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. In modern obstetric practice, virtually there is hardly any place for destructive operations. Neglected obstetrics requiring destructive operations are completely preventable. These procedures are difficult and may be dangerous too unless the operator is sufficiently skilled. Unfortunately, one may have to perform such operations while working in the unorganized sector. Some commonly performed operations are discussed here. There are four types of operations:
♦Craniotomy ♦Evisceration ♦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 labor with dead fetus: This is the most common indication of craniotomy in the referral hospitals of the developing countries.
■ Hydrocephalus even in a living fetus: This is applicable both for the forecoming and the aftercoming head .
■ Interlocking head of twins.
CONDITIONS TO BE FULFILLED: (1) The cervix must be fully dilated and (2) baby must be dead (hydrocephalus being excluded).
CONTRAINDICATION: (i) The operation should not be done when the pelvis is severely contracted so as to shorten the true conjugate to less than 7.5 cm (3"). In such condition, the baby cannot be delivered, as the bimastoid diameter (base of the skull) of 7.5 cm cannot be compressed. (ii) Rupture of the uterus where laparotomy is essential.
PROCEDURES: Preliminaries: The preliminary preparations are the same as mentioned in p. 642. The operation is to be done under general anesthesia.
Actual steps
Step I: The two fingers (index and middle) are introduced into the vagina and the finger tips are to be placed on proposed site of perforation. However, when the suture line cannot be defined because of big caput, the perforation should be done through the dependent part.
Sites of perforation: Vertex: On the parietal bone either side of the sagittal suture. Suture is avoided to prevent collapse of the bone thereby preventing escape of the brain matter. Face: Through the orbit or hard palate. Brow: Through the frontal bone.
Step II: The Oldham’s perforator with the blades closed is introduced under the palmar aspect of the fingers protecting the anterior vaginal wall and the adjacent bladder until the tip reaches the proposed site of perforation.
Step III: By rotating movements the skull is perforated. During this step, an assistant is asked to steady the head per abdomen in a manner of first pelvic grip. After the skull is perforated, the instrument is thrust up to the shoulders and the handles are approximated so as to allow separation of the sharp blades for about 2.5 cm. The blades are again apposed by separating the handles. The instrument is brought out keeping the tip of the blades still inside the cranium. The instrument is rotated at right angle and then again thrust in up to the shoulders. The handles are once more to be compressed so as to separate the blades for about 2.5 cm. The perforated area now looks like a cross. The instrument with the blades closed is then thrust in beyond the guard to churn the brain matter. The instrument, with the blades closed, is brought out under the guidance of the two fingers still placed inside the vagina.
Alternative to Oldham’s perforator, similar procedure could be performed using a sharp-pointed Mayo’s scissors.
Step IV: With the fingers brain matter is evacuated. The idea is to make the skull collapse as much as possible.
Step V: When the skull is found sufficiently compressed, the extraction of the fetus is achieved either by using a cranioclast or by two giant volsella. Giant volsella are used to hold the incised skull and scalp margins.
Step VI: The traction is now exerted in the same direction as like that mentioned in forceps operation. Step VII: After the delivery of the placenta, the uterovaginal canal must be explored as a routine for evidence of rupture uterus or any tear. Injection methergine 0.2 mg is to be given intravenously with the delivery of the anterior shoulder. The rest of the delivery is completed as in normal delivery.
Forceps versus craniotomy in a dead fetus: If the delivery of the uncompressed head can be accomplished without much force with consequent injuries to the mother, forceps delivery is preferred. But if it is found difficult and damaging to the mother, craniotomy is safer.
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 vaginum. INDICATION:
(1) Neglected shoulder presentation with dead fetus where neck is easily accessible.
(2) Interlocking head of twins.
PROCEDURES: Preliminaries — The preliminaries to be followed are the same as outlined earlier. The operation is done under general anesthesia.
Actual Steps
Step I: If the fetal hand is not prolapsed, bring down a hand. A roller gauze is tied on the fetal wrist and an assistant is asked to give traction towards the side away from the fetal head to make the neck more accessible and fixed.
Step II: Two fingers of the left hand (middle and index) are introduced with the palmar surface downwards and the finger tips are to be placed on the superior surface of the neck—the proposed site of decapitation.
Step III: The decapitation hook with knife is to be introduced flushed under the guidance of the fingers placed into the vagina, the knob pointing towards the fetal head. The hook is pushed above the neck and rotated to 90° so as to place the knife firmly against the neck. The internal fingers, in the meantime, are placed on the under surface of the neck to guard the tip of the hook.
Step IV: 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. While removing the decapitation hook—it is to be pushed up; rotated to 90° and then to take out under the guidance of the internal fingers. The decapitated head is pushed up and the trunk is delivered by traction on the prolapsed arm.
Step V: Delivery of the decapitated head—Any of the following methods may be usually effective:
• By hooking the index finger into the mouth • By holding the severed neck with giant vulsellum and delivery of the head as that of aftercoming head in breech • Using forceps.
Step VI: Routine exploration of the uterovaginal canal to exclude rupture of the uterus or any other injury.
EVISCERATION
The operation consists of removal of thoracic and abdominal contents piecemeal through an opening on the thoracic or abdominal cavity at the most accessible site. The object is to diminish the bulk of the fetus which facilitates its extraction. If difficulty arises, the spine may have to be divided (spondylectomy) with embryotomy scissors.
The indications are: (1) Neglected shoulder presentation with dead fetus; the neck is not easily accessible and (2) fetal malformations, such as fetal ascites or hugely distended bladder or monsters.
CLEIDOTOMY
The operation consists of reduction in the bulk of the shoulder girdle by division of one or both the clavicles.The operation is done only in dead fetus (anencephaly excluded) with shoulder dystocia. The clavicles are divided by the embryotomy scissors or long straight scissors introduced under the guidance of left two fingers placed inside the vagina.
POSTOPERATIVE CARE FOLLOWING DESTRUCTIVE OPERATIONS
♦ Exploration of the uterovaginal canal must be done to exclude rupture of the uterus or lacerations on the vagina or any genital injury.
♦A selfretaining (Foley’s) catheter is put inside, especially following craniotomy for a period of 3–5 days or until the bladder tone is regained.
♦Dextrose saline drip is to be continued till dehydration is corrected. Blood transfusion may be given, if required.
♦Ceftriaxone 1 g IV infusion is given twice daily.
COMPLICATIONS: (1) Injury to the uterovaginal canal (2) rupture of uterus (3) postpartum hemorrhage—atonic or traumatic (4) shock—due to blood loss and/or dehydration (5) puerperal sepsis (6) subinvolution (7) injury to the adjacent viscera— bladder—vesicovaginal fistula or rarely to rectal wall leading to rectovaginal fistula and (8) prolonged ill health.
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