Abstract
Males and females are affected differently by natural disasters due to biologic, social, cultural, and reproductive health differences. Out of the female population, 25% are in the reproductive stage of their lives (age 15–45) and 20% of them are pregnant. While as many as 10% of natural disaster victims seeking medical assistance may need an obstetrician or gynecologist, these needs are not usually given high selection priority, whereupon rescue teams are likely to lack those essential specialists. The chapter gives clinical guidelines for managing labor in field hospital settings and dealing with ethical issues arising from treating pregnant women in disaster areas. Based on the literature and the authors’ experience, this chapter covers the effects of a disaster on women’s health in general and especially on pregnant women. The recommendation for the obstetric/gynecologic team composition, the medications and medical equipment needs, and how to arrange an Ob/Gyn department in a field hospital are given. The chapter gives clinical guidelines for managing labor in field hospital settings and dealing with ethical issues arising from treating pregnant women in disaster areas.
The chapter lists the recommendations on prevention and management of the consequences of sexual violence, reduction of HIV transmission, prevention of excess maternal and neonatal mortality and morbidity, and planning of comprehensive reproductive health services in the early days and weeks of an emergency.
Introduction
A field hospital can be deployed in many different scenarios. The needs are different in different scenarios and the field-hospital design should be modular, flexible, and “tailored” to meet the specific needs of the current mission.
Nevertheless, the inclusion of an obstetrics and gynecology team in a humanitarian mission will serve a crucial role in saving lives, bringing new lives to the disaster area, giving some comfort and hope for a better future to the affected population, and as a source of comfort to the field hospital staff.
Several studies have shown that males and females are affected differently by natural disasters due to biologic, social, cultural, and reproductive health differences. The average female:male death ratio is 3:1 in natural disaster areas[1]; 75% of most refugee populations are women and children including 30% adolescents. Out of the female population, 25% are in the reproductive stage of their lives (age 15–45) and 20% of them are pregnant[2,3]. While as many as 10% of natural-disaster victims seeking medical assistance may need an obstetrician or gynecologist[4], these needs are not usually given high selection priority[5], whereupon rescue teams are likely to lack those essential specialists.
In developing countries, it is customary for women with uncomplicated pregnancies not to seek medical support and to deliver without the aid of formal medical facilities; in Haiti, for example, only 25% of the deliveries are performed in medical institutions or under some other formal medical care. It is therefore not surprising that a field hospital with a gynecological team quickly becomes a referral center for other medical teams in the affected area, and approximately 50% of the cases the Israel Defense Forces (IDF) hospital gynecological team encountered in Haiti were complicated deliveries[6]. All these facts strengthen the need for experienced obstetrics and gynecology personnel to be included in international rescue team efforts and the need to ensure that they are provided with the necessary supplies to perform both routine and difficult deliveries.
The Effect of Earthquakes on Pregnancy Outcomes
An increase in miscarriages, premature deliveries, intrauterine growth restriction, and low birth weight infants has been reported following natural disasters[7]. Furthermore, increased seismic activity may increase delivery rate and preterm births up to 48 hours following an earthquake. A significantly higher rate of premature births was reported over a seven-month period in the wake of the 2007 earthquake in Japan[8].
Tan and colleagues compared 6638 pre-earthquake and 6365 post-earthquake newborns after a major earthquake in Wenchuan, China, in 2008. Those authors reported lower birth weights and low Apgar scores in the post-earthquake group. The ratio of preterm birth post-earthquake (7.41%) to pre-earthquake (5.63%) was statistically significant[9]. It is therefore not surprising that 5 of 16 (31.25%) deliveries at the IDF hospital in Haiti were preterm, compared to the much lower reported preterm delivery rate of 14.1% (WHO report)[10]. Tocolytic treatment, steroids (for lung maturity), specific antibiotics, and neonatal intensive care units (NICUs) should be included as part of the disaster rescue team’s equipment to treat preterm deliveries.
Psychological Aspects of Earthquakes on Pregnant Women
Depression and post-traumatic stress disorder (PTSD) have been reported[11,12]. These could be related to the psychological burden imposed by the natural disaster forced displacement. In their systematic review, Harville and colleagues concluded that disasters of various types could impact maternal mental health, and that these mental-health issues need to be addressed either by psychologists if present or otherwise by the obstetrics and gynecology team[13].
The Obstetrics and Gynecology Team
Personnel
The composition of the team should be determined by the nature of the expected work at the disaster site.
Most of the surgeries performed in a field hospital, which is usually operational at the disaster area 80–120 hours after the earthquake, are orthopedic, and usually are semielective in nature and will occupy most of the operating room time. Conversely, the majority of cesarean sections in a disaster area will be urgent (the indications for cesarean sections will be discussed later in this chapter), resulting in the need to perform them independently. Therefore, our recommendation is to include at least two well-trained gynecologists, but preferably three, along with one midwife and three nurses.
The Facility (figs. 20.1, 20.2, 20.3)
The Ob/Gyn domain should include a triage area, a hospitalization area, and a labor and delivery room; usually in three connected tents or rooms with an offered total dimension of 5–6 × 12 m (60–72 m2).
The triage and an examination tent/area (5–6 m × 3 m) should be equipped with a reception desk and a computer, a gynecological examination chair, and portable ultrasound.
The short-stay area should have room for 6–8 beds and cribs for postpartum/postsurgery patients (5–6 m over 6 m).
The labor and delivery tent/room (5–6 m over 3 m) should be equipped with a gynecological chair and a cardiotocograph (a fetal heartrate monitor and uterine contractions monitor), a newborn warmer, and all the equipment needed for the anesthesiologist to perform an epidural or spinal analgesia for vaginal delivery or cesarean sections. One should bear in mind that a cesarean section could be performed in this room if an emergency surgery is indicated and the operating room (OR) is occupied.
Figure 20.1 Obstetric ward layout
Emergency Medical Team (EMT) Type 2: Inpatient Surgical Emergency Care
These teams have staff to provide inpatient acute care, and to perform general and obstetric surgery for trauma and other major conditions.
Figure 20.2 Labor and delivery tent
Figure 20.3 Monitoring active labor in hospitalization tent
The team can perform a cesarean section, but the surgery is often performed by a general surgeon and not by Ob/Gyn specialists.
The nurses are ICU nurses and midwives are lacking. To allow at least some basic obstetrical care abilities, a type 2 EMT should include a surgeon who can perform a cesarean section and dilatation and curettage (D&C), and a nurse that can manage a vaginal delivery (preferably a midwife).
Those teams should have sets of surgical instruments for at least one cesarean section and one D&C.
Moreover, since these teams lack the ability to treat premature neonates, pregnant women with suspected preterm labor when the fetal estimated birth weight is less than 2000 g should not be treated in a type 2 EMT and should be transferred to a local hospital or to EMTs that have NICU capabilities.
Predeployment Planning
There are several major differences in patient management between a field hospital and a conventional facility:
1. Scarce resources limit the access to the OR and monitors
2. Lack of adequate hygienic environment may increase risk of infection
3. Limited number of hospitalization beds (shortens the stay after labor and surgery)
4. Many patients have no home to go back to, and forced to stay out on the street to recover
5. Lack of continuous medical follow-up
Cesarean section indications and considerations will differ from the typical paradigm and force the team to perform a cesarean section only when it is absolutely necessary.
1. Breech presentation: fetuses with expected birth weight 3700 g or less are to be delivered vaginally (provided there is a trained physician)
2. Intermittent fetal heart rate (FHR) monitoring: with only one FHR monitor, monitoring has to be carried out intermittently, with a higher tolerance to variable deceleration leading to a cesarean section
3. Managing the delivery according to the wellbeing of the woman and fetus and not strictly according to Freidman’s curve, allowing women more time to deliver to avoid an unnecessary cesarean section as long as the FHR is normal
4. Ability to perform a cesarean section in the delivery room due to fact that all the cesarean sections are urgent and the OR may be unavailable due to the severe overload of trauma patients
5. Women after cesarean section should stay in the field hospital for three days
Predeployment Planning: Normal Vaginal Delivery
1. Managing the labor up to full dilation in the short-stay tent, preserving the delivery room for urgent cases that might appear without any notice
2. Early discharge: due to lack of sufficient beds, patients often need to be discharged prematurely; women after normal vaginal delivery should stay in the field hospital 6–8 hours or overnight
3. Intermittent FHR monitoring
The IDF Experience in the Field Hospital in Haiti
A total of 24 pregnant women sought medical care; none of whom had received routine prenatal care. There were 16 deliveries: 13 were vaginal births (including two twin deliveries) and three were cesarean sections. All the cesarean sections were performed in the delivery tent since the OR tent was occupied with other emergency surgeries. All three caesarian sections were urgent.
The first case was a case of premature rapture of membranes with umbilical cord prolapse. The second was a case of eclampsia and late decelerations on fetal monitoring, which necessitated an emergency cesarean section. The third case was a case of dying fetus with severe bradycardia and an estimated fetal weight of 980 g. He suffered severe fetal distress and died 15 minutes after birth.
Of the 16 delivered women, 8 (50%) had preeclampsia. There were 5 (31.25%) preterm deliveries at 30–32 weeks’ gestation, and the newborns weighed between 980 g and 1700 g. There were two manual removals of the placenta.
The team also provided routine prenatal and gynecological care; the latter included two urgent gynecological procedures, vaginal-wall repair after pelvic fracture, D&C for severe perimenopausal bleeding, and 2 D&Cs for missed abortion.
In the second week of deployment, routine pregnancy follow-up care was provided, and minor gynecological problems were treated.
Related posts:
Chapter 6 – Training and Accreditation
Chapter 3 – Definitions, Needs, Scenarios, Functional Concept, and Modes of Deployment
Chapter 11 – Auxiliary Medical Services in a Field Hospital
Chapter 7 – Personnel
Chapter 18 – Orthopedics in a Field Hospital
Chapter 25 – Infectious Diseases and Public Health in a Field Hospital
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