Saturday, March 23, 2019

Baby’s head separated from torso during delivery at the PHC: The medical possibilities behind such cases

The head of a baby got separated from its torso during delivery at a primary health centre in Koovathur near Chennai, as per a recent report. Doctors said the baby had died in the mother’s womb.

Allegation: Staff nurses at the health care centre ignored her pleas for pain relief medication and went ahead with vaginal delivery. There were no doctors at the PHC. Nurses removed only the baby’s head from the mother’s womb, leaving the torso inside. The woman was then rushed to the Chengalpattu Government Medical College in Kancheepuram for an emergency surgery, where doctors extracted the torso.


·         Delivery was done in an emergency situation.
·         It was an intrauterine death.
·         The baby had to be removed to save the life of a woman.
·         The baby weighed just 1.5 kg; so, they decided that vaginal labour would not be a hazard. But during vaginal delivery the head got separated.

A similar incident has been reported in January this year from Rajasthan, where the delivery of a 24-year-old woman was conducted by the nursing staff at Ramgarh primary health centre (PHC) in Jaisalmer without the presence of a doctor despite her being a high-risk case. The nursing staff pulled out the baby during delivery using force, leaving the baby’s head in the womb.  After the incident, they asked family members to take the woman to Jaisalmer claiming that the opening of the womb had closed and it was difficult to take the umbilical cord out. The woman had to be rushed to Jodhpur in a serious condition. They hid the body of the baby and handed it over only after a police complaint was registered by the family. The family came to know about it after they were informed by the doctors in Jodhpur, who surgically removed the baby’s head. The family reached Ramgarh police station on Wednesday and lodged a case against the two nurses.

What does the published literature say?

·         Blunt trauma to the head and neck of a new-born during delivery process is a rare event. 
A peculiar case of decapitation of a live fetus during vacuum-assisted delivery is mentioned where excessive traction on the head of the full-term macrosomic fetus with shoulder dystocia resulted in overstretching of the neck up to the point of decapitation (Am J Forensic Med Pathol. 2011 Sep;32(3):245-7).

·         An interesting case of complete fetal decapitation with uterine rupture due to a high-velocity motor vehicle collision is described. The external examination of the fetus showed a disconnection between the cervical vertebrae C3 and C4 (Am J Forensic Med Pathol. 2015 Mar;36(1):6-9).

·         In a retrospective observational study, the course of labor was analyzed in 10 stillborn fetuses with a varying grade of maceration during the third trimester. In one case of macerated stillborn fetus, head traction resulted in decapitation, therefore extraction with Braun hooks placed into axillary fossae was done to extract the retained macerated fetal body (Fetal Diagn Ther. 2008;24(1):42-6).

·         Traumatic fetal decapitation has not been mentioned in the medical literature as a known complication of spontaneous abortion. We report an extremely rare and unusual case of traumatic fetal decapitation due to selfdelivery during spontaneous abortion in a 26yearold woman who presented at 15 weeks' gestation with gradually worsening vaginal bleeding and lower abdominal pain and with the fetal head still lying in the uterine cavity. During our search for similar cases, we came across just 1 other case report describing traumatic fetal decapitation after spontaneous abortion, although there are reports of fetal decapitation from amniotic band syndrome, vacuumassisted deliveries, and destructive operations (J Ultrasound Med. 2015 Oct;34(10):1913-4).

·         Congenital malformation may present as spontaneous intrauterine decapitation as has been described in a case report of an acephalic fetus in the Archives of Disease in Childhood.  According to the author, decapitation must occur during the 3rd month of gestation or later and is thought to be due to strangulation by a band of tissue of amniotic or chorionic origin (Arch Dis Child. 1967;42(226):636-41).

·         Ledall et al have also reported subtotal decapitation of a fetus in the course of normal delivery with very peculiar bone dystrophy due to disturbance of intrauterine metabolism of tissue polysaccharides (Bull Fed Soc Gynecol Obstet Lang Fr. 1964 Nov-Dec;16:549-51).

·         Lymphangioma of the axilla as an obstacle to delivery has also been reported (Geburtshilfe Frauenheilkd. 1956 Aug;16(8):706-8).

·         Decapitation can also be therapeutic. Marsden et al reported four cases of impacted transverse lie in late labor as illustrative of clinical situations where decapitation of a dead fetus in a transverse lie is a practical alternative to Caesarean section (Aust N Z J Obstet Gynaecol. 1982 Feb;22(1):46-9).


·         Decapitation of the fetus during delivery is a rare event but can happen. It is a known complication of delivery.
·         Usually seen in intrauterine deaths, premature babies, low birth babies, accidental trauma, excessive force
·         It is negligence, if it is done intentionally or with the knowledge or by an untrained person.
·         It is an accident, when the applied force is misjudged.

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

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