INTERNAL PODALIC VERSION-Revival Of A Disappearing Art

Dr Charu Mittal MD, DNB, MICOG, MNAMS

Ex-Asst Professor Member FOGSI Quiz & Member FOGSI Quiz & Clinical Research CommitteesClinical Research Committees

Prof L.N ChauhanMD, DGOMD, 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 %)

2005 25 03 (12.0 %) 22 (88.0 %) 0TOTAL 350 54 (15.4%) 267 (76.3%) 29 (8.3%)

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

IPV can be easily and successfully attempted in

cases of dead baby in transverse lie at > 4 cm

dilatation of the cervix.

Dilatation of cervix No. of cases % of cases

3 / < 3 cm 01 2%

4 - 7 cm 10 18%

> 7 cm 43 80%

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 PROFILEMorbidity No. of cases % of casesPerineal 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.

MORTALITYThere 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 Thus, management of all cases of Transverse Lie should be tailored Transverse Lie should be tailored

accordingly.accordingly.

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