DESTRUCTIVE
OPERATIONS
Presented By:
Ms. Priya
M.Sc. Nursing 2nd Year
Introduction
The place of destructive operations in
modern obstetrics is highly controversial. In most
of the western countries leaving aside the special
case of hydrocephalic fetus, caesarean section has
without any doubt superseded this complicated
procedure. But in developing countries like India,
it is still practiced in rural obstetrics. Where a lot
of areas are still untouched by the advanced
medical and surgical practice.
Definition
The destructive operations are designed to
diminish the bulk of the fetus so as to facilitate
easy delivery through the birth canal.
Purposes
To reduce baby’s size (head, shoulder girdle or
body) which is too large to pass intact through
the birth canal.
To facilitate easy delivery through the birth
canal.
Indications
If the labour is prolonged and neglected and the
fetus is dead.
Skill staff is not available to carry out CS
immediately.
Risk of overwhelming infection.
The patient or relative insist on a vaginal delivery,
and do not give consent for CS.
There will be no skilled supervision in the
subsequent pregnancy hence, she does not want a
cesarean.
Decompression of gross hydrocephalus.
“Destructive for the Fetus, Constructive for the
living Mother”
Types of Destructive Operations
1.Decompression of hydrocephalic head.
2.Craniotomy
3. Decapitation
4. Evisceration
5. Cleidotomy
6. spondylotomy
1. Decompression of Hydrocephalic Head
Indication: Dead Hydrocephalic Fetus
Cerebrospinal fluid (CSF) is drained (before full dilatation)
by the most accessible presenting part per vaginam.
Head collapses, it can be delivered per vaginally, after
the cervix is fully Dilated
Decompression by drainage of C.S.F
2. Craniotomy
It is an operation to make a perforation on the fetal
head, to evacuate the contents followed by extraction of the
fetus.
It literally means opening of the cranium (head) of the fetus.
This is done in order to decompress the head and diminish
the bulk of the head of the fetus (by removing accumulated
fluid and brain matter) with the objective to permit easy
delivery of the dead fetus through the parturient canal.
This operation is still being practiced and is one of the easiest
to perform.
Indications
Cephalic presentation producing obstructed labour with
dead fetus.
Hydrocephalus even in a living fetus.
Interlocking head of twins.
Conditions to be fulfilled
1. The cervix must be fully dilated
2. Baby must be dead (hydrocephalus being extracted)
Contraindication:
The operation should not be done when the pelvis is
severely contracted as shorten the true conjugate to less
than 7.5cm.
Rupture of the uterus where laparotomy is essential.
3. Decapitation
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
vaginum.
Indications:
Neglected shoulder presentation with dead fetus where neck
is easily accessible.
Interlocking head of the twins.
4. Evisceration
The operation consists of removal of thoracic and
abdominal contents piecemeal through an opening on the
thoracic or abdominal cavity at the most accessible.
Indications:
Neglected shoulder presentation with dead fetus; the
neck is not easily accessible.
Fetal malformations, such as fetal ascites or hugely
distended bladder or monsters.
5. Cleidotomy
The operation consists of reduction in the bulk of the
shoulder girdle by division of one or both the clavicles.
Indication
Done only on the dead fetus (anencephaly excluded)
with shoulder dystocia.
Spondylotomy
It involves fracturing and cutting the spine and may
be used in conjunction with any other operations.
Prerequisites
The fetus must be dead or grossly malformed with the
malformations being incompatible with life.
The pelvis should not be grossly contracted. True
conjugate should be more than 7.5 cm. the maternal pelvis
must have sufficient room to accommodate the destructive
instruments, permitting their application and manipulation
and allowing extraction of the body of the fetus.
Cervix more than three-forth dilated – The more dilated
the cervix, the safer the operation. In case of gross
hydrocephalus, the uterus ruptures before full dilatation of
cervix.
There should not be any pathological lesion of the cervix
(carcinoma ).
There should not be any obstructing pelvic tumor
(fibromyoma, ovarian tumor) is carried out
Ultasonography is carried out to confirm fetal status (if
available & possible)
Postoperative care after Destructive operations
Exploration of the uterovaginal canal must be done to
exclude rupture of the uterus or lacerations on the vagina or
any genital injury.
A self –retaining (Foley’s) catheter is put inside, especially
following craniotomy for the period of 3-5 days or until the
bladder tone is regained.
Dextrose saline drip is to be continuing till dehydration is
correct. Blood transfusion may be given, if required.
Ceftriaxone 1g IV infusion is given twice daily.
Complications
Vaginal and cervical lacerations.
Uterine rupture (generally lower uterine segment)
Injury to adjacent viscera –
Urinary Bladder- vesicovaginal fistula (VVF) formation.
Rectal wall- rectovaginal fistula (RVF) formation.
Postpartum hemorrhage
Traumatic
Atonic
Shock
Hemorrhagic
Hypovolemic
Neurogenic
Puerperal sepsis
Subinvolution of the uterus
Prolonged ill health
Role of Destructive Operations
No role in modern obstetrics.
Unpleasant and unacceptable level of maternal
traumatic and psychological morbidity.
Complicated intrauterine procedure.
Chances of injury to obstetrician in HIV era.
Caesarean section is much safer alternative.
Research Evidence
Destructive Operation- A vanishing art in modern
obstetrics: 25 years experience at a tertiary care center in
India
Research study has been done in PGIMER over 25
years from 1983 to 2007, study was planned to define the
changing role of destructive operations in obstetrics over
the years as much number of abdominal deliveries are
conducted in modern day obstetrics than these procedures it
was a retrospective analysis from a total of 85952 deliveries
in these 25 years there were 25,474 cesarean section
(29.63%) and 8,826 (10.26%) operative vaginal deliveries.
Total no. of destructive operations performed was 230
(0.26%). There were 202 craniotomies (87.8%), 13
decapitations (5.75%), 8 eviscerations (3.6%) and 7
cleidotomies (2.9%). There should be an individualized
approach to each case of obstructed labour. If the fetus is
dead, a destructive procedure can be considered in place of
abdominal- route delivery which carries considerable risk
to the debilitated mother in neglected labour.
Counseling is the key to prevent the mother from
prolonged psychological morbidity.
