Obstet Gynecol 2000;95:163–5
Laparoscopic vaginal delivery:
Mack Barham, MD
163 VOL. 95, NO. 1, JANUARY 2000 0029-7844/00/$20.00
I review the literature on laparoscopically assisted vaginal delivery, present and discuss a case, and describe the technique. Laparoscopically assisted vaginal delivery will emerge as a triumphant obstetric innovation that will radically transform operative obstetrics in the 21st century.
(Obstet Gynecol 2000;95:163–5. © 2000 by The American College of Obstetricians and Gynecologists.)
In recent years we have witnessed an expanding role of laparoscopy in gynecology. Few operations, generally those involving the vulva, have not been improved vastly by the addition of endoscopic technology. The dearth of randomized controlled trials showing the benefit of such technology dissuade only the most archaic troglodytes in our specialty.The final frontier of laparoscopy has now been reached. Laparoscopic radical hysterectomy with pelvic node dissection,1 aortic node dissection,2 and other radical pelvic and abdominal cancer operations3–5 are now commonly done endoscopically. Obstetrics is one of the few remaining areas in our specialty that has not fully embraced the manifest benefits of laparoscopically assisted operations, but that is beginning to change. An article on endoscopic removal of adnexal masses in pregnancy6 and a case report of an endoscopic uterine suspension during pregnancy7 have been published recently. The logical extension of the technology is into operative obstetrics.
Recent debate about high cesarean rates and concerns about birth injuries from vacuum extraction and mid-forceps, combined with inadequate resident training in operative vaginal delivery, have caused thoughtful clinicians to consider alternative approaches to assisting vaginal delivery. A review of the literature, including a MEDLINE search, manual review of the Index Medicus back to 1974, and an Internet search on PubMed, AltaVista, Yahoo, and Lycos found no reports of laparoscopically assisted vaginal delivery. A search of EBay found no related current auctions. Herein is reported the first case of laparoscopically assisted vaginal delivery.
A 24-year-old woman, gravida 4, para 3-0-0-2, presented at 39 weeks’ gestation in active labor. Her first infant was delivered by midforceps rotation and had a depressed skull fracture that required surgical elevation in the neonatal period. That child is developmentally delayed and has seziures. Her second infant was delivered by vacuum extraction, had a severe subgaleal hemorrhage, and died at 2 days of age. Her third infant was delivered by emergency low transverse cesarean because of a prolapsed umbilical cord. Postoperatively, the mother had a pelvic abscess and subsequent abdominal wall dehiscence that required reoperation and 43 days of hospital care.
In the current pregnancy there were no prenatal problems. Initial fetal heart rate tracings were reassuring and epidural anesthesia was used. She progressed to complete dilatation and pushed for 3 hours. The vertex was at 11 station and was left occiput transverse. There had been no descent during the previous 2 hours.Thick meconium was noted, and there was decreased baseline variability on the fetal monitor strip. After discussing the options of midforceps rotation, vacuum extraction, and cesarean, the woman vehemently refused to consent to any of those procedures. When she was offered an experimental laparoscopically assisted vaginal delivery she eagerly consented, having had abysmal luck with the available alternatives.
After she was placed in modified lithotomy position, two 12-mm ports were inserted above the umbilicus and four 12-mm ports were inserted in the four quadrants of the abdomen using transillumination. The markedly dilated vascular structures in the abdominal wall were easy to see and several of them were successfully avoided. The video laparoscope was used so everyone in the delivery suite could view the procedure.
A basketball net was inserted into the abdomen through one of the supraumbilical ports. The bottom of the net was closed with a purse-string suture. Half of the net’s suspension loops were attached to each of two dog leashes, creating an apparatus not entirely unlike a two-legged macrame jellyfish.
The open end of the net was guided over the top of the fundus with grasping probes inserted through the upper ports. The ends of the leashes were then exteriorized through the lower ports. Two crowbars inserted through the upper ports were placed across the top of the fundus under direct vision. Only 2 hours and 52 minutes after the initial skin incision, all was in readiness.
We are confident we can reduce the operating time slightly as we gain additional experience. A photograph of the apparatus applied to a uterine simulator is shown in Figure 1.
With the next contraction the woman was instructed to push. Simultaneous, vigorous caudad traction was applied to the leashes while an assistant, using the abdominal wall as a fulcrum, directly applied fundal pressure with the crowbars. The fetal head descended rapidly and a viable 3800-g boy was delivered over an intact perineum. Apgar scores were 9 at 1 minute and 10 at 5 minutes.
We saw the incidental rupture of the previous uterine scar that occured just as the infant was delivered. It was easily repaired endoscopically using standard techniques. Her postpartum course was uncomplicated, except for transient hypotension and anemia that responded to transfusion of 14 units of packed red blood cells. The neonate had a transient checkerboard rash on his buttocks, lower back, and thighs that resolved before discharge. He had an uneventful course in the nursery.
This case illustrates the feasibility and desirability of laparoscopically assisted vaginal delivery. The neonate had an excellent outcome. We are convinced that the maternal complications were in no way related to the laparoscopically assisted vaginal delivery. We anticipate that she would have been ready for hospital discharge the day after delivery had her uterus not ruptured. Much as Richardson and O’Connor-O’Sullivan retractors have vanished on all progressive gynecology services, forceps and vacuum extractors soon will be relegated to museum shelves next to craniotomes, fetoscopes, and other outdated obstetric accoutrements. Laparoscopically assisted vaginal delivery will become the standard of care and emerge as the triumphant obstetric innovation of the 21st century.
Hospitals and physicians who do not promptly adopt this procedure will be left standing by the wayside. Patients will demand it. The marketability of laparoscopically assisted vaginal delivery will make it mandatory long before pedantic, time-consuming, prospective randomized clinical trials will confirm its superiority.
The only marketing drawback to laparoscopically assisted vaginal delivery is the unfortunate similarity of its acronym (which the reader will have to infer as it is not yet a standard abbreviation and cannot be used in this journal) to an abbreviation for certain urban southern California sexually transmitted diseases. We are currently contemplating terminology modification to laparoscopically assisted birth. The acronym for laparoscopically assisted birth should make marketing even easier as labrador retrievers are one of the most popular breeds in America. I can see the ads now: "Let laparoscopically assisted birth retrieve your baby without the danger of cesarean delivery, forceps, or vacuum extraction!"
The additional equipment necessary to implement laparoscopically assisted vaginal delivery is inexpensive and can be found at most sporting goods outlets, pet shops, and hardware stores. Physicians in remote locations can find everything needed at any WalMart store.
Figure 1. Crowbars and basketball net with attached leashes positioned for laparoscopically assisted birth are shown applied to a uterine simulator.
164 Barham Laparoscopic Delivery Obstetrics & Gynecology
We are currently modifying our technique to allow laparoscopically assisted cesarean delivery, but that will be the subject of a future communication. I recently established The American Association of Obstetric Laparoscopists to facilitate credentialing and exchange of ideas among colleagues.
In the 20th century the three factors that have most altered obstetrics are safe blood transfusion, effective antibiotics, and trial lawyers. Without a doubt, laparoscopically assisted vaginal delivery will radically alter the practice of obstetrics in the 21st century. Modesty forbids me from presupposing that my name will become as hallowed as Chamberlen when the history of operative obstetrics is recorded. Only time will tell.
What is clear is that practioners who do not quickly adopt this innovative advance will not thrive and flourish. The transition from evidence-based medicine to marketing-based medicine has never been more apparent. Early attendance of one of the economical weekend laparoscopically assisted vaginal delivery courses offered at various sites around the country in the near future is essential to your professional survival.
Do not be left behind. The millennium is upon us.
1. Kim DH. Laparoscopic radical hysterectomy with pelvic lymphadenectomy for early, invasive cervical carcinoma. J Am Assoc Gynecol
2. Nezhat CR, Burrell MO, Nezhat FR, Benigno BB, Welander CE.
Laparoscopic radical hysterectomy with para-aortic and pelvic node dissection. Am J Obstet Gynecol 1992;166:864 –5.
3. Ramshaw BJ. Laparoscopic surgery for cancer patients. CA Cancer
J Clin 1997;47:327–50.
4. Hatch KD, Hallum AV 3rd, Surwit EA, Childers JM. The role of laparoscopy in gynecologic oncology. Cancer 1995;76:2113– 6.
5. Childers JM, Brzechffa PR, Hatch KD, Surwit EA. Laparoscopically assisted surgical staging (LASS) of endometrial cancer. Gynecol Oncol 1993;51:33– 8.
6. Soriano D, Yefet Y, Seidman DS, Goldenberg M, Mashiach S,
Oelsner G. Laparoscopy versus laparotomy in the management of adnexal masses during pregnancy. Fertil Steril 1999;71:995– 60.
7. Matsumoto T, Mutsumasa N, Yokata M, Masaharu I. Laparoscopic treatment of uterine prolapse during pregnancy. Obstet Gynecol 1999;93:849.
Address reprint requests to:
Mack Barham, MD
Received June 7, 1999.
Received in revised form July 14, 1999.
Accepted July 29, 1999.
Copyright © 2000 by The
Amrican College of Obstetriians and Gynecoloists.
VOL. 95, NO. 1, JANUARY 2000 Barham Laparoscopic Delivery 165