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Difficult extraction of the fetus presented in aicog 09.01.19
OF THE FETUS
• Obstetrics is not an exact science
Greater the difficulty
, greater the glory !!!
Many difficulties attend Caesarean section, and many disasters
can follow it
Difficulty in extraction of the fetus
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
Deliver breech first
If instead of leg,
hand comes out
reposit it back and
then search for
Legs are recognized
by feeling of the
Heel, ankle is held
like a cigarette butt
between index and
You may have to
make an inverted
''T' incision on rare
If baby alive
inscision , if
the upper end
If baby dead :
• The dorsosuperior (back up) transverse lie may be
delivered as a footling breech through a low transverse
• 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
• Extremely low birth weight infants (premature or growth
restricted) present many challenges at caesarean
• 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.
• 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.
• 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.
• The best methods to dislodging the deeply engaged foetal
• 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.
PATWARDHAN’S SHOULDERS FIRST
• 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
• 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.
Modified Patwardhan manoeuvre
Assistant can push head through vagina before opening
Don't lever head out with your whole hand, because this
can cause vertical downward tears in the lower segment
Difficulty in delivering head in
USE OF A HEAD
• Foetal head elevators or obstetrical
spoons are available in several
variations, including the Coyne spoon,
the Sellheim spoon and the Murless
• 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
REVERSE BREECH EXTRACTION
• Described by Fong and Arulkumaran in Singapore in
• 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.
• 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
• 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
• The abdominal and uterine incisions should be
sufficiently large to allow easy, atraumatic fetal
• A low transverse hysterotomy incision is adequate in
most term or near-term pregnancies
• 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.
• 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
• Delivery of floating, non-engaged head can be facilitated
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.
• Video of VECTIS Application for extraction of Fetal Head.
• Conjoined twins are identical twins whose bodies are
joined in utero.
• It’s a rare phenomenon with an incidence of 1 in 50,000-
• The incidence is somewhat higher incidence in Africa
and Southwest Asia.
• Females are affected more often than males.
• 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.
• Inadequate incision or wrong abdominal incision
• Head stuck near previous lscs scar in the uterus
Reduction of tension
Wide U-shaped transverse incision
with the point of the '‘U' lying
across the middle of the scar
HEAD IS STUCK TIGHTLY
UNDER AN OLD SCAR IN
If her uterus does tear, it will do
so near the midline, where you can
more easily see and repair it
If Uterine incision tears
while removing head
If tear not seen
broad and round
ligament to avoid
injury to ureter
on bleeding edges
sutures in the
area of tear
IF BLEEDING NOT CONTROLLED THEN TO DO
SYSTEMATIC DEVASCULARISATION PROCEDURE
“ATRAUMATIC DELIVERY IS THE GOAL
OF AN OBSTETRICIAN”
Possible causes of injury
• Haste or difficult delivery
• Inappropriate or inadequate uterine incision trapping the fetal
• Deep or uncontrolled uterine incision lacerating the fetal parts
• 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