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

MEDICATIONS

MAGNESIUM SULFATE

  • 500mg /ml solution

FOR ECLAMPSIA

  • 4 g intravenous loading dose
  • Immediately followed by 10 g intramuscularly – 5 mg in each buttock
  • Followed by 5 g intramuscularly every 4 hours in alternating buttocks
  • Check patellar reflexes before each injection
  • If weak or absent wait another 4 hours before giving next injection

MISOPROSTOL

  • Tablet Cytotec 200 µg

FOR INDUCTION IN IUFD

Gestational age < 26 weeks

  • ORAL ADMINISTRATION (preferred)
    • One tablet diluted in 10 cc
      • 2 cc orally every 6 hours
  • VAGINAL ADMINISTRATION
    • ½ tablet in vagina every 6 hours

Gestational age > 26 weeks

  • ORAL ADMINISTRATION (preferred)
    • One tablet diluted in 10 cc
      • 1 cc orally every 4 hours
  • VAGINAL ADMINISTRATION
    • ¼ tablet in vagina every 4 hours
    • One tablet diluted in 10 cc
      • 1 cc in vagina every 4 hours

Use only exceptionally and with greatest precaution for induction with alive fetus

FOR POSTPARTUM BLEEDING

ORAL ADMINISTRATION (preferred)

  • 2 to 3 tablets orally

RECTAL ADMINISTRATION

  • 2 to 4 tablets rectally

VALIUM

For Eclampsia:

  • 5 to10 mg i.v. or rectally
  • Repeat after 10 to 15 minutes up to a maximum dose of 30 mg
  • If needed repeat after 2 to 4 hours.
  • Keep a syringe loaded with 10 mg at bedside
  • Give immediately i.v. when a seizure is noted

OXYTOCIN

FOR INDUCTION OF LABOUR

  • 10 units in 500 cc Normal Saline solution
  • Start i.v. infusion with 10 ml per hour
  • increase by 20 ml every 20 minutes until contractions occur

FOR POSTPARTUM HEMORRHAGE

  • 30 units in 500 CC Normal Saline
  • Infused over 2 to 4 hours

NEFIDIPINE

For Hypertension:

  • 10 mg 3 times daily

For Premature Labor:

  • 10 to 40 mg
  • Followed by 10 to 20 mg every 6 to 8 hours

LIDOCAINE

For Eclampsia:

  • 2mg/kg i.v. as a bolus

2mg/kg/h i.v. as maintenance

SALBUTAMOL

  • Tablets 4 mg

For Premature Labor:

  • 4 mg four times daily

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

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

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