Internal Podalic Version Research Articles

Difficult fetal extraction in cesarean section: Number 8 - 2024.

The main causes of difficult fetal extraction during cesarean section are deeply impacted fetal head and floating presentation of the fetus. Studies of management techniques for difficult fetal extraction during cesarean section and the maternal and neonatal results lack scientific evidence, as these predominantly come from case reports, small case series and expert opinions. The deeply impacted fetal head is usually associated with prolongation of the expulsion period and/or unsuccessful attempts at operative vaginal delivery. The main maternal complications associated with the management of the deeply impacted fetal head are lacerations in the lower uterine segment, hematomas in the uterine ligaments and injuries to the uterine vessels, cervix and/or urinary tract. The main neonatal complications associated with the management of a deeply impacted fetal head are intracranial hemorrhage, fractures of the skull and/or cervical spine, nerve injuries, perinatal asphyxia and even death. Among the maneuvers for delivery of the deeply impacted fetal head, the abdominovaginal delivery (push method) seems to be the most associated with maternal and neonatal complications. In the non-insinuated and floating fetal head, the internal podalic version followed by pelvic extraction differs from the reverse breech extraction (pull method). When the fetal head is high in the pelvis, the fetus is internally ejected before the extraction of its body segments, similar to the internal version performed in the vaginal delivery of the second twin with floating presentation of the fetus.

Real-time ultrasound to assist during a vaginal breech delivery

We report a novel application of intrapartum sonography, herein used to assist the internal podalic version and the vaginal delivery of a transverse-lying second twin. Following the vaginal delivery of the first cephalic twin, the internal podalic version was performed under continuous ultrasound vision, leading to the uncomplicated breech delivery of a healthy neonate.

Highlights from the International Twins Congress 2021

Highlights from the International Twins Congress 2021

Internal podalic version of second twin: Improving feet identification using a simulation model

BackgroundPodalic version and breech extraction require high obstetrical expertise. Identifying fetal extremities is the first crucial step for trainees. When this skill is not polished enough, it increases the inter-twin delivery interval and can even jeopardize the whole manoeuver. Material and methodsWe present a model for simulating and training this specific skill, with obstetrical mannequin, and 3D printed hands and feet. Five feet and five hands (five rights and five lefts of each one) were printed in 3D after initial ultrasound acquisition of a near term fetus. Each foot and hand, was individually set in a condom filled with 100 cc of water and closed with a knot. A Sophie’s Mum Birth Simulator Version 4.0 de MODEL-med was placed on the edge of the table. Each hand and foot was inserted into the pelvic mannequin.An evaluation of the students’ skills using this model was performed. A significant reduction of the global mean to extract the first foot and all the feet was noticed at three month of interval. ConclusionThis model is an option to train and assess a crucial skill for version and breech extraction.

Total breech extraction of the second twin in trial of labor after cesarean

Maternal and neonatl outcomes in trial of labor after cesarean (TOLAC) deliveries of twins are similar to singleton TOLACs. We examined whether internal podalic version and total breech extraction of the second twin adversely impacts outcome. A retrospective multicenter study was conducted including data on deliveries occurring between 2005-2020. We included TOLACs only, at 320/7 gestational weeks and on, of twin gestations with a vertex presenting first twin upon labor admission. The exposed group was defined as deliveries with a non-vertex second twin at admission to labor, while the comparison group included deliveries with a vertex second twin at admission. Only parturients who attempted vaginal delivery were included. Cases of pre-labor fetal death of either twin or major fetal anomalies were excluded. The primary outcome was uterine rupture. Two hundred thirty-six twin TOLACs were included, of whom 128 presented with a non-vertex second twin, and 108 presented with a second vertex twin. There was no difference in the primary outcome of uterine rupture (1/128, 0.9% vs. 1/108, 0.8%, p=1.000) (Table 1). Successful TOLAC of both twins occurred in 76.6% of the exposed group vs. 81.5% in the comparison group, while cesarean delivery (CD) of both twins was performed in 21.9% of the exposed group vs. 17.6% of the comparison group (p=0.418, OR=1.32, CI 0.7-2.5). There were 2 cases of CD for the second twin in the exposed group and one case in the comparison group (1.6% vs. 0.9%, respectively, p=1.000) (Table 2). There was no difference between the groups in maternal outcomes, including rates of postpartum hemorrhage, blood transfusion, placental abruption, etc. (Table 1). Neonatal outcomes were also comparable between the groups. Non-cephalic second twin in TOLAC deliveries results in favorable maternal and neonatal outcomes, comparable with vertex-vertex TOLACs. Second twin non-cephalic presentation should not discourage parturients and caregivers from considering TOLAC if desired.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Simulation-based training of vaginal twin delivery for experienced gynaecologists: Useful or not?

ObjectiveIt is important to train clinicians to maintain and optimise maternal and neonatal outcomes after vaginal twin delivery. Simulation-based training provides opportunities for training in a realistic way without harming patients. The aim of this study is to evaluate the effect of simulation-based training concerning twin vaginal delivery on knowledge and comfort of obstetrician-gynaecologists. Study designObstetrician-gynaecologists participated in a twin vaginal delivery simulation between March 2018 and May 2019. Simulation-based training consisted of standardized patient interviews, didactic sessions and three different simulation-based scenarios: internal podalic version and breech extraction, assisted vaginal delivery and vaginal breech delivery with problems of aftercoming head. Pre- and posttraining, participants were asked to fill out questionnaires exploring knowledge concerning vertex-vertex twin deliveries and vertex-nonvertex twin deliveries, level of comfort performing various obstetric manoeuvres and counselling on mode of delivery for women pregnant with twins. Our primary outcome of interest was a change in knowledge or comfort surrounding vaginal twin delivery after completion of the simulation-based training. ResultsThe estimated median number of vaginal twin deliveries performed by the participating thirty-four obstetrician-gynaecologists was 50 (IQR 20–100). Significant improvements were seen in knowledge regarding twin deliveries with vertex-nonvertex presentation (p < 0.01). In two of three questions regarding twin delivery with vertex-vertex presentation significant improvements were seen as well (p < 0.01). Before training, 40.6% of participants felt comfortable to perform internal podalic version compared to 91.2% afterwards (p < 0.01). Comfort with breech extraction increased from 69.7% to 97.1% pre- and posttraining, respectively (p < 0.01). Before training only 55.9% would strongly counsel patients towards vaginal twin delivery as opposed to 73.5% after training (p = 0.07). ConclusionsSimulation-based training results in beneficial effects on knowledge and comfort concerning vaginal twin deliveries for obstetrician-gynaecologists. This training suggested a potential impact on provider practice with a more favourable attitude towards twin vaginal birth.

Internal podalic version for delivery of high floating head during cesarean section and neonatal outcome.

To evaluate the technique of internal podalic version for delivery of high floating head during cesarean section as an alternative for other methods for its delivery and its effects on neonatal outcome. This study used clinical randomized controlled study design. Three groups of patients each group has 50 patients who attended for elective cesarean section and found to have high floating head during operation, Group I: the babies were delivered by internal podalic version. Group II: the babies were delivered by short curved forceps. Group III: the babies were delivered by vacuum. All groups were compared in regard to time required for delivery of baby, fetal condition, maternal complications, fetal complications and postoperative complications. Hundred-and-fifty patients were selected in the course of preparation of elective cesarean section, all had high floating fetal head, and they were randomly distributed into three groups, each group had 50 patients. There was significant relationship for the favor of Group 1 (study group) as regard the time required for the maneuver as calculated from the end of uterine incision till delivery of whole baby, (24.86, 59.48,54.52 s for Group I, Group II, Group III, respectively) with P-value <0.00001*. Also there was significant relationship as regard the intraoperative maternal complications for the favor of Group I with P-value =0.004. While there was an insignificant relationship between the three groups as regard preoperative data, APGAR score, fetal birth weight, postoperative pain and postoperative maternal data. Despite that there was a significant difference as regard the postoperative neonatal complications, with P-value =0.002*, all these complications were minor and did not need long-term treatment. Use of internal podalic version for delivery of high floating head during cesarean section is a safe and rapid technique, with less maternal and neonatal complications.

Impact of intertwin interval on short-term neonatal outcomesof the second twin in dichorionic pregnancies withvaginal delivery.

To examine the effect of intertwin interval on umbilical cord pH and Apgar scores of the second twin after vaginal delivery. A retrospective study of twin deliveries at a university hospital in Spain between August 2012 and September 2017. Inclusion criteria were vaginal delivery of both twins at 32 gestational weeks or more. Exclusion criteria were monochorionic pregnancies and indication for cesarean delivery. The sample was dichotomized by intertwin interval (<10 and ≥10minutes). Neonatal outcomes including Apgar scores and umbilical cord pH were evaluated. Overall, 323 twin deliveries were included. Intertwin interval was less than 10minutes in 277 (85.6%) cases, and 10minutes or longer in 46 (14.2%). There were no differences in maternal or obstetric characteristics between the groups. Incidence of instrumental delivery (P<0.001) and internal podalic version (P<0.001) for the second twin was higher in the longer interval group. A longer interval was associated with higher frequencies of 1-minute Apgar score below 4 (P=0.009), 5-minute Apgar score below 7 (P<0.001), and umbilical cord pH below 7.15 (P<0.001). Second twins with an intertwin interval of 10minutes or longer are more likely to have poorer Apgar scores and arterial blood pH below 7.15.

Twin vaginal delivery: To maintain skill - simulation is required

BackgroundAlthough most societies of obstetrics advocate vaginal delivery of twins, there has been a steady rise in the rate of twin cesarean sections. We risk perhaps losing in a single generation our obstetrical learning and skills because of medicolegal and emotionally charged issues. MethodsWe have therefore designed a realistic as possible simulation model of second twin delivery and tested it on residents in obstetrics. FindingsBetween two trials, we noted a significant improvement in the time required for internal podalic version and breech extraction. We also observed a significant improvement in the confidence score between the two trials. InterpretationWe have designed a simulation device that improves obstetrical skills for second twin delivery and which we hope will participate in the comeback of vaginal delivery for this indication and contribute to the fight against the dangerous trend of rising rates of cesarean delivery for twins. Our model completely fits the paradigm of simulation in medical pedagogy.

Internal Podalic Version and Breech Extraction: Enhancing Realistic Sensations in a Simulation Model.

Experience with internal podalic version and breech extraction is diminishing, especially in the younger generation of obstetricians. Simulation training is essential to teach and maintain these skills. We present a mannequin-based simulation method that enhances realistic sensations during training. By positioning the fetal mannequin into a thin plastic bag filled with water, the impression of palpating, grabbing, and pulling the fetal feet through the plastic bag is similar to reaching feet through intact membranes. The unique approach of this realistic simulation model makes the experience fun and memorable, which contributes to the didactic value and success of the model. The simulation model we present mimics the situation and sensation obstetricians experience while performing internal podalic version and breech extraction.

The predicting factors and outcomes of caesarean section of the second twin

The aim of this study was to review the indications for caesarean delivery of second twins after vaginal delivery of a first twin (combined delivery) and the associated foetal outcomes of the second twin. Possible factors that could be employed to predict combined delivery were explored.This was a retrospective review of all twin pregnancies delivered in a tertiary maternity unit between 2000 and 2013. All twins (> =24 week gestation) with vaginal delivery of the first twin were reviewed. Of a total of 1039 pairs of twins, 441 pairs had vaginal delivery of the first twin, of which 47 (10.7%) needed combined delivery. Presentation of the second twin was found to be significantly associated with combined delivery (p < .001). The odds ratio for combined delivery for breech second twin was 2.4 compared with vertex second twins while the odds ratio for transverse lie second twin was 182.8. Second twins who were delivered by combined delivery had a higher incidence of 5 min Apgar score <7.The extremely high odds ratio for combined delivery for second twins in transverse lie would probably indicate that attempts at vaginal delivery of these vertex/transverse twin pregnancies would not be worthwhile.Impact statementIt remains controversial in the literature whether non-vertex second twins are associated with a higher risk for combined delivery as compared to vertex second twins. Almost all previous studies have analysed the non-vertex second twins as a whole group rather than separating them into breech presentation and transverse lie. There is only one study analysing breech presentation and transverse lie of second twin separately but it has recruited only 14 patients.To our knowledge, the cohort is the largest available dataset comparing the odds ratio for combined delivery of breech and transverse lie of the second twin separately. We found that transverse lie of the second twin have extremely high rates of combined delivery with an odds ratio 182.8 and this may be ascribed to the lack of attempts to perform internal podalic version.Combined delivery is associated with higher maternal and neonatal morbidities. With such a high risk of transverse lie second twin in having combined delivery, it appears reasonable to advise women with vertex/transverse twins not to attempt vaginal delivery unless there are obstetricians who have experience in performing internal podalic version at the time of delivery. This is useful for patient counselling regarding the decision of the mode of delivery.

Internal Podalic Version an Option for Developing Countries

Objective: To study the role of internal podalic version (IVP) in the management of transverse lie with fetal demise in labour and to assess the success and outcome of this almost obsolete procedure in obstetrics. Materials and Methods: Quasi experimental study was done in Shaheed Ziaur Rahman Medical College and Mohammad Ali Hospital, Bogra from January 2001 to December 2006. Results: Within this period total 180 cases transverse lie with intrauterine fetal death (IUFD) were studed. All these case were undiagnosed transverse lie with IUFD in labour and admitted in the hospital through the emergency department. In 60 cases IPV and in 120 cases lower uterine segment caesarean section (LUCS) were done to deliver the dead for per operative and post operative blood transfusion were only 03.33% in cases where IVP was done, and 41.66% in those who under went LUCS (P&lt;.001). Hospital stay in IVP group was only 1.3 days where as 10 days for those who under went LUCS (P&lt;.001). Regarding complications it was almost same in both groups. IVP was also very cost effective required some of taka 300 only where as for LUCS it required about 3000 taka. Conclusion: The success rate of IVP is good. It is cost effective, preserve the future fertility and prevent DOI: http://dx.doi.org/10.3329/jbcps.v32i1.21030 J Bangladesh Coll Phys Surg 2014; 32: 16-20

Rediscovering the lost art of internal podalic version: two case reports

Internal podalic version was once widely used for the management of placenta praevia. In modern obstetrics, it has been replaced by caesarean section which can lead to uterine rupture in a subsequent pregnancy. However, if the foetus is dead or very small, internal podalic version still may be carried out without major complication to avoid unnecessary caesarean section in developing countries where follow up is not satisfactory and the foetal prognosis is poor.

Non-intégrité des membranes en cas de manœuvres : facteur de risque de césarienne sur deuxième jumeau

ObjectivesTo evaluate if internal version with ruptured membranes is a risk factor of cesarean section for the second twin. Patients and methodsTwo hundred and fifty-nine twins vaginal deliveries after 33 weeks of gestation from 1997 to 2009 in a level 3 maternity. A retrospective case–control study comparing two groups: cases of cesarean section on second twin and five twins vaginal deliveries following the case. Active management of the second twin delivery was performed with a short intertwin delivery. ResultsEleven cesarean sections on the second twin were performed (4.2%). The main indication was failure of internal version. The risk of cesarean section was significantly greater when the internal version was performed with ruptured membranes (OR: 25.4 IC 95% [2.3–275.7] P<0.003) and when intertwin time delivery interval was increased (8.1±5.1 vs 16.7±6.3, P<0.001). Discussion and conclusionThe rupture of amniotic membranes before or during the internal podalic version is associated with a risk of failure and cesarean for the second twin. We recommend to perform the internal podalic version with unruptured membranes according to the French recommendations.

Designing a combined neonatal and obstetric air ambulance service: the birth of ‘Airborn’

The combination of a perception of ‘low risk’ and professional pressures contribute to women travelling internationally throughout their pregnancy. If specialty care is required, mothers may find themselves in the...

Internal podalic version with breech extraction

Internal podalic version with breech extraction

Internal podalic version for neglected shoulder presentation with fetal demise

In modern obstetrics, the role of internal podalic version (IPV) is limited to delivery of the second twin. A retrospective study was conducted to assess the efficacy of IPV in singleton neglected shoulder presentation with fetal demise. Women with live fetuses, previous CS or contracted pelvis were excluded. The procedure involved repositioning the prolapsed hand under anaesthetic followed by breech extraction. 12 women were identified over a 19 month period and all underwent successful IPV. One woman had a postpartum haemorrhage. We conclude that, in singleton pregnancies with a transverse lie, IPV has a role to play in the delivery of dead fetuses.

Intravenous nitroglycerin: a potent uterine relaxant for internal podalic version: case

Dear Editor, The uterine-muscle relaxation required for complicated obstetric situations traditionally has been achieved by use of a potent inhalation anesthetic. However, this procedure exposes the obstetric patient with full stomach to unnecessary general anesthesia, with the attendant risk and potentially lethal complications. Emergent uterine relaxation may be required for conditions such as retained placenta, uterine inversion, internal podalic version (IPV), and breech extraction. EVective on smooth muscle tissue and a venodilator, nitroglycerin is a short-acting and a potent uterine relaxant [1, 2]. Safety, predictability, and ease of intravenous (IV) administration of this drug have been established, and it has attracted the attention of obstetricians. Nitroglycerin is primarily indicated for the treatment or prevention of angina pectoris. Nitroglycerin has been used during manual extraction of retained placenta without clinically signiWcant hemodynamic eVects [1] and during replacement of a contracted, completely prolapsed uterus [1, 2]. Its use as a tocolytic has been reported in cesarean delivery of twins performed under spinal anesthesia: two cases of intrapartum external cephalic version, internal intrapartum podalic version of the second twin, and for the fetal head entrapment during vaginal breech delivery [1]. We report a case of IPV of intrauterine fetal demise (IUFD) in which relaxation of the uterus was accomplished quickly and safely with the use of IV nitroglycerin. A 30-year-old gravida 4 para 3 at 38 weeks gestation presented in active labor with antepartum hemorrhage since 2 h. Ultrasound conWrmed transverse lie, abruption placentae and IUFD; and examination revealed 4 cm dilated cervix. Her vitals were stable, hematocrit was 28% and coagulation proWle was normal. She made good progress, reaching 8 cm cervical dilatation over the next 4 h after which she started having hematuria so the decision was taken immediately to deliver the fetus by IPV. Uterine relaxation was achieved by direct IV nitroglycerin bolus 50 mcg along with ketamine hydrochloride 30 mg IV for sedation. Infusion of nitroglycerin at the rate of 50 mcg/min was started after 1 min of loading dose. When the uterus was relaxed (conWrmed with manual palpation), approximately 45 s after bolus, the obstetrician performed IPV and breech extraction. The procedure was completed in 4 min and 30 s. The total dose of nitroglycerin was 250 mcg. The placenta delivered spontaneously with no unusual cord traction. Transabdominal massage of the uterus and oxytocin infusion improved uterine tone. The hematocrit had decreased from 28 to 22%. One unit blood transfusion was given and she remained stable in the postpartum period. Hematuria was cleared in 2 h postpartum. Monitoring consisted of electrocardiogram, SpO2 and non-invasive blood pressure measurement. Hypotension occurred 1 min after nitroglycerin injection, which was normalized within 50 s with rapid infusion of crystalloids. The heart rate increased at the same time to 130 bpm. Side M. N. Gandhi · H. R. Iyer Department of Anaesthesiology, B. Y. L. Nair Charitable Hospital, T. N. Medical College, Dr. A. L. Nair road, Bombay 400008, Maharashtra, India

Role Of Internal Podalic Version In Developing Countries

Results: There were 41 (15.8%) cases of internal podalic version out of 261 cases of transverse lie. All these cases were undiagnosed transverse lie with intrauterine fetal death in labour. None of these cases had any form of antenatal care. Half of the cases were more than 37 weeks gestation. 31 (76%) cases were with >7cm cervical dilatation. Version resulted into minor complications like 5 cases of cervical tears, 7 cases of para- urethral and vaginal tears. No case of rupture uterus or obstetric shock was reported. There were 2 cases of failure of version one of which was followed by LSCS and the other by vaginal birth following reductive surgery. There was one maternal mortality which was due to the eclampsia and not related to the internal podalic version.

OVARIAN CYST FORMATION: MANY YEARS AFTER HYSTERECTOMY FOR HEMORRHAGIC COMPLICATIONS IN TWIN DELIVERY

After a subtotal hysterectomy for severe postpartum hemorrhage due to rupture uterus, followingcomplication at internal podalic version and breech extraction for a second twin, in a primipara; a longterm follow up and management by a wedge resection of ovary, ovariotomy, and removal of cyst was carriedout by the same surgeon in three different Hospitals, so unique in our context, is reported.Key Words: TwinDelivery, Internal Podalic Version.