An Interesting Country Case : Csesarion Section

Kai Tiaki : the journal of the nurses of New Zealand, Volume IV, Issue 1, 1 January 1911, Page 31

An Interesting Country Case : Csesarion Section

Mrs. 8., a primipara, was examined by doctor a week before her expected confinement. The breech was then presenting, and the only other abnormality observed was the height at which the breech was held. It could not easily be made to engage m the brim of the pelvis. No vaginal examination was made, that being thought inadvisable for fear of sepsis ; no very great difficulty was expected however. Membranes ruptured mid-day Monday, 12th, and rhythmic uterine contractions immediately set m. Patient was seen by doctor 10 p.m. She was then evidently m first stage of labour, pains about every quarter of an hour, severe, but of short duration. Spontaneous version had occurred, and child now presented R.O.A. The head did not descend well into the pelvic brim. ISTo vaginal examination was made. Pains continued at quarter hour intervals all night. All Tuesday pains came on more frequently, and by the evening recurred every ten minutes. Patient exam, vagin. by doctor ; exam, showed hard cervix (firm, and not evidently easily dilatable) into which the head was not forced, even with the help of a pain ; it would just admit three fingers. The head could not be pushed up, when an attempt was made to do this the cranial tones were indented, and sprung out again when the p-essure Was removed. I v iq. amnii leaked away with each pain. About three a.m. on 14th pains became severe, and much longer m duration ; the head, however, was not pressed into the cervix, it was not even engaging m the pelvic brim, and it was immovable. That it was not impacted m the bony pelvis was proved by the very easy passage of a soft catheter.

Manual dilatation was attempted, and persevered with by the doctor until 5.30 a.m. When the os with difficulty would allow of the application of forceps (under chloroform) the doctor tried steady pulling with each pain for one hour, but that was of no avail, the head could not be brought into cervix. More force was then used, until as much power was brought to bear as possible. This onty resulted m dragging down the whole uterus with the head. Doctor again carefully examined vaginally, and found that the lower uterine segment was occupied by a firm mass, which faded away below to the posterior part of cervix, and could not be followed above. Doctor said it was evidently a fibroid, more diffuse than usual. Posterior longitudinal division of- the cervix he rejected on the ground that he could not then be certain of obtaining sufficient room, nor could he by its help be sure of delivering a dismembered child without possibility of serious damage to uterus, and risk of sepsis.

Consultation with doctor B. resulted m decision for operation. Morphia was given to patient meantime to check uterine contractions whilst preparations were m hand, but it had practically no effect. From 8 a.m. till 11.30 a.m. pains were very frequent — every three minutes — pulse rapidly increased m frequency, and the uterus gradually closed around child, as the liquor amnii escaped. The head had made no advance. Caesarian section was performed m usual manner. doctor's notes. Abdominal incision eight inches long, with centre at umbilicus ; uterus packed

round with gauze, against which abdominal wall was compressed. Uterus opened m midline m front (incision six inches long). The placenta was divided and furious bleeding resulted, but was quickly stopped by pressure on the ovarian and uterine arteries, after the child had been rapidly extracted. Placenta and membranes separated, then uterus closed by deep catgut sutures, which did not actually enter cavity. The operation so far had lasted 50 minutes, and patient was not standing it well. There was then very little opportunity of carefully examining the uterus, but it was greatly thickened behind over the lower uterine segment. The limits of this thickening cannot be clearly defined. One small subserous fibroid nodule was noted m the anterior uterine surface. As rapidly as possible the abdominal wound was closed m layers ; catgut being used throughout and a coll odium dressing applied. Ether (by the op n method) was given during the whole operation, but m spite of this anaesthetic, which was very well taken, the shoek — probably due to loss of blood — was considerable.