International Journa! of GYNECOLOGY & OBSTETRICS

International Journal of Gynecology and Obstetrics 84 (2004) 287-290

www.elsevier.com/locate/ijgo

Case report

Self-inflicted cesarean section with maternal and fetal survival

A. Molina-Sosa, H. Galván-Espinosa, J. Gabriel-Guzman, R.E Valle,*

Hospital General Dr. Manuel Velasco Suárez, San Pablo, Huixtepec, Zimatlán, Oaxaca, México

Department of Obstetrics and Gynecology, Northwestem University Medical School, Chicago, IL, USA

Received 30 May 2003; received in revised form 4 August 2003; accepted 11 August 2003

Abstract:

An unusual case of self-inflicted cesarean section with maternal and child survival is presented. No similar event was found in an Internet literature search. Because of a lack of medical assistance and a history of fetal death in utero, a 40-year-old multiparous woman unable to deliver herself alone vaginally sliced her abdomen and uterus and delivered her child. She was transferred to a hospital where she underwent repair of the incisions and had to remain hospitalized. Mother and child survived the event. Unusual and extraordinary measures to preserve their offspring sometimes moves women to extreme decisions endangering their own lives. Social, educational, and health measures should be instituted all over the world, particularly in rural areas of developing countries, to avoid such extreme events.

@ 2003 International Federation of Gynecology an.d Obstetrics. Published by EIsevier Ireland Ltd. All rights reserved. Keywords: Cesarean section; Emergency cesarean; Self-inflicted cesarean.

1. Introduction The natural, innate maternal instinct for preservation of offspring may result in the mother' s disregard for self-safety, and even for her own life. An unusual case of self-inflicted cesarean section with maternal and child survival is presented. Anthropological, economic, and sociologic factors, as well as non-existent health care provision, contributed to make this event possible [1].

2. Case report

A 40-year-old, gravida 9, para 9, with 8 surviv- ing children, was admitted to the hospital with a history of recent delivery by self-inflicted cesarean section due to a lack of medical careo Apparently, the patient' s previous pregnancy had ended in fetal death 2 years before because of obstructed labor. She had gone into labor at term but was unable to deliver her infant spontaneously. Rather than expe- rience fetal death in utero again, she used her skills at slaughtering animals. She took 3 small glasses of hard liquor and, using a kitchen knife, sliced her abdomen in 3 attempts in the right paramedial region, cut the uterus itself longitudi- nally, and delivered a male infant that breathed immediately and cried. Apparently, she did not bleed excessively and asked one of her children to call a local nurse for help before she lost con- sciousness. The nurse provided some health care.

Fig. 1. Uterine incision at the time of abdominal exploration and uterine repair.

but no prenatal care to the inhabitants of that small village deprived of running water, electricity, and sanitation. She found the patient eviscerated and proceeded to reposition bowel loops, suturing the skin with an ordinary sewing needle and cotton thread. The patient was then transferred to the nearest hospital, 8 h away by caro Sixteen hours later she underwent exploratory laparotomy, repair of the right paramedial uterine incision, tubal ligation, and bowel exploration to rule out any injury. The abdominal cavity was irrigated profusely. The uterine and abdominal walls were c1osed in layers. A Penrose drain was placed on each flank and the patient was given triple antibiotic therapy. Her recovery was protracted because of an absence of bowel sounds and abdominal distention that increased by the third postoperative day. A flat plate of the abdomen demonstrated dilated intestinal loops with fluid levels and a nasogastric tube was placed. Because no relief was obtained from nasogastric suction, consultation with a surgeon was requested. On the seventh postoperative da y she underwent exploratory laparotomy to rule out mechanical intestinal obstruction. No mechanical obstruction was found; an adhesion that caused the descending colon to be twisted, however, was released upon division. The patient recovered well, and was discharged from the hospital on the tenth postoperative day (Figs. 1-4).

3. Discussion

While there have been anecdotal accounts of self-inflicted cesarean sections and accidental inju ries to pregnant women that resulted in the delivery of an infant through a traumatic hysterotomy, no detailed reports of self-inflicted cesarean section with maternal and fetal survival was found in an Internet search of the literature [2,3].

This case represents an unusual and extraordinary decision by a woman in labor who, unable to deliver herself spontaneously, and with no medical help or resources, decided to perform a cesarean section upon herself to prevent possible fetal demise-an experience that she did not want to repeat. The infant survived and so did the mother, despite a protracted and difficult postsurgical periodo.

The maternal instinct for preservation of the offspring can, under unusual circumstances, move women to perform extraordinary acts, disregarding even their own safety and life. Health care, unfor- tunately, does not reach rural areas in many parts of the

Fig. 2. Wound closed with a Penrose drain in the right flank.

world. And when difficulties occur in the prenatal period or at delivery, pregnancy usually ends in fetal death and, occasionally, also in maternal death [4]. This case, which would not have occurred if prenatal and delivery care had been available, should make health providers aware that the basic reproductive needs of women are not meto At all levels, health providers and

Fig. 3. Patient breastfeeding baby while recovering in hospital.

appropriate govemmental authorities should implement measures to avoid cases like the one presented, and be ready to make every effort to ensure that women all over the world are offered essential. reproductive care.

Fig. 4. Incision healed, observed 4 weeks after surgery

References

[1] Campbell O, Koblinsky M, Taylor P. Off to a rapid start: appraising maternal mortality and services. Int J Gynecol Obstet 1995;48:533-552.

[2] Gould GM, Pyle WL. 1900 ed. Anomalies and curiosi- ties of medicine: 19th century medical curios, obstetric anomalies. Philadelphia: W.B. Saunders, 1896. p. 44- 45.

[3] Flores-Troncoso FdeA. Historia de La Medicina-1888. In: Gallegos Cigarroa RH, editor. Florilegio medico Mexicano. Cronicas, documentos y relatos de la epoca colonial. Mexico, DF: Sintex Labs Publ, 1994. p. 76- 77.

[4] Bulatao RA, Ross JA. Rating maternal and neonatal health services in developing countries. Bull WHO 2002;80:721-727.