Schmitt, Alexander Hunter

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The Linacre QuarterlyVolume 13 | Number 4 Article 3October 1945Comparative Safety in Five or More RepeatedCesarian SectionsAlexander Hunter SchmittFollow this and additional works at: http://epublications.marquette.edu/lnqRecommended CitationSchmitt, Alexander Hunter (1945) "Comparative Safety in Five or More Repeated Cesarian Sections," The Linacre Quarterly: Vol. 13:No. 4, Article 3.Available at: http://epublications.marquette.edu/lnq/vol13/iss4/316 THE LIN ACRE QUARTERLY COMPARATIVE SAFETY IN FIVE OR MORE REPEATED CESARIAN SECTIONS ALEXANDER HUNTElt SCHMITT, M.D., F.A.C.S. Directol· of Gynecology and Obstet'rics, Misel·icordiia Hospital, New York, N. Y. Visiting Gynecologist and Obstetric'ian, St. Vincent's Hospital, New York, N. Y. T HE technique and llIortality rate of Cesarean operations of 1910 compared with those of today, may be regarded as an excellent indi-cation of the extent to which obstetrics has kept pace with the devel-opment in other surgical specialties during the past thirty-five years. * In 1910, while I was a resident at the Manhattan Maternity and Dispensary, there were 1,409 deliveries with five Cesarean sections; two of the mothers died, giving a maternal death rate of 40% . In 1930, there were in the same hospital, 1,344 deliveries with twenty-nine Cesarean sections; three of the mothers died, giving a maternal death rate of 10%. In 1945, there were at St. Vincent's, 1,375 deliveries with seventy-six Cesarean sections, without a single maternal death. Since the most frequent indication for a Cesarean section is a perma-nent anatomical indication, namely, a contracted pelvis or mechanical dystocia, it seems logical to expect that Cesarean sections would be repeated on the same mother. It is still an unwritten law for many in the obstetrical profession that sterilization of the mother after the third Cesarean section is not only justified but is mandatory. One of our great authorities says: "Probably most Americans will feel that when a woman has exposed herself to the rlangers of death three times, she has done her duty to her state." In the large maternity clinies throughout the country, sterilization of the mother after the third section is routine procedure. Many recommend sterilization after a second section. Little is said in medical literature concerning the fourth of fifth repeated section. The reasons given for not attempting repeated sections are the strong likelihood of a ruptured uterus, either spontaneous during the last month of pregnancy or at the time of operation, and the dangers of operative hemorrhage and shock. In my experience as an obstetrician over a period of thirty-five years or more, I have naturally seen many post-Cesarean pregnancies in clinics, in my private practice and in consultation. I have also performed a large number of Cesarean sections. During this long period, I have encountered only one rupture of a scar following Cesarean section. The patient was * Read at the Clinical-Pathological Conference on March 1, 1946, at St.Vincent's Hospital. THE LIN ACRE QUARTERLY 17 a diabetic waiting in the hospital for her third section and the rupturc occurred spontaneously several hours before I operated. The mother recovered but the baby was stillborn. Quoting again the authority I have just mentioned: "Rupture of It low Cesarean scar during pregnancy is exceedingly rare ... I know of only three and there cannot be many more or I would have heard of them." Despite this, we hear so much of the danger of a ruptured uterus, if preg-nancy occurs after the third section. Patients are given warnings which are difficult to defend on the basis of obstetrical experience. If a low segment operation is performed and perfect technique is used in suturing the uterine wall which heals by primary union, the likelihood of a scar ruptm·ing spontaneously during a subsequent pregnancy is cxtremely small. Similarly, there is not much danger that a well sutured and clean abdominal incision may rupture in subsequent years if the woman happens to become pregnant and delivers at tenn. Finally, it is hard to see why the danger of hemorrhage or shock or infect.ion should be greater at the fifth than at the first or second Cesarean section. If anything, a patient in preparation for her fifth Cesarean section would certainly receive from her physician the best possible attention and should, therefore, have an excellent prognosis. The patient is more likely to be given ample time for rest prior to the operation. The section should take place under the most favorable conditions. In view of all of this, an analytic study of 1,000 consecutiv~ Cesarean sections performed at the Chicago Lying-In Hospital on the service of Dr. Fred L. Adair is interesting. Of these 1,000 mothers, 465, or 46.5% , were sterilized, 406 by re-section of the tubes and 59 by Porro section. Of the 465 mothers who were sterilized, 186 were thus operated upon in connection with their first Cesarean section. 233 mothers had one previous section, 42 had two and four had t.hree previous sections. The st.atement. will be generally accepted, I believe, that throughout the country, mothers Me sterilized after the third repeated Cesarean sectioJl or eveJl earlier. I am of the impression that in the Cat.holic hospitals, we find it greater number of repeated Cesarean sectioJls and certainly, it much lower per-centage of sterilizations. In one of the Catholic hospitals which I visit, out of seventy-six Cesareall sections, there was ollly olle fourth repeated sec-tion and one sixth repeated section. I wish now to report my findings on eight patients who had had five and six repeated sections. I observed these eight mothers personally dur-ing the ante-partum period; I operated on them myself and followed them for months after the operation. This group of eight mothers had forty-one Cesarean sections, twenty-two of which I performed myself. There were no maternal deaths and the illnesses were few and of a minor nature. Through these forty-one Cesarean sections, forty-three live babies were delivered, there being two pairs of twins. There was one neo-natal death. I was fortunate enough recently to meet seven of the eight mothers. 18 THE LIN ACRE QUARTERLY I examined them in my office and found them to be all in excellent health. There was no visccral ptosis, no ventral herniae and no weakened scars were found. Pelvic examination showed the uterus in all cases to be well involuted and in normal position. The necessary records are not available to describe accurately the technique employed in the forty-one operations. The obstetrician who perfonTIs the fourth and fifth repeated Cesarean sect ion l, lUst keep in lllind, fir st, the correct timing for the operation; secondly, a reduction of the length of time r equired for the operation; a nd thirdly, preventive treatment against shock, hemorrhage and infection. Personally, I prefer to perform the section at least two weeks before the expected date of delivery and sometimes earlier if the size of the baby warrunts this. The duration of the operation should not exceed thirty minutes. Preventive treatment will include the choice of the anaesthetic and proper provision and preparation for emergencies. If I have an expert anaes thetist, I pre-fer cyclo-propane. Intravenous saline glucose 5 % is administered at. the time of operation and is cont.inued unt.il 1,000 cc. has been given. Plasma and citrat.ed blood a re at hand. In conclusion, I would say, first, that in view of present day results which arc possible to obt.ain in a modernly equipped hospital a nd wit.h an efficient staff, the risks and hazards of a fifth or a sixt.h section are not much greater than those of the first or second. Secondly, I am of the opinion that t.he rout.ine operative st.erilizat.ion of mother s after the second and t.hird Cesarean sect.ion is not. justified. I fully realize that I may be accused of basing Iny conclusions on a mere handful of patients but this number of patients, I believe, shows what. can be done. Besides, this llIuch is clear to me, that if the direct sterilization of women is ethically and pl·ofessionally unjus tifiable, little cOlllfort can be derived by the advocate of ste rilizatiotl f!"OlIl the alleged hazards or risks attendan t upon repeated Cesa rean sections. Despite all of this, I am not oblivious of the responsibilities of the surgeon in performing a Cesarean section. In the hospital in which I am practicing, a Cesarean operation is never permitted unless a consultation has been held with the directo r of the department or a ranking obstetri-cian. In the consultation are involved not merely the approval or dis-approval of the Cesarean section but also advice concern ing the t ype of operation to be performed. ' ,Vhoever operates must be an accredited obstetric surgeon. If precautions such as these could be enforced in all of our hospitals, there would be a great decrease in maternal mortality as well as a decided reduction in the number of Cesarean sections whieh are performed. There would a lso result education for both the profession and the public and when the comparative safety of repeated Cesarean sections is appreciated, the routine sterilization of mothers after the second or third Cesarean section will surely be abandoned. 

Comparative Safety in Five or More Repeated Cesarian Sections

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Comparative Safety in Five or More Repeated Cesarian Sections

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