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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_970_Библиотеки_им_академика_М_И_Перельмана.pdf
Carlos Pilasi Menichetti and Rebekka Troller
19 Obstetrics in Limited-Resource
Settings
INTRODUCTION
The reproductive health risks that all women face are
greatly exacerbated when healthcare facilities are inadequate, equipment and medications are in short
supply, and well-trained medical staff are few and far
away. This is unfortunately the reality of many women
living in resource-limited environments (RLE). Human
resources present, or sent to collaborate in a humanitarian mission, are reduced in number; therefore, they
are required to be flexible and cover areas that may be
out of the surgeons’ comfort zone. This is certainly what
happens to a general surgeon sent to assist in a natural
disaster or an armed conflict when exposed to obstetric
emergencies. It must be mentioned that assisting in a
humanitarian capacity or military operations may cover
a spectrum of resources and environmental constraints
when delivering emergency surgical care.
As published by the Lancet commission, there is a
high proportion of the world’s population without
access to safe surgical and anaesthetic care.
Moreover, if you also consider the density of surgeons, anaesthetists, and obstetricians, we can see
that the same geographical regions around the world
have less access to safe surgery; these regions are also
the highest in maternal mortality related to childbirth and caesarean sections worldwide.
A peak in maternal mortality occurs during the
intrapartum period around childbirth and the first
day post-partum. Women are at risk of dying because
of obstetric problems, and these are unfortunately
prevalent in RLE; it is very likely that these women
will present at a medical facility even though it has
not been defined as a maternity.
Regarding armed conflicts, there is growing evidence to show the profound negative impact of
conflict on maternal mortality: populations that
have experienced armed conflict have among the
highest rates. For these reasons, whenever an
emergency response team is deployed to a limited
resource area where a sudden onset disaster (SOD)
has occurred or to medically assist victims in an
armed conflict emergency obstetric skills must be
ensured.
The five main causes of direct maternal death are
the following:
1. Haemorrhage
2. Hypertensive disorders
3. Sepsis
4. Obstructed labour
5. Abortion
What are effective interventions to reduce maternal
mortality?
There have been many strategies to reduce maternal
mortality; however, the only proven approach to save
the lives of the 75% of women who die in pregnancy
and giving birth, and the 25% who die after birth, is
the provision of emergency obstetric and newborn
care. This can either be basic (BEmONC) or comprehensive (CEmONC). CEmONC interventions include
safe blood transfusion, capacity to perform caesarean
sections, manual removal of the placenta, assisted
vaginal delivery, abortion, and resuscitation of the
newborn; BEmONCs do not provide blood transfusion nor caesarean sections.
What can be done for each problem?
PPH MANAGEMENT
Stop the bleeding
T.T.T.T
Uterus empty
• Manual removal
of placenta
• Curettage
• Manual vacum
aspiration
Tear in:
Uterus
Cervix
Vagina
Atony
Whole blood
transfusion
No
No NoYes
Yes
Yes
Repair
Drugs
Uterine
tamponade
Surgery
B-Lynch
Uterine artery
ligation
Resuscitate
Blood products (whole blood)
Tranexamic acid
Minimise crstalloids
Triple artery
ligation
Still bleeding Still bleeding Still bleeding
T
issue
T
rauma
T
one
T
hrombin
224 | Fundamentals of Frontline Surgery
HAEMORRHAGE
Obstetric haemorrhage remains the leading cause of
maternal mortality worldwide. In 2012, the World
Health Organization (WHO) published new guidelines for the prevention and treatment of postpartum haemorrhage.
The management must cover adequate resuscitation, including the use of tranexamic acid, and
identification of the cause for adequate treatment.
The antifibrinolytic therapy in post-partum haemorrhage has shown to be effective in reducing
maternal mortality by 31% (reduction in death from
bleeding when given to women for treatment of
postpartum haemorrhage (PPH) within 1–3 hours
after delivery).
The treatment, as with other life-threatening
Haemorrhage, is to resuscitate the
patient and identify the cause.
Causes of PPH: (remember the 4Ts)
Postpartum haemorrhage, the loss of more than
500 mL of blood after delivery, is the most common
maternal morbidity in developed countries. It may be
caused by uterine atony after delivery, partial or
complete placenta separation disorder, laceration of
the genital tract, or uterine rupture.
The 4Ts for the common cause of bleeding
(Figure 19.1):
Tone – Atonic uterus
Tissue – Retained placenta
Tears – Perineum/Cervix
Thrombin – Clotting abnormalities
Management
Rapid assessment, resuscitation, and observations
(HR, BP, RR) should be undertaken. The patient
should lie flat. Uterine atony is treated by bimanual
uterine compression and massage, followed by drugs
Figure 19.1 PPH management algorithm rest annotated.
Figure 19.2 Technique of bimanual massage.
Obstetrics in Limited Resource Settings | 225
(Oxytocin 20 IU L
−1
of normal saline, Carboprost
0.25 mg IM, Misoprostol (Cytotec) 1000 mcg rectally,
Methylergonovine 0.2 mg IM). Two large-bore cannulas and blood test should be sent; then the bladder
must be catheterised.
Diagnose the cause of the bleeding (4Ts)
and stop the bleeding.
Bimanual compression of the uterus (Figure 19.2):
one hand is introduced into the vagina, the fist compressing the cervix, while the external hand presses the
fundus against the internal hand (Hamilton manoeuvre). The compression is maintained until the
bleeding is controlled and the uterus contracted.
Examination under anaesthetic for persistent
uterine atony often caused by retained placenta or
clots. Ensure the uterine cavity is empty and suture
tears if necessary.
Internal uterine tamponade:
A Foley catheter with a 30-mL balloon is easy to
acquire (Figure 19.3). Insert the catheter inside a
condom and tie the condom to the catheter with a vicryl suture without closing the catheter channel. Insert
some water to ensure it is not leaking or too loose.
The condom can be inserted into the vagina and
uterus and the catheter filled with water. Make sure the
catheter is spigoted; otherwise, the water will pour out.
The balloon will take 200–500 mL, depending on
the type.
Leave the balloon in place for 6–24 hours with
antibiotic cover.
A sterile glove can also be used in place of a condom.
B-Lynch Suture:
The most common and effective technique is
the B-Lynch suture (Figure 19.4). The aim of this
suture is to reduce the volume of the uterus. The
Figure 19.3 Foley catheter.
226 | Fundamentals of Frontline Surgery
Figure 19.4 B-Lynch suture.
technique is described later. It can be done after
normal delivery or caesarean section.
Packing the uterus with gauze soaked in anti-
septic. The pack should be removed after 12 hours.
Major haemorrhage needs compression of the aorta,
ligation of the internal iliac arteries, or a hysterectomy (Figure 19.1).
HYPERTENSIVE DISORDERS
Pre-eclampsia and eclampsia are still estimated to
cause approximately 30,000 maternal deaths annually worldwide, mostly in low- and middle-income
countries.
antihypertensive drugs; magnesium sulphate for severe preeclampsia and eclampsia.
eclampsia is the termination of the pregnancy. This can
be achieved by inducing labour, conducting a spontaneous labour, or via caesarean section. It is very important to highlight that in RLE, it is not possible to
ensure that the patient will have access to a medical
facility in her next pregnancy. This is relevant as the
risk of leaving a uterine scar can be life-threatening for
the mother following pregnancy. Having said that, if it
is indicated, every effort should be made to provide
caesarean section for the woman in need.
11
The first line of treatment is resuscitation with
The definitive treatment of eclampsia and pre-
SEPSIS
The WHO published a statement on maternal sepsis in
2017: ‘Maternal sepsis is a life-threatening condition
defined as organ dysfunction resulting from infection
during pregnancy, childbirth, post-abortion, or postpartum period’. Undetected or poorly managed
maternal infections can lead to sepsis, death, or disability for the mother and increased likelihood of early
neonatal infection and other adverse outcomes.
ABORTION
Unsafe abortion is a persistent, preventable pandemic.
The WHO defines unsafe abortion as a procedure to
terminate an unintended pregnancy either by individuals without the necessary skills, an environment
that does not conform to minimum medical standards,
or both. The main causes of death from unsafe abortion
are haemorrhage, infection, sepsis, genital trauma, and
bowel injuries. There are fewer data on nonfatal longterm health complications, but they include poor
wound healing, infertility, consequences of organ injury
(urinary and stool incontinence from vesicovaginal or
rectovaginal fistulas), and bowel resections.
Provision of safe abortion (medical and
surgical options) is a proven strategy
to reduce maternal mortality.
OBSTRUCTED LABOUR
Another important source of mortality is obstructed
labour. Despite some indications and conditions for
instrumental deliveries (vacuum or forceps), caesarean section is probably the most frequent technique. When medically justified, a caesarean section
can effectively prevent maternal and perinatal mortality and morbidity. However, there is no evidence
showing the benefits of caesarean delivery for women
or infants who do not require the procedure. As with
any surgery, caesarean sections are associated with
Obstetrics in Limited Resource Settings | 227
short- and long-term risk which can extend years
beyond the current delivery and affect the health of
the woman, her child, and future pregnancies. These
risks are higher in women with limited access to
comprehensive obstetric care.
⚫
It must be remembered that leaving a woman with
a uterine scar increases her risks in future
pregnancies (higher risks of uterine rupture and
abnormal placentation), and therefore, the
decision deserves a thoughtful analysis.
⚫
Even though there are different options for
management, there is also a role for surgery in
all five main causes of maternal death.
⚫
Providing safe caesarean section and managing
the bleeding related to pregnancy, especially postpartum haemorrhage (PPH), can reduce up to 70%
of direct maternal deaths.
⚫
Caesarean section provision and PPH
management are two skills that a surgeon
deployed to assist in a humanitarian projects
must be familiar with.
⚫
It is not expected that an emergency hospital
dealing with different pathologies will transform
into a maternity; however, women with obstetric
complications will present if there is no other
facility. Having the availability to perform
emergency caesarean section as well as blood
transfusion and management of post-partum
haemorrhage must be part of the services provided.
⚫
Training on caesarean sections as well as
management of post-partum haemorrhage are
skills a general surgeon must acquire before
deployment to humanitarian missions in low
resource settings.
CAESAREAN SECTION
Indications
In austere environment, emergency indications for
caesarean section (CS) are predominant – there is rarely
an elective operation, dictated by rudimental infrastructure. Severe pre-eclampsia or eclampsia are the
most important indication due to maternal condition.
More frequent indications are when the foetus is at risk
such as cord prolapse, strangulation, protracted or
obstructed labour, placental insufficiency, infection, or
prematurity causing fetal distress.
Obstructed labour, amnion infection, and placental abruption are the most important ones.
If the foetus has already died, caesarean
section should be avoided in cases with
placental abruption.
Techniques
Preoperative:
Check fetal heart.
Blood test (group and safe, Hb), electrolytes,
coagulatory test.
Consent and examine the patient prior to
caesarean section.
Epidural anaesthesia and IV line with infusion. Premedication with Ranitidine or
Magnesium trisilicate 300 mg.
2 units of blood ready, if available.
Urinary catheter, WHO safety checklist, skin
disinfection, and patient covered with sterile
sheets.
Tilt the operating table to reduce aorto-caval
compression.
Operation technique:
Ensure adequate analgesia by testing the area
below umbilicus with forceps.
Right-handed surgeons stand on the right side of the
patient. A Pfannenstiel incision (Figure 19.5) is performed: 10–12-cm straight incision 2 cm above the
symphysis pubis. Alternatively, a lower abdominal
midline incision (between umbilicus and symphysis)
provides fast opening of the abdomen and it’s easier to
perform. The subcutaneous tissues are incised and
brought down to the fascia at the centre of the incision.
The fascia is incised transversely with the scalpel
(2 cm) and extended laterally with heavy curved Mayo
scissors, or blunt with fingers. The superior edge of
the fascia is grasped and elevated, and the fascia gently
pulled cranially and caudally. Slowly stretch the
muscle and subcutaneous tissue by bimanual bilateral
traction and separate the rectus muscles with fingers.
Use a Doyen’s retractor to handle the lower segment
and pull the bladder down (Figure 19.6).
The peritoneum is opened sharply transversely and
extended bluntly with both index fingers, aiming high
Pfannenstiel incision Rectus fascia
Rectus muscle spread
Peritoneum
228 | Fundamentals of Frontline Surgery
Figure 19.5 Pfannensteil incision.
Figure 19.6 Doyen’s retractor to handle the lower segment and pull the bladder down.
up the peritoneum (Figure 19.7). The gravid uterus will
now be under direct vision. After the peritoneum is
opened, the serosa at the site of the plica vesico-uterina
has to be cut transversely; push the bladder downwards.
below the upper margin of the peritoneal reflection
in the midline is the incision of choice until the
membranes bulge (Figure 19.8). Insert fingers and
open the uterus by stretching laterally.
Replace the bladder retractor under the opened
peritoneum.
Be careful not to injure the foetus, particularly in
cases where the fluid is reduced or has already
Make sure the bladder is reflected down,
exposing the uterus. You do not want
to enter the uterus via the bladder!
A 3-cm transverse incision is made with a scalpel
in the lower uterine segment; approximately 1 cm
The operator’s right hand is passed into the
uterine cavity between the foetal head and symphysis
pubis. The head is carefully flexed and elevated
drained by premature rupture
of the membranes.
Peritoneum
cut
Peritoneum
Rectus
muscles
Figure 19.7 Sharp dissection of the peritoneum.
Obstetrics in Limited Resource Settings | 229
upwards into the uterine opening, and only then will
the assistant provide mild fundal uterine pressure
(Figure 19.9).
After the head, both shoulders are delivered with
gentle traction. Two clamps are placed on the umbilical cord at least 10 cm from the abdomen and cut
between the clamps with scissors. Hand the baby to
the midwife.
Asked the anaesthetist to give Syntometrine or
Oxytocin and antibiotic prophylaxis.
Now, the placenta is removed manually by a constant but controlled traction on the cord. Massaging
the uterus with one hand can be helpful.
The placenta should be inspected for completeness
and the womb should be checked for retained tissue
or membranes using fingers or sterile swab.
Grab inferior and posterior edge of uterine incision and suture the uterus with a running-lock suture about 1 cm apart for haemostasis using Vicryl O
suture. Start a second layer of suture just lateral to
the lateral angle sutures. If necessary, additional
cross-stitches can be placed wherever significant
bleeding is still prevalent. Large blood clots are removed in the paracolic gutters with a swab on a stick.
Haemostasis should be checked at each layer. Fascial
closure is done by running suture using Vicryl or
PDS; skin closure with Monocryl or clips. A vaginal
examination is performed to spot ongoing bleeding.
Clots of blood from the vagina can be removed with
a swab on a stick.
Postoperative Care
Assess the patient for vaginal bleeding prior to
transfer to the ward. Do regular observations; consider 24 hours of antibiotics in cases of sepsis or
prolonged rupture of membranes.
CAESARIAN SECTION FOR BREECH DELIVERY
Good exposure is essential. The abdominal and
uterine incision should be of sufficient size. If the
head is stuck in the pelvis, pulling the head from
below could be necessary to deliver the baby.
Female genital mutilation (FGM)
This problem is not considered as a main source of
mortality worldwide; however, it is prevalent in certain countries. More than 200 million girls and
women alive today have been cut in 30 countries in
Africa, the Middle East, and Asia, where FGM is
concentrated.
Surgeons who will be deployed to high-prevalence
FGM regions require a more in-depth preparation
and information on this matter.
Some facts about FGM:
⚫
FGM includes procedures that intentionally alter
or cause injury to the female genital organs for
non-medical reasons.
Ureters
Uterus
Bladder
Incision
Uterus
Bladder
Vagina
Incision
(a)
(b)
230 | Fundamentals of Frontline Surgery
Figure 19.8 Uterine incision location.
⚫
The procedure has no health benefits for girls and
women.
⚫
Procedures can cause severe bleeding, infection,
and – in the longer run – urinating problems as
well as complications in childbirth and increased
risk of newborn deaths.
⚫
FGM is mostly carried out on young girls between
infancy and age 15.
⚫
FGM is a violation of the human rights of girls
and women.
TYPES AND DEFINITIONS
Female genital mutilation is classified into four
major types by the WHO. These procedures are
Figure 19.9 Delivery of foetus.
Obstetrics in Limited Resource Settings | 231
almost always done by traditional circumcisers who
often play other central roles in communities, such
as attending to childbirths. The poor hygiene conditions contribute to the already massive harm done
to these girls. However, surgeons as any other health
care providers, must not perform it based on the
erroneous belief that the procedure is safer when
medicalised.
16
The WHO clearly and strongly call on
health professionals not to perform such procedures
because there is no medical indication for it and
there are not health benefits. On the contrary, it
violates a person’s rights to health, security and
physical integrity, their right to be free from torture
and cruel, inhuman or degrading treatment, and the
right to life when the procedure results in death. It is
nearly always carried out in minors and, therefore, is
a violation of the rights of children.
⚫
Type 1: Often referred to as clitoridectomy, this
is the partial or total removal of the clitoris or, in
very rare cases, only the prepuce.
⚫
Type 2: Often referred to as excision, this is the
partial or total removal of the clitoris and the labia
minora, with or without excision of the labia majora.
⚫
Type 3: Often referred to as infibulation, this is
the narrowing of the vaginal opening through the
creation of a covering seal. The seal is formed by
cutting and repositioning the labia minora, or
labia majora, sometimes through stitching, with
or without removal of the clitoris.
⚫
Type 4: This includes all other harmful
procedures to the female genitalia for non-medical
purposes (e.g., pricking, piercing, incising,
scraping, and cauterising the genital area).
It is unlikely for an expatriated surgeon to face acute
complications because of the hidden nature and
cultural beliefs where this procedure is performed. It
is more frequent to face late complications that will
become more evident during childbirth. Because of
scarring and alteration of normal anatomy, FGM can
be a cause of obstructed labour that will require
some specific management.
Deinfibulation. This term refers to the practice
of cutting open the sealed vaginal opening in a
woman who has been infibulated, which is often
necessary to improve health and well-being and to
allow intercourse or facilitate childbirth. If the scarring tissue allows then deinfibulation as shown in
Figure 19.10 can be undertaken. In case the introitus
is exposed and there is scarring, an episiotomy (even
bilaterally) may be needed during delivery.
As a medical professional, it is not accepted to reinfundibulise (cannot be sutured back to the way it was
prior to deinfibulation) because it would counter the
principle of ‘do not harm’ that all doctors subscribe to.