THE MODERNCAESAREAN

PRACTICESECTION-

SOME CONTROVERSIAL

OF

VIEWSBY S. G. CLAYTON, M.D., M.S., F.R.C.S., M.R.C.O.G.

Obstetric Surgeon to Out-patients, King's College Hospital and Queen Charlotte's Hospital

The title of this article may need some qualifica-tion. The views expressed are not modem in thesense of expressing the current general opinion,for controversial topics have deliberately beenchosen. Nor can the article claim to be modern inthe sense of new; the choice between the extra-and intra-peritoneal approach has been discussedfor a century, and the place for Caesarean sectionin the treatment of placenta praevia has beenargued for 50 years. All that is attempted is toelaborate the points on which modern opinionsdiffer most.

In any practical debate indications and tech-nique should be discussed together, as each willaffect the other, and for that reason the subjectis here subdivided as follows :-i. Caesarean sec-tion for dystocia (a) before labour or early inlabour; (b) late in labour. 2. Caesarean sectionfor antepartum haemorrhage. 3. Caesarean sectionfor other maternal or foetal indications.

i. Caesarean section for dystocia (a) before labouror early in labour. The management of the' borderline case ' of contracted pelvis has latelybeen authoritatively reviewed by Munro Kerr(I948), who stresses the value of radiologicalpelvimetry, but a warning may not be out of placehere against unskilful photography, or even worse,faulty interpretation of the films, which may leadan inexpert obstetrician to perform unnecessaryoperations for minor pelvic abnormalities (Allen,1947). The simple truths that the effectiveness ofthe forces and the degree of moulding are un-known before labour cannot be overstressed, andindeed it must be added that the size of the foetalhead is often uncertain too. Expert radiology isentirely helpful, and more often influences theobstetrician against oper4tion than in favour of it(Williams and Phillips, I946). Barnett (I942) hassuggested that modem radiological pelvimetry willallow the revival of the induction of labour forprimiparae with suspected disproportion, but thisis not yet to be accepted. While it is true that in-duction will ' prevent ' a* few sections that wouldfollow if subsequent trial labour failed, induction is

only suitable for the cases with slight dispro -portion, and it is in just this group that easy de-livery so often occurs in trial labour. On thewhole it is still true that more harm will be done byinducing much unnecessary prematurity than bydoing a few avoidable sections (see discussionProc. R.S.M., I936; Davidson, 1936; Mac-Lennan, I944). For multigravidae in whom thedisproportion is not gross, induction is generallyrecommended, and in a few cases may be usedafter a previous Caesarean, especially if the pre-vious labour was one in which the delay was partlydue to inertia.Although it is accepted that the lower segment

operation is the safest procedure for patients inlabour, or in cases in which there is a risk of in-fection, there is no such agreement when theoperation is performed before labour. Even if thelower segment is not fully formed before labour, itis always possible to make a transverse incisionbelow the line of firm attachment of peritoneum tothe uterus, and the only good argument againstdoing this is that the classical incision is easier. Itmay be easier for the surgeon, but what of thepatient ? The advantages that the low scar is un-likely to become adherent to bowel, and that it isunlikely to rupture in a subsequent. pregnancyseem to be conclusive, even if a repeat Caesarean isproposed for any later pregnancy. If subsequentvaginal delivery is possible, the chance of the scargiving way in labour must also be weighed, andhere we are on less certain ground. It is my ownstrong belief that the lower scar is the safer, but itmust be admitted that there is no satisfactorystatistical proof of this. Although many more rup-tures of the upper segment have been reported, theupper segment operations have been morenumerous in the past, and sometimes performed byless expert surgeons. Williams (I939) has formany years advocated the use of silkworm gutsutures for the classical operation, and claims thatthe risk of rupture is small with this material. It issometimes said that the classical route is safer forthe inexperienced surgeon, but this is surely an

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improper suggestion; for if the patient is not inlabour there is time to refer her to another surgeon,and if 'she is in labour then the greater risk ofsepsis with the classical operation will outweighthe slightly greater difficulty of the lower approach.(The place of the classical technique for cases ofplacenta praevia, or for cases in which the foetalhead is deeply fixed in the pelvis, is discussedbelow.)

It is convenient to mention here the treatmentof cases of dystocia due to fibromyomata or ovariantumours in the pelvis. It is well known that afibroid that occupies the pelvis early in pregnancywill often rise up as the uterus enlarges, and cometo lie above the presenting part at term. It is lesswell known that a pelvic fibroid, attached to thelower segment, may be drawn up during the firststage of labour, and if a fibroid is not too firmly im-pacted it may be worth waiting for a short time inthe hope that it will be drawn up, before per-forming a Caesarean section. If an ovarian tumouris found during labour, and cannot be pushed upabove the presenting part, Caesarean section isusually necessary, as the cyst is inaccessible untilthe uterus is emptied and can be drawn forward orto one side. Even if it is sometimes possible toallow vaginal delivery to proceed after laparotomyand removal of the cyst, this treatment seems to megrossly unkind, unless the cervix happens to befully dilated and the forceps used to complete de-livery under the anaesthetic (see Discussion inBritish Medical Journal, I945).

i. Caesarean section for dystocia (b) late in labouror in the 'suspect' case. Even with intact mem-branes, and in the absence of vaginal examination,vaginal bacteria can often be found in the uterusafter labour of more than six hours' duration(Harris and Brown, 1927; Brown, 1939)- Inpatients-who have been in labour for more than24 hours with the membranes ruptured, Douglas(I941) found anaerobic streptococci in the uterusat Caesarean section in 52 per cent. of cases, andaerobic non-haemolytic streptococci in 26 percent. of cases. These organisms are often foundin the vagina before labour, and even in theabsence of vaginal examination may ascend.Although they have not the virulence of the ' ex-trinsic ' haemolytic streptococci, they are commoninvaders in cases of prolonged labour.

Before the introduction of the lower seginentoperation even vaginal examination might in-fluence the obstetrician against Caesarean section,but the risk of properly conducted vaginal ex-amination has probably been exaggerated. Thisstatement must not be misunderstood; vaginalexamination' has some risk, and should never bedone needlessly, but it is now agreed that evenafter repeated examination a necessary section

should not be refused. It is often advised thatrectal examination is preferable, especially during.a trial labour, but this is very doubtful. Withcareful technique the only organisms that arelikely to be carried through the cervix by vaginalexamination are those already present in thevagina, which will in any case be in the liquor.Rectal examinations may be less trouble, but oftenlead to inexact diagnosis, and since the posteriorvaginal wall is pushed into the os, carry vaginalorganisms upward with certainty. In I937, beforechemotherapy was available, Sir William Gilliattreported a series of lower segment operations per-formed during labour, and though the figures arenot large enough to be ' significant' they at leastsuggest that morbidity is not very obviously re-lated to the number of vaginal examinationsperformed.

No. of Vaginal No. of CasesExaminations No. of Cases Morbid

0-2 20 83-4 20 65-6 12 47-10 8 I

The following very similar figures are taken fromMarshall's ' Caesarean Section' (1939), cases offailed forceps and of surgical induction beingexcluded.

No. of Vaginal No. of CasesExaminations No. of Cases Morbid

0-2 20 33-4 13 35-6 4 I7-9 5 0

When we turn to consider the case in whichsurgical induction of labour has been attempted orperformed, the danger of subsequent'Caesareansection is greater. The risk of section followinginduction by bougies or stomach tube is high, asorganisms are carried for some distance betweenthe membranes and uterine wall, and the riskafter plugging has often been reported. Marshall(1939) reported 14 cases of section after tube orbougie induction, and eight were morbid. Therisk of section after rupture of the membranes isprobably somewhat less, and with the help ofchemotherapy few would now withhold anessential Caesarean if induction by artificial rup-ture had failed. The examples may be given of acase induced for toxaemia in which the cord pro-lapsed, or of a case induced for disproportion inwhich foetal distress occurred. The risk ofCaesarean section would have been quite un-

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304 POST GRADUATE MEDICAL JOURNAL Yuly 1949

justifiable before the lower segment operation andchemotherapy were available; Holland (1921) forexample, stated that the mortality of Caesareansection after induction was 14 per cent., thoughthis gross figure needs qualification, as methodsand intervals are not considered.The gravest risks arise when section. is per-

formed in cases of prolonged labour, whether dueto abnormalities of the birth canal or to inertia.(In cases due to malpresentation without dis-proportion vaginal delivery is frequently possibleand preferable.) Gross disproportion is usuallyrecognized before labour; it is the minor degreeof disproportion, often associated with inertia,that may only be discovered after labour has beenin progress for some time, or sometimes only afterattempted delivery with the forceps. Equaldanger arises in cases of stubborn inertia (or in-co-ordinate uterine action), as intervention mayonly be proposed when the patient's general con-dition has started to deteriorate. We can con-sider these cases together and ask two questions.Firstly, can we safely perform more sections now thatchemotherapy is available ? Secondly, if section isperformed in late labour, what technique is best ?No series of cases has been published that

proves conclusively that the risk of Caesareansection has been much altered by chemotherapy,although this is the general impression. Goodsurgical technique may be equally important. Forexample in I937 Sir W. Gilliatt reported 75 con-secutive cases of the lower segment operation per-formed during labour, without a maternal death.In 55 of these cases three or more vaginal examina-tions had been made, and in 30 of the cases themembranes had been ruptured for between i i and8o hours, yet the post-operative temperature onlyexceeded I00.40 F. in eight cases. In I939Marshall reported 70 operations in suspect or in-fected cases, including I3 cases which were febrilebefore operation, 5 cases of failed forceps, andI5 cases in which surgical induction had beenattempted. No mother died, and the morbidityrate was 30 per cent. These results could hardlybe bettered with chemotherapy.Too much must not be expected from chemo-

therapy, as in these cases of prolonged labour in-fection may be due to insensitive bacteria, althoughthe anaerobic streptococci are sensitive to high

concentrations of penicillin. This must be re-membered when penicillin is used for prophylaxis,and large doses given. The value of the localimplantation of sulphonamides at operation mayalso be discussed. High local concentration can beobtained by placing the powder in the utero-vesical pouch, or under the bladder flap (Kenny,1945). On the other hand Hesseltine and Theeler(1946) found no evidence of reduction of infectionin these cases, and advised agaiist the local use ofsulphonamides as there was risk of sensitization.The intrauterine use of sulphonamides has alsobeen recommended (Brown, I944), but the rate ofabsorption is uncertain, and the drug can onlyreach the danger zone in the outer part of theuterine wound by the blood stream. The writer'sown opinion is that there is no advantage in addingsulphonamides to penicillin in these cases.Few individual surgeons perform many sections

for cases late in labour, so that statistics are oftencrude aggregations, without sufficient detail for faircomparison. There is a widespread opinion thatmore liberties can now be taken with the suspectcase, and the following figures from QueenCharlotte's Hospital at least show that the numberof sections done for prolonged labour has in-creased and that there is no obvious reason toregret this.Yet the suggestion that special technique and

chemotherapy will permit Caesarean section evenin infected cases, is a most dangerous doctrine thatneeds critical consideration. It must never beforgotten that in many of these cases, particularlyafter failure to deliver with the forceps, the childhas a poor chance of survival however delivered,and often dies after delivery from infection. It isimpossible for the individual with limited personalexperience to lay down firm rules, but to read thenotes of a series of these late cases is depressing,and with the after-the-event wisdom of thespectator, it appears that cases with no evidence ofprogress are too often left in the hope that theuterus will suddenly alter its ways, a hope thatbecomes a dangerous disappointment as time goeson. The third day of a prolonged labour fre-quently seems to be the day on which the vitaldecision between vaginal and abdominal deliveryshould be made. That is not to say thata Caesarean should always be done then, but that

No. of cases of Caesarean Sectionafter more than 48 hours' labour

Total No. of No. of cases in which labourdeliveries lasted more than 48 hours Morbidal

No. Maternal deaths Cases

1936-43 22,474 555 10 2 3I 944-46 * * * 9,963 217 12 2

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it should be realized at that stage that if the case isleft much longer then Caesarean section will be-come increasingly dangerous.When all cases in which Caesarean section was

performed during labour for inertia and obstruc-tion are considered, the following figures areobtained (Q.C.H. Reports) -

Labour over 48 Labour less thanhours 48 hours

C Mother MotherCases Cases -

Mor- Mor-__Died bid Died bid

1933-38 I5 4 30 6'939-43 4 I 17 - I1944-46 I2 I 2 15 - -

31 3 6 6z - 7

The figures are too small to permit any deduc-tion to be drawn from the penicillin and sul-phonamide ' years,' but they show how thematernal risk increases after the first 48 hours.

In the past cases of prolonged labour due toobstruction were not uncommon, today delay ismore often due to incoordinate uterine action;but this is hardly less dangerous. Among 674cases in which the first stage of labour lasted morethan 48 hours, -in the absence of disproportion,there were five maternal deaths (7.4 per cent.), 82still-births (12.2 per cent.) and i8 neonatal deaths(2.6 per cent.), (Q.C.H. Reports, I937-46), and foreach addition to the duration of labour the risksrise progressively. These cases differ from those ofcontracted pelvis, as delivery can be completedwith the forceps as soon as the os is fully dilated.Even if the cervix is not quite full, and foetaldistress occurs, it may be possible to apply theforceps and then to push up the rim of cervix, oreven incise it ; or.if the foetus is dead perforationand weight traction. are also possibilities.Caesarean section is not necessary for any of thesecases. But when the os is half or less dilated, andthere is maternal or foetal distress, the problem isfar more difficult. For these cases manual dilata-

tion of the cervix or incision are usually con-demned, as forcible dilatation easily causes shock,and there is risk of a laceration extending up-wards into the lower segment. On the other handthe risk of late section is high. The figuresbelow are taken from the Q.C.H. Reports.

Although these figures are small they do notencourage a belief that Caesarean section is safeafter the third day. The risk is not only uterine orperitoneal infection, but may be cardiac failure,and a common complication is ileus, even in theabsence of evident peritonitis.

In my own opinion any case that is undeliveredafter 48 hours of definite labour should be assessedcritically. If progress is being made, howeverslow, perhaps as a result of general sedation anduterine stimulation, then it may be justifiable tocontinue, especially if the uterus relaxes com-pletely between the contractions, and the maternaland foetal condition is good. But in the absenceof progressive dilatation, especially if the uterus is' irritable,' this is the time to consider section,even though the condition of mother and child isyet good. The protest that this may lead to afew unnecessary sections leaves me unmoved;cases that show no progress after 48 hours definitelabour are not common, and the present resultsare deplorable.

In cases of obstructed labour there is no generalagreement about the place of Caesarean section.It would be agreed that lower segment Caesareansection or Caesarean hysterectomy would bechosen if the child is alive, and many obstetricianswould even consider the operation if forceps de-livery had been attempted an-d the foetus was stillin good condition, which it seldom is. Withpenicillin ' cover' the maternal risk is thought tobe reduced, and the penicillin will also reach thechild and help to reduce the risk of neonatal deathfrom infection.

If the child is dead, some have suggested thatmodern Caesarean section is safer than craniotomy.Green Armytage (I93 I) reported that among I04craniotomies the maternal mortality was 32.7 percent., whereas among 75 lower segment operations(including 48 ' septic cases ') the mortality was

CASES IN WHICH THE FIRST STAGE; OF LABOUR LASTED MoRE THAN 48 HOURS IN THE ABSENCE OF DISPROPORTION:

Caesarean Section

ChildNo. of Mother |- Duration of labour in these cases

cases died S.B. Died (Fatal cases in bold figures)

1937-38 *. .. .. .. .. 2 I I 65, 801939-43 * * * 4 I - 5o, 69, 96, 100

1944-46 .. .. .. .. .. 6 I - 52, 58, 88, 94, 145

12 3

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Manual Dilatation of the Cervix and Forceps, or Craniotomy and Weight Traction

ChildNo. of Mother Duration of labour in these casescases died S.B. Died (Fatal cases in bold figures)

1937-38 . . .. .. .. 5 - 3 - 73, 84, 87, I IO, I821939-43 * .* - * 5 I 2 I 79, 8o, 96, 112, 1261944-46 .. .. .. .. .. 4 - 84, 96, 115, 155

=4 5

C.S. after 48 Craniotomy afterhours' labour 48 hours' labour All craniotomies.

No. Mat. deaths No. Mat. deaths No. Mat. deaths

1,933-38 .. .. .. 5 5 6 26 61939-43 * * . 4 I 3 I 10 I1944-46 2. *. .. IZ 4 -

31 3 I9 7 40 7

14.6 per cent. In a case in which the head is freeabove the brim this contention may be true, par-ticularly with severe pelvic contraction and if thecervix is incompletely dilated, but in most casescraniotomy is far safer. Craniotomy has the dis-advantages of a longer anaesthetic and of greaterrisk to maternal tissues, but the danger ofperitonitis is less. Craniotomy was performed 79times at Queen Charlotte's Hospital during theyears I930-46, excluding cases of hydrocephaly orbreech birth. Sixteen mothers died, but thiscrude figure cannot fairly be compared with thatfor all cases of Caesarean section during labour,and the only fair comparison is with sections per-formed after 48 hours of labour.At first sight it would appear that Caesarean

section is the safer operation, but when it is foundthat the foetus survived in 25 of the cases ofCaesarean section, it is evident that the generalcondition of these.cases was far better than that ofthose subjected to craniotomy, and the samecriticism may well apply to other published series.

Operative technique for the ' suspect case.' InBritain the intraperitoneal lower segment opera-tion is usually chosen, with the occasional per-formance of Caesarean hysterectomy for themultiparous or more elderly patient. The extra-peritoneal operation has been much recommendedon the Continent and in America, and merits con-sideration. The modern operation dates fromI906, when Frank of K6ln approached the lowersegment through a transverse supra-vesical in-cision. Kronig (I9I2) soon realized that the chiefadvantage of Frank's operation was the low incisionthat could be covered by free peritoneum, and ithas yet to be proven that the risk of the intra-

peritoneal lower segment operation is greater thanthat of any extraperitoneal operation. The pelvicperitoneum has a high resistance, and so long as itis efficiently closed so that constant reinfection doesnot occur, will usually localize any infection.. Thehope of such localization is much greater with thelow incision, not only because the free peritoneallayer can be closed more securely, but because anyinfection first occurs in the utero-vesical pouch,where it is easily confined by adhesion between thesurfaces. Any true extraperitoneal operation,whether by the Latzsko or Waters technique, opensup much more cellular tissue, with consequentrisk of the spread of infection, and indeed the veryobject of conserving the peritoneum intact oftenfails. Norton (1935) reported 26 operations, inthe course of which the periteoneum was openednine times and the bladder once, and Aldridge(I937) reported 27 operations, during which theperitoneum was opened five times and the bladderonce. Among Waters (I940) first 32 cases, theperitoneum was opened six times, and unless asurgeon decided to perform this type of operationin early cases so as to gain facility, which wouldseem to be unjustifiable, then he is likely to openthe peritoneum at least as often. Another seriousdisadvantage of the operation is that it takes muchlonger, and while this is an obvious danger to thefoetus it is hardly less a danger to the mother afterprolonged labour.

It is difficult to judge from published reportswhether the operation is on the whole safer thanthe orthodox lower segment operation. Norton(1935) reported 26 cases performed 15 to go hoursafter rupture of the membranes without a maternaldeath, and Aldridge (I937) reported 27 cases per-

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formed on the average 40 hours after rupture ofthe membranes, with one maternal death; but wehave already seen that Gilliatt (I937) and Marshall(1939) published equally good results from theintraperitoneal operation. In none of these caseswas chemotherapy used. Dieckman (I945) men-tions that Waters has performed 250 extra-peritoneal operations with only two deaths, butpoints out that most of these operations were per-formed for teaching purposes, and not for thedangerous cases of late labour.*There is not space here to describe technique;

the reader is referred to the articles of Waters andAldridge.An unusual operation for the infected case is

that of Portes (I924) in which the uterus is de-livered unopened through the abdominal wound,and the parietal peritoneum is sutured about itscervical portion. After delivery of the child theexteriorized uterus is kept covered with moistdressings, and only returned to the abdomen aftersome days (Phaneuf, 1938). It may be askedwhether the tubes would not become occluded byadhesions, with loss of the reproductive functionthat the operation is designed to conserve.

Intraperitoneal lower segment section remains theoperation of choice for the suspect case, with theoccasional performance of Caesarean hysterectomy(Adair, 1938). In a suspect case details of tech-nique are of the greatest importance and thefollowing are selected for mention. The operationmay be preceded by the intramuscular injection ofa large dose of penicillin (150,000 units). Pre-operative vaginal instillations of antiseptics havebeen recommended (Brown, 1939) and althoughit cannot be denied that such instillations may re-duce the total number of organisms, they willcertainly not destroy them all, and those that havespread furthest will most probably escape. Tobe effective repeated instillations are required,and an immediately pre-operative instillation is oflittle or no value. Any temporary bacteriostasiswill not be continued in the dangerous post-operative period, and for these various reasons thewriter does not recommend this treatment.

Perhaps the most important point is to reducethe 'spill' of infected liquor as much as possible.Packing will only partly achieve this, as the mostcarefully placed packing becomes loose when theuterus is emptied, but lateral packs will at leastmop up some of the fluid. An efficient suctionapparatus is essential. It is most dangerous toplace the patient in the Trendelenburg position.

Since this was written M. L. McCall (Am. J. Obst.Gyn., I949, 57, 520) has reported i8 extraperitonealoperations on grossly infected cases without a maternaldeath.

Fortunately, however, the lower segment in latelabour is easily accessible. Many surgeons have.suggested that the peritoneal layers should bestitched together so as to shut off the area of theincision from the general peritoneal cavity, and ofthe many methods described that of Cooke (1938)seems to be the most practical, and deserves anextended trial.

If the head is free it is easily delivered, butthere may be real difficulty with a deeply engagedhead. Having tried most things, including pressurefrom behind with a hand in the recto-vaginalpouch, and Murless's instrument, the writer pre-fers the simple use of his hand, or in a difficultcase Wrigley's forceps. Willett's forceps are usefulif the head can be elevated so that part of thescalp can be seen. Bourne and Williams (1948)have suggested that classical section may be saferfor some of these cases, so that traction on thebreech is possible, but even with chemotherapythe risk of sepsis would deter most of us; it mightbe safer to direct an assistant to push the head upwith two fingers in the vagina.

If the cervix is widely open, the placenta andmembranes can be expressed through the vagina,but since infected liquor has already escaped thepoint is of secondary importance. It is a seriouserror to pass the hand inside the peritoneal cavityto the fundus; if expression is attempted itshould be done by external pressure. As soon asthe uterine muscle is closed infected packs shouldbe removed and gloves changed. It has beensuggested that a tube may be placed to drain thesubperitoneal space into the vagina through theuterine incision, but my own opinion is that sucha tube might serve as an avenue of infection ratherthan a drain.

2. Caesarean sectionfor antepartum haemorrhage.The treatment of placenta praevia is discussed inanother article in this number, and this section istherefore brief. Great improvement in the resultshas been recorded, but this is as much due tobetter facilities for transfusion, and to the practiceof transferring cases to hospital without vaginalinterference, as to any particular operation. Thereis general agreement that Caesarean section is thebest treatment for Type 3 and 4 cases (exceptthe moribund), and equally that section is un-necessary for Type i (Berkeley, 1936; Macafee,I945). Difference of opinion remains about theType 2 cases, and the writer may be allowed toexpress his personal opinion that section should beadvised for most of these cases that have reachedthe 36th week, except when the cervix is alreadywidely dilated. Whatever the type, Caesareansection should never be employed for the severelyshocked patient until she has been resuscitated,but with modern facilities the moribund patient

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is becoming a rarity. In the case of a patient whohas had only slight bleeding, and in whom thediagnosis is not yet established, practice haschanged in recent years, or at least we now openlyteach what many formerly practised in doubt.Delay in intervention is now permitted as long asthe patient is in a fully staffed obstetric unit, withgood transfusion facilities, with the object of post-poning the delivery of a premature infant for aslong as possible. Marshall (I939) has suggestedthat cases of placenta praevia can be diagnosed onthe history alone, without vaginal examination,but this is surely wrong, for it is not uncommon tosee cases in which the diagnosis seems highlyprobable, but when a finger is passed through thecervix the placenta is not reached, and sectionwould be quite unnecessary for such cases.'Blind' Caesareans cannot be recommended, andthe risk of vaginal examination is small if it is per-formed on the operating table.With regard to the actual technique of the

operation, the majority advise the classical opera-tion, though my own more limited experiencewould certainly support Marshall (I939) andMacafee (I945) in their advocacy of the lower seg-ment route (see Cameron (I945) and corres-pondence B.M.J.). It is nQt denied that bleedingcan be troublesome in the low operation, and thisis perhaps the one case in which a surgeon who hasto operate in an emergency, and is unaccustomedto the lower segment operation, should avoid it,though in other hands the advantages of less sepsisand a better scar would justify it. If a small'central incision is made, the incision can be ex-tended quickly, and this seems better than tryingto control vessels with Bonney's compressor orGreen Armytage forceps.For accidental haemorrhage conservative treat-

ment is now usually practised, even for concealedhaemorrhage (Gibberd, 1945), though Caesareansection may be considered for the unusual case ofsevere external bleeding with a living child.

3. Caesarean section for other maternal or foetalindications. No attempt is made here to set fortha textbook list of indications for the operation, butonly to select a few controversial points for dis-cussion. Fewer operations are now performed forsuch maternal indications as cardiac disease andtoxaemia, but the number of sections for foetalindications has greatly increased, probably to anunwise extent. To put it crudely, it is not alwaysnecessary to cut the mother open to achieve apremature delivery. If the patient is a multi-gravida induction is almost invariably preferable.Even in the case of a primigravida, if the preg-nancy has reached the 36th week an`d the cervix is' ripe,' induction should be chosen unless termina-tion is really urgent. There is sometimes a lack of

consistency in this matter; cases of toxaemia arealmost invariably induced as that is customary,whereas section will be suggested 'for other casesthat are no more urgent for either mother or child.To advise Caesarean section to permit sterilizationis utterly wrong; unless there is another goodreason for the section the sterilization can be donemore safely during the puerperium. On the otherhand, when urgent termination is required beforethe 34th week (e.g. for severe toxaemia), par-ticularly in primigravidae, Caesarean section mayreasonably be considered.Many writers have stated that the foetal risk of

Caesarean section is higher than that of normal de-livery, but this may be questioned. The grossfoetal mortality is high because so many Caesareaninfants are premature and because so many of thepregnancies are pathological. Between I93I and1946, 852 sections were performed at QueenCharlotte's Hospital, with 24 still-births and 52neonatal deaths, a foetal mortality of 8.9 per cent.But if cases of elective section for disproportionare considered, in which there are no complicatingfoetal factors, the true foetal mortality due to theoperation can be found. There were 36I suchcases, with two still-births and nine neonataldeaths; but in four cases the foetus died fromgross malformation, so that the foetal mortality dueto the operation and anaesthetic was i.9 per cent.Brandberg (I940) found no foetal death irf II5elective Caesarean sections for 'mechanicalreasons.' He also concluded that the mortality fora premature Caesarean infant does not differ fromthe general mortality of premature infants of thesame weight, but it is difficult to be certain of this,as sections are only done in pathological cases. Itwould, therefore, seem justifiable to operateoccasionally for ' bad obstetric history' or elderlyprimiparity, although each case must be severelyjudged on its own merits. Post-maturity isanother matter, and the writer does not believe thatsection can be justified for this reason alone,particularly as there is no real evidence of placentalfailure (Masters and Clayton, I940 Clayton,1941 ; Calkins, 1948 ; Rathburn, I943).For cases of h3pertension and albuminuria re-

quiring termination, induction is usual, but forprimiparae who need termination before the 34thweek section may be considered as induction issomewhat uncertain, also in the not unusualcase of an elderly primigravida with essentialhypertension. Section for threatened eclampsia isnot recommended; if a fit is thought to be im-minent sedative treatment is preferable. In a fewcases of albuminiria Caesarean section may bejustified if there have been previous foetal deaths.

In diabetics premature delivery is essential andCaesarean section is usually recommended, though

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July 1949 CLAYTON: The Modern Practice of Caesarean Section 309

in multigra-idae induction may be consideredunless (as is often the case) the previous deliverywas abdominal. Similarly premature delivery isoften advised in cases in which there is good reasonto suspect foetal haemolytic disease, although itsvalue is not established with certainty; in thesecases the patient is a multigravida and inductionshould more often be chosen.The place of Caesarean section in the manage-

ment of a primigravida who is found to have anextended breech presentation at term has been muchdiscussed. It will be agreed that section should berecommended for the case with some additionalcomplication, including ' elderly primiparity,' butwhat of the young primipara ? The risk to thefoetus in full-term uncomplicated breech deliveryis at least ii per cent. (Peel and Clayton, 1948).Yet many breech deliveries are very easy, and if wecould only anticipate the difficult cases we shouldno doubt advise more operations in that group,but there seems to be no certain method of select-ing the difficult cases. Radiological pelvimetryshould be secured for every case, and section ad-vised if the pelvis is small or of android tvpe. Ifthe pelvis is normal it is still felt that Caesareansection is unwise for the young primigravida,chiefly because of the maternal risk of section, butalso because subsequent pregnancies must beconsidered. (The value of premature induction isnot discussed here. In brief, the writer is op-posed to wholesale induction because the risks ofinertia and prematurity outweigh the advantage ofa smaller baby.)

Maternal risk of Caesarean section. In con-clusion it may be well to state that the maternalmortalitv of Caesarean section is still more than 2per cent. for the country as a whole, though manyindividual operators have published lower figures.At Queen Charlotte's Hospital between 193I andI 946, 852 operations were recorded, with i8maternal deaths (2.I per cent.). In six of thesecases death was chiefly due to pre-existing disease(cardiac disease five cases, Wernicke's en-cephalopathy one case), and in eight cases deathwas a direct sequel of the operation (pulmonaryembolus one case, ileus three cases, sepsis fourcases). In the remaining four cases the partplaved by the operation was doubtful (cardiacfailure one case, placenta praevia one case, uterine

inertia two cases). But with every allowance forpreceding disease, the risk of the operation remainsat i per cent., even in experienced hands. Most ofthe indications for section are relative and notabsolute, and we must always weigh and comparethese risks against those of vaginal delivery. Thenumber of Caesarean operations has certainly in-creased in recent years, and on the whole justifi-ably, but each extension of surgery in obstetricsmust be critically considered.

BIBLIOGRAPHY

ADAIR, F. L. (1938), Amer. J. Obst. Gyn., 35, 474.ALDRIDGE, A. H. (1937), Ibid., 33, 788.ALLEN, P. (1947), Brit. J7. Radiol., 20, 205.BARNETT, V. H. (I942), Y. Obst. Gyn. Brit. Emp., 49, 524.BERKELEY, C. (I936), Ibid., 43, 3.BOURNE, A. W., and WILLIAMS, L. H. (I948), 'Recent Ad-

vances in Obstetrics and Gynaecology,' London, Churchill, 126.BRANDBERG, O., Acta Paediatrica, 27, 403.BROWN, T. K. (I939), Amer. J7. Obst. Gyn., 38, 969.BROWN, W. E. (I944), Ibid., 48, 254.CALKINS, L. A. (1948), Ibid., 56, I67.CAMERON, S. J. (I945), and correspondence, Brit. Med. 3., I,

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784.DISCUSSION (1936), Proc. Roy. Soc. Med., 29, 1473.DOUGLAS (1941), quoted by Stander in Williams' ' Obstetrics,'

New York, Appleton Century, pp. i199 and 1215.GIBBERD, G. F. (1948), Canad. Med. Assoc. Y., 58, 53.GILLIATT, W. (I937), Proc. Roy. Soc. Med., 30, 24.GREEN-ARMYTAGE, V. B. (I93I), Indian Med. Gaz., 66, I84.HARRIS, J. W., and BROWN, J. H. (1927), Amer. Y. Obst. Gyn.,

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HESSELTINE, J. W., and THEELER, C. (1946), Ibid., 52, 358.HOLLAND, E. (192I), 7. Obstet. Gyn. Brit. Emp., 28, 358.KENNY, M. (I945), Ibid., 52, 376.KERR, J. MUNRO (I948), Ibid., 55, 401.KRONIG (I9I2), Kronig-Doderlein 'Operative Gynakologie.'MACAFEE, C. G. H. (I945), J. Obst. Gyn. Brit. Emp., 52, 313.MACLENNAN, H. R. (s944), Ibid., 51, 293.MARSHALL, C. McINTOSH (I939), 'Caesarean Section,'

Bristol, Wright.MASTERS, M., and CLAYTON, S. G. (1940), 7. Obst. Gyn. Brit.

Emp., 47, 437.NORTON, J. F. (I935), Amer. J. Obst. Gyn., 30, 209.PEEL, J. H., and CLAYTON, S. G. (1948), Y. Obst. Gyn. Brit.

Emp., ss, 614.PHANEUF, L. E. (1938), Amer. J. Obst. Gyn., 35, 476.PORTES (I924), Gynec. et Obst., I0, 225.RATHBURN, L. S. (I943), Amer. J. Obst. Gyn., 46, 278.WATERS, E. G. (I940), Ibid., 39, 423.WILLIAMS, L. R., and PHILLIPS, L. G. (1946), J. Obst. Gyn.

Brit. Emp., 53, I39.WILLIAMS, L. H. (I939), in 'Recent Advances in Obstetrics and

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