Destructive Operation and Caesarian Section

8/13/2019 Destructive Operation and Caesarian Section

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DESTRUCTIVE OPERATION


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INTRODUCTION

The destructive operations are designed todiminish the bulk of the fetus so as to facilitateeasy delivery through the birth canal.

These procedures are difficult and may be

dangerous too unless the operator is sufficientlyskilled.


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Commonly performed operations are

Craniotomy

Evisceration

Decapitation

Cleidotomy


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1. CRANIOTOMY

It is an operation to make a perforation on thefetal head to evacuate the contents followed byextraction of the fetus.

INDICATIONS:

Cephalic presentation producing obstructedlabour with dead fetus

Hydrocephalus even in a living fetus

Interlocking head of twins.


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CONDITIONS TO BE FULFILLED

The cervix must be fully dilated Baby must be dead

CONTRAINDICATIONS

The operation should not be done when thepelvis is severely contracted

Rupture of the uterus where laprotomy isessential


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PROCEDURE

PRELIMINARIES Take consent

The patients is asked to empty her bladder.

She is to lie on her back with the shouldersslightly raised and the thighs slightly flexed.

Administer anaesthesia


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Step 2 : the Oldhams perforator with the blades

close, is introduced under the palmar aspect ofthe fingers protecting the anterior vaginal walland the adjacent bladder until the tip reachesthe proposed site of perforation

Step 3: by rotating movements the skull isperforated. During this step, an assistant isasked to steady the head per abdomen in amanner of first pelvic grip. After the skull isperforated, the instrument is thrust up to theshoulders and the handles are approximated soas to allow separation of the sharp blades forabout 2.5cm.


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The blades are again apposed by separating thehandles. The instrument is brought out keepingthe tip of the blades still inside the cranium. Theinstrument is rotated at right angle and thenagain thrust in up to the shoulders. The handles

are once more to be compressed so as toseparate the blades for about 2.5 cm. Theinstrument with the blades close is then thrust inbeyond the guard to churn the brain matter. The

instrument, with the blades closed is brought outunder the guidance of the two fingers still placedinside the vagina.


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Step 4: with the fingers brain matters is

evacuated. The idea is to make the skull collapseas much as possible

Step 5: when the skull is found sufficientlycompressed, the extraction of the fetus isachieved either by using a cranioblast or by twogiant volsella. Giant volsella are used to hold theincised skull and scalp margins.

Step 6: the traction is now exerted


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Step 7: after the delivery of the placenta, the

utero vaginal canal must be explored as aroutine for evidence of rupture of uterus or anytear.

Inj. Methergin 0.2 mg is to be given IM with the

delivery of the anterior shoulder. The rest of thedelivery is completed as in normal delivery.

Alternative to Oldhams perforator, similarprocedure could be performed using sharppointed Mayos scissor


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DECAPITATION

it is a destructive operation whereby the fetalhead is severed from the trunk and the deliveryis completed with the extraction of the trunk andthat of the decapitated head per vaginam.

INDICATION

Neglected shoulder presentation with dead fetus

where neck is easily accessible Interlocking head of twins


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PROCEDURES

Preliminaries : same as before.

ACTUAL STEPS

Step 1: if the fetal hand is not prolapsed, bringdown a hand. A roller gauze is tied on the fetalwrist and an assistant is asked to give tractiontowards the side away from the fetal head to

make the neck more accessible and fixed.


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Step 2 : two fingers of the left hand (middle andindex) are introduced with the palmar surface

downwards and the finger tips are to be placedon the superior surface of the neck theprolapsed site of decapitation.

Step 3: the decapitation hook with knife is to beintroduced flushed under the guidance of thefingers placed into the vagina, the knob pointingtowards the fetal head. The hook is pushed

above the neck and rotated to 900

so as to placethe knife firmly against the neck. The internalfingers,in the mean time, are placed on theunder surface of the neck to guard the tip of the

hook.


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Step 4: by upward and downward movements of

the hook with knife, the vertebral column issevered (evident by sudden loss of resistance).The rest of the soft tissue left behind may besevered by the same instrument or by

embryotomy scissors. While removing thedecapitation hook- it is to be pushed up; rotatedto 900and then to take out under the guidanceof internal fingers. The decapitated head is

pushed up and the trunk is delivered by tractionon the prolapsed arm.


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EVISCERATION

The operation consists in removal of thoracicand abdominal contents piecemeal through anopening on the thoracic or abdominal cavity at

the most accessible site. The object is todiminish the bulk of the fetus which facilitatesits extraction.

INDICATION

Neglected shoulder presentation with deadfetus; the neck is not easily accessible

Fetal malformation such as fetal ascites orhugely distended bladder or monsters


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CLEIDOTOMY

The operation consists of reduction in the bulkof the shoulder girdle by division of one or boththe clavicles.

The operation is done only in dead fetus(anencephaly exclude) with shoulder dystocia.The clavicles are divided by the embryotomyscissors or long straight scissors introduced

under the guidance of left two fingers placedinside the vagina.


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POST OPERATIVE CARE FOLLOWING

DESTRUCTIVE OPERATION

Exploration of the utero- vaginal canal must bedone 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 3-5 days or until the bladder tone is regained.

Dextrose saline drip is to be continued tilldehydration is corrected. Blood transfusion maybe given, if required.

Ceftriaxone 1 gm IV is given twice daily.


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It is an operative procedure whereby the

foetuses after the end of 28thweek are deliveredthrough an incision of the abdominal anduterine walls.

The first operation performed on a patient isreferred to as a primary caesarean section.

When the operation is performed in subsequentpregnancies, it is called repeat caesarean section.


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FACTORS FOR INCREASING CS RATE

Identification of risk foetusesbefore term (IUGR)

Identification of risk mothers

Wider uses of repeat CS incases with previous Caesareandelivery

Rising rates of induction oflabour and failure of induction

Decline in operative vaginaland manipulative vaginaldelivery (rotational forceps

Decline in vaginal breechdelivery

Increased number of womenwith age > 30 and associatedmedical complication.

Adoption of small family normneither the obstetrician northe patients are ready toaccept any risk of abnormallabour.

Wider use of electronic fetalmonitoring and increaseddiagnosis of fetal distress

Caesarean delivery ondemand.


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INDICATIONSABSOLUTE RELATIVE

Vaginal delivery is not possible.Caesarean delivery is neededeven with a dead fetus.

Central placenta previa

Contracted pelvis or cephalopelvic disproportion.

Pelvic mass causingobstruction.

Advanced carcinoma cervix.

Vaginal obstruction

Vaginal delivery may be possiblebut risks to the mother and or tothe baby are high.

More often multiple factors maybe 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- gynaecologicaldisorders


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COMMON

PRIMIGRAVIDAE

Failed induction

Fetal distress

CPD

Dystocia Malposition and mal

presentation

MULTIGRAVIDAE

Previous LSCS

APH

Malpresentation


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TYPE OF OPERATON

ACCORDING TO TIME

ELECTIVE

EMERGENCY

ACCORDING TO THE SITE OF INCISION

LOWER SEGMENT CLASSICAL OR UPPER SEGMENT


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ELECTIVE CS

when the operation is done at prearranged timeduring pregnancy to ensure the best quality ofobstetrics, anaesthesia, neonatal resuscitationand nursing services.

Time Maturity is certain: the operation is done about

one week prior to the expected date ofconfinement.

Maturity is uncertain: Ultrasound assessment.Amniocentesis for L:S ratio is used t ensure fetalmaturity. Otherwise spontaneous onset of labouris awaited and then CS is done.


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EMERGENCY

when operation is performed due to unforeseenor acute obstetric emergencies.


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LOWER SEGMENT CAESAREAN SECTION

In this operation, the extraction of baby is donethrough an incision made in the lower segmentthrough 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 successfullythan an incision in the upper segment of theuterus. There is less muscle and more fibroustissue in he lower segment, which reduces therisk of rupture in the subsequent pregnancy


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It is commonly performed through a transverseincision on the abdomen, the pfannenstiel orbikini line incision.


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Transverse incision

Advantages Disadvantages

Post operative comfort is more

Fundus of the uterus can bebetter palpated during

immediate post operativeperiod

Less chance of wounddehiscence

Cosmetic value

Less chance of incisionalhernia

Takes little longer time and assuch unsuitable in acuteemergency operation

Blood loss is little more

Requires competency duringrepeat section

Unsuitable for classicaloperation


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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.


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Incision on the abdomen: the surgeon may

choose either a vertical or a transverse skinincision. Vertical incision may be infraumbilicalmidline or paramidline. Transverse incision,modified Pfannenstiel made 3cm above the

symphisis pubis The anatomical layers incised are:

Fat

Rectal sheathMuscle (rectus abdominis)

Abdominal peritoneum

Uterine muscle


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REMOVAL OF THE PLACENTA AND

MEMBRANES

The placenta is extracted by traction on the cordwith simultaneous pushing of the uterus towardsthe umbilicus per abdomen using the left hand

The membranes are to be carefully removedpreferably intact and even a small piece, ifattached to the deciduas should be removed

using a dry gauze.


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SUTURE OF THE UTERINE WOUND

The margins of the wound are picked up by Allistissue forceps or Green Armitage Hemostaticclamp.

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 rectusabdominis in to alignment. The subcutaneous fatis sometimes sutured and finally the skin isclosed with sutures or clips


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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 75-100mg.

Ambulation- can sit, can get out for bladderempting.

Baby- feeding.


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Day 1: oral fluid in the form of plain orelectrolyte water or raw tea may be given. Activebowel sounds are observed by the end of the day.

Day 2:light solid diet of the patients choice isgiven. Bowel care: 3-4 teaspoons of lactulose is

given at bed time, if the bowels do not movespontaneously.

Day 5 -6: the abdominal skin stitches are to beremoved on the D5 or D6

Discharge: the patient is discharged on the dayfollowing the removal of the stitches


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Lower segment ClassicalTechnique Technically slight difficult

Blood loss is lessThe wall is thin and as such apposition is perfectPerfect peritonisation is possible

Technical difficulty in placenta praevia or

transverse lie

Technically easyBlood loss is moreThe wall is thick and apposition of the margins is

not perfect

Not possibleComparatively safer in such circumstances.

Post operative Haemorrhage and shock lessPeritonitis is less even in infected uterus because

of perfect peritonisation and if occurs, localised to

pelvisPeritonel adhesion and intestinal obstruction are

lessConvalescence is betterMorbidity and mortality are much lower

MoreChance of peritonitis is more in presence of

uterine sepsisMore because of imperfect peritonisationRelatively poorMorbidity and mortality are high.

Wound healing The scar is better healed The scar is weakDuring future

pregnancyScar rupture is less More risk of scar rupture


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INTRA OPERATIVE COMPLICATION

Extension of uterine incision

Uterine lacerations

Bladder injury

Urethral injury

GI tract injury Haemorrhage

Morbid adherent placenta


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Destructive Operation and Caesarian Section

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