- Email: [email protected]
An Analysis of Four Hundred Consecutive Cesarean Sections
AN ANALYSIS OF FOUR HUHDB.ED CONSECUTIVE CESAREAN SBCTIONS GEORGE
S.
ZAROU,
M.D.,
BROOKLY:t\,
N. Y.
(From the Department of Obstetrics and Gynerology, Norwegian Hospital)
interest in the use of cesar·ean section has developed in WIDESPREAD recent years, due to the increasing safety of the operation. Many
authors1 have reported long series with little or no maternal mortality, and an increasing fetal salvage. This has been attributed to improvement in surgical technique, the availability of the antibiotics, the blood bank, and a broader knowledge in the field of anesthesia. As a result, liberalization of the indications for cesarean section has taken plaee. D'Esopo 2 has shown that abdominal section is slowly replacing the formidable midforceps delivery, and that a cesarean section rate of approximately fi.O per cent should he adequate to eliminate the trauma, both maternal an!l fetal, caused by difficult vaginal operations. He further points out that overutilization of the operation may develop. Although the results of the following survey have been gratifying from the standpoint of maternal mOI'tality and infant survival, we feel that the eesarean section operation is still a formidable one, as demonstrated by morbidity rates and postoperative complications, and our ohject is to attempt to limit this trend toward overntilization.
Material This survey ineludes 400 consecutive cesarean sections, done betvveen April 15, 1944, and April 1, 1951. All operations were performed either hy a member of the obstetric staff or by the obstetric resident under supervision of a staff member. All patients received adequate prenatal care. The average length of gestation was 38.4 weeks. The average postoperative hospital sta.y was 10.5 days. There were no Negro patients. Apart from this factor, the total of patients delivered comprised a heterogeneous group representing a cross section of the population of a large city. lncidence.-Table I shows the total and yearly incidence of section in our clinie. The total incidence is 1 per cent lower than the av;lrage for a representative group of hospitals in the eastern half of the country. 3 This we attribute, first, to the strict prenatal supervision given our patients, and, second, to the fact that there were no Negroes in this group. Kistner 1 and D'Esopo" have pointed out the higher incidence of section in the Negro, due mainly to cephalopelvic disproportion. The rising annual incidence, as illustrated in Table T, has been brought out by many writers, and large series of consecutive sections with little or no maternal mortality would indicate that this trend is justifiable. The end results of liberalization of this procedure have been an increase in fetal salvage and a decrease in maternal trauma. 122
Volume 63 Number 1
123
ANALYSIS OF FOUR HUNDRED CESAREAN SECTIONS TABLE I.
1945 1946 1947 1948 1949 1950
YEARLY INCIDENCE OF CESAREAN SECTIONS
1,155 1,461 1,696 1,664 1,652 1,622 10,173
Total
2.16 3.83 4.13 4.33 4.48 5.19 3.93
25 56 70 72 74 84
400
Age and Parity.-Tab1e II shows the relation of age and parity to the number of sections. The high incidence of cephalopelvic disproportion and previous section in patients of low parity accounts for the large number of operations in this group. Our policy of sterilization at the time of the third section has made the operative incidence low in women of high parity. The average age was 31.5 years. The large number in primiparas, aged 35 years or over, were done in order to effect a higher fetal salvage. These patients were subjected to shorter trials of labor, and there was a reluctance to use Pituitrin and difficult vaginal operations. TABLE II.
CESAREAN SECTIONS IN RELATION TO AGE AND PARITY
14 3 0
iv
0
73 26 14 2
46 14 8 6
133 43
22
8
Anesthesia.-Spinal anesthesia was employed for 377, or 94.3 per cent, of the cases. In 226 of these, Pentothal Sodium was used in combination with the spinal anesthetic following delivery. Twelve operations were performed under local and 11 under inhalation anesthesia. Ten of the latter were done because of severe hemorrhage. No maternal or fetal deaths were attributable to the anesthetic. We concur in the findings of Lull 4 that absence of narcosis in the infant, excellent relaxation during surgery, and a minimum of postoperative distention make this the anesthetic of choice for section. In our series, spinal headache was a negligible factor and serious abdominal distention rare, intestinal drainage being required in only 2 cases. As pointed out by Kistner/ the trained anesthesiologist is an important addition to the cesarean section team. Indications.-Table III shows the primary indications for operation. Secondary indications were present in many cases. In the previous section group, it has been our policy to adhere to reoperation, especially since 60 of the repeat sections were done for cephalopelvic disproportion initially. Labor taxes not only the old uterine scar but the obstetrician as well. A small number of patients admitted in active labor, the head well engaged and the cervix partially dilated, were delivered vaginally. In the disproportion group, 81 patients received a trial of labor, while 32 did not. 'l'he latter included 5 cases of pelvic deformity incompatible with
ZAROU
12-±
Am.]. Obst. & Gynec. January, 1952
\'aginal delivery, one hydrocephalic infant, 2 patients with dermoid cysts in the cul-de-sac, and 3 with myomas in the lower uterine segment. The remainder of the 32 cases were classified as absolute disproportion by x-ray pelvimetry and clinical evaluation. Of the patients receiving a trial of labor, :36 were in labor over 12 hours, and 22 had ruptured membranes over 12 houn;, Four per cent of the total sections were clone in multiparas for disproportion. A history of stillbirth or neonatal death was present in 11 of these cases, and of prolonged labor and difficult vaginal delivery in alL DilP has emphasized the frequency with which disproportion oecurs in the multipara. TABLF;
Ill.
PRIMARY lN!HCATIOI>; S F'Ol' CESARE.\~ 8ECT]()N
JN!JICA'l'!OXS
Previous cesarean Cephalopelvic disproportion Placenta previa Pre·eclamptic toxemia Uterine inertia Malpresentations Breech in elderly primipara 'l'ransverse presentation Large breech Brow presentation Previous gynecological surgery Previous vaginal plastic Previous myomectomy Previous hysterotomy Premature separation of placenta Elderly primipara Prolapse of umbilical cord Fibromyomas of the uteruA Hising Rh antibody titer E~sential hypertension Chronic nephriti;; Diabetes mellitus Rheumatic heart disease Partial rupture of a rudimentary horn of the uteru;;
{i5 ____ _
<'ASES
ll:l .jj
28.25 14.25
Hl
IX Ii-I
4.75 4.50 4.50
11
2·.i5
R 5
2.00 1.25 1.25 1.00 1.00 0.75 O.i5 0.75 0.7fi
lO
. ,,
5
4 4
;:; il
;:; :~
0.25
Thirty-nine of the 57 sections performed for plaeenta previa were done in the last three and one-half years of the series. This demonstrates the more liberal use of cesarean section in recent years. Sterile vaginal examination was done in 44 cases. Severe blood loss and shock made vaginal examination impractical in the remainder. Cystography has proved an unsatisfactory diagnostic aid. Twenty-three patients had central placenta previa, and blood loss in excess of 500 c.c. was present in 18. Attempt is made to accomplish vaginal delivery in cases of partial placenta previa when blood loss is minimal and the cervix ripe, especially in the multipara. Our treatment in pre-eclampsia. depended on the condition of the cervix, parity, severity of symptoms, and response to therapy. In the group sectioned, the cervix was unfavorable, and all resisted vigorous treatment. Sixteen of the 19 were primiparas. Of the group operated upon for uterine inertia, all had apparently ample pelves. With the increasing use of the Pituitrin infusion, the need for section should decrease for this complication. Our policy is to deliver abdominally those patients who have had previous gynecological surgery, especially the myomectomy patient in whom the uterine cavity had previously been entered. One operation was done for previous
Volume 63 Number I
ANALYSIS OF FOUR HUNDRED CESAREAN SECTIONS
125
hysterotomy followed by repair of a ureterovaginal fistula. Earlier in the series, 4 sections were done for rising Rh 'antibody titer. There was an associated 50 per cent infant mortality. Since then, experience has taught us that cesarean section before term offers no advantage to the potentially erythroblastotic infant. Similarly, 3 sections were done in cardiac patients in the earlier years. It has proved more efficacious to allow these patients to undergo labor and vaginal delivery. Section iR resorted to only when there is an additional obstetrical complication. Type of Cesarean Section and Other Operative Procedures Of the 400 cases, 91.5 per cent were of the low flap type. We have used this section routinely with favorable results, and have reserved the classical type for emergency cases where speed in operating time is important for maternal or fetal survival. Although classical section is advocated by some in placenta previa, we have usf.ld the low flap type. Avoiding incision over the placental site seems to offer little advantage. Heffernan6 has emphasized the greater safety of the low flap operation. Our experience with the extraperitonea l section is limited and our number of grossly infected patients few. However, in view of the comparatively low morbidity rate and the great number of potentially infected patients, as evidenced by long periods of ruptured membranes, it seems reasonable to assume that the low flap section combined with the antibiotics favorably handles the majority of cases for which the extraperitonea l section may unnecessarily be utilized. Table IV shows the morbidity in relation to the type of section. Morbidity is defined as a temperature elevation of 100.4° or more during any two postpattum days, exclusive of the first 24 hours. The lowest morbidity was found in the low flap section. The comparative strength of the scar cannot be compared, since we have had no ruptures of section scars. It is g·enerally agreed, however, that the classical section offers the greater hazard of rupture. TABI,E
IV.
RELATION OF MORBIDITY TO TYPE OF CESAREAN SEC'riON
TYPE OF OPERATION
28 6 400
Extra peritoneal Total
8 3 106
28.57 50.00 28.50
---~~~~-------
Other surgical procedures are shown in Table V. In general we do not approve of surgical procedures incidental to cesarean section. The Pomeroy tubal ligation is an exception to this rule. Of the eight myomectomies, five were for myomas in the line of the incision, and three for pedunculated fibroids. One patient was operated upon because of a partial rupture of a rudimentary uterine horn during the seventh month of gestation. The fetus, which weighed 900 grams, was stillborn. 'rABLE
v.
OTHER SeRGICAr. PRocEDVREs
48 Porneroy tubal ligation 8 Myomectomy a Repair of perforation o:f bladder 2 Cesarean hysterectomy 2 Right salpingo-oophorectomy 1 Repair of umbilical hernia l _ _ _ _ __ -··-------- Right_oo-=p_h_or_e_ct_o_m.::.y_ _ _ _ _ _ _ _ _ _ _ _ _ _
ZAROU
126
Am .
.J.
Obst. & Gyne.-. January, l'l52
Maternal Morbidity and Postoperative Complications As illustrated in Table VI, prophylactic penicillin has caused a decline in the morbidity rate. The average number of postoperative hospital days wa~ 10.5. This decrease is largely due to early ambulation in addition to the antibiotics. Table VII reveals that in general the morbidity has been directly proportional to the length of la hm· and the length of time the membranes have been ruptured. 'Luu,t; Vl.
HELA'l'H!;>.: OF l\lOI\HlDJ1'Y TO THE
llfn:
o~- PHOPHYLAC'l'!C PENICIU,J:\
PrOphylactic pelticniin·-g)ve-~~ Prophylactic penicillin not given ·Total cases········--·············-····-········ ... _ --TABLE
Vli.
:l6.!l4 :l8.50
400
Rr;LATION OJ<' 1\IORBllllTY TO 00NIJ!q'IOK OF 1\h;MBRANES AK'D DCRATIOK
LABOR OR LABOR OH.
cases No. of morbid patients Morbidity __ l~!~~nt l__
l:l
Ill
:21.55
33.33 TABLE
VIII.
LABOR OR
LABOR OR RUPTURED MEMBRANES OVER 36
5
TOTAL
lOli
;)/.14
55.55
~i'\.50
PosTOl'ERATIVE CoMPLJCA'riOKS
Severe Endometritis Postoperative hemorrhagll Pyelitis Wonnd infection
61
Acute pharyngitis 'rhrombophlebitis
Transfusion reaction Cvstitis Mastitis Evisceration Postpartum eclampsia Pneumonia Atelectasis Congestive heart failure (mild) Pulmonary infarction Laparo-uretero-uterine :fi!ltula
Hematoma of wound (small) Degenerating fibroid Protracted vomiting Acute coronary thrombosis Paralytic ileus Pelvic abscess Acute bronchitis Postpartum psychosis Acute rheumatic endocarditis, congestive failure, pulmonary infarction, and death
fi ~0
6 5 4 4
..
" :l "
:\
:; :l :! ~
1
1 I l I
1
1
I 1
J
The postoperative complications are listed in Table VIII. There was one maternal death in this series, or an incidence of 0.25 per cent. The patient was
Volume 63 Number I
127
ANALYSIS OF FOUR HUNDRED CESAREAN SECTIONS
a 25-year-old primigravida with rheumatic heart disease. She was hospitalized during the fifth month of gestation for cardiac decompensation. In the thirtysixth week she was admitted again for elective section. Postoperatively she developed a recurrence of acute rheumatic fever, and signs of congestive failure on the eighth postoperative day. She died on the nineteenth postoperative day. Autopsy revealed acute rheumatic fever, endocarditis, and pulmonary infarction. Fetal Mortality Although the general erroneous opinion exists that fetal hazard is greater with section than with vaginal delivery, this is not upheld when the complication for which the operation was done and the corrected infant mortality are taken into consideration. As illustrated in Table IX, the gross infant mortality was 5 per cent. Corrected, it was 2.75 per cent, which is the approximate rate we have found for vaginal delivery. Thus it appears that section offers no added hazard to the infant aside from the emergency for which the operation is being performed. TABLE
IX.
INFANT MORTALITY BELOW
2,500 GRAMS (PRE·
NEONATAL
INDICATIONS
separation of placenta Severe pre-eclampsia Erythroblastosis Partial rupture of rudimentary horn of uterus Previous hysterotomy Previous section Brow presentation Diabetes mellitus
3 2
2
1 1 0
1 0
0
0
2 1
0
0 1 0 1
0 0 2
0 0 1 0
3 0 0
0 2 2
1 0
1 0
Summary and Conclusions 1. A seven-year survey of 400 consecutive cesarean sections is presented. All patients received adequate prenatal care, either by the private physician or through the clinic. 2. In 10,173 deliveries, there was a total incidence of 3.93 per cent. A rising annual incidence was noted. This incidence seems justifiable in view of the decreasing maternal risk and the better fetal prognosis, especially in conditions such as placenta previa and uterine inertia. 3. Most of the operations were performed on para o and para i patients, due to the prominence of cephalopelvic disproportion and previous section in this group. Elderly primiparas account for 17.5 per cent of the total sections. 4. Ninety-four and three-tenths per cent of the operations were done under spinal anesthesia. There were no maternal or fetal deaths attributable to the anesthesia. We have reserved inhalation anesthesia for patients presenting severe hemorrhage and shock.
ZAROU
12b
Am.
J. Obst.
& Gyncc.
January, !952
5. 'l'he indications for cesarean section ate uiscussed. CephalopelYk disproportion, previous section, and placenta previa were the major eausex. The incidence in placenta previa is increasing. (i. Ninety-one and five-tenths per (•ent. of the operations were of the lo'\v flap variety. Classical section is done only where speed in operating time is important. vVe have found little plaee for extraperitoneal cesarean sections. Morbidity rates are lowest with the low flap section. Ovel'-all morbidity was 28.GO per cent. 7. Morbiclity was markedly lowt>rNI in patients rt>eeiYing prophylad.i<· penicillin, and increased proportionately to tlw lt?ngth of l1dJOr or r·upture(1 membranes. 8. 'l'here was one maternal mortality, or· a rate of 0.25 per eent. 9. Corrected fetal mortality is not higher than in vaginal delivery. 'rlte author wi~hes to thank llrA. B1·n•·c Hnni,, Hr., and Bru<'e Hnrris, .Tr..• for in the preparation of this pap•'r.
References 1. Kistner, R. \\'.; AM .•J. 0BST. & GYNEC. 61: 11H, 1l!.'iJ. :;, D 'Esopo, D. A.: AM . .T. 0BS'r. & GYNEC. 59: 80, 1950. :1, Conti, E. A.: AM. J. 0BS1'. & GYN~~c. 60: 8!11, lfJ51l. 4. Lull, C. B.: AM. J. OBST. & GYNEc. 57: 1190, lf!+fl. 5. Dill, L. v.: AM. J. OBST. & GYNEC. 56: 515, 194(1. fi. Heffernan, R. ,J.. anrl Rullivan. <'. L.: New }Jnglan•l .J. Mecl. 238: 241, 1948. 461 100
STRJ<:ET
tft~Jir
aid
S.
ZAROU,
M.D.,
BROOKLY:t\,
N. Y.
(From the Department of Obstetrics and Gynerology, Norwegian Hospital)
interest in the use of cesar·ean section has developed in WIDESPREAD recent years, due to the increasing safety of the operation. Many
authors1 have reported long series with little or no maternal mortality, and an increasing fetal salvage. This has been attributed to improvement in surgical technique, the availability of the antibiotics, the blood bank, and a broader knowledge in the field of anesthesia. As a result, liberalization of the indications for cesarean section has taken plaee. D'Esopo 2 has shown that abdominal section is slowly replacing the formidable midforceps delivery, and that a cesarean section rate of approximately fi.O per cent should he adequate to eliminate the trauma, both maternal an!l fetal, caused by difficult vaginal operations. He further points out that overutilization of the operation may develop. Although the results of the following survey have been gratifying from the standpoint of maternal mOI'tality and infant survival, we feel that the eesarean section operation is still a formidable one, as demonstrated by morbidity rates and postoperative complications, and our ohject is to attempt to limit this trend toward overntilization.
Material This survey ineludes 400 consecutive cesarean sections, done betvveen April 15, 1944, and April 1, 1951. All operations were performed either hy a member of the obstetric staff or by the obstetric resident under supervision of a staff member. All patients received adequate prenatal care. The average length of gestation was 38.4 weeks. The average postoperative hospital sta.y was 10.5 days. There were no Negro patients. Apart from this factor, the total of patients delivered comprised a heterogeneous group representing a cross section of the population of a large city. lncidence.-Table I shows the total and yearly incidence of section in our clinie. The total incidence is 1 per cent lower than the av;lrage for a representative group of hospitals in the eastern half of the country. 3 This we attribute, first, to the strict prenatal supervision given our patients, and, second, to the fact that there were no Negroes in this group. Kistner 1 and D'Esopo" have pointed out the higher incidence of section in the Negro, due mainly to cephalopelvic disproportion. The rising annual incidence, as illustrated in Table T, has been brought out by many writers, and large series of consecutive sections with little or no maternal mortality would indicate that this trend is justifiable. The end results of liberalization of this procedure have been an increase in fetal salvage and a decrease in maternal trauma. 122
Volume 63 Number 1
123
ANALYSIS OF FOUR HUNDRED CESAREAN SECTIONS TABLE I.
1945 1946 1947 1948 1949 1950
YEARLY INCIDENCE OF CESAREAN SECTIONS
1,155 1,461 1,696 1,664 1,652 1,622 10,173
Total
2.16 3.83 4.13 4.33 4.48 5.19 3.93
25 56 70 72 74 84
400
Age and Parity.-Tab1e II shows the relation of age and parity to the number of sections. The high incidence of cephalopelvic disproportion and previous section in patients of low parity accounts for the large number of operations in this group. Our policy of sterilization at the time of the third section has made the operative incidence low in women of high parity. The average age was 31.5 years. The large number in primiparas, aged 35 years or over, were done in order to effect a higher fetal salvage. These patients were subjected to shorter trials of labor, and there was a reluctance to use Pituitrin and difficult vaginal operations. TABLE II.
CESAREAN SECTIONS IN RELATION TO AGE AND PARITY
14 3 0
iv
0
73 26 14 2
46 14 8 6
133 43
22
8
Anesthesia.-Spinal anesthesia was employed for 377, or 94.3 per cent, of the cases. In 226 of these, Pentothal Sodium was used in combination with the spinal anesthetic following delivery. Twelve operations were performed under local and 11 under inhalation anesthesia. Ten of the latter were done because of severe hemorrhage. No maternal or fetal deaths were attributable to the anesthetic. We concur in the findings of Lull 4 that absence of narcosis in the infant, excellent relaxation during surgery, and a minimum of postoperative distention make this the anesthetic of choice for section. In our series, spinal headache was a negligible factor and serious abdominal distention rare, intestinal drainage being required in only 2 cases. As pointed out by Kistner/ the trained anesthesiologist is an important addition to the cesarean section team. Indications.-Table III shows the primary indications for operation. Secondary indications were present in many cases. In the previous section group, it has been our policy to adhere to reoperation, especially since 60 of the repeat sections were done for cephalopelvic disproportion initially. Labor taxes not only the old uterine scar but the obstetrician as well. A small number of patients admitted in active labor, the head well engaged and the cervix partially dilated, were delivered vaginally. In the disproportion group, 81 patients received a trial of labor, while 32 did not. 'l'he latter included 5 cases of pelvic deformity incompatible with
ZAROU
12-±
Am.]. Obst. & Gynec. January, 1952
\'aginal delivery, one hydrocephalic infant, 2 patients with dermoid cysts in the cul-de-sac, and 3 with myomas in the lower uterine segment. The remainder of the 32 cases were classified as absolute disproportion by x-ray pelvimetry and clinical evaluation. Of the patients receiving a trial of labor, :36 were in labor over 12 hours, and 22 had ruptured membranes over 12 houn;, Four per cent of the total sections were clone in multiparas for disproportion. A history of stillbirth or neonatal death was present in 11 of these cases, and of prolonged labor and difficult vaginal delivery in alL DilP has emphasized the frequency with which disproportion oecurs in the multipara. TABLF;
Ill.
PRIMARY lN!HCATIOI>; S F'Ol' CESARE.\~ 8ECT]()N
JN!JICA'l'!OXS
Previous cesarean Cephalopelvic disproportion Placenta previa Pre·eclamptic toxemia Uterine inertia Malpresentations Breech in elderly primipara 'l'ransverse presentation Large breech Brow presentation Previous gynecological surgery Previous vaginal plastic Previous myomectomy Previous hysterotomy Premature separation of placenta Elderly primipara Prolapse of umbilical cord Fibromyomas of the uteruA Hising Rh antibody titer E~sential hypertension Chronic nephriti;; Diabetes mellitus Rheumatic heart disease Partial rupture of a rudimentary horn of the uteru;;
{i5 ____ _
<'ASES
ll:l .jj
28.25 14.25
Hl
IX Ii-I
4.75 4.50 4.50
11
2·.i5
R 5
2.00 1.25 1.25 1.00 1.00 0.75 O.i5 0.75 0.7fi
lO
. ,,
5
4 4
;:; il
;:; :~
0.25
Thirty-nine of the 57 sections performed for plaeenta previa were done in the last three and one-half years of the series. This demonstrates the more liberal use of cesarean section in recent years. Sterile vaginal examination was done in 44 cases. Severe blood loss and shock made vaginal examination impractical in the remainder. Cystography has proved an unsatisfactory diagnostic aid. Twenty-three patients had central placenta previa, and blood loss in excess of 500 c.c. was present in 18. Attempt is made to accomplish vaginal delivery in cases of partial placenta previa when blood loss is minimal and the cervix ripe, especially in the multipara. Our treatment in pre-eclampsia. depended on the condition of the cervix, parity, severity of symptoms, and response to therapy. In the group sectioned, the cervix was unfavorable, and all resisted vigorous treatment. Sixteen of the 19 were primiparas. Of the group operated upon for uterine inertia, all had apparently ample pelves. With the increasing use of the Pituitrin infusion, the need for section should decrease for this complication. Our policy is to deliver abdominally those patients who have had previous gynecological surgery, especially the myomectomy patient in whom the uterine cavity had previously been entered. One operation was done for previous
Volume 63 Number I
ANALYSIS OF FOUR HUNDRED CESAREAN SECTIONS
125
hysterotomy followed by repair of a ureterovaginal fistula. Earlier in the series, 4 sections were done for rising Rh 'antibody titer. There was an associated 50 per cent infant mortality. Since then, experience has taught us that cesarean section before term offers no advantage to the potentially erythroblastotic infant. Similarly, 3 sections were done in cardiac patients in the earlier years. It has proved more efficacious to allow these patients to undergo labor and vaginal delivery. Section iR resorted to only when there is an additional obstetrical complication. Type of Cesarean Section and Other Operative Procedures Of the 400 cases, 91.5 per cent were of the low flap type. We have used this section routinely with favorable results, and have reserved the classical type for emergency cases where speed in operating time is important for maternal or fetal survival. Although classical section is advocated by some in placenta previa, we have usf.ld the low flap type. Avoiding incision over the placental site seems to offer little advantage. Heffernan6 has emphasized the greater safety of the low flap operation. Our experience with the extraperitonea l section is limited and our number of grossly infected patients few. However, in view of the comparatively low morbidity rate and the great number of potentially infected patients, as evidenced by long periods of ruptured membranes, it seems reasonable to assume that the low flap section combined with the antibiotics favorably handles the majority of cases for which the extraperitonea l section may unnecessarily be utilized. Table IV shows the morbidity in relation to the type of section. Morbidity is defined as a temperature elevation of 100.4° or more during any two postpattum days, exclusive of the first 24 hours. The lowest morbidity was found in the low flap section. The comparative strength of the scar cannot be compared, since we have had no ruptures of section scars. It is g·enerally agreed, however, that the classical section offers the greater hazard of rupture. TABI,E
IV.
RELATION OF MORBIDITY TO TYPE OF CESAREAN SEC'riON
TYPE OF OPERATION
28 6 400
Extra peritoneal Total
8 3 106
28.57 50.00 28.50
---~~~~-------
Other surgical procedures are shown in Table V. In general we do not approve of surgical procedures incidental to cesarean section. The Pomeroy tubal ligation is an exception to this rule. Of the eight myomectomies, five were for myomas in the line of the incision, and three for pedunculated fibroids. One patient was operated upon because of a partial rupture of a rudimentary uterine horn during the seventh month of gestation. The fetus, which weighed 900 grams, was stillborn. 'rABLE
v.
OTHER SeRGICAr. PRocEDVREs
48 Porneroy tubal ligation 8 Myomectomy a Repair of perforation o:f bladder 2 Cesarean hysterectomy 2 Right salpingo-oophorectomy 1 Repair of umbilical hernia l _ _ _ _ __ -··-------- Right_oo-=p_h_or_e_ct_o_m.::.y_ _ _ _ _ _ _ _ _ _ _ _ _ _
ZAROU
126
Am .
.J.
Obst. & Gyne.-. January, l'l52
Maternal Morbidity and Postoperative Complications As illustrated in Table VI, prophylactic penicillin has caused a decline in the morbidity rate. The average number of postoperative hospital days wa~ 10.5. This decrease is largely due to early ambulation in addition to the antibiotics. Table VII reveals that in general the morbidity has been directly proportional to the length of la hm· and the length of time the membranes have been ruptured. 'Luu,t; Vl.
HELA'l'H!;>.: OF l\lOI\HlDJ1'Y TO THE
llfn:
o~- PHOPHYLAC'l'!C PENICIU,J:\
PrOphylactic pelticniin·-g)ve-~~ Prophylactic penicillin not given ·Total cases········--·············-····-········ ... _ --TABLE
Vli.
:l6.!l4 :l8.50
400
Rr;LATION OJ<' 1\IORBllllTY TO 00NIJ!q'IOK OF 1\h;MBRANES AK'D DCRATIOK
LABOR OR LABOR OH.
cases No. of morbid patients Morbidity __ l~!~~nt l__
l:l
Ill
:21.55
33.33 TABLE
VIII.
LABOR OR
LABOR OR RUPTURED MEMBRANES OVER 36
5
TOTAL
lOli
;)/.14
55.55
~i'\.50
PosTOl'ERATIVE CoMPLJCA'riOKS
Severe Endometritis Postoperative hemorrhagll Pyelitis Wonnd infection
61
Acute pharyngitis 'rhrombophlebitis
Transfusion reaction Cvstitis Mastitis Evisceration Postpartum eclampsia Pneumonia Atelectasis Congestive heart failure (mild) Pulmonary infarction Laparo-uretero-uterine :fi!ltula
Hematoma of wound (small) Degenerating fibroid Protracted vomiting Acute coronary thrombosis Paralytic ileus Pelvic abscess Acute bronchitis Postpartum psychosis Acute rheumatic endocarditis, congestive failure, pulmonary infarction, and death
fi ~0
6 5 4 4
..
" :l "
:\
:; :l :! ~
1
1 I l I
1
1
I 1
J
The postoperative complications are listed in Table VIII. There was one maternal death in this series, or an incidence of 0.25 per cent. The patient was
Volume 63 Number I
127
ANALYSIS OF FOUR HUNDRED CESAREAN SECTIONS
a 25-year-old primigravida with rheumatic heart disease. She was hospitalized during the fifth month of gestation for cardiac decompensation. In the thirtysixth week she was admitted again for elective section. Postoperatively she developed a recurrence of acute rheumatic fever, and signs of congestive failure on the eighth postoperative day. She died on the nineteenth postoperative day. Autopsy revealed acute rheumatic fever, endocarditis, and pulmonary infarction. Fetal Mortality Although the general erroneous opinion exists that fetal hazard is greater with section than with vaginal delivery, this is not upheld when the complication for which the operation was done and the corrected infant mortality are taken into consideration. As illustrated in Table IX, the gross infant mortality was 5 per cent. Corrected, it was 2.75 per cent, which is the approximate rate we have found for vaginal delivery. Thus it appears that section offers no added hazard to the infant aside from the emergency for which the operation is being performed. TABLE
IX.
INFANT MORTALITY BELOW
2,500 GRAMS (PRE·
NEONATAL
INDICATIONS
separation of placenta Severe pre-eclampsia Erythroblastosis Partial rupture of rudimentary horn of uterus Previous hysterotomy Previous section Brow presentation Diabetes mellitus
3 2
2
1 1 0
1 0
0
0
2 1
0
0 1 0 1
0 0 2
0 0 1 0
3 0 0
0 2 2
1 0
1 0
Summary and Conclusions 1. A seven-year survey of 400 consecutive cesarean sections is presented. All patients received adequate prenatal care, either by the private physician or through the clinic. 2. In 10,173 deliveries, there was a total incidence of 3.93 per cent. A rising annual incidence was noted. This incidence seems justifiable in view of the decreasing maternal risk and the better fetal prognosis, especially in conditions such as placenta previa and uterine inertia. 3. Most of the operations were performed on para o and para i patients, due to the prominence of cephalopelvic disproportion and previous section in this group. Elderly primiparas account for 17.5 per cent of the total sections. 4. Ninety-four and three-tenths per cent of the operations were done under spinal anesthesia. There were no maternal or fetal deaths attributable to the anesthesia. We have reserved inhalation anesthesia for patients presenting severe hemorrhage and shock.
ZAROU
12b
Am.
J. Obst.
& Gyncc.
January, !952
5. 'l'he indications for cesarean section ate uiscussed. CephalopelYk disproportion, previous section, and placenta previa were the major eausex. The incidence in placenta previa is increasing. (i. Ninety-one and five-tenths per (•ent. of the operations were of the lo'\v flap variety. Classical section is done only where speed in operating time is important. vVe have found little plaee for extraperitoneal cesarean sections. Morbidity rates are lowest with the low flap section. Ovel'-all morbidity was 28.GO per cent. 7. Morbiclity was markedly lowt>rNI in patients rt>eeiYing prophylad.i<· penicillin, and increased proportionately to tlw lt?ngth of l1dJOr or r·upture(1 membranes. 8. 'l'here was one maternal mortality, or· a rate of 0.25 per eent. 9. Corrected fetal mortality is not higher than in vaginal delivery. 'rlte author wi~hes to thank llrA. B1·n•·c Hnni,, Hr., and Bru<'e Hnrris, .Tr..• for in the preparation of this pap•'r.
References 1. Kistner, R. \\'.; AM .•J. 0BST. & GYNEC. 61: 11H, 1l!.'iJ. :;, D 'Esopo, D. A.: AM . .T. 0BS'r. & GYNEC. 59: 80, 1950. :1, Conti, E. A.: AM. J. 0BS1'. & GYN~~c. 60: 8!11, lfJ51l. 4. Lull, C. B.: AM. J. OBST. & GYNEc. 57: 1190, lf!+fl. 5. Dill, L. v.: AM. J. OBST. & GYNEC. 56: 515, 194(1. fi. Heffernan, R. ,J.. anrl Rullivan. <'. L.: New }Jnglan•l .J. Mecl. 238: 241, 1948. 461 100
STRJ<:ET
tft~Jir
aid