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The abuse of cesarean section
The indication in one-third of the cases was deformity of the bony pelvis. The maternal Eclampsia was responsible for one-sixth but appears rarely after 1922. death rate of 41.5 per cent in these sections should be sufficient to conclusivcl~ Many of the indications seemed insufficient to warrant exclude such treatment. not furnish an indication. lnparotomy. Malposition of the fetus, per YP, should Nearly two-thirds of the patients had a febrile convalesceuce which iu itself would In 17 cases followcomplete the indications for section in subsequent pregnancy. The total ing t,he classical operation, serious dilatation of the stomach occurred. maternal mortality Was 16.1 per cent but 16 of the 47 deaths ww listed as due to eclampsin. It is quite apparent that the death rate in cesarean section increases in direct proportion to the length of time the membranes have been ruptured, the number of vagina1 examinations, and the att.cmpts at previous delivery. In spite of a high gross fetal and maternal mortality, there has been a gratifying decrease in the latter years. Also the incidence of resarean section has definitely decreased from its peak in 1921. Cr00D~IOli
Iljkevich, Selicky and. Levy: Cesarean Section (1921-1927). J. Skush. i ihcnsk boliez. 40:
in Moscow 166, 1929.
C.
During
R~~~L~vLER.
Seven
Years
In a period of six years 743 cesarean sections were performrtl in a series of 309,468 deliveries. In Moscow the percentage of cesnreans has rapidly increased. While in 1921 for 36,000 deliveries only 10 eesnrean scetions were done. Iu 1927, sections rose to 233 for 53,000 deliveries (4.4 per 1000). This the author believes is due to the fact that inexperienced physicians now are performing many unnccessary operations and that cesareans are uow doue in a11 maternity homes and not as before only in clinics by head physicians and their assistants. The mniu indications for operations were : (1) pelvic auomalics (422 cases) ; (2) placcnt:l previ:i (127 cases) ; (3) eclampsia (106) ; and (4) unusual indications (88). Most often the methods of Saenger, Fritseh, Miller and Polano were employed, more reccnt,ly the method of Kroenig-Opitc. Of 71 tr:i~lsl~~~ritc~ne:~l-retroveuic:tl opera tions 31 had a febrile course but no mortality to be charged to the operation. Of two deaths one was due to thrombosis of the pulmonary artery and the other caused by an eclampsia in a patient with a goiter and syphilis of the brain. The high classical cesarean sections had a 4.4 per cent mortality from sepsis and the lovv cesareans of 3.3 per cent. In regard t.o pucrperal morbidity the most unfavorable results were obtained with the low ccsarean which was 26.6 per cent. Iu this respect the retrovesical operation ranks next with 21.2 per cent and the classical rcsnrrnn with only 18.1 nel cent postoperatirc infection. ntssasDER
Toombs, Percy W.: The Abuse of Gesarean Section.
Illinois
t:.
N.
GAIiImLI:\s~.
J. 54:
~78,
l:fl’&
During the past quarter century it has been learned at a high cost how real]! dangerous cesarean section is in the second stage of labor, after repeated vaginal examinations and attempts at manunl delivery. Patients of the well-to-do class often insist on it and the physician yields. In the small hospitals, the surgeons predominate and more cesareans arc done. Williams went on record as saying, “that insurmountable disproportion between the size of the head and the p&is, and obstruction by a tumor are practically the only indications concerning which there can be no dispute.” A breech presentation occurring in an elderly primiparn with a rigid cervix and a normal pelvis may be an indicatiou.
Of
In Massachusetts in 1922, II66 cesarcan sections were done, the mothers, 102 died, the mortality being 8.8 per cent.
Placenta previa is most generally an indication exception being severe bleeding with no dilatation crnarean might be fully justified.
for Voorhees in a preria
I to every
78 births.
bag induction, the centralis, when a JIrsrr,s’rrL.\.
Martin E., Hirsch.
and Spieckhoff: The “New Way” Monatschr. f. Gchurtsh. II. Gvniik.
in 81:
Obstetrics 154, 1929.
as Suggested
by
M.
As an answer to -II. Hirsch’s plea for more cesarean sections and fev;er vaginal deliveries, the authors analyzed their statistics from 1919 to 1928. Among 405 abdominal cesarean sections there was a maternal mortality of 4.4 per cent (corrected to 2.4 per cent) and :I fetal mortality of 3.7 per cent (corrected to 0.7 per cent). For 313 vaginal ccsarean sections the maternal mortality was 4.5 per cent (corrected to 1.2 per cent) and the fetal mortality \vas 15 per eent (corrected to 9.!? per cent). In :t series of 114 versions and extractions, 11.4 per cent of the mothers died (corrected to 3..? per cent) and 23.7 per cent of the children died Thr maternal mortality for 630 forceps operations was (corrected to 10 per cent). 0.7 per cent (corrected to 0) and the frtnl death rate ~vas 3.2 per cent (corrected to 1.3 per cent). For the 58 perforntious thr maternal mortality was 6.S per cent (corrc&d to 0). Hence the maternal mortality for the 1114 vaginal deliveries nas 3.5 per cent (corrected to 0.7 per cent) and the fetal mortality was 16.3 per cent, (corrected to 4.6 per cent). The authors conclude that abdominal ccsarean section exacts a greater toll of mothers ’ lives than delivery tllrough the vagina. J. I’.
FitsPatrick, Section.
Gilbert: Illinois
An Ethical i\l.
J.
52:
458,
Consideration
of the Indication
~RF.EXIIILI,.
for Cesarean
1927.
The indications for cesareun section have been so widened that the operation is being done for trivial complications of pregnancy and the operation is being abused as an obstetric procedure. Although the operation is easier than almost any other important operative procedure and almost certainly insures a living child, we must as well consider the ultimate effects of the operation on the mother and the rights of both parents and of the State. The mortality rate, especially in hands of physicians not trained in obstetric procedure is high. It is an injustice to the parents and to the State to perform any unnecessary cesarean section. The fact of the great extension of section deliveries is an indictment of the inadcquncy of obstetric knomledgc and an indication of obstetric failure. GF.NR
Paine, A. Ii.:
The Ethics of Cesarean Section.
New
England
M.
KASPF‘K.
J. Med.
201:
445,
1929. Cesarean section is recognized as having in itself the highest maternal of any delivery’ operation. In Massachusetts, in 1928, 456 maternal reported; in 56 of them a cesarean section had been performed, one in marked variations in recent literature reported in different localities, different services, etc., indicate that somet,hing other than scientific involved in the frequent resort to this operation. in
The his
obstetrician conduct of
faces a duty, a moral obligation t.o rise suptrior a delivery. The outcome of a slo\v and difficult
mortality deaths were eight. The hospitals, in obstetrics is
to espcdiencv labor will be
Iljkevich, Selicky and. Levy: Cesarean Section (1921-1927). J. Skush. i ihcnsk boliez. 40:
in Moscow 166, 1929.
C.
During
R~~~L~vLER.
Seven
Years
In a period of six years 743 cesarean sections were performrtl in a series of 309,468 deliveries. In Moscow the percentage of cesnreans has rapidly increased. While in 1921 for 36,000 deliveries only 10 eesnrean scetions were done. Iu 1927, sections rose to 233 for 53,000 deliveries (4.4 per 1000). This the author believes is due to the fact that inexperienced physicians now are performing many unnccessary operations and that cesareans are uow doue in a11 maternity homes and not as before only in clinics by head physicians and their assistants. The mniu indications for operations were : (1) pelvic auomalics (422 cases) ; (2) placcnt:l previ:i (127 cases) ; (3) eclampsia (106) ; and (4) unusual indications (88). Most often the methods of Saenger, Fritseh, Miller and Polano were employed, more reccnt,ly the method of Kroenig-Opitc. Of 71 tr:i~lsl~~~ritc~ne:~l-retroveuic:tl opera tions 31 had a febrile course but no mortality to be charged to the operation. Of two deaths one was due to thrombosis of the pulmonary artery and the other caused by an eclampsia in a patient with a goiter and syphilis of the brain. The high classical cesarean sections had a 4.4 per cent mortality from sepsis and the lovv cesareans of 3.3 per cent. In regard t.o pucrperal morbidity the most unfavorable results were obtained with the low ccsarean which was 26.6 per cent. Iu this respect the retrovesical operation ranks next with 21.2 per cent and the classical rcsnrrnn with only 18.1 nel cent postoperatirc infection. ntssasDER
Toombs, Percy W.: The Abuse of Gesarean Section.
Illinois
t:.
N.
GAIiImLI:\s~.
J. 54:
~78,
l:fl’&
During the past quarter century it has been learned at a high cost how real]! dangerous cesarean section is in the second stage of labor, after repeated vaginal examinations and attempts at manunl delivery. Patients of the well-to-do class often insist on it and the physician yields. In the small hospitals, the surgeons predominate and more cesareans arc done. Williams went on record as saying, “that insurmountable disproportion between the size of the head and the p&is, and obstruction by a tumor are practically the only indications concerning which there can be no dispute.” A breech presentation occurring in an elderly primiparn with a rigid cervix and a normal pelvis may be an indicatiou.
Of
In Massachusetts in 1922, II66 cesarcan sections were done, the mothers, 102 died, the mortality being 8.8 per cent.
Placenta previa is most generally an indication exception being severe bleeding with no dilatation crnarean might be fully justified.
for Voorhees in a preria
I to every
78 births.
bag induction, the centralis, when a JIrsrr,s’rrL.\.
Martin E., Hirsch.
and Spieckhoff: The “New Way” Monatschr. f. Gchurtsh. II. Gvniik.
in 81:
Obstetrics 154, 1929.
as Suggested
by
M.
As an answer to -II. Hirsch’s plea for more cesarean sections and fev;er vaginal deliveries, the authors analyzed their statistics from 1919 to 1928. Among 405 abdominal cesarean sections there was a maternal mortality of 4.4 per cent (corrected to 2.4 per cent) and :I fetal mortality of 3.7 per cent (corrected to 0.7 per cent). For 313 vaginal ccsarean sections the maternal mortality was 4.5 per cent (corrected to 1.2 per cent) and the fetal mortality \vas 15 per eent (corrected to 9.!? per cent). In :t series of 114 versions and extractions, 11.4 per cent of the mothers died (corrected to 3..? per cent) and 23.7 per cent of the children died Thr maternal mortality for 630 forceps operations was (corrected to 10 per cent). 0.7 per cent (corrected to 0) and the frtnl death rate ~vas 3.2 per cent (corrected to 1.3 per cent). For the 58 perforntious thr maternal mortality was 6.S per cent (corrc&d to 0). Hence the maternal mortality for the 1114 vaginal deliveries nas 3.5 per cent (corrected to 0.7 per cent) and the fetal mortality was 16.3 per cent, (corrected to 4.6 per cent). The authors conclude that abdominal ccsarean section exacts a greater toll of mothers ’ lives than delivery tllrough the vagina. J. I’.
FitsPatrick, Section.
Gilbert: Illinois
An Ethical i\l.
J.
52:
458,
Consideration
of the Indication
~RF.EXIIILI,.
for Cesarean
1927.
The indications for cesareun section have been so widened that the operation is being done for trivial complications of pregnancy and the operation is being abused as an obstetric procedure. Although the operation is easier than almost any other important operative procedure and almost certainly insures a living child, we must as well consider the ultimate effects of the operation on the mother and the rights of both parents and of the State. The mortality rate, especially in hands of physicians not trained in obstetric procedure is high. It is an injustice to the parents and to the State to perform any unnecessary cesarean section. The fact of the great extension of section deliveries is an indictment of the inadcquncy of obstetric knomledgc and an indication of obstetric failure. GF.NR
Paine, A. Ii.:
The Ethics of Cesarean Section.
New
England
M.
KASPF‘K.
J. Med.
201:
445,
1929. Cesarean section is recognized as having in itself the highest maternal of any delivery’ operation. In Massachusetts, in 1928, 456 maternal reported; in 56 of them a cesarean section had been performed, one in marked variations in recent literature reported in different localities, different services, etc., indicate that somet,hing other than scientific involved in the frequent resort to this operation. in
The his
obstetrician conduct of
faces a duty, a moral obligation t.o rise suptrior a delivery. The outcome of a slo\v and difficult
mortality deaths were eight. The hospitals, in obstetrics is
to espcdiencv labor will be