second stage cesarean section : patwardhan

different methods of disimpaction of head in cesarean section

1. Comparison Of Two Methods Of Delivery Of The Deeply Engaged Fetal Head At Cesarean Delivery By : Dr. Monicapreet kaur Moderator : Dr Shalini K M akkar

2. The majority of pregnant women as well as obstetricians aim for normal vaginal birth. Dystocia, which complicates up to 20% of all vaginal deliveries is often diagnosed in the second stage of labor , when the fetal head is engaged in the pelvis, and vaginal delivery is replaced by cesarean . However, caesarean delivery cannot provide assurance against maternal and neonatal morbidity when there is difficulty in disengaging a deeply impacted fetal head, a situation that may result in serious maternal and neonatal morbidity Introduction

3. 1.Push method i.e., pushing through the vagina. 2.Pull method, i.e., a reverse breech technique. 3.Patwardhan technique i.e. shoulders first technique. 4.Using simple device- Fetal Disimpacting System. 5.Extraction of fetal head with Murless head extractor/ C-snorkel Extraction of the impacted fetal head may be done by

4. the fetal head is extracted following pushing through the vagina, assisted from below by another person/self and is hence referred to as the push method The 'Push Technique

5. In the reverse breech extraction the fetus in cephalic presentation is extracted through the uterine incision by the podalic pole this maneuverer entails grasping the fetal feet , performing a semi-version, and delivering the fetus by total breech extraction Reverse Breech Extraction' or the 'Pull Technique'

6. first described by Dr. Patwardhan . incision is made in the lower uterine segment, shouders are present usually at incision level in deeply engaged head ,the anterior shoulder is delivered out by hooking the arm. With gentle traction on this shoulder, the posterior shoulder is also delivered out Next , the surgeon holds the trunk of baby gently with both thumbs parallel to spine and with fundal pressure given by assistant the buttocks are delivered followed by legs Now the baby’s head which is the only part of the foetus which is still inside the uterus, is gently lifted out of the pelvis by making an arc The Patwardhan Method (Shoulders First Method)

7. Murless head extractor

8. Fetal Disimpacting System

9. Pushing the fetal head from below through the vagina by an assistant is the most used technique. The most recently favored method is the reverse breech extraction (pull method). The objective of this study was to compare neonatal and maternal outcomes associated with “push” versus “ pull” methods for delivery of the impacted fetal head at CD. OBJECTIVE

10. The study was done at Christian Medical College , Vellore ( tertiary care hospital) in South India. This data base is meticulously maintained by the senior staff nurse in Labour Room and checked by the Consultant in charge of the Perinatal Audit . All delivery data from January 1, 2014 to June 31, 2015 The total number of impacted fetal heads at CD requiring either of the 2 commonly used methods was noted. Study site and population

11. Women who delivered at term (> 37 weeks gestation) Who were fully dilated on per vaginal examination cephalic presentation with very low station of the fetal head (+1, +2 station) signs of obstructed labor Inclusion criteria

12. Women with previous CD Twin gestation preterm delivery anomalies of the fetus and uterus . Exclusion criteria:

13. Maternal demographic risk factors like parity, body mass index (BMI ) and birth weight at delivery were noted. The indication for CD, blood loss and blood transfusion at CD were recorded as well . Maternal complications of the surgical procedure like unexpected extension of the uterine incision, presence of postoperative pyrexia, surgical site infection (SSI), presence of urinary tract infections , intra operative bowel or bladder injury, the use of inverted T or J shaped uterine incision to facilitate delivery of the fetal head without extension of the uterine incision and re-laparotomy were looked into. Neonatal complications like fracture of the humerus or other long bones as a result of difficult delivery and asphyxia for the neonate were noted. Maternal and Neonatal Outcomes:

14. The association between risk variables and outcome were tested using Chi-square test with Yates correction. Statistical significance was considered at p-values <0.25 . Statistical methods:

15. RESULTS

16. During the period of the study, there were a total of 343 CDs performed in the second stage of labor . Of these 343 second stage CDs , there were 63 CDs where the fetal head was impacted and required either the push 44(69.8%) or pull 19 (30.2%) method for fetal head extraction.

17. Most of the sampled women were primiparous 46 (73%) and the rest were multiparous women 17 (27%). There were 30 (52.6%)women in the normal BMI category More number of women who had fetal head impaction belonged to the obese category of BMI 27 (47.4 %). Among these obese women , 78% of them had push type of delivery, when compared to the non obese women by bivariate analysis , the statistical significance was 0.09. Demographic characteristics:

18. The indications for CD arrest of dilatation in 30(47.6%) arrest of descent in 23(36.5 %), cephalopelvic disproportion (CPD) in 8 (12.7 %) deep transverse arrest (DTA) in 2(3.2%). Most (72 %) the women who required assistance for delivery of the impacted fetal head, had either one of two dysfunctional labor patterns i.e. arrest of dilatation or arrest of descent . Obstetric considerations

19. Post operative fever was reported in 20(31.7%) women . 15 % with pull method, 85 % with push method Only 8 (12.7%) of the women had a urinary tract infection 7 (87.5%) were in push group 1 (12.5 %) in pull group. Surgical site infection ( SSI) was present only in 4 (6.3%) 3(75%) in push 1 (25%) in the pull group.

20. Second stage CD is commonly associated with bowel and bladder injuries , only 2 (1 in each method) bladder injuries were reported . The uterine incision was surgically converted to a J shaped or an inverted T incision in 4 (6.3%) women, in order to avoid an unnatural extension, all of them in the pull method . Relaparotmy was required in one (1.6%) woman, who had push type of delivery of the head.

21. one neonate with fracture of the humerus in the pull method delivery. APGAR score was low in 8 neonates 5 of them belonged to the push group 3 to the pull group . neonatal outcomes

22. postpartum hemorrhage (PPH) occurred only in 2 women in the pull method. Blood was transfused in 9 (14.3%) women 6 (66.7%) in push group 3(33.3%) in pull group . It was found that all extensions of the uterine incision added up to 27 (42.9%) the push method was used 89% had extensions , when compared to 11% in the pull method

23. Considering important complications, namely, extension of uterine incision and post operative pyrexia , the newer “pull” method or reverse breech, appears to be a safer alternative to the “push” method. Conclusion

24. A randomized prospective study of 108 Nigerian patients, in which morbidity and mortality rates associated with the two methods were compared . Patients with a live fetus in obstructed labor at term were randomized to either the intraoperative ‘‘push’’ or the ‘‘pull’’ procedure . Patients in the ‘‘push’’ group had significantly longer operation time,more blood loss, extension of the uterine incision, postpartum endometritis , longer hospital stay and, consequently, higher hospital bills . In addition, the fetal morbidity was worse in the ‘‘push’’ group . The authors concluded that the ‘‘pull’’ method is safer and faster than the ‘‘push’’ method OTHER STUDIES

25. Records of 182 women with a single fetus in cephalic presentation, who had undergone cesarean section at cervical dilatation at 7 cm, with the vertex at or below zero station, were reviewed. Extension of the uterine incision occurred in significantly more women during ‘cephalic’ delivery as compared to ‘reverse breech extraction’ (22.8% versus2.2%;p0.001). Use of ‘reverse breech extraction’ is an attractive and safe alternative to the standard methods for intra-operative disengagement of a deeply impacted fetal head in order to reduce maternal and fetal morbidity. Acta Obstetricia et Gynecologica. 2009; 88: 1163 1166 Department of Obstetrics and Gynecology , Postgraduate Institute of Medical Education & Research (PGIMER),Sector-12, Chandigarh 160012, India

26. Out of 98 cases reviewed, 46 belonged to group A ( Patwardhan ) and 52 belonged to group B (push). Patients in the push group had statistically significant higher rates of maternal morbidity in terms of uterine extension and other related complications . However ; there were no differences in neonatal outcomes in both the groups International Journal of Reproduction, Contraception, Obstetrics and Gynecology BeereshCSet al. Int J Reprod Contracept Obstet Gynecol. 2016 Jan

27. THANKS