This document discusses destructive obstetric operations that were historically performed to facilitate delivery when the fetus could not be delivered intact due to cephalopelvic disproportion or other complications. It describes procedures such as craniotomy, decapitation, cleidotomy, evisceration, and spondylotomy. These procedures aimed to reduce the size of the fetal head, shoulders, or trunk to allow vaginal delivery but carried risks of injury, hemorrhage, and infection and have largely been replaced by Caesarean section. The document provides details of how each procedure was performed and notes that they require general anesthesia and careful post-operative monitoring of the mother.

1. DESTRUCTIVE OPERATIONS
BY:
MS.LOORTHU SELVI
M.SC(N)

2. INTRODUCTION
• The destructive operations are designed to
diminish the bilk of the uterus to facilitate
easy delivery through the birth canal. It
may occasionally be necessary to destroy
the fetus in the interest of saving the
mother life.

3. DEFINITION
• These are a group of operations aims at reducing the
size of the head, shoulder girdle or trunk of the dead
fetus to allow its vaginal delivery. It has been
abandoned from the modern obstetrics in favor of
caesarean section which is safer to the mother.

4. PROCEDURES
• Craniotomy.
• Decapitation.
• Cleidotomy.
• Evisceration
• Spondylotomy.

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

6. • 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.

7. CRANIOTOMY
• Definitions
• Craniotomy: perforation of the foetal head (cranium).
• Cranioclasm: crushing of the cranium.
• Cephalotripsy: crushing of the whole head including
the base of the skull.

8. • Indications
• Hydrocephalus.
• Retained after-coming head of a dead foetus.
• Cephalopelvic disproportion with a dead foetus.
• Impacted malpresented dead foetus as mento-
posterior and brow presentation.

9. • Sites of Perforation
• Vertex presentation: The anterior fontanelle or in the
parietal bone as near as to it.
• After - coming head:
– The roof of the mouth.
– The foramen magnum.

10. – The occipital bone behind the mastoid .
– Through the spina bifida if present by a stiff
catheter passed up to the spinal canal .
• Face: The orbit.
• Brow: The frontal bone.

12. Procedure
• Perforation
• Under general anesthesia the bladder is evacuated and
head is steadied by an assistant.
• 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.

13. • 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 perforator is closed, rotated 90o and re-opened
again thus producing a cruciate incision. The resultant
hole is enlarged by the closed perforator which is
pushed to allow drainage of the CSF and brain matter.

14. • The closed perforator is withdrawn while its tip is
protected by the fingers.
• Alternative methods:
– Needle aspiration vaginally: through the fontanels or
suture line after steadying the head with Jacob’s
tenaculum.
– Trans - abdominal aspiration with a syringe or spinal
needle.

15. • Extraction
• Spontaneous delivery can occur after reduction of the
size of hydrocephalus.
• Two volsella or Willet’s scalp forceps may be applied
for traction.
• Forceps can be applied if there is no disproportion.

16. • 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 after - coming head is delivered as in breech
delivery.
• The birth canal should be explored after delivery.

18. DECAPITATION
• Definition
• It is severing of the fetal head from the trunk.
• Indication
• Neglected shoulder with a dead fetus.
• Locked twins.
• Double -headed monsters.

21. • Procedure
• Under general anesthesia, the prolapsed arm is
grasped to bring the neck within easier access.
• The decapitation hook, protected by the palm of the
left hand, is passed up over the child’s shoulder and
turned over the neck.

22. • If the hook is sharp, the neck is severed by sawing
movement and if it is blunt, rotate it to cause fracture
dislocation of the cervical spines then the soft tissue
is cut by an embryotomy scissors with a blunt tip.

23. • The trunk is delivered first by traction on the arm.
• The head is then delivered by hooking a finger into
the mouth or with a forceps.
• Explore the birth canal.

25. CLEIDOTOMY
• Definition
• It is division of one or both clavicles with an
embryotomy scissors to reduce the biacromial
diameter in shoulder dystocia with a dead fetus.

27. EVICERATION
• Definition
• It is incision of the abdomen and/ or thorax to evacuate
its viscera so reducing its size and allowing its vaginal
delivery.
• Indications
• Foetal ascitis.
• Thoracic or abdominal tumours.

28. • Procedure
• Under general anesthesia, a large incision is made in
the fetal abdomen with an embryotomy scissors then
the viscera are evacuated manually.
If the thorax has to be incised first the abdominal
viscera can be reached via the diaphragm.

30. SPONDYLOTOMY
• Definition
• It is division of the vertebral column.
• Indications
• Transverse impaction of a dead fetus when the neck
cannot be reached.
• In addition to evisceration when the fetus is large or
pelvis is deformed.

31. • Procedure
• The vertebral column is divided by an embryotomy
scissors. The fetus is delivered in 2 halves by traction
on one arm to deliver a half and on a leg to deliver the
other.

32. POSTOPERATIVE CARE
• A self retaining catheter inserted following
craniotomy till 3-5 days until bladder tone is
regained.
• IV to be continued until dehydration is corrected.
Blood transfusion if necessary.
• Antibiotics.

33. COMPLICATIONS
• Injury to uterovaginal canal
• PPH
• Shock due to blood loss
• Puerperal sepsis
• Sub involution of uterus
• Vesicovaginal fistula or rectovaginal fistula

34. CONCLUSION
• Dear future mothers, eat health, stay safe and don’t
make to die due to your carelessness. And my soul
can’t bare this kind of operations. And as a nurse
midwife we should know about the procedures and its
pre and post care to prevent further complications
which can arise to the mother.

35. THANKYOU