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