Low-Resource Operative Obstetrics

Low-Resource Operative Obstetrics

Abida Hasan

Kelli Barbour

Bakari Rajab


Physical Examination

  • Reliance on physical examination over diagnostic studies (examples include)

    • Vital signs

    • Dry mucous membranes

    • Pallor of conjunctiva, tongue, and palms of hands

    • Leopold maneuvers

Differential Diagnosis

  • Arriving at a diagnosis and management plan poses a challenge due to several barriers.

  • Barriers to optimal care outcomes when compared to high-resource settings can be conceived as barriers to the five Ss: staff, supplies, space, systems, and social support (1).

    • Health-care workforce barriers: Limited skilled staff to perform procedures and assist with recovery (Staff)

    • Physical barriers: Limited operating room availability (Space), limited room supplies (drapes, gowns, and instruments) (Supplies), limited laboratory studies, antibiotics availability and resistance patterns, limited diagnostic technology (Systems), and limited blood supply for transfusion

    • Patient factor barriers: Access to care (remote location from care and unable to afford care) (Systems), limited health literacy, poor hygiene (limited access to water and soap), malnutrition (Support)

  • Compensatory advantages

    • Excellent physical examination skills, cost-effective and targeted use of laboratory testing, extensive experience in managing complications with few resources

Nonoperative Management

  • Nonoperative management can be considered for many obstetric conditions, but limited or absent capacity for follow-up and limited medications can discourage medical management.

    • Ectopic: Limited availability of methotrexate, laboratory studies (beta-human chorionic gonadotropin, complete/full blood count, comprehensive metabolic profile), and distance from hospital

    • Abortion: Mifepristone is not readily available, although misoprostol is usually available.

    • PPH: Methergine and carboprost tromethamine are expensive and/or require cold storage, which is not cost-effective and often impossible in a resource-limited setting. Beyond a condom catheter, balloon catheters are expensive and may not be available to use. Interventional radiology is generally not available.

    • Peritonitis: Treatment requires broad-spectrum antibiotics, which can then be narrowed according to wound cultures. Wound culture is not always available in constrained settings. Broad-spectrum antibiotics are often not available, and there maybe high-resistance patterns.


  • Ultrasound may be available either through radiology or through point-of-care units. Ultrasound gel may not always be readily available. When ultrasound gel is not available, alternative sonographic mediums may be available for purchase or to make locally with items such as cassava slurry, cornstarch slurry, and vegetable oil (2,3,4).

  • The x-ray may be available in referral hospitals, district hospitals, health centers, and clinics. Formal interpretations of radiologic studies may not be readily available or may come at an additional cost to the woman.

  • Computed tomography (CT) studies may be available in referral hospitals, district hospitals, and health centers. Private clinics may have better availability of CT technology.

  • Magnetic resonance imaging (MRI) may be available in some settings but will generally still be limited owing to expensive ancillary materials and maintenance.


  • Conditions to be addressed

    • Health literacy

      • Potential for patient-provided medical history to be unreliable

    • Malnutrition/dehydration

    • Lack of hygiene

    • Infectious diseases (malaria, tuberculosis, human immunodeficiency virus [HIV], schistosomiasis, typhoid)

    • Underlying medical comorbidities (undiagnosed diabetes, hypertension, rheumatic heart disease)

    • Prior surgical/delivery history corroborated by physical examination findings including lack of documentation of uterine scar for prior cesarean delivery

  • Material to be reviewed

    • “Health Passport” or equivalent for individual health record

    • Imaging (as above) most likely including obstetric ultrasound for fetal evaluation


  • General surgical concerns in low-resource settings that span the breadth of surgical management include both patient factors and resource-related limitations.

    • Patient factors include delays in receiving care (whether owing to access and proximity to health care or owing to distrust), hygiene, self-administered treatments such as self-induced abortions, malnutrition, lack of family support, lack of finances, and ability to follow-up reliably.

    • Resource-related limitations include limited availability or lack of a variety of medications such as antibiotics and surgical materials including drapes, gowns, sterilized equipment, surgery-specific instruments, and suture. Technologically advanced options for surgical management such as laparoscopy are often not available.

    • When laparoscopy is available, its use can be limited by reliable electricity, availability of carbon dioxide and disposable supplies (e.g., trocars) as well as the learning curve necessary to overcome to perform the procedures safely.

    • Ultimately, the presence of equipment alone may not be sufficient to overcome the many barriers present for implementation.

    • Minimally invasive surgery is not limited to laparoscopy. A so-called minilaparotomy is often the procedure of choice in low-resource settings. This can be performed quickly with adequate exposure for many procedures. It is inexpensive and entails fewer wound complications and less need for postoperative analgesia.

    • In many low-resource settings, postoperative pain control is limited to a nonsteroidal inflammatory medication (ibuprofen or diclofenac most commonly) and paracetamol. Opioids and opioid-like analgesics are often in short supply or unavailable, even for major abdominal surgery.

    • Epidural anesthesia is generally not available owing to limited personnel, experience, and supplies. Spinal anesthesia is often available.


  • Positioning generally remains the same in limited-resource settings as in high-resource settings. Types of stirrups may be limited by setting.


  • Surgical approach in low-resource settings for abdominal surgery is most often via laparotomy.

  • Office-based procedures may be preferred over taking a woman to the operating room for an equivalent procedure. For example, manual vacuum aspiration (MVA) may be chosen over dilation and curettage based on the availability of an operating room, anesthesia, and supplies.

Sep 9, 2022 | Posted by in OBSTETRICS | Comments Off on Low-Resource Operative Obstetrics
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