Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Basic Obstetrics and Obstetric Surgery in a Mission Setting
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previa is from lakes of maternal blood, whereas bleeding from vasa previa involves
the loss of fetal blood, which is even more serious. Fetal blood can be recognized as
nucleated red cells picked up with Wright’s stain. Section is indicated secondary to
fetal distress.
Abruptio Placentae
Abruption occurs about twice as often as placenta previa, about one in every 120
pregnancies. It classically presents as painful vaginal bleeding. It may be precipitated
by maternal hypertension, drug use, or trauma. It can also occur with sudden emptying
of the uterus as in rupture of membranes in a case of hydramnios or after
delivery of the first of a set of multiples.
To make the diagnosis, proceed as with a suspicion of placenta previa. Perform a
careful speculum exam to confirm the source of the bleeding and attempt to determine
the amount of cervical dilatation. Monitor the fetus by whatever methods are
available. Monitor for contractions. If ultrasound is available, determine the location
of the placenta to rule out previa and look for a clot between the placenta and
the uterus. Even in experienced hands, ultrasound is only about 50% sensitive in
recognizing abruption. If your ultrasound rules out previa or a low-lying placenta
and bleeding is significant, the diagnosis is abruption.
Begin fluid resuscitation of the mother. Deliver by Cesarean section if the fetus is
mature, distressed, or labor has begun.
Management of IUFD
If the fetus dies before 20 weeks of gestation, it is defined as a spontaneous
abortion and managed as described in (A) above. After 20 weeks of gestation, loss of
the pregnancy is termed intrauterine fetal demise.
The diagnosis of fetal demise can be confirmed in a variety of ways. Fortunately,
there is no need for haste, since, it is reasonable to practice expectant management
for up to one month after the fetal death. Assuming that fetal scalp electrodes and
abdominal or transvaginal ultrasound are not available to you, suspect fetal demise
when fetal movements are not appreciated by the mother or palpated by the examiner
and fetal heart beat cannot be auscultated while following the patient for up to
one month. The uterus will fail to grow and may in fact shrink. If the fetus has not
been expelled after one month, consider cervical ripening and induction of labor.
Monitor her clotting time. Also consider the possibility that the pregnancy was an
abdominal ectopic which she will be unable to expel. A simple mechanical method
for dilating the cervix to 3 cm is by placement of a Foley catheter, passing the catheter
through the cervical os and inflating the balloon with 30 cc of saline. Tape the
Foley to the patient’s leg under gentle traction. When the Foley falls out, the cervix
has dilated to 3 cm. By clipping of the tip, the Foley can also be used to instill dilute
prostaglandins into the uterine cavity for induction of labor (e.g., 100 µg/ml PGE2,
delivering 1-2 ml Q2 hours, titrated to achieve effective contractions.)
If the baby died during an obstructed or otherwise complicated labor, it may be
difficult to complete the delivery. An assisted delivery or destructive procedure may
be needed. If still undeliverable, a Cesarean section is indicated.
Ectopic Pregnancy
As mentioned in (A) above, a dangerous source of bleeding (and generally, pain)
in the first half of pregnancy is an ectopic implantation. This occurs in roughly 1%
of all pregnancies. Overwhelmingly, implantation is in the fallopian tubes. More
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