- Email: [email protected]
Abdominal wound dehiscence
Volume Number
Corresoondence
130 4
do not prove the efficacy of this approach for breeches weighing less than 1,500 grams. We agree that it is likely that some of the morbidity and mortality rates associated with vaginal delivery may be prevented by intensive intrapartum care, but feel it is unlikely that all of the excessive morbidity and death associated with premature breech delivery can be eliminated by this approach alone. That portion of improvement in perinatal outcome that will result from each approach remains a researchable question. We feel, therefore, that the retrospective data we presented together with the legitimate questions raised about our interpretation of those data clearly call for a prospective randomly controlled trial of prophylactic cesarean section versus intensive intrapartum care followed by a vaginal delivery to determine the optimal delivery method for premature breeches weighing less than 1,500 grams. For breech fetuses weighing more than 1,500 grams, our data suggested that “with careful management and the willingness to perform cesarean section for the same indications one would use in the term breech,” it may be possible to deliver infants in this category “with mortality and morbidity rates approaching those of vertex delivery.” Nevertheless, the retrospective analysis showed that when fetuses greater than 1,500 grams were given “intensive intrapartum care,” vaginally delivered breech infants did have a slightly higher mortality rate than vertex infants of the same weight and did have twice the number of depressed infants as indicated by Apgar score at 5 minutes. In this series, infants weighing more than 1,500 grams delivered by cesarean section did poorly when compared with either vaginally delivered vertex or breech infants. Our interpretation of these findings suggested that the poor outcome for cesarean birth occurred because virtually all cesarean sections were done for fetuses in distress prior to delivery. We did state clearly that we know of no data indicating survival or morbidity rates for uncompromised premature infants delivered prophylactically by cesarean section in this or any other weight group. Until such data are available, together with a properly controlled clinical trial of intensive intrapartum care, the correct management of women with a premature breech in labor will remain unresolved. Robert L. Goldenberg, M.D. Departments Uniuersit~~ Birmingham,
of
Kathleen of Obstetrics and Gynecology Alabama in Birmingham ,4labama 35294
G. Nelson, M.D. and Pediatrics
of
Abdominsl wound dehiscence To the Editors:
Dr. Helmkamp, when commenting on his results (“Abdominal wound dehiscence,” AM. J. OBSTET.
501
GYNECOL. 128: 803, 1977), made no mention of the fact that only three Pfannenstiel incisions contributed to 49 wound dehiscences in gynecologic cases, and there were no dehiscences of Pfannenstiel incisions reported in 2 1 obstetric cases. In routine obstetric and gynecologic surgery the incision of choice should always be the Pfannenstiel incision unless the size of the tumor to be removed or the type of surgery that is planned is a distinct contraindication. All of the obstetric operations described by Dr. Helmkamp could easily have been performed through a Pfannenstiel incision, and 45 of 49 of the gynecologic operations could also have been done through a Pfannenstiel incision. Obesity is not a cvlitr-ailidication of this approach. Quite the contrary, due to the excellent healing of the incision and its inherent strength. it is the incision of choice when a patient is obese. With the cesarean section rate now approaching 20 per cent and the mortality rate associated with catastrophic disruption also around 20 per cent,’ wound dehiscence will soon be contributing significantly to maternal death unless greater efforts arc made to move from the midline to the low transverse incision. Mowat and BonnaI-2 reported 540 cesarean sections in which a low transverse incision was used without a single complete dehiscence. yet a midline incision resulted in complete dehiscence in 1.5 per cent of’ I.635 cesarean sections. Dr. Helmkamp’s data also provided an excellent sounding board for this message. Unfortunately, like many authors on this subject, he paid more attention to the type of sutures used, the occurrence of paralytic ileus, and the occurrence of postoperative vomiting, coughing, etc., rather than emphasizing the fundamental point that in most cases the chaise of incision was in error. Wound dehiscence in obstetric and gynecologic surgery will remain “a problem” as long as the midline incision continues to be routinely used. K’est Virginia Univrrsity School of Medicine Department of Obstetrics and Gyrwcolop Morgantown, West Virginia 26506 REFERENCES
Baggish, M. S., and Lee, W. K.: Abdominal wound disruption, Obstet. Gynecol. 46: 530, 1975. 2. Mowat, J., and Bonnar, J.: Abdominal wound dehiscence after caesarean section, Br. Med. J. 2: 256, 1971. 1.
To the Editors:
A close study of the paper “Abdominal wound dehiscence,” by B. F. Helmkamp in the JOURNAL (128: 803, 1977) leaves the feeling that the author failed to adequately emphasize the importance of the type of incision utilized, as regards subsequent dehiscence. It is significant that no obstetric operations and only three
Corresoondence
130 4
do not prove the efficacy of this approach for breeches weighing less than 1,500 grams. We agree that it is likely that some of the morbidity and mortality rates associated with vaginal delivery may be prevented by intensive intrapartum care, but feel it is unlikely that all of the excessive morbidity and death associated with premature breech delivery can be eliminated by this approach alone. That portion of improvement in perinatal outcome that will result from each approach remains a researchable question. We feel, therefore, that the retrospective data we presented together with the legitimate questions raised about our interpretation of those data clearly call for a prospective randomly controlled trial of prophylactic cesarean section versus intensive intrapartum care followed by a vaginal delivery to determine the optimal delivery method for premature breeches weighing less than 1,500 grams. For breech fetuses weighing more than 1,500 grams, our data suggested that “with careful management and the willingness to perform cesarean section for the same indications one would use in the term breech,” it may be possible to deliver infants in this category “with mortality and morbidity rates approaching those of vertex delivery.” Nevertheless, the retrospective analysis showed that when fetuses greater than 1,500 grams were given “intensive intrapartum care,” vaginally delivered breech infants did have a slightly higher mortality rate than vertex infants of the same weight and did have twice the number of depressed infants as indicated by Apgar score at 5 minutes. In this series, infants weighing more than 1,500 grams delivered by cesarean section did poorly when compared with either vaginally delivered vertex or breech infants. Our interpretation of these findings suggested that the poor outcome for cesarean birth occurred because virtually all cesarean sections were done for fetuses in distress prior to delivery. We did state clearly that we know of no data indicating survival or morbidity rates for uncompromised premature infants delivered prophylactically by cesarean section in this or any other weight group. Until such data are available, together with a properly controlled clinical trial of intensive intrapartum care, the correct management of women with a premature breech in labor will remain unresolved. Robert L. Goldenberg, M.D. Departments Uniuersit~~ Birmingham,
of
Kathleen of Obstetrics and Gynecology Alabama in Birmingham ,4labama 35294
G. Nelson, M.D. and Pediatrics
of
Abdominsl wound dehiscence To the Editors:
Dr. Helmkamp, when commenting on his results (“Abdominal wound dehiscence,” AM. J. OBSTET.
501
GYNECOL. 128: 803, 1977), made no mention of the fact that only three Pfannenstiel incisions contributed to 49 wound dehiscences in gynecologic cases, and there were no dehiscences of Pfannenstiel incisions reported in 2 1 obstetric cases. In routine obstetric and gynecologic surgery the incision of choice should always be the Pfannenstiel incision unless the size of the tumor to be removed or the type of surgery that is planned is a distinct contraindication. All of the obstetric operations described by Dr. Helmkamp could easily have been performed through a Pfannenstiel incision, and 45 of 49 of the gynecologic operations could also have been done through a Pfannenstiel incision. Obesity is not a cvlitr-ailidication of this approach. Quite the contrary, due to the excellent healing of the incision and its inherent strength. it is the incision of choice when a patient is obese. With the cesarean section rate now approaching 20 per cent and the mortality rate associated with catastrophic disruption also around 20 per cent,’ wound dehiscence will soon be contributing significantly to maternal death unless greater efforts arc made to move from the midline to the low transverse incision. Mowat and BonnaI-2 reported 540 cesarean sections in which a low transverse incision was used without a single complete dehiscence. yet a midline incision resulted in complete dehiscence in 1.5 per cent of’ I.635 cesarean sections. Dr. Helmkamp’s data also provided an excellent sounding board for this message. Unfortunately, like many authors on this subject, he paid more attention to the type of sutures used, the occurrence of paralytic ileus, and the occurrence of postoperative vomiting, coughing, etc., rather than emphasizing the fundamental point that in most cases the chaise of incision was in error. Wound dehiscence in obstetric and gynecologic surgery will remain “a problem” as long as the midline incision continues to be routinely used. K’est Virginia Univrrsity School of Medicine Department of Obstetrics and Gyrwcolop Morgantown, West Virginia 26506 REFERENCES
Baggish, M. S., and Lee, W. K.: Abdominal wound disruption, Obstet. Gynecol. 46: 530, 1975. 2. Mowat, J., and Bonnar, J.: Abdominal wound dehiscence after caesarean section, Br. Med. J. 2: 256, 1971. 1.
To the Editors:
A close study of the paper “Abdominal wound dehiscence,” by B. F. Helmkamp in the JOURNAL (128: 803, 1977) leaves the feeling that the author failed to adequately emphasize the importance of the type of incision utilized, as regards subsequent dehiscence. It is significant that no obstetric operations and only three