Cleidotomy

CLEIDOTOMY, cleidotomy (from Greek cleis- clavicle and temno- I cut), an obstetric operation involving the cutting of one or both of a fetus's clavicles with the aim of reducing the size of its shoulder girdle. The need to apply cleidotomy arises when it is impossible for the fetus to pass through the birth canal without reducing the volume of its shoulders. Such impossibility is created by a spatial disproportion between the size of the fetus's shoulder girdle and the dimensions of the mother's pelvis and depends, besides rare cases of deformities, on excessive fetal development (so-called giant children, according to Winter, weighing more than 5,000 g) with a normal maternal pelvis, or on a narrow pelvis of the latter with normal fetal weight and size, and sometimes on both factors together, in which case the pelvic constriction may be relatively insignificant, while the fetal weight may exceed the average norm by 0.5 kg or a little more. Cleidotomy is performed either as an additional maneuver for extracting a previously perforated fetus, whose shoulders become stuck in the narrowed pelvis after the head is extracted, or as an independent operative aid when there is a need for it after the independent birth of an unreduced head or its extraction with forceps. In the first case it is a variety of embryotomy in general and, besides perforation, is combined with other maneuvers to reduce the child. Thus, Gerf (Negri) in 1889, besides cleidotomy, also applied the cutting of the two upper ribs in his case. As a separate operation, cleidotomy was first proposed in 1895 by Professor Phenomenov, who emphasized its independence, typicality, and simplicity of execution and gave it the name cleidotomy. However, according to Perondi, this operation was indicated as early as 1887 by Fornani. With a known disproportion between the fetus's shoulder girdle and the mother's pelvis, the head, born independently or with the aid of forceps from the vaginal opening, does not perform an external rotation; the face thus remains pressed against the perineum because the shoulders at this moment are in the transverse or oblique diameter of the pelvic inlet or above it. Attempts to lower the fetus by the born head meet elastic resistance, forcing the head to 'retreat' into the vaginal opening. In order to palpate the fetal neck and orient oneself regarding the position of the shoulders, it is necessary to insert fingers deeply into the birth canal. In the event of difficulty in passing the shoulders through the birth canal, one should try to pull vigorously on the head, simultaneously assisting the advancement of the fetus by pressing on the fundus of the uterus along the axis of the pelvic canal. If this attempt fails, two to four fingers are inserted into the birth canal and an attempt is made either to change the position of the shoulders, transferring them from the transverse to the direct or oblique diameter if the shoulders have entered the pelvis, or to the oblique if they are at the pelvic inlet or above it. Furthermore, a useful attempt is to advance at least one shoulder with a finger inserted into the axillary fossa, or (according to the advice of Bumm) to lower the fetal arm. However, all these attempts may yield no result. In such cases, Phenomenov recommends resorting to cleidotomy. The technique of cleidotomy consists of the following: after pulling the head strongly to the side, the corresponding hand is inserted into the vaginal canal, under the control of which the clavicle on one side is cut with long blunt-ended strong scissors (of the Phenomenov type), and then the same is done on the other side. The ends of the cut clavicles are shifted and interlock, thereby reducing the biacromial diameter. The reduced shoulder girdle (up to 5 cm according to Liebich) slips through the pelvic canal with vigorous pulling downward on the head. It is possible to limit oneself to cutting only one clavicle; to facilitate the passage of the shoulders in this case, it is recommended to lower the arm, which is significantly facilitated by the preceding cleidotomy. If, after cutting the clavicles, pulling on the head still yields no result, the passage of the shoulders is assisted by pulling the fetus with a finger or fingers inserted into the axillary fossa. This last measure can be replaced by pulling with a hook placed (as Jolly advises) on the chest side. Descriptions of cases of applying cleidotomy to a living fetus (as far as is known) do not exist. However, theoretically it is conceivable (Strassmann, Liebich) to perform cleidotomy in these cases. Bearing this possibility in mind, Liebich advises, in the event of the situation arising, not to lose time on other attempts to extract the shoulders, but to immediately proceed to cleidotomy, and in order to avoid injuring vessels, he advises cutting the clavicles with a Gilley saw, introduced behind the clavicle with an aneurysm needle after a preliminary incision of the skin over the clavicles. However, injury to vessels can also be avoided when cutting the clavicles with the aforementioned blunt-ended scissors, as demonstrated by the case of Strassmann. After cleidotomy on a living fetus, the use of a hook is not recommended due to the possibility of damaging the vessels and nerves of the axillary fossa. Cleidotomy, proposed by Phenomenov as an independent, typical, and simple obstetric operation, having found quite numerous supporters and followers (e.g., Strassmann, Liebich, and others), met with objections from Jolly, who points out that this operation is technically not simple and does not achieve its purpose by itself, since with its aid the mechanism of passage of the shoulders is not changed, according to which for successful passage of the shoulders through the birth canal one shoulder must first descend into the pelvis, and then the other. This circumstance, in Jolly's opinion, as in his two cases and in cases where cleidotomy was applied by others, caused the need for subsequent application of a hook, lowering of the arm, etc.

2–3.5%, 4%, 3% Adding butter to buttermilk was proposed long ago by various authors. Kleinshmidt had the idea to replace buttermilk (diluted) in the main Cherny-Kleinshmidt food in cases where, after an acute nutritional disorder in the child, repair occurs (frequent stools, liquid with mucus admixture) and the child requires complete food, i.e., containing protein and carbohydrates as well as fat, but still cannot digest Cherny-Kleinshmidt food. In such cases (the discussion concerns small children, often underweight and in institutions), protein milk is usually applied. Kleinshmidt's proposal boils down to the fact that in these cases, instead of protein milk, buttermilk with added flour and butter should be used. For two days (after the cessation of acute nutritional disorder symptoms), pure buttermilk is given, to which flour and butter are added: first 2% butter and 3% flour, and then 3 1/2% flour + 3 1/2% butter. Finally, sugar is added in an amount of 4–5%. Kleinshmidt proposes giving this type of food in cases where protein milk is usually applied, because according to his observations, when it is prescribed, recurrences and exacerbations of diarrhea are observed less frequently than with protein milk during the repair period, and moreover because this food can be used for a long time, which cannot be said about protein milk. Kleinshmidt recognizes the advantage of this mixture over concentrated protein milk in that with buttermilk there is no intermediate pathological stage manifesting itself by the formation of fatty-soapy stool. The role of fat in this food is to enhance the secretion of intestinal juice, promoting putrefactive processes, which in turn suppresses fermentation and neutralizes acids. Nimann proposes giving this mixture as a 'correcting' food for liquid and frequent stools not caused by acute or chronic nutritional disorder. Instructions for preparing food according to Zhorno. Instead of buttermilk, boiled milk with 1% fat in the form of cream is used. Fermentation starter is introduced and the acidity is brought to 5.5° (5/10), it is curdled on a water bath, the settled curd is strained through a sieve (or simply the whey is poured off), sugar is dissolved in the strongly heated whey and the dough made separately from flour and butter is added once, and the whole mixture is brought to a boil once. When the mixture cools to 40°, the strained curd is introduced. Preparation of dough: butter (melted) is placed in a pot over the fire, melted and brought to a boil; then flour (previously fried to a light brown color) is added and the mixture is kept on the fire with strong and rapid stirring for 1–2 minutes. In recent years, buttermilk with added flour and butter has found frequent application for feeding (and not only as therapeutic food). It is prescribed for children of the earliest age, when they require complementary feeding in addition to breast milk.

2-3.5%, 4%, 3% Adding butter to buttermilk was proposed long ago by various authors. Kleinshmidt had the idea to replace buttermilk (diluted) in the main Cherny-Kleinshmidt food in cases where, after an acute nutritional disorder in the child, repair occurs (frequent stools, liquid with mucus admixture) and the child requires complete food, i.e., containing protein and carbohydrates as well as fat, but still cannot digest Cherny-Kleinshmidt food. In such cases (the discussion concerns small children, often underweight and in institutions), protein milk is usually applied. Kleinshmidt's proposal boils down to the fact that in these cases, instead of protein milk, buttermilk with added flour and butter should be used. For two days (after the cessation of acute nutritional disorder symptoms), pure buttermilk is given, to which flour and butter are added: first 2% butter and 3% flour, and then 3 1/2% flour + 3 1/2% butter. Finally, sugar is added in an amount of 4–5%. Kleinshmidt proposes giving this type of food in cases where protein milk is usually applied, because according to his observations, when it is prescribed, recurrences and exacerbations of diarrhea are observed less frequently than with protein milk during the repair period, and moreover because this food can be used for a long time, which cannot be said about protein milk. Kleinshmidt recognizes the advantage of this mixture over concentrated protein milk in that with buttermilk there is no intermediate pathological stage manifesting itself by the formation of fatty-soapy stool. The role of fat in this food is to enhance the secretion of intestinal juice, promoting putrefactive processes, which in turn suppresses fermentation and neutralizes acids. Nimann proposes giving this mixture as a 'correcting' food for liquid and frequent stools not caused by acute or chronic nutritional disorder. Instructions for preparing food according to Zhorno. Instead of buttermilk, boiled milk with 1% fat in the form of cream is used. Fermentation starter is introduced and the acidity is brought to 5.5° (5/10), it is curdled on a water bath, the settled curd is strained through a sieve (or simply the whey is poured off), sugar is dissolved in the strongly heated whey and the dough made separately from flour and butter is added once, and the whole mixture is brought to a boil once. When the mixture cools to 40°, the strained curd is introduced. Preparation of dough: butter (melted) is placed in a pot over the fire, melted and brought to a boil; then flour (previously fried to a light brown color) is added and the mixture is kept on the fire with strong and rapid stirring for 1–2 minutes. In recent years, buttermilk with added flour and butter has found frequent application for feeding (and not only as therapeutic food). It is prescribed for children of the earliest age, when they require complementary feeding in addition to breast milk.

2-3.5%, 4%, 3% Adding butter to buttermilk was proposed long ago by various authors. Kleinshmidt had the idea to replace buttermilk (diluted) in the main Cherny-Kleinshmidt food in cases where, after an acute nutritional disorder in the child, repair occurs (frequent stools, liquid with mucus admixture) and the child requires complete food, i.e., containing protein and carbohydrates as well as fat, but still cannot digest Cherny-Kleinshmidt food. In such cases (the discussion concerns small children, often underweight and in institutions), protein milk is usually applied. Kleinshmidt's proposal boils down to the fact that in these cases, instead of protein milk, buttermilk with added flour and butter should be used. For two days (after the cessation of acute nutritional disorder symptoms), pure buttermilk is given, to which flour and butter are added: first 2% butter and 3% flour, and then 3 1/2% flour + 3 1/2% butter. Finally, sugar is added in an amount of 4–5%. Kleinshmidt proposes giving this type of food in cases where protein milk is usually applied, because according to his observations, when it is prescribed, recurrences and exacerbations of diarrhea are observed less frequently than with protein milk during the repair period, and moreover because this food can be used for a long time, which cannot be said about protein milk. Kleinshmidt recognizes the advantage of this mixture over concentrated protein milk in that with buttermilk there is no intermediate pathological stage manifesting itself by the formation of fatty-soapy stool. The role of fat in this food is to enhance the secretion of intestinal juice, promoting putrefactive processes, which in turn suppresses fermentation and neutralizes acids. Nimann proposes giving this mixture as a 'correcting' food for liquid and frequent stools not caused by acute or chronic nutritional disorder. Instructions for preparing food according to Zhorno. Instead of buttermilk, boiled milk with 1% fat in the form of cream is used. Fermentation starter is introduced and the acidity is brought to 5.5° (5/10), it is curdled on a water bath, the settled curd is strained through a sieve (or simply the whey is poured off), sugar is dissolved in the strongly heated whey and the dough made separately from flour and butter is added once, and the whole mixture is brought to a boil once. When the mixture cools to 40°, the strained curd is introduced. Preparation of dough: butter (melted) is placed in a pot over the fire, melted and brought to a boil; then flour (previously fried to a light brown color) is added and the mixture is kept on the fire with strong and rapid stirring for 1–2 minutes. In recent years, buttermilk with added flour and butter has found frequent application for feeding (and not only as therapeutic food). It is prescribed for children of the earliest age, when they require complementary feeding in addition to breast milk.