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      Think Globally Act Locally: The Case for Symphysiotomy

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      Publication date (Electronic):
      Journal: PLoS Medicine
      Publisher: Public Library of Science

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          Abstract

          When expatriate doctors from developed countries working in sub-Saharan Africa suggest to the local doctors and midwives that symphysiotomies should sometimes be done, they are silenced neither with quotations from the medical literature nor with tales of patients seen, but with: “If symphysiotomies are such good operations why don't you perform them at home?” Here is why.

          Abstract

          Although symphysiotomy is rarely taught to trainee obstetricians, the operation can benefit women in obstructed labour, and their offspring, argues Verkuyl.

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          Maternal morbidity associated with multiple repeat cesarean deliveries.

          Robert M Silver, Mark Landon, Dwight J Rouse … (2006)
          Although repeat cesarean deliveries often are associated with serious morbidity, they account for only a portion of abdominal deliveries and are overlooked when evaluating morbidity. Our objective was to estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries. Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002). There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively. Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery. II-2.
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            Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group.

            E Hodnett, David Hannah, S Hewson … (2000)
            For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies. At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat. Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0.0001). There were no differences between groups in terms of maternal mortality or serious maternal morbidity (41 of 1041 [3.9%] vs 33 of 1042 [3.2%]; 1.24 [0.79-1.95]; p=0.35). Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.
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              Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999-2002.

              Linda Bartlett, Shairose Mawji, Sara Whitehead … (2015)
              Maternal mortality in Afghanistan is uniformly identified as an issue of primary public-health importance. To guide the implementation of reproductive-health services, we examined the numbers, causes, and preventable factors for maternal deaths among women in four districts. We did a retrospective cohort study of women of reproductive age (15-49 years) who died between March 21, 1999, and March 21, 2002, in four selected districts in four provinces: Kabul city, Kabul province (urban); Alisheng district, Laghman province (semirural); Maywand, Kandahar province (rural); and Ragh, Badakshan province (rural, most remote). Deaths among women of reproductive age were identified through a survey of all households in randomly selected villages and investigated through verbal-autopsy interviews of family members. In a population of 90 816, 357 women of reproductive age died; 154 deaths were related to complications during pregnancy, childbirth, or the puerperal period. Most maternal deaths were caused by ante-partum haemorrhage, except in Ragh, where a greater proportion of women died of obstructed labour. All measures of maternal risk were high, especially in the more remote areas; the maternal mortality ratio (per 100,000 livebirths) was 418 (235-602) in Kabul, 774 (433-1115) in Alisheng, 2182 (1451-2913) in Maywand, and 6507 (5026-7988) in Ragh. In the two rural sites, no woman who died was assisted by a skilled birth attendant. Maternal mortality in Afghanistan is high and becomes significantly greater with increasing remoteness. Deaths could be averted if complications were prevented through optimisation of general health status and if complications that occurred were treated to reduce their severity--efforts that require a multisectoral approach to increase availability and accessibility of health care.
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                Author and article information

                Journal
                Journal ID (nlm-ta): PLoS Med
                Journal ID (publisher-id): pmed
                Title: PLoS Medicine
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Print): 1549-1277
                ISSN (Electronic): 1549-1676
                Publication date (Print): March 2007
                Publication date (Electronic): 27 March 2007
                Volume: 4
                Issue: 3
                Electronic Location Identifier: e71
                Article
                Publisher ID: 06-PLME-ES-0392R2
                DOI: 10.1371/journal.pmed.0040071
                PMC ID: 1831724
                PubMed ID: 17388656
                SO-VID: 3d98115b-cd9c-42b8-9748-7d1a90ac0644
                Copyright © Copyright: © 2007 Douwe Arie Anne Verkuyl. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                History
                Page count
                Pages: 6
                Categories
                Subject: Essay
                Subject: Critical Care and Emergency Medicine
                Subject: Non-Clinical Medicine
                Subject: Non-Clinical Medicine
                Subject: Obstetrics
                Subject: Pediatrics and Child Health
                Subject: Pediatrics and Child Health
                Subject: Public Health and Epidemiology
                Subject: Public Health and Epidemiology
                Subject: Women's Health
                Subject: Obstetrics
                Subject: Neonates
                Subject: Women's Health
                Subject: Pregnancy
                Subject: Medicine in Developing Countries
                Custom metadata
                citation Verkuyl DAA (2007) Think globally act locally: The case for symphysiotomy. PLoS Med 4(3): e71. doi: 10.1371/journal.pmed.0040071

                ScienceOpen disciplines: Medicine
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                ScienceOpen disciplines: Medicine

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