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Prof. dr. Mgs. H. Usman Said, SpOG (K)

Subbagian Fertilitas Endokrinologi & ReproduksiDepartemen Obstetri & GinekologiFK. Unsri / RSUP Dr. Muhammad Hoesin Palembang2010

EMBRIOTOMY

Destructive Vaginal Delivery

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• Definition : Definition Reductive surgical procedure performed on the dead fetus to reduce its size and make vaginal delivery possible.

• Important features :Important features Need few instruments Leaves the mother with intact uterus If she is already infected risk of spread of infection to the peritoneum low Shorter time in bed

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• Craniotomy • Decapitation • Evisceration • Cleidotomy

TYPES:

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• Rate of DVD in Eth. :• Study done in TAH (1997-2002) 7.8 DVDs per

1000 deliveries Craniotomy (94%) for CPD(89%)

• Average BW -2957gm GA 31-45 wks- preterm(13%), post term (7%) & term(54%) Labor >24hrs in 88%

• Fistulas , infection & genital trauma Currently almost never practiced in the developed world

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• Indications of DVD :CPD, Breach delivery, Transverse lie

Prerequisites for DVD :• Dead fetus –exceptions(malformation or tumor

incompatible with life,• Cleidotomy & needle aspiration for hydrocephalus) • Fully dilated cervix • No risk of uterine rupture 2/5 or less of his head

must be above the brim • Back up operative facilities

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• Live fetus• Markedly contracted pelvis

( conjugate vara <5.5cm) • Cervix <7cm dilated • Obstructing pelvic tumors• Imminent uterine rupture

CONTRAINDICATIONS OF DVD

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• Perforation of the skull and emptying the head of brain tissue so that the head collapses. It is used when the fetus presents with the head or in a case of retained head in a breech.

• Indications - obstructed labor with a vertex or face presentation - arrested aftercoming head - hydrocephalus- - Interlocked head of twins - contracted pelvis is the most common indication

CRANIOTOMY

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• Scalp is held with a tissue forceps and incision is made with a perforator and contents of the brain are evacuated.

• Sites-vertex-parietal bone -face-orbit/hard palate -brow-frontal bone -aftercoming head-foramen magnum

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• Hydrocephalus - forecoming head- a large needle is inserted near the suture line and fluid is drained - aftercoming head-after delivery of the shoulder base of the skull is exposed & fluid is drained or transabdominal encephalocentesis can be done

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• IS cutting the neck and separating the head from the truncus followed by version and extraction Ind.- obstructed labor in shoulder presentation when the neck is easily accessible, as well as in the rare cases of locked twins Instruments- decapitating wire & Blond- heidler thimble

DECAPITATION

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• IS perforation of the truncus (chest or abdomen) with removal of all internal organs so that the body collapses and a version and extraction can be done without the risk of rupturing the uterus.

• Ind-in shoulder presentation where it is difficult to reach the neck - fetal malformation(ascites, huge distended bladder, hydronephrosis) - after decapitation

EVISCERATION

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Procedure - pull on the prolapsed arm & his axilla -protect the vaginal wall with speculum -make an opening in the chest or abd. Wall- remove the viscera (liver, heart, and lungs) - If necessary perforate his diaphragm with scissors.

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• Cutting of one or both clavicles to reduce the width of the shoulder

• This is considered in cases where the head is delivered, large shoulders are obstructing delivery and other maneuvers for shoulder dystocia have been unsuccessful

• Ind- fetus with shoulder dystocia • Skin at the base of the pos. ∆ is perforated

&opening is made to gain access to the clavicle. • Clavicle is cut and the baby is delivered.

CLEIDOTOMY

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• Trauma to birth canal • PPH • Shock • Puerperal sepsis • Injury to adjacent organs• VVF,UVF or RVF Iatrogenic• Ux rupture

COMPLICATIONS