NEGLECTED SHOULDER PRESENTATION (A Study of 61 Cases)

BIMAN CHAKRAVARTY, M.B.B.S., D.G.O. (Cal.), M.R.C.O.G. (Eng.)

Neglected shoulder presentation is very rapid or slow, showing signs of a rare condition in more developed foetal distress. The maternal condi parts of the world. That it is not un tion of almost all was one of exhaus common in the less developed coun tion, partly from persistent uterine tries is indicated by the fact that 61 contractions; in many of them the ute cases were collected in a period of rus was tonically contracted with no only two years. All the cases were relaxation in beween the contractions. delivered in a district hospital. The A number of them had rise of tem hospital serves a wide area and is the perature from superimposed infec only hospital with specialist service tion. in about forty square miles. The po pulation is a mixed one with various Incidence types of religious dogma and with a Garner et al. reported 65 cases in big percentage of illiterate people. 15 years in 27,249 deliveries-one in Many of them have yet to learn the 419 deliveries, Hall et al. gave an in importance of antenatal care. They cidence of 1 in 217. The present shun the hospital unless they are series was collected from 8000 deli forced to attend it. veries-an incidence of 7.5 per thou This paper does not deal with all sand. the cases of transverse lie that attend ed the hospital, but only those that Age came in very late in labour. As the Average age of the patients was 26 name suggests the cases were in such years, though there were patients in a condition on admission that they all age groups, the youngest being 15 required immediate interference; in years and the oldest 40. all of them the membranes had rup TABLE I tured for over four hours and in most cases one hand was prolapsed Up to 20 years 14 cases with or without prolapsed cord. Foe 21 years to 25 years 19 cases tal heart was not heard in more than 26 years to 30 years 19 cases 31 years to 35 years 5 cases 75 per cent cases on admission; in the 36 years to 40 years 4 cases rest foetal heart was feeble, either Department of Obstetrics and Gynaeco As shown in the above table the logy, Rao J. N. Roy Hospital, Berhampore, cases are mostly in the 20 to 35 years West Bengal, India. group.

t NEGLECTED SHOULDER PRESENTATION 753

Parity pitation was particularly difficult. The other case where hysterectomy The average parity of the patients was done, was an eighth gravida, 40 was 4.9. More than 75 % of the cases years old, for whom caesarean sec were grande multiparae i.e. they had tion was decided, but on laparatomy 5 or more pregnancies; there were uterine rupture through the lower two cases who were eleventh parae, segment was detected. Subtotal hys ,. Seven of the cases were primigravi terectomy was performed along the dae, giving an incidence of 11% . Hall rupture and the patient made an un et al. report 8% primigravidae in eventful recovery. In one case of their series. twin pregnancy, whe;re the first baby TABLE II had shoulder presentation with hand 1st 2nd/4th 5th/7th 8th/11th prolapsed, caesarean section was per formed. Both the babies were born 8 23 19 11 alive; the second baby was present ing as vertex. Of the six destructive operations five had decapitation and I . Terminations one had evisceration. In 1963 in two To help analysis, the cases have cases of classical section rupture of been grouped in two different years. uterus was detected on laparotomy, ·The number of cases during the and so the section was followed by year 1962 was 23, in 1963 the num hysterectomy. One of them was a ber was 38. The author had the op ninth gravida, 38 years old, the other portunity to look after the cases who was 23 years old and had two child were admitted from the period of ren. In one case twin pregnancy re October 1962 to December, 1963. mained undiagnosed until the first During the period qf 1962 the 23 baby, who had a prolapsed hand, was cases terminated in the way as shown delivered by internal version. Intra in the following table (table III). venous ergometrine was injected with

TABLE ill

Caesarean section Spontaneous Destructive Version Hysterectomy delivery operations Classical Lower

1962 1 1 6 10 5 2 1963 9 12 7 9 1 2

In 1962, in 4 cases of classical delivery of the baby. The presence caesarean section ligation of fallopian of the second baby was diagnosed tubes was done. In one case of des only after the first was delivered. The tructive operation rupture of the ute second baby was presenting by ver rus was detected following decapita tex, with the head above the pelvic tion, for which hysterectomy was brim. As soon as this misadventure performed. In this particular case was detected the second baby was de both hands were prolapsed and deca- livered as breech by internal version. 754 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA

The baby was alive and had no in Of the 38 cases in 1963, there were tracranial injury. The first baby was 39 babies including a pair of twins. found macerated on delivery. In an- . Of these only five living babies could other case of internal version in a be delivered. Three of the live-born fifth gravida, aged 35, the foetal heart babies were delivered by internal was heard on admission and cervix podalic version and two by caesarean was fully dilated. The membranes section. It was only in six cases that were ruptured about 6 hours before foetal heart was present on ,adrn'is she came in. It was decided to do an sion. Only one of the six babies was ·. internal version in the operation lost, the one which after-verson could theatre, with the patient prepared not be delivered easily due to con for caesarean section, if version fail- traction ring. . ed. The version was performed with Thirteen live-born babies out of 63 out much difficulty, but a contraction gives a percentage of 20 living-babies ring developed at the region of inter and 80 % foetal mortality, Garber et nal os and obstructed the delivery of al report foetal mortality of more the aftercoming head. Anaesthesia than 94 % when labour has be2n pro was deepened with increased con longed for more than 24 hours. centration of ether but the contrac tion ring persisted. It was only after Hospital Stay injecting adrenalin, one in thousand This district hospital is so much solution 1 c.c., intravenously tliat overcrowded that the normal deli the ring relaxed and the baby could very cases are· discharged 48 hours ... be delivered, but this long delay in after delivery. delivery of the aftercoming head led to foetal death. The baby weighed 7 TABLE IV lbs. and had irreversible asphyxia. In Hospital Stay another case during internal version Spontaneous delivery 3 days type II placenta praevia was detected. Intunal podalic version 4.3 The foetus was already dead and ver Destructive operations 5.5 sion was completed without causing Caesarean section 21.5 any vaginal bleeding. Of the 7 cases of destructive operations performed The cases of transverse lie that in 1963, 4 had decapitation and in delivered spontaneously had a hos three evisceration was performed. pital stay of only 3 days. Those with internal version required hos Foetal Salvage pitalization on the average for 4.3 days. The cases who had destructive Of the 23 cases in 1962 there were operations had an average stay of 5.5 24 babies including one pair of twins. days. The patients who had a caesa Of these 24, eight were live-born. rean section, on the other hand, re One of the twins died in the neonatal quired an average stay of 21.5 days. period from infection. All the eight One case had to stay as long as 57 living babies were delivered by cae days before being discharged cured. sarean section. Four cases had to stay more than a NEGLECTED SHOULDER PRESENTATION 755

month after caesarean section. The on admission was significant. The main postoperative complication was softening of the foetal bones perhaps infection. It is interesting to note helped in the process of expulsion in that patients who required hysterec stead of causing rupture of uterus, tomy had a smooth postoperative thougli most of the babies were not period, and they were discharged macerated. within a fortnight after operation. The author would not like to con clude that spontaneous delivery in Discussion neglected shoulder presentation is to In the Chapter on "Results of neg be expected in all cases but this series lected shoulder presentation" in the just shows that this type of termina British Obstetric and Gynaecological tion is not as rare as it is thought. Practice, MacLenan, Wrigley and Per Internal Version cival write that spontaneous deli very is possible, though extremely It is interesting to note that in the rare, when the lie is uncorn'!cted. In year 1962 there was only one case of this series of 61 cases, there have internal version, whereas in 1963, been 10 cases who delivered them there were 12 cases which were ter selves, the spontaneous delivery rate minated by internal podalic version. is, therefore, more than 16(; . In these 12 cases there was not a sin In all these 10 cases the baby was gle case of ruptured ut2rus. The dead. In all but one case the baby author feels that if internal version was over six pounds in weight. Only is carefully done, the risk of rupture four babies were macerated. One can be minimised. The decision can case was premature, of 32 weeks' only be made after the patient is pregnancy. Most of the cases of spon anaesthetised. If the uterus relaxes t:meous delivery ended by spontane and there is no contraction ring, in ous expulsion i.e. the entire foetus ternal version can be attempted. doubled up and was expelled, back Gentle manoeuvre is the secret. In foremost, the head and feet appearing some cases it was possible to pull last. Two patients were delivered by down the legs, the lie being corrected, spontaneous evolution, in which the the foetus was left to be delivered breech was driven down first and the spontaneously. This increased num baby was finally delivered as breech. ber of versions has minimised the It seems that if sufficient time is al number of caesarean sections. When lowed in labour these cases will either the foetal heart is present the author expel the foetus themselves or have would advise caesarean section even rupture of the uterus. Due to trans if the cervix is fully dilated. In cases port difficulties many of the patients of neglected shoulder presentation arrived in the hospital late in labour, the babies are moribund, if not al and perhaps that explains the high ready dead, and so it is advisable to rate of spontaneous delivery in this deliver them with minimum foetal series. The parity of the mother did manipulation which is possible only not influence this method of deli by caesarean section. Failure to fol very. That the babies were all dead low this rule cost the life of a 7 lb .

• 756 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA baby whose aftercoming head . was capitation thimble and wire saw. In obstructed by a contraction ring, as all cases after decapitation, explora has been described before. · · But the tion of the uterus was performed to '"' cases where the foetus was already exclude rupture of uterus. Some dead, internal version gave a much times the uterus that has ruptured better postoperative period than in before coming into the hospital is the caesarean section cases. These only diagnosed by exploration after cases usually are infected and give a removing the baby. In one of the stormy postoperative period. after a cases of this series, rupture was de major operation like caesarean sec tected after decapitation. In this case tion; they are mostly anaemic and decapitation was specially difficult stand blood loss adversely. In many because both the hands were prolaps the uterus is so much retracted that ed, and it is possible that manipula only a classical section can deliver the tions caused the rupture. The patient - baby. Classical section in a dehydrat required hysterectomy after decapita ed, anaemic, infected patient, is never tion and had an uneventful postopera very safe. Fortunately, in this group tave period. In no case of this series we did not lose any patient, but one was there any vesico-vaginal or case of caesarean section had to stay recto-vaginal fistula, but in cases in hospital as long as 57 days. The where there is risk of operative in lack of free availability of blood adds jury, bladder should be continuous- to the danger of section. ly drained for at least a week. All these cases had prophylactic antibio- " Destructive Operations tics. The cases of destructive opera Both eviscerations and decapita tion required hospitalization on the · tions are difficult operative proce average for only 5.5 days as against dures and the cases should be care 21.5 days after caesarean section. In fully chosen. This should always be a busy district hospital like this it undertaken by people who have suffi makes a difference in the burd2n on cient experience in these types of ope hospital beds. The author makes a rations. The type of destructive ope plea that in cases of neglected shoul ration will depend upon the most der presentation where the baby is approachable presenting part. As a dead, destructive operation gives . rule decapitation is a cleaner op2ra equally good results as caesarean sec- .,. ~ tion than evisceration and should be tion, if not better, in relation to ma preferred if the neck of the foetus is ternal morbidity and mortality. easy to approach. Both these opera In cases where the uterus is toni tions are meant for babies who are cally contracted, any uterine mani already dead. If carefully performed pulation, including decapitation, is there is very little risk of maternal in liable to fail and prove practically jury and a smooth postoperative dangerous, and in these cases caesa period is expected. In the present rean section is preferred. In Hall's series decapitation knife was used in series of 85 cases there were three the usual way. The author had no maternal deaths. All the deaths were ... opportunity to use Blond-Heidler de- in the first ten years of 1924 to 1958 .

. ' NEGLECTED SHOULDER PRESENTATION 757

There were no deaths in the later condition was also found in seven years. In the present series, of 61 primigravidae. In none of these pri cases there were no maternal deaths migravidae was any gross pelvic con though in 60 % cases vaginal delivery traction detected. Hall and O'Brien was undertaken. Antibiotics and ex found no cause in 79 7o of their series. pert anaesthesia have ~a~e vagi:r:al delivery safer. In India, m the dis Conclusion tricts blood is not yet freely available Neglected shoulder presentation is for tr'ansfusion and cannot be readily an avoidable condition. It can only organised in case of emergen~y. ~n be found in countries where antenatal view of this, caesarean sectwn m care is far from satisfactory. It is al neglected shoulder presentation ways associated with a very high foe should be carefully considered and tal mortality and maternal morbidity under the present conditions in this and mortality. The author has col country should be avoided if possible. lected 61 cases during a period of two Ceval Babumea of Istanbul seems to years in a district hospital and has have worked in similar circumstances analysed the results of the various as in India, and he has also ad methods of treatment. Where the vocated destructive operations when baby is alive caesarean section is the the baby is dead. He reports 26 case~ method of choice, but if the baby is without a maternal death. He had already dead internal podalic version two cases of ruptured uterus, one was or decapitation should be carefully _ treated conservatively and the other considered as possible alternative~. had hysterectomy. He quotes support Spontaneous expulsion may occur in from Eastman, Kurtz, Etal, and Ried. some cases but should not be awaited Discussing on Garber et al's paper for. Holmes commented that internal ver I am grateful to Dr. (Miss) Bose, sion was an ideal operation in its ap the lady medical officer of the Unit, propriate field and it would be wise for her help in collecting the cases. I to realize that· caesarean section was would like to thank Dr. Bhattacharya not a panacea for all obstetric compli for allowing me to collect the cases cation, and other obstetric operations that were under his care. My thanks still had a definite place as a means are due to Dr. Roy Choudhury, the of delivery. The author's experience Chief Medical Officer, and Dr. in this series is in complete agree Chakravarty, the Superintendent of ment with Holmes's view. the hospital, for allowing me to pub lish th2 hospital cases. I am grateful Aetiology to Mr. Mukherjee for kindly typing In this present series no cause for the manuscript for me. transverse presentation could be de tected in 58 cases. In one there was References pJacenta praevia and there were two cases of twins. No uterine abnorma- 1. Babuna, Ceval: Am. J. Obst. & , lity was detected in any case; 28 cas~s Gynec. 87, 1963. were grand multiparae, but this 2. Eastman, N. J.: Obstetrics, ed. 10, 29 758 JOURNAL OF OBSTE'l'lUCS AND OYNAECOLOGY OF. IN:OIA

New York, 1950, Applaton Century Obstetrics and Gynaecological Crofts, Inc. -Practice, ed., London, 1955, Heine 3. Garber, E. C. (Jr.), Fayetteville, mana, p. 631. N. C., Hudnall Wave, H. (Jr.)" ~. Kurtz, G. R., Stall, W. A., and Sat Richmond, V. A.: Am . .J. Obst. & tenspiel, E. and Bull E.: Margaret Gynec. 61: 62, 1951. Hagne Maternity Hospital 3: 18, 4. Hall Stanley C., O'Brien, Francis, 1950. B.: Am. J. Obst. & Gynec. 82: 1180, 7. Reid, D. E.: A Text-book of Obs 1961. tetrics, Philadelphia, 1962, W. B. 5 . Holland E. and Bourne, A.: British Saunders Company.

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