Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Basic Obstetrics and Obstetric Surgery in a Mission Setting
119
E. Third stage (delivery of the placenta).
One must recognize problems with the placenta, and avoid/recognize uterine
inversion.
F. Fourth stage (stabilization of the mother).
Management of this stage includes recognition and repair of lacerations
and management of postpartum hemorrhage.
G. Puerperium (up to six weeks postpartum).
One may encounter potentially fatal hemorrhage, infection, hypertensive disorders,
and thrombotic or amniotic fluid emboli.
Obstetric surgical interventions may be called for in any of the four stages of
labor.
General Surgical Principles
Prepare Yourself
Plan every operation in your mind, step-by-step and communicate the plan to
your assistants. In the context of this chapter, the operation may be any of the following:
(1) surgery for ectopic pregnancy; (2) vacuum or low forcep assisted delivery;
(3) symphysiotomy; (4) primary or repeat Cesarean section (low transverse,
classic vertical, or extraperitoneal), with or without uterine artery ligation, Lynch
suture for atony or hysterectomy.
Consider how to act if you encounter any of the common complications of the
procedure you will undertake. At a minimum, these include bleeding, infection,
incidental damage to viscera.
Establish clear methods for communicating your needs and intentions intraoperatively.
Discuss anticipated problems and probable solutions with your assistants
before the case.
Determine risks to the surgical team: HIV, HBV, etc. Be sure that the team
remains alert to these problems.
Formulate a plan for anethesia/analgesia: Pudendal, local, general. The availability
of epidural anesthesia (or of an anesthetist) may be considered a luxury.
Prepare the Patient
With gravid patients, surgery is often not elective, but nevertheless can be anticipated.
If patients are near term but not in active labor there may be an opportunity
to improve hydration and nutrition and to treat fevers and infections preoperatively.
When the need arises, make best efforts to explain the procedure and its indications,
risks and benefits to the patient and her family.
Nausea is likely with abdominal surgery and especially with manipulation of the
uterus. Take steps to avoid aspiration of gastric contents. Give 30 cc of bicitra p.o.,
and/or consider ranitidine 50 mg IM one hour prior to surgery, or 150 mg p.o. Q6
hrs preceeding an elective procedure. Also consider placement of an NG tube to
aspirate gastric contents and provide a neutralizing lavage.
If laboratory is limiting, obtain a blood sample to determine hematocrit with or
without the aid of centrifugal force and also test formation of a “wall-clot”.
Assess hydration status by physical exam and through recording of oral intake vs.
urine and stool output. Make appropriate adjustment for insensible losses in current
environmental conditions.
Obtain historical information, including exposures to TB, HIV, HBV. Prior
obstetric history is critical, including proven prior birthweights. Include a complete
15