DESTRUCTIVE OPERATIONS

                                    DESTRUCTIVE OPERATIONS

The destructive operation are designed to diminish the bulk of the  fetus so as to  facilitate easy delivery  through the birth canal. Neglected obstrectics  requiring destructive operations are completely preventable. These procedure are difficult and may be dangerous too unless the operator is sufficiently skilled. Some commonly performed operations are

Craniotomy

Evisceration

Decapitation

Cleidotomy

CRANIOTOMY

Definition

It is an operation to make a perforation on the fetal head , to evacuate thecontent followed by extraction of the fetus.

Indications

      Cephalic presentation producing obstructed labour with dead fetus

      Hydrocephalus  even in a living fetus – this is applicable for bith forecoming and aftercoming head .

      Interlocking head of twins

Condition to be full filled 

®    The cervix must be fully dilated

®    Baby must be dead

Contraindication

®    The operation should not be done when the pelvis is severly contracted. So as to shortened the true conjugate to less than 7.5cm (3``). In such condition the baby cannot be delivered as the bimastoid diameter 7.5cm which cannot be compressed.

®    Rupture of the uterus were laprotomy is essential

Procedure

Step1

Two fingers are introduced in to the vagina and the finger tips are to be planned 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.

Site of preparation

Vertex:- on the parietal bone either side of the sagittal sutures is avoided to prevent collapse of the bone thereby preventing escape of the brain matter

Face :- through the orbit or hard plate

Brow :-  through the frontal bone

Step 2

The Oldham’s perforator , with the blades closed , is introduced under the palmaraspect of the fingers protecting the anterior vaginal wall and the adjacent bladder until the tip reaches the proposed site of perforation.

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 shoulder and the handles approximated ,so as to allow separation of the sharp blades for about 2.5 cm .   

            The blades are again apposed by separating the handles. The instruments is brought out keeping the tip of the blades still inside the cranium the instruments is rotated at right angle and then again threst inup to the shoulders. The handles are once more to be compressed of as to separate the blades for about 2.5cm. The perforator area now looks like a cross. The instruments with the blades closed is then thrust in beyond the guard to churn the brain matter. The instruments 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.

Step 4 :- With the fingers brain matter is evaluated. The idea is to make the skull collapsed as much as possible.

Step 5 :-when the skull is found sufficiently compressed, the extraction of the fetus is achieved either by using cranioclast or by two Gaint Vulsella are used to hold the incised skull and scalp margins.

Step 6 :- the traction is now excreted in the same direction is like that mentioned in forceps operations.

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. Methergin 0.2mg is to be given intravenously with the delivery of the anterior shoulder. The rest of the delivery is completed as in normal delivery.

Forceps Vs craniotomy in a dead fetus

If the delivery of the uncompressed head can be accomplished with out much force with consequent injuries to the mother, forceps delivery is preferred. But if it is found difficult and damaging to the mother, craniotomy is safer.

DECAPITATION 

Definition

It is a destructive operation where by 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 vaginam.

Indication

¨      Neglected shoulder presentation with dead fetus where neck is easily assessable

¨      Interlocking head of the twins

Procedure

The operation should be done at general anesthesia

Actual step

Step 1 :- if the fetal hand is not prolapsed bring down the hand. A roller gauze is tied on the fetal wrist and assistant is asked to give the traction towards the side away from the fetal head to make the neck more assessable and fixed

Step 2 :- two fingers of the left hand are introduced with the palmar surface downwards and the finger tips are to be placed on the superior surface of the neck –the prolapsed site of decapitation.

Step 3 :- the decapitation hook with knife is to be introduced flushed under the guidance of the fingers placed in to the vagina, trhe knob pointing toward the fetal head. The hook is pushed above the neck and rotated to 90 ̊ , so as to placed the knife firmly against the neck.

Step 4 :- by upward and downward movement of the hook with knife the vertebral column is severed.

Step 5:- delivery of the decapitation head – the methods are

• By hooking the index fingers into the mouth
• By holding the severed head with Giant Vulsellum and delivery of he head as that of aftercoming head in breech.
• Using forceps

Step 6 :- routine exploration of the utero vaginal canal to exclude rupture of the uterus or any other injury.

EVISCERATION

The operation consists in removal of thoracic and abdominal contents piecemeal through an opening on the thoracic or abdominal cavity at the most accessible site. The object is to diminish the bulk of the fetus which facilitates its extraction.

If difficulty arises , the spine may haveto be divided ( spondylotomy) with embryotomy scissors.

Indication 

Ø  Neglected shoulder presentation with dead fetus , the neck is not easily assessable.

Ø  Fetal malformation such as fetal ascites or hugely distended bladder or monsters.

CLEIDOTOMY

The operation consists of reduction in the bulk of the shoulder girdle by division of one or both the clavicles.

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.

Post operative care following destructive operation

®    Exploration of the utero-vaginal canal must be done to exclude rupture of the uterus or lacerations on the vagina or any genital injury.

®    A self retaining 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 .

®    Ceftriaxone 1gm IV infusion is given twice daily.

Complications

Ø  Injury to the utero-vaginal canal

Ø  Rupture of the uterus

Ø  Post partum haemorrhage-atonic or traumatic

Ø  Shock due to blood loss and or dehydration

Ø  Puerperal sepsis

Ø  Subinvolution

Ø  Injury to the adjacent viscera

Ø  Prolonged ill health

Nursing diagnosis

1.      Alteration in comfort due to pain related to delivery process

®    Assess the types of pain ,types , duration and intensity

®    Provide comfortable  left lateral position to the mother

®    Provide psychological reassurance  to the mother

2.      Potential for complication related to destructive operation

®    Assess for any types of laceration

®    Maintain aseptic technique

®    Handle the case carefully

®    Case should handle by experts

®    Clean the perineal area with betadine

3.      Potential for infection  related to destructive operation  

Assess for any scar

®    Maintain strict aseptic technique

®    Clean the surrounding

®    Avoid many visitors

4.      Fear and anxiety of parents related to delivery process

®    Provide proper explanation about babies condition

®    Give information about progress of delivery frequently

®    Provide psychological reassurance to the mother 

®    Clarify the mother doubts