Craniotomy - operation, which resulted in the reduction of the volume of the head of the fruit. Used primarily for the elimination of the spatial mismatch between the head of the foetus and the family channel, which happens at a narrow pelvis (when reducing the true compared to 7.5 cm below the delivery is only possible by means of cesarean section or by reducing the size of the head of the fruit); incorrect previa and inserted the head - rear view front previa, frontal presentation, zaznamenano inserting; hydrocephalus; narrowing soft generic ways scars, swelling; intrauterine fetal death in severe condition of the pregnant woman (toxicosis of pregnancy, decompensated heart disease).
Conditions for craniotomy is no absolute narrow pelvis (true conjugate above 6.5 cm), the opening of the fallopian pharynx 2-3 cross your fingers (if such disclosure only in reducing the size of the head of the fruit, removing the perforated head is possible only upon achievement of full disclosure uterine throat); static standing head, which is achieved by fixing it to the outside through the abdominal wall throughout the operation. Failure to do so may result in slippage instruments with head and soft tissue injury generic ways.
Craniotomy consists of three stages (surgical techniques): perforation (rupture of the fetal skull); exteremely (emptying the contents of the skull); kranichsee (extraction reduced in size head chroniclecom).
Perforation of the head is the formation of an artificial hole in the skull through which removed the brain, resulting in the reduction of the volume of the head. Perforation heads produce special tools, perforators. The most common trepanobiopsy punch N. N. Fenomenov and monicajody punch Block (see Obstetric-gynecological tools). Perforator N. N. Fenomenov has several great advantages, as put on his sleeve protects the soft tissue mothers against possible damage. When using punch Block the possibility of injury of soft tissues is much higher. Perforator N. N. Fenomenov allows perforation any part of the skull (seam, springs, directly bone). Hammer Blo bone perforated with great difficulty, the edges of the holes in the bones become uneven, comminuted, so they should only punch sutures and fontanelles.
For perforation predlagay head needed: wide long vaginal mirrors, perforator, kranichrast, long curved scissors, bone forceps, a large blunt spoon, a catheter with a double shock, rubber tube, irrigator set. Operation is performed on the operating table or hot beds.
Preparation mothers: disinfect the external genitals and the anterior abdominal wall, the lower the urine. During the operation assistant commits the head outside the entrance to the pelvis. The operation is performed under inhalation anesthesia. If the perforation must be sure that the fetal heartbeat. To clarify the conditions of production and operation of choosing the place of perforation advance vaginal examination. In the back of the form occipital presentation is most favorable for the perforation is an area of small fontanel and swept joint, extensor abnormal presentations - the area of a large fontanel at the front - frontal joint, personal - area of the eye. At various other deviations from normal biomechanism of labor should be perforated in any part of the skull, opened adjacent to fix the cervix. When perforation follow-head operation is carried out through the great foramen (front view) or sublingual region (at the back).
The technique of perforation is determined by the choice of the puncher. Hammer N. N. Fenomenov (Fig. 1) the perforation produce under visual control. Vaginal mirrors naked vagina, which guarantees the safety of the operation and creates the possibility of clarity in the activities of a midwife. The skin of the head of the fruit capture forceps-dvosobni, cut with a scalpel for 2-3 refer To the bare bones of the forehead, the tip of the puncher make closely so that its axis is perpendicular to the surface of the skull, drill a hole in the skull increase spiral motion clockwise.
Perforation any sharp guide (hammer Blo) is under the control of the hand, which come from the front, the rear surface towards fold (Fig. 2). Perforator injected into the head (better in the area of the seams or springs) or at the front previa in the area of orbit. At the time when the punch handle the last lower back. The hole in the skull of the fruit makes cross, which after breeding branch in the same direction, turn the handle of the hammer (not removing it from the cavity of the skull) 90 degrees, and make a second cut perpendicular to the first.
Aksceleracija - destruction and the destruction of the brain of the fetus through the punched hole. Brain destroy a blunt spoon; the remains of his wash sterile physiological solution of mugs esmarkha placed at a height of approximately 1.5 m, through a rubber hose is attached to the tip. For exteremely also used the spoon-catheter designed B. N. Agafonova (excelerator). For complete emptying of skull from the substance of the brain through the skull cavity go through about 2 l of a solution.
Chroniclethe - removing the fetus special tools (chroniclecom) - the final stage craniotomy. It is produced with the full disclosure of the cervix. After perforation, conducted by the incomplete disclosure of uterine throat, resorted to the imposition of skin-head forceps with the suspension of cargo to the handle forceps (200-300 g) and stimulation of labor activity oxytocin. Independent fetus when reduced in size head is possible only in good labor activity and satisfactory condition of the woman.
Kranichrast impose in all departments and sizes of the small pelvis. Bending spoons of kranichrast must match the head line (front) curvature. First enter through the punched hole massive spoon (Fig. 3), then outside on the face impose fenestrated spoon (Fig. 4). The ends spoons maximum pull together and lock nut (Fig. 5). After using kranichrast make sure that is not captured by the soft tissues of the generic ways. After the trial traction resort to removing the head (Fig. 6). Removing the perforated head is made according to the rules existing for extracting its tongs. Thus reproduce certain moments of biomechanism of labor. When the head, standing in the entrance to the pelvis, traction doing on socks, when the head of the pelvic cavity is on his knees, head down on the pelvic floor muscles,- to the person sitting to the obstetrician.
Perforation subsequent heads produce great foramen (Fig. 7). Recommend before this cut neck skin with a scalpel. Perforated cylinder, remove manual techniques while pressing on it from above or chroniclecom.
The technique of operations may be significantly more complicated, if after the birth of the body the head is high above the entrance to the pelvis or touching it. To penetrate into the great foramen is only possible when the partition of the Atlanta with the occipital bone. R. M. Romanovsky recommends to summarize the point of the puncher to the suboccipital pit, which must be pre groping fingers of the left (auxiliary) hands. 's safer to do it under visual control by entering the lift to protect the soft tissues of the mother from damage possible from sliding punch.

Fig. 1. Perforation head hammer Fenomenov. Fig. 2. Perforation head hammer Blo. Fig. 3. The introduction of massive spoons kranichrast in the skull cavity after perforation. Fig. 4. The imposition of the second spoons kranichrast. Fig. 5. Fixing the head by screwing the nut kranichrast. Fig. 6. Removing the head of the fruit by kranichrast.