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)

• Review for indications.

• Review general care principles and

  apply antiseptic solution to the vagina.

• Perform an episiotomy, if required.

CEPHALIC PRESENTATION

• 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.

BREECH PRESENTATION WITH ENTRAPPED HEAD

• 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)

• Review for indications.

• Review general care principles  and apply antiseptic solution to the vagina.

• Make a large episiotomy, if required.

FULLY DILATED CERVIX

• 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

CLOSED 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. 

AFTERCOMING HEAD DURING BREECH DELIVERY

• After the rest of the body has been delivered, insert a large-bore spinal needle through the dilated cervix and foramen magnum (Fig P-31).

• Aspirate the cerebrospinal fluid and deliver the aftercoming head as in breech delivery .

Figure P-31

Craniocentesis of the aftercoming head

DURING CAESAREAN SECTION

• After the uterine incision is made, pass a large-bore spinal needle through the hydrocephalic skull. 

• Aspirate the cerebrospinal fluid until the fetal skull has collapsed.

• Deliver the baby and placenta as in caesarean section.

POST-PROCEDURE CARE

• 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.

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