Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Basic Obstetrics and Obstetric Surgery in a Mission Setting
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Grasp and elevate the distal portion of the tube. Place a second clamp across the
distal portion of the tube, again incorporating mesosalpinx, and bringing the tips of
the two clamps together on the mesosalpinx at the midpoint of the ectopic. Cut
along your clamps to release the ectopic. Use catgut suture to ligate behind each
clamp. You may perforate the mesosalpinx to do this in bites. Doubly ligate and
confirm hemostasis. Remove packs, irrigate the pelvis and close the incision in the
usual manner.
Managing Labor
Normal Labor and Delivery
A review of this vast topic is beyond the scope of this brief guideline. However,
the following few suggestions may be useful to you if you are inexperienced in obstetric
management.
Clinical Pelvimetry
Complete an assessment of clinical pelvimetry prior to or early in labor. The goal
is to anticipate cephalopelvic disproportion (CPD), a leading contributor to dysfunctional
labor and dystocia.
1. Assessment of the pelvic inlet: The best estimate of the adequacy of the
pelvic inlet is obtained by measuring the diagonal conjugate. This is easiest
to do in late pregnancy when tissues are more distensible. Either place the
patient in stirrups or put a firm pillow under her buttocks for the exam.
Place your middle and index fingers in the vagina, and use the tip of your
middle finger to palpate the sacral promontory. Mark the lateral edge of
your hand just where it emerges from beneath the pubic arch. To reach the
promontory, you will probably have to press the knuckles of your third and
fourth fingers into the perineum below. Measure the total length from the
finger tip to your mark. This is the diagonal conjugate, from which you can
subtract 1.5 cm to estimate the diameter of the pelvic inlet between sacral
promontory and the inner surface of the symphysis pubis (obstetric conjugate).
A diagonal conjugate of 12.5-13.0 cm (obstetric conjugate of 11.5
cm) is considered adequate.
Note: If the head is engaged, the inlet is adequate! With the vertex at the
level of the spines (usually 5 cm below the inlet), the biparietal diameter
(3-4 cm above the vertex) must almost certainly be below the pelvic brim
(inlet) as well.
2. Assessment of the pelvic outlet: Premeasure the width of your closed fist at
the nuckles, then use your fist to measure the biischial diameter by placing
your closed fist between the ischial tuberosities. A diameter over 8 cm is
considered adequate. Also assess the pubic arch. You should be able to fit
two fingerbreadths beneath the symphysis, and the pubic rami should curve
outward to create a broad arch. The descending inferior pubic rami should
form an angle of 90-100 degrees. Palpate the sacrum and coccyx for curvature
and flexibility. If the sacrum and coccyx are angled forward, this results
in narrowing of the sacrospinous notch and pelvic diameters. If angled back,
the result will be a shorter and roomier pelvis.
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