Cesarean Section Survey 
Grand Rapids, Michigan 
January 1, 1935 to June 30* 19^0 
\'JSP 
Prior to an analysis of the cesarean sections which took place in 
the city of Grand Rapids hospitals, an4 Blodgett Hospital in East Grand Rapids, 
it may be well to pause for review of the total situation of obstetrical 
practice in this city vsixty-six month period of 'this survey. 
The estimated population of Grand Rapids, Michigan, during the 
interim of this survey, wsfev individuals, A total of 16,063 deliveries 
were recorded in the time between January 1, 1935 to June 30, 
Included in this number were U7S stillbirths. There were then 15,585 living infants 
born of pregnant women prior to the allocation of deliveries by residence. The 
’’adjusted” number of births (corrected for residence allocation) was 15,016 total 
births (resident cases). This number included UlO "resident” stillbirths leaving 
thereby lU,6o6 living infants born of resident patients. These calculations would 
indicate, then, that IOU7 non-resident deliveries occurred in the city of Grand 
Rapids, The incidence of non-resident deliveries in the city was 6.5 per cent. 
Sixty-eight stillbirths occurred among these non-resident deliveries. 
In the first 60 of the 66 months of the period of this study we find a 
total of 71 maternal deaths (after allocation) and 368 illegitimate pregnancies 
(as listed in five Michigan Department of Health annual reports). The figures for 
the first six months of 19*+0 were not available. 
The above statistics will be at some variance with those of the State 
Health Department figures as the latter includes all illegitimate births while the 
City Health Department does not include such births for the state law provides that 
birth certificates of illegitimate pregnancies should be filed only at the state 
office. It is common knowledge, however, that the incidence of illegitimacy varies 
between 2.2$ and 3.5$ of all deliveries in the state. Hence, any discrepancy in 
the above unallocated figures, those of the City Health Department and the State 
Health Department corrected annual reports, will not vary beyond this percentage 
range. 
Incidence of Cesarean Section 
The crude incidence of cesarean section to the number of unallocated 
total infant births was 2.1$. Approximately every forty-eighth delivery among 
all city births was effected by the abdominal route. 
Ten thousand nine hundred and seventy-nine (10,979) the total 16,063 
Grand Rapids deliveries took place in three Grand Rapids hospitals, or 68,3$ were 
hospital deliveries. The incidence of cesarean section to the total hospital 
deliveries, in this 66 month period, was 3.09$ or one cesarean section to each 
32 deliveries. Interestingly enough, this was the same ratio found by Doctor 
de Normandie in his 1938 cesarean section survey of the State of Massachusetts. 
The relationship "between the total number of deliveries to the number 
of cesarean sections for each of the three hospitals, "by years, is illustrated 
in table I, Table X 
Total Humber of Deliveries and Cesarean Sections 
Cases 
January 1, 1935 to June 30» 19^0 
Hospital A 
Hospital B 
Hospital 
C 
All 
Hos-pitals 
Year 
Ho.Del. 
ITo. Sec. 
Ho.Del. 
. Ho.Sec. 
Ho. Del. IT 
0.Sec. 
Ho.Del, 
. Ho.Sec. 
1935 
60S 
1+1+ 
36S 
18 
5ll+ 
12 
1^90 
7^ 
1936 
665 
?-5 
1+20 
16 
5I+8 
10 
1633 
51 
1937 
S31 
31 
517 
IS 
718 
17 
2066 
66 
193S 
SU6 
is 
5I-P4- 
29 
789 
19 
2179 
66 
1939 
935 
20 
. 571 
17 
753 
20 
2259 
57 
I9I+O 
- 
12 
31^ 
10 
1+91 
1+ 
1352 
26 
(6 mos. 
Total 
) 
1+U32 
150 
27p - 
108 
3813 
82 
10979 
3U0 
There were 180, 108, and 82 cesarean sections performed respectively in 
hospitals A, 3, and C. Two hundred forty-seven of the cesarean sections were 
performed upon resident cases while the remaining 93 cases occurred among the non- 
resident group. The hospitals did not furnish the number of, non-resident total 
deliveries per year and accordingly these figures must be omitted. Table II depicts 
the residency and hospital distribution of these cesarean sections. 
Table II 
Residency and Hospital Distribution of Cases 
Hospital A 
Hospital B 
Hospital C 
All Hospitals 
Total 
Res. Hon-Res. 
Res. 
ITon-Res. • 
Res. 
Non-Res. 
Res, 
, Non-Res. 
Cases 
1935 Ul 3 
11 
7 
8 
14 
60 
lU 
. 7^ 
1936 19 6 
.10 
6 
8 
2 
37 
lU 
51 
1937 27 U 
10 
8 
10 
7 
*+7 
19 
66 
193S 16 2 
20 
9 
Ik 
5 
50 
16 
66 
1939 13 7 
10 
7 
13 
7 
36 
21 
57 
19U0 8 
8 
2 
1 
3 
17 
9 
26 
(6 mos) 
• , 
Total 113 26 
69 
39 
5^ 
28 
2U7 
93 
Total all 
causes . 150 
108 
82 
3^0 
3^0 
The changing incidence of cesarean section, during calendar intervals 
in the,study, and the approximate ratio of that operation per number of pregnancies 
delivered.by other routes is depicted in table III. To illustrate the trends in 
percentage of cesarean sections in each hospital the chart was further developed 
upon an annual "basis. The highest incidence of cesarotomy happened in 1935 in 
hosnital A, where - every fourteenth delivery was effected through the abdominal 
route. In contrast to this, one notes the unusual record of every one hundred and 
twenty-second birth, through the abdominal route, at hospital C in the first six 
months of 19^0. 3 
Table III 
The Changing Incidence of Cesarean Section 
Percentage and Approximate Ratio 
Hospital A 
Hospital B 
Hospital C 
All Hospitals 
Incidence 
Incidence 
Incidence 
Incidence 
/» 
Ratio 
7° 
Ratio 
4 
7° 
Ratio 
* 
Rat i 0 
1935 
7.2 
l jiU 
k.B 
U21 
2.3 
l:U2 
M 
1520 
1936 
3-7 
is 27 
3.8 
i;26 
1.8 
1J 5U 
3.1 
1:32 
1937 
3-7 
1:27 
3.^ 
1:29 
2.3 
l:U2 
3.1 
15 31 
1938 
2.1 
lsU6 
5.3 
It 19 
2.k 
l:Ul 
3.0 
1*33 
1939 
2.1 
l:^7 
2.9 
1:3U 
2.6 
1:27 
2.5 
1*39 
i9*+0 
(6 mos. 
2.2 
) 
iM 
3.1 
1:26 
0.8 
15122 
1.9 
1:52 
66 moe. 
3-'4 
1:39 
3.9 
1:25 
2.1 
iM 
3.09 
1:32 
The numbers of cesarean operations per each of two hospitals was double 
checked by a comparison of the lists submitted and the day to day search of the 
operating room sponge books. Cesarotomy, in this survey, includes only those abdom- 
inal operations done to remove a viable fetus through an uterine incision. Abdominal 
hysterotomies performed before the time of viability were placed in the category 
of therapeutic abortions. It was of particular and incidental interest to observe 
in passing, however, that 17 hysterectomies were done upon early pregnant patients 
to effect a sterilization. Such procedures would appear somewhat radical and 
especially so when one discovers that 8 of these surgical cases were under the 
supervision of one operator. 
Types of Cesarean Section 
The choice of operative technics used in these cesarean sections 
were distributed as follows: 
Table IV 
Types of Cesarean Section 
Hospital 
Classical 
Section 
Low Cervical Section 
Porro 
Section 
Total 
Ho. 
* 
Ho. 
V 
? 
Ho. 
* 
Ho. 
A 
135 
90 
2 
l.U 
13 
2.6 
150 
3 
97 
S9.8 
6 
5.5 
5 
102 
C 
67 
21.7 
7 
2. 6 
g 
9.7 
22 
All Grand Rapids 299 
S7-9 
15 
26 
7.6 
3^0 
There were 267 elective cesarean sections and among this number 26U cases 
were recorded definitely, by various descriptions, as not in labor while in the 
remaining small number of 3 patients the status of labor was not mentioned by any 
of the usual indications. These three cases were added to'the 26U patients whose 
charts stated they we re not in labor. ’’Elective cesarean section” will be the 
term used in this survey for these patients submitting to cesarotomy prior to the 
onset of actual labor pains. In short, of all the cesarean sections done 
in Grand Rapids were ’’elective cesarean sections”. These elective sections were 
further subdivided a.s in ta.blc V. Table V 
Elective Cesarean Sections 
Total Humber 
of Cases 
Percentage 
Legend 
267 
78.5 $ 
of all cesarean sections were ’’elective11 
237 
of all cesarean sections were elective classical 
type _ : 
237 
. SS.9fo 
of .all classical cesareans elective 
10 
’• 3.7^ 
of.all low cervical sections were elective 
20 
; 7. * 
of all Porro cesarean sections were elective 
Approximately seven of each ten cesarean sections were operated upon 
in the usual classical type of operative approach. It is of considerable interest 
to note, although the smaller numbers do not permit emphasis, the fact that the. 
ratio of Porro elective sections (26 total and 20 not in labor, 76.6vO was found 
to have occurred in approximately three of every four cases. 
It would appear that when 20 patients out of a total series of cases 
(5.9$) were forced to have the uterus "electively” removed at the seme time 
cesarean section was performed that the surgical care of difficult cases was 
somewhatradical, and more so, in view of the statistical fact that more than 
three-fourths of these Porro sections were performed upon women not.in labor. 
To provide basic data for further cens.idera,tion by individual doctors interested 
in the numbers of patients in labor and not in labor table VI was constructed. 
Table VI 
Cesarean Section Survey 
Grand Hap ids, Mich igan 
January 1, 1935 to June 30*. 19^0 
Relation of Labor to Cesarean Section 
Type of Section 
Hot in Labor 
Hospital A 
Hospital B Hospital C 
All Grand Rapids 
Classical 
Il6 
SO 
Ul 
237 
Low cervical 
2 
5 
3 
10 
Porro 
9 
5 
6 • 
20 ; 
Total Electives 
127 
90 
In Labor 
50 
267 - 
Classical. 
19 
17 
26. 
62 
Low cervical 
0 
1 
5 
Porro ; 
0 
2 
8 
Total Eon-elective 
'."z 23;: 
> 18. . 
■32 
73 
All types, elective and 
; / 
non-elective 
. 150 
106 , ‘ * 
S2 ■ 
3^0 Table VI illustrates the statistical conclusions that hospital C, when 
studied on a ratio basis, tends to defer operative interference at least until the 
patient has had some degree of a test of labor. This conclusion is further 
supported when one considers the indications for cesarean section on those cases 
both in labor and not in labor. The gross figures are included in this report 
so the authorities of each hospital may have comparable data to compute and 
compare the minor differences of their institutions' to others in the city. The 
general purpose of this survey' was but to point out the highlights of cesarean 
sections in Grand Rapids, and one such fact is that hospital C does report that 
about two of every three cesarean patients (65$) does permit some ’’test of labor" 
prior to surgery. This is in contrast to hospital A wherein nearly 9 of each 10 
patients ( are operated upon before labor is present. In hospital B the 
same ration was present, ,83*3$ operated upon prior to labor onset. 
Age and Parity of Patients 
Age 
The youngest patient was sixteen years old while the eldest patient 
was fifty-one years of age. The greatest incidence of cesarean section took 
place in the group between the ages of twenty-six to thirty. Table VII discovers 
the age distribution in this series of case records. 
Table VII 
Age at Time of Cesarean Section 
Grand Rapids, Michigan 
Age Interval 
Number 
Age Interval 
Number 
16 - 20 
21 
36 - ko 
in 
21 - 25 
82 
kl - 
13 
26 - 30 
100 
51 
1 
31 - 35 
82 
Total 
3'1+d" 
Parity 
There were one hundred and twelve women pregnant with their first full 
term pregnancy who submitted to cesarean section, 32,9$* remaining group 
of 227 women reported one or more previous children, 68,1$, One patient’s record 
failed to reveal parity. The 227 women who gave a history of previous pregnancies 
reported a total of 533 previous pregnancies, exclusive of their pregnancy at 
the time of their cesarean section. 
Table VIII 
Parity at Time of Cesarean Section 
Grand Rapids, Michigan 
January 1, 1935 to June 30» 19^0 
Parity- 
Number 
No, Previous 
Parity 
Number 
No, Previous 
Children 
Children 
Unknown 
1 
Seven 
2 
14 
Zero 
112 
Eight 
3 
24 
One 
98 
98 
Nine 
1 
9 
Two 
62 
124 
Ten 
2 
20 
Three 
21 
63 
Eleven 
1 
11 
Pour 
21 
84 
Pive 
10 
50 
Totals 
340 
533 
Six 
6 
36 • The distribution of the ,rprimiparousn patients in the three hospitals 
is correlated with their ages, in half decades, in table IX 
Table IX 
Correlation of Para 0 Cases with Ages by Half Decades 
Ages Interval 
A 
B 
Hospital 
C 
All 
16 - 20 
3 
2 
5 
10 
21 - 25 
ik 
10 
18 
k2 
26 - 30 
3 ' 
9 
7 
25 
31 - 35 
7 
9 
■ 3 
19 
36 - Uo 
2 
7 
2 
11 
41 - k$ 
1 
1 
1 
3 
51 
1 . .. 
0 
0 
1 
Totals 
37' 
32 
' ' 37 
112 
Among the age interval group, l6 to 20, ten were para 0, nine were 
para I, and two were para II, Those patients in the age interval Ul to 51 had 
their parity distributed as follows: -para. 0, 4; para I, none; para II, 3» 
para III, 1; pafa IV, 1; para V, 2; para X, 2; and para XI, 1, 
The Relationship of Petal Position and Presentation 
to Types of Cesarean Section 
The long axis of the fetus with vertex presentation was found in 290 
of the patients. In 15 other cases the position or presentation of the 
fetus was not recorded. There were thus 35 unusual positions and presentations 
of the fetus. The correlation of the position and presentation of the fetus to 
the type of cesarean section for each hospital is illustrated in table X. Position and Iresentation 
of Fetus 
Hospital A 
C LC P 
Hospital 
C LC 
B 
P 
Hospital G 
C LC P 
All City 
C LC P 
Grand Total 
All types 
OLA 
7^ 
i 
5 
50 
3 
2 
27 
k 
2 
151 
8 
9 
168 
OHA 
3i 
i 
1+ 
21 
1 
1 
15 
2 
1 
67 
h 
,6 
77 
OLP 
2 
0 
0 
8 
1 
0 
3 
1 
0 
13 
2 
0 
15 - 
OHP 
5 
0 
1 
8 
0 
1 
6 
0 
0 
19 
0 
2 
21 
OLT 
1 
0 
0 
1 
0 
0 
1 
0 
0 
3 
0 
•0 
3 
OPT 
k 
0 
0 
0 
0 
0 
1 
0 
0 
5 
0 
0 
5 
Breech, all types 
9 
0 
1 
h 
1 
1 
7 
0. 
0 
20 
1 
2 
23 
Twins 
3 
0 
3 
0 
0 
0 
3 
0 
0 
6 
0 
0 
6 
Shoulder 
0 
0 
1 
1 
0 
0 
1 
0 
2 
2 
0 
3 
5 
Face 
0 
0 
0 
2 
0 
0 
0 
0 
0 
2 
0 
0 
2 
Unknown 
6 
0 
1 
2 
0 
0 
3 
0 
3 
11 
0 
k 
* 15 
Totals 
135 
2 
13 
97 
6 
5 
67 
7 
8 
299 
15 
26 
3^0 
GHAKD TOTALS 
150 
108 
82 
3U0 
Table X 
Relation of Petal Position and Presentation to Type of Cesarean Section 
Grand Rapids, Michigan 
January 1, 1935 to June J>0y 19UO 
C - Classical; LC - Low Cervical; P - Porro The Primary Indications for Cesarean Section 
The leading indications for these cesarean sections included in 
this survey may he grouped generally as shown in table XI, 
Table XI 
Primary Indications for Cesarean Section 
Grand Rapids, Michigan 
January 1, 1935 to June 30» 19^0 
Primary Indication 
A 
B 
Ho spitals 
c 
All 
Grand 
Total 
c 
LC 
P 
c 
LC 
P 
c 
LC 
P 
C 
LC 
p 
All Types 
Bony Parts 
Passage 
15 
0 
1 
15 
0 
0 
10 
0 
1 
1+0 
0 
2 
1+2 
Soft Parts 
57 
0 
5 
29 
3 
2 
18 
k 
1 
10k 
7 
8 
119 
Passenger 
13 
1 
1 
10 
1 
0 
ik 
0 
1 
37 
2 
2 
1+1 
Other )Hem, 
10 
0 
3 
18 
0 
2 
18 
3 
5 
1+6 
3 
10 
59 
Maternal )Tox, 
6 
0 
0 
9 
0 
0 
1 
0 
0 
16 
0 
0 
16 
Indications)Other 
28 
1 
3 
16 
2 
1 
6 
0 
0 
50 
3 
k 
57 
No Indications 
6 
0 
0 
0 
0 
0 
0 
0 
0 
6 
0 
0 
6 
Total 
GRAND total 
135 
2 
150 
13 
97 
6 
108 
5 
67 
7 
82 
8 
299 
15 
3U0 
26 
3 
31+0 
The bony passage of the mother was deemed responsible as the primary 
indications for cesarean section in Us cases, 12,of the group. The principal 
single cause given as the primary indication for cesarean section was that involving 
the soft parts of the maternal passage. This group included 119 patients or 32$, 
The passenger was held accountable for Ul of the primary indications. Other maternal 
indications for cesarean section included 59 cases on the basis of maternal hem- 
orrhage, Id cases of maternal toxemia, and 57 other cases had to Classified as' 
"other" maternal indications. In 6 instances the records, all in hospital A, gave 
no single clue as to the indication for operative delivery via the abdominal route. 
The greatest single causes listed as indication for Porro cesarean sec- 
tion included "soft parts" of the maternal passage in S cases, and hemorrhage on 
the part of the mother in 10 cases. 
The Specific Primary Indications as Distributed in Each Hospital 
Subdivisions 
The larger general primary indications for the cesarean sections are 
subdivided for each hospital in the following tabulations. In that immediately 
following all sections were performed by the classical operative technics while 
the more special operative technics will be given with their specific indications 
in a second tabular listing. Subdivision of Cesarean Section Indications Classified 
Under the General Connotation "Maternity Passage, 
(all cases delivered by classical operation) bony parts" 
Bony parts of Maternal Passage 
of Cases in 
Hospital A 
Hospital B 
Hospital C 
All Hospitals 
"Polio*1 pelvis 
2 
1 
0 
3 
"Butterfly Sacrum" 
1 
0 
0 
i 
"Generally contracted pelvis" 
10 
12 
k 
26 
Low Assimilation pelvis 
1 
0 
0 
1 
Bilateral Congenital Hips 
1 
0 
0 
l 
"Traumatic" Pelvis (Post-accident 
al) 0 
1 
0 
1 
"Acute" dumbo-sacral angle 
0 
1 
0 
1 
"Plat" pelvis 
0 
0 
2 
2 
History "difficult labor" with 
infants stillborn 
0 
0 
2 
2 
Haegele Pelvis 
0 
0 
1 
1 
Large Promontory of Sacrum 
0 
0 
1 
1 
Totals 
15 
15 
10 
Uo 
Subdivisions of Primary Indications 
for Cesarean Section (Classical Type) 
Included Under General Category of 
"Maternal Passage, Soft Parts" 
Specific Indications Hospital 
Number of cases in 
A Hosjjital B Hospital C 
All Hospitals 
Ono previous cesarean section 
3S 
22 
10 
70 
Two previous cesarean sections 
7 
2 
0 
9 
Previous plastic operation 
0 
2 
1 
3 
Congenital atresia upper third vagina 
i 
0 
0 
1 
To "protect" previous laparotomy scar 
0 
0 
1 
l 
Previous "difficult labors" but 
infants all lived 
g 
0 
1 
9 
Failure "Labor Induction" 
1 
0 
0 
i 
Pear of Breech Delivery (mother’s 
tissues) 
0 
1 
1 
2 
Uterus didelphys 
1 
0 
0 
1 
Vaginal Hernia 
1 
V 0 
0 
1 
"Inertia" 
0 
2 
k 
6 
Totals 
57 
29 
lg 
10k The Passenger (Fetus) as the Primary Indication for Classical 
Cesarean Section in Grand Rapids 
Specific Primary Indication 
Hospital A 
Hospital B 
Hospital C 
All Hospitals 
“Pace” Presentation 
0 
1 
0 
1 
Monster or .dead baby 
••• . 1 . 
1 
0 
2 
Mother was 'an ""Elderly Primipara" 
3 V 
■■2 
2 
7 
11 Twins" 
1 
0 ... 
0 
1 
Post-maturity 
5 
1 
2 
g 
Cephalo-pelvic disproportion 
(Primarily Petal) 
2 
■k 
9 
15 
Posterior Position 
1 
1 
1 
3 
Totals 
• 13 
10 
ik 
37 
"Hemorrhage" of Mother as the Primary Indication 
for Classical Cesarean Section 
Grand Rapids 
Specific Primary Indication 
Number 
A 
of 
B 
cases in 
C 
Each Hospital 
All Hospitals 
Abruptio Placenta 
3 
2 
5 
10 
Placenta Previa (all types) 
6 
16 
12 
3^ 
Ruptured Uterus 
i 
0 
1 
2 
Totals 
10 
18 
18 
U6 
"Toxemia" of Mother as the Primary Indication 
for Classical Cesarean Section 
Grand Rapids 
Specific Primary Indication 
Number 
of 
cases in 
Each Hospital 
A 
B 
C 
All Hospitals 
"Hypertension" 
1 
0 
0 . 
1 
Preeclarnpsia 
1 
5 
1 
7 
Nephritic Toxemia 
k 
k 
0 
8 
Totals 
6 
9 
1 
16 
’’Other" Maternal Factors Given as the Primary Indication 
for Classical Cesarean Section 
Grand Rapids 
Specific Primary Indication 
Humber 
of cases 
in 
Each Hospital 
A 
B 
C 
All Hospitals 
Fulminating Hydramnios 
0 
0 
1 
1 
Cardiac Condition in Mother 
5 
1 
0 
6 
Court Order Sterilization at 
time of delivery 
/ 
5 
k •' 
0 
9 
Pyelitis 
i 
0 
2 
3 
Sterilization of Mother(Voluntary) Ik 
10 
0 
2k 
Thoracoplasty (Mother) 
0 
0 
1 
1 
Uterine "Tumor” (usually fihroid)l 
0 
2 
3 
Hydronephrosis One Kidney 
i 
0 
0 
1 
Kyphosis of Spine 
i 
0 
0 
l 
Torsion of Ovarian Cyst during 
0 
1 
0 
1 
Labor 
Totals 
28 
16 
6 
50 In six instances a classical cesarean section was performed, all in 
Hospital A, with no specific primary indication for such procedure as indicated 
by a detailed perusal of the patients1 hospital records or the sponge count books. 
Two of these six patients were sterilized at the time of cesarotomy, 
A glance at the detailed indications for cesarean section will reveal 
certain relevant conclusions although brevity forbids a lengthy mention of 
obviously apparent inconsistencies between the different hospital primary indi- 
cations in this section survey. It is worthy of note, however, that the 
indication of 11 one previous section" was nearly four times more common in 
hospital A than in hospital C. Hospital A also evidences the greater number of 
primary indications for classical cesarean section (31 different factors) in 
contrast to hospital B (21 different factors) and hospital C with 23 different 
primary indications. In short, the chance for cesarean section would seem to 
be one third greater in hospital A which had a larger choice of primary indi- 
cations to explain its increased numbers of cesarean sections as opposed to the 
records of the other two hospitals in Grand Rapids. 
The Specific Primary Indications for Specialized Cesarean Sections 
(Porro and Low Cervical) 
Grand Rapids 
In view of the fact that the Porro cesarean section entails loss of 
the uterus following operative delivery the specific primary indications were 
deemed important enough to list separately and thereby permit the reader to 
judge in his own mind whether the radical operation was justified upon the basis 
of the primary indication for such a procedure. To add contrast to this tabulation 
the laparotrachelotomy operation (low cervical section) is included in this 
compilation, < 
Specific Primary Indication 
Number 
of Cases 
in Each Hospital 
for Section 
A 
B 
C 
All 
Low 
Porro 
Low 
Porro 
Low Porro 
Low 
Cervical 
Cervical 
Cervical 
Cervical Porr 
Ruptured Uterus 
0 
2 
0 
0 
0 
3 
0 
5 
CDS Pelvis (?Android) 
0 
1 
0 
0 
0 
0 
0 
1 
Dead Baby Anencephalus 
0 
1 
0 
0 
0 
0 
• 0 
1 
Pyeliti s 
0 
1 
0 
0 
0 
0 
0 
1 
Hydronephrosis 
1 
0 
0 
0 
0 
0 
1 
0 
Two previous sections 
0 
3 
0 
0 
0 
0 
0 
3 
Sterili zation 
1 
i 
1 
1 
0 
0 
2 
2 
Previous Vesico-Vaginal Fistula 
0 
i 
0 
0 
0 
0 
0 
1 
Repaired 
Previa (central) 
0 
i 
0 
0 
0 
0 
0 
1 
Bandl'1 s Ring SOW rup, 2 days 
0 
i 
0 
0 
0 
0 
0 
1 
TBC of Spine SOW rup, 2 days 
0 
i 
0 
0 
0 
0 
0 
1 
Fractured Pelvis Torn Plexus 
0 
0 
0 
0 
0 
1 
0 
1 
Cephalo-pelvic disproportion 
0 
0 
2 
0 
2 
0 
k 
0 
Abrupt!o Placenta 
0 
0 
• 0 
1 
1 
2 
1 
3 
Placenta Previa 
0 
0 
0 
1 
2 
0 
2 
i 
One previous section 
0 
0 
0 
0 
2 
0 
2 
0 Habitual Neonatal Death 
(2 previous occasions) 
0 
0 
o • 
0 
0 
Lived 
1 
0 
i 
Fibroids 
0 
0 
0 
2 
0 
1 
0 
3 
Cardiac (Mother) 
0 
0 
1 
0 
0 
0 
1 
0 
Extensive Vaginal Repair 
0 
0 
1 
0 
0 
0 
1 
0 
Breech Delivery- 
0 
0 
1 
0 
0 
0 
1 
0 
Totals 
2 
13 
6 
■5 • 
7 
g 
15 
26 
Hospital A found 10 different primary indications to justify the radical 
Porro cesarean section while in hospital B we find U different indications and in 
hospital C there were but 5 different factors involved. In contrast to this state- 
ment we find U primary indications for laparatrachelotomy at hospital C; 5 separate 
factors at hospital B and but 2 different indications for the less radical low 
cervical cesarean section. 
The Story of ’’Previous Cesarean Sections" 
Up to this point in the survey the general term "previous cesarean section 
was used only to connote a specific indication for the operative deliveries as 
reported in the study* It was obvious that some of those cases having had a 
cesarean section upon a previous occasion may require a second or even a third 
section for totally different primary indications than simply "previous section". 
To illustrate the total primary indications for all types of cesarean section 
cases which gave also a previous history of cesarean section, Table XII was 
developed. In all 95 women gave a history of previous operative delivery 
(abdominal route) and of these 53 cases were found in records of hospital A; 
27 cases at hospital B; and 15 cases at hospital C, In each of the three hos- 
pitals, two cases (total of six cases) who in each gave a history of two 
"previous sections". 
Among this series of patients there were more than one-fourth of 
that number who gave a history of one or more previous sections and among this 
group of 95 patients five cases were found to have ruptured uterus at the time of 
their last delivery and three gave a direct history of previous sterilization 
failure (and subsequent pregnancy and section; the latter cases were all in 
hospital A,) Table XII 
Primary Indications for the Last Cesarean Section 
Among Patients Giving a History of Previous Cesarean Section 
Specific Primary Indication 
for Last Section 
A 
Number of Cases 
B 
in 
0 
Each Hospital 
All Hospitals 
None (not given) 
16 
2 
6 
2k 
Two previous sections 
11 
2 
0 
13 
Placenta previa 
1+ 
0 
2 
6 
Separation of symphysis 
1 
0 
0 
1 
Ruptured uterus 
1 
0 
0 
1 
Cephalo-pelvic disproportion 
2 
2 
3 
7 
Generally contracted pelvis 
6 
2 
i 
9 
"Borderline" pelvis 
5 
2 
2 
9 
Fractured and deformed pelvis 
0 
2 
0 
2 
Nephritic toxemia 
2 
1 
0 
3 
Other toxemia 
1 
0 
1 
2 
Cardiac condition 
1 
0 
0 
1 
Sterili zation 
3 
12 
0 
15 
Failure test of labor 
0 
1 
0 
1 
Vaginal repair 
0 
1 
0 
1 
Totals 
53 
27 
15 
95 
Anesthesia in Cesarean Section 
The choice of anesthesia varied in the three hospitals. Hospital A 
physicians favored a combination of ethylene and nitrous oxide while hospital 0 
surgeons selected cyclopropane as their choice and hospital B adhered to the com- 
bination of nitrous oxide and ether although the latter did use local anesthesia 
and spinal anesthesias more than the other two hospitals. The Choice Anesthesia in Cesarean Section- 
Grand Rapids, Michigan 
January 1, 1935 to June 19^-0 
Table XIII 
Anesthesia 
A 
Hospitals 
B C 
All Hospitals 
Nitrous oxide alone 
15 
25 
19 
59 
Nitrous oxide and ether 
35 
6 
S5 
Nitrous oxide and ethylene 
62 
1 
0 
63 
Nitrous oxide and ether and ethylene 
33 
0 
1 
3^ 
Nitrous oxide and avertin 
0 
1 
0 
1 
Cyclopropane 
0 
7 
37 
m- 
Cyclopropane and ether 
0 
0 
1 
1 
Cyclopropane and nitrous oxide 
0 
2 
0 
2 
Spinal 
1 
5 
0 
6 
Ether alone 
1 
3 
15 
19 
Ether and ethylene 
0 
1 
2 
3 
Local 
2 
11 
1 
ik 
Local and nitrous oxide 
1 
k 
0 
5 
Local and cyclopropane 
0 
1 
0 
1 
Totals 
150 
108 
82 
3U0 
The Physicians Doing Cesarean Section in Grand Rapids 
There were physicians who performed the total cesarean sections 
in the three hospitals of Grand Rapids during the 66 month interim of this sur- 
vey, It was observed that six of these doctors performed cesarean sections in 
each of the three hospitals, while 8 physicians operated their cases in each of 
two hospitals and the remaining 20 surgeons limited their cesarean operations to 
a single institution. The distribution of cesarean section cases per operator is illustrated 
in the following table XIV, The master code number of each operator occupies 
the first column, the number of hospitals in which the operator performs his 
cesarean sections is listed in column two, while column three lists the total 
number of patients delivered by cesarean section by the individual physicians. 
The type of cesarean sections performed by each operator is illustrated in the 
three columns on the right. • • 
Table XIV 
Cesarean Section Survey 
Grand Rapids, Michigan 
Master Code Number 
Number of 0, R, 
Total number of 
Distribution 
of Types 
of Operator 
Hospitals in which 
Cesarean Sec- 
of 
Cesarean Section 
the Operator per- 
tions by 
by individual 
forms cesarean 
individual 
operator 
sections 
operators 
Classical Low 
Porro 
Cervical 
1 
3 
ks 
*+3 
0 
5 
IT 
3 
ifif 
0 
3 
3 
1 
If5 
32 
0 
T 
15 , 
3 
5k 
5k 
0 
0 
! 3 • . 
2S 
26 
2 
0 
22 
3 
17 
10 
7 
0 
2S 
2 
11 
10 
0 
1 
20 
2 
10 
9 
0 
1 
39 
3 
10 
10 
0 
0 
33 
2 
10 
6 
3 
1 
0.9 
1 
3 
S 
0 
0 
16 
2 
S 
s 
0 
0 
6 
1 
8 
s 
0 
0 
5 
2 
6 
6 
0 
0 
7 
1 
6 
6 
0 
0 
6o 
1 
6 
if 
1 
1 
5k 
2 
if 
3 
0 
1 
6U 
1 
U 
k 
0 
0 
66 
1 
U 
3 
0 
1 
2k 
1 
3 ■ 
3 
0 
0 
25 
1 
3 
2 
0 
1 
13 
1 
2 
1 
0 
1 
9 
1 
2 
2 
0 
0 
52 
2 
2 
2 
0 
0 
51 
1 
2 
0 
1 
1 
1 
2 
2 
0 
0 
1 
2 
1 
0 
1 
32 
2 
2 
2 
0 
0 
63 
1 
2 
2 
0 
• 0 
so 
1 
1 
1 
0 
0 
52 ■ 
1 
1 
0 
0 
1 
62 
1 
1 
1 
0 
0 
50 
1 
1 
0 
1 
0 
71 
1 
1 
1 
0 
0 
3k Operators 
3^0 
299 
15 
26 A review of table XIV will reveal that there were but four operators 
performing more than a total of 30 cesarean sections each during the whole 66 
month period of this survey. These four doctors performed IjU of the total 
operations in this series, or 53*5$ of the total number. However, it was of 
interest to observe that not a single operator in this group doing over half the 
cesarean sections in Grand Rapids elected to perform the low cervical cesarean 
section although three of this group did perform 15 of the total 26 Porro cesarean 
sections. Operators with the code numbers 1 and 3 did have much more liberal 
indications for cesarotomy than did the other two operators and although these 
specific indications were studied for each doctor the numbers were such as to 
lead to actual identity were the indications listed. Suffice it to say that these 
same two individuals performed more associated sterilization operations at the 
time of the cesarean section and also performed 13 of a total of 17 hysterectomies 
(done as a means to interrupt early pregnancy, on indication, and accomplish 
sterilization at the same time). These cases were gathered from the operating room 
records and are not included, in the series save as a casual although striking observe- 
tion. There were five operators who did but one cesarean section each in 
five and one-half years and one of these individual's only operative case was 
the more difficult Porro cesarean sectionl 
Eight operators (code number 60, 5*+» 66, 25, 13» 5d» and 5$) who 
did a total of 2U cesarean sections in the whole 5J- year period actually performed 
the difficult Porro cesarean section operation on 8 cases or one-third of all 
the women submitting to cesarean section operation by this group also lost their 
uterus. This figure is a decided contrast to the four operators (code numbers 
1, 17, 3» and. 15) who performed a total of lyU cesarean sections in the same 
period of time and found Porro section necessary but on 15 occasions, or in 8.6$ 
of their cases which on statistical analysis reveals that the chance of a woman 
losing her uterus following cesarean section was slightly more than four times as 
great if she permitted the "dabbler in cesarean section" to do the operative delivery1. 
If the loose indications given for some of the Porro sections by the two less 
stringent operators in the more experienced group (in numbers) were removed the 
chance of hysterectomy was actually increased to ten times in the group of the 
less experienced operators (in numbers). In summary the indications for Porro 
sections were loose and abstract in both the well experienced and the less 
experienced operators, although conservatism predominated in the former, 
None of the four operators doing over half of the sections in the survey 
series performed the laparotrachelotomy (low cervical flap) operation. 
The Consultants on Cesarean Section Cases 
There were SO physicians who referred or acted as consultants in this 
series of patients although but of their number actually performed the sur- 
gery, Among these 80 physicians it was found that 22 individuals acted as consul- 
tants and jk as operators while the remaining lU physicians acted only in the 
capacity of referring doctors. In 100 instances there was no consultation service 
rendered these patients, slightly less than one third the entire series. The 
remaining cases seen by consultants are listed in the following table so 
constructed that one can compare the total number of operations to the total 
number of each individual doctor's consultations. Table XV 
Correlation of Number of Operations and Consultations 
of 3ach Participating" Operator or Consultant 
Master Code No, of 
Doctor Total No, 
of Sections by Operator 
Total No, of Times 
This Operator Acted 
as Consultant 
No consultation at 
all 
on 
records 
100 . 
0 
■ 17 
57 
3 
U5 
51 
3^ 
Uo 
k 
28 
32 
6o 
6 
2-1 
39 
10 
g 
1 
U8 
5 
28 
11 
. 5 
5 
6 
3 
33 
10 
3 
19 
8 
2 
23 
0 
2 
6l 
0 
2 
2 
0 
1 
9 
1 
1 
22 
17 
1 
2k 
3 
1 
25 
3 
. -i 
63 
2 
1 
6U 
■ i . 
k •• 
1 
67 
.... ... 
0 
1 
SO 
1 
1 
29U 
2U0 
Operator operated 1 
upon 
his 
, 
personal cases without 
advice 
of other doctors 
U6 
0 
Total 
3U0 
2U0 
A glance at table XV reveals that in U6 instances the operator performed 
a cesarean section upon his own personal patients without seeking any advice of 
a medical confrere. These -cases were distributed about equally among all these 
institutions. There were four physicians who were adjudged to be competent conr- 
sultants although they themselves performed no surgical deliveries via the 
abdominal route. 
Among the four surgeons performing a total of cesarean sections (of 
the total of cases) we find their consultants to be limited largely to men of 
their experience, in general, or as in one instance, ignoring the consultation 
service. Table XVI illustrates this observation. -Table X\TI 
To Demonstrate the Humber •of- Consultants Used by the Four Operators 
Doing the (Greatest Number of Cesarean Sections 
4 Operators -.176 Cases 
Consultants 
Operator1s 
Master Code Number 
Hospital A 
Hospital B 
Hospital 
G 
All 
Hospitals 
1 
17 
15 
3 
1 
■ 17 
15 
3 
1 ' 
17 
15 
3 
1 
17 
15 
3 
63 
0 
0 
0 
0 
0 
0 
1 
0 
k 
0 
0 
0 
k 
0 
1 
0 
1 
0 
0 
0 
0 
0 
0 
0 
a 
0 
0 
0 
0 
0 
0 
0 
0 
17 
0 
0 
0 
0 
T 
Ik 
12 
0 
1 
1 
2 
0 
s 
15 
Ik 
0 
15 
0 
0 
0 
0 
0 
16 
0 
6 
6 
1 
9 
0 
0 
17 
9 
6 
60 
0 
0 
0 
0 
0 
10 
1 
0 
0 
0 
0 
0 
0 
10 
1 
0 
3 
6 
0 
1 
17 
0 
0 
0 
0 
0 
0 
0 
0 
6 
0 
1 
17 
None 
12 
2 
0 
13 
2 
2 
0 
0 
10 
1 
0 
0 
2^4 
5 
0 
13 
k 
2 
0 
1 
12 
0 
0 
0 
0 
0 
0 
0 
0 
2 
0 
1 
12 
SO 
0 
0 
0 
1 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
1 
20 
0 
0 
0 
1 
0 
0 
0 
0 
0 
0 
0 
0 
. 0 
0 
0 
1 
25 
0 
0 
0 
1 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
1 
2 
1 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
1 
0 
0 
0 
3? 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
1 
0 
0 
0 
1 
0 
o4 
0 
0 
0 
0 
1 
0 
0 
0 
0 
0 
0 
0 
1 
0 
0 
0 
28 
0 
0 
0 
0 
0 
0 
0 
0 
2 
0 
0 
0 
2 
0 
0 
0 
Totals 
21 
2 
2 
U5 
10 
h2 
Ik 
6 
17 
3 
12 
0 
kz 
28 
145 
When the operators master code number is traced across the columns from 
the same number on the left that code number listed under each hospital and in the 
last four columns the number indicated illustrates the number of cases both seen in 
consultation and operated upon by that physician. When the legend (none) is traced 
across to each code number that number depicts the number of cases in which the 
doctor acts as the private physician, the consultant and the surgeon on the same 
case, e,g, operator Ho, 1 brought in 24 cases (50$) of his personal series of 48 
patients and in these 24 instances he was the personal physician, the consultant, 
and surgeon to each patient in this group. 
The portion of the survey which includes a discussion of the physicians 
doing the cesarean sections could have been extended into a much more valuable 
report, if it were possible to have been able to have ascertained the number of 
deliveries per each doctors, as was done in the Pontiac cesarean section survey. 
.The G-rand Rapids City Health Department, however, does not have as extensive and 
basic demographic data available as did the aforementioned city. 
Other Operations Associated with Cesarean Sections 
Among the patients submitting to cesarean section one can demonstrate 
186 additional operations performed upon this group. Slightly more than one-half 
of these patients experienced some operative procedure other than cesarotomy 
at the time of their operation, or soon following it (as in U cases). The largest number of secondary operations were those of sterilization 
by means of tubal ligation. These various operations of sterilization, all with 
the same ba„sis principle, that of crushing or ligation of the Fallopian tubes, 
constituted of the 186 associated surgical procedures, or nearly three-quarters 
(?5#8$) of all the secondary operations were sterilization by ligation. To this 
number of sterilization operations could be added further 26 hysterectomy operations 
(Porro sections) and 9 cases of bilateral salpingo-oophorectomy, for a total of 
176 (9^.6fo) of the 186 secondary operations which left the patient sterilized by 
operative procedure. 
The distribution of these secondary operations at the time or soon fol- 
lowing cesarean section is given in the following chart, viz,: . 
Table XVII 
Associated Surgical Procedures With or Following Cesarean Section 
Associated Surgical Procedures 
A 
Hospital 
B 
c 
All 
Hysterectomy (Porro sections) 
13 
5 
8 
26 
Sterilizations (ligation of tubes) 
80 
6i 
0 
ikl 
Bilateral salpingectomy' 
8 
0 
1 
9 
Unilateral salpingectomy 
0 
i 
0 
1 
Myomectomy 
1 
i 
1 
3 
Appendectomy 
1 
0 
0 
1 
Removal Twisted Pedicle Cyst 
0 
1 
0 
1 
Exploratory Laparotomy (Sec. for 
Obstruction) 
3 
0 
0 
3 
Repair Evisceration kth P.O. Day 
1 
0 
0 
1 
Totals 
107 
69 
10 
186 
Inasmuch as the number of hysterectomies included some interesting 
indications for this procedure it was thought best to list them separately under 
each hospital: 
Porro Cesarehn Sections (Hysterectomy) following Section 
Hospital A 
1, Ruptured-uterus 
2, DCS pelvis (dystocia dystrophy pelvis) X-ray measurements normal 
3, Dead baby - anencepholus (Para 2 Gravida 3) 
U, Placenta previa centralis with uterine fibroid 
5, Premature ruptured membranes (US hours ), X-ray measurements normal, 
baby lived (Mother reputed to have tuberculosis of spine, was Para 0, 
Gravi da I) 
6, Two previous sections ( 1 stillborn by normal d.elivery, Para 31 Gravida 1+) 
7, Two previous sections (Para U Gravida 5) all 5 children living 
8, Elective Porro section - for sterilization (So written on chart) 
9, Ruptured uterus 
10, Previous vesico-vaginal fistula repaired (Para 1, Gravida 2) 
11, Premature Rupture of Membranes (US hours) Bandl’s contraction ring 
12, Pyelitis (Patient had hematuria 8 days preoperatively) 
13* Two previous sections (uterus failed to contract) Para 2, Gravida 3 Hospital B ; •• 
1, Placenta previa centralis 
2, Pibroid on anterior wall of uterus - orange size 
3, Pibroid uterus (orange size) - maternal toxemia 
U, No indication given. Sterilization mentioned. One previous section. 
Para 1, Gravida 2, 
5. Abruptio placenta with thrombosed broad ligaments 
Hospital C 
1, Torn venous plexases in broad ligament 
• 2. Convelaire uterus (severely thrombosed blood vessel), Abruptio. 
3. Ruptured uterus - hand sized window 
U, Bicomate uterus - two previous stillbirths, Para U, Gravida 5. 
5, Uterine fibroids (large sized) 
6, Ruptured uterus with "rigid cervix" (Patient died on third P,0 day) 
7, Ruptured uterus. (Patient died on fourth P,0. day) 
8, Abruptio placenta with severe uterine changes. 
The Progeny of Patients Delivered by Cesarean Section 
There were 350 infants born of the women delivered by cesarean section. 
There were five sets of twins. Two sets died following delivery at hospital C. 
In S3 instances it was impossible to secure information anent the sex or status 
of the baby - this difficulty was encountered at hospital A where the separate 
record systems were used and the number of the babyrs charts were not listed on 
the record of the mother as is done in most institutions. 
Among the 2SJ known infants there were 62 deaths .and 26 of these babies 
were stillborn in the following number, per each hospital; hospital A, 6 still- 
births; hospital B, 10 stillbirths; and hospital C, 10 stillbirths. The remaining 
36 infants died in their neonatal period, i,e, prior to discharge from the hos- 
pital, Table XVIII shows the findings in each of the three hospitals. 
Table XVIII 
The Progeny of Patients Undergoing Cesarean Section 
Sex of Infant 
A 
Living Dead 
3 
Living 
Hospital 
Dead 
c 
Living 
Dead 
All Hospitals 
Living Dead 
Male 
33 10 
9 
32 
10 
109 
29 
Female 
35 7 
8 
25 
12 
107 
27 
Unknown 
63 0 
0 
0 
0 
0 
63 
0 
Twins 
2 0 
0 
0 
1 , 
2 
3 
2 
Totals 
133 17 
91 
17 
58 
2k 
232 
58 
150 
10s 
32 
3l+0 Cesarean Section Fatalities 
Among the cesarean section patients there occurred 12 fatalities, 
an operative mortality of three and one half (3.,5/°)» Six of these fatal out- 
comes following cesarotomy took place in hospital C; four fatalities at hospital 
A; and two fatalities at hospital B, 
Hospital • 
Total No, of Sections 
.Total No, of Fatalities 
Percentage 
Operative Mortality 
A 
150 
k 
2.6$ 
B 
108 
2 
i.s $ 
C 
82 
6 
7.3$ 
All 
3^0 
12 
3.5$ 
The operative mortality per individual operator is illustrated in the 
following table. 
Master Code No, 
Total No, of 
No, of Fatalities 
Operative 
Approximate Mortality 
of Operator 
Sections 
Mortality 
Ratio Incidence 
1 
1+8 
1+ 
s.3$ 
1 to 12 
3 
1+5 
2 
k.kjo 
1 to 23 
7 
6 
1 
i5.6$ 
1 to 6 
15 
2 
5.3^ 
1 to 17 
17 
1 
2.1% 
1 to 1+7 
20 
10 
1 
10.0$ 
1 to 10 
28 
11 
1 
5.0/5 
1 to 11 
The cause of deaths of the patients submitting to cesarean section included 
these items: at hospital A, one death from bronchopneumonia, two deaths following 
postoperative shock and one death resultant from generalized peritonitis following 
the separation of suture line in the uterus; in hospital B, one death on the 2Sth 
hospital day and the 7 th postoperative after section done for preeclampsia which 
failed to respond to 21 days of conservative medical care, and another death 
occurring from bronchopneumonia on the postoperative day (this patient was 
discharged against advice with distinct morbidity and died on her readmittance); 
in hospital C, five fatalities from postoperative shock (included 2 cases with 
previous diagnosis of ruptured uterus), and one patient succumbed on her 9th post- 
operative day from nephritic toxemia and its resultant uremia. 
Further correlations were made but the figures lack statistical signif- 
icance, and were unfair to individual operators, in view of the smaller numbers 
upon which certain deductions must be made. In summary, hospital C evidenced the 
highest operative mortality, hospital A was next, while hospital B had the lowest 
mortality percentage figure, No comments relevant to individual operators is 
necessary other than reference to the preceding table. The Febrile Morbidity 
There were 1059 days of febrile morbidity among this group of 
cesarean section patients. The morbidity included in this category was any tem- 
perature above 100° Fahrenheit exclusive of the first two postoperative days. 
There were 10b patients who experienced no febrile morbidity, on the basis of the 
aforementioned criterion of febrile morbidity. This indicates that but slightly 
less than one-third (30,6$) of the patients evinced no abnormal febrile morbidity. 
In the three hospitals the following number of patients gave evidence of febrile 
morbidity: 
Hospital 
Total iTo. 
'Sections 
of 
Afebrile 
Cases 
Afebrile 
Febrile 
Cases 
1° 
Febrile 
A 
150 
kl 
31.3$ 
103 
6S,7?S 
B 
108 
32 
zsM 
76 
70.U$ 
C 
82 
25 
30 M 
57 
69.6 
All 
3^0 
10k 
30.6 $ 
236 
6 
table for 
The numbers of hospital days 
each institution. 
of febrile 
temperature 
is given in the 
100° Febrile Morbidity or Over After Cesarean Section 
(Exclusive of First Two Postoperative Days) 
Days of Febrile.Temperature 100° 
or above exclusive of first two 
postoperative days 
A 
Hospitals 
B C 
All 
None 
32 
25 
10U 
1 
6 
■ !10 ■ 
9 
' 25 
2 
2k 
15 
15 
5U 
3 
' 23 
l6 
12 
51 
h 
11 
7 
5 
23 
5 
11 
k 
3 
18 
6 
8 
5 
1 
Ik 
7 
5 
5 
3 
13 
8 
k 
4 
2 
10 
9 
2 * 
3 
2 
7 
10 
5 
1 
2 
8 
ii 
2 
2 
1 
5 
12 
0 
0 
1 
1 
13 
0 : 
2 
0 
2 
15 • 
• • 0 
1 
0 
1- 
16 
0 
1 ■ 
0 
1 
19 
0 
0 - 
1 
1 
20 
1 
0 
■ 0 
1 
30 
1 
0 
0 
1 
150 
10s 
82 
3^0 23 
Inasmuch as this study was designed merely as a fact finding survey, 
by an out of the city individual conducting the demographic search, no conclusions 
will be listed, Ho recommendations will be made for the same reason although it 
is felt that each of the three institutions participating in this study may wish 
to make a few obvious changes in their conduct of supervision over potential 
cesarean section patients, by recommending some constructive changes in their 
hospital staff rulings and regulations. 
The author of this survey was given every support to facilitate his 
task and he wishes to thank the Maternal Health Committee of the Kent County 
Medical Society, the three hospital obstetrical staffs, and their departments of 
records personnel for their helpful and constructive suggestions. 
Respectfully submitted 
Bureau of Maternal and Child Health 
Michigan Department of Health 
per Clair S, Folsome, M.S,, M,D,, B.A.C.S, 
Michigan Department of Health 
k - 7 - k2 Hr 125 INDEX 
Status of Obstetrics During Period of Section Survey., 1 
Incidence of Cesarean Section 1 
Residency and Non-Residency 2 
Types of Cesarean Sections 3 
Relation of Labor to Type Cesarean Section U 
Age and Parity of Patients 5 
Petal Position and Presentation as Related to Type of Section £ 
The General Primary Indications for Cesarean Section g 
The Specific Primary Indications for Classical Section in Each Hospital 8 
The Specific Primary Indications for Specialized Cesarean Sections 11 
(Low cervical and Porro Types) 
The "Story of Previous Cesarean Sections" Specific Primary Indications 12 
Anaesthesias Used in Cesarean Sections lU