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AFRO-NETS> Request for Obstetrics Assistance (4)
Request for Obstetrics Assistance (4)
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On Dec 19 1997, Prof. Stephen N. Kinoti wrote:
> In any case, would you offer to manage this patient in
> Zimbabwe, or come over and assist? No one is interested in
> receiving any money but assistance with the management
> without charging the patient. Information and advice on the
> clinical management is also useful. May be you can offer one
> of these. Try to be helpful please.
O.K IF YOU REALLY WANT THIS REQUEST TAKEN SERIOUSLY there it goes.
Here in Bulawayo there are 4 Government gynaecologist responsible for
the more complicated Obs & Gyn problems of a population twice the size
of that of Lesotho. Our annual salaries after tax are a little less
than you estimate the cost of this one pregnancy. We supervise or do
for that salary among all our other duties 3000 caesareans a year in-
cluding ante and post natal care. If managing these patients including
their "endometritis" would cost as much as you estimate then these 3000
caesars would cost a quarter of the total health budget of Zimbabwe's
11 million people (including the cars of the chefs). Zimbabwe has
around 24.000 caesars a year.
How to manage this patient:
Risks: Some more chance of prematurity, breech presentation, obstructed
labour and somewhat unusual caesarean section. No major obstetrical
complications anticipated unless, but that seems unlikely from your de-
scription, it is really an extrauterine pregnancy. VLBW phase already
passed (high tech neonatal care for those is of course expensive).
As with every pregnancy, but a little bit more important with this one,
the patient should have a plan. If anything goes wrong how long will it
take to come to the hospital? Will the car of the nearby shopkeeper
take me? How often is the car not there? If no fast transport can be
more or less guaranteed can she stay with relatives near the hospital
or should she stay in the pregnant women shelters at the hospital
grounds? Those shelters should be there. I was involved, in passing, in
the fund raising and have seen them.
In general one can say there is not much difference between this preg-
nancy and any other. The baby will come the natural way or not. More
chance of not in this pregnancy but still every pregnancy might end in
a caesar, and if you look in the old theatre books I have done a few in
Quiting in the 1976-82 period doing a locum from Mafeteng if there hap-
pened not to be a doctor in Quiting.
You might find the names of Drs Perk, de Vries, de Rhoter, Haisma, Lam-
berts, Harlaar and v Geldermalsen and Ewalds. All local heroes espe-
cially Perk I bet people still talk about him. In this period there was
always a doctor in Quiting often two and Mohaleshoek, Mafeteng,
Quachasnek even Scott hospital were all involved in making sure all
hospitals were covered (but there were no doubt less workshops to relax
then).
Caesars often meant giving your own anaesthesia (often spinal, when in
shock ketamine), operating, resuscitating the baby if needed, start-
ing/repairing the generator etc. I am prepared to bet that our perina-
tal/maternal mortality was not worse than these days even excluding the
HIV effect.
Most patients did not pay or peanuts. There was then, 20 years ago cer-
tainly the capacity to manage patients like these.
Now you say that this patient needs constant monitoring but from your
first e-mail of 18.12. when she is supposed to be 30 weeks it is clear
that her next appointment will be 7-1-1998. Is this part of this thor-
ough expensive monitoring "the continuos monitoring of the foetal de-
velopment" ?.
Yes it would be nice to do twice a week a CTG but foetal movements
monitoring and listening with a foetal stethoscope is also fine.
If the foetus is still alive 7-1-98 then it is 33/40 and has an excel-
lent chance if preterm labour occurs or other complications make deliv-
ery necessary. The baby will be around 2 kg then.
Vaginal examination is needed to decide if:
A. A vaginal delivery is possible for trial of labour most septae go to
the side at delivery.
B. Removal of septum is possible before labour (tie and cut on two
sides)
C. Elective Caesar at say 38 weeks is to be planned (in case of doubt
if the septum or the other uterus will interfere with labour or in
the case of a non-cephalic presentation).
At caesar (midline incision) it is important after opening the abdomen
to study the anatomy for a moment. Is the lower segment wide enough to
allow removal of the foetus or is a somewhat higher transverse incision
called for. A lower segment vertical incision (deLee incision) might
also be a good alternative.
Douwe Verkuyl MRCOG / Sandra Rutgers MD MPH
9 Chancellor Av, Kumalo, Bulawayo,
Zimbabwe
mailto:[email protected]
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