obstetrical condition

1. MISS.BRIITO.VMISS.BRIITO.V
MSC(N) IN OBGMSC(N) IN OBG
VMCON.VMCON.
EMBRYOTOMIESEMBRYOTOMIES
(DESTRUCTIVE(DESTRUCTIVE
OPERATIONS)OPERATIONS)

3. OUTLINEOUTLINE
 INTRODUCTIONINTRODUCTION
 CRANIOTOMYCRANIOTOMY
 DECAPITATIONDECAPITATION
 EVICERATIONEVICERATION
 CLEIDOTOMYCLEIDOTOMY

4. INTRODUCTIONINTRODUCTION
 The destructive operations are designedThe destructive operations are designed
to diminish the bulk of the fetus toto diminish the bulk of the fetus to
facilitate easy delivery through the birthfacilitate easy delivery through the birth
canal. It may occasionally be necessary tocanal. It may occasionally be necessary to
destroy the fetus in the interest of savingdestroy the fetus in the interest of saving
the mother’s life. There are 4types ofthe mother’s life. There are 4types of
operations.operations.

5. CRANIOTOMYCRANIOTOMY
 It is an operation to make a perforation on the fetalIt is an operation to make a perforation on the fetal
head to evacuate the contents followed by extraction ofhead to evacuate the contents followed by extraction of
the fetus. The various instruments used for craniotomythe fetus. The various instruments used for craniotomy

6. INDICATIONSINDICATIONS
- Cephalic presentation producing obstructed laborCephalic presentation producing obstructed labor
with a dead fetus. This is the commenestwith a dead fetus. This is the commenest
indication of craniotomy in the referral hospitalsindication of craniotomy in the referral hospitals
of the developing countries.of the developing countries.
- Hydrocephalus even in a living fetus, this isHydrocephalus even in a living fetus, this is
applicable to the forecoming and after-comingapplicable to the forecoming and after-coming
head.head.
- Interlocking heads of twins.Interlocking heads of twins.
For the procedure to be done safely ,For the procedure to be done safely ,
the cervix must be fully dilated.the cervix must be fully dilated.

7. SITES FOR PERFORATIONSITES FOR PERFORATION
 Vertex:Vertex: on the parietal bone, on eitheron the parietal bone, on either
side of the sagittal suture.side of the sagittal suture.
 Face:Face: through the orbit or hard palate.through the orbit or hard palate.
 Brow:Brow: through the frontal bone.through the frontal bone.
Suture is avoided to preventSuture is avoided to prevent
collapse of the bone there bycollapse of the bone there by
preventing escape of brain matter.preventing escape of brain matter.

8. PROCEDUREPROCEDURE
 The obstetrician introduces two fingers (index &The obstetrician introduces two fingers (index &
middle ) into the vagina and the fingertips are placed onmiddle ) into the vagina and the fingertips are placed on
the proposed site of perforation. If the suture linethe proposed site of perforation. If the suture line
cannot be defined because of a big caput, thecannot be defined because of a big caput, the
perforation is done through the dependent part.perforation is done through the dependent part.
 An assisstant fixes the head suprapubically while theAn assisstant fixes the head suprapubically while the
operator introduces the perforator with the bladesoperator introduces the perforator with the blades
closed, protecting the anterior vaginal wall and theclosed, protecting the anterior vaginal wall and the
bladder with the fingers in the vagina. when the tipbladder with the fingers in the vagina. when the tip
reaches the site of perforation , the skull is perforatedreaches the site of perforation , the skull is perforated
using rotating movements. After the skull is perforated ,using rotating movements. After the skull is perforated ,
the instrument the instrument is advanced further andthe instrument the instrument is advanced further and
handles are approximated so as to allow separation ofhandles are approximated so as to allow separation of

9. the sharp blades which will extend the perforation.the sharp blades which will extend the perforation.
The blades are then apposed and brought outThe blades are then apposed and brought out
keeping the tip of blades still inside the cranium.keeping the tip of blades still inside the cranium.
The perforation is then rotated at right angles andThe perforation is then rotated at right angles and
the above step is perforated to make thethe above step is perforated to make the
perforated area look like a cross.perforated area look like a cross.
The instrument with the blades closed in againThe instrument with the blades closed in again
thrust beyond the guard , to churn the brainthrust beyond the guard , to churn the brain
matter. After the brain matter is churned, thematter. After the brain matter is churned, the
perforator is brought out under the guidance of 2perforator is brought out under the guidance of 2
fingers still placed in the vagina.fingers still placed in the vagina.

10.  Similar procedure could be performed using aSimilar procedure could be performed using a
sharp- pointed mayo scissors. With the fingers,sharp- pointed mayo scissors. With the fingers,
the brain matter is evacuated in order to makethe brain matter is evacuated in order to make
the skull collpase as much as possible.the skull collpase as much as possible.
 When the skull is found sufficiently compressed ,When the skull is found sufficiently compressed ,
the extraction of the fetus is achived either bythe extraction of the fetus is achived either by
using a cranioclast or by two giant vulsella.using a cranioclast or by two giant vulsella.
Trction is now exerted in the same direction as inTrction is now exerted in the same direction as in
forceps operation. After the delivery of theforceps operation. After the delivery of the
placenta, the vaginal canal and uterus areplacenta, the vaginal canal and uterus are
explored for evidence of any tear or rupture.explored for evidence of any tear or rupture.
Injection methergine is given and rest of theInjection methergine is given and rest of the
delivery is completed as in normal delivery.delivery is completed as in normal delivery.

11.  In after coming head of breech , the perforationIn after coming head of breech , the perforation
is done through the occipital bone while theis done through the occipital bone while the
baby is being pulled forwards or backwards tobaby is being pulled forwards or backwards to
fix the head during perforation. After thefix the head during perforation. After the
perforation , the brain matter is evacuated byperforation , the brain matter is evacuated by
traction on legs.traction on legs.

12. DECAPITATION

13. DECAPITATIONDECAPITATION
- It is a destructive operation in which the fetal head is- It is a destructive operation in which the fetal head is
severed from the trunk and the delivery is completedsevered from the trunk and the delivery is completed
with the extraction of the trunk and then of thewith the extraction of the trunk and then of the
decapitated head per vagina. Special instrument useddecapitated head per vagina. Special instrument used
for decapitation.for decapitation.

14. INDICATIONSINDICATIONS
 neglected shoulder presentation with dead fetusneglected shoulder presentation with dead fetus
where the neck is easily accessiblewhere the neck is easily accessible
 Interlocking head of twins.Interlocking head of twins.

15. PROCEDUREPROCEDURE
 If the fetal hand is not prolapsed , a hand isIf the fetal hand is not prolapsed , a hand is
brought down. For this, a roller gauze is tied onbrought down. For this, a roller gauze is tied on
the wrist and an assisstant gives head to makethe wrist and an assisstant gives head to make
the neck more accessible and fixed. Two fingersthe neck more accessible and fixed. Two fingers
of the hand (index & middle) are thenof the hand (index & middle) are then
introduced into the vagina with the palmarintroduced into the vagina with the palmar
surface downwards and the fingertips are placedsurface downwards and the fingertips are placed
on the superior surface of the neck. Theon the superior surface of the neck. The
decapitation hook with knife is introduced underdecapitation hook with knife is introduced under
the guidance of the fingers in the vagina, thethe guidance of the fingers in the vagina, the
knob pointing towards the fetal head. The hookknob pointing towards the fetal head. The hook

16. is pushed above the neck and rotated about 90is pushed above the neck and rotated about 90
degree to place the knife firmly against the neck.degree to place the knife firmly against the neck.
- By upward and downward movement of theBy upward and downward movement of the
hook with knife , the vertebral column ishook with knife , the vertebral column is
severed. The rest of the soft tissue may besevered. The rest of the soft tissue may be
severed by the same instrument or by ansevered by the same instrument or by an
embryotomy scissors. The decapitated head isembryotomy scissors. The decapitated head is
pushed up and the trunk is delivered by tractionpushed up and the trunk is delivered by traction
of the prolapsed arm.of the prolapsed arm.
- The decapitated head is delivered by using theThe decapitated head is delivered by using the
crochet or forceps. The neck is severed by thecrochet or forceps. The neck is severed by the
wire saw after passing the wire loop aroung thewire saw after passing the wire loop aroung the
fetal neck.fetal neck.

17. EVICERATIONEVICERATION

18. EVICERATIONEVICERATION
- The operation consists of thoracic andThe operation consists of thoracic and
abdominal contents piecemeal throughabdominal contents piecemeal through
an opening on the thoracic oran opening on the thoracic or
abdominal cavity at the most accessibleabdominal cavity at the most accessible
site. The objective is to diminish thesite. The objective is to diminish the
bulk of the fetus, which facilitates thebulk of the fetus, which facilitates the
extraction.extraction.

19. INDICATIONSINDICATIONS
- Gross fetal malformations such as fetalGross fetal malformations such as fetal
ascitis or hugely distended bladder.ascitis or hugely distended bladder.
- Neglected shoulder presentation withNeglected shoulder presentation with
dead fetus and neck is not easilydead fetus and neck is not easily
accessible. The procedure is moreaccessible. The procedure is more
feasible in a breech presentation.feasible in a breech presentation.
Embryotomy scissors are used for theEmbryotomy scissors are used for the
procedure.procedure.

20. CLEIDOTOMY

21. CLEIDOTOMYCLEIDOTOMY
 the operation consists of reduction ofthe operation consists of reduction of
the width of the shoulder girdle bythe width of the shoulder girdle by
division of one or both the clavicles.division of one or both the clavicles.
The operation is done only in deadThe operation is done only in dead
fetus with shoulder dystocia. Thefetus with shoulder dystocia. The
clavicles are divided by theclavicles are divided by the
embryotomy scissors or long straightembryotomy scissors or long straight
scissors introduced under the guidancescissors introduced under the guidance
of two fingers of left hand placed insideof two fingers of left hand placed inside
the vagina.the vagina.

22. Postoperative care following destructivePostoperative care following destructive
operationsoperations
1. Self retaining (folys) catheter is1. Self retaining (folys) catheter is
inserted following craniotomy andinserted following craniotomy and
maintained for 3 to 5 or until bladdermaintained for 3 to 5 or until bladder
tone is regained.tone is regained.
2. Intra venous drip is to be continued2. Intra venous drip is to be continued
until dehydration is corrected. Blooduntil dehydration is corrected. Blood
transfusion may be given if required.transfusion may be given if required.
3. Antibiotic is given either parentally or3. Antibiotic is given either parentally or
orally.orally.

23. COMPLICATIONSCOMPLICATIONS
 Injury to the uterovaginal canal.Injury to the uterovaginal canal.
 Postpartum hemorrhage: atonic or traumaticPostpartum hemorrhage: atonic or traumatic
 Shock: due to blood loss and or dehydrationsShock: due to blood loss and or dehydrations
 Puerpheral sepsisPuerpheral sepsis
 Subinvolution of the uterusSubinvolution of the uterus
 Injry to the adjacent viscera.Injry to the adjacent viscera.

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