Tag: intrauterine fetal death

DESTRUCTIVE DELIVERY / INTRAUTERINE FETAL DEATH

Posted on by The Rebel Surgeon in DESTRUCTIVE DELIVERY
  • In intrauterine fetal death (IUFD) do not perform C/S.
    • Severe maternal infection with fatal sepsis is a substantial risk.
  • Deliver vaginally
    • By destructive delivery if needed

INSTRUMENTS

From left to right: Basiotribe – Perforator – Heavy scissors – Delivery hook

CEPHALIC PRESENTATION

CRANIOTOMY

  • Perforate the skull with perforator or a pair of heavy scissors
  • In face presentations use an eye as entry point
  • Open the shanks of the perforator
  • Break all intracranial septa
  • Apply the basiotribe with the solid leg inside and fenestrated leg outside of the skull  
  • Be careful not to catch part of cervix or vagina in the grip
  • Tighten grip as much as possible
  • Extract the fetus.
  • Do this slowly
    • Allow time for the head to collapse.
  • In lack of a basiotribe use:
    • Ordinary delivery forceps
    • Several heavy toothed clamps
  • Remove the placenta manually
  • Check with a hand in the uterine cavity for rupture
Craniotomy I
Craniotomy II

RETAINED HEAD in BREECH

CRANIOTOMY

  • Apply firm traction on the neck
  • Perforate the back of the skull in occipital area
  • Be sure to perforate the skull
  • Do not the perforate upper part of the cervical spine
  • Open the shanks of the perforating instrument
  • Destruct all intracranial septa
  • Deliver head by Mauriceau-Levret’s maneuver
    • Introduce index finger into the mouth
    • Flex the head with index finger
    • Apply traction to the neck with a forked finger grip applied to the back of the neck
    • Extract the head by traction on the neck
  • Proceed slowly to allow time for the head to collapse
Craniotomy in Breech

SEPARATION OF HEAD FROM NECK

Attempts to extract the head by forcefull traction may result in a fractured spine with an elongated neck. Further traction will separate the head from the trunk.

Separation of head may also occur if you by mistake perforate the upper part of the spine

In case of such a scenario:

  • Remove the body
  • Extract the head from the uterus
    • With a finger in the mouth
    • The fractured spine in the palm of your hand
Retained Head Separated from the Neck

COMPOUND TRANSVERSE PRESENTATION (transverse presentation with prolapsed arm)

There are two scenarios:

I. YOUR FINGERS CAN REACH AROUND THE NECK

DECAPITATON

  • Apply the delivery hook around neck
  • Fracture the cervical spine forcefully with the hook
  • Apply traction to the prolapsed arm by assistant
  • Cut the neck with
    • Scalpel or
    • Heavy scissors
  • Deliver the body by traction to the arm
  • Extract the head from the uterus
    • With a finger in the mouth
    • Fractured spine in the palm of your hand
  • Remove placenta
  • Manually assess the uterine cavity for rupture
Decapitation in Compound Transverse Presentation

II. YOUR FINGERS CAN NOT REACHED AROUND THE NECK

EXVISCERATION

  • Apply traction to the prolapsed arm by assistant
  • Perforate abdomen / thorax
  • Insert a hand into the abdominal / thoracic cavity
  • Remove all internal organs from abdomen / thorax
  • Grasp one or both feet
    • Perform internal version and extraction
  • If unsuccessfull
    • Fracture the spine with the delivery hook
    • Cut the body in two parts
    • Deliver the body parts separately with traction on foot or arm

PLACENTAL ABRUPTION

Posted on by The Rebel Surgeon in PLACENTAL ABRUPTION

Symptoms and signs:

  • Sudden onset of painfull uterine contractions
  • Vaginal bleeding
  • Shock
  • Uterus tender on palpation

FETUS ALIVE

  • Gestational age > 36 weeks   
    • Deliver by C/S
  • Gestational age < 36 weeks    
    • Vaginal delivery
  • Gestational age unknown
    • Use best guess

FETUS DEAD

  • Vaginal delivery 
  • Destructive delivery if needed    

The uterus appears battered:

TRANSVERSE PRESENTATION

Posted on by The Rebel Surgeon in TRANSVERSE PRESENTATION

Transverse presentation is often accompanied by arm prolapse (compound transverse presentation).

  • Compound transverse presentation
    Alive fetus
  • Neglected compound transverse presentation
    Dead fetus

GESTATIONAL AGE < 32 WEEKS / WEIGHT < 1500 GRAM

  • Vaginal delivery

GESTATIONAL AGE > 32 WEEKS / WEIGHT > 1500 GRAM

ALIVE FETUS

  • Cervix closed:
    • Cesarean Sectio

  • Cervix closed and membranes intact:
    • External Version

  • Cervix fully dilated / Membranes ruptured recently / Contractions not very strong:
    • Internal version and extraction using one or both feet
      • Introduce one hand in uterus
      • Search for small parts of the fetus
      • Identify one or both feet
        • Foot has a heal
        • Hand has a thumb
      • Grasp one or both feet with forked fingergrip from behind
      • Apply strong traction on the foot/feet
      • Rotate the fetus with a combination of
        • Traction on foot/feet
        • Upward pressure on caput with other hand on mother’s abdomen
      • Continue strong traction on foot/feet
      • Combined with pumping movements
      • Grasp front of knee with the other hand
      • Extract the upper part of body by a combination of
        • Strong traction
        • Pumping movements
      • Grasp pelvis with both hands
      • Extract upper part of body by a combination of
        • Strong traction
        • Pumping movementsRelease arms
      • Deliver head by Mauriceau-Levret’s maneuver

DEAD FETUS

  • Destructive delivery
    • Decapitation
    • Exvisceration

BETWEEN 32 – 34 WEEKS / 1500 – 2500 gram

Relay on your own judgement