Rediscovering the lost art of internal podalic version: two case reports

Introduction

The first description of the use of the internal podalic version (IPV) for the management of placenta praevia that we are aware of was by Professor Jacobs in 1784. ¹ It is a procedure of combined internal podalic version with external version, performed through a partially dilated cervix for the management of placenta praevia. As soon as the cervix allows the passage of two fingers, the practitioner inserts his/her fingers through the cervix until one or both lower limbs of the foetus is reached and brought down to the maternal pelvis by steady traction and the delivery is completed by breech traction. During this procedure, the left hand of the practitioner is placed on the maternal abdominal wall in order to make the foetal lower limbs more accessible.

IPV is an obsolete procedure but it was once widely applied. In modern obstetrics it has been replaced by the caesarean section and is now seldom employed. Most obstetricians are not proficient in this art and most have not seen it performed.

However, IPV has been used in carefully selected cases in our hospital by experienced obstetricians. We believe that IPV is the optimal route for the delivery of dead or pre-viable foetuses with placenta praevia in developing countries as performing an unnecessary caesarean section will often lead to a scarred uterus which is a major predisposing factor for uterine rupture in any subsequent pregnancy. ²

Case reports

Discussion

The scar of a caesarean section can lead to uterine rupture during any subsequent labour of mothers who live in rural areas with poor antenatal care and who are unable to reach the large hospital promptly. This is an extremely common phenomenon in developing regions such as sub-Saharan Africa and South Asia. Therefore, unnecessary caesarean sections should be prevented in areas where there are only small rural hospitals with few resources (staff, equipment and training programmes). In this situation, IPV is sometimes the best alternative for abdominal delivery.

In this study, we have reported two cases in which delivery was uneventful after IPV. Each patient had a transverse lie with placenta praevia and a small foetus which was either dead or nonviable. The IPVs were performed by competent and experienced obstetricians. Although the women’s cervixes were partially dilated, the cervical application to the presenting part was loose enough that it did not impede the manipulation. Neither of the patients suffered uterine rupture. This procedure can be performed by well-trained, competent operators without any resulting major complications. The cases should be prudently selected and must meet the following conditions: placenta praevia; a small foetus which is either dead or nonviable; no evidence of obstructed labour; where there is no possibility of excessive intrauterine manipulation; and the patient has been prepared for fluid resuscitation and emergency caesarean section when possible.

In some cases, the labour may fail to progress after IPV and, in these cases, putting a bandage around the feet of the foetus and pulling with a weight (0.5–1 kg) is a feasible option. As the buttocks push the placenta, the bleeding will stop or diminish and dilatation, in a controlled way, is realized. Do not pull or rotate the foetus by brute force as this may tear the not fully dilated cervix or even the body of the uterus causing severe, or even fatal, bleeding.

Not only is IPV an optimal option in delivering a small dead foetus, it is also helpful in the vaginal delivery of the second of a pair of twins. One can never know for certain how the second twin will present after the first one is delivered and IPV is sometimes performed when there is a second twin with a transverse or oblique lie. Under certain circumstances, such as signs of maternal shock due to infection and/or blood loss, IPV can be a good option as it may stop the bleeding quickly by emptying the uterus expeditiously and by avoiding a caesarean section and thus reducing the chance of serious infection. The sooner the delivery is completed the better the prognosis. Moreover, IPV must be done very soon after membrane rupture in order to avoid uterine rupture and foetal death.

The potential maternal complications of IPV are: uterine inversion; postpartum haemorrhage; cervical laceration vaginal perineal trauma; infection; and failure of the procedure. All patients should receive broad-spectrum antibiotics. For those who suffer a failure of the procedure, dilation and extraction should be considered for early foetal death (gestational age less than 24 weeks) as, for late foetal death (more than 24 weeks), a caesarean section is the last resort.

Conclusion

These case reports are rare and should remind obstetricians that the lost arts of IPV and breech traction definitely have a role to play in the delivery of dead or pre-viable foetuses with placenta praevia, especially in developing countries where follow up is unsatisfactory and the foetal prognosis is poor. In experienced hands and selected patients, the procedure is comparatively safe and can avoid unnecessary caesarean section and subsequent uterine rupture.