Presentation of foot through intact anus during breech delivery

Abstract

0 NE of the most startling birth injuries that has occurred during my practice was a laceration of the rectum with presentation of a foot through an intact anal sphincter, during the course of an apparently normal breech delivery. DeLee,l in his text, mentions that “there have been cases where the rectovaginal septum gives way over the advancing presenting part, head, arm, or breech, and the latter appears at the anus. ” A review of the literature reveals several cases. Leroux* reports expulsion of a massive ovarian cyst through the rectum, after laceration of the rectum in the course of labor. Yussufs reports rupture of a retrouterine hematocele into the rectum with passage of a fetus per rectum. In 1934, Hein described in an apparently normal primiparous delivery, the appearance of the anterior leg vaginally, with the posterior leg presenting through the intact anus so that the child was ( ( literally riding on the perineum. ’ ’ Later in the same year, Pohl5 described an almost identical case. Kassebohm and Schreibere report two cases of delivery complicated by rectal stricture in which rupture of the rectum occurred during the course of delivery. Both of these lacerations were apparently not detected at the time of delivery, and both patients died; in the other cases, recognized and appropriately treated, the patients made uneventful and complete recoveries. Pate17 writes of a gravida ii who delivered spontaneously through the rectum, the cervix opening into the rectum. He concluded that the first delivery had also taken place through the rectum. Preston6 saw a Kikuyu woman who had delivered a stillborn child through the rectum three days previously. The apparent cause for rectal delivery in this case was the presence of massive keloid growths around the vagina resulting from circumcision, and almost obliterating the vaginal orifice. This patient died of sepsis. Perry9 reports delivery of a dead fetus, apparently an ectopic pregnancy, through the rectum. The cervix was virginal, and three months later there was fullness in the right fornix which was considered the site of the extrauterine pregnancy. Findleylo and Young11 report similar cases, the former describing the protrusion through the anus of first the right hand and arm, then the left hand during the course of a low forceps delivery (left occipitoanterior position). In the. latter case, the right foot pushed through the rectal mucosa and appeared through the anus. It is surprising that except in those cases in which there was previous rectal or vaginal damage, the outcome for the mother was good. The methods of handling the cases varied. Usually, the bridge of anus and perineum was severed prior to completion of delivery of the infant. In one case, the foot appearing at the rectum was pushed into the vagina and delivery accomplished. In some cases the rent, which was clean cut and almost bloodless, was repaired in layers. In others the defect was merely packed. Aftercare varied; in some cases the bowels were moved early; in others the bowels were “locked” for a week. Mrs. M. S., a white woman, aged 30 years, was first seen in the office on May 10, 1946. The date of thk last menstrual period was March 15, 1946. The physical examination revealed a normal healthy white woman. The past history was not significant. There had been one miscarriage on Jan. 13, 1946, at two and one-half months, cause undetermined. The external measurements were normal. It was later determined that a multiple (twin) pregnancy existed. The patient gained 20% pounds during her pregnancy.