The Science and Art of Obstetrics: Laparotrachelotomy: Low Cervical Cesarean SectionJohn Calhoun

DATE: 1936
LENGTH: 35 min
CATEGORY: Educational & Instructional, Sound, Black & White, Clinical & Surgical
PRODUCER/PUBLISHER: Joseph B. DeLee, M.D., M. Edward Davis, M.D., Fox Movietone Scientific


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[The Science and Art of Obstetrics]

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[Laparotrachelotomy: Low, cervical cesarean section, by Joseph B. DeLee, M.D. and M. Edward Davis, M.D.]

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[Taken at the Chicago Lying-In Hospital, Fox Movietone Scientific]

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[…]

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[Dr. DeLee appears, no audio present]

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[Dr. DeLee:] …in eighteen hundred and five.

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And he did the operation,

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he did the operation twice.

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Both of the patients died,

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but he realized that it was a step in advance,

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and recommended it for all cases
requiring abdominal delivery.

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The mortality of the
classic cesarean section

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has improved as
time has gone on,

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and it did not seem that we needed

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a better method of abdominal delivery.

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But, our ideas of what was good also improved.

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In 1870, the mortality of 15 percent in Cesarean section was not bad.

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In 1900, the mortality of four percent was considered excellent.

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In 1930, a mortality of one percent is too much.

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Therefore, when in 1906 Fritz Frank of Bonn

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introduced the operation of Osiander,

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the low cervical incision, it was eagerly seized

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by the German operator, and its use has been spread over Europe

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and now in the United States, it likewise

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is receiving recognition.

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The principle of
the new operation

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is that the incision is made in the lower uterine segment,

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the neck of the uterus,

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and not in the fundus.

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And all the superiority
of the new operation

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grows out of this fact.

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There are two kinds of low cervical Cesarean:

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one where the incision being made just above the pubis,

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approach to the
lower uterine segment

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is gained by cutting through
the peritoneal cavity.

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This is called the
intraperitoneal method.

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The other kind is where the incision is made

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just above the pubis, and the peritoneum

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is pushed upward towards the navel…also the bladder.

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And the bladder is pushed to the side,

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and an area of lower uterine segment exposed,

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sufficiently large for
the delivery of the baby.

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This is called
extraperitoneal method,

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the general peritoneal
cavity not being opened.

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The majority of men prefer the direct route,

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the intraperitoneal method.

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The indications for the low
cervical Cesarean section

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are exactly the same as for
the classic Cesarean section.

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But owing to the safety
of the low operation,

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we can extend the field
in which it may be done.

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Now it is a fact that
in the United States,

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too many Cesarean
sections are being done.

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And it is also a fact that if the new operation

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were generally practiced, the total number

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of Cesareans done in the
United States would be reduced.

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I shall have occasion to
refer to this point later on.

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The contraindications to
the operation are very few.

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In a woman with a
pendulous belly,

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it may be hard to get access to
the lower part of the abdomen

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to make the incision.

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And if you are going
to do a Porro,

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it is hardly worthwhile
to do the low operation.

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But if at any time you
have to do the old classic,

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make it as low in the uterus as
possible so as to get as many

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of the advantages of the low
operation as are to be had.

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Now a few words about the surgical anatomy.

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Here is a model of a woman
at term, but not in labor.

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Here is the cervix, and here the lower uterine segment,

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which is about nine centimeters long.

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This is variable, but it nearly
always is long enough for you

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to extract the baby through it.

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Here is the loop peritoneum over the lower uterine segment,

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and here is the fascia, this white line,

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the fascia that
extended from the vagina

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upward, and loses itself towards
the fundus of the uterus.

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It is about this point that
the grey seam is located.

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You will hear a great deal about the grey seam

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during the operation.

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Here is a model of a woman who
has been in the second stage

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for a long time.

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And you can see how long
and thin the lower uterine

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segment and cervix are.

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They are fully 15 centimeters long,

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and the lower uterine segment almost invites you to cut into it.

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When you do your
first low cervical,

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select the place
where the labor has

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been on for a considerable
length of time.

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And that makes it much easier.

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You see how thin it is.

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Here is the peritoneum again,

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and here is the contraction rate.

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Now gentlemen, a few words about local anesthesia.

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It is particularly well-adapted to the low cervical cesarean section

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And I prefer it to
the spinal anesthesia,

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indeed to general
anesthetics, too.

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No one can deny that
spinal anesthesia

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is more dangerous than
a local infiltration.

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And since we can, in 90 percent of the cases,

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succeed with local
infiltration anesthesia,

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this should be the
method of choice.

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And I have here in my
hand the instruments

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that we use at the
Chicago Lying-In Hospital.

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They facilitate the operation,
but ordinary syringes

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will do the work just as well.

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We use a novacaine-cocaine solution, one half of one percent,

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And we add two minims of adrenaline

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to every ounce of the solution.

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We use seven or eight ounces, sometimes nine or ten,

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and we have never had any cases of poisoning,

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or any trouble whatever.

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After the baby is born, a
quarter of a grain of morphine

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and 1/150th of scopolamine are given.

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Solomon said that you should
have an understanding heart.

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And this will help you a great deal in your

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operating under local anesthesia.

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No tugging, no pulling,
no jarring of the patient.

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Gentleness all the time,
and you will succeed.

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Now gentlemen, let us
proceed to the amphitheater

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where we will do the operation.

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Now Mrs. Herman, we
are ready to start.

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Don’t be afraid.

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It will hurt just a little
when the baby comes.

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I’ll prepare you.

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If any of my work should
give you pain, say ouch.

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But don’t move.

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Pubis.

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Navel.

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We use a very fine needle to make a wheel in the skin.

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Then the big needle doesn’t
hurt when it goes in.

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Inject the novocaine into the skin itself, and, of course,

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into the fascia
right under the skin.

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Inject as you move
the needle in and out.

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Do you feel that?

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[Patient:] No.

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[Dr. DeLee:] Do you feel that?

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[Patient:] No, Doctor.

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[Dr. DeLee:] That’s good.

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You’re going to see the grey seam,

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where the loose peritoneum
of the uterus becomes firmly
adherent.

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See how loose it is here?

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…but I prefer the scissors.

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[…]

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On this drawing, you see where the clamps go,

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and how the scissors cut the lower uterus in the front.

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On this pelvis, you see how
the forceps are to be applied,

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and the head delivered.

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See the hammer
effect of the forceps.

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Slowly, no hurry.

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Now Mrs. Herman, the
baby is about to come.

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Be brave.

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Don’t squirm.

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Breathe quietly.

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And in a very few moments, you will hear the baby cry.

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[…]

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I am putting my finger
in the baby’s mouth

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to bring it to the front.

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Be careful,

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you can injure the little mouth.

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Wipe out the baby’s mouth because if it gasps,

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it might suck in the liquor amnii.

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[Baby crying]

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Lift the forceps blade
under the lip of the womb.

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Be very careful of that.

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Take lots of time,
very slowly and gently.

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All the instruments have
been removed from the womb.

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Slow…

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Take lots of time.

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No hurry.

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[Baby crying]

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Be ready to [INAUDIBLE].

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Carmen, will you have a lap sponge [INAUDIBLE]

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[Baby crying]

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Now Mrs. Herman,
you go to sleep.

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You have a fine, healthy baby.

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And also, you had a hypodermic.

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Gentlemen, we will now proceed to the repair of the womb.

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In this animated drawing,
which Mr. Carlson made,

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you will see the
course of the suture.

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Avoid the mucosa.

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Swing the needle around.

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Now in the upper
part of the uterus,

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the muscle is much thicker
and is likely to retract up

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into the body of the uterus.

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[Observer;} What kind of suture material
do you use, Dr. DeLee?

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[Dr. DeLee:] We use number two catgut for the first row.

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The second row,
we use number one.

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And for the peritoneum, number one.

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Very important to get a good apposition here,

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in order to have a firm
scar in the lower portion

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of the fundus and the cervix.

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Don’t catch the gauze in the needle.

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Pull it out a little there.

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The complications of the third stage…

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very seldom is there
post-partum hemorrhage

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in laparotrachelotomy,

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especially if you use local anesthesia.

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And we give ergot 15 minutes

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before the baby is
born, and a [INAUDIBLE]

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pituitary right afterwards.

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If there should be hemorrhage,
we pack the uterus.

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But I do that as a routine.

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And if you wanted
to give pituitary

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as it’s been necessary, inject it under the peritoneum as…

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I put it under the peritoneum.

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because if the solution is infected and makes an abscess,

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the abscess is not open
into the peritoneal cavity.

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Some accoucheurs believe
that placenta previa is not

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a good indication for
laparotrachelotomy.

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But our experience in 40
cases without mortality

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proves the contrary.

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There are three or possibly four things that must be remembered.

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In the first place,
in anemic cases

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precede the operation by
a transfusion of blood.

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And second, save blood
throughout the whole course

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of the operation.

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Don’t waste any.

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Third, deliver the baby
by version and extraction,

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and proceed slowly so as
not to do any tearing.

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Fourth, clamp all
the bleeding vessels,

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and hold them securely clamped
until they are sutured.

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Now gentlemen, do not
fear the difficulties

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that you might encounter.

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The field is open before you,

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and you can meet the emergencies as they arise.

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The hemorrhage, you can control by the ordinary tools and surgical method.

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And mechanical difficulties
are overcome by taking time,

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and by art instead of strength.

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Let me again recommend
the low cervical cesarean

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or laparotrachelotomy, as
well as the local anesthesia.

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Any of the difficulties, an
ordinarily skilled surgeon

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can overcome.

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And if you will perform
this operation as a routine,

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I am sure that you will
cut your mortality in half.

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What are the particular
features of the low cesarean

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that make it so superior?

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As I said before the operation,
these points of superiority

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grow out of the fact
that the incision is

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in the lower uterine segment.

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And I will now give you 10 of
these points of superiority.

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The first point is that the
incision is in the lower

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part of the abdomen.

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All the surgeons know
that the lower abdomen

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is more resistant to infection than the upper abdomen.

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The intestines and the omentum will rarely come into view,

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and are not touched.

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Therefore, shock is small,

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and there is less tendency to vomiting after the delivery,

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and to ileus.

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The spill is located
right around the womb

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and has very little
distribution,

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which also helps prevent shock, ileus, and nausea

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and vomiting.

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The cervix, in which the incision is made,

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is more resistant to infection, being used to it.

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Every gynecologist knows how
much the cervix can stand.

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I will now show you
this on another chart.

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This chart shows the delivery…

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shows the uterus a few
hours after delivery.

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As you see, the cervix shrinks
and drops into the pelvis,

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out of the general
peritoneal cavity.

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This was point five.

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Point six. In this chart you see the uterus a few hours after delivery.

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And as you will notice,
the wound in the cervix

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has dropped down into the
cavity of the pelvis, far away

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from the general peritoneal cavity.

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That was point five in
the list of superiority.

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One of the greatest
advantages of the low incision

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lies in the security of the
scar in subsequent pregnancies

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and labors.

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Only a few cases of rupture
of the scar during pregnancy

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have been put on record.

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And the number of ruptures of
this scar during actual labor

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is only a small
fraction of those

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that occur after the
classic cesarean section.

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The reason for this
security from rupture

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is easily seen by a
reference to these charts.

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In this operation, the wound is in the lower uterine segment,

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which is at rest and
can heal in peace.

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It is not disturbed by the turmoil going on in the fundus above.

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Compare that wound with this, after the classic cesarean section.

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Here, the wound
is in the fundus,

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which is in a constant
state of unrest.

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The uterine contractions,
the afterpain,

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keep up a constant motion,

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and sooner or later, one of these stitches or more

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[INAUDIBLE] will tear, and
let the cut, the lochia

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and bacteria into the wound
and into the peritoneal cavity.

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Point of superiority,
number seven.

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In the old classic cesarean,

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the lochia has a chance to seep through the uterus

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into the general peritoneal
cavity, causing peritonitis.

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In the new operation,
the low cervical,

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the lochia is prevented
from seeping through,

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and is confined to the
neighborhood of the cervix

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and under the bladder.

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Should infection occur,
which is not common,

00:21:39 – 00:21:44
see how easy it is to drain
the area that is infected.

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Either you can pull the
cervix down with a vulsellum

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and make an anterior colpotomy,

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thus reaching the abscess under the bladder,

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or you can burrow a finger through the stitches,

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into the abscess.

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Or, what is most common, nature helps you

00:22:05 – 00:22:12
in that the pus burrows under the bladder, around the bladder,

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through the cavity urethras.

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And by taking out one, two
or three of these stitches,

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you can let the pus out,

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and usually, healing is very rapid and complete.

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For comparison, see
where the infection

00:22:30 – 00:22:36
would travel after a
classic cesarean section,

00:22:36 – 00:22:44
beginning here in the endometrium,

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all through the peritoneal cavity.

00:22:53 – 00:22:58
Adhesions are common after the classic cesarean section,

00:22:58 – 00:23:02
and the reason is very plain.

00:23:02 – 00:23:06
Then the infection and pus is in
the intestines and the omentum.

00:23:06 – 00:23:11
On the other hand, after the low operation,

00:23:11 – 00:23:13
adhesions are very rare,

00:23:13 – 00:23:15
and you can see why.

00:23:15 – 00:23:19
The wound is dropped down into the pelvis, far away

00:23:19 – 00:23:21
from the general peritoneal cavity,

00:23:21 – 00:23:25
and the omentum almost never comes down so low,

00:23:25 – 00:23:27
the intestines hardly ever.

00:23:27 – 00:23:33
And when the bladder fills, the peritoneal line of suture,

00:23:33 – 00:23:36
that little line of suture I showed you at the operation,

00:23:36 – 00:23:39
drops down into
a deep cul-de-sac

00:23:39 – 00:23:42
and is further protected.

00:23:42 – 00:23:45
Finally here, but there are many other reasons.

00:23:45 – 00:23:49
The classical cesarean section is only safe

00:23:49 – 00:23:51
when it is an operation of election.

00:23:51 – 00:23:53
We can give a woman
a good test of labor,

00:23:53 – 00:23:57
and then perform a low
cervical cesarean section.

00:23:57 – 00:24:00
And therefore, by giving
a woman a test of labor,

00:24:00 – 00:24:03
a great many cesareans will be unnecessary,

00:24:03 – 00:24:06
and thus, the total percentage in the United States

00:24:06 – 00:24:07
will be reduced.

00:24:07 – 00:24:12
Now gentlemen, in conclusion, I have here the mortality statistics

00:24:12 – 00:24:16
of the United States Census Bureau in Washington.

00:24:16 – 00:24:19
And from these
tables we can learn

00:24:19 – 00:24:25
that over 500 women die from
cesarean section every year.

00:24:25 – 00:24:28
This is an enormous
number, and brings upon us

00:24:28 – 00:24:31
the opprobrium of the community,

00:24:31 – 00:24:34
when our statistics of maternal mortality

00:24:34 – 00:24:37
are compared with those of other nations.

00:24:37 – 00:24:42
If laparotrachelotomy was generally practiced in the United States,

00:24:42 – 00:24:47
I am sure that most of this mortality would be reduced.

00:24:47 – 00:24:49
And this is the reason that I have spent

00:24:49 – 00:24:53
a great deal of time, a great deal of effort,

00:24:53 – 00:24:55
and not a little
money in spreading

00:24:55 – 00:24:58
the gospel of the low
cervical cesarean section,

00:24:58 – 00:25:02
or laparotrachelotomy.

00:25:02 – 00:25:23
[bells ringing]

00:25:23 – 00:25:27
Ladies and gentlemen,
it is now six years

00:25:27 – 00:25:30
since the picture which
you just saw was published.

00:25:30 – 00:25:34
And I am going to tell you what has happened to the operation,

00:25:34 – 00:25:37
laparotrachelotomy, during this time.

00:25:37 – 00:25:41
But first, I want to
show you those babies.

00:25:41 – 00:25:49
Boys, will you come in?

00:25:49 – 00:25:52
I believe that Cesones do better

00:25:52 – 00:25:57
mentally and physically than children delivered from below.

00:25:57 – 00:26:07
Attention, salute,
left face, march.

00:26:07 – 00:26:09
What has happened
to the operation

00:26:09 – 00:26:11
during these six years?

00:26:11 – 00:26:14
Several modifications
have been suggested,

00:26:14 – 00:26:16
and we have tried them.

00:26:16 – 00:26:18
But we have found
that the method

00:26:18 – 00:26:20
which you saw on the screen,

00:26:20 – 00:26:25
and which was perfected after 14 years of trial, is still the best.

00:26:25 – 00:26:39
For example, the transverse surgical incision, like this.

00:26:39 – 00:26:41
A transverse, curvilinear incision

00:26:42 – 00:26:48
is made above the bladder.

00:26:48 – 00:26:52
We tried the operation
10 times, and gave it up.

00:26:52 – 00:26:57
One severe hemorrhage from the
base of the broad ligament,

00:26:57 – 00:27:00
one dangerous
extension of the womb,

00:27:00 – 00:27:03
a big baby, twice difficulty

00:27:03 – 00:27:06
in suturing the upper
to the lower flap.

00:27:06 – 00:27:09
The upper muscular lamellae

00:27:09 – 00:27:12
had retracted into the funds of the uterus,

00:27:12 – 00:27:19
and one almost fatal pulmonary embolism.

00:27:19 – 00:27:23
The literature records the fact that there are

00:27:23 – 00:27:27
more pulmonary embolisms after the transverse incision

00:27:27 – 00:27:29
than after the longitudinal.

00:27:29 – 00:27:34
We had one embolism in
10 transverse incisions,

00:27:34 – 00:27:40
and we had only one
embolism in the 1,800

00:27:40 – 00:27:42
other laprotrachelotomies.

00:27:42 – 00:27:46
The surgeons or gynecologists
would be very happy

00:27:46 – 00:27:51
if they could record 1,800 consecutive laparotomies

00:27:51 – 00:27:54
with only one
pulmonary embolism.

00:27:54 – 00:28:03
This is the median incision.

00:28:03 – 00:28:08
If the baby is large, you
can extend it up or down

00:28:08 – 00:28:09
towards the cervix.

00:28:09 – 00:28:13
If a tear occurs, it does
not go into the basis

00:28:13 – 00:28:18
of the broad ligament where the big vessels and the urethra are.

00:28:18 – 00:28:20
If the wound should
get infected,

00:28:20 – 00:28:27
the dangerous areas, the big veins, are far away.

00:28:27 – 00:28:30
[Observer:] Doctor, do you still use packing?

00:28:30 – 00:28:31
[Dr. DeLee:] Oh, yes.

00:28:31 – 00:28:34
We pack the uterus routinely.

00:28:34 – 00:28:39
But we are now using
acriflavine, iodine,

00:28:39 – 00:28:41
and glycerine on the gauze.

00:28:41 – 00:28:46
I wonder if there really is
an antiseptic that does good.

00:28:46 – 00:28:49
But we have a better ergot preparation.

00:28:49 – 00:28:54
It is called ergonovine.

00:28:54 – 00:28:57
Regarding post-operative
adhesions,

00:28:57 – 00:29:01
we have done second and
third laprotrachelotomies

00:29:01 – 00:29:04
on 345 patients.

00:29:04 – 00:29:08
And we found adhesions
to be the exception.

00:29:08 – 00:29:11
Whereas, after the classic cesarean section,

00:29:11 – 00:29:13
adhesions are the rule.

00:29:13 – 00:29:19
And they not seldom cause
serious late complications.

00:29:19 – 00:29:22
Fertility, likewise,
is not compromised

00:29:22 – 00:29:27
by the low operation as
it is by the classic.

00:29:27 – 00:29:31
Rupture of the uterus in subsequent pregnancy and labor…

00:29:31 – 00:29:35
the cervical scar has
proven its superiority.

00:29:35 – 00:29:39
There are only three cases on
record of rupture of the scar

00:29:39 – 00:29:40
during pregnancy.

00:29:40 – 00:29:44
And during labor, there are
less than 50 cases on record.

00:29:44 – 00:29:48
Whereas the classic
cesarean is notoriously

00:29:48 – 00:29:50
dangerous in this respect.

00:29:50 – 00:29:54
There are thousands of
ruptures to its discredit.

00:29:54 – 00:29:58
[Observer:] Doctor, how about placenta previa?

00:29:58 – 00:30:02
[Dr. DeLee:] We have done 120 laprotrachelotomies

00:30:02 – 00:30:05
in placenta previa without a single death.

00:30:05 – 00:30:10
Some doctors claim that the
classic cesarean section

00:30:10 – 00:30:14
is better in this complication.

00:30:14 – 00:30:17
But we believe
just the opposite.

00:30:17 – 00:30:20
We want to make the
opening in the uterus

00:30:20 – 00:30:23
over the bed of the placenta, where we can attack

00:30:23 – 00:30:26
a hemorrhage should one occur.

00:30:26 – 00:30:32
You make the incision a little bit higher on the uterus than usual.

00:30:32 – 00:30:35
The bleeding is only marked
if the placenta happens

00:30:35 – 00:30:38
to be on the anterior wall.

00:30:38 – 00:30:42
You burrow through the
placenta, grab the foot,

00:30:42 – 00:30:45
and slowly bring the
breech into the opening,

00:30:45 – 00:30:50
just the same as you do
when delivering from below.

00:30:50 – 00:30:54
If, after the
placenta is delivered

00:30:54 – 00:30:58
the bed of the placenta bleeds,
you simply sew it up like this.

00:30:59 – 00:31:02
You see it is very easy
to stop the bleeding.

00:31:02 – 00:31:14
You lip over the bed of the placenta with number 0 catgut.

00:31:14 – 00:31:17
Regarding infected
cases, we have not

00:31:17 – 00:31:20
broadened the indication
for laparotrachelotomy

00:31:20 – 00:31:24
to cover the frankly
infected case.

00:31:24 – 00:31:28
But we have risked it,
even when the bag of waters

00:31:28 – 00:31:30
has been ruptured a long time,

00:31:30 – 00:31:33
when several vaginal examinations have been made,

00:31:34 – 00:31:37
when labor has been prolonged, and when forceps

00:31:37 – 00:31:43
has been attempted, providing there was a reasonable amount of cleanliness.

00:31:43 – 00:31:48
The Porro operation is still the best for the frankly infected patients.

00:31:48 – 00:31:52
But, although it is sad to have to say it,

00:31:52 – 00:31:58
craniotomy may still be considered in rare instances.

00:31:58 – 00:32:00
Local anesthesia.

00:32:00 – 00:32:03
Local anesthesia has
helped materially

00:32:03 – 00:32:06
to reduce our
maternal mortality.

00:32:06 – 00:32:10
It is better than
spinal in every way.

00:32:10 – 00:32:13
And even the neurologists
are telling us

00:32:13 – 00:32:17
of late diseases resulting
from this invasion

00:32:17 – 00:32:19
of the spinal canal.

00:32:19 – 00:32:25
Laparotrachelotomy is
the ideal cesarean.

458
00:32:25 – 00:32:29
And experience the world over has justified

00:32:29 – 00:32:32
all the claims we have made for it.

00:32:32 – 00:32:34
You remember I told
you that it would

00:32:34 – 00:32:37
cut your mortality in half?

00:32:37 – 00:32:44
Well, look at this chart.

00:32:44 – 00:32:49
City of Chicago,
1934, 490 classics.

00:32:50 – 00:32:53
Deaths, five and a half percent.

00:32:53 – 00:32:59
Laparotrachelotomies, 541, two percent.

00:32:59 – 00:33:04
Germany, classics 438.

00:33:04 – 00:33:07
Deaths, six and four-tenths percent.

00:33:07 – 00:33:10
Laparotrachelotomies, 3,554.

00:33:10 – 00:33:14
Deaths, three and seven-tenths percent.

00:33:14 – 00:33:18
Chicago Lying-In
Hospital, 1914 to 1936.

00:33:18 – 00:33:21
Out of 60,000 deliveries-

00:33:21 – 00:33:28
60,000 deliveries-classics 168, deaths six percent.

00:33:28 – 00:33:35
Laparotrachelotomies, eighteen hundred and eleven…one-thousand eight hundred eleven.

00:33:35 – 00:33:38
Deaths, 18 from all causes.

00:33:38 – 00:33:47
Tuberculosis, eclampsia, heart disease, et cetera, one percent.

00:33:47 – 00:33:54
Now ladies and
gentlemen, a final word.

00:33:54 – 00:33:58
I believe in view of all these facts,

00:33:58 – 00:34:02
that I may in all fairness
ask you this question.

00:34:02 – 00:34:06
Does a man, in performing the old classic cesarean section,

00:34:06 – 00:34:11
when the low cervical operation could be done,

00:34:11 – 00:34:14
does he give his
patient all the benefits

00:34:14 – 00:34:21
of modern obstetric art?

00:34:21 – 00:34:35
[Music]