Fundal Rupture with Breech Expulsion through it in Primigravida: Role of Destructive Procedure (Decapitation) in Modern Obstetrics

BACKGROUND

Obstructed labor is one of the common causes of maternal mortality and one of the leading causes of perinatal mortality.¹ It holds the case fatality rate of 87–100%.² The cases with an unduly prolonged and obstructed labor with a jammed fetal head are rarely seen in developed countries today but are still prevalent in the developing countries. It accounts for 8% of maternal deaths in developing countries annually.³ It is also one of the common causes of uterine rupture, hence increasing maternal mortality and morbidity. As per WHO, the prevalence of uterine rupture in developed countries is 0.006% but varies from 1 in 2,000 to 1 in 200 deliveries in developing countries.⁴ Rupture of the uterus during labor is a real catastrophic emergency. However, rupture is uncommon in an unscarred uterus.⁵ Primigravidas were thought to be immune against rupture but was proved incorrect.⁶ It is noticed that the incidence of rupture uterus (whether scarred or unscarred) has increased in the last decade.⁷ Hereby, we present a case of primigravida referred to us with a prolonged labor and a partially delivered baby with the head and upper limbs expelled and obstructed at the level of scapula. The decision for laparotomy was taken on complete clinical assessment and it was found that there was a fundal rupture through which lower limbs and breech had expelled and obstructed at the level of abdomen. The case holds significance because of various challenges faced by us in management. It was a dilemma and final decision was an aggressive procedure of decapitation to deliver the baby. With this case, we discuss the problems at peripheral centers to be dealt with, for better assessment, early referral in order to reduce maternal mortality, and stillbirth in developing countries. Also, we emphasize on the significance of destructive procedures that cannot be obsolete in developing countries.

CASE DESCRIPTION

A 21-year primigravida at a term gestation was referred to our tertiary hospital from a peripheral hospital (160 km away) in view of undelivered IUFD baby obstructed at the level of scapula with the head, both upper limbs, and placenta already expelled out. Baby could not be further delivered despite their efforts (Fig. 1). The patient had total two antenatal visits at nearby PHC. She had received 2 tetanus toxoids and erratic intake of iron and folic acid tablets. The patient reported at term to a nearby PHC in labor with a complaint of fever and decreased fetal movement for past three days. As per referral note, her ultrasonography done on day of admission confirmed IUFD. Though the duration of labor, any use of uterotonics, induction, augmentation, or instrumentation was not mentioned. The patient was referred to our center as the baby could not be delivered from the level of scapula. At the PHCs, they tried to complete the delivery (by fundal pressure and traction as per history elicited from attendants and patient herself), but failed and subsequently referred the woman to a tertiary care hospital with hemoglobin as 7.7 and B negative blood group. They had transfused one unit packed RBCs.

On admission at our center, the patient was stable hemodynamically. Though her pulse was 110/minutes and blood pressure 110/70, clinically pallor was present. Urgent emergency investigations were sent, primary measures were taken to maintain her vitals, and adequate blood and blood products were arranged. On clinical examination, per abdominally, it gave a picture of Bandl’s ring with upper abdomen retracted and lower abdomen distended. On local examination, head and upper limbs had expelled but firmly obstructed at the level of scapula (Fig. 1), with skin peeling noticed, suggesting old IUFD. On per vaginal examination, the cervix seem soft and fingers could be easily swept throughout the rim but cannot be further inserted through the back of baby for evaluation of any undiagnosed obstructing mass. Baby did not appear to get delivered vaginally. The diagnosis and management was a dilemma, whether it was a Bandl’s ring due to obstructed labor or undiagnosed mass like neural tube defects or saccrococcygeal teratoma was obstructing the delivery. Hence, the decision for laparotomy was taken with all consent in overall benefit of patient.

DIFFERENTIAL DIAGNOSIS: DIAGNOSTIC DILEMMA

DISCUSSION AND CONCLUSION

Obstructed labor is failure of descent of fetal presenting part despite good uterine contractions, hence leading to various maternal and fetal complications. The common causes are cephalopelvic disproportion, contracted pelvis (which seems the cause in this case), macrosomic baby, fetal malposition, fetal anomalies, tumors in ovary, uterus, vagina, etc.⁸ Rupture of uterus as a result of obstruction is life-threatening and difficult to diagnose especially in unscarred uterus primigravida (as in this case). There should be high index of suspicion in case of intractable abdominal pain in laboring women, which indicates uterine ischemic events and uterine rupture. Risk for uterine ruptures increases in multiparty, advanced age, low socioeconomic status, lack of antenatal care, uterine anomalies, induction and augmentation of labor, instrumentation, and attempted forceps delivery.⁹

In India, 70% is a rural population with a lack of better obstetric facilities and care.¹⁰ Proper antenatal care is either not available or not availed. Patients do not understand the importance of antenatal visits and many still prefer home deliveries by untrained female attendant/dais. Such patients usually report to nearby PHCs in case of complication such as obstructed labor or PPH, both being common reasons for maternal mortality. In India, 50% deliveries lack skilled or trained assistance.¹⁰ The patient is referred to higher centers from PHCs in inevitable last phase, which are often quiet a distance away requiring more time. As in the present case, the patient was referred from a PHC at 160 km away from our tertiary center, which further increased the morbidity of the patient. These situations emphasize on the need to train the PHC doctors and staff in proper assessment of progress of labor and partograph with early referral before grave complications.

Secondly, PHC doctors should also be trained in performing destructive surgeries and judging situations where these are apt. Although obstructed labor is banished from the western world; hence, destructive operations are obsolete. In developing countries such as India, obstructed labor with dead fetus and severe infection is a sad reality, and destructive operations becomes an essential part and we consider that destructive operation still becomes necessity, especially in developing countries. The reported indices of fetal destructive operations vary between 0.2 and 1.6% deliveries.¹¹ In many situations, destructive surgeries should be preferred over a cesarean delivery, which needs much better facilities and greater morbidity. There is a great need for training PHC doctors by deputing a competent person from a teaching hospital to a PHC or vice versa on regular intervals.

CLINICAL SIGNIFICANCE/TAKE HOME MESSAGES

India is a developing country, we are taking many measures and have many programs to reduce maternal mortality and still birth, yet there is a lack of a proper maternal evaluation, assessment, and early referral facilities at the periphery level.

• Many patients do not understand the importance and necessity of proper antenatal visits, checkup, and institutional delivery
• We should stress over judicious use of uterotonics especially oxytocin in labor with careful watch over contractions. Using partograph, pelvic assessment in active phase is key in early detection of obstructed labor
• Practices such as fundal pressure should be prohibited
• Had the patient reported early or referred early, maybe rupture uterus and stillbirth could be avoided
• Obstetrics is unpredictable, every case is a new case, and no procedure can be obsolete in benefit of mother and baby. Destructive procedure can have a role even in modern obstetrics, especially in developing countries
• PHC doctors should also be trained on regular intervals in assessment of labor progress, in performing destructive surgeries and judging situations and early referral before inevitable consequences

PATIENT’S PERSPECTIVE

The patient agreed that she failed for antenatal checkups during her pregnancy. But she was happy that her life was saved with the grief of the loss of her baby.

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