Presentation

1. Ashenafi Getachew
Year 1 OBGYN resident
2005 E.C
Moderator; Professor Lkman

2.  Introduction
 Incidence and Types
 Prerequisites
 Preparations
 Craniotomy
 Decapitation
 Evisceration
 Craniocentesis
 Cleidotomy
 Postoperative management
 Complication
 Comparison of C/S Vs. DVD
 References

3.  Destructive vaginal deliveries are procedures
performed in obstructed labor to reduce the bulk of
a dead fetus (lethal abnormality ) in order to permit
its passage through the birth canal.
 Its main advantages are prevention of cesarean
delivery and dissemination of infection associated
with obstructed and neglected labor.
 Other than the Craniocentesis, the procedures have
no place in modern obstetrics in high income
regions with well developed health services,

4. but they have some use full features.
 Need few instruments & simple anesthesia - can
be done in health
center if referral is difficult
 Leave the mother with intact uterus which is less
likely to rupture in subsequent pregnancy
 If she is already infected less likely to spread
infection to peritoneum than c/s
 Stays shorter time in bed than c/s

5.  In inexperienced hands more dangerous than c/s so it
needs to fellow the instruction carefully.
 It may be done
A) A cephalic presentation with normal or
hydrocephalus head
B) A breech delivery when normal or hydrocephalus
after
coming head has stuck
C) Transverse lie with prolapsed arm.
 In cases of obstructed labor, the options may vary with

6.  When the fetus is dead, CPD can be relieved by
reducing the size of the head by craniotomy, and
obstruction due to transverse lie can similarly be
relieved by decapitating the fetus.
 When labor is obstructed by transverse lie or
compound presentation and the fetus is alive, the
route of delivery is by cesarean section.
 without doing an evisceration first, internal version
and breech extraction is not a safe alternative as
any attempt at manipulating the fetus is almost

7.  Vary between 0.2 and 1.6% of deliveries from
reports originating in Ghana, Nigeria and India
 Retrospective study on destructive delivery
performed by residents in obstetrics- gynecology
from 1997 to 2002 in Ethiopia.
 Overall, there were 7.8 DVDs per 1000
deliveries, with an
increasing trend during the five years of the
study.

8. Types of destructive vaginal delivery
 Craniotomy
 Decapitation
 Evisceration
 Craniocentesis
 Cleidotomy

9.  Fetus must be dead
 Cervix must be at least 7cm dilated and preferably
fully dilated.
 2/5 or less of his head must be above the pelvic
brim (for expert may be
don at 3/5)
 Head must be impacted
 Uterus must be un ruptured and not in imminent

10.  Hydration and resuscitation of the woman with I.V
fluid.
 There must be access to do immediate laparotomy
or should be done in the OR
 hemoglobin, blood group and cross match.
 Catheterize must be inserted (at least for 48hours)
 General anesthesia or regional anesthesia
combined with sedation is ideal .

11.  As alternative, an IV injection of pettidine 50mg and
diazepam 10mg will provide sufficient analgesia and
relaxation.
 Pre op broad spectrum antibiotic (chloramphenicol 1
g IV or penicillin 5 mega units IV+ streptomycin 1gm
I.M)
 Informed consent from the patient/ parent
 Put her in lithotomy position.

12.  Refers to perforation of the head of dead fetus
to evacuate the brain tissue and decrease its
size to permit its passage through the birth
canal.
 May be used in cephalic presentation ,or after
coming head.
 For cephalic presentation, an assistance
have to hold 1 or 2 speculum in her vagina to

13.  Another assistance to steady the fetal head
suprapubically, in order not to be pushed during the
procedure.
 Make a cruciate incision on the fetal scalp right down to
the bon and peal the four flaps off the skull.
 With a finger feel for a suture line or a fontanel between
the bones
 Push a close perforator (simpson’s perforater) or
scissors between the bones and enter into the cranium.

14.  Choose to enter the cranium through his hard palate
or his orbit for face presentation .
 The scissors is then retained in the fetal skull and
open and close repeatedly in all directions to
facilitate evacuation of the brain tissue.
 Check with your finger for complete removal and
remove if any remaining.
 Tray to remove all the parietal and frontal bon, not to
tear the vagina during delivery.

15.  Remove any loose pieces of bones.
 Attach 3-4 strong volsellum forceps, kochers or
heavy-toothed forceps on the skin and the remaining
skull and tray to bring the posterior fontanel under
symphysis pubis.
 Protect her vagina from sharp edge of bones with
your finger (remove
them).

16.  Hold the 3 forceps together and pull and twist with
contraction, if a piece of his skull pulls of, reattach
the forceps with deeper bite of skull close to his
base.
 Do an episiotomy and deliver the head.
 If delivery of shoulder is difficult, put a hand behind
him and tray to rotate 90 or 180 degree then tray to
deliver the shoulder again.
 If this fails bring down his hand one by one.

17.  Feel his posterior hand behind him on her vagina
and gently pull it down, rotate him and deliver the
other arm.
 Alternative cut his clavicle( cleidotomy)
 For after coming head, make an incision at the
base of the neck
 Inter the cranium by inserting the perforator or
scissors through the
incision and tunneling subcutaneously to reach

18.  Is severing the head of dead fetus from its trunk
followed by extraction of trunk and head.
 May be used in obstructed labor with dead fetus,
transverse lie and cervix is 8cm or more dilated.
 Prepare her in labor ward and OR as for craniotomy.
 Good anesthesia is more important than craniotomy
b/c you have to operate higher in her birth canal.so
give her GA.

19.  Under anesthesia, put one hand in to her vagina and support
the fundus with the other and observe
1. for cervical dilatation (>8cm),
2. condition of her lower segment(not ruptured)
3. the exact position of the baby,
4. which of his arm is prolapsed? where exactly are
 his head,
 neck,
 chest,
 abdomen and back?

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

21.  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.

22.  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 the wire
saw and put this on your right middle finger.
 Pass the thimble over his neck, and down the other
side.

23.  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.
 .

24.  Keep the handles close together, not to injure the vagina
and Protect it with specula.
 Cut his neck with a few firm rubs.
 To deliver his body, pull on his prolapsed arm and use
your hand to protect her vagina from any sharp pieces of
bone in his neck.
 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 after coming head
of a breech.

25.  If the head is big craniotomy my be done .
 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

26.  Is opening the babies trunk and remove the organ
from the chest and abdomen.
 May be used
 For a transverse lie when his body is well down
but neck is difficult to reach or after
decapitation.
 Ask your assistant to pull on his prolapsed arm,
and find his axilla.

27.  Protect her vaginal wall with one or two specula.
 Make a large opening in his abdomen or chest with
a knife or strong scissors .
 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.

28.  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.

29.  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.

30.  Refers to drainage of excess cerebrospinal fluid from
dead hydrocephalic fetus.
 May be used in cephalic or after coming head.
 For alive fetus c/s is indicated.
 If presentation is cephalic, CSF can be drained
abdominally using a spinal needle, preferably under
ultrasound guidance.

31.  As labor progresses it may be necessary to drain
additional fluid transvaginally using a sharp
instrument such as Simpson’s perforator or spinal
needle or a pair of scissors.
 In after coming head ,the base of the occiput is
perforated per vaginam to facilitate decompression.
 If there is an accompanying spina bifida the CSF can
be drained by passing a catheter through the defect
up the vertebral column into the cranium.

32.  Is division of the clavicles on one or both sides to
reduce the width of the shoulders of a large dead
baby.
 Used in shoulder dystocia.
 Use embryotomy scissors to make a small cut in the
skin of his neck.

33.  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

34.  Remove the placenta manually, and
immediately feel inside
for tears of her uterus and lower segment.
 Give her ergometrine 0.25 mg intravenously
as she deliver.
 If it has ruptured, do a laparotomy and repair
it.
 Check her cervix, vagina, and vulva for tears.
If there is tear
suture it

35.  Catheter should be left in the bladder for at least
48hours.
 If his head has been impacted in her pelvis for many
days, leave a
Foley catheter in for 14 days to prevent fistula.
 Continue the perioperative antibiotics.
 Wraps up the baby immediately he is delivered. His
mother must not
see him.

36.  Maternal morbidity in reported series was felt due to
prolonged obstructed labor for which the operations
were performed.
Postpartum hemorrhages in the first 24 hours
Acute urinary retention in the first 24 hours.
Infection of her genital tract after 24 hours.
Infection of her urinary tract at 7 to 10 days.
cervical and vaginal tears
Fistula( Vesico-vaginal fistula and recto-vaginal
fistula )
Uterine rupture following destructive operations (in
Ghana)

37.  Truly prolonged obstructed labor may result in
excessive maternal mortality rates when
cesarean sections are performed rather than
destructive procedures.
 Sahu reported a figure of 7.5% maternal
mortality for cesarean section deliveries as
opposed to 2.7% when alternative methods
were undertaken, in patients presenting with
obstructed labor and fetal demise.

38.  In another report, the figures for the respective
procedures were 12.5% and 5.8%.
 These confirm the efficacy and safety of destructive
operations over cesarean section in dealing with
obstructed labor.
AVOID CAESAREAN SECTION FOR
OBSTRUCTED LABOUR AND
A DEAD BABY, UNLESS YOU THINK VAGINAL
DELIVERY
WOULD BE TOO DANGEROUS.

39.  Primary surgery volume one,chapter10
 Surgery in Africa monthly-review
 Ethiop Med J. 2007 Jan;45(1):39-45.
 Management protocol on selected obstetrics
topics (FMOH) Ethiopia January, 2010