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without any doubt superseded this complicated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.