Omer Cobanoglu ( Dr. Zekai Tahir Burak Maternity Hospital, Ankara, Turkey. )
Kubilay Vicdan ( Dr. Zekai Tahir Burak Maternity Hospital, Ankara, Turkey. )
Muammer Dogan ( Dr. Zekai Tahir Burak Maternity Hospital, Ankara, Turkey. )
Oya Gokmen ( Dr. Zekai Tahir Burak Maternity Hospital, Ankara, Turkey. )
Laparoelytrotomy or abdominal delivery without uterine incision is a rare condition in obstetrics. After prolonged labour when the cervix is completely dilated, vaginal entry may occur incidentally or intentionally1-3. This paper reports such a case seen in our hospital:
A.H., a 33 year old primigravid woman, was at 38 week’s gestation. She had myomectomy two years ago. When she was hospitalized for delivery, it was seen that the cervix was completely dilated. The vertex was at +1 station in the left anterior position. Because of the past myomectomy history and foetal distress we decided to perform a caesarean section. The phannenstiel incision was accomplished to enter the abdomen. The peritoneal cavity was entered. After retraction of the bladder, the vagina over the foetal vertex had a ballooned out, shiny appearance. The vagina was entered through a transverse incision under retracted cervix. The foetal head was taken out from bony pelvis and a 50 cm, 3200 g, male infant was delivered through the vaginal incision. The baby was in a good condition with 7 apgar. The operation area was carefully observed. The vaginal incision was closed in two layers with continued vicryl. The bladder was approximated over the incision. She had 800.000 U of procain penicillin two times a day and 80 mg gentamycin three times a day for five days. After a benign postoperative course, she and the infant were discharged home on the fifth postoperative day. The patient was seen at the time of 6 week postpartum check, the vaginal incision was established well healed, only a minimal scar.
At the time of caesarean section, the choice of uterine incision either vertical or transverse is so important, because there are a large number of opportunities for complications. ASter prolonged labour when the cervix is completely dilated, vaginal entry may occur by accident and it is considered as a complication. When it happens, the ureters and bladder are at higher risk than they would be with a properly placed incision1. There are only a few reports in literature about this subject2,3. Goodlin et al reported that the procedure is known as laparoelytrotomy when vaginal entry is planned2. According to them, there are some necessities to utilize this procedure. The cervix should be completely dilated, elevated and retracted. The foetal vertex should be well into the vagina and the vesiëouterine fold should be freed downward further than in the conventional caesarean section. They also suggested that this procedure has some advantages and disadvantages. The advantages are that the uterus remains intact and that the thin vaginal tissue will have a reduced amount of bleeding. Possible disadvantages of the procedure include the following: The patient must be in the late second stage. There is a risk of infection with the transperitoneal approach to the vagina. It is unknown whether the scarred vagina might rupture or obstruct delivery in future labour. We think this procedure can be used in selected cases as an alternative method to conventional caesarean section, when it is necessary. The vaginal incision sometimes may facilitate delivery of the foetal head in the second stage of labour and prevent foetal and uterine complications.
1. Rogers, RE. Complications at ceaarean section. Obstet, Cynecol. Clin. North Am., 1988; 15: 673-84.
2. Goodlin, R.C., Scotto, J.C., Woods. RE. and Anderson, J.C., Laparoelytrotomy or abdominal deliverywithout uterine incision. Am.J. Obstet. Gynecol., 1982;144:990-1.
3. Isik, Al. and Gulmezoglu, M. Laparoelytrotomy: abdominal delivery without uterine incision. Am.J.Obstet, Gynecol., 1991;165:781.