PURPOSE OF DESTRUCTIVE OPERATIONS

 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.
 What is Modern obstetrics ?

 Is there any role of destructive operations in current

obstetric practice?
MODERN OBSTETRICS

 It is evidence based practice of obstetrics.

 Accountable and unbiased.
 Offers best possible outcome to mother & baby.
 It has least morbidity to mother & new born.
 Nearly litigation free.
 Modern obstetrician must be expert in destructive
operations & second stage L.S.C.S.
DESTRUCTIVE OPERATIONS

 Needs few instruments & simple anaesthesia.

 Uterus remains intact , ( no L.S.C.S. scar ).
 Subsequent pregnancy will be safer.
 Operative morbidity is lesser .
 Hospital stay is shorter.
 They need to be taught to young doctors
ROLE OF DESTRUCTIVE OPERATIONS

 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
 Caesarean section is much safer alternative
Most of these procedures are

 Intrauterine
 Learning phase is longer
 Higher complications
 L.S.C.S is more safe
Studies
 Nigerian study-15 yrs
 Tropical [Link],vol19-2,2002
 2947 patients with obstructed labor
 67 met the criteria for Destructive
Operation
 Only 11 underwent Destructive Operation
 56 underwent LSCS
 3 maternal deaths in LSCS group
 Infection, blood transfusion, Asherman higher in
LSCS group
 No death in craniotomy
 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
 In 2001 Biswas 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.
IN MODERN OBSTETRICS – IS
DESTRUCTIVE OPERATION
FEASABLE

 Psychological Effect
 Beginners Not to Experiment on Patients
 Litigation Problems.
 Complications May Be Life Threatening
CONTRAINDICATIONS
 Living normal fetus
 Markedly contracted pelvis
 Cervix less than 3/4th dilated
 Neoplasms obstructing the pelvis
DANGERS
 Lacerations of vagina, cervix, uterus, bladder or
rectum
 Uterine rupture
 Hemorrhage from lacerations and uterine atony
 Infection
 CLASSIFICATION
Living fetus:
 Needle drainage in hydocephaly
 Fracture of clavicle or arm- in shoulder dystocia and
breech with nuchal arm

Dead fetus
 Craniotomy-hydrocephaly
-when delivery of intact head is impossible
 Decapitation- neglected transverse lie
- interlocked twins
CLASSIFICATION
 Cleidotomy -shoulder dystocia
-breech with nuchal arms
 Spondylectomy- breech with hydocephaly
 Evisceration or morcellation
 Hydrops fetalis with marked ascites
 Monsters
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
Perforator
Smellie’s perforator
Naegele's Perforator
Simpson's Spring Loaded
Perforator
Hooks/Crochets
Cranioclast
 FOUR MAIN TYPES OF
OPERATIONS

CRANIOTOMY DECAPITATION EVISCERATION CLEIDOTOMY

CRANIOTOMY
 Method to reduce the fetal head size so as to effect
easy vaginal delivery

 OR

 It is an operation to make perforation on the fetal

head , to evacuate contents followed by extraction of
the fetus
INDICATIONS
 Obstructed labor with dead fetus
 Hydrocephalus live or dead
 Specially unfavourable position of child-impacted
mento-posterior, brow, or occipitoposterior
positions-following a prolonged labour
 Interlocking of twins
PREREQUISITES

 Fetus is dead (hydrocephalus excluded)

 Two fifth or less head Palpable above the brim
 Head is impacted
 Cervix is at least 7 cm dilated
 Uterus unruptured/no Imminent rupture
 True conjugate not < 7.5 cm
PRE TREATMENT

 Correct dehydration
 Treat ketoacidosis
 Draw blood for cross-matching, investigations
 To arrange blood
 Prophylactic antibiotics
 Catheterize the bladder
 CRANIOTOMY

Perforation Extraction
SITES FOR PERFORATION

• Parietal bone in fore coming head

• Occiput / post-lateral fontanelle in
aftercoming head

• Palate / orbit in face

• Frontal bone in brow
 Anaesthesia
 General anaesthesia
 Spinal anaesthesia with IV sedation better option
 These are not available then pudendal block,
paracervical block or intravenous sedation may be
given
Craniotomy of the Fore-coming
Head
 The first step is perforation.

 This is carried out by the perforator, of which

there are two different types -the scissors and
the trephine forms.
 Scissors variety only used; trephine perforator is
obsolete
 Scissors variety has shoulder to each blade, so
that the blades might be prevented from passing
completely into the skull.
 With this instrument the opening in the skull is made by
separating the handles
 The two most generally employed at the present day are
those of Oldham and of Simpson PERFORATOR .
 The perforator has two cutting blades, each being
limited by a shoulder.
 The handles, when the blades are in apposition, are wide apart,
and in the case of Simpson's model a hinged crossbar holds the
handles apart.

 This crossbar is so hinged that it only permits of approximation

of the handles when the hinge is pressed inwards. By pressing
the handles together the blades are separated
 The steps in perforating are
as follows:

 The head of the child is

steadied from above the
Symphysis by an assistant
grasping it and pressing it
against the pelvic brim.

 The operator holds the

perforator in his right hand.

 Under protection of the fore

and middle fingers of his left
hand, placed in the vagina, the
point of the instrument is
directed up against the skull
and pushed through it.
 In pushing or boring the instrument through the skull,
the direction of the instrument should be, as far as
possible, at right angles to the surface of the child's
head, otherwise there is danger of the instrument
glancing off the skull and doing injury to the soft parts of
the mother.

 In order to get the perforator at right angles to the -

surface of the skull, the shanks of the instrument should
be depressed against the perineum.
 The blades of the instrument,
having been pushed through the
skull as far as their shoulders,
should then be separated, and
this is done by pressing the
handles together .

 A large tear in the skull having

been made in one direction, the
instrument should be turned
round and a similar tear made at
right angles.

 The points of the instrument

should be pushed into the skull
and the brain broken up in all
directions. The instrument is now
withdrawn under protection of
the left hand.
EXTRACTION- METHODS
 Left to natural forces
 Use forceps/ vulsellum
 Cephalotribe
 Cranioclasm
 Cephalotribe  Method of extraction
 Showing the ideal
grasp of the head with
the three-bladed
cephalotribe:

 one blade is well down

over the face, and the
other over the occiput
 Showing the effect of
crushing only one half of the
head in a case of posterior
parietal presentation.
 In the flat rachitic pelvis-the pelvic deformity most
commonly encountered - the head engages in the
transverse diameter of the pelvis, with the anterior and
posterior fontanelles about the same level.

 In the simple cases where the sagittal suture is

equidistant from the promontory and symphysis, the hole
in the skull can readily be made in the middle line, through
or near the anterior fontanelle, and the blades of the
cephalotribe can be applied over the face and occiput
 When, however, the sagittal suture is placed nearer the
promontory or nearer the symphysis, and an anterior or a
posterior" parietal presentation" exists,

 The opening in the head will come through the presenting

parietal bone, and the blades of the cephalotribe will tend
to grasp the head parallel to midline, but to one or other
side of the middle line
Craniotomy in brow presentation
 In cases where maternal pelvis is contracted in all
diameters, the head becomes extremely flexed, and the
most accessible area usually is – nearby posterior
fontanelle.

 Consequently, if the presenting part is perforated, the

blade of the cephalotribe, which should reach over the
face, cannot be placed over the face farther than the
child's forehead naturally, therefore, when traction is
made, the instrument tends to slip off the head.
 The three-bladed cephalotribe is
slipping off the head because the
anterior blade has not been
applied far enough down over the
face. This results if the perforation
is made in the region of the
posterior fontanelle
 After perforation the instrument should be
pushed into the skull and the brain substance
thoroughly broken up.

 This having been done, the cranium may be

washed out with a double channelled uterine
douche tube (Bozeman).
After coming of head
 The operation of perforation of the after-coming head is
carried out as follows:

 The arms of the child having been brought down, the

assistant grasps the legs and directs traction upon them
in the direction desired by the operator.

 The operator carries the perforator, protected by the

two fingers of the left hand, along the dorsal aspect of
the trunk until he reaches the skull.
 He then pushes the instrument through the skull in the
neighbourhood of the postero-lateral fontanelle .

 The perforator is pushed through the skull, and an

opening made in the manner already described for
perforation of the fore-coming head.
PERFORATING THE AFTER-COMING HEAD
THROUGH THE POSTEROLATERAL
FONTANELLE
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 foetus is generally quick
and easy, and this is especially so as the child's trunk is
usually small.
HYDROCEPHALUS BABY

 If desired, however, a Volsella 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
DELIVERY OF HYDROCEPHALIC
BABY
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
IDENTIFICATION OF COMPLICATIONS

 Fresh Bleeding
 Urine Dribbles
 Faecal Matter Flows
PREVENTION
 Catheterisation
 Willingness To Abandon
 Good Assistance
 Adequate Light Source
 Use Large Sims Speculum

 Incise ( Nick) The Scalp And Perforate

 Guide And Protection Of Soft Tissues By Left Hand

TREATMENT

 Bladder & Urethral Injuries:

 Don’t Abandon Procedure

 Repair & Catheterize for 14 Days
 Check in the next follow-up
 Vaginal, Cervical tears Repair

 Rupture Uterus-laparotomy

 Rectal, Intestinal injuries Repair

 It is important to rule out rupture of uterus before

and after craniotomy
DECAPITATION
 Indications
 Neglected shoulder with hand
prolapse
 Interlocked twins.

 Prerequisites:
 Neck of the fetus should be accessible
per vagina.
 No evidence of impending rupture.
 Cervix should be atleast 7 cm dilated
Technique
 The operator mounts the
thimble on his thumb and
attaches the wire to the slot in
the thimble.

 Pulling gently to exert counter-

tension on the prolapsed arm of
the foetus, he introduces the
whole hand into the vagina; the
thumb is passed in front of the
foetal neck and the fingers
behind.
 The middle finger now feels
for the metal loop that
projects from the thimble
and, having secured it, pulls
the thimble with the
attached wire off the thumb
and round the foetal neck.

 The ends of the wire are

now mounted on the
handles and by a to and fro
motion the neck is severed.
 This method of decapitation is safer and less
barbarous than the use of decapitating
hooks.

 After the head is completely severed, the

trunk is removed by traction on the arm.

 There now remains the removal of the

severed head, and this is easily
accomplished manually by a finger hooked
into the mouth and pulling on the jaw, or
with forceps, unless the pelvis is deformed.
 Should the pelvis be contracted, the head is steadied by
suprapubic pressure, perforated, and then removed with
the cranioclast, crotchet, etc.

 Care must be taken, in extracting the head, that the ragged

neck does not injure the soft parts
 EVISCERATION

Indications

 Neglected shoulder presentation with dead fetus;

Neck not easily assesible
 Fetal malformations such as fetal ascitis or
monsters
EVISCERATION

 The operation of evisceration consists in the removal of

the abdominal and thoracic contents, with the object of
diminishing the bulk of the child, and so permitting it being
extracted.

 Especially should care be exercised if the foetus is large or

the cervix inadequately dilated.
 The operation is occasionally necessary in monsters, and
where the abdomen or thorax of the child is distended
with fluid or a tumour.

 The operation is performed by first making a large opening

(with a perforator) into the abdomen or thorax; the viscera
are then broken up and removed manually.

 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) vulsella: may
be employed for this purpose.
CLEIDOTOMY

 The operation of cleidotomy, or division of the clavicles,

has for its object the reducing of the bulk of the shoulder
girdle.

 The clavicles are divided by a short-bladed knife or long,

strong, straight scissors. Two fingers of the left hand are
passed along the ventral aspect of the child, and under the
protection of them the scissors is introduced and the
clavicle divided.
 Considerable power is required to snip the hard bone.

 The only danger is injuring the soft parts of the

mother

 Care must be taken to identify the position of the

clavicles. It is difficult sometimes to be sure which is
the ventral side of the foetus, as the head is rotated so
easily. One can quite easily divide the spine of the
scapula by mistake
Clavicles were divided in this case
MORCELLATION

 Cutting the fetus into pieces is necessary on rare

occasions before vaginal delivery can be accomplished
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.
Post delivery care

 Active management of third stage

 Oxytocin infusion contd for 6-8hours as the as the risk
of atonic PPH following prolonged obstructed labour is
high
 Careful inspection of genital tract for signs of trauma
including uterine exploration to rule out rupture
 Bladder should be catheterised for 5-7days in cases
where bladder distension was for prolonged time
 Broad spectrum antibiotics
 Thrombophophylaxis
 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
References
 DC dutta text book of obstetrics
 Human labour – oxornforte
 Munrokerr’s operative obstetrics
Thank you