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Sir,

I agree with Dr Dawson that training young obstetricians how to perform destructive operations won't be easy, mainly because the number of cases are limited thus residents do not have much of an opportunity to do such operations during their training period. I would like to draw to Dr Dawson's attention the experience of Lawson and Stewart (1967) in Africa who have mentioned the minor details of craniotomy and decapitation. Unfortunately, these details are missing in recent standard text books. I also feel that application of obstetric forceps before proceeding to perforation is ideal when the head is not deeply jammed in the pelvis. In late referral cases, there is not much space available for the forceps blades, and there is no danger of the head being displaced due to the application of perforator with a firm fundus pressure.

I have always resorted to decapitation in a neglected shoulder presentation in the absence of enlarged fetal abdomen for which a spondylating procedure is ideal. Furthermore, I would like to stress two practical points as far as decapitation is concerned:

  • 1
    A firm controlled traction must be given to the prolapsed arm after tying it with a sterile ribbon gauze so that the neck is within reach; this will also prevent the further stretching of the lower segment of uterus.
  • 2
    Leaving aside the described instruments, such as the embryotomy decapitation saw, I have always found a sharp scissors very useful for cutting the cervical spine after introducing it along and below the palmer surface or the left hand placed over the neck. Once the neck is severed from the body the extraction of the rest of the body is very quick and easy. I have no experience in using the Blond Heidler decapitation saw which seems to be ideal for this purpose

I agree that wherever possible fetal death should be confirmed by ultrasound. However, this facility is not available at the primary and secondary level hospitals in developing countries, where the decision is taken based upon clinical grounds only. This is usually not difficult as patients usually reach hospital quite late and one can confidently take the decision on clinical grounds alone. Informed consent of the patient and family, however, must always be taken to avoid medico-legal implications.

References

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  2. References
  • Trimble E. L. et al. (1993) J Clin Oncol 2, 24052410.