Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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328 Surgery and Healing in the Developing World
if the law says that all deliveries must be done in a maternity of hospital, it has been
found that about 60 to 80% of deliveries in Zaire are at home, done with the help of
a traditional midwife’. In our own health district, probably only 20-25% are home
deliveries.
From the aetiological point of view, the primary uterine rupture is that most
commonly encountered (72.4% of cases in our series). The remaining ruptures originated
from an already scarred uterus, of which 85.7% were old caesarean scars. A
similar frequency of different types of rupture was reported by Lambillon et al. 13 In
Belgian Congo and also by Vaudin et al14 in Rwanda.
The maternal mortality is high in our study (18.3%) compared with Shreve and
Russo10 who cited between 3-11% and Nasah and Drouin5 who recorded only 8.5%
mortality in their study in Cameroun.
The perinatal mortality is also high (80%), and is greater than those put forward
by Nasah and Drouin5 and Shreve and Russo10 which are, respectively, 58.6% and
between 20-30%. The mean weight of the newborns was 3185 g, compared with
2500 g in Cameroun. 5 With the above authors we agree that, in the case of
premarurity, the rupture often occurs in former caesarean scars.
Table 3 shows the influence of the woman’s gravida on the occurrence of the
uterine rupture. This agrees with the studies of all the authors consulted. 3,7,10 The
grande-multipara is at greater risk than those in the first to fifth pregnancy.
Care remains a subject of controversy in the literature: repair or hysterectomy?
Each method has its defenders: repair has been recommended by Nasah and Drouin5 and also by Dodson7 who suggests that hysterectomy following rupture is associated
with a high morbidity and mortality. The opposite position is taken by Hibbard9 who finds that hysterectomy is the best treatment in most cases of complete uterine
rupture. We believe that the general state of the patient and the local conditions in
the course of the surgical exploration must dictate the treatment. We have found
that patients who had a hysterectomy had a higher mortality rate than those who
had uterine repairs. Evidently, those who required hysterectomy were already at
greater risk of death since their condition was already worse than those who had a
repair only.
Conclusions
Uterine rupture remains an important problem in Africa. Maternal and perinatal
mortalities remain high and pose particular problems to solve in difficult working
conditions. Grande-multiparity appears to be the major predisposing factor.
Treatment must be dictated by the general state of the patient and also by the
conditions found at the time of surgical operation.
This very serious problem would be better prevented than treated. Prevention
however, depends on adequate family planning advice, prenatal care, early detection
of high risks and competent maternity care and follow-up.
In situations with multiple socio-economic, and political constraints (technical,
cultural, professionnel, material, accessibility, etc), a realistic system for prevention
is elusive. Nevertheless, we have established the following strategies, in the hope of
reducing the incidence of ruptured uteri in this and neighbouring health districts by
50% within years:
1. An experienced midwife, together with a specialist obstetrician will be invited
to evaluate the midwifery care given in the hospitals and in rural
health centres and to establish guidelines for the monitoring and transfer of