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An intrauterine separation of fetal scalp
POSNER:
IN'rRAU'l'ERINE SEPARATION OF FE'l'AL SCALP
705
Contraindications.-1. It should not be used when the head is partially engageu unless it is possible to disengage the head and bring its lower portion to the lower angle of the uterine incision. In prolonged labors where marked caput succedaneum has been formed, it should not be employed. 'fhe reasons for this are that in sueh case,.,, the blade cannot he inst>riPd between the lower part of the head and the uterus. 2. It should not b"l employed when the bladder attachment is so high that the uterine incision cannot be made owr tho head unless the bladdrr can be well dis· secteu off. Other technique must be employed in extracting the fetus in these conditions. Teclmique.-1. The patient l'he>uld he in the Trendelenlmrg position aml the head should he vushed well above the pelvic brim. 'fhe same JJreeautiuns aml (oare arc observed as in any low eeHare:m Kedion us far as the expo~uro of tlw lower uterine segment and suctioning off the spill. However no pituitrin or pitocin should be injected until after the posterior or main hhl(lP has heen inserted in place. ~. 'fhe lower angle or portion of the uterine incision (be it longitudinal, trans· verEe semilunar, or 'f-shaped) should be near the lower pole of the head at about the level of the parietal prominence. 1002
TAFT AVENUE
AN INTRAUTERINE SEPARATION OF FETAL SCALP A. CHARLES PosNER, M.D., F.A.C.S., NEw YoRK, N.Y. (From the Obstetrical Service of the Harlem Hospital)
MRS. E. A., aged twenty-four years, a eolored hospital maid, was first1932.admitted Her
to the Obstetrical Service of the Harlem Hospital on April 23, previous history was negative except for one stillbirth and one miscarriage. Her last menstrual period took place on Sept. 8, 1931. The patient stated that the membranes had ruptured shortly before admission and that labor pains were occurring at intervals of thirty minutes. The cervix admitted one finger, membranes being intact, felt between examining finger and presenting part. The fetal heart was heard in the left lower quadrant; the rate was 130. Fetal movements were felt. As the pains eeased and the patient wished to return home, she was discharged on April 27 with a diagnosis of false labor and was referred to the Antepartum Clinic for further observation. The patient was readmitted to the Hospital on May 2; Rhe eomplained of more frequent labor pains and of the passage of bloody fluid, hut no clots, from the vagina. There was no history of trauma, headache, vomiting, chills, or fever. On examination, the cervix admitted one finger. The uterus was the size of a seven months' pregnancy. The fetus was presenting as a vertex in the right occipito· anterior position; the fetal heart could not be heard. The patient's temperature and pulse were normal; her general condition was considered good. Blood Wassermann and Kahn tests were both negative. Vaginal smear showed many gonococci. On May 4, eleven days after the first admission, a hair-covered piece of fetal scalp about 7 em. in diameter passed through the vagina. Sharp spicules of bone could be felt within the cervix, which at that time admitted four fingers. With the patient under ether anesthesia, an attempt was made to remove the fetus by
706
AMERICAN ,JOURNAL OJ<' OBS'l'ETRICS AND GYNECOLOGY
craniotomy. This failed, however, because several pieces of the fetal skull became detached, and it was impossible to grasp, ~ruRh, and deliver the entire head through the partly dilated cervix. The cervix was dilatecl manually, and the macerated fetuH, weighing 4 pounds and 2 ounces, waH delivered by vNsion and breech cxtradion. This form of delivery, while contraindimtted by the pre~enee of infection, wa~ nL sorted to because it was the one only other possible way ,,f delivering this patient expeditiouRly. Frank, greeniHh yellow pus was present on the amniotic surfa<·e of the membranes, but not in the uterine cavity. Nonhemolytic streptoeocei aml staphylococci were obtained on culture of this pus. 'rhe patient made an uneventful recovery and was d.isPharged on May 17, 1P:i:!. This case is reported for three reasons: First, be(•au~e we have not been a hie to find any case of spontaneous intrauterine separation of the fetal ~r.alp rrporte
EM!T 901'H STREET
STRANGULATION OF THE FALLOPIAN TUBE H.
E.
BowLEs,
M.D.,
HoNOLULU, HAWAII
(From the Queen's Hospital)
T
HE patient was operated upon by us under the mistaken diagnosis of a probable gangrenous or ruptured appendix:
M. M., an unmarried schoolgirl, aged sixteen, Hawaiian-Caucasian, was admitted as an acute emergency to Queen's Hospital, at 9:30 the evening of April 24, 1936. Chief complaints were nausea, vomiting, and right lower abdominal pain. Marked eonstipation was present and there was a heavy feeling over the entire lower abdomen for two days before admission. At about this time, a normal menstrual period began. Seven and a half hour~ before admission the patient had eaten a meal of chop suey. Two hours and thirty minutE>ft after thRt, Hhe had attacks of eramplike pain around the umbilicus. She vomited almost simultaneouBly, first the recently ingested food, then greenish ftuid. Nausea ami vomiting then gave way to retching which continued until the time of admission, at which time the patient raised only small amounts of red-streaked mucus. Three or four Bemiliquia stools were passed shortly after the onset of the pain. These were believed to be due to a proprietary cathartic which the patient had taken earlier in the day. There is nothing of note in the patient's past history except that she waR kept under observation for two or three days just a year previously for a suspected subacute appendicitis. A dull nagging ache and constipation were present and cleared up promptly under small repeated doses of caroids and bile salts. The blood count was normal at that time. Menses commenced at thirteen and have been regular with a minimum of discomfort. Tonsils were taken out under local anesthesia two weeks before the present illness. Convalescence was uneventful. The patient is one of 10 healthy children, and her parents are living and well. Positive physical findings were as follows: An acutely ill part Hawaiian girl, retching, and complaining of severe pain in the right lower abdomen. Temp. 99.6° F.
IN'rRAU'l'ERINE SEPARATION OF FE'l'AL SCALP
705
Contraindications.-1. It should not be used when the head is partially engageu unless it is possible to disengage the head and bring its lower portion to the lower angle of the uterine incision. In prolonged labors where marked caput succedaneum has been formed, it should not be employed. 'fhe reasons for this are that in sueh case,.,, the blade cannot he inst>riPd between the lower part of the head and the uterus. 2. It should not b"l employed when the bladder attachment is so high that the uterine incision cannot be made owr tho head unless the bladdrr can be well dis· secteu off. Other technique must be employed in extracting the fetus in these conditions. Teclmique.-1. The patient l'he>uld he in the Trendelenlmrg position aml the head should he vushed well above the pelvic brim. 'fhe same JJreeautiuns aml (oare arc observed as in any low eeHare:m Kedion us far as the expo~uro of tlw lower uterine segment and suctioning off the spill. However no pituitrin or pitocin should be injected until after the posterior or main hhl(lP has heen inserted in place. ~. 'fhe lower angle or portion of the uterine incision (be it longitudinal, trans· verEe semilunar, or 'f-shaped) should be near the lower pole of the head at about the level of the parietal prominence. 1002
TAFT AVENUE
AN INTRAUTERINE SEPARATION OF FETAL SCALP A. CHARLES PosNER, M.D., F.A.C.S., NEw YoRK, N.Y. (From the Obstetrical Service of the Harlem Hospital)
MRS. E. A., aged twenty-four years, a eolored hospital maid, was first1932.admitted Her
to the Obstetrical Service of the Harlem Hospital on April 23, previous history was negative except for one stillbirth and one miscarriage. Her last menstrual period took place on Sept. 8, 1931. The patient stated that the membranes had ruptured shortly before admission and that labor pains were occurring at intervals of thirty minutes. The cervix admitted one finger, membranes being intact, felt between examining finger and presenting part. The fetal heart was heard in the left lower quadrant; the rate was 130. Fetal movements were felt. As the pains eeased and the patient wished to return home, she was discharged on April 27 with a diagnosis of false labor and was referred to the Antepartum Clinic for further observation. The patient was readmitted to the Hospital on May 2; Rhe eomplained of more frequent labor pains and of the passage of bloody fluid, hut no clots, from the vagina. There was no history of trauma, headache, vomiting, chills, or fever. On examination, the cervix admitted one finger. The uterus was the size of a seven months' pregnancy. The fetus was presenting as a vertex in the right occipito· anterior position; the fetal heart could not be heard. The patient's temperature and pulse were normal; her general condition was considered good. Blood Wassermann and Kahn tests were both negative. Vaginal smear showed many gonococci. On May 4, eleven days after the first admission, a hair-covered piece of fetal scalp about 7 em. in diameter passed through the vagina. Sharp spicules of bone could be felt within the cervix, which at that time admitted four fingers. With the patient under ether anesthesia, an attempt was made to remove the fetus by
706
AMERICAN ,JOURNAL OJ<' OBS'l'ETRICS AND GYNECOLOGY
craniotomy. This failed, however, because several pieces of the fetal skull became detached, and it was impossible to grasp, ~ruRh, and deliver the entire head through the partly dilated cervix. The cervix was dilatecl manually, and the macerated fetuH, weighing 4 pounds and 2 ounces, waH delivered by vNsion and breech cxtradion. This form of delivery, while contraindimtted by the pre~enee of infection, wa~ nL sorted to because it was the one only other possible way ,,f delivering this patient expeditiouRly. Frank, greeniHh yellow pus was present on the amniotic surfa<·e of the membranes, but not in the uterine cavity. Nonhemolytic streptoeocei aml staphylococci were obtained on culture of this pus. 'rhe patient made an uneventful recovery and was d.isPharged on May 17, 1P:i:!. This case is reported for three reasons: First, be(•au~e we have not been a hie to find any case of spontaneous intrauterine separation of the fetal ~r.alp rrporte
EM!T 901'H STREET
STRANGULATION OF THE FALLOPIAN TUBE H.
E.
BowLEs,
M.D.,
HoNOLULU, HAWAII
(From the Queen's Hospital)
T
HE patient was operated upon by us under the mistaken diagnosis of a probable gangrenous or ruptured appendix:
M. M., an unmarried schoolgirl, aged sixteen, Hawaiian-Caucasian, was admitted as an acute emergency to Queen's Hospital, at 9:30 the evening of April 24, 1936. Chief complaints were nausea, vomiting, and right lower abdominal pain. Marked eonstipation was present and there was a heavy feeling over the entire lower abdomen for two days before admission. At about this time, a normal menstrual period began. Seven and a half hour~ before admission the patient had eaten a meal of chop suey. Two hours and thirty minutE>ft after thRt, Hhe had attacks of eramplike pain around the umbilicus. She vomited almost simultaneouBly, first the recently ingested food, then greenish ftuid. Nausea ami vomiting then gave way to retching which continued until the time of admission, at which time the patient raised only small amounts of red-streaked mucus. Three or four Bemiliquia stools were passed shortly after the onset of the pain. These were believed to be due to a proprietary cathartic which the patient had taken earlier in the day. There is nothing of note in the patient's past history except that she waR kept under observation for two or three days just a year previously for a suspected subacute appendicitis. A dull nagging ache and constipation were present and cleared up promptly under small repeated doses of caroids and bile salts. The blood count was normal at that time. Menses commenced at thirteen and have been regular with a minimum of discomfort. Tonsils were taken out under local anesthesia two weeks before the present illness. Convalescence was uneventful. The patient is one of 10 healthy children, and her parents are living and well. Positive physical findings were as follows: An acutely ill part Hawaiian girl, retching, and complaining of severe pain in the right lower abdomen. Temp. 99.6° F.