Chauhan AR
Obstructed labor is still seen in developing countries and is an important preventable cause of maternal and perinatal morbidity and mortality. Potential risks of obstructed labor are uterine rupture, traumatic and/ or atonic postpartum hemorrhage, sepsis and death; it is responsible for 8% of all maternal deaths. In rare situations with obstructed labor and a dead baby, the obstetrician is faced with the dilemma of a difficult second stage cesarean section (CS) with its attendant maternal morbidity versus saving the mother a surgery and performing a destructive, or more accurately, a reductive procedure.
Literature search of studies from India shows that destructive operations account for a very small proportion of obstetric cases, mainly carried out for obstructed labor with intrauterine fetal demise (IUFD). A 25 year analysis by Sikka in a tertiary care center in Chandigarh found that destructive operations accounted for 0.26 % of all obstetric cases, with craniotomy being the most common in 87.8%, followed by decapitation, evisceration and cleidotomy. In a retrospective analysis of 7 years by Singhal et al, craniotomy was the commonest destructive procedure. They reported complications like PPH, genital tract injuries and sepsis in as many as 45% of their cases.
What is the concept of modern obstetrics? It is evidence or fact -based, keeping the best interests of the mother and newborn as the focus. In cases where the baby is already dead, maternal safety is of prime concern. If patients of obstructed labor present early to well equipped healthcare facilities, irrespective of fetal status, it is prudent to perform CS. But this concept of "modern obstetrics" is an oxymoron in many parts of rural India, which supports the argument in favor of destructive procedures: in remote parts of the country, where healthcare expertise and transport facilities are lacking or poor, destructive procedures may be life saving; for example, with a few instruments and local anesthesia, simple tapping of the hydrocephalus head may aid vaginal delivery and obviate the need for CS and attendant operative morbidity.
Though horrific barbaric instruments like cephaloclast and cranioclast, saws, hooks and perforators should be relegated to the museum, cephalocentesis may have a role to play in certain cases. Hydrocephalus is one of the common congenital malformations, easily diagnosed with USG. Traditionally, most cases especially those with gross hydrocephalus and severe cortical loss have poor perinatal outcomes. On the other hand, cephalocentesis is associated with fetal demise in majority of cases. The scenario is however changing, and fetal survival is possible hence the parents should be counseled regarding the pros and cons of cephalocentesis and CS, and tapping should be done only with consent of the patient. Reduction in the size of the head can be simply achieved by cephalocentesis, a term used to describe puncturing or tapping the fontanelle and draining the cerebrospinal fluid. In most cases this is achieved per vaginum after at least half to 3/4th dilatation using a long wide bore spinal needle. In cases when the large hydrocephalic head fails to engage, suprapubic tapping, after ensuring that the bladder is empty, can help in reduction of the fetal skull diameters and affect a vaginal delivery. Similarly, in breech presentation, after delivery of the limbs and trunk, the aftercoming head can be decompressed vaginally or abdominally. Immediate complications are genital tract trauma and injury to the bladder and rarely, rectum.
Can we do away with destructive procedures? The answer lies in the continued occurrence of obstructed labor and is a sad commentary on the state of healthcare in developing countries. Till the incidence of obstructed labor is not decreased or ceases to exist, obstetricians will need this skill -set to tackle neglected and poorly managed cases.
This issue carries an interesting case of USG guided cephalocentesis which prompted this article on the role of destructive procedures in modern obstetrics; we hope that both will be of interest to the reader.