A critical survey of 1,066 cesarean sections

Abstract

In the face of bare figures, the high classical technique stands convicted of a high maternal mortality, 3.9 per cent for all the classical operations as against 1.8 per cent for all the low flap operations. It has been shown, however, in this analysis that type of operation alone cannot be condemned. The classical technique bore the brunt of responsibility for such indications as toxemia and nephritis and cardiac and pulmonary diseases where the patient did not enter the operating room in good general physical condition, and where speed of operation was a most important consideration. There was one instance, however, where the high classical operation did fail badly, namely in the prevention of sepsis. The low flap technique has in this series been responsible for no fatality from sepsis. As was shown in the discussion on labor the fatal cases following the low flap technique were attributable more to the technique of the operator than to the technique of the operation. The factor of experience of the obstetrician is one that cannot be overlooked. In listing the fatal cases in chronologic order and including the name of the operator, in preparing this study, it was an outstanding fact that the younger men of the service were much more frequently associated with maternal mortality. As time progressed and these men became more experienced their names did not nearly so frequently appear in this listing. This fact is noteworthy, for it occurred in spite of the organization of our service which demands and provides for careful supervision of younger men by those of greater experience. This factor of personal experience must receive due consideration in evaluating any group of figures.In concluding this survey, stress must be laid upon certain points. The maternal mortality of cesarean section is high, too high following some indications, particularly the toxemias of pregnancy. These weak spots must either be eradicated or bolstered by a change in technique. Because of its greater incidence of sepsis and poorer results in repeat operations, the classical operation should be reserved for those cases where the element of time is of prime importance. The low flap operation is slightly more difficult in its performance, particularly in the obese patient, and the mortality associated with it can be more frequently attributed to the operator than to the operation. If cesarean section is to take its proper place as a means of escaping obstetric difficulties, the following postulates must be rigidly observed: There must be a correct indication for operation. The proper type of operation must be performed at the proper time. The operation must be performed by an obstetrician with surgical experience.