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Fetal loss in cesarean section
Fetal loss in cesarean section A. H. MACLENNAN, M.D. Edmonton, Alberta
total of 5 77 cesarean sections were performed including 11 which resulted in the birth of twins. In this period the cesarean section rate has not varied greatly except for 1958, but a review of the indications for operation in that year fails to reveal any gross deviation from the usual pattern. The average section rate was 2.21 per cent (Table I). To a minor degree, this rate does not reflect the actual practice in the hospital because a certain number of patients are admitted for their final cesarean section who have been delivered previously in hospitals where sterilization is not performed.
T n r s review of cesarean sections performed in the Royal Alexandra Hospital, Edmonton, was undertaken primarily to study the fetal loss in comparison with the total fetal loss. The hospital is an open general hospital with a separate maternity building. The staff is composed of a number of general practitioners and certified obstetricians and at present 40 to 45 per cent of the patients admitted have received their prenatal care from general practitioners. These patients are attended in the hospital by their own physician unless some complication requires a consultation. All major obstetric procedures and cesarean sections are performed by certified obstetricians. The hospital perinatal committee follows the standard of viability and the coding procedure of the Provincial Perinatal Committee which, until 1960, used 1,000 grams and 28 weeks' gestation as the standard of viability. These limits have now been lowered to 750 grams and 24 weeks' gestation. All infants delivered by cesarean section are admitted directly to the observation nursery which is operated in conjunction with the premature nursery for the hospital, before being transferred to the regular floor nursery. During the 5 year period reviewed, there were 20,065 deliveries and 312 twins. A
Maternal mortality
Two mothers died following cesarean section. The first was a 39-year-old gravida iii who had weighed over 200 pounds since age 20 and was suffering from hypertension with superimposed pre-eclampsia. Her youngest child was 10 years old. Cesarean section was performed after ineffective medical induction. Death resulted from pulmonary embolism on the third postoperative day. The second patient died from acute bulbar poliomyelitis 10 days after admission. She was in the thirty-seventh week of gestation and was delivered of a living baby by cesan:•an section two days after admission. Obstetric trauma
From the Royal Alexandra Maternity Hospital and the University of Alberta Medical School. Presented at the Sixteenth Annual Meetin;r of the Societ'Y of Obstetricians and Gynaecologists of Canada, Jasper, Alberta, June 10-12, 1960.
During this 5 year period there were 2 instances of rupture of the lower uterine segment, one from extension of an old cervical laceration, and one a transverse laceration in the lower uterine segment. The
22
Fetal loss in cesarean section 23
Volume 82 Number 1
Table I. Cesarean section rate and perinatal death rate Fetal loss per I ,000 births Cesarean section Year
I
Cesarean sections
Deliveries
Rate
(%)
1955 1956 1957 1958 1959 577(+11)
26065(+312)
Total
Hospital total
No. Newborn \ Stillborn
5
2.13 2.10 2.17 2.68 2.08
23.5 24.6 24.8 20.7 30.0
5 6 3
0 1 2 1t 0
2.21
22.7
22
4
3
I
Rate
48.0 37.4 63.6t 40.0 25.8
44.2
*Twins. tFour of 5 neonatal deaths associated with placenta previa. tBirth weight 565 grams.
first resulted from an assisted breech delivery in a para ii with a 9 pound infant. The patient survived after abdominal hysterectomy. The other occurred in a para i with a 7 pound infant delivered by version and extraction for prolapsed cord. This patient survived after repair of the laceration. One maternal death followed a chain of events that possibly had its beginning in a vault laceration incurred in the delivery of a 10 pound, 14 ounce stillborn infant. This patient received unmatched blood and developed anuria, but died of septic pulmonary emboli and acute bronchopneumonia.
Perinatal deaths Table I reveals a perinatal loss for all deliveries of 22.7 per 1,000 births while the loss associated with cesarean section was 44.2. It will be noted, however, that in 1959 the total perinatal loss has been reduced to Table II. Type of operation and anesthesia Type of operation Low Year
1955 1956 1957 1958 1959
I No. 102 106 107 146
116 Total 577
ITJHH..
I I Cesarean
I
h'\Jdu'Y...
I
Type of anesthesia
I
{;pt'J-
r.Jn~t:;.,.
1·;;;~~ ;;;~~Y ~~-;i· \spinazl ~;~-~ 88 100 103 129 106
3
11
0 0 5 0
6 12 10
526
8
43
4
7
95 101 97 116
5 10 30
493
32 84
20 per 1,000 births and that the loss associated with cesarean section approached the same rate, having diminished to 25.8. The fetal loss associated with cesarean section is comprised of 22 newborn and 4 stillborn infants. An autopsy was performed on 20. In 1957, 4 of the 5 neonatal deaths were associated with placenta previa, and the stillborn infant in 1958 weighed only 565 grams.
Type of operation It is apparent from Table II that few cesarean hysterectomies are performed, this procedure being restricted largely to cases of myomata uteri. It is probable, however, in view of the experience of others who have used this operation more frequently and with safety, and in the best interest of certain patients, that the uterus should be removed more often at the time of the final section. The so-called "classical" entry to the uterine cavity is rarely employed-being utilized only in certain cases of placenta previa and at times when the lower uterine segment is difficult to expose. At repeat section, following a previous low transverse incision in the uterus, defects of varying size and degree are not uncommon. These, however, have never resulted in any serious complications and there appears to be no reason to perform a repeat
24
Maclennan
·\m.
section before term for fear of scar disruption. Therefore, it is felt that allowing all patients for repeat section to continue to term or until labor begins, rather than terminating the pregnancy at a calculated date short of term, will avoid the risk of delivery of an occasional premature infant. Anesthesia
It is interesting to note, too, that in the last 2 years there has been an increase in the use of general anesthesia. There are two factors that have influenced this trend: first, the advances in anesthetic agents and techniques of administration have made general anesthesia more suitable for this operation; second, the fear that, should complications follow spinal anesthesia, such a procedure might be difficult to justify in court since some neurologists are quite positive in their view that spinal anesthesia is dangerous and should not be used. Fetal loss
In studying the clinical and pathological features of the babies that died, one finds the most common picture to be one of clinical respiratory failure, and after autopsy the pathologist usually reports "hyaline mem-
Table III. Fetal loss and maternal state Primary section Placenta previa Abruptio placentae Diabetes mellitus Abnormal presentation Eclampsia Acute poliomyelitis Incoordinate uterine action and preeclampsia Repeat section Premature labor; 35 weeks; 3 pounds, 12 ounces; respiratory distress syndrome Premature labor; 35 weeks; 3 pounds, 9 ounces; respirator; distress syndrome Acute hydramnios; 33 weeks; 3 pounds, 4 ounces; stillbirth (previous classical) Elective Cardiac hypertrophy Diaphragmatic hernia Respiratory distress syndrome Erythroblastosis Breech, spina bifida
8 3 2 2 I
1
I
.'i
J.
July, 1961 Ob;t. & Gyn~r.
brane disease'' and "atelectasis.'' It is proposed, therefore, for the sake of brevity and simplicity, to designate this clinical and pathological picture as "respiratory distress syndrome'' ( RDS). Eighteen babies were lost at the first section, the majority of these having been delivered of patients suffering from antepartum bleeding-8 with placenta previa and 3 with premature separation (Table III). The 2 diabetic mothers were delivered electively at 35 weeks. The babies weighed 8 pounds, 2 ounces and 6 pounds, 14 ounces, respectively, and both died of RDS. One lived only 9 hours while the other lived 43 hours. One pregnancy was terminated at 26 weeks because of acute fulminating eclampsia in an unmarried mother who had had no prenatal care. The infant weighed only 565 grams. One patient with pre-eclampsia had labor induced with some difficulty. Cesarean section was performed after 60 hours of poor labor and 24 hours after artificial rupture of the membranes. The baby died of pneumonia. This case was coded preventable and "physician error in judgment." One cesarean section was performed on a patient with acute bulbar poliomyelitis. It will be noted that of the 8 babies lost at repeat section, 3 were premature--2 due to premature labor-and both died of RDS. The third was stillborn at 33 weeks; the mother had had a previous classical section and developed acute hydramnios. This infant was microcephalic. Of the other 5 babies delivered by elective repeat section, one had the typical picture of RDS and one had moderate cardiac hypertrophy, atelectasis, and chronic passive congestion. The other three had conditions incompatible with life. Antepartum bleeding
Table IV reveals our experience with antepartum bleeding. Eighty cesarean sections were performed for this complication -13.86 per cent of the total-with a total fetal loss of 11, or 13.75 per cent.
Volume 82
Fetal loss in cesarean section 25
Number 1
In 1959, however, only one baby was lost and its death could not be attributed either to the antepartum bleeding or to the operation. This infant died on the ninth day of life. Its progress had been satisfactory until it accidentally became overheated from being too close to a radiator. The autopsy diagnosis was "acute hemorrhagic pneumonia." Two of the 11 were stillborn (one anencephalic). The remaining 8 died of RDSall proved by autopsy. The records of the mothers of these 8 reveal severe blood loss and some degree of shock before resuscitation and operation. This would suggest that prompt delivery of the infant, to prevent excessive blood loss, is imperative; and, to prevent such circumstances, the bleeding patient should be watched carefully.
Neonatal deaths The RDS was diagnosed in 16 of the 22 cases of neonatal death-in 14 at autopsy (Table V). The 2 cases of pneumonia must be considered as preventable--the first resulting from a "physician error in judgment" and the second from an unfortunate incident in the premature nursery. The remaining 4 had congenital abnormalities incompatible with life and beyond correction or treatment. From Table VI it is apparent that one half of the total deaths from RDS occurred in association with antepartum bleeding and that RDS was the cause of death in 10 per cent of the babies delivered by cesarean section of mothers with antepartum bleeding, but in only 1.2 per cent of babies whose mothers underwent cesarean section for all other indications. The average weight of the 8 infants associated with antepartum bleeding was 4 pounds, 7 ounces, and the average period of gestation was 34 weeks. It would thus appear that the weight and age of these infants may not be the determining factors in their failure to survive, for it is reasonable to expect fewer fatalities in infants of this weight and age. However, as previously noted, the mothers of these 8 infants suffered severe blood loss before operation.
Table IV. Fetal loss in antepartum bleeding Sections for Total Year
Fetal loss
102
12
1958 1959
106 107 146 117
12 15 20 21
Total
577
80
1955 1956
1957
Table V. Neonatal deaths Respiratory distress syndrome Pneumonia
14 2
Congenital defects
3
(Autopsy) (Clinical) After 60 hrs. labor, lived 3 days Acute, 9 days of age Diaphragmatic hernia, lived ;12 hour Brow presentation, meningocele Breech plus spina bifida ( 2 previous sections) Lived 3 hours
2
Erythroblastosis Total
22
Table VI. Neonatal deaths from respiratory distress syndrome Maternal state
No.
Antepartum bleeding Repeat section Diabetes mellitus Acute poliomyelitis Eclampsia ( 26 weeks)
8
Total
~
(10% of 80 sections) }1.2% of 497 sections
1* 16
*Weight, 565 grams.
Table VII. Stillbirths Previous classical-acute hydramnios-33 weeksweight 3 pounds, 4 ounces-microcephaly Placenta previa-35 weeks-weight 3 pounds, 10 ounces-marked blood loss Abruptio placentae-age 44-hypertension-transverse lie-anencephaly-severe bleeding Transverse lie-41 weeks
26 Maclennan
Our experience with antepartum bleeding, therefore, would suggest some relationship between the maternal state and the occurrence of the respiratory distress syndrome.
Stillbirths The 4 stillbirths are listed in Table VII. Possibly the first of these mothers could have been delivered vaginally had the fetal diagnosis been made preoperatively; since the previous classical scar did not rupture with the development of hydramnios, it would probably have withstood the delivery of a small fetus. The other 3 stillbirths were unavoidable. Summary 1. The cesarean section rate for the years 1955 to 1959 was 2.21 per cent. 2. There was one maternal death from pulmonary embolism and one from acute bulbar poliomyelitis.
.July, 19111 Am.
J.
()b,L & Gyncc.
3. The average perinatal loss for all deliveries in the hospital was 22.7 per 1,000 births, and for cesarean section the average loss was 44.2 per 1,000 births. In 1959 these rates were 20.0 per 1,000 births for all deliveries and 25.8 per 1,000 births for delivery by cesarean section. 4. The total fetal loss with cesarean section was 26, comprised of 22 neonatal deaths and 4 stillbirths. One infant weighed only 565 grams and 6 others had congenital abnormalities incompatible with life. 5. Sixteen of 22 neonatal deaths were due to the respiratory distress syndrome and one half of these were associated with antepartum bleeding. This cause of fetal loss occurred in 10 per cent of cases when operation was performed for antepartum bleeding but in only 1.2 per cent when operation was performed for all other indications. 6. Antepartum bleeding was the indication for operation in 11 of the 26 perinatal deaths.
total of 5 77 cesarean sections were performed including 11 which resulted in the birth of twins. In this period the cesarean section rate has not varied greatly except for 1958, but a review of the indications for operation in that year fails to reveal any gross deviation from the usual pattern. The average section rate was 2.21 per cent (Table I). To a minor degree, this rate does not reflect the actual practice in the hospital because a certain number of patients are admitted for their final cesarean section who have been delivered previously in hospitals where sterilization is not performed.
T n r s review of cesarean sections performed in the Royal Alexandra Hospital, Edmonton, was undertaken primarily to study the fetal loss in comparison with the total fetal loss. The hospital is an open general hospital with a separate maternity building. The staff is composed of a number of general practitioners and certified obstetricians and at present 40 to 45 per cent of the patients admitted have received their prenatal care from general practitioners. These patients are attended in the hospital by their own physician unless some complication requires a consultation. All major obstetric procedures and cesarean sections are performed by certified obstetricians. The hospital perinatal committee follows the standard of viability and the coding procedure of the Provincial Perinatal Committee which, until 1960, used 1,000 grams and 28 weeks' gestation as the standard of viability. These limits have now been lowered to 750 grams and 24 weeks' gestation. All infants delivered by cesarean section are admitted directly to the observation nursery which is operated in conjunction with the premature nursery for the hospital, before being transferred to the regular floor nursery. During the 5 year period reviewed, there were 20,065 deliveries and 312 twins. A
Maternal mortality
Two mothers died following cesarean section. The first was a 39-year-old gravida iii who had weighed over 200 pounds since age 20 and was suffering from hypertension with superimposed pre-eclampsia. Her youngest child was 10 years old. Cesarean section was performed after ineffective medical induction. Death resulted from pulmonary embolism on the third postoperative day. The second patient died from acute bulbar poliomyelitis 10 days after admission. She was in the thirty-seventh week of gestation and was delivered of a living baby by cesan:•an section two days after admission. Obstetric trauma
From the Royal Alexandra Maternity Hospital and the University of Alberta Medical School. Presented at the Sixteenth Annual Meetin;r of the Societ'Y of Obstetricians and Gynaecologists of Canada, Jasper, Alberta, June 10-12, 1960.
During this 5 year period there were 2 instances of rupture of the lower uterine segment, one from extension of an old cervical laceration, and one a transverse laceration in the lower uterine segment. The
22
Fetal loss in cesarean section 23
Volume 82 Number 1
Table I. Cesarean section rate and perinatal death rate Fetal loss per I ,000 births Cesarean section Year
I
Cesarean sections
Deliveries
Rate
(%)
1955 1956 1957 1958 1959 577(+11)
26065(+312)
Total
Hospital total
No. Newborn \ Stillborn
5
2.13 2.10 2.17 2.68 2.08
23.5 24.6 24.8 20.7 30.0
5 6 3
0 1 2 1t 0
2.21
22.7
22
4
3
I
Rate
48.0 37.4 63.6t 40.0 25.8
44.2
*Twins. tFour of 5 neonatal deaths associated with placenta previa. tBirth weight 565 grams.
first resulted from an assisted breech delivery in a para ii with a 9 pound infant. The patient survived after abdominal hysterectomy. The other occurred in a para i with a 7 pound infant delivered by version and extraction for prolapsed cord. This patient survived after repair of the laceration. One maternal death followed a chain of events that possibly had its beginning in a vault laceration incurred in the delivery of a 10 pound, 14 ounce stillborn infant. This patient received unmatched blood and developed anuria, but died of septic pulmonary emboli and acute bronchopneumonia.
Perinatal deaths Table I reveals a perinatal loss for all deliveries of 22.7 per 1,000 births while the loss associated with cesarean section was 44.2. It will be noted, however, that in 1959 the total perinatal loss has been reduced to Table II. Type of operation and anesthesia Type of operation Low Year
1955 1956 1957 1958 1959
I No. 102 106 107 146
116 Total 577
ITJHH..
I I Cesarean
I
h'\Jdu'Y...
I
Type of anesthesia
I
{;pt'J-
r.Jn~t:;.,.
1·;;;~~ ;;;~~Y ~~-;i· \spinazl ~;~-~ 88 100 103 129 106
3
11
0 0 5 0
6 12 10
526
8
43
4
7
95 101 97 116
5 10 30
493
32 84
20 per 1,000 births and that the loss associated with cesarean section approached the same rate, having diminished to 25.8. The fetal loss associated with cesarean section is comprised of 22 newborn and 4 stillborn infants. An autopsy was performed on 20. In 1957, 4 of the 5 neonatal deaths were associated with placenta previa, and the stillborn infant in 1958 weighed only 565 grams.
Type of operation It is apparent from Table II that few cesarean hysterectomies are performed, this procedure being restricted largely to cases of myomata uteri. It is probable, however, in view of the experience of others who have used this operation more frequently and with safety, and in the best interest of certain patients, that the uterus should be removed more often at the time of the final section. The so-called "classical" entry to the uterine cavity is rarely employed-being utilized only in certain cases of placenta previa and at times when the lower uterine segment is difficult to expose. At repeat section, following a previous low transverse incision in the uterus, defects of varying size and degree are not uncommon. These, however, have never resulted in any serious complications and there appears to be no reason to perform a repeat
24
Maclennan
·\m.
section before term for fear of scar disruption. Therefore, it is felt that allowing all patients for repeat section to continue to term or until labor begins, rather than terminating the pregnancy at a calculated date short of term, will avoid the risk of delivery of an occasional premature infant. Anesthesia
It is interesting to note, too, that in the last 2 years there has been an increase in the use of general anesthesia. There are two factors that have influenced this trend: first, the advances in anesthetic agents and techniques of administration have made general anesthesia more suitable for this operation; second, the fear that, should complications follow spinal anesthesia, such a procedure might be difficult to justify in court since some neurologists are quite positive in their view that spinal anesthesia is dangerous and should not be used. Fetal loss
In studying the clinical and pathological features of the babies that died, one finds the most common picture to be one of clinical respiratory failure, and after autopsy the pathologist usually reports "hyaline mem-
Table III. Fetal loss and maternal state Primary section Placenta previa Abruptio placentae Diabetes mellitus Abnormal presentation Eclampsia Acute poliomyelitis Incoordinate uterine action and preeclampsia Repeat section Premature labor; 35 weeks; 3 pounds, 12 ounces; respiratory distress syndrome Premature labor; 35 weeks; 3 pounds, 9 ounces; respirator; distress syndrome Acute hydramnios; 33 weeks; 3 pounds, 4 ounces; stillbirth (previous classical) Elective Cardiac hypertrophy Diaphragmatic hernia Respiratory distress syndrome Erythroblastosis Breech, spina bifida
8 3 2 2 I
1
I
.'i
J.
July, 1961 Ob;t. & Gyn~r.
brane disease'' and "atelectasis.'' It is proposed, therefore, for the sake of brevity and simplicity, to designate this clinical and pathological picture as "respiratory distress syndrome'' ( RDS). Eighteen babies were lost at the first section, the majority of these having been delivered of patients suffering from antepartum bleeding-8 with placenta previa and 3 with premature separation (Table III). The 2 diabetic mothers were delivered electively at 35 weeks. The babies weighed 8 pounds, 2 ounces and 6 pounds, 14 ounces, respectively, and both died of RDS. One lived only 9 hours while the other lived 43 hours. One pregnancy was terminated at 26 weeks because of acute fulminating eclampsia in an unmarried mother who had had no prenatal care. The infant weighed only 565 grams. One patient with pre-eclampsia had labor induced with some difficulty. Cesarean section was performed after 60 hours of poor labor and 24 hours after artificial rupture of the membranes. The baby died of pneumonia. This case was coded preventable and "physician error in judgment." One cesarean section was performed on a patient with acute bulbar poliomyelitis. It will be noted that of the 8 babies lost at repeat section, 3 were premature--2 due to premature labor-and both died of RDS. The third was stillborn at 33 weeks; the mother had had a previous classical section and developed acute hydramnios. This infant was microcephalic. Of the other 5 babies delivered by elective repeat section, one had the typical picture of RDS and one had moderate cardiac hypertrophy, atelectasis, and chronic passive congestion. The other three had conditions incompatible with life. Antepartum bleeding
Table IV reveals our experience with antepartum bleeding. Eighty cesarean sections were performed for this complication -13.86 per cent of the total-with a total fetal loss of 11, or 13.75 per cent.
Volume 82
Fetal loss in cesarean section 25
Number 1
In 1959, however, only one baby was lost and its death could not be attributed either to the antepartum bleeding or to the operation. This infant died on the ninth day of life. Its progress had been satisfactory until it accidentally became overheated from being too close to a radiator. The autopsy diagnosis was "acute hemorrhagic pneumonia." Two of the 11 were stillborn (one anencephalic). The remaining 8 died of RDSall proved by autopsy. The records of the mothers of these 8 reveal severe blood loss and some degree of shock before resuscitation and operation. This would suggest that prompt delivery of the infant, to prevent excessive blood loss, is imperative; and, to prevent such circumstances, the bleeding patient should be watched carefully.
Neonatal deaths The RDS was diagnosed in 16 of the 22 cases of neonatal death-in 14 at autopsy (Table V). The 2 cases of pneumonia must be considered as preventable--the first resulting from a "physician error in judgment" and the second from an unfortunate incident in the premature nursery. The remaining 4 had congenital abnormalities incompatible with life and beyond correction or treatment. From Table VI it is apparent that one half of the total deaths from RDS occurred in association with antepartum bleeding and that RDS was the cause of death in 10 per cent of the babies delivered by cesarean section of mothers with antepartum bleeding, but in only 1.2 per cent of babies whose mothers underwent cesarean section for all other indications. The average weight of the 8 infants associated with antepartum bleeding was 4 pounds, 7 ounces, and the average period of gestation was 34 weeks. It would thus appear that the weight and age of these infants may not be the determining factors in their failure to survive, for it is reasonable to expect fewer fatalities in infants of this weight and age. However, as previously noted, the mothers of these 8 infants suffered severe blood loss before operation.
Table IV. Fetal loss in antepartum bleeding Sections for Total Year
Fetal loss
102
12
1958 1959
106 107 146 117
12 15 20 21
Total
577
80
1955 1956
1957
Table V. Neonatal deaths Respiratory distress syndrome Pneumonia
14 2
Congenital defects
3
(Autopsy) (Clinical) After 60 hrs. labor, lived 3 days Acute, 9 days of age Diaphragmatic hernia, lived ;12 hour Brow presentation, meningocele Breech plus spina bifida ( 2 previous sections) Lived 3 hours
2
Erythroblastosis Total
22
Table VI. Neonatal deaths from respiratory distress syndrome Maternal state
No.
Antepartum bleeding Repeat section Diabetes mellitus Acute poliomyelitis Eclampsia ( 26 weeks)
8
Total
~
(10% of 80 sections) }1.2% of 497 sections
1* 16
*Weight, 565 grams.
Table VII. Stillbirths Previous classical-acute hydramnios-33 weeksweight 3 pounds, 4 ounces-microcephaly Placenta previa-35 weeks-weight 3 pounds, 10 ounces-marked blood loss Abruptio placentae-age 44-hypertension-transverse lie-anencephaly-severe bleeding Transverse lie-41 weeks
26 Maclennan
Our experience with antepartum bleeding, therefore, would suggest some relationship between the maternal state and the occurrence of the respiratory distress syndrome.
Stillbirths The 4 stillbirths are listed in Table VII. Possibly the first of these mothers could have been delivered vaginally had the fetal diagnosis been made preoperatively; since the previous classical scar did not rupture with the development of hydramnios, it would probably have withstood the delivery of a small fetus. The other 3 stillbirths were unavoidable. Summary 1. The cesarean section rate for the years 1955 to 1959 was 2.21 per cent. 2. There was one maternal death from pulmonary embolism and one from acute bulbar poliomyelitis.
.July, 19111 Am.
J.
()b,L & Gyncc.
3. The average perinatal loss for all deliveries in the hospital was 22.7 per 1,000 births, and for cesarean section the average loss was 44.2 per 1,000 births. In 1959 these rates were 20.0 per 1,000 births for all deliveries and 25.8 per 1,000 births for delivery by cesarean section. 4. The total fetal loss with cesarean section was 26, comprised of 22 neonatal deaths and 4 stillbirths. One infant weighed only 565 grams and 6 others had congenital abnormalities incompatible with life. 5. Sixteen of 22 neonatal deaths were due to the respiratory distress syndrome and one half of these were associated with antepartum bleeding. This cause of fetal loss occurred in 10 per cent of cases when operation was performed for antepartum bleeding but in only 1.2 per cent when operation was performed for all other indications. 6. Antepartum bleeding was the indication for operation in 11 of the 26 perinatal deaths.