DESTRUCTIVE OPERATIONS

Definition The destructive operations are designed to diminish the bulk of the fetus so as to facilitate easy delivery through the birth canal

Types Craniotomy Eviceration Decapitation Cleidotomy

CRANIOTOMY Definition It is an operation to make a perforation on the fetal head to evacuate the contents followed by extraction of the fetus

Indications Cephalic presentation producing obstructed labour with dead fetus Hydrocephalus even in a living fetus Interlocking head of twins

Conditions to be fulfilled The cervix must be fully dilated Baby must be dead Contraindication When the pelvis is severely contracted Rupture of uterus where laparotomy is essential

Procedures PRELIMINARIES General anaesthesia Lithotomy position Surgical asepsis Empty the bladder Vaginal examination

Cont… ACTUAL STEPS Step 1 Introduce two fingers into the vagina (index and middle) Do incision through the suture line or dependent part

Sites of perforation Vertex - On the parietal bone either side of the sagittal suture Face -Through the orbit or hard palate Brow -Through the frontal bone

Step 2 Introduce the Oldham’s perforator or Sharp pointed Mayo scissors with the blades closed Step 3 By rotating movements perforate the skull Step 4 Evacuate the brain matter with the fingers

Cont… Step 5 Extract the fetus either by using a cranioclast or by two giant volsella Step 6 Exert traction Step 7 Explore the utero-vaginal canal after the delivery of the placenta

DECAPITATION Definition It is a destructive operation whereby the fetal head is severed from the trunk and the delivery is completed with the extraction of the trunk and that of the decapitated head per vaginam

Indication Neglected shoulder presentation with dead fetus where neck is easily accessible Interlocking head of twins

PROCEDURE Actual Steps Step 1 Bring down a hand and tie a roller gauze on the fetal wrist and give traction towards the side away from the fetal head Step 2 Two fingers of the left hand are introduced with palmar surface downwards and the finger tips to be placed on the superior surface of the neck.

Cont…. Step 3 The decapitation hook with knife is introduced flushed under the guidance of the finger placed into the vagina the knob pointing towards the fetal head The hook is pushed above the neck and rotated to 90 degree so as to place the knife firmly against the neck The internal fingers are placed on the under surface of the neck to guard the tip of the hook

Cont… Step 4 By upward and downward movements of the hook with knife ,the vertebral column is severed (evident by sudden loss of resistance) The rest of the soft tissue left behind may be severed by the same instrument or by embryotomy scissors The decapitation hook is pushed up and rotated to 90 degree and then to taken out under the guidance of the internal fingers The decapited head is pushed up and the trunk is delivered by traction on the prolapsed arm

Cont… Step 5 Delivery of the decapited head By hooking the index finger into the mouth By using crochet after fixing it with lower jaw By holding the severed neck with giant vulsellum and delivery of the head as that of aftercoming head in breech Using forceps or following perforation after fixing the head with forceps blades Step 6 Routine exploration of the utero-vaginal canal to exclude rupture of the uterus or any other injury

DECAPITATION USING BLOND- HEIDLER THIMBLE AND WIRES SAW The neck is severed by the wire saw after passing the wire loop around the fetal neck

EVISCERATION Definition The operation consists in removal of thoracic and abdominal contents piecemeal through an opening on the thoracic or abdominal cavity at the most accessible site

Indication Neglected shoulder presentation with dead fetus Fetal malformations ,such as fetal ascites or hugely distended bladder or monsters

CLEIDOTOMY Definition The operation consist of reduction in the bulk of the shoulder girdle by division of one or both the clavicles Indications Dead fetus with shoulder dystocia Procedure The clavicles are divided by the embryotomy scissors or long straight scissors introduced under the guidance of left two fingers placed inside the vagina

POST OPERATIVE CARE Exploration of the utero-vaginal canal Self retaining catheter Dextrose saline drip Blood transfusion Ampicillin 500mg at 6 hours interval

COMPLICATION Injury to the utero-vaginal canal Post partum haemorrhage Shock Puerperal sepsis Subinvolution Injury to the adjacent viscera Prolonged ill health

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