Low-Resource Operative Obstetrics
Low-resource operative obstetrics encompasses the adaptation or modification of obstetric procedures to resource-limited settings wherein myriad of barriers affect the cost-effectiveness, efficiency, and quality of care.
Ectopic pregnancy, abortion, cerclage, spontaneous vaginal delivery, operative vaginal deliveries, laceration repair, cesarean delivery, placenta accreta, uterine rupture, hysterectomy, retained placenta, postpartum hemorrhage (PPH) management, infectious morbidities, postpartum sterilization procedures
Practices different from high-resource settings: Low threshold for hysterectomy when excessive uterine bleeding and/or uterine rupture occurs, use of intermittent auscultation (IA), use of surgical management over medical management for ectopic pregnancies and abortions, adaptation to a different variety of and/or limited availability of medications, sutures, blood and blood products
Obstetrician-gynecologists coming from high-resource settings to practice in a low-resource setting must prepare for “onthe- ground” realities that can hamper their effectiveness and safe practice in a new setting. In other words, insight is critical.
It is always best to examine the practices of colleagues in this setting and not rush to judgment before gaining experience working with highly constrained supplies, equipment, and personnel.
Surgical improvisation, although often considered unethical outside of clinical trials in high-resource settings, is often necessary to preserve life in low-resource settings.
Knowing when and how to improvise is difficult and comes only with experience.
Reliance on physical examination over diagnostic studies (examples include)
Dry mucous membranes
Pallor of conjunctiva, tongue, and palms of hands
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)
Excellent physical examination skills, cost-effective and targeted use of laboratory testing, extensive experience in managing complications with few resources
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.
IMAGING AND OTHER DIAGNOSTICS
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
Potential for patient-provided medical history to be unreliable
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
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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.
Procedures and Techniques
Conservative management may not be possible owing to lack of methotrexate, lack of familiarity with medications by health-care staff, inability to immediately assess blood count, kidney and liver functions via laboratory studies, and patient’s remoteness from the hospital.
Patients often have limited or no transport, limited ability to communicate with the hospital, and there are often no emergency systems (i.e., 911) in place. Therefore, medical management can only be considered in select patients.
With advances in the ability to make the diagnosis earlier and improvements in microsurgical techniques in high-resource settings, conservative surgery has replaced the once-standard laparotomy with salpingectomy.
In low-resource settings, ectopic pregnancies are often diagnosed late as most patients delay initiation of antenatal care to 16 weeks’ gestation or later. The reasons for this are multifactorial and include cultural beliefs, access, and health systems limitations.
Owing to this, laparotomy with salpingectomy is still widely practiced as the standard of care. Many women present hemodynamically unstable with large, ruptured ectopic pregnancies.
Interstitial cornual ectopic and abdominal pregnancies are probably more common in this setting (5).
Salpingostomy is often contraindicated because of lack of beta-human chorionic gonadotropin testing, poor follow-up, lack of reliable transport and emergency services, and so on.
Laparotomy and salpingectomy are also preferred for surgeons inexperienced in laparoscopy and for women in whom a laparoscopic approach is difficult (e.g., secondary to the presence of multiple prior surgeries with a risk of dense adhesions, obesity, or in the unstable patient with massive hemoperitoneum).
If disseminated intravascular coagulation is not suspected, all surgical patients should receive tranexamic acid preoperatively to possibly limit blood loss (6,7).
Laparotomy is performed via the appropriate incision.
Time is of the essence in the management of ectopic pregnancies especially when blood products are scarce. It is not uncommon to have an only unit of blood or none at all and be forced into management of the patient with severe anemia.
In the absence of pronounced adhesions, the uterus and ectopic should be immediately grasped and elevated to terminate active bleeding. This can be an invaluable step to allow hemodynamic stabilization of the patient with massive blood loss.
Communication with the anesthesia team is essential. Many anesthetists will be reluctant to induce anesthesia in the unstable, bleeding patient without blood immediately available. These conversations can be had before a patient is encountered in distress to discuss techniques of anesthesia induction that might limit blood pressure effects. (Ketamine is often available in low-resource settings and is safer than vasodilatory drugs for anesthesia.)
Most ectopic pregnancies can be managed with small laparotomy incisions even in the unstable patient. In the hemodynamically stable patient, a minilaparotomy (5 cm) should be considered to speed recovery and decrease the chances of wound infection.
Often, surgical suction and abdominal packs are limited or absent, which makes exposure and management of the operative field a challenge. Use of any sterile, absorptive material is indicated, including the inner wrap for the surgical instruments or even extra cotton surgical drapes.
The involved tube is identified and freed from surrounding structures; a dilute solution of vasopressin (usually not available) can then be instilled into the mesosalpinx to minimize bleeding.
If not ruptured, a salpingostomy technique can be used: A 1- to 2-cm incision is made on antimesenteric side of the tube with a needle electrode (electrocautery). The ectopic pregnancy can then be removed from the tube. Hemostasis should then be obtained in the remaining decidual bed.
Limitations of salpingostomy in low-resource settings are discussed above. Safety both during surgery and postoperatively should be paramount in decision making.
Salpingectomy, either total or partial, is preferable to salpingostomy in most cases: Clamp the tube between the uterus and the ectopic pregnancy ensuring control of the vessels in the mesosalpinx. Cut portion of the tube with the ectopic free and suture ligate the pedicle.
Continue to clamp, cut, and ligate the mesosalpinx until the tube is free and can be removed while preserving the utero-ovarian ligament.
Regardless of the method, hemostasis should be obtained quickly via pressure, electrocautery, and suture ligation as needed.
Elective abortion may not be available in many areas owing to local or national statutes.
Misoprostol and mifepristone, where available and legal, can be used for inducing abortion in appropriately counseled women.
One may choose to admit a patient who lives far from the hospital with no transport until the procedure is complete.
Dilation with suction and possibly sharp curettage or MVA are surgical options that are usually available in low-resource settings.
For spontaneous abortions, conservative management with expectant management can be considered, as can the use of misoprostol. Dilation and curettage or MVA can also be used for spontaneous abortions, particularly when there is heavy bleeding, when patients live remote from the health-care facility, or per patient preference when appropriately counseled.
MVA may be more readily available, can usually be performed outside of an operating room, and can have a higher likelihood of success compared to misoprostol (8).
MVA was described first in the 1970s as a possible method for managing incomplete miscarriage.
Confirmation of miscarriage should be obtained by physical examination and ultrasound.
Preprocedural counseling and consent are essential for all procedures.
A sterile speculum is inserted into the vagina to expose the cervix, and the cervix is washed or with an antiseptic solution, such as povidone-iodine, or just water. The operator uses sterile instruments and sterile gloves and takes care never to touch that part of the instrument that will enter the uterus—the “no-touch” technique, as it is called.
With the cervix visualized, a local anesthetic is injected at 12 o’clock. A single-tooth tenaculum is then placed on the cervix at 12 o’clock in a vertical position. The paracervical block is then completed.
Dilation of the cervix is then performed.
Misoprostol, when available, can be used before the procedure to allow easier and potentially safer dilation.
Safe dilation depends on the surgeon. Failure to appreciate the position of the uterus by physical examination and ultrasound may result in perforation.
When possible, ultrasound-guided instrumentation of the uterus is advised. The implications of uterine perforation and bowel or bladder injury in the low-resource settings are dire, and additional care should be taken at all times.
The next step is mechanical dilation if needed. Care should be taken to insert the dilators slowly and gently for the safety and comfort of the woman.
If resistance is experienced, it is advised to return to the previous dilator, reinsert it, and allow it to remain in place for a minute or so before attempting to insert the next large dilator.
Having achieved dilation of the cervix, the vacuum cannula is introduced and uterine evacuation is performed by creating a vacuum within the syringe canister (typically a 60-cc manual syringe).
The cannula is then moved back and forth in the endometrium similar to a dilation and curettage.
The operator can feel that vacuum aspiration is completed by the gritty feeling of the cannula scraping over the uterine lining and by the increased resistance to moving the cannula. The placental site can sometimes be appreciated as a softer, smoother area.
A sharp metal curette can confirm that the cavity is empty if needed. Although there is no need to perform a complete sharp curettage after manual vacuum evacuation, because of the lack of proper working syringes or the right gauge cannula, a sharp curette may be necessary to ensure completion of the procedure.
The cannula and syringe are then removed, and hemostasis is assessed and assured.
Cerclage use is potentially controversial in all settings, but particularly so in low-resource settings. It is often difficult or impossible to get an accurate history to ensure cervical incompetence because of incomplete record keeping and patient knowledge about past medical encounters. This should be taken into account before performing cervical cerclage in low-resource settings.
If there is any suspicion of preterm labor/infection as a cause for cervical dilation, a cerclage should not be performed as the risk to the woman will be magnified considerably.
The McDonald cerclage technique is associated with less operative time, expertise, blood loss, and less anesthesia compared to the Shirodkar technique.
Steps of a cerclage are not affected by resource limitations. Suture choice, however, may be limited. Prolene (polypropylene), Mersilene suture or Mersilene tape (polyethylene terephthalate), or Ethibond (polyethylene terephthalate) are typically described as the sutures for cerclage (9). These sutures are chosen for the availability of a larger caliber and for their nonabsorbable nature. The use of silk and nylon has been described in the literature and can be considered for use for cerclage (10).
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