American Journal of
Obstetrics and Gynecology volume 13.5 number 4
CLINICAL
This stection reports opinion diagnosis and management kight to twenty typed pages, ify the author’s management. Frederick P. Zuspan, M.D.,
OCTOBER
15,1979
OPINION
on the handling of clinical situations, i.e., the clinical of certain disease entities. Papers should range from including illustrations, tables, and figures which clarReferences are limited to sixteen citations. Mail to Editor.
Modern indications for cesarean section LEON
I.
MANN,
JANICE
GALLANT,
Burlin@on,
Verkont
M.D. P.A.-C.
Total cesarean sectibn rates and rates of various indications for primary cesaiean section were reviewed for four yearly periods during the past decade. The time periods studied were chosen to follow the introduction of new obstetric practices and techndlogic advances in monitoring fetal condkon. The total cesarean section rate increased from 6.8% to 17.1% during this time. The most common ir@kation for primary cesarean sect& was cephalopelvic disproportion, which represented approximately 40% of cases durina each study period. Primary cesarean section for fetal distress increased to 28.2% but has decreased over the past 2 years to a present rate of 11.7%. Primary cesarean section for breech presentation increased from 12.3% to 21%. From the perspective of this review a total cesarean section rate of 15% is predicted for the futtire. (Ati. J. OBSTET. GYNECOL. 135437,
1979.)
N E v E R B EFO RE has thle practice of medicine beei subject to surveillance by consumer and government groups as at the present time. Both groups are questioning our practice procedures and demanding costbenefit and scienlific justification before application of our technologic adva’i-ices. Nowhere is this more eviFrom the Department College of Medicine,
of Obstetrics and Gynecology, University of Vertiont.
Reprint requests: L.eon I. Mann, M.D., Department of Obstetrics and Gynecology, Universi~ of Vermont College of Medic&e, Burlington, Vermont 05401. 0002-9378/79/200437+05$00.50/0~
1979 The C.V.Mosby
Co.
dent than in the field of obstetrics, where fetal monitoring has become almost routine and cesarean section rates approaching 25% are suggested.’ Instead of SC;entifically based studies to support and confirm the reduction in mortality and morbidity rates that result from these technologic advances, studies which are poorly controlled and show no improvement are widely publicized and discussed. Whether the incidence of home delivery is 3% or 507’6, no patient should choose this alternative because of a lack of confidence and trust in the hospital and i;s staff. Our response must be 437
‘Fable 1. N~:~:ms ___l~
of deliveries
and cesarean section rates cesarean sections
-
Primary
cesarean sections
3tuq penoil
ii69-12169 s173-6174 T/76-6177 7177-6i78
2,388 1,768 1,910 1,851
6.8 13.7
17.1 17.1
163 242 325 317
4.4 9.6 12.5
11.1
.3 :2:-ei’111 d:idjvA of our most recent advances and a cicar presentation of their risks and benefits. We must n3t be guilty of practicing de~e~ivr medicine but be able ;G support our practices from carefully performed ::vaiuations. Where support is not documented, reeval!i,ition and revision are necessary. it is the purpose of this paper to evaluate the changtr:g trends in indications for cesarean section. This has !>cen accomplished by reviewing cesarean section rates ,illd indications din-ing four time periods over the past decade. Each time period represented a change in de;,artmental policy or procedure that reflected current cbbstetric opinion and technologic advances. The results :i:e presented and a clinical opinion is expressed. tudy
106 170 238 206
65.0 70.2 73.2 65.0
2.4 4.1 4.6 5.0
57 72 87 ?!I
35.0 29.8 “6.8 35.0
orc progress but ex&ding breech and ,?L;XI rna!p:rserrtations and malpositions, were grouped under- cepha-Iopeivic disproportion. Fetal distress %&asdefined differently throughout the study periods. In the first tMo study periods it was defined primarii)by FHR drcelerations by clinical auscultation and/or meconium. ln the 19761977 period fetal distress eras defined b! FHR-UC patterns and during the past tear by FSE-yH determinations when possibie. The perinatal mortaiiq rate is presented as the number of deaths of‘ infanrs weighing more than 1,000 grams through ttic first 28 days of life/ 1,000 totai births. Statistical significance of differences was calculated by appropriate comparisorl of means and expressed in terms of probability P values.
8 and methods
?atient charts for four time periods were reviewed. 1’1~ time periods extend from July through June except for the 12 month period in 1969 which was frdm januar-J- through December. In 1969 the Perinatal Cen:er had not heen established at the University of Verlr;ont Cnliege of Medicine and fetal heart rate-uterine ~.ont;.action (FHR-UC) monitoring was performed by ,iinical auscuitation. In the 1973-1974 period, re;ionalization of neonatal intensive care was firmly es:ab!ished and maternal fetal medicine was initiated. F‘HR-UC monitoring was used in approximately 25%, e.),’patients. During the 1976-1977 period the Maternal i+etal Medicine Service came under new direction, :iansport of maternal-fetal problems was more com:~:on, F‘HR-L’C monitoring was utilized in over 50% of i&ents. and fetal scalp blood pH (FSB-pH) determimtions were initiated. By the most recent period, ‘977-1978, a regional perinatal center was firmly es,a!~lished. FHR-UC monitoring was used in approxi:natcIy 45% of the patients, and FSB-pH determinaIons were performed for ominous decelerations when ;>ossible (approximately 20% of patients were moni:c>red). In delermining the indication for cesarean sec:;on where multiple indications existed, the one most i~heiy to result in cesarean section by itself was utilized. ill dystocia problems, including uterine inertia or lack
Total primary and repeat ~e~area~ section rates. The number of deliveries and total pr:mary and repeat cesarean section rates are shown in ~l‘ilbk I. The percentage of total deliveries resulting in cesarean section increased from 6.8% in 1969 to 17.1% during the period 1976-1977. There was no further increase in the cesarean section rate during 1977-1978. The primary cesarean section rate increased almost threefold from 4.4% to 12.5%’ from 1969 through June, 1977. During 1977-1978 the primary rate decreased insignificantly to 11.1%. The repeat cesareac section rate nearly doubled from 1969 through June, 1977, and increased further to 6.0% during 1977-197X. The trend in percentage of cesarean section by primar!, or repeat indications fo!lows the figures presented for total deliveries. Indications for primary cesarean section. The number and percentage of primaq cesarean sections performed for various indications are shown in Table II. The absolute number and percentage of cesarean sections that were primary peaked during the period 1976-1977 and decreased slightly durirlg 1977-1978. Cephalopelvic disproportion accounted for approximately 40% of the primary sections and did not seem to differ in any significant pattern 01-c:’ the four stud)
Volume Number
Table
135 4
Modern
II. Number
and percentage
of cesarean
sections performed
Thirdtrimester bleeding
Breech
1169-12169 7173-6174 7176-6177 7177-6178
106 170 238 206
44 69 79 87
41.6 40.7 33.2 42.2
17 48 58 24
16.0 28.2 24.4 11.7
No.
7%
13 30 50 45
12.3 17.6 21.0 21.8
periods. The prilmary cesarean section rate for fetal distress increased significantly during 1973-1974, decreased slightly in 1976-1977, and then was halved significantly to a rate of 11.7% during 1977-1978. Breech as an indicatio’n for primary cesarean section increased significantly from 12.3% during 1969 to 21% in the 1976-1977 period and has remained stable over the last year. Third-trimester bleeding and malpresentations and malpositions did not vary significantly over the time period studied. The number of patients having a primary cesarean. section for failed Pitocin induction increased almost threefold, from 2.8% to 6.3%, over the past 9 years. The miscellaneous category, which includes prolapsed cord, previous uterine surgery, severe erythroblastosis, active herpes, and others, did not show a trend over the periods studied.
Comment It is difficult to determine what the proper cesarean section rate is for a particular institution. With the trend toward regionalization of perinatal care and referral of high-risk ob:stetric patients, cesarean section rates for the tertiary-care centers should theoretically rise while those of the referring hospitals should decrease. The character of the patient population served would also influence the cesarean section rate by factors such as parity, age, and socioeconomic status. The p&natal mortality rate and the long-term morbidity should decrease as the cesarean section rate rises if we are to justify the increased cesarean section rate. It is difficult to isolate cesarean section from other changes in obstetric practice and technologic advances that have occurred and complicate the analysis. It must also be considered that an increase in the primary cesarean section rate for a period of time will result in an increase in the repeat section rate in succeeding years, even though the primary rate may have decreased. An analysis of trends in scesarean section rates must look, therefore, at the indications for primary cesarean section and the question of repeat section vs. vaginal delivery in future pregnancies. A professional activity study (PAS) performed by the
for various
indications
for cesarean
Malpresent&ion, malposition
Failed Pitocin
Miscel-
laneou.5
%
No.
%
No.
%
14
13.2 6.5 9.7 8.3
; 12 9
47 1:2 5.0 4.4
3 5
2.8 2.9 4.2 6.3
23 17
439
reasons
No.
11
section
Table III. Projected by indication
cesarean
10 13
No.
%
10
9.4
:
2.9 2.5 5.3
11
section rates
/ RePeat
6.0
Primary:
Cephalopelvic disproportion Fetal distress Ereech Third-trimester bleeding Malpresentation and malposition Failed Pitocin induction BAiscellaneous Total cesarean section rate
4.7
1.3 0.9 0.9 0.5 0.5
0.5 15.3
Commission on Hospital Activities reported that cesarean section as a percentage of all deliveries from 124 PAS hospitals from 1967-1974 increased from 5.2% to 10.0%.2 This represented a 92.3% increase in the percentage of deliveries by cesarean section. For large hospitals the range was from 3.8% to 16.6%. This study did not attempt to differentiate large from small hospitals in terms of the pattern of referral of high-risk obstetric patients. At the Medical Center Hospital of Vermont (MCHV) the cesarean section rate has increased 2% times from 6.8% to 17.1% during the past 9 years. The primary cesarean section rate tripled from 4.4% to 12.5%. These trends are quite similar to those reported from other institutions that function as a perinatal referral center.3, 1 If the present downward trend in primary cesarean section continues, the total cesarean section rate should stabilize. A further reduction in the total cesarean section rate would depend on an institutional policy of delivering women who have had previous sections by the vaginal route. This policy has in fact been gaining momentum as our own experience and that of others indicates that, with close observation of mother and fetus by modern monitoring techniques, “once a section always a section” may not be warranted. The analysis of the trend in primary cesarean section indications showed little if any change in the areas of cephalopelvic disproportion, third-trimester bleeding,
mdipreseiiciixm and maiposrtio!i, and :he miscclla:~roi;s category. Approximately 40% of the prirnary cesarean sections performed were done because of cephalopelvic disproportion. These rates are similar to :;2ose presented from other institutions and would be rmlikely to be influenced in the future unless vacuum rotation and traction to an easy outlet forceps delivery gains acceptance in American obstetrics. Third-trmester bleeding problems that require primary cesar,oan section are obstetric emergencies which are difiicult to predict and manage otherwise. Expectant management of placenta previa has resulted in improved perinatal salvage by prolonging fetal lung matliration but has not decreased the incidence of cesarean section for this problem. Fetal distress as an indication for prim;iry cesarean section has contributed significantly to the increased rate of cesarean section. Of major significance from the present study is the direct correiation of an increase in the primary cesarean section rate for fetal distress with :he introduction of FHk-UC monitoring. Of greater significance; however, is the reduction in this rate from 24.4% to 11.7% when FSB-pH determinations were performed when ominous decelerations were noted.“. ti The 11.7% rate for primary cesarean section due to fetal distress (1.3%, of total deliveries) in the last year of study was the lowest rate recorded in a decade in this institution. As other institutions institute FSB-pH determinations for objective evaluation of fetal distress, the primary cesarean section rate for this indication should decrease proportionately. The increased rate of cesal-ean section for breech presentations has also contributed significantly to the increased totai cesarean section rate in most institutions. The paucity of adequately controlled or even carefully screened retrospective studies to support the suggestion made by some that all breeches should be deiivered by cesarean section is appalling. In a recent clinical opinion presented from review of cases, albeit re:rospectively, we could not find an improved perinatal mortality rate for the breech presentation delivered by cesarean section in contrast to vaginal delivery in other than the 1,000 to 1,500 grams category.’ From 1969 through 1977 in this institution, the primary cesarean section rate for breech presentation increased irom 12.3% to 21.0%. During the past year ofstudy the raze plateaued and, it is hoped. will decline over succeeding years as our attendings return to sectioning for determined fetal-pelvic disproportion, hyperextended head, or other specific factors. The primary cesarean section rate for failed Pitocin induction doubled over the 7ears of study but contribured, in absolute numbers, only a few cases, These patients represent medical complications of pregnancy,
5tich
ds sewre
&abticr
, ,ilKi
!I,$ pYle.l=Al:i
3L xliier;ib
with premature rupture of membraws ~6ho mr:st be Lielivered and in whom Pitocin inducrion has f’ailed. Future predictions for cesarean section rates can be ~eimously developed from analyses of trends during the past decade. With the use of the classification of mdications presented in this study, the experience gained from this analysis, and an assumption as to FLJLure management of the breech, cesarean section raps can be calculated (‘Fable III). The figures used for breech presentations assume an incidence of breech of. 3% with a 30% primary cesarean section rate, The hgure for fetal distress assumes that caiculation from 3ur institution for the year 1977-1978 Gil continl:e. A primary cesarean section rate of approximately 9.3% and a repeat cesarean section rate of 6% will resulr in a :utal cesarean section rate of approximately 15%. With rhese figures it cou!d be predicted that approximately 60% of a!1 cesarean sections jvould be performed for primary indications. A reduction in thk predicted total cesarean section rate could be accomplished by careful :,eexamination of the need for repeat cesearean section in all situations. The safety of vaginal delivery following a previous cesarean section must be studied and ai?aly-zed carefully in the near future. The reduction in perinatal mortali:y rates recorded o\er the past decade in C)LII- instiiutior! to a present rate of 9.8/1,000 total births of infants weighing more than !,OOO grams has occurred o\‘er a time period when obstetric practice and management have changed dramatically. How much of this decline in the perimtai mortality rate can be attributed to tbe increased rate of Lesarean section is difficult to say. Improved training and experience in maternal-fetal medicine, establish-merit of regional perinataf care and centers, dramatic improvement in the care of neonates in neonatal in:ensive-care units, development of noninvasive rechcliques for evaluating fetal matilrity and condition, ail these result in a m&variant problem which eludes exact statistical analysis. Long-term morbidity in term.s of developmental disabilities seems to be decreasing for the more severe forms oi cerebral damage, while the more rninor forms of minimai brain d!;sfunction seem to be increasing as diagnostic techniques, and therefore identification of such children, have been improved h; intensive research programs. It seems evident that more infants are surviving the perinatal period and rhat the quality of their life has been significantly improved. We cannot comh~de that these improvements in perinataloutcome are a direct result of a more liberal use of cesarean secf,ion. Vaginal delivery remains the safest method of delivery for mother and child and :)nly after increased risk has been carefully riocumented should a cesarean section be perform&
Volume Number
135 4
Modern
REFERENCES
1. Jones, 0. H.: Gesarean section in present-day obstetrics: Presidential address, AM. J. OBSTET. GYSECOL. 126:521, 1976. 2. Slee, U. N. editor: PAS Reporter: Caesarean sections in U. S. PAS Hospitals, 14: 1976. 3. Hibbard, L. T.: Changing trends in cesarean section, Arvt. J. OBSTET. GYNECOL. 125:798, 1976. 4. Haddad, H., and Lundy, L. E.: Changing indications for cesarean section-A 3%year experience at a community hospital, Obstet. Gynecol. 51:133, 1978.
Information
indications
for cesarean
section
441
5. Tejani, N., Mann, L. I. Bhakthavathsalan, i\., et. al.: Correlation of FHR-UC patterns with fetal scalp blood pH, Obstet. Gynecol. 46:392, 1975. 6. Tejani. N., Mann, L. I., and Bhakthavathsalan, A.: Correlation of FHR-UC patterns and fetal pH with neonatal outcome, Obstet. Gynecol. 48:460, 1976. 7. Mann, L. I., and Gallant, J, M.: Modern management of the breech delivery, AM. J. OBSTET. GYNECOL. (in press.)
for authors
MOSI. of the provisions of the Copyright Act of 1976 became effective on January 1. 1978. Therefore, all manuscripts must be accompanied by the following written statement, signed by one author: “The undersigned author transfers all copyright ownership of the manuscript (title of article) to The C. V. Mosby Company in the event the work is published. The undersigned author warrants that the article is original, is not under consideration by another journal, and has not been previously published. I sign for and accept responsibility for releasing this material on behalf of any and all co-authors.” Authors will be consulted, when possible, regarding republication of their material.
Obstetrics and Gynecology volume 13.5 number 4
CLINICAL
This stection reports opinion diagnosis and management kight to twenty typed pages, ify the author’s management. Frederick P. Zuspan, M.D.,
OCTOBER
15,1979
OPINION
on the handling of clinical situations, i.e., the clinical of certain disease entities. Papers should range from including illustrations, tables, and figures which clarReferences are limited to sixteen citations. Mail to Editor.
Modern indications for cesarean section LEON
I.
MANN,
JANICE
GALLANT,
Burlin@on,
Verkont
M.D. P.A.-C.
Total cesarean sectibn rates and rates of various indications for primary cesaiean section were reviewed for four yearly periods during the past decade. The time periods studied were chosen to follow the introduction of new obstetric practices and techndlogic advances in monitoring fetal condkon. The total cesarean section rate increased from 6.8% to 17.1% during this time. The most common ir@kation for primary cesarean sect& was cephalopelvic disproportion, which represented approximately 40% of cases durina each study period. Primary cesarean section for fetal distress increased to 28.2% but has decreased over the past 2 years to a present rate of 11.7%. Primary cesarean section for breech presentation increased from 12.3% to 21%. From the perspective of this review a total cesarean section rate of 15% is predicted for the futtire. (Ati. J. OBSTET. GYNECOL. 135437,
1979.)
N E v E R B EFO RE has thle practice of medicine beei subject to surveillance by consumer and government groups as at the present time. Both groups are questioning our practice procedures and demanding costbenefit and scienlific justification before application of our technologic adva’i-ices. Nowhere is this more eviFrom the Department College of Medicine,
of Obstetrics and Gynecology, University of Vertiont.
Reprint requests: L.eon I. Mann, M.D., Department of Obstetrics and Gynecology, Universi~ of Vermont College of Medic&e, Burlington, Vermont 05401. 0002-9378/79/200437+05$00.50/0~
1979 The C.V.Mosby
Co.
dent than in the field of obstetrics, where fetal monitoring has become almost routine and cesarean section rates approaching 25% are suggested.’ Instead of SC;entifically based studies to support and confirm the reduction in mortality and morbidity rates that result from these technologic advances, studies which are poorly controlled and show no improvement are widely publicized and discussed. Whether the incidence of home delivery is 3% or 507’6, no patient should choose this alternative because of a lack of confidence and trust in the hospital and i;s staff. Our response must be 437
‘Fable 1. N~:~:ms ___l~
of deliveries
and cesarean section rates cesarean sections
-
Primary
cesarean sections
3tuq penoil
ii69-12169 s173-6174 T/76-6177 7177-6i78
2,388 1,768 1,910 1,851
6.8 13.7
17.1 17.1
163 242 325 317
4.4 9.6 12.5
11.1
.3 :2:-ei’111 d:idjvA of our most recent advances and a cicar presentation of their risks and benefits. We must n3t be guilty of practicing de~e~ivr medicine but be able ;G support our practices from carefully performed ::vaiuations. Where support is not documented, reeval!i,ition and revision are necessary. it is the purpose of this paper to evaluate the changtr:g trends in indications for cesarean section. This has !>cen accomplished by reviewing cesarean section rates ,illd indications din-ing four time periods over the past decade. Each time period represented a change in de;,artmental policy or procedure that reflected current cbbstetric opinion and technologic advances. The results :i:e presented and a clinical opinion is expressed. tudy
106 170 238 206
65.0 70.2 73.2 65.0
2.4 4.1 4.6 5.0
57 72 87 ?!I
35.0 29.8 “6.8 35.0
orc progress but ex&ding breech and ,?L;XI rna!p:rserrtations and malpositions, were grouped under- cepha-Iopeivic disproportion. Fetal distress %&asdefined differently throughout the study periods. In the first tMo study periods it was defined primarii)by FHR drcelerations by clinical auscultation and/or meconium. ln the 19761977 period fetal distress eras defined b! FHR-UC patterns and during the past tear by FSE-yH determinations when possibie. The perinatal mortaiiq rate is presented as the number of deaths of‘ infanrs weighing more than 1,000 grams through ttic first 28 days of life/ 1,000 totai births. Statistical significance of differences was calculated by appropriate comparisorl of means and expressed in terms of probability P values.
8 and methods
?atient charts for four time periods were reviewed. 1’1~ time periods extend from July through June except for the 12 month period in 1969 which was frdm januar-J- through December. In 1969 the Perinatal Cen:er had not heen established at the University of Verlr;ont Cnliege of Medicine and fetal heart rate-uterine ~.ont;.action (FHR-UC) monitoring was performed by ,iinical auscuitation. In the 1973-1974 period, re;ionalization of neonatal intensive care was firmly es:ab!ished and maternal fetal medicine was initiated. F‘HR-UC monitoring was used in approximately 25%, e.),’patients. During the 1976-1977 period the Maternal i+etal Medicine Service came under new direction, :iansport of maternal-fetal problems was more com:~:on, F‘HR-L’C monitoring was utilized in over 50% of i&ents. and fetal scalp blood pH (FSB-pH) determimtions were initiated. By the most recent period, ‘977-1978, a regional perinatal center was firmly es,a!~lished. FHR-UC monitoring was used in approxi:natcIy 45% of the patients, and FSB-pH determinaIons were performed for ominous decelerations when ;>ossible (approximately 20% of patients were moni:c>red). In delermining the indication for cesarean sec:;on where multiple indications existed, the one most i~heiy to result in cesarean section by itself was utilized. ill dystocia problems, including uterine inertia or lack
Total primary and repeat ~e~area~ section rates. The number of deliveries and total pr:mary and repeat cesarean section rates are shown in ~l‘ilbk I. The percentage of total deliveries resulting in cesarean section increased from 6.8% in 1969 to 17.1% during the period 1976-1977. There was no further increase in the cesarean section rate during 1977-1978. The primary cesarean section rate increased almost threefold from 4.4% to 12.5%’ from 1969 through June, 1977. During 1977-1978 the primary rate decreased insignificantly to 11.1%. The repeat cesareac section rate nearly doubled from 1969 through June, 1977, and increased further to 6.0% during 1977-197X. The trend in percentage of cesarean section by primar!, or repeat indications fo!lows the figures presented for total deliveries. Indications for primary cesarean section. The number and percentage of primaq cesarean sections performed for various indications are shown in Table II. The absolute number and percentage of cesarean sections that were primary peaked during the period 1976-1977 and decreased slightly durirlg 1977-1978. Cephalopelvic disproportion accounted for approximately 40% of the primary sections and did not seem to differ in any significant pattern 01-c:’ the four stud)
Volume Number
Table
135 4
Modern
II. Number
and percentage
of cesarean
sections performed
Thirdtrimester bleeding
Breech
1169-12169 7173-6174 7176-6177 7177-6178
106 170 238 206
44 69 79 87
41.6 40.7 33.2 42.2
17 48 58 24
16.0 28.2 24.4 11.7
No.
7%
13 30 50 45
12.3 17.6 21.0 21.8
periods. The prilmary cesarean section rate for fetal distress increased significantly during 1973-1974, decreased slightly in 1976-1977, and then was halved significantly to a rate of 11.7% during 1977-1978. Breech as an indicatio’n for primary cesarean section increased significantly from 12.3% during 1969 to 21% in the 1976-1977 period and has remained stable over the last year. Third-trimester bleeding and malpresentations and malpositions did not vary significantly over the time period studied. The number of patients having a primary cesarean. section for failed Pitocin induction increased almost threefold, from 2.8% to 6.3%, over the past 9 years. The miscellaneous category, which includes prolapsed cord, previous uterine surgery, severe erythroblastosis, active herpes, and others, did not show a trend over the periods studied.
Comment It is difficult to determine what the proper cesarean section rate is for a particular institution. With the trend toward regionalization of perinatal care and referral of high-risk ob:stetric patients, cesarean section rates for the tertiary-care centers should theoretically rise while those of the referring hospitals should decrease. The character of the patient population served would also influence the cesarean section rate by factors such as parity, age, and socioeconomic status. The p&natal mortality rate and the long-term morbidity should decrease as the cesarean section rate rises if we are to justify the increased cesarean section rate. It is difficult to isolate cesarean section from other changes in obstetric practice and technologic advances that have occurred and complicate the analysis. It must also be considered that an increase in the primary cesarean section rate for a period of time will result in an increase in the repeat section rate in succeeding years, even though the primary rate may have decreased. An analysis of trends in scesarean section rates must look, therefore, at the indications for primary cesarean section and the question of repeat section vs. vaginal delivery in future pregnancies. A professional activity study (PAS) performed by the
for various
indications
for cesarean
Malpresent&ion, malposition
Failed Pitocin
Miscel-
laneou.5
%
No.
%
No.
%
14
13.2 6.5 9.7 8.3
; 12 9
47 1:2 5.0 4.4
3 5
2.8 2.9 4.2 6.3
23 17
439
reasons
No.
11
section
Table III. Projected by indication
cesarean
10 13
No.
%
10
9.4
:
2.9 2.5 5.3
11
section rates
/ RePeat
6.0
Primary:
Cephalopelvic disproportion Fetal distress Ereech Third-trimester bleeding Malpresentation and malposition Failed Pitocin induction BAiscellaneous Total cesarean section rate
4.7
1.3 0.9 0.9 0.5 0.5
0.5 15.3
Commission on Hospital Activities reported that cesarean section as a percentage of all deliveries from 124 PAS hospitals from 1967-1974 increased from 5.2% to 10.0%.2 This represented a 92.3% increase in the percentage of deliveries by cesarean section. For large hospitals the range was from 3.8% to 16.6%. This study did not attempt to differentiate large from small hospitals in terms of the pattern of referral of high-risk obstetric patients. At the Medical Center Hospital of Vermont (MCHV) the cesarean section rate has increased 2% times from 6.8% to 17.1% during the past 9 years. The primary cesarean section rate tripled from 4.4% to 12.5%. These trends are quite similar to those reported from other institutions that function as a perinatal referral center.3, 1 If the present downward trend in primary cesarean section continues, the total cesarean section rate should stabilize. A further reduction in the total cesarean section rate would depend on an institutional policy of delivering women who have had previous sections by the vaginal route. This policy has in fact been gaining momentum as our own experience and that of others indicates that, with close observation of mother and fetus by modern monitoring techniques, “once a section always a section” may not be warranted. The analysis of the trend in primary cesarean section indications showed little if any change in the areas of cephalopelvic disproportion, third-trimester bleeding,
mdipreseiiciixm and maiposrtio!i, and :he miscclla:~roi;s category. Approximately 40% of the prirnary cesarean sections performed were done because of cephalopelvic disproportion. These rates are similar to :;2ose presented from other institutions and would be rmlikely to be influenced in the future unless vacuum rotation and traction to an easy outlet forceps delivery gains acceptance in American obstetrics. Third-trmester bleeding problems that require primary cesar,oan section are obstetric emergencies which are difiicult to predict and manage otherwise. Expectant management of placenta previa has resulted in improved perinatal salvage by prolonging fetal lung matliration but has not decreased the incidence of cesarean section for this problem. Fetal distress as an indication for prim;iry cesarean section has contributed significantly to the increased rate of cesarean section. Of major significance from the present study is the direct correiation of an increase in the primary cesarean section rate for fetal distress with :he introduction of FHk-UC monitoring. Of greater significance; however, is the reduction in this rate from 24.4% to 11.7% when FSB-pH determinations were performed when ominous decelerations were noted.“. ti The 11.7% rate for primary cesarean section due to fetal distress (1.3%, of total deliveries) in the last year of study was the lowest rate recorded in a decade in this institution. As other institutions institute FSB-pH determinations for objective evaluation of fetal distress, the primary cesarean section rate for this indication should decrease proportionately. The increased rate of cesal-ean section for breech presentations has also contributed significantly to the increased totai cesarean section rate in most institutions. The paucity of adequately controlled or even carefully screened retrospective studies to support the suggestion made by some that all breeches should be deiivered by cesarean section is appalling. In a recent clinical opinion presented from review of cases, albeit re:rospectively, we could not find an improved perinatal mortality rate for the breech presentation delivered by cesarean section in contrast to vaginal delivery in other than the 1,000 to 1,500 grams category.’ From 1969 through 1977 in this institution, the primary cesarean section rate for breech presentation increased irom 12.3% to 21.0%. During the past year ofstudy the raze plateaued and, it is hoped. will decline over succeeding years as our attendings return to sectioning for determined fetal-pelvic disproportion, hyperextended head, or other specific factors. The primary cesarean section rate for failed Pitocin induction doubled over the 7ears of study but contribured, in absolute numbers, only a few cases, These patients represent medical complications of pregnancy,
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with premature rupture of membraws ~6ho mr:st be Lielivered and in whom Pitocin inducrion has f’ailed. Future predictions for cesarean section rates can be ~eimously developed from analyses of trends during the past decade. With the use of the classification of mdications presented in this study, the experience gained from this analysis, and an assumption as to FLJLure management of the breech, cesarean section raps can be calculated (‘Fable III). The figures used for breech presentations assume an incidence of breech of. 3% with a 30% primary cesarean section rate, The hgure for fetal distress assumes that caiculation from 3ur institution for the year 1977-1978 Gil continl:e. A primary cesarean section rate of approximately 9.3% and a repeat cesarean section rate of 6% will resulr in a :utal cesarean section rate of approximately 15%. With rhese figures it cou!d be predicted that approximately 60% of a!1 cesarean sections jvould be performed for primary indications. A reduction in thk predicted total cesarean section rate could be accomplished by careful :,eexamination of the need for repeat cesearean section in all situations. The safety of vaginal delivery following a previous cesarean section must be studied and ai?aly-zed carefully in the near future. The reduction in perinatal mortali:y rates recorded o\er the past decade in C)LII- instiiutior! to a present rate of 9.8/1,000 total births of infants weighing more than !,OOO grams has occurred o\‘er a time period when obstetric practice and management have changed dramatically. How much of this decline in the perimtai mortality rate can be attributed to tbe increased rate of Lesarean section is difficult to say. Improved training and experience in maternal-fetal medicine, establish-merit of regional perinataf care and centers, dramatic improvement in the care of neonates in neonatal in:ensive-care units, development of noninvasive rechcliques for evaluating fetal matilrity and condition, ail these result in a m&variant problem which eludes exact statistical analysis. Long-term morbidity in term.s of developmental disabilities seems to be decreasing for the more severe forms oi cerebral damage, while the more rninor forms of minimai brain d!;sfunction seem to be increasing as diagnostic techniques, and therefore identification of such children, have been improved h; intensive research programs. It seems evident that more infants are surviving the perinatal period and rhat the quality of their life has been significantly improved. We cannot comh~de that these improvements in perinataloutcome are a direct result of a more liberal use of cesarean secf,ion. Vaginal delivery remains the safest method of delivery for mother and child and :)nly after increased risk has been carefully riocumented should a cesarean section be perform&
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REFERENCES
1. Jones, 0. H.: Gesarean section in present-day obstetrics: Presidential address, AM. J. OBSTET. GYSECOL. 126:521, 1976. 2. Slee, U. N. editor: PAS Reporter: Caesarean sections in U. S. PAS Hospitals, 14: 1976. 3. Hibbard, L. T.: Changing trends in cesarean section, Arvt. J. OBSTET. GYNECOL. 125:798, 1976. 4. Haddad, H., and Lundy, L. E.: Changing indications for cesarean section-A 3%year experience at a community hospital, Obstet. Gynecol. 51:133, 1978.
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5. Tejani, N., Mann, L. I. Bhakthavathsalan, i\., et. al.: Correlation of FHR-UC patterns with fetal scalp blood pH, Obstet. Gynecol. 46:392, 1975. 6. Tejani. N., Mann, L. I., and Bhakthavathsalan, A.: Correlation of FHR-UC patterns and fetal pH with neonatal outcome, Obstet. Gynecol. 48:460, 1976. 7. Mann, L. I., and Gallant, J, M.: Modern management of the breech delivery, AM. J. OBSTET. GYNECOL. (in press.)
for authors
MOSI. of the provisions of the Copyright Act of 1976 became effective on January 1. 1978. Therefore, all manuscripts must be accompanied by the following written statement, signed by one author: “The undersigned author transfers all copyright ownership of the manuscript (title of article) to The C. V. Mosby Company in the event the work is published. The undersigned author warrants that the article is original, is not under consideration by another journal, and has not been previously published. I sign for and accept responsibility for releasing this material on behalf of any and all co-authors.” Authors will be consulted, when possible, regarding republication of their material.
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