Head entrapment syndrome: a management dilemma of an intrapartum intra-uterine death
Head entrapment syndrome: a management dilemma of an intrapartum intra-uterine death |
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Department of Obstetrics and Gynaecology
1Diana, Princess of Wales Hospital,
Northern Lincolnshire and Goole Hospitals NHS Trust
Scartho Road, Grimsby DN33 2BA
2University of Sheffield
Sheffield
2Corresponding Author, Telephone 01472 874111, Facsimile 01472 875452, Email iibolaji@yahoo.com
Abstract
Many issues have been resolved in the management of singleton term breech
pregnancies but that of the preterm breech continues to be source of controversy.
A case of head entrapment in a preterm vaginal breech presentation with intrapartum
intrauterine death is presented which was successfully resolved by laparotomy.
In this emergency, there were no better alternatives for the delivery of the
entrapped after-coming head. The choice among suboptimal options available
will need to be made very rapidly to ensure survival of baby and reduce morbidity
to mother. Alternative therapeutic interventions are discussed.
Key words: Head entrapment syndrome; preterm; breech
Introduction
The benefits of caesarean section delivery in pre-term breech have continued
to be controversial. Since the initial reports of better survival for selected
low birth weight babies in breech presentation after caesarean section (1),
many investigators have recommended caesarean section for preterm breech presentation.
However, other investigators have been unable to find a survival advantage
with caesarean section once the data are compounded for gestational age and
birth weight (2)(3).
The issue of term breech has been resolved by the international multicentre
randomised controlled Term Breech Trial showing that perinatal mortality, neonatal
mortality, or serious neonatal morbidity was significantly lower for the planned
caesarean section group (1.6%) than for the planned vaginal birth group (5·0%).
There were no differences between groups in terms of maternal mortality or
serious maternal morbidity, the incidence was 3·9% and 3·2% respectively
(4).
The need to maintain the skill in breech delivery is illustrated in this case
report and the fact that breech presenting fetuses will be encountered at advanced
second stage when caesarean section may be impractical. We present a case of
head entrapment in a preterm vaginal breech with intrapartum intrauterine death
which was successfully resolved by laparotomy.
Case report
The patient, RS an 18 year old, multiparous lady (Gravida 2 Para 1) was booked
late into antenatal clinic at 23 weeks gestation. She had one previous pre-term
normal delivery of a living female infant at 34 weeks gestation 12 months earlier.
She is a known smoker and had no cervical screening previously. She was admitted
at 28 completed weeks and 6 days following a spontaneous rupture of the membranes.
Baseline investigations were normal, cardiotocograph (CTG) was satisfactory
and steroid therapy was commenced. Ultrasound examination revealed oligohydramnios,
footling breech presentation and normal growth. It was planned that caesarean
section would be carried out if she went into labour. Conservative treatment
was adopted but the patient took her own discharge from the hospital. The community
midwife reviewed her at home daily during the ensuing two consecutive days
when all observations were reported as normal. She returned to the labour ward
after 3 days with mild uterine contractions every 15 minutes.
On admission she appeared uncomfortable but was not in distress. Initial observations
were satisfactory. Pelvic examination revealed meconium-stained liquor and
full cervical dilatation. Expulsive contractions started during examination
by the midwife and fetal heart rate decelerations with slow recovery were observed.
This was followed by spontaneous delivery of the baby’s legs, buttocks
and body in the presence of obstetric registrar. The uterine cervix was observed
to be clamped round the baby’s neck. Incisions on the cervix and episiotomy
(to allow instrumentation) failed to achieve delivery of the after coming head.
Thirteen minutes after baby’s body had been delivered, she was transferred
to the operating theatre in lithotomy position and general anaesthesia was
induced. Further attempts to deliver the after coming head vaginally failed.
At a laparotomy, uterine pressure was applied from inside the abdomen without
uterine incision. This was assisted by Mauriceau-Smellie-Veit manoeuvre vaginally,
resulting in the delivery of a fresh stillborn infant. The cervical tear and
episiotomy were repaired,
abdomen was closed in layers and an indwelling catheter was inserted into the
bladder. Apart from the patient’s obvious grief at the loss of her
baby, her postnatal recovery was uneventful.
Discussion
After coming head entrapment by the cervix is a rare but dreaded risk of pre-term
breech delivery. The incidence for vaginal breech deliveries from 28-36 weeks
gestation is 7.7% and 5.2% at caesarean section (5). Despite proper management,
arrest of the after coming head may still occur without warning in about 1
in 12 vaginal breech deliveries (6).
Ideally, the optimal mode of delivery of preterm breech fetus should be tested
in a randomised-controlled trial of vaginal delivery and caesarean section
for preterm breech presentation. Two such trials, however, were interrupted
because of prejudice on the part of the obstetricians wanting to participate
in the trial (7)(8).
Manoeuvres such as application of obstetric forceps, administration of halothane,
an intravenous dose of terbulatine or nitro-glycerine to mother or extension
of cervical incision have been used in the past to correct an entrapped head
(5). There have been cases of successful outcomes after severe head entrapment
of term infants using different techniques. These include abdominal rescue
using vacuum assisted delivery performed from above through a caesarean section
incision once the head was entrapped with a good neonatal outcome (9), adoption
of McRoberts manoeuvre (10). Another is after a Zavanelli manoeuvre with endotracheal
intubation of the neonate at caesarean section while the impacted fetal thorax
was released by the obstetrician (11). The entrapment of the after-coming head
of the baby can be caused by soft or bony components of the maternal pelvis.
This case demonstrates a cervical cause, which is a potential problem in all
cases of premature breech delivery.
In this emergency, we could think of no better alternatives for the delivery
of the entrapped after-coming head. The choice among suboptimal options available
needs to be made very quickly (12). If the fetus is already dead, non-viable
or unsalvageable, attention can be turned to ensuring a good maternal outcome
as in this case. Destructive procedures such as fetal craniotomy or less invasive
procedures like simple symphysiotomy have been reported, but in non-European
environment.
We emphasise the need to continue to teach the art of vaginal delivery despite
the results of term breech trial.
suboptimal options available needs to be made very quickly (12). If the fetus is already dead, non-viable or unsalvageable, attention can be turned to ensuring a good maternal outcome as in this case. Destructive procedures such as fetal craniotomy or less invasive procedures like simple symphysiotomy have been reported, but in non-European environment.
We emphasise the need to continue to teach the art of vaginal delivery despite the results of term breech trial.
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