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ORIGINAL ARTICLE
Year : 2003  |  Volume : 57  |  Issue : 5  |  Page : 187-191
 

Cesarean section in a wedged head.


Department of Obstetrics and Gynaecology, Pt. B.D. Sharma PGIMS, Rohtak,

Correspondence Address:
H. No. 60, Sector-1, Urban Estate, Rohtak-124 001, India
anjuhuria@rediffmail.com


Keywords: Adult, Cesarean Section, Female, Head, Human, Infant, Newborn, Labor Complications, surgery,Labor Presentation, Pregnancy, Pregnancy Outcome, Retrospective Studies,


How to cite this article:
Khosla A H, Dahiya K, Sangwan K. Cesarean section in a wedged head. Indian J Med Sci 2003;57:187-91

How to cite this URL:
Khosla A H, Dahiya K, Sangwan K. Cesarean section in a wedged head. Indian J Med Sci [serial online] 2003 [cited 2014 Sep 21];57:187-91. Available from: http://www.indianjmedsci.org/text.asp?2003/57/5/187/11911


Cesarean section (CS) sometimes has to be done late in labour with the head deeply wedged in the pelvis. This situation may be rare in developed countries where labour is well supervised but is fairly common in developing countries where women like to be delivered at home by the traditional birth attendant (TBA) and report to the hospital late in labour if the TBA fails in her endeavours. This deeply wedged head may be a consequence of cervical dystocia with the head deep in the pelvis, deep transverse arrest, arrest in occipito posterior position, acute fetal distress late in first stage of labour with the head deep in the pelvis and unanticipated cephalopelvic disproportion late in labor.

In all the above situations CS had to be done with a deeply engaged head, there is difficulty in the delivery of the head. The head may need disimpaction by the upward pressure of an asistant per vaginum.[1] This is probably preferable to the operator trying to pass his hand below the head, which may stretch the lower segment excessively and extend the incision into the adnexae and uterine vessels.[2]

For these cases of deply wedged head, a technique called 'Patwardhan Technique' was used for the extraction of the baby in fifty patients. To our knowledge, one record of this technique is given in medical literature.[3]


 ¤ Material and methods Top


This is a retrospective analysis of 100 cases where cesarean section had to be done late in labour in patients attending the labour ward of PGIMS, Rohtak (India) from January 2000 to December 2001.

The indications for cesarean section were as follows:

[Table - 1]

In all these patients at the time of cesarean section of lower segment was thin and the fetal head deeply engaged. The baby was delivered by the Patwardhan Technique in 50 cases (group 1) and fetomaternal outcome was compared with 50 cases (group II) where this method was not used (delivered as head).

Patwardhan Technique[3]

a) In cases of occipito transverse or occipito anterior positions of the vertex, when a transverse incision is made in the lower uterine segment, most often it is found to be at the level of the shoulder; the anterior shoulder, usually, fairly 'pops' out of the incision line. If it does not, it is delivered out. This is shown in [Figure - 1].

b) Next, the posterior shoulder is also delivered out of the incision line. This is shown in [Figure - 2].

c) Now the surgeon hooks the fingers through both the axillae and with gentle traction, aided by fundal pressure by the assistant the body of the fetus is brought out of the uterus [Figure - 3].

d) At the end of step c, the baby's head is still wedged in the pelvis but from neck to feet, the baby is delivered out and the obstetrician gently lifts the baby, delivering the head [Figure - 4].

e) When the back is posterior after delivering the anterior shoulder, hand is introduced into the uterus and a foot is sought. By traction on the foot coupled with fundal pressure breech is delivered followed by thr trunk. The head is delivered by the traction on the legs.


 ¤ Observations Top


Fifty cases of caesarean section in which Patwardhan's method of delivery was used were compared with 50 cases where this method was not used.

There was no significant difference in the age, parity, duration of pregnancy and preoperative Fib status of the two groups as shown in [Table - 2].

Group I - Patwardhan's method

In this group there was no extension of the incision either laterally upwards or downwards. Thirteen units of blood were transfused intraoperatively. Indication was atonic postpartum haemorrhage in 5 cases and anemia in 4 cases.

Postoperative period was uneventful except for fever in one patient (2%) and superficial wound infection in 3 (6%) patients. Out of 50 babies, 13 (26%) had to be shifted to nursery for moderate to severe birth asphyxia. Two babies died of septicaemia and 48 were discharged in healthy condition.

In group II there was extension of incision both laterally and downwards in 12 (24%) cases. Thirty four units of blood were transfused intraoperatively. Indication was traumatic bleeding due to extension in 12 cases, due to atonic PPH in 4 cases and anemia in 3 cases. Postoperative period was uneventful except for fever in 3 patients, urinary tract infection in 2 patients and wound infection in 2 patients.

Out of 50 babies, 20 had to be shifted to nursery, 4 died due to septicaemia and 46 were discharged in healthy condition.


 ¤ Discussion Top


Extension of the uterine incision during delivery of the fetal head typically occurs in advanced labour when the lower segment is thin and the fetal head is deeply engaged. Extension into the broad ligament is the commonest reason for hemorrhage at cesarean section.[4] Hemorrhage due to extension of incision requiring blood transfusion occurred in 24% of patients in group II as compared to nil in group I as there was no case of extension of incision in this group. Extension of the incision into the upper segment is a contraindication to subsequent labour. Such scars have an approximately 12 percent incidence of symptomatic and often catastrophic rupture during labour.[5] Extension into the lower segment (vertically downwards) is difficult to repair but the risk of scar dehiscence in subsequent labour is probably no different from those labouring with a prior low transverse incision.[6] Extension of uterine incision with its problems of haemorrhage, difficulty in repairing, subsequent scar dehiscence is totally avoided by delivering the fetus by the 'Patwardhan Technique'. This technique is easy to learn and needs to be more widely publicized.


 ¤ Summary Top


Cesarean section many a times, has to be done late in labour when the head is deeply wedged in the pelvis. The techniques described in standard text books, usually result in extension of the incision either laterally into the broad ligament or vertically upwards into the upper segment or downwards posterior to the bladder from the centre of the incision line. In this study we have reviewed the Patwardhan's technique for the extraction of baby and fetomaternal outcome was compared with cases where this technique was not used. There was no extension of the incision either laterally into broad ligament or upwards or downwards. Haemorrhage due to extension of incision requiring blood transfusion occurred in 24% of patients in group II as compared to nil in group I.

 
 ¤ References Top

1.Cunningham FG, MacDonald PC, Gant NF, et at. Cesarean delivery and cesarean hysterectomy. In: William's Obstetrics, 20th edn, Appleton and Lange 1997:: p. 518.  Back to cited text no. 1    
2.Dickinson JE. Cesarean section. In: James DK, Steer PJ, Weiner CP, Gonik B, editors. High risk pregnancy. New York, WB Saunders 1999: p. 1222.  Back to cited text no. 2    
3.Patwardhan BB, Motashaw ND. J Obstet Gynaec Ind 1957; 8:1.  Back to cited text no. 3    
4.Murphy KW. Reducing the complications of cesarean section. In: Bonnar J, editor. Recent Advances in Obstetrics and Gynaecology. London: Churchill Livingstone, 1999: p. 144.  Back to cited text no. 4    
5.Halperin ME, Moore DC, Hannah WJ. Classical versus low segment transverse incision for preterm cesarean section: Maternal complications and outcome of subsequent pregnancy. Br. J Obstet Gynecol 1988: 95:990.  Back to cited text no. 5    
6.Adair CD, Sanchezhamos L, Whitaker D, et al. Trial of labour in patients with a previous lower uterine cesarean section. AM J Obstet Gynecol 1996,174:966.  Back to cited text no. 6    


Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

Tables

[Table - 1], [Table - 2]
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