Obstetric aims and priorities

Mothers die from the diseases listed in the previous section. Between 5 and 10 per cent of their babies die in the perinatal period (from 28 weeks of pregnancy to 7 days after delivery). When they die in utero their deaths are often unexplained, but preventable causes include malaria, syphilis, and obstructed labour. Most perinatal deaths in Africa are of normally formed, normal weight babies who die avoidably from trauma, asphyxia, or infection. Many neonatal deaths occur in babies whose low birthweight is due to their being born too soon (prematurity), or to not having grown normally before birth (intrauterine growth retardation, or IUGR). The deaths of both mothers and babies are mostly due to the material and social conditions under which they live. Here we are concerned with the obstetric causes of their deaths.

Obstetrics differs from surgery in that there is no surgical equivalent of the midwife. This is because birth is usually sufficiently routine for most obstetrics to be done by non[nd]doctors, whereas all but the the most minor surgery has to be done by doctors. The surgery in these manuals is therefore for doctors. Obstetrics, on the other hand can be divided into: (1) The more difficult and less commonly needed procedures, which are normally only done by doctors, and which are assembled here. (2) The easier, common procedures which can be done by doctors, or by midwives. These are in the fourth volume in this series[md]Primary Mother Care, which is a manual of ''paramedical obstetrics and gynaecology', rather than traditional midwifery (In preparation 1989). The distinction between what only doctors can do, and what both doctors and midwives can do, is however somewhat arbitrary. There are, for example, some midwives and many medical assistants who can do a Caesarean section. The next few chapters and Primary Mother Care form a whole, so that unless you can refer to Primary Mother Care, what you read here will be incomplete. For example, you may wish to look up the selection of cases for hospital delivery (M 5.3), the management of normal labour (M 18.11), vacuum extraction (M 22.3), outlet forceps (M 22.6), or the closed method of symphysiotomy (M 22.7). Some conditions, such as postpartum haemorrhage, are managed differently by a midwife in a clinic and by a doctor in a hospital, so these are described twice, but from different perspectives. Primary Mother Care describes methods of terminating pregnancy early, including menstrual regulation. Following the wishes of one of our contributors we have not included methods of termination later in pregnancy here.

THE NEXT FEW CHAPTERS ARE NOT COMPLETE WITHOUT ''PRIMARY MOTHER CARE' Despite the challenges of pregnancy and childbirth, the most important task in many communities is to reduce the frequency with which pregnancy occurs. The priority of priorities is likely to be a national population policy[md]most countries in sub-Saharan Africa don't yet have one. Populations there, and to a lesser extent those elsewhere, are growing so fast that they are causing acute pressure on land, on food, on the wood to cook it with, on jobs, on education, and on the health and other social services. In some areas this population pressure is already finding its expression in desertification and starvation, in abject poverty and in civil disorder. Your own community may not have reached this point yet, but is it already exerting such pressure on its environment that ''ecological collapse' is not far away? If it occurs your community may become ''ecological refugees', if indeed there is anywhere to flee to. If birth rates don't fall, death rates may rise to their old values or higher, with a much larger population in a much impoverished environment (''the demographic trap'). Part of the answer is to make sure that family planning services are available at all health units. Many families who would like to use them still don't have access to them.

Because so much obstetrics has to be delegated, the instruction and supervision of those to whom you delegate it is critical. Some mothers will be delivered in hospital, and some by midwives in health centres. Most of them will probably be delivered at home, attended either by their families, or by traditional birth attendants (TBAs), such as the dais of India. One way to reduce the maternal and perinatal mortality in your district may therefor be to start with the TBAs, to concern yourself with what they do, and to retrain them where you can. If a specialist group of TBAs are at work in your area, each of whom delivers several mothers every year, try to run retraining courses for them.

Fig. 15-2 SOME OF THE EQUIPMENT you will need. STETHOSCOPE fetal, plastic, three only. These don't bend so easily as aluminium stethoscopes.

DOPPLER FETAL HEART DETECTOR, ''Sonicaid' pattern or equivalent, one only. This is comparatively inexpensive (about $250) and very useful.

SPECULUM, vaginal, Sims', double-ended, medium size, 27[mu]30 mm, three only. This is the most generally useful vaginal speculum.

SPECULUM, vaginal, Cusco's, duckbill, small and large, stainless steel, three of each size only. These specula open like the beak of a duck, and in doing so enable you to examine the cervix.

SPECULUM, vaginal, weighted, Auvard's, chromium-plated, one only. The weight on this speculum presses it downwards, and so keeps the vagina open.

FORCEPS, uterine vulsellum, curved, 1[mu]2 teeth and 3[mu]4 teeth, box joint, 230 mm, one only of each size. Use these to grasp the non[nd]pregnant cervix when you curette it. In pregnancy, ring (sponge) forceps are better.

SOUND, uterine, malleable, metric, graduated shaft, two only. Use this to measure the depth of the uterus before inserting dilators. A sound is a dangerous instrument in a pregnant uterus, because you can easily perforate it.

DILATORS, cervix, double-ended, Hegar's, 222 mm, set of 12 sizes, 1/2 mm to 23/24 mm, one, or preferably two sets only. Use these to dilate the cervix before curetting it. You are likely to have several patients needing dilatation and curettage on the same list, so two sets of dilators will be useful.

MANIPULATOR, uterine, one only. Use this to bring the uterine fundus up against the abdominal wall when you do a minilaparotomy.

FORCEPS, ovum, curved, screw joint, McClintock 250 mm, one only. Use this to remove the products of conception from an incomplete abortion, after you have dilated the cervix. If you don't have them, use sponge-holding forceps.

CURETTE, uterine, double-ended, blunt and sharp, 8 mm and 5 mm, two only of each size. The great danger with a curette is that you may push it through the wall of the uterus, especially a pregnant uterus. Opinions differ as to whether a blunt curette is more dangerous than a sharp one. Let a curette lie gently in your fingers, so that you can ''feel' the wall of the uterus[md]don't grasp it firmly.

CURETTE, suction, stainless steel, reusable, sizes 8 and 10 Hegar, one only of each size. Use this for evacuating moles (it causes much less bleeding than dilatation and curettage), and for terminating a pregnancy which has lasted less than 12 weeks.

CURETTE AND SYRINGE for menstrual regulation, sterile, plastic, disposable, five hundred only. You will only need these if you intend to introduce menstrual regulation as part of your family planning activities.

CATHETER, Drew[nd]Smythe, one only. This is useful for rupturing the membranes if the head is high, especially if there is polyhydramnios, to control the gush of fluid and to prevent prolapse of the cord (19.13).

CANNULA, cervical, Leech Wilkinson or Miller, one only. This is for doing a salpingogram.

SCISSORS, episiotomy, Vant, one only. These have straight blades and round points.

VACUUM EXTRACTOR, Bird's modification of Malmstrom's, complete with 3 suction cups 40, 50, 60 mm, one posterior cup, traction handle, vacuum hand pump, chain, spare vacuum bottle and spare baskets, one only. Bird's modification is better than the original Malmstrom extractor, and is quicker and easier to assemble. The anterior and posterior cups are not really necessary. Some workers advise the 50 mm cup only.

FORCEPS, outlet, Wrigley, one only. Outlet forceps are the only safe ones for anyone but an experienced obstetrician.

FORCEPS, obstetric, Neville Barnes, one only. You will need these for the aftercoming head of a breech delivery, for which Wrigley's forceps do not have long enough handles. For the uses and dangers of forceps, see Section 18.1.

FORCEPS, haemostatic, straight, Green-Armytage, 203 mm, six only. Optional. Use these for clamping the cut edges of the uterus during a Caesarean section, and for repairing a ruptured uterus.

BREECH HOOK and CROTCHET combined, one only. Use this to deliver a dead baby presenting by his breech.

PERFORATOR, Simpson's, one only. This is the standard instrument for opening the skull when doing a destructive operation.

RETRACTOR, Doyen's, one only. Use this for Caesarean section, it has a curved lip which fits over the lower end of the wound and keeps the bladder out of the way of the operation.

RETRACTOR, Kirschner, one only. This gives an excellent exposure for laparotomy, with a good view for operating in the pelvis.

SCISSORS, embryotomy, Queen Charlotte's pattern, one only. These scissors were specifically designed for destructive operations.

SAW, decapitation, Blond[nd]Heidler, complete with ring, thimble and blades, one only. Use this for decapitating a dead baby when labour is obstructed by a transverse lie. It is a piece of wire with teeth on it, hooks at each end to fit handles, and pieces of tubing to prevent it from cutting his mother. It also has a thimble you can push round his neck to fix the saw to. Alternatively, you can use large scissors, preferably the embryotomy scissors described above.