102 Communications in brief
January I , 1978 Am. J. Obstet. Gynecol.
Fig. I. Representative sample of internal monitor tracing.
lation. However, such a hypothesis is difficult to prove. Observation of a fetal heart rate pattern with these unusual characteristics should provoke concern, for clinical management becomes difficult if one suspects that irreparable fetal damage has already occurred. One is faced with the dilemma of whether to perform operative delivery of a fetus possibly too severely damaged to survive or to allow labor to continue and perhaps lose a potentially salvageable fetus. I would be interested to learn if others have had experience with cyclic heart rate patterns such as this, for only with further clinical observation will the ultimate significance and proper management of such problems become know.
REFERENCE I. Baskett, T. F., and Koh, K. S.: Sinusoidal fetal heart pattern, a sign of fetal hypoxia, Obstet. Gynecol. 44: 379, 1974.
Revival of the extraperitoneal cesarean section H . HANSON
Anchorage, Alaska
THE EXTRAPERITONEAL cesarean section was used to prevent contamination of the peritoneal cavity. With the advent of the antibiotic era, this procedure has been relegated to history. However, Reid,t in 1973, reviewed 18 cases of fatal puerperal sepsis following transperitoneal cesarean section and concluded that Reprint requests: Dr. H. Hanson, Providence Professional Bldg., Suite 212, 3300 Providence Dr., Anchorage, Alaska 99504 .
the fatal peritonitis might have been avoided by the extraperitoneal approach or cesarean hysterectomy. The transperitoneal cesarean section was "not safe enough." Sporadic articles stressing the virtue of the extraperitoneal cesarean section continue to appear. During my residency, the extraperitoneal approach was used in obviously infected cases where the patient had been transferred to the medical center. One could not help but note that the patients who had extraperitoneal cesarean section had a remarkably benign postoperative course; invariably these patients did very well. Slowly the obvious question evolved: Why was the extraperitoneal cesarean section not performed on all patients? Thus, in private practice, I broadened my indications to include purely elective cases. The articles coupled with personal experience have made three points apparent: (I) The extraperitoneal cesarean section is a sound surgical procedure; (2) the extraperitoneal cesarean section could be applied to the majority of cesarean sections; (3) the patient will benefit from the extraperitoneal approach. To support these points, 45 consecutive extraperitoneal cesarean sections were reviewed. I performed these cesarean sections in Anchorage, Alaska, between july 1, 1972, and February I, 1977. The data relate only to extraperitoneal cesarean sections; there are no control data from transperitoneal cesarean sections performed during this same period of time. . Preoperative data are summarized in Table I. Prophylactic antibiotics were not utilized . Preoperative antibiotics were administered to three patients-"'with premature rupture of the membranes, fever, and positive cultures of the amniotic fluid. The operative technique, a lateral approach to the bladder through the paravesical space, pioneered by Latzko in 1909, was used throughout this series. Op· erative data are summarized in Table II. Prolonged operative time and prolonged incision-to-delivery times have been cited as major disadvantages of this
Volume J:lO
Communications in brief
Number I
Table I. Preoperative data from a series of 45 cases l ndications Infected Potentially infected Elective ' Febrile prior to operation Antibiotics Internal fetal monitoring Prophylactic antibiotics
3
26
16 3 3 18 0
Table II. Operative data Incision-to-delivery time (min.) Operative time (min.) Apgar score I min. 5 min. Positive endometrial cultures
6.8 29.3 7.2 9.5 3i45
Table III. Postoperative data Mean hospitalization (days) Meperidine (mg.), average for postoperative pain Postoperative distention and gas pains Postoperative vomiting and ileus
3.9 75 Oi45 0/45
Table IV. Postoperative complications in a series of 45 cases
Endometritis Urinarv tract infection Bladde~ injury Required transfusions Wound infection
4 I 1 I 0
operative procedure. However, the incision-to-delivery time of 6.8 minutes and operative time of 29 minutes compare favorably with average time for transperitoneal
January I , 1978 Am. J. Obstet. Gynecol.
Fig. I. Representative sample of internal monitor tracing.
lation. However, such a hypothesis is difficult to prove. Observation of a fetal heart rate pattern with these unusual characteristics should provoke concern, for clinical management becomes difficult if one suspects that irreparable fetal damage has already occurred. One is faced with the dilemma of whether to perform operative delivery of a fetus possibly too severely damaged to survive or to allow labor to continue and perhaps lose a potentially salvageable fetus. I would be interested to learn if others have had experience with cyclic heart rate patterns such as this, for only with further clinical observation will the ultimate significance and proper management of such problems become know.
REFERENCE I. Baskett, T. F., and Koh, K. S.: Sinusoidal fetal heart pattern, a sign of fetal hypoxia, Obstet. Gynecol. 44: 379, 1974.
Revival of the extraperitoneal cesarean section H . HANSON
Anchorage, Alaska
THE EXTRAPERITONEAL cesarean section was used to prevent contamination of the peritoneal cavity. With the advent of the antibiotic era, this procedure has been relegated to history. However, Reid,t in 1973, reviewed 18 cases of fatal puerperal sepsis following transperitoneal cesarean section and concluded that Reprint requests: Dr. H. Hanson, Providence Professional Bldg., Suite 212, 3300 Providence Dr., Anchorage, Alaska 99504 .
the fatal peritonitis might have been avoided by the extraperitoneal approach or cesarean hysterectomy. The transperitoneal cesarean section was "not safe enough." Sporadic articles stressing the virtue of the extraperitoneal cesarean section continue to appear. During my residency, the extraperitoneal approach was used in obviously infected cases where the patient had been transferred to the medical center. One could not help but note that the patients who had extraperitoneal cesarean section had a remarkably benign postoperative course; invariably these patients did very well. Slowly the obvious question evolved: Why was the extraperitoneal cesarean section not performed on all patients? Thus, in private practice, I broadened my indications to include purely elective cases. The articles coupled with personal experience have made three points apparent: (I) The extraperitoneal cesarean section is a sound surgical procedure; (2) the extraperitoneal cesarean section could be applied to the majority of cesarean sections; (3) the patient will benefit from the extraperitoneal approach. To support these points, 45 consecutive extraperitoneal cesarean sections were reviewed. I performed these cesarean sections in Anchorage, Alaska, between july 1, 1972, and February I, 1977. The data relate only to extraperitoneal cesarean sections; there are no control data from transperitoneal cesarean sections performed during this same period of time. . Preoperative data are summarized in Table I. Prophylactic antibiotics were not utilized . Preoperative antibiotics were administered to three patients-"'with premature rupture of the membranes, fever, and positive cultures of the amniotic fluid. The operative technique, a lateral approach to the bladder through the paravesical space, pioneered by Latzko in 1909, was used throughout this series. Op· erative data are summarized in Table II. Prolonged operative time and prolonged incision-to-delivery times have been cited as major disadvantages of this
Volume J:lO
Communications in brief
Number I
Table I. Preoperative data from a series of 45 cases l ndications Infected Potentially infected Elective ' Febrile prior to operation Antibiotics Internal fetal monitoring Prophylactic antibiotics
3
26
16 3 3 18 0
Table II. Operative data Incision-to-delivery time (min.) Operative time (min.) Apgar score I min. 5 min. Positive endometrial cultures
6.8 29.3 7.2 9.5 3i45
Table III. Postoperative data Mean hospitalization (days) Meperidine (mg.), average for postoperative pain Postoperative distention and gas pains Postoperative vomiting and ileus
3.9 75 Oi45 0/45
Table IV. Postoperative complications in a series of 45 cases
Endometritis Urinarv tract infection Bladde~ injury Required transfusions Wound infection
4 I 1 I 0
operative procedure. However, the incision-to-delivery time of 6.8 minutes and operative time of 29 minutes compare favorably with average time for transperitoneal
