Re: obstructed labour
From: =?utf-8?q?Dr. Bülent Potur?= (bpotur@yahoo.com)
Sun Dec 30 01:06:42 2007
Around here inverted T incision is used instead of J incision. This is because of the fear of extending the incision and repair to a place with vessels and ureter ; the upper lip of the transverse incision is nicked 1 or 2 cm in the mid-line towards the head of the patient. This often provides ample space for delivery with a low segment midline and transverse incision coalition. Then first this mid-line part is repaired with an interrupted suture or two. Transverse part is as usual, re-approximated with a continuous suture.
I agree with Dan's classical rule. Cesarean is first done to have a healthy mother and healthy babe. With Dan's rule you will have the least damage for both.
I see dystocia problems in cesarean where we work in completely soft tissues. We may seek vacuum extractor or forceps sometimes to deliver a baby's head. Long bone fractures of the babe may happen while trying to extract him/her. The uterus may be torn irreparably during version and extraction during cesarean section too, especially in patients with low food, vitamin C intake with low prolin, hydroxy prolin bonds and defective collagen. Patients not seen much in private hospital settings. If the labor has progressed and there are no waters left, the uterus is tightly contracted over the babe the risk of the above mentioned complications increases.
By the way as far as cesarean is concerned these are all soft tissue dystocias. So as a heroic measure you may cut them all. As for the anesthesia part you may increase the dosage of muscle relaxants for the abdominal wall. For the uterus halothane used to be recommended to relax a tight uterus during C/S in the past. Does any listmate has any experience or any working knowledge to suggest to relax a tight uterus around the fetus during cesarean section?
Bulent Potur MD Obgyn
Kirikkale TURKEY
"Garry E. Siegel, M.D." <garrys@mindspring.com> wrote: Upper transverse incision? Haven't heard of that either, but I, as many
others, find a foot and pull upwards towards the ceiling.
Garry
At Sat, 29 Dec 2007, Raymond Stephen wrote:
>
>Having never done an upper segment incision and equally never a vertical
>incision I cannot understand this problem. Push your hand over the top
>of the body and find a foot and pull. The baby will roll over, the
>prolapsed arm will go back and the delivery will be breech extraction.
>I think my experience allows me to be dogmatic about this. I cannot
>envisage any need for a classical any time. If the lower segment is
>poorly formed, or unformed, then incise the upper by all means, but
>still it should be transverse. Oh, wait, just remembered two patients
>in succession who had placenta percreta in a previous Caesar scar that
>we had a month apart just recently where I did a classical to deliver
>the baby then proceeded to hysterectomy!
>
>Steve
>
>-----Original Message-----
>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Dr
>Eberhard W Lisse
>Sent: Saturday, 29 December 2007 11:27 PM
>To: Multiple recipients of list OB-GYN-L
>Subject: Re: obstructed labour
>
>Dan,
>
>where is this rule postulated?
>
>I used to feel that a transverse lie might warrant a vertical skin
>incision because
>you had better access that way and a Classical, or Low Classical
>Uterine Incision.
>
>However, with the Joel Cohen skin incision I have been able to get to
>every baby so I
>feel there is no need for Vertical Incision any more, which in any
>case takes more
>time.
>
>As far as uterine incision goes, you are dead wrong, in my opinion. In
>a transverse,
>and especially compound presentation, a low segment transverse
>incision should
>be used which is a little bit angled up on the far side of the
>surgeon. If you can't
>get the baby out easily, then you just extend the far corner upwards,
>so for a surgeon
>standing on the right you have an incision in the form of a J. Put
>your left index and
>second finger between the baby and the uterine wall to protect the baby.
>
>Works, very well, is fast, repairs well and you only have to leave the
>lower segment
>if and when you need to.
>
>The issue in this particular situation, by the way, is not what
>technique, but not to panic.
>
>I have seen surgeons visibly age in this situation (me not excluded)
>but doing this a
>few times does help. The other issue is the question of repair. I
>nowadays obtain
>written consent for a subtotal hysterectomy in transverse positions,
>even if I anticipate
>her to remain in an area with ermergency C/S capability, afterwards.
>
>And, it is important to go to her the very next morning and explain
>clearly what
>has had to be done. A good translator is required unless you speak her
>language
>well. And document all of this!
>
>Tirupati,
>
>live mother, live baby is a good outcome, even if there had been an
>Erb's palsy, or
>hysterectomy. Remember, you were dealing with the most frightening
>Obstetric
>emergency I know.
>
>el
>
>On Dec 29, 2007, at 13:46, R. Daniel Braun wrote:
>
>> As a rule in obstetrics. the uterine incision should be
>> PERPENDICULAR to the
>> long axis of the fetal body. In other word, it should be vertical in a
>> transverse lie.
>>
>> Dan
>>
>> On Dec 29, 2007 12:45 AM, tirupati seshasai
>> wrote:
>>
>>> A primi gravid at 41 weeks pregnancy with transverse lie and fetal
>>> back is
>>> to- words cervix and with leaking membranes with stretch lower
>>> segment and
>>> distended bladder reported from 100kms with a live fetus on 19Th
>>> December
>>> 2007. In emergency LS CS when incision of transverse given the
>>> child moved
>>> her right hand out of incision. As the right arm is out we are
>>> unable to
>>> push into the uterus the arm.
>>> there is no place to hold the foot as the uterus contracted
>>> tightly. with
>>> grate difficult we are able to hold the right foot and extracted
>>> out and the
>>> neonate was delivered.
>>> there was extent ion of the incision and lacerations are repaired,
>>> the neonate had much oedema in right arm and by 3days able to move
>>> normally the arm.
>>> so as a rule in obstetrics the acoucher has to hold either the head
>>> or the
>>> limbs of lower extrimity but never the hands,
>>>
>>> ------------------------------
>>> Save all your chat conversations. Find them
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>>
>> --
>> R. Daniel Braun, MD FACOG(L) CMT
>> Professor Emeritus
>> Dept. of Obstetrics and Gynecology
>> Indiana U. School of Medicine
>>
>> R. Daniel Braun
>>
>> "Science without Religion is LAME; Religion without Science is
>> BLIND"
>> Einstein 1941
>
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--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
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