Elective cesarean hysterectomy: A 5 year comparison with cesarean section DAVID L. BARCLAY, M.D. BYRON L. HAWKS, M.D. DAVID M. FRUEH, M.D. JON DAVID POWER, M.D. R. HARLAN STRUBLE, M.D.
Little Rock, Arkansas
Elective cesarean sections performed on the obstetric service at the University of Arkansas Medical Center were reviewed for the period january 1, 1970, through December 31, 1974. The purpose of the review was to compare operative and postoperative complications of cesarean section, cesarean section and tubal ligation, and cesarean section and elective hysterectomy. A total of 1,255 cesarean sections were performed of which 207 ( 17 per cent) were associated with tuba/ligation and 242 (18 per cent) with hysterectomy. Elective cesarean hysterectomies were performed for elective sterilization (68 pf'r cent), for medicalZy indicated sterilizations (11 per cent), or for d~finitive treatment of uterine pathology (21 per cent). All cesarean sections were obstetrically indicated with the exception of 34 primary cesarean hysterectomies performed as definitive treatment of carcinoma in situ of the cervix. The operative procedures wl're compared in regard to the following characteristics or complications: operating time; incidence of blood transfusions, urinary tract injuries~ postoperative bleeding, febrile morbidity, and other postoperative complications; and postoperative hospital days.
used, and that in our institution postoperative morbidity after cesarean hysterectomy is less than after cesarean section. The purpose of this study is to compare complications of elective total cesarean hysterectomy with those of elective cesarean section or cesarean section and tubal ligation during a 5 year period of time.
UNDER EMERGENCY circumstances, removal of the uterus at the time of cesarean section is accepted as a life-saving procedure. Elective removal of the puerperal uterus after an obstetrically indicated cesarean section simply for sterilization or for removal of a diseased uterus is controversial. The primary argument against elective cesarean hysterectomy is the reportedly high incidence of blood transfusions, urinary tract injuries, and postoperative morbidity. 1• 2 The experience of the senior author has suggested that injury to the urinary tract is not a serious problem, that the incidence of blood transfusions can be reduced to acceptable levels if proper operative technique is
Materials and methode Fromjanuary 1, 1970, through December 31, 1974, on the obstetric service at the University of Arkansas Medical Center, all patients undergoing an obstetrically indicated cesarean section who requested sterilization were offered the option of tubal ligation or hysterectomy. In addition, particularly during 1973 and 1974, primary cesarean section and hysterectomy were offered to patients who had uterine pathology for which a hysterectomy was indicated and had been scheduled 2 to 3 months postpartum. The primary indication in the latter group was carcinoma in situ of the cervix. To evaluate the relative risk of cesarean hysterectomy and cesarean section with or without tubal
From the Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences. Presented !Jy invitation at the Eighty-sixth Annual Meeting of the American Assocmtion of Obstetricians and Gynecologists, Hot Springs, Virginia, September 4-6, 1975. Reprint requests: Dr. David L. Barcla_v, Department of Obstetrics and Gynecology, University of Arkansas Medical Cenier, 4301 W. Markham, Little Rock, Arkansas 72201.
900
Volume 124 Number 8
ligation, all abdominal deliveries from January 1, 1970, through December 31, 1974, were teviewed (Table I). During the study period there were 13,568 deliveries, of which 1,388 were abdominal deliveries on patients of more than 28 weeks' gestation ( 10 per cent cesarean section rate). Operations resulting in sterilization were performed on 1,047 patients (7.7 per cent). Fifty-four cesarean and cesarean tubal ligation records and one cesarean hysterectomy patient record were incomplete and not included in these data. There were no deaths or prolonged hospitalizations in the group that was not reviewed. Cesarean sections performed for vaginal bleeding were reviewed, classified as emergency, and excluded from the cesarean section study group; therefore, 806 elective cesarean section and 207 elective cesarean and tubal ligation patient records were studied. A total of 257 cesarean hysterectomies were performed (18.5 per cent of abdominal deliveries) during the 5 year period of study. Twelve hysterectomies performed for bleeding were classified as emergency operations and excluded from this study as were two radical hysterectomies for invasive cervical cancer and one patient whose record was not available for study. Complications and results of 242 elective cesarean hysterectomies will, therefore, be compared with 806 elective cesarean sections and 207 elective cesarean sections with tubal ligation. The number of requests for surgical sterilization has increased dramatically in recent years. Due to limited operating time, postpartum tubal ligations are performed selectively. Thirtyfive per cent of patients undergoing an elective cesarean section received a procedure that resulted in sterilization; 207 ( 17 per cent) tubal ligations and 242 (18 per cent) hysterectomies were performed. Fiftyfour per cent of procedures resulting in sterilization in conjunction with cesarean section were hysterectomies. Prenatal care and preoperative preparation. Approximately 50 per cent of our patients reside in the metropolitan area and the remainder are referred from throughout the state. During prenatal care, most patients received an interview concerning child spacing and family planning. If surgical sterilization was requested, a complete explanation was provided by the Public Health Nurse which included illustrations of the various procedures, i.e., postpartum tubal ligation or, if elective cesarean section was indicated, tubal ligation or hysterectomy. If uterine pathology existed which should be treated by hysterectomy, the patient was so counseled by the physician. During the last 3 years of the study, patients found to have a positive cervical cytologic smear either prior to or during pregnancy were evaluated by colposcopy. If the lesion was
Elective cesarean hysterectomy
901
Table I. Deliveries, 1970 to 1974 Years 1970
Total
Total 2,826 2,851 2,746 2,511 2,634 13,568 deliveries Abdominal 299 252 264 294 279 1,388 deliveries 167 154 806 151 168 166 Elective cesarean section 18 14 64 11 12 9 Emergency cesarean section 14 31 207 Cesarean 37 57 68 tubal ligation 583 72 166 122 167 Postpartum 56 tubal ligation 47 243 Elective 49 71 46 30 cesarean hysterectomy 0 3 12 3 4 Emergency 2 cesarean hysterectomy 0 2 Radical 0 0 cesarean hysterectomy
completely visualized and the examiner was confident that the cervix had been adequately evaluated and biopsied, diagnostic conization was not recommended. If indicated, cervical conization was performed during the second or early third trimester. Also, during the last 3 years, fetal maturity was estimated on all patients scheduled for elective cesarean section by performance of an outpatient amniocentesis and determination of a lecithin/sphingomyelin ratio. When fetal maturity was demonstrated, the elective operative procedure was scheduled accordingly. Appropriate sterilization papers were completed by the patient and her husband during the prenatal period. After admission to the hospital, patients who were scheduled for a sterilization procedure, either in conjunction with cesarean section or by postpartum tubal ligation, were interviewed by the Chief Resident in Obstetrics. Institutional sterilization papers were completed and approved by a staff physician, who usually interviewed all patients who had elected hysterectomy for sterilization or definitive treatment of uterine pathology. Routine preoperative studies were completed and two to four units of whole blood were typed and cross-matched. Vaginal preparation was not routinely carried out. Age. The age distribution of each group of patients is outlined in Table II. Approximately 15 per cent of patients who deliver on our service each year are age
902
Barclay et al. Am.
Table II. Age distribution No. of patients
Age
45 Total
Cesarean hysterectomy ()
21 70 (ill
41
29 13
Cesarean tubal ligation
95 421 1911
53 22 16 I
2 43 78 3.1 25 13 10
Total
97 48.5 346 !56 88 58 24
0
()
]
I
242
806
207
1,255
Cesarean tubal ligation
Total
Table III. Parity distribution Parity ()
I
2
3 4
5 6 or> Total
Cesarean hysterectomy
5 21 60 49 :l3 22
447 240 63 22 14
52 242
14 806
6
8 68 67 20 9 12 23
207
460 329 190 91 56 40 89 1,255
16 or less and one third are 18 or less, of which approximately 10 per cent are multiparas. Ninety-five elective cesarean sections were performed on patients less than 16 years of age; two patients, para one or two, received a medically indicated tubal ligation. The incidence of procedures resulting in sterilization increased from 13 per cent of those in the 16 to 20 year age group to 96 per cent of women over age 40. The incidence of hysterectomy increased from 20 per cent of elective cesarean sections in the 21 to 25 year age group to 51 per cent of patients over age 36. Parity. Parity was defined as the number of deliveries prior to the pregnancy under consideration. The parity distribution of each group of patients is indicated in Table III. Eight para 0 patients received a medically indicated tubal ligation for the following reasons: heart disease, four; diabetes, three; hemoglobinopathy, one. Indications for hysterectomy performed on five para 0 patients were medically indicated sterilization (three), large degenerating uterine fibroids (one), and one patient was over 40 years of age and elected hysterectomy for sterilization. A tubal ligation was performed on 21 per cent and hysterectomy on 6 per cent of para 1 patients. Among para 2 patients, 35 per cent received a tubal ligation and 32 per cent a hysterectomy. Parity of 3 or greater
J
April l.'i. l9i6 Obstet. Gyneml.
was recorded for 276 patients; 23 per cent of these patients received a tubal ligation and 57 per cent a hysterectomy, which was often performed for uterine pathology. Operative procedure. Atropine was administered as a drying agent. Spinal or epidural anesthesia was used as the primary anesthetic in 85 per cent of elective cesarean sections and a local anesthetic was used in 2 per cent. General anesthesia was used as a primary anesthetic in 13 per cent and as a secondary anesthetic in 9 per cent of cesarean section patients. A low vertical abdominal incision was generally used, although a transverse incision was not contraindicated. If hysterectomy was to be performed, the bladder flap was completely developed prior to incising the uterus; the presence of adhesions often required sharp dissection which was performed more easily if the fetal head was in the lower uterine segment. The uterus was entered through a low cervical incision in 98 per cent of cesarean sections with or without tubal ligation; 73 per cent were transverse. Extension into the uterine fundus with elective cesarean section was reserved for obstetric complications such as malpresentation or an excessively large fetus. A low vertical incision was preferred with hysterectomy (95 per cent of operations), although in 22 per cent of patients the incision was extended into the fundus to facilitate delivery. A finger placed in the upper pole of a vertical incision by an assistant provided excellent traction on the uterus. Technical details of total cesarean hysterectomy have been published elsewhere. 3 • 4 All but eight of the tubal ligations were Pomeroy procedures, using plain catgut and excising a segment of Fallopian tube from each side for pathologic examination. Nine patients undergoing cesarean section with or without tubal ligation received a unilateral oophorectomy for benign ovarian pathology and six underwent ovarian cystectomy. Twenty patients (8.3 per cent) undergoing hysterectomy received a salpingooophorectomy which was unilateral for bleeding (14) or a benign cystic teratoma (one) and bilateral in five women over age 36. Appendectomy was performed during 5 cesarean sections and 16 (6.6 per cent) hysterectomies. One bilateral hypogastric artery ligation was performed during cesarean section on a patient who was bleeding from Stage II cancer of the cervix. Other operative procedures performed in conjunction with hysterectomy were removal of a wide vaginal cuff (34), lysis of adhesions (12), incisional or umbilical hernia repair (three), and Marshall-Marchetti-Krantz procedure (five). Adhesions were listed only if severe,
Elective cesarean hysterectomy
Volume 124 Number 8
903
Table IV. Number of prior cesarean sections Number of prior cesarean sections
Cesarean hysterectomy
Cesarean section
Cesarean tubal
128 43 48 17
563 209 30
60 94 46 6 1 207
None One Two Three Four or> Total
4
6
242
806
Table V. Indications for primary cesarean section Major indication
Fetopelvic disproportion Malpresentation Pre-eclampsia eclampsia Prolapsed cord Prolonged ruptured membrane Diabetes Isoimmunization Uterine fibroids Cancer cervix Fetal distress Vaginal bleeding Miscellaneous Total
Cesarean hysterectomy
Cesarean tubal
13
335
16
23
7
114 43
21 3
2 16
22 15
3 1
6
9 5 34 4 6 3
128
5 5 1 4* 6
0 7 557
6 3 0 1* 4
Percent cesarean section(%)
751 346 124
59.8 27.6 9.9 2.7
1,255
TOO
2~ }
Table VI. Associated disease Disease
Hypertension Without toxemia With toxemia Pre-eclampsia Eclampsia Chronic renal disease Rheumatic heart disease Diabetes Epilepsy Hemoglobinopathy
Cesarean hysterectomy
Cesarean tubal
10
1
4 5 134 11 4
2
3
5
14 3
10 8 4
12 2 2
13 5 9 1
1
4 11 1
2
0
2 60
*Invasive cancer of the cervix. such as fixation of the uterus to the anterior abdominal wall. Dense adhesions were lysed during 31 cesarean sections and during 15 cesarean tubal ligation operations. During cesarean section two patients required a small bowel resection because of adhesions to a prior classical uterine scar.
Indications for cesarean section A primary cesarean section was performed in 7 51 patients, which was 60 per cent of the 1,255 operations. Seventy per cent of cesarean sections, 29 per cent of cesarean tubal ligations, and 53 per cent of cesarean hysterectomies were primary cesarean sections. In 296 patients (23 per cent) an elective repeat and in 34 patients (carcinoma in situ of the cervix) an elective primary cesarean section was performed. Therefore, a scheduled operation on a nonlabor patient was performed with approximately 14 per cent of cesarean sections, 53 per cent of cesarean tubal ligation operations, and 45 per cent of cesarean hysterectomies. Primary cesarean section in 751 patients was followed by tubal ligation in 60 (8 per cent) patients and hysterectomy in 128 (17 per cent) patients. A repeat cesarean section in 504 patients was associated with
tubal ligation in 147 (29 per cent) and hysterectomy in 114 (23 per cent). A second cesarean section was performed in 346 patients; tubal ligation was performed on 94 (27 per cent) and hysterectomy on 43 ( 12 per cent) patients. The third, fourth, or fifth cesarean section on 158 patients was followed by a tubal ligation on 53 (34 per cent) and a hysterectomy on 71 (45 per cent) patients; 79 per cent of patients requested sterilization or uterine pathology warranted a hysterectomy. The number of prior cesarean sections in each group is recorded in Table IV. Indications for primary cesarean section are listed in Table V. The principal indication was listed, although multiple indications were often present. Cesarean sections performed for diabetes, isoimmunization, or pre-eclampsia were usually preceded by a trial of induction oflabor. Fetal distress or prolonged rupture of the fetal membranes often precipitated cesarean section; however, the primary disease process was listed as the indication for cesarean section. The principal associated diseases in each patient group are listed in Table VI. Vaginal bleeding from placenta previa (five) or abruptio placentae (one) was included in the hysterectomy group when the indication for hysterectomy was elective but was excluded from the other two groups. Fetopelvic disproportion and malpresentation were the most common indications for
904 Barclay et al.
Aprill5, 1':176
Am
Year 1970
Elective steri1ization Medical steri1ization Uterine pathology Carcinomain situ Uterine fibroids Amnionitis Total
38
55
Total
5
12
6
4
2 2 3
I
49
7T
39
18
15
165
8
0
26
7
20
14
51
5
17
9
34
2
3
47
46
9 4 29
8 242
Table VIII. Preoperative and postoperative mean hematocrit values ± 1 S.D. Patients
Cesarean hyswrectomy
All patients Preoperative Postoperative Not transfused Preoperative Postoperative Transfused Preoperative Postoperative
(N = 242) 35.6 ± 3.5 32.9 ± 4.2 (N = 195) 36 ± 3.2 32.5 ± 4.13 (N = 47) 33.8 ± 4.24 31.0 ± 4.09
Cesarean tubal
= 806) 36 ± 4.3 32.9 ± 4.1 (N = 777) 35.8 ± 5.9 32.5 ± 5.7 (N = 29) 32.14±5.3 30.17±3.2 (N
Obstet.
Little Rock, Arkansas
Elective cesarean sections performed on the obstetric service at the University of Arkansas Medical Center were reviewed for the period january 1, 1970, through December 31, 1974. The purpose of the review was to compare operative and postoperative complications of cesarean section, cesarean section and tubal ligation, and cesarean section and elective hysterectomy. A total of 1,255 cesarean sections were performed of which 207 ( 17 per cent) were associated with tuba/ligation and 242 (18 per cent) with hysterectomy. Elective cesarean hysterectomies were performed for elective sterilization (68 pf'r cent), for medicalZy indicated sterilizations (11 per cent), or for d~finitive treatment of uterine pathology (21 per cent). All cesarean sections were obstetrically indicated with the exception of 34 primary cesarean hysterectomies performed as definitive treatment of carcinoma in situ of the cervix. The operative procedures wl're compared in regard to the following characteristics or complications: operating time; incidence of blood transfusions, urinary tract injuries~ postoperative bleeding, febrile morbidity, and other postoperative complications; and postoperative hospital days.
used, and that in our institution postoperative morbidity after cesarean hysterectomy is less than after cesarean section. The purpose of this study is to compare complications of elective total cesarean hysterectomy with those of elective cesarean section or cesarean section and tubal ligation during a 5 year period of time.
UNDER EMERGENCY circumstances, removal of the uterus at the time of cesarean section is accepted as a life-saving procedure. Elective removal of the puerperal uterus after an obstetrically indicated cesarean section simply for sterilization or for removal of a diseased uterus is controversial. The primary argument against elective cesarean hysterectomy is the reportedly high incidence of blood transfusions, urinary tract injuries, and postoperative morbidity. 1• 2 The experience of the senior author has suggested that injury to the urinary tract is not a serious problem, that the incidence of blood transfusions can be reduced to acceptable levels if proper operative technique is
Materials and methode Fromjanuary 1, 1970, through December 31, 1974, on the obstetric service at the University of Arkansas Medical Center, all patients undergoing an obstetrically indicated cesarean section who requested sterilization were offered the option of tubal ligation or hysterectomy. In addition, particularly during 1973 and 1974, primary cesarean section and hysterectomy were offered to patients who had uterine pathology for which a hysterectomy was indicated and had been scheduled 2 to 3 months postpartum. The primary indication in the latter group was carcinoma in situ of the cervix. To evaluate the relative risk of cesarean hysterectomy and cesarean section with or without tubal
From the Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences. Presented !Jy invitation at the Eighty-sixth Annual Meeting of the American Assocmtion of Obstetricians and Gynecologists, Hot Springs, Virginia, September 4-6, 1975. Reprint requests: Dr. David L. Barcla_v, Department of Obstetrics and Gynecology, University of Arkansas Medical Cenier, 4301 W. Markham, Little Rock, Arkansas 72201.
900
Volume 124 Number 8
ligation, all abdominal deliveries from January 1, 1970, through December 31, 1974, were teviewed (Table I). During the study period there were 13,568 deliveries, of which 1,388 were abdominal deliveries on patients of more than 28 weeks' gestation ( 10 per cent cesarean section rate). Operations resulting in sterilization were performed on 1,047 patients (7.7 per cent). Fifty-four cesarean and cesarean tubal ligation records and one cesarean hysterectomy patient record were incomplete and not included in these data. There were no deaths or prolonged hospitalizations in the group that was not reviewed. Cesarean sections performed for vaginal bleeding were reviewed, classified as emergency, and excluded from the cesarean section study group; therefore, 806 elective cesarean section and 207 elective cesarean and tubal ligation patient records were studied. A total of 257 cesarean hysterectomies were performed (18.5 per cent of abdominal deliveries) during the 5 year period of study. Twelve hysterectomies performed for bleeding were classified as emergency operations and excluded from this study as were two radical hysterectomies for invasive cervical cancer and one patient whose record was not available for study. Complications and results of 242 elective cesarean hysterectomies will, therefore, be compared with 806 elective cesarean sections and 207 elective cesarean sections with tubal ligation. The number of requests for surgical sterilization has increased dramatically in recent years. Due to limited operating time, postpartum tubal ligations are performed selectively. Thirtyfive per cent of patients undergoing an elective cesarean section received a procedure that resulted in sterilization; 207 ( 17 per cent) tubal ligations and 242 (18 per cent) hysterectomies were performed. Fiftyfour per cent of procedures resulting in sterilization in conjunction with cesarean section were hysterectomies. Prenatal care and preoperative preparation. Approximately 50 per cent of our patients reside in the metropolitan area and the remainder are referred from throughout the state. During prenatal care, most patients received an interview concerning child spacing and family planning. If surgical sterilization was requested, a complete explanation was provided by the Public Health Nurse which included illustrations of the various procedures, i.e., postpartum tubal ligation or, if elective cesarean section was indicated, tubal ligation or hysterectomy. If uterine pathology existed which should be treated by hysterectomy, the patient was so counseled by the physician. During the last 3 years of the study, patients found to have a positive cervical cytologic smear either prior to or during pregnancy were evaluated by colposcopy. If the lesion was
Elective cesarean hysterectomy
901
Table I. Deliveries, 1970 to 1974 Years 1970
Total
Total 2,826 2,851 2,746 2,511 2,634 13,568 deliveries Abdominal 299 252 264 294 279 1,388 deliveries 167 154 806 151 168 166 Elective cesarean section 18 14 64 11 12 9 Emergency cesarean section 14 31 207 Cesarean 37 57 68 tubal ligation 583 72 166 122 167 Postpartum 56 tubal ligation 47 243 Elective 49 71 46 30 cesarean hysterectomy 0 3 12 3 4 Emergency 2 cesarean hysterectomy 0 2 Radical 0 0 cesarean hysterectomy
completely visualized and the examiner was confident that the cervix had been adequately evaluated and biopsied, diagnostic conization was not recommended. If indicated, cervical conization was performed during the second or early third trimester. Also, during the last 3 years, fetal maturity was estimated on all patients scheduled for elective cesarean section by performance of an outpatient amniocentesis and determination of a lecithin/sphingomyelin ratio. When fetal maturity was demonstrated, the elective operative procedure was scheduled accordingly. Appropriate sterilization papers were completed by the patient and her husband during the prenatal period. After admission to the hospital, patients who were scheduled for a sterilization procedure, either in conjunction with cesarean section or by postpartum tubal ligation, were interviewed by the Chief Resident in Obstetrics. Institutional sterilization papers were completed and approved by a staff physician, who usually interviewed all patients who had elected hysterectomy for sterilization or definitive treatment of uterine pathology. Routine preoperative studies were completed and two to four units of whole blood were typed and cross-matched. Vaginal preparation was not routinely carried out. Age. The age distribution of each group of patients is outlined in Table II. Approximately 15 per cent of patients who deliver on our service each year are age
902
Barclay et al. Am.
Table II. Age distribution No. of patients
Age
45 Total
Cesarean hysterectomy ()
21 70 (ill
41
29 13
Cesarean tubal ligation
95 421 1911
53 22 16 I
2 43 78 3.1 25 13 10
Total
97 48.5 346 !56 88 58 24
0
()
]
I
242
806
207
1,255
Cesarean tubal ligation
Total
Table III. Parity distribution Parity ()
I
2
3 4
5 6 or> Total
Cesarean hysterectomy
5 21 60 49 :l3 22
447 240 63 22 14
52 242
14 806
6
8 68 67 20 9 12 23
207
460 329 190 91 56 40 89 1,255
16 or less and one third are 18 or less, of which approximately 10 per cent are multiparas. Ninety-five elective cesarean sections were performed on patients less than 16 years of age; two patients, para one or two, received a medically indicated tubal ligation. The incidence of procedures resulting in sterilization increased from 13 per cent of those in the 16 to 20 year age group to 96 per cent of women over age 40. The incidence of hysterectomy increased from 20 per cent of elective cesarean sections in the 21 to 25 year age group to 51 per cent of patients over age 36. Parity. Parity was defined as the number of deliveries prior to the pregnancy under consideration. The parity distribution of each group of patients is indicated in Table III. Eight para 0 patients received a medically indicated tubal ligation for the following reasons: heart disease, four; diabetes, three; hemoglobinopathy, one. Indications for hysterectomy performed on five para 0 patients were medically indicated sterilization (three), large degenerating uterine fibroids (one), and one patient was over 40 years of age and elected hysterectomy for sterilization. A tubal ligation was performed on 21 per cent and hysterectomy on 6 per cent of para 1 patients. Among para 2 patients, 35 per cent received a tubal ligation and 32 per cent a hysterectomy. Parity of 3 or greater
J
April l.'i. l9i6 Obstet. Gyneml.
was recorded for 276 patients; 23 per cent of these patients received a tubal ligation and 57 per cent a hysterectomy, which was often performed for uterine pathology. Operative procedure. Atropine was administered as a drying agent. Spinal or epidural anesthesia was used as the primary anesthetic in 85 per cent of elective cesarean sections and a local anesthetic was used in 2 per cent. General anesthesia was used as a primary anesthetic in 13 per cent and as a secondary anesthetic in 9 per cent of cesarean section patients. A low vertical abdominal incision was generally used, although a transverse incision was not contraindicated. If hysterectomy was to be performed, the bladder flap was completely developed prior to incising the uterus; the presence of adhesions often required sharp dissection which was performed more easily if the fetal head was in the lower uterine segment. The uterus was entered through a low cervical incision in 98 per cent of cesarean sections with or without tubal ligation; 73 per cent were transverse. Extension into the uterine fundus with elective cesarean section was reserved for obstetric complications such as malpresentation or an excessively large fetus. A low vertical incision was preferred with hysterectomy (95 per cent of operations), although in 22 per cent of patients the incision was extended into the fundus to facilitate delivery. A finger placed in the upper pole of a vertical incision by an assistant provided excellent traction on the uterus. Technical details of total cesarean hysterectomy have been published elsewhere. 3 • 4 All but eight of the tubal ligations were Pomeroy procedures, using plain catgut and excising a segment of Fallopian tube from each side for pathologic examination. Nine patients undergoing cesarean section with or without tubal ligation received a unilateral oophorectomy for benign ovarian pathology and six underwent ovarian cystectomy. Twenty patients (8.3 per cent) undergoing hysterectomy received a salpingooophorectomy which was unilateral for bleeding (14) or a benign cystic teratoma (one) and bilateral in five women over age 36. Appendectomy was performed during 5 cesarean sections and 16 (6.6 per cent) hysterectomies. One bilateral hypogastric artery ligation was performed during cesarean section on a patient who was bleeding from Stage II cancer of the cervix. Other operative procedures performed in conjunction with hysterectomy were removal of a wide vaginal cuff (34), lysis of adhesions (12), incisional or umbilical hernia repair (three), and Marshall-Marchetti-Krantz procedure (five). Adhesions were listed only if severe,
Elective cesarean hysterectomy
Volume 124 Number 8
903
Table IV. Number of prior cesarean sections Number of prior cesarean sections
Cesarean hysterectomy
Cesarean section
Cesarean tubal
128 43 48 17
563 209 30
60 94 46 6 1 207
None One Two Three Four or> Total
4
6
242
806
Table V. Indications for primary cesarean section Major indication
Fetopelvic disproportion Malpresentation Pre-eclampsia eclampsia Prolapsed cord Prolonged ruptured membrane Diabetes Isoimmunization Uterine fibroids Cancer cervix Fetal distress Vaginal bleeding Miscellaneous Total
Cesarean hysterectomy
Cesarean tubal
13
335
16
23
7
114 43
21 3
2 16
22 15
3 1
6
9 5 34 4 6 3
128
5 5 1 4* 6
0 7 557
6 3 0 1* 4
Percent cesarean section(%)
751 346 124
59.8 27.6 9.9 2.7
1,255
TOO
2~ }
Table VI. Associated disease Disease
Hypertension Without toxemia With toxemia Pre-eclampsia Eclampsia Chronic renal disease Rheumatic heart disease Diabetes Epilepsy Hemoglobinopathy
Cesarean hysterectomy
Cesarean tubal
10
1
4 5 134 11 4
2
3
5
14 3
10 8 4
12 2 2
13 5 9 1
1
4 11 1
2
0
2 60
*Invasive cancer of the cervix. such as fixation of the uterus to the anterior abdominal wall. Dense adhesions were lysed during 31 cesarean sections and during 15 cesarean tubal ligation operations. During cesarean section two patients required a small bowel resection because of adhesions to a prior classical uterine scar.
Indications for cesarean section A primary cesarean section was performed in 7 51 patients, which was 60 per cent of the 1,255 operations. Seventy per cent of cesarean sections, 29 per cent of cesarean tubal ligations, and 53 per cent of cesarean hysterectomies were primary cesarean sections. In 296 patients (23 per cent) an elective repeat and in 34 patients (carcinoma in situ of the cervix) an elective primary cesarean section was performed. Therefore, a scheduled operation on a nonlabor patient was performed with approximately 14 per cent of cesarean sections, 53 per cent of cesarean tubal ligation operations, and 45 per cent of cesarean hysterectomies. Primary cesarean section in 751 patients was followed by tubal ligation in 60 (8 per cent) patients and hysterectomy in 128 (17 per cent) patients. A repeat cesarean section in 504 patients was associated with
tubal ligation in 147 (29 per cent) and hysterectomy in 114 (23 per cent). A second cesarean section was performed in 346 patients; tubal ligation was performed on 94 (27 per cent) and hysterectomy on 43 ( 12 per cent) patients. The third, fourth, or fifth cesarean section on 158 patients was followed by a tubal ligation on 53 (34 per cent) and a hysterectomy on 71 (45 per cent) patients; 79 per cent of patients requested sterilization or uterine pathology warranted a hysterectomy. The number of prior cesarean sections in each group is recorded in Table IV. Indications for primary cesarean section are listed in Table V. The principal indication was listed, although multiple indications were often present. Cesarean sections performed for diabetes, isoimmunization, or pre-eclampsia were usually preceded by a trial of induction oflabor. Fetal distress or prolonged rupture of the fetal membranes often precipitated cesarean section; however, the primary disease process was listed as the indication for cesarean section. The principal associated diseases in each patient group are listed in Table VI. Vaginal bleeding from placenta previa (five) or abruptio placentae (one) was included in the hysterectomy group when the indication for hysterectomy was elective but was excluded from the other two groups. Fetopelvic disproportion and malpresentation were the most common indications for
904 Barclay et al.
Aprill5, 1':176
Am
Year 1970
Elective steri1ization Medical steri1ization Uterine pathology Carcinomain situ Uterine fibroids Amnionitis Total
38
55
Total
5
12
6
4
2 2 3
I
49
7T
39
18
15
165
8
0
26
7
20
14
51
5
17
9
34
2
3
47
46
9 4 29
8 242
Table VIII. Preoperative and postoperative mean hematocrit values ± 1 S.D. Patients
Cesarean hyswrectomy
All patients Preoperative Postoperative Not transfused Preoperative Postoperative Transfused Preoperative Postoperative
(N = 242) 35.6 ± 3.5 32.9 ± 4.2 (N = 195) 36 ± 3.2 32.5 ± 4.13 (N = 47) 33.8 ± 4.24 31.0 ± 4.09
Cesarean tubal
= 806) 36 ± 4.3 32.9 ± 4.1 (N = 777) 35.8 ± 5.9 32.5 ± 5.7 (N = 29) 32.14±5.3 30.17±3.2 (N
Obstet.
