ORIGINAL COMMUNICATIONS CESAREAN SECTION: A SEVEN.YEAR STUDY

Leroy R. Weekes, MD, FAGS Los Angeles, California

This paper reports a seven-year study of ce- From 1974 to 1980, 2,060 cesarean sections sarean section practices at the Queen of An- were performed at Queen of Angels Hospital, Los gels Hospital, Los Angeles, California. Indica- Angeles, California. This report concerns the indi- tions for this procedure are listed in detail and cations, incidence, and critical analysis of the an attempt is made to explain its increasing series. Cephalopelvic disproportion, fetal distress, frequency. Practicing physicians were inter- and breech presentations were the most common viewed and testimony seemed to indicate, as indications for primary cesarean sections. The was suspected, that fear of malpractice suits incidence rose from 12.5 percent to 18.7 percent was one of the reasons for cesarean section. during this study. Forceps delivery dropped from The conventional wisdom of "once a section 21.7 percent to 8.2 percent, and vaginal breech always a section" is questioned with regard to deliveries decreased from 35.8 percent to 30.0 per- an increasing number of trials of labor and vag- cent. Spinal anesthesia was used in 75 percent of inal deliveries, when they are considered the cases. feasible and safe. The federal government is manifesting serious interest in this increased number of operative deliveries in the light of cost effectiveness. PATIENT STUDY During the seven-year study period, 2,060 ce- sarean sections were performed at the Queen of Angels Hospital delivery service. During this period there were 12,217 deliveries. The cesarean section rate was 12.5 percent in 1974 and increased to 20.2 percent in 1979. Of these cesarean sec- Presented at the 86th Annual Convention and Scientific As- tions, 7 percent were primary (Table 1). Duration sembly of the National Medical Association, Atlanta, Georgia, of hospitalization averaged six days. July 19-23,1981. Requests for reprints should be addressed to Dr. Leroy R. Weekes, 1828 South Western Avenue, Los Indications, maternal and perinatal morbidity, Angeles, CA 90006. and mortality were recorded (Table 2). Cephalo-

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 75, NO. 5, 1983 465 CESAREAN SECTION

TABLE 1. CESAREAN SECTION RATE: 1974 THROUGH 1980 Repeat Primary Cesarean Section Cesarean Section Year No. (%) No. (%) Percent 1974 29(1.7) 181(11.3) 12.5(210/1,680) 1975 74(4.0) 181 (10.0) 14.0(255/1,809) 1976 59 (4.0) 194(13.8) 17.1 (253/1,475) 1977 85 (4.9) 218(12.4) 17.3 (303/1,747) 1978 81 (4.3) 273(14.4) 17.7(354/1,881) 1979 94(5.2) 265 (14.8) 20.2 (359/1,781) 1980 109(5.9) 237(12.8) 18.7(346/1,844)

TABLE 2. INDICATIONS FOR PRIMARY CESAREAN SECTION Indication No. (%) Cephalopelvic 881 (56.8) disproportion Breech presentation 244(15.7) Fetal distress 151 (9.7) Failure to progress 92(5.9) Placenta previa 39 (2.5) Hypertensive disorders 30(1.9) of Abruptio placentae 19(1.2) 4(0.26)

TABLE 3. FETAL MORTALITY AND MORBIDITY Percent Percent Fetal Fetal Year Mortality Morbidity 1974 1.2(21/1,699) 4.2(71/1,699) 1975 1.3(24/1,826) 2.5 (46/1,826) 1976 1.4(21/1,493) 3.0(46/1,493) 1977 0.5(10/1,760) 1.7 (31/1,760) 1978 0.8(16/1,906) 1.5(30/1,906) 1979 1.0(19/1,799) 1.6 (30/1,799) 1980 0.6(12/1,859) 1.6 (30/1,859)

pelvic disproportion, breech presentations, and mortality showed a decline over the course of the fetal distress were the most common indications study (Table 3). for primary cesarean section. Fetal morbidity and Forceps deliveries dropped from 21.7 to 8.2

466 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 75, NO. 5, 1983 CESAREAN SECTION percent and vaginal breech deliveries decreased TABLE 4. DECREASE OF FORCEPS DELIVERIES from 35.8 to 23.7 percent (Table 4). The inverse relationship between forceps and abdominal deliv- Percent Forceps eries is illustrated in Figure 1. Year Deliveries Table 5 indicates the decreasing incidence of 1974 21.7(365/1,680) vaginal breech deliveries. It appears that the art of 1975 14.5(263/1,809) breech vaginal delivery is disappearing with the 1976 13.0(193/1,475) increasing utilization of cesarean section to solve 1977 13.0(238/1,747) this problem. 1978 11.9(223/1,881) 1979 9.9(177/1,781) Figure 2 illustrates the inverse relationship of 1980 8.2(151/1,844) the cesarean section rate and perinatal mortality,

Cesarean Section Rate

------Forceps Delivery Rate

0

0

0 0 0 20 '/

c" 15 % a: 0 0

in U oO. U)rCD)

5

U -~ ~ ~~ ~ ~~ ~~ ~~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~~~~~~

1974 1975 1976 1977 1978 1979 1980 Figure 1. Inverse relationship, forceps and cesarean sections

which decreased from 1.2 to 0.6 percent. pital (Table 6). There was little significant differ- In recent years, the use of general anesthesia ence in Apgar scores whether delivery occurred appears to be on the rise at Queen of Angels Hos- within the first three minutes after anesthesia or in

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 75, NO. 5,1983 467 CESAREAN SECTION

TABLE 5. INCIDENCE OF BREECH DELIVERY: 1974 THROUGH 1980 Breech Vaginal Deliveries Total Breech Year Presentations No. (%/6) 1974 67 24 (35.8) 1975 59 18(30.5) 1976 48 14(29.0) 1977 59 20 (35.4) 1978 84 20 (23.7) 1979 76 19(24.0) 1980 70 24 (30.0)

Cesarean Section Rate ------Perinatal Mortality Rate

O 20 1.50 0)~~~~~

i1.25 15 X 0.75', ,0 0 0 0) "0010%~~~0()C 0~~~~%1 0.75 Cu~~ -,,,'' ' s Q

J/ %% 0.50' 0 6 1974 1975 1976 1977 1978 1979 1980 Figure 2. The inverse direction of the cesarean section rate and perinatal mortality, which decreased from 1.2% to 0.6%

four to eight minutes. In earlier years, spinal and urinary tract and wound infections were the major local infiltration were used more frequently. Some causes of morbidity. There were no maternal hospitals exclusively used epidural block, which deaths. calls for anesthesiologists with special training. Any significant increase in the frequency of a This technique is beginning to emerge at Queens major operation procedure is inevitably shrouded as an alternative. in controversy. This study was undertaken to add Cesarean section hysterectomies were rarely to the knowledge regarding the rising incidence performed. The most common indications were of indications for and maternal and fetal conse- fibroids and hemorrhage. Puerperal sepsis and quences of cesarean section.

468 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 75, NO. 5, 1983 CESAREAN SECTION

TABLE 6. PERINATAL MORBIDITY AND MORTALITY Percent Percent Year Perinatal Morbidity Perinatal Mortality 1974 4.1 (71/1,699) 1.2(21/1,699) 1975 2.5(46/1,826) 1.3(24/1,826) 1976 3.0(46/1,493) 1.4(21/1,493) 1977 1.7(31/1,760) 0.5(10/1,760) 1978 1.5(30/1,906) 0.8(16/1,906) 1979 1.6(30/1,799) 1.0(19/1,799) 1980 1.6(30/1,859) 0.6(12/1,859)

10

5

1960 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 Figure 3. Cesarean section rate in California. 1960 and 1965-75 (Courtesy Petitt D, et al: Am J Obstet Gynecol 1970; 133:391-397)

CESAREAN SECTION IN CALIFORNIA: garding 4.3 million births during 1960 to 1975. Dur- 1960 to 1975 ing this time, the cesarean section rate rose from 4.8 percent to 12.7 percent (Figure 3).2 The highest The cesarean section rate has been rising in rate reported by any hospital was 6.5 percent in California since 1965.1 A group examined data re- 1960 and 28 percent in 1975. Rates have risen uni-

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 75, NO. 5,1983 469 CESAREAN SECTION formly for women of different ethnic groups and DISCUSSION have increased disproportionately for younger mothers and for primiparous women. Rates have more than tripled for women younger than age 24, Indications and they have doubled for women over 30. Like- The indications for cesarean section have wise, rates for primiparous women have tripled, greatly broadened in recent years, particularly due whereas they have only doubled for other parity to more sophisticated fetal monitoring and labora- groups. tory studies indicating . The Despite the undeniable benefits of cesarean number of abdominal deliveries for fetopelvic dis- section delivery in certain cases, the high and ris- proportion, failed induction of labor, and uterine ing cesarean section rate is a cause for concern. dysfunction has been increased while the number Cesarean section has been linked to iatrogenic of forceps deliveries has decreased.4 prematurity and an increased incidence of respira- tory distress syndrome. Cesarean section is asso- ciated with more maternal morbidity and mortality than may be readily apparent from examination of the small numbers at any one institution. High INCREASED CESAREAN BIRTH RATE rates of cesarean section for young women will The threefold rise in the cesarean birth rate that perpetuate the increase in overall rates if obstetri- has occurred in the United States during the past cians continue to practice under the dictum "once decade is a source of concern to both obstetricians a section always a section." The adverse medical and the general public.5 Maternal mortality from and legal climate of California has probably con- cesarean birth has become rare. Perinatal mortal- tributed to the increase in the cesarean section ity is less than one third of that reported three rate. decades ago and there is evidence that the selec- Improved fetal outcome is the impetus for the tive use of cesarean section delivery can improve marked increase in cesarean section. Breech pre- the prognosis for the . Older patients are sentation and fetal distress are the main reasons more likely to have cesarean sections. Similarly, for the surgery. With increased operative safety clinic patients are more likely today than in the and improvement in medical care, even small pre- past to have cesarean section delivery. In addi- mature infants may survive. Maternal morbidity tion, more obstetric care today is provided by ob- and mortality have declined, but is still higher than stetricians, who perform cesarean sections more vaginal delivery. Prophylactic antibiotics are being often than do nonobstetricians. Increased third- used more widely.3 party payment of perinatal expenses may also be For many years the rate for performing cesar- related to increased birth rates. ean sections was stable at approximately 3 to 4 Changes in the cesarean birth rate pattern ac- percent of all deliveries. Since the late 1960s, cording to indication are shown in Table 2. Cesar- however, a gradual increase in this rate has been ean section for dystocia is the largest category noted in most institutions. At some hospitals, the with repeat cesarean births, representing nearly 25 rate actually tripled and quadrupled. A better fetal percent of the increase in such births. Changes in outcome has resulted, as experience has improved the management of breech presentation and the management for such indications as breech pre- increased use of fetal monitoring procedures also sentation and fetal distress. are related to the increase in cesarean births. A The procedure is generally used whenever selective approach could be used to reduce repeat delay or trauma associated with vaginal delivery is cesarean section deliveries. There may also be a believed to be a serious detriment to the health or safe means of modifying the management of dys- safety of either the fetus or the mother. In recent tocia so that cesarean birth rates will decline. years, however, there have been significant These and other possible means of reducing cesar- changes in the emphasis placed on physical indi- ean birth rates have received appropriate empha- cations and greater awareness of patient-related sis in recent literature and/or in residency training factors (such as age), as well as improvements in programs. the quality of medical care. In one hospital's reported series, dystocia

470 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 75, NO. 5, 1983 CESAREAN SECTION

(fetopelvic disproportion, uterine dysfunction, In the current study, the protocol using herpes failure to progress) was the most common indica- cultures as a means of diagnosis provides a simple, tion for primary cesarean section. Twenty-six per- reliable, and cost-effective way to reduce the cent of these patients had radiologic evidence of number of cesarean sections by enabling a better disproportion, but only 25 percent of the remain- selection of the route of delivery for patients with ing patients who underwent cesarean section for clinically suspicious symptoms of genital herpes. this had an attempt at stimulation. This suggests that, in the absence of disproportion, the more traditional approaches to abnormalities in the active stage of labor indicate that a judicious use of intravenous oxytocin may have alleviated FORCEPS DELIVERIES VS the need for cesarean section in some cases.6 CESAREAN SECTIONS Other indications (genital herpes, multiple ges- The trend of most busy obstetric services is an tation, fetal growth retardation, prematurity and inverse relationship between forceps deliveries prolonged rupture of the membranes, amnionitis, and cesarean sections performed for cephalopelvic and grand multiparity with uterine dysfunction) disproportion. Chez et al have stated that midfor- have increased by 5 to 60 percent. ceps operations are an anachronism and that only outlet forceps have any place in modem and suggest that long-term fetal outcome is im- proved by eliminating midforceps procedures.8 Reports such as that of Chez et al provide com- Methods of Reducing Sections bustible fuel for lawyers and such a philosophy A number of patients who have had cesarean may be detrimental to the training of obstetric sections for nonpersistent or nonrecurrent indica- house staff. Most obstetricians believe that there tions probably could be delivered safely vaginally. is a place for the judicious use of forceps. Many Furthermore, scalp blood sampling for pH could of today's house officers receive little, if any, well provide supplemental information that would instruction from persons experienced in forceps reduce the number ofsurgical interventions because operations. Management has reduced itself to the of abnormal electronic monitoring. easy outlet forceps operation or cesarean section, Questions have been raised regarding the deliv- and obstetrics as a discipline is subject to increas- ery of the second of twins. In many instances, ing criticism from government and other agencies depending on the size of the second twin, version for the rising incidence of cesarean sections. On and extraction of the second twin is entirely ap- the other hand, the medicolegal implications of a propriate. Difficulties may be encountered when midforceps delivery, with the father present in the the diagnosis of twin gestation is not made prior to delivery room as a biased observer and witness, delivery. are disturbing. The bottom line is that in the final A simple protocol of repeat herpes simplex cul- analysis we must act as the trained physicians that tures in symptomatic pregnant women can sub- we are, and realize that there still are safe, albeit stantially reduce the number of cesarean sections gray, zones where we can perform our function now performed to avoid neonatal herpes infec- successfully with respect to the mother and baby. tion.7 Women whose cultures were positive and Routine cesarean section done for impending remained so until 38 weeks' gestation or later were preterm breech delivery has reduced neonatal delivered by cesarean before rupture of mem- mortality and morbidity as well as long-term de- branes. Those who were culture negative were al- velopmental sequelae. This approach seems to be lowed vaginal delivery unless a suspicious lesion justified even in very early deliveries (at 27 to 30 appeared at the onset of labor. No cases of neo- weeks of gestation) provided that adequate ob- natal herpes were identified in infants of mothers stetric and neonatal intensive care is available.9 in the study. The only case of neonatal herpes Most postoperative complications were related identified at Vanderbilt University7 during that to sepsis. There was no indication that invasive period occurred in the baby of a totally asympto- fetal monitoring contributed to excessive maternal matic woman with no prior history of herpes. infection. The trend toward increasing cesarean

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 75, NO. 5, 1983 471 CESAREAN SECTION section deliveries raises questions concerning the theless, there has been an inverse relationship be- risks and benefits of this procedure. Additional tween the cesarean section rate and perinatal data from other institutions may help in resolving mortality. the risk benefit status of cesarean section. Fetal distress as an indication for primary ce- sarean section has contributed to approximately 15 percent of the increase in the rate of primary cesarean births. Cesarean birth for fetal distress was 7.4 percent in those managed by continuous Fetal Distress electronic fetal monitoring as opposed to 1.2 percent During the past decade the number of cesarean in those managed by intermittent auscultation.10 sections for fetal distress has increased with the There is still a great deal of difficulty in identify- use of electronic fetal monitoring, which has ing the distressed fetus. Fetal scalp blood samples resulted in a sevenfold increase in surgical inter- for the determination of pH in those with abnormal vention. 10 tracings may reduce the number of cesarean sec- A stress-related release of catecholamines with tions. Combining fetal scalp pH determinations vasoconstriction and reduced uteroplacental blood with electronic monitoring may reduce surgical in- flow'1 with fetal may also be factors in tervention for fetal distress by more than 50 percent. the interpretation of fetal distress. Introduction of obstetric ultrasonography and improvement in electronic fetal monitoring and biochemical testing have improved fetal assess- ment. Estriol and human placental lactogen levels, fetal activity and oxytocin challenge tests, scalp OBSERVATION blood sampling for pH determination, and amni- We are concerned about the promptness with otic fluid analyses aid in the evaluation of the fetus which house staff and some practicing physicians before and during delivery. However, single tests will resort to cesarean section for the delivery may be deceptive and do not always accurately of the second twin, should it be presenting as a reflect the fetal outcome. breech. Two areas in the rate investigation discipline of We must remember that there is such a thing as obstetrics and gynecology are under scrutiny: hys- a difficult breech delivery from below, in deliver- terectomy and cesarean section. Cesarean section ing the head, and we must remember that in the is now being investigated by congressional com- operating room we still see difficulty from above mittees, the Federal Trade Commission, and with delivery of the head. High forceps deliveries agencies of the Department of Health and Human are to be condemned and midforceps should be Services. There are several contracts with non- applied infrequently and with a high degree of medical groups investigating cesarean section. selectivity. The reason is the rate, which can be related to How can the cesarean section rate be reduced? cost. II Obviously, there must be critical standards estab- If a maternal cesarean section rate of 25 percent lished. A number of patients who have had cesar- is appropriate, then it must be justified. The best ean sections for nonpersistent or nonrecurrent figures for 1977 put the maternal rate at just under indications probably could be delivered safely vag- 13 percent. Assuming a total birth number of 3 inally. Furthermore, scalp blood sampling for pH million, the difference in the number of cesarean could well provide supplemental information sections between 13 percent and 25 percent is that would reduce the number of sections done 360,000. Conservative estimates say that the ex- for abnormal electronic monitoring tracings.'2 penditure for a cesarean section is at least $1,000 During the time of an increasing incidence of more than the expenditure for a vaginal delivery. cesarean section, there were also tremendous im- This then brings a new expenditure of $360 mil- provements in prenatal and neonatal care. Im- lion. Is the additional expenditure justified? It will provement in neonatal intensive care has probably be if there are better results. contributed more to the decrease in perinatal mor- Nationally, four factors have been identified as tality than increased surgical intervention. Never- chiefly responsible for the increasing cesarean

472 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 75, NO. 5, 1983 CESAREAN SECTION section rate: (1) Dystocia, defined as fetopelvic carries more risk, particularly in regard to above- disproportion, abnormal pelvis, or prolonged average-sized infants of primigravidas. Today labor, has been responsible for 29 percent of the many institutions routinely deliver their primi- overall increase. (2) Repeat cesarean sections gravidas by cesarean section. It is also liberally have contributed 27 percent to the increase. (3) utilized for multiparous patients with breech pre- Cesarean section for breech presentation has ac- sentations unless there are strong indications that counted for 15 percent ofthe rise. (4) Fetal distress a good outcome is likely with vaginal delivery. was responsible for 10 percent of the increase. All The role of cesarean section in delivery of pre- other indications have remained constant or in- mature breeches is also undergoing careful evalu- creased only slightly. ation. It has already been suggested that cesarean In its conclusions, the Consensus Development section may improve the outcome of these high- Conference expressed deep concern over the ris- risk infants. Further study is needed, however, to ing cesarean section rate and further stated that weigh the benefits against the risks. Undoubtedly, the rising cesarean birth rate could be stopped, this change in management will markedly influ- and perhaps reversed, while improvements con- ence the handling of breech presentation in the tinued to be made in maternal and fetal outcome, future. Since graduating residents in many training the twin goals of clinical obstetrics today. programs receive only limited experience in deliv- 1. Allow a trial of labor and vaginal delivery in ering breeches vaginally, they can be expected to carefully selected patients who have had previous favor utilizing cesarean section. It is quite con- low-segment cesarean births. ceivable that in the future the vast majority of 2. Carefully reassess the diagnosis and man- breech infants will be delivered by cesarean sec- agement of dystocia to include sedation, rest, etc. tion. However, if the result is improved fetal 3. Refine the diagnosis of fetal distress. morbidity and mortality, the overall effect will be 4. Retain vaginal delivery as an option for the beneficial. term breech where the following conditions are Many older obstetricians still believe in the favorable: safety of breech deliveries in mature babies, al- * Estimated fetal weight of less than 8 pounds though the newer generation of obstetricians is re- * Normal pelvic dimensions and architecture sorting to cesarean section more often. Undoubt- * Frank breech without the extended head edly the trend will continue. A higher incidence of * Delivery to be conducted by physician experi- cesarean section will be performed for breech pre- enced in vaginal breech deliveries. Currently sentations, even if there are no associated minor about 70 percent are delivered by cesarean section or major complications. Certainly most babies and the physician described above may soon be- born by cesarean section are better off than those come obsolete. delivered vaginally. It is mandatory that hard data be available very Most reviews of breech suggest that abdominal soon. How many neonates are saved by the higher delivery may be associated with less risk to the cesarean section rate? What about morbidity? premature fetus. Choice of the abdominal route is Does the fetal monitor increase the rate to an ab- complicated by increased maternal and fetal risk. normally higher level? Is there close evaluation by Both vaginal and abdominal breech deliveries are peer review? Have present criteria been estab- associated with an increase in both morbidity and lished? These questions will have to be answered mortality when compared with vertex presentation. in order to justify the high cesarean section rate. Where the route of a breech delivery is con- cerned, one must also consider fetal maturity, congenital abnormalities, fetal size, type of breech presentation, and pelvic adequacy. X-ray pelvimetry, where not otherwise con- BREECH DELIVERY traindicated, and ultrasonic measurement of the Two indications for cesarean section have been fetal biparietal diameter should be carried out in all studied in detail during the past decade: breech primigravidas and many multiparas who have presentation and fetal distress. These studies indi- breech presentation. These two data should be cate that vaginal delivery of breech presentation known in making a determination between deliver-

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 75, NO. 5, 1983 473 CESAREAN SECTION ing the baby from below or doing a cesarean sec- terms of reduced hospital stay and maternal mor- tion. Certainly, if either of these two measure- bidity) considerable. In general, we agree with the ments show any abnormality, a cesarean section selection in this study, ie, nonrecurring vaginal should be done. indication, transverse low cervical incision, vertex Hester feels that breech extraction should be presentation, and availability of continuous moni- condemned except when an obstetric emergency toring labor. occurs, the cervix is fully dilated, and immediate Repeated elective cesarean section is based on cesarean section cannot be performed. Hester various indications, including more than one pre- feels that we should be more induced to perform a vious section, persistent indication for cesarean cesarean section by one or several of the follow- section, presentation anomalies, placenta previa ing:13 1) age of the patient, 2) poor obstetric and low placental position within the area of the history, 3) difficulty becoming pregnant (artificial uterine scar, longitudinal scar after classic section, insemination), 4) dysfunctional labor, 5) primigravi- and hysterographic demonstration of severe scar das, and 6) premature rupture of the membranes. defects. Other factors must be considered, includ- Queenan feels that we should not follow gener- ing severe wound infection at the time of previous alities; we cannot say that every woman who has a cesarean section, age and parity of the patient, breech presentation should have a cesarean sec- unfavorable obstetric findings and prior cesarean tion, although one might feel that way in regard to section due to placenta previa, abruptio placentae, an occasional patient with a breech presentation. 14 oblique presentation, or . Possibly more time should be spent with man- For attempted spontaneous vaginal delivery nequin demonstrations and other means of training there must be meticulous monitoring of labor ac- younger physicians in the technique of breech ex- tivity, cardiac frequency, and maternal vital signs, traction. One could simplify the procedure and as well as adequate blood supply. A competent improve prognosis, especially in the case of a obstetrician, anesthesiologist, and well-equipped frank breech, if the patient is made aware of the operating room must be readily available. Lack situation and encouraged to cooperate to the point of such facilities should mitigate against such an where the buttocks are visible, she could then be attempt and well-prepared cesarean section is completely anesthetized and extraction could be preferable. Difficult vaginal operative delivery performed with greater ease. should be avoided, particularly on a woman with- The management of breech presentation re- out prior delivery. Manual or instrumental palpa- mains controversial. The preliminary results of tion of the uterine scar should be mandatory for this prospective study suggest that, if the pelvis is demonstration of eventually existing, but as yet adequate on x-ray examination, full-term frank asymptomatic, scar rupture. Labor-inducing med- breeches of moderate size can be quite safely de- ication should be avoided. livered vaginally. About one half of the patients randomized to vaginal delivery were ultimately delivered abdominally. As expected, maternal morbidity was increased in those patients who underwent cesarean section.'5 TRIAL OF LABOR BEFORE Several authorities have suggested reconsider- REPEAT CESAREAN ation of the obstetric dictum, "once a section, al- The greatest inroads against high cesarean sec- ways a section," as a means of holding down the tion rate can be made by avoiding routine repeat increasing cesarean section role.'6 About one half cesareans, but more precise management of dys- of patients with a single low cervical transverse tocia and fetal distress can also lower the section cesarean section can delivery vaginally. This rate for these indications. study demonstrates, as have a number of earlier This statement was made by a panel of physi- reports, that planned vaginal delivery can be cians'7 sponsored by the March of Dimes Birth undertaken with reasonable safety on selected pa- Defects Foundation and New York University of tients with previous cesarean sections. The risks Medicine. The scientific evidence is clearly in are relatively small given careful selection and favor of a trial of labor in a woman who has had a meticulous care during labor and the benefits (in previous cesarean section. The continued resist-

474 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 75, NO. 5, 1983 CESAREAN SECTION ance to the evidence is a result of habit, institu- portion was the diagnosis leading to cesarean sec- tionalized prejudice, and unwillingness to accept a tion, a vaginal delivery was achieved in a later small degree of risk. Several of the panelists pregnancy. agreed to this. Dr. Erich Saling, professor of obstetrics and Dr. Bruce K. Young, Director of Maternal Fetal perinatal medicine at Free University of Berlin Medicine at New York University School of Med- believes that physicians wishing to avoid unneces- icine and Chief of Obstetrics Service at Bellevue sary cesareans for fetal distress are hampered by a Hospital Center, New York, said "the data made lack of consensus on what constitutes a sufficient it difficult to accept risk for a catastrophic uterine indication for intervention. rupture as a rationale for a repeat section, since Dr. Young said that a cesarean section should the risk is small enough to be statistically tolerable." not be performed for fetal distress unless the diag- However, the safety of vaginal delivery after a nosis of fetal distress is clearly established. Fetal previous cesarean section has not been demon- distress may be defined as a condition that, unless strated statistically because of the small number of corrected promptly, is likely to result in a severely such patients, compared with the large number damaged or dead neonate. If delivery is delayed who have been safely delivered abdominally after beyond one hour, the condition may be diagnosed an elective repeat cesarean section (Young). One by a combination of specific fetal heart rate ab- of the panelists reported that a catastrophic rup- normalities and fetal . A substantial num- ture has never been seen at his hospital in 20 ber of preacidotic will recover if the years' experience with trials of labor. mother is placed on her side, oxygen is given, and oxytocin is withheld. An even greater number of acidotic fetuses probably would respond if the B-mimetic drugs used to inhibit contractions were available. TRIAL OF LABOR: Few heart rate patterns by themselves are indi- AN ACCEPTED PRACTICE cations that the fetus is in severe distress, but im- Another panelist, Dr. Frank L. Miller of the mediate intervention is needed if the pattern University of Southern California School of shows bradycardia and , severe brady- Medicine, Los Angeles, said that he saw two cardia (less than 90 beats per minute), or tachy- cases of in 1981, including one cardia of more than 190 beats per minute with case in which the fetus was expelled into the some other complications such as late decelera- abdomen and died. He recommended that women tions. Some invasive diagnostic techniques have with a previous cesarean section should not under- been identified as factors contributing to maternal take a trial of labor unless blood is immediately morbidity. Short-term prophylactic antibiotic ther- available and the hospital has a full support team apy in selected high-risk patients may reduce ready to manage possible complications. He also febrile morbidity by more than 75 percent.3 reported that dystocia is the most problematic area Despite improvement in surgical technique, an- in preventing unnecessary cesarean sections, esthesia, and blood replacement in postoperative since the diagnosis of dystocia is imprecise and care, mortality following cesarean section is four often not based on reliable data. times that following vaginal delivery. Of course, it Dr. Albert Hirch, professor of obstetrics at the is the high-risk patient who is more likely to have a University of Zurich (Switzerland), said that with cesarean section. well-defined precautions, a trial of labor after a Critical analyses ofthe consequences during the previous cesarean section is an accepted practice next decade may result in a stabilization of, or in his department. The decision to permit a trial of decrease in, the incidence of cesarean sections. labor can only be made on an individual basis. The concept of "once a section, always a sec- With breech presentation as an indication for the tion"18 has been challenged. Selective subsequent previous cesarean section a vaginal delivery was vaginal delivery when there is not a recurrent indi- subsequently attempted in 71 percent of the cases cation for cesarean section seems to involve little and was successful in 67 percent. Even the 10 per- maternal and fetal risk. However, in some hospital cent of the cases in which cephalopelvic dispro- environments the risk of a trial of labor in women

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 75, NO. 5, 1983 475 CESAREAN SECTION who have had a previous cesarean section may Acknowledgments exceed the risk to both mother and infant of a The authors express their appreciation and acknowl- properly timed elective repeat cesarean section edge their gratitude to Mrs. Leonora Munar, Mrs. Rosa Moore, the Record Room Department and Library Staff of birth. We need more data regarding the risk of Queen of Angels Hospital, and the staff members who made labor in patients with previous low-segment trans- their cases available for this study. verse uterine incisions. Reduction in the number ofcesarean sections could also result from resurrec- tion ofa trial oflabor in a patient with a questionably adequate pelvis and a cephalic presentation.19 A desire for sterilization is not an adequate indication for cesarean hysterectomy when a more minor procedure can be carried out with less risk. Hysterectomy following cesarean section exposes the patient to a 40 to 50 percent increased chance of a need for blood transfusion and a tenfold in- Literature Cited crease in mortality. 1. Petitt D, Olson RO, Williams RL. Cesarean section rate in California. Am J Obstet Gynecol 1979; 133:391-397. Maternal mortality may be reduced through pa- 2. Bottoms SF, Rosen MG, Sokol RJ. The increase in tient education, more accessible and effective the cesarean birth rate. N EngI J Med 1980; 302:559-563. conception control, early identification of high- 3. D'Angelo LJ, Sokol RJ. Short-term long-course pro- phylactic antibiotic treatment in cesarean section patient. risk obstetric patients, and early diagnosis and Obstet Gynecol 1980; 55:583-585. vigorous treatment of obstetric infections. 4. Jones OH. Cesarean section in present day obstet- rics. Am J Obstet Gynecol 1976; 126:521-523. 5. Minkoff HL, Schwarz RH. The rising cesarean sec- tion rate: Can it safely be reversed? Obstet Gynecol 1980; 56:135-140. 6. Evord JR, Gold EM, Cahill TE. Contemporary as- MEDICOLEGAL CONSIDERATION sessment. J Reprod Med 1980; 24:147-152. 7. Boehm FH. Herpes. Ob-Gyn News 1981; 16(12):4. One reason for the rise in cesarean section rates 8. Chez RK, Ekblodh L, Friedman EA, Hughey MJ. in many areas can be found in the medicolegal Mid-forceps delivery: Is it an anachronism? Contemp Ob/Gyn 1980; 15:82-84. implications. As anyone knows who has dealt ex- 9. Brenner WE, Bruce RD, Hendricks CH. The charac- tensively with legal activity in the obstetric field, teristics and perils of breech presentation. Am J Obstet one of the major claims that frequently reach Gynecol 1974; 118:700-704. 10. Haverkamp AD, Orleans M, Langendoerfer S, et al. A trial court concerns the failure to perform cesarean controlled trial of the different effects of intrapartum fetal section in cases where there are subsequent monitoring. Am J Obstet Gynecol 1979; 134:399-401. disabilities. Doctors have created the 11. Draft Report of the Task Force on Cesarean Child- birth. Washington, DC: Consensus Development Confer- attitude that a cesarean delivery implies a perfect ence of Cesarean Childbirth, September 1980. baby. There is no doubt that this is one of the 12. Duenhoelter JH, Wells CE, Resich JS, et al. A paired factors that contribute to an increase in cesar- controlled study of vaginal and abdominal delivery of the low birth weight breech fetus. Obstet Gynecol 1979; 54: ean section rates as we presently see them. 310-314. 13. Brenner WE, Bruce RD, Hendricks CH. The charac- teristics and perils of breech presentation. Am J Obstet Gynecol 1974; 118:700-712. 14. Queenan JT. Breech presentation. Am J Obstet Gynecol 1974; 118:700-712. CONCLUSIONS 15. Collea JV, Rabin SC, Weghorst CR, Quilligan EJ. Randomized management of term frank breech presenta- The issue of the cesarean section rate is a com- tion: Vaginal delivery vs cesarean section. Am J Obstet plex odle since it involves potential improved out- Gynecol 1978; 131:186-195. come and potential changes in morbidity for two 16. Merrill BS, Gibbs CE. Planned vaginal delivery fol- lowing cesarean section. Obstet Gynecol 1978; 52:50-52. patients-the mother and the child. As medical 17. International Medical News Service. Ob Gyn News practice changes, it is critical that we understand 1981; 16(2):14-15. not only the direction of the change but also the 18. Crogin EB. Conservation on obstetrics. NY Med J 1916; 104:1-5. reasons, and whether the changes have resulted in 19. O'Driscol K. Rupture of the uterus proceeding. K improved outcome. Soc Med 1966; 59:65-69.

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