One of our group wrote to the Department of Health to see what they know of the situation. After a few false starts this was the reply. With her comments ***xxx***

14 August 2000

Thank you for your letter of 3 July to Alan Milburn about hysterectomy following a caesarean section.

I was sorry to read about your condition. I am aware of the pain and stress that such an operation can have.

You asked first of all for statistics on the number of hysterectomies that are performed in such circumstances as yours. It can be difficult to obtain figures on exact procedures. In 1997 – 98 (the latest year for which figures are available) there were 64 cases nationally where a hysterectomy was performed following caesarean section in the same episode in hospital.

There were a variety of causes that led to these hysterectomies. Information on these causes is not readily available. **a cover up?** Diagnoses are difficult to interpret as some are for the caesarean rather than the hysterectomy. **surely this cant be right?!** However, working on the basis that the primary diagnosis would be for the caesarean itself, the secondary diagnoses and number of cases are as follows:

Malignant neoplasm of cervix uteri 2
Acute post haemorrhagic anaemia 1
Abnormality of pelvic organs 4
Placenta praevia with haemorrhage 3
Interpartum haemorrhage 2
Rupture of uterus during labour 1
Postpartum haemorrhage 18

We think that the remaining 33 hysterectomies were planned at the time the caesarean was arranged.
**!!!!!!!!!!!!!!

The Pregnancy book says that that there are situations where a caesarean section is the safest option for the mother, the baby or both. There are such circumstances. Hysterectomy though is major surgery and like all major surgery has risks attached, however much doctors seek to minimise those risks.
**I feel the book says it differently it starts a paragraph with ‘the operation is safe and takes about 30 – 40 minutes’ it also says – remember I was refused skin to skin contact due to the tent… ‘One advantage of an epidural is that you are awake at the moment of delivery **delivery! Surgical removal!** and you can see and hold your baby immediately’**

We can certainly bring your concerns to the attention of the authors for the next edition. The Pregnancy book aims to be comprehensive it cannot hope to go into full details about every eventuality. Although circumstances such as yours are tragic for the individuals concerned they are few in number. The authors of The Pregnancy book must balance the need to give relevant information against that of avoiding unnecessary alarm.
**informed decision is unnecessary alarm?! What about our alarm when it is done with no pre-warning.

As for advice, you should certainly talk to your own doctor as the best source of advice for your particular circumstances. In the wider field of advice you might wish to contact some of the bodies listed at the back of The Pregnancy book. There may be local organisations you could contact. Your local library or Citizens Advice Bureau would be the best place to start. I see that you have already spoke with some women who have undergone hysterectomy.

Yours sincerely

(signed)

JOHN RUTHERFORD
Women’s Health and Maternity Services Team

**To me it appears a complete cop out and the hospitals are not admitting to the amount of hysterectomies that are going on 2 – 3 women per year per hospital! or 1 in a 1000. These figures are no where near!

(Home page www.a-little-wish.co.uk)
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Summary of information from Department of Health

A friend did a quick search and found the following ...

These stats look a bit suspicious to me - I wonder if there is some under-reporting going on here? Because when I was searching for studies on obstetric hysterectomy after caesarean, the stats were:

- One emergency hysterectomy required after every 110 caesareans, compared to one after every 824 deliveries overall (vaginal or caesarean) [1, USA 1975-1981]

- Caesarean hysterectomy was performed in 0.17% (1 in 588) of caesareansections and a hysterectomy was done in 0.02% (1 in 5,000) of cases following a vaginal delivery.[2, Singapore, 1998]

- hysterectomy rate during or after cesarean section was 0.44% (1 in 227) and after vaginal delivery was 0.02% (1 in 5,000) [3, Italy, 1991]

- From 1978 to 1982, 70 cases of emergency hysterectomy for obstetric hemorrhage were performed at Los Angeles County/University of Southern California Women's Hospital. Sixty hysterectomies followed cesarean section, and ten were performed for hemorrhage after vaginal delivery [4, 1984]

- The incidence of obstetric hysterectomy was 1 in 1420 deliveries. Overall, 0.32% (1 in 313) of caesarean sections and 0.02% (1 in 5,000) of vaginal deliveries were complicated by emergency obstetric hysterectomy. [5, Hong Kong, 1997]

So in these studies, between 1 in 110 and 588 caesareans ended in hysterectomy. Let's use 1 in 500 as a (very) conservative estimate. Now, if only 60 - odd post-caesarean hysterectomies were being reported in the UK, that means that either a) there are only around 30,000 caesarean operations a year in the UK (I thought it was higher - any numbers, anyone?), or b) the UK has a dramatically lower incidence of obstetric hysterectomy after c/s than any other country for which I've been able to find stats, or c) not all cases are being reported.

I'm still trying to get hold of the big study on obstetric hysterectomy which was published last year - as I don't have access to a medical library at the moment (bit hard to just turn up at the local hossie with 2 small sprogs in tow and ask to use their journal room!), I'd be incredibly grateful if anyone who has a copy could send one to me. It's : Gould, D et al, 'emergency obstetric hysterectomy - an increasing
incidence', Journ. Obset. Gynaecol. 1999 vol 19 p580-583

Cheers, Angela

REFS

[1]
TITLE: Cesarean hysterectomy at Louisiana State University, 1975 through 1981.
AUTHORS: Plauche WC; Wycheck JG; Iannessa MJ; Rousset KM; Mickal A
SOURCE: South Med J 1983 Oct;76(10):1261-3
CITATION IDS: PMID: 6623139 UI: 84017742

[2]
TITLE: Caesarean and postpartum hysterectomy.
AUTHORS: Chew S; Biswas A
AUTHOR AFFILIATION: Department of Obstetrics and Gynaecology, National University Hospital, Singapore.
SOURCE: Singapore Med J 1998 Jan;39(1):9-13
CITATION IDS: PMID: 9557096 UI: 98217844

[3]
TITLE: [Ablative cesarean section and post-partum hysterectomy: review of 11 years of obstetric practice]
VERNACULAR TITLE: Taglio cesareo demolitore ed isterectomia post-partum: rassegna di 11 anni di attivita ostetrica.
AUTHORS: Dindelli M; Ferrari S; Potenza MT; Ferrari D; Ferrari A
AUTHOR AFFILIATION: Clinica Ostetrico-Ginecologica L. Mangiagalli, Universita degli Studi di Milano.
SOURCE: Ann Ostet Ginecol Med Perinat 1991 May-Jun;112(3):179-87
CITATION IDS: PMID: 1812802 UI: 92255178

[4]
TITLE: Emergency hysterectomy for obstetric hemorrhage.
AUTHORS: Clark SL; Yeh SY; Phelan JP; Bruce S; Paul RH
SOURCE: Obstet Gynecol 1984 Sep;64(3):376-80
CITATION IDS: PMID: 6462567 UI: 84271569

[5]
TITLE: Ten years experience of caesarean and postpartum hysterectomy in a teaching hospital in Hong Kong.
AUTHORS: Lau WC; Fung HY; Rogers MS
AUTHOR AFFILIATION: Department of Obstetrics and Gynaecology, Chinese University of Hong Kong, Shatin NT, Hong Kong.
SOURCE: Eur J Obstet Gynecol Reprod Biol 1997 Aug;74(2):133-7
CITATION IDS: PMID: 9306105 UI: 97451129