Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Medical Adventures in the Nigerian Bush
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Obstetrics
Obstetrics is interesting in Africa because phsyciians get to see only the complications
that childbirth can afford, since all routine obstetrics, from antenatal care
through delivery, is handled by the native-trained midwives. The complication rate
was high, however, not so much because of the midwifery, but because the local
tribes had android pelves, nutrition—especially as regards anemia—was poor, and
the native women generally gave themselves a “trial of labor” amounting of several
days before coming to the hospital. Because of these prolonges obstructed labors,
complications uncommon in civilization were everyday occurrences in the bush.
Vesicovaginal fistulae were plentiful and persistent problems. At one time there were
seven patients in the hospital awaiting repair or rerepair of vesicovaginal and
rectovaginal fistulae, as well as many of such outpatients wandering about as pitiful
social outcasts searching for blood donors while they passed the time for the immediate
postpartum inflammation to subside. Destructive deliveries were done on those
patients who had labored for so many days that they came to the hospital after fetal
death. The most dreaded complication with a high mortlaity rate was the common
story of some woman who had labored a few days in the bush without progress, but
was brought to the hospital when her labor abruptly stopped, her abdomen swelled,
and she became shocky. On one such patient, immediate abdominal section revealed
twins floating free in the abdominal cavity. Ruptured uteri accounted for the
majority of obstetric mortality.
The midwives are taught to use the Maelström vacuum extractor in lieu of forceps
to assist difficult deliveries. Another technique, practiced in this region in preventing
the necessity for an even higher number of abdominal deliveries, is that of
the symphysiotomy. Loosening the ligaments at the symphysis pubis by a careful
percutaneous incision saved half of obstructed labors form Caesarian section. Once
done, the symphysiotomy also corrected cephalopelvic disproportion for the patient’s
next pregnancy. Caesarian sections remained a surgical staple, however running second
only incarcerated hernia repairs as the most common emergency operation. We
each performed one of obstetrics’ more demanding maneuvers, delivering two patients
who were in labor with transverse lie malpositions by internal podalic versions—another
method to obviate abdominal delivery in selected patients.
We first presumed we would be treating many women with demands for birth
control assistance in circumstances where the need for population limitation was so
obvious. Much to our surprise, the reverse was true—had not limits been placed on
such use of the physician’s time, it would have been to easy to become involved in
running a full-time infertility clinic. The greatest sociologic and economic disgrace
among the natives was to be barren. Most of the girls of the area were married by
menarche; marriage was declared when a down payment on the bride price was
agreed upon, the standard bridewealth being 25 pounds—half the price of a prize
Fulani cow. From the time the bride price arrangement was made to menopause or
death, the prematurely aged girls were expected to produce a child every other year.
They would request help for fecundity if they did not live up to this schedule, imposed
upon the women by an immemorial tradition which was based on the grim
survival statistics of the bush. To insure survival of a few children. A dozen births
were once mandatory; now half of these babies can be expected to mature. The stress
of this population growth rate is no doubt the casue of some of the social, economic,
and political strains evident in such an underdeveloped country. It was not without
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