Difficult extraction of the fetus presented in aicog 09.01.19

Techniques for delivering transverse lie,Deeply impacted head,LSCS breech delivery,Use of forceps in LSCS,Conjoint twin delivery

1. Difficult extraction of the fetus

2. Obstetrics is not an exact science Greater the difficulty , greater the glory !!!

3. Many difficulties attend Caesarean section, and many disasters can follow it Difficulty in extraction of the fetus Torrential bleeding Disasters with the urinary tract and many other………. Fortunately, most of the others are rare. Some of these many difficulties are only seen in the developing world, where operators find themselves working under difficult circumstances.

4. Transverse lie

5. Transverse lie

6. The dorsosuperior (back up) transverse lie may be delivered as a footling breech through a low transverse incision. Consequently, a vertical incision in the uterus is usually employed in these cases. If the foetal membranes are intact at the time the caesarean delivery is performed, intra-abdominal version of the foetus can convert the transverse lie to a cephalic or breech presentation allowing delivery through a low-segment transverse incision.

7. Video of Transverse Lie

8. Extremely low birth weight baby

9. Extremely low birth weight infants (premature or growth restricted) present many challenges at caesarean delivery. The lower uterine segment is less well-developed ( thicker myometrium , smaller area) . Thus, the uterine incision is deeper and bloodier, and an adequate transverse incision to allow atraumatic extraction of the foetus may not be possible. It is also easy to inadvertently lacerate the foetus , especially in the setting of premature ruptured membranes, if the deepest layers if the myometrium are not incised carefully.

10. Also, because of the markedly reduced foetal size, the uterus is significantly smaller and occupies less of the abdomen and pelvis than larger, term pregnancies. Thus, the mother's intestines , which are usually confined to the upper abdomen in a caesarean delivery, frequently descend into the operative field and need to be manually displaced with either retractors or packing.

11. Deeply impacted head

12. Deeply engaged foetal heads that are difficult to deliver complicate about 1.5 percent of caesarean deliveries. These cases often follow a prolonged second stage and failed attempts at operative vaginal delivery. The impacted head places the infant at increased risk of intracranial haemorrhage, skull fractures, neck fractures, and asphyxia injuries, while simultaneously increasing the risk of maternal complications , such as severe uterine lacerations, damage to the uterine vessels, and injury to the lower urinary tract.

13. The best methods to dislodging the deeply engaged foetal head include: Abdominovaginal delivery : An assistant cups the foetal head vaginally in one hand and elevates to meet the operator’s hand. The mother's legs are abducted into the "Whitmore" or "frog" position on the operating room table.

14. Patwardhan’s shoulders first technique: The technique involves first delivering the anterior shoulder and arm and then rotating the foetus and delivering the posterior shoulder and arm. The foetal trunk, breech, and lower limbs are then successively delivered through the incision using a combination of gentle traction on the arms, fingers beneath the thorax, and fundal pressure. Once the body is delivered, the head is lifted out of the pelvis in the same manner as a reverse breech extraction.

15. Modified Patwardhan’s technique If back of the baby is posterior, anterior shoulder is first delivered followed by the corresponding lower limb. Then the contralateral lower limb is delivered. The foetal breech and the truck are then successively delivered followed by the posterior shoulder and arm.

16. Modified Patwardhan Technique

17. Difficulty in delivering head in obstructed labour

18. Use of a head elevators Foetal head elevators or obstetrical spoons are available in several variations, including the Coyne spoon, the Sellheim spoon and the Murless head extractor. All three instruments essentially function as obstetrical "shoe horns." They take up less space than the obstetrician's hand, thus they are easier to get around a tightly impacted head.

19. Murless head extractor

20. Reverse breech extraction technique: Described by Fong and Arulkumaran in Singapore in 1997. The operator's hand is inserted into the uterus towards the fundus to grasp the foetal feet , which are then pulled to perform a footling breech extraction. When grasping, and pulling the feet, care must be taken to apply traction only parallel to the axis of the legs to avoid fracturing the foetal tibia and/or fibula.

21. Compared with the traditional abdominopelvic delivery technique, the reverse breech extraction technique has been reported to reduce uterine lacerations/extension of the incision, as well as maternal infectious morbidity and blood loss.

22. Video of Deep Impacted Head

23. Lscs Breech delivery

24. Abdominal delivery no different from vaginal breech extraction with many of the risks Limb manipulated through natural range of movement Delivery of after coming of head Avoid trapping of the after coming of head retracting uterus especially in premature breech Mauriceau Smellie Veit maneuver Forcep application

25. The abdominal and uterine incisions should be sufficiently large to allow easy, atraumatic fetal extraction. A low transverse hysterotomy incision is adequate in most term or near-term pregnancies

26. Video of breech

27. Use of forcepS

28. Floating head Head might not be engaged during caesarean section with a poorly formed and highly vascular lower uterine segment. Foetus should be manipulated in longitudinal lie and steadied with lateral support .

29. After amniotomy , the liquor should be allowed to drain completely as this facilitates the descent of head especially in cases of polyhydramnios . The floating foetal head is difficult for the obstetrician to grasp or establish traction; it cannot readily be pulled and guided through the incision. Applying fundal pressure is often inadequate and tends to push the head laterally rather than towards the hysterotomy .

30. Delivery of floating, non-engaged head can be facilitated by : Vectis / Forceps extraction or Vaccum : In some cases, single blade of the forceps can be used as a Vectis for baby delivery . Previously Barton’s forceps, which had a hinged anterior blade and sliding lock, was used. Preference is to place an obstetrical vacuum extractor over the flexion point to deliver the foetal head.

31. Video of VECTIS Application for extraction of Fetal Head.

32. Internal Podalic Version (IPV) : Another option is to perform internal podalic version and delivery of the foetus as a breech. The obstetrician reaches into the uterus with one hand, grasps one or both foetal feet and pulls them through the uterine incision while guiding the head to the fundus with his/her other external hand. This technique causes the foetus to rotate from a vertex presentation to a footling breech presentation.

33. Conjoint twin delivery

34. Conjoined twins are identical twins whose bodies are joined in utero .  It’s a rare phenomenon with an incidence of 1 in 50,000-100,000 births. The incidence is somewhat higher incidence in Africa and Southwest Asia. Females are affected more often than males.

35. Video of conjoint twins

36. Management of conjoined twins begins when the diagnosis is made. Elective termination is often advised when there is a cardiac or cerebral fusion, as separation is rarely successful, and is often considered if severe deformities are anticipated after separation. If the pregnancy is continued, elective Clasical cesarean section or Inverted T shape incision on Lower uterine segment extending to upper uterine segment.

37. others Inadequate incision or wrong abdominal incision Head stuck near previous lscs scar in the uterus

38. IF BLEEDING NOT CONTROLLED THEN TO DO SYSTEMATIC DEVASCULARISATION PROCEDURE

39. Injury to the fetus

40. “ Atraumatic delivery is the goal of an obstetrician” Possible causes of injury Haste or difficult delivery Inappropriate or inadequate uterine incision trapping the fetal parts Deep or uncontrolled uterine incision lacerating the fetal parts

41. Summary BE SAFE BE SURE OF WHAT YOUR DOING BE SWIFT IN YOUR SURGERY BE SOUND IN YOUR CLINICAL AND SURGICAL SKILLS DO SURGERY RELENTLESSLY & BLOODLESS OBSTETRICIANS SHOULD HAVE LADIES FINGERS LIONS HEART EAGLES EYES & GOOD HAND DEXTERITY