Re: Warraich Q, Esen U. 2009. Perimortem caesarean section. Journal of Obstetrics and Gynaecology 29:690–693

Dear Sir,

After reading the interesting and fascinating review by Warraich and Esen (2009), I did a search on this topic on PubMed, with the search terms ‘perimortem caesarean section’ and ‘Nigeria’. I found no results and would now like to share my own experience as a general practice obstetrician with more than 12 years' extensive experience in rural obstetrics in Nigeria (West Africa) and Mozambique (Southern Africa).

Most rural and peripheral health facilities in Nigeria and Mozambique lack basic maternal and fetal resuscitative equipment in the emergency room for adequate management of cardiac arrest, cerebrovascular accidents or pulmonary embolism in pregnancy, which in my experience is rare or never reach the hospital in rural sub-Saharan African countries. Also, because of the lack of sophisticated equipment, even in the specialist and tertiary hospitals in both countries, the idea of a scheduled caesarean section in a brain-dead woman or in a woman in a persistent vegetative state, as stated in Warraich and Esen's paper, may not arise in these countries.

The indications for perimortem caesarean section (PCS), as outlined in the review, are different from rural practice in sub-Saharan Africa. I have performed PCS on three patients. The first patient had severe haemorrhagic shock (from a ruptured spleen) following a road traffic accident. She was 36 weeks' pregnant, was near-dead on arrival and there was no immediate emergency blood transfusion available. In the failed attempt to keep her alive and prepare for surgery, a PCS had to be done to save the fetus, since maternal survival could not be guaranteed.

The second case was a full-term pregnant teenager who was crippled by poliomyelitis and with a contracted pelvis. She never had any antenatal care, was brought in after eclamptic convulsions at home, with generalised oedema, severe anaemia, severe proteinuria and high blood pressure. She had not made urine for about 10 days. The baby was alive but in distress. In my opinion, the patient was in a near-dead state. The nearest specialist hospital was about 4–5 hours by bumpy road and the family was unable to pay for the transportation. In addition, the hospital had no ambulance to convey her to the hospital for the specialist care of her renal complications. A PCS was therefore performed to save the baby, since the mother could not be saved.

The third case was a woman who had her upper arms and face blown off by landmines, while picking up farm produce in northern Mozambique. She was 36 weeks' pregnant with severe trauma to the head and neck and skull fracture, exposed brain tissues and leaking cerebrospinal fluid. She was clinically brain-dead but the fetus was alive. Transportation to Maputo, the capital of Mozambique, for specialist care is a 3-day journey by road, or 2 hours by air. A PCS was done to save the baby because, as previously stated, the mother could not be saved.

These three cases show the dilemma general practice obstetricians face in rural practice in sub-Saharan Africa, where there are rarely any practicing specialist obstetricians. As noted, PCS often results in high mortality for mother and or fetus and is a crisis for the healthcare professional managing such cases (Warraich and Esen 2009). In the cases presented, all the mothers died but the babies were alive because of the quick decision to perform a PCS, since the women's chances of survival were zero to minimal in this part of the world. Is it therefore justified to use the term ‘premortem’ caesarean section in rural practice in sub-Saharan Africa?

Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.