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Cesarean section: A 15-year review of changing incidence, indications, and risks
Cesarean section: A 15-year review of changing incidence, indications, and risks HASSAN
AMIRIKIA,
BOHDAN TOMMY Detroit,
M.D.,
ZAREWYCH, N.
F.A.C.O.G.,
F.A.C.S.,
F.R.C.S.(C.)
D.O.
EVANS,
M.D.,
F.A.C.O.G.,
F.A.C.S.
Michigan
During 15 years (1965 through 1979) 9,718 cesarean sections were performed at Hutzel Hospital. This report concerns the indications, incidence, morbidity, and mortality. Dystocia, fetal distress, and breech presentations were the most common indications for primary cesarean section. The incidence rose from 9.8% to 16.8% during this study. Forceps deliveries dropped from 47.5% to 12.0%, and vaginal breech deliveries decreased from 86% to 35%. Spinal anesthesia was used in 90%. Cesarean section hysterectomies were performed in 128. The most common indications were carcinoma in situ of the cervix, uterine leiomyoma, and hemorrhage. Puerperal sepsis and urinary tract and wound infections were the major causes of morbidity. Perinatal mortality decreased from 40% to 29%. There were 10 maternal deaths. Sepsis was the major cause of death. At least four deaths could have been avoided if ultra-high-risk patients had not been pregnant in the first place. (AM.
J. OBSTET.
GYNECOL.
140:81,
1981.)
REDUCTION of perinatal mortality during the past decade has been associated with a rising incidence of cesarean section.’ Cesarean births in the United States have increased almost threefold from 5.5% of all deliveries (195,OOOoperations) in 1970 to 15.2% (510,000) in 1978.’ Any dramatic increase in the frequency of a major operative procedure inevitably is shrouded in controversy. This study was undertaken to add to the body of knowledge regarding the changing incidence of, indications for, and maternal and fetal consequences of cesarean section.
Study group During a 15-year period (1965 cesarean sections were performed University Obstetrical Service at I). Of these, 60% were primary. between 13 and .51 years with an
through 1979), 9,718 on the Wayne State Hutzel Hospital (Table Maternal age ranged average
From the Department of Gynecology Wayne State University and Hutzel
of 25. Gravid-
Presented at the Forty-eighth Annual Meeting of The Central Association qf Obstetricians and Gynecologists, Minneapolis, Minnesota, September 25-27, 1980.
0002-9378/81/090081+10$01.00/0
0
1981
The
C. V. Mosby
Year 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 Total (15 years’
Total No. of deliveries 3,972 3,870 4,062 4,488 5,622 6,121 6,079 5,723 5,584 4,972 5,070 5,132 5,515 5,571 5,922 77,703 duration)
Hospital,
Total No. of cesarean sections 388 404 384 405 534 551 585 608 662 697 775 833 929 965
998 9.718
Rate (‘31)
9.8 10.4 9.4 9.0 9.5 9.0 9.6 10.6 11.8 14.0 15.3 16.2 16.8 17.3 16.8 12.50
ity was 1 to 8 with a median of 2.2. Duration of hospitalization averaged 7.57 days. Indications, maternal and perinatal morbidity and mortality, and complications were recorded.
and Obstetrics, Hospital.
Reprint requests: Hacsan Amirikia, M.D., Department Gynecology and Obstetrics, Wayne State University, Hutzel Hospital, 4707 St. Antoine Blvd., Detroit. Michigan 48201.
Table I. Cesarean sections at Hutzel 1965 through 1979
of
Results Cesarean section rates rose from 9.8% in 1965 to 16.8% in 1979 (Table I). The cesarean rate was stabi-
Co.
81
82
Amirikia,
Table
Zarewych,
and Evans
II. Cesarean
section rate, 1965 through Repent
Year
Table
1965 1966 1Y67 1Y6X lY6Y
3,972 3,870 4.062 4,488 4,622
lY70 lY71
6,121 6,079
1972 1973 1974 1Y75 lY7ti lY77 1978 1979
5 723 ii:,,4 4,972 5.070 5,132 5.515 5,571 5,922
III.
Indications
19’79
cesarean .tection Rate
Total
Rate
Total
262
6.6 5.0 4.7 3.8 5.4 4.5 4.3 3.9 4.5 4.2 5.3 5.6 6.0 6.5 6.2
126 208 194 232 232 278 323 385 409 590 503 546 597 60 1 629
3.1 5.4 4.x 5. 1 4.1 4.5 5.3 6.7 7.3 Y.8 Y.9 10.6 10.8 10.8 10.6
388 404 384 405 534 551 585 608 662 697 775 833 929 965 9Y8
302 273 262 223 253 207 271 286 331 363 368
cesarean NO.
Indication
cesarean suction
7’otal
196 I90 173
for primary
Primary
section
Table
IV. Forceps deliveries,
Fetal distress Breech Prolonged rupture of membranes Hypertensive disorders
pregnanc.y Malpresentation Diabetes
mellitus
Placenta previa Abruptio placentae Rh isoimmunization Total
2.137
37.1
998 898 383
17.1 15.5 6.7
1965 1966 1967 1968
of
346
6.1
208 202 260 242
3.6 3.4 4.5 4.1
109 5,783
___1.9 100.0
196Y 1970 1971 1972
1973 lY74
1975 1976 1977 1978 lY7Y
lized at around 10%’ in the first 8 years of the study with a sharp rise thereafter and a plateau during the last 4 years between 16%’ and 17%. Primary operations increased from Y. 1% to 10.6% while repeat cesarean sections remained almost constant at 6% or less (Table II). Dystocia resulting from an obstructed labor associated with cephalopelvic disproportion or fetal malpresentation and abnormalities of the forces of labor was the most common indication for primary section (Table III). Forceps deliveries dropped from 47.5%’ to 12.0’% (Table IV). The inverse relationship between forceps and abdominal deliveries is illustrated in Fig. 1. Vaginal breech deli\,eries decreased from a peak of 86% in 1968 to 35% in 1979 (Table V). Fig. 2 illustrates the inverse direction of the cesarean section rate and perinatal mortality which decreased from W.5% 10 28.8% (Table VI) and neonatal mortality dropped ti-om 20%, to lS.t% during the last year ot the study (Table VII).
(o/o)
9.8 10.4 Y.4 9.0 Y.5 Y.0 Y.6
10.6 11.X 14.0 15.3
16.2 16.8 17.3 16.8
1979
No.
Rate 1%) Year
Dystocia
1965 through
Ratr
of deliveries
3,972 3,870 4,062 4,488 5,622
Forceps ddweries
1,888 1,941 2,503 2,655 2.7lY
6,121 6,079 5,723 5,584 4,972 5,070
47.5 .50. 1 61.6 57.1 58.3
3,141
51.3
2,748 2,495 2,253 1,861 t.586
45.2 43.5 40.3 37.4 31.2 27.3 20.9 14.1
5,132
1,402
5,515 5,57 5,922
1,155 787 714
1
7c
12.0
Spinal anesthesia ~+‘as used in more than 90% of the cesarean sections. and the low transverse cervical operation was performed in 970/(,. Cesarean hysterectomies were performed in 128 (Table VIII). Carcinoma in situ of the cervix was the most common indication.
Maternal morbidity and mortality Endometritis, urinary tract infection. and wound infection were among the major causes of postoperative morbidity (Table IX). There were 10 maternal deaths (0.1%). Infection was a major contributing factor in .i (Table X). At least four deaths could have been avoided if ultra-high-risk patients had not been pregnant in the first place (Table X, patients 4, 5, 7, and 9). Only 6.3% received blood transfusions which varied from 1 to 40 units with an average of 2.3.
Volume Number
Cesarean
140 1
W
Table V. Incidence of breech delivery, 1965 through 1979 Breech vaginal
presentation
No.
134 114 159 200 164 227 153 180 203 199 227
115 87 85 150 115 106 85 84 112 90 81
1968 1969 1970 1971 1972 1973 1974 1975 1976- 1977 1977-1978 1978-1979
SECTION
FORCEPS
delivery
83
RATE
DELIVERY
RATE
I
r 16
60
Total breech Year
CESAREAN
C------e
section
-16
% E 53 75 70 46 55 46 60 45 35
8
50-
& w z
4540-
d P
35-
;
30-
: e
25-
-9
zo-
-6
15-
-7
IO-
-6
5-
-5 L
I 65
67
69
71
73
75
77
79
YEAR
Table
VI. Perinatal Total
Year
live births
1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979
3,944 3854 4,058 5,312 6,110 6,115 6,709 6,372 6,168 5,509 5,056 5,136 5,505 5,595 5,939
mortality,
1965 through No. of
perinatal
deaths
156 155 165 204 208 202 207 199 224 175 154 149 143 136 171
1979
Perinatal mortality rate
Fig. 1. Change in incidence of forceps deliveries and cesarean sections.
39.5 40.2 40.6 38.4 34.0 34.5 30.8 31.2 36.3 31.7 30.3 29.0 25.9 24.4 28.8
xc*-o---o
C-SECTION
-
PEAINATAL
+-
I,
Comment There is no indication that the rising cesarean section rate has reached a plateau. Among the more commonly reported causes of the increased incidence of cesarean birth are cephalopelvic disproportion, fetal distress, malpresentation, and especially breech presentation.‘j. ’ Most reviews of breech births suggest that abdominal delivery may be associated with less risk to the premature fetus.’ Choice of the abdominal route is complicated by increased maternal and fetal risk. Breech birth via either the vaginal or abdominal route is associated with an increase in both morbidity and mortality when compared with vertex presentation6 When the route of delivery of a breech is considered, one must also consider fetal maturity, congenital anomalies, fetal size, and type of breech presentation as well as pelvic adequacy. Although breech presentation has been associated with a higher perinatal mortality rate, neonatal mortal-
-
-
-
, 65
67
MORTALITY
NEONATAL
( 69
MORTALITY
,1,,,,,,, 71
I 73
75
77
79
YEAR
Fig. 2. Perinatal and neonatal mortality and the frequency of cesarean section. ity among low-birth weight infants (less than 2,500 gm) has been reported to show no consistent difference following primary cesarean birth although there is a suggestion that in infants less than 1,500 gm the risk is lower among cesarean births. Primary cesarean delivery of infants weighing more than 2,500 gm has been associated with a far lower neonatal mortality rate than that of vagina1 breech deliveries. Breech presentation accounts for about 15%: of the rise in the cesarean section rate. Although breech presentations are now usually managed by cesarean section, those infants delivered vaginally and abdominally may have a similar prognosis.7 The number of abdominal deliveries for fetopelvic
84
Amirikia,
Table
Zarewych,
VII.
Neonatal
and Evans
mortality.
1965 through
1979
Table IX. Cesarean section morbidit\, I965 through 1979 Complication
1965 1966
1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979
3,944
79
20.0
3,854 4,058 5,312 6.110 6,115 6,709 6,372 6.168 5,509 5,056 3,136 5,505 5,595
79 85 100 90 99 105 102 118 102 83 77 67 73 x0
20.5 20.9 18.8 14.7 16.2 15.7 16.0 19.1 18.5 16.4 14.9 12.1 13.0 13.4
5.939
Table VIII. Cesarean 1965 through 1979
section hysterectomies,
Indzcation
(:arcinoma in situ of cervix Uterine leiomyoma Hemorrhage (uterine atony) Placenta previa Placenta accreta Amnionitis Sterilization Carcinoma of cervix. invasive Uterine rupture ‘I’otal
I
‘VO.
69
14 11 10 6 . ; 4 4 128
Endometritis Urinary tract infection Wound infection Anemia Upper respiratory infection Paralytic ileus Intestinal obstruction Delayed hemorrhage Pelvic abscess Pulmonary emboli Thrombonhlebitis Febrile mhrbidit! Total
60%
.’
’
During the past decade the number of cesarean sections fin. fetal distress has increased with the use of electronic fetal monitoring. which has been reported to increase surgical intervention by severalfold.X. !’ Xccurate interpretation as well as misinterpretation of monitor tracings, an altered environment of the parturient patiem 1~): the monitoring equipment,’ a stress-related release ot catecholamines with vasoconstriction, and a reduced uteroplacental blood How with fetal bradycardia”’ may also be f’actors. Nevertheless, there has been an inverse relationship between the cesarean section rate and perinatal mortality.’
7.0 6.0 3.8 4.5 1.4 0.6 0.4 0.2 0.2 0.5 3.7 28.3
Fetal distress as an indication for primary cesarean section has contributed to approximately 1.i? of. the increase in the rate of primary cesarean births.!’ C;esarean birth for fetal distress was 7.4’i( in I hose managed by continuous electronic fetal monitoring as opposed to I.!% in those managed by intermittent auscultation.” Others have reported no significant increase in CCsarean births in a monitored group of’ high-risk patients compared with nonmonitored control patients. There is still a great deal ot‘dif‘ticulty in identifying the distressed fetus. Fetal scalp blood samples for deter-mination of‘ pH in those with ominous tracings IIIXJ rc’duce the number of cesarean sections.“. ” C:omhining fetal scalp pH determinations with electronic monitoring ma> ixduc~ surgical intervention for fetal distress tJV
disproporlion, failed induction of labor, and uterine dysfrmction has increased while the number of forceps deliveries has decreased.’ Other indications include genital herpes, multiple gestation, fetal grow& retardation, prematurity and prolonged rupture of’ the membranes. amnionitis. and grand multiparity with uterine dvsfilnction, which have increased from 5% to
683 584 386 451 104 iY .i 3X 1X “i) 4x 360 2.7.X
KlOI‘C
1 h-111 ‘
.i,()‘;;
Introduction of obstetric Iiltr-asorlogr~ll~h~ and improvemenfs in electronic fetal moiliroring and biochemical testing have improved fetal assessment. E:,trio1 and human placental lactogen levels, f’etal activit! and oxytocin challenge tests, scalp blood sampling ti)~ pH dctrrmination, and many amniotic fluid analyses aid in the evaluation ot‘ the fetus befLrc and during parturition. However. single tests may be deceptive anti do not alkvays retlect accurately the letal outcome’. Improved fetal outcome cannot be attributed solel) to operative intervention. The uusatle 10 imptwe the outcome of pregnant\ has resulted in a rapid iucrrase in the number of’ neonatal intensive care units with growth in the specialty areas of’ maternal and fetal medicine and neonatology and improved technologyfor maternal, f’etal, and neonatal care. Increased infant survival reHects more medical interventions. of’ which cesarean section is only a part. Neurological deficits in the newborn infant are still an enigma. Neurological sequelae folknving deliver! b\
Volume Number
Cesarean section
110 1
Table
X. Maternal
Case No.
DIC:
any
Year
Age
Indication
I. H.
1967
22
Cephalopelvic disproportion; premature rupture of membranes Failed forceps; cephalopelvic disproportion Premature rupture of membranes; amnionitis; failed induction Repeat cesarean section: tubal sterilization
Sepsis Endotoxic
Renal failure Congenital heart disease Sepsis
30
1967
37
M. K.
1969
24
2. M.
1970
37
Anemia; chronic renal ease; preeclampsia
S. M.
1970
22
M. V.
1972
24
Preeclampsia; gangrenous appendicitis Myasthenia gravis
J. G.
1973
32
Abruptio
D. N.
1974
30
G. B.
1979
17
Abruptio placentae; preeclampsia; drug dependent Fetal distress; cephalopelvic disproportion
Disseminated
route
may
intravascular
involve
retardation, group
athetosis,
Cause of death
1967
chomotor large
mortality
Patient
B. P.
labeled global
85
mental
Pulmonary emboli Sepsis DIC Rheumatic disease
dis-
heart
Respiratory -failure Amniotic fluid embolism Sepsis DIC
placentae
Sepsis DIC
Pulmonary edema Peritonitis None
Culture S. faecalis (blood) E. coli (endomettium)
Infant Live-born
Live-born
None
Live-born
Severe mitral stenosis and mitral insufficiency Hydrothorax None
Live-born
None
Stillborn
Live-born
Live-born Died Pyelonephritis Pneumonitis Cardiomegaly Pyelonephritis
Group B streptococcus (cervix) B. fragilis Gram-negative bacteria (blood) Gram-negative bacteroides (uterine) E. coli (urine)
Stillborn
Live-born
coagulation.
acquired and
shock
Autofisy findings
hydrocephalus,
hearing
“cerebral retardation,
palsy”
loss
psy-
as well
(ataxia, seizures,
as the choreo-
and
spas-
ticity). Retrospective studies of cerebral palsy populations have confirmed the synergism of marked prematurity, abnormal presentation (especially breech), and perinatal asphyxia.‘” Another complicating factor in assessing the effect of cesarean delivery on brain damage is the lack of good correlation of the infant’s status at birth with eventual neurological development. Even complete perinatal cardiac arrest can be followed by normal neurological development when the heartbeat has returned within 5 minutes and spontaneous respirations have occurred within 30 minutes after the asphyxial event.‘” Significant differences in the perinatal mortality rates in the United States in comparison with those of other countries mainly reflect differences in the patient populations involved and especially the percentage of high-risk obstetric patients.
Medicolegal considerations Negligence in performance of-a cesarean section is a frequent cause of malpractice action, usually involving injuries sustained during delivery comparable to those occurring in other surgical procedures. e.g., sponges or instruments left behind, deaths related to anesthesia, and infection. The biggest malpractice area related to cesarean section concerns failure to perform cesarean delivery which the plaintiff argues was indicated and if performed would have prevented injury or death. Misdiagnoses suggesting that surgery is not required may result in liability. There have been many cases alleging negligence in the failure to discover the necessity of performing a cesarean section or in delaying the decision to perform one by which point the woman or her infant has sustained damage. Maternal morbidity and mortality are still too high. Parturition, premature rupture of the membranes, and internal fetal monitoring14, ITI have been identified as factors contributing to maternal morbidity. Short-term prophylactic antibiotic therapy in selected high-risk
86 Amirikia, Zarewych, and Evans
patients
may reduce
tebrile
morbidity
by more
than
7.5’%.‘” Despite improvement in surgical technique, anesthesia. blood replacement, and postoperative care, mortality fhllowing cesarean section is four times that following vaginal delivery. Elective repeat cesarean section carries two times the risk of’maternal mortality.’ Of course, it is the high-risk patient who is more like]) to have an operative delivery. (Iriticat analyses of the consequences during the next decade may result in a stabilization of‘or decrease in the incidence ol‘ cesarean sections. The concept of “once a section, always a section” has been challenged.X Selective subsequent vaginal delivery when there is not a recurrent indication for cesarean section seems to involve little maternal and fetal risk. However, in some hospital environments the risk of a trial of labor in women who have had a previous cesarean section may esceed the risk of both mother and infant of a propel-l!
1.
REFERENCES Minkoff. H. L., and Schwarz. R. H.: The rising cesarean section rate: Can it safely be reversed? Obstet. Gynecol.
timed electi\;e reprat cesarean birth. F$‘e need nu~i.c data regarding the risk ot‘trials oflahr)r in patierlts b\.itll previous low-segment lransversr uterine incisions. Kcduction in the numhrr of cesarcan se< tiorls c.onld alst~ result from resurrection ot a trial of’ tahor ii1 a patier with a clnestionably adequate petvis ant1 ;I ceptlalic. prcsentation. A desire for sterilisation is non an atlequatc indication ti)r cesarean hysterectoniv when ;I more minol proreclure can be carried out with less risk. Hvstcrrc,tomy tbllorving cesarean section cspohes I hc patient to a 40% to 50%. incI.eased chance of ;I nerd fi,i- blood transfllsion and a tenfold increase in mortalit\. Maternal mortality may be reduced through patient education, more accessible and effective conception control in and early identification of high-risk obstetric patients, and early diagnosis and \.igorons treatnlent of obstetric infections.
9.
56: 13.5, 1980. 2.
3.
4.
2.
6.
7.
8.
Obstetrical Practices in the United States, 1978, Hearing before the Subcommittee on Health and Scientific Research of the Committee on Human Resources, United States Senate, Washington, D. C., 1978. Government Printing Office. Hughey, $1. J., LaPata, R. E., McElin, T. W.. and Lussky, R.: The effect of fetal monitoring on the incidence of cesarean section, Obstet. Gynecol. 49:513, 1977. Fianu. S.: Fetal mortality and morbidity following breech delivery, Arta Obstet. Gynecol. Stand. (Suppt.) 56:s. 1976. Duenhoelter, J. H., Wells, C. E., Resich, J. S., SantosRamos, R., and limenez, I. M.: A paired controlled study of vaginal and abdominaidelivery*of the low birth weight breech fetus, Obstet. Gvnecol. 54:310. 1979. Brenner, W. E., Bruce,‘R. D., and Hendricks, C. H.: The characteristics and perils of breech presentation, AM, J. OBSTET. GYNECOL. 118:700, 1974. W’earing. M. P.: Comparison of vaginal delivery and cesarean section in breech presentation, AM. J. OBSTET. GYNECoL. 136:1083, 1980. Bottoms, S. F., Rosen, M. G., and Sokol, R. J.: The increase in the cesarean birth rate, N. Engl. J. Med. 302:559, 1980.
Editon’ mte: This manuscript discussions were presented.
was revised
after
these
Discussion DR. ROBERT P. PUJUAM, Beckley, West Virginia. The issue of the cesarean section rate is a complex one since it involves potential improved outcome as well as
10.
11. 12.
13. 14.
15.
16.
Haverkamp, A. D.. Orleans. M.. Langendoerfer. S., McFee. J., Murphy, J.. and Thompson. H. E.: A controlled trial of the different effects of intrapartum fetal monitoring, AM. J. OBSTET. GYNECOL. 134:$99. 1979. Morishima. H. 0.. Yeh. M. N.. and .s lame. S. L.: Reduced uterine blood flow and fetal hypoxemia with acute maternal stress: Experimental observation in the pregnant baboon, AM. J. OBSTET. GYNECOL. 134:270, 1979. %alar, R. W.. and Quilligan. E. J.: The inHuence of scalp sampling on the cesarean section rate for fetal distress, AM. J. OBSTET. GYNECOL. 135:239, 1979. McBride, W. G.. Black. B. P., Brown, (:. J., Dolby. R. 111.. Murray, A. D., and Thomas, D. B.: Method of deliver! and developmental outcome at five years of age. Mrd. J. Aust. 1:301, 1979. Steiner, J.. and Neligan. G.: Perinatal cardiac al-rest: quality of the survivors, Arch. Dis. Child. 50:696, 1975. Gassner, C. B.. and Ledger, W. J.: The relationship of hospital-acquired maternal infection to in\Tasive intrapal-turn monitoring technique. AM. J. OBSTET. GYXFXOL. 126:33, 1976. Gibbs, R. S., Listwa, H. M., and Read, J. A.: The effect of internal fetal monitoring on maternal‘infection following cesarean section, Obstet. Gynecol. 48:653. 1976. D’Angelo, L. J., and Sokol, R. J.: Short-term long-cout.se prophylactic antibiotic treatment in cesarean section patient, Obstet. Gynecol. 55:583, 1980.
potential changes in morbidity for two patientsmother and child. As medical practice changes, it is therefore critical that we understand not only the direction of change but also the reasons for the change and whether the changes have resulted in improved outcome. The change in medical practice, a significant increase in cesarean section rate, is adequately confirmed by this
Volume Number
Cesarean section
140
87
1
study as well as numerous others. For example, the most recent New York City experience documents a cesarean section rate of 17.3% for 1978. The repeat cesarean section rate for 1978 of 5.8% is equal to the total cesarean section rate for 1968. The change is apparent in all geographic regions and all types of hospitals, at all birth weights, and irrespective of reimbursement source. In this study the 10% primary cesarean section rate is firm evidence that the overall rate will continue to increase as the large number of primary cesarean section patients reenter the pregnancy pool. The reasons for this change in medical practice are also adequately identified in this presentation although possibly the indication descriptions could have been broader. Nationally, four factors have been identified as chiefly responsible for the increasing cesarean section rate: (1) Dystocia, defined as fetopelvic disproportion, abnormal pelvis, or prolonged labor, has been responsible for 29% of the overall increase. (2) Repeat cesarean sections have contributed 27%’ to the increase. (3) Cesarean section for breech presentation has accounted for 15% of the rise. (4) Fetal distress was responsible for 10% of the increase. All other indications have remained constant or increased only slightly. Surgical techniques, sterilization percentages, anesthetic selection, and the morbidity and mortality of cesarean sections are also well documented by the authors and are consistent with those of other studies. The authors have identified the change in medical practice as being an increasing cesarean section rate; they have identified the reasons for change-dystocia, repeat cesarean sections, breech deliveries, and fetal distress. However, the bottom line in this study and all other studies should be whether the change in medical practice has resulted in improved outcomes for mother and infant. How can we evaluate results? Is the decrease in perinatal mortality, as described by the authors, related to the increasing rate of cesarean births or is it a change so complex that simple crude rate changes are incapable of adequately demonstrating the relationship? This dramatic increase in the cesarean rate led to a call published in the Federal Registry of July 1, 1980, for the National Institutes of Health Consensus Conference on Cesarean Childbirth, which was held in Washington. D. C. September 22 and 23, 1980. A draft document, 55 1 pages in length, investigating all aspects of cesarean births was prepared for this conference. The authors of the document came from varied backgrounds-physicians, social workers, lawyers, consumers, epidemiologists, and others. This document discussed in detail such things as the historical overview: techniques; national, continental, and worldwide experience; maternal mortality: anesthesia; respiratory distress syndrome; dystocia; repeat cesarean section births; breech presentation; fetal distress; behavioral
effects on mother, family, and infant; ethical concerns; medical-legal concerns; and economic concerns. In its conclusions, the Consensus Development Conference expressed deep concern over the rising cesarean section rate and further stated that the rising cesarean birth rate could be stopped and perhaps reversed while improvements continue to be made in maternal and fetal outcome, which are the twin goals of clinical obstetrics today. The conference made major recommendations on how this could be done: (1) Allow a trial of labor and vaginal delivery in carefully selected patients who have had previous low-segment cesarean births. (2) Carefully reassess the diagnosis and management of dystocia to include sedation, rest, oxytocin, etc. (3) Refine the diagnosis of fetal distress. (4) Retain vaginal delivery as an option for the term breech where the following conditions are favorable: (a) estimated fetal weight of less than 8 pounds, (b) normal pelvic dimensions and architecture, (c) frank breech without hyperextended head, and (d) delivery to be conducted by physician experienced in vaginal breech deliveries. Parenthetically, currently about 70% of breeches are delivered by cesarean section and the physician described above may soon become, if he has not already, as rare as the proverbial dodo bird. All of these recommendations are tempered with, and I quote, “informed consent” participation by patient and family. The present study thus elucidates direction of change and reason for change but fails to address adequately the more important question of relationship of change to improvement in outcome. Perhaps a retrospective or prospective case-by-case review of 500 cesarean sections might have been more significant in identifying the appropriateness of the procedure. No, appropriateness of the procedure is a poor choice of words; the question should be, “Are there unnecessary cesarean sections and, if so, can we identify the reasons and change the practices for the benefit of the patient?” The Consensus Conference Draft carefully avoids the word unnecessary, even though it stares at the reader from every page. We need to answer that question, not by documenting the trends, as has been done so adequately in this paper, but by documenting improvement in outcome. REFERENCE
1. Draft Report of the Task Force on Cesarean Childbirth, prepared for the Consensus Development Conference on Cesarean Childbirth, Washington, D. C., September 22 and 23. 1980.
DR. C. J. EATON, Albuquerque, New Mexico. Looking backward to the “good,” or possibly the “bad,” old days only emphasizes the tremendous revolution with respect to route of delivery. I reviewed the obstetric activity at the University of
88
Table
Amirikia,
Zarewych,
I. Incidence
and Evans
of cesarean
No. of deliveries No. of cesarean sections Percentage of cesarean sections
section, University
of. Michigan,
1951
1952
1953
1954
1955
1956
1957
1958
7btal
1,082 37 3.4
1,241
1,288
1,415 48 3.4
1,424 45 3.2
1,538
1,602
1,618
1.617
12,825
41 3.4
33 2.6
II.
so.
Percentage of total
235 215
52.3 47.7
Michigan fiwm I950 through 1958. and there were a total of’ 12,825 deliveries, ofwhich only 450 were cesarcan sections. This represents an overall incidence of 3.5% (Table I). The ratio of‘primary to repeat cesarean sections was 52% to 48% (Table II), which is still fairly representative, as compared to 60% and JO’%. as reported bv the aurhors. The uncorrected maternal mortality. howe\rr, was only O.YQ and. with one exception, these patients all died of’ nonobstetric intercurrent disease. such as adcanced malignancy, bulbar polio. etc.. ?‘h~ maternal morbidity \V;IS 12% and most of‘ thrsc patients wci-e diagnosed as having urinar) tract and superficial ~\ountl infections. Only two had serious morbidity. one a pulmonar) infarct and the other a \wr~ntl dihisc cnc‘e. 1 certainly do not wish to infer criti(.ism of’ the authors’ outconic wit 1-i respect to maternal morbidity anal mortality. as 1 realize that the pop~ilation sainplrs in these series cannot and should not be compar-cd. In reviewing our experience at Presbyterian Hospital (:entcr in Albuquerque, New Mexico, from 1970 through 197X (Table III). and more especially the years I!)77 and 1978, \VC’ see a total cesarean section &idcncr ot’approximately 16% to 17% (Table IV) and primary and repeat incidencrs of 1 I% and 5%. respectively. ?‘hesc* hgures closelv reflect the experience of the
1958
1950
Primary \:ersus repeat cesarean sections, I’tliversity of‘ Michigan, 19.50 through 1958(450 cases)
Table
1950 through
autho~~s.
\Vithout dwelling upon Lhe indications for primar) suger\, which have been well delineated. 1 should. holvever. like to discuss the inverse relationship of forceps deliveries and cesarean sections, performed for “cephalopelvic disproportion.” This bears out the general trend of most busy obstetric services. What is of’ great concern to me are articles such as that appearing in the May, 1980, issue of Contemporary OBIGYN, in which the authors’ stated that midforceps operations are an anachronism and that only outlet forceps have any place in modern obstetrics. The article implies that the fetal outcome in the long term is improved by elim-
62 4.0
60 3.9
70 4.2
54 3.4
450
3.5
inating midforceps procedures. Dr. Amirikia and his colleagues suggest that improved fetal outcome may. in part, be a result of better neonatal care and support systems. This type of article provides \-et.)- combustible f’uel tin- lawyers. I am afraid that this philosoph!ma\ be detrimental to the training ot. obstetric hotw officers and the obstetric patients themselves and that fetal outcome need not necessarily be improved. I believe there is a place for a judicious trial of forceps. .T‘he key word is judicious. Most of us i\-ere thoroughI\ trained in the bony and sof’t tissue anatom!’ of’ the pel\is and the fetal head. M’e were led hand on hand by our professors to the proper application of fiwc eps with respect to this anatomy. It’e uwc repeated]! showi that an easv rotation was indeed eas!‘. U’e also learned that a difficult application and/or- rotation requiring undue force could be a \er1 had thing. Most importanl, we learned to foresee what wot~lcl likely rcsuit in a difficult operation and to duelop a “f&l” fin. the ~a!- the delivery was going. ~vhich offered ample opportunity to reassess the situation. Man\- of’ toda\,‘s house officers recei1.e little, if’ anv, instruction and c‘sperience in forceps operations. The situation Ilas hecome black or white, that is, an easy spontaneous or outlet forceps delivery or a cesarean section. \l’ithout belaboring a point, we tind ourselves in the unenviable position of increasing criticism by go\crnmental and la! agencies because of the rising incidence of cesarean section. On the other hand, the mcdicalilegal implications of’ a midf’orceps delivery, with the tather present in the delivery room as a somewhat biased obser\er and witness. are disturbing. It‘ the fruit of‘his loins develops acne. a stammer, or hair)/ pahns at puberr\- we. as obstctricians. may find oursel\,es riding on the back of’s \‘eq hungry tiger! My plea is that ~‘e continue to he first. and foremost, physicians, well trained in all f’accts of‘ our art. also that we realize there is still a saft, albeit gray, done where we can perform our f’unctions saf’ei! with respect to the mother and baby If you will indulge me, with due respect to adwcates of’ LeBoyer, let us not cast out the obstetrician with the bath water! I realize that the role of‘ a discussant of a paper presented before the Central Association is to bury Caesar (and his sections) and not to praise him. However, I commend the authors in that they raise questions rather than give answers. We have seen where we were and where we are xvith respect to cesarean sections. I hope the authors will
Volume Number
Cesarean section
140 1
Table III. Number and proportion of cesarean sections performed, Albuquerque, New Mexico, 1970 through 1978
No. of deliveries Percentage of increase (decrease) of deliveries No. of cesarean sections Percentage of increase (decrease) of cesarean sections Percentage of cesarean sections/ total deliveries
Table IV. Primary versus repeat 1970 through 1978
Hospital
Center,
1970
1971
1972
1973
1974
1975
1976
1977
1978
Total
2,600
2,324 (10.6)
2,363 1.7
2,510 6.2
2,654 5.7
2,489 (6.2)
2,884
3,372
4,358
-
16.9
29.2
25,554 67.6 3,044 385.1
(6.5)
208 44.4
243 16.8
280 15.2
312 11.4
421 34.9
535 27.1
747 39.6
5.9
6.2
8.8
9.7
10.5
12.5
14.6
15.8
17.1
cesarean
89 3.4 65
144
16.9
154 -
1970
No. of primary cesarean sections Percentage of increase (decrease) of primary cesarean sections Percentage of primary cesarean sections/total deliveries No. of repeat cesarean sections Percentage of increase (decrease) of repeat cesarean sections Percentage of repeat cesarean sections/total deliveries
Presbyterian
89
sections, Presbyterian 1971
(I& 3.4
(&
2.5
2.7
1972
138
1973
159
Hospital 1974
186
Center, 1975
219
Albuquerque,
11.9
New Mexico,
1976
1977
1978
Total
477.5
2,019
72.5
15.2
17.0
17.7
382 28.8
352 52.0
514 46.0
5.8
6.3
7.0
8.8
9.8
10.4
11.8
7.9
70
9.3
84 20.0
11.9
139 49.5
183 31.6
233 27.3
1,025 258.5
3.0
3.3
3.5
4.8
5.4
5.3
4.0
continue their quest that we may see where we are to go in the future. REFERENCE
1. Chez, R. A., Ekbladh, L., Friedman, E. A., and Hughey, M. J.: Mid-forceps delivery: Is it an anachronism? Contemp. OBlGYN 15:82, 1980.
DR. LEE B. STEVENSON, Farmington Hill, Michigan. One of the factual spin-offs of the Michigan Maternal Mortality Study is the fact that more maternal deaths occur in hospitals that have residence programs. Therefore, in a hospital in which more infants are delivered than in any other hospital in Michigan, we would certainly expect that, since there is a residency program, there would be some maternal deaths that are included in this study. Were the increases in the number of blood transfusions in the cesarean hysterectomy group a result of your study, this conclusion, or the review of the literature? My other question, already raised by one of the discussants, regarding the data on perinatal mortality and its decrease as time passes, was this related purely to cesarean section or was it related to the general trend and improvements in perinatal care? DR. JEROMEB. MENAKER,Wichita, Kansas. I have been concerned about the promptness with which our
94
(111:) 3.7
house staff and some of our practicing physicians are quick to pick up the knife for the delivery of a second twin, should it be presenting as a breech, and I would like to know what the essayist thinks about that as an indication for cesarean section. DR. PETERE. FEHR, Minneapolis, Minnesota. One question was not presented here. With almost 9,000 cesarean sections, many of them primary, how many patients with primary cesarean sections were allowed to go on to vaginal delivery? I think this is a trend with the high primary cesarean section rate for breeches and minor problems. How many of these patients were allowed to deliver vaginally the next time, and in those cases what type of problems occurred? I think this is going to have to be a trend we will have to look at in the future. DR. WILLIAM B. GODDARD,Lakewood, Colorado. I think we must remember that there is such a thing as a difficult breech delivery from below, a difficulty of delivering the head. I think we must remember that in the operating room we still see difficult breech deliveries from above, with delivery of the head. DR. AMIRIKIA (Closing). Probably it is preferable to place those cases involving cephalopelvic disproportion, uterine dysfunction and arrested labor, and failed induction of labor all into one category of dystocia. Although there has been a remarkable decrease in the frequency of forceps deliveries while the incidence
90
Amirikia,
Zarewych,
and Evans
ofcesarean section has increased, there remain a number of situations in which forceps deliveries are obviously indicated. High-forceps deliveries are to be condemned and midforceps should be applied infrequently and with a high degree of selectivity, usually involving patients with an inadequate pelvis and transverse arrest or persistent occipitoposterior positions. In general, the maternal mortality rate in our institution is high compared with that of many others primarily because of the characteristics of the patient population we serve, many of whom are transferred to us for the first time in a crisis situation. Nevertheless, the incidence of maternal mortality in the c‘esarean section series is approximately 50% less than that reported in many others. Most of the maternal deaths were really preventable. Several patients should not have been pregnant in the first place because they were obviously in a high-risk category before conception. Another had a ruptured appendix tar several days in another hospital before being transferred to us critically ill with an erroneous diagnosis ofabruptio placentae. Still another had premature rupture of the membranes and amnionitis in another hospital before she was transferred to us in septic shock. Should the cesarean section rate be reduced and, if
so. how can this be accomplished? Obviously, there must be critical standards established. A number who have had cesarean sections for nonpersistent or nonrecurrent indications probably could be delivered saf’el) vaginally. Furthermore, scalp blood sampling for pH could well provide supplemental information which would reduce the number of surgical interventions because of abnormal electronic monitoring tracings. With regard to the question of deli\,ering the second of twins, in many instances, depending on the si,e ot the second twin, version and extraction of the second twin is entirely appropriate. Real difficulties may be encountered when the diagnosis of‘ twin gestation was not made in advance of delivery. The excessive number of blood transfusions again is related in a great degree to the characteristics of the patient population, many of whom are anemic before parturition. Dr. Stevenson’s question regarding the causes of’ the reduction of perinatal mortality deserves critical analysis. During the time of an increasing incidence ofcesarean section there were also tremendotls improvements in prenatal and neonatal care. Improvement in neonatal intensive care probably has contributed more CO the decrease in perinatal mortality than increased SINgical intervention.
AMIRIKIA,
BOHDAN TOMMY Detroit,
M.D.,
ZAREWYCH, N.
F.A.C.O.G.,
F.A.C.S.,
F.R.C.S.(C.)
D.O.
EVANS,
M.D.,
F.A.C.O.G.,
F.A.C.S.
Michigan
During 15 years (1965 through 1979) 9,718 cesarean sections were performed at Hutzel Hospital. This report concerns the indications, incidence, morbidity, and mortality. Dystocia, fetal distress, and breech presentations were the most common indications for primary cesarean section. The incidence rose from 9.8% to 16.8% during this study. Forceps deliveries dropped from 47.5% to 12.0%, and vaginal breech deliveries decreased from 86% to 35%. Spinal anesthesia was used in 90%. Cesarean section hysterectomies were performed in 128. The most common indications were carcinoma in situ of the cervix, uterine leiomyoma, and hemorrhage. Puerperal sepsis and urinary tract and wound infections were the major causes of morbidity. Perinatal mortality decreased from 40% to 29%. There were 10 maternal deaths. Sepsis was the major cause of death. At least four deaths could have been avoided if ultra-high-risk patients had not been pregnant in the first place. (AM.
J. OBSTET.
GYNECOL.
140:81,
1981.)
REDUCTION of perinatal mortality during the past decade has been associated with a rising incidence of cesarean section.’ Cesarean births in the United States have increased almost threefold from 5.5% of all deliveries (195,OOOoperations) in 1970 to 15.2% (510,000) in 1978.’ Any dramatic increase in the frequency of a major operative procedure inevitably is shrouded in controversy. This study was undertaken to add to the body of knowledge regarding the changing incidence of, indications for, and maternal and fetal consequences of cesarean section.
Study group During a 15-year period (1965 cesarean sections were performed University Obstetrical Service at I). Of these, 60% were primary. between 13 and .51 years with an
through 1979), 9,718 on the Wayne State Hutzel Hospital (Table Maternal age ranged average
From the Department of Gynecology Wayne State University and Hutzel
of 25. Gravid-
Presented at the Forty-eighth Annual Meeting of The Central Association qf Obstetricians and Gynecologists, Minneapolis, Minnesota, September 25-27, 1980.
0002-9378/81/090081+10$01.00/0
0
1981
The
C. V. Mosby
Year 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 Total (15 years’
Total No. of deliveries 3,972 3,870 4,062 4,488 5,622 6,121 6,079 5,723 5,584 4,972 5,070 5,132 5,515 5,571 5,922 77,703 duration)
Hospital,
Total No. of cesarean sections 388 404 384 405 534 551 585 608 662 697 775 833 929 965
998 9.718
Rate (‘31)
9.8 10.4 9.4 9.0 9.5 9.0 9.6 10.6 11.8 14.0 15.3 16.2 16.8 17.3 16.8 12.50
ity was 1 to 8 with a median of 2.2. Duration of hospitalization averaged 7.57 days. Indications, maternal and perinatal morbidity and mortality, and complications were recorded.
and Obstetrics, Hospital.
Reprint requests: Hacsan Amirikia, M.D., Department Gynecology and Obstetrics, Wayne State University, Hutzel Hospital, 4707 St. Antoine Blvd., Detroit. Michigan 48201.
Table I. Cesarean sections at Hutzel 1965 through 1979
of
Results Cesarean section rates rose from 9.8% in 1965 to 16.8% in 1979 (Table I). The cesarean rate was stabi-
Co.
81
82
Amirikia,
Table
Zarewych,
and Evans
II. Cesarean
section rate, 1965 through Repent
Year
Table
1965 1966 1Y67 1Y6X lY6Y
3,972 3,870 4.062 4,488 4,622
lY70 lY71
6,121 6,079
1972 1973 1974 1Y75 lY7ti lY77 1978 1979
5 723 ii:,,4 4,972 5.070 5,132 5.515 5,571 5,922
III.
Indications
19’79
cesarean .tection Rate
Total
Rate
Total
262
6.6 5.0 4.7 3.8 5.4 4.5 4.3 3.9 4.5 4.2 5.3 5.6 6.0 6.5 6.2
126 208 194 232 232 278 323 385 409 590 503 546 597 60 1 629
3.1 5.4 4.x 5. 1 4.1 4.5 5.3 6.7 7.3 Y.8 Y.9 10.6 10.8 10.8 10.6
388 404 384 405 534 551 585 608 662 697 775 833 929 965 9Y8
302 273 262 223 253 207 271 286 331 363 368
cesarean NO.
Indication
cesarean suction
7’otal
196 I90 173
for primary
Primary
section
Table
IV. Forceps deliveries,
Fetal distress Breech Prolonged rupture of membranes Hypertensive disorders
pregnanc.y Malpresentation Diabetes
mellitus
Placenta previa Abruptio placentae Rh isoimmunization Total
2.137
37.1
998 898 383
17.1 15.5 6.7
1965 1966 1967 1968
of
346
6.1
208 202 260 242
3.6 3.4 4.5 4.1
109 5,783
___1.9 100.0
196Y 1970 1971 1972
1973 lY74
1975 1976 1977 1978 lY7Y
lized at around 10%’ in the first 8 years of the study with a sharp rise thereafter and a plateau during the last 4 years between 16%’ and 17%. Primary operations increased from Y. 1% to 10.6% while repeat cesarean sections remained almost constant at 6% or less (Table II). Dystocia resulting from an obstructed labor associated with cephalopelvic disproportion or fetal malpresentation and abnormalities of the forces of labor was the most common indication for primary section (Table III). Forceps deliveries dropped from 47.5%’ to 12.0’% (Table IV). The inverse relationship between forceps and abdominal deliveries is illustrated in Fig. 1. Vaginal breech deli\,eries decreased from a peak of 86% in 1968 to 35% in 1979 (Table V). Fig. 2 illustrates the inverse direction of the cesarean section rate and perinatal mortality which decreased from W.5% 10 28.8% (Table VI) and neonatal mortality dropped ti-om 20%, to lS.t% during the last year ot the study (Table VII).
(o/o)
9.8 10.4 Y.4 9.0 Y.5 Y.0 Y.6
10.6 11.X 14.0 15.3
16.2 16.8 17.3 16.8
1979
No.
Rate 1%) Year
Dystocia
1965 through
Ratr
of deliveries
3,972 3,870 4,062 4,488 5,622
Forceps ddweries
1,888 1,941 2,503 2,655 2.7lY
6,121 6,079 5,723 5,584 4,972 5,070
47.5 .50. 1 61.6 57.1 58.3
3,141
51.3
2,748 2,495 2,253 1,861 t.586
45.2 43.5 40.3 37.4 31.2 27.3 20.9 14.1
5,132
1,402
5,515 5,57 5,922
1,155 787 714
1
7c
12.0
Spinal anesthesia ~+‘as used in more than 90% of the cesarean sections. and the low transverse cervical operation was performed in 970/(,. Cesarean hysterectomies were performed in 128 (Table VIII). Carcinoma in situ of the cervix was the most common indication.
Maternal morbidity and mortality Endometritis, urinary tract infection. and wound infection were among the major causes of postoperative morbidity (Table IX). There were 10 maternal deaths (0.1%). Infection was a major contributing factor in .i (Table X). At least four deaths could have been avoided if ultra-high-risk patients had not been pregnant in the first place (Table X, patients 4, 5, 7, and 9). Only 6.3% received blood transfusions which varied from 1 to 40 units with an average of 2.3.
Volume Number
Cesarean
140 1
W
Table V. Incidence of breech delivery, 1965 through 1979 Breech vaginal
presentation
No.
134 114 159 200 164 227 153 180 203 199 227
115 87 85 150 115 106 85 84 112 90 81
1968 1969 1970 1971 1972 1973 1974 1975 1976- 1977 1977-1978 1978-1979
SECTION
FORCEPS
delivery
83
RATE
DELIVERY
RATE
I
r 16
60
Total breech Year
CESAREAN
C------e
section
-16
% E 53 75 70 46 55 46 60 45 35
8
50-
& w z
4540-
d P
35-
;
30-
: e
25-
-9
zo-
-6
15-
-7
IO-
-6
5-
-5 L
I 65
67
69
71
73
75
77
79
YEAR
Table
VI. Perinatal Total
Year
live births
1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979
3,944 3854 4,058 5,312 6,110 6,115 6,709 6,372 6,168 5,509 5,056 5,136 5,505 5,595 5,939
mortality,
1965 through No. of
perinatal
deaths
156 155 165 204 208 202 207 199 224 175 154 149 143 136 171
1979
Perinatal mortality rate
Fig. 1. Change in incidence of forceps deliveries and cesarean sections.
39.5 40.2 40.6 38.4 34.0 34.5 30.8 31.2 36.3 31.7 30.3 29.0 25.9 24.4 28.8
xc*-o---o
C-SECTION
-
PEAINATAL
+-
I,
Comment There is no indication that the rising cesarean section rate has reached a plateau. Among the more commonly reported causes of the increased incidence of cesarean birth are cephalopelvic disproportion, fetal distress, malpresentation, and especially breech presentation.‘j. ’ Most reviews of breech births suggest that abdominal delivery may be associated with less risk to the premature fetus.’ Choice of the abdominal route is complicated by increased maternal and fetal risk. Breech birth via either the vaginal or abdominal route is associated with an increase in both morbidity and mortality when compared with vertex presentation6 When the route of delivery of a breech is considered, one must also consider fetal maturity, congenital anomalies, fetal size, and type of breech presentation as well as pelvic adequacy. Although breech presentation has been associated with a higher perinatal mortality rate, neonatal mortal-
-
-
-
, 65
67
MORTALITY
NEONATAL
( 69
MORTALITY
,1,,,,,,, 71
I 73
75
77
79
YEAR
Fig. 2. Perinatal and neonatal mortality and the frequency of cesarean section. ity among low-birth weight infants (less than 2,500 gm) has been reported to show no consistent difference following primary cesarean birth although there is a suggestion that in infants less than 1,500 gm the risk is lower among cesarean births. Primary cesarean delivery of infants weighing more than 2,500 gm has been associated with a far lower neonatal mortality rate than that of vagina1 breech deliveries. Breech presentation accounts for about 15%: of the rise in the cesarean section rate. Although breech presentations are now usually managed by cesarean section, those infants delivered vaginally and abdominally may have a similar prognosis.7 The number of abdominal deliveries for fetopelvic
84
Amirikia,
Table
Zarewych,
VII.
Neonatal
and Evans
mortality.
1965 through
1979
Table IX. Cesarean section morbidit\, I965 through 1979 Complication
1965 1966
1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979
3,944
79
20.0
3,854 4,058 5,312 6.110 6,115 6,709 6,372 6.168 5,509 5,056 3,136 5,505 5,595
79 85 100 90 99 105 102 118 102 83 77 67 73 x0
20.5 20.9 18.8 14.7 16.2 15.7 16.0 19.1 18.5 16.4 14.9 12.1 13.0 13.4
5.939
Table VIII. Cesarean 1965 through 1979
section hysterectomies,
Indzcation
(:arcinoma in situ of cervix Uterine leiomyoma Hemorrhage (uterine atony) Placenta previa Placenta accreta Amnionitis Sterilization Carcinoma of cervix. invasive Uterine rupture ‘I’otal
I
‘VO.
69
14 11 10 6 . ; 4 4 128
Endometritis Urinary tract infection Wound infection Anemia Upper respiratory infection Paralytic ileus Intestinal obstruction Delayed hemorrhage Pelvic abscess Pulmonary emboli Thrombonhlebitis Febrile mhrbidit! Total
60%
.’
’
During the past decade the number of cesarean sections fin. fetal distress has increased with the use of electronic fetal monitoring. which has been reported to increase surgical intervention by severalfold.X. !’ Xccurate interpretation as well as misinterpretation of monitor tracings, an altered environment of the parturient patiem 1~): the monitoring equipment,’ a stress-related release ot catecholamines with vasoconstriction, and a reduced uteroplacental blood How with fetal bradycardia”’ may also be f’actors. Nevertheless, there has been an inverse relationship between the cesarean section rate and perinatal mortality.’
7.0 6.0 3.8 4.5 1.4 0.6 0.4 0.2 0.2 0.5 3.7 28.3
Fetal distress as an indication for primary cesarean section has contributed to approximately 1.i? of. the increase in the rate of primary cesarean births.!’ C;esarean birth for fetal distress was 7.4’i( in I hose managed by continuous electronic fetal monitoring as opposed to I.!% in those managed by intermittent auscultation.” Others have reported no significant increase in CCsarean births in a monitored group of’ high-risk patients compared with nonmonitored control patients. There is still a great deal ot‘dif‘ticulty in identifying the distressed fetus. Fetal scalp blood samples for deter-mination of‘ pH in those with ominous tracings IIIXJ rc’duce the number of cesarean sections.“. ” C:omhining fetal scalp pH determinations with electronic monitoring ma> ixduc~ surgical intervention for fetal distress tJV
disproporlion, failed induction of labor, and uterine dysfrmction has increased while the number of forceps deliveries has decreased.’ Other indications include genital herpes, multiple gestation, fetal grow& retardation, prematurity and prolonged rupture of’ the membranes. amnionitis. and grand multiparity with uterine dvsfilnction, which have increased from 5% to
683 584 386 451 104 iY .i 3X 1X “i) 4x 360 2.7.X
KlOI‘C
1 h-111 ‘
.i,()‘;;
Introduction of obstetric Iiltr-asorlogr~ll~h~ and improvemenfs in electronic fetal moiliroring and biochemical testing have improved fetal assessment. E:,trio1 and human placental lactogen levels, f’etal activit! and oxytocin challenge tests, scalp blood sampling ti)~ pH dctrrmination, and many amniotic fluid analyses aid in the evaluation ot‘ the fetus befLrc and during parturition. However. single tests may be deceptive anti do not alkvays retlect accurately the letal outcome’. Improved fetal outcome cannot be attributed solel) to operative intervention. The uusatle 10 imptwe the outcome of pregnant\ has resulted in a rapid iucrrase in the number of’ neonatal intensive care units with growth in the specialty areas of’ maternal and fetal medicine and neonatology and improved technologyfor maternal, f’etal, and neonatal care. Increased infant survival reHects more medical interventions. of’ which cesarean section is only a part. Neurological deficits in the newborn infant are still an enigma. Neurological sequelae folknving deliver! b\
Volume Number
Cesarean section
110 1
Table
X. Maternal
Case No.
DIC:
any
Year
Age
Indication
I. H.
1967
22
Cephalopelvic disproportion; premature rupture of membranes Failed forceps; cephalopelvic disproportion Premature rupture of membranes; amnionitis; failed induction Repeat cesarean section: tubal sterilization
Sepsis Endotoxic
Renal failure Congenital heart disease Sepsis
30
1967
37
M. K.
1969
24
2. M.
1970
37
Anemia; chronic renal ease; preeclampsia
S. M.
1970
22
M. V.
1972
24
Preeclampsia; gangrenous appendicitis Myasthenia gravis
J. G.
1973
32
Abruptio
D. N.
1974
30
G. B.
1979
17
Abruptio placentae; preeclampsia; drug dependent Fetal distress; cephalopelvic disproportion
Disseminated
route
may
intravascular
involve
retardation, group
athetosis,
Cause of death
1967
chomotor large
mortality
Patient
B. P.
labeled global
85
mental
Pulmonary emboli Sepsis DIC Rheumatic disease
dis-
heart
Respiratory -failure Amniotic fluid embolism Sepsis DIC
placentae
Sepsis DIC
Pulmonary edema Peritonitis None
Culture S. faecalis (blood) E. coli (endomettium)
Infant Live-born
Live-born
None
Live-born
Severe mitral stenosis and mitral insufficiency Hydrothorax None
Live-born
None
Stillborn
Live-born
Live-born Died Pyelonephritis Pneumonitis Cardiomegaly Pyelonephritis
Group B streptococcus (cervix) B. fragilis Gram-negative bacteria (blood) Gram-negative bacteroides (uterine) E. coli (urine)
Stillborn
Live-born
coagulation.
acquired and
shock
Autofisy findings
hydrocephalus,
hearing
“cerebral retardation,
palsy”
loss
psy-
as well
(ataxia, seizures,
as the choreo-
and
spas-
ticity). Retrospective studies of cerebral palsy populations have confirmed the synergism of marked prematurity, abnormal presentation (especially breech), and perinatal asphyxia.‘” Another complicating factor in assessing the effect of cesarean delivery on brain damage is the lack of good correlation of the infant’s status at birth with eventual neurological development. Even complete perinatal cardiac arrest can be followed by normal neurological development when the heartbeat has returned within 5 minutes and spontaneous respirations have occurred within 30 minutes after the asphyxial event.‘” Significant differences in the perinatal mortality rates in the United States in comparison with those of other countries mainly reflect differences in the patient populations involved and especially the percentage of high-risk obstetric patients.
Medicolegal considerations Negligence in performance of-a cesarean section is a frequent cause of malpractice action, usually involving injuries sustained during delivery comparable to those occurring in other surgical procedures. e.g., sponges or instruments left behind, deaths related to anesthesia, and infection. The biggest malpractice area related to cesarean section concerns failure to perform cesarean delivery which the plaintiff argues was indicated and if performed would have prevented injury or death. Misdiagnoses suggesting that surgery is not required may result in liability. There have been many cases alleging negligence in the failure to discover the necessity of performing a cesarean section or in delaying the decision to perform one by which point the woman or her infant has sustained damage. Maternal morbidity and mortality are still too high. Parturition, premature rupture of the membranes, and internal fetal monitoring14, ITI have been identified as factors contributing to maternal morbidity. Short-term prophylactic antibiotic therapy in selected high-risk
86 Amirikia, Zarewych, and Evans
patients
may reduce
tebrile
morbidity
by more
than
7.5’%.‘” Despite improvement in surgical technique, anesthesia. blood replacement, and postoperative care, mortality fhllowing cesarean section is four times that following vaginal delivery. Elective repeat cesarean section carries two times the risk of’maternal mortality.’ Of course, it is the high-risk patient who is more like]) to have an operative delivery. (Iriticat analyses of the consequences during the next decade may result in a stabilization of‘or decrease in the incidence ol‘ cesarean sections. The concept of “once a section, always a section” has been challenged.X Selective subsequent vaginal delivery when there is not a recurrent indication for cesarean section seems to involve little maternal and fetal risk. However, in some hospital environments the risk of a trial of labor in women who have had a previous cesarean section may esceed the risk of both mother and infant of a propel-l!
1.
REFERENCES Minkoff. H. L., and Schwarz. R. H.: The rising cesarean section rate: Can it safely be reversed? Obstet. Gynecol.
timed electi\;e reprat cesarean birth. F$‘e need nu~i.c data regarding the risk ot‘trials oflahr)r in patierlts b\.itll previous low-segment lransversr uterine incisions. Kcduction in the numhrr of cesarcan se< tiorls c.onld alst~ result from resurrection ot a trial of’ tahor ii1 a patier with a clnestionably adequate petvis ant1 ;I ceptlalic. prcsentation. A desire for sterilisation is non an atlequatc indication ti)r cesarean hysterectoniv when ;I more minol proreclure can be carried out with less risk. Hvstcrrc,tomy tbllorving cesarean section cspohes I hc patient to a 40% to 50%. incI.eased chance of ;I nerd fi,i- blood transfllsion and a tenfold increase in mortalit\. Maternal mortality may be reduced through patient education, more accessible and effective conception control in and early identification of high-risk obstetric patients, and early diagnosis and \.igorons treatnlent of obstetric infections.
9.
56: 13.5, 1980. 2.
3.
4.
2.
6.
7.
8.
Obstetrical Practices in the United States, 1978, Hearing before the Subcommittee on Health and Scientific Research of the Committee on Human Resources, United States Senate, Washington, D. C., 1978. Government Printing Office. Hughey, $1. J., LaPata, R. E., McElin, T. W.. and Lussky, R.: The effect of fetal monitoring on the incidence of cesarean section, Obstet. Gynecol. 49:513, 1977. Fianu. S.: Fetal mortality and morbidity following breech delivery, Arta Obstet. Gynecol. Stand. (Suppt.) 56:s. 1976. Duenhoelter, J. H., Wells, C. E., Resich, J. S., SantosRamos, R., and limenez, I. M.: A paired controlled study of vaginal and abdominaidelivery*of the low birth weight breech fetus, Obstet. Gvnecol. 54:310. 1979. Brenner, W. E., Bruce,‘R. D., and Hendricks, C. H.: The characteristics and perils of breech presentation, AM, J. OBSTET. GYNECOL. 118:700, 1974. W’earing. M. P.: Comparison of vaginal delivery and cesarean section in breech presentation, AM. J. OBSTET. GYNECoL. 136:1083, 1980. Bottoms, S. F., Rosen, M. G., and Sokol, R. J.: The increase in the cesarean birth rate, N. Engl. J. Med. 302:559, 1980.
Editon’ mte: This manuscript discussions were presented.
was revised
after
these
Discussion DR. ROBERT P. PUJUAM, Beckley, West Virginia. The issue of the cesarean section rate is a complex one since it involves potential improved outcome as well as
10.
11. 12.
13. 14.
15.
16.
Haverkamp, A. D.. Orleans. M.. Langendoerfer. S., McFee. J., Murphy, J.. and Thompson. H. E.: A controlled trial of the different effects of intrapartum fetal monitoring, AM. J. OBSTET. GYNECOL. 134:$99. 1979. Morishima. H. 0.. Yeh. M. N.. and .s lame. S. L.: Reduced uterine blood flow and fetal hypoxemia with acute maternal stress: Experimental observation in the pregnant baboon, AM. J. OBSTET. GYNECOL. 134:270, 1979. %alar, R. W.. and Quilligan. E. J.: The inHuence of scalp sampling on the cesarean section rate for fetal distress, AM. J. OBSTET. GYNECOL. 135:239, 1979. McBride, W. G.. Black. B. P., Brown, (:. J., Dolby. R. 111.. Murray, A. D., and Thomas, D. B.: Method of deliver! and developmental outcome at five years of age. Mrd. J. Aust. 1:301, 1979. Steiner, J.. and Neligan. G.: Perinatal cardiac al-rest: quality of the survivors, Arch. Dis. Child. 50:696, 1975. Gassner, C. B.. and Ledger, W. J.: The relationship of hospital-acquired maternal infection to in\Tasive intrapal-turn monitoring technique. AM. J. OBSTET. GYXFXOL. 126:33, 1976. Gibbs, R. S., Listwa, H. M., and Read, J. A.: The effect of internal fetal monitoring on maternal‘infection following cesarean section, Obstet. Gynecol. 48:653. 1976. D’Angelo, L. J., and Sokol, R. J.: Short-term long-cout.se prophylactic antibiotic treatment in cesarean section patient, Obstet. Gynecol. 55:583, 1980.
potential changes in morbidity for two patientsmother and child. As medical practice changes, it is therefore critical that we understand not only the direction of change but also the reasons for the change and whether the changes have resulted in improved outcome. The change in medical practice, a significant increase in cesarean section rate, is adequately confirmed by this
Volume Number
Cesarean section
140
87
1
study as well as numerous others. For example, the most recent New York City experience documents a cesarean section rate of 17.3% for 1978. The repeat cesarean section rate for 1978 of 5.8% is equal to the total cesarean section rate for 1968. The change is apparent in all geographic regions and all types of hospitals, at all birth weights, and irrespective of reimbursement source. In this study the 10% primary cesarean section rate is firm evidence that the overall rate will continue to increase as the large number of primary cesarean section patients reenter the pregnancy pool. The reasons for this change in medical practice are also adequately identified in this presentation although possibly the indication descriptions could have been broader. Nationally, four factors have been identified as chiefly responsible for the increasing cesarean section rate: (1) Dystocia, defined as fetopelvic disproportion, abnormal pelvis, or prolonged labor, has been responsible for 29% of the overall increase. (2) Repeat cesarean sections have contributed 27%’ to the increase. (3) Cesarean section for breech presentation has accounted for 15% of the rise. (4) Fetal distress was responsible for 10% of the increase. All other indications have remained constant or increased only slightly. Surgical techniques, sterilization percentages, anesthetic selection, and the morbidity and mortality of cesarean sections are also well documented by the authors and are consistent with those of other studies. The authors have identified the change in medical practice as being an increasing cesarean section rate; they have identified the reasons for change-dystocia, repeat cesarean sections, breech deliveries, and fetal distress. However, the bottom line in this study and all other studies should be whether the change in medical practice has resulted in improved outcomes for mother and infant. How can we evaluate results? Is the decrease in perinatal mortality, as described by the authors, related to the increasing rate of cesarean births or is it a change so complex that simple crude rate changes are incapable of adequately demonstrating the relationship? This dramatic increase in the cesarean rate led to a call published in the Federal Registry of July 1, 1980, for the National Institutes of Health Consensus Conference on Cesarean Childbirth, which was held in Washington. D. C. September 22 and 23, 1980. A draft document, 55 1 pages in length, investigating all aspects of cesarean births was prepared for this conference. The authors of the document came from varied backgrounds-physicians, social workers, lawyers, consumers, epidemiologists, and others. This document discussed in detail such things as the historical overview: techniques; national, continental, and worldwide experience; maternal mortality: anesthesia; respiratory distress syndrome; dystocia; repeat cesarean section births; breech presentation; fetal distress; behavioral
effects on mother, family, and infant; ethical concerns; medical-legal concerns; and economic concerns. In its conclusions, the Consensus Development Conference expressed deep concern over the rising cesarean section rate and further stated that the rising cesarean birth rate could be stopped and perhaps reversed while improvements continue to be made in maternal and fetal outcome, which are the twin goals of clinical obstetrics today. The conference made major recommendations on how this could be done: (1) Allow a trial of labor and vaginal delivery in carefully selected patients who have had previous low-segment cesarean births. (2) Carefully reassess the diagnosis and management of dystocia to include sedation, rest, oxytocin, etc. (3) Refine the diagnosis of fetal distress. (4) Retain vaginal delivery as an option for the term breech where the following conditions are favorable: (a) estimated fetal weight of less than 8 pounds, (b) normal pelvic dimensions and architecture, (c) frank breech without hyperextended head, and (d) delivery to be conducted by physician experienced in vaginal breech deliveries. Parenthetically, currently about 70% of breeches are delivered by cesarean section and the physician described above may soon become, if he has not already, as rare as the proverbial dodo bird. All of these recommendations are tempered with, and I quote, “informed consent” participation by patient and family. The present study thus elucidates direction of change and reason for change but fails to address adequately the more important question of relationship of change to improvement in outcome. Perhaps a retrospective or prospective case-by-case review of 500 cesarean sections might have been more significant in identifying the appropriateness of the procedure. No, appropriateness of the procedure is a poor choice of words; the question should be, “Are there unnecessary cesarean sections and, if so, can we identify the reasons and change the practices for the benefit of the patient?” The Consensus Conference Draft carefully avoids the word unnecessary, even though it stares at the reader from every page. We need to answer that question, not by documenting the trends, as has been done so adequately in this paper, but by documenting improvement in outcome. REFERENCE
1. Draft Report of the Task Force on Cesarean Childbirth, prepared for the Consensus Development Conference on Cesarean Childbirth, Washington, D. C., September 22 and 23. 1980.
DR. C. J. EATON, Albuquerque, New Mexico. Looking backward to the “good,” or possibly the “bad,” old days only emphasizes the tremendous revolution with respect to route of delivery. I reviewed the obstetric activity at the University of
88
Table
Amirikia,
Zarewych,
I. Incidence
and Evans
of cesarean
No. of deliveries No. of cesarean sections Percentage of cesarean sections
section, University
of. Michigan,
1951
1952
1953
1954
1955
1956
1957
1958
7btal
1,082 37 3.4
1,241
1,288
1,415 48 3.4
1,424 45 3.2
1,538
1,602
1,618
1.617
12,825
41 3.4
33 2.6
II.
so.
Percentage of total
235 215
52.3 47.7
Michigan fiwm I950 through 1958. and there were a total of’ 12,825 deliveries, ofwhich only 450 were cesarcan sections. This represents an overall incidence of 3.5% (Table I). The ratio of‘primary to repeat cesarean sections was 52% to 48% (Table II), which is still fairly representative, as compared to 60% and JO’%. as reported bv the aurhors. The uncorrected maternal mortality. howe\rr, was only O.YQ and. with one exception, these patients all died of’ nonobstetric intercurrent disease. such as adcanced malignancy, bulbar polio. etc.. ?‘h~ maternal morbidity \V;IS 12% and most of‘ thrsc patients wci-e diagnosed as having urinar) tract and superficial ~\ountl infections. Only two had serious morbidity. one a pulmonar) infarct and the other a \wr~ntl dihisc cnc‘e. 1 certainly do not wish to infer criti(.ism of’ the authors’ outconic wit 1-i respect to maternal morbidity anal mortality. as 1 realize that the pop~ilation sainplrs in these series cannot and should not be compar-cd. In reviewing our experience at Presbyterian Hospital (:entcr in Albuquerque, New Mexico, from 1970 through 197X (Table III). and more especially the years I!)77 and 1978, \VC’ see a total cesarean section &idcncr ot’approximately 16% to 17% (Table IV) and primary and repeat incidencrs of 1 I% and 5%. respectively. ?‘hesc* hgures closelv reflect the experience of the
1958
1950
Primary \:ersus repeat cesarean sections, I’tliversity of‘ Michigan, 19.50 through 1958(450 cases)
Table
1950 through
autho~~s.
\Vithout dwelling upon Lhe indications for primar) suger\, which have been well delineated. 1 should. holvever. like to discuss the inverse relationship of forceps deliveries and cesarean sections, performed for “cephalopelvic disproportion.” This bears out the general trend of most busy obstetric services. What is of’ great concern to me are articles such as that appearing in the May, 1980, issue of Contemporary OBIGYN, in which the authors’ stated that midforceps operations are an anachronism and that only outlet forceps have any place in modern obstetrics. The article implies that the fetal outcome in the long term is improved by elim-
62 4.0
60 3.9
70 4.2
54 3.4
450
3.5
inating midforceps procedures. Dr. Amirikia and his colleagues suggest that improved fetal outcome may. in part, be a result of better neonatal care and support systems. This type of article provides \-et.)- combustible f’uel tin- lawyers. I am afraid that this philosoph!ma\ be detrimental to the training ot. obstetric hotw officers and the obstetric patients themselves and that fetal outcome need not necessarily be improved. I believe there is a place for a judicious trial of forceps. .T‘he key word is judicious. Most of us i\-ere thoroughI\ trained in the bony and sof’t tissue anatom!’ of’ the pel\is and the fetal head. M’e were led hand on hand by our professors to the proper application of fiwc eps with respect to this anatomy. It’e uwc repeated]! showi that an easv rotation was indeed eas!‘. U’e also learned that a difficult application and/or- rotation requiring undue force could be a \er1 had thing. Most importanl, we learned to foresee what wot~lcl likely rcsuit in a difficult operation and to duelop a “f&l” fin. the ~a!- the delivery was going. ~vhich offered ample opportunity to reassess the situation. Man\- of’ toda\,‘s house officers recei1.e little, if’ anv, instruction and c‘sperience in forceps operations. The situation Ilas hecome black or white, that is, an easy spontaneous or outlet forceps delivery or a cesarean section. \l’ithout belaboring a point, we tind ourselves in the unenviable position of increasing criticism by go\crnmental and la! agencies because of the rising incidence of cesarean section. On the other hand, the mcdicalilegal implications of’ a midf’orceps delivery, with the tather present in the delivery room as a somewhat biased obser\er and witness. are disturbing. It‘ the fruit of‘his loins develops acne. a stammer, or hair)/ pahns at puberr\- we. as obstctricians. may find oursel\,es riding on the back of’s \‘eq hungry tiger! My plea is that ~‘e continue to he first. and foremost, physicians, well trained in all f’accts of‘ our art. also that we realize there is still a saft, albeit gray, done where we can perform our f’unctions saf’ei! with respect to the mother and baby If you will indulge me, with due respect to adwcates of’ LeBoyer, let us not cast out the obstetrician with the bath water! I realize that the role of‘ a discussant of a paper presented before the Central Association is to bury Caesar (and his sections) and not to praise him. However, I commend the authors in that they raise questions rather than give answers. We have seen where we were and where we are xvith respect to cesarean sections. I hope the authors will
Volume Number
Cesarean section
140 1
Table III. Number and proportion of cesarean sections performed, Albuquerque, New Mexico, 1970 through 1978
No. of deliveries Percentage of increase (decrease) of deliveries No. of cesarean sections Percentage of increase (decrease) of cesarean sections Percentage of cesarean sections/ total deliveries
Table IV. Primary versus repeat 1970 through 1978
Hospital
Center,
1970
1971
1972
1973
1974
1975
1976
1977
1978
Total
2,600
2,324 (10.6)
2,363 1.7
2,510 6.2
2,654 5.7
2,489 (6.2)
2,884
3,372
4,358
-
16.9
29.2
25,554 67.6 3,044 385.1
(6.5)
208 44.4
243 16.8
280 15.2
312 11.4
421 34.9
535 27.1
747 39.6
5.9
6.2
8.8
9.7
10.5
12.5
14.6
15.8
17.1
cesarean
89 3.4 65
144
16.9
154 -
1970
No. of primary cesarean sections Percentage of increase (decrease) of primary cesarean sections Percentage of primary cesarean sections/total deliveries No. of repeat cesarean sections Percentage of increase (decrease) of repeat cesarean sections Percentage of repeat cesarean sections/total deliveries
Presbyterian
89
sections, Presbyterian 1971
(I& 3.4
(&
2.5
2.7
1972
138
1973
159
Hospital 1974
186
Center, 1975
219
Albuquerque,
11.9
New Mexico,
1976
1977
1978
Total
477.5
2,019
72.5
15.2
17.0
17.7
382 28.8
352 52.0
514 46.0
5.8
6.3
7.0
8.8
9.8
10.4
11.8
7.9
70
9.3
84 20.0
11.9
139 49.5
183 31.6
233 27.3
1,025 258.5
3.0
3.3
3.5
4.8
5.4
5.3
4.0
continue their quest that we may see where we are to go in the future. REFERENCE
1. Chez, R. A., Ekbladh, L., Friedman, E. A., and Hughey, M. J.: Mid-forceps delivery: Is it an anachronism? Contemp. OBlGYN 15:82, 1980.
DR. LEE B. STEVENSON, Farmington Hill, Michigan. One of the factual spin-offs of the Michigan Maternal Mortality Study is the fact that more maternal deaths occur in hospitals that have residence programs. Therefore, in a hospital in which more infants are delivered than in any other hospital in Michigan, we would certainly expect that, since there is a residency program, there would be some maternal deaths that are included in this study. Were the increases in the number of blood transfusions in the cesarean hysterectomy group a result of your study, this conclusion, or the review of the literature? My other question, already raised by one of the discussants, regarding the data on perinatal mortality and its decrease as time passes, was this related purely to cesarean section or was it related to the general trend and improvements in perinatal care? DR. JEROMEB. MENAKER,Wichita, Kansas. I have been concerned about the promptness with which our
94
(111:) 3.7
house staff and some of our practicing physicians are quick to pick up the knife for the delivery of a second twin, should it be presenting as a breech, and I would like to know what the essayist thinks about that as an indication for cesarean section. DR. PETERE. FEHR, Minneapolis, Minnesota. One question was not presented here. With almost 9,000 cesarean sections, many of them primary, how many patients with primary cesarean sections were allowed to go on to vaginal delivery? I think this is a trend with the high primary cesarean section rate for breeches and minor problems. How many of these patients were allowed to deliver vaginally the next time, and in those cases what type of problems occurred? I think this is going to have to be a trend we will have to look at in the future. DR. WILLIAM B. GODDARD,Lakewood, Colorado. I think we must remember that there is such a thing as a difficult breech delivery from below, a difficulty of delivering the head. I think we must remember that in the operating room we still see difficult breech deliveries from above, with delivery of the head. DR. AMIRIKIA (Closing). Probably it is preferable to place those cases involving cephalopelvic disproportion, uterine dysfunction and arrested labor, and failed induction of labor all into one category of dystocia. Although there has been a remarkable decrease in the frequency of forceps deliveries while the incidence
90
Amirikia,
Zarewych,
and Evans
ofcesarean section has increased, there remain a number of situations in which forceps deliveries are obviously indicated. High-forceps deliveries are to be condemned and midforceps should be applied infrequently and with a high degree of selectivity, usually involving patients with an inadequate pelvis and transverse arrest or persistent occipitoposterior positions. In general, the maternal mortality rate in our institution is high compared with that of many others primarily because of the characteristics of the patient population we serve, many of whom are transferred to us for the first time in a crisis situation. Nevertheless, the incidence of maternal mortality in the c‘esarean section series is approximately 50% less than that reported in many others. Most of the maternal deaths were really preventable. Several patients should not have been pregnant in the first place because they were obviously in a high-risk category before conception. Another had a ruptured appendix tar several days in another hospital before being transferred to us critically ill with an erroneous diagnosis ofabruptio placentae. Still another had premature rupture of the membranes and amnionitis in another hospital before she was transferred to us in septic shock. Should the cesarean section rate be reduced and, if
so. how can this be accomplished? Obviously, there must be critical standards established. A number who have had cesarean sections for nonpersistent or nonrecurrent indications probably could be delivered saf’el) vaginally. Furthermore, scalp blood sampling for pH could well provide supplemental information which would reduce the number of surgical interventions because of abnormal electronic monitoring tracings. With regard to the question of deli\,ering the second of twins, in many instances, depending on the si,e ot the second twin, version and extraction of the second twin is entirely appropriate. Real difficulties may be encountered when the diagnosis of‘ twin gestation was not made in advance of delivery. The excessive number of blood transfusions again is related in a great degree to the characteristics of the patient population, many of whom are anemic before parturition. Dr. Stevenson’s question regarding the causes of’ the reduction of perinatal mortality deserves critical analysis. During the time of an increasing incidence ofcesarean section there were also tremendotls improvements in prenatal and neonatal care. Improvement in neonatal intensive care probably has contributed more CO the decrease in perinatal mortality than increased SINgical intervention.