Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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120 Surgery and Healing in the Developing World
review of systems in your physical assessment, as this may be your only medical
record.
Complete the Procedure
Clean the patient very well. Antiseptic cleanser is essential, but the field will
NOT be sterile. Positioning is key, as in any surgery. With obstetric patients, preferred
position is dorsal supine, with a leftward tilt (in an effort to avoid the supine
hypotensive problem). In Cesareans, a small amount of Trendelenberg will be desirable,
both to bring the baby out of the pelvis and to employ gravity in holding the
gut out of the operative field. The patient’s respiratory function must be closely
watched. If the operating table is improvised, one may need to arrange for the placement
of removable blocks to achieve both the left tilt and a few degrees of
Trendelenberg.
Avoid entering through infected tissue. If you do need to cut through infected
tissue, consider delayed primary closure of the wound to avoid abcess formation.
One principle of microbiology is that contamination increases with exposure time.
This is one reason to work as quickly as safety allows.
Blood loss is also proportional to operative time. Many experts will assert that
time should not be spent in efforts to control bleeding from minor vessels when
entering the abdomen for a Cesarean. Much of this bleeding will cease spontaneously,
and the rest can be controlled prior to closure after the baby has been delivered.
Of course, it is helpful to observe the course of more major vessels and to
ligate, cauterize, or avoid transecting them whenever possible. If bleeding affects
visualization in the operative field, it should be attended to. The duration of anesthesia,
the onset of pain, and the rate of complications, are all also proportional to
operative time.
Provide Postoperative Care
After a vaginal birth, with or without vacuum or forceps assistance, explore the
uterus to remove clots, placental fragments, membranes. After operative deliveries,
provide IV hydration. If NPO, place a Foley and monitor fluid input and output.
Provide pain control. Encourage early breastfeeding (both for baby’s well being and
to encourage oxytocin release and uterine involution). Encourage coughing and
provide chest physiotherapy to stave off atelectatic fever. Encourage early ambulation
and frequent position changes to reduce the risk of thrombotic events. Be vigilant
for signs of the four major causes of mortality in obstetrics: hemorrhage, infection,
hypertension and its sequellae, and embolism.
Prenatal Management
Management of Early Pregnancy Bleeding
For the purpose of this discussion, early pregnancy bleeding will be defined as
bleeding that occurs within less than 20 weeks of the mother’s last menstrual period.
There are two prominent entities in the differential diagnosis of bleeding in the
first half of a confirmed pregnancy: spontaneous abortion and ectopic pregnancy.
Both are common, the latter is quite dangerous and will be dealt with separately.
Bleeding may also have an infectious etiology or result from trauma. Less common
etiologies include molar pregnancy and underlying coagulopathy. Hypothetically,
bleeding may also result from luteal phase defects and the “vanishing twin” syn-