The abuse of cesarean section

0 NE of the serious criticisms of modern obstetrica practice is to be found in the frequency with which cesarean sections are performed. The development of the modern types of operation and the improvement in general surgicaI technique have resulted in a very considerabIe broadening of the indications for the performance of the operation as compared with those indications which were considered adequate a generation ago. This is to be expected, and while peIvic dystocia stiI1 is, and probabIy aIways w-i11 be the chief indication for the performance of cesarean section, yet there are numerous other situations in which delivery in this manner may well be the procedure of choice. At the same time, how,e\-er, it wouId appear that this broadening of the indications for the operation has at times resuIted in a more or Iess indiscriminate resort to it as a means of deIivery, and often it is performed on pretexts that may fairIy be regarded as triviaI. Some idea of the frequency with which cesarean sections are performed may be obtained from the report of the New York Academy. of Medicine on materna1 mortaIity in New York City from 1930-1932 and from the similar report of the PhiladeIphia County Medical Society for 1931, 1932 and 1933, In New York the deIiveries by cesarean section constituted 2.2 per cent of all deliveries occurring in the hospitals reporting, whiIe in PhiIadeIphia the figure was 2.6 per cent.. These figures are more than twice as great as those reported from most European clinics. The gross mortaIity recorded in the New York series was 6. I per cent, while in Philadelphia it was 5.6 per cent. That the operation is being abused and is performed many times unnecessarily is unquestionable, and that many women die each year as a result of this abuse is equaI13, true. As I see the situation, it wouId appear that this abuse of cesarean section is brought about in one or more of three ways, namely (I) extreme Iaxness in the recognition of proper indications for the operation, (2) failure to perform the operation at the proper time, or (3) poor judgment in the selection of the proper type of cesarean section when the operation is indicated. These three factors a11 contribute their share to the unnecessariIy high mortaIity which attends the performance of cesarean sections. In discussing Iegitimate indications for the performance of cesarean section, that of pelvic dystocia stiI1 occupies first place, and probabIy always will. It is of the greatest importance to remember, however, that the mere diagnosis of a contracted peIvis does not necessariIy demand the performance of cesarean section. Thus the Iate J. Whitridge WiIIiams found in his series that incIuding a11 types of contracted peIvis, delivery through the natura1 channels could be expected in nearIy 80 per cent of such women. Whether such an outcome is possible or not will obviously depend on such factors as the type and degree of contraction present as we11 as the size of the child and the consistency of its head. In many women presenting contracted pelves the decision as to the Iine of procedure to foIIow is not diffrcuIt for the experienced person. Thus those presenting extreme degrees of pelvic contraction should ordinariIy be deIivered by cesarean section at an elective