Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Basic Obstetrics and Obstetric Surgery in a Mission Setting
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deliveries. Bleeding may initially be scant, while delivery of the placenta by strong
traction may result in copious hemorrhage. If this occurs, and your exam of the
placenta reveals missing cotyledons or fragments, you must explore the uterus to
locate these fragments and attempt their removal. In cases of accreta/increta/percreta,
no cleavage plane will develop and the fragments will remain adherent. If bleeding
has become profuse, treatment is immediate hysterectomy. If the abnormal placental
attachment was subtotal and bleeding appears to be slight, a trial of conservative
management may be considered. This involves removing as much placenta as possible
and packing the uterus. Couple this with administration of oxytocin or ergot
amines as available. In well-equipped hospitals, the risk of abdominal surgery is less
than the risk of death with conservative management so the choice between conservative
management and hysterectomy will depend not only upon the relative degree
of hemorrhage but also upon your clinical environment.
Uterine Inversion
Incautious delivery of the placenta by traction on the umbilical cord without
performing the Brandt-Andrews maneuver to keep the uterus within the pelvis may
result in uterine inversion. Uterine inversion is also a likely complication of efforts
to deliver an adherent placenta as in cases of accreta/increta/percreta as discussed
above. Management of uterine inversion depends upon whether the inversion is
partial or complete, and on whether the placenta can be separated easily or remains
adherent. In any case, support from anesthesia and immediate treatment of hypovolemia
is essential.
If the placenta is easily separated, an inverted uterus may be replaced immediately
by pushing up on the fundus with your fist or palm. Direct force towards the
umbilicus.
If the placenta is adherent, and if the inversion cannot be replaced immediately,
administer a tocolytic agent to relax the uterus. Next, separate the placenta and push
the uterine fundus up through the cervix. Once the uterus has been replaced, stop
the tocolytic and give oxytocin. Bimanual uterine compression should be maintained
until hemorrhage is controlled.
If a contraction ring has formed that prevents replacement of the uterus, you
must take the patient to your operating theater, rapidly prep her and enter the abdomen
by laparotomy. Place a traction suture in the fundus, and pull the uterus back
into the abdomen with the help of further pushing from below.
Obstetric Lacerations
Lacerations of the vagina and perineum are categorized as follows:
1. First Degree: Lacerations of the fourchette, skin, and vaginal mucosa that
do not penetrate the underlying fascia or muscle. If these do not bleed,
leave them unsutured. If sutures are required, use 4-0 gut in simple interrupted
sutures.
2. Second Degree: Lacerations that penetrate the skin and vaginal mucosa to
involve fascia and muscle of the perineal body, but do not damage the rectal
sphincter. Close the vaginal mucosa and submucosa using 2-0 or 3-0 in a
continuous locked suture. Tie this off or drive the needle under the hymenal
ring to emerge at the top of the perineal laceration and set it aside. Use
a separate piece of suture material to place a few interrupted sutures
reapproximating the deeper fascia and incised muscles of the perineum.
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