This is a retrospective analysis of all second stage caesarean sections performed in Govt. Medical College Hospital, Sector-32, Chandigarh, India, in the years from 2004 to 2006. The reason for choosing these years was that Patwardhan technique had started to be practised in 2004, prior to which “Push” and “Pull” method was used for extraction of the foetus. All caesarean sections were performed by third year registrars or consultants. The aim of this study was to compare the Patwardhan technique with “Push” and “Pull” method in terms of maternal and neonatal morbidities.

The cases were divided into two groups; Group 1 was assigned to all cases in which deliveries of babies were done by Patwardhan technique and Group 2 was assigned to patients in whom deliveries of babies were either done by vertex or by breech extractions.

A total of 79 patients underwent second stage Caesarean sections from 2004 to 2006. A total of 35 patients belonged to Group 1 and 44 patients belonged to Group 2.

Both the groups were statistically comparable in terms of periods of gestation, as has been outlined in [Table/Fig-1] below.

Labour characteristics of both the groups, including duration of labour and duration of rupture of membranes, were also found to be statistically comparable, as have been described in [Table/Fig-2].

[Table/Fig-3] outlines the cases of foetal distress, including those with foetal bradycardia and meconium stained liquor.

Foetal distress was present in 51% of cases in-Group 1 and in 47% cases in Group 2, which were statistically similar.

Liquor was meconium stained in 22.9 % of patients in Group 1 and in 29.5% patients in Group 2, which was not statistically significant.

The above table compares the extension of uterine incision in both the groups.

Extension of uterine incision during caesarean section occurred in 10 patients in Group 2 and in none in Group 1. This difference was statistically significant (p=0.002), indicating the superiority of this technique as compared to that of the conventional “Push” and “Pull” method [Table/Fig-4].

Blood transfusions were required in 3 patients in Group 1 as compared to 12 patients in Group 2 and this difference was statistically significant [Table/Fig-5].

Neonatal profiles of both the groups were also assessed. The mean birth weights of the babies in both the groups have been given in [Table/Fig-6].

Birth weights were comparable in both groups.

The Apgar scores of the babies in both the groups, were also compared and they were not statistically significant, as can be seen in [Table/Fig-7].

Need for NICU care has been given in [Table/Fig-8] and it was not found to be statistically significant when both the groups were compared.

Caesarean sections done in second stage of labour with impacted foetal heads, are associated with increased trauma to lower uterine segment and associated structures, as well as, increased haemorrhage and infections [3]. A prolonged second stage of labour increases the attenuation of lower uterine segment and impaction of foetal head, which gives rise to a thin, easily lacerated lower uterine segment and cervix, which is predisposed to more extensions while delivering foetal head [4]. Extensions may also occur in cervix and broad ligament, thus increasing incidence of haemorrhage and need for blood transfusions and contributing to maternal morbidity. The incidence of extension of incision or intraoperative trauma in second stage caesarean sections seen in “Push” and “Pull” method used for extraction of foetus, has been found to be about 15% to 50% in various studies [2–4,8]. In our study, extension rate was 22% in “Push” and “Pull” mode of extraction of foetus. However, no extension was noted while Patwardhan technique was used as method of extraction of foetus, thus demonstrating the safety and efficacy of this technique. Less extensions led to decreased chances of traumatic haemorrhage and thus, they decreased need for blood transfusions. Our study shows the significant difference in need for transfusions between the two methods.

Extension of incision also has long-term implications on the patients’ future obstetric careers and it is a contraindication to allowing subsequent vaginal delivery [4,8]. The results of our study were similar to those of a study done by Khosla et al., [7]. In this study too, no extensions occurred while Patwardhan technique was used.

Our results were also similar to those of the study conducted by Mukhopadhyay et al., in which they concluded that extension of the uterine incision and injury to the surrounding structures during LSCS is common in obstructed labour, when the hand is forcibly introduced into the pelvis to deliver the head which is impacted and jammed in the pelvis, since the lower uterine segment is oedematous and fragile. Patwardhan’s shoulder first technique avoids this and it needs to be employed more widely [9].

There were no differences in the neonatal outcomes in both the groups, in our study. Babies born by second stage caesarean sections have increased incidences of birth asphyxia caused by prolonged second stage labour [8,10,11]. However, our study indicated that there was no increased risk of neonatal injuries or asphyxia with this technique, as was compared to that seen in vertex or breech extractions.

Extension of the uterine incision during lower segment caesarean sections is common in second stage of labour, when the hand is forcibly introduced into the pelvis to deliver the head which is impacted in the pelvis, since the lower uterine segment is oedematous and fragile. Use of Patwardhan’s technique can prevent this maternal injury and it can thus reduce the need for blood transfusions. It also does not increase neonatal morbidity.