COMPARISON OF PATWARDHAN AND PUSH METHOD FOR IMPACTED FETAL HEAD EXTRACTION DURING CAESAREAN SECTION

Reha Rakholia and Geeta Jain. Department of Obs&Gynae, Government Medical College, Haldwani. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 22 February 2019 Final Accepted: 24 March 2019 Published: April 2019 Copy Right, IJAR, 2019,. All rights reserved.


ISSN: 2320-5407
Int. J. Adv. Res. 7(4), 1203-1206 1204 5. Non cephalic presentation 6. Push technique More common technique for deeply impacted head during caesarian section in which fetal head is dislodged by pushing it through vagina Patwardhan technique 1. In case of occipito-anterior and transverse positions with the head deeply impacted in the pelvis, incision is made in the lower uterine segment, shouders are present usually at incision level in deeply engaged head ,the anterior shoulder is delivered out by hooking the arm . 2. With gentle traction on shoulder, the posterior shoulder is also delivered out. 3. Next, the surgeon holds the trunk of baby gently with both thumbs parallel to spine and with fundal pressure given by assistant the buttocks are delivered followed by legs. 4. Now the baby's head which is the only part of the foetus which is still inside the uterus, is gently lifted out of the pelvis by making an arc.

Discussion:-
A prolonged second stage of labour increases the attenuation of lower uterine segment and impaction of foetal head, which gives rise to a thin, easily lacerated lower uterine segment and cervix, which is predisposed to more extensions while delivering foetal head,.Extensions may also occur in cervix and broad ligament, thus increasing incidence of haemorrhage and need for blood transfusions and contributing to maternal morbidity. In our study, extension rate was 18.5% in "Push" and 1.6% in Patwardhan thus demonstrating the safety and efficacy of this technique. Less extensions led to decreased chances of traumatic haemorrhage and thus, they decreased need for blood transfusions. Our study shows the significant difference in need for transfusions between the two methods 1.6%in Patwardhan and 30% in push.
Extension of incision also has long-term implications on the patients' future obstetric care and may be contraindication to allowing subsequent vaginal delivery .The results of our study were similar to those of a study done by Khosla et al 6 . In this study ,no extensions occurred when Patwardhan technique was used.
Our results were also similar to those of the study conducted by Mukhopadhyay et al 7 ., In which they concluded that the extent of uterine incision and lesions to surrounding structures during LSCS is common in obstructed labor, when the hand is forcibly introduced into the pelvis to deliver the head that is struck and blocked in the pelvis, because the inferior uterine segment is edematous and fragile. Patwardhan's first shoulder technique avoids this and should be used more widely. Berhan and Berhan reported that push method was associated with nearly 8 fold increased increase risk of lateral or inferior uterine extensions, higher estimated blood loss, greater need of blood transfusion, and increase in mean operating time as compared to Patwardhan technique.
Mitali Mahapatra 9 , studied advantages of Patwardhan technique over push and pull technique are less injury to bladder and ureter, less traumatic PPH, no extension of scar , decrease neonatal injury and birth asphyxia.
Manju Merina Bara et al. says that the patwardhan technique is superior and quite safe method for delivery of baby in second stage cesarean section and has minimal complication if anticipated and done skillfully.
Pradeep Kumar Sahu et al 10 did Retrospective analysis of all caesarean sections performed in full dilatation of cervix . All the cases were divided into two groups. Group 1 is the Patwardhan technique and group 2 where the 1205 baby was delivered as a cephalic or as a breech. Maternal morbidity in terms of uterine extensions, the need for blood transfusions and neonatal morbidity were compared between the two techniques The review of 79 patients revealed a significantly lower number of uterine extensions, as well as the need for blood transfusions with the Patwardhan technique, which meant a decrease in maternal morbidity. However, there were no differences in neonatal outcomes in both groups.
In the study of Partha Mukhopadhyayh Patwardhan technique of first shoulder release was adopted in 50 cases (study group) and compared to 50 cases (control group) in which this method was not used. RESULTS: The extension of the incision, both transverse and vertical, was observed only in four cases in the study group compared to 19 in the control group. Excessive bleeding due to extension of the incision, bladder lesions, need for hysterectomy and need for blood transfusions were much less in the study group. The perinatal result was almost similar in both.
All the results of these studies were similar to those of our study in terms of maternal morbidity (extension of the uterine incision, laceration of the uterine artery, trauma per hour, blood transfusion) neonatal outcome.

up iscussion2
Results:-During study period 116 patients whose caesarean section was done for 2 nd stage arrest/obstructed labour. Among 116 cases, 54(47%) babies were delivered by push method and 62 (53%) were delivered by Patwardhan technique.Both the Groups were comparable in terms of age and parity of patient. In our study, it was found that majority of the patients were unbooked emergencies Out of 116 cases, 78% of them were from rural areas. Though 22% were from urban, all cases were emergency admissions.Majority patients were referred from primary health centres. Some of the patients werereferred due to late recognition of inherent obstetric complication and some due to complication during the course of labour. 70% of the patients were illiterate and hence their ignorance regarding the standard of health and nutrition and lack of knowledge of antenatal care and hospital delivery contributed largely in not taking medical care.
The above study shows that 78% of patients were from lower-socio economic status. Factors influencing maternal mortality are unbooked cases, extremes of age in reproductive period, high parity& low socio economic status.In the present study most of the babies had birth weight in the range of 2.5-3 kgs. In our study 12% of the neonates required NICU admission. The duration of NICU stay in 60% of the cases was more than 3 days, higher in advanced cases than those who were referred earlier. The fetal salvage was directly related to the degree of obstruction rather than methods of delivery.Baby outcome was almost similar in both the groups.
In our study there were a total of 116 patients whose cesarean section was performed for the second stage / obstructed labor. Among 116 cases, 54 (47%) children were delivered with the push method and 62 (53%) were delivered with the Patwardhan technique. Extensions of the uterine incision were significantly less 1 (1.6%) in the