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In developing countries 8% of labors get obstructed midway needing assistance for the jammed head.

Historically, childbirth is can be  dangerous. An obstructed labor, is a common, obstetric complication, with risks of death of mother and baby. Lee [Destructive obstetric instruments: what do they destroy? | HKMJ] relates to the 18^th century story of a princess who, after two days of difficult labor, delivered a stillborn baby. The princess died the next day, and then the doctor killed himself.

In a situation, where both can  die,  it makes sense to sacrifice one. Lee states that Francois Mauriceau, a French obstetrician,  described a way of extracting a stuck baby by a craniotomy. He was a pioneer, making a hole in the baby’s head and extracting the brain, to collapse the  skull  and remove the baby vaginally. This killed the baby, but it did save the mother.

This was before 1846: when Mr Morton had not yet discovered anesthesia, and it was not easy to carry out a cesarean section to extract a stuck baby (Cesarean Section History (news-medical.net)).

In the nineteenth-century anesthesia was still dangerous. Therefore, even after cesareans become commonplace, it was still  better to destroy the dead baby and not risk the mother’s life. Compared to a cesarean section, a destructive procedure has fewer maternal complications and shorter hospital stay.

Soon, obstetricians devised more versatile methods of cutting the baby into smaller parts.

Types of procedures

a) Craniotomy– for a fetal hydrocephalous (52%), Obstructed labor (19%), after coming head of breech, arrested labor(7%), cord prolapse at full dilatation with a dead baby (5%), persistent mento-posterior (4%) and placental abruption (4%).

b) Decapitation- separation of the head from the trunk, for a baby in a transverse lie.

c) Cleidotomy– Dividing the fetal clavicles to allow a vaginal birth in a macrosomic baby with shoulder dystocia, and patient medically unfit for a cesarean section.

d) Evisceration-Removal of the fetal abdominal organs, piecemeal in a dead or abnormal fetus in transverse lie, using scissors.

e) Symphysiotomy– cutting the  symphysis pubis bone to increase space in fetus with stuck shoulders.

Who are the patients requiring these procedures

1. A dead fetus
2. Mal-presentations – breech or transverse lie.
3. A Hydrocephalic fetal head
4. A lethal fetal anomaly

When some procedures are contraindicated.

1. Baby is alive
2. Macrosomia
3. Cephalopelvic disproportion
4. Obstructed labor with suspected uterine rupture
5. Previous uterine scars

Type of Instruments

a) Decapitation hook for transverse lie

b) Decapitation wire saw with thimble for transverse lie

c) Breech hook- for dead breech

d) Simpson’s perforator for a craniotomy.

e) Embryotomy scissors for evisceration

Advantages of destructive operations versus a cesarean section

1.  A reduced maternal morbidity

2. Achieving a vaginal birth.

3. Shorter hospital stay

4. Reduced chance of blood transfusion

5. Earlier recovery

A craniotomy forceps (Source: Wikipedia, https://commons.wikimedia.org/wiki/File:Simpson%27s_craniotomy_forceps_or_cranioclast_Wellcome_L0006283.jpg)

Complications of destructive procedures

1. Ascending infection.
2. Bladder injury.
3. Vesico-vaginal fistulas- in poorly selected cases.
4. Perineal trauma.
5. Postpartum hemorrhage.
6. Urinary tract infection.
7. Fecal incontinence.

” The guiding principal is to select the appropriate patient, the appropriate method, the best instrument and a  timely intervention- by the safest route.”

The knowledge and the wisdom to do or not to do.

Caution! as the skill is slowing dying out due to reasons, like lack of training, easy resort to a cesarean, unethical practices, lack of awareness.

These operations are safe when the facility of a trained obstetrician is available. Units with blood, antibiotics, oxytocic drugs, anesthesia  and a quick resort to surgery are available.

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