Acta Obstet Gynecol Scand 57: 245-248, 1978
CAESAREAN SECTION A clinical study with special reference t o the increasing section rate
Eva Patek and Bertil Larsson From the Department of Obstetrics and Gynecology, Huddinge Hospital, Huddinge, Sweden
Abstract. At Huddinge University Hospital 539 Caesarean Sections (C.S.) were made among 8415 deliveries from October 1972 to June 1976, corresponding to an over all C.S. rate of 6.4%. Over these years the rate has increased from 3.5 % in 1972 to 9.7% in 1976. The main increase was due to a higher incidence of abdominal deliveries in cases of imminent fetal asphyxia. The maternal complication rate and the neonatal morbidity rate were both 6.5 times higher and the neonatal mortality rate was 4.1 times higher in emergency than in elective surgery. There was neither any mortality nor any morbidity in infants delivered by elective C.S. from healthy mothers at term.
Recently an increased rate of C.S. was reported not only in Sweden, but also in USA and West Germany (5-7). With the growing emphasis on the antenatal and intrapartum status of the fetus and with the addition of laboratory tests and technical progress of internal fetal monitoring, an increased rate of C.S. should be expected (1). However, there must be an optimal rate of C.S. in which the maternal risks are in balance with the benefits of the fetus-child. In a recent paper it was pointed out that C.S. should still be regarded as the most dangerous way of delivery, not only for the mother but also for the child (7). The aim of the present study was to evaluate the maternal risks in a series with an increasing rate of C.S. and make comparisons of the complications between emergency and elective C.S., associating them with the indications. Studies were also made of neonatal mortality and morbidity during these same conditions.
1972, when the hospital was opened, through June 1976 (Fig. 1). As shown in Fig. 1 there was a
threefold increase in the frequency of C.S. during this almost four year period. The number of children delivered by C.S. was 545, including four sets of twins and one set of triplets. In more than half of the patients (57.9%) Caesarean delivery was performed on primiparae. Several patients were sectioned twice or thrice and two four times. The patients with C.S. were 16-46 years of age with a predominance of 21-35 years (85.5%).
INDICATIONS Indications for the 525 C.S. performed from 1973June 1976 are summarized in Table I. Only the main indication for each operation was recorded. Patients with a pelvic outlet of less than 29.5 cm or between 29.5-3 1.5 cm (borderline) after X-ray pelvimetry were summarized as cephalopelvic dis-
n 250
230 210
190 170
150 130 110
FREQUENCY PARITY AGE At Huddinge University Hospital 539 C.S. (6.4%) were made among 8415 deliveries from October
4h
c s.
12 11 10 9 0 7 6 5 L 3 2 1
1
Fig. 1 . Number of deliveries every month from October 1972-June 1976 at Huddinge University Hospital. C.S. ratio in % calculated three times per year. Acta Obstet Gynecol Scand 57 f 1978)
246
E. Patek and B . Larsson
Table I. Indications for C.S. in %per year at Huddinge University Hospital I973-June I976 1973 % Vertex & cephalopelvic 37.9 disproportion Breech & cephalopel. 15.5 disprop. or premat. Fetal distress 9.7 Placenta praevia 9.7 Abruptio placentae 1.9 Prolapsed unbilical cord Diabetes mellitus 1.9 Toxaemia of pregnancy 4.9 Malpresentation Uterine anomaly or uterine scar 1.o Fetal growth retardation 1.o Dysfunction of placenta 2.9 Serious maternal disease Obstetrically old 2.9 primipara 2.9 Psychiatric indication 1.0 “Bad obstetrical history” Imminent uterine rupture 1.o Previous corporal longitudinal incision 1 .O 4.9 Uterine inertia 1.o Miscellaneous
1974 %
1975 %
1976 %
27.0
17.5
25.4
12.2 14.8 2.6 4.3 2.6 3.5 7.0 5.2
17.5 22.8 3.5 5.8 3.5 1.2 3.5 1.8
18.0 26.1 3.7 3.7
2.6 3.5 -
1.2 1.8 4.7 I .8
0.7 1.5 1.5 2.2
3.5 0.9 2.6 0.9
4.7 1.8 2.3 -
3.7 2.2 0.7 1.5
3.5
0.6 3.5 0.6
0.7 1.5 0.7
-
-
4.5 1.5
proportions (3). The same diagnosis incorporated a true conjugate of the pelvic inlet of less than 9.5 cm or a conjugate of 9.5-11 cm (borderline). Breech presentation, delivered by C.S., was always combined with either cephalopelvic disproportion or prematurity. Transverse lie, mentum-posterior and face-posterior presentations are included under the heading of malpresentations. Multiparity with a history of several intrauterine fetal deaths was registered as “bad obstetrical history”, as were cases with previous complicated deliveries.
OPERATIVE PROCEDURE Induction of anaesthesia was made with a single dose of propanid (Epontol, BAYER) followed by endotracheal intubation and maintenance of anaesthesia with nitrous oxide and oxygen plus neurolept (Dridol, LEO). Muscular relaxation was achieved by an intravenous dose of succinyl choline (Celocurin, VITRUM). Epidural anaesthesia was given 10 times. A low midline incision was made in all women except in 67 (12.4%) where the Pfannenstiel method was employed. The uterus was entered through a transverse lower segment incision. Longitudinal incisions of the uterus were made in 10 cases because of previous cervico-corporal incisions, transverse lie or placenta praevia. All patients were observed for 6-12 hours in a postoperative department and all children were taken care of by a paediatrician or by a trained anaesthetist. Additional surgery was performed in 19 cases (3.5%): Tuba1 sterilization was camed out in 12 women, unilateral oophorectomies in two cases due to benign cysts, ovarian resections in one woman for the same reason and oophorectomies plus hysterectomy in one patient because of ovarian cancer. Appendicitis was diagnosed in three women and a C.S. was made at the same time as the appendectomy.
COMPARISON BETWEEN ELECTIVE AND EMERGENCY C.S. Out of 539 Caesareans 241 were elective and 298 were made under emergency conditions. The C.S. was made earlier than the 38th gestational week and
Table 11. Complications during elective and emergency C . S . at Huddinge University Hospital, October 1972-June 1976. Neonatal mortality. Neonatal morbidity
Complications (a) Intra-operative ( b ) Post-operative I. Major complications 11. Minor complications Neonatal mortality Neonatal morbidity .Ictri Obstet Gvnecol Scond57 (1978)
Elective C.S. n =24 1=44.7 % n of infants=241
Emergency C.S. n=298=55.3% n of infants=304 4 twins, 1 triplet
(%)
(%I
0.8 2.5 0.8 1.7
0.7
] 2.5
,::I 3.3 10.9
16.5
Caesarean section
Table 111. Ten patients with major maternal complications after delivery by Caesarean Section under emergency condition at Huddinge University Hospital October 1972-June 1976 1 amnionitis+peritonitis 1 amnionitis+peritonitis+ paralytic ileus. Abscess of the
Douglas’ pouch which was incised. Wound infection I amnionitis. Relaparotomy due to abscess in the uterine wall+ileus followed by sepsis. The patient was nursed in an intensive care unit for 19 days I relaparotomy due to suspected intraabdominal haemorrhage I paralytic ileus. Relaparotomy+secondary wound revision 2 sepsis 1 peritonitis+ileus. Relaparotomy. Stenosis of tracheae post op. Secondary sut. of wound 1 intraabdominal haemorrhage. Relaparotomy followed by sepsis and serious wound infection 1 haematoma+parametritis followed by septicaemia Five of the patients with serious complications underwent relaparotomies
later than the 42nd week in 92 of the patients (17.1 %). Both intra-operative and post-operative complications were encountered. The post-operative complications have been divided into major and minor ones. Zntra-operative complications. The number of intra-operative complications was equal in both elective and emergency C.S. Three bladder injuries were encountered and were duly sutured, as was one subcutaneous haemorrhage. Post-operative complications. Major postoperative complications were only noted in emergency Caesareans (Table 111). In five of the 10 patients with such complications re-laparotomies had to be made. Minor post-operative adversities occurred in 2.5 % in the elective C.S. and in 13.1 % of the C.S. done under emergency conditions. The most common complication was fever. There was one maternal death due to severe toxaemia corresponding to a maternal mortality rate of 1.9 per thousand of all abdominal deliveries and 0.1 per thousand of all deliveries during this period of time. The patient died five weeks after a C.S. from pulmonary and cerebral abscesses and renal failure. There were ten neonatal deaths among the infants delivered by emergency C.S. corresponding to a neonatal mortality rate of 3.3%. Seven of the infants died of severe asphyxia and one of lethal congenital abnormalities. Half of the 10 neonatal deaths
247
were in the gestational age of 29-30 weeks and one in the 43rd week. Two of the infants delivered by elective surgery died during the neonatal period, corresponding to a neonatal mortality of 0.8 %. The two mothers of the infants suffered from serious pre-eclampsia. One, weighing only 800 g , was delivered in the 34th gestational week and died after a few hours from IRDS. The other baby was delivered in the 39th week, a boy weighing 1300 g, and died from Potter’s syndrome and a tentorium rupture. The registered disorders in the early neonatal period of the infants delivered by emergency C.S. was 10.9% compared with a rate of 1.7% in the elective C.S. group. All children delivered by elective surgery and suffering from disorders in the neonatal period were at term. In contrast 57.6% of the infants with neonatal morbidity in the emergency group were in the 3 1st-37th gestational week. The neonatal mortality rate for all C.S. was 2.2 % and the total neonatal morbidity rate was 6.6%. There was neither any morbidity nor any mortality of infants delivered by elective C.S. from healthy mothers at term.
DISCUSSION A threefold increase of C.S. (3.5-9.7%) has been observed at Huddinge University Hospital during the period October 1972-June 1976. This coincides with reports from several large obstetrical units in USA and Europe where a C.S. rate of 10-13% has been registered in the 1970s (4-6). A somewhat lesser rate, however, would be expected in the Scandinavian countries, where a primary C.S., for example, is not an indication for repeat Caesareans. A remarkably high frequency of C.S. in patients aged less than 20 and more than 35 has been noted by Plotho & Podesser in Austria in 1975 (8). This
Table IV. Fetal distress (asphyxia) as the main indication for C.S. October 1972-June 1976 in 103 patients (19.1 % of all C . S . performed) at Huddinge University Hospital Asphyxia
1972 3 months 1973
n
2
10 Acttr
1974
1975
1976 6 months
17
39
35
Obstet G y e c o l ScandS7 (1978)
248
E. Patek and B . Larsson
has not been our experience, but might be due to many pregnant women in these age groups demanding abortion in Sweden. In the present study both the maternal and the neonatal morbidity rate of emergency C.S. exceeded that of elective section by 6.5 times. Moreover, the neonatal mortality rate was 4.1 times higher in the emergency than in the elective C.S. group. Thus, the elective C.S. can be regarded as a fairly safe procedure both for mother and child. Fetal asphyxia as an indication for C.S. has become more common during the period investigated (Table IV). In four years 103 cases of fetal distress were noted. In 27 pregnancies (26.2% of all asphyxias) a combination of several prognostically severe indices were observed (low or falling estriol values, intrauterine growth retardation as measured by ultrasound, toxemia), In these high risk pregnancies, spontaneous or induced labour by oxytocin resulted in CTG abnormalities which aroused clinical concern, and the patients were delivered by emergency C.S. Babies born to such mothers (5% of all C.S. in our study) are known to exhibit glycogen depletion with higher neonatal mortality as well as morbidity ( 2 , 9, 10). It is therefore our attitude to consider delivery by elective C.S., when the fetal hazards of vaginal delivery cannot be appraised. This procedure might, however, still increase the C.S. rate. In the remaining “asphyxia” group the diagnosis of fetal hypoxia was based on CTG abnormalities, which served as the sole indications for section. It seems reasonable, as shown by several authors (4, 7), that a combination of CTG with fetal blood sampling could rule out several cases of suspected fetal depression, and thus eventually decrease the
rate of C.S. Such a prospective study is now in progress at Huddinge University Hospital. REFERENCES 1. Aaro, L. A. & Saed, F.: Low-incidence caesarean
section; 12 year experience. Obstet Gynecol Surv 31: 22-23, 1976. 2. Beard, R. W.: The effect of fetal blood sampling on caesarean section for fetal distress. J Obstet Gynecol Br Comm 75: 1291-1295, 1968. 3. Borell, U. & Fernstrom, I.: Radiologic pelvimetry. Acta Radiol, Suppl. 191, 1960. 4. Edington, P. T., Sibanda, J. & Beard, R. W.: Influence on clinical practice of routine intra-partum fetal monitoring. Br Med J3: 341-343, 1975. 5. Hibbard, L. T.: Changing trends in caesarean section. Am J Obstet Gynecoll25: 798-804, 1976. 6. Johnell, H. E., Ostberg, H. & Wghlstrand, T.: Increasing caesarean section rate. Acta Obstet Gynecol Scand55: 95-100, 1976. 7. Lehmann, W. D., Neumann, G. K., Kessler, K. F. & Jonatha, W. D.: Operationshaufigkeit und perinatale Sterblichkeit vor und nach Einfurung der fetalen Blutgasanalyse und der kontinuierlichen Uberwachung der fetalen Herzfrequenz. Geburtshilfe Frauenheilkd 36: 247-255, 1976. 8. Plotho, B. & Podesser, H.: Sectio caesarea. Eine 5-Jahres Studie der Ergebnisse einer mittelgrossen Abteilung fur Geburtshilfe und Frauenheilkunde. Fortschr Med3l: 1533-1536, 1975. 9. Shelley, H. J.: The metabolic response of the fetus to hypoxia. J Obstet Gynecol Br Comm 76: 1-15, 1969. 10. Thalme, B., Belfrage, P. & Raabe, N.: Diagnos av fetal hypoxi medelst skalpblod. En fallbeskrivning. Opusc Med 17:66-70, 1972. Submitted for publication Feb. 21, 1977
Eva Patek Dept of Obstetrics and Gynecology Huddinge Hospital S-14186 Huddinge Sweden
CAESAREAN SECTION A clinical study with special reference t o the increasing section rate
Eva Patek and Bertil Larsson From the Department of Obstetrics and Gynecology, Huddinge Hospital, Huddinge, Sweden
Abstract. At Huddinge University Hospital 539 Caesarean Sections (C.S.) were made among 8415 deliveries from October 1972 to June 1976, corresponding to an over all C.S. rate of 6.4%. Over these years the rate has increased from 3.5 % in 1972 to 9.7% in 1976. The main increase was due to a higher incidence of abdominal deliveries in cases of imminent fetal asphyxia. The maternal complication rate and the neonatal morbidity rate were both 6.5 times higher and the neonatal mortality rate was 4.1 times higher in emergency than in elective surgery. There was neither any mortality nor any morbidity in infants delivered by elective C.S. from healthy mothers at term.
Recently an increased rate of C.S. was reported not only in Sweden, but also in USA and West Germany (5-7). With the growing emphasis on the antenatal and intrapartum status of the fetus and with the addition of laboratory tests and technical progress of internal fetal monitoring, an increased rate of C.S. should be expected (1). However, there must be an optimal rate of C.S. in which the maternal risks are in balance with the benefits of the fetus-child. In a recent paper it was pointed out that C.S. should still be regarded as the most dangerous way of delivery, not only for the mother but also for the child (7). The aim of the present study was to evaluate the maternal risks in a series with an increasing rate of C.S. and make comparisons of the complications between emergency and elective C.S., associating them with the indications. Studies were also made of neonatal mortality and morbidity during these same conditions.
1972, when the hospital was opened, through June 1976 (Fig. 1). As shown in Fig. 1 there was a
threefold increase in the frequency of C.S. during this almost four year period. The number of children delivered by C.S. was 545, including four sets of twins and one set of triplets. In more than half of the patients (57.9%) Caesarean delivery was performed on primiparae. Several patients were sectioned twice or thrice and two four times. The patients with C.S. were 16-46 years of age with a predominance of 21-35 years (85.5%).
INDICATIONS Indications for the 525 C.S. performed from 1973June 1976 are summarized in Table I. Only the main indication for each operation was recorded. Patients with a pelvic outlet of less than 29.5 cm or between 29.5-3 1.5 cm (borderline) after X-ray pelvimetry were summarized as cephalopelvic dis-
n 250
230 210
190 170
150 130 110
FREQUENCY PARITY AGE At Huddinge University Hospital 539 C.S. (6.4%) were made among 8415 deliveries from October
4h
c s.
12 11 10 9 0 7 6 5 L 3 2 1
1
Fig. 1 . Number of deliveries every month from October 1972-June 1976 at Huddinge University Hospital. C.S. ratio in % calculated three times per year. Acta Obstet Gynecol Scand 57 f 1978)
246
E. Patek and B . Larsson
Table I. Indications for C.S. in %per year at Huddinge University Hospital I973-June I976 1973 % Vertex & cephalopelvic 37.9 disproportion Breech & cephalopel. 15.5 disprop. or premat. Fetal distress 9.7 Placenta praevia 9.7 Abruptio placentae 1.9 Prolapsed unbilical cord Diabetes mellitus 1.9 Toxaemia of pregnancy 4.9 Malpresentation Uterine anomaly or uterine scar 1.o Fetal growth retardation 1.o Dysfunction of placenta 2.9 Serious maternal disease Obstetrically old 2.9 primipara 2.9 Psychiatric indication 1.0 “Bad obstetrical history” Imminent uterine rupture 1.o Previous corporal longitudinal incision 1 .O 4.9 Uterine inertia 1.o Miscellaneous
1974 %
1975 %
1976 %
27.0
17.5
25.4
12.2 14.8 2.6 4.3 2.6 3.5 7.0 5.2
17.5 22.8 3.5 5.8 3.5 1.2 3.5 1.8
18.0 26.1 3.7 3.7
2.6 3.5 -
1.2 1.8 4.7 I .8
0.7 1.5 1.5 2.2
3.5 0.9 2.6 0.9
4.7 1.8 2.3 -
3.7 2.2 0.7 1.5
3.5
0.6 3.5 0.6
0.7 1.5 0.7
-
-
4.5 1.5
proportions (3). The same diagnosis incorporated a true conjugate of the pelvic inlet of less than 9.5 cm or a conjugate of 9.5-11 cm (borderline). Breech presentation, delivered by C.S., was always combined with either cephalopelvic disproportion or prematurity. Transverse lie, mentum-posterior and face-posterior presentations are included under the heading of malpresentations. Multiparity with a history of several intrauterine fetal deaths was registered as “bad obstetrical history”, as were cases with previous complicated deliveries.
OPERATIVE PROCEDURE Induction of anaesthesia was made with a single dose of propanid (Epontol, BAYER) followed by endotracheal intubation and maintenance of anaesthesia with nitrous oxide and oxygen plus neurolept (Dridol, LEO). Muscular relaxation was achieved by an intravenous dose of succinyl choline (Celocurin, VITRUM). Epidural anaesthesia was given 10 times. A low midline incision was made in all women except in 67 (12.4%) where the Pfannenstiel method was employed. The uterus was entered through a transverse lower segment incision. Longitudinal incisions of the uterus were made in 10 cases because of previous cervico-corporal incisions, transverse lie or placenta praevia. All patients were observed for 6-12 hours in a postoperative department and all children were taken care of by a paediatrician or by a trained anaesthetist. Additional surgery was performed in 19 cases (3.5%): Tuba1 sterilization was camed out in 12 women, unilateral oophorectomies in two cases due to benign cysts, ovarian resections in one woman for the same reason and oophorectomies plus hysterectomy in one patient because of ovarian cancer. Appendicitis was diagnosed in three women and a C.S. was made at the same time as the appendectomy.
COMPARISON BETWEEN ELECTIVE AND EMERGENCY C.S. Out of 539 Caesareans 241 were elective and 298 were made under emergency conditions. The C.S. was made earlier than the 38th gestational week and
Table 11. Complications during elective and emergency C . S . at Huddinge University Hospital, October 1972-June 1976. Neonatal mortality. Neonatal morbidity
Complications (a) Intra-operative ( b ) Post-operative I. Major complications 11. Minor complications Neonatal mortality Neonatal morbidity .Ictri Obstet Gvnecol Scond57 (1978)
Elective C.S. n =24 1=44.7 % n of infants=241
Emergency C.S. n=298=55.3% n of infants=304 4 twins, 1 triplet
(%)
(%I
0.8 2.5 0.8 1.7
0.7
] 2.5
,::I 3.3 10.9
16.5
Caesarean section
Table 111. Ten patients with major maternal complications after delivery by Caesarean Section under emergency condition at Huddinge University Hospital October 1972-June 1976 1 amnionitis+peritonitis 1 amnionitis+peritonitis+ paralytic ileus. Abscess of the
Douglas’ pouch which was incised. Wound infection I amnionitis. Relaparotomy due to abscess in the uterine wall+ileus followed by sepsis. The patient was nursed in an intensive care unit for 19 days I relaparotomy due to suspected intraabdominal haemorrhage I paralytic ileus. Relaparotomy+secondary wound revision 2 sepsis 1 peritonitis+ileus. Relaparotomy. Stenosis of tracheae post op. Secondary sut. of wound 1 intraabdominal haemorrhage. Relaparotomy followed by sepsis and serious wound infection 1 haematoma+parametritis followed by septicaemia Five of the patients with serious complications underwent relaparotomies
later than the 42nd week in 92 of the patients (17.1 %). Both intra-operative and post-operative complications were encountered. The post-operative complications have been divided into major and minor ones. Zntra-operative complications. The number of intra-operative complications was equal in both elective and emergency C.S. Three bladder injuries were encountered and were duly sutured, as was one subcutaneous haemorrhage. Post-operative complications. Major postoperative complications were only noted in emergency Caesareans (Table 111). In five of the 10 patients with such complications re-laparotomies had to be made. Minor post-operative adversities occurred in 2.5 % in the elective C.S. and in 13.1 % of the C.S. done under emergency conditions. The most common complication was fever. There was one maternal death due to severe toxaemia corresponding to a maternal mortality rate of 1.9 per thousand of all abdominal deliveries and 0.1 per thousand of all deliveries during this period of time. The patient died five weeks after a C.S. from pulmonary and cerebral abscesses and renal failure. There were ten neonatal deaths among the infants delivered by emergency C.S. corresponding to a neonatal mortality rate of 3.3%. Seven of the infants died of severe asphyxia and one of lethal congenital abnormalities. Half of the 10 neonatal deaths
247
were in the gestational age of 29-30 weeks and one in the 43rd week. Two of the infants delivered by elective surgery died during the neonatal period, corresponding to a neonatal mortality of 0.8 %. The two mothers of the infants suffered from serious pre-eclampsia. One, weighing only 800 g , was delivered in the 34th gestational week and died after a few hours from IRDS. The other baby was delivered in the 39th week, a boy weighing 1300 g, and died from Potter’s syndrome and a tentorium rupture. The registered disorders in the early neonatal period of the infants delivered by emergency C.S. was 10.9% compared with a rate of 1.7% in the elective C.S. group. All children delivered by elective surgery and suffering from disorders in the neonatal period were at term. In contrast 57.6% of the infants with neonatal morbidity in the emergency group were in the 3 1st-37th gestational week. The neonatal mortality rate for all C.S. was 2.2 % and the total neonatal morbidity rate was 6.6%. There was neither any morbidity nor any mortality of infants delivered by elective C.S. from healthy mothers at term.
DISCUSSION A threefold increase of C.S. (3.5-9.7%) has been observed at Huddinge University Hospital during the period October 1972-June 1976. This coincides with reports from several large obstetrical units in USA and Europe where a C.S. rate of 10-13% has been registered in the 1970s (4-6). A somewhat lesser rate, however, would be expected in the Scandinavian countries, where a primary C.S., for example, is not an indication for repeat Caesareans. A remarkably high frequency of C.S. in patients aged less than 20 and more than 35 has been noted by Plotho & Podesser in Austria in 1975 (8). This
Table IV. Fetal distress (asphyxia) as the main indication for C.S. October 1972-June 1976 in 103 patients (19.1 % of all C . S . performed) at Huddinge University Hospital Asphyxia
1972 3 months 1973
n
2
10 Acttr
1974
1975
1976 6 months
17
39
35
Obstet G y e c o l ScandS7 (1978)
248
E. Patek and B . Larsson
has not been our experience, but might be due to many pregnant women in these age groups demanding abortion in Sweden. In the present study both the maternal and the neonatal morbidity rate of emergency C.S. exceeded that of elective section by 6.5 times. Moreover, the neonatal mortality rate was 4.1 times higher in the emergency than in the elective C.S. group. Thus, the elective C.S. can be regarded as a fairly safe procedure both for mother and child. Fetal asphyxia as an indication for C.S. has become more common during the period investigated (Table IV). In four years 103 cases of fetal distress were noted. In 27 pregnancies (26.2% of all asphyxias) a combination of several prognostically severe indices were observed (low or falling estriol values, intrauterine growth retardation as measured by ultrasound, toxemia), In these high risk pregnancies, spontaneous or induced labour by oxytocin resulted in CTG abnormalities which aroused clinical concern, and the patients were delivered by emergency C.S. Babies born to such mothers (5% of all C.S. in our study) are known to exhibit glycogen depletion with higher neonatal mortality as well as morbidity ( 2 , 9, 10). It is therefore our attitude to consider delivery by elective C.S., when the fetal hazards of vaginal delivery cannot be appraised. This procedure might, however, still increase the C.S. rate. In the remaining “asphyxia” group the diagnosis of fetal hypoxia was based on CTG abnormalities, which served as the sole indications for section. It seems reasonable, as shown by several authors (4, 7), that a combination of CTG with fetal blood sampling could rule out several cases of suspected fetal depression, and thus eventually decrease the
rate of C.S. Such a prospective study is now in progress at Huddinge University Hospital. REFERENCES 1. Aaro, L. A. & Saed, F.: Low-incidence caesarean
section; 12 year experience. Obstet Gynecol Surv 31: 22-23, 1976. 2. Beard, R. W.: The effect of fetal blood sampling on caesarean section for fetal distress. J Obstet Gynecol Br Comm 75: 1291-1295, 1968. 3. Borell, U. & Fernstrom, I.: Radiologic pelvimetry. Acta Radiol, Suppl. 191, 1960. 4. Edington, P. T., Sibanda, J. & Beard, R. W.: Influence on clinical practice of routine intra-partum fetal monitoring. Br Med J3: 341-343, 1975. 5. Hibbard, L. T.: Changing trends in caesarean section. Am J Obstet Gynecoll25: 798-804, 1976. 6. Johnell, H. E., Ostberg, H. & Wghlstrand, T.: Increasing caesarean section rate. Acta Obstet Gynecol Scand55: 95-100, 1976. 7. Lehmann, W. D., Neumann, G. K., Kessler, K. F. & Jonatha, W. D.: Operationshaufigkeit und perinatale Sterblichkeit vor und nach Einfurung der fetalen Blutgasanalyse und der kontinuierlichen Uberwachung der fetalen Herzfrequenz. Geburtshilfe Frauenheilkd 36: 247-255, 1976. 8. Plotho, B. & Podesser, H.: Sectio caesarea. Eine 5-Jahres Studie der Ergebnisse einer mittelgrossen Abteilung fur Geburtshilfe und Frauenheilkunde. Fortschr Med3l: 1533-1536, 1975. 9. Shelley, H. J.: The metabolic response of the fetus to hypoxia. J Obstet Gynecol Br Comm 76: 1-15, 1969. 10. Thalme, B., Belfrage, P. & Raabe, N.: Diagnos av fetal hypoxi medelst skalpblod. En fallbeskrivning. Opusc Med 17:66-70, 1972. Submitted for publication Feb. 21, 1977
Eva Patek Dept of Obstetrics and Gynecology Huddinge Hospital S-14186 Huddinge Sweden
