Obstetrics and the general surgeon.

From a small Pacific island country of Tuvalu, an analysis of 132 obstetric and gynecologic patients operated upon by one general surgeon during a 20.5 month period from 1988 to 1989 was performed. The operations comprised 50 percent of all surgical procedures and were associated with complicated pregnancy and delivery in 48 percent of the patients, birth control and infertility in 34 percent and gynecologic neoplasms, infections and bleeding ex utero in 18 percent. There was no mortality and 11 patients had lesser complications. Of the 38 cesarean sections, 76 percent were emergency operations. The main indications for cesarean section were dystocia in 55 percent of the patients and previous cesarean section in 24 percent. There was no maternal mortality. The complication rate was 13 percent and included two neonatal deaths. The cesarean birth rate during the study period was 7.6 percent, a nearly fivefold increase from the previous 9.5 years. With other factors remaining unchanged, the increase in cesarean birth rate corresponded to a decrease in neonatal death rate from 35.7 to 15.7 per 1,000 live-born infants. It is concluded that a considerable share of work of a general surgeon in developing countries consists of obstetric and gynecologic procedures. This should be taken into consideration when training and recruiting surgeons for that kind of work. A general surgeon with obstetric experience can perform cesarean section with an acceptable morbidity rate and should not hesitate to do it whenever labor does not progress as expected. The decision to operate can be based on physical examination with close cooperation with the midwife. In developing countries, increasing cesarean birth rates alone seem to reduce considerably the neonatal death rates.