The Rebel Surgeon's personal experience from working in remote facilities with limited resources
Author: The Rebel Surgeon
Danish Surgeon/Orthopedic with large experience from working in remote areas with limited resources.
Known to the public as "The Rebel Surgeon" after the documentary with same title
Do not intervene before the lower part of the body has been delivered unless the heartbeat slows down critically
As soon as the lower part of the body has been delivered palpate the umbilical cord for pulsations.
If feeble or absent proceed urgently with EXTRACTION OFBREECH
Let body be delivered spontaneously
Let arms be delivered spontaneously
Leave body hanging by the head for a short moment (Burn-Marshall maneuver)
Grasp both feet from the front with a forked finger grip
Lift the body vertically by both feet
Let the head be delivered spontanesously (Bratt’s procedure)
ASSISTED BREECH DELIVERY
Be prepared
for a retained caput!
Catheterize the bladder.
Leave the catheter indwelling
Place the patient with legs in stirrups
Buttocks hanging free of the table
Infiltrate the pubic area with local anesthesia
Have the following items at hand:
Large vaginal speculum
Delivery Forceps
Scalpel
Heavy scissors
Check fetal heart rate continuously
Do not intervene before the lower part of the body has been delivered
Unless fetal heartbeats slow down critically
As soon as the lower part of the body has been delivered palpate the umbilical cord for pulsations.
If feeble or absent proceed urgently with EXTRACTION OFBREECH
Release the posteriorly positioned arm first
Use left hand when the back is turned to the (mother’s) right
And vice versa
Place left thumb on the frontal aspect of the truncus
Left index and middle fingers on the back
Slide hand inwards
Along the truncus
Until the thumb reaches the axilla
With a sweeping movement
Across the head
Bring the arm down
With index and middle fingers
Change hands
Release the anteriorly positioned arm
Using same technique
Check fetal heartbeats
Check puls in umbillical cord
Posterior arm release
Anterior arm release
In case the anteriorly positioned arm is difficult to release, rotate the truncus 180 ° bringing the arm to a posterior position and release /as described above
Leave the body hanging free for a short moment to facilitate the descent of the head in the birth canal. (Burn-Marshall maneuver)
Burn-Marshall maneuver
Deliver the head by Mauriceau-Levret’s maneuver:
Introduce index finger in the mouth
Flex the head with the index in the mouth
Apply traction with a forked finger grip posteriorly to the neck with the other hand
Apply fundal pressure by assistant
Fundal pressure
Forked fingergrip
Index in mouth
Assisted Breech Delivery
EXTRACTION OF BREECH
In case of fetal distress do a fast extraction:
Grasp one foot / both feets
Use forked finger grip with heel(s) in the palm of the hand
Grasp knee(s) with other hand
Apply strong traction
Combine with exaggerated pumping movements
Release arms
Perform Burn-Marshall’s procedure
Deliver head by Mauriceau-Levret’s maneuver
Extraction of Breech
RETAINED HEAD/ FETUS ALIVE
Be prepared!
Make a generous episiotomy. That might solve the problem by itself.
If needed to buy time:
Have an assistant lift the body vertically by the feet
Place large speculum posteriorly in the vagina.
Apply downward traction on the speculum
This will keep the airway free and accessible for suction.
Make a symphysiotomy:
Push the catheterized urethra to the side with two fingers in the vagina
Cut through the symphysis strictly in the midline with a scalpel
Cut until the pubic bones separate and you can feel the gap
Deliver the head with Mauriceau-Levret’s maneuver
Symfysiotomy in Breech
RETAINED HEAD DUE TO HYDROCEPHALUS
If not detected by previous palpation and/or
ultrasound, the diagnosis will come into light when a myelomeningocele becomes
visible as the lower part of the body is being delivered.
Puncture the hydrocephalic head suprapubically with a large bore needle
Drain the cerebrospinal fluid
Deliver the collapsed head by Mauriceau-Levret’s maneuver
Puncture and drainage of the head does not harm the child
Suprapubic Puncture and Drainage of Hydrocephalic Head
RETAINED HEAD / FETUS DEAD
Craniotomy
Apply firm traction on the neck
Perforate the back of the skull in the occipital area.
Be sure to perforate the skull. Not the upper part of the cervical spine.
Open the shanks of the perforating instrument
Destruct all intracranial septa.
Perform Mauriceau-Levret’s maneuver as follows:
Introduce index finger in the mouth
Flex the head with the index finger
Apply traction to the neck with a forked finger grip to the back of then neck
Extract the head by traction on the neck
Proceed slowly
Allow time for the head to collapse
Craniotomy in Breech
Occasionally attempts to extract the head by forceful traction to the neck have been attempted. The result may be a fractured spine with an elongated neck. When applying further traction to the neck the head will inevitably separate from the trunk.
Separation of head and trunk also occurs if you by mistake perforate the upper part of the spine instead of the skull.
In case of such a scenario:
Remove the body
Extract the head from uterus with a finger in the mouth and the fractured spine in the palm of your hand
Small transverse incision strictly in the midline throuigh the subcutaneous tissue and fascia
Split the fascia by sliding a pair of slightly opened scissors transversely to the right and left.
That will spare the subcutaneous vessels avoiding unnecessary bleeding
Stretch the wound manually in a vertical direction
Open the peritoneum bluntly with your fingers
Stretch the wound further by manual traction in a transverse direction
Place a retractor distally in the wound
Apply downward traction to the retractor by assistant
Small transverse incision in the upper part of the lower segment of the uterus
Maintain a safe distance away from the bladder.
The more the lower segment is stretched, the higher the incision should be
3 to 5 fingers above the bladder.
Do not incise the bladder peritoneum and push down the bladder to make the incision low in the lower segment as described in many textbooks. That’s a recipe for troublesome vaginal tears.
Stretch the uterine incision manually in a transverse direction
Apply fundal pressure by assistant
Lift out the presenting part with
One hand
Sellheim’s Obstetrical Lever
One blade of pair of ordinary obstetrical forceps
Deliver the baby
Clamp and cut the umbilical cord
Lift out uterus from the abdominal cavity
Squeeze out placenta by fundal pressure
Or remove it by hand from the uterine cavity
Close the incision in the lower segment with a continuous inverting suture from one corner of the incision to the other.
Use resorbable suture such as Chromic Catgut or Polyglycolic Acid.
One layer is enough.
Remove blood from the abdominal cavity
Return uterus into the abdomen
Close the fascia with a continuous suture
Close the skin
Sellheim’s obstetrical lever
Cesarean Sectio
CHALLENGES WITH CESAREAN SECTIO
FULL BLADDER
Empty bladder by suprapubic puncture
Full Bladder in C/S
DEEPLY IMPACTED HEAD
There are two options:
Have an assistant push the head from below with a hand in vagina
Pushing Impacted Head from Below
2) Perform internal version and extraction on a foot through the uterine incision
C/S with Internal Version
LATERAL TEARS OF THE UTERINE INCISION
Close the wound with two continuous sutures
Start suturing separately in each corner
Tie the sutures together in the midline
BLEEDING FROM
UTERINE ARTERY
Clamp the artery above and below the bleeding point
Apply suture-ligation
Bleeding from Uterine Artery
MYOMA
Make the uterine incision in a convenient place
Avoid the myoma(s) in the incision
Do not try to shell out or remove the myoma(s)
It may cause torrential and fatal bleeding.
Myoma in C/S
HIV POSITIVE PATIENT:
Use protection
Give prophylactic medication before surgery
ABDOMINAL PACK
Be sure to remove all abdominal packs before wound closure
In intrauterine fetal death (IUFD) do not perform C/S.
Severe maternal infection with fatal sepsis is a substantial risk.
Deliver vaginally
By destructive delivery if needed
INSTRUMENTS
From left to right: Basiotribe – Perforator – Heavy scissors – Delivery hook
CEPHALIC PRESENTATION
CRANIOTOMY
Perforate the skull with perforator or a pair of heavy scissors
In face presentations use an eye as entry point
Open the shanks of the perforator
Break all intracranial septa
Apply the basiotribe with the solid leg inside and fenestrated leg outside of the skull
Be careful not to catch part of cervix or vagina in the grip
Tighten grip as much as possible
Extract the fetus.
Do this slowly
Allow time for the head to collapse.
In lack of a basiotribe use:
Ordinary delivery forceps
Several heavy toothed clamps
Remove the placenta manually
Check with a hand in the uterine cavity for rupture
Craniotomy I
Craniotomy II
RETAINED HEAD in BREECH
CRANIOTOMY
Apply firm traction on the neck
Perforate the back of the skull in occipital area
Be sure to perforate the skull
Do not the perforate upper part of the cervical spine
Open the shanks of the perforating instrument
Destruct all intracranial septa
Deliver head by Mauriceau-Levret’s maneuver
Introduce index finger into the mouth
Flex the head with index finger
Apply traction to the neck with a forked finger grip applied to the back of the neck
Extract the head by traction on the neck
Proceed slowly to allow time for the head to collapse
Craniotomy in Breech
SEPARATION OF HEAD FROM NECK
Attempts to extract the head by forcefull traction may result in a fractured spine with an elongated neck. Further traction will separate the head from the trunk.
Separation of head may also occur if you by mistake perforate the upper part of the spine
In case of
such a scenario:
Remove the body
Extract the head from the uterus
With a finger in the mouth
The fractured spine in the palm of your hand
Retained Head Separated from the Neck
COMPOUND TRANSVERSE PRESENTATION (transverse presentation with prolapsed arm)
There are two scenarios:
I.YOUR FINGERS CAN REACH AROUND THE NECK
DECAPITATON
Apply the delivery hook around neck
Fracture the cervical spine forcefully with the hook
Apply traction to the prolapsed arm by assistant
Cut the neck with
Scalpel or
Heavy scissors
Deliver the body by traction to the arm
Extract the head from the uterus
With a finger in the mouth
Fractured spine in the palm of your hand
Remove placenta
Manually assess the uterine cavity for rupture
Decapitation in Compound Transverse Presentation
II. YOUR FINGERS CAN NOT REACHED AROUND THE NECK
EXVISCERATION
Apply traction to the prolapsed arm by assistant
Perforate abdomen / thorax
Insert a hand into the abdominal / thoracic cavity
Remove all internal organs from abdomen / thorax
Grasp one or both feet
Perform internal version and extraction
If unsuccessfull
Fracture the spine with the delivery hook
Cut the body in two parts
Deliver the body parts separately with traction on foot or arm
OBSTETRICS 