Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Basic Obstetrics and Obstetric Surgery in a Mission Setting
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pressure on the chin of the fetus through the perineum. This gives you better bimanual
control of the process.
After checking for a nuchal cord and suctioning the mouth and nose, deliver the
trunk and shoulders in a controlled fashion while maintaining your support of the
perineum.
Clamp and cut the cord, and deliver and dispose of the placenta, according to
local traditions.
Recognizing Dysfunctional Labor
Maternal death due to obstructed labor and/or ruptured uterus are rare in developed
countries but may be common where obstetric help is limited. King, et al,
cited an incidence as high as 70% in some areas.
The “partogram” or “partograph” described by WHO is a derivative of the Friedman
curves describing the normal progression of labor in terms of cervical dilatation
and descent of the presenting part. The purpose of following the progression of
all labors in this way is to recognize “obstructed labor” and then to manage it appropriately.
It is therefore essential that a labor curve be initiated for all patients who
may be in labor. After her initial detailed exam, the patient should be reevaluated
every 2-4 hours.
Although the parameters of the Friedman curve were developed in the west, they
are not believed to vary among different ethnic groups. In the table below, the numbers
represent the mean duration of each stage and the maximum duration that you
should tolerate before intervention should be planned.
Record the progress of labor on a partograph or labor curve, and learn to use this
tool to recognize when it is time to intervene and help the mother complete her
labor. (Partographs designed by WHO are premarked with “action” lines to aid in
recognition of obstructed labors. Obtain these or produce your own and teach their
use to the community providers.)
In addition to the partograph/labor curve which records information regarding
dilatation and station, you need also to consider position, presentation, moulding
or caput, and the adequacy of maternal contractions and pushing. Over-riding all of
these factors may be your recognition of a distressed condition of the fetus or mother.
You will be able to recognize several different patterns of dysfunctional labor.
These are tabulated below with suggested responses for management.
Dysfunctional Labor Patterns
Prolonged Latent Phase (See Table 1)
Prolonged latent phase may be subdivided according to hypotonic vs. hypertonic
uterine activity. When latent phase is prolonged despite active uterine contractions,
the patient may benefit from seconal or other medication to allow her a period
of rest. If her latent phase is prolonged due to hypotonic uterine activity, an oxytocin
drip and or artificial rupture of membranes (AROM) may be appropriate.
Protraction of Dilatation
Cervical change at a rate below the minimum indicated in Table I may be treated
by artificial rupture of membranes (assuming that the head is well-applied) and/or
institution of a pitocin drip. Lace of cervical change over a period of two hours is
clear evidence of protraction of dilatation.
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