International Journal of Reproduction, Contraception, Obstetrics and Gynecology

Bansiwal R et al. Int J Reprod Contracept Obstet Gynecol. 2016 May;5(5):1562-1565

www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789

DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20161325
Research Article

Safety of patwardhan technique in deeply engaged head

Reeta Bansiwal*, HP Anand, Meera Jindal

Department of Obstetrics and Gynaecology, VMMC and Safdarjung Hospital, New Dehi, India

Received: 09 March 2016

Revised: 08 April 2016
Accepted: 12 April 2016

*Correspondence:
Dr. Reeta Bansiwal,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Deeply engaged head in second stage caesarean section is not new, every obstetrician must have faced
it and its associated problems many times in their career. Caesarean sections done at full cervical dilatation with
impacted foetal heads are technically difficult as the lower segment is thinned out and oedematous and hence
associated with an increased incidence of maternal and foetal morbidities. The objective of this study was to compare
patwardhan technique with Push and pull technique of delivering deeply impacted head and to assess the safety of
patwardhan technique by correlating them with maternal and fetal outcome.
Methods: It is a retrospective study including all caesarean sections done in second stage at Tertiary care centre, New
Delhi, India in the years from 2011 to 2013. Patients were divided into two groups: group -1 where baby delivered by
Patwardhan technique and group 2 where baby delivered by push or pull technique. Both groups were compared in
terms of maternal outcomes as uterine incision extensions, PPH, blood transfusions and neonatal outcomes in terms of
their weight, APGAR and NICU stay.
Results: There were total 135 patients who underwent caesarean section for obstructed labour during 2011-2013. Out
of 135, 71 babies were delivered by push and pull method and 64 babies got delivered by Patwardhan technique.
There was significant less uterine incision extensions in patwardhan group as compared to push and pull technique
(3.1%, 23.9%: p=0.01). The traumatic PPH and blood transfusion was also significantly high in push and pull method
as compared to patwardhan technique (1.5%, 22.5%: p=0.01). Baby outcome was almost similar in both the groups.
Conclusions: The patwardhan technique needs expertise but is safe and has minimal complications if anticipated and
done skill fully. It is easy to learn and needs to be more widely publicized and utilized.

Keywords: Patwardhan technique, Push and pull technique, Caesarean section, Deeply engaged head

INTRODUCTION Caesarean sections done at full cervical dilatation with

impacted foetal heads are technically difficult as the
Deeply engaged head in second stage caesarean section is lower segment is thinned out and oedematous and hence
not new; every obstetrician must have faced it and its associated with an increased incidence of maternal and
associated problems many times in their career. The foetal morbidities.
incidence of second stage caesarean sections is more in
developing countries, where babies are delivered at home Obstetricians have tried many techniques to deliver the
by traditional birth attendants and where the mothers baby as by pushing the deeply engaged head through
report to hospital late in labour, when the traditional birth vagina (push method), as cephalic by putting the hand in
attendants fail in their endeavours. Second stage lower segment or by pulling the legs of the baby and
caesarean section account for one-fourth of all primary delivering as breech (pull method). All the above said
caesarean sections.1

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 Bansiwal R et al. Int J Reprod Contracept Obstet Gynecol. 2016 May;5(5):1562-1565

manoeuvres have their own maternal and fetal  Now the baby’s head which is the only part of the
complications. foetus which is still inside the uterus, is gently lifted
out of the pelvis by making an arc
Patwardhan technique is a unique technique which was
introduced by Dr. Patwardhan in 1957 to ease the Modified patwardhan technique
delivery of deeply impacted head in second stage
caesarean sections and having less maternal and fetal  In case of occipito-posterior position with the head
morbidities, but still not very popular among deeply impacted in the pelvis, incision is made in the
obstetricians.2 lower uterine segment, shouders are present usually
at incision level in deeply engaged head ,the anterior
Our hospital is a teaching hospital with a vast referral shoulder is delivered out by hooking the arm first by
area and has more than 25,000 deliveries annually. Many hooking the arm followed by delivering the same
women are referred from periphery in advanced stages of side leg
obstructed labour. Sometimes, unfortunately, a few  The other side leg is then delivered gently followed
women even in our hospital do develop features of by same side arm
obstruction while waiting in a long queue for caesarean  Buttocks and the trunk of baby and are delivered by
section due to heavy rush. gently pulling baby legs
 Lastly the baby head is delivered
There are only few studies which actually compared all
the above said techniques to deliver the deeply engaged Points for easy and safe delivery of baby
head in second stage caesarean sections and the maternal
and fetal outcomes. Hence this study was undertaken to  Always give a curvilinear (smiling) incision on lower
compare the patwardhan technique with push and pull uterine segment with concave side up
methods and also to evaluate the safety of patwardhan
 Be gentle and patient throughout the procedure.
technique.
The mothers were also traced on phone to know the
METHODS
present status of the baby in terms of milestones achieved
till date.
This is a retrospective analysis of all caesarean sections
done in second stage at tertiary care centre, New Delhi,
RESULTS
India in the years from 2011 to 2013. The reason for
choosing these years were to evaluate the present status
There were total 135 patients who underwent caesarean
of the babies born to mothers underwent caesarean
section for obstructed labour during 2011-2013. Out of
sections during the above said period. Patients were
135, 71 babies were delivered by push and pull method
divided into two groups: group 1 where baby delivered
and 64 babies got delivered by Patwardhan technique
by patwardhan technique and group 2 where baby
(Figure 1).
delivered by push or pull technique.

Both groups were compared in terms of maternal

outcomes as uterine incision extensions, PPH, blood
transfusions and neonatal outcomes in terms of their
weight, APGAR and NICU stay.

Patwardhan technique

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 Figure 1: Caesarean section for obstructed labour
at incision level in deeply engaged head ,the anterior during 2011-2013.
shoulder is delivered out by hooking the arm first by
hooking the arm. Both the Groups were comparable in terms of age and
parity of patients (Figure 2).
 With gentle traction on this shoulder, the posterior
shoulder is also delivered out Uterine incision extension was more in the push and pull
 Next, the surgeon holds the trunk of baby gently with method when compared to patwardhan technique (3.1%,
both thumbs parallel to spine and with fundal 23.9%: p=0.01) (Table 1). Same was true for the
pressure given by assistant the buttocks are delivered traumatic PPH and blood transfusion which was
followed by legs significantly high in push and pull method as compared

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 Bansiwal R et al. Int J Reprod Contracept Obstet Gynecol. 2016 May;5(5):1562-1565

to patwardhan technique (1.5%, 22.5%: p=0.01 ) Table 3: Correlation of MOD with blood transfusions.
(Table 2, 3).
Mode of delivery Blood transfusion
Patwardhan technique 1 (1.5%) p=.01
Push and pull technique 16 (22.5%)

Baby outcome was almost similar in both the groups

(Figure 3).

Figure 2: Demographic data.

Table 1: Correlation of MOD with uterine incision

extension.

Uterine incision Figure 3: Correlation of MODE with body outcome.

Mode of delivery
extension
Patwardhan technique 2 (3.1%) p=0.01 Out of 135 babies delivered, 4 were IUD and 3 were early
Push and pull technique 17 (23.9%) neonatal death as they had severe birth asphyxia due to
prolonged second stage arrest.
Table 2: Correlation of MOD with traumatic PPH. Only 67 patient’s phone number were present on the case
sheets and of which only 43 could be traced in which 29
Mode of delivery Traumatic PPH delivered by patwardhan technique and rest by push and
Patwardhan technique 1 (1.5%) p=0.01 pull technique and all were doing fine.
Push and pull technique 16 (22.5%)

Table 4: Correlation of MOD with baby outcome.

APGAR APGAR
Mode of delivery Birth weight (Kg)
NICU Stay 1 min 5 min
Patwardhan technique 19 2.8 6 8
p=0.34 p=0.57
Push and pull technique 19 2.9 7 8

DISCUSSION blood transfusions were also low in Patwardhan

technique when compared to Push and Pull technique
Obstructed labor accounts for 9.5% of total maternal (1.5%, 22.5%: p=0.01). Other studies also find the same
deaths in India.3 This high incidence is mainly due to results.4-6 Extension of incision also has long-term
traditional beliefs and practices, neglected obstetric care, implications on the patients’ future obstetric careers and
poor utilization of available health services, and poor it is a contraindication to allowing subsequent vaginal
transport facilities. Caesarean sections done in second delivery.4,7
stage of labour with impacted foetal heads are associated
with increased trauma to lower uterine segment and Post op complications like fever and wound infections
associated structures, as well as, increased haemorrhage were not taken into considerations as they have other
and infections. Our study got 23.9% extensions in the contributing factors also like prolonged leaking,
push and pull group as compared to patwardhan group prolonged labour and less bearing on the mode of
where only 3.1% had extensions which was comparable delivering the baby. There were no differences in the
to other studies of Mahapatra M et al, Mukhopadhyay P neonatal outcomes in both the groups, in our study which
et al and Khosla et al.4-6 As the extensions were less in shows Patwardhan technique not only safe for mother but
patwardhan technique, the traumatic PPH and need for also for the baby. Our study has few limitations also like

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 Bansiwal R et al. Int J Reprod Contracept Obstet Gynecol. 2016 May;5(5):1562-1565

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Cite this article as: Bansiwal R, Anand HP,

Jindal M. Safety of patwardhan technique in
deeply engaged head. Int J Reprod Contracept
Obstet Gynecol 2016;5:1562-5.

International Journal of Reproduction, Contraception, Obstetrics and Gynecology Volume 5 · Issue 5 Page 1565