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UNIT 15.

2 Destructive Operations (Embryotomy)
Definition
Destructive operations are a group of operations aims at reducing the size of the head, shoulder
girdle or trunk of the dead unborn fetus to allow its easy vaginal delivery. These procedures were
adopted in the past to deliver the dead fetus when a mother suffering from an obstructed labour
and threatened uterine rupture. These operations are performed rarely in places where the facility
of caesarean section is not available or when the fetus is already dead.
Types of destructive operations
1. Craniotomy craniocentesis
2. Decapitation
3. Cleidotomy
4. Evisceration
5. Spondylotomy
Contraindications

Living foetus except in certain congenital anomalies incompatible with life as
anencephaly which may be associated with large shoulder girdle. However, destruction of
a living foetus for whatever the cause may not be accepted from the religious point of
view.

Extreme degree of contracted pelvis i.e. true conjugate < 5.5 cm.

Partially dilated cervix.

Rupture or impending rupture uterus.

Obstructing pelvic tumours.

Cancer of the cervix with pregnancy.

Complications

 Cephalotripsy: crushing of the whole head including the base of the skull. 1.  Injuries to the genital tract. CRANIOTOMY Definitions  Craniotomy: perforation of the foetal head (cranium). Uterine rupture. Craniotomy (skull perforation) is an operation to make a perforation of the fetal head to evacuate the contents followed by extraction of the fetus. Indications  Hydrocephalus even in living fetus  Dead fetus in obstructed labour with a cephalic presentation  Retained after-coming head of a dead fetus in breech delivery  Cephalopelvic disproportion with a dead fetus  Impacted malpresented dead foetus as mento-posterior and brow presentation  Interlocking head of twins Contraindication     Live fetus: caesarean section is the choice Major degrees placenta previa Pelvic tumour obstructing labour Gross pelvic contractions .  Cranioclasm: crushing of the cranium.

 After . .  Brow: The frontal bone. 4.  Face: The orbit. 5. o The foramen magnum. o The occipital bone behind the mastoid. 3. The cervix must be fully dilated 2. The fetus must be dead (hydrocephalus being excluded) 3. Catheter Perforator (old ham) Budin’s double channel catheter Cranioclast Bone nibbing forceps Crotchet Criteria for craniotomy 1. 2. Consent should be taken Sites of Perforation  Vertex presentation: The anterior fontanelle or in the parietal bone as near as to it. 6. o Through the spina bifida if present by a stiff catheter passed up to the spinal canal. Procedure Perforation  Under general anaesthesia the bladder is evacuated and head is steadied by an assistant.coming head: o The roof of the mouth.  Suspected uterine rupture Free floating fetal head Instruments for craniotomy 1.

 Forceps can be applied if there is no disproportion.  The perforator is closed.  The after . Extraction  Spontaneous delivery can occur after reduction of the size of hydrocephalus. The resultant hole is enlarged by the closed perforator which is pushed to allow drainage of the CSF and brain matter. rotated 90o and re-opened again thus producing a cruciate incision. The Simpson’s perforator is held closed in the operator’s hand while its tip is protected by the fingers of the other hand which guide it through the birth canal up to the site of perforation and applied perpendicular to it. o Trans .coming head is delivered as in breech delivery. Complications: .  The cranioclast (2 blades) or the combined cranioclast and cephalotribe (3 blades) are used to crush and extract the head if there is disproportion.  The birth canal should be explored after delivery.  The tip is forced into the site of perforation up to shoulders of the perforator which is then opened to produce a linear incision in the skull bones.  The closed perforator is withdrawn while its tip is protected by the fingers.  Alternative methods: o Needle aspiration vaginally: through the fontanelle or suture line after steadying the head with Jacob’s tenaculum.abdominal aspiration with a syringe or spinal needle.  Two volsella or Willet’s scalp forceps may be applied for traction.

rectum. the mother potentially infected and lower segment thinned out. . Indication  Neglected shoulder with a dead foetus. 5.  Double -headed monsters.  Interlocking head of twins. 4. bladder. vagina. 2. 3. Rupture uterus Injury to cervix. sacral promontory and pelvic floor Traumatic PPH Shock Sepsis 2.1. DECAPITATION Definition It is severing of the fetal head from the trunk for impacted shoulder presentation when the baby was dead.

is passed up over the child’s shoulder and turned over the neck. protected by the palm of the left hand. rotate it to cause fracture dislocation of the cervical spines then the soft tissue is cut by an embryotomy scissors with a blunt tip. 3.Instrument for decapitation 1.  The decapitation hook. 2. the neck is severed by sawing movement and if it is blunt.  If the hook is sharp. 6.  The trunk is delivered first by traction on the arm. 4. Catheter Decapitation hook and knife Embryotomy scissors Bone ribbing forceps Crotchet Obstetric forceps Cranioclast Procedure  Under general anaesthesia.  The head is then delivered by hooking a finger into the mouth or with a forceps. . 7.  Explore the birth canal. the prolapsed arm is grasped to bring the neck within easier access. 5.

strong straight embryotomy scissors or mayo’s scissors can be introduced to cut the clavicle. if the fetus is dead.3. CLEIDOTOMY Definition It is division of one or both clavicles with an embryotomy scissors or straight scissors introduced under the guidance of left two fingers placed inside the vagina to reduce the biacromial diameter in shoulder dystocia with a dead fetus. EVISCERATION Definition It is incision of the abdomen and/ or thorax to evacuate its viscera so reducing its size and allowing its vaginal delivery. Indication Dead fetus in shoulder dystocia Procedure One hand is placed vaginally along the ventral aspect of the fetus and under this protection a Kocher clamp can be introduced anteriorly to the clavicle and pulled back against the clavicle to fracture it. It is best to cut the skin over the clavicle first and push the scissors round the bone. Indications  Foetal ascitis  Neglected shoulder presentation with dead fetus  Thoracic or abdominal tumours. 4. Procedure . Alternatively.

 In addition to evisceration when the foetus is large or pelvis is deformed. Indications  Transverse impaction of a dead foetus when the neck cannot be reached.Under general anaesthesia. If the thorax has to be incised first the abdominal viscera can be reached via the diaphragm. 5. a large incision is made in the foetal abdomen with an embryotomy scissors then the viscera are evacuated manually. Procedure The vertebral column is divided by an embryotomy scissors. SPONDYLOTOMY Definition It is division of the vertebral column. Management of woman before destructive operation (from book) . The foetus is delivered in 2 halves by traction on one arm to deliver a half and on a leg to deliver the other.