---

OPERATIVE INTERVENTION FOR DELIVERY OF THE DEAD FOETUS

Purnima Satoskar*, Vinita Salvi**
*Associate Prof; **Prof; Dept of Obstetrics and Gynaecology, Seth GS Medical College, Parel, Mumbai - 400 012.

---

The mode of delivery in 488 patients with intrauterine foetal death delivering at KEM Hospital between January, 1992 and March, 1995 was studied. Operative interventions were required in 51 (10.5%) of patients. These included forceps application, vacuum extraction, versions, destructive operations and caesarean section. Caesarean section was performed in 2.7% of cases mainly for life threatening maternal indications. Maternal mortality (19.6%) was attributable mainly to the underlying disorder and unrelated to route of delivery.

INTRODUCTION

Intrauterine foetal death is a situation where the vaginal route is definitely preferred for delivery. However, assistance may be required in the form of forceps, versions or destructive operations. Caesarean section may be necessary in severe foetopelvic disproportion, impending uterine rupture or to expedite delivery in life threatening circumstances such as antepartum haemorrhage. All patients requiring operative interventions in the presence of intrauterine death at the KEM Hospital, Mumbai over a three year period between 1st January, 1992 and 15th March, 1995 were evaluated in this study.

MATERIAL AND METHODS

488 patients with intrauterine death delivering at the KEM Hospital over a 3 year period from 1991 to 1993 were studied. Underlying maternal complications as well as complications leading to intrauterine death were noted. The mode of delivery was studied with respect to any operative intervention required. The details of the procedure performed, indication for operative intervention and ensuing maternal outcome was noted and analysed.

RESULTS

During the study period, out of 14409 patients delivering at KEM Hospital 488 (3.4%) intrauterine death. 51 patients (10.5%) required operative intervention in the presence of a dead foetus and were evaluated in this study. 45% of patients were primigravidas.Gestational age at delivery was < 37 wks in 53% of the cases.13 patients were antenatally registered while 38 patients were emergency admissions.Operative interventions performed are listed in Table 1. Four patients required forceps delivery following a destructive operation. Indications for caesarean section are detailed in Table 2. Complications occurred in 9.8% of these patients and included cervical tear in 2 patients, rupture uterus in 1 and septicaemia in 1. There were 10 maternal deaths (19.6%). Death was due to the underlying maternal illness in all the cases (Table3).

Table 1
Operative interventions in intrauterine foetal death
Intervention	Number
Caesarean section	13
Forceps delivery	12
Internal podalic version with breech extraction	6
Tapping of hydrocephalus	5
Breech extraction	14
Craniotomy	2
Vacuum extraction	2
Decapitation	1
Total	55

Table 2
Indications for LSCS in intrauterine death
Indication	Number
Previous two LSCS	2
Placenta praevia	2
Failed vacuum / forceps	2
Suspected rupture	2
Failure to progress	1
Cephalopelvic disproportion	1
Brow presentation	1
Failed internal podalic version (transverse lie)	1
Failed induction	1
Total	13

Table 3
Causes of maternal death
Cause of death	Number
Preeclampsia / Eclampsia with multiorgan failure	6
Acute fatty liver with coagulopathy	1
Septicaemia with acute renal failure	1
Pulmonary oedema in rheumatic mitral valve disease	1
Intracerebral bleed in a case of leukaemia	1
Total deaths	10

DISCUSSION

Foetal demise may occur in the antepartum or intrapartum period due to asphyxia, prolonged labour, cord prolapse, chorioamnionitis or rupture uterus. [1] A majority of these patients have a spontaneous vaginal delivery. In this study 437 out of 488 patients delivered vaginally. Forceps were applied in 12 cases mainly to cut short 2nd stage in maternal medical disease, exhaustion or unconsciousness.

Caesarean section may be necessary in the presence of factors such as severe foetopelvic disproportion, maternal haemorrhage, obstructed labour or failed induction

Caesarean section for a dead foetus may pose special problems in developing countries such as refusal of consent, increased risk of infection in neglected labour or danger of rupture of the uterine scar in subsequent pregnancy if the patient is not likely to deliver at a hospital.[1, 2] Destructive operations and symphysiotomy have been found to be useful in well selected cases. Tapping of hydrocephalic head either vaginally or abdominally facilitates delivery and was performed in 5 patients. Craniotomy was performed in 2 and decapitation in 1 patient.


In malpresentations internal podalic version and breech extraction can be done as foetal survival is not a concern. However version may cause uterine rupture if performed in advanced labour. Rupture uterus occurred in one patient out of six undergoing internal podalic version in our study. Decapitation and separate delivery of the head is superior to version for transverse lie if the operator is experienced.

An extraperitoneal Caesarean section is preferred in the presence of intrauterine infection. If the lower segment is overdistended a low vertical incision prevents lateral tearing during foetal extraction.[3] Maternal deaths occurred in seriously ill mothers in whom the underlying illness was responsible for both foetal and maternal death. No maternal death was directly related to operative intervention.

CONCLUSION

The mode of delivery of a dead foetus depends upon the clinical setting in which the foetal death has occurred. Most patients can be successfully delivered vaginally. Destructive operations, versions and symphysiotomy may obviate the need for caesarean section in well selected cases. Caesarean section should not be denied in life threatening cir cumstances or if rupture is suspected.


REFERENCES

1. Osato F Giwa - Osagie, Bernard B Azzar. Destructive operations. In John Studd. (Ed.) Progress in obstetrics and Gynaecology, Churchill Livingstone 1987; 6 : 211-21.
2. Gogoi MP. Maternal Mortality from Caesarean section in infected cases. The Journal of Obstetrics and Gynaecology of the British Common Wealth 1971; 78 : 373-6.
3. Beazley JM. Special circumstance affecting labour. In Dewhurst’s Textbook of Obstetrics and Gynaecology for postgraduates CR Whitfield (Ed.) Blackwell Science Ltd, Oxford 1995; 328.

---

To Section TOC