Using an Allis, the anesthesia was evaluated and found to be adequate. The scalpel was used to make a Pfannenstiel incision in the skin of the lower abdomen. The scalpel was used to extend the incision through the shallow subcutaneous layer. The rectus fascia was incised in the midline and the incision in the rectus fascia was extended transversely on each side in a curvilinear fashion with the Mayo scissors. The rectus fascia was grasped with a Kocher forceps and the median raphe was incised with a scalpel, both upper and lower edges. The rectus muscles were sharply and bluntly dissected away from the midline. At the upper aspect of the incision, the preperitoneal fat and connective tissue was dissected down to the peritoneum and the peritoneum was nicked and entered. The incision in the peritoneum was extended both superiorly and inferiorly under direct visualization.
The bladder blade was placed at the lower angle of the abdomen. The Metzenbaum scissors were used to incise the serosa of the lower uterine segment transversely. The scalpel was used to incise the lower uterine segment transversely down to the uterine cavity. The back of the scalpel was used to enter the uterine cavity. The incision in the lower uterine segment was extended transversely on each side with blunt dissection. Rupture of the membranes showed thick meconium. Immediately obvious when opening the uterine cavity was the baby's mouth directly upward and the lips were moving. I inserted my hand into the uterine cavity and maneuvered my hand beneath the head and attempted to rotate the head a little bit so that it could be flexed into the incision. There was much difficulty doing this. The baby's head would not rotate left or right. A Maylard muscle cutting incision was made on the patient's right, the head remained in a direct OP presentation, and I again attempted to deliver the head unsuccessfully. The head would not rotate at all and maintained the direct occiput posterior presentation. A Maylard muscle cutting incision was then performed on the patient's left rectus muscle. I then inserted my hand into the uterine cavity and the baby's head was delivered in a direct occiput posterior presentation without difficulty, followed by the body. The mouth and nostrils were immediately suctioned. The cord was doubly clamped and ligated.Any help would be appreciated.Thanks!!