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Obstetrics Simplified - Diaa M. EI-Mowafi

Destructive Operations (Embryotomy)

Definition

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

Procedures

  • Craniotomy.       
  • Decapitation.        
  • Cleidotomy.     
  • Evisceration  
  • Spondylotomy.

Contraindications

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

Complications

  • Uterine rupture. 
  • Injuries to the genital tract.

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.

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.

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.
    • 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.

Procedure

Perforation

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  • The closed perforator is withdrawn while its tip is protected by the fingers.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

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.
  • 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.

DECAPITATION

Definition

It is severing of the foetal head from the trunk.

Indication

  • Neglected shoulder with a dead foetus.
  • Locked twins.
  • Double -headed monsters.

Procedure

  • Under general anaesthesia, 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.
  • 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.
  • 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.

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 foetus.

EVISCERATION

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.

Procedure

Under general anaesthesia, a large incision is made in the foetal 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.

SPONDYLOTOMY

Definition

It is division of the vertebral column.

Indications

  • Transverse impaction of a dead foetus when the neck cannot be reached.
  • In addition to evisceration when the foetus is large or pelvis is deformed.

Procedure

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