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Place of Internal Podalic Version in Modern Obstetrics PLACE OF INTERNAL PODALIC VERSION IN MODERN OBSTETRICS by R. v. BHATT, M.D., D.C.H., and H. B. KoTWAL, M.B., B.S. Introduction Increased safety of anaesthesia, blood transfusion and availability of Till the advent of 19th century in­ potent antibiotic drugs have resulted ternal podalic version was resorted in increased safety of caesarean sec­ to when immediate delivery of the tion even when performed late in foetus was necessary and for every labour and has considerably limited conceivable form of dystocia. In­ the scope of internal podalic version. ternal podalic version till last century It is our impression that the pro­ was the sheet anchor of an obste­ cedure of internal podalic version is trician when faced with an obstetric fast receding into the background. difficulty. An obstetrician of those A resident of today gets very few days felt secure with a leg of the opportunities to see even the opera­ foetus in his hands! The procedure tion of internal podalic version, much of internal podalic version was a less does he get an opportunity to do boon especially when maternal it himself. From the current trends mortality following abdominal deli­ of obstetric practice, it appears that very was formidably high. But this operation may become of histori­ methods, like human beings, grow cal interest only. old, become decrepit and die. The Very few articles have appeared safety ensured to both mother and in recent years on internal podalic foetus as a result of abdominal mode version. The outstanding ones are d delivery has practically replaced by Keetel et al (1952), Townbridge internal podalic version from modern (1950), Apthrop (1950), Amigo obstetrics. The incidence of internal (1952), etc. No article is published podalic version is falling to a low ebb discussing the status of internal in all big obstetric centres of the podalic version in countries where world. The fall of internal podalic slightly different conditions prevail. version, as a means of delivery, frmil It is our endeavour to evaluate the its high pedestal of glory is due to true status of internal podalic version higher incidence of cervical tears, in modern obstetrics. uterine rupture and high foetal mortality. Material and Methods N. W. Maternity Hospitnl, Pm·el, Bam- This is a critical analysis of 200 bay-12 . cases of internal podalic versions .. PLACE OF INTERNAL PODALIC VERSION IN MODERN OBSTETRICS 405 performed at Nowrosjee Wadia Analysis -c Maternity Hospital, Bombay, be- Table I shows that incidence of in- tween 1954 and 1959, i.e. 6 years. ternal podalic version has fallen frc1m Internal podalic versions performed · 0.52 o/c in 1933-39 to 0.32 % between in the same hospital between 1933 1954 and 1959. Keetel et al mention and 1939 are also compared when 1% incidence at Iowa City Hospital records were available. Incidentally between 1926 and 1940, whereas the the period of 1933-1939 falls before incidence between 1941 and 1950 the advent of antibiotics. fell to 0.1 % . Krishna Menon quotes The cases are analysed in relation an incidence of 1.2% between 1934 to age, parity, degree of cervical and 1938 and 0.6 % between 1953 dilatation, maternal mortality and and 1957 at Madras Medical College. morbidity and foetal loss. Interest- This shows an overall fall of internal ing cases of internal podalic version podalic versions in most of the cen­ are discussed and criticised when tres. Two hundred cases of internal necessary. podalic version in six years may TABLE I Incidence of lnterna~ Poda~ic Versions (1954-1959) 6 years) Total Internal pod. ver. Forceps Caesarean Year confine- ments No. % No. % No. % 1954 8,872 25 0.28 104 1.17 97 1.09 1955 8,970 33 0.36 121 1.34 103 1.14 1956 8,323 43 0.51 191 2.28 138 1.65 1957 9,363 19 0.20 128 1.36 155 1.65 1958 10,264 39 0.38 156 1.52 174 1.59 1959 9,839 44 0.44 170 1.74 193 1.96 Mean 0.52 1.34 1.31 TABLE I-A Incidence of Interna~ Podalic Versions (1934-1939, 6 years) Total Internal pod. ver. Forceps Caesarean Year confine- ments No. % No. % No. % 1934 4,653 31 0.68 39· 0.83 21 0.45 1935 4,654 18 0.38 60 1.28 26 0.55 1936 4,728 28 0.59 49 1.03 25 0.52 1937 5,o70 17 0.35 88 1.73 21 0.41 1938 5,163 18 0.34 81 1.56 27 0.52 1939 5,211 17 0.32 62 1.18 25 0.47 Mean 0.44 1.26 0.49 TABLE I-A appear a very high figure to some. Booked cases 85 It must be explained that Nowrosjee Emergency cases 115 Wadia Maternity Hospital is situated in a labour area and unregistered and Total cases 200 neglected cases from out of the way -- -·-----··~ I 4()6 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA places are admitted in fair number TABLE IV when the foetal heart sounds have Duration of Gestation at the disappeared and there is an abnormal Time of Labour lie, mostly a transverse lie. Table I 28 weeks .. 34 cases also draws attention to the rising in­ 36 weeks . 31 cases cidence of caesarean section. Fuil-term 135 cases Table II analyses the internal Total 200 cases podalic versions in relation to age TABLE II Incidence of Internal Podalic Versions in relation to Age and Parity ----- Age in Para years Total I II III-V VI-IX X+ -- ----- ------ Upto 20 16 16 4 36 21 - 25 5 21 39 5 70 26 - 30 1 4 36 19 60 31 - 35 1 10 16 2 29 36 + 2 2 1 5 ----- Total 22 42 91 42 3 200 ---- and parity. Majority of the versions Table IV shows the duration of have been performed between the gestation. One-third of these cases age group of 20-30 years and parity were premature. Abnormal lie is a between III and V. common occurrence in the earlier weeks of gestation. It is possible TABLE Ill Presentations that these 65 cases may not have a transverse lie if they had gone to full Vertex 18 cases term. Transverse 181 cases TABLE V Thoracopagus 1 case Associated Obstetrical Complications Total 2()0 cases Hand prolapse 95 cases Cord prolapse alone 13 cases Table III mentions the presenting Hand + cord prolapse 39 cases part at the time of admission. It is Compound presentation 6 cases a common experience that correct Placenta praevia 18 cases diagnosis of presentation is difficult Toxaemia of pregnancy 4 cases especially when patient is get­ Accidental haemorrhage 2 cases ting strong pains or has come late in labour. Keetel et al mention in their analysis that presentation was Table V summarises the associated wrongly diagnosed in 70 % of their obstetrical complications. cases. There were 22 cases of twin Table VI enumerates the obstetric pregnancy. manouvres unsuccessfully tried be- PLACE OF INTERNAL PODALIC VERSION IN MODERN OBSTETRICS 407 TABLE VI proportion at the brim; craniotomy Obstetrical Manoeuvres Unsuccessfully was performed. As there was no Tried before Internal Podalic Version progress for 3 hours after perfora­ ----------·-----· tion; base of the skull was crushed External version . 31 cases -with crimioclast. In spite of the Replacement of cord loops 4 cases crushing of the base of the skull the Craniotomy and cephalo- baby did not deliver, possibly be­ tripsy 1 case cause crushing was not properly Craniotomy alone 1 case done. So internal podalic version Rotation of face with Leffs' was performed with some difficulty forceps 1 case and a male baby, stillborn weighing Manual rotation of head . 1 case 8 lbs., was delivered. Self-retaining Willet's forceps 1 case catheter was kept for 72 hours. Internal podalic version tried Patient developed a vesico-vaginal by general practitioner fistula on the · 5th day. The fistula outside . 1 case was repaired after 6 months and she Replacement of prolapsed arm delivered a full-term baby by caesa­ failed outside 1 case rean section 2 years later. In two cases the rotation of the head was successful but during the fore internal podalic version was at­ _rota,tion the head receded and be­ tempted. External version was tried came absolutely floating. It in 31 cases and failed. This does not was mean that external version always thought that high forceps will be dangerous so internal podalic version failed at this hospital. The cases where external version succeeded was carried out. The baby on whom Leff's forceps rotation was done was may have delivered normally and so still-born whereas the baby on whom no record of success of external manual rotation was done was living version may be available. and well. Craniotomy was performed on one Table VII summarises the outcome case. It was a case of compound of the foetus in relation to dilatation presentation (head + hand) with of cervix and duration of gestation. absent foetal heart sounds and three­ It is seen that internal podalic version fourths dilated cervix. The head was resorted to earlier when babies could not be delivered even after were premature than when the babi8s craniotomy. So internal podalic were full-term. Moreover premature version was performed and a female babies were mostly extracted soon baby, weight 5 lb. 2 oz., was extract­ after version, whereas in full-term ed. babies only the leg was pulled out Craniotomy and cephalotripsy and kept under traction till cervix were performed on one case. She dilated fully.
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