Fruit-destroying operations

Fetal destruction (embryotomy) is performed to reduce the fetal volume, 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, event: 
2. the operation of dividing the fetus into parts and extracting it in parts decapitation, spondylotomy, exarticulation; 
3. operations that reduce the volume of the fetal body by maximizing the mobility between its individual parts: cladotomy, puncture of the skull with hydrocephalus, fractures of the bones of the limbs.

Craniotomy, decapitation and cladotomy are performed more often and therefore refer to typical embryotomies.

Spondylotomy and evisceration, or evention, are atypical embryotomies. The main indication for conducting fertile operations in modern obstetrics is the presence of a dead fetus. In exceptional situations, embryotomies are also performed with a live fetus (severe fetal malformations that are incompatible with life). In addition, embryotomy is performed under extreme conditions threatening the life of the parturient woman, in the absence of conditions for delivery in other ways.

Craniotomy

The term "craniotomy" includes such sequential interventions:

• perforation of the head (perforatio capitis);
• excisebration of the head (excerebratio capitis) - destruction of the brain and removal of the brain substance;
• cranioclasia (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 of more than 2500 g, prevention of birth canal graft, mismatch between the size of the pelvis of the mother and the fetal head, improper insertion and presentation of the head (front view of the facial presentation, frontal presentation, posterior insertion) and lie down the subsequent head of the fetus with pelvic presentation.

Prerequisites for the implementation of craniotomy:

• Absence of an absolutely narrow pelvis (vera> 6 cm);
• the opening of the cervix during perforation and head eccerberation should exceed 6 cm, and with cranioclasia it should be full of the day of the size of the extracted fruit;
• the fetal head should be fixed by an assistant at all three points of the craniotomy operation;
• craniotomy is performed under anesthesia, it provides an anesthetic effect, protects the psyche of the mother in childbirth, facilitates the fixation of the fetal head by an assistant through the abdominal wall;
• the operation should be performed under the control of vision, even in cases where the fetal head is well fixed in the cavity of the small pelvis when the cervix is fully opened.

For the operation of craniotomy the following special tools are needed:

• Phenomenov's perforator, or Blok's puncher, or Scully's scissor-type perforator;
• a spoon-catheter (Agafonov's excerator), or a large blunt spoon, or a dull curette;
• Brown's cranioclast;
• vaginal mirrors and a lift;
• bicuspid or bullet forceps;
• scalpel;
• scissors Phenomenov or Zybold.

[1]

Perforation of the fetal head

Using wide flat vaginal mirrors, access to the cervix and the lower pole of the fetal head is opened. When the fetal head is unstable, special attention should be paid to the usefulness of its fixation by an assistant. In order to guarantee better fixation, two pairs of powerful tongs or two forceps (or forceps) are applied to the scalp, preferably with a scalpel or scissors, to open the skin to the bone of the skull of the fetus for 2-3 cm, preferably perpendicular to the arrow-shaped seam. Then the finger from the hole peel the skin from the bones of the skull. The perforator with respect to bare bones is fed perpendicularly (vertically), but not obliquely, as otherwise slipping and traumatizing the birth canals is possible. Blok perforator easily perforate the seams and temechko, much more difficult - the skull bones. Drilling the bone is done very carefully, as long as the widest part of the perforator can not be compared with the diameter of the perforation hole. After that, a spear-shaped end of the perforator with expanding plates is introduced into the perforation hole and rotated vigorously on one side and the other (approximately 90 °), achieving expansion of the perforation in the skull to 3-4 cm in diameter.

The HF puncher HH Phenomenov looks like a drill. At one end of the tool, the handle is equipped with a crossbeam, and on the other end with a drill-like cone-shaped tip. The tool consists of a fuse in the form of a sleeve, which is put on the puncher. The edges of the perforation hole, obtained by perforating the Blot pen, are acute and can cause trauma to the birth canal. The edges of the hole in the skull after the perforation carried out by Phenomenov's perforator have a relatively smooth surface and are therefore less dangerous when extracted through the birth canal.

Perforation is carried out in the head region, which is located along the leading axis of the small pelvis. With synclinic insertion of the head and occipital presentation of the perforation, an arrow-shaped suture or small fontanelle is available. With asyntactic insertion, the head is perforated through the bone. At anterior preposition, the place of perforation is a large fontanel, with frontal presentation - frontal bone or frontal suture, with facial presentation - an eye hole or a hard palate, with the presentation of other parts of the head - anterior cervical fossa or submandibular region.

Excercise

A large blunt spoon (spoon of Phenomenov) or a large curette is injected into the perforation by which the brain of the fetus is destroyed and evacuated. You can use a vacuum aspirator.

With severe hydrocephalus, it is enough to make a puncture of the head and evacuate the fluid. After that, the size of the head decreases, and later the spontaneous birth of the fetus is possible.

For the purpose of removing the perforated head, it is possible to impose dermal-head forceps or several multi-toothed alligator type clips. With a satisfactory condition of the woman in labor and good labor, the birth can end spontaneously. 

If there is evidence for the immediate completion of labor, then anesthesia is performed cranioclase. For this purpose, Brown's cranioclast is used.

Cranioclast is constructed like a thorn and consists of two branches - external and internal. Like acoureximetry forceps, the cranioclast consists of branches, a lock, a handle with an adapted screw-nut device. Spoons cranioclast have pelvic curvature. The inner spoon is massive, solid; on the inner surface there are transverse furrows. The outer spoon is final, it is wider than the inner spoon.

In the perforation, under the control of the fingers of the left arm, the inner spoon is always introduced first. After this, the handle of the inserted spoon is handed over to the assistant. The outer spoon is also injected under the control of the left arm, so as not to injure the walls of the vagina, and superimpose on the outer surface of the skull in such a way that it corresponds to the position of the inner branch. The outer branch is superimposed with great care and follows its direction so as not to make a mistake and not to grab the soft tissues near the uterine throat. After making sure that the branches of the cranioclast are correctly applied, a screw-and-nut mechanism is applied and by closing it is closed. 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 on the facial or occipital part of the skull.

Before starting traction, the obstetrician once again checks the correctness of the application of cranioclast branches. Already the first, trial traction usually shows how correctly the cranioclast is applied, whether there is any compliance with the head. The direction and nature of traction should be the same as when applying obstetric forceps: with a high head standing - down, with the head on the pelvic floor - horizontally; when the suboccipital fossa appears upward. Spoons of cranioclast are removed as soon as the head is removed from the genital cleft.

[2], [3], [4], [5],

Decapitation

After separating the head from the trunk, the trunk and the cut off head are removed alternately. After the termination of operation necessarily carry out manual inspection of a uterus and survey of patrimonial ways. In connection with the possible trauma of the mother's birth canal in some cases, despite the death of the fetus, preference is given to the cesarean section.

[6], [7], [8]

Indication for decapitation

The transverse position of the fetus.

Prerequisites for it:

• full opening of the uterine throat;
• accessibility of the fetal neck for examination and manipulation;
• sufficient pelvic size (s.Vera> 6 cm).

The toolkit is a Brown hook and Zybold's scissors.

Technique of decapitation

The fallen handle of the fetus is fixed with a gauze loop and passed to the assistant, who takes it down and towards the pelvic end of the fetus. 

Then put your hand into the vagina, then into the uterus, and also, if the handle does not fall out, look for the neck of the fetus and grab it by placing the first finger in front, and the remaining four - on the neck from behind. Slithering on the arm, a decapitation hook is inserted into the uterus (with a button down) and is placed on the neck of the fetus. After this, the handle of the Brown hook is tightened upwards and rotational movements are made. With a fracture of the spine, a characteristic crunch is heard. Having removed the hook under the control of the inner hand, the soft tissue of the neck of the fetus is cut with scissors. When crossing soft tissues, it is very important that one or two long instruments (clamps) of the soft tissues of the head are grasped or stitched with a thick long ligature so that after the removal of the trunk it is possible to bring it closer to the cervix.

Typically, the extraction of the trunk occurs without difficulty in the case of pulling on the fallen handle. Nevertheless, sometimes when hanging the shoulders, difficulties arise. In such cases, they cross the clavicles (spend a cladotomy). Removing the head involves considerable difficulties. The head from the uterine cavity is extracted by hand. For convenience and reliability, the finger of the inner hand is inserted into the mouth of the fetus. If attempts to extract the head are unsuccessful, craniotomy is done, then - ekscherebraciyu and the head is removed with a tool, preferably with all two-tooth forceps.

After completing the operation, it is necessary to manually check the walls of the uterus with a previous removal of the afterbirth to make sure the integrity of the uterine walls. This rule is mandatory for all types of fruit-destroying operations.

Crossing of clavicle

Cladotomy 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 stay in the birth canals and the birth of the fetus is suspended. This complication is most often observed with gas previa, but it occurs with the headache (dystocia of the shoulders).

Indications: difficulty in removing the shoulders of the fetus.

Circumference of the shoulder girdle with one-sided gladotomy decreases by 2.5-3 cm, with a bilateral one - by 5-6 cm. The assistant pulls the fetal head born to the bottom. The operator enters two fingers of the left hand into the vagina, palpates the front clavicle, takes the right blunt scissors (Phenomenova or Zybold) with her right hand, reaches the clavicle and dissects it. The fingers of the left hand reach the back of the collarbone, which is cut in the same way. The operation is most often performed after craniotomy.

[9], [10], [11], [12], [13]

Evisceration and spondylotomy

Zvitseratsiyu (removal of internal organs from the abdominal or thoracic cavity) and spondylotomy (dissection of the spine) is carried out in cases where the neck of the fetus is inaccessible or difficult to access.

Far from always when the transverse position of the fetus is started, it is possible to reach the neck of the fetus. It can be located very high, and decapigapia becomes impossible. In this case, it is necessary to reduce the volume of the trunk of the fetus by removing the organs of the abdominal or thoracic cavity and extract the fruit in a folded or doubled form.

In exceptional cases, there is a need after evisceration to make a dissection of the spine at any level - spondylotomy.

Technique of operation

• insertion of the left hand into the vagina and search for a place for perforation of the trunk wall (thorax or abdominal cavity);
• the introduction of a perforator under the control of the inner hand; 
• perforation of the trunk in the intercostal space and gradual expansion of the perforation. If necessary, cut one or two ribs;
• Through the hole formed in the trunk, abortion or forceps gradually remove the destroyed organs of the abdominal or thoracic cavity. The incision of the spine is carried out with scissors Fenoma Nova or Zybold. Evisceration is also shown with the merged double or the presence of other obvious deformities. In this case, depending on the situation, the additional head is decapitated, the extra head is eccerbered or the extra thoracic or abdominal cavity is euthsized, and so on.

Spondylotomy is performed with scissors inserted into the perforation. Violation of the integrity of the spine is also possible with the help of the decapitation hook, after which under the control of vision, the thoracic (abdominal) wall is scissorized and the head and the foot ends of the fetus are extracted alternately.

After any fruit-destroying operation, it is necessary to carefully check the integrity of the birth canal, perform a manual examination of the walls of the uterus, check the bladder by catheterization.