- Email: [email protected]
The delivery of a quadriplegic patient confined to a respirator
THE
DELIVERY DONALD
(‘Prom
the Depnrtmmt
QQ E.?;ILSSON, of
N.D.,
ROCKVILTX
Gynecology-Obstetrics,
The
CENTRE,
13voo7u’lyrk Hospital,
N.
Y. Brooklyn,
N. I’.)
III? problem of antepartum care and delivery of a. woman who has been a victim of poliomyelitis with resulting quadriplegia is fortunately rarely eneountered but is not necessarily insurmountable. In the present case, although death finally resulted from renal complications of the quadriplegic state, delivery from below had been accomplished. In 1906, Cushnyl established the fact that the automatic rhythmic uterine contractions are myogenic, rather than neurogenic, and that completion of the first stage of labor is possible after severance of all nerves to the uterus. It has been demonstrated that the uterus will contract after division not only of the spinal cord but also of the sympathetic nerve supply to the uterus. Uterine contractions have been noted in poliomyelitis victims and in patients paralyzed as a consequence of tumor of the cord, spondylitis and vertebral fracture.2 After the cervix is fully dilated and the head has descended to a low ha,tion, complete paralysis of all the voluntary muscles with the absence of the socalled secondary forces of labor definitely hinders the progress of the second stage of labor. Paralysis of the bladder and distention of that organ and of an atonic bowel may interfere with the normal third stage of contractions, thus increasing the possibility of hemorrhage at this time. Paralysis and overdistention of the bladder and bowel during pregnancy, with constantly reforming fecal impactions, necessitate frequent cathartics and enemas which may aceentuate the Braxton Hicks contractions, and premat,ure labor may be induced.3 Renal infections are also prone to occur due to the overdistention and incomplete emptying of the bladder. These may be cystitis or ascending infections leading to pyelonephritis. Marked distent,ion of the large intestine caused by fecal impactions ma,y produce pressure on the paralyzed diaphragm and may increase an already serious hypoxia.* In their study, Kleinberg and Horwitz” found roentgenographic evidence of some degree of pelvic asymmetry in 79.21 per cent of 3.01 paralytic women. While the incidence of “deformed pelves” was high, the degree of contraction or flattening noted was generally slight, and only exceptionally was it marked. The following factors were considered in association with pelvic def0rmit.y: (1) the effect, of associated lumbosacral scoliosis, (2) the role of weight-bearing, especially as influenced by the use of external appliances and reconstructive procedures, (3) the shortening of a lower limb, (4) muscle imbalance due especially to paralysis of the pelvifemoral. a.nd pelvispinal muscles, (5) paralysis 1334
Volume Number
65 6
DELIVERY
OF
QUADRIPLEGIC
PATIENT
IN
RESPIRATOR
1335
of muscles below the hip. Th.ey found that .in bedridden patients and, similarly, i:n patients who walked with crutches and bore little or no weight on their legs, the pelves remained large and fairly symmetrical. IrIelms,5 Morrow and Luria,6 McGoogaq7 Peelens and Lewing all seem to be od the opinion that emptying of the uterus should be reserved for cases in which the enlargement of the uterus is sufficient to hamper respiration by encroachment on the paralyzed diaphragm, and in which respiration and lung aeration will be facilitated by delivery. Lewin also advocates this procedure in cases in which there is severe cystitis or other complications. The incidence and types of complications of pregnancy have been noted to be practically the same in the paralytic and nonparalytic woman.2 L. A. was a 29-year-old white housewife. She had quadriplegia which was a sequela of an attack of poliomyelitis in 1949. At that time, she spent six months in a respirator at another hospital. This was followed by rehabilitation therapy until August, 1950, when she left that hospital against advice. During the period of treatment she had been home for brief visits. Her last normal menstrual period had been in March, 1950. Previously she had had two normal pregnancies which ha.d terminated in normal deliveries. The larger baby ‘had weighed 6 pounds, 8% ounces at birth. The patient had no untoward symptoms during the third pregnancy until three weeks prior to her admission to the Meadowbrook Hospital on Sept. 21, 1950. At that time she began to have dyspnea which became progressively more severe. !!Jhe patient was well developed, but poorly nourished and emaciated. She had generalized atrophy and paresis of the musculature of the trunk and all extremities. Mild respiratory distress was present. The temperature was 98.6” F., the pulse rate 80, the respiratory rate 23 per minute, and the blood pressure lZO/SO. The physical examination was not otherwise remarkable. The uterus contained a vertex presentation in the left occiput transverse position which was unengaged. The fundus extended 18 cm. above the s;ymph.ysis pubis. The fetal heartbeat was heard in the left lower quadrant of the abThe red blood cell count was 4.10 per c.mm. and the domen. at a rate of 136 per minute. hemoglobin level was 11.6 Gm. per 100 c.c., or 80 per cent. The urinalysis revealed 5 to 10 red bllood cells and 5 to 7 white cells per high-power field. During the first few hospital days, the patient did well and required a respirator On the eleventh and thirteenth hospital days she passed only during the hours of sleep. grossly bloody urine and had slight tenderness in the flank. A flat film of the abdomen was made on the nineteenth hospital day which showed a single 6month fetus and calcifications to be present in the right lower and left upper abdominal quadrants. An intravenous pyelogram was made on the twenty-first hospital day, but was unsatisfactory because of the difficulty in preparing a quadriplegic patient. However, the film suggested that the calcification in the left upper quadrant was a renal calculus. During the ensuing days, the patient had occasional bouts of hematuria, and became increasingly dependent on the respirator until she was able to remain out of it for only 20 minutes at a time. Attempts were made to accustom the woman to the use of a positive pressure hood, anticipating delivery, but these were met with minimal success because of the patient’s extreme apprehension in the hood. On the evening of the sixty-first hospital day, the patient began to complain of intermittent epigastric and left upper quadrant pain which was not accompanied by observable The pain continued the next day and abdominal distention was prouterine contractions. Cn the sixty-fourth hospital day the abdomen was tympanic, hyperactive bowel gressive. sounds were heard, and dilated loops of small intestine were seen through the thin abdominal wall. Pelvic examination revealed no masses, an unengaged vertex presentation A flat film of the abdomen revealed seatdisplaced to the left, and a long closed cervix. tered distention of both the large and small bowels which was suggestive of a mild ileus,
NILSSO?i but there was no evidence of intestinai obstruction. d Cantor t.ube wari inserted and Wangensteen suctiitn was started. Surgical intervention was believed to be contraindicated, and Kangensteen drainage was continued. Intravenous therapy was emplored to retain electrolytic balance. On the seventieth hospital day the patient passed three formed stools, the iast being hard and about the size of a small orange. Following this, the abdominal distention subsided. After this episode, she followed a more or less uncomplicated course in the respirator with occasional attacks of mild dist,ention of the bowel and occasional faintness. One remarkable episode of severe faintness, cyanosis, and apprehension occurred while she was in the positive pressure hood of the respirator. Subseciuentlp all attempts to use the hood were abandoned. On the evening of the one hundred seventh hospital day the patient went into labor spontaneously. After an uncomplicated first stage of eight hours and thirty minutes and a. second stage of one hour and forty minutes under light Nembutal, Demerol, and scopolamine, she was delivered by low forceps extraction from a right occiput anterior position because of an absence of the secondary forces of labor. A 1 per cent procaine pudendal block anesthesia was administered. Delivery was accomplished by alternately pulling the woman in and out of the respirator on a doll:-, since she was able to remain out of the respirator only about seven minutes at a time. The result was the birth of a living male infant who weighed 5 pounds, 13 ounces, who suhsecluentlp developed bilateral rephalhematomas. An intravenous preparation of Ergotrate was administered with the delivery of the anterior shoulder; the placenta was expressed after a ten-minute third stage. There was a third-degree laceration extending through the rectal sphincter which was repaired. E’ollowing delivery, the patieht was given procaine penicillin, 3(10,000 units twice ~laily, for 14 days as a proph>-lactic measure. She made a dramatic recover?from tbe previous antepartum respiratory distress, so that she was able to remain out of the respirator almost all of the time 1)~’ the sixth postpartum rlay (one hundred thirteenth hospitai day). The laceration healed well, and the uterus involuted without any evidence of endometritis or parametritis. The woman was admitted to the hospital more, and was shorvn to have kidney stones examination. She finallp died in renal failure.
several times by cpstoscopic
during the following y-ear or and retrograde ppelographic
Summary The literature is reviewed, and a case of the management and deliver? from below of a quadriplegic patient, confined to a respirator, is reported. The patient, who had been partially rehabilitated and taught to hreathe by using her diaphragmatic musculature, was seen after the fifth month of gestation, She had begun to have progressive respiratory difficulty, necessitating increasing periods of confinement. in a respiralor. The complications were those of a paralyzed respirator patient, and not those of pregnant-. Conservative management of renal stones with concomitant pyelonephritis was carrietl out. Nonsurgical management of a temporary intestinal obstruction caused br a high fecal impaction was necessary. Labor progressed normally, but delivery was complicated by the absence of the secondary forces of labor, necessitating operative intervention in the second &age. Recovery during the postpartum period, both obstetrically and as to respiratory status, was rapid and remarkable, This while the 1;:. Freeman
case was observed at the Meadowbrook Hospital, author was a resident there, and it is presented Miller, Chairman of the Division of Obstetrics.
East Hempstead. Long with the kind permission
Island, of Dr.
‘Volume Number
65 6
DELIVERY
OF
QUADRIPLEGIC
PATIENT
IN
R,ESPIRATOR
1337
References 1. 3. 3. 4. .5. 6. 7. 8. 9.
Cushny, Arthur R.: J. Physiol. 35: 1, 1906. Kleinberg, S., and Horwitz, T.: Surg., Gynec. & Obst. 72: .58, 1941. Xiller, N. F.: J. Michigan M. Soe. 23: 55, 1924. Strauss, Hyman, and Bluestone, Seymour R.: AM. J. OBST. & GYNEC. 51: 114, 1946. Helms, K., and Willcocks, TV. .J.: M. J. Australia 1: 467, 1941. Morrow, Joseph R., and Luria, Sanford A.: J. A. X. A. 113: 1561, 1939. McGoogan, L. S.: AM. J. OBST. & GYNEC.~~: 215,1932. Petalen, J. W.: J. Michigan M. Sot. 42: 30, 1943. Infantile Paralysis, Philadelphia, 1941, W. B. Saunders Company, pp. Le-win, Philip:
206.2Oi.
DELIVERY DONALD
(‘Prom
the Depnrtmmt
QQ E.?;ILSSON, of
N.D.,
ROCKVILTX
Gynecology-Obstetrics,
The
CENTRE,
13voo7u’lyrk Hospital,
N.
Y. Brooklyn,
N. I’.)
III? problem of antepartum care and delivery of a. woman who has been a victim of poliomyelitis with resulting quadriplegia is fortunately rarely eneountered but is not necessarily insurmountable. In the present case, although death finally resulted from renal complications of the quadriplegic state, delivery from below had been accomplished. In 1906, Cushnyl established the fact that the automatic rhythmic uterine contractions are myogenic, rather than neurogenic, and that completion of the first stage of labor is possible after severance of all nerves to the uterus. It has been demonstrated that the uterus will contract after division not only of the spinal cord but also of the sympathetic nerve supply to the uterus. Uterine contractions have been noted in poliomyelitis victims and in patients paralyzed as a consequence of tumor of the cord, spondylitis and vertebral fracture.2 After the cervix is fully dilated and the head has descended to a low ha,tion, complete paralysis of all the voluntary muscles with the absence of the socalled secondary forces of labor definitely hinders the progress of the second stage of labor. Paralysis of the bladder and distention of that organ and of an atonic bowel may interfere with the normal third stage of contractions, thus increasing the possibility of hemorrhage at this time. Paralysis and overdistention of the bladder and bowel during pregnancy, with constantly reforming fecal impactions, necessitate frequent cathartics and enemas which may aceentuate the Braxton Hicks contractions, and premat,ure labor may be induced.3 Renal infections are also prone to occur due to the overdistention and incomplete emptying of the bladder. These may be cystitis or ascending infections leading to pyelonephritis. Marked distent,ion of the large intestine caused by fecal impactions ma,y produce pressure on the paralyzed diaphragm and may increase an already serious hypoxia.* In their study, Kleinberg and Horwitz” found roentgenographic evidence of some degree of pelvic asymmetry in 79.21 per cent of 3.01 paralytic women. While the incidence of “deformed pelves” was high, the degree of contraction or flattening noted was generally slight, and only exceptionally was it marked. The following factors were considered in association with pelvic def0rmit.y: (1) the effect, of associated lumbosacral scoliosis, (2) the role of weight-bearing, especially as influenced by the use of external appliances and reconstructive procedures, (3) the shortening of a lower limb, (4) muscle imbalance due especially to paralysis of the pelvifemoral. a.nd pelvispinal muscles, (5) paralysis 1334
Volume Number
65 6
DELIVERY
OF
QUADRIPLEGIC
PATIENT
IN
RESPIRATOR
1335
of muscles below the hip. Th.ey found that .in bedridden patients and, similarly, i:n patients who walked with crutches and bore little or no weight on their legs, the pelves remained large and fairly symmetrical. IrIelms,5 Morrow and Luria,6 McGoogaq7 Peelens and Lewing all seem to be od the opinion that emptying of the uterus should be reserved for cases in which the enlargement of the uterus is sufficient to hamper respiration by encroachment on the paralyzed diaphragm, and in which respiration and lung aeration will be facilitated by delivery. Lewin also advocates this procedure in cases in which there is severe cystitis or other complications. The incidence and types of complications of pregnancy have been noted to be practically the same in the paralytic and nonparalytic woman.2 L. A. was a 29-year-old white housewife. She had quadriplegia which was a sequela of an attack of poliomyelitis in 1949. At that time, she spent six months in a respirator at another hospital. This was followed by rehabilitation therapy until August, 1950, when she left that hospital against advice. During the period of treatment she had been home for brief visits. Her last normal menstrual period had been in March, 1950. Previously she had had two normal pregnancies which ha.d terminated in normal deliveries. The larger baby ‘had weighed 6 pounds, 8% ounces at birth. The patient had no untoward symptoms during the third pregnancy until three weeks prior to her admission to the Meadowbrook Hospital on Sept. 21, 1950. At that time she began to have dyspnea which became progressively more severe. !!Jhe patient was well developed, but poorly nourished and emaciated. She had generalized atrophy and paresis of the musculature of the trunk and all extremities. Mild respiratory distress was present. The temperature was 98.6” F., the pulse rate 80, the respiratory rate 23 per minute, and the blood pressure lZO/SO. The physical examination was not otherwise remarkable. The uterus contained a vertex presentation in the left occiput transverse position which was unengaged. The fundus extended 18 cm. above the s;ymph.ysis pubis. The fetal heartbeat was heard in the left lower quadrant of the abThe red blood cell count was 4.10 per c.mm. and the domen. at a rate of 136 per minute. hemoglobin level was 11.6 Gm. per 100 c.c., or 80 per cent. The urinalysis revealed 5 to 10 red bllood cells and 5 to 7 white cells per high-power field. During the first few hospital days, the patient did well and required a respirator On the eleventh and thirteenth hospital days she passed only during the hours of sleep. grossly bloody urine and had slight tenderness in the flank. A flat film of the abdomen was made on the nineteenth hospital day which showed a single 6month fetus and calcifications to be present in the right lower and left upper abdominal quadrants. An intravenous pyelogram was made on the twenty-first hospital day, but was unsatisfactory because of the difficulty in preparing a quadriplegic patient. However, the film suggested that the calcification in the left upper quadrant was a renal calculus. During the ensuing days, the patient had occasional bouts of hematuria, and became increasingly dependent on the respirator until she was able to remain out of it for only 20 minutes at a time. Attempts were made to accustom the woman to the use of a positive pressure hood, anticipating delivery, but these were met with minimal success because of the patient’s extreme apprehension in the hood. On the evening of the sixty-first hospital day, the patient began to complain of intermittent epigastric and left upper quadrant pain which was not accompanied by observable The pain continued the next day and abdominal distention was prouterine contractions. Cn the sixty-fourth hospital day the abdomen was tympanic, hyperactive bowel gressive. sounds were heard, and dilated loops of small intestine were seen through the thin abdominal wall. Pelvic examination revealed no masses, an unengaged vertex presentation A flat film of the abdomen revealed seatdisplaced to the left, and a long closed cervix. tered distention of both the large and small bowels which was suggestive of a mild ileus,
NILSSO?i but there was no evidence of intestinai obstruction. d Cantor t.ube wari inserted and Wangensteen suctiitn was started. Surgical intervention was believed to be contraindicated, and Kangensteen drainage was continued. Intravenous therapy was emplored to retain electrolytic balance. On the seventieth hospital day the patient passed three formed stools, the iast being hard and about the size of a small orange. Following this, the abdominal distention subsided. After this episode, she followed a more or less uncomplicated course in the respirator with occasional attacks of mild dist,ention of the bowel and occasional faintness. One remarkable episode of severe faintness, cyanosis, and apprehension occurred while she was in the positive pressure hood of the respirator. Subseciuentlp all attempts to use the hood were abandoned. On the evening of the one hundred seventh hospital day the patient went into labor spontaneously. After an uncomplicated first stage of eight hours and thirty minutes and a. second stage of one hour and forty minutes under light Nembutal, Demerol, and scopolamine, she was delivered by low forceps extraction from a right occiput anterior position because of an absence of the secondary forces of labor. A 1 per cent procaine pudendal block anesthesia was administered. Delivery was accomplished by alternately pulling the woman in and out of the respirator on a doll:-, since she was able to remain out of the respirator only about seven minutes at a time. The result was the birth of a living male infant who weighed 5 pounds, 13 ounces, who suhsecluentlp developed bilateral rephalhematomas. An intravenous preparation of Ergotrate was administered with the delivery of the anterior shoulder; the placenta was expressed after a ten-minute third stage. There was a third-degree laceration extending through the rectal sphincter which was repaired. E’ollowing delivery, the patieht was given procaine penicillin, 3(10,000 units twice ~laily, for 14 days as a proph>-lactic measure. She made a dramatic recover?from tbe previous antepartum respiratory distress, so that she was able to remain out of the respirator almost all of the time 1)~’ the sixth postpartum rlay (one hundred thirteenth hospitai day). The laceration healed well, and the uterus involuted without any evidence of endometritis or parametritis. The woman was admitted to the hospital more, and was shorvn to have kidney stones examination. She finallp died in renal failure.
several times by cpstoscopic
during the following y-ear or and retrograde ppelographic
Summary The literature is reviewed, and a case of the management and deliver? from below of a quadriplegic patient, confined to a respirator, is reported. The patient, who had been partially rehabilitated and taught to hreathe by using her diaphragmatic musculature, was seen after the fifth month of gestation, She had begun to have progressive respiratory difficulty, necessitating increasing periods of confinement. in a respiralor. The complications were those of a paralyzed respirator patient, and not those of pregnant-. Conservative management of renal stones with concomitant pyelonephritis was carrietl out. Nonsurgical management of a temporary intestinal obstruction caused br a high fecal impaction was necessary. Labor progressed normally, but delivery was complicated by the absence of the secondary forces of labor, necessitating operative intervention in the second &age. Recovery during the postpartum period, both obstetrically and as to respiratory status, was rapid and remarkable, This while the 1;:. Freeman
case was observed at the Meadowbrook Hospital, author was a resident there, and it is presented Miller, Chairman of the Division of Obstetrics.
East Hempstead. Long with the kind permission
Island, of Dr.
‘Volume Number
65 6
DELIVERY
OF
QUADRIPLEGIC
PATIENT
IN
R,ESPIRATOR
1337
References 1. 3. 3. 4. .5. 6. 7. 8. 9.
Cushny, Arthur R.: J. Physiol. 35: 1, 1906. Kleinberg, S., and Horwitz, T.: Surg., Gynec. & Obst. 72: .58, 1941. Xiller, N. F.: J. Michigan M. Soe. 23: 55, 1924. Strauss, Hyman, and Bluestone, Seymour R.: AM. J. OBST. & GYNEC. 51: 114, 1946. Helms, K., and Willcocks, TV. .J.: M. J. Australia 1: 467, 1941. Morrow, Joseph R., and Luria, Sanford A.: J. A. X. A. 113: 1561, 1939. McGoogan, L. S.: AM. J. OBST. & GYNEC.~~: 215,1932. Petalen, J. W.: J. Michigan M. Sot. 42: 30, 1943. Infantile Paralysis, Philadelphia, 1941, W. B. Saunders Company, pp. Le-win, Philip:
206.2Oi.