1. DESTRUCTIVE OPERATIONS

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

3. Types
Craniotomy
Eviceration
Decapitation
Cleidotomy

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

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

6. 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

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

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

9. 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

10. 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

11. 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

12. 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

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

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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

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

21. 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

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

23. 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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