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Intrapartum rupture of the umbilical cord
780
AMERICAN
.JOTTRXhI,
OF
OHRTETRI(‘S
AND
GYNE:(WI>OGT
incision; a broad H. This perhaps makes tht> dissection slightly Iesr diWeult. Otherwise it makes no material differtancr whctlrcbl O~P nnderminrls a puvkrt aho\{, au11 helow, or makes the two flaps (Fig. 2 I. 4. A six-inch curved Ochsner hemostat is t,hru shoved through the avascular area, from behind forward. ThtiJ hemostat below the ovarian ligament, near the uterus, is then made to pick up the round ligament, and drags it through thr hroad ligament! taking care to prevent undue twisting of the included l,ound ligament. ‘I’hr loo11 iu then caught with two Allis clamps, spread out in fan shape and the* proved;re is rrThe two ligaments :~re thrn sutnred Itr0~1 to loolr peated on the opposite-ligament. Albout c~~u;tl t+msion should into the floor of the denuded posterior wall of the ntclrus. be made on each ligament, so that the uterus may be well aud ~rrnly suspended iu the midpelvis. Sutures are of No. 1 chromic gut so placed as to iu~*lutlt~ onI1 :L part ul’ They the thickness of each ligament and to take :I firm ltitr into thta utcriucb muscle. should not be tied tightly enough ttr strangulates (Fig. :I). 5. The two flaps or pockets ar? then sutured over the emhecldetl round ligaments, preferably with No. 0 rhromic yut. either au interrupted or running suture may he ilsed (Fig. 4).
The advantages: The fanning out. gives a broader sliug or hammock. The selected area of implantat,ion, with t.he broad sling, prevents overhanging or underslinging of t,he fundus as was prone to happen when the old Baldy-Webster met.hod was carried out, depending on the low or high placement of the ligaments. There is ample mobility of the fundus, laterally or forward? but not backward. The security of the implantation is obviously greater. When completed all is well covered and protected. Pregnancy and labor are not interfered with. There is an absence of the forward tug experienced and consciousness of lumps complained of so frequent,ly, following the forward suspensions. When advisable, the above procedure may be supplement.ed by any one of the usual methods of shortening the uterosacral ligaments commonly in use. 215
ARTS Bur~mm
MEDICAL
INTRAPARTUM
RUPTURE
B.
NELSON
SACKETT,
OF THE
M.D., F.A.C.S.,
UMBILICAL NEW
CORD”
YORK,
8’.
Y.
of the umbilical cord has been occasionally reported, usually in the UPTURE form of a complete separation at the navel, placenta, or in the intervening portion, usually resulting in the death of the fetus. Absolute or relative shortening of the cord, precipitate labor, cord tumrlrs and varices, autl operative trauma are the most frequent causes. Ineomplete rupture or bursting of the cord is a rare complication, which in the ease to be reported, led to distressing compIications in the delivery.
R
case Report.--Mrs. 1933. The first *Presented
to
M. B., aged thirty-seven, confinement in 1918, after the
Nem
York
Obstetrical
an
Society.
gravida iii! eleven-hour November
due
NM
labor, 14.
1933.
ou Feb. 24, resulted in a
SACKETT
:
IKTRAPARTUM
RUPTURE
OF
ITI/I131LIC:AI~
(‘ORD
781
difficult forceps delivery of a 9 pound, 10 ounce boy. The cervix and perineum were badly torn, and the patient had severe bladder trouble for a ~onsiderahlc period of time. The second labor in 1919, resulted in a forceps delivery of a 7 pound, 4 ounce boy, with a recurrence of inability to void urine. Physical examination revealed a short, stocky woman with a male habitus. The pelvis gave the impression of being fairly large but funnel-shapcltl. Tht> pelvic floor showed a healed laceration, and the rcrvis was high, postcrillr, n11(1 deeply scarred by a healed stellate laceration. After a normal pregnancy the patient spontaneously ruptured the membranes and began labor at 7:30 A.M., Feb. 10, 1933, and entered the Woman’s Hospital. Examination at 10 A.M. revealed the cervix two and one-half to three fingers dilated, the canal approximately 2 cm. long, the consistency alternately soft or lough due to scar tissue. The head wax floating above the brim in R.O.1’. position, poorly flexed, and elear amniotic fluid was leaking from the uterus. At 2 P.M., after six hours of hard contractions every five to three minutes, lasting for forty to sixty-five seconds, the cervix was found to be four and one-half fingers dilated, with a tough, thick rim surrounding the head which now dipped into the brim but was not engaged. The fetal heart, which had previously varird between 130 and 144, now dropped to 80 with each pain, anI1 later to 70, but recovered after the pains. At P:40 P.M. the nurse reported the fetal heart “very slow,” and this was confirmed with the patient under an anesthetic by a steady rate of 80. At operation the fetal head was found to ha\-e rotated from K.O.P. to R.O.A. position; it was partly flexed, and the vertex was 0.5 (!m. hclow the line adjoining the ischial spines. There was very little caput. ant1 no moulding. The cervix was fully dilated but not fully effaced and the frnestrated forceps blades were successfully applied betwern it and the head. AS thrrr was no advancement with two firm trac:tions, and as the uterus hall relaxed un~ler pther, the forceps was discarded and preparations made for version. On rntvriug the uterus the hand encountered two loops of cord around the baby’s neck, ant1 at the same time a short loop of cord prolapsed to the vulva an(i was seen to be bleeding actively. Podalic version was completed with some tlifficulty, owing to the scarcity of amniotic fluid, but the breech cxtracti~~n involved little difficulty with the after-coming head. During all this operation blood was spurting in a jet from the prolapsed cord; and the bahy breathed twice in utero and ‘1 third time while the head was still in the vagina. The placenta was removed manually; and the entire birth canal examined digitally and packed with io(loform gauze. The patient had no inordinate degree of shock, and esrcpt for a colon bacillus cystitis and the usual inability to void, made an unrvcntful rocovery, the temperature falling to normal on the sixth day. The 7 pound, 6+” ounce female child, in spite of losing considerable biood. breathed spontaneously; but was immediately given a subcutaneous injection of 30 C.C. of whole blood from the mother. Superficial abrasions over the jaw angles healed without scarring, no signs of anemia or cerebral irritation developetl: and the child is developing normally at nine months. The unusually harh caranium had very prominent parietal bosses and almost no moulding; the hiparictal diameter was 10 cm., the suboccipitobregmatie 10 cm., and the bizygomatic* 9.5 em. The cord stump presented a dark ret? mottlc,cl surface tlue to suhamnitrti~~ infiltration. The cord measured 96 cm. in length and was sharply divided into two portions. The placental portion measured 56 cm. long by 0.8 cm. in diameter, and had the usual narrow, pale appearance. The fetal portion was 40 cm. long, with a diameter varying from 1.5 to 2 cm., and distinguished bv the extreme tortuosity and varieosity of its blood vessels, and by massive subamniotic hemor-
The plac*cnta prcscntcrl three hmall sucecnturiatc lobes on Ihe $urfaee t)f the iranion? which latter rises 5 cm. hoforo joining the cord. Otherwise the placenta snd mcmhranes are normal. Discussion.-In the face of such an alarming hemorrhage frum the umbilical tord, with a mild dcgrcc of dispropllrtion hetw-cen the fctu.3 and the bony pelvis, lnd with a uterus inc~~mplctely reiaxe& i(eIivcrv involvetl a disagreeable choice of alternatives. It was tempting to tie thv corrl to stop the loss of blood from t,he baby, hut t.his involvtd that danger of the baby breathing before vcarsion snd extraction could be accompIiah~:d. The second altcrnatirc> of allowing the :~ord to bleed was chosen, and horc thtl neccxssity for speerl was associated with the danger of rupturing the utthrur. -4 third alternatix-e, ccsarcan section, had earlier been rejected in view of the previous obstetric history. Although it, is impossihlc to eliminate the forcqs blade as the (pause of the injury to the cord, (1 study of the specimen points l,sther to spontaneous rupture due to relative Aortening of the cord coiled tn i1.r~ ::rounh the neck, and its curnpression between the head and the pelrix. with l~onsrqucnt distention, hyprremia, friability, and varicosity of the distal half of thl~ rar~rd. and rupture at the weakest point. 120 EAST
SEVEXTY-FIFTH
STINRT
~~~HORIO~EPITHELIOb~A. FOLLOWED RALPH
M.
REACH,
TREATED WITH RY HYSTERECTOMY* M.D.,
F.A.C.S.,
BR~OKLYX,
RADIUM
K,
P.
,
RS. J. R. was first seen by me in January, 1929. She was nineteen years old at that time and was rurrttc,d for an incomplete abortion. One year later, January, 1930, I delivered her at the Methodist Maternity of a full-term live baby. &bout two years later, Dec. 7, 1931, she reappeared at the office with the history of )eing about two months’ pregnant. and having stained for the past two weeks. This Ipotting had been increasing in amount and I~ad on two occasions come in distinct ;ushes. The uterus at this time was distinctly larger than normal? soft and boggy. ,4 liagnosis of inevitable abortion was made and she was sent to the hospital on Dee. 16, 1931. Vaginal examination at the time revealed that the cervix was partially open and the bleeding was rather active. Cnder complete asepsis sterile gauze was +ssed into the uterus and t,he cervix and upper vagina were tightly packed. The Following day the uterus was emptied of an hydatid mole. She ran a normal :ourse in the hospital and was discharged on the eighth day postaborta1. Three days later she returned to the hospital with fairly active bleeding and a liagnostic curettage was performed. While the eurettings at this time were sugTestive, a positive diagnosis of chorioncpithelioma was not made, and it was decided ;o await further developments.
M
*Presented
at
a meeting
of
the
Krwoklyn
Gynecological
Society,
October
6.
1923.
AMERICAN
.JOTTRXhI,
OF
OHRTETRI(‘S
AND
GYNE:(WI>OGT
incision; a broad H. This perhaps makes tht> dissection slightly Iesr diWeult. Otherwise it makes no material differtancr whctlrcbl O~P nnderminrls a puvkrt aho\{, au11 helow, or makes the two flaps (Fig. 2 I. 4. A six-inch curved Ochsner hemostat is t,hru shoved through the avascular area, from behind forward. ThtiJ hemostat below the ovarian ligament, near the uterus, is then made to pick up the round ligament, and drags it through thr hroad ligament! taking care to prevent undue twisting of the included l,ound ligament. ‘I’hr loo11 iu then caught with two Allis clamps, spread out in fan shape and the* proved;re is rrThe two ligaments :~re thrn sutnred Itr0~1 to loolr peated on the opposite-ligament. Albout c~~u;tl t+msion should into the floor of the denuded posterior wall of the ntclrus. be made on each ligament, so that the uterus may be well aud ~rrnly suspended iu the midpelvis. Sutures are of No. 1 chromic gut so placed as to iu~*lutlt~ onI1 :L part ul’ They the thickness of each ligament and to take :I firm ltitr into thta utcriucb muscle. should not be tied tightly enough ttr strangulates (Fig. :I). 5. The two flaps or pockets ar? then sutured over the emhecldetl round ligaments, preferably with No. 0 rhromic yut. either au interrupted or running suture may he ilsed (Fig. 4).
The advantages: The fanning out. gives a broader sliug or hammock. The selected area of implantat,ion, with t.he broad sling, prevents overhanging or underslinging of t,he fundus as was prone to happen when the old Baldy-Webster met.hod was carried out, depending on the low or high placement of the ligaments. There is ample mobility of the fundus, laterally or forward? but not backward. The security of the implantation is obviously greater. When completed all is well covered and protected. Pregnancy and labor are not interfered with. There is an absence of the forward tug experienced and consciousness of lumps complained of so frequent,ly, following the forward suspensions. When advisable, the above procedure may be supplement.ed by any one of the usual methods of shortening the uterosacral ligaments commonly in use. 215
ARTS Bur~mm
MEDICAL
INTRAPARTUM
RUPTURE
B.
NELSON
SACKETT,
OF THE
M.D., F.A.C.S.,
UMBILICAL NEW
CORD”
YORK,
8’.
Y.
of the umbilical cord has been occasionally reported, usually in the UPTURE form of a complete separation at the navel, placenta, or in the intervening portion, usually resulting in the death of the fetus. Absolute or relative shortening of the cord, precipitate labor, cord tumrlrs and varices, autl operative trauma are the most frequent causes. Ineomplete rupture or bursting of the cord is a rare complication, which in the ease to be reported, led to distressing compIications in the delivery.
R
case Report.--Mrs. 1933. The first *Presented
to
M. B., aged thirty-seven, confinement in 1918, after the
Nem
York
Obstetrical
an
Society.
gravida iii! eleven-hour November
due
NM
labor, 14.
1933.
ou Feb. 24, resulted in a
SACKETT
:
IKTRAPARTUM
RUPTURE
OF
ITI/I131LIC:AI~
(‘ORD
781
difficult forceps delivery of a 9 pound, 10 ounce boy. The cervix and perineum were badly torn, and the patient had severe bladder trouble for a ~onsiderahlc period of time. The second labor in 1919, resulted in a forceps delivery of a 7 pound, 4 ounce boy, with a recurrence of inability to void urine. Physical examination revealed a short, stocky woman with a male habitus. The pelvis gave the impression of being fairly large but funnel-shapcltl. Tht> pelvic floor showed a healed laceration, and the rcrvis was high, postcrillr, n11(1 deeply scarred by a healed stellate laceration. After a normal pregnancy the patient spontaneously ruptured the membranes and began labor at 7:30 A.M., Feb. 10, 1933, and entered the Woman’s Hospital. Examination at 10 A.M. revealed the cervix two and one-half to three fingers dilated, the canal approximately 2 cm. long, the consistency alternately soft or lough due to scar tissue. The head wax floating above the brim in R.O.1’. position, poorly flexed, and elear amniotic fluid was leaking from the uterus. At 2 P.M., after six hours of hard contractions every five to three minutes, lasting for forty to sixty-five seconds, the cervix was found to be four and one-half fingers dilated, with a tough, thick rim surrounding the head which now dipped into the brim but was not engaged. The fetal heart, which had previously varird between 130 and 144, now dropped to 80 with each pain, anI1 later to 70, but recovered after the pains. At P:40 P.M. the nurse reported the fetal heart “very slow,” and this was confirmed with the patient under an anesthetic by a steady rate of 80. At operation the fetal head was found to ha\-e rotated from K.O.P. to R.O.A. position; it was partly flexed, and the vertex was 0.5 (!m. hclow the line adjoining the ischial spines. There was very little caput. ant1 no moulding. The cervix was fully dilated but not fully effaced and the frnestrated forceps blades were successfully applied betwern it and the head. AS thrrr was no advancement with two firm trac:tions, and as the uterus hall relaxed un~ler pther, the forceps was discarded and preparations made for version. On rntvriug the uterus the hand encountered two loops of cord around the baby’s neck, ant1 at the same time a short loop of cord prolapsed to the vulva an(i was seen to be bleeding actively. Podalic version was completed with some tlifficulty, owing to the scarcity of amniotic fluid, but the breech cxtracti~~n involved little difficulty with the after-coming head. During all this operation blood was spurting in a jet from the prolapsed cord; and the bahy breathed twice in utero and ‘1 third time while the head was still in the vagina. The placenta was removed manually; and the entire birth canal examined digitally and packed with io(loform gauze. The patient had no inordinate degree of shock, and esrcpt for a colon bacillus cystitis and the usual inability to void, made an unrvcntful rocovery, the temperature falling to normal on the sixth day. The 7 pound, 6+” ounce female child, in spite of losing considerable biood. breathed spontaneously; but was immediately given a subcutaneous injection of 30 C.C. of whole blood from the mother. Superficial abrasions over the jaw angles healed without scarring, no signs of anemia or cerebral irritation developetl: and the child is developing normally at nine months. The unusually harh caranium had very prominent parietal bosses and almost no moulding; the hiparictal diameter was 10 cm., the suboccipitobregmatie 10 cm., and the bizygomatic* 9.5 em. The cord stump presented a dark ret? mottlc,cl surface tlue to suhamnitrti~~ infiltration. The cord measured 96 cm. in length and was sharply divided into two portions. The placental portion measured 56 cm. long by 0.8 cm. in diameter, and had the usual narrow, pale appearance. The fetal portion was 40 cm. long, with a diameter varying from 1.5 to 2 cm., and distinguished bv the extreme tortuosity and varieosity of its blood vessels, and by massive subamniotic hemor-
The plac*cnta prcscntcrl three hmall sucecnturiatc lobes on Ihe $urfaee t)f the iranion? which latter rises 5 cm. hoforo joining the cord. Otherwise the placenta snd mcmhranes are normal. Discussion.-In the face of such an alarming hemorrhage frum the umbilical tord, with a mild dcgrcc of dispropllrtion hetw-cen the fctu.3 and the bony pelvis, lnd with a uterus inc~~mplctely reiaxe& i(eIivcrv involvetl a disagreeable choice of alternatives. It was tempting to tie thv corrl to stop the loss of blood from t,he baby, hut t.his involvtd that danger of the baby breathing before vcarsion snd extraction could be accompIiah~:d. The second altcrnatirc> of allowing the :~ord to bleed was chosen, and horc thtl neccxssity for speerl was associated with the danger of rupturing the utthrur. -4 third alternatix-e, ccsarcan section, had earlier been rejected in view of the previous obstetric history. Although it, is impossihlc to eliminate the forcqs blade as the (pause of the injury to the cord, (1 study of the specimen points l,sther to spontaneous rupture due to relative Aortening of the cord coiled tn i1.r~ ::rounh the neck, and its curnpression between the head and the pelrix. with l~onsrqucnt distention, hyprremia, friability, and varicosity of the distal half of thl~ rar~rd. and rupture at the weakest point. 120 EAST
SEVEXTY-FIFTH
STINRT
~~~HORIO~EPITHELIOb~A. FOLLOWED RALPH
M.
REACH,
TREATED WITH RY HYSTERECTOMY* M.D.,
F.A.C.S.,
BR~OKLYX,
RADIUM
K,
P.
,
RS. J. R. was first seen by me in January, 1929. She was nineteen years old at that time and was rurrttc,d for an incomplete abortion. One year later, January, 1930, I delivered her at the Methodist Maternity of a full-term live baby. &bout two years later, Dec. 7, 1931, she reappeared at the office with the history of )eing about two months’ pregnant. and having stained for the past two weeks. This Ipotting had been increasing in amount and I~ad on two occasions come in distinct ;ushes. The uterus at this time was distinctly larger than normal? soft and boggy. ,4 liagnosis of inevitable abortion was made and she was sent to the hospital on Dee. 16, 1931. Vaginal examination at the time revealed that the cervix was partially open and the bleeding was rather active. Cnder complete asepsis sterile gauze was +ssed into the uterus and t,he cervix and upper vagina were tightly packed. The Following day the uterus was emptied of an hydatid mole. She ran a normal :ourse in the hospital and was discharged on the eighth day postaborta1. Three days later she returned to the hospital with fairly active bleeding and a liagnostic curettage was performed. While the eurettings at this time were sugTestive, a positive diagnosis of chorioncpithelioma was not made, and it was decided ;o await further developments.
M
*Presented
at
a meeting
of
the
Krwoklyn
Gynecological
Society,
October
6.
1923.