There is currently insufficient knowledge on the effectiveness of individual obstetric first aid procedures and the contribution that first aid as a strategy may make on saving women's lives. The concept of obstetric first aid is given scant attention in current obstetric literature. A rapid search of the standard medical and nursing databases (Embase, Medline, Cinahl, Cochrane Library) since 1996 revealed only four articles specifically relevant to obstetric first aid. Some first aid procedures are described as part of emergency obstetric care, but as a distinct entity, its components are poorly defined. One reason for differentiating between emergency care and first aid is to encourage the generation of evidence for individual components of first line care. Evidence is available on the utility of procedures already included as standard emergency care, such as administration of oxytocics, anticonvulsants and antibiotics, some of which may also be used in first aid. Conversely, for a number of simpler procedures, such as nipple stimulation for treatment in acute postpartum haemorrhage1 and umbilical injection of oxytocics,2 evidence is limited or lacking (Table 1).
|Obstetric emergency||Basic procedures||Specific interventions|
|Postpartum haemorrhage||Bladder emptying||Manual compression of the aorta|
|Nipple stimulation||Internal uterine bimanual compression|
|External uterine massage||Parenteral oxytocics|
|Umbilical injection of oxytocics|
|Obstructed labour||Bladder emptying||Symphysiotomy|
|Disimpaction manoeuvres for shoulder dystocia|
First aid is different from other medical procedures in that it has a unique place as first line treatment—usually where there are no facilities, medical equipment or specialist professionals. For this reason, testing of the effectiveness of the components of first aid will need to take account of the circumstances in which the drug or procedure is proposed for use. In contrast to evidence on efficacy, the effectiveness of prostaglandin analogues in treatment of postpartum haemorrhage, for instance, may be different in community settings (or for first line treatment), compared with its use for emergency care in health facilities, with consequent implications on how the product is recommended for public health or clinical practice.2
As recommendations for emergency procedures change, a closer assessment of older and more established practices is warranted, so as to establish their place in first line obstetric care. Despite the evidence supporting magnesium sulphate as the drug of choice for emergency treatment of eclampsia within a health facility, it is less well known that diazepam is still recommended3 when magnesium sulphate is not available for example, in the community, in very basic health facilities, or where there is insufficient expertise present. If attention is not given to maintaining established and relatively effective procedures in appropriate circumstances, decline in practice of simpler procedures can result. This has occurred in the case of caesarean section in favour of symphysiotomy. A resurgence of interest has only recently been seen for the potential of symphysiotomy as a lifesaving procedure.4 By defining obstetric first aid as a distinct entity made up of certain components with a pre-determined function, it is more likely that effective but simple techniques can be maintained and used appropriately. It may also be possible to generate evidence on the value of first aid as a strategy suitable for difficult circumstances where health facilities and trained personnel are unavailable.
Although improving knowledge of obstetric first aid is only one of the many possible ways forward, it serves to illustrate a number of key issues related to the reduction of maternal mortality. The limitations imposed by poor infrastructure and few resources in many developing countries remain a reality for many. If we are to put what we know into practice, we need to take account of the context within which we work and apply existing knowledge selectively and appropriately. Research can play a role by generating evidence that is applicable to different situations, not ignoring those circumstances that present most difficulties. Too many of the poorest women live too remotely from hospitals, midwives and obstetricians, so solutions need to be found for what can be done when expertise and medical support is at its most basic.