18.9 Destructive operations

For an obstructed labour with a dead baby a destructive operation is usually, but not always, better than a Caesarean section. You may need to do one for: (1) A cephalic presentation with a normal or hydrocephalic head. (2) A breech delivery when a normal or hydrocephalic aftercoming head has ’stuck’. (3) A transverse lie with a prolapsed arm.

To cope with these situations you can: (1) Open his skull with large scissors, or a special perforator, and remove his brain (craniotomy). (2) Sever his neck from his body (decapitation), and then deliver them separately. (3) Cut his clavicles (cleidotomy). (4) Open his trunk and remove the the organs from his chest and abdomen (evisceration or embryotomy). For a cephalic or breech presentation, craniotomy is usually all you need do. A transverse lie requires decapitation, and often evisceration also, which is more difficult than craniotomy; but even so, it is often wiser than Caesarean section (see Section 18.1), which is particularly dangerous for a neglected infected transverse lie.

These operations are sometimes said to be old-fashioned, and to have no place in modern obstetrics. Old-fashioned perhaps, but they have some useful features: (1) They need few instruments and only simple anaesthesia, so that they can be done in the health centre where a mother is first seen. If she cannot be referred, they save her life. If referral is difficult, they avoid the risks and delays of a long journey (they are therefore also described in Primary Mother Care). (2) They leave her with an intact uterus, which will be less likely to rupture if she decides to deliver herself at home next time. (3) If she is already infected, they are less likely than Caesarean section to spread the infection to her peritoneum. (4) She stays a shorter time in bed than she does after a Caesarean section.

The case for destructive operations is strongest in unsophisticated communities where people marry as children. A mother may not be fully grown when she first becomes pregnant, so that her pelvis is small and her first labour obstructs. It will continue to grow until she is 25, so, if she can be delivered vaginally with her first pregnancy, her later ones may be normal and without the risks of a scarred uterus.

Besides their distasteful messiness, the main argument against these operations is that, in inexperienced hands, they are liable to be even more dangerous than Caesarean section. This is unlikely to be true—if you follow the instructions carefully! To those who decry them, we reply that, if the obstetric circumstances of disadvantaged communities still existed in advantaged ones, destructive operations would be routine there too.