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Laminaria tent for gradual and safe cervical dilatation
Communications
Fig. 1. Case 3369. LDH iso??. Basal plate. (x300.)
Fig. 2. Case 3369. LDH is&. Same time of incubation. Basal plate. “X” cells show strong activity (arrow). (x300.)
REFERENCES
I. Gerebtzoff, M. A.: C. R. Sot. Biol. 160: 1323, 1966. 2. Cahn, R. D., Kaplan, N. O., Levine, L., and Zwilling, E.: Science 136: 962, 1962.
Laminaria tent for gradual safe cervical dilatation YUKIO
MANABE,
Department of Obstetrics Kyoto University School Kyoto, Japan
and
M.D.
and Gynecology, Medicine,
of
in brie?
743
I N T H E E A R L Y and middle stages oi plegnancy, obstetricians often need suficicnt cervical dilatation before performing certain intrairtl:rinc obstetric maneuvers. Hegar dilators c-an atl.ain rapid and direct cervical dilatation to a t.erlain extent. However, this method has limitations, and sometimes more gradual and extensive clil.ltatic)ll is necessary. Laminaria tents have been prcferrcd ior thth purpose of gradual cervical dilataCon for mott’ than 100 years in Germany, Japan, Switzt~rland,~ and elsewhere. Textbooks of obstetrics ii, (;crmany and Japan have devoted several parrc~s for this convenient material. Description of tllis material has appeared in textbooks puttlishecl in Great Britain,’ but American tcssthocrks I~:Iv(. never mentioned it. Laminaria tents arc n~atlr from the root of a seaweed, viz., Lnrnin~~ic~ di‘qitutu. Dried and rounded in a stick-likr sliapt‘, if is 5.5 to 6.0 cm. long and has a diantrtcht- 01 0.3 to 0.5 cm. with strong silk thrrad at on< end. When inserted into the cervix, they qr;ldually swell to several times their original diam~~tc~r ovc.1 12 to 24 hours. This is done by the ai~orp~iou of moisture from the cervix. Sinccs thiv prclcesa is quite gradual, the patient does not sullt~ ftonl pain, and? since if hrromes soft and f1~.~iblc ~II the course of time, the cervix is never d,~tr~agcd during the treatment. When thr tt’ntr :NV rcmoved at the proper time, the remix is Ilot onI) dilated CO scvrral times the preillscrtion clialt>c*ter but it is also markedly softened. This thcqn pel’mits funher direct dilatation by means ot lil:zdl dilators, if necessary. Since mechvnic~al xtinlut;ltion works on the uterus. insertion of t!*llt\ ill the cewis sometimes wokcs weak zltc.titlt’ (YEW tractions, and rarely the undama#cd icitt’ and placenta in the unrupturcd membranc~s ;II t’ spantanrously delivered folltrwirrg rcwcwl r,i the tcmts.
Laminaria trnts arc used for tht. f~,llowiq conditions: ( 1 ) dilatation of thla c,pwis II hich is too narrow and stiff to br dilattd sllliicientl) at one time as sometimes encountcrtd ill young primigravidas rwn in the second and third cr<:tiitionat months /Weeks 5 to 12 j , LL!ntlq.r LI~c-~thcsia and after thorough disinfwtiolt of the vagina, the cervix is very carefully clilar<~d tn .L certain extent. and one or two nw-ow t,.ntd arc insertrd side b)- side. One-step artificial .thtrrtion is performed on the following dav. 2: ISlat+ tion of the wrvix, in cxither primi- 111 multigravidas. in the early fourth gestational month (\Verks 13 and 13‘1. Foliobving cervic~al ri ilaIation
744
Communications
in brief Amer.
A
B
July J. Obstet.
1, 1971 Gynw
c
Fig. 1. A, Laminaria properly inserted in the cervix. B, Laminaria improperly inserted in the cervix. Internal cervical OS stays closed. C, Laminaria pushed too far, causing difficulty at removal. by Hegar dilators up to Nos. 12 to 16, 2 or 3 tents are inserted into the cervix. On the following day, after further dilatation of the cervix by Hegar dilators (No. 20 or more, if necessary), one-step evacuation of the uterine contents is performed. The suction method is not suited for this stage. The placental forceps is carefully utilized with the aid of an oxytocic injection during the operation. (3) Cervical dilatation before application of metreurynter in midpregnancy (Week 14 and onward) for artificial induction of labor. With insertion, care must be taken that the laminaria tents are inserted deep enough so the end just passes beyond the internal cervical OS, while the opposite end remains outside of the cervix a little bit (Fig. 1) . Tent(s) should be placed neither too tightly nor too loosely in order to make removal easier and to avoid their displacement. There are 3 possible drawbacks in the use of laminaria tents, namely: ( 1) infection due to failure to remove them on time, (2) difficulty of removal, and (3) injury of the cervical wall due to initial misplacement of Hegar dilator and later the insertion of tent(s) into this injured tissue. The complication of infection due to leaving them too long in the cervix was occasionally reported before World War I, and this was certainly the main reason why laminaria has be-
come less used, at least in Great Britain. There is, however, no apprehension of this kind in modern days because of the advances in antibiotics and the sterilization techniques used in the preparation of tents. Difficulty in removal of tents is an annoying complication which may be occasionally encountered. This can usually be avoided by using 2 or 3 narrow tents instead of one thick tent. It is customary to pass a sterilized gauze through the loops of the thread, and the corners of the gauze are tied and packed gently in the vagina. This anchors the tents, prevents their displacement, and also helps the removal of the tents. Some obstetricians prefer to cover one or two tents with a square-shaped gauze moistened with disinfectant solution and push them together into the cervical canal, leaving the gauze corners in the vagina. Upon removal of the tents, the gauze is pulled out with the tent(s) inside. To avoid the very rare but possible mistake of placing the tents in the Hegar dilator-perforated cervical wall, care should be taken to dilate the cervix correctly and carefully by Hegar dilators. While the tent(s) are in the cervix it is not always necessary for the patient to remain in the hospital. To leave them longer than 24 hours in the cervix is not only meaningless but merely increases the chance of infection and thus must be avoided. It is advisable to use antibiotics
Communications
~~)phylactically during the treatment. The samt: tents can 1~ used 2 ro 3 times by washing. and storing in dehydrate alcohol. sterilization, f-lowrvel.. cthylcne oxide-sterilized disposable lents arc available and preferred in Japan iI1 t’ecent yearc. Laminaria tents are now favored by physicians in many countrirs, and this techniqur I$ an illdisprnsahtc one used in performing a qrc;rr n~m~ller of therapeutic ahortiona in Japan.
in brie!
745
Due to these facts presented, I would lik(. II.) sthc+ the appraisal of this material hy rhr .InI(‘ricau I)hysicians. REFERENCES
1. Clayton, S. G., et al.: The Queers Charlc*tte’h Text-book of Obstetrics. ed. 10. London. 1960. J. & -4. Churchill, Ltd.,‘p. 380. 2. Watteville, H. de: Proc. Roy. Sot. Mtad. 62: 828. 1969.
Fig. 1. Case 3369. LDH iso??. Basal plate. (x300.)
Fig. 2. Case 3369. LDH is&. Same time of incubation. Basal plate. “X” cells show strong activity (arrow). (x300.)
REFERENCES
I. Gerebtzoff, M. A.: C. R. Sot. Biol. 160: 1323, 1966. 2. Cahn, R. D., Kaplan, N. O., Levine, L., and Zwilling, E.: Science 136: 962, 1962.
Laminaria tent for gradual safe cervical dilatation YUKIO
MANABE,
Department of Obstetrics Kyoto University School Kyoto, Japan
and
M.D.
and Gynecology, Medicine,
of
in brie?
743
I N T H E E A R L Y and middle stages oi plegnancy, obstetricians often need suficicnt cervical dilatation before performing certain intrairtl:rinc obstetric maneuvers. Hegar dilators c-an atl.ain rapid and direct cervical dilatation to a t.erlain extent. However, this method has limitations, and sometimes more gradual and extensive clil.ltatic)ll is necessary. Laminaria tents have been prcferrcd ior thth purpose of gradual cervical dilataCon for mott’ than 100 years in Germany, Japan, Switzt~rland,~ and elsewhere. Textbooks of obstetrics ii, (;crmany and Japan have devoted several parrc~s for this convenient material. Description of tllis material has appeared in textbooks puttlishecl in Great Britain,’ but American tcssthocrks I~:Iv(. never mentioned it. Laminaria tents arc n~atlr from the root of a seaweed, viz., Lnrnin~~ic~ di‘qitutu. Dried and rounded in a stick-likr sliapt‘, if is 5.5 to 6.0 cm. long and has a diantrtcht- 01 0.3 to 0.5 cm. with strong silk thrrad at on< end. When inserted into the cervix, they qr;ldually swell to several times their original diam~~tc~r ovc.1 12 to 24 hours. This is done by the ai~orp~iou of moisture from the cervix. Sinccs thiv prclcesa is quite gradual, the patient does not sullt~ ftonl pain, and? since if hrromes soft and f1~.~iblc ~II the course of time, the cervix is never d,~tr~agcd during the treatment. When thr tt’ntr :NV rcmoved at the proper time, the remix is Ilot onI) dilated CO scvrral times the preillscrtion clialt>c*ter but it is also markedly softened. This thcqn pel’mits funher direct dilatation by means ot lil:zdl dilators, if necessary. Since mechvnic~al xtinlut;ltion works on the uterus. insertion of t!*llt\ ill the cewis sometimes wokcs weak zltc.titlt’ (YEW tractions, and rarely the undama#cd icitt’ and placenta in the unrupturcd membranc~s ;II t’ spantanrously delivered folltrwirrg rcwcwl r,i the tcmts.
Laminaria trnts arc used for tht. f~,llowiq conditions: ( 1 ) dilatation of thla c,pwis II hich is too narrow and stiff to br dilattd sllliicientl) at one time as sometimes encountcrtd ill young primigravidas rwn in the second and third cr<:tiitionat months /Weeks 5 to 12 j , LL!ntlq.r LI~c-~thcsia and after thorough disinfwtiolt of the vagina, the cervix is very carefully clilar<~d tn .L certain extent. and one or two nw-ow t,.ntd arc insertrd side b)- side. One-step artificial .thtrrtion is performed on the following dav. 2: ISlat+ tion of the wrvix, in cxither primi- 111 multigravidas. in the early fourth gestational month (\Verks 13 and 13‘1. Foliobving cervic~al ri ilaIation
744
Communications
in brief Amer.
A
B
July J. Obstet.
1, 1971 Gynw
c
Fig. 1. A, Laminaria properly inserted in the cervix. B, Laminaria improperly inserted in the cervix. Internal cervical OS stays closed. C, Laminaria pushed too far, causing difficulty at removal. by Hegar dilators up to Nos. 12 to 16, 2 or 3 tents are inserted into the cervix. On the following day, after further dilatation of the cervix by Hegar dilators (No. 20 or more, if necessary), one-step evacuation of the uterine contents is performed. The suction method is not suited for this stage. The placental forceps is carefully utilized with the aid of an oxytocic injection during the operation. (3) Cervical dilatation before application of metreurynter in midpregnancy (Week 14 and onward) for artificial induction of labor. With insertion, care must be taken that the laminaria tents are inserted deep enough so the end just passes beyond the internal cervical OS, while the opposite end remains outside of the cervix a little bit (Fig. 1) . Tent(s) should be placed neither too tightly nor too loosely in order to make removal easier and to avoid their displacement. There are 3 possible drawbacks in the use of laminaria tents, namely: ( 1) infection due to failure to remove them on time, (2) difficulty of removal, and (3) injury of the cervical wall due to initial misplacement of Hegar dilator and later the insertion of tent(s) into this injured tissue. The complication of infection due to leaving them too long in the cervix was occasionally reported before World War I, and this was certainly the main reason why laminaria has be-
come less used, at least in Great Britain. There is, however, no apprehension of this kind in modern days because of the advances in antibiotics and the sterilization techniques used in the preparation of tents. Difficulty in removal of tents is an annoying complication which may be occasionally encountered. This can usually be avoided by using 2 or 3 narrow tents instead of one thick tent. It is customary to pass a sterilized gauze through the loops of the thread, and the corners of the gauze are tied and packed gently in the vagina. This anchors the tents, prevents their displacement, and also helps the removal of the tents. Some obstetricians prefer to cover one or two tents with a square-shaped gauze moistened with disinfectant solution and push them together into the cervical canal, leaving the gauze corners in the vagina. Upon removal of the tents, the gauze is pulled out with the tent(s) inside. To avoid the very rare but possible mistake of placing the tents in the Hegar dilator-perforated cervical wall, care should be taken to dilate the cervix correctly and carefully by Hegar dilators. While the tent(s) are in the cervix it is not always necessary for the patient to remain in the hospital. To leave them longer than 24 hours in the cervix is not only meaningless but merely increases the chance of infection and thus must be avoided. It is advisable to use antibiotics
Communications
~~)phylactically during the treatment. The samt: tents can 1~ used 2 ro 3 times by washing. and storing in dehydrate alcohol. sterilization, f-lowrvel.. cthylcne oxide-sterilized disposable lents arc available and preferred in Japan iI1 t’ecent yearc. Laminaria tents are now favored by physicians in many countrirs, and this techniqur I$ an illdisprnsahtc one used in performing a qrc;rr n~m~ller of therapeutic ahortiona in Japan.
in brie!
745
Due to these facts presented, I would lik(. II.) sthc+ the appraisal of this material hy rhr .InI(‘ricau I)hysicians. REFERENCES
1. Clayton, S. G., et al.: The Queers Charlc*tte’h Text-book of Obstetrics. ed. 10. London. 1960. J. & -4. Churchill, Ltd.,‘p. 380. 2. Watteville, H. de: Proc. Roy. Sot. Mtad. 62: 828. 1969.