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Post instrumental incomplete uterine rupture with left ovarian cyst a rare case.

CASE REPORT: P3L3 delivered a male baby of weighing 3.5kg at 11AM by forceps application for prolonged second stage of labor in a government hospital and she was referred to our hospital at 5:30PM with history of post-partum hemorrhage (PPH) with 1 pint of packed cells on flow there was delay of about 5% hours to reach our hospital after delivery. On general examination patient was in shock with pulse rate 120/min, BP-90/60mmHg, P/A-uterus was contracted and retracted. P/S examination a sutured episiotomy wound seen with vaginal lacerations along with active bleeding from posterior fornix, cervical os was intact. Patient was diagnosed as P3L3 with immediate post natal day with traumatic PPH due to forceps application.

Her investigations revealed Hb-6gm%, blood group O positive, platelet count-2.61 lakhs/cmm, coagulation profile within normal limits. Patient was immediately posted for exploration & suturing in OT after arranging adequate blood & packed cells, & FFPs. Under general anesthesia vaginal suturing done but bleeding continued.

After thorough Re-examining a tear in the posterior fornix noted which was communicating into the pouch of Douglas. Then immediate decision for laparotomy was taken. Intraoperative findings revealed uterus to be well contracted and retracted, along with a huge solid left ovarian cyst of about 10*10cms (Fig. no. 1) along with incomplete uterine rupture at the level of lower uterine segment on left side along with the broad ligament hematoma. The peritoneum was intact with the myometrial rupture. The peritoneum picked up, separated and pushed down along with the bladder. Then total peripartum hysterectomy along with cystectomy on left side done. Intraoperatively 2 pints of whole blood & 2 pints of FFP were transfused. Postoperative period was uneventful. After removal of sutures on 8th post-operative day patient was discharged.

DISCUSSIONS: The status of forceps delivery is constantly under discussion within the specialty and with pediatrics colleague. Even though there are lots of controversies, efforts are made for improvement in application of this instrument in the interest of mother and the baby which is life saving and rewarding experience when applied properly. (3) So we can say that forceps application after fulfillment of criteria's in an expert hand is an art but not a dangerous instrument in a skilled obstetrician. There are varieties of forceps available but high forceps, mid cavity and rotational forceps has no role in modern obstetrics. (4) Now a day an outlet forceps only should only be applied after maternal verbal consent.

Uterine Rupture is one of the most common Obstetrics Emergencies threatening the lives of both Mother and Fetus. There are two types of Uterine Rupture:

1. Complete--were the whole thickness of uterine wall is involved, usually occurring in an Unscarred uterus.

2. Incomplete, where the visceral peritoneum remains intact as seen in scar dehiscence.

In our case it was an incomplete rupture in a un scarred uterus at the level of lower uterine segment with intact peritoneum. Ovarian cyst may be the region for prolonged second stage and forceps application.

The risk factors for uterine rupture include obstructed labor, grand multiparty, previous scarred uterus, uterine anomalies, inappropriate prostaglandin and oxytocin usage, previous instrumental abortions, vacuum extraction and forceps delivery.

The necessary requirements for forceps application are that the fulfillment of criteria and after confirming proper application, traction should be applied during contraction with prior episiotomy.

The amount of traction should be least necessary to accomplish safe fetal head descent. In biomechanical studies, safe limit of 45 founds in primi Para & 30 pounds in multi Para have been suggested. Though there is no consensus on the amount of traction force, (5) the angle of traction is important so to ensuring that everything has been done accordingly to proper protocols, if no progress is observed in three traction, an attempt to abdominal delivery should be considered. After all forceps deliveries a thorough examination of both mother and the new born is mandatory.

The maternal complications like perinial tear vaginal tear cervical tear, extension of episiotomy, traumatic PPH, urinary and fecal in continence, and the fetal complications like impression mark, abrasions on the face, cephalohematoma, skull fracture, and cerebral palsy can occur.

In our case it was an incomplete rupture in a un scarred uterus at the level of lower uterine segment with intact peritoneum. Ovarian cyst may be the region for prolonged second stage and forceps application.

CONCLUSION: We can conclude that obstetrics' forceps has a significant place in obstetrics'. As it is a lifesaving procedure for mother and fetus in many situation.in skilled hand it is very safe and important to cut short of second stage of labor or even prophylactic use also. Successful result can be achieved more only by skill and not by force.

Sound clinical evaluation and adherence to the ground rule and skill of operator will minimize the risk of failure and complication. Using outlet forceps the overall rates of maternal and perinatal morbidity and mortality are negligible and even comparable to spontaneous vaginal delivery.

Over the years cesarean delivery rate has increased while instrumental delivery date has fallen dramatically over past decade. ACOG 2011 recommends forceps delivery has on acceptable and safe option for delivery. Outlet forceps plays a very important role in obstetrics practice and remain appropriate tools in the armamentarium of the modern obstetrics, so in modern obstetrics outlet forceps is having a definite role.

All the young obstretitician must have knowledge and confidence in applying the instrumental vaginal deliveries. Even nowadays government of India in Emoc training for medical officer in service (MBBS) included the forceps and vacuum delivery in the syllabus to teach them, so they can help the nation in decreasing the maternal mortality rate.

DOI: 10.14260/Jemds/2015/1598

REFERENCES:

(1.) Dennen PC. Dennen & #8217; s Forceps Deliveries 3rd ed, Davis Company, F. A, New York, 1989; 188.

(2.) American College of Obstetrics and Gynecology. Operative vaginal delivery. Clinical management guidelines for obstetrician-gynecologists. American College of Obstetrics and Gynecology. Int J Gynaecol Obstet. 2001; 74(1): 69-76. [Pubmed]

(3.) Johnson JH, Figueroa R, Garry D, Elimian A, Maulik D. Immediate maternal and neonatal effects of forceps and vacuum-assisted deliveries. Obstet Gynecol. 2004; 103(3):513-8. http://dx.doi.org/10.1097/01.AOG.0000114985.22844.6d [Pubmed]

(4.) ACOG Medical Teaching /Module 2011 forceps incidence in modern Era.

(5.) Yancey MK, Herpolsheimer A, Jordan GD, Benson WL, Brady K. Maternal and neonatal effects of outlet forceps delivery compared with spontaneous vaginal delivery in term pregnancies. Obstet Gynecol. 1991; 78(4):646-50. [Pubmed]

Vijayalakshmi B [1], Divya Kannari [2]

AUTHORS:

[1.] Vijayalakshmi B.

[2.] Divya Kannari

PARTICULARS OF CONTRIBUTORS:

[1.] Associate Professor, Department of Obstetrics and Gynaecology, Vijayanagara Institute of Medical Sciences.

[2.] Resident, Department of Obstetrics and Gynaecology, Vijayanagara Institute of Medical Sciences.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Vijayalakshmi B, H. No: 10/2, Ward No. 19, Behind Government School, Patel Nagar, Ballari-583101. E-mail: vijaya.b.yadav72@gmail.com

Date of Submission: 21/04/2015.

Date of Peer Review: 22/04/2015.

Date of Acceptance: 23/07/2015.

Date of Publishing: 06/08/2015.
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Article Details
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Author:Vijayalakshmi, B.; Kannari, Divya
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Case study
Date:Aug 6, 2015
Words:1186
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