia was used only in 4 cases not because of failure to realize the value of this technique but because spinal anesthesia given by our highly experienced anesthesiologists has proved to be so timesaving, safe, and efficient. Comment This series of 282 cases of 4 or more repeat cesarean sections, which we believe to be the largest reported from one institution, should be of significant statistical value. Our data indicate that repeat cesareans, regardless of number, can be performed without added risk to the mother and the fetus provided they are done by qualified physicians with adequate hospital facilities. Although, except under most favorable conditions, we do repeat cesarean sections on patients who have had previous cesareans, our over-all incidence of cesarean sections remains only 6.2 per cent which is average for this country. Even with a fairly liberal election of primary cesarean sections, our primary section rate is comparatively low at 2.5 per cent. As long as repeat cesarean sections occur in the favorable age group under 35, waiting until the thirty-eighth week of gestation does no increase the danger of weakness of the previous scar and assures a mature baby which was proved in our series in which the average baby was St/, pounds. Our low incidence of dehiscence may well be caused by the fact that 95 per cent of the cases were done with the low transverse cervical incision. The leading difficulty found at the time of operation was bladder adhesions to the lower uterine segment. This complication and weakness of the scar were in direct proportion to the number of cesarean sections. It is important to note that the incidence
Multiple
repeat
cesarean
section:
817
of placenta previa in repeat cesarean settions is more than ten times that of all deliveries. Also, a placenta implanted in the lower uterine segment overlying a previous scar may be complicated by a placenta accreta. This would be caused by the ahscncc of endometrium over the fibrous tissue of the scar: providing a fertile area for this unfortunate complication. For the 11 cases in which hysterec-tom! was necessary at the time of cesarean st‘rtion. 9 were caused by complications resulting from the multiple repeat cesareans. ‘I’his eventually, therefore, must be considered when multiple repeat cesarean sections are done. The necessity for blood transfusions and the incidence of postoperative complications and morbidity were proved to be no hieher than for primary cesarean sections or for ;~ny major abdominal procedures. Summary A review of 282 patients with four or more cesarean sections over a period of 7 years (1956 through 1962) at an eschtsively maternity hospital is presented. The statistical data indicate that waiting until the thirty-eighth week of gestation does not increase the danger of weakness of the previous scar and assures a mature baby. The incidence of placenta previa is mart’ than ten times that of all deliveries. Placenta accreta seems to occur sufficiently often in cases in which the placenta cn.erlies the previous scar to warrant serious consideration. The possibility of hysterectomy for placenta accreta or a weakened scar rnlmt bc anticipated. The over-all incidence of postoperative morbidity and complications are no higher than for primary cesarean sections or any other major abdominal procedures. Repeat cesarean sections, regardless of number, can be performed without the addition of significant risk to the mother or the fetus, provided they are done by qualified physicians and with adequate hospital facilities.
918
Thein
and
McSweeney
REFERENCES
1. McNally, H. B., and Fitzpatrick, J. A. M. A. 160: 1005, 1956. 2. McNally, H. B., and Fitzpatrick, South. M. J. 54: 360, 1961. 3. Bremmer, J. X., and Dillon, J. Gynec. 6: 85, 1955.
V.
de
P.:
V.
de
P.:
Obst.
&
R.:
4.
McSweeney, D. 39: 155, 1940.
90 Cushing Dorchester,
J.:
AM.
Avenue Massachusetts
J. OBST.
02125
& GYNEC
THEIN, J.
M.D.
McSWEENEY,
M.D.
Massachusetts
C E S A R E A N section, although many times lifesaving and health-preserving to mother, baby, or both, is much maligned and criticized and accused of making a woman an ‘iobstetrical cripple.” Complications following both primary and repeat cesarean section are considered to be so much greater than those from vaginal delivery that ultraconservatism, which is often detrimental to both mother and baby, is considered the accepted method of management. Yet, it is sure, we can all reiterate the sage observation of Eastman who has said, in effect, that he regretted more instances in which he had not done a cesarean section than those in which he had done so unnecessarily. If it were shown that repeat cesareans do not offer too great a risk and that multiple cesareans may be done with relative impunity, then primary sections may be performed with broader indications, thus resulting in increased fetal salvage and prevention of birth trauma which may handicap the baby for life and also make a “vaginal cripple” of a woman because of pelvic relaxation, vaginal and cervical lacerations with sensitive scars, and consequent dyspareunia and pelvic discomfort. This report considers the question as to whether as many as 4 or more, even 8, repeat cesareans may be performed without undue risk to the mother or the fetus, provided the cases are done by qualified and
well-trained surgeons with good judgment and technical skill in a hospital with adequate facilities for covering every type of complication and with anesthesiologists particularly trained in obstetrical anesthesia. In 1956 McNally and Fitzpatrick1 published an excellent analysis of 130 patients and in 1961 2 of 7 10 patients who had 4 or more cesareans in several different hospitals. There were no maternal deaths in either series. They concluded that “the capabilities and integrity of the childbearing uterus in the patient with cesarean sections and relatively high parity have been underestimated.” Bremner and Dillon3 in 1955 reported upon 105 women who had three or more cesareans from two hospitals. There were no maternal deaths. They believe that ‘
material
From 1956 through 1962 at St. Margaret’s Hospital, there were 282 casts of four or more repeat cesarean sections on 196 different patients. During the 7 years of this study there were 32.543 deliveries of which 813 were primary cesarean sections and 1,23 I repeat sections, with an incidence of 2.5 per cent primary sections, 3.7 per cent repeat sections, and a total incidence of cesareans of 6.2 per cent. These data would indicate an
From the Departments of Gynecology and Obstetrics, St. Margaret’s Hosfiital and Tufts Uniuersity Medical School.
913
914
Thein
and
Table I. Surgical repeat
cesarean
McSweeney
difficulties section
at time
of
/ No. / 96 Bladder adhesions (high bladder) Weakness of previous uterine scar Beginning dehiscence of previous scar
Injury
to bladder
Adhesions of omentum to abdominal wall .4dhesions of bowel to parietal peritoneum Extension of incision into broad
ligament Hemorrhage
average not
13.82 9.92
12
4.25
3
1.06
(severe)
degree be
39 28 9 4
criticized
of
conservatism by
the
most
4
1.41
8
2 83
and staunch
3.91 1.41
could sup-
porters of vaginal delivery. The rules of the hospital demand that cesarean sections be done only by board qualified or certified specialists and consultations are required on all primary sections no matter who the surgeon may be. Repeat sections are done on all patients who have been delivered of their first baby by section and on all other patients who had previous section and started in labor spontaneously, but who showed a poorly effaced, undilated, or firm cervix cn examination. We are not heroic in our attempts to deliver a patient vaginally after a previous section. We elect vaginal delivery only if the apparent risk involved is practically nil as in the case of efficient labor, soft dilatable cervix, and small baby. In this 7 years’ study there were only 34 patients who were delivered vaginally after section, although the incidence of vaginal delivery postcesarean is increasing. In the first 5 years of the study there were only 11 patients delivered vaginally, while in the last 2 years there were 23, with the number of repeat sections remaining fairly constant. Statistical data The average age of the patients was 33. with the majority being in the favorable age group under 35. The younaest was 22 and the oldest was 44. There were 169 instances of 4 cesareans, 78 of 5 sections, 25 of 6 sections, 8 of 7 sections, and 2 of 8 cesarean sections.
Most of our repeat cesareans are donf, after the thirty-seventh week of gestation. We do not, as a rule, await labor before WC’ perform the operation, but prefer elective operation when careful appraisal of fetal size in utero suggests a fetal weight of 6 pounds or over. Eight per cent of the repeat sections were done at 37 weeks; 45 per cent at 38 weeks: 31 per cent at 39 weeks; and 9 per cent at 40 weeks. The remaining 7 per cent, which were done before the thirty-seventh week. were associated with some complication which required premature intervention. We found no evidence that waiting until the thirty-eighth week of gestation or later increased the danger of dehiscence or weakening of the lower segment scar. We would not recommend waiting so long if the scars were all in the corpus of the uterus, although one of us has reported 9 cesareans on 1 patient, all, with the exception of the eighth, being classical incisions.” Cephalopelvic disproportion (C.P.D.) was the original indication in 50 per cent of the cases. Placenta previa in 19 per cent, toxemia in 7 per cent, and abruptio placentae in 7 per cent were next in order of frequency. There were numerous other indications too rare to be significant. We give all patients with possible C.P.D. a test of labor, usually at least 8 hours from beginning dilatation and active labor, before resorting to cesarean section. We treat a11 cases of placenta previas by cesarean section: after the thirty-seventh week if possible, except marginal previas in which the bleeding is checked by rupture of membranes. Severe toxemia is treated by cesarean section if the cervix is unfavorable and the toxemia does not respond to treatment within 12 hours. Induction is attempted if the cervix is 50 per cent effaced, 2 cm. dilated, and response to intravenous oxytoxin assures delivery within 24 hours. Two hundred and fifty cases, 89 per cent of the total, were done electively on an appointed date. Twenty-two cases, 8 per cent, were done because labor had started and progress was not satisfactory enough to as-
Volume IVumbrr
90 7: part
Multiple
I
sure prompt delivery vaginally or the membranes had ruptured without labor. Ten cases, 3 per cent, presented indications which, per se, would have warranted cesarean section. These included 5 cases of placenta previa, 2 cases of abruptio placentae, and 1 case each of toxemia, Rh incompatibility with rising titer, and erythroblastosis with intrauterine fetal death. Ninety-five per cent of the cases were done by the low transverse cervical technique which permits more repeat sections than the low vertical or classical methods. Only 1 per cent were performed with a vertical incision in the lower segment. There were 4 per cent in which the incision was made vertically in the corpus and because the lower segment was inaccessible caused by adhesions, a transverse lie, or because of a placenta previa which precluded the low segment operation. There were two most common difficulties found at time of operation (Table I) . There were bladder adhesions in 39 cases (13.82 per cent). In 9 of these cases the adhesions were so severe that a classical incision was necessary because of the impossibility of separating the bladder from the lower segment. Weakness of the previous scar was found in 37 cases ( 13.12 per cent). In 28 cases (9.92 per cent) the previous scar was very thin and in 9 cases (3.91 per cent) there was dehiscence with membranes protruding through. There were no actual ruptures.
Table II. Complications
in relation
Adhesions
Weakness of scar Injury to bladder Hemorrhage during Others Placenta previa Abruptio placenta Placenta Placenta Hysterectomy
accreta located
(169
to the number
bladder
operation
on previous
at cesarean
scar section
4 cases) 23
cesarean
sections
915
Of the 28 patients in whom the thin scar was found, 2 underwent hysterectomy following unsuccessful attempt to resutllre. Of the 9 patients with dehiscence, 2 had hysterectomies without attempt to ~VSIIture. In one case the placenta had implanted in this area and was attached to the po$terior wall of the bladder. Other difficulties at time of cesarcan XVtion were 4 cases in which the bladder was injured {lacerated) and resutured. None 01 these patients had any postoperative complications in relation to this trauma. This proves that a bladder injury at time ~jf operation should not cause any further c~omplications if properly managed. Omentat and bowel adhesions to the parietal perit.ont:um were found in 15 cases (5.31 per ct%nt ‘i These adhesions were only cut 01. Iysrtl if they were in the field of operation anti intcrfered with the procedure. In 4 cases there were lacerations d the broad ligament by extension and in 1 of these was salpingo-oophorectom;< a unilateral necessary. Severe hemorrhage from tht* literine incision or extension into the broad ligament was present in 8 cases (2.83 per writ) An incisional hernia was repaired in 8 cases (2.83 per cent) and an umbilical hernia was repaired in 3 cases ( 1.06 per cent’;, Adhesions of the bladder to the 1owe1 uterine segment increased with thr numbex of cesareans as did weakness of thrx scar (Table II). Other complications did not increase any more than with increased p:srity.
of cesarean NO.
Complications including high
repeat
5 (78 cases) 19
of cezarean //
’ (25 cases) 8
22 3 4 3 10 2
10 3 6 8 2
2 11
2 8
1 2
3
3
3
sections ~-
...^. .~..
sectioflf /
(8 ,7,Ses) / .i
4
1 1
I 3 1
.-
1
’ (2 cases) 1
--
i .__--
916
Table
Thein
III.
and
McSweeney
Abnormal
-. Placenta
previa
<
Abruptio
placenta
Placenta
accreta
<
Plarenta
located
over
Table IV. morbidity.
but only 2 were diagnosed before and required immediate intervention.
placentas / No.
Complete Partia, Fzz?Jte previous
Postoperative
1%
7 14
2.48 4.96
t
y.77
jiii:l
-%J-~-
21
scar
5
1.77
5
1.77
21
7.44
complications
and
INo. Postpartum hemorrhage Wound dehiscence and Hematoma of abdominal Cecum dilatation Intestinal obstruction Paralytic ileus Postoperative infection Cystitis Pyelonephritis Acute bronchitis Bronchopneumonia Thrombophlebitis Wound infection
%
2 3 1 1 1 6 28 6
evisceration wound
(total)
a 3 3 5 3
Total
7.44
42
0.7 1.06 0.35 0.35 0.35 2.12 9.92 2.12 2.83 1.06 1.06 1.77 1.06 15
Abnormalities of the placenta were found in 31 cases. Placenta previa was found in 21 cases (7.44 per cent). This is considerably higher than the normal incidence of placenta previa which at St. Margaret’s Hospital is 0.6 per cent of all deliveries. Seven of these were complete and 14 were partial. As mentioned before, only 5 of these 21 patients showed any bleeding before operation and were operated upon before the scheduled date. The remainder were incidental findings during elective operation (Table III). There is a definite tendency for a placenta previa
at
the
site
of
an
old
scar
to
also
be-
come placenta accreta. Of the 21 cases of placenta previa, there were 15 in which implantation occurred partially or completely on the previous scar. There were 5 cases of placenta accreta, all of which were implanted on the previous scar. All of these were partial accretas and the area of abnormality involved the fibrous tissue of the scar in all instances. There were 5 cases of abruptio placenta,
of
the
abruptio
2 In 11 cesarean dence of previas,
partial,
placentas and
were 1 central
also
operation Thrrt* placenla previa.
cases hysterectomy at time of section was necessary--~-an inci3.9 per cent. Five were panhysterectomies and 6 supracervical hysterecFour were performed because of tomies. placenta accreta; 4 because the tissue was too friable for suturing as there was dehiscence of the scar; 2 were done because of hemorrhage; and 1 because of dehiscence with placenta attached to the posterior wall of bladder. Only 30 patients, 10 per cent of the 282 in the series, required blood transfusions. Only 5 patients, less than 2 per cent, needed more than two units. We require two units of blood cross-matched and ready before operation, and transfusions are given only if required because of blood loss or shock. Complications were no greater than with any major abdominal procedure (Table IV). The intestinal tract seemed particularly vuInerable to adynamic ileus, and abdominal wound dehiscence occurred on three occasions possibly caused by the repeated use of the same site for the abdominal incision. Complications did not increase with the number of cesarean sections. The most prevalent infection site was in the bladder and kidneys. Infection of the uterus, parametrium, or peritoneum was not mentioned in the records. Whether these areas were not involved in infection, mistakenly diagnosed as infection of the bladder or kidneys, or were aborted by antibiotics before a definitive diagnosis could be made is controversial. The general average baby weight was 6% pounds. Seventy-five per cent weighed 7 pounds or more. Only 20 babies, 7 per cent, were under 5% pounds and these included 8 twins. Th e gross permatal mortality rate was 3% per cent, which included 3 stillbirths, 1 case of erythroblastosis, 3 premature babies, 2 cases of hyaline membrane disease, and 1 case of pneumonitis.
Volume Number
90 7,
part
1
All
of our anesthesias are administered certified anesthesiologists. Ninety-five t)Y per cent were spinal anesthesias, solely or in combination with inhalation agents, usually nitrous oxide, given after the birth of the baby. Primary inhalation anesthesia, usually nitrous oxide and cyclopropane, was used in 4 per cent. Local anesthesia was used only in 4 cases not because of failure to realize the value of this technique but because spinal anesthesia given by our highly experienced anesthesiologists has proved to be so timesaving, safe, and efficient. Comment This series of 282 cases of 4 or more repeat cesarean sections, which we believe to be the largest reported from one institution, should be of significant statistical value. Our data indicate that repeat cesareans, regardless of number, can be performed without added risk to the mother and the fetus provided they are done by qualified physicians with adequate hospital facilities. Although, except under most favorable conditions, we do repeat cesarean sections on patients who have had previous cesareans, our over-all incidence of cesarean sections remains only 6.2 per cent which is average for this country. Even with a fairly liberal election of primary cesarean sections, our primary section rate is comparatively low at 2.5 per cent. As long as repeat cesarean sections occur in the favorable age group under 35, waiting until the thirty-eighth week of gestation does no increase the danger of weakness of the previous scar and assures a mature baby which was proved in our series in which the average baby was St/, pounds. Our low incidence of dehiscence may well be caused by the fact that 95 per cent of the cases were done with the low transverse cervical incision. The leading difficulty found at the time of operation was bladder adhesions to the lower uterine segment. This complication and weakness of the scar were in direct proportion to the number of cesarean sections. It is important to note that the incidence
Multiple
repeat
cesarean
section:
817
of placenta previa in repeat cesarean settions is more than ten times that of all deliveries. Also, a placenta implanted in the lower uterine segment overlying a previous scar may be complicated by a placenta accreta. This would be caused by the ahscncc of endometrium over the fibrous tissue of the scar: providing a fertile area for this unfortunate complication. For the 11 cases in which hysterec-tom! was necessary at the time of cesarean st‘rtion. 9 were caused by complications resulting from the multiple repeat cesareans. ‘I’his eventually, therefore, must be considered when multiple repeat cesarean sections are done. The necessity for blood transfusions and the incidence of postoperative complications and morbidity were proved to be no hieher than for primary cesarean sections or for ;~ny major abdominal procedures. Summary A review of 282 patients with four or more cesarean sections over a period of 7 years (1956 through 1962) at an eschtsively maternity hospital is presented. The statistical data indicate that waiting until the thirty-eighth week of gestation does not increase the danger of weakness of the previous scar and assures a mature baby. The incidence of placenta previa is mart’ than ten times that of all deliveries. Placenta accreta seems to occur sufficiently often in cases in which the placenta cn.erlies the previous scar to warrant serious consideration. The possibility of hysterectomy for placenta accreta or a weakened scar rnlmt bc anticipated. The over-all incidence of postoperative morbidity and complications are no higher than for primary cesarean sections or any other major abdominal procedures. Repeat cesarean sections, regardless of number, can be performed without the addition of significant risk to the mother or the fetus, provided they are done by qualified physicians and with adequate hospital facilities.
918
Thein
and
McSweeney
REFERENCES
1. McNally, H. B., and Fitzpatrick, J. A. M. A. 160: 1005, 1956. 2. McNally, H. B., and Fitzpatrick, South. M. J. 54: 360, 1961. 3. Bremmer, J. X., and Dillon, J. Gynec. 6: 85, 1955.
V.
de
P.:
V.
de
P.:
Obst.
&
R.:
4.
McSweeney, D. 39: 155, 1940.
90 Cushing Dorchester,
J.:
AM.
Avenue Massachusetts
J. OBST.
02125
& GYNEC