Destructive operations
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This document discusses various destructive operations that can be performed on a dead fetus to facilitate delivery through the birth canal when the fetus is too large to pass intact. It defines destructive operations and describes their purposes. It then discusses different procedures like craniotomy, decapitation, evisceration, cleidotomy, and spondylectomy. For each procedure, it provides indications, prerequisites, steps to perform the procedure, and risks. It notes that most destructive operations are no longer recommended and have been replaced by caesarean section for safety reasons.
Destructive operations
- 1. DESTRUCTIVE OPERATIONS Neethu S.S. Second year MSc nursing Govt. College of nursing Kozhikode
- 2. DEFINITION Destructive operations are procedures that reduce the size of the head, shoulder girdle, or trunk of the dead fetus to allow its delivery through the vaginal route.
- 3. Purposes To reduce baby’s size(head, shoulder girdle or body) and so enable the vaginal delivery of baby which is too large to pass intact through the birth canal Or, operations that are designed to diminish the bulk of the fetus so as to facilitate easy delivery through the birth canal.
- 4. Needs few instruments & simple anesthesia. Uterus remains intact , ( no L.S.C.S. scar ). Subsequent pregnancy will be safer. Operative morbidity is lesser . Hospital stay is shorter.
- 5. ROLE in modern obstetrics No role in modern obstetrics Unpleasant and unacceptable level of maternal traumatic and psychological morbidity Complicated intrauterine procedure Chances of injury to obstetrician in HIV era Abandoned in favor of cesarean section which is safer to the mother.
- 6. Most of these procedures are Intrauterine learning phase is longer Higher complications
- 7. CONTRAINDICATIONS Living normal fetus Markedly contracted pelvis Cervix less than 3/4th dilated Neoplasms obstructing the pelvis
- 8. DANGERS Lacerations of vagina, cervix, uterus, bladder or rectum Uterine rupture Hemorrhage from lacerations and uterine atony Infection
- 9. CLASSIFICATION Living fetus: Needle drainage in hydrocephaly Fracture of clavicle or arm- in shoulder dystocia and breech with nuchal arm
- 10. Dead fetus Craniotomy-hydrocephaly -when delivery of intact head is impossible Decapitation- neglected transverse lie interlocked twins Cleidotomy -shoulder dystocia breech with nuchal arms Spondylectomy- breech with hydrocephaly Evisceration or morcellation Hydrops fetalis with marked ascites Monsters
- 11. Perforators Frightful instruments were used earlier to open the head of the fetus in craniotomy Used to open the thorax and abdomen of fetus in evisceration
- 15. Hooks/Crochets
- 21. CRANIOTOMY It is an operation to make a perforation on the fetal head, to evacuate the contents followed by extraction of the fetus.
- 22. INDICATIONS 1. Cephalic presentation producing obstructed labor with dead fetus 2. Hydrocephalus even in a living fetus 3. Interlocking head of twins 4. Specifically unfavorable position of child-impacted mento-posterior, brow, or occi-puto posterior positions-following a prolonged labor
- 23. Conditions to be fulfilled 1. The cervix must be fully dilated 2. Baby must be dead (hydrocephalus being excluded) 3. Two fifth or less head Palpable above the brim 4. Head is impacted 5. Uterus unruptured/no Imminent rupture 6. True conjugate not < 7.5 cm
- 24. Contraindications Severely contracted pelvis so as to shorten the true conjugate < 7.5 cm Rupture of the uterus
- 25. PRE TREATMENT Correct dehydration Treat ketoacidosis Draw blood for cross-matching, investigations To arrange blood Prophylactic antibiotics Catheterize the bladder
- 26. PROCEDURE Preliminaries: Anesthesia- either general or local Lithotomy position Full surgical asepsis Empty the bladder Vaginal examination
- 27. Steps Step 1: The two fingers 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
- 28. Step 2 The Oldham’s perforator with the blades is closed is introduced under the palmer aspect of the fingers protecting the anterior vaginal wall and the adjacent bladder until the tip reaches the proposed site of perforation
- 29. Step 3 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.
- 30. 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 2.5cm. 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.
- 31. Step 4 With the fingers brain matter is evacuated. The idea is to make the skull collapse as much as possible. Step 5 When the skull is found sufficiently compressed, the extraction of the fetus is achieved either by using a cranioclast or by 2 giant valsella. Giant valsella are used to hold the incised skull and scalp margins.
- 32. Step 6 The traction is now exerted. Step 7 After the delivery of the placenta, the uterovaginal canal must be explored as a routine for evidence of rupture uterus or any tear. Inj. Methergine 0.2 mg IM given with the delivery of anterior shoulder. The rest of the delivery is completed as in normal delivery.
- 33. DECAPITATION It is the 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 vagina.
- 34. Indications • Neglected shoulder with a dead fetus. • Locked twins. • Double -headed monsters.
- 35. Prerequisites: Neck of the fetus should be accessible per vagina. No evidence of impending rupture. Cervix should be at least 7 cm dilated
- 36. Procedure Done under general anesthesia 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.
- 37. 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
- 38. 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.
- 39. 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 valsellum 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.
- 43. 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 objective is to diminish the bulk of the fetus which facilitates its extraction. If difficulty arises, the spine may have to be divided (spondylotomy) with embryotomy scissors.
- 44. Indications • Neglected shoulder presentation with dead fetus; the neck is not easily accessible • Fetal malformations, such as fetal ascites or hugely distended bladder or monsters. • Thoracic or abdominal tumors
- 45. The operation is performed by first making a large opening (with a perforator or embryotomy scissor) into the abdomen or thorax The viscera are then broken up and removed manually. If the thorax has to be incised first, the abdominal viscera are reached via the diaphragm. During these manipulations, if the lie is transverse, the trunk of the child may be steadied by pulling down an arm but if that is not possible (trunk presentation) valsella: may be employed for this purpose.
- 46. CLEIDOTOMY The operation consists of reduction in the bulk of the shoulder girdle by division of one or both the clavicles to reduce the biacromial diameter 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.
- 47. Indications To reduce the width of the shoulder in large fetus that cannot be delivered vaginally. When maneuvers for shoulder dystocia are unsuccessful
- 48. Procedure Follow all general principles of conducting destructive operation. Make a small cut in the skin of neck of the dead fetus Place one hand vaginally along with the ventral aspect of the fetus and identify clavicle Use embryotomy scissors and cut the clavicle into two and reduce the width of the shoulder and deliver the fetus.
- 49. SPONDYLECTOMY Spondylectomy is transection of the spine of the delivered thorax. In breech presentation it may allow drainage of CSF It is done when the back is anterior and head and neck are out of reach. In cases of hydrocephalus when there is communication between the ventricles and spinal cord the fluid may be drained from brain in this way thus obviating the need for craniotomy
- 50. Hydrocephalus Pelvis to be of ordinary capacity Perforation can be made by any suitable sharp instrument, Provided cervix is sufficiently dilated to allow two fingers to be introduced. After perforation and collapse of the head, spontaneous expulsion of the fetus is generally quick and easy, and this is especially so as the child's trunk is usually small.
- 51. HYDROCEPHALUS BABY If desired, however, a Valsella or Willitt's forceps can be attached to the scalp and constant traction made by means of a one-pound weight hung over the end of the bed. Puncturing & draining is all that necessary in most of the cases Per vaginal drainage Abdominal drainage Spinal tapping in aftercoming head
- 53. COMPLICATIONS During perforation Injuries to: Bladder And Urethra Vagina, cervix and Uterus Rectum And Intestines During extraction Wrong tissue holding Injuries to soft tissues Wrong directions of pulling Spicules of bones
- 54. Prevention Catheterization Willingness To Abandon Good Assistance Adequate Light Source Use Large Sims Speculum Incise The Scalp And Perforate Guide And Protection Of Soft Tissues By Left Hand
- 55. MORCELLATION Cutting the fetus into pieces is necessary on rare occasions before vaginal delivery can be accomplished
- 56. Complications of destructive operations Injury to the uterovaginal canal Rupture of uterus Postpartum hemorrhage— atonic or traumatic Shock—due to blood loss and/or dehydration Puerperal sepsis Subinvolution Injury to the adjacent viscera— bladder—vesico-vaginal fistula or rarely to rectal wall leading to recto-vaginal fistula Prolonged ill health.
- 57. POSTOPERATIVE CARE FOLLOWING DESTRUCTIVE OPERATIONS • Wrap the baby immediately. • Exploration of the uterovaginal canal must be done to exclude rupture of the uterus or lacerations on the vagina or any genital injury • Oxytocin infusion continued for 6-8hours as the as the risk of atonic PPH following prolonged obstructed labor is high • A self-retaining (Foley’s) catheter is put inside specially 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.
- 58. Broad spectrum antibiotics – ceftriaxone 1g IV infusion is given twice daily Thromboprophylaxis As much possible the infant must be restored anatomically with suturing This along with careful placement of blankets should help reduce trauma to the parents when they view their new born dead infant Psychological wellbeing of husband / wife and family members should be taken care Plans for subsequent pregnancy care
- 59. Nursing diagnosis Anxiety related to fetal loss and destructive procedures Powerlessness related to lack of choice in childbirth options Knowledge deficit related to destructive operations, pain relief Grieving related to fetal demise Altered family process related to fetal loss Risk for injury related to operative inferences Risk for infection related to operative inferences
- 60. Related studies In 2005 Singhal et al , Hospital in Haryana, reported 51 destructive operations done for obstructed labor with dead fetus over a 7 year period. 68.62% women had craniotomies, 19.60% had decapitation, 7.84% had evisceration and 3.92% had cleidotomy. Cephalopelvic disproportion was the commonest indication. Two fetuses were grossly malformed, 49.05% weighed between 3 and 4 kg, and 9.43% were macrosomic. 49.09% women developed complications like atonic postpartum hemorrhage, vaginal and perineal tears, puerperal sepsis, and urinary infection
- 61. In 2011Biswas et, Kolkata, reported a 1.17% (141 in 12,034 deliveries over a year) incidence of obstructed labor – 0.29% or 36 with dead fetus. 44.4% underwent craniotomy and 55% evisceration. Cephalopelvic disproportion was the commonest cause of obstruction. There was one traumatic rupture of the uterus but no maternal death.
- 62. Thank you