ROHILKHAND COLLEGE OF NURSING, BAREILLY

LESSON PLAN
ON
DESTRUCTIVE SURGERIES

SUBMITTED TO: SUBMITTED BY:

 IDENTIFICATION DATA

NAME OF STUDENT TEACHER .........................................

SUBJECT:...............................

UNIT:.................................

TOPIC:....................................

GROUP................................

NO. OF STUDENTS: .......................

DURATION: 45 Minutes

VENUE: .................... Class room

METHOD OF TEACHING: Lecture cum discussion teaching method

A.V Aids: PPT & Black Board, Flash cards, Charts, Pamphlet etc.

PREVIOUS KNOWLEDGE: The students may have some knowledge regarding destructive surgeries
GENERAL OBJECTIVE: By the end of class presentation, the students will be able to gain knowledge about destructive surgeries and they
can use in their future life.

SPECIFIC OBJECTIVES: At the end of the teaching session the group will be able to

o Introduce the destructive surgeries

o Define the destructive surgeries
o Explain the purposes of destructive surgeries
o Enlist the advantages of destructive surgeries
o State the role in modern obstetrics
o Discuss the contraindication of destructive surgeries
o Describe the dangers of destructive surgeries
o Discuss the classification of destructive surgeries
o Explain the perforaters
o Describe the type of destructive vaginal operation
o Enumerate the other types of destructive vaginal operation.
o Enlist complication during perforation and extraction
o Discuss the prevention during perforation and extraction
o Define morcellation
o Elaborate the post operative care following destructive operation.
S.No TIM SPECIFIC CONTENT TEACHING A.V EVALUATI
E OBJECTIVE LEARNING AIDS ON
ACTIVITY
TEACHI LEARNIN
NG G
1 INTRODUCTION: Guess the
3 To Introduce the Lecture Students PPT & topic?
min destructive surgeries These are a group of operations aims at reducing the size of cum are actively black
the head, shoulder girdle or trunk of the dead foetus to allow discussion participatin board
its vaginal delivery. It has been abandoned from the modern method g.
obstetrics in favour of caesarean section which is safer to the
mother.

2 DEFINITION:
2 Define the Lecture Students PPT & What is
min destructive surgeries Destructive operations are procedures that reduce the size of cum are actively black destructive
the head, shoulder girdle, or trunk of the dead fetus to allow discussion participatin board surgeries.?
its delivery through the vaginal route. method g

PURPOSES What are the

3. 3 Explain the purposes  To reduce baby’s size(head, shoulder girdle or body) Lecture Students PPT & purposes of
min of destructive and so enable the vaginal delivery of baby which is cum are actively black destructive
surgeries too large to pass intact through the birth canal discussion participatin board surgeries?
 Or, operations that are designed to diminish the bulk method g
of the fetus so as to facilitate easy delivery through
the birth canal.
 ADVANTAGES
 Needs few instruments & simple anesthesia. Lecture Students PPT & Describe the
4. 3 Enlist the advantages  Uterus remains intact , ( no L.S.C.S. scar ). cum are actively black advantages of
min of destructive  Subsequent pregnancy will be safer. discussion participatin board destructive
surgeries method g surgeries?
 Operative morbidity is lesser .
 Hospital stay is shorter.

ROLE IN MODERN OBSTETRICS Lecture Students PPT & Explain the

5. 3 State the role in  No role in modern obstetrics cum are actively black role in modern
min modern obstetrics  Unpleasant and unacceptable level of discussion participatin board obstetrics?
maternaltraumatic and psychological morbidity method g
Complicated intrauterine procedure
 Chances of injury to obstetrician in HIV era
 Abandoned in favor of cesarean section which is
 safer to the mother.
CONTRAINDICATIONS Lecture Students PPT & What are the
6. 2 Discuss the cum are actively black contraindicati
min contraindication of  Living normal fetus discussion participatin board on destructive
destructive surgeries  Markedly contracted pelvis method g surgeries?
 Cervix less than 3/4th dilated
 Neoplasms obstructing the pelvis

7. DANGERS Lecture Students Discuss the

3 Describe the dangers  Lacerations of vagina, cervix,uterus, bladder or cum are actively dangers of
min of destructive rectum discussion participatin destructive
surgeries  Uterine rupture method g surgeries?
 Hemorrhage from lacerations and
 uterine atony
 Infection
8 5 Discuss the C LASSIFICATION What are the
min classification Living fetus: Lecture Students PPT & classification
destructive surgeries cum are actively black of destructive
 Needle drainage in hydrocephaly discussion participatin board surgeries?
 Fracture of clavicle or arm- in shoulder dystocia and method g
breech with nuchal arm

Dead fetus
Craniotomy-hydrocephaly (when delivery of intact head is
impossible )
Decapitation- neglected transverse lie, interlocked twins
Cleidotomy -shoulder dystocia, breech with nuchal arms
Spondylectomy- breech with hydrocephaly
Evisceration or morcellation Hydrops fetalis with
marked ascites Monsters

9 3 Explian the PERFORATORS What is

min perforaters Lecture Students PPT & perforaters?
 Frightful instruments were used earlier to open the cum are actively black
head of the fetus in craniotomy discussion participatin board
 Used to open the thorax and abdomen of fetus in method g
evisceration
Perforaters , Smellie Perforaters, Simpsons spring loaded
Perforaters, Hooks/Crochets, cranioclast,Rambosthams
decapitating hook , decapitating hook (jardine’s).

10 15 Describe the types of TYPES OF DESTRUCTIVE VAGINAL OPERATIONS How many

min destructive vaginal Lecture Students PPT & types of
operation. − Craniotomy cum are actively black destructive
− Decapitation discussion participatin board vaginal
− Evisceration method g operation.?
− Cleidotomy

CRANIOTOMY
It is an operation to make a perforation on the fetal head,
to evacuate the contents followed by extraction of the fetus.

INDICATIONS
1. Cephalic presentation producing obstructed labor with
dead fetus
2. Hydrocephalus even in a living fetus
3. Interlocking head of twins
4. Specifically unfavorable position of child-impacted
mento-posterior, brow, or occi-puto posterior positions-
following a prolonged labor

Conditions to be fulfilled
1. The cervix must be fully dilated
2. Baby must be dead (hydrocephalus being excluded)
3. Two fifth or less head Palpable above the brim
4. Head is impacted
5. Uterus unruptured/no Imminent rupture
6. True conjugate not < 7.5 cm

Contraindications
 Severely contracted pelvis so as to shorten the true
conjugate < 7.5 cm
 Rupture of the uterus
PRE TREATMENT
 Correct dehydration
 Treat ketoacidosis
 Draw blood for cross-matching, investigations
 To arrange blood
 Prophylactic antibiotics
 Catheterize the bladder

PROCEDURE
Preliminaries:
Anesthesia- either general or local
 Lithotomy position
 Full surgical asepsis
 Empty the bladder
 Vaginal examination

STEPS
 Step 1: The two fingers are introduced into the
vagina and the finger tips are to be placed on
proposed site of perforation. However, when the
suture line cannot be defined because of big caput,
the perforation should be done through the
dependent part.

Sites of perforation:
Vertex: on the parietal bone either side of the
sagittal suture. Suture is avoided to prevent collapse of the
bone thereby preventing escape of the brain matter
Face: through the orbit or hard palate
Brow: through the frontal bone

 Step 2- The Oldham’s perforator with the blades is

closed is introduced under the palmer aspect of the
fingers protecting the anterior vaginal wall and the
adjacent bladder until the tip reaches the proposed
site of perforation
 Step 3 By rotating movements the skull is
perforated. During this step, an assistant is asked to
steady the head per abdomen in a manner of first
pelvic grip. After the skull is perforated, the
instrument is thrust up to the shoulders and the
handles are approximated so as to allow separation
of the sharp blades for about 2.5 cm. The blades are
again apposed by separating the handles. The
instrument is brought out keeping the tip of the
blades still inside the cranium. The instrument is
rotated at right angle and then again thrust in up to
the shoulders. The handles are once more to be
compressed so as to separate the blades for about
2.5cm. The perforated area now looks like a cross.
The instrument with the blades closed is then thrust
in beyond the guard to churn the brain matter. The
instrument, with the blades closed, is brought out
under the guidance of the two fingers still placed
inside the vagina. Alternative to Oldham’s
perforator, similar procedure could be performed
using a sharp- pointed Mayo’s scissors.
 Step 4 With the fingers brain matter is evacuated.
The idea is to make the skull collapse as much as
 possible.
 Step 5 When the skull is found sufficiently
compressed, the extraction of the fetus is achieved
either by using a cranioclast or by 2 giant valsella.
Giant valsella are used to hold the incised skull and
scalp margins.
 Step 6 The traction is now exerted. Step 7 After
the delivery of the placenta, the uterovaginal canal
must be explored as a routine for evidence of rupture
uterus or any tear. Inj. Methergine 0.2 mg IM given
with the delivery of anterior shoulder. The rest of the
delivery is completed as in normal delivery.

DECAPITATION
It is the destructive operation whereby the fetal head is
severed from the trunk and the delivery is completed with
the extraction of the trunk and that of the decapitated head
per vagina.

Indications
• Neglected shoulder with a dead fetus.
• Locked twins.
• Double -headed monsters.

Prerequisites:
 Neck of the fetus should be accessible per vagina.
 No evidence of impending rupture.
 Cervix should be at least 7 cm dilated
PROCEDURE
Done under general anesthesia
Step— I: If the fetal hand is not prolapsed, bring down a
hand. A roller gauze is tied on the fetal wrist and an
assistant is asked to give traction towards the side away from
the fetal head to make the neck more accessible and fixed.

Step—II: Two fingers of the left hand (middle and index)

are introduced with the palmar surface downwards and the
finger tips are to be placed on the superior surface of the
neck—the proposed site of decapitation.

Step—III: The decapitation hook with knife is to be

introduced flushed under the guidance of the fingers placed
into the vagina, the knob pointing towards the fetal head.
The hook is pushed above the neck and rotated to 90° so as
to place the knife firmly against the neck. The internal
fingers, in the meantime, are placed on the under surface of
the neck to guard the tip of the hook

Step—IV: By upward and downward movements of the

hook with knife, the vertebral column is severed (evident by
sudden loss of resistance). The rest of the soft tissue left
behind may be severed by the same instrument or by
embryotomy scissors . While removing the decapitation
hook—it is to be pushed up; rotated to 90° and then to take
out under the guidance of the internal fingers. The
decapitated head is pushed up and the trunk is delivered by
traction on the prolapsed arm.

Step—V: Delivery of the decapitated head—Any of the

following methods may be usually effective :
• By hooking the index finger into the mouth
• By holding the severed neck with giant valsellum and
delivery of the head as that of aftercoming head in breech
• Using forceps

Step—VI: Routine exploration of the uterovaginal canal to

exclude rupture of the uterus or any other injury.

EVISCERATION
The operation consists of removal of thoracic and
abdominal contents piecemeal through an opening on the
thoracic or abdominal cavity at the most accessible site. The
objective is to diminish the bulk of the fetus which
facilitates its extraction. If difficulty arises, the spine may
have to be divided (spondylotomy) with embryotomy
scissors

Indications
• Neglected shoulder presentation with dead fetus; the neck
is not easily accessible
• Fetal malformations, such as fetal ascites or hugely
distended bladder or monsters.
• Thoracic or abdominal tumors

Procedure-
The operation is performed by first making a large opening
(with a perforator or embryotomy scissor) into the
abdomen or thorax The viscera are then broken up and
removed manually. If the thorax has to be incised first, the
abdominal viscera are reached via the diaphragm. During
these manipulations, if the lie is transverse, the trunk of the
child may be steadied by pulling down an arm but if that is
not possible (trunk presentation) valsella: may be
employed for this purpose
 CLEIDOTOMY
The operation consists of reduction in the bulk of the
shoulder girdle by division of one or both the clavicles to
reduce the biacromial diameter The operation is done only in
dead fetus (anencephaly excluded) with shoulder dystocia.
The clavicles are divided by the embryotomy scissors or
long straight scissors introduced under the guidance of left
two fingers placed inside the vagina.
Indications To reduce the width of the shoulder in large
fetus that cannot be delivered vaginally. When maneuvers
for shoulder dystocia are unsuccessful

Procedure
Follow all general principles of conducting destructive
operation. Make a small cut in the skin of neck of the dead
fetus Place one hand vaginally along with the ventral
aspect of the fetus and identify clavicle Use embryotomy
scissors and cut the clavicle into two and reduce the width
of the shoulder and deliver the fetus

11 5 Enumerate the other OTHERS What are the

min types of destructive Spondylectomy Lecture Students PPT & other types of
vaginal operation.  Spondylectomy is transection of the spine of the cum are actively black destructive
delivered thorax. discussion participatin board vaginal
 In breech presentation it may allow drainage of CSF. method g operation.?
 It is done when the back is anterior and head and
neck are out of reach.
 In cases of hydrocephalus when there is
communication between the ventricles and spinal
cord the fluid may be drained from brain in this way
thus obviating the need for craniotomy
 Hydrocephalus
 Pelvis to be of ordinary capacity
 Perforation can be made by any suitable sharp
instrument,
 Provided cervix is sufficiently dilated to allow two
fingers to be introduced.
 After perforation and collapse of the head,
spontaneous expulsion of the fetus is generally
quick and easy, and this is especially so as the child's
trunk is usually small.

HYDROCEPHALUS BABY
 If desired, however, a Valsella or Willitt's forceps
can be attached to the scalp and constant traction
made by means of a one-pound weight hung over the
end of the bed.
 Puncturing & draining is all that necessary in most
of the cases
 Per vaginal drainage
 Abdominal drainage
 Spinal tapping in aftercoming head

12 3 Enlist the COMPLICATIONS What are the

min complication during During perforation Lecture Students PPT & complication
perforation and Injuries to: cum are actively black occurs during
extraction Bladder And Urethra discussion participatin board perforation
 Vagina, cervix and Uterus method g and
 Rectum And Intestines extraction?

During extraction
 Wrong tissue holding
 Injuries to soft tissues
 Wrong directions of pulling
 Spicules of bones
2 Discuss the
Prevention
13 min prevention during Lecture Students PPT &
 Catheterization cum are actively black What are
perforation and
extraction  Willingness To Abandon discussion participatin board prevention use
 Good Assistance method g during
 Adequate Light Source perforation
 Use Large Sims Speculum and
 Incise The Scalp And Perforate extraction.?
 Guide And Protection Of Soft Tissues By Left Hand

14 2 Define morcellation MORCELLATION Lecture Students PPT & What is

min Cutting the fetus into pieces is necessary on rare occasions cum are actively black Morcellation ?
before vaginal delivery can be accomplished discussion participatin board
method g
15 5 Explain the Complications of destructive operations What are
min complications of Lecture Students PPT & complication
destructive  Injury to the uterovaginal canal cum are actively black of destructive
operations  Rupture of uterus discussion participatin board operations ?
 Postpartum hemorrhage— atonic or traumatic method g
 Shock—due to blood loss and/or dehydration
 Puerperal sepsis
 Subinvolution
 Injury to the adjacent viscera— bladder—vesico-
vaginal fistula or rarely to rectal wall leading to
recto-vaginal fistula Prolonged ill health.

16 5 Elaborate the POSTOPERATIVE CARE FOLLOWING Explain the

min postoperative care DESTRUCTIVE OPERATIONS Lecture Students PPT & postoperative
following cum are actively black care following
destructive • Wrap the baby immediately. discussion participatin board destructive
operations • Exploration of the uterovaginal canal must be done to method g operations?
exclude rupture of the uterus or lacerations on the vagina or
any genital injury
• Oxytocin infusion continued for 6-8hours as the as the risk
of atonic PPH following prolonged obstructed labor is high
• A self-retaining (Foley’s) catheter is put inside specially
following craniotomy for a period of 3–5 days or until the
bladder tone is regained.
• Dextrose saline drip is to be continued till dehydration is
corrected. Blood transfusion may be given, if required.

Broad spectrum antibiotics – ceftriaxone 1g IV infusion is

given twice daily
 Thromboprophylaxis
As much possible the infant must be restored anatomically
with suturing
This along with careful placement of blankets should help
reduce trauma to the parents when they view their new born
dead infant
Psychological wellbeing of husband / wife and family
members should be taken care
Plans for subsequent pregnancy care

SUMMARY:
9. .2
min To summarize the In this presentation we have discussed about Introduce the Lecture Students are
topic. destructive surgeries,define the destructive surgeries, Method actively
purposes of destructive surgeries, advantages of destructive participating
surgeries , role in modern obstetrics, contraindication of .
destructive surgeries ,dangers of destructive surgeries,
classification of destructive surgeries ,perforaters, type of
destructive vaginal operation, other types of destructive
vaginal operation., during perforation and extraction,
prevention during perforation and extraction, Define
morcellation ,post operative care following destructive
operation

.2 To conclude the CONCLUSION:

10. min topic. Destructive operations still have a role in the management of
obstructed labour particularly if the foetus is dead. However,
the trend is on a decrease due to risk of complications that
may lead to litigation. Index Terms— Obstructed labour,
 Dead foetus, Destructive Operations.

ASSIGNMENT/ APPLICATION:
Assignment Topic- An Assignment on. Types of destructive
surgeries
Date of Submission.....................................
REFERENCES:
 Dutta’s Dc, A Textbook Of Obstetrics, Eight
To enhance the
Editions, the Health Science Publisher, P.P: 552-556
Further reading.
 Myles. A Text Book For Midwifery 16th
Edition,2014.Published By Elsevier.pp 54-56
 Jacob Annamma. A Text Book Of Midwifery &
Gynaecological Nursing 4th Edition2015,Jaypee
Brothers Medical Publishers(P)Ltd: Page No. 638-
11. 640
 Sharma Jb . A Textbook Of Midwifery And
Gynaecological Nursing 2018, Avichal Publishing
Company :Page No.662-667
 Ajit virkud Modern Obstetrics, APC Publishers
Mumbai, 3rd edition 2017.pp 584-586