Fertilizing operations

Fetal-destroying operations (embryotomies) are performed to reduce the size of the fetus, which makes it possible to extract it through the natural birth canal with minimal trauma to the mother.

All fruit-destroying operations are divided into three groups:

1. operations that reduce the volume of the fetus: craniotomy, eventerania:
2. operations of dismembering the fetus into parts and extracting it piece by piece: decapitation, spondylotomy, exarticulation;
3. operations that reduce the volume of the fetus's body by maximizing the mobility between its individual parts: cleidotomy, cranial puncture for hydrocephalus, fractures of the limb bones.

Craniotomy, decapitation and cleidotomy are performed more frequently and therefore are considered typical embryotomies.

Spondylotomy and evisceration, or eventration, are atypical embryotomies. The main indication for performing fetal-destroying operations in modern obstetrics is the presence of a dead fetus. In exceptional situations, embryotomies are also performed on a living fetus (severe fetal malformations incompatible with life). In addition, embryotomy is performed in extreme conditions that threaten the life of the mother in labor, in the absence of conditions for delivery by other methods.

Craniotomy

The term "craniotomy" includes the following sequential interventions:

• perforation of the head (perforatio capitis);
• excerebration of the head (excerebratio capitis) - destruction of the brain and removal of brain matter;
• cranioclazia - compression of the perforated head with subsequent removal through the birth canal.

Indications for craniotomy: all cases of fetal death with an expected body weight over 2500 g, prevention of birth canal trauma, discrepancy between the sizes of the mother's pelvis and the fetal head, incorrect insertion and presentation of the head (anterior face presentation, brow presentation, posterior parietal insertion), lack of ability to lie down the subsequent head of the fetus in breech presentation.

Prerequisites for performing craniotomy:

• absence of an absolutely narrow pelvis (c. vera > 6 cm);
• the opening of the cervix during perforation and excerebration of the head should exceed 6 cm, and in case of cranioclasm - be equal to the size of the fetus being extracted;
• the fetal head must be fixed by an assistant at all three moments of the craniotomy operation;
• craniotomy is performed under general anesthesia, which provides an analgesic effect, protects the psyche of the woman in labor, and facilitates the fixation of the fetal head by an assistant through the abdominal wall;
• The operation must be performed under visual control, even in cases where the fetal head is well fixed in the pelvic cavity with the cervix fully open.

To perform a craniotomy operation, the following special instruments are required:

• Fenomenov's hammer drill, or Blo's hammer drill, or Smellie's scissor-like hammer drill;
• spoon-catheter (Agafonov excerbator), or a large blunt spoon, or a blunt curette;
• Brown's cranioclast;
• vaginal speculums and lift;
• two-pronged or bullet forceps;
• scalpel;
• Fenomenov or Siebold scissors.

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Perforation of the fetal head

Using wide flat vaginal speculums, access is opened to the cervix and the lower pole of the fetal head. If the fetal head is in an unstable position, special attention should be paid to the completeness of its fixation by an assistant. To ensure better fixation, two pairs of powerful bidentate forceps (or bullet forceps) are applied to the skin of the head, preferably in the center, after which the skin is opened with a scalpel or scissors to the bone of the fetal skull by 2-3 cm, preferably perpendicular to the sagittal suture. Then, with a finger, the skin is peeled away from the bones of the skull through the opening. The perforator is brought perpendicular (vertically) to the exposed bone, but not obliquely, since otherwise it may slip and injure the birth canal. The Blo perforator easily perforates the sutures and the crown, but it is much more difficult to perforate the bones of the skull. The bone is drilled very carefully until the widest part of the perforator is equal to the diameter of the perforation hole. After this, the spear-shaped end of the perforator with sliding plates is inserted into the perforation hole and vigorously rotated in one direction and the other (approximately 90°), achieving an expansion of the perforation hole in the skull to 3-4 cm in diameter.

The HH Fenomenov perforator resembles a drill. At one end of the instrument, the handle is equipped with a crossbar, and at the other - a drill-like cone-shaped tip. The instrument consists of a fuse in the form of a sleeve, which is put on the perforator. The edges of the perforation hole obtained during perforation with the Blo perforator are sharp and can cause injury to the birth canal. The edges of the hole in the skull after perforation performed by the Fenomenov perforator have a relatively smooth surface and are therefore less dangerous when removed through the birth canal.

Perforation is performed in the area of the head that is located along the leading axis of the small pelvis. In case of synclitic insertion of the head and occipital presentation, the sagittal suture or small fontanel are accessible for perforation. In case of asynctic insertion, the head is perforated through the bone. In case of anterior cephalic presentation, the perforation site is the large fontanel, in case of brow presentation - the frontal bone or frontal suture, in case of face presentation - the eye opening or hard palate, in case of presentation of other parts of the head - the suboccipital fossa or submandibular region.

Excerebration

A large blunt spoon (Fenomenov's spoon) or a large curette is inserted into the perforation hole, which is used to destroy and evacuate the fetal brain. A vacuum aspirator can be used.

In case of severe hydrocephalus, it is enough to puncture the head and evacuate the fluid. After this, the size of the head decreases, and in the future, spontaneous birth of the fetus is possible.

In order to extract the perforated head, it is possible to apply skin-head forceps or several multi-pronged alligator-type clamps. If the mother's condition is satisfactory and labor is good, the birth may end spontaneously. 

If there are indications for immediate completion of labor, then cranioclasy is performed under anesthesia. For this purpose, Brown's cranioclast is used.

The cranioclast is constructed like a cranioclast and consists of two branches - external and internal. Like obstetric forceps, the cranioclast consists of branches, a lock, a handle with a screw-and-nut device. The cranioclast spoons have a pelvic curvature. The internal spoon is massive, solid, there are transverse grooves on the internal surface. The external spoon is fenestrated, it is wider than the internal one.

The internal spoon is always inserted into the perforation opening under the control of the fingers of the left hand first. After this, the handle of the inserted spoon is handed to the assistant. The external spoon is also inserted under the control of the left hand so as not to injure the vaginal walls, and is applied to the external surface of the skull so that it corresponds to the position of the internal branch. The external branch is applied with great care and its direction is monitored so as not to make a mistake and not to capture the soft tissues near the cervical os. Having made sure that the branches of the cranioclast are correctly applied, the screw-and-nut mechanism is applied and closed by screwing it. Circumstances force the cranioclast to be applied to the part of the skull that is most accessible, but if there is a choice, it is best to apply the cranioclast to the facial or occipital part of the skull.

Before starting the traction, the obstetrician checks once again the correctness of the application of the cranioclast branches. The first, trial traction usually shows how correctly the cranioclast is applied, whether the head is pliable. The direction and nature of the traction should be the same as when applying obstetric forceps: if the head is high - downwards, if the head is on the pelvic floor - horizontally; when the suboccipital fossa appears - upwards. The cranioclast spoons are removed as soon as the head is brought out of the genital slit.

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Decapitation

After the head is separated from the body, the body and the severed head are extracted one after the other. After the operation, a manual examination of the uterus and inspection of the birth canal are mandatory. Due to the possible trauma to the mother's birth canal, in some cases, despite the death of the fetus, preference is given to a cesarean section.

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Indication for decapitation

Advanced transverse fetal position.

Prerequisites for its implementation:

• complete opening of the cervical os;
• accessibility of the fetal neck for examination and manipulation;
• sufficient pelvic dimensions (s. vera > 6 cm).

Tools - Brown hook and Siebold scissors.

Technique of decapitation surgery

The prolapsed arm of the fetus is secured with a gauze loop and passed to an assistant, who moves it down and towards the pelvic end of the fetus. 

Then insert the hand into the vagina, then into the uterus, and if the handle has not fallen out, find the fetus's neck and grasp it, placing the first finger in front and the other four on the neck from behind. Sliding along the hand, insert the decapitation hook (button down) into the uterus and place it on the fetus's neck. After that, pull the handle of the Braun hook down strongly and make rotational movements. When the spine is fractured, a characteristic crunch is heard. Having removed the hook under the control of the inner hand, use scissors to cut the soft tissues of the fetus's neck. When cutting soft tissues, it is very important to grasp the soft tissues of the head with one or two long instruments (clamps) or suturing them with a thick long ligature so that after removing the body, it is possible to bring it closer to the cervix.

As a rule, the body is easily removed by pulling on the fallen handle. However, sometimes difficulties arise when removing the shoulders. In such cases, the clavicles are cut (cleidotomy is performed). Removing the head is associated with significant difficulties. The head is removed from the uterine cavity by hand. For convenience and reliability, a finger of the inner hand is inserted into the fetus's mouth. If attempts to remove the head are unsuccessful, a craniotomy is performed, then an excerbation and the head is removed with an instrument, preferably with two-pronged forceps.

After completing the operation, a manual revision of the uterine walls is mandatory, with prior removal of the placenta, to ensure the integrity of the uterine walls. This rule is mandatory for all types of fetal-destroying operations.

Crossing the clavicle

Cleidotomy is performed to reduce the volume of the shoulder girdle by cutting the clavicles. The operation is performed when, due to the large size of the shoulders, they are retained in the birth canal and the birth of the fetus is suspended. This complication is most often observed in gas presentation, but also occurs in cephalic presentation (shoulder dystocia).

Indication: difficulty in bringing out the fetal shoulders.

The circumference of the shoulder girdle with a unilateral cleidotomy is reduced by 2.5-3 cm, with a bilateral one - by 5-6 cm. The assistant pulls the born head of the fetus downwards. The operator inserts two fingers of the left hand into the vagina, palpates the anterior clavicle, takes strong blunt-ended scissors (Phenomenov or Siebold) with the right hand, reaches the clavicle with them and dissects it. With the fingers of the left hand, the operator reaches the posterior clavicle, which he dissects in the same way. The operation is most often performed after craniotomy.

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Evisceration and spondylotomy

Excision (removal of internal organs from the abdominal or chest cavity) and spondylotomy (splitting of the spine) are performed in cases where the fetal neck is inaccessible or difficult to access.

It is not always possible to reach the fetal neck in advanced transverse fetal position. It may be located very high, and decapigapia becomes impossible. In this case, it is necessary to reduce the fetal body volume by removing the abdominal or thoracic organs and extract the fetus in a folded or doubled form.

In exceptional cases, after evisceration, it is necessary to perform a spinal dissection at any level - spondylotomy.

Technique of operation

• insertion of the left hand into the vagina and search for a place to perforate the wall of the body (chest or abdominal cavity);
• insertion of the perforator under the control of the inner hand; 
• perforation of the trunk in the intercostal space and gradual widening of the perforation opening. If necessary, one or two ribs are dissected;
• through the hole formed in the body, the destroyed organs of the abdominal or thoracic cavity are gradually removed with an abortion forceps or pliers. The spine is incised with Fenomenov or Siebold scissors. Evisceration is also indicated in cases of fused twins or other obvious deformities. In this case, depending on the situation, decapitation of the additional head, exceretherapy of the additional head, or evisceration of the additional thoracic or abdominal cavity, etc., is performed.

Spondylotomy is performed with scissors inserted into the perforation hole. The integrity of the spine can also be violated using a decapitation hook, after which, under visual control, the chest (abdominal) wall is dissected with scissors and the head and foot ends of the fetus are extracted one by one.

After any feto-destructive surgery, it is necessary to carefully check the integrity of the birth canal, perform a manual examination of the uterine walls, and check the bladder by catheterization.