This document provides guidelines for performing destructive operations to deliver a dead baby when the cervix is dilated. Key steps include: 1. Performing the operation in the operating theater with a laparotomy set ready in case of uterine rupture. 2. Using an Olhams perforator to perforate the fetal skull and evacuate the brain matter before extracting the fetus. 3. Checking for tears after delivery and providing antibiotics and oxytocics to reduce infection risk and ensure uterine contraction. 4. Monitoring closely for postpartum hemorrhage, urinary retention, and infection in the first two weeks.

1. Operations

3.  REDUCE THE OBSTRUCTION
 AVOID SCAR FOR A DEAD BABY
PREVENT INFECTION
 EARLY RECOVERY

4.  􀂉Need few instruments & simple anesthesia.
 􀂉Uterus remains intact , ( no scar of L.S.C.S.
).
 􀂉Subsequent pregnancy will be safer.
 􀂉Operative morbidity is lesser .
 􀂉Hospital stay is shorter.
 􀂉Useful specially in teenage pregnancy.

8.  (1) The baby must be dead.
 (2) 2/5 or less of his head must be above the brim
(if it is higher than this, Caesarean section is
usually safer, although if you are expert you may
be able to do it at 3/5).
 (3) His head must be impacted.

9.  (4) His mother's cervix must be at least 7 cm
dilated, and preferably fully dilated. One
contributor gives 5 cm as the minimum.
 (5) Her uterus must be unruptured, and not in
imminent danger of rupturing.

11.  Always do a destructive operation in the
theatre with a laparotomy set ready for
immediate use.

12.  Chloramphenicol 1 g intravenously. Or,
 Penicillin 5 megaunits intravenously with
streptomycin 1 g intramuscularly.

14.  Catheterize her bladder.
 Ask assistant to hold 1 or 2 Sims' specula in
her vagina

15.  Ask another assistant, standing on a
footstool if necessary, to steady the baby's
head suprapubically,

17.  THE TWO FINGERS are introduced in to the
vagina and finger are placed on the proposed
site of perforation

18.  VERTEX
 On the parietal bone on either side of sagital
suture

19.  Frontal bone

20.  Orbit or hard palate

21.  The olhams perforator with blades closed
introduced under the palmar aspect of the
fingers

23.  By rotating movements skull is perforated
and handles are approximated.
 The instrument again rotated at right angle
and repeat procedure.

24.  With fingers brain matter evacuated

25.  Extaction of fetus

26.  METHODS OF EXTRACTION
 1) LEFT TO NATURAL FORCES
 2)USE FORCEPS/ VULSELLUM
 3)CEPHALOTRIBE
 4)CRANIOCLASM

29.  Traction same like forceps

30.  Delivery of placenta

31.  In which fetal head is severed from trunkand
the delivery is completed with the extraction
of the trunk and that of the decapitated
head pervaginum

32.  No role in modern obstetrics
 􀂉Unpleasant
 􀂉Unacceptable level of maternal traumatic and
psychological morbidity
 􀂉Complicated intrauterine procedure
 􀂉Chances of injury to obstetrician
 In HIV era
 􀂉Caesarean section is safer alternative

33.  Neglected shoulder presentation with dead
fetus
 Interlocking head of twins

35.  If fetal hand prolapsed ,bring down a hand
.roller gauze is tied on the wrist and assitant
is asked to give traction away from fetal
head

37.  Two fingers and placed over superior surface
of neck

43.  CAUTION ! After any destructive operation,
be sure your assistant wraps up the baby
immediately he is delivered. His mother must
not see him.

44.  Remove the placenta manually, and immediately
feel for tears of her uterus and lower segment.
 Give ergometrine 0.25 mg intravenously.
 Check uterus by feeling inside it to make sure it has
not ruptured. If it has ruptured, do a laparotomy and
repair it.
 Check cervix, vagina, and vulva for tears. If tear is
present in cervix it will need suturing.

45.  If her uterus is not well contracted, set up an
intravenous oxytocin drip with 20 units in 500 ml.
Continue the saline drip for 24 hours.
 Continue the perioperative antibiotics .

46.  She is at risk from:
(1) Postpartum haemorrhage in the first 24 hours.
(2) Acute urinary retention in the first 24 hours.
(3) Infection of her genital tract after 24 hours.
(4) Infection of her urinary tract at 7 to 10 days.
(5) A fistula.

47.  If his head has been impacted in her pelvis for many
days, leave a Foley catheter in for 14 days. This will
help to prevent a fistula.
 Obstructed labour with a transverse lie does not
cause pressure necrosis of the vagina, so a few days'
drainage is enough.

48.  Remove the placenta manually, and
immediately feel for tears of her uterus and
lower segment.
 Give her ergometrine 0.25 mg intravenously
as he is delivered.
 Check her uterus by feeling inside it to make
sure it has not ruptured. If it has ruptured,
do a laparotomy and repair it .
 Check her cervix, vagina, and vulva for tears.
If she has a tear of her cervix it will need
suturing

49.  Do you think destructive operations can be
performed on a live baby ?

50.  Moribund baby.
 FHR below 40 per minute , Sinusoidal pattern
, non re-assuring FHR pattern.
 􀂉Where LSCS is hazardous to mother.
 Severe anemia , shock , poor anesthetic
risks.
 􀂉LSCS scar is not acceptable in view of future
child bearing performance

52.  􀂉2947 PATIENTS WITH OBSTRUCTED LABOR
 􀂉67 MET THE CRITERIA FOR
DEST.OPERATION
 􀂉ONLY 11 UNDERWENT DEST.OPERATION
56 UNDERWENT LSCS

53.  3 MATERNAL DEATHS IN LSCS GROUP
 􀁹NO DEATH IN CRANIOTOMY
 􀁹INFECTION, BLOOD TRANSFUSION, VVF,
ASHERMAN HIGHER IN LSCS GROUP
 􀁹CONSULTANTS MORE LIKELY TO DO
DESTRUCTIVE OPERATIONS