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TABLE OF CONTENTS
CONSENSUS STATEMENTS FROM THE 15TH CONFERENCE ON PRIORITIES IN PERINATAL CARE IN
SOUTHERN AFRICA........................................................................................................................... 1
EDUCATION PROGRAMMES
THE IMPACT OF THE PERINATAL EDUCATION PROGRAMME ON THE INTERPRETATION OF
ANTENATAL CARDS AND PARTOGRAMS BY MIDWIVES. GB Theron ......................................... 3
DOES SUCCESSFUL COMPLETION OF THE PERINATAL EDUCATION PROGRAMME RESULT IN
IMPROVED OBSTETRIC PRACTICE? E le Roux.............................................................................. 5
EVALUATION OF THE USE OF THE NEONATAL MANUAL OF THE PERINATAL EDUCATION
PROGRAMME.DH Greenfield ............................................................................................................ 9
TRAINING TRADITIONAL BIRTH ATTENDANTS (TBAs): THE ZIMBABWE EXPERIENCE.
SP
Munjanja ............................................................................................................................................. 10
SARTORIAL ELOQUENCE. GR Howarth ..................................................................................................... 12
LABOUR
VAGINAL PROSTAGLANDIN E2 GEL VS. INTRAVENOUS OXYTOCIN VS. EXPECTANT MANAGEMENT FOR
PRELABOR RUPTURE OF MEMBRANES AT TERM. A RANDOMIZED CLINICAL TRIAL.
M Hannah ............................................................................................................................................. 14
A RANDOMISED CONTROLLED TRIAL COMPARING VAGINALLY ADMINISTERED MISOPROSTOL TO
VAGINAL DINOPROSTONE GEL IN LABOUR INDUCTION. P Steytler ......................................... 15
MECONIUM ASPIRATION SYNDROME: IMPORTANCE OF THE MONITORING OF LABOUR. M Adhikari 17
AMNIOINFUSION IN DEVELOPING COUNTRIES. GJ Hofmeyr .................................................................. 19
1
PREGNANCY
DOUBLE BLIND RANDOMISED CONTROLLED TRIAL OF THE USE OF LOW DOSE DOPAMINE IN POST
PARTUM PRE-ECLAMPTIC WOMEN WITH OLIGURIA. GD Mantel ............................................. 20
PREGNANCY OUTCOME IN PRIMIGRAVIDAE WITH HYPERTENSIVE DISEASE. J Moodley ................. 22
PERINATAL OUTCOME OF HYPERTENSIVE DISORDERS OF PREGNANCY IN BLACK SOUTH AFRICAN
WOMEN. NM Rankhethoa ................................................................................................................ 26
THE EFFECT OF DEXAMETHASONE ON THE IMMUNE SYSTEM OF WOMEN WITH PRETERM
PREMATURE RUPTURE OF MEMBRANES: A RANDOMISED CONTROLLED TRIAL. M Funk . 29
THE VALUE OF DOPPLER STUDIES OF THE MIDDLE CEREBRAL ARTERY 9MCA0 IN THE MANAGEMENT
OF PREGNANCIES WITH SEVERE PLACENTAL INSUFFICIENCY. L Geerts.............................. 31
REFERRAL OF PATIENTS WITH PRELABOUR RUPTURE OF THE MEMBRANES FROM RETREAT MOU TO
GROOTE SCHUUR HOSPITAL. AA Van Coeverden de Groot........................................................ 33
NEONATAL INTENSIVE CARE
A COMPARATIVE PROFILE OF INFANTS VENTILATED IN TERTIARY AND PRIVATE INTENSIVE CARE
UNITS IN SOUTH AFRICA. GF Kirsten ............................................................................................ 35
EXTUBATION OF VENTILATED INFANTS: DIRECT EXTUBATION FROM LOW RATES COMPARED WITH
EXTUBATION FROM CPAP. JC Stephen ........................................................................................ 36
COMPARISON OF INTRAVENOUS AND ORAL IRON IN PRETERM INFANTS RECEIVING RECOMBINANT
HUMAN ERYTHROPOIETIN. M Meyer ............................................................................................ 39
INFECTIONS
NOSOCOMIAL INFECTIONS IN A NEONATAL HIGH CARE AND INTENSIVE CARE UNITSD Delport ..... 41
ANTIBIOTICS AND SUSPECTED SEPSIS IN THE NEONATE: AN AUDIT. M Adhikari .............................. 43
2
SHOULD SYMPTOMATIC CONGENITAL SYPHILITICS BE OFFERED VENTILATION? THE BARAGWANATH
EXPERIENCE. CJ Hauptfleisch ........................................................................................................ 45
ASYMPTOMATIC BACTERIURIA: SIGNIFICANCE AND TREATMENT DURING PREGNANCY.
DR
Hall ..................................................................................................................................................... 47
GENITAL INFECTIONS IN THE ETIOLOGY OF LATE FETAL DEATH : AN INCIDENT CASE-REFERENT
STUDY. NB Osman .......................................................................................................................... 49
APPROPRIATE TECHNOLOGIES
NEW INSTRUMENTS FOR MONITORING GROWTH AND NUTRITION OF CHILDREN AND MOTHERS.
HdeV Heese ....................................................................................................................................... 50
PREVENTION OF LOW BIRTH WEIGHT INFANTS (POLO) PHASE ONE : DEVELOPING A RISK SCORE. LR
Pistorius.............................................................................................................................................. 53
BEDSIDE FETAL LUNG MATURITY TESTING. WKH Kuchenbecker ......................................................... 55
THE INTRA-UTERINE GROWTH GRAPH AND SCORE REVISITED: A PRAGMATIC CLINICAL TOOL OF
FOETAL WELLBEING. PM Garde .................................................................................................... 57
PRIMARY CARE FETAL ASSESSMENT: LOW-COST FETAL ACOUSTIC STIMULATION. TA Lawrie ..... 59
THE OXYGEN CONCENTRATOR - EVALUATION AND POTENTIAL USE IN THE NEONATE. IT Hay .... 61
WEIGHT GAIN & PREGNANCY HYPERTENSION - PART II. I Kennedy .................................................... 63
COMMUNITY OBSTETRICS
ARE THERE MEASURABLE EFFECTS OF THE INTRODUCTION OF FREE MATERNAL CARE? PA Cooper
........................................................................................................................................................... 66
A COMMUNITY BASED INVESTIGATION OF MATERNAL MORTALITY DUE TO OBSTETRIC
HAEMORRHAGE IN RURAL ZIMBABWE. S Fawcus ...................................................................... 68
3
COMMUNITY HEALTH WORKERS INVOLVED IN POSTNATAL CARE OF PATIENTS IN KHAYELITSHA. L
Linley .................................................................................................................................................. 70
PERINATAL HEALTH IN THE CHIAWELO DISTRICT OF SOWETO. EJ Buchmann ................................. 72
A PROSPECTIVE ANALYSIS OF ALCOHOL INGESTION IN 400 PREGNANT WOMEN IN RURAL AND
URBAN AREAS IN THE WESTERN CAPE. DL Viljoen ................................................................... 74
HIV
VERTICAL TRANSMISSION OF HIV-INFECTION. EFFECT OF VAGINAL WASHING. A Justesen ......... 76
MATERNAL AND OBSTETRICAL FACTORS IN MOTHER TO CHILD TRANSMISSION OF HIV IN SOWETO,
SOUTH AFRICA. JA McIntyre........................................................................................................... 78
THE MIDWIFE'S EXPERIENCE OF A HIV-POSITIVE DELIVERY. M de Jager ........................................... 81
MEDICAL STUDENTS AND HIV EXPOSURE. EC de Coning ...................................................................... 83
POSTERS
MOU PROFILES - A COMPARISON OF THE SOCIO-OBSTETRIC PROFILES OF 2 ADJACENT MIDWIFE
OBSTETRIC UNITS IN CAPE TOWN. HA van Coeverden de Groot ............................................... 85
CLINICAL EVALUATION OF NORMAL UMBILICAL ARTERY DOPPLER AND PERINATAL OUTCOME.K
Norman .............................................................................................................................................. 87
MATERNAL NUTRITION AND LOW BIRTH WEIGHT. K Kyriazis ................................................................ 89
AN OVERVIEW OF PERINATAL MORTALITY IN SOUTH AFRICA. H Saloojee ........................................ 92
UNBOOKED PATIENTS. M Mokoana .......................................................................................................... 94
THE UNBOOKED MOTHER AT BARAGWANATH HOSPITAL AFTER THE INTRODUCTION OF FREE
ANTENATAL CARE. D Dawood ...................................................................................................... 96
AN EVALUATION OF THE INCIDENCE OF EPISIOTOMIES AND PERINEAL TEARS IN PATIENTS AT
PELONOMI HOSPITAL. EC De Coning .......................................................................................... 98
4
SCREENING FOR ANAEMIA IN PREGNANCY. COMPARISON BETWEEN COPPER SULPHATE AND
HAEMOGLOBINOMETER METHODS. LR Pistorius..................................................................... 100
ADRENALIN AS AN INOTROPE IN CRITICALLY ILL, HYPOTENSIVE NEONATES. H Saloojee ............. 102
USING THE PERINATAL PROBLEM IDENTIFICATION PROGRAMME IN MIDWIFE OBSTETRIC UNITS IN
CAPE TOWN. DH Greenfield ......................................................................................................... 104
AUDIT ON ANTENATAL CARE BEFORE AND AFTER THE INTRODUCTION OF THE PERINATAL
EDUCATION PROGRAMME AND FREE ANTENATAL CARE IN ATTERIDGEVILLE. R Pfau .... 106
ACCURACY OF ASSESSMENT OF CERVICAL DILATATION. M Funk .................................................... 108
UPDATE ON THE IMPORTANCE OF TOUCH. K Hansen ......................................................................... 110
THE INTERNET AND TEACHING IN PERINATAL CARE. A Kent ............................................................. 112
ANTENATAL PREDICTIVE FACTORS OF NEURODEVELOPMENTAL DELAY IN VERY LOW BIRTH WEIGHT
(VLBW) INFANTS. PA Smith .......................................................................................................... 114
REVIEW OF RISK FACTORS FOR THE PREDICTION OF FETAL LUNG HYPOPLASIA AND ULTRASOUND
PREDICTORS THEREOF. CJM Stewart ........................................................................................ 115
POOR CORRELATION BETWEEN FETAL HEART RATE PATTERNS AND UMBILICAL ARTERY BLOOD
GASES IN HIGH RISK PATIENTS DELIVERED LONG BEFORE TERM. C A Oettlé ................... 116
SOCIAL AND EDUCATIONAL BACKGROUND OF THE TEENAGE MOTHERS AT GA-RANKUWA
HOSPITAL.NJ Kekesi ...................................................................................................................... 117
FACTORS CONTRIBUTING TO THE MORTALITY OF VERY LOW BIRTH WEIGHT INFANTS < 1500g
ADMITTED TO GA-RANKUWA HOSPITAL. F Muwazi.................................................................. 119
5
CONSENSUS STATEMENTS FROM THE 15TH CONFERENCE ON PRIORITIES
IN PERINATAL CARE IN SOUTHERN AFRICA
Delegates to the 15th Conference on Priorities in Perinatal Care in Southern Africa, held at Goudini Spa from 5-8
March 1996, adopted consensus statements on three topics which have been the subject of considerable
discussion and research over the past 15 years. These conferences are the annual meetings of the Priorities in
Perinatal Care Association, and are attended by a broad spectrum of rural and urban health workers with an
interest in perinatal care, including midwives, neonatal nurses, neonatologists and obstetricians.
1.
A patient carried antenatal record
It is in the best interest of pregnant women that they keep with them medical information of importance
to their pregnancy. All health care workers should provide pregnant women with written information
preferably in the form of a structured card or book. Antenatal cards should be made available to all
providers of maternal care. The information should include:
Relevant history and clinical findings
Blood group
Results of other laboratory investigations, particularly syphilis screening
Results of ultrasound examination, if available
Estimated date of delivery
2.
A partogram
All pregnant women should be monitored during labour using a partogram. The partogram must
accompany a woman who is transferred during labour. The partogram should consist of the following
sections:
The well being of the woman (blood pressure, pulse, temperature, urine output and
urinalysis)
The well being of the fetus (heart rate and pattern, and colour of the liquor)
Graphical presentation of the progress of labour (cervical effacement and dilatation,
decent of the presenting part, fetal position, station, caput and moulding)
The alert and actions lines
Latent and active phases of labour recorded on the same sheet
Medication, including analgesia
Both oral and intravenous fluid
There should also be place for :
Patient's name, age, gravidity and parity
Address and telephone number of clinic
A problem list with high risk factors
Assessment of fetal size, and pelvimetry is indicated
1
Haemoglobin concentration, blood group and results of syphilis screening
It is essential that a relevant training course be used when partograms are introduced for the first time.
3.
Treatment of newborn infants born to women with syphilis
All infants born to women who have proven or suspected syphilis during pregnancy should be treated
with penicillin unless the mother has been adequately treated. Adequate maternal treatment consists of
three weekly intramuscular doses of 2,4 million units of benzathine penicillin. The treatment must be
completed before the last month of pregnancy. Women who have not been screened for syphilis during
their pregnancy should be screened at delivery. If the mother cannot be screened for syphilis, it is
recommended that the infant be regarded as at an increased risk for congenital syphilis and treated.
The choice of treatment of the newborn infant depends on the clinical examination of the infant at birth.
Unfortunately radiography and immunological tests are only of limited diagnostic value.
Infants with any clinical signs of syphilis should receive 50 000 units/kg of procaine penicillin by
intramuscular injection daily for 21 doses, preferably on consecutive days. Every effort must be made to
keep the mother and infant together during treatment. These infants should be followed until they are
thriving and all signs of syphilis have disappeared.
Infants who appear healthy with no signs of clinical syphilis should be given 50 000 units/kg of
benzathine penicillin as a single intramuscular dose. No further follow-up is needed.
2
THE IMPACT OF THE PERINATAL EDUCATION
no differences regarding the age, level of training
PROGRAMME ON THE INTERPRETATION OF
and experience between the two groups.
ANTENATAL CARDS AND PARTOGRAMS BY
ability to interpret findings on antenatal cards and
MIDWIVES.
partograms during the pretesting also did not differ
between the study and control towns.
The
The post-
GB Theron
testing showed a significant improvement (0,001)
Department of Obstetrics and Gynaecology,
with regards to interpretation of both the antenatal
University of Stellenbosch
cards and the partograms (Tables I and II).
The
mean score with the antenatal cards improved by
A previous study has shown that the Perinatal
32,9% and the partograms by 17,2%. There was a
Education Programme (PEP) significantly increased
significant (p=0,0001) improvement in the attitude
the cognitive knowledge of midwives concerning
towards work in the study town with the means
maternal and infant care as assessed by multiple-
score improving by 24,6% (Table III). Post-tests in
choice testing.1 This study assessed the ability of
the control towns revealed no changes.
midwives that studied the Maternal Care Manual of
PEP to correctly interpret antenatal cards and
Discussion:
partograms.
The Maternal Care Manual of PEP significantly
An assessment of their attitude
improved midwives ability to correctly interpret
towards their work was also made.
information on the antenatal cards and partograms.
Their attitude towards their work also improved
Methods:
A prospective controlled study was conducted in a
significantly.
region where PEP has not been implemented at all.
ante- and intrapartum care rendered in regions
A study town and 2 control towns were selected.
where PEP has been studied.
Pretests were conducted in all 3 towns. Attitudes
towards work were tested with a questionnaire.
Five antenatal cards had to be interpreted by all
midwives rendering antenatal care in these towns
and 5 partograms by the midwives working in the
labour wards. The Maternal Care Manual of PEP
was subsequently studied in the study town. The
Programme was introduced in the usual way and
managed by a regional and local coordinators. On
completion of the Programme the same tests were
conducted in all 3 towns.
The interpretations of
the antenatal cards and partograms were marked
strictly according to a preset memorandum.
Results:
A total of 40 and 53 midwives were included in the
study and control towns respectively. There were
3
These achievements will improve
Table 1 Antenatal Cards (scored out of 20)
STUDY TOWN
Pretest
*
*
*
mean (s)
median
range
8,4 (4,3)
9,0
0-15
Post test
p-value*
15,0# (4,9)
15,0
12-19
0,000
Post test
p-value
10,4 (4,7)
12,0
0-16
0,744
CONTROL TOWN
Pretest
*
*
*
mean (s)
median
range
10,4 (5,0)
10,5
0-17
* Student's t test
# Mean improvement = 33%
Table 2 Partograms (scored out of 20)
STUDY TOWN
Pretest
*
*
*
mean (s)
median
range
11,3 (3,0)
11,0
7-17
Post test
p-value*
14,8# (3,0)
13,5
10-20
0,001
Post test
p-value
9,0 (3,5)
9,5
1-19
0,640
CONTROL TOWN
Pretest
*
*
*
mean (s)
median
range
8,3 (3,4)
8,0
2-17
* Student's t test
# Mean improvement = 18%
Table 3 Attitude towards work (scored out of 25)
STUDY TOWN
Pretest
*
*
*
mean (s)
median
range
14,5 (6,4)
15,5
0-25
Post test
p-value*
20,6# (3,6)
21,0
13-25
0,000
Post test
p-value
16,0 (4,0)
16,0
4-22
0,646
CONTROL TOWN
Pretest
*
*
*
mean (s)
median
range
16,7 (4,5)
17,0
6-25
* Student's t test
# Mean improvement = 24%
4
DOES SUCCESSFUL COMPLETION OF THE
with at the end of August and the beginning of
PERINATAL
PROGRAMME
September. For antenatal care assessment the
RESULT IN IMPROVED OBSTETRIC PRACTICE?
“before” control group consisted of data collected at
EDUCATION
Marapyane in 1994, and the “during” control group
E le Roux, RC Pattinson, W Tsaku*, JD Makin
data collected at Pankop.
Department of Obstetrics & Gynaecology, University
consisted of data collected at Marapyane (in 1995)
of
and Mmametlhake Clinics. For intrapartum care the
Pretoria
and
Kalafong
Hospital,
and
The study group
“before” control group consisted of data collected at
*Mmametlhake Hospital, Mpumalanga
Marapyane in 1994, and from July-August 1995,
Objective:
and Mmametlhake Clinic July-August 1995, i.e.
To determine whether the successful completion of
before studying the intrapartum chapters in PEP,
the Perinatal Education Programme (PEP) improves
and the “during” control group data collected from
obstetric practice.
Pankop Clinic. The study group consisted of data
collected at Marapyane Clinic from September-
Method:
November, and at Mmametlhake Clinic from
Three midwife obstetric units (MOU's) - Marapyane,
September-October.
Mmametlhake and Pankop clinics, in the Moretele
District of Mpumalanga were included in the study.
Outcome Measures:
PEP was run at Marapyane and Mmametlhake and
In antenatal care, the obstetric history, syphilis
Pankop served as a control. Data was collected by
testing, blood group testing, haemoglobin and
analysing the obstetric files after the patient had
uterine growth assessment were assessed along
delivered. The analysis was performed using two
with whether appropriate action was taken. For
systems, firstly a code was given if an observation
intrapartum care, the estimated fetal weight,
or procedure was or was not performed and
pelvimetry, blood pressure, urine, head above
whether
e.g.
pelvis, fetal heart rate, contractions and plotting
haemoglobin measurement. The second coding
cervical dilatation as well as whether the appropriate
system was used to assess whether or not
actions were taken, were assessed.
it
was
correctly
performed,
appropriate action, where applicable, was taken.
Results:
Data was collected from all three clinics from July to
Eight midwives went through the Obstetric Manual
October 1995, and from Marapyane in July and
of PEP, all demonstrated a significant improvement
August 1994, 6 months before PEP was initiated.
in knowledge, and all but 2 scored above 80% at the
Two control groups were established; a “before”
final examinations. Five of
group, consisting of data collected before doing the
relevant chapters in PEP, and a “during” group,
where data was collected at the time of studying
PEP from Pankop clinic, which did not do PEP. The
antenatal part of PEP was completed by July and
the chapters dealing with the partogram were dealt
5
eight midwives did the course at Marapyane and
Details are given in Table 1 below.
three of five at Mmametlhake.
Table1. Totals for pre- and post- test scoring of candidates doing PEP.
Candidates
Before
1
168
56%
After
P-value
3
2
193
64%
296
266
92%
88%
<0,001
<0,001
4
148
155
49%
51%
249
212
83%
70%
<0,001
<0,001
5
6
7
148
211
257
49%
70%
85%
238
262
270
79%
87%
90%
<0,001
<0,001
<0,05
8
All
231
188,8
77%
62,9%
250
252
83%
84,2%
<0,05
<0,001
was appropriate action taken. Syphilis testing was
272 Patients case files were studied from the
not performed in 18-41% of cases with significantly
various clinics (Marapyane 145, Mmametlhake 60
less testing occurring in all places in 1995. The
and Pankop 67 representing 18%, 35% and 82% of
haemoglobin was tested in only 4-15% of patients
deliveries respectively). There was no change in
with no difference before or after PEP. Where a
the referral patterns of any of the clinics during the
problem was detected in uterine growth, there was
study period.
no response in 81-100% of patients and no
The obstetric history was taken well but in no group
difference before or after PEP was ascertained.
was there a satisfactory response to a detected
See Tables 2 and 3.
problem where, in only 0-12% of cases
Table 2. Antenatal observations and procedures done correctly.
Key Observations
Study Group (S)
n = 234
“Before” Control (B)
n = 62
“During” Control (D)
n = 67
P=value
Obstetric History
222 = 94,8%
57 = 92%
59 = 88%
S/B, S/D - NS
STS
137 = 58,5%
51 = 82%
43 = 64%
S/B - <0.001,
Bloodgrouping
134 = 57,2%
51 = 82%
44 = 66%
S/B - <0.001,
Haemoglobin
22 = 9,4%
9 = 14,5%
3 = 4%
S/B, S/D - NS
Gestational age
161 = 68%
39 = 62,9%
43 = 64%
S/B, S/D - NS
S/D - NS
S/D - NS
STS - Serological tests for syphilis; S/B - Study group versus “Before” control; Study group versus “During” control; NS - Not statistically
significant
6
Table 3. Appropriate actions taken where necessary.
Obstetric History
STS
Study Group
“Before” Control
“During” Control
P=Value
4/33 = 12%
0/7 = 0%
0/6 = 0%
S/B, S/D - NS
15/82 = 18,2%
26/36 = 72%
7/17 = 41%
S/B - <0.001,
S/D - <0.05
Bloodgrouping
1/66 = 1,5%
0/5 = 0%
1/12 = 8,3%
S/B, S/D - NS
Gestational age
6/53 = 11,3%
0/20 = 0%
0/18 = 0%*
S/B, S/D - NS
STS - Serological tests for syphilis; S/B - Study group versus “Before” control; Study group versus “During” control; NS - Not statistically
significant
Estimation of fetal weight and pelvimetry was poorly
Where problems were detected, appropriate
performed across all groups, the uterine and fetal
actions taken during labour improved but not
heart rate documentation was moderately well done
significantly at Marapyane (44-79%) but no change
in all groups and the blood pressure, head above
was detected at Mmametlhake (70-67%) and there
pelvis, contractions and plotting of cervical dilatation
was no difference between Marapyane and
was performed well in all groups. No differences
Mmametlhake after PEP and Pankop (79%). See
before and after PEP were detected.
Tables 4 and 5.
Table 4. Partogram observations and procedures correctly done.
Key observations
Study Group (S)
n = 76
“Before” Control (B)
n = 116
Estimated fetal weight
28 = 36%
48 = 41%
Pelvimetry
0 = 0%
2 = 1,7%
Bloodpressure
63 =82,9%
“During” Control (D)
n = 42
26 = 62%
P-value
S/B - NS,
S/D - <0.01
2 = 5%
23 = 60%
102 = 87,7%
S/B, S/D - NS
S/B - NS,
S/D - <0.001
Urine
43 =56,5%
60 = 51,7%
Head above pelvis
65 = 85%
98 = 84,4%
25 = 64%
25 = 64%
S/B, S/D - NS
S/B - NS,
S/D - <0.005
Fetal heart rate
48 = 63%
10 = 26%
86 = 74,1%
S/B - NS,
S/D - <0.005
Contractions
69 = 90%
109 = 93,9%
33 = 85%
S/B, S/D - NS
Cervical dilatation
73 = 96%
113 = 97,4%
33 = 85%
S/B - NS,
S/D - <0.005
S/B - Study group versus “Before” control; Study group versus “During” control; NS - Not statistically significant
Table 5. Intrapartum care: Appropriate action taken where necessary.
Study Group (S)
Appropriate action
15/20 = 75%
“Before” Control (B)
20/32 = 63%
“During”Control (C)
19/24 = 79%
P=value
S/B, S/D - NS
S/B - Study group versus “Before” control; Study group versus “During” control; NS - Not statistically significant
Discussion:
This study is the first to assess whether completion
There are various explanations of this finding; firstly
of Obstetrics Manual of PEP results in improved
not all the midwives at the clinics volunteered for the
care of pregnant women. It did not do so in this
programme, thus the effect the midwives doing the
study, however, it very clearly improved the
programme might have had, may have been diluted;
knowledge of the midwives doing the programme.
secondly, the midwives doing the course may not
7
have been able to alter management protocols laid
down by the hospital and may not have had the
skills to try and negotiate for change; thirdly that
PEP improves knowledge, but improved knowledge
does not result in altered behaviour.
It is important to note the number of midwives
involved in this study are too few to draw general
conclusions, and other studies like this should be
performed on larger samples.
Conclusion:
PEP improved the knowledge of the midwives but
no alteration in practice was detected.
8
EVALUATION OF THE USE OF THE NEONATAL
Umbilical catheterisation
MANUAL OF THE PERINATAL EDUCATION
Gestational age scoring
PROGRAMME
Examination of an infant
Blood sugar estimation
DH Greenfield
Department of Paediatrics, UCT
Results
The Perinatal Education Programme is a self-
1.
Knowledge
UPH
mean score
before
after
63(53%)
105(88%) 15,049
T
<10-6
p
DNH
mean score
before
71(60%)
after
95(80%)
T
4,798
p
=0,03
Difference in Improvement
DNH
UPH
23(19%)
42(35%)
T
3,364
p
=0,0025
after
102(82%) 20,054
T
<10-6
P
after
66(54%)
T
0,144
P
=0,89
directed, problem-orientated learning programme
for health workers in the field of perinatal care. It
has been developed as a means of improving
perinatal care, and is based on Southern African
experience.
2.
Skills
UPH
mean score
before
55(45%)
DNH
mean score
before
67(55%)
Aim
The aim of this evaluation is to assess changes, if
any, in cognitive knowledge, skills, practice and
attitudes of those who use the Programme. Only
the effects on cognitive knowledge and skills are
reported here.
Conclusions
Methods
The use of the programme has made a significant
This was a prospective controlled study conducted
difference to the knowledge and skills of those who
in Uitenhage Provincial Hospital (UPH) - the test
used it.
hospital and in Dora Nginza Hospital (DNH) - the
knowledge was not shown to have occurred in the
control hospital. Both these hospitals are situated in
staff at the control hospital, where the skills tested
the Eastern Cape. 24 midwives at UPH studied the
had not improved at all.
Newborn Care Manual of the programme, while 10
The evaluation of practice should show whether this
midwives from DNH underwent the testing without
improvement in knowledge and skills makes a
having
difference to patient care.
used the programme.
Cognitive knowledge was tested before and after
the use of the programme by means of a multiple
choice question paper (MCQ). Skills were tested
before and after the use of the programme by
means
of
an
Objective
Structured
Clinical
Examination (OSCE). The skills tested were:
Endotracheal intubation
9
The same degree of improvement in
TRAINING TRADITIONAL BIRTH ATTENDANTS
Results
(TBAs): THE ZIMBABWE EXPERIENCE
A total of 981 TBAs, 981 mothers and 55 nurses
were interviewed. The median number of deliveries
SP Munjanja, F Majoko, I Zhanda
done by a TBA per year was two. The perinatal
Dept of Obstetrics & Gynaecology, University of
mortality for TBA practice was 39/1000 births.
Zimbabwe
There was no coordination of the TBA training
programme at national level. There has been no
Introduction
training
In developing countries the traditional birth
Commitment to the programme varied widely
attendant (TBA) continues to play an important role
among provinces, and even among districts in the
in maternity care. The upgrading of the knowledge,
same province.
attitudes and practices of TBAs has been
responsible for most of the training. The training
recommended as an important way of making their
period ranged from 14 to 21 days spaced over
deliveries
several months.
safer.
Zimbabwe
TBA
training
programmes
in
the
urban
centres.
The nurses in the RHCs were
The method of selection for
programme was introduced in 1983 and had not
training favoured older less literate but more
been evaluated nationally until this survey in 1994.
experienced TBAs. Trained TBAs were reasonably
The aim of the training programme was to make
knowledgeable about pregnancy complications and
safe and clean deliveries available to women
were more likely to refer patients to the RHC. The
throughout the country through the upgrading of the
cost-effectiveness of the TBA training programme
knowledge and practices of the TBA.
could not be assessed from the available material.
The major problem affecting TBAs in their work are
Methodology
lack of delivery kit items, lack of transport for
The study was a descriptive cross-sectional survey
referrals and lack of renumeration for services
conducted in randomly selected districts in all the
rendered.
ten provinces of Zimbabwe.
among TBAs was poor.
Information was
The knowledge
about HIV infection
collected from mothers recently delivered by TBAs,
nurses at rural health centres (RHC) and TBAs
Recommendations
(both trained and untrained). Teams of research
Future evaluations of the TBA programme should
assistants went into selected districts after a 3-day
concentrate on outcomes which can be changed by
training workshop to conduct interviews.
A
training. Training should be uniform in the country
questionnaire was designed for each group (i.e.
with provincial targets being set and examined
mothers,
group
regularly. A major revision of the goals and the
discussions were held with TBAs and the mothers.
need for TBA training should be undertaken. The
TBAs,
nurses)
and
focus
cost-effectiveness of continuing to train large
numbers of TBAs who will do 1-2 deliveries per year
needs to be re-assessed. A better option would be
to train fewer, literate TBAs whose workload will
increase, leading to more experience. It would be
10
easier to phase out the programme if there were
fewer, highly trained TBAs since they may be further
upgraded.
11
be
they consider the doctor to be most trustworthy,
maintained in the training hospital obstetrician -
most competent, most friendly and with which would
patient relationship?
they feel was the easiest to form a patient-doctor
SARTORIAL
ELOQUENCE:
Should
it
relationship. All 5 photographs in each set were to
be considered for each attribute. If patients felt that
GR Howarth, T Mabale, J Makin.
at least two dress codes equally represented a
Aim:
particular attribute they were able to nominate both.
To establish patients' preferences as regards
The patients were also informed that the attire with
medical personnel's attire.
the most positive responses would be considered to
be the most acceptable to the patient. Where more
Methods and patients:
than two dress codes were thought to best
A research mid-wife interviewed 100 antenatal
represent an attribute or no dress code was
patients attending their first antenatal clinic visit
nominated, the ballot was considered to be spoilt.
using their home language where possible. Patients
There were 5 photographs of each individual and it
were interviewed early in the morning prior to being
was assumed that each photograph would be
exposed to medical personnel, so that the attire of
assigned one fifth (20%) of the votes by chance.
the medical personnel would not influence their
Chi-square test was performed in comparing
decisions. The researcher wore nothing to identify
proportions.
her as a health care worker and she did not identify
describe results that differ significantly from what
herself to the patients.
would be expected by chance.
All interviews were
performed in privacy so that patients would not be
influenced by other patients' opinions. The main
outcome
measures
were
patients'
positive
responses assigned to photographs of differing
medical attire.
Patients were shown 2 sets of 5 photographs. Attire
of the female doctor consisted of (A) blouse, skirt,
white coat and closed shoes; (B) blouse, skirt and
closed shoes; (C) blouse, long pants and closed
shoes; (D) skirt, white safari suit top and closed
shoes; (E) casual shirt, denim jeans and track
shoes.
Attire of the male doctor consisted of (A)
long sleeved shirt, tie, trousers, closed white coat
and closed shoes; (B) long sleeve shirt, tie, trousers
and closed shoes; (C) the same attire without a tie;
(D) white safari suit top, trousers and closed shoes;
(E) casual shirt, denim jeans and track shoes.
Patients were requested to evaluate each set of
photos for four different attributes, in which attire did
12
P values and confidence intervals
Results
MALE
TRUST
A
B
C
D
E
NO CHOICE
PAIRS
DENOMINATOR
COMPETENCE
35/126 (40%)
23/126 (18%)
*3/126 (2%)
30/126 (24%)
*10/126 (8%)
9/100 (9%)
26/100 (26%)
126
FRIENDLY
*45/122 (37%)
23/122 (19%)
*4/122 (3%)
23/124 (23%)
*8/122 (7%)
14/100(14%)
22/100 (22%)
122
*48/124 (39%)
23/124 (19%)
*7/124 (7%)
33/124 (27%)
*6/124 (5%)
*9/100 (9%)
24/100 (24%)
124
RELATIONSHIP
*49/124 (40%)
*49/124 (40%)
*5/124 (4%)
32/124 (26%)
*8/124 (6%)
8/100 (8%)
24/100 (24%)
124
TOTAL
*193/496 (39%)
91/496 (18%)
*17/496 (3%)
123/496 (25%)
*32/496 (6%)
40/496 (8%)
496
FEMALE
TRUST
A
B
C
D
E
NO CHOICE
PAIRS
DENOMINATOR
COMPETENCE
*45./119 (39%)
15/119 (13%)
*8/119 (7%)
*38/119 (32%)
*1/119 (>1%)
12/100 (12%)
19/100 (19%)
119
FRIENDLY
35/115 (30%)
15/115 (13%)
*8/115 (7%)
*39/115 (34%)
*2/115 (2%)
16/100 (16%)
15/100 (15%)
115
*42/113 (37%)
*11/113 (10%)
*10/113 (9%)
*37/113 (33%)
*2/113 (2%)
11/100 (11%)
13/100 (24%)
113
RELATIONSHIP
*46/116 (40%)
14/116 (12%)
*8/116 (6%)
*38/116 (33%)
*2/116 (2%)
8/100 (8%)
16/100 (16%)
116
TOTAL
*168/463 (36%)
*55/463 (12%)
*34/463 (7%)
*152/463 (33%)
*2/463 (2%)
47/463 (10%)
463
*
indicates statistical significance
No choice is where patients either had no preference or more than two.
Pairs are the number of patients with two choices
Discussion
Patients prefer their doctors to be more formally
dressed.
VAGINAL
PROSTAGLANDIN
E2
GEL
the TermPROM Study Group, University of Toronto,
VS.
Canada.
INTRAVENOUS OXYTOCIN VS. EXPECTANT
MANAGEMENT FOR PRELABOR RUPTURE OF
MEMBRANES AT TERM. A RANDOMIZED
Background
CLINICAL TRIAL
As the duration of membrane rupture increases, so
may the risk of fetal and maternal infection. It is not
M Hannah, A Ohlsson, D Farine, S Hewson, E
known if inducing labor will reduce this risk or if one
Hodnett, T Myhr, E Wang, J Weston, A Willan, for
induction method is better than another.
13
Methods
We studied 5041 women with prelabor rupture of
membranes at term. The women were randomly
assigned to induction of labor with intravenous
oxytocin,
induction
of
labor
with
vaginal
prostaglandin E2 gel, expectant management and
induction of labor with intravenous oxytocin if
complications
developed,
or
expectant
management and induction of labor with vaginal
prostaglandin E2 gel if complications developed.
The primary outcome was neonatal infection.
Secondary outcomes were caesarean section and
women's evaluations of their treatment.
Results.
Neonatal infection and Caesarean section rates
were not significantly different between groups.
Neonatal infection rates ranged from 2.0 percent to
3.0 percent. Caesarean section rates ranged from
9.6 percent to 10.9 percent.
induction/oxytocin
group
Women in the
compared
with
the
expectant/oxytocin group were less likely to develop
clinical chorioamnionitis (4.0 percent vs. 8.6
percent, P<0.001) or postpartum fever (1.9 percent
vs. 3.6 percent, P=0.008). Women in the induction
groups were less likely to say they liked 'nothing'
about their treatment than women in the expectant
groups.
Conclusions.
Induction of labor with oxytocin or prostaglandins
and expectant management result in similar rates of
neonatal infection and Caesarean section. Women
view induction of labor more positively than
expectant management. Induction of labor with
intravenous oxytocin results in a lower risk of
maternal infection than expectant management.
14
A
RANDOMISED
COMPARING
TRIAL
prostaglandins were re-administered according to
ADMINISTERED
initial randomisation, again by the investigator not
CONTROLLED
VAGINALLY
MISOPROSTOL TO VAGINAL DINOPROSTONE
involved in clinical management of the patient.
GEL IN LABOUR INDUCTION.
Patients not in established labour 12 hours after trial
entry were managed according to the attending
P Steytler, GR Howarth, M Funk, L Pistorius, J
physicians's choice, who remained unaware of
Makin, RC Pattinson.
which trial drug had been administered. Failure to
respond to further doses of prostaglandins was
Aim:
considered an indication for caesarean section for
To compare misoprostol to dinoprostone vaginal gel
failed induction. Caesarean section was performed
in the induction of labour.
for suspected fetal distress when changes in the
fetal heart pattern disturbed the attending staff and
Materials and methods:
persisted despite intra-uterine resuscitation.
Seventy two patients were entered into the trial.
Established labour with arrest of cervical dilatation
Inclusion criteria were (1) singleton pregnancy, (2)
despite at least two hours of adequate contractions
longitudinal lie, (3) cephalic presentation, (4) fetal
was considered failure to progress.
well-being, (5) anticipated fetal mass exceeding
2000g, (6) intact membranes, (7) unfavourable
Records of uterine contractions and fetal heart rate
cervix. Exclusion criteria were standard exclusions
traces were evaluated by a single investigator,
for the use of prostaglandins.
GRH, who was unaware which prostaglandin had
been administered.
Polysystole was diagnosed
Patients were randomised to receive either 100ug
when there were more than 5 contractions per 10
misoprostol
commercially
minutes for at least a 20 minute period.
vaginal gel placed in the
Hyperstimulation was recorded when polysystole
Prior to trial entry cervical
was accompanied by either suspicious or ominous
or
1mg
manufactured PGE2
posterior fornix.
of
the
changes in the fetal heart rate pattern.
assessment was performed by attending labour
ward staff.
The same staff, unaware of the
induction agent used, were responsible for patient
Results:
management
regarding
Maternal age, parity, gestational age, indications for
rupturing membranes, augmentation of labour,
induction and pre-induction cervical scores were
analgesic
for
similar in the two groups. There was no difference
All prostaglandins were
in the need for oxytocin augmentation between the
including
administration
caesarean section.
decisions
and
indications
administration by an investigator not involved in
two groups.
patient management.
difference between the two groups in analgesic
Fetal heart and uterine
There was also no significant
monitored
administration. Polysystole alone, occurred in 14/36
electronically throughout the study period. If the
(39%) of the misoprostol group and significantly less
cervix, as assessed by attending labour ward staff,
often in the dinoprostone group 3/36 (8%), P<0,05.
remained unfavourable six hours after trial entry,
However, hyperstimulation was similar in both
contractions
were
continuously
15
groups and occurred in 5 cases where misoprostol
Discussion:
was administered and 4 of the dinoprostone group.
Misoprostol is as effective as the more expensive
The table shows the outcome indices of both
dinoprostone for induction of labour, however, the
groups.
correct dose and safety has not been confirmed. At
present misoprostol should only be used in a strictly
controlled research environment.
Table 1 Outcome Indices
MISOPROSTOL
DINOPROSTONE
n
36
36
Delivered within 6 hours
12
3
Delivered within 12 hours
30
12
Not in labour after 12 hours
1
11
Induction delivery time (minutes)
507 (170-1540)
1000 (250-2135)
Caesarean sections (Total)
6
15
Apgar at 5 minutes
10 (7-10)
10 (8-10)
NS
Weight (g)
3220 (2260-4200) 2880 (2100-4020) NS
Data is presented as median with ranges, whole numbers are used where appropriate
NS = not statistically significant
16
P
<0,05
<0,05
<0,05
<0,05
<0,05
MECONIUM
ASPIRATION
IMPORTANCE
OF
THE
black.
SYNDROME:
MONITORING
Birth weights of 3.0 to 3.49 kg were recorded in
OF
26/53 (49%) babies, greater than 3.5 kg in 14
LABOUR
(27%), 2,5 to 2.99 kg in 8 (15%) and less than 2.49
*M Adhikari, *E Gouws, +SC Velaphi, #P
kg in 5/53 (9%). Thirty-five (64%) of the babies
Gwamanda, *P Matchaba
were males and 19 (36%) females. Gestational age
*Departments of Paediatrics, Obstetrics & Medical
was appropriate in 38/53 (73%), 9/53 (17%) were
Research Council University of Natal
small for gestational age, 5 (10%) were wasted and
+Department of Paediatrics, University of the
27/50 (54%) babies were post term.
Witwatersrand
Forty-six, 46/55 (84%) were inborn and 9/55 (16%)
#Department of Paediatrics Medical University of
outborn. Twenty-seven were delivered vaginally
Southern Africa.
and twenty-six by caesarean section.
The overall mortality was 14.5% (8/55). Seven of
Introduction
the deaths occurred in the ventilated babies (30%)
The aim of this study was to determine whether
and one in the non-ventilated babies. The cause of
obstetric and paediatric interventions play a role in
death in the latter was severe hypoxic ischaemic
the prevention of MAS in the busy labour wards of a
encephalopathy with renal involvement. Two babies
developing world.
died in the thirty-six monitored labours while five
died in the twelve unmonitored labours, p = 0.009.
Patients and Methods
All babies admitted over, either a 3 month or a 6
Multivariate Analysis with Logistic Regression
month period to the Neonatal Units at King Edward,
Prolonged resuscitation was associated with a
Baragwanath and Garankuwa Hospitals and
worse chest x-ray, p = 0.057, RR 6.34, 95% CI:
diagnosed as having MAS were included in the
(0.90; 44.5). Tracheal suction showed a marginally
study.
significant association with chest x-ray changes (p =
The diagnosis of MAS was based on the presence
0.071). Mortality was significantly associated with
of meconium staining of the liquor, respiratory
prolonged resuscitation, p = 0.035, RR 13.7, 95% CI
distress
: (1.2; 156.2) and with labour monitored, p = 0.023,
at
birth
and
radiological
changes
compatible with the diagnosis of MAS.
RR 11.7, 95% CI: (139; 100).
Outcome was assessed as mortality and morbidity.
Need for ventilation was associated with labour
Morbidity was measured in terms of whether the
monitored, p = 0.017, RR 28.6, 95% CI : (1.83; 443)
baby was ventilated or not and the severity of chest
and with prolonged resuscitation p = 0.014, RR
x-ray changes (mild or moderate to severe).
17.4, 95% CI : (2.83; 77.8).
Results
Fifty-five babies were studied, twenty-one were from
Medunsa, twenty-one from Baragwanath and
thirteen from King Edward Hospital and all were
No difference in the severity of the chest x-ray
changes, number of babies ventilated and mortality
17
was found in the post term babies. Grades II and III
low pH with grades of radiographic changes
meconium staining of the liquor was associated with
supporting the latter concept.
a higher number of moderate to severe chest x-rays
Recognition of the high risk patient, notably post
compared to Grade I p = 0.022, RR 4.76 (95% CI :
maturity, the monitoring of the labour to detect fetal
1.32; 17.34).
compromise and expeditious delivery are the
In those babies suffering hypoxic
ischaemic encephalopathy (8/39) the mortality was
important
preventive
factors
for
MAS.
significantly higher, p = 0.022, RR 5.167, 95% CI :
Amnioinfusion in the presence of thick meconium
1.437 - 18,571.
will need further study. It is a simple, cheap and
safe technique and may be an effective therapy to
avoid MAS.
Discussion
Those labours that were monitored resulted in
better survival of the babies, fewer prolonged
resuscitations, fewer babies requiring ventilation
and chest x-rays that demonstrated milder changes
of meconium aspiration. The results of this study
favour caesarean section unlike the retrospective
study conducted by Usta et al which revealed that
the risk factors for MAS were non-reassuring fetal
heart tracings, intubation and suction for meconium
below the cords, Apgar of 4 or less at one minute,
present and previous caesarean section.
Although half the number of babies studied were
post term these babies did not experience a higher
morbidity or mortality. Not unexpectedly prolonged
resuscitation predicted more severe radiographic
changes, higher mortality and more babies requiring
ventilation. Of the 8 babies who died the majority
were
ventilated
and
hypoxic
ischaemic
encephalopathy was associated with these deaths.
Severity of the disease was not influenced by
whether the nose and mouth of the babies had been
suctioned before the delivery of the thorax.
However, direct tracheal suctioning below the vocal
cords for meconium as associated with worse x-ray
changes, the need for ventilation and death,
confirming severity of the aspiration. Fetal acidosis
is associated with fetal compromise and has been
linked to pulmonary dysfunction.
Although the
numbers are small there is some correlation of a
18
checked with fetal scalp sampling. We have only
AMNIOINFUSION IN DEVELOPING COUNTRIES
limited information on the relative risks and benefits
GJ Hofmeyr, AM Gulmezoglu, VC Nikodem, M de
of amnioinfusion in a situation in which electronic
Jager, T Lawrie.
fetal heart rate monitoring is not used.
Department of O&G, Coronation Hosp. and Univ. of
important that a technique with potentially very
the Witwatersrand
positive effects on fetal outcome and maternal
It is
complications be assessed in a South African
Amnioinfusion is a simple technique for augmenting
context. We have reported results of a multicentre
amniotic fluid volume or diluting meconium during
randomised trial of amnioinfusion for meconium-
labour. Randomized trials have shown beneficial
stained liquor.
effects when used to manage oligohydramnios or
rates was shown (Fig. 1). The overall incidence of
meconium-stained liquor. Part of the latter effects
meconium aspiration syndrome was lower than
may be due to correction of oligohydramnios, for
expected.
which thick meconium-staining is a marker. Recent
thousand women will be needed to determine
reports
whether amnioinfusion has a meaningful effect on
have
questioned
the
safety
of
No effect on caesarean section
Given this incidence, a trial of several
this outcome.
amnioinfusion. Although a causal relationship has
not been established, complications reported
include uterine hyperactivity, maternal pulmonary
In view of the extremely high incidence of
oedema, and amniotic fluid embolism. We suggest
meconium-staining of the amniotic fluid in South
that
from
Africa (as high as 30% in some communities,
extraamniotic placement of the catheter, or
possibly related to ingestion of herbal smooth
disruption of the amniotic membrane covering the
muscle stimulants such as isihlambezo) it is most
lower uterine segment. We recommend that during
important that larger trials be undertaken to
placement of any intrauterine catheter, care be
determine whether amnioinfusion will have a
taken to introduce the catheter close to the fetal
meaningful effect on the incidence of meconium
presenting part, and that intraamniotic placement be
aspiration syndrome.
such
complications
could
result
confirmed by aspiration of amniotic fluid before
DOUBLE BLIND RANDOMISED CONTROLLED
infusion is commenced.
TRIAL OF THE USE OF LOW DOSE DOPAMINE
Much of the research on amnioinfusion has been
IN POST PARTUM PRE-ECLAMPTIC WOMEN
conducted in North America.
WITH OLIGURIA
The results may or
may not be relevant to practice in a less developed
environment. In particular, many of the benefits of
GD Mantel, J Makin
amnioinfusion appear to be related to the correction
Department of Obstetrics & Gynaecology, University
of early or variable fetal heart rate decelerations.
of Pretoria
These patterns are usually not associated with fetal
distress, but may be used as an indication for
Introduction
caesarean section when the fetal condition is not
Oliguria is a common complication in pre-
19
eclampsia. While one small fluid challenge can
6 hours prior to and for the 6 hours of the
safely be given, repeated boluses can precipitate
intervention.
pulmonary oedema and contribute to the high
maternal morbidity and mortality associated with
Results
pre-eclampsia. Therefore, without the facilities for
40 patients were studied. The median intravenous
invasive central haemodynamic monitoring to
fluid input, urine output and an estimated fluid
correct for any pre-renal dehydration, most
balance for the 6 hours prior to the trial and for the 6
clinicians recommend that such patients have a
hours of the trial is given in Table 1. No differences
restricted fluid intake, awaiting a spontaneous
in blood pressure or pulse were found between the
diuresis. Most women recover, but if oliguria is
two groups on admission, immediately prior to the
prolonged, there is an increased risk of developing
trial or during the trial. All patients had proteinuria of
acute renal failure and, possibly, of long term renal
1 to 3 plus on 'dipstix'. Complications prior to and
damage.
during the trial are given in Table 2.
The use of dopamine for oliguria has
been described in animal and non-pregnant human
studies. A case report and two small descriptive
studies of pre-eclamptic or eclamptic women have
reported a significant increase in urine output from
baseline oliguric levels after the use of a low dose
intravenous dopamine infusion. All these patients
were treated in an intensive care setting with
expensive and invasive central haemodynamic
monitoring. The aim of this study was to
prospectively compare low dose dopamine with a
placebo in oliguric post-partum pre-eclamptic
women in the labour ward setting, without the use of
intensive care type facilities.
Method
A double blind, randomised controlled study
conducted in the high care area of the Kalafong
hospital labour ward. Post partum pre-eclamptic or
eclamptic women with oliguria, defined as less then
30ml per hour for two consecutive hours, who had
not responded to a 300ml crystalloid fluid challenge
were included. Dopamine was infused at a rate of 1
microgram per kilogram per minute and increased
by 1 microgram every hour to a maximum of 5
microgram per kilogram per minute. Sterile water
was given as placebo in the same dilution. Urine
output, blood pressure and pulse was measured for
20
Table 1:
Input, output and fluid balance prior to and during trial
Dopamine group
n=20
Placebo group
n=20
900
(700 to 3150)
950
(720 to 1320)
p=0.419
Median urine output for the 6 hours prior to trial in
mls (range)
125
(60 to 360)
81.5
(18 to 285)
p=0.29
Median fluid bolus pre-trial in mls (range)
300
(180 to 600)
300
(200 to 600)
+1248
(-180 to +3100)
+1371
(-240 to +4005)
Median fluid input for the 6 hours of the trial in mls
(range)
720
(450 to 910)
720
(450 to 720)
Median urine output for the 6 hours of the trial in
mls (range)
344
(10 to 2760)
135
(30 to 700)
Median fluid balance for the 6 hours of the trial in
mls (range)
+343
(-2310 to +710)
Median fluid input for the 6 hours prior to trial in mls
(range)
Median fluid balance pre-trial in mls (range)
+543
(+200 to +690)
p=0.0023
p=0.004
mls = millilitres. + = positive. - = negative. Statistical significance determined using the Mann-Whitney U Test.
Table 2. Complications before and during the trial.
Conclusions
After excluding hypovolaemia clinically, the use of
Dopamine group
n=20
Placebo group
n=20
Placental abruption
2
1
Eclampsia
0
3
Transient blindness
1
0
responded to a single fluid challenge, without a
Hellp syndrome
3
3
detrimental effect on the blood pressure or pulse.
Postpartum
haemorrhage
1
0
pulmonary oedema
0
1
Trial drug overdose
0
1
low dose dopamine in a labour setting significantly
improved the urine output in post partum preeclamptic women with oliguria who had not
PREGNANCY OUTCOME IN PRIMIGRAVIDAE
At Kind Egward VIII Hospital (KEH) hypertension
WITH HYPERTENSIVE DISEASE
affects approximately 18% of all pregnant women at
some stage of their pregnancies and it remains the
J Moodley, M Mphatsoe, E Gouws
most common cause of both perinatal and maternal
MRC/UN Pregnancy Hypertension Research Unit,
mortality and morbidity in the Natal region. Much of
Faculty of Medicine, University of Natal, Durban
the morbidity and mortality due to hypertension in
pregnancy occurs in multiparous women. Further
early onset pre-eclampsia (EOPE) i.e. pre-
Introduction
21
eclampsia occurring prior to the 28th week of
illnesses were excluded from the study. Patients
pregnancy occurs much more frequently in
were recruited when they presented for the first time
multigravidae, consequently, obstetric mortality and
in the labour ward. Pertinent medical observations
morbidity may be limited to this group of patients
were performed on all patients recruited to the
only, as they have a higher incidence of essential
study, in labour and the immediate post partum
hypertension and chronic renal disease. In contrast,
period.
late
pre-eclampsia
admitted to antenatal wards. Their progress and
occurring after the 37th week of pregnancy is
management in the antenatal wards were followed
usually seen in primigravidae, is of unknown
until delivery and discharge. Neonatal data were
aetiology and may not be associated with high rates
also recorded. The main outcome measures were
of morbidity and mortality. The aim of this study
maternal
therefore was to specifically evaluate the obstetric
Descriptive statistics were calculated for all the
and fetal outcome of primigravid patients with
variables: Analysis of variance and Student's t-test
hypertensive disorders of pregnancy.
was used to compare continuous data, while the
onset
pre-eclampsia
i.e.
Patients who were not delivered were
and
fetal
morbidity and
mortality.
Chi-square test was performed on categorical data.
Material and Methods:
A p-value < 0.05 was regarded statistically
The study was conducted at KEH over a 2 month
significant.
period. Every second primigravid patient presenting
to the labour ward with hypertension, defined as a
Results
blood pressure of >140/90mmHg after a 6 hour
Table 1 shows the demographic data of all patients.
period of bed rest was recruited. All patients were
Investigations
managed by standard methods.
performed in 78% of hypertensive patients and were
Primigravid
patients with a history of co-existing medical
in the antenatal period were
found to be normal in 90%.
Hypertensive therapy was used in 60% of the
hypertensive group and a single antihypertensive
agent, alpha methyl dopa, adequately lowered high
blood pressure in 68% of the patients.
The
standard dose of therapy was sufficient to lower
high blood pressure in 63% of patients and in 37%
maximum doses of therapy had to be used to
"control" hypertension. In 71% (95% CI: 65%-77%)
of
patients
treatment
of
hypertension
was
successful, resulting in the pregnancy being carried
to term.
Table 1 Demographic Data
Hypertensive (n=161)
Age (years)
Antenatal care
"Booked"
Controls (n=144)
20.1 (15-43)
20.1 (14-32)
94.0
96.0
22
p-Value
NS
"Unbooked"
6.0
4.0
NS
Placing of Antenatal Care
Clinic
Hospital
74.0
26.0
71.0
29.0
NS
113.2 (90-200)
71.3 (60-120)
108.7 (90-160)
67.4 (60-90)
0.011
0.004
Initial Blood Pressure
Systolic (mean) mmHg
Diastolic (mean) mmHg
(Means and ranges for continuous data and percentages for categorical data)
Using the dipstix method to test proteinuria, 84.4%
phenobarbitone and administration of standard
of the hypertensive patients did not have proteinuria
antihypertensive drugs e.g. dihydrallazine.
while 15.6% had proteinuria ranging from + to +++.
There was need for obstetric intervention viz.
Whilst "booking" blood pressures were normal in
delivery in 58% (95% CI: 50.4-65.6%) of patients.
both groups, in the hypertensive group the blood
The indications for delivery included intrauterine
pressure was elevated on admission. The mean
growth retardation (IUGR) in 4%; renal impairment
blood pressure on booking was 113.2 mmHg
in 4%; uncontrollable hypertension in 13% and
systolic (SD 18.4) and 71.3mmHg diastolic (SD
hypertension at term in 79%.
14.2) for hypertensive patients but on admission to
termination was by induction of labour and
the labour ward it was 156.5mmHg systlic (SD
subsequent vaginal delivery in 67% of patients while
18.9) and 106.8mmHg diastolic (SD 13.3). The
33% had caesarean sections.
mean gestational age on admission to the labour
The mean birthweight of babies born to mothers
ward was 36.8 (SD 2.8) weeks for hypertensive
with proteinuric hypertension was 2.4kg (SD 0.82).
patients and 37.9 weeks (SD 1.2) for controls
This was significantly lower than the birthweight of
(p=0.0001). Sixty two percent of patients did not
babies born to hypertensive mothers without
have proteinuria. Hypertension was not associated
proteinuria (2.8kg; SD 0.66) (p=0.001). It was also
with complications in 135 (84%) patients but was
significantly lower than for babies born to
associated with imminent eclamplsia in 3 (1.9%)
normotensive mothers which was 3.02kg (SD 0.54)
patients and eclampsia in 20 (12.4%) patients and
(p=0.0001). The difference in birthweight between
other complications e.g. placental abruption were
babies born to normotensive mothers and those
found in 2 (1.2%) patients. In 86% of patients the
born to hypertensive mothers without proteinuria
blood pressure settled on sedation with sodium
was significant, p=0.009.
There was no significant difference in APGAR
eclamptics). If these two were excluded from the
scores between babies born to hypertensive
proteinuric hypertesive group then the perinatal
mothers, whether proteinuric or not as compared to
mortality was 18.4% for mothers with hypertension
normotensive mothers.
Overall there were 9
and proteinuria. There was one maternal death.
perinatal deaths. All occurred in the proteinuric
This occurred in a 20 year old primigravida, who
hypertensive group and included 5 fresh stillbirths, 3
initially had antenatal care at a community antenatal
macerated stillbirths and 1 perinatal death. This
clinic from the 30th week of pregnancy.
The method of
gives an overall perinatal mortality of 17% (95% CI:
8-26%). Of the nine babies who demised, two were
Discussion
born to mothers with eclampsia, giving a perinatal
This study, shows a higher maternal and fetal
mortality in this subgroup of 10% (2 of 20
morbidity in
23
hypertensive
primigravidae
with
proteinuria
as
compared
to
normotensive
eclampsia. In the meantime strong consideration to
primigravidae. Morbidity suffered by hypertensive
delivery should be given to women with proteinuric
primigravidae was shown by a higher caesarean
hypertension irrespective of parity, once fetal
section rate in the hypertensive group as compared
maturity has been established.
to controls. Furthermore, 20 patients in the study
had eclampsia and all had proteinuric hypertension.
Two patients in the hypertensive group also
required intensive care facilities for post partum
management and care, while one patient with
eclampsia
demised.
This
high
maternal
complication rate probably reflects the referral
nature of the base hospital. It may appear that
there was an overly high number of patients who
had eclampsia. This complication is common in the
region and approximately 120 cases per year are
seen at KEH.
Babies born to hypertensive mothers had lower birth
weights when compared to normotensive mothers.
The birthweights were significantly lower if the
hypertension was complicated by proteinurua
(p=0.0001).
Although there are no data on
gestational ages, there is evidence in the literature
that babies born to hypertensive mothers with
proteinuria have a higher incidence of intrauterine
growth retardation. It is surprising that the group
with aproteinuric hypertension did not differ from the
normotensive group in respect to birthweight and
perinatal mortality rate. It does imply that such
patients usually present in late gestation and
undergo
induction
of
labour
in
controlled
circumstances. Seventy eight percent of patients
with hypertension were induced at term in this study.
It is also probable that this form of management
accounts for the lower caesarean section in the
group
with
aproteinuric
hypertension
when
compared to the normotensive group. It is only by
instituting the primary health care approach and
appropriate referral systems that developing
countries will reduce the incidence of pre-
24
25
PERINATAL OUTCOME OF HYPERTENSIVE
Methods
DISORDERS OF PREGNANCY IN BLACK SOUTH
Maternal and neonatal data were recorded for all
AFRICAN WOMEN
hypertensive patients admitted to KEH over a 2
month period from January to June 1995.
In
NM Rankhethoa, J Moodley, M Adhikari, E Gouws
addition, similar data from normotensive women
MRC/UN Pregnancy Hypertension Research Unit,
was recorded. The latter formed the control group.
Faculty of Medicine, University of Natal, Durban
Descriptive statistics consisting of means and
standard deviations or frequencies and percentages
Background
were calculated to describe the sample.
For
Perinatal mortality rates (PMR) associated with
continuous data, the student t-test was used. The
hypertension are known to be high but there have
Chi-square test was used for categorical data.
been isolated reports that primigravidae who
Appropriate tests of analysis of variance were used
develop hypertension late in pregnancy have a
for multiple comparisons.
better PMR than normotensive gravid women. The
aim of this study was to verify these reports in Black
Results
African women attending King Edward VIII Hospital
Three hundred and fifty seven women were entered
(KEH), and to compare the perinatal outcome in
into the study. Their clinical data is shown in Table
differing categories of hypertensive disorders of
1.
pregnancy.
Table 1
Total no. of
women (n=345)
GROUP A (N=189)
GROUP B (N=148)
APROTEINURIC
(n=63)
Mean(SD)
MODERATE
(n=47)
Mean (SD)
SEVERE
(n=83)
Mean (SD)
Age (years)
26
(6)
24
(6)
23
(6)
24
(6)
Parity
2
(2)
1
(2)
1
(1)
1
(1)
Gestational age
(weeks)
36
(3)
35
(4)
33
(4)
31
(3)
Antenatal care*
57*
(93%)#
41*
(93%)#
68*
(82%)#
101*
(69%)#
* = patients received antenatal care;
Group
A
consisted
of
189
#
= patients did not attend antenatal clinic;
patients
= no statistical difference
with
significant differences betweent the groups in
hypertension, while Group B consisted of 148
relation to maternal age, parity and period of
normotensive pregnant women. There were no
gestation.
More women in the hypertensive group had
group than in the hypertensive group (p=0.031).
caesarean sections than in the control group (study
More importantly, the number of perinatal deaths in
group 75 vs control 32: p=0.001). Their perinatal
the aproteinuric group was significantly different
outcome was significantly greater in the control
from
26
the
control
group
(a proteinuric group = 2; control group = 26;
(hypertensive 2.30kg vs control 1.65kg: p=0.0001:
p=0.007).
Table 2).
The birthweights in the hypertensive
group were greater than those in the control group
Table 2 Obstetric and Neonatal Data
CATEGORY
APROTEINURIC
n=63
MODERATE
n=47
SEVERE
n=83
TOTAL
n=189
CONTROL
n=148
Caesarean Section
33
25
65
123
32
Normal vaginal
delivery
30
22
23
75
124 (9 pairs
twins)
Birth weight (kg)
2.66 (0.74)
2.42 (0.92)
1.99 (0.84)
2.3 (0.88)
1.65 (0.46)
Alive
61
43
85
190
130
Stillbirths
0
2
5
7
4
Neonatal
2
2
8
12
22
() standard deviation; *p=0.0001 - significant differences from each other at 5% significance level
Table 3 shows the gestational age according to
Ballard's
score.
Women
with
The control group had a higher frequency of
proteinuric
neonatal complications such as respiratory distress,
hypertension had a greater number of SGA babies
hyaline membrane disease and sepsis than the
than the aproteinuric group. Furthermore, 38 of the
hypertensive group. Hyaline membrane disease
83 severe hypertensive group had SGA babies.
(13% vs 30% for controls : p-=0.001).
Table 3 Gestational Age according to Ballard Score
HYPERTENSION
GROUP
Aproteinuric
(n=63)
Mean(SD)
Moderate
(n=47)
Mean(SD)
Severe
n=83)
Mean(SD)
TOTAL
CONTROLS
n=157*
Mean(SD)
Mean(SD)
AGA
31
[47.7%]
30
[58.8%]
43
[46.4%]
104
[50.0%]
83
[53.2%]
SGA
20
[30.8%]
16
[31.4%]
38
[41.3%]
74
[37.0%]
69
[44.2%]
LGA
14
[21.5%]
5
[9.8%]
11
[12.0%]
30
[14.4%]
4
[2.5%]
Comparison of all 4 groups : p=0.001; Hypertension vs Controls : p=0.001; Aproteinuric vs Proteinuric vs Severe : p=NS
* = 9 pairs twins
27
Discussion
This
study
hypertensive
confirms
previous
disorders
are
reports
that
associated
with
increased perinatal mortality rates. Twenty of the
63 patients (37%) with aproteinuric hypertension
had SGA babies in comparison to 54 of 143 (38%)
patients with severe hypertension. In the control
group, 46% had SGA babies. It is difficult in our
setting to distinguish between chronic hypertension
and superimposed pre-eclampsia but the study
confirms the overall high incidence of SGA babies,
not only in the control group, but also in the differing
categories of hypertensive disorders of pregnancy.
The birthweights of babies born to the hypertensive
mothers were greater than the control group but
birthweights of the severe hypertensive group were
less than the other categories of hypertension.
The lower rate of complications, viz. intraventricular
haemorrhage, respiratory distress and patent
ductus arteriosus in neonates born to the
hypertensive group is postulated to be due to
accelerated maturity of the adrenocortical system
and the positive effect of cortisol on pulmonary
maturation.
There was an accepted high rate of stillbirths in the
severe hypertension group, but this study shows
that although patients with aproteinuric hypertension
have a relatively high incidence of SGA babies, their
perinatal mortality rate is similar to that of the
population served by KEH.
28
THE EFFECT OF DEXAMETHASONE ON THE
To test cell-mediated immune response, the
IMMUNE SYSTEM OF WOMEN WITH PRETERM
Multitest®CMI was applied to the ventral forearm of
PREMATURE RUPTURE OF MEMBRANES: A
patients at trial entry and read after 48 hours. The
RANDOMISED CONTROLLED TRIAL
investigators collected blood for full blood count and
froze serum for determination of C-reactive protein
RC Pattinson, JD Makin, M Funk, H Fickl*
(CRP), Interleukin-6 (11-6) and Tumour Necrosis
Department of Obstetrics and Gynaecology,
Factor- (TNF-) at trial entry, 48 hours and 7 days
University of Pretoria, Kalafong Hospital
thereafter.
*Department of Immunology, University of Pretoria
nephelometry and 11-6 and TNF- by photometric
CRP was determined by lazer
enzyme immunoassay as a batch.
A recent systematic review of randomised trials on
Management of patients was independent of these
antenatal administration of corticosteroids before
results.
preterm delivery, showed significant reduction in the
The dexamethasone and placebo groups were
occurrence of respiratory distress syndrome in
compared using the t test or Mann-Whitney U test
neonates.
for continuous data, while categorical data were
Concerns that corticosteroids might
analysed using the x2 - test or Fisher's exact test.
increase susceptibility to intrauterine infection, or
delay its recognition, could however not be
Results
substantiated by the available trials.
The median Multitest®CMI score was 7(range 0-19)
Objective
in the dexamethasone group, compared to 12.5
To investigate the effect of dexamethasone on the
(range 0-29) in the placebo group (p=0.07).
immune response of
Significantly higher leucocyte counts (13.08+4.02vs.
patients
with preterm
10.24+2.31 x 109/l; p=0.03) and neutrophil counts
premature rupture of membranes.
(9.86+3.64 vs. 6.93+3.25 x 109/l; p=0.04) occurred
Method
in the dexamethasone group at 48 hours. From trial
As a subgroup of the "Dexiprom" trial, thirty patients
entry to 48 hours, leucocyte counts increased by
with confirmed premature rupture of membranes,
3.54+2.21 x 109/l in the dexamethasone group,
between 28 and 34 weeks of gestation, participated
compared to -0.08+2.52 x 109/l in the placebo group
in this double blind randomised controlled trial.
(p=0.002). The change in neutrophil counts was
Patients with clinical evidence of infection or an
2.82+1.94 and -0.62+3.58 x 109/l respectively
indication for immediate delivery were excluded.
(p=0.009). No significant differences were detected
Dexamethasone
between the groups in levels of CRP, 11-6 or TNF-
24
mg
or
placebo
was
administered intramuscularly in divided doses, 24
48 hours or 7 days after trial entry.
hours apart.
In addition, all patients received
The change in levels of CRP, 11-6 and TNF- from
amoxycillin 500 mg and metronidazole 400 mg 8-
trial entry to 48 hours did not differ between the
hourly.
groups.
Spontaneous
chorioamnionitis,
labour,
occurrence
of
suspected
an
obstetric
The median time to delivery was 3.8 days (range
complication, or completion of 34 weeks gestation
0.3-27.2) in the dexamethasone group, compared to
were indications for delivery.
4.1 days (range 0.5-32.5) in the placebo group
29
(p=0.71).
Two patients in each group were
delivered for suspected infection and patients'
highest postpartum temperature did not differ
between the groups.
Conclusion
Dexamethasone administration to patients with
preterm premature rupture of membranes was
associated with significant increases in leucocyte
and neutrophil counts over 48 hours. There was
some evidence of suppressed cell-mediated
immunity. The "Dexiprom" trial should answer the
question whether dexamethasone influences clinical
maternal or neonatal infectious morbidity.
30
THE VALUE OF DOPPLER STUDIES OF THE
investigated during the last two weeks of pregnancy
MIDDLE CEREBRAL ARTERY 9MCA0 IN THE
were analyzed. Patients with an anomalous fetus, a
MANAGEMENT
monochorionic twin pregnancy or incomplete results
OF
PREGNANCIES
WITH
were excluded. Analysis was repeated for fetuses
SEVERE PLACENTAL INSUFFICIENCY.
with a birth weight above 800 gram and for
L Geerts, D Grove.
subgroups with or without spontaneous fetal death
Ultrasound Unit, Department of Obstetrics and
or distress.
Gynaecology, MRC Perinatal Mortality Research
Main outcome parameters:
Unit, Tygerberg Hospital.
Correlation between abnormal Doppler results and
the spontaneous onset of fetal death or distress and
poor fetal outcome (death or major morbidity).
Background:
Blood flow redistribution occurs in severe placental
insufficiency
due
to
increasing
Results:
cerebral
vasodilatation. With progressive insufficiency this
Selection criteria were met in 79 patients. Sixty -two
vasodilatory capacity is finally lost. These changes
mothers had serious medical problems and 30 were
precede fetal distress by a short interval, making
delivered for maternal reasons.
them potentially useful to determine the ideal time
gestational age at birth as 30.2 + 3.3 weeks and
for elective delivery.
the birthweight 1003.7 + 375.7 gram (56 babies
The mean
weighed more than 800 gram). Thirty fetuses died
Hypothesis:
in utero, 8 in the neonatal period and 5 during
Extreme degrees of brainsparing or the loss of
infancy (total mortality 54.4%).
brainsparing is associated with impending fetal
developed in 31 cases (63.3% of the liveborn
distress.
babies), in 7 due to abruptio placentae. Only 10
Fetal distress
babies had no major problems.
Study design and methods:
The majority of patients (49) had only 1 Doppler
Descriptive analytical study. Patients with absent
investigation. Serial Dopplers (>=3) to detect the
end-diastolic velocities in the umbilical artery
"nadir" of cerebral resistance could be obtained in
(AEDV-UA) were prospectively followed up with
only 20 patients. Delivery occurred 2 (0-47) days
repeated duplex-Doppler investigations of the UA
after the first and 1 (0-12) days after the last
and MCA (Pulsatility index (PI)).
Doppler study.
Patients
An abnormally low PI-MCA (n-61) did not correlate
Positive predictive values were high but negative
with fetal death or distress or poor short term
values were very low. Although not significant, this
outcome.
high ratio was also associated with a higher risk for
The PI-UA/MCA ratio indicated
brainsparing in 78 patients.
Values above 2.0
spontaneous fetal death or distress for all (OR 4.0
significantly predicted fetal death or distress in
(0.92-17.70)) and for babies weighing more than
babies weighing more than 800 gram (p=0.027).
800 gram (OR 5.78 (0.98-34.13)). The cumulative
Values above 2.5 correlated significantly with poor
percentage over time of babies delivered for fetal
short term outcome for all babies (p=0.015) and for
death or distress demonstrated that significantly
babies weighing more than 800 gram (p=0.012).
more babies with a high ratio (79%) died or
31
developed distress within 4 days (logrank test
p=0.0367).
Doppler trends could only be investigated in 30
patients. The presence (n=23) or absence (n=7) of
brainsparing from the first investigation onwards
and the subsequent loss (n=2) or gain(n=6) of it did
not predict outcome.
Conclusions:
In most patients ony single Doppler results will be
obtained.
A markedly raised PI-UA/MCA ratio (>2.5) indicates
poor shortterm outcome and a high risk for fetal
death or distress within the next 4 days.
No specific pattern of serial Doppler studies
involving the MCA is predictive of outcome.
Recommendations:
The presence of less than extreme brainsparing is
not reassuring and these babies should still be
monitored intensively. The presence of a very high
PI-UA/MCA ratio predicts serious fetal problems in
the near future and elective delivery in these cases
could possibly be of benefit.
32
hospital.
REFERRAL OF PATIENTS WITH PRELABOUR
RUPTURE
OF
RETREAT
MOU
THE
TO
MEMBRANES
GROOTE
FROM
Patients and Methods
SCHUUR
This retrospective pilot study, covered the period
HOSPITAL.
July 1994 to December 1995.
Only patients
AA Van Coeverden de Groot, HA Van Ceoverden
referred with PROM Retreat to MOU to Groote
de Groot.
Schuur Hospital were included.
Departments of Obstetrics and Gynaecology and
Medical Informatics, Univ. of Cape Town and
Results
Groote Schuur Hospital.
Of the 179 patients referred with PROM, 141 folders
(78%) were traced.
Of the latter, 19 had been
In the Peninsula Maternal and Neonatal Service in
incorrectly labelled as having PROM.
Cape Town, a patient admitted to a Midwife
remaining 122 patients were included in the study.
Obstetric Unit (MOU) with prelabour rupture of the
A total of 111 patients had PROM confirmed in
membranes (PROM) is transferred to the referral
hospital. This amounted to 90% of the 122 patients
hospital. There was a concern that such patients
entered in the study. Assuming a "worst scenario",
might be subjected to an unnecessary speculum
where all 38 patients whose folders were untraced
examination,
speculum
had been correctly referred but did not have PROM
This could be
confirmed in the hospital, the percentage with
interpreted as a rejection of the midwife's diagnosis,
confirmed PROM would have been 111/160 or 69%.
which would inevitably lead to loss of community
The diagnosis of PROM in the MOU was made by
credibility. Moreover, a speculum examination is
(number of patients in brackets):
uncomfortable and should only be done for a valid
*
Observing the drainage of liquor amnii (93)
reason.
*
Noting of a pad soaked with liquid amnii(78)
*
Noting a colour change, using litmus paper
or
even
a
examination, in the hospital.
repeat
(68)
Objectives
To establish in patients referred from the MOU with
*
Speculum examination (39)
a diagnosis of PROM:
*
Digital vaginal examination (4)
1.
2.
The percentage who had this
In many patients several diagnostic features were
diagnosis confirmed in the hospital.
present.
The methods used to diagnose
Confirmation of PROM in hospital was by means of
PROM, both in the MOU and in the
*
*
*
The prevalence of unnecessary
speculum
A doctor's statement to that effect in the
folder.
hospital.
3.
The
examination
in
Detecting ferning on microscopy of vaginal
fluid.
the
A vaginal, with or without a speculum
Of the 39 speculum examinations done in the MOU,
examination.
31 (79%) were repeated in hospital.
In all, 86
patients (70% of the 122 study patients) had this
33
examination in the hospital.
Of the study patients, 45 (37%) received antibiotics,
whether sepsis had been proven to be present or
not.
Conclusions
1.
Of the patients in the study, who had been
referred with PROM from the MOU, 90%
had this diagnosis confirmed in the hospital.
2.
Many patients
are
subjected
to
an
unnecessary speculum examination, to
confirm PROM, in hospital.
3.
In view of the appreciable maternal
morbidity, the current protocol, whereby
MOU patients with PROM are referred to
hospital, should be continued.
4.
This pilot study involved only one MOU. A
prospective study is planned to include all 6
MOUs; to keep better track of "lost" folders,
and to follow up those patients whose
PROM was not confirmed in the hospital.
34
INFANTS
infants with birth weights below 1000g and above
VENTILATED IN TERTIARY AND PRIVATE
2500g compared to the academic NICUs (Fig 1).
INTENSIVE CARE UNITS IN SOUTH AFRICA
Respiratory distress syndrome (RDS) was the most
A
COMPARATIVE
PROFILE
OF
important indication for admission to the private
GF Kirsten, CL Kirsten
NICUs (Fig 2).
More infants with meconium
Dept of Paediatrics, Tygerberg Hospital & University
aspiration were admitted to the academic NICUs
of Stellenbosch
compared to the private NICUs (Fig 2). Necrotising
enterocolitis (NEC) occurred significantly more often
Introduction:
in infants admitted to the academic NICUs (Fig 3).
Increasing numbers of neonates are ventilated in
No differences were noted regarding mortality in the
more intensive care units (ICU) in South Africa
different birth weight categories between infants
every year.
ventilated in private and academic NICUs.
Incomplete information exists on the
profile and outcome of infants ventilated at tertiary
hospitals in this country.
Conclusion:
No information is
Academic and private NICUs each have unique
available from private institutions.
problems as identified by this study. Academic
Objective:
NICUs are burdened by the admission of a large
To obtain baseline information on infants ventilated
number of infants with preventable disorders such
at university-affiliated tertiary and private neonatal
as meconium aspiration and NEC while private
intensive care units (NICUs) in South Africa over a
NICUs treat mostly surfactant deficient respiratory
12-month period.
distress which could indicate a critical re-evaluation
of antenatal steroid administration.
Study Design:
Prospective cohort analytic study.
Study Setting:
Four university-affiliated NICUs in South Africa and
16 private hospital NICUs in South Africa and
Namibia.
Patients and Methods:
All infants ventilated at these institutions between 14
August 1994 and 14 August 1995 were admitted to
the study. Information was entered on a data form
by the attending paediatrician or a senior sister
specifically identified for this task.
Results:
The private NICUs admitted significantly more
35
INFANTS:
After obtaining parental consent, infants were
DIRECT EXTUBATION FROM LOW RATES
weaned to a rate of 8-6 breaths per minute, and
COMPARED WITH EXTUBATION FROM CPAP
randomised into three groups.
EXTUBATION
OF
VENTILATED
Group 1: extubation immediately from a
JC Stephen, VA Davies, AD Rothberg, DE Ballot
low rate.
Dept.
Group 2:
of
Paediatrics,
University
of
the
extubation after 1 to 3 hours
CPAP.
Witwatersrand.
Group 3: extubation after 12 to 24 hours
CPAP.
Introduction:
CPAP (continuous positive airway pressure)
Post-extubation chest x-rays were done within 24
improves functional residual capacity, decreases
hours to exclude atelectasis.
post-extubation atelectasis, prevents apnoea and
intubated
stabilises the chest wall.
recurrent apnoea or stridor occurred.
CPAP may be given
if
Infants were re-
respiratory acidosis,
atelectasis,
during ventilation via endotracheal tube (ETT) after
extubation via nasal cannulae, or before extubation
Selection of Sample Size:
with spontaneous breathing for 1 or 24 hours.
A target sample size of 60 infants in each of the
Advantages of pre-extubation CPAP have not been
three groups was selected to comply with the
proven. Disadvantages include apnoea and CO2
following statistical requisites:
retention in infants under 1250g, prolonged ICU stay
a significance level (alpha value) = 0.05
and increased costs.
expected successful extubation rate (P1 value)
= 0,95
current successful extubation rate (P2 value)
Aim:
1.
= 0,75
To ascertain current practices of extubating
ventilated infants at South African Teaching
a beta value (P1-P2)
= 0,2
Hospital Neonatal Intensive Care Units
a power factor (1-beta)
= 0,8
(NICUs) and selected private clinics by
2.
postal questionnaire.
Results of the Survey:
To conduct a prospective randomised study
The results of the survey of extubation practices at
comparing
various NICUs in South Africa are shown in Table 1.
pre-extubation
CPAP
with
extubation from low rates in ventilated
infants less than 1 week old.
Method:
A prospective randomised study was done on all
infants with respiratory distress ventilated at
Johannesburg and Baragwanath Hospital Neonatal
ICUs. Babies with congenital abnormalities, severe
birth asphyxia, and those ventilated post-operatively
were excluded.
36
Table 1:
atelectasis. Direct extubation from a low rate is a
EXTUBATION PRACTICES AT
NICUs
reasonable alternative to pre-extubation CPAP and
No CPAP 1-3 hrs 3-12 hrs
12-24 hrs
Kalafong
KEH
Garden City
BARA
Tygerberg
GSH
Morningside
JHB
Sandton
Flora
Park Lane
At most centres, VLBW infants are given longer CPAP.
may be useful where limited physical and financial
resources necessitate shorter ICU stays in
ventilated newborns.
The reported failed extubation rates at the various
Table 3:
centres are shown in Table 2.
COMPARISON OF HOSPITAL
RESULTS
Table 2:
FAILED EXTUBATION RATES AT
Number
Male:female
Group 1
Group 2
Group 3
Birth wt <1250g
Failed extubation
Atelectasis
Aminophyllin
Dopamine
Pancuronium
Dexamethasone
Surfactant
NICUs
2%
5%
7%
100%
20%
40%
Flora
Garden City, Park Lane
KEH
GSH
BARA
Sandton, Morningside
VLBW Sandton, Morningside
Tygerberg
Results:
JHB
%
51
1:1.8
33
35
31
16
17
3
52
46
25
15
37
BARA
%
49
1 : 1 . 2 NS
37
31
32
24
17
2
54
51
35
4
9
p
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
<0.05
<0.01
The extubation groups and the 2 hospital groups
Table 4:
were comparable in terms of entry criteria. (Table
3).
193 infants were enrolled, of which 13 of 68 in group
Number
Male:female
Group 1
Group 2
Group 3
Birth wt <1501g
Birth wt >1501g
Pancuronium
Surfactant
Dopamine
Dexamethasone
Daminophyllin
1 (19%) failed extubation, compared to 13 of 64
group 2 (20%) and 7 of 61 in group 3 (12%).
There was no significant difference between the
groups in failed extubation rates or atelectasis rates,
or between the two hospitals Table 4).
(The
different rates or surfactant and dexamethasone
use between the two hospitals reflect the different
policies and practices at the time of the study).
Significantly more infants failed if birth weight was
less than 1,5kg (p<0,0001), or if they had received
dexamethasone (p<0,05) or dopamine (p<0,1) or
aminophyllin (p<0,01) (Table 5) which may reflect
their prematurity, but these infants did not show
different failure rates between the 3 groups studied.
Conclusion:
Pre-extubation CPAP does not influence the
success
of
extubation
or
post-extubation
37
RESULTS
STUDY
OF
FAILED EXTUBATION
No
Yes
%
%
83
17
1:1.8 1:1.0
81
19
80
20
88
12
72
28
92
8
16
19
22
27
12
22
15
37
8
25
EXTUBATION
p
NS
NS
NS
NS
<0.0001
NS
NS
<0.1
<0.05
<0.01
Table 5:
TOTAL
Failed extubation
% Failed extubation
% Dexamethasone
% Dopamine
RESULTS OF INFANTS
28
37
< 1501g <1501g
87
24
8
15
23
>1501g
103
8
TOTAL
190
32
17
17
11
p=0.000
p=0.03
17
38
p=0.04
COMPARISON OF INTRAVENOUS AND ORAL
an intravenous group (IV) who received parental
IRON
iron sucrose (Venofer, Vifor) at a dose of
IN
PRETERM
INFANTS RECEIVING
6mg/kg/week of elemental iron, or an oral group
RECOMBINANT HUMAN ERYTHROPOIETIN
(OG) who received ferrous lactate orally at a dose
M Meyer et al
of 12mg/kg/day of elemental iron.
Department of Paediatrics, University of Cape Town
Both
groups
were
given
rHuEpo
(Eprex)
600U/kg/week in 3 divided doses subcutaneously.
Introduction
Other supplements given to all infants were a daily
It is clear that recombinant human erythropoietin
multivitamin supplement containing 50mg vitamin C
(rHuEpo) will in the future form part of an overall
and 25U Vitamin E.
strategy to reduce the need for blood transfusions in
which contained folate 40ug/100ml and iron
preterm infants. There is still considerable debate
1.1mg/100ml.
presently, however, as to indications for its use and
Preterm infants were eligible provided they were 7-
optimum dosage.
30 days old, weighed <1500g at study entry, and the
A further point of debate is the use of iron and other
venous haematocrit (HCT) was <38%.
substrate
rHuEpo
requirements were stable respiratory status ie not
In 3 recent trials iron was
on IPPV and requiring <40% oxygen, tolerating full
supplementation
administration.
during
absence
of
infection
or
Other
supplemented orally in a dose of 2-6mg/kg/day of
feeds,
elemental iron; all noted significantly decreased
malformations.
serum ferritin levels with rHuEpo therapy, and it is
Blood for laboratory tests was obtained at study
unclear if iron insufficiency may lead to limited
entry and weekly thereafter.
erythropoiesis.
complete blood count (CBC) with percentage
In the study of Meyer et al on the use of rHuEpo in
hypochromic cells, reticulocyte counts, serum iron
anaemia of prematurity, 20% of infants receiving
and total iron binding capacity, and serum ferritin
oral iron supplementation at 3mg/kg/day developed
levels.
low ferritin levels.
hypochromic cells were log-transformed.
Despite increasing oral iron
and
Infants received a formula
major
Tests included a
Serum ferritin values and percentage
supplements to 6-10mg/kg/day in a subgroup of 9
Blood loss was estimated to be approximately
infants, ferritin levels decreased in 5.
2ml/week.
Iron supplementation is usually given orally. The
The indications for a blood transfusion were similar
value and effect of parenteral iron has not received
to those described in the previous study of Meyer et
much attention.
al.
Aim
Results
This study was undertaken to determine whether
Twenty-one patients were enrolled in each group.
intravenous (IV) iron could avert the decrease in
There were no significant differences in the preterm
ferritin levels, and enhance the response to rHuEpo.
infants assigned to receive supplemental or
intravenous iron either at birth or at the time of entry
Methods
to the study.
Forty-two preterm infants were randomised to either
Twenty patients in the oral and 19 in the IV group
39
completed the study. One patient in the OG was
Intercurrent events included NEC with 1 case
withdrawn because full enteral feeds were not
each in the OG and I group. This prevalence of
tolerated.
2/39, or 5% was lower than the prevalence of 13%
Two patients in the IV group were
withdrawn from the study.
One developed NEC
concurrently recorded for infants <1500g in the
while another developed hepatitis.
nursery when an outbreak was in progress.
Both groups had a low transfusion rate: 2 out of 20
in the OG and none in the IV group.
This
Conclusions
difference was not significant.
1.
Oral iron (in a high dose) is favoured in
There were no significant differences in the
infants receiving rHuEpo because of ease
haematocrit values at study entry and exit between
of administration. Some of these infants
the oral and IV groups.
(15% in the present study) may, however,
There was however, a
small decline in HCT with time that was most
deplete their iron stores as reflected by
marked in the OG.
low serum ferritin levels.
Both oral and IV groups showed a significant
increase in absolute reticulocyte counts.
2.
Mean
IV iron sucrose is safe and efficacious in
infants receiving rHuEpo. Their serum
values at the end of the 1st week were at least
ferritin levels remained stable or
double those at entry.
increased marginally and their weight gain
The numbers of hypochromic cells were similar at
was significantly more.
study entry.
By completion the numbers had
increased significantly in both groups. The route of
iron administration had a significant effect with
increased hypochromic cells in the OG.
The
logarithm of the percentage hypochromic cells did
not correlate with serum ferritin, serum iron, or
percentage saturation of transferrin.
Logarithms of ferritin levels at the end of the study
were markedly different with a mean of 117
(2.3)ng/ml in the OG vs 246 (1.6)ng/ml in the IV
group (p<0.001). Three of 20 infants in the OG
had ferritin levels below normal at study
completion vs none in the IV group.
Other haematological parameters measured were
not different between the 2 groups.
The mean weekly weight gain in grams was
significantly higher in the IV group.
Intercurrent Events
No immediate side effects were apparent with
either preparation.
40
NOSOCOMIAL INFECTIONS IN A NEONATAL
prospectively.
HIGH CARE AND INTENSIVE CARE UNIT
Logistic regression analysis was used to
determine risk factors for the development of NI.
SD Delport, T. Urquhart
Department of Paediatrics, Kalafong Hospital and
Results
the University of Pretoria
Study population
A total of 426 infants were admitted to the NHCU
Introduction
and NICU during the period 1/11/1994 -
Advances in the care of critically ill neonates have
31/10/1995. Of these 426 infants, 343 were
improved survival but have created a greater risk
studied, because they had been hospitalised for
for nosocomial infections (NI). Recognition of
48 hours or more. Of the latter 343 infants, 210
predisposing factors for NI is crucial to facilitate
were admitted to the NHCU and 133 to the NICU.
early diagnosis and effective treatment.
The mean birth weight (BW) of the infants
admitted to the NICU was 1797 gram (range 840 -
Aims
3740). The mean BW of the infants admitted to
To determine the prevalence of NI in neonates
the NHCU was 1320 gram (range 960 - 4350).
admitted to a high care unit and an intensive care
unit and to determine the risk factors, sites of
Prevalence of NI
infection and etiologic agents.
Of the 210 infants admitted to the NHCU, 42
(20%) developed NI on 46 occasions (21,9/100
Patients and Methods
admissions) and their mean BW was 1402 gram
Infants admitted over a period of 12 months to the
(range 960 - 2200). The mean BW of the 210
neonatal high care unit (NHCU) and the neonatal
infants who did not develop NI was 1320 gram
intensive care unit (NICU) were included in the
(range 980 - 4350).
study. NI were defined as infections occurring
Of the 133 infants admitted to the NICU, 54
after a stay of 48 hours in either unit.
(40,6%) developed NI on 59 occasions (44,4/100
Surveillance for NI was carried out by clinical
admissions) and their mean BW was 1526 gram
evaluation, blood cultures, complete blood count
(range 840 - 3740). The mean BW of the 79
(CBC) and C-reactive protein (CRP). The special
infants who did not develop NI was 1983 gram
investigations were carried out at least twice
(range 680 - 4200). Severity of illness was
weekly or more often if indicated. A nosocomial
similar in the 2 groups with mean Score for
infection was documented in the event of a
Neonatal Acute Physiology (SNAP) of 16,0 (range
positive blood culture. In the absence of the
0-40) for infants who developed NI and 14,3
latter, a raised CRP(>10mg/l)or a neutropaenia
(range 1-40) for infants who did not develop NI.
(1000/mm3) or an immature to total neutrophil
ratio equalling or exceeding 0.2 in the presence of
Microbiology of NI
clinical signs were used as markers of a
An etiologic agent was identified in 30 (63%) of 46
nosocomial infection. X-rays and spinal taps
episodes of NI in the NHCU and 45 (64%) of 59
were performed if indicated. Data were collected
episodes of NI in the NICU.
41
Klebsiella pneumoniae was identified in 38% and
factor for developing NI in the NICU.
32% of the positive cultures from the NHCU and
the NICU respectively.
6.
The most common etiologic agent in the
NHCU and NICU was a Klebsiella
Sites of NI
pneumoniae.
Septicaemia and necrotising enterocolitis were the
most common NI in the NHCU while septicaemia
and bronchopneumonia were the most common
NI in the NICU.
Risk Factors
Infants at highest risk for NI in the NHCU were
those with a BW less than 1500 gram (OR 8.8))
and infants at highest risk for NI in the NICU were
infants with a BW less than 2000 gram (OR 2.9).
Outcome
In the NHCU the mortality was 28,6% for infants
who acquired NI and 0,02% for those who did not.
In the NICU the mortality was 25,9% for infants
who acquired NI and 21,5% for those who did not.
Conclusions
1.
The prevalence of NI is high in both the
NHCU and NICU at Kalafong Hospital.
2.
Infants who developed NI in the NICU had
a similar degree of illness as infants who
did not develop NI.
3.
Infants who developed NI in the NICU had
a similar mortality than infants who did not
develop NI. However, infants who
develop NI in the NHCU had a higher
mortality than those who did not.
4.
A BW less than 1500 gram was a risk
factor for developing NI in the NHCU.
5.
A BW less than 2000 gram was a risk
42
ANTIBIOTICS AND SUSPECTED SEPSIS IN
neurological signs, hepatosplenomegaly, positive
THE NEONATE: AN AUDIT
blood cultures and chest x-ray showing
pneumonia. Further, prematurity, light for dates
-M Adhikari, +H van Erp, +M Hoefnagels.
(LFD) babies, history of prolonged rupture of
*Department of Paediatrics University of Natal
membranes, abnormal white cell and platelet
+Department of Paediatrics University of
counts were factors regarded as supportive of
Groningen, Holland.
infection.
Background
Results
Suspected sepsis is a common diagnosis in the
During the period of study there were 898
Neonatal Unit. The incidence of neonatal
deliveries, 100 deaths occurred and there were
infections is 1-8 cases per 1000 live births and the
197 low birth weight infants (LBWI) (LBW rate
mortality approximately 25%. Suspected sepsis
21.9%). The mean maternal age was 25 (range
is a diagnosis based on a history of infection in
16-43) and 36 were primipara. The average
the mother, physical signs in the baby, abnormal
number of children was 2.4, 13 women had
haemoglobin, white cell or platelet counts. The
previous abortions, 6 previous stillbirth, 1 a
decision to discontinue antibiotics is influenced by
neonatal death and 3 had children who had died
the culture results, repeat haematological findings
of non-obstetric causes. The syphilis serology
and the clinical response of the baby. At King
was positive in 24 cases (23%), and was unknown
Edward Hospital penicillin and gentamycin are the
in 11 cases (10.4%). Pregnancy induced
first line antibiotics, third generation
hypertension was diagnosed in 32. Two had a
cephalosporins are reserved for gram negative
febrile illness during labour. Six mothers were
bacterial meningitis.
HIV positive and 2 had pulmonary tuberculosis.
Of 510 high risk neonates (57% of live births)
Aims
admitted to the Nursery 106 (21%) received
The aim of this study was to determine if
antibiotics. The mean birth weight was 2068gms
antibiotics were prescribed for appropriate clinical
with a range of 900-3850gms, 72 (68%) were low
situations, the incidence of proven infections and
birth weight, 71 preterm and 38 weighed less than
to review the common physical signs of infection.
1500gms. The gestational age ranged from 2733 weeks, 68 were appropriate for gestational age
Method
and 84% of LFD babies, preterm. Proven
For the month of May 1995 all babies who
infections were diagnosed in 31 (30%) of those
received antibiotics were studied. Maternal,
treated. The incidence of proven infection was 35
neonatal data and clinical features suggestive of
per 1000.
sepsis were recorded. The diagnosis of proven
sepsis was based on the presence of the
nonspecific signs of infection, pulmonary and
Of the babies with proven infection the majority 25
syphilis (7 preterm infants), 12 pneumonia and 10
(81%) were preterm. Nine babies had congenital
positive blood cultures. Of those with unproven
43
infection 25 had HMD, 29 had neurological signs,
deaths. Antibiotics were prescribed appropriately
of whom 25 had intraventicular haemorrhage
and the duration of treatment was influenced by
(IVH) and in 12 preterm or LFD maternal syphilis
the number of babies with congenital syphilis and
serology was positive. Mean Hb 16.03 (SD 3.42),
those requiring intensive care. Seventy percent
WCC 15.96 (SD 7.34) platelets 233.6 (SD 99.86).
of the patients were treated for 7 days or less and
The mean duration of antibiotic treatment was 6.8
eight-four percent for 10 days or less.
days (range 1-28 days),, 19% had antibiotics for
The high risk of infection and prematurity is a
1-3 days, 51% for 4-7 days, 13% 8-10 and 16%
major concern and has been shown previously to
for more than 10 days. Eighty-seven (82%) of
be associated with IVH. Strategies for detecting
the 106 patients were treated for a period of 10 or
and managing antenatal and intrapartum infection
less. (Mean 5.2 SD 2.2 days). Of those
is a crucial issue.
receiving antibiotics for 10 days or more, 13 of
these 17 babies had proven infection.
Of the 11 deaths 3 (27%) were due to congenital
syphilis, 8 respiratory problems, 6 IVH, 2
associated with HIV positive mothers. Six
mothers had tuberculosis and their babies had
proven infection.
The following risk factors did not predict proven
infection - prematurity, LFD, abnormal WCC, low
platelets and a maternal history of prolonged
rupture of membranes.
DISCUSSION
The infection rate in this small sample of patients
studied was very high 4 to 5 five times the figures
of 8 per thousand quoted in the literature.
Positive blood cultures, congenital syphilis and a
chest x-ray of pneumonia was present in 30% of
those treated. Not unexpectedly the majority were
preterm infants, however, the other expected risk
factors did not predict infection, this is possibly
due to the small number of patients studied in this
sample. The physical signs suggestive of
infection were not unusual. Congenital syphilis
was a major cause of death and was second to
the respiratory causes, IVH contributed to
mortality and morbidity. Maternal HIV infection
and PTB were associated with three of the
44
SHOULD SYMPTOMATIC CONGENITAL
were followed up for one year at three monthly
SYPHILITICS BE OFFERED VENTILATION?
intervals.
THE BARAGWANATH EXPERIENCE.
Results
CJ Hauptfleisch, H Saloojee, PA Cooper,
A total of 58 neonates with SCS were enrolled, of
Department of Paediatrics, Baragwanath Hospital
which 33 (57%) needed ventilation. vSCS
and the University of the Witwatersrand.
accounted for 8% of all the NICU admissions.
There were no demographic differences between
Introduction
the vSCS and non vSCS with respect to:
Congenital syphilis remains a significant yet
*
booking status - 61% unbooked in the
vSCS
preventable cause of perinatal morbidity and
*
mortality in South Africa. In June 1994 free
mean maternal age = 24 years (28% were
teenagers).
antenatal care was introduced in South Africa.
The 'unbooked' rate at Baragwanath Hospital prior
*
maternal RPR titres.
to the introduction of free antenatal care was +
Mothers who were RPR positive had an increased
20%. By January 1995, it had dropped to + 5%.
risk of being HIV positive, ie.
The introduction of free antenatal care has
21% were HIV positive as compared with a 12%
rekindled the debate as to whether symptomatic
rate for the general Baragwanath maternity
congenital syphilitics (SCS) should be
population.
discriminated against, particularly with respect to
Table 1:
ventilation.
Morbidity data in ventilated
congenital syphilitics.
OUTCOME
Aims
Hepatitis ( ALT/AST)
Platelets < 100 000
WCC > 30 000
IVH
Feeding intolerance
PDA
The aims of this study were to:
(i)
assess the mortality and morbidity of
ventilated SCS (vSCS).
(ii)
identify poor prognostic features in SCS.
(iii)
establish whether the outcome of vSCS
differed from the general NICU
population.
Methods
A prospective, observational study of all
symptomatic congenital syphilitics (SCS) born at
Baragwanath Hospital and its satellite Soweto
clinics from May 1994 to December 1995. SCS
were defined using Kaufman's criteria. vSCS
were compared with all 1994 NICU admissions
using the unit's computer database. The infants
45
%
73
49
42
33
33
24
TABLE 11:
Comparison between ventilated SCS (vSCS) and all 1994 NICU admissions.
vSCS(n = 33)
All NICU 94(n = 619)
p value
Gestation (weeks)
34,7
31.8
<0.001*
Mass (grams)
1770
1846
ns
Stay in NICU (days)
8.3
6.7
ns
Intubated (days)
6.3
4.8
ns
Died
17
52%
235
38%
0.17
Metabolic acidosis
17
52%
210
34%
0.06
Pressors
17
52%
296
48%
0.81
IVH
11
33%
64
10%
<0.001*
PDA
8
24%
65
11%
0.02*
Nosocomial infection
7
21%
73
12%
0.16
NEC
2
6%
13
2%
0.18
did not differ from the general NICU population.
Comparing the vSCS with the general NICU
Thus, SCS cannot be denied on purely medical
population, it was noted that despite the vSCS
criteria. However, hydropic syphilitics who were
being significantly older (gestational age 34.7 vs
ventilated did extremely poorly (100% mortality in
31.8 weeks, p value <0.001) they had a higher
6 patients ) and we believe that this subgroup
incidence of both IVH (24% vs 10%, p value
should not be considered for ventilation. It is a
<0.001) and PDA (24% vs 11%, p value 0.02).
moot point as to whether some babies, eg. babies
There were no significant differences between the
of 'unbooked' mothers, be denied NICU facilities
two groups with respect to length of stay in NICU
on non-medical criteria particularly in areas where
nor in days intubated. While the vSCS had a
antenatal care is easily accessible.
higher mortality (52%) than the general NICU
Routine on-site maternal screening for syphilis
population (38%) this was not statistically
during pregnancy and its management must be
significant.
targeted as a national health priority, particularly in
Since NICU beds are a scarce commodity,
the rural areas where screening is virtually non-
decisions re: ventilation often need to be made at
existent. This could result in a significant
birth.
reduction in the wanton use of expensive
The three best predictors of mortality at birth in
secondary and tertiary care facilities for the
vSCS were:
*
need for vasopressors 82% ppv
*
IVH
74% ppv
*
acidosis (pH<7.2)
71% ppv
treatment of an easily preventable disease.
The best overall predictor of mortality was the
need for vasopressor support.
Conclusions
The mortality and duration of ventilation of vSCS
46
ASYMPTOMATIC BACTERIURIA:
Ninety-one (6,2%) of the group had asymptomatic
SIGNIFICANCE AND TREATMENT DURING
bacteriuria and of these 64 could be studied in
PREGNANCY
terms of treatment modality, success thereof and
pregnancy outcome. A control group of 151
DR Hall, GB Theron, W van der Horst.
patients without asymptomatic bacteriuria was
Department of Obstetrics and Gynaecology,
studied in the same manner.
University of Stellenbosch
Results:
Objectives:
The initial course of antibiotic therapy was
To study the efficacy of single dose antibiotic
successful in 63% of cases where a single dose
treatment of asymptomatic bacteriuria in pregnant
regimen was used while only 43% responded
patients as well as their eventual outcome.
after the first multiple dose regimen. Sensitivity
of the isolate to the given antibiotic was of
Design:
doubtful value. Patients with persisting
Cohort analytic study.
asymptomatic bacteriuria tended to have more
pre-term labour and pyelonephritis.
Setting:
Tygerberg Hospital, Cape Town, a center
Conclusions:
rendering primary to tertiary services.
Single dose therapy for asymptomatic bacteriuria
in this study was more effective than conventional
Subjects:
therapy. Patients with persistent asymptomatic
Over a seven month period, the urine cultures of
bacteriuria are at higher risk for pregnancy
all patients booking at our antenatal clinic were
complications.
checked.
Table 1:
OUTCOME OF PREGNANCY: STUDY VERSUS CONTROL
Outcome
Study
PTL/PPRROM
(22w<x<34w)
Pyelonephritis
Control
Significance
(n=64)
(n=151)
7
3
5
2
p=0,03 (Fisher)
NS
Table 2:
OUTCOME OF PREGNANCY IN CLEARED VERSUS PERSISTED SUBGROUPS OF
ASYMPTOMATIC BACTERIURIA
Outcome:
Persisted
PTL/PPROM
(22w<x<34w)
Pyelonephritis
Cleared
Significance
(n=31)
(n=33)
5
3
2
0
NS
NS
47
Table 3:
Dose of first drug
Single
Multiple
TREATMENT MODALITIES IN THE CLEARED AND PERSISTED SUBGROUPS OF
ASYMPTOMATIC BACTERIURIA
Persisted (n=31)
Cleared (n=33)
10
21
17
16
63%cured
43% cured
48
GENITAL INFECTIONS IN THE ETIOLOGY OF
was 1954g and in liveborns 3223g (p=0.001). The
LATE FETAL DEATH : AN INCIDENT CASE-
corresponding prevalence of LBW was 78% in
REFERENT STUDY
cases and 0% among second referents (p<0.001).
Histological chorioamnionitis was significantly
NB Osman, Dept Obs/Gyn, Central Hospital,
more prevalent in cases than in second referents
Maputo, Mozambique
(OR=4.97). Syphilis was significantly more
E Folgosa, Dept Microbiology, Faculty of
common in cases than in first (OR=7.71) and
Medicine, UEM, Maputo
second referents (OR=5.30). In the vaginal and
C Gonzalez, Dept Pathology, Central Hospital,
endocervical cultures no clearcut pattern was
Maputo, Mozambique
demonstrated, though E. coli was found in 25% of
S Bergström, Dept Obs/Gyn, Akademiska
cardiac blood among stillborns at sterile autopsy.
Hospital, Uppsala, Sweden
For details see:
Journal of Tropical Paediatrics 1995; 41: 258-266.
Women with prelabour fetal death in the third
semester were recruited in order to study the
association between intrauterine death and
maternal genital colonization of bacteria.
Fifty-eight women with verified fetal death were
compared with a group of 58 women matched for
age, parity and gestational length (the first
referent group) and with women delivering
liveborn neonates (the second referent group).
Cultures from the vagina, endocervix, the amniotic
fluid, the placenta, the conjunctivae of the
newborn and the secretion of gastric aspirate of
the newborn were carried out. Blood was taken
for haemoglobin, thick film (malaria) and syphilis
and HIV serology.
Cases were more affected by previous stillbirths
than first referents (OR=11.88). Preterm delivery
was significantly more common in cases than in
second referents (OR=57.70). Cases had
significantly more often < 3 antenatal visits
(OR=2.38). Cases had a lower body mass index
than first referents (OR=2.38). Temperature >
37C was twelve times more frequent in cases
than in first referents (OR=21.20) and four times
more frequent than in second referents
(OR=6.60). Average birth weight among stillborns
49
NEW INSTRUMENTS FOR MONITORING
and alternative methods of monitoring are being
GROWTH AND NUTRITION OF CHILDREN
investigated. The effectiveness of the current
AND MOTHERS
"Pre-School-Card" issued in South Africa to
promote the health and monitor the growth of
HdeV Heese, JT Berelowitz, D Harrison,
children has not been evaluated on a national
H Harke, MD Mann.
scale. There are indications suggesting that for
Department of Paediatrics, University of Cape
many reasons it is being under utilised and not the
Town.
effective tool visualised when it was first
introduced in 1972.
Growth monitoring of pre-school children has
Reasons for this underutilisation include problems
been advocated as an effective, simple and
with staffing, training and education of mothers.
inexpensive way to assess health and to prevent
The current growth charts are not 'user friendly'
most childhood malnutrition in developing
because of close centile lines and lack of space
countries. The links in the chain of successful
especially when plotting infants. Furthermore,
growth monitoring at a primary health care level
loss of normal weight gain or abnormal loss in
include issuing and regular use of growth charts;
weight is at times not recognised because the
knowing the correct weight of a child at a given
visual impact of a rising line on the growth chart
date; correct weighing and plotting the obtained
often misleads personnel. They fail to perceive
weight accurately on the chart; recognising the
that the child is crossing centiles and therefore do
difference between normal growth and poor
not consider whether this represents a normal
growth; and the identification and explanation of
pattern of growth or more often growth faltering
reasons for poor growth by clinic staff and
requiring appropriate action.
mothers.
To complete and interpret growth charts correctly,
In a busy clinic, quick mental calculation of age
nursing staff must in the shortest time possible
are often approximations which may be out by two
have quick access to correct information on age,
to three weeks. The perceived assessment of
weight and the weight centile of a given child.
growth and nutrition may be invalid. Furthermore,
Ready information on weight at birth, weight
measurements should be recorded in a manner
centile and gestational age of such a child are
which is easily understandable by mothers and
important, especially during infancy. To motivate
older children and by health personnel who often
the mothers to be involved in promoting the health
have to deal with large numbers of children under
of her child the meaning of the plots on growth
less than ideal conditions. Growth charts or child
chart must be explained to her.
health pre-school cares have been developed for
Problems experienced by nursing staff were
this purpose and to facilitate communication
investigated and the perceptions of,
between health staff and education of mothers.
understanding of and difficulties that mothers
Although growth monitoring has been advocated
have with the current Road-to-Health card were
as an effective, simple and inexpensive way to
identified. An electronic calculator and personal-
prevent most child malnutrition, its value and
retained health record incorporating new
implementation have also been widely questioned
horizontal growth charts developed with the
50
assistance of health personnel and mothers
same curve fitting routines described above are
appeared to offer possible solutions. The idea of
employed for intrauterine growth centiles and to
using electronic calculators, or a simple slide rule,
categorise the infant at birth as being
to simplify nutritional assessment is not new nor
approximate, small or large for gestational age. In
are horizontal types of growth charts.
a similar fashion anthropometric data may be
The health personnel wanted a calculator to assist
analysed during pregnancy and the first post-
them to calculate age and to derive other clinical
partum year e.g. Body Mass Index to give an
relevant indices such as food requirements and
indication of the nutritional state of the mother.
storage of statistics in an organised database.
Nursing staff and mothers favoured the
The premise for this request was the belief that
development of a personal-health record booklet.
automation of nursing or administrative activities,
The latter contains sections for health staff to
where possible, would be of benefit, both to
complete including the child's personal
nursing staff and to the patients. The code space
information, records of home visits, vision and
within the calculator's ROM currently contains
hearing tests, immunisation schedules, growth
anthropometric look-up tables of centile
charts (horizontal and conventional) and return
distributions and standard deviations published by
visits. Mothers also wished to have space to
the National Centre for Health Statistics (NCHS).
make notes. A section on milestones allows both
The software has been designed to enable
staff and mothers to record observations. For
adaptation of different reference tables should
educational purposes, both nursing staff and
these be desired. Z-scores (reference values
mothers favoured a section on immunisation
favoured by the World Health Organisation) are
advice, feeding, common medical conditions,
automatically generated along with the centile
diarrhoea, infectious diseases, clinic times and
result. The calculator can be set up by the user to
telephone numbers of support groups in the Cape
request centiles in a given child for weight only or
Town area. Nutritional information provided
centiles for weight, height and head
conforms to current advice provided by the
circumference.
nutritional services of the Department of Health of
The calculator can be programmed to maintain an
the Western Cape and clinics of the Cape Town
accumulative record of babies breastfed, births
City Council and Regional Service Council.
under 2.5kg, the presence of nutritionally related
It is hoped that the title of the personal health
diseases (marasmus, kwashiorkor, etc.)
record i.e. MY ROAD-TO HEALTH BOOK
symptoms such as coughs and diarrhoea which
(Afrikaans: MY PAD-NA-GESONDHEID BOEK
may be pointers to an impending epidemic,
and Xhosa INCWADI YAM) will encourage the
referrals to a doctor or a hospital and the number
mother to regard the book as belonging to her
of deaths. These summary statistics can later be
infant and not to the 'clinic', 'sister' or
downloaded to a personal computer or manually
'government'.
recorded for further analysis.
Early results of ongoing evaluation studies show
In addition it is possible to substitute intrauterine
that the new horizontal centile charts, book and
growth centile tables and maternal anthropometric
calculator have approval of 75%, 88% and 73%
data and use the same curve fitting routines. The
respectively of 35 experienced nursing staff.
51
Ninety-five percent and 50% of 68 mothers
preferred the new book and horizontal growth
charts respectively. Current charts were
commonly favoured by mothers with other
children.
Methods of growth monitoring however are not
easily implemented in practice and it remains to
be seen whether or not the technologies proposed
here make growth monitoring effective in South
Africa.
References on request. Financial grants from the
Bernard and Rite Brodie Research Fellowship in
Nutrition and Johnson & Johnson are
acknowledged.
52
PREVENTION OF LOW BIRTH WEIGHT
would be determined whether a simple risk score
INFANTS (POLO) PHASE ONE : DEVELOPING
for the delivery of a low birth weight infant and
A RISK SCORE
perinatal mortality could be developed. If such a
score could be developed and validated, a
LR Pistorius, M Funk, RC Pattinson
randomised intervention study would follow, to
Dept of Obstetrics and Gynaecology, University of
determine whether it is possible to decrease
Pretoria
perinatal mortality and the prevalence of low birth
weight.
Introduction
One out of every five babies delivered at Kalafong
Patients and Methods:
Hospital weighs less than 2500g, and one out of
One thousand patients were followed up
every five of these babies dies. These infants
prospectively at Kalafong Hospital and its
consist of two disparate groups, namely infants
community clinics. Data was collected at the first
delivered before term, and infants who suffered
antenatal visit (on parameters that might predict
intra-uterine growth deprivation. As the managing
low birth weight) and at delivery. The predictive
clinician is often uncertain of exact gestational
value of the Creasy score as well as other
age, it is difficult to separate these two groups in
combinations of risk factors were evaluated.
our population.
Three approaches have traditionally been used to
Results:
decrease the prevalence of low birth weight:
An interim analysis was performed after 750
firstly, tocolysis and enhancement of lung
patients had delivered. The prevalence of low
maturation in patients presenting with preterm
birth weight was 17%. The following factors had a
labour; secondly, population-based intervention
significant correlation with low birth weight: a
strategies such as food supplement programmes;
previous history of the delivery of a preterm infant,
and thirdly, identification of a high risk group, with
a previous history of a second trimester loss,
specific interventions aimed at this group.
current hypertension (systolic blood pressure
Tocolysis and enhancement of fetal lung
above 140mmHg and diastolic blood pressure
maturation can be of undoubted value for the
above 90mmHg), current bacterial vaginosis
individual patient. globally, though, this approach
(whether diagnosed by a positive amine test, clue
has made little impact on the total number of
cells on wet mount microscopy or both), current
preterm deliveries. Population-based food
multiple pregnancy, and maternal weight below
supplementing programmes have also met with
40kg. Other factors, which had no significant
little success.
correlation with low birth weight included previous
Identification of the patient at high risk for preterm
first trimester loss, previous stillbirth, socio-
delivery, as proposed by Creasy, has been
economic status, level of education, strenuous
successful in some populations, and less
physical employment, daily travel, vaginal
successful in others. It was therefore decided to
trichomoniasis or candidiasis.
launch a project to determine whether Creasy's
Factors which correlated significantly with
risk score is applicable to our patients. If not, it
perinatal mortality were a previous history of the
53
delivery of a preterm infant, a previous history of a
clue cells on wet mount microscopy or both).
second trimester loss, current hypertension
There was no correlation between maternal
(systolic blood pressure above 140mmHg and
weight and perinatal mortality in patients with
diastolic blood pressure above 90mmHg), and
multiple pregnancies, the numbers were small,
current bacterial vaginosis (whether diagnosed by
and the confidence intervals for the relative risk
a positive amine test,
included one.
Creasy's risk score was therefore compared to a
local risk score, which included the factors
associated with both low birth weight and perinatal
mortality. The predictive value of Creasy's and
the local risk scores were as follows:
Risk
score
% of patient with
high risks
Relative risk for low
birth weight (95%
confidence intervals
Sensitivity
Specificity
Positive
predictive
value
Proportional
attributable risk
Creasy
23.6
2.0
(1.3-3.0)
38.1%
79.1%
25.0%
19.0%
POLO
31.1
3.5
(2.4-5.1)
61.2%
74.3%
30.6%
43.6%
Importantly, POLO score performed equally well
BEDSIDE FETAL LUNG MATURITY TESTING
in parous and nulliparous patients, whereas the
Creasy score performed better in parous than
LR Pistorius, WKH Kuchenbecker
nulliparous patients. The Creasy score predicted
Department of Obstetrics and Gynaecology,
42% of perinatal losses with a specificity of 77%,
University of Pretoria
whereas the POLO score predicted 63% of
perinatal losses with a specificity of 70%.
Introduction
Management of our high risk obstetric patients is
Conclusion
often complicated by uncertain gestational age
The simpler locally developed risk score (using a
due to uncertain menstrual dates, late bookings
history of a previous low birth weight or second
and no early ultrasound. Elective delivery,
trimester delivery, hypertension or a positive whiff
considered for maternal benefit thus, often poses
test on booking or a multiple pregnancy in the
the risk of delivering a premature infant. Hyaline
current pregnancy) appears to predict low birth
membrane disease of prematurity is the major
weight equally well, or better than, the more
contributor to the high morbidity and mortality
complex Creasy score. If these results are
associated with prematurity. Confirmation of fetal
confirmed once all 1000 patients' data are
lung maturity could initiate early delivery with
analysed, the local risk score will be prospectively
improved maternal outcome and more objective
tested. If it is validated, the last phase, a
neonatal outcome.
randomised intervention trial, will follow.
Since its introduction by Gluck et al in 1971, the
L/S ratio has been considered the gold standard
54
of fetal lung maturity testing. However, it is a
The use of betamethazone was noted.
time consuming and costly test with poor
availability on a 24 hour basis in most hospitals.
Bedside Tests Performed:
Its major disadvantage remains its poor negative
1.
Visual assessment
predictive value. Many tests have become
Turbidity of unspun amniotic fluid that
available that are simple and quick to perform with
would not permit the reading of newsprint
a good predictive value for a mature test. Little
through it can be an accurate predictor of
evidence is available to correlate the test results
maturity.
with neonatal outcome.
2.
Tap test
1ml of amniotic fluid was mixed with one
Aim
drop of 6N HCI (concentrated
To establish if bedside tests for fetal lung maturity
hydrochloric acid diluted 1:1) in a 16 x
predict the need for neonatal ventilation and
150mm glass test tube. After adding
whether these tests correlate with conventional
1,5ml diethylether the tube was tapped
laboratory tests?
four times. 200-300 bubbles are formed
in the ether layer. Persistence of 5 or
Methodology
less bubbles after 10 minutes was
Prospective descriptive study of clinical outcome.
considered a mature test and >5 bubbles
Inclusion: All high risk obstetric patients where
an immature test. Occasional bubbles
elective delivery was considered with an EBW
confined to the amniotic fluid layer were
500g - 2500g
ignored and if the test result was doubtful
Exclusion: Maternal diabetes, multiple
it was repeated.
pregnancies and maternal age below 18 years.
After informed consent a detailed obstetric
ultrasound and amniocentesis was performed.
NB: Amniotic fluid contaminated by blood
or meconium can give a false mature
result and has to be centrifuged at 400g
for 5 minutes.
3.
Shake Test: Test was performed as
described by Clements et al.
4.
Ultrasonographic placental maturity
grading Grade III maturity changes in all
areas of the placenta can be an accurate
predictor of maturity.
Laboratory Tests Performed:
L/S ratio, phosphatidylglycerol, OD 650 and the
shake test.
55
All neonates delivered within 7 days after
-
amniocentesis were observed for the need for
-
ventilation.
2
Results:
multi-organ immaturity
67 Neonates delivered within seven days
The following table represents the ability of the
6 Neonates needed ventilation
tests to predict neonatal ventilation:
Test
Sensitivity
%
5 for hyaline membrane disease
1 for congenital pneumonia
Neonates were not ventilated due to extreme
Specificity
%
Predictive Value
of
immature test
%
Predictive Value
of
mature test
%
Visual
80
46
11
97
Shake Test
100
13
9
100
Tap test
80
85
31
98
Placental Maturity
75
9
4
80
L/S Ratio
100
55
16
100
PG
100
58
17
100
OD 650
100
77
33
100
Discussion:
It is clear that the tap test has a far better
specificity and especially predictive value of an
immature test than the commonly used shake test
and the L/S ratio. One of the neonates needing
ventilation was incorrectly predicted to be mature
explaining the sensitivity of 80%. The test was
not performed to description, since the specimen
was contaminated by blood,
but not centrifuged, thus causing a false mature
test.
In conjunction with a study by Rodriquez - Macias
we feel that the tap test is a rapid easy and
accurate predictor of fetal lung maturity. Strict
adherence to precautions and testing methods
should be applied.
56
THE INTRA-UTERINE GROWTH GRAPH AND
lady.
SCORE REVISITED: A PRAGMATIC CLINICAL
It is essential that the team are trained to an exact
TOOL OF FOETAL WELLBEING
technique, with no more than one centimetre
intraobserver difference for reliability. (The
technique is demonstrated in detail in the Holistic
PM Garde
Health Manual).
Introduction
These findings are then graphed according too
Fundal meaurements were presented in the early
the gestational age, and a score between -1 to 3
1980s, but were overshadowed by ultrasound and
given to each according to the expected growth
scepticism of the fundal height. Now that fundal
rate of 1cm/week and 1kg/month.
height measurements are in routine use, and
The sum is the growth score, which has a 90%
ultrasound viewed with realism, the intrauterine
sensitivity for a well growing foetus, if between 3-
growth score can be re-appraised after 15 years
7; and a specificity of 92% for an IUGR foetus if
of use on the Prenatal patient-carrying Health
falling over 3 weeks to 2 or below. Above 7 was
cards of Kwazulu Natal.
linked with multiple pregnancies, mild preelampsia, polyhydramios, large babies and some
The need
preterm labours, but figures were too small for
There are now 300 rural clinics bringing holistic
significance rating. A well trained health worker
primary health care within 5 kilometres of 90% of
takes + 2 minutes at the bedside to execute the
the population in KwaZuluNatal. The next step is
measurements and graph them.
the improvement of infrastructure and staff
The ideal we strive for is a mother and father
training in Primary Health Care. Part of this
planning a pregnancy by commencing with a
objective is the provision of clinically reliable tools
preconception check to ensure optimal health in
for detecting moderate and high risk patients for
both; stopping family planning method; a
referral. It is this context that the present patient-
menstrual calendar and optimum lifestyle while
carrying card system and intrauterine growth
conceiving; early booking clinic after two missed
graph have proved reliable.
periods; and a growth graph to monitor the crucial
20-34 weeks. The patient is brought back more
The intrauterine growth score
frequently if there is a deviation from the norm.
It is a composite approach to the growth rate,
Any cause is investigated at the primary level. If
(and by assumption - the wellbeing) of the foetus.
persistent over 4 weeks, the patient is referred to
The three parameters are: the height of fundus,
a secondary unit for care.
the maternal girth in cm/week growth (which
represents the volumetric increase of the uterus);
Training implications
and the maternal weight (at 1kg/month). These
Recent papers have borne out our experience -
rates were found as the mean foetal growth in
that screening graphs, whether intra-uterine,
healthy pregnancies in rural Zulu women. Note
labour or well baby growth graphs, require specific
that at 8-10 weeks the uterus of Zulu women is
thought training that must include:
already palpable at the pubis, unlike the British
*
57
an observation/bonding/copying education
process of an efficient health worker
model.
-
experiential hands-on repetitive training
under direct supervision in a Primary
Health team
*
personal responsibility for continuing
education without supervision when
deemed competent, with in-service peer
audit. This develops clinical confidence.
*
curriculum discipline, that every health
worker we release from basic training
MUST HAVE these three skills, checked
out in their final assessment procedures,
and recorded for medicolegal purposes in
a CAT.
From 15 years experience we motivate for the
inclusion of the intra-uterine growth graph on
patient-carrying Health cards for Africa.
For further details on scoring method see:
Tropical Doctor 1986; 16: 71-74.
58
PRIMARY CARE FETAL ASSESSMENT: LOW-
using a sound level meter in the "slow response"
COST FETAL ACOUSTIC STIMULATION
mode. The sensor of the sound pressure meter
was placed in contact with the plastic membrane
GJ Hofmeyr, TA Lawrie, A Daponte
below the fluid layer, and the sound stimulus
Department of Obstetrics and Gynaecology,
applied directly to the membrane over the tissue
Coronation and Baragwanath Hospitals, Wits
layer.
University
The sound stimulus was applied randomly using a
commercially available fetal acoustic stimulator
The main diagnostic test used to assess fetal
and a random selection of empty aluminium soft
well-being is the non-stress test. However, it has
drink and beer cans. The cans were held with
been shown that the time required for non-stress
the bottom against the tissue surface with the
testing can be reduced by vibro-acoustic
thumb and the middle finger supporting the rim of
stimulation. Conventional acoustic stimulators
the can.
tests require expensive electronic monitoring
sound by depressing the opener ring partially or
equipment and vibro-acoustic stimulators which
completely against the lid and allowing it to snap
are not available in most primary care settings.
back. The tests with the cans were divided into
Attempts to simplify the procedure have included
those making a metallic or rattling sound, and
the use of maternal perception of evoked fetal
those making a resonant sound, and whether the
movements and the use of an electric toothbrush
opener ring was depressed partially or completely.
The index finger then generated the
or razor instead of the purpose-built vibro-acoustic
stimulator.
The results favourably compared to the
Even these simpler devices are not
available in most primary care settings and may
commercial acoustic stimulator for all varieties of
be difficult to obtain, need to be protected from
cans but the closest approximation to the acoustic
theft and may not have working batteries when
stimulator was by the cans that gave a resonant
needed.
sound, with partial depression of the opener ring
An in vitro experiment comparing the sound
to about 5mm. (Table 1) Most cans could be
pressure generated by a soft drink can to that of a
made to produce a resonant sound by moving the
commercially available fetal acoustic stimulator
opener ring sideways to eliminate any rattling.
was conducted. To simulate the attenuation of
We are now proceeding with the clinical
sound through tissue and fluid when passing into
evaluation of the can as an acoustic stimulator,
the intra-uterine environment a model was
our objective being to determine the relationship
constructed with a tissue layer consisting of
between a simplified method of antenatal fetal
30mm of fresh placenta above a 30mm layer of
arousal testing and the non-stressed CTG. Study
normal saline, separated by thin plastic
subjects are pregnant women in whom antenatal
membranes. Sound pressure was measured
fetal heart rate testing is requested.
A baseline fetal heart rate is recorded using a
drink can is then administered midway between
Pinard stethoscope or doptone. This is recorded
the symphysis pubis and the umbilicus.
as the average number of beats in 10 seconds.
Immediately after the sound is produced, the FHR
Acoustic stimulation by means of an empty soft
is recorded for the subsequent six 10 second
59
periods.
The presence or absence of fetal
Of the 5 subjects who subsequently developed
movement is noted. This is then followed by an
fetal distress, 3 were predicted by the NST and 1
NST.
by the can test. The NST incorrectly diagnosed
Clinical details of participants are
recorded.
fetal distress in 5 well subjects and the can test in
So far we have admitted 50 women into the study.
7 subjects. In the subjects with no fetal distress
When comparing the can test to the NST, our
the NST was reactive in 24 subjects and the can
preliminary results show that there is a good
test in 21 subjects. These numbers are very
correlation between a responsive can test and a
small and the differences are not statistically
reactive NST, however there is a poor correlation
significant. However we plan to modify our study
between a non-responsive test and a non-reactive
design in order to improve the accuracy of our
NST.
results.
We recommend that other researchers
make use of the soft drink can as a vibro-acoustic
stimulator in their research in order that its role be
elucidated.
TABLE 1: FETAL ACOUSTIC STIMULATION TESTING USING AN EMPTY SOFT DRINK CAN
Simulated intrauterine sound pressure transmission through tissue and fluid medium
(measured in dB A)
n
mean SD
median
range
Corometrics 146 fetal
acoustic stimulator
22
68.7
2.1
69
64-72
Cans with resonant sound:
firm flick
20
76.3
1.7
76
74-80
gentle flick
25
67.5
1.8
68
64-71
Cans with rattling sound:
firm flick
12
72.0
2.3
72.5
66-74
gentle flick
7
64.5
1.1
64
63-66
60
At 2 litres flow per minute for 10 hours per day
THE OXYGEN CONCENTRATOR EVALUATION AND POTENTIAL USE IN THE
the cost is a quarter of that of oxygen cylinders.
NEONATE
This becomes even more favourable when usage
is increased. Maintenance is required at
IT Hay, L Mattheyse, SD Delport
approximately 10 000 hours of usage when the
Department of Paediatrics, Kalafong Hospital and
filter requires replacement. These costs are
the University of Pretoria
included in the previous simplified cost
comparison. The expensive logistics of transport
The oxygen concentrator is a medical device that
of cylinder oxygen to remote facilities, makes the
produces oxygen on demand. The apparatus
oxygen concentrator an attractive example of
separates nitrogen from oxygen in air. The
appropriate technology. A nasal cannula and
device uses an electrically powered compressor
pulse oximeter could complete a simple delivery
to force compressed air through synthetic
system.
aluminium silicate (zeolite) a regenerative
The WHO publication on "Oxygen therapy for
absorbent material, which reversibly binds
acute respiratory infections in young children in
nitrogen. It delivers up to 95,5% pure oxygen
developing countries" does not make specific
(manufacturer's specifications) which is then
mention of the use of the oxygen concentrator in
withdrawn from a reservoir for use by the patient
neonates but lists indications for oxygen as (i) an
at a required flow in litres.
increase in respiratory rate; (ii) soft tissue
retraction; (iii) cyanosis; (iv) grunting in infants; (v)
METHOD
inability to take feeds; and (vi) restlessness.
An Airsep Newlife oxygen concentrator was
Weber and Palmer found that nasal prongs were
evaluated by the General Chemistry Section of the
a more appropriate method of administering
South African Bureau of Standards. The device
oxygen to young children with acute lower
delivered 98.75% at 1 litre, 98.6% at 2 litres,
respiratory tract infection than by nasal
98.4% at 3 litres and 96.5% at 4 litres flow.
pharyngeal catheter. Locke and Wolfson showed
The
right and left hand flowmeters were correctly
that 0,3cm diameter nasal prongs administered
calibrated and delivered the specified litres/minute
9,8cm H2O of "inadvertent" PEEP at 2
flow thus confirming its efficacy. In a simulated
litres/minute flow. Benaron and Berwitz showed
infant hood model, where sampling occurred at
that maximum stability of oxygen delivery could be
7cm below the top of the hood (at the anticipated
achieved by administering low flows at 100% via
position of the neonates mouth) an oxygen
nasal cannulae. Cochran and Shaw, assessing
concentration of only 26,3% was achieved with 4
the use of pulse oximetry in prematures found that
litres of 96.5% oxygen flow. This underlies the
limiting the SaO2 at 93% was likely to prevent
poor efficacy of the hood. When connected to an
hyperoxia and maintain the paO2 below 12kPa.
endotracheal tube, 1 litre of flow/minute generated
Nasal prongs can deliver a higher concentration of
a pressure of 8cm of water.
oxygen (30-35%) than the hood, are less prone to
The cost of an oxygen concentrator when
dislodgement, allow mobility for nursing
compared to oxygen cylinders, is very favourable.
procedures and do not present the risk of carbon
61
dioxide accumulation with a low flow.
above 90%.
A pilot study of 5 neonates, suffering from
This proposal requires an intervention study.
congenital pneumonia or transient tachypnoea
who met the criterion for oxygen therapy (as
CONCLUSION
specified previously) were treated by
1.
The Airsep Newlife oxygen concentrator
administration of 2 litres of oxygen from the
meets its technical specifications and may
oxygen concentrator. This was delivered via a
be cost effective appropriate technology
terminally occluded feeding tube (with cut
for health care facilities.
apertures to approximate the nasal openings) that
2.
Its use in the oxygen dependant neonate
was strapped to the cheeks and upper lip. The
in these settings may be appropriate by
rise in SaO2 (average 86% to 95%) and fall in
administering oxygen via a simplified
respiratory rate (average 70/min to 55/min) within
nasal delivery system and pulse oximeter
1 hour was satisfactory. Hyperoxaemia to two
monitoring.
patients resulted in a termination of the pilot study
3.
The unit is electrically driven and a solar
and in the need to develop a set protocol.
powered energy source may be an
A proposed protocol for further study in rural
appropriate modification/addition.
facilities is as follows:
1.
4.
If the neonate meets the criteria for
protocol in a rural setting is planned.
oxygen therapy.
(a)
Measure SaO2. Count the
respiratory rate.
(b)
If SaO2 is below 85%, administer
100% O2 at 2 litres/minute via
simplified nasal
delivery system.
(c)
Set the pulse oximeter high alarm
at 93%.
(d)
Reduce the flow/minute by
decrements of 1/4 litre every five
minutes until the SaO2 is 93%.
(e)
Count the respiratory rate.
(f)
Refer neonates whose:
i)
respiratory rate doesn't
settle below 60/minute.
ii)
whose cyanosis/
retraction doesn't
improve.
iii)
An intervention study of the proposed
whose oxygen saturation
cannot be maintained
62
WEIGHT GAIN & PREGNANCY
so far, including 83 non-hypertensive controls, 92
HYPERTENSION - PART II
PEs and 45 Chronic Hypertensives. The study
continues.
I Kennedy
Bamalete Lutheran Hospital, Ramotswa,
Results
Botswana
In our 1993 study, Table 1, there were more than
twice as many PEs in the Spurt group (clustering)
Introduction
than in any other group showing the trend.
In 1993 we presented a pilot study of weight (Wt)
If we look at the 1995 study results, Table 2, they
gain in PreEclampsia (PE) and pregnant Chronic
again show that the PEs are strongly clustered in
Hypertensives (ChrHPT) and showed that there
the Spurt group (57%). Chronic Hypertensives
are basically four patterns of weight gain in
are also concentrated in the normal and poor
pregnancy.
weight groups.
(a)
Steady excessive gain
If we look at the results by BP group, Table 3, PE
(b)
Steady gain followed by a sudden spurt in
patients again dominate the Spurt group, but also
later pregnancy
the excessive weight gain group. Non
(c)
Normal gain about the 50th Wt centile
Hypertensives are concentrated in the normal and
(d)
Poor gain below the 50th Wt Centile
poor weight groups.
Previous studies had not noted this except for
A contingency table comparing PEs with the Spurt
Chesney because only the total wt gain in
group, Table 4, shows that though the p-value
pregnancy had been studied and not changes in
seems to be highly significant, unfortunately the
the rate of gain during pregnancy.
sensitivity and specificity are low.
Method
We repeated the study covering the period from
1982 to 1995, 220 patients have been entered
Table 1 Results of 1993 Study - Pre Eclampsia and Chronic Hypertension - 1991/2 (n=36)
Distribution of Wt groups
Wt Group
Gain
7
Spurt
16
50 Cent
1
Poor
1
25
Strong clustering of PE in Spurt group
PE
ChrHT
1
1
6
5
13
8
17
7
6
36
63
Table 2 Results of 1995 Study - 1982/95 including Controls (NoHPT) [%] n=220
Distribution of Wt groups
NoHPT n=83
PE n=92 ChrHT n=45
Wt Group
Gain
Spurt
50 Cent
Poor
1.
2.
3.
7
19
32
57
39
12
22
12
100%
100%
NoHPT clustered in Spurt & 50th C Groups
PE strongly clustered in Spurt Group
ChrHPT also greatest in Spurt group - (Not in 1993)
12
38
26
24
100%
Table 3 Distribution of BP Groups
Distribution of Wt groups
Gain n=28
BP Group
NoHPT
21
PE
61
ChrHPT
17
100%
1.
2.
3.
4.
Steady gain group Spurt Group 50th Centile Poor Gain
Spurt n=93
50C n=54 Poor n=39
28
55
17
100%
59
20
20
100%
PE Dominant
PE also dominant
"NoHPT' Dominant - (Not in 1993)
ChrHPT Group Dominant
spurt.
Table 4 2x2 Tables of PE x Wt Spurt
("EPIINFO")
Conclusions
Wt Spurt
Y
N
PE
Y
N
1.
51
42
93
41
86
127
Odds Ratio
95% Confidence Limit
Risk Ratio
95% Confidence Limit
P (TAYES) = 0.001
Sensitivity=55%
Specificity=63%
92
128
220
graphs, not in tables.
2.55
1.41<OR<4.63
1.69
1.24<OR<2.30
2.
also put on a spurt late in pregnancy that
commonly heralds the onset of HPT.
3.
4.
4.
It remains to be seen whether such action
They are significantly more likely than
can alter the outcome of PE in these
normal patients to show excessive gain or
patients.
'WATCH WEIGHT CHANGES during pregnancy"
If they are going to show a wt spurt, they
gain more during the first phase before
Acknowledgements
the spurt but the amount gained during
My thanks to Dr Johanna Goldbach for reading
the spurt is not much more than non PEs.
this paper for me at the conference and to Dr
The mean onset of HPT is 5 wks after
Gerhard Theron for his advice and help.
start of Wt spurt.
5.
It is important to pay close attention to the
pattern of wt gain of potential PE patients.
PE patients are on average, heavier at
a wt spurt.
3.
Many patients who develop PE show a
tendency to gain excessive wt and many
booking than non PE patients.
2.
Weight changes in pregnant women
should still always be recorded and on
Summary of our Findings
1.
46
28
26
100%
25% of spurts show HPT before the wt
64
65
ARE THERE MEASURABLE EFFECTS OF THE
antenatal clinics and the reduction in the
INTRODUCTION OF FREE MATERNAL CARE?
unbooked rate.
There was also no change in the number of
PA Cooper, H Saloojee, CJ Hauptfleisch,
neonates who required admission to the neonatal
JA McIntyre. Departments of Paediatrics and
wards, while the percentage of neonatal deaths
Obstetrics & Gynaecology University of the
due to birth asphyxia remained constant at close
Witwatersrand.
to 20% of all neonatal deaths. There was,
however, a 30% reduction in cases of
One of the first policy changes introduced by the
symptomatic congenital syphilis in 1995 compared
new government in the field of health care was
with previous years.
that children under 6 years and pregnant women
should receive free health care.
Johannesburg Hospital:
The policy was
introduced in June 1994 and this study was
The delivery numbers had increased from 150 per
conducted to assess the effects of this policy over
month prior to 1990 to 455 per month in the first
the first 18 months at two major hospitals in
five months of 1994 prior to the introduction of
Johannesburg.
free care. There was an immediate increase in
the monthly delivery numbers of a further 25%
Baragwanath Hospital:
after the introduction of free care with the result
The total number of deliveries in the Baragwanath
that the maternal and neonatal services found
Hospital/Soweto Clinic system fell from almost 36
themselves overwhelmed by the increase in
000 in 1990 to just over 25 000 in 1994. This
numbers.
reduction of almost 30% was largely due to
There was little change in the unbooked rate
desegregation of other major hospitals, while it is
(from 19% to 15%). Maternal mortality and
also probable that more women became eligible
neonatal deaths due to asphyxia, both of which
for private health care. As a result of this
had previously increased, continued to show an
decrease and "protection" of the Hospital by the
increase. This, however, was probably a
Soweto clinics preventing direct self-referrals, the
continuation of the trend that had seen the
moderate increase in antenatal visits could be
clientele of the hospital change from a largely
managed. Average time of first attendance at
white population prior to 1990 to a largely black
antenatal clinic fell from 28 weeks gestation to 23
population coming from a much poorer socio-
weeks and the unbooked rate fell from about 14%
economic environment. No change in the
to 5%. In the 18 months following the
number of cases of congenital syphilis was
introduction of free health care, there was no
observed.
increase in delivery numbers suggesting that the
elimination of the need for payment was not an
Comments:
immediate incentive to become pregnant. Table
While some encouraging trends in relation to
1 shows that there was no noticeable impact on
antenatal booking status and congenital syphilis
maternal mortality, stillbirth rate or neonatal
were seen at Baragwanath Hospital, it would
mortality as a result of the earlier attendance at
appear that a longer period of time is required
66
before improvements in mortality rates may
occur. Where the infrastructure was not in place
to handle an increased load, as was experienced
at Johannesburg Hospital, no measurable health
benefits were seen, but staff frustration levels
increased enormously.
Table 1 Mortality in the Baragwanath Hospital/Soweto Clinic Service
1990
1991
1992
1993
Jan-June 1994
July-Dec 1994
Jan-June 1995
Maternal mortality per
per 100 000 births
44,6
30,2
65,8
62,1
54,1
72,3
42,6
Stillbirths
per 1000 births
23,1
22,4
19,8
25,7
25,7
26,1
23,1
67
Neonatal Deaths per
per 1000 live births
12,4
11,5
12,8
11,2
11,1
10,4
11,3
A COMMUNITY BASED INVESTIGATION OF
There were 26 maternal deaths from obstetric
MATERNAL MORTALITY DUE TO OBSTETRIC
haemorrhage. The following results refer to
HAEMORRHAGE IN RURAL ZIMBABWE
them.
Causes of haemorrhage
S Fawcus*, M Mbizvo#, G Lindmarkx,
Four women died from antepartum haemorrhage
L Nystrom^
(1 abruptio placentae, 1 placenta praevia and 2
*University of Cape Town, # University of
indeterminate). 8 women died from intrapartum
Zimbabwe, X University Uppsala,
haemorrhage due to ruptured uterus. 14 women
^
University
died from postpartum haemorrhage (2 ruptured
UMEA
uterus, 8 uterine atony, 1 retained placenta and 3
Introduction
post Caesarean section bleeding).
During 1989 and 1990 a community based case-
Background characteristics
control study of maternal mortality was conducted
Eleven (42%) of the women were more that 35
in a rural province (Masvingo) and an urban area
years old and 14 (54%) had a parity of more than
(Harare) of Zimbabwe. The maternal mortality
5. These findings differed significantly from
rate (MMR) was 85 and 168 per 100 000 live
controls. There was no significant difference
births for Harare and Masvingo respectively.
from controls with respect to marital status,
Obstetric haemorrhage was the leading cause of
income, education, religion, or percentage of
maternal mortality in Masvingo, accounting for 26
unwanted pregnancies; the latter accounted for
(25%) of the 109 maternal deaths, as compared
approximately 35% of both cases and controls.
to the urban area where it accounted for 6 (9,8%)
Access to health facilities
of the 66 maternal deaths.
Fifteen (58%) of the maternal deaths lived more
This paper provides further data and analysis on
than 50kms from a hospital. Twenty two (85%) of
the haemorrhage related deaths in the rural area,
the women booked for antenatal care and in 19 of
Masvingo.
these, a hospital delivery was recommended.
Place of death
Study Design
Twelve (42%) of the women died at home or en-
Maternal deaths were identified via community
route to a health facility. The health facility most
networking techniques and health service
commonly accessed before death was a district
structures. Controls were surviving women
hospital. Altogether 13 (50%) had no treatment
delivering at the same level of care. A
at all for haemorrhage before their death.
questionnaire was used to collect information from
relatives and/or neighbours in the community and
all health personnel involved in order to describe
the operational factors associated with the
maternal deaths.
Results
Avoidable factors
avoidable factor identified, contributing to delays
Lack of transport to a health facility was a major
causing death in 12 (42%) of the women.
68
Transport between health facilities was an
additional problem, as was also backup support
to rural clinics and traditional birth attendants.
For all 14 (58%) of women who accessed a health
facility before death, one or more avoidable
factors could be identified. These included
delays in diagnosis of the cause of haemorrhage
and inadequate management related to shortage
of trained staff and supplies/equipment.
Conclusions
Deaths from obstetric haemorrhage are a major
cause of maternal mortality in the rural area and
may be preventable by simple measures. Such
measures include: community involvement,
improved transport and communications in rural
areas, family planning, backup support for rural
clinics and traditional birth attendants, more
effective antenatal care, maternity waiting
shelters, expanding midwifery skills and
responsibilities, and strengthening the capacity of
district hospitals to manage obstetric
haemorrhage emergencies.
69
II
COMMUNITY HEALTH WORKERS INVOLVED
Improving community perception and
IN POSTNATAL CARE OF PATIENTS IN
therefore use of the MOU as a health
KHAYELITSHA
care facility
III
Educating mothers in the community
about health in the postnatal period.
L Linley, D Hewitson, G Derbyshire, B Wright, T
Mshumpden
Neonatal Service GSH+, SACLA Health Project,
Participants:
Khayelitsha MOU
I
Community-chosen Community Health
Workers (CHUWs) employed by SACLA
Background
Health Project and resident in Site B, and
Previously, postnatal home visits in The Peninsula
Site C, Khayelitsha
Maternal and Neonatal Service were conducted
II
The staff of Khayelitsha MOU.
by nurses of the various Midwife Obstetric Units
III
Postpartum mothers and their infants
(MOUs) and maternity hospitals in the service. In
resident in Site B and Site C who have
1990, these home visits were stopped, and have
delivered at the MOU.
not been reinstated. This, therefore, shifts the
responsibility for postnatal care entirely on the
Methods
mother.
*
A training course to train CHWs was held
An audit done in 1994 showed the monthly
at Khayelitsha MOU in October 1994.
average postnatal follow-up rate Khayelitsha MOU
More recently, when it became evident
to be approximately 45%.
that more extensive breastfeeding
The postulated reasons for this were threefold:
education was necessary, a
I
Follow-up available only at the MOU
comprehensive breastfeeding course was
II
Poor community perception of the MOU
included as an adjunct to the initial
as a health care facility
training. Two 8 week courses have now
From anecdotal evidence, postnatal
been completed by 36 CHWs and 5 of the
health awareness and education seemed
MOU staff.
III
*
largely inadequate in the community.
Statistics are kept
(a)
Aim :
I
by the MOU: of (i) patients
To improve postnatal follow-up and
referred to the CHWs; (ii) patients
primary intervention where indicated
seen at the MOU for postnatal
through :
checks.
(b)
Providing postnatal follow-up at home
Details recorded include name of patient, address
by the CHWs: of the patients they see
the service is currently underway.
of patient, name of CHW and his or her coordinator, date of each visit and general condition
Results
of patient and reason for referral back to the MOU
The percentage of births, in Site B and Site C
where indicated.
receiving postnatal care has risen from
*
approximately 45% in 1994 to more than 60%
Evaluation of community satisfaction with
70
since initiation of this project.
maintaining postnatal care and health education
Of the patients seen, 37% have been sent by the
at home where this has ceased to exist.
CHWs and 63% by Khayelitsha MOU staff, with
between 3% and 16% of patients being referred
back to the MOU by the CHWs. More than 80%
of the first visits by the CHWs are within 48 hours
of delivery.
Discussion
Initial analysis of the evaluation which is presently
underway has indicated that our MOU figures may
be artificially inflated. However, the community
health worker figures are accurate and a
significant improvement in the number of patients
receiving postnatal follow-up is evident.
Ongoing audit has been an essential part of this
project. This has enabled problems to be
identified and addresses as they have arisen.
Conclusions
I
There has been a significant improvement
in the number of patients receiving
postnatal follow-up.
II
Home visits to newborn infants and their
mothers in an informal settlement have
been re-established.
III
Workers do refer patients back to the
MOU when necessary.
As we have had no missed problems reported to
date, it seems that extreme caution is being used
in selecting patients suitable for referral for
community health worker follow-up. We have in
fact a number of excellent referrals back to the
MOU by the CHWs.
In closing, I'd like to state that these Community
Health Workers, who are outside of the officially
recognised health care system, must form a vital
new grass roots tier to comprehensive health care
in the informal settlements by re-establishing and
71
PERINATAL HEALTH IN THE CHIAWELO
complications are shown in Table 1. Mothers
DISTRICT OF SOWETO
giving birth to infants weighing less than 1000g
are excluded.
Table 1 Labour complications n=2009
EJ Buchmann
Department of Obstetrics and Gynaecology,
Complication
Number
Percent
Meconium passage
506
25
Nonproteinuric hypertension
179
9
Baragwanath Hospital and the Soweto clinics
Pre-eclampsia
160
8
provide perinatal care for a population of about
Antepartum haemorrhage
26
1.3
Baragwanath Hospital and the University of the
Witwatersrand
two million people. Referral from the midwife-run
clinics to hospital is governed by management
There were 253 Caesarean Sections, a rate of
protocols. Reports on perinatal problems are
12.6%. Vacuum deliveries numbered 27 (1.3%)
generally hospital-based and biased towards high-
and forceps four (0.2%). The low birth weight rate
risk conditions, whereas routine clinic statistics
(Less than 2500g) was 12.8%. One hundred and
are collected separately and not easily assimilated
sixty-three babies (8.2%) required neonatal unit
with hospital figures.
admission, with 28 (1.4%) needing assisted
A study of the catchment population of Chiawelo
ventilation. The perinatal mortality rate was 29.0
clinic was undertaken, to describe the incidence
per thousand births. The stillbirth to early
of perinatal problems irrespective of place of
neonatal death ratio was 21.6 to 7.5 (2,9:1). The
delivery and to audit the referral system from clinic
use of clinic and hospital facilities is summarised
to hospital.
in Table 2.
Table 2 Use of clinic and hospital (n=2009)
Methods
Place
Number
Percent
Chiawelo clinic is situated in southwestern corner
Complete clinic confinement
524
26
Clinic delivery, referred
postpartum
312
15
Chiawelo addresses, were counted, from October
Clinic labour referred for delivery
373
19
1994 to May 1995. This was done using the birth
Complete hospital confinement
736
37
register at Chiawelo clinic and maternal and
"Born before arrival"
64
3.2
of Soweto about nine kilometres from
Baragwanath. All births, where mothers gave
neonatal case-files at the hospital.
This gives a ratio of hospital to clinic deliveries of
58:42. Audit of the 373 referrals in labour showed
87% of hypertensive referrals and 99% of
Results
meconium referrals to be correct. Twenty-four
There were 2070 births. The rate of unbooked
percent of referrals for slow progress and fetal
mothers was 4.7%, that of grand multiparae 2.8%,
distress required operative delivery. Analysis of
with 17.5% of nulliparae aged 17 years or less;
hospital deliveries for risk factors shows at least
10.8% of mother tested rapid plasma reagin
88% of mother to have delivered appropriately in
(RPR)-positive. The incidence of labour
72
hospital. Antenatal risks and labour problems are
similar to those listed in the maternal care manual
of the Perinatal Education Programme. This is
shown in Table 3.
Table 3 Hospital deliveries and risk factors
n=1109
Risk factor
Number
Cumulative %
Birthweight < 2000g
68
6
Parity > 4
49
11
Maternal age < 16
23
13
Antenatal risks
494
57
Labour problems
297
84
Operative delivery
44
88
Neonatal outcomes following referral to hospital in
labour were significantly worse than those
following clinic delivery (8/365 vs 2/834; Relative
risk 9.1, p=0.002). Neonatal referrals following
delivery at the clinic were mostly for meconium
passage during labour (192/277). Only four of
these infants required admission and none
needed ventilation, with no deaths.
Conclusion
Morbidity and mortality patterns are typical of the
urban poor in South Africa. The high rates of
hypertension and meconium passage during
labour render many labours "high risk" resulting in
a greater need for hospital delivery. The ratio of
stillbirths to neonatal deaths reflects the
imbalance of a poor community, a moderately
good obstetric service and an excellent neonatal
care facility. Audit of referrals from the clinic
showed that the hospital was not overutilised, with
the exception of neonatal referral for meconium
passage during labour. This analysis has
provided a model and standard, similar to the
Western Cape midwife-obstetric units, for
planning new obstetric services in urban areas.
73
A PROSPECTIVE ANALYSIS OF ALCOHOL
regions. Four hundred women were interviewed
INGESTION IN 400 PREGNANT WOMEN IN
and demographic details, pregnancy histories,
RURAL AND URBAN AREAS IN THE
social circumstances, medical histories, and data
WESTERN CAPE
regarding religion, income, nutrition ,a and
smoking and alcohol ingestion were accumulated.
DL Viljoen, JA Croxford
The investigation was peer-reviewed by the UCT
Department of Human Genetics, University of
Ethics Committee and the interviewees gave
cape Town Medical School
informed consent prior to admission to the study.
Fetal alcohol syndrome (FAS) is the most
Results
common preventable cause of mental retardation
Of the 400 persons interviewed, 80% were of
in all communities worldwide. It is the teratogenic
Mixed Ancestry, 14% Black and 1% Caucasian in
consequence of maternal ingestion of significant
ethnic origin. The monthly family income varied
quantities of alcohol at any stage during
from R300 (30% of the study group) to more than
pregnancy. The characteristic clinical
R2500 (6%), with a further 22.4% of patients
manifestation are pre- and post-neonatal growth
where income was unknown.
deficiency, mental retardation, pathognomonic
The age distribution of the cohort is shown in
facial features and multiple organ system
Table 1.
derangements. The clinical features are easily
Table 1
AGE IN YEARS
recognised in the classic case, but can vary
considerably according to the amount and timing
of maternal alcohol ingestion, maternal nutrition
and health, other substance abuse, generic
factors and concomitant medicinal drug use.
NUMBER OF PATIENTS
< 20
20-30
31-40
> 40
48
248
57
47
12%
62%
14%
12%
TOTAL
400
100%
FAS is a frequent cause of mental handicap and
Within the study of 400 women, 54% abstained
has a prevalence of 1/750 liveborns in First World
completely from drinking alcohol. The pattern of
settings. However, the frequency is much higher
drinking of the remaining 46% is shown in Table
in certain populations such as the native American
2.
Indian, Inuit and squatter peri-urban communities
throughout the world. FAS is reported frequently
in children in the Western Cape, but the exact
prevalence is unknown.
A prospective investigation into the drinking habits
of pregnant women in the poorer socio-economic
communities in Cape Town and the peripheral
areas of Vredenburg, Saldanha, Oudtshoorn and
George was promulgated in May 1995. The
questionnaire was administered by JAC to women
attending routine antenatal clinics in these
74
investigations will ascertain the exact risk factors
Table 2 Pattern of Drinking
Occasional
Moderate
Mod. Binges
Heavy
Heavy Binges
Very Heavy
QUANTITY
CONSUMED
PERCENTA
GE
<5 units/week
5-10 units/week
5-10 units/occ
11-20 units/week
> 10 units/occ
> 20 units/week
19.6%
5.8%
10.0%
6.0%
4.2%
0.4%
and true prevalence of FAS in disadvantaged
communities in the Western Cape.
1 Unit = 10ml of Absolute Alcohol
Beer was the main type of drink ingested (93.5%),
followed by wine (8.3%), spirits (4.8%) and exotic
alcohol (1.7%). Seventeen of 184 persons drank
combinations of alcohol.
With regard to the religious affiliations of persons
drinking in pregnancy, these are detailed in Table
3.
Table 3 Religious Affiliations
Christians
Muslims
Others
Drinkers
34.6%
1.0%
10.4%
Abstainers
43.6%
4.4%
6.0%
Of the total cohort of women, 173 of the 400
(43%) smoked regularly, while 116 (29%) smoked
and drank alcohol, 56 (14%) smoked and
abstained from drinking completely and 68 (17%)
drank and did not smoke.
As the study is still far from complete, very little
data regarding the pregnancy outcome and
effects on the newborn are as yet available.
Summary
In a random study of 400 pregnant women
attending routine antenatal clinics within the
poorer socio-economic communities of Cape
Town, George, Oudtshoorn, Vredenburg and
Saldanha, 106 women drank moderately or
heavily during their pregnancy. These subjects
may be at a 50 percent risk of giving birth to
babies with the fetal alcohol syndrome. If this
estimation is realised, 53 children (13.25%) would
be born with the stigmata of FAS. Ongoing
75
VERTICAL TRANSMISSION OF HIV-
RESULTS
INFECTION
Among all of the enrolled women 30.2% were HIV
EFFECT OF VAGINAL WASHING
positive. Among the 982 babies of HIV positive
women with a singleton vaginal birth, seen for
RJ Biggar1, TE. Taha2, A Justesen3, PG Miotti2,
follow up at least once within 12 weeks, 27.4%
LA Mtimavalye3, R Broadhead3, G Liomba3,
were HIV infected (PCR). There was no
JD Chipangwi3, J Goedert1.
difference in overall HIV transmission between the
1National
non-intervention babies (27.9%): "intent to treat"
2Johns
Cancer Institute, Bethesda, USA
analysis.
Hopkins/College of Medicine Research
This did not change when only those
Project, Blantyre
who would have been washed in the control
3Queen
phase and those who were actually washed
Elizabeth Central Hospital, Blantyre,
during the intervention were considered (26.4%
Malawi
versus 25.3%). The vaginal wash significantly
INTRODUCTION
reduced vertical transmission only when the
From studies of twin deliveries and elective
membranes were ruptured more than 4 hours
Caesarean Sections it is possible that a
prior to delivery (38.7% versus 24.4%, p=0.02).
considerable proportion of neonatal HIV-infections
Several other factors were considered, such as
occurs during parturition possibly due to
the number of washes, the timing of the wash in
prolonged exposure of the foetus to infectious
relation to rupture of the membranes or to
material in the birth canal. In this intervention
delivery, but none changed the rate of vertical
study it was postulated that washing the birth
transmission.
canal with an antiseptic solution during labour
However, the maternal postpartum infections and
might reduce vertical HIV-transmission.
neonatal sepsis were significantly reduced by the
intervention. Neonatal sepsis among the
METHODS
newborns admitted to the special care nursery
In 1994 from June through November 6996
reduced from 9.2% to 4.6% (OR=0.47, 95% CI
women were enrolled (3355 in the control group
0.29 - 0.76). Maternal postpartum infections
and 3641 in the intervention group). Intervention
among the women with postpartum morbidity also
consisted of washing the birth canal with 0.25%
decreased significantly from 14.2% to 5.7%
chlorhexidine prior to each vaginal examination in
(OR=0.36, 95% CI 0.12 - 0.91).
labour. The newborn was also washed with the
was independent of the HIV status of the women.
This decrease
same solution immediately after birth. Maternal
HIV status was determined in ELISA testing of the
CONCLUSIONS
cordblood (Genetic Systems EIA, Seattle, WA).
Vaginal washing with chlorhexidine 0.25% during
The infant was tested at the age of 6 and 12
labour is cheap, safe and readily accepted by staff
weeks by polymerase chain reaction (PCR) using
and patients alike. Maternal and neonatal
blood from a heel prick collected on filter paper
morbidity and mortality due to sepsis can be
(Roche Diagnostic Systems, Nutly, NJ).
reduced significantly by
76
this procedure, and this is independent of their
child, except when the membranes have been
HIV status. However, vaginal washing has no
ruptured longer than 4 hours prior to delivery.
influence on HIV transmission from mother to
Table 1 HIV transmission rates in the non-intervention and intervention groups
"intent to treat"
"eligible to wash"
and
"actual wash"
ROM 0 - 4 hours
> 4 hours
27.9%
non-interv.
interv.
26.9%
NS
26.4%
25.3%
NS
25.0%
38.8%
28.2%
24.4%
NS
p=0.02
Table 2 Influence of vaginal washing on postpartum sepsis
Admission to SCBU
Neonatal sepsis
(as % of admissions
to SCBU)
Neonatal deaths (/1000)
total
infectious causes
Maternal postpartum sepsis
(as % of women with postpartum morbidity)
* OR = 0.49, 95% CI 0.30 - 080
non-interv.
19.7%
9.2%
37.6%
7.5%
14.2%
interv.
17.4% p=0.03
4.7%
p-0.005*
29.4% p=0.07
2.5%
p=0.01
5.7% p=0.03**
** OR = 0.36, 95% CI 0.12 - 0.91
77
HIV at Baragwanath.
MATERNAL AND OBSTETRICAL FACTORS IN
MOTHER TO CHILD TRANSMISSION OF HIV IN
Objectives:
SOWETO, SOUTH AFRICA
To investigate the relationship between maternal
JA McIntyre, GE Gray, SF Lyons
factors, progression of HIV disease, mode of
Perinatal HIV Research Unit, Department of
delivery, and other obstetrical events in the
Obstetrics and Gynaecology, Baragwanath
transmission of HIV from mother to child.
Hospital & The University of the Witwatersrand,
Method:
Johannesburg, South Africa.
Five hundred HIV positive women at Baragwanath
Introduction
HIV Clinic have been enrolled in a prospective
HIV transmission from mother to child occurs in
follow-up study. The maternal medical and
25 to 40% of cases in an African setting. A
obstetrical outcomes were determined and infants
number of factors have been shown to influence
followed for eighteen months. Follow-up of the
the rate of transmission, including the maternal
children included a full clinical assessment, CD4
conditions and the severity of the HIV-1 disease,
counts and PCR analysis. Infections of the child
premature delivery, chorio-amniotic, mode of
was determined by positive PCR or positive HIV
delivery and time of rupture of membranes. More
antibody test at after 15 months.
than half of the transmission is thought to occur at
the time of labour and delivery.
Results:
Baragwanath Hospital is one of the largest
An interim analysis of 163 mother-infant pairs has
hospitals in the Southern hemisphere, serving the
been undertaken, where follow-up information
estimated 3 million population of the Greater
was available up to 18 months or to 3 months
Soweto area, outside Johannesburg. The
after the cessation of breast feeding in infants still
Baragwanath Maternity Hospital delivers between
breastfed at this time. Follow-up is continuing on
15 000 and 20 000 women each year, and
the remaining mother-infant pairs.
oversees the care of a further 10 000 pregnant
The majority of the mothers (95%) were
women at midwife units in Soweto. The current
asymptomatic with no evidence of progression of
HIV seroprevalence at Baragwanath is close to
HIV disease. In all of the five symptomatic
15%, with an estimated doubling time of 15
women, tuberculosis was the opportunistic
months. A Perinatal HIV Clinic at the Maternity
infection. Active or recent Herpes zoster was
Hospital provides prenatal and postnatal care for
found in 3 of the 163 mothers. None of the
HIV positive women and follow-up for their
women had received Zidovudine or any other
children, together with counselling and
antiviral agent.
psychological and social support. Women
Maternal CD4 cell counts ranged from 55 to 2542
attending this clinic were enrolled into a
per mm3 with a mean of 544 per mm3 in the whole
prospective follow-up study to determine the
group. In mothers who transmitted HIV to their
factors influencing mother to child transmission of
children the mean CD4 count was 536 per mm 3
78
(Range 55-2542) and in non-transmitters the
means was 548 per mm3 (Range 68 - 1959).
Conclusions
CD4 counts of below 200 per mm3 were present
This is an interim analysis based on about one-
in 9.1% of the mothers. The Caesarean section
third of the mother-infant pairs enrolled in this
rate in this group of women was 27%, which was
study. Ongoing follow-up of the other participants
very similar to the hospital average over the same
is continuing and analysis of the complete sample
time period.
may or may not confirm these findings.
The rate of mother to child transmission of HIV in
Most of the HIV positive pregnant women seen at
this study was 38.1%. In this sample of
Baragwanath Hospital are asymptomatic at
predominantly healthy HIV-positive women, there
present, although almost 10% of the mothers
was a non-significant trend towards a higher
have low CD4 counts (below 200 per mm 3), which
transmission rate with CD4 counts less than 200
would classify them as having AIDS by the 1993
per mm3 (43% vs 38%). Other indicators of
CDC criteria.
maternal condition, such as infectious illnesses
In this setting, mother to child transmission of HIV
during pregnancy, showed no association with
seems to be determined more by the mode of
increased transmission.
delivery and choice of infant feeding than by the
The length of labour, duration of rupture of
maternal condition or duration of labour. Most
membranes, use of fetal scalp electrodes,
labour events appear to have little influence on
episiotomy and assisted delivery showed no
HIV transmission. Both elective Caesarean
significant association with HIV transmission,
section and formula feeding appear to be
although the number of women who experienced
protective against transmission. In the light of
some of these factors was small. Average time of
this, appropriate interventions to provide
rupture of membranes in the group was 4.5 hours.
Caesarean section or the safe use of breast milk
When Caesarean section was performed before
substitutes for identified HIV positive women may
the onset of labour, transmission was significantly
prove important in reducing mother to child
reduced at 14.3% {RR 0.44(95% CI 0.07 - 2.87)}.
transmission of HIV in an urban developing world
This was not the case where Caesarean section
situation.
was performed after onset of labour, where the
rate was 35%. In this interim analysis, the
numbers of women who delivered by Caesarean
section after the onset of labour was not large
enough to consider the effect of various durations
of rupture of membranes prior to Caesarean
section.
The majority of women breastfed their children
and only 29% were exclusively formula fed. The
transmission rates in the group of formula fed
infants was 18% compared with 46% in breastfed
children {RR 0.18 (95% CI 0.07-0.46)}.
79
THE MIDWIFE'S EXPERIENCE OF A HIV-
and caring for the mother and the baby, will have
POSITIVE DELIVERY
a direct influence on the community's attitude.
The goals for the research were:
M de Jager, AGW Nolte & CS Dörfling
To determine the experience of a midwife who did
a delivery of a HIV-positive patient.
The issue of AIDS and the patient that is carrying
To set guidelines to guide the midwife.
the HIV virus has become of more and more
To set up guidelines by which the midwife can
important since 1988 in South Africa. At the
protect herself against HIV-contamination.
moment women count about one third of all HIV-
We used a hospital in Johannesburg where all the
positive people around the world, and in Africa the
patients are tested for HIV during their antenatal
majority of infected people are women, sexually
period. Five midwives were asked to participate,
active in the age group between 29-40 and thus in
of whom each one must have done at least one
their fertile years. It is in midwifery where the
delivery of a known HIV-positive patient. The
effect of HIV is noticed best because of the large
research was done in the form of an interview and
amount of pregnant patients that are HIV-positive
recorded with a tape recorder. One question was
and it is the midwife who is mostly looking after
asked of each of them, "Tell me in as much detail
these mothers, doing their deliveries and caring
as possible all the feelings you experienced while
for their babies. The midwife must know her own
you were doing you first HIV-positive delivery".
attitudes and feelings to be able to care for the
The interviews were transcribed and analysed.
women in labour and to do her delivery.
Words, phrases and themes were categorised
The AIDS epidemic evokes major personal and
under main experiences.
professional reactions from health care workers.
The results were as follows: emotional reactions
In the literature it is found that health care
occurred like they were negative about the whole
workers, who doesn't necessarily work with these
situation of admitting the patient, scared to do the
people's blood products, verbalise the following
delivery, because of the possibility of
feelings: physical exhaustion, aggression, fury,
contaminating themselves by a needle prick,
helplessness, denial, ignoring, afraid, scared,
contamination of other patients or colleagues,
anxiety, tension, negativity, sympathy and
scared to work with the patient, not enough
avoidance. In the work situation health care
protection. They were unsure about methods of
workers have to adapt, for instance, certain
protection, cleaning procedures and the general
procedures have to be carried out with gloves all
management of the patient. Feelings of fury were
the time. These factors have the potential to
mentioned because they felt that they were put
influence the health care workers and the nurse.
unnecessarily in danger especially with those
The general public also has fears concerning the
patients that weren't co-operative. Some felt that
person who is HIV-positive, and the community,
it was unfair that their lives were put at risk, and
the HIV-positive person and the family are looking
feelings of aggression and irritation were
at the health care worker's reactions and attitude
mentioned.
against the HIV-patient and react according to
The majority said that they were scared to
this. Thus the midwife who is doing the delivery
perform certain procedures like rupturing of
80
membranes, giving sedation and to suture a tear
or episiotomy. Everybody said that they felt sorry
for the mother and the baby and a lot of guilt
feelings were mentioned on how they felt and the
way that some of them treated the patients.
Physical exhaustion during and after the delivery
and stigmatising of certain cultures was also
found.
Recommendations made, were that the midwives
must be guided by a midwife that is preferably
working with them, with group sessions in which
the midwife can get support from her colleagues,
get to know her own feelings and being educated
about the disease. Further guidelines must be set
for the implementation of universal precautions
especially protective clothing, face-shields, plastic
gowns and feet protection.
More education is needed and more research on
all health care worker's knowledge and feelings of
working with the HIV-positive patient.
81
10,2%, L&B measurement 38,7% versus 16% and
MEDICAL STUDENTS AND HIV EXPOSURE
insertion of an infusion 52,2% versus 26%.
EC de Coning, EC Booysen, AMH Pretorius
Forty -three point seven percent regarded the
Department of Obstetrics and Gynaecology
wearing of goggles a prerequisite during surgery,
University of the Orange Free State
although a mere 14% actually did so. With
deliveries 31,8% versus 12% and with episiotomy
Introduction
19,6% versus 10,2% wore goggles.
The health worker will always remain at risk, being
51,2% of students had already been exposed,
exposed to HIV with every incident. Although the
with the majority being in their sixth medical year.
chance of contracting HIV within a single incident
Thirty percent of student became contaminated
in only 0,4%, this risk increases with every
when drawing blood, 15% when assisting with
possible exposure. All patients should therefore
surgery, 15% when inserting an infusion, 5%
be regarded as potentially infected, with the
when suturing a wound, 4% in urine testing and
effective cure being total prevention of
2% with vaginal examination.
contamination.
Of the patients seen by contaminated students
10,2% were HIV positive and in 47,2% of cases
Method
the HIV status was not known.
Descriptive study including all medical students of
The procedure to be followed after exposure
the UOFS in their fourth, fifth or sixth year.
includes wound treatment, report of the incident,
testing of the patient for HIV, testing for sero-
Aim
conversion after 6 weeks, 3 months and 6
To determine the prevalence of medical student'
months. Ideally prophylactic antiviral therapy and
exposure and contamination via blood and other
counselling must also be considered.
body fluids and their knowledge of the post
Although 38% of students felt they knew what
contamination procedures.
procedure to follow after contamination, less than
5% were actually correct, 85% were wrong and
the rest partially correct.
Results
The first question concerned student involvement
in different procedures increasing the potential
risk of contamination. The procedures in which
students are mostly involved include drawing
blood 79,9%, urine testing 46,7%, vaginal
examinations 40,7% and assisting with surgery
44%.
Secondly, student were asked if the wearing of
gloves was deemed necessary in certain
instances. Although 51,3% regarded it as a
necessity when drawing blood, only 23,4%
actually wore them. Urine testing 18,1% versus
82
Conclusion
Although medical student are at risk of
contamination, very few take the necessary
precautions. More than half the students were
already contaminated with potentially infected
blood or body fluids. The majority of students do
not have the necessary knowledge of postcontamination procedures. Only 18,5% received
counselling.
83
MOU PROFILES - A COMPARISON OF THE
order to provide appropriate perinatal care
SOCIO-OBSTETRIC PROFILES OF 2
for a particular community.
ADJACENT MIDWIFE OBSTETRIC UNITS IN
Patients and Methods
CAPE TOWN
All patients booked at KMOU and MPMOU during
HA van Coeverden de Groot, AA van Coeverden
the period January-June 1993 were entered into
de Groot, KB Sundgren.
the study and had a number of socio-obstetric
Department of Obstetrics and Gynaecology,
parameters recorded.
University of Cape Town
Results
During the study period, KMOU booked 2538 and
The Peninsula Maternal and Neonatal Service
MPMOU 2170 patients. Of these, 11% and 26%
(PMNS) in Cape Town is the only fully
respectively, were referred in the antepartum
regionalized 3-tiered community perinatal service
period. The main indications for the antenatal
in South Africa. The primary perinatal care
referrals were hypertension; prolonged pregnancy;
facilities in the PMNS are called Midwife Obstetric
previous Caesarean section; abnormal
Units MOUs). Uniform referral criteria and
presentations and medical problems. There were
management protocols apply throughout the
few referrals for prolonged pregnancy and
PMNS Region. Nevertheless, it has been
medical problems from KMOU.
apparent for some considerable time that major
There were 1 848 deliveries at KMOU and 1 399
differences exist between the socio-obstetric
at MPMOU.
profiles of 2 of the MOUs in the region, viz
Intrapartum referrals were 449 and 445
Khayelitsha MOU and Mitchell's Plain MOU.
respectively. The main indications were
These custom-built MOUs are identical and serve
prolonged labour; hypertension; preterm labour;
adjacent communities. The former caters almost
prolonged rupture of the membranes and fetal
exclusively for the Black community of
distress. Of those referred, 66% of the KMOU
Khayelitsha, a large proportion of whom live in
and 76% of the MPMOU patients delivered
informal settlements. On the other hand,
spontaneously.
Mitchell's Plain MOU has a largely coloured and
The perinatal mortality rate (PNMR)/1 000 births
more affluent clientele. This presentation reports
was 37,4 for KMOU and 17,9 for MPMOU. About
on those perceived differences.
a quarter of the stillbirths in both MOUs weighed
>2 499g.
Of the neonatal deaths, 33% at KMOU
Objectives
and 9% at MPMOU weighed >2 499g. The main
1.
To document the differing socio-obstetric
causes of perinatal deaths (PNDs) were hypoxia;
profiles of the 2 main population groups
immaturity; syphilis; intra-uterine death of
served by the Khayelitsha (K) and
unknown cause and abruptio placentae.
Mitchell' Plain (MP) MOUs.
At KMOU unbooked patients (UPs) made up
To demonstrate thereby the need for
some 6% of admissions but accounted for 44% of
accurate socio-obstetric data collection, in
the PNDs. The respective figures for infants born
2.
84
before arrival (BBAs) were about 6% and 19%.
The corresponding data for MPMOU were 3% and
27% for (UPs) and 3% and 18% for the BBAs.
Conclusions
1.
Major differences between KMOU and
MPMOU include the frequency of and
indications for referrals, both antenatally
and intrapartum; the PNMRs; the
contribution made to PNDs by unbooked
patients, and the prevalence of the main
causes of PNDs.
2.
As uniform referral criteria and
management protocols apply throughout
the PMNS Region, these findings are
unlikely to be due to differing standards of
perinatal care. It is much more plausible
that they are the result of the marked
discrepancy in the socio-economic
circumstances of the two communities.
This study has yet again demonstrated
that good perinatal care per se is
insufficient to reduce perinatal mortality
and morbidity to levels found in developed
countries.
85
CLINICAL EVALUATION OF NORMAL
A pilot study performed in this Unit showed that it
UMBILICAL ARTERY DOPPLER AND
is unnecessary to repeat Doppler tests if the RI is
PERINATAL OUTCOME
on or below the 50th centile, unless the patient
develops PIH or PET. This study aims to test
K Norman, M Smith, HJ Odendaal.
prospectively in a clinical trial, the RI centile
MRC Perinatal Mortality Research Unit, Dept of
below which a normal perinatal outcome may be
Obstetrics, Tygerberg Hospital
expected.
Symphysis-fundus growth (SFG) measurement if
Method
the most appropriate primary screening method
Umbilical artery Doppler velocimetry was done
to detect patients with poor fetal growth in
every 2 weeks on 360 patients with poor SFG. RI
developing countries. We use Doppler
values were plotted on our normal centile chart.
velocimetry of the umbilical artery as the second
line diagnostic test for poor fetal growth in our
Results
Unit. Abnormal Doppler velocimetry is
Twenty three patients with normal RI values had
significantly associated with IUGR and adverse
PIH/PET at the time of referral and were
perinatal outcome, whereas normal Doppler flow
excluded, leaving a study sample with no
is associated with a favourable outcome.
maternal complications.
However, these is no consensus as to how often a
normal Doppler test should be repeated.
Perinatal characteristics of Study group excluding PIH/PET
(Centile)
(<50th)
(50-75th) (75th-95th)
(>95th)
number
81
106
100
Gest. 1st RI (w)
31.5 (3.5)*
32.7(4.3) 32.6 (3.9) 31.9 (4.1)
Gest. birth (w)
38.3 (2.7) 39.3 (2.6) 38.9 (3)* 35.6 (4.3)
Birth et (g)
2787 (624)
2932 (481)*
2597 (618)*
SGA (%)
25 (30.8) 22 (20.7) 41 (41)
29 (78)
mean (SD)
p=0.16
p=0.01
p=0.0002
*
denotes p<0.01 versus next zone, Mann Whitney U test
37
1767 (725)
Significantly less babies born SGA < 75th versus 75-95th centile, p=0.008 or 0.48 (0.28-0.84)
Perinatal Mortality of Normal RI group
IUD
Reason:
LNND
< 75th centile
n=2
* Unknown, macerated, 40w, 1900g
no Doppler for 5w
* 100% abruptio, 38w, 2650g
75 - 95th centile
n=1
* Diabetic, cord around neck 38w, 2760g
n=1
* PET, prematurity, 30w, 1195g
n=1
* PET, prematurity, 32w, 775g
n=3
* anencephaly
* tricuspid atresia, hypoplastic ventricle
* caudal regression syndrome
n=1
* Trisomy 18
Congenital Abnormality
86
These results lead us to the following criterion
MATERNAL NUTRITION AND LOW BIRTH
which can be used in an effort to save on the
WEIGHT
number of RI tests done: Once a patient has a RI
value ON or BELOW the 75th centile we postulate
Obstetrics & Gynaecology - RC Pattinson, K
that it unnecessary for further tests. This method
Kyriazis, J Makin, B Demyttenare
does, however, have a risk, in that a patient may
Paediatrics - O Ransome, J v/d Vyver, A Grobler
have a sudden increase in RI. There were 7
Dieticians - A Pretorius, D v Rensburg
patient's RI that increased above the 95th centile.
Chemical Pathology - H Vermaak, R Delport
Four babies were born SGA but had normal
outcome; two premature deliveries due to onset of
Aim
preelampsia and one premature labour and
To ascertain whether maternal nutrition is
abruptio which is the true risk case not detected
associated with low birth weight in the population
by Doppler.
served by Kalafong Hospital.
The work load for a normal Doppler test was 446
tests. Additional tests done where the RI is still
Methods
below 75th centile was 259. However 24 patients

case/control study type
developed PIH/PET and had 32 additional tests.

for thorough maternal nutrition
These patient's tests must be repeated in order to
assessment
reduce the risk. The savings therefore are (259-

32)/446 which means 50.8% fewer tests. Use of
study populations divided by birth mass
into Group 1 1000g to 2500g Group 2 >
this rule would have a risk for an abnormal
2500g
Doppler at 2,6% i.e. (total patients at risk)/total

sample which is 5 (encl PET)/187. However the
exclusion criteria:
hypertensive disorders of
risk for an abnormal perinatal outcome is 1.06%
pregnancy
or 2 (excl 4x SGA)/187.
gestational diabetes
chronic maternal disease
Conclusions
tuberculosis
In a patient with a suspected IUGR fetus a normal
renal disease
perinatal outcome may be expected if the RI of
hypertension
the umbilical artery is below the 75th centile. No
diabetes
further testing is necessary, unless the maternal
syphilis
condition changes. A significant number of repeat
multiple pregnancies
tests may be saved without risk to the fetus.
stillbirths or IUD
Use of this guideline for the diagnosis and

management of the suspected growth retarded
Measures
Maternal physical nutritional
fetus may aid in the integration of Doppler
assessment: mass, length, body
velocimetry into clinical practice.
mass index*, daily diet
Gestational age scored by Ballard
et al's maturity score
87
Biochemical - nutritional
* Body mass index is calculated by dividing mass
assessment of mother and baby
by length sq i.e.: BMI =kg/l2

urea, creatinine, total
Statistical workup done with Mann
protein albumin, pre-
Whitney U test unless otherwise
albumin, cholesterol
specified.

retinol binding protein,
transferrien, Vit B6 Vit
B12, folic acid and
homocysteine
88
Data expressed as medians (range)
Table 1 Demographic data
Group 1
1000-2500g
Group 2
> 2500g
Population
number
53
56
Age years
p Value
24 (15-42)
26 (16-40)
0.5
Parity
Gravity
1 (0-5)
1 (1-6)
1 (0-5)
2 (1-6)
0.34
0.54
Number of
antenatal visits
13,2%
23%
13,2%
73%
5,6%
7,5%
23%
71%
1%
3,5%
66%
24%
5,6%
3,7%
73%
20,7%
3,7%
1,8%
Education
presecondary
secondary
post
secondary
unknown
Occupation
Light
Medium
Heavy
Unknown
Table 2 Maternal Results
Group one
1000-2500g
Group two
> 2500g
p Value
Mass (kg)
62 (47-94.2)
71 (50-130)
0.001
Length (m)
1.6 (1.4-1.8)
1.57 (1.34-1.72)
0.08
75.6%
24.3%
36.5%
63.5%
0.00039
OR 5.38
CL 1.98-14
60%
40%
40%
60%
0.43
OR 2.307
CL 0.44-12
Body mass index
*
healthy
*
overweight
Dividing overweight into:
*
*
overweight
obese and very obese
(OR=Odds Ratio), CL= Confidence Levels)
Hemoglobulin (g%)
11.1 (8-14.2)
11 (9-14.5)
0.38
Urea (mmol/l)
2.7 (2.4-12.5)
2.8 (0.5-6.3)
0.30
Creatinine (ol/l)
57 (35-134)
61 (44-147)
0.42
Total Protein (g/l)
64 (42-80)
65 (32-75)
0.81
Albumin (g/l)
35 (24-44)
35 (29-49)
0.56
Total Bilirubin (ol/l)
5 (1.6-23.2)
3.8 )1.8-41)
0.031
Cholesterol (mmol/l)
4.7 (2.6-7.2)
4.5 (1.52-6.0)
0.67
144.5 (71-312)
161 (81-213)
0.61
13.5%
16%
81%
15.6%
56%
28%
Transferrin (g/l)
3.6 (2.14 - 4.6)
3.46 (1.89 - 4.89)
0.37
Homocysteine (ol/l)
7.62 (2.88-27.3)
8.82 (3.38-16.9)
0.24
B6 (nmol/l)
11.3 (1.36-63.63)
12 (3.55-68)
Pre-albumin (mg/l)
Retinol binding protein (mg/l)
< 10
> 30
>10 <30
B12 (pmol/l)
>1440
1-200
200 - 1440
10.5%
34.2%
55.2%
0%
61.7%
38.2%
Folic acid (nmol/l)
>5
<5
92.1%
7.9%
88.4%
11.5%
1.
Conclusion
0.74
Chi square
NS
Chi square
NS
The population served by Kalafong
Hospital is not underweight.
89
Chi square
NS
2.
The mothers with the bigger babies i.e.
Group 2, tended to be overweight.
3.
The nutritional content of the daily diets
during pregnancy between groups is still
being analysed.
4.
The neonatal data will be presented in a
separate paper.
90
5.
AN OVERVIEW OF PERINATAL MORTALITY IN
Genetic factors and the incidence of
congenital abnormalities.
SOUTH AFRICA
6.
The health status of the population as a
whole.
H Saloojee, K Kalian
7.
Department of Paediatrics and Obstetrics and
The organisation and standards of
obstetric and paediatric care.
Gynaecology, Baragwanath Hospital
Introduction
Problems with the definition of perinatal
The perinatal mortality rate (PNMR) is regarded to
mortality
be a valuable index of maternal and child health in
Considerable confusion still exists internationally
a community/region. A PNMR for South Africa
as to the definition of a live birth, stillbirth, the
has yet to be established and available perinatal
perinatal period, and therefore what constitutes
mortality (PNM) data are patchy and not easily
the PNMR.
found.
The 10th revision of the International
Classification of Diseases suggests that the
Aim: To collate PNMR statistics from several
calculation of perinatal mortality rates be based on
hospitals, districts and provinces in South Africa to
a minimum weight of 1000 grams, or in the
facilitate national and international comparisons.
absence of weight data on 28 completed weeks
gestation or a length of 35cm from crown to heel.
Method : Review of published and/or reported
WHO has proposed that the term "live birth" when
South African PNMR data.
used in international comparisons, should exclude
fetuses of very low birth weight, i.e. below 1000
Results : Recent PNMRs at various institutions
grams, except in cases of congenital
and in different regions are summarised in Table
abnormalities where the recommended minimum
1 and 2.
weight is 55grams.
Lawson has proposed that a livebirth be defined
Discussion
as the complete expulsion or extraction form its
Many factors affect the PNMR and need to be
mother of a product of conception weighing 500
considered when analysing the differences
grams or more, irrespective of the duration of
between the different hospital and regions. Some
pregnancy, which, after such separation, breathes
of these include:
or shows any evidence of life, such as the beating
1.
The definition of perinatal mortality and
of the heart, pulsation of the umbilical cord, or
the way statistical data are collected.
definite movement of the voluntary muscles,
The mother's social and biological
whether or not the umbilical cord has been cut or
characteristics, e.g. height, parity, age,
the placenta is attached. If a product of
education and standards of living.
conception weighing less than 500 grams shows
The frequency of preterm and posterm
evidence of life 24 hours after birth it should be
deliveries.
considered as a livebirth.
The number of LBW and VLBW babies.
It is the authors' recommendation that Lawson's
2.
3.
4.
91
proposal be accepted for the collection of PNMR
Conclusions
data in South Africa. The advantage of the 500
Historically "black" hospitals continue to have
gram cut-off is that it facilitates national
higher PNMRs despite the desegregation of
comparisons, as well as improving the accuracy
facilities. Substantial differences also exist in the
of data of those stillbirths weighing more than
PNMRs in the various provinces. The overall
1000 grams for international comparisons.
PNMR for South Africa is estimated to be
between 30-60. A plea is made for the urgent
standardisation of PNM data collection in South
Africa.
Table 1
Hospital
Year
Deliverie
s
PNMR
SB
ENM
SB/ENM
King Edward*
93
12 621
85.7
59.6
27.7
2.2
Baragwanath
94
15 731
56.0
42.1
14.5
2.9
Pelonomi
94
6 000
42
Johannesburg
95
2 236
36.2
18.7
17.7
1.1
Livingstone
94
9 504
36.0
25.6
10.5
2.4
Hlabisa
91-4
16 245
32.0
Tygerberg
93
1 Military
91-3
7.8
10.3
0.7
21
1 650
*Includes deaths 500-999 grams
18.1
SB= stillbirths, ENM= early neontal mortality
Table 2
District/Region
Year
Deliveries
PNMR
SB
ENM
SB/ENM
Soweto
94
23 450
37.6
28.2
9.6
2.9
Cape Town MOUs*
93
17 541
25.0
17.6
7.5
2.3
Natal
91-93
102 019
51.2
Gauteng
95
42 204
31.0
21.0
10.1
2.1
Cape Province
89-91
373 768
26.8
17.9
9.1
1.97
* Includes deaths 500-999grams
2
SB=stillbirths, ENM=early neonatal mortality
92
labour ward and ante-natal clinic.
UNBOOKED PATIENTS
The interviews were carried out by : a Chief
M Mokoana, P Jass, M Siko, V Moniez
Professional Nurse, or a Senior Professional
Maternity Unit - Alexandra Health Centre and
Nurse or a Professional Nurse.
University Clinic
Data from time period October 1994 - January
1995 and October 1995 - January 1996 was
Objective
analysed and the unbooked rate looked at.
1.
To observe the effects of free health
During the study period, unbooked and booked
services since its inception in October
patients were then compared in terms of their
1995.
responses to the questionnaires. Endpoints
To identify the possible socio-economic
included age, language, parity, schooling,
characteristics leading to being unbooked.
previous booking status, previous delivery, marital
To identify reasons why some people do
status, residence, financial status and social
not book.
problems.
2.
3.
Reasons for the importance of attending clinic and
Method
what they expected from the clinic were also
Quantitative and Comparative Research
looked into.
There were 25 unbooked patients and 50 booked
women interviewed.
from December 1995 - February 1996 in the
Results
Table 1 BEFORE
PERCENT
YEAR/MONTH
BOOKED
UNBOOKED
BOOKED
UNBOOKED
October
262
22
92.2%
7.8%
November
279
23
92.4%
7.6%
December
292
18
92.2%
5.8%
January
295
11
95.7%
4.3%
1994-1995
93
Table 2 AFTER
PERCENT
YEAR/MONTH
BOOKED
UNBOOKED
BOOKED
UNBOOKED
October
328
18
94.8%
5.2%
November
285
19
93.8%
6.2%
December
276
20
93.2%
6.8%
January
252
17
93.7%
6.3%
1995-1996
There is no obvious difference between the
Table 4 KIND OF SERVICE THEY EXPECT
unbooked rate before the study period and during
16/26 were pleased with the services
Advertisement of free health services
Exercise for pregnant women
Clinic should be opened on Saturdays
Health Education
Good attitude of the staff
the study period.
In reviewing the unbooked and booked groups
there was no difference found regarding age,
language parity, schooling and role of delivery.
Discussion
They differed with regard to; marital status: with
The clinic aims to decrease the unbooked rate by
more unbooked mothers living apart from their
advertising early booking and free health services
partners; time of residence in the area with 50%
on "Alex FM" (the radio station in Alexandra
of its unbooked spending less than a year there;
Township) and having Health Educators for Ante-
and employment with more of the unbooked being
natal, Labour Unit and Family planning.
unemployed 81% compared to 54%.
The responses to the questions are shown in
Conclusion
Table 3.
1.
A major problem is that the people have
just moved into Alexandra, and we cannot
do anything about it.
Table 3
WHY UNBOOKED?
Has just moved to Alexandra
No money, not aware of free health services
Still planning to book
Knew that they would be referred to hospital,
refusing to go
Psychosocial problems
WHY IS IT IMPORTANT TO BOOK?
To check if I have problems
To check well being of baby
To check both the mother and baby
2.
= 9/25
= 7/25
= 5/25
Intervention should be at National and
Provincial level.
3.
= 2/25
= 3/25
Education, advertisement of free health
services and the implementation of the
patient retained card at National level.
= 18/25
= 3/25
= 6/25
4.
Success of patients retained cards.
five patients who had booked in other
hospitals and clinics came with their
cards.
THE UNBOOKED MOTHER AT
BARAGWANATH HOSPITAL AFTER THE
D Dawood, E Buchmann
INTRODUCTION OF FREE ANTENATAL CARE
Department of Obstetrics and Gynaecology,
94
The
Baragwanath Hospital and University of the
Table 1 Gestational ages of the cases and
controls
Witwatersrand
Gestational age groups
Introduction
Unbooked
n=112
Booked
n=112
21-24 weeks
10
10
25-28 weeks
20
20
29-32 weeks
14
14
33-36 weeks
18
18
37 - 40> weeks
50
50
With the introduction of free maternity services,
the rate of unbooked mothers has decreased by
half to ten percent at Baragwanath Hospital. This
study was designed to describe characteristics of
unbooked mothers, to find out why they do not
make any antenatal visits before delivery, and to
Results
compare perinatal outcomes of booked and
Maternal characteristics are shown in Table 2.
unbooked mothers. For the purpose of this study
There was no significant difference in age
the unbooked mother was defined as any
between the two groups. More mothers were
pregnant woman who made no antenatal visits
primigravids, married and unemployed in the
before delivery.
booked group. Literacy was defined as standard
four level or more. Fourteen percent of unbooked
Method
compared to six percent of booked patients
A case-control study was undertaken between
smoked.
August 1995 and September 1995. A total of 224
Table 3 refers to reasons for not booking.
patients evenly divided into 112 unbooked and
Reasons for booking were also asked. Forty six
112 booked patients were interviewed in the
percent of women booked for fetal and maternal
postpartum period, using the same questionnaire
wellbeing. Seventeen percent booked after being
for both groups. The unbooked mothers were
advised by friends and parents. Sixteen percent
selected from the labour ward register. Booked
booked after consultation with a medical doctor
mothers were matched for gestational age and
for ill health and were subsequently told that they
were randomly selected from the labour ward
were pregnant.
register. Table 1 illustrate how patients were
Table 4 refers to maternal problems. Twenty
matched:
percent booked patients and thirteen percent
unbooked patients were hypertensive. Eclampsia
and abruptio was twice as high in the unbooked
group compared to the booked group. Positive
Wasserman - reaction was higher in the
unbooked group.
Primigravids
Unemployed
Income
<R500p.m.
Literate
Smoking
Married
Table 2 Maternal Characteristics
Age
Unbooked
n=112
Booked
n=112
Statistical
Significance
26,4 yrs
26,0yrs
N/S
95
32(29%)
70(63%)
47(42%)
86(77%)
P=0.036
P=0.020
79(71%)
99(88%)
16(14%)
19(17%)
86(77%)
91(81%)
7 (6%)
40(36%)
N/S
N/S
p=0.046
p=0.001
Live in Soweto
59(53%)
67(60%)
N/S
Table 5 Perinatal mortality and morbidity
N/S = not significant
Unbooked
n=112
Table 3 Reasons for not booking n=112
Booked
n=112
p
Number
Percentage
Intended to book
10
9
Too lazy
15
13
Unaware of pregnancy
15
13
Too busy working or studying
14
12
Discussion
Attending a private doctor
9
8
Compared with controls, unbooked mothers could
Financial problems
9
8
be characterised as being unmarried, smokers
Fear of parents knowing
8
6
and employed.
Nurses attitude
3
2
Reasons for not booking included laziness, lack of
Not given
29
26
time from work and being unaware of pregnancy.
Stillbirth rate
Early neonatal death
rate
Perinatal mortality
rate
Birth weight <2500g
205
9
241
9
N/S
N/S
214
250
N/S
62 (54%)
52(46%)
N/S
Patients with poor obstetrical history book at
Table 4 Maternal problems
Previous C/S
Hypertension
Eclampsia
Abruptio
Preterm Labour
Wasserman-reaction
positive
Baragwanath Hospital. Perinatal outcomes were
Unbooked
n=112
Booked
n=112
p
12(11%)
15(13%)
4 (3.6%)
4 (3.6%)
31 (28%)
22(28%)
15(13%)
20(20%)
2 (1%)
2 (1%)
32(29%)
14(13%)
N/S
N/S
N/S
N/S
N/S
N/S
similarly poor in both groups, mostly associated
with complications resulting in preterm birth.
Syphilis as a cause of perinatal death was
however more frequent in the unbooked group of
mothers.
Conclusion
Poverty is no longer a barrier to antenatal care at
Baragwanath. Unbooked mothers may form a
risk-taking minority of urban pregnant women.
Previous researchers have found higher
incidences of perinatal complications in unbooked
mothers but these differences were not noted in
this study after controlling for gestational age.
96
AN EVALUATION OF THE INCIDENCE OF
Results
EPISIOTOMIES AND PERINEAL TEARS IN
The incidence of episiotomies was 25,57% and
PATIENTS AT PELONOMI HOSPITAL
that of tears 6,86%
The multigravidae formed the majority of patients
EC De Coning, BL Faber, J Duminy, A Louw, U
(63,1% versus 36,9%).
Snyman, R Tracey, I Niemand
The mean age of the primigravidae were 20,07
Department Obstetrics and Gynaecology, UOFS
years versus the 27,26 years of the multigravidae.
The average birth weight of the babies of the
Introduction
primigravidae was 2667,4 grams versus 2776,1
Episiotomies are always justified by four
grams of the multigravidae.
perceptions, namely: the prevention of damage to
Midwives delivered 57,5% of babies, nursing
anal sphincter and rectal mucosa, the prevention
students 20,8%, medical students 17,4% and
of serious damage to pelvic floor musculature, the
doctors 4,3%.
prevention of trauma to the fetal head and that
The mean duration of the second stage of labour
episiotomies recover faster than tears.
was 28,04 minutes for the primigravidae versus
The routine use became a controversial issue
16,39 minutes for the multigravidae.
after several studies showed the incidence of
Nearly half of the primigravidae received an
severe lacerations occurring after midline
episiotomy (49,1%) versus 15% of the
episiotomies, to be approximately 50 times and
multigravidae. Only 8,3% of primigravidae
after mediolateral episiotomy, approximately 8
develop a tear versus 31,8% of the multigravidae.
times greater than in the case of spontaneous
Considering the tears, 86,6% were a first degree,
tears. Furthermore, pelvic muscle floor strength
11,6% second degree and 1,8% a third degree.
seemed weaker after an episiotomy than after a
Of the 9,8% in lithotomy, two thirds (66,6%)
spontaneous tear.
received an episiotomy and a quarter (25,6)
developed a tear.
Question
To determine the incidence of episiotomies and
Conclusion
perineal tears at Pelonomi Hospital and their
Personal preference plays a major role in
relationship.
determining whether or not an episiotomy is
performed.
Sample
The 25,5% incidence of episiotomies correlates
525 women who delivered vaginally at Pelonomi
well with the Belgian (28%) and Swedish (30%)
Hospital
figures although it is significantly lower than that of
the US (61,9%) and Denmark (56%).
The majority of tears were first degree (86,6%)
and approximately 43% of the primigravida
delivered normally without an episiotomy or a tear
compared to the 53% multigravidas.
97
98
SCREENING FOR ANAEMIA IN PREGNANCY
each unaware of the other's findings. On each
COMPARISON BETWEEN COPPER
patient a Coulter haemoglobin estimation was
SULPHATE AND HAEMOGLOBINOMETER
performed. The effectiveness of screening for a
METHODS
haemoglobin level below 10g% was calculated for
each method, as well as the accuracy (systematic
LR Pistorius*, AF Swanepoel**
error) and precision (random error) of the
* Department of Obstetrics and Gynaecology,
haemoglobinometer.
Kalafong Hospital, ** Obstetric Unit, Pretoria West
Results
Hospital
There were five patients with haemoglobin level
below 10g%, as estimated by the Coulter method.
Introduction
Both the copper sulphate method and the
Anaemia in pregnancy can be caused by the
physiological dilutional effect of a disproportionate
haemoglobinometer detected two of these
increase in plasma volume relative to red cell
patients. With each method, the lowest
mass. In nutritionally disadvantaged
haemoglobin of the patients with false negative
communities, a dietary deficiency of iron (and to a
screening was 9,5g%. The copper sulphate
lesser extent folic acid) intake, commonly causes
method had three false positives, and the
anaemia. Anaemia can be a contributory cause
haemoglobinometer four false positives.
in many cases of maternal mortality, but is easily
The accuracy of the haemoglobinometer as
detected by simple screening tests, and in most
compared with the Coulter estimation was -0,8%,
cases easily treated.
and the precision 1,0g%. The errors ranged from
Different screening methods exist. Common
-5,0 to +0,9g%. 89% of the errors with
methods include the use of a hand-held
haemoglobinometer estimation were larger than
haemoglobinometer, micro-haematocrit, or
1g%, 57% larger than 1,5g%, and 43% larger than
laboratory assays. The copper sulphate method
2,0g%. In other words, in only 11% of patients,
for screening for pregnancy anaemia is sensitive,
were the haemoglobinometer readings within 1g%
specific, inexpensive and uncomplicated.
of the Coulter values.
As the effectiveness of a screening test can vary
in different populations, the copper sulphate
Conclusion
method was compared with the
The prevalence of anaemia in this population was
haemoglobinometer in a different population.
too small to draw any conclusions about the
comparative effectiveness of the two methods
Methods
from this small study. However, the imprecision
One hundred consecutive pregnant patients at the
of the haemoglobinometer is a cause for concern.
antenatal clinic of Pretoria West Hospital who
needed screening for anaemia, qualified for the
study. Each patient was screened for anaemia
with both the copper sulphate method and using a
haemoglobinometer by two different midwives,
99
100
ADRENALIN AS AN INOTROPE IN CRITICALLY
Mean birth weight was 1419g (+511g) and mean
ILL, HYPOTENSIVE NEONATES
gestational age 31.7 weeks (+3.5wks).
Age on admission to the NICU varied from 1 hour
S Velaphi, H Saloojee
to 10 days.
Department of Paediatrics, Baragwanath Hospital,
Initial diagnoses were congenital pneumonia (4),
Johannesburg
septicaemia (2), hyaline membrane disease (3),
NEC (1) and birth asphyxia (1). There was
Introduction:
suspicion of infection in 7 of the 11 babies but
Ill Neonates often die from severe hypotension
none of the blood cultures were positive.
that is unresponsive to inotropes like dopamine
All 11 babies were initially started on dopamine
and isoprenaline, and volume replacement. This
and the dose was increased to maximum 20
is particularly common in septic babies. Poor
ug/kg/min. No response was seen in 3 and a
responsiveness to dopamine may be explained by
non-sustained response in 8 babies.
a decrease in the sensitivity of beta-receptors to it,
Isuprenaline was then started in 5 babies, of
as well as reduced dopamine beta-hydroxylase
whom 2 showed a non-sustained response.
activity in septic shock. Adrenalin has been
11 babies, therefore, required adrenaline with 3
shown to be a useful inotrope in cases of
showing no response, but the other 8 all had a
unresponsive hypotension in animal models and
sustained improvement in blood pressures.
in adult studies. No studies reporting its use in
The doses of adrenalin used ranged from
neonates exist.
0.1ug/kg/min to 1ug/kg/min. No side effects from
All
adrenalin use were documented like
Aim:
tachyarrhythmias or anuria. The response to
To review our experience of the use of adrenalin
adrenaline and dopamine together was
as an inotrope in ill neonates.
significantly better than dopamine alone
(p=0.004). Plasma bolus/es were used before
Methods:
and during the administration of inotropes but did
A retrospective review of NICU babies with
not influence outcome.
unresponsive hypotension that required the use of
Eight of the babies eventually died; 3 directly
adrenalin. We evaluated the effectiveness of all
related to uncontrolled hypotension - 2 with
therapies used to manage the hypotensive
septicaemia and 1 with IVH grade 4. Causes of
episode/s. Hypotension was defined as a mean
death in the other 5 babies where the hypotension
arterial blood pressure less than the 10th
was controlled were septicaemia (3), IVH grade 4
percentile for gestational age. Response to all
(3), birth asphyxia (1) and NEC.
inotropes was coded as being nil, non-sustained
Conclusion:
(<6hrs) or sustained.
1.
The data suggests that adrenalin has a
Results:
definite role to play in hypotension
Adrenalin was used in 11 cases over a ten month
unresponsive to other inotropes with a
period.
73% success rate.
101
2.
However, 63% of the babies ultimately
died, despite successful control of the
blood pressure with adrenalin.
3.
No significant side-effects were
associated with its use.
4.
A prospective, randomised controlled
study is being planned to evaluate
adrenalin's safety and value in sick
neonates.
102
USING THE PERINATAL PROBLEM
The causes of death and avoidable factors were
IDENTIFICATION PROGRAMME IN MIDWIFE
classified and entered into the programme by the
OBSTETRIC UNITS IN CAPE TOWN
investigator.
DH Greenfield
Results
Department of Paediatrics, UCT
There are summarised in the tables below.
Identification of the causes of perinatal death, and
Recommendations
of possible or probable avoidable factors is an
This programme should be used in District (and
ongoing activity. The main purpose is to be able
also Regional) Hospitals for analysing data
to implement appropriate in service training, in
relating to perinatal deaths.
order to reduce, where possible, the perinatal
Conclusions
morbidity and mortality.
PPIP is simple to use both for data entry and
Methods
producing analysis and reports. The reports are
All MOU related perinatal deaths occurring during
easy to understand. The programme achieves its
1994 were entered in PPIP, and into the currently
major aim of identifying the problems related to
used database using EPI INFO 5. The
perinatal deaths. The classification of causes of
classification of causes of death in both systems,
death (especially final neonatal causes) can be
although slightly different, were both based on the
improved upon. The results are the same as
Whitfield classification.
those produced from EPI INFO 5, but are
produced in a more user friendly form.
Table 1 Primary obstetric causes of death
Spont. preterm labour
500-999g 1000-1499g
54
16
Infections
- Syphilis
- AFIS
5
4
APH
- Abruptio
- Other
8
1500-1999g
4
7
2
6
9
1
GPH
3
Fetal abnormality
Intra partum hypoxia
- labour related
- other
IUD - unexplained
- fresh
- macerated
1
1
22
>2500g
Total
74
8
3
11
5
10
1
Idiopathic IUGR
2000-2499g
6
9
10
37
23
43
1
2
12
4
20
2
2
3
10
6
4
6
9
26
1
1
1
3
1
48
5
52
8
1
8
1
9
2
11
2
20
7
70
3
Table 2 Final causes of Neonatal Death
Premature related
500-999g 1000-1499g
29
13
1500-1999g
2
103
2000-2499g
>2500g
Total
43
Asphyxia
1
1
Infection
- syphilis
- other
2
4
1
Congenital abnormality
1
1
1
1
4
4
6
3
5
9
19
62
Inadequate antenatal care
Delay in seeking help
Other
40
17
5
Medical Personnel Related
*
Deficient monitoring in labour
(fetal distress/progress of labour)
*
Delay in referral/getting expert help
*
Other
Administrative Problems
*
Transport
45
23
7
15
6
6
104
32
2
1
Table 3 Avoidable Factors
Patient Related
*
*
*
24
general.
AUDIT ON ANTENATAL CARE BEFORE AND
AFTER THE INTRODUCTION OF THE
PERINATAL EDUCATION PROGRAMME AND
Results
FREE ANTENATAL CARE IN ATTERIDGEVILLE
This study showed an improvement in available
results of essential tests like Hb, Rh and STS. At
Kalafong unavailable Hb results were reduced
R Pfau, RC Pattinson, J Makin
from 39% to 1992 to 5% in 1995 (PEP-Clinics
Introduction
1992 27%, 1995 3%).
Effective antenatal care has been proven to lower
Similarly significant were the improvements in Rh
the perinatal and the maternal mortality.
testing at Kalafong (no test 1992 52%, 1995 8%)
Antenatal coverage and accessibility is a major
and at the PEP-Clinics. STS testing had
problem in developing countries, especially in
improved at Kalafong but the rate of not testing
rural areas and in the socio-economically
remained unacceptably high (16%) at the PEP-
disadvantaged population groups.
Clinics.
The introduction of the home-based motherhood
After the introduction of PEP improvement was
card at Kalafong Hospital and in the greater
found in the counselling for family planning. At
Pretoria region was one step to improve the
Kalafong 74% of patients were not counselled in
quality of antenatal care. Health worker education
1992. This was reduced to 23% in 1995.
via the Perinatal Education Programme (PEP) and
At Kalafong the appropriate action was not taken
free antenatal care were other measures
1995 in 33% of cases (PEP-Clinics 36%).
introduced .
Interpretation of a patient's history and taking the
The changes and effects of these measures on
required action remained a major problem. At
antenatal care were evaluated in this study.
Kalafong appropriate action was not taken 1995 in
Methods
44% of cases (1992 64%) (PEP-Clinics 1995
The study compared 125 standard motherhood
52%, 1992 58%).
charts sampled during the first two weeks in June
The problem list was filled in more often. In the
1992, six months after the introduction of the
PEP-Clinics in 1995 15% were not filled in, 36%
chart. Those cards were compared with 124
were filled in incorrectly. (1992 25% were not
charts sampled during the last two weeks in
filled in, 41% were incorrect). At Kalafong 10% of
September 1995, approximately three years after
patients had the problem list not filled in 1995
the active implementation of the motherhood
(1992 11%). The number of incorrect filled
chart. The parameters on the motherhood chart
problem lists came down from 48% (1992) to 12%
were scored individually or in groups depending
(1995).
on their clinical importance. The interpretation of
The presenting part in the last trimester was
pathological parameters or parameter-groups was
palpated more often in 1995 but in the PEP-
also scored. The change in antenatal care was
Clinics 42% were not palpated (1992 62%). The
compared amongst Kalafong Hospital, clinics
basic level of not palpating the presenting part
which participated in the Perinatal Education
was 36% at Kalafong (1992 54%).
Programme (PEP-Clinics) and referral clinics in
The SF-graph was filled in very well. Only 3% had
105
the graph not filled at the PEP-Clinics (1992 1%).
Hb-estimation via the copper sulphate method
At Kalafong all charts had a completed graph in
brought a marked improvement in available test
1992 and 1995. As seen with other parameters
results. The testing for syphilis had improved in
the interpretation of the graph was a problem. At
general and in Kalafong but remained unchanged
Kalafong and at the PEP-Clinics the required
in the PEP-Clinics. Some of these clinics have
action was not taken in 57% and 65% (1992:
not introduced the rapid STS-Test yet.
Kalafong 33%, PEP-Clinics 40%).
Although there has been an improvement in
investigations performed and problem lists filled
The weight graph was completed well at Kalafong
in, indicating possibly the effect of PEP teachings,
(1992 4% had no weight graph, 1995 3%). But at
the basic problem seems to be in the
the PEP-Clinics 32% were left without a weight
interpretation of pathological data.
graph which was worse than 1992 (9%). Almost
Antenatal care free of charge as part of the action
half (43%) of the weight graphs at the PEP-Clinics
plans to improve reproductive health has changed
were incorrectly filled (36% at Kalafong).
the gestational age at the booking visit
From all the 171 patients delivering in the 1995
significantly.
study period 124 (72,5%) had a standard
motherhood chart. 7,6% were provided with other
Conclusion
motherhood charts than the standard from
In general there is an overall improvement of
analysed in this study. Only ,3% (4 patients)
antenatal care after the introduction of the
forgot their chart at home and only one patient lost
Perinatal Education Programme and free
her chart. 2,3% attended antenatal care at a
antenatal care. A target area for further
private practitioner who didn't issue a chart. 4,1%
improvement should be the gap between the
attended a clinic without being given a
collection of data and the interpretation thereof. A
motherhood chart. 4,8% of patients were
second target should be the total cover of all
unbooked at delivery.
patients with on-site tests, especially STS. The
In 1995 antenatal care and delivery were free of
implementation of a standardised motherhood
charge. After the introduction of free antenatal
chart which is issued by all providers of antenatal
care patients booked at Kalafong 7 weeks earlier
care would be the third target area.
(clinics 4 weeks). This was statistically significant.
A tendency towards an increase in the number of
antenatal visits was observed (Kalafong 1992 5
visits, 1995 7 visits).
Discussion
There was a significant reduction of essential
tests like Hb, STS and Rh which were not done or
the results not available in 1995 compared to
1992. The introduction of the rapid Rh-test and
106
ACCURACY OF ASSESSMENT OF CERVICAL
standard deviation for each observer. The mean
DILATATION
error (representing accuracy) and standard
deviation (representing precision) were also
M Funk, LR Pistorius, J Levin*, GR Howarth, RC
calculated for the different occupational groups
Pattinson
that participated, and for every dilatation tested.
Department of Obstetrics and Gynaecology,
To obtain a clearer indication of the magnitude of
University of Pretoria, Kalafong Hospital
error, the corresponding mean absolute errors
* Medical Research Council, Pretoria.
(ignoring the direction of error) and standard
deviations were also calculated.
Cervical assessment is one of the cornerstones of
The effect of different observers, different
the management of women in labour.
occupational groups and the extent of dilatation
Significant intra- and inter-observer variation in
on the accuracy of assessments were examined
assessment of cervical dilatation may lead to
by fitting a Mixed Model, using the Residual
misclassification of normal or poor progress,
Maximum Likelihood (REML) procedure.
resulting in either unnecessary or delayed
Results
intervention.
The overall mean error in estimation of diameter
Objective
was -0.24+0.74 cm and the overall mean absolute
To determine the accuracy (systematic error) and
error was 0.50+).59 cm. Error ranged from
precision (random error) within and between
underestimation by 3.5 cm to overestimation by 2
observers in estimation of the diameter of a circle,
cm. Thirty-seven percent of the 1400 estimations
representing cervical dilatation.
were underestimations (6% were
underestimations by more than 1 cm), 49% were
Method
exactly correct and 14% were overestimations
Six midwives, 4 consultants, 15 registrars, 3
(1% were overestimations by more than 1 cm).
medical officers and 7 interns, responsible for
Ninety-three percent of estimations were within 1
management of women in labour, participated in
cm of the true diameter.
this observational study. A series of 10 circles
Inter-observer variation in accuracy was
were cut into cardboard sheets to simulate
significantly greater than intra-observer variation
cervical dilatations from 1 to 10 cm. Participants
(stratum variances 5.67/0.41 on 30,1365 df). The
were unable to see these circles, which were
variation in accuracy was not significant between
presented to them in a vertical plane through the
different occupational groups.
side of a box, in a predetermined random order.
The extent of dilatation had a significant effect on
Each observer performed 40 estimations by
both accuracy and precision of estimations. The
putting his hand through an opening in the front of
mean error was -0.18+0.38 cm for diameters 1-3
the box and then stating his answer to the nearest
cm, -0.19+0.69 cm for diameters 4-6 cm and -
half centimetre.
0.33+0.94 cm for diameters 7-10 cm. The
The accuracy and precision of estimations were
corresponding mean absolute errors were
determined by calculating the mean error and
0.25+0.34 cm, 0.50+0.52 cm and 0.68+0.72 cm.
107
Conclusion
It is reassuring that 93% of estimations were
within 1 cm of the true diameter. Inter-observer
variation was significantly greater than intraobserver variation. The danger of
misclassification of progress of labour still
remains due to random error and inter-observer
variation.
108
functioning.
UPDATE ON THE IMPORTANCE OF TOUCH
Subjects received a 15 minute massage twice
L Bluff & K Hansen
weekly for five weeks - investigators found that
Johnson & Johnson (Pty) Ltd
although levels of the stress hormone cortisol
decreased, participants reported no drowsiness.
Scientists are now confirming what many cultures
Instead they experienced heightened alertness.
have long known, Touch and Massage have
EEGs confirmed that after massage, subjects had
pronounced benefits. Touch therapy, especially
decreased alpha and increased beta and theta
massage, produces measurable and beneficial
brain waves - alterations that are consistent with
physiologic changes - facilitating growth and
heightened alertness.
development in infants, children and adolescents;
As an additional test of mental function, subjects
improving health across the lifespan; reducing
were given computational problems to solve.
stress and certain types of pain; and delivering
They completed the tasks approximately twice as
health benefits to those who administer as well as
quickly as they did before massage, with only half
those who receive it. Recent research indicates
the errors.
that touch can reduce levels of stress hormones,
positively affect the immune system, and even
Positive effects on the immune system
alter brain waves.
There has been a remarkable link between touch
and immune system functioning in adults - in one
Reduction in Stress Hormones
study of adult men with HIV who were massaged
Infants and adults exhibit physiologic responses to
five times a week for one month, researchers
stress and it has been determined that even
documented significant increases in natural killer
preterm infants can mount a strong biochemical
cell numbers and cytotoxicity, suggesting
response to stress marked by increased
beneficial effects on the immune system.
concentrations of catecholomines (such as
No massage related changes were observed in T
norepinephrine) and cortisol.
cells the components of the immune system
Recent studies have shown that massage can
normally attacked by HIV. However, by
decrease levels of certain stress hormones in the
enhancing the functioning of the NK cells,
body. This reduction in stress hormones may
massage may prove helpful in preventing some of
help explain why massage alleviates depression
the secondary infections associated with AIDS.
and anxiety.
In an unusual study of grandparent volunteers
HIV Exposed Preterm Infants
who administered massage in infants, subjects
This study, which is now underway is designed to
reported less anxiety and depression after giving -
examine the impact of therapeutic massage on
rather than receiving massages.
the behavioural and immune functioning of HIVexposed infants. Mothers in the study have been
Alterations in Brain Functioning
instructed to administer a 15 minute massage
Massage may have an impact on mental
three times daily for the first two weeks of life.
109
Preliminary results have shown that massaged
*
Peak flow meter readings improve
infants:
*
Depression and anxiety decrease
Gain more weight (33 grams per day
*
Pulse is lowered
compared with 26 grams per day in the
*
Restlessness decreases
control group).
*
Affect improves
*
*
Perform better on Brazelton motor and
orientation clusters.
*
Exhibit less excitability, better motor tone,
better state regulations and greater
responsiveness.
In addition, the researchers have noted an
impressive rate of compliance on the part of the
mothers - nearly 100%.
Massage Effects on Cocaine-exposed preterm
neonates
This study examined the effects of massage
therapy on the behaviour and motor functioning of
cocaine-exposed NICU infants. A 15 minutes
massage was administered three times daily to
the infants for a 10 day period. The massaged
infants demonstrated:
*
Fewer postnatal complications and stress
behaviours
*
A 28% greater daily weight gain
*
More mature motor behaviours on the
Brazelton scale
Asthmatic Children
This investigation, which is also still underway, is
designed to examine the impact of massage on
asthmatic symptomatology and
anxiety/depression levels. Each mother is
instructed to administer a daily 20 minute
massage to her child for one month. Preliminary
results have shown that immediately after
massage.
110
THE INTERNET AND TEACHING IN
range of students and the idea of different
PERINATAL CARE
schools using the same questions on the
same day becomes an intriguing
possibility.
A Kent
Department of Obstetrics and Gynaecology,
3.
University of Cape Town
Curriculum Development
There is a need to define the essential
The Internet's strength is its ability to allow the
knowledge, skills and attitudes required
transfer of information.
by students.
There are a number of
practical ways that we can turn this to the
The quest for the Core Curriculum can be
advantage of educators in Perinatal Care.
explored using Internet linkages in real
Undergraduate and postgraduate students in all
time or by swopping the facts and
the health sciences require teaching and
information deemed crucial by one
reference material. Computers plus the Internet
department and comparing it with others.
can provide just that. From the teacher's point of
There is pressure looming to define
view there are several exciting prospects on the
priorities for students to learn according to
horizon.
prevalences and the swift exchange of
1.
Teaching Material Exchange
agreed "givens" could assist consensus.
Locally produced booklets, manuals,
Special study modules or standard
lecture notes and documents can be
projects would be usefully compared
shared between departments with mutual
between universities.
benefit. Academic literature can be
4.
standardised, updated and made
2.
Computer Assisted Learning
available to all students at a fraction of the
Learning software, instructive or
cost of printed books.
interactive, commercial or academic will
Whether a "virtual text" of basic
help solve the problem of the dwindling
knowledge for Southern Africa could be
numbers of academic teaching staff.
built up remains to be seen. Hypertext
Students bring computer literacy skills
technology makes possible "click
with them to Medical Schools with
searches" for more information,
increasing frequency. CD ROM
explanations, underlying anatomy,
technology opens audiovisual
pathophysiology and references.
possibilities not envisaged in the pre-
Examinations
computer/Internet era.
If examiners pooled questions using
e-Mail or Web pages, many more multiple
Continuing Medical Education (CME) should be
choice questions (MCQs) and Objective
available to doctors, nurses and midwives in
Structured Clinical Examination (OSCE)
areas distant from academic centres. The
stations would be available. Their validity
Internet presents the option of distance learning.
and reliability could be tested over a wide
This is possible in midwifery and neonatology in
111
South Africa and the process is being assisted by
the Medical Association of South Africa which is
promoting in electronic linkages to rural
practitioners.
112
ANTENATAL PREDICTIVE FACTORS OF
positive syphilis serology, previous antepartum
NEURODEVELOPMENTAL DELAY IN VERY
haemorrhage and Betamethasone usage did not
LOW BIRTH WEIGHT (VLBW) INFANTS
influence outcome. Gestational Proteinuric
Hypertension (GPH) with deteriorating renal
PA Smith, J Anthony, C Thompson,
function was the only delivery indication that
S Buccimazza, A Malan
placed the infant at higher risk of handicap. None
Department of Paediatrics, University of Cape
of the routinely used monitoring modalities (fetal
Town
heart rate monitoring, ultrasound for growth and
liquor volume and umbilical Doppler velicometry)
had predictive value for disability.
Antenatal predictive factors for poor long term
outcome in VLBW infants in our population are
not clear. It is important to establish these for
Conclusion : Prediction of neurodevelopmental
appropriate antenatal and intrapartum care,
delay remains difficult. Multiparity, older maternal
individual patient counselling and general health
age and GPH with deteriorating renal function
resource management.
were found to be predictive factors in this study
group. None of the current monitoring modalities
were able to predict poor outcome.
Aim of study : To establish if there were any
maternal factors or antenatal monitoring
modalities that could predict neurodevelopmental
delay in surviving VLBW infants.
Methodology : Antenatal notes of all infants
weighing <1250gm who survived to 2 yrs of age
and who were admitted to the Groote Schuur
Neonatal ICU (GSH NICU) during the study year
from 1 July 1988 were retrospectively reviewed.
Statistical comparison was done of maternal
factors and results of monitoring modalities
between those infants that were normal and those
that were handicapped at 2 yrs of age.
Results : Ninety-seven of the initial 235 infants
were followed up to 2 years of age. Of these 21
(22%) were assessed as having a major handicap
(3 cerebral palsy (CP), 15 Developmental quotient
(DQ) <80 and 3 both CP and DG<80).
The older multiparous patient appeared to be
more at risk of having an impaired infant. Past
obstetric and medical history, booking status,
113
REVIEW OF RISK FACTORS FOR THE
40%, specificity of 86% and positive predictive
PREDICTION OF FETAL LUNG HYPOPLASIA
value of 67%. TC:AC ratio had a sensitivity of
AND ULTRASOUND PREDICTORS THEREOF
100%, specificity of 90% and positive predictive
value of 67%. Lung length measurement had a
poor predictive value.
CJM Stewart, SK Tregoning, *H Wainwright
Department of Obstetrics & Gynaecology,
University of Cape Town
CONCLUSIONS:
*Department of Pathology, University of Cape
Neither the gestational age nor the duration of
Town
membrane rupture was predictive of lung
hypoplasia. Thoracic to abdominal
All neonatal postmortems in the 3 year period
circumference ratio was the best ultrasound
1993 - 1995 were reviewed. The association of
predicator.
the following factors with lung hypoplasia was
These data correlate with international literature
determined: a) Gestational age at onset of
findings.
oligohydramnios; b) Duration of oligohydramnios;
c) Amniotic fluid index (AFI). A prospective study
was then embarked upon to assess the predictive
value of the above factors as well as ultrasound
measurements of thoracic circumference (TC),
thoracic to abdominal circumference ratio
(TC:AC) and lung length in a group of patients
with rupture of membranes less than 28 weeks
gestation.
RESULTS:
468 neonatal postmortems were performed of
which 99 patients (21%) demonstrated lung
hypoplasia. 64% of these were associated with
congenital anomalies. The remainder were
related to other causes of which oligohydramnios,
secondary to either prolonged membrane rupture
or impaired fetal growth, was the commonest.
There was no statistically significant difference
noted in the average gestational age at
membrane rupture, duration of membrane rupture
or AFI between the group of patients with lung
hypoplasia versus those without. In terms of the
value of the ultrasound predictors of lung
hypoplasia, TC measurement had a sensitivity of
114
POOR CORRELATION BETWEEN FETAL
Results:
HEART RATE PATTERNS AND UMBILICAL
A total of 54 patients were studied, 36 of whom
ARTERY BLOOD GASES IN HIGH RISK
had good FHRP and 18 of whom had poor
PATIENTS DELIVERED LONG BEFORE TERM
patterns. Amongst the two groups, the means of
gestational age at delivery, of birth weight, and the
C A Oettlé, H J Odendaal, M Smith
proportion of small of gestational age (SGA)
Department of Obstetrics and Gynaecology,
babies did not differ significantly. Of those with
Tygerberg Hospital and Medical School
good patterns, 8,3% had a pH of <7,1; 13,9% had
a base excess of < - 12 and 14,3% had 5 minute
Background:
Apgar scores of <7 compared with 16,7%, ll.8%
At Tygerberg Hospital, intensive six hourly fetal
and 16,7% respectively for those with poor
monitoring is carried out routinely from 28 weeks
patterns. None of these differences approached
to delivery on mothers with high risk pregnancies,
statistical significance.
to aid in the timing of delivery.
Conclusions:
Aim:
Though the study numbers were very small, the
To determine the extent to which poor fetal heart
study did not refute the contention that ominous
rate patterns (FHRP) predicted fetal blood gas
prelabour changes in the FHRP are poor
changes or poor Apgar scores.
predictors of fetal blood gas changes; it is more
likely that they reflect more complex responses of
Methods:
the fetus to stress. That notwithstanding, the
Five minute Apgar scores were noted, and
policy of delivering when these changes occur has
umbilical artery blood was submitted for blood gas
been shown over the years in this unit be highly
analysis immediately after delivery by Caesarean
effective in preventing intrauterine fetal loss.
section. Each FHRP immediately preceding
delivery was assessed in blind fashion for
baseline variability, and the presence or absence
of decelerations. A poor pattern was defined as
that showing a baseline variability of < 5
beats/minute, and/or persistent late/variable
decelerations. A variability of >5 beats/minute,
with or without accelerations, and without
decelerations, was defined as a good pattern.
115
SOCIAL AND EDUCATIONAL BACKGROUND
The mean age of the teenage mothers was 17.5
OF THE TEENAGE MOTHERS AT GA-
years. There was one 13 years old who was
RANKUWA HOSPITAL
raped. A similar number of mothers came from
rural areas (21), urban areas (25) and informal
NJ Kekesi
settlements (24). The majority of the teenage
Department of Paediatrics and Child Health -
mothers were primigravidas (59), while 10 were
MEDUNSA
pregnant for the second time and one was
pregnant for the third time.
Introduction
Family breakdown played a major role amongst
Teenage pregnancy is a well-recognised world-
the teenage mothers as shown by the fact that
wide problem that needs urgent solutions. In Ga-
51,3% of them were not staying with both of their
Rankuwa Hospital in the year of 1994, of the total
parents. The two most important reasons given
1,470 admissions to the neonatal unit, 356(24%)
were either that the parents had divorced or that
were born to mothers less than 19 years of age.
the mother was never married.
This study was done with the hope that with the
Most of them (41), had known their partner for
data obtained, more relevant programmes could
less than 2 years (period of pregnancy inclusive)
be developed to try and curb the escalating rate of
and 4 admitted that they had wanted a baby.
pregnancy among teenagers. Teenagers who
The majority of the teenage mothers (57.1%)
may still fall pregnant despite intervention
were in the standard 6 to 8 class at the time of
programmes can also then be assisted if their
pregnancy and only 2 were in the tertiary
problems are known.
institution.
Ten teenage mothers had an acceptable
knowledge of menstruation and 11 could explain
Aim
1.
2.
To describe the social and educational
how pregnancy occurs. Fifty-seven knew about
background of the teenage mothers at
sexually transmitted diseases although limited to a
Ga-Rankuwa Hospital
maximum of 3 diseases with gonorrhoea being
To determine the outcome of pregnancy
the most commonly known.
Although 53 knew about different contraceptive
Method
methods, only 34 had used contraceptives and
The researcher interviewed 70 mothers with the
only 5 were on contraceptives at the time of
use of an interview schedule between April and
conception.
September 1995. Only those mothers who could
Only 2.2% of the teenage mothers had used a
speak Tswana or English were interviewed. The
condom as a method of contraception and
mothers who delivered vaginally were interviewed
although most of them (61.4%) said that it should
between 24 and 72 hours of delivery and those
be used to prevent sexually transmitted diseases,
delivered by Caesarean section were interviewed
none of them had used it for that purpose. This
between 72 and 96 hours of delivery.
poses a very serious problem considering the
increasing rate of HIV infection among
adolescents.
Results
116
A high percentage had preterm deliveries (32.7%)
FACTORS CONTRIBUTING TO THE
as compared to other studies. The mothers were
MORTALITY OF VERY LOW BIRTH WEIGHT
asked what they planned to do after discharge
INFANTS < 1500g ADMITTED TO GA-
and although only 55 were at school at the time of
RANKUWA HOSPITAL
conception, 58 wanted to go back to school fulltime while 2 wanted to study part-time. Only 5 of
M Driessen, F Muwazi, P Gwamanda
the subjects volunteered the information that they
Department of Paediatric and Child Health,
were going to start using contraceptives seriously.
Medunsa
They did not seem to be worried by the fact that
CA van der Merwe
there was a baby to look after, that was someone
Department of Quantitative Management, UNISA
else's responsibility.
Introduction
Conclusion
During a 16 month period (from May 1994 to
The majority of the teenagers fall pregnant while
September 1995) the neonatal unit at Ga-
still at school which results in the disruption of
Rankuwa Hospital participated in an international
their education.
neonatal network, developing the CRIB (Clinical
The teenagers who left school because of
Risk Index for Babies) score. The CRIB score is
pregnancy are likely to fall pregnant again within a
a simple accurate system for measuring initial
short period.
clinical risk and disease severity in small or
Parents, educators and health workers do not
preterm infants of < 1500g birthweight. Certain
seem to discuss menstruation, pregnancy,
conditions were identified which could contribute
contraception and sexually transmitted diseases
to the mortality in this group of infants.
with the teenagers.
There is a high rate of premature delivery
Methodology
amongst teenagers.
All infants admitted to the unit during the study
Irrespective of their social background teenagers
period who weighed 1500g or less were enrolled.
are at an increased risk for unwanted
The following data were collected for each:
pregnancies.
*
birthweight
From the above observations, it can be concluded
*
gestational age
that teenagers at Ga-Rankuwa Hospital follow
*
Apgar score at 5 minutes
international trends.
*
presence of congenital malformation
*
maximum base excess before 12 hours
*
minimum appropriate FiO2 before 12
Recommendation
A multidisciplinary approach to teenage health
hours
care involving physicians, educators, family
-
planners, social workers and behavioural
maximum appropriate FiO2 before 12
hours
scientists.
117
*
admission temperature
*
was antenatal care received
*
congenital syphilis
*
born inside or outside Ga-Rankuwa
Hospital
*
CRIB score
*
outcome (discharged or demised)
Results
A total of 1572 neonates were admitted during the
study period, of whom 400 had a birthweight of <
1500g, comprising 25,45% of all admissions.
Table 1
Mortality
Number of infants
< 1500g
Nr
%
118
Mortality
400
157
39,3
No antenatal care
400
197
49,3
Born outside GaRankuwa Hospital
400
69
17,3
Hypothermic on
admission (<36oC)
400
331
82,8
Syphilis serology
positive
345
34
9,9
Congenital
abnormalities
396
8
2
Table 2
Mean
Birth weight (grams)
Standard
deviation
Range
Total no of infants
< 1500g
1146,3
233,35
510 - 1500
400
Gestational age (weeks)
30,8
2,85
21-37
386
CRIB score
6,4
5,45
0-20
393
Apgar at 5 minutes
7,4
2,04
1-10
333
Admission temperature (oC)
34,7
1,49
26-39,4
399
Minimum appropriate FiO2 before 12 hours
48,5
40,29
0-100
390
Maximum appropriate FiO2 before 12 hours
57,3
40,35
0-100
392
Worst base deficit before 12 hours of life
-8,6
6,39
-29,6-+9,4
346
Figure 1
The relation between the CRIB score and the % deaths
The CRIB Score in relation to the % of infants that
died at each score is shown in Figure 1. The
119
following conditions were found to be significantly
associated with mortality:
*
lack of antenatal care (p=0.00509
Pearson Chi-Square)
-
hypothermia (temp <36oC) on admission
(p=0.0029 Pearson Chi-Square)
Discussion/Recommendation
Very low birth weight infants comprise a large
percentage (25,45%) of admissions to the
neonatal unit. For these patients, lack of
antenatal care and hypothermia were identified as
risk factors for death. Efforts should be made to
improve antenatal care and to provide more
trained persons and facilities for safer childbirth.
The Midwife Obstetric Units (MOUs) that exist in
the Cape could serve as a model to improve basic
obstetric care in this area. In addition, the PEP
(Perinatal Education Programme) should be
promoted and used more extensively to improve
the standard of perinatal care.
120