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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 


Section 3 - Procedures

Craniotomy and craniocentesis

In certain cases of obstructed labour with fetal death, reduction in the size of the fetal head by craniotomy makes vaginal delivery possible and avoids the risks associated with caesarean delivery. Craniocentesis can be used to reduce the size of a hydrocephalic head to make vaginal delivery possible.

  • Provide emotional support and encouragement. If necessary, give diazepam IV slowly or use a pudendal block.

 CRANIOTOMY (skull perforation)


  • Make a cruciate (cross-shaped) incision on the scalp (Fig P-28).

Figure P-28

Cruciate incision on scalp

  • Open the cranial vault at the lowest and most central bony point with a craniotome (or large pointed scissors or a heavy scalpel). In face presentation, perforate the orbits.

  • Insert the craniotome into the fetal cranium and fragment the intracranial contents.

  • Grasp the edges of the skull with several heavy-toothed forceps (e.g. Kocher’s) and apply traction in the axis of the birth canal (Fig P-29).

Figure P-29

 Extraction by scalp traction 


  • As the head descends, pressure from the bony pelvis will cause the skull to collapse, decreasing the cranial diameter.

  • If the head is not delivered easily, perform caesarean section.

  • After delivery, examine the woman carefully and repair any tears to the cervix  or vagina, or repair episiotomy.

  • Leave a self-retaining catheter in place until it is confirmed that there is no bladder injury.

  • Ensure adequate fluid intake and urinary output.


  • Make an incision through the skin at the base of the neck.

  • Insert a craniotome (or large pointed scissors or a heavy scalpel) through the incision and tunnel subcutaneously to reach the occiput.

  • Perforate the occiput and open the gap as widely as possible.

  • Apply traction on the trunk to collapse the skull as the head descends.


CRANIOCENTESIS (skull puncture)


  • Pass a large-bore spinal needle through the dilated cervix and through the sagittal suture line or fontanelles of the fetal skull (Fig P-30).

  • Aspirate the cerebrospinal fluid until the fetal skull has collapsed and allow normal delivery to proceed. 

Figure P-30

 Craniocentesis with a dilated cervix


  • Palpate for location of fetal head.

  • Apply antiseptic solution to the suprapubic skin.

  • Pass a large-bore spinal needle through the abdominal and uterine walls and through the hydrocephalic skull.

  • Aspirate the cerebrospinal fluid until the fetal skull has collapsed and allow normal delivery to proceed. 


Figure P-31

Craniocentesis of the aftercoming head



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Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support


General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages



Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems


Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia


External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section


Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy


Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy



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