DESTRUCTIVE OPERATION

INTRODUCTION
The destructive operations are designed to diminish the bulk of the fetus so as to facilitate easy delivery through the birth canal. These procedures are difficult and may be dangerous too unless the operator is sufficiently skilled.

Commonly performed operations are Craniotomy Evisceration Decapitation Cleidotomy

1. CRANIOTOMY
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

CONTRAINDICATIONS The operation should not be done when the pelvis is severely contracted Rupture of the uterus where laprotomy is essential

PROCEDURE
PRELIMINARIES Take consent The patients is asked to empty her bladder. She is to lie on her back with the shoulders slightly raised and the thighs slightly flexed.

Administer anaesthesia

 Step 1: The two fingers are introduced into the vagina and the finger tips are to be placed on proposed site of perforation. 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 : the Oldhams perforator with the blades close, is introduced under the palmar aspect 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 shoulders and the handles are approximated so as to allow separation of the sharp blades for about 2.5cm.

 The blades are again apposed by separating the handles. The instrument is brought out keeping the tip of the blades still inside the cranium. The instrument is rotated at right angle and then again thrust in up to the shoulders. The handles are once more to be compressed so as to separate the blades for about 2.5 cm. The instrument with the blades close is then thrust in beyond the guard to churn the brain matter. The instrument, with the blades closed is brought out under the guidance of the two fingers still placed inside the vagina.

 Step 4: with the fingers brain matters is evacuated. The idea is to make the skull collapse as much as possible Step 5: when the skull is found sufficiently compressed, the extraction of the fetus is achieved either by using a cranioblast or by two giant volsella. Giant volsella are used to hold the incised skull and scalp margins. Step 6: the traction is now exerted

 Step 7: after the delivery of the placenta, the utero vaginal canal must be explored as a routine for evidence of rupture of uterus or any tear. Inj. Methergin 0.2 mg is to be given IM with the delivery of the anterior shoulder. The rest of the delivery is completed as in normal delivery. Alternative to Oldhams perforator, similar procedure could be performed using sharp pointed Mayos scissor

DECAPITATION
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

PROCEDURES Preliminaries : same as before. ACTUAL STEPS Step 1: if the fetal hand is not prolapsed, bring down a hand. A roller gauze is tied on the fetal wrist and an assistant is asked to give traction towards the side away from the fetal head to make the neck more accessible and fixed.

 Step 2 : two fingers of the left hand (middle and index) 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 into the vagina, the knob pointing towards the fetal head. The hook is pushed above the neck and rotated to 900 so as to place the knife firmly against the neck. The internal fingers,in the mean time, are placed on the under surface of the neck to guard the tip of the hook.

 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. While removing the decapitation hook- it is to be pushed up; rotated to 900 and then to take out under the guidance of internal fingers. The decapitated head is pushed up and the trunk is delivered by traction on the prolapsed arm.

Step 5: delivery of the decapitated head any of the following method may be usually effective. By hooking the index finger into the mouth By holding the severed neck with giant vulsellum and delivery of the head as that of after coming 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. INDICATION Neglected shoulder presentation with dead fetus; the neck is not easily accessible 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 exclude) 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 vaginal or any genital injury. A self retaining (Foleys ) catheter is put inside specially following craniotomy for a period of 35 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 1 gm IV is given twice daily.

COMPLICATIONS
Injury to the utero-vaginal canal Rupture of uterus Postpartum haemorrhage Shock Puerperal sepsis Sub involution Injury to the adjacent organs Prolonged ill health

 It is an operative procedure whereby the foetuses after the end of 28th week are delivered through an incision of the abdominal and uterine walls. The first operation performed on a patient is referred to as a primary caesarean section. When the operation is performed in subsequent pregnancies, it is called repeat caesarean section.

INCIDENCE The incidence of caesarean section is steadily rising. During the last decade there has been two to three fold rise in the incidence from the initial rate of about 10%.

FACTORS FOR INCREASING CS RATE

Identification of risk foetuses before term (IUGR) Identification of risk mothers Wider uses of repeat CS in cases with previous Caesarean delivery Rising rates of induction of labour and failure of induction Decline in operative vaginal and manipulative vaginal delivery (rotational forceps Decline in vaginal breech delivery Increased number of women with age > 30 and associated medical complication. Adoption of small family norm neither the obstetrician nor the patients are ready to accept any risk of abnormal labour. Wider use of electronic fetal monitoring and increased diagnosis of fetal distress Caesarean delivery on demand.

INDICATIONS
ABSOLUTE RELATIVE Vaginal delivery may be possible but risks to the mother and or to the baby are high. More often multiple factors may be responsible. Cephalo pelvic disproportion. Previous caesarean delivery. Non reassuring FHR. Dystocia APH Mal presentation Failed surgical induction Failure to progress in labour Bad obstetric history Hypertensive disorders Medical- gynaecological disorders

Vaginal delivery is not possible. Caesarean delivery is needed even with a dead fetus. Central placenta previa Contracted pelvis or cephalo pelvic disproportion. Pelvic mass causing obstruction. Advanced carcinoma cervix. Vaginal obstruction

COMMON
PRIMIGRAVIDAE Failed induction Fetal distress CPD Dystocia Malposition and mal presentation MULTIGRAVIDAE Previous LSCS APH Malpresentation

TYPE OF OPERATON
ACCORDING TO TIME ELECTIVE EMERGENCY ACCORDING TO THE SITE OF INCISION LOWER SEGMENT CLASSICAL OR UPPER SEGMENT

ELECTIVE CS
when the operation is done at prearranged time during pregnancy to ensure the best quality of obstetrics, anaesthesia, neonatal resuscitation and nursing services. Time Maturity is certain: the operation is done about one week prior to the expected date of confinement. Maturity is uncertain: Ultrasound assessment. Amniocentesis for L:S ratio is used t ensure fetal maturity. Otherwise spontaneous onset of labour is awaited and then CS is done.

EMERGENCY
when operation is performed due to unforeseen or acute obstetric emergencies.

LOWER SEGMENT CAESAREAN SECTION

In this operation, the extraction of baby is done through an incision made in the lower segment through a transperitoneal approach. It is the only method practised in present day obstetrics In a LSCS, a transverse incision is made in the lower segment; this heals faster and successfully than an incision in the upper segment of the uterus. There is less muscle and more fibrous tissue in he lower segment, which reduces the risk of rupture in the subsequent pregnancy

 It is commonly performed through a transverse incision on the abdomen, the pfannenstiel or bikini line incision.

Transverse incision
Advantages Disadvantages

Post operative comfort is more Fundus of the uterus can be better palpated during immediate post operative period Less chance of wound dehiscence

Takes little longer time and as such unsuitable in acute emergency operation Blood loss is little more Requires competency during repeat section Unsuitable for classical operation

Cosmetic value
Less chance of incisional hernia

CLASSICAL CAESAREAN SECTION

This is relatively easy to perform. Abdominal incision is always longitudinal and about 15 cm in length. 1/3 rd of which extends above the umbilicus. A longitudinal incision of about 12.5 cm is made on the midline of the anterior midline of the anterior abdominal wall of the uterus starting from below the fundus. The baby is delivered commonly as breech extraction. IV oxytocin 5IU or methergin 0.2 mg is administered following delivery if the baby. The placenta is extracted by traction on the cord or removed manually.

PREOPERATIVE PREPARATION
Informed written permission for the procedure, anaesthesia and blood transfusion is obtained. Abdomen is scrubbed with soap and nonorganic iodide lotion. Hair may be clipped. Premediactive sedative must not be given Non-particulated antacid(0.3molar sodium citrate, 30ml) is given orally before transferring the patient to theatre. Ranitidine (H2 blocker) 150mg is given orally night before( elective procedure) and it is repeated one hour before surgery Metaclopromide(10mg IV) is given The stomach should be emptied The bladder should be emptied by a foley catheter FSH should be checked ones more at this stage Neonatologist should be made available. Cross match blood when above average blood loss is anticipated.

 Anaesthesia may be spinal, epidural or general. However, choice of the patient and urgency of delivery are also considered. Position of the patient the patient is placed in the dorsal position. In susceptible cases, to minimise the any adverse effects of venacaval compression, a 150 tilt to her left using a wedge till delivery of the baby is beneficial. Antiseptic painting- the abdomen is painted with7.5% Povidone Iodine solution or Savlon lotion and to be properly draped with sterile towels.

 Incision on the abdomen: the surgeon may choose either a vertical or a transverse skin incision. Vertical incision may be infraumbilical midline or paramidline. Transverse incision, modified Pfannenstiel made 3cm above the symphisis pubis The anatomical layers incised are: Fat Rectal sheath Muscle (rectus abdominis) Abdominal peritoneum Uterine muscle

DELIVERY OF THE HEAD

The membranes are ruptured if still intact. The blood mixed amniotic fluid is sucked out by continuous suction. The head is delivered by hooking the head with the fingers which are carefully inserted between the lower uterine flap and the head until the palm is placed below the head. As the head is drawn to the incision line, the assistant is to apply pressure on the fundus. If the head is jammed, an assistant may push up the head by sterile gloved fingers introduced into the vagina. The head can also be delivered using either Wrigleys or Barton forceps.

DELIVERY OF THE TRUNK

As soon as the head is delivered, the mucus from the mouth, pharynx and nostrils is sucked out using rubber catheter attached to an electric sucker. After the delivery of shoulders, intravenous oxytocin 20 units or methergin 0.2 mg to be administered. The rest of the body is delivered slowly and the baby is placed in a tray placed in between the mothers thighs with the head tilted down for gravitational drainage. The cord is cut in between two clamps and the baby is handed over to the nurse.

REMOVAL OF THE PLACENTA AND MEMBRANES

The placenta is extracted by traction on the cord with simultaneous pushing of the uterus towards the umbilicus per abdomen using the left hand The membranes are to be carefully removed preferably intact and even a small piece, if attached to the deciduas should be removed using a dry gauze.

SUTURE OF THE UTERINE WOUND

The margins of the wound are picked up by Allis tissue forceps or Green Armitage Hemostatic clamp. SUTURE OF THE UTERINE INCISION A continuous suture A second layer of interrupted suture The third layer of continuous suture Repair of rectal sheath brings the rectus abdominis in to alignment. The subcutaneous fat is sometimes sutured and finally the skin is closed with sutures or clips

POST OPERATIVE CARE

First 24 hours (day 0) Observation- pulse, BP, amount of bleeding, behaviour of uterus Fluid-2-2.5L of NR or RL. Prophylactic antibiotic Analgesics- inj pethadine hydrochloride 75100mg. Ambulation- can sit, can get out for bladder empting. Baby- feeding.

 Day 1: oral fluid in the form of plain or electrolyte water or raw tea may be given. Active bowel sounds are observed by the end of the day. Day 2:light solid diet of the patients choice is given. Bowel care: 3-4 teaspoons of lactulose is given at bed time, if the bowels do not move spontaneously. Day 5 -6: the abdominal skin stitches are to be removed on the D5 or D6 Discharge: the patient is discharged on the day following the removal of the stitches

Lower segment

Classical

Technique

Technically slight difficult Blood loss is less The wall is thin and as such apposition is perfect Perfect peritonisation is possible Technical difficulty in placenta praevia or transverse lie

Technically easy Blood loss is more The wall is thick and apposition of the margins is not perfect Not possible Comparatively safer in such circumstances.

Post operative

Haemorrhage and shock less Peritonitis is less even in infected uterus because of perfect peritonisation and if occurs, localised to pelvis Peritonel adhesion and intestinal obstruction are less Convalescence is better Morbidity and mortality are much lower

More Chance of peritonitis is more in presence of uterine sepsis More because of imperfect peritonisation Relatively poor Morbidity and mortality are high.

Wound healing During future pregnancy

The scar is better healed Scar rupture is less

The scar is weak More risk of scar rupture

INTRA OPERATIVE COMPLICATION Extension of uterine incision Uterine lacerations Bladder injury Urethral injury GI tract injury Haemorrhage Morbid adherent placenta

POST OPERATIVE COMPLICATIONS Maternal : immediate, remote Immediate Post partum haemorrhage Shock Anaesthetic hazards Infections Intestinal obstructions Deep vein thrombosis and thromboembolic disorders Wound complication Secondary postpartum haemorrhage

Remote Gynaecological menstrual irregularities, chronic pelvic pain or back ache General surgical- incisional hernia, intestinal obstruction due to adhesion and bands Future pregnancy- the risk of scar rupture Fetal Iatrogenic prematurity and development of RDS (when fetal maturity is uncertain)