Challenges in operative obstetrics in rural areas

Challenges in Operative Obstetrics in Rural Areas

Dr. Shantanu Abhyankar

Wai

Satara

II मा�तृ� दे�वो� भवो IISaturday, April 15, 2023

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DR.SHANTANU ABHYANKAR

Rural practice is a subspeciality in itself…

• Low cost high risk practice.• One wo/man show.• You are forced to be alert, to be innovative, to be an electrician, a plumber, a nurse and a doctor all rolled into one

• Diploma in rural medical practice• Dip. M.P.R.P.S.

DR.SHANTANU ABHYANKAR

Tight rope walk

• Poor paramedical support • No health insurance• Shoestring budgets and packages• Monsoon economy

–Farmer suicides

OBSTETRICS IS BLOODY BUISNESS

OPERATING SANS BLOOD

Where the mind is without fear: and the head is held high,

Where blood is free,

Where blood comes from voluntary healthy donors,

Where blood has been broken up into fragments by the refrigerated centrifuge,

Where the clear stream of blood and blood products from the RBTC has found its way to the remotest storage centers,

Where tireless updating, CMEs & net surfing stretches its arms towards perfection,

Where blood banking is led forward by thee into ever widening network and action,

Into that heaven of rural blood banking my father let my country awake.

THINK OF AUTOLOUGUS

DONATION / TRANSFUSION

• ANY WOMEN WITH NO OTHER CONTRAINDICATION FOR DONATION & Hb OF 10+ & PCV 35%+ MAY DONATE BLOOD

THINK OF AUTOLOUGUS DONATION / TRANSFUSION

• ADVANTAGES– NO MISMATCH– NO TTD– NO GRAFT V/S HOST

REACTION– MEDICO LEGAL

SAFETY• RISKS

– CLERICAL ERRORS– SENSITIVITY TO

STABILISERS– CONTAMINATION

A FRESH LOOK AT SOME DEFINITIONS

HIGH RISK…IF

• DISTANCE FROM THE NEAREST BLOOD BANK,

• NEAREST COLLEAGUE• NEAREST REFERRAL

UNIT

IS MORE THAN AN HOUR , IN TERMS OF DURATION OF TRAVEL

EVERY CASE IS HIGH RISK

ALLWAYS ON ALERT

Always on alert

• Hb for all • and coagulation screen for all high risk cases• BT CT PC PT ARE LATE MARKERS• APTT TT FDP NOT AVAILABLE• ICTERUS MEANS DOOM• IF A CLOT FORMS AND DISSOLVES IT SPELLS DOOM

• RESPONSIBLE RELATIVE

Always on alert• Wide bore intracath in situ

Always on alert

• Callibrated drapes to measure loss

Always on alert• Active management of (all) stages of labor

• Consider Misoprostole P/R– No magic pill this– Takes 20 min– Not very useful for massive loss

Always on alert• Well equipped and well trained staff in the labor room• PPH box/equipment tray• PPH display charts• PPH drills

पी�.पी�.एच. झा�ले� मा�रा� बों बों ;हा�य रिरास्कच� करा� नों द.


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देया� हे�ड लो� , देया� लिलोथो� टॉ�मा�


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कॅ� थो�टॉर घा�लो� ब्लो�डरमाधी�


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सो�ळा� नं�बर इं�ट्रा�कॅ� थो , दे�न्हे� हे�तृ��नं� लो�वो� स्टॉ�टॉ


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घ्या� भरपू%र ब्लोड सो�म्पलो


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मागच सो)रु कॅर� रिंर,गरच� नंळा


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मासो�ज कॅर� , क्लो�टॉ कॅ�ढा�, टॉ�कॅ� घा�लो� झटॉपूटॉ


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रक्त सो�कॅळातृ�या कॅ� बघा� , नं�हे�तृर या�ईलो आफतृ.


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च�र ऍम्प्या%लो पू�टॉ�सो�नं ब�टॉलो7तृ टॉ�कॅ�


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इं�ज�क्शनं मा�थो�ज9नं आया.व्हे�. ठो�कॅ�


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देया� प्रो�स्टॉ�ड�नं मा��ड�माधी�


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आणि> च�र सो�याटॉ�टॉ�कॅ **माधी�


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ऑक्सिक्सोजनंच� चढावो� मा�स्कॅ


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पू�श�टॉलो� ठो� वो� गरमा खा�सो


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रक्त चढावो� , ड�कॅ� लोढावो� , रहे� सोदे� देक्ष...


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Always on alert• Well equipped and well staffed labor room• PPH box/equipment tray• PPH display charts• PPH drills

PPH BOX / TRAY

Always on alert• Well equipped and well staffed labor room• PPH box/equipment tray• PPH display charts• PPH drills

WHEN IT HAPPENS…

• ASSISTANTS AND COLLEAGUES MUST BE TUNED TO THE SITUATION

– LABOUR WARD DRILLS• RAISE AN ALARM 1

• LARGE BORE I/V ACCESS + BLOOD SAMPLES +2

• MASSAGE / UTEROTONICS (MDR) +1

• O2 BY MASK +1

• CATHETER

• HEADLOW

• EXAMINATION

PRE –OP PREPARATION• PLAN YOUR INCISION

– ABDOMINAL• MIDLINE VERTICAL FOR A CLASSICAL OPERATION• CONSIDER PREVIOUS SCARS

– UTERINE• PLACENTAL POSITION• VASCULARITY

PRE –OP PREPARATION• BLOOD & BLOOD PRODUCTS• AUTOLOGUS TRANSFUSION

– r Hu EPO IS NOW AVAILABLE– IATROGENIC POLYCYTHEMIA IS POSSIBLE

PRE –OP PREPARATION• MATURITY CHECK

– MORE IMPORTANT IF COMPLICATIONS HAVE SET IN LIKE GEST DM, PIH, IUGR– EARLY USG– L/S RATIO …. AMNIO…CHECK L BODIES– BUBBLE STABILITY TEST– PRE-TREATMENT WITH STEROIDS AND MgSO4

WHEN IT HAPPENS…• BACK UP POWER SUPPLY• BACK UP SUCTION MACHINE• HAVE STIRRUPS AVAILABLE SO THAT FROG LEG POSITION (MIND YOU, NOT LITHOTOMY) IS POSSIBLE

INTRA–OP • INCISION

– EXCESSIVE BLEEDING IS NOTED RIGHT FROM THE CUTANEOUS INCISION– USE CAUTERY

– USE A STAY SUTURE ON THE LOWER EDGE

INTRA–OP • APPROACH THROUGH THE PLACENTA?• OR PAST THE PLACENTA? (PREFFERED)

INTRA–OP • AORTIC PRESSURE• EXTERIORISE THE UTERUS• PACK TIGHT WITH ALL YOUR MIGHT WITH A HOT MOP• FOUR VESSEL LIGATION• CHECK• SOS IIL• SOS HYSTERECTOMY

INTRA–OP

• PROGRESSIVE DEVASCULARISATION– OVARIAN VESSELS

– UTERINES– INTERNAL ILIAC LIGATION

INTRA–OP • POSTERIOR PLACENTA

– BLEEDING BED• HOT MOPS & FIGURE OF EIGHT SUTURES

INTRA–OP • ANTERIOR PLACENTA

– BLEEDING ‘ROOF’• CIRCUMFERNTIAL SUTURES ALONG THE EDGES

INTRA–OP • B-LYNCH SUTURE• HAYMAN SUTURE

– VERTICAL AND HORIZONTAL CERVICO-ISTHUMIC SUTURES

• CHO MULTIPLE SQUARE SUTURES– HAVE DIAGRAMS IN

PPH KITS

INTRA–OP

• B-LYNCH SUTURE• HAYMAN SUTURE

– VERTICAL AND HORIZONTAL CERVICO-ISTHUMIC SUTURES

• CHO MULTIPLE SQUARE SUTURES– HAVE DIAGRAMS IN

PPH KITS

INTRA–OP • PLACENTA ACCRETA

– DIAGNOSIS• PRE OP• INTRA OP

– Wring the uterine neck and chop off the uterus

• LEAVING PLACENTA IN SITU– CLOSE MONITORING

INTRA–OP • OBSTETRIC HYSTERECTOMY

– SUBTOTAL MAY NOT SUFFICE– REMAIN INSIDE THE UTERINES

– CC CC SO TL– CLAMP-CUT; CLAMP-CUT …. SPECIMEN OUT… TRANSFIX & LIGATE

INTRA–OP • PACKING

– PELVIS; POST HYSTERECTOMY

BATTLING BLOOD LOSS SANS BLOOD.

• RESTORE AND MAINTAIN ADEQUATE BLOOD VOLUME.

• WRAP BOTTLES IN BP CUFFS & PUMP• CRYSTALLOIDS: THRICE THE ESTIMATED

BLOOD LOSS• COLLOIDS AND STARCH SOLUTIONS ONLY

LATER

BATTELING BLOOD LOSS SANS BLOOD

• OXYGEN, WARM BLANKETS,EVEN PLASTIC GOWNS AND…• WARM FLUIDS…USE MICROWAVE, PUT BOTTLES IN HOT WATER

• HEATLOSS ADDS TO SHOCK AND DIC

VENOUS ACSESS

• 14 OR 16 G INTRAVENOUS CANNULA• FEMORAL VEIN• SUBCLAVIAN• INT JUGULAR

– POST APPROACH– ANT APPROACH

• Keep diagrams on the notice boards

BATTELING BLOOD LOSS SANS BLOOD.

• MAINTAIN SUFFICIENT OXYGEN CARRYING CAPACITY. KEEP HER INTUBATED, IF NEED BE, TILL BLOOD IS AVAILABLE.• SECURE HEAMOSTASIS. AT TIMES OPERATING WITHOUT BLOOD IS SAFER THAN AWAITING BLOOD.

SOME PRACTICAL TIPS• CUT A BOTTLE OF NS AT IT’S BASE & KEEP JUST

100ml OF NS

• ADD 1000iu INJ HEPARIN

• POUR SALVAGED BLOOD THROUGH 6 LAYERED GAUSE

• MIX WELL

• INFUSE

PACK TIGHT WITH ALL YOUR MIGHT

OTHER THERAPIES• INTRA-OP CELL SALVAGE

• FACTOR VII

• SELECTIVE EMBOLISATION

RCOG GUIDELINES

DIAMOND POSITION

caaOkT PaaoJaIXana

Never change the brands of injectables, medicines, i/v fluids

etc:

remember you are dealing with persons wrapped in white saris and not ‘nurses’

A place for everything and everything in its place

RCOG GUIDELINES

• SYMPHISIOTOMY, O’SULLIVAN’S TECHNIQUE FOR INVERSION OF UTERUS… FORCEPS / CRANIOTOMY FOR AFTER COMING HEAD… GENUPECTORAL POSITION FOR PROLAPSED CORD… MANUAL ROTATION FOR POP… ARE FOR REAL!!!

RCOG GUIDELINES

• ENSURE THE AVAILABILITY OF AN ANESTHETIST & ONLY THEN DECLARE THE NEED FOR CS

RCOG GUIDELINES

• IF THE TABLE DOES NOT TILT SHOVE A BOTTLE OF SALINE UNDER THE MATTRESS BELOW THE RIGHT HIP

RCOG GUIDELINES

• SHIFT THE PATIENT OUT OF THE THEATER AS LATE AS POSSIBLE…

RCOG GUIDELINES

• AN OCCASIONAL UNINDICATED CS DOEN NOT AN AUDIT MAKE!!!!

• ERR ON THE SIDE OF TOO SOON RATHER THAN TOO LATE…

RCOG GUIDELINES

• THICK MSL… NO ANESTHETIST

• LLP• ATROPINE• AMNIOINFUSION

• OXYGEN, SODABICARD OF DOUBTFUL EFFICACY

RCOG GUIDELINES

• BICEPS & TRICEPS ARE AT TIMES SAFER THAN VACCUM & FORCEPS

• BEREADY TO USE THE MIDPELVIC APPLICATION

RCOG GUIDELINES

• YOU ARE A TIRTIARY LEVEL PHYSICIAN WORKING AT THE PRIMARY LEVEL

• YOU NEED TO BE MORE SKILLED THAN YOUR URBAN COLLEAGUE

• A JACK OF ALL AND A MASTER OF ALL

THANK YOU

• DR. VILAS PARAMANE• DR. VIDYADHAR GHOTAWDEKAR• DR. VINAY JOGALEKAR• DR. SHIVDE (LONAND)• DR. LATA PATIL• DR. ULKA POL

LAMELLAR BODIES INSTEAD OF L/S RATIO

• There is another factor to consider when addressing the relevance of FLM testing: due to improvements in gestational age dating, maternal administration of corticosteroids that accelerate fetal lung maturity in at-risk pregnancies, and exogenous surfactant replacement therapies, the number of newborn deaths due to RDS has continued to decline over the last 15 years. Interestingly, most laboratories have noted a decline in the number of FLM tests that they perform each year. This trend reflects the decreased use of the tests by obstetricians, many of whom indicate that the tests are no longer needed for patient care.1 When one considers these facts in light of the Bates study, it becomes legitimate—and provocative—to ask the question: “Are tests of fetal lung maturity obsolete?”

April 15, 2023 MATRU DEWO BHAVA

Challenges in operative obstetrics in rural areas

Health & Medicine

Transcript of Challenges in operative obstetrics in rural areas