DESTRUCTIVE DELIVERY / INTRAUTERINE FETAL DEATH

  • 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

SYMPHYSIOTOMY

A cut through the symphysis will cause the pubic bones to separate and increase the pelvic circumference with three or more cm (two fingers). Sufficient to resolve a mechanical disproportion due to a large head and/or a narrow pelvis

Indications:

  • Fetal head stuck so firm and deep in the birth canal that C/S is not an option
  • Shoulder dystocia
  • Retained head in breech

To avoid damage to urethra a catheter in the bladder is most important . The urethra with the indwelling catheter is pushed aside when the cut through the symphysis is made.

OPEN SYMPHYSIOTOMY

Preferred method for unexperienced

  • Local infiltration anesthesia
  • Insert a catheter in the bladder
  • Make a 4 to 5 cm long vertical incision through the skin and subcutaneous tissue in front of the symphysis
  • Insert a self-retaining wound retractor
  • With two fingers in the vagina push the urethra to either side
  • Cut strictly in the midline with a scalpel
  • Confirm visually and by palpation that the pubic bones have separated
  • Deliver the baby
  • Close the incision
  • Keep the catheter indwelling for 24 hours
  • Mobilize the patient immediately and without any restrictions

CLOSED SYMPHYSIOTOMY

Preferred method for more experienced

  • Insert a catheter in the bladder
  • Local infiltration anesthesia
  • Use the injection needle to probe and define the exact location of the symphysis
  • Push the urethra to the side with two fingers in the vagina
  • Cut strictly in the midline with a scalpel
  • Confirm by palpation in vagina or suprapubically that the pubic bones have separated
  • Deliver the baby
  • The small incision does not need suturing
  • Keep catheter indwelling for 24 hours
  • Mobilize patient immediately and without any restrictions
Symphysiotomy I
Symphysiotomy II
Symphysiotomy in Breech