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"Internal podalic version- revival of a disappearing art"
"Internal podalic version- revival of a disappearing art"
"Internal podalic version- revival of a disappearing art"
INTERNAL PODALIC VERSION-
  Revival Of A Disappearing Art
Dr Charu Mittal
MD, DNB, MICOG, MNAMS
Ex-Asst Professor
Member FOGSI Quiz &
Clinical Research Committees
Prof L.N Chauhan
MD, DGO
Ex-Professor & HOD
Medical College, Baroda
INTRODUCTION
Obstetric emergencies constitute a major
problem in a tertiary care hospital, which is
a referral centre for many nearby villages.

Cases of advanced labour with transverse lie
are a result of inadequate ANC & delayed
           access to health facilities.
• In cases where the fetus is dead in-utero, is
  pre-viable or has congenital anomalies not
  compatible with life, giving the mother a
  scar on her uterus with a dead baby
  predisposes her to more morbidity in this
  pregnancy & a high risk next pregnancy.
• Performing Internal Podalic Version (IPV), a
  technique which requires expertise and art,
  will save a scar on the uterus, if performed in
  properly selected cases.
AIM AND OBJECTIVE


To analyze the total number of cases of
transverse lie which reported at the
labor room of SSG Hospital, Baroda;
which were managed by IPV, thus
emphasizing its continuing importance
     in modern          obstetrics.
MATERIALS AND METHODS
Retrospective study involving labour room records of
all cases of transverse lie managed by IPV at labour
room of SSGH from January 1997 to December 2005.

The total number of cases of IPV, socio-demographic
factors such as age, residential area, associated
obstetric complications, mode of presentation, parity,
cervical dilatation at the time of IPV & complications of
IPV were studied and following observations were
made.
OBSERVATIONS
Table 1. YEARLY DISTRIBUTION OF CASES
YEAR TRANS. LIE       IPV         LSCS        RUPTURE
                                               UTERUS
1997      61       5 (8.2 %)    49 (80.3 %)   7 (11.5 %)

1998      28       3 (10.7 %)   19 (67.9 %) 6 (21.4 %)

1999      41       2 (4.9 %)    37 (90.2 %)   2 (4.9 %)
2000      53      10 (18.9 %)   38 (71.7 %)   5 (9.4 %)

2001      45      11 (24.4 %)   30 (66.6 %)   4 (9.0 %)
2002      35      10 (28.5 %)   21 (60.0 %)   4 (11.4 %)
2003      32      05 (15.6 %)   27 (84.4 %)       0
2004      30      05 (16.6 %) 24 (80.0 %) 1 (3.4 %)
TOTAL 350      54 (15.4%) 267 (76.3%) 29
2005      25      03 (12.0 %) 22 (88.0 %)     0
Table 2. SOCIO-DEMOGRAPHIC FACTORS

  Residence    Number of cases   % of cases
  Urban           05              9.3 %
  Semi-urban      04               7.4 %
  Rural           45              83.3 %
  Urban slum      00              00

• None of them were
  booked cases.
• 46% were emergency
  cases and 54% were
  referred.
Table 3. PARITY-WISE DISTRIBUTION
               OF CASES
 Parity            No. of cases     % of cases
Primigravida           05                9%
2nd- 3rd gravida       40                74%
4th- 5th gravida       08                15%
> 5th gravida          01                 2%
Maximum number of cases of IPV were performed in
second and third gravida (74%).
IPV done in patients who still want child-bearing can
give an advantage of preventing risk of a scar in a
future pregnancy.
Table 4. RELATION WITH WEEKS OF
            GESTATION
GEST.WEEKS   NUMBER OF CASES        % OF CASES

26-28 wks           03                    5%

28-32wks           06                     11%

32-37wks           14                     26%

>37wks              31                    58%

Thus, utility of IPV need not be restricted to
preterm fetuses alone.
5. ASSOCIATED OBSTETRIC CONDITION

MODE OF PRESENTATION   NO. OF CASES   % OF CASES
Shoulder presentation          12      22%
Twins (2nd baby transverse)     02      4%
Impacted shoulder               01      2%
Hand prolapse                   28     52%
Cord prolapse                   02      4%
Cord with hand prolapse         04      7%
Eclampsia                      02       4%
Placenta praevia               02       4%
3rd degree cervical prolapse   01       2%
Maximum number of IPV were performed in c/o
hand prolapse without impacted shoulder.
IPV was done in 2 cases of eclampsia to accelerate
the delivery while preventing the morbidity &
complications of LSCS in such cases.
It was done successfully in 2 cases of placenta
previa type1 and 2A with a dead fetus & in one case
of impacted shoulder where there were no signs of
obstruction
Table 6. CERVICAL DILATATION
          AT THE TIME OF IPV

Dilatation of cervix   No. of cases   % of cases
     3 / < 3 cm             01            2%
     4 - 7 cm               10             18%
     > 7 cm                 43             80%

IPV can be easily and successfully attempted in
cases of dead baby in transverse lie at > 4 cm
dilatation of the cervix.
Table 7. BIRTHWEIGHT
  Birth weight        No. of cases    % of cases
    < 1.5 KG               10              18.5%
    1.5 – 2.0 KG           10              18.5%
    2.0 – 3.0 KG           33              61.0%
    > 3.0 KG               01              2.0%
In maximum number of cases the birth weight was
between 2 to 3 kgs suggesting that IPV can be
successfully attempted at such birth weights.
Table 8. MORBIDITY PROFILE
Morbidity                    No. of cases   % of cases
Perineal tear (1st degree)        01             7%
Cervical tears                    05            32%
Vaginal tears                     01             7%
Para-labial tears                 01             7%
Para-urethral tears               06            40%
Colporrhexis                      01            7%
Rupture uterus                    00
Obstetric shock                   00

Morbidity was present in 28% (15 / 54) of the cases of
IPV which was mainly due to cervical & para-urethral
tears.
Table 9. SURGEON’S EXPERIENCE
Years of experience    No. of cases      % of cases
   < 3 years               17                31%

    3 - 5 years            10                19%

    > 5 years              27                50%

 The availability and presence of a senior surgeon
 with more experience increases the chances of
 success with attempted IPV.
FAILURE OF IPV
Four such cases were reported. In three cases the
reason was difficulty in reaching the foot by a less
experienced operator (<3yrs). This was followed by
LSCS.
In fourth case the reason for failure was not
mentioned. IPV was followed by evisceration and
vaginal birth.

             MORTALITY
There was one maternal mortality which was not
related to IPV or its complication but due to the
associated obstetric condition (eclampsia).
CONCLUSION

IPV was performed successfully in 15.7% cases of
transverse lie where fetus was either dead and / or
premature, cervix was sufficiently dilated and there
were no signs of obstruction.
Timely referral services, early diagnosis & appropriate
indication with management by an experienced person
can give good results in cases of transverse lie
managed by IPV.
Such technical skill can be taught during residency
training and maintained through use in clinical practice
This can prevent a scar on the uterus and morbidity
due to it in this pregnancy as well as in the next
pregnancy, as a mother with a dead baby with an
LSCS done, is often a village woman who lives miles
away from the hospital and does not have facilities to
attend the antenatal clinic regularly.
While in certain cases of transverse lie where there is a
danger of rupture uterus and complications from
intrauterine manipulations, it is better perform LSCS.
    Thus, management of all cases of
    Transverse Lie should be tailored
              accordingly.
THANK   YOU

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"Internal podalic version- revival of a disappearing art"

  • 4. INTERNAL PODALIC VERSION- Revival Of A Disappearing Art Dr Charu Mittal MD, DNB, MICOG, MNAMS Ex-Asst Professor Member FOGSI Quiz & Clinical Research Committees Prof L.N Chauhan MD, DGO Ex-Professor & HOD Medical College, Baroda
  • 5. INTRODUCTION Obstetric emergencies constitute a major problem in a tertiary care hospital, which is a referral centre for many nearby villages. Cases of advanced labour with transverse lie are a result of inadequate ANC & delayed access to health facilities.
  • 6. • In cases where the fetus is dead in-utero, is pre-viable or has congenital anomalies not compatible with life, giving the mother a scar on her uterus with a dead baby predisposes her to more morbidity in this pregnancy & a high risk next pregnancy. • Performing Internal Podalic Version (IPV), a technique which requires expertise and art, will save a scar on the uterus, if performed in properly selected cases.
  • 7. AIM AND OBJECTIVE To analyze the total number of cases of transverse lie which reported at the labor room of SSG Hospital, Baroda; which were managed by IPV, thus emphasizing its continuing importance in modern obstetrics.
  • 8. MATERIALS AND METHODS Retrospective study involving labour room records of all cases of transverse lie managed by IPV at labour room of SSGH from January 1997 to December 2005. The total number of cases of IPV, socio-demographic factors such as age, residential area, associated obstetric complications, mode of presentation, parity, cervical dilatation at the time of IPV & complications of IPV were studied and following observations were made.
  • 10. Table 1. YEARLY DISTRIBUTION OF CASES YEAR TRANS. LIE IPV LSCS RUPTURE UTERUS 1997 61 5 (8.2 %) 49 (80.3 %) 7 (11.5 %) 1998 28 3 (10.7 %) 19 (67.9 %) 6 (21.4 %) 1999 41 2 (4.9 %) 37 (90.2 %) 2 (4.9 %) 2000 53 10 (18.9 %) 38 (71.7 %) 5 (9.4 %) 2001 45 11 (24.4 %) 30 (66.6 %) 4 (9.0 %) 2002 35 10 (28.5 %) 21 (60.0 %) 4 (11.4 %) 2003 32 05 (15.6 %) 27 (84.4 %) 0 2004 30 05 (16.6 %) 24 (80.0 %) 1 (3.4 %) TOTAL 350 54 (15.4%) 267 (76.3%) 29 2005 25 03 (12.0 %) 22 (88.0 %) 0
  • 11. Table 2. SOCIO-DEMOGRAPHIC FACTORS Residence Number of cases % of cases Urban 05 9.3 % Semi-urban 04 7.4 % Rural 45 83.3 % Urban slum 00 00 • None of them were booked cases. • 46% were emergency cases and 54% were referred.
  • 12. Table 3. PARITY-WISE DISTRIBUTION OF CASES Parity No. of cases % of cases Primigravida 05 9% 2nd- 3rd gravida 40 74% 4th- 5th gravida 08 15% > 5th gravida 01 2% Maximum number of cases of IPV were performed in second and third gravida (74%). IPV done in patients who still want child-bearing can give an advantage of preventing risk of a scar in a future pregnancy.
  • 13. Table 4. RELATION WITH WEEKS OF GESTATION GEST.WEEKS NUMBER OF CASES % OF CASES 26-28 wks 03 5% 28-32wks 06 11% 32-37wks 14 26% >37wks 31 58% Thus, utility of IPV need not be restricted to preterm fetuses alone.
  • 14. 5. ASSOCIATED OBSTETRIC CONDITION MODE OF PRESENTATION NO. OF CASES % OF CASES Shoulder presentation 12 22% Twins (2nd baby transverse) 02 4% Impacted shoulder 01 2% Hand prolapse 28 52% Cord prolapse 02 4% Cord with hand prolapse 04 7% Eclampsia 02 4% Placenta praevia 02 4% 3rd degree cervical prolapse 01 2%
  • 15. Maximum number of IPV were performed in c/o hand prolapse without impacted shoulder. IPV was done in 2 cases of eclampsia to accelerate the delivery while preventing the morbidity & complications of LSCS in such cases. It was done successfully in 2 cases of placenta previa type1 and 2A with a dead fetus & in one case of impacted shoulder where there were no signs of obstruction
  • 16. Table 6. CERVICAL DILATATION AT THE TIME OF IPV Dilatation of cervix No. of cases % of cases 3 / < 3 cm 01 2% 4 - 7 cm 10 18% > 7 cm 43 80% IPV can be easily and successfully attempted in cases of dead baby in transverse lie at > 4 cm dilatation of the cervix.
  • 17. Table 7. BIRTHWEIGHT Birth weight No. of cases % of cases < 1.5 KG 10 18.5% 1.5 – 2.0 KG 10 18.5% 2.0 – 3.0 KG 33 61.0% > 3.0 KG 01 2.0% In maximum number of cases the birth weight was between 2 to 3 kgs suggesting that IPV can be successfully attempted at such birth weights.
  • 18. Table 8. MORBIDITY PROFILE Morbidity No. of cases % of cases Perineal tear (1st degree) 01 7% Cervical tears 05 32% Vaginal tears 01 7% Para-labial tears 01 7% Para-urethral tears 06 40% Colporrhexis 01 7% Rupture uterus 00 Obstetric shock 00 Morbidity was present in 28% (15 / 54) of the cases of IPV which was mainly due to cervical & para-urethral tears.
  • 19. Table 9. SURGEON’S EXPERIENCE Years of experience No. of cases % of cases < 3 years 17 31% 3 - 5 years 10 19% > 5 years 27 50% The availability and presence of a senior surgeon with more experience increases the chances of success with attempted IPV.
  • 20. FAILURE OF IPV Four such cases were reported. In three cases the reason was difficulty in reaching the foot by a less experienced operator (<3yrs). This was followed by LSCS. In fourth case the reason for failure was not mentioned. IPV was followed by evisceration and vaginal birth. MORTALITY There was one maternal mortality which was not related to IPV or its complication but due to the associated obstetric condition (eclampsia).
  • 21. CONCLUSION IPV was performed successfully in 15.7% cases of transverse lie where fetus was either dead and / or premature, cervix was sufficiently dilated and there were no signs of obstruction. Timely referral services, early diagnosis & appropriate indication with management by an experienced person can give good results in cases of transverse lie managed by IPV. Such technical skill can be taught during residency training and maintained through use in clinical practice
  • 22. This can prevent a scar on the uterus and morbidity due to it in this pregnancy as well as in the next pregnancy, as a mother with a dead baby with an LSCS done, is often a village woman who lives miles away from the hospital and does not have facilities to attend the antenatal clinic regularly. While in certain cases of transverse lie where there is a danger of rupture uterus and complications from intrauterine manipulations, it is better perform LSCS. Thus, management of all cases of Transverse Lie should be tailored accordingly.
  • 23. THANK YOU