Surgical treatment of obstetric hemorrhage

Technique of breech extraction

The process is divided into four consecutive stages: delivery to the navel, to the angle of the scapulae, liberation of the shoulder girdle, and birth of the subsequent head.

Rules of grasp and traction (first stage):

• The foot is grasped with the whole hand (optimally above and below the knee), and the thumb is extended along the leg.
• The force vector depends on the fetal pelvic position: in the wide part of the maternal pelvis, traction is directed obliquely backward; upon transition to the narrow part, it is directed downward (toward oneself).
• In footling presentation, the second foot is brought down only after the formation of the fixation point (fetal ischium below the lower edge of the pubic symphysis).

The first stage concludes with lateral flexion of the fetal spine. The obstetrician places their thumbs on the sacrum and grasps the thighs with the remaining fingers. Applying pressure to the fetal abdomen is strictly prohibited.

Second stage: Traction is performed obliquely backward until the lower angle of the scapulae is delivered. At this stage, the head with the arms enters the pelvic inlet, compressing the umbilical cord. From this moment, the countdown of the critical 5 minutes begins, within which the operation must be completed to prevent severe hypoxia.

Complications: nuchal arms and delayed head

The third and fourth stages (liberation of the arms and head) are performed according to the rules of the classic manual maneuver. The most frequent complication is nuchal displacement of the arms (grade I — in front of the face, grade II — at ear level, grade III — behind the head). Causes: pulling on the torso or extraction with incomplete cervical dilatation.

Algorithm for arm liberation:

1. The posterior-facing arm is always delivered first. The legs are pulled toward the mother's groin (opposite the fetal spine).
2. The obstetrician's hand is inserted from the sacral concavity side, reaches the elbow crease, and delivers the arm with "washing" motions.
3. If the anterior arm does not deliver, the torso is rotated with both hands so that the spine passes under the pubic symphysis and the arm moves to the sacrum, after which it is extracted.

Head extraction (flexion maneuver): Used in iatrogenic head extension. The obstetrician inserts the index finger of the left hand into the fetal mouth for flexion and places the fingers of the right hand on the clavicles. The assistant gently pushes the head through the uterine fundus. Traction follows strictly along the pelvic axis: in the wide part — in the oblique diameter, in the pelvic outlet plane — in the direct diameter.

Destructive operations (embryotomy)

The goal of embryotomy is to reduce the dimensions of a dead fetus for its extraction. These include: craniotomy (incision of the skull), cleidotomy (section of the clavicles), decapitation, evisceration, and spondylotomy. Today, craniotomy is used predominantly.

Conditions for craniotomy: cervical dilatation of at least 5–6 cm, normal pelvic dimensions, tightly fixed head, and absence of the amniotic sac.

Stages of craniotomy:

1. Fixation: the scalp is grasped with Museux forceps and incised with a scalpel from front to back.
2. Perforation: Fenomenov's spear-shaped perforator or Blo's scissors-like perforator is introduced with a drilling motion (through the fontanelle, orbit, or mouth). The opening is widened to 3–4 cm by rotating the instrument.
3. Excerebration: destruction and removal of brain tissue using a large curette.

Craniotomy of the subsequent head (in breech presentation) requires deflection of the fetal torso backward. Under the protection of a vaginal speculum, the perforator is introduced into the foramen magnum (foramen magnum).

Trauma in obstetric surgery

Breech extraction and embryotomy are extremely traumatic.

Maternal complications:

• Tears of the vagina, perineum, and cervix (up to avulsion from the fornices in case of incomplete dilatation).
• Diastasis of the pubic symphysis or sacroiliac joints.

Fetal complications (technique errors):

• Incorrect foot grasp or extraction by the inguinal crease leads to fractures of the femur and lower leg.
• Direct pressure on the humeral bone during an attempt to liberate a nuchal arm guaranteed causes its fracture.
• Rapid forceful extraction provokes central nervous system trauma, tentorium cerebelli rupture, and cervical spine injuries.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Medico-social indications for late-term artificial abortion
• Elective and emergency cesarean section: indications and laparotomy incisions
• Obstetric forceps and vacuum extraction of the fetus: technique and complications
• Biomechanics of traction during the passage of the head through the pelvic planes

Other topics in the "Obstetrics" section

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