I had read with interest about inversion of the uterus in obstetric practice. Though I did not get to see one as a resident doctor, I had read all about it from every book and journal available. When I became head of my unit, the Registrar called me at midnight once and reported a case of acute inversion of the uterus. Since it has to be corrected by the person available on the spot, I asked him to correct it. He was very happy he got to do it, because he had expected I would go to the hospital to do it myself. He did not realize it had nothing to do with my personal happiness but with appropriate treatment of the patient. We did not get any inversion of the uterus in my unit in the next twenty three years. Though as an academician it was my wish to see one sometime, I could not wish that on any patient.
It came as a bolt from the blue when I least expected it. I was assisting my Registrar during a cesarean section on a patient with two previous cesarean sections. She separated the bladder from the lower segment properly, incised the lower segment and delivered the baby. While I lost visual contact with the operative field and her operating hands momentarily placing the baby in the baby tray, she planted her right foot on the ground firmly, grabbed the umbilical cord with the cord clamp, and pulled out the placenta mightily. When I turned around to the operative field, there was something I could not comprehend for a moment. She was holding the clamp and the cord, the placenta was hanging down at the lower end of the cord, and there was no uterus.
“Where is the uterus?” I asked her.
“It is in this only” she said, indicating the placental mass with her chin.
I looked carefully and realized I was looking at an acutely inverted uterus that I had always wanted to see but had hoped I would never have to see. The uterus lay under membranes which spread out from the edge of the placenta covering the endometrial surface of the inverted uterus. I have shown it diagrammatically below.
There was no time to think. I placed the fingers of both hands on the placenta and corrected the uterine inversion. Then I asked the anesthetists if the patient's blood pressure had fallen. It had not. Then I turned my attention to the surrounding structures and found that the urinary bladder had torn where it had been adherent to the lower segment above the place of the incision. I repaired it satisfactorily. After the patient was wheeled to the postoperative ward I asked the resident why she had pulled on the cord before the placenta had separated. She either did not have answer or she would not answer the question. The patient made an uneventful recovery. But that is beside the point. I was given a learning opportunity by my resident, but I cannot be grateful to her for that. The bottomline is that the nightmare called my Registrar continued to remain where it was, to do whatever it chose to do unless we were nearby to stop it.
Friday, May 14, 2010
Nightmares in Obstetrics Gynecology: 2
I had read with interest about inversion of the uterus in obstetric practice. Though I did not get to see one as a resident doctor, I had read all about it from every book and journal available. When I became head of my unit, the Registrar called me at midnight once and reported a case of acute inversion of the uterus. Since it has to be corrected by the person available on the spot, I asked him to correct it. He was very happy he got to do it, because he had expected I would go to the hospital to do it myself. He did not realize it had nothing to do with my personal happiness but with appropriate treatment of the patient. We did not get any inversion of the uterus in my unit in the next twenty three years. Though as an academician it was my wish to see one sometime, I could not wish that on any patient.
It came as a bolt from the blue when I least expected it. I was assisting my Registrar during a cesarean section on a patient with two previous cesarean sections. She separated the bladder from the lower segment properly, incised the lower segment and delivered the baby. While I lost visual contact with the operative field and her operating hands momentarily placing the baby in the baby tray, she planted her right foot on the ground firmly, grabbed the umbilical cord with the cord clamp, and pulled out the placenta mightily. When I turned around to the operative field, there was something I could not comprehend for a moment. She was holding the clamp and the cord, the placenta was hanging down at the lower end of the cord, and there was no uterus.
“Where is the uterus?” I asked her.
“It is in this only” she said, indicating the placental mass with her chin.
I looked carefully and realized I was looking at an acutely inverted uterus that I had always wanted to see but had hoped I would never have to see. The uterus lay under membranes which spread out from the edge of the placenta covering the endometrial surface of the inverted uterus. I have shown it diagrammatically below.
There was no time to think. I placed the fingers of both hands on the placenta and corrected the uterine inversion. Then I asked the anesthetists if the patient's blood pressure had fallen. It had not. Then I turned my attention to the surrounding structures and found that the urinary bladder had torn where it had been adherent to the lower segment above the place of the incision. I repaired it satisfactorily. After the patient was wheeled to the postoperative ward I asked the resident why she had pulled on the cord before the placenta had separated. She either did not have answer or she would not answer the question. The patient made an uneventful recovery. But that is beside the point. I was given a learning opportunity by my resident, but I cannot be grateful to her for that. The bottomline is that the nightmare called my Registrar continued to remain where it was, to do whatever it chose to do unless we were nearby to stop it.
