Destructive operations

For an obstructed labour with a dead baby a destructive operation is usually, but not always, better than a Caesarean section. You may need to do one for: (1) A cephalic presentation with a normal or hydrocephalic head. (2) A breech delivery when a normal or hydrocephalic aftercoming head has ''stuck'. (3) A transverse lie with a prolapsed arm.

To cope with these situations you can: (1) Open his skull with large scissors, or a special perforator, and remove his brain (craniotomy). (2) Sever his neck from his body (decapitation), and then deliver them separately. (3) Cut his clavicles (cleidotomy). (4) Open his trunk and remove the the organs from his chest and abdomen (evisceration or embryotomy). For a cephalic or breech presentation, craniotomy is usually all you need do. A transverse lie requires decapitation, and often evisceration also, which is more difficult than craniotomy; but even so, it is often wiser than Caesarean section (see Section 18.1), which is particularly dangerous for a neglected infected transverse lie.

These operations are sometimes said to be old fashioned, and to have no place in modern obstetrics. Old-fashioned perhaps, but they have some useful features: (1) They need few instruments and only simple anaesthesia, so that they can be done in the health centre where a mother is first seen. If she cannot be referred, they save her life. If referral is difficult, they avoid the risks and delays of a long journey (they are therefore also described in Primary Mother Care). (2) They leave her with an intact uterus, which will be less likely to rupture if she decides to deliver herself at home next time. (3) If she is already infected, they are less likely than Caesarean section to spread the infection to her peritoneum. (4) She stays a shorter time in bed than she does after a Caesarean section.

The case for destructive operations is strongest in unsophisticated communities where people marry as children. A mother may not be fully grown when she first becomes pregnant, so that her pelvis is small and her first labour obstructs. It will continue to grow until she is 25, so, if she can be delivered vaginally with her first pregnancy, her later ones may be normal and without the risks of a scarred uterus.

Besides their distasteful messiness, the main argument against these operations is that, in inexperienced hands, they are liable to be even more dangerous than Caesarean section. This is unlikely to be true[md]if you follow the instructions carefully! To those who decry them, we reply that, if the obstetric circumstances of disadvantaged communities still existed in advantaged ones, destructive operations would be routine there too.

DESTRUCTIVE OPERATIONS For destructive operations at Caesarean section, see Section 18.10. For destructive operations at a breech delivery, see Section 19.8.

INDICATIONS FOR CRANIOTOMY. All the following conditions must hold: (1) The baby must be dead. (2) 2/5 or less of his head must be above the brim (if it is higher than this, Caesarean section is usually safer, although if you are expert you may be able to do it at 3/5). (3) His head must be impacted. (4) His mother's cervix must be at least 7 cm dilated, and preferably fully dilated. One contributor gives 5 cm as the minimum. (5) Her uterus must be unruptured, and not in imminent danger of rupturing. If she is multigravid and has been in labour for a long time, her lower segment will be very thin. If it is tender and distended, it is certainly very thin. She can only be saved by Caesarean section; any destructive operation, except pushing a needle into a hydrocephalic head, will rupture it.

PREPARATION. Always do a destructive operation in the theatre with a laparotomy set ready for immediate use; unless you, and your theatre and obstetric team, are very quick and expert indeed (when you can do some destructive operations in the labour ward). You must be able to do an immediate laparotomy, either: (1) immediately instead of a destructive operation, if you find that the indications are unsuitable, or (2) immediately afterwards, if you discover that her uterus has ruptured. You will need an anaesthetist, a scrub nurse, and a ''runner'.

In the labour ward confirm that the baby is dead, set up a drip, take blood for cross-matching, give her pethidine 50 mg and diazepam 10 mg intravenously, and shave her for a vaginal operation and a laparotomy.

PERIOPERATIVE ANTIBIOTICS. Give her chloramphenicol 1 g intravenously. Or, give her penicillin 5 megaunits intravenously with streptomycin 1 g intramuscularly. See also 2.9.

EQUIPMENT. For decapitation use a Blond[nd]Heidler saw (16.1), or large blunt-ended scissors, preferably special embryotomy scissors.

ANAESTHESIA. General anaesthesia with intubation, especially if she has a transverse lie. If you cannot intubate her, use subarachnoid anaesthesia or local infiltration anaesthesia.

FOR A CEPHALIC PRESENTATION CRANIOTOMY. Put her into the lithotomy position, and clean and drape her vulva and perineum.

If you are not using general anaesthesia, give her pethidine 25[nd]50 mg slowly intravenously (check what she was given in the labour ward). And give her diazepam 5[nd]10 mg slowly intravenously until she is just asleep (A 8.8). Infiltrate her perineum with 0.5% or 1% lignocaine (A 5-1).

Catheterize her bladder. Ask your assistant to hold 1 or 2 Sims' specula in her vagina so that you can see the baby's head well.

CAUTION ! Ask another assistant, standing on a footstool if necessary, to steady the baby's head suprapubically, so that it is not pushed upwards whenever you do anything to it.

With a scalpel make an ''X'[nd]shaped incision through the skin of his scalp right down to the bone. Peel the four flaps of scalp off his skull. Put your fingers through her cervix to rest against his skull. Feel for a suture line or fontanelle. Push a closed pair of strong pointed scissors or, better, Simpson's perforator between the bones. For a face presentation, choose his hard palate or his orbit. Move the handles back towards her perineum, so as to point the blades at the centre of his skull. Open and close them a few times while you turn them round. Brain will flow from the hole. Put your finger into his skull, check that all brain compartments have been opened, and remove any remaining brain. His skull will now collapse.

Try to remove all his frontal and parietal bones. If you don't remove them, they may tear her vagina as he delivers. Remove any loose pieces of bone. Attach 3[nd]4 strong vulsellum forceps, Kocher's or Willet's forceps to his scalp and the remains of his skull. Pull on them and try to bring his posterior fontanelle under her symphysis. If sharp edges of bone stick out, protect her vagina with your finger.

Wait until she has a contraction. Hold the three pairs of forceps together, and pull and twist. His collapsed head should now deliver. His body will follow. If a piece of his skull pulls off, reattach the forceps taking a deeper bite of skull closer to its base. Make a large episiotomy and deliver the remains of his head.

CAUTION ! (1) Don't include folds of her vaginal wall or cervix. (2) Use a good light and a large Sims' speculum, so as to make sure you grasp only his skull.

If delivering his shoulders is difficult, put a hand behind him and try turning him through 90[de] or 180[de]. Then try delivering his shoulders again.

If you cannot bring down his shoulders by turning him, bring down his arms one by one. Put a hand behind him in her vagina and feel for his posterior arm. Gently pull it down. Don't worry if it breaks, but don't damage her vagina. Then turn him through 180[de] and deliver his other arm in the same way. Delivery should now be easy.

Alternatively, cut his clavicles (cleidotomy, see below).

Fig. 18-9 A TRANSVERSE LIE. A, if a community health worker meets this, she is advised to refer the patient to you urgently! B, a shoulder presentation. (1) The incision for decapitation, leaving the head attached to an arm. (2) Caution! Don't try to remove an arm, leave it attached to the head or the body, to help you to bring these down. A, From David Werner's ''Where there is no Doctor'. B, from Howie, Beryl, ''High Risk Obstetrics', Macmillan, with kind permission. 7

DESTRUCTIVE OPERATIONS [s7]FOR A TRANSVERSE LIE INDICATIONS. Her baby is dead, the lie is transverse, her cervix is 8 cm or more dilated, and her uterus is not ruptured. For a transverse lie, see Section 19.9. For destructive operations at Caesarean section, see Section 18.10.

EXAMINATION UNDER ANAESTHESIA. Prepare her in the labour ward and the theatre as for craniotomy. Good anaesthesia is even more important than it is for craniotomy, because you have to operate higher in her birth canal. Give her a general anaesthetic.

Put her into the lithotomy position, clean and drape her vulva, and catheterize her bladder. Put one hand into her vagina and support her fundus with the other. Observe: (1) The dilatation of her cervix. If it is [lt]8 cm, section is probably safer. (2) The condition of her lower segment; explore it as far as you can without using force. If it is ruptured, section her. (3) The exact position of the baby. Which of his arms have prolapsed? Where exactly, are his head and neck, chest, abdomen, and back?

Choose between these 3 alternatives: (1) If his neck and body are still high in her birth canal, section her (18.10). (2) If you can reach his neck easily, decapitate him. (2) If his neck is difficult to reach, but his body is well down, eviscerate him.

CAUTION ! (1) Don't try an internal version without doing an evisceration first: you will rupture her uterus. (2) Don't attempt decapitation, or evisceration, through her vagina, if he is still high in her birth canal; you will not be able to protect her vaginal wall and cervix adequately. A Caesarean section is her only hope.

DECAPITATION. Pull on his prolapsed arm with one hand, and feel for his neck with your other hand.

If possible, bring an arm down (if it is not already down), and ask an assistant to pull on it. This: (1) prevents him being pushed upwards by your hand in her uterus, (2) prevents her distended lower segment being stretched, and (3) it brings his neck lower and makes it easier to feel.

Feel his neck to find out how large it is, and how easy it is to put a finger round. If he is small and macerated, you can usually cut his neck with strong scissors. If he is larger, you will have to use the saw.

If you are using a saw, fix the thimble to it and put this on your right middle finger. Pass the thimble over his neck, and down the other side. If this is difficult, because there is little room between his neck, his head, and his chest, try putting the saw over his neck and under his arm. Or improvise a smaller thimble by fixing something else, such as a piece of wire, to the end of the saw. Remove the thimble, and fix handles to each end of the saw. Insert the rubber sleeves on the saw. Keep the handles close together, so that her vagina is not injured. Protect it with specula. Cut his neck with a few firm strokes.

CAUTION ! Hold the handles close together. If you don't do this, you will cut her tissues.

To deliver his body, pull on his prolapsed arm. As you do so, use your hand to protect her vagina from any jagged pieces of bone in his neck.

To deliver his head, put a hand in her vagina, and turn his head so that his neck points downwards. Grasp the stump of his neck with large forceps, and put a finger in his mouth. Then deliver his head, as if it were the aftercoming head of a breech. This will prevent the stump from injuring her birth canal. If his head is very large, you may need to do a craniotomy. Some operators leave an arm attached to his head to help delivery.

If you delivered his head first, deliver his body by pulling on his other arm. Don't try version, his cut neck might damage her uterus.

If you are using scissors, hook one or two fingers round his neck and pull it down. Ask an assistant to protect her vaginal wall with a speculum. Gently pull his arm. When you do this, you will feel his neck. Try to see what you are cutting with each cut. You can easily cut her uterus or bladder. Cut his neck a little at a time, then deliver him as above.

CAUTION ! (1) Don't cut if you cannot see his neck. After each cut, pull his neck. It will come a little further down with each cut until you have cut right through.

Fig. 18-10 DECAPITATION FOR A DEAD BABY will leave a mother with an intact uterus, which will be less likely to rupture if she decides to deliver herself at home next time. Cut through his neck with a Blond[nd]Heidler saw. A, push the thimble round his neck. B, pull the loop of the thimble down the other side of his neck. C, saw through it. D, remove his head with forceps. Pieces of rubber tube cover the outer third of each end of the saw. Kindly contributed by John Lawson.

OTHER DESTRUCTIVE OPERATIONS EVISCERATION for a transverse lie is indicated: (1) when his neck is difficult to reach, but his body is well down, (2) after decapitation. Ask your assistant to pull on his prolapsed arm, and find his axilla. Protect her vaginal wall with one or two specula. With a knife or strong scissors make a large opening in his abdomen or chest. Put one or two fingers into the opening and remove all his internal organs. Make sure you remove his liver, heart, and lungs. If necessary perforate his diaphragm with scissors.

Now reassess the situation, and try whichever of these manoeuvres seems best: (1) Put two fingers behind his pelvis and hook his breech down. (2) Grasp a leg or foot and bring that down. (3) Try to bring his neck down for decapitation by pulling on his arm. (4) If all this fails, don't hesitate to section her.

Alternatively, separate his prolapsed arm at his shoulder. Push the embryotomy scissors through his axilla and divide his internal structures from inside his skin, while keeping your other hand between him and her uterus, as a constant guide. Finally, divide his skin and superficial tissues under direct vision, and deliver him in two halves.

CRANIOTOMY FOR A HYDROCEPHALIC HEAD. Push a large needle through her abdominal wall. As the fluid is withdrawn, his head will collapse. Or, guided by your examining finger, you can push a large needle (2 mm[mu]25 cm) through a suture from her vagina, and drain off as much fluid as you can.

CLEIDOTOMY (division of the clavicles) on one or both sides, will reduce the width of the shoulders of a large dead baby. Use embryotomy scissors to make a small cut in the skin of his neck. Through this, guided by the fingers of your other hand, feel inside his skin, until you can snip a clavicle between the tips of the opened blades. Be sure it is his clavicle and not the spine of his scapula. The ends of his clavicle will then overlap and narrow his shoulders.

DESTRUCTIVE OPERATIONS FOR THE ''STUCK BREECH' see Section 19.8.

POSTOPERATIVELY, [s7]AFTER ANY DESTRUCTIVE OPERATION Remove the placenta manually, and immediately feel for tears of her uterus and lower segment. Give her ergometrine 0.25 mg intravenously as he is delivered. Check her uterus by feeling inside it to make sure it has not ruptured. If it has ruptured, do a laparotomy and repair it (18.17). Check her cervix, vagina, and vulva for tears. If she has a tear of her cervix it will need suturing (18.15).

If her uterus is not well contracted, set up an intravenous oxytocin drip with 5[nd]20 units in 500 ml. Continue the saline drip for 24 hours. Continue the perioperative antibiotics (2.9).

She is at risk from: (1) Postpartum haemorrhage in the first 24 hours. (2) Acute urinary retention in the first 24 hours. (3) Infection of her genital tract after 24 hours. (4) Infection of her urinary tract at 7 to 10 days. (5) A fistula (18.10).

If his head has been impacted in her pelvis for many days, leave a Foley catheter in for 14 days. This will help to prevent a fistula. Obstructed labour with a transverse lie does not cause pressure necrosis of the vagina, so a few days' drainage is enough.

CAUTION ! After any destructive operation, be sure your assistant wraps up the baby immediately he is delivered. His mother must not see him.

AVOID CAESAREAN SECTION FOR OBSTRUCTED LABOUR AND A DEAD BABY, UNLESS YOU THINK VAGINAL DELIVERY WOULD BE TOO DANGEROUS