Definition

The destructive operations are designed to

diminish the bulk of the fetus so as to

facilitate easy delivery through the birth

canal
Types

 Craniotomy

 Eviceration

 Decapitation

 Cleidotomy
 CRANIOTOMY

 Definition

It is an operation to make a perforation on the fetal

head to evacuate the contents followed by extraction of

the fetus
Indications

 Cephalic presentation producing obstructed labour with

dead fetus

 Hydrocephalus even in a living fetus

 Interlocking head of twins

 Conditions to be fulfilled

 The cervix must be fully dilated

 Baby must be dead

 Contraindication

 When the pelvis is severely contracted

 Rupture of uterus where laparotomy is essential

Procedures
 PRELIMINARIES
 General anaesthesia

 Lithotomy position

 Surgical asepsis

 Empty the bladder

 Vaginal examination
Cont…

 ACTUAL STEPS

 Step 1

 Introduce two fingers into the vagina (index and

middle)

 Do incision through the suture line or dependent

part
Sites of perforation

 Vertex - On the parietal bone either side of the

sagittal suture

 Face -Through the orbit or hard palate

 Brow -Through the frontal bone

 Step 2

 Introduce the Oldham’s perforator or Sharp pointed

Mayo scissors with the blades closed

 Step 3

 By rotating movements perforate the skull

 Step 4

 Evacuate the brain matter with the fingers

Cont…
 Step 5
 Extract the fetus either by using a cranioclast or by
two giant volsella
 Step 6

 Exert traction

 Step 7

 Explore the utero-vaginal canal after the delivery

of the placenta
 DECAPITATION

 Definition

It is a 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 vaginam

Indication

 Neglected shoulder presentation with dead fetus where

neck is easily accessible

 Interlocking head of twins

PROCEDURE

 Actual Steps

 Step 1

 Bring down a hand and tie a roller gauze on the fetal wrist
and give traction towards the side away from the fetal head

 Step 2

 Two fingers of the left hand are introduced with palmar

surface downwards and the finger tips to be placed on the
superior surface of the neck.
Cont….
 Step 3

 The decapitation hook with knife is introduced flushed under

the guidance of the finger placed into the vagina the knob
pointing towards the fetal head

 The hook is pushed above the neck and rotated to 90 degree

so as to place the knife firmly against the neck

 The internal fingers are placed on the under surface of the

neck to guard the tip of the hook
Cont…
 Step 4
 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

 The decapitation hook is pushed up and rotated to 90 degree and

then to taken out under the guidance of the internal fingers

 The decapited head is pushed up and the trunk is delivered by

traction on the prolapsed arm
Cont…
 Step 5
 Delivery of the decapited head
 By hooking the index finger into the mouth
 By using crochet after fixing it with lower jaw
 By holding the severed neck with giant vulsellum and
delivery of the head as that of aftercoming head in breech
 Using forceps or following perforation after fixing the head
with forceps blades
 Step 6
 Routine exploration of the utero-vaginal canal to exclude
rupture of the uterus or any other injury
DECAPITATION USING BLOND- HEIDLER
THIMBLE AND WIRES SAW

 The neck is severed by the wire saw after passing the

wire loop around the fetal neck

 EVISCERATION

 Definition

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
Indication

 Neglected shoulder presentation with dead fetus

 Fetal malformations ,such as fetal ascites or hugely

distended bladder or monsters

 CLEIDOTOMY
 Definition

The operation consist of reduction in the bulk of the shoulder

girdle by division of one or both the clavicles

 Indications

 Dead fetus with shoulder dystocia

 Procedure

 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

 Exploration of the utero-vaginal canal

 Self retaining catheter

 Dextrose saline drip

 Blood transfusion

 Ampicillin 500mg at 6 hours interval

 COMPLICATION

 Injury to the utero-vaginal canal

 Post partum haemorrhage

 Shock

 Puerperal sepsis

 Subinvolution

 Injury to the adjacent viscera

 Prolonged ill health