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Relation of early rising to morbidity in cesarean section
RELATION OF EARLY RISING TO MORBIDITY IN CESAREAN SECTION DoNALD M. HEADINGS, M.D., F.A.C.S., AND RuFus E. PALMER, III, B.R., M.D., NoRRISTOWN, PA. (From the Montgomery and Sacred Heart Hospitals)
N 1945 Johnston1 read a paper before the American Association of Obstetrics
Gynecology in which he stated that in 1923 to 1926 in Houston, Texas, Iwhileand general surgeons were doing cesarean sections, the maternal mortality was 14.4 per cent. He condemned the operation in the hands of general surgeons. This statement caused us to review our records and compare our standards with those published by other authors as to maternal mortality, fetal mortality, and maternal morbidity. Dieckmann 2 states that maternal mortality should be below 0.5 per cent. In the period from Jan. 1, 1940, to Jan. 1, 1946, the senior author has performed 207 consecutive cesarean sections without a maternal death. This compared with the figure offered by Johnston 1 of 2.2 per cent; Smith, 3 of 0.9 per cent; Free/ of 0.4 per cent; Gustafson, 5 of 0.96 per cent; Barney, et al., 6 of 1.7 per cent; Rosenson/ of 3.2 per cent; Briscoe, 8 of 0.7 per cent; and DeNormandie,9 of 2.5 per cent. In Norristown, Pennsylvania, there are no obstetricians who perform cesarean sections. However, there are obstetric chiefs of service who are consulted concerning obstetric practice and emergencies. These men refer the cases to the surgeon for operation. Most of the cesarean sections, therefore, are done on a consultation basis. From Jan. 1, 1944, to Jan. 1, 1946, 102 cesarean sections were performed by the senior author. The number of hospital deliveries was 2,756, and the total number of cesarean sections by all surgeons was 132, giving an incidence of 4.8 per cent. 'rhis is not a true figure, ho\vever, because some of our cases are sent from surrounding communities which have hospitals, and many home deliveries are still being done. The indications for this series are outlined in Table I. In this series our maternal mortality was zero. Our fetal mortality was 5 per rent. Three of these babies were stillborn, and the other two died within twentyfour hours after delivery. The first stillborn was one of twins, in a 17-year-old unmarried Negro girl who had no prenatal care. The fetus was macerated and gave evidence of being dead for a number of days. The other twin was normal and was discharged with the mother. She was admitted as a convulsive eclamptic and was operated upon on the fifth day after admission. The second was a 22-year-old gravida ii, seven months pregnant, who had a premature separation of the placenta. Because of the distance involved in traveling, she was not sectioned until two hours after the onset. The baby was found compressed by a huge clot. The third case was also in a patient with premature separation of 661
662
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY TABLE
1. 2. 3. 4. 5.
6. 7. 8. 9. 10. 11.
l. INDICATIONS FOR SECTIOJ\S
Eclampsia Placenta previa Previous section Cardiac pathology Cephalopelvic disproportion By x-ray By trial labor Elderly primigravida Patient's desire Abnormal position Deformity of mother Premature separation of placenta Contracted pelvis
6
fl
15 ~
7
25
18
12 7 2
3
14
the placenta. The other two deaths were due to prematurity. The first was a 21-year-old, gravida i, who began to bleed profusely from placenta previa at seven months. The baby survived twelve hours. The other case was a 32-yearold gravida ii who had a previous section. She went into labor prematurely at seven and one-half months, and the baby died fifteen hours after delivery. Using the standard of the American Committee of Maternal Welfare (temperature 38° C. or over, for two or more consecutive days), our morbidity is 9 per cent. The causes of this morbidity are listed in Table II. Our percentage TABLE
1. Endometritis 2. Pyelonephritis 3. Wound infection
II.
CAUSES OF MORBIDITY
6
2
1
compares favorably with figures offered by Smith, 3 33 per cent; Free/ 31 per cent; and Gustafson, 5 26.6 per cent in elective cases and 53 per cent in emergency cases as compared with Barney et al., 6 45 per cent; Briscoe, 8 23.2 per cent for classical sections, and 9.5 per cent for low cervical operations. There are certain factors which, we feel, definitely influen<'e morbidity. First, is the type of the operation and the skill of the surgeon. We use a six inch Pfannenstiel type of incision and. do a low cervical operation, with suturing of the parietal peritoneum to the uterovesical peritoneum to preven't contamination of the general peritoneal cavity. The uterus is closed in two layers with a continuous suture of chromic catgut No. 1, and a cotton techniqlH' is used for the closure of the abdominal wound; cotton No. 40 for anterior sheath of the rectus; cotton No. 70 for subcutaneous tissue and skin. The second factor is the use of continuous spinal anesthesia for all cases. We use pontocaine and glucose mixture. The continuous method is used so that the smallest possible amount of anesthetic agent may be given, but more is available if needed. We have found no contraindications for the use of this type of anesthesia. The third factor is good prenatal care. Most of our referring physicians are meticulous concerning this factor. The fourth factor is the avoidance of postoperative catheterization. Early rising and bathroom privileges obviate this complication. Furmethide is used occasionally when necessary.
IIEADIKGS AND PALMER:
EARLY RISING IN CESAREAK SECTIO:\'
663
The fifth factor is an early decision to operate. If the indication is present, the operation should be done before the patient loses strength, and rupture of the membranes or frequent examinations a1low opportunity for sepsis to develop. The sixth and most important factor is early rising postoperatively. We feel that early rising postoperatively definitely lowers the morbidity. During the latter half of 1944, because of favorable reports from various authors10- 14 concerning early rising, we started allowing our patients out of bed on the third postoperative day. Because they did so well, we allowed a few out of bed on the second postoperative day. The results were still more satisfactory, so we routinely allowed all patients out of bed on the first postoperative day. Fortynine patients were allowed out of bed on the first postoperative day, eleven on the second, and ten on the third. Thus, seventy of our one hundred two cases were out of bed on the third day or before. In this group only two were morbid, a percentage of 2.8 per cent! The first patient was a 24-year-old primipara who was in labor thirty-six hours before we were called. Her temperature was elevated to 101° F., on the second postoperative day, and 101.3° E'. on the third day. Following this her temperature returned to normal and remained so. The second case was a 33-year-old gravida v who was admitted to the hospital in a condition of eclampsia with convulsions. She had concurrently a pyelonephritis with a preoperative temperature ranging between 102° to 104° F. She was delivered of a viable baby and had a normal postoperative course until the sixth day, when the pyelonephritis recurred. This was controlled within a few days. In this series of 102 cases, there were no cases of thrombophlebitis, phlebothrombosis, upper respiratory infection, pulmonary embolism, eystitis, or wound dehiscence, and only one wound infection. The wound infection occurred in the eclamptic with the macerated fetus. By careful postoperative examination we found no cases of subinvolution of the uterus, prolapse of the uterus, formation of cystocele or rectocele that could in any way be attributed to the fact that the patients were allowed out of bed early. We, therefore, feel that early rising definitely lowers morbidity following cesarean sedion, and that no complications occurred from its use. Because our patients are ambulatory and do not develop complications, they are allowed home on the seventh day and eighth day postoperatively. This allows a considerable economic saving to the patient and gives a quicker hospital turnover, allowing full use of the available hospital facilities. Summary
1. Two hundred seven cesarean sections were presented with the maternal mortality of 0. One hundred two consecutive cases are reported with a fetal mortality of 5 per cent, and maternal morbidity of 9 per cent. In cases in which patients were allowed out of bed early, the morbidity was only 2.8 per cent. 2. No complications developed from the routine practice of getting all patients out of bed on the first postoperative day.
664
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
3. Early rising definitely limits the incidence of postpartum and postoperative complications. 4. Early rising leads to considerable economic saving to the patient and allows full use of the available hospital facilities. 5. The patients are grateful not only for lessened expense, but also because of the definite improvement in the postoperative sense of well-being and avoidance of the marked weakness so noticeable in patients kept in bed twelve or fourteen days. 6. The foregoing statistics definitely prove that in the hands of the welltrained general surgeon, the operation of cesarean section ~an, and is, a safe procedure. The morbidity and mortality can be, and sometimes are, lower in such hands than in those whose work is strictly limited to obstetrics. Since acceptance of this article for publication, twenty-six cesarean sections were performed; all were ambulatory on the first day with no mortality, and only one patient was morbid for thirty-six hourR.
References 1. 2. 3. 4. 5. 6.
7. 8. 9. 10. 11. 12. 13. 14.
Johnston, R. A.: AM. J. 0Bs'r. & GYNEC. 49: 576, 1945. Dieckmann, Wm.: Quoted by Smith. Smith R. H.: Discussion of Free's Article. 4 Free, E."G.: Am. J. Obst. & Gynec. 49: 401, 1945. Gustafson, G. W.: AM. J. 0BST. & GYNEC. 48: 841, 1943. Barney, W. R., Fish, J. 8., and Reimanschneider, E. A.: AM. J. 0BST. & GYNEC. 48: 733, 1944. Rosenson, M., Kushner, J. I., and Wahrsinger, P. B.: AM. J. OBST. & GYNEC. 48: 274, 1944. Briscoe, C. C.: AM. J. OBsT. & GYNEC. 48: 16, 1944. DeNormandie, R. L.: New England J. Med. 227: 533, 1942. Ashkins, J.: New England J. Med. 233: 33, 1945. Neidegsen: Zentralbl. f. Chir. 67: 554, 958, 1940. Camp.eanu: Arch. ital. de chir. 51: 12, 1938. Leithauser and Gergo: Arch. Surg. 42: 1085, 1941. Schafer and Draestedt: Surg., Gvnec. & Obst. 81: 93. 1945.
N 1945 Johnston1 read a paper before the American Association of Obstetrics
Gynecology in which he stated that in 1923 to 1926 in Houston, Texas, Iwhileand general surgeons were doing cesarean sections, the maternal mortality was 14.4 per cent. He condemned the operation in the hands of general surgeons. This statement caused us to review our records and compare our standards with those published by other authors as to maternal mortality, fetal mortality, and maternal morbidity. Dieckmann 2 states that maternal mortality should be below 0.5 per cent. In the period from Jan. 1, 1940, to Jan. 1, 1946, the senior author has performed 207 consecutive cesarean sections without a maternal death. This compared with the figure offered by Johnston 1 of 2.2 per cent; Smith, 3 of 0.9 per cent; Free/ of 0.4 per cent; Gustafson, 5 of 0.96 per cent; Barney, et al., 6 of 1.7 per cent; Rosenson/ of 3.2 per cent; Briscoe, 8 of 0.7 per cent; and DeNormandie,9 of 2.5 per cent. In Norristown, Pennsylvania, there are no obstetricians who perform cesarean sections. However, there are obstetric chiefs of service who are consulted concerning obstetric practice and emergencies. These men refer the cases to the surgeon for operation. Most of the cesarean sections, therefore, are done on a consultation basis. From Jan. 1, 1944, to Jan. 1, 1946, 102 cesarean sections were performed by the senior author. The number of hospital deliveries was 2,756, and the total number of cesarean sections by all surgeons was 132, giving an incidence of 4.8 per cent. 'rhis is not a true figure, ho\vever, because some of our cases are sent from surrounding communities which have hospitals, and many home deliveries are still being done. The indications for this series are outlined in Table I. In this series our maternal mortality was zero. Our fetal mortality was 5 per rent. Three of these babies were stillborn, and the other two died within twentyfour hours after delivery. The first stillborn was one of twins, in a 17-year-old unmarried Negro girl who had no prenatal care. The fetus was macerated and gave evidence of being dead for a number of days. The other twin was normal and was discharged with the mother. She was admitted as a convulsive eclamptic and was operated upon on the fifth day after admission. The second was a 22-year-old gravida ii, seven months pregnant, who had a premature separation of the placenta. Because of the distance involved in traveling, she was not sectioned until two hours after the onset. The baby was found compressed by a huge clot. The third case was also in a patient with premature separation of 661
662
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY TABLE
1. 2. 3. 4. 5.
6. 7. 8. 9. 10. 11.
l. INDICATIONS FOR SECTIOJ\S
Eclampsia Placenta previa Previous section Cardiac pathology Cephalopelvic disproportion By x-ray By trial labor Elderly primigravida Patient's desire Abnormal position Deformity of mother Premature separation of placenta Contracted pelvis
6
fl
15 ~
7
25
18
12 7 2
3
14
the placenta. The other two deaths were due to prematurity. The first was a 21-year-old, gravida i, who began to bleed profusely from placenta previa at seven months. The baby survived twelve hours. The other case was a 32-yearold gravida ii who had a previous section. She went into labor prematurely at seven and one-half months, and the baby died fifteen hours after delivery. Using the standard of the American Committee of Maternal Welfare (temperature 38° C. or over, for two or more consecutive days), our morbidity is 9 per cent. The causes of this morbidity are listed in Table II. Our percentage TABLE
1. Endometritis 2. Pyelonephritis 3. Wound infection
II.
CAUSES OF MORBIDITY
6
2
1
compares favorably with figures offered by Smith, 3 33 per cent; Free/ 31 per cent; and Gustafson, 5 26.6 per cent in elective cases and 53 per cent in emergency cases as compared with Barney et al., 6 45 per cent; Briscoe, 8 23.2 per cent for classical sections, and 9.5 per cent for low cervical operations. There are certain factors which, we feel, definitely influen<'e morbidity. First, is the type of the operation and the skill of the surgeon. We use a six inch Pfannenstiel type of incision and. do a low cervical operation, with suturing of the parietal peritoneum to the uterovesical peritoneum to preven't contamination of the general peritoneal cavity. The uterus is closed in two layers with a continuous suture of chromic catgut No. 1, and a cotton techniqlH' is used for the closure of the abdominal wound; cotton No. 40 for anterior sheath of the rectus; cotton No. 70 for subcutaneous tissue and skin. The second factor is the use of continuous spinal anesthesia for all cases. We use pontocaine and glucose mixture. The continuous method is used so that the smallest possible amount of anesthetic agent may be given, but more is available if needed. We have found no contraindications for the use of this type of anesthesia. The third factor is good prenatal care. Most of our referring physicians are meticulous concerning this factor. The fourth factor is the avoidance of postoperative catheterization. Early rising and bathroom privileges obviate this complication. Furmethide is used occasionally when necessary.
IIEADIKGS AND PALMER:
EARLY RISING IN CESAREAK SECTIO:\'
663
The fifth factor is an early decision to operate. If the indication is present, the operation should be done before the patient loses strength, and rupture of the membranes or frequent examinations a1low opportunity for sepsis to develop. The sixth and most important factor is early rising postoperatively. We feel that early rising postoperatively definitely lowers the morbidity. During the latter half of 1944, because of favorable reports from various authors10- 14 concerning early rising, we started allowing our patients out of bed on the third postoperative day. Because they did so well, we allowed a few out of bed on the second postoperative day. The results were still more satisfactory, so we routinely allowed all patients out of bed on the first postoperative day. Fortynine patients were allowed out of bed on the first postoperative day, eleven on the second, and ten on the third. Thus, seventy of our one hundred two cases were out of bed on the third day or before. In this group only two were morbid, a percentage of 2.8 per cent! The first patient was a 24-year-old primipara who was in labor thirty-six hours before we were called. Her temperature was elevated to 101° F., on the second postoperative day, and 101.3° E'. on the third day. Following this her temperature returned to normal and remained so. The second case was a 33-year-old gravida v who was admitted to the hospital in a condition of eclampsia with convulsions. She had concurrently a pyelonephritis with a preoperative temperature ranging between 102° to 104° F. She was delivered of a viable baby and had a normal postoperative course until the sixth day, when the pyelonephritis recurred. This was controlled within a few days. In this series of 102 cases, there were no cases of thrombophlebitis, phlebothrombosis, upper respiratory infection, pulmonary embolism, eystitis, or wound dehiscence, and only one wound infection. The wound infection occurred in the eclamptic with the macerated fetus. By careful postoperative examination we found no cases of subinvolution of the uterus, prolapse of the uterus, formation of cystocele or rectocele that could in any way be attributed to the fact that the patients were allowed out of bed early. We, therefore, feel that early rising definitely lowers morbidity following cesarean sedion, and that no complications occurred from its use. Because our patients are ambulatory and do not develop complications, they are allowed home on the seventh day and eighth day postoperatively. This allows a considerable economic saving to the patient and gives a quicker hospital turnover, allowing full use of the available hospital facilities. Summary
1. Two hundred seven cesarean sections were presented with the maternal mortality of 0. One hundred two consecutive cases are reported with a fetal mortality of 5 per cent, and maternal morbidity of 9 per cent. In cases in which patients were allowed out of bed early, the morbidity was only 2.8 per cent. 2. No complications developed from the routine practice of getting all patients out of bed on the first postoperative day.
664
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
3. Early rising definitely limits the incidence of postpartum and postoperative complications. 4. Early rising leads to considerable economic saving to the patient and allows full use of the available hospital facilities. 5. The patients are grateful not only for lessened expense, but also because of the definite improvement in the postoperative sense of well-being and avoidance of the marked weakness so noticeable in patients kept in bed twelve or fourteen days. 6. The foregoing statistics definitely prove that in the hands of the welltrained general surgeon, the operation of cesarean section ~an, and is, a safe procedure. The morbidity and mortality can be, and sometimes are, lower in such hands than in those whose work is strictly limited to obstetrics. Since acceptance of this article for publication, twenty-six cesarean sections were performed; all were ambulatory on the first day with no mortality, and only one patient was morbid for thirty-six hourR.
References 1. 2. 3. 4. 5. 6.
7. 8. 9. 10. 11. 12. 13. 14.
Johnston, R. A.: AM. J. 0Bs'r. & GYNEC. 49: 576, 1945. Dieckmann, Wm.: Quoted by Smith. Smith R. H.: Discussion of Free's Article. 4 Free, E."G.: Am. J. Obst. & Gynec. 49: 401, 1945. Gustafson, G. W.: AM. J. 0BST. & GYNEC. 48: 841, 1943. Barney, W. R., Fish, J. 8., and Reimanschneider, E. A.: AM. J. 0BST. & GYNEC. 48: 733, 1944. Rosenson, M., Kushner, J. I., and Wahrsinger, P. B.: AM. J. OBST. & GYNEC. 48: 274, 1944. Briscoe, C. C.: AM. J. OBsT. & GYNEC. 48: 16, 1944. DeNormandie, R. L.: New England J. Med. 227: 533, 1942. Ashkins, J.: New England J. Med. 233: 33, 1945. Neidegsen: Zentralbl. f. Chir. 67: 554, 958, 1940. Camp.eanu: Arch. ital. de chir. 51: 12, 1938. Leithauser and Gergo: Arch. Surg. 42: 1085, 1941. Schafer and Draestedt: Surg., Gvnec. & Obst. 81: 93. 1945.