Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Basic Obstetrics and Obstetric Surgery in a Mission Setting
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joint using a scalpel to incise carefully and gradually until the joint opens. Do not
allow more than 3 cm of separation. Assistants to support the patient’s legs at this
point are essential.
In conjunction with an episiotomy, this procedure should allow immediate delivery
of the baby. You may require vacuum-assist, but DO NOT use forceps. Strain
on the sacro-iliacs must now be diligently avoided.
Repair the symphysiotomy with subcutaneous and subcuticular sutures. Repair
your episiotomy in the usual fashion. Leave a Foley in place. The patient should not
attempt to walk for 48 hours so DVT prophylaxis will be appropriate. She should be
fully ambulatory by days 7-10. The symphysis should heal well, leaving an expanded
pelvis that should facilitate future labors.
Cesarean Section
In the developed nations, the Cesarean is the most common major surgery, constituting
20% of births in United States and even higher elsewhere (e.g., Taiwan).
Cesarean is also the most common emergency surgery in the mission setting. Practical
knowledge of this procedure will therefore be of very high yield.
There are two key decisions to be made en route to performing a Cesarean section.
(1) When is a Cesarean indicated? (2) What type of Cesarean is indicated (low
transverse, classic vertical, or more rarely, extraperitoneal Cesarean or
Cesarean-hysterectomy). The risks and benefits of these related procedures are distinct,
should be understood and when appropriate should be explained to the patient
and her family.
Indications for Cesarean are described in C1 and C2 below. Cesarean is indicated
in cases of footling breech, breech with unfavorable pelvimetry, transverse or
brow presentation. Cesarean is the only option for placenta previa and abruption.
Contraindications to Cesarean include a head that is deeply engaged in the pelvis
(either push it back up Zavinelli-like or consider a symphysiotomy), and fetal demise
(in which case a destructive operation is far safer for the bereaved mother).
Low Transverse Cesarean Section (LTCS - or Lapara-Trachelotomy)
Indications
A common indication for LTCS is dysfunctional labor (dystocia). Dysfunctional
labor patterns include (1) primary dysfunction (failure to achieve a normal rate of
dilatation in the first stage) and (2) secondary arrest of dilatation (arrest or failure to
maintain a normal rate of dilatation in the first stage), both of which patterns must
be recognized by use of a labor curve or “partograph”. Dysfunctional labor also
includes secondary arrest of descent, e.g., the patient achieves full dilatation but is
unable to bring the baby’s head (in vertex presentations) down to the ischial spines
after two hours of pushing. In the latter case, LTCS should be considered if progress
is not made after the following interventions.
a. Empty the bladder by use of a straight catheter.
b. If the patient is tired and pushing efforts inadequate, provide moderate
fundal pressure with contractions and see if descent is gained.
If the presenting part remains 3/5 or more above the pelvic brim, outlet forceps
or vacuum extraction are inappropriate, and symphysiotomy would be problematic.
Section is indicated.
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