Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Basic Obstetrics and Obstetric Surgery in a Mission Setting
C. Cesarean section
C1. Transverse
C2. Vertical
C3. Special cases
Postmortem Cesarean
Extraperitoneal Cesarean
C4. Hemorrhagic complications
Uterine artery ligation
B-Lynch suture for postpartum hemorrhage
C5. Cesarean with hysterectomy
Assisted Delivery
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Definition and Indications
A single approach to assisted delivery will be considered here, that of
vacuum-assist/extraction. Forceps deliveries require expertise that is rare among
nonobstetricians, and in fact forceps experience is declining among those currently
trained in OB-GYN. In a mission setting, applying forceps for anything but an
outlet extraction would be far more dangerous than performing a Cesarean section.
At the outlet (scalp is visible without separating the labia), a vacuum-assist may do
just as well, and has definite advantages for the nonspecialist.
Use of the vacuum avoids injury that might occur secondary to misapplication
of the forceps. However, do not think that the availability of a vacuum-assist allows
you to forgo a careful assessment of the station, position and attitude of the fetal
vertex. You need to identify the occiput, since that is where the vacuum should be
applied.
Assisted delivery is indicated when there is delay in the second stage, in other
words, an arrest disorder when the cervix is fully dilated. Using your partograph,
you will consider assisted delivery when there is an arrest in second stage lasting over
30 minutes in a multipara, or one hour in a nullipara. If the arrest is due to an
occiput posterior position or to asynclytism, vacuum can be put to good use. Rarely
it may be necessary to consider an assist prior to full dilatation if there is fetal distress.
An assist may also be appropriate for an exhausted mother or one with a surgically
scarred uterus or cardiovascular disease, in both of whom the effort of pushing
should be minimized.
Success requires adequate uterine contractions, a vertex presentation with less
than 1/5 of the head above the pelvic brim, and palpable descent of the head with
contractions and maternal effort. You may have your assistant or midwife apply
fundal pressure with pushing to confirm that further descent of the head is achievable.
Vacuum-assist is contraindicated if there is severe CPD; vacuum cannot overcome
this. (You may discover CPD by failing a trial of vacuum; these patients go to
Cesarean section.) The risk of intracranial hemorrhage precludes the use of vacuum
to deliver a preterm infant; if these babies become distressed a section is required.
Procedure
Identify the posterior fontanel and confirm the position of the head. Apply the
vacuum cup to the vertex, preferably over the posterior fontanelle, and create the
vacuum. Allow a few moments for caput to form within your vacuum cup. Pull
steadily with controlled traction and be prepared to control delivery of the head. A
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