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TABLE OF CONTENTS CONSENSUS STAT by fjhuangjun

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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.         The
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 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
                  1
choice testing.       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.       An assessment of their attitude              The Maternal Care Manual of PEP significantly
towards their work was also made.                              improved midwives ability to correctly interpret
                                                               information on the antenatal cards and partograms.
Methods:                                                        Their attitude towards their work also improved
A prospective controlled study was conducted in a              significantly.   These achievements will improve
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
Table 1 Antenatal Cards (scored out of 20)
                               STUDY TOWN

                                  Pretest          Post test     p-value*

 *           mean (s)          8,4 (4,3)           15,0# (4,9)   0,000
 *           median            9,0                 15,0
 *           range             0-15                12-19

                              CONTROL TOWN

                                  Pretest          Post test     p-value

 *           mean (s)          10,4 (5,0)          10,4 (4,7)    0,744
 *           median            10,5                12,0
 *           range             0-17                0-16
* Student's t test                                                       # Mean improvement = 33%

Table 2 Partograms (scored out of 20)
                               STUDY TOWN

                                  Pretest          Post test     p-value*

 *           mean (s)          11,3 (3,0)          14,8# (3,0)   0,001
 *           median            11,0                13,5
 *           range             7-17                10-20

                              CONTROL TOWN

                                  Pretest          Post test     p-value

 *           mean (s)          8,3 (3,4)           9,0 (3,5)     0,640
 *           median            8,0                 9,5
 *           range             2-17                1-19
* Student's t test                                                       # Mean improvement = 18%

Table 3 Attitude towards work (scored out of 25)
                               STUDY TOWN

                                  Pretest          Post test     p-value*
                                                       #
 *           mean (s)          14,5 (6,4)          20,6 (3,6)    0,000
 *           median            15,5                21,0
 *           range             0-25                13-25

                              CONTROL TOWN

                                  Pretest          Post test     p-value

 *           mean (s)          16,7 (4,5)          16,0 (4,0)    0,646
 *           median            17,0                16,0
 *           range             6-25                4-22
* Student's t test                                                       # Mean improvement = 24%




                                                   4
DOES SUCCESSFUL COMPLETION OF THE                            with at the end of August and the beginning of
PERINATAL         EDUCATION          PROGRAMME               September. For antenatal care assessment the
RESULT IN IMPROVED OBSTETRIC PRACTICE?                       “before” control group consisted of data collected at
                                                             Marapyane in 1994, and the “during” control group
E le Roux, RC Pattinson, W Tsaku*, JD Makin                  data collected at Pankop.         The study group
Department of Obstetrics & Gynaecology, University           consisted of data collected at Marapyane (in 1995)
of   Pretoria    and    Kalafong     Hospital,   and         and Mmametlhake Clinics. For intrapartum care the
*Mmametlhake Hospital, Mpumalanga                            “before” control group consisted of data collected at
                                                             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    it   was    correctly   performed,    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.

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.

                                                   3
 Candidates                1          2                         4             5          6              7             8               All
                                             148          155                                                   231              188,8
 Before              168        193                                     148          211          257


                     56%                     49%          51%                                                   77%              62,9%
                                64%                                     49%          70%          85%
                                             249          212                                                   250              252
 After               296        266                                     238          262          270
                                             83%          70%                                                   83%              84,2%
                     92%        88%                                     79%          87%          90%
                                             <0,001       <0,001                                                <0,05            <0,001
 P-value             <0,001     <0,001                                  <0,001       <0,001       <0,05


                                                                           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)            “Before” Control (B)        “During” Control (D)                P=value
                                     n = 234                      n = 62                      n = 67
 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,
                                                                                                                            S/D - NS
 Bloodgrouping                     134 = 57,2%              51 = 82%                          44 = 66%                    S/B - <0.001,
                                                                                                                            S/D - NS
 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
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.
                                   Study Group                “Before” Control            “During” Control                 P=Value
 Obstetric History                  4/33 = 12%                    0/7 = 0%                    0/6 = 0%                    S/B, S/D - NS
 STS                              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)            “Before” Control (B)        “During” Control (D)                P-value
                                      n = 76                       n = 116                      n = 42
                                                                                         26 = 62%
 Estimated fetal weight         28 = 36%                    48 = 41%                                                        S/B - NS,
                                                                                                                           S/D - <0.01
 Pelvimetry                      0 = 0%                      2 = 1,7%                     2 = 5%                          S/B, S/D - NS
                                                                                         23 = 60%
 Bloodpressure                  63 =82,9%                   102 = 87,7%                                                     S/B - NS,
                                                                                                                           S/D - <0.001
                                                                                         25 = 64%
 Urine                          43 =56,5%                   60 = 51,7%                                                    S/B, S/D - NS
 Head above pelvis              65 = 85%                    98 = 84,4%                   25 = 64%                           S/B - NS,
                                                                                                                           S/D - <0.005
 Fetal heart rate               48 = 63%                    86 = 74,1%                   10 = 26%                           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)           “Before” Control (B)         “During”Control (C)                P=value
                                                          20/32 = 63%                 19/24 = 79%                    S/B, S/D - NS
 Appropriate action          15/20 = 75%
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
                                                             1.       Knowledge
                                                             UPH
The Perinatal Education Programme is a self-                 mean score
                                                             before           after               T         p
directed, problem-orientated learning programme              63(53%)          105(88%) 15,049     <10-6

for health workers in the field of perinatal care. It        DNH
                                                             mean score
has been developed as a means of improving                   before             after             T         p
                                                             71(60%)            95(80%)           4,798     =0,03
perinatal care, and is based on Southern African
                                                             Difference in Improvement
experience.                                                  DNH                 UPH              T         p
                                                             23(19%)             42(35%)          3,364     =0,0025

                                                             2.       Skills
Aim
                                                             UPH
The aim of this evaluation is to assess changes, if          mean score
                                                             before             after             T         P
any, in cognitive knowledge, skills, practice and            55(45%)            102(82%) 20,054   <10-6
                                                             DNH
attitudes of those who use the Programme. Only               mean score
                                                             before             after             T         P
the effects on cognitive knowledge and skills are            67(55%)            66(54%)           0,144     =0,89

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.     The same degree of improvement in
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
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    programmes   in   the   urban   centres.
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.    The nurses in the RHCs were
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   safer.     Zimbabwe      TBA     training        several months.    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.    The knowledge     about HIV infection
ten provinces of Zimbabwe.         Information was            among TBAs was poor.
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,     TBAs,    nurses)   and   focus    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
                                                              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
SARTORIAL         ELOQUENCE:         Should      it   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
                                                                 relationship. All 5 photographs in each set were to
GR Howarth, T Mabale, J Makin.                                   be considered for each attribute. If patients felt that
                                                                 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.   P values and confidence intervals

her as a health care worker and she did not identify             describe results that differ significantly from what

herself to the patients.          All interviews were            would be expected by chance.

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
Results
MALE
                       TRUST                 COMPETENCE            FRIENDLY            RELATIONSHIP        TOTAL

       A                  35/126 (40%)         *45/122 (37%)          *48/124 (39%)      *49/124 (40%)      *193/496 (39%)
       B                  23/126 (18%)          23/122 (19%)           23/124 (19%)      *49/124 (40%)       91/496 (18%)
       C                   *3/126 (2%)           *4/122 (3%)            *7/124 (7%)        *5/124 (4%)        *17/496 (3%)
       D                  30/126 (24%)          23/124 (23%)           33/124 (27%)       32/124 (26%)       123/496 (25%)
       E                  *10/126 (8%)           *8/122 (7%)            *6/124 (5%)        *8/124 (6%)        *32/496 (6%)
   NO CHOICE                9/100 (9%)          14/100(14%)             *9/100 (9%)         8/100 (8%)         40/496 (8%)
     PAIRS                26/100 (26%)          22/100 (22%)           24/100 (24%)       24/100 (24%)
 DENOMINATOR                   126                   122                    124                124                 496

FEMALE
                       TRUST                 COMPETENCE            FRIENDLY            RELATIONSHIP        TOTAL

       A                 *45./119 (39%)         35/115 (30%)          *42/113 (37%)      *46/116 (40%)      *168/463 (36%)
       B                  15/119 (13%)          15/115 (13%)          *11/113 (10%)       14/116 (12%)       *55/463 (12%)
       C                   *8/119 (7%)           *8/115 (7%)           *10/113 (9%)        *8/116 (6%)        *34/463 (7%)
       D                 *38/119 (32%)         *39/115 (34%)          *37/113 (33%)      *38/116 (33%)      *152/463 (33%)
       E                  *1/119 (>1%)           *2/115 (2%)            *2/113 (2%)        *2/116 (2%)         *2/463 (2%)
   NO CHOICE              12/100 (12%)          16/100 (16%)           11/100 (11%)         8/100 (8%)        47/463 (10%)
     PAIRS                19/100 (19%)          15/100 (15%)           13/100 (24%)       16/100 (16%)
 DENOMINATOR                   119                   115                    113                116                 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      VS.             the TermPROM Study Group, University of Toronto,
INTRAVENOUS OXYTOCIN VS. EXPECTANT                                       Canada.
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.          Women in the
induction/oxytocin    group   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           CONTROLLED               TRIAL           prostaglandins were re-administered according to
COMPARING            VAGINALLY            ADMINISTERED               initial randomisation, again by the investigator not
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     or    1mg      of     the     commercially           minutes for at least a 20 minute period.

manufactured PGE2        vaginal gel placed in the                   Hyperstimulation was recorded when polysystole

posterior fornix.      Prior to trial entry cervical                 was accompanied by either suspicious or ominous

assessment was performed by attending labour                         changes in the fetal heart rate pattern.

ward staff.     The same staff, unaware of the
induction agent used, were responsible for patient                   Results:

management        including     decisions         regarding          Maternal age, parity, gestational age, indications for

rupturing membranes, augmentation of labour,                         induction and pre-induction cervical scores were

analgesic     administration        and     indications   for        similar in the two groups. There was no difference

caesarean section.          All prostaglandins were                  in the need for oxytocin augmentation between the

administration by an investigator not involved in                    two groups.       There was also no significant

patient management.         Fetal heart and uterine                  difference between the two groups in analgesic

contractions     were       continuously         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


                                                                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                     P
n                                        36                        36
Delivered within 6 hours                 12                         3                        <0,05
Delivered within 12 hours                30                        12                        <0,05
Not in labour after 12 hours             1                         11                        <0,05
Induction delivery time (minutes)        507 (170-1540)            1000 (250-2135)           <0,05
Caesarean sections (Total)               6                         15                        <0,05
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
MECONIUM            ASPIRATION           SYNDROME:            black.
IMPORTANCE          OF    THE     MONITORING       OF         Birth weights of 3.0 to 3.49 kg were recorded in
LABOUR                                                        26/53 (49%) babies, greater than 3.5 kg in 14
                                                              (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   at   birth    and    radiological   changes        : (1.2; 156.2) and with labour monitored, p = 0.023,
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).     In those babies suffering hypoxic          compromise and expeditious delivery are the
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
Discussion                                                   avoid MAS.
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
AMNIOINFUSION IN DEVELOPING COUNTRIES                          checked with fetal scalp sampling. We have only
                                                               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.         It is
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
                                                               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.    No effect on caesarean section
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.     Given this incidence, a trial of several
which thick meconium-staining is a marker. Recent              thousand women will be needed to determine
reports   have      questioned     the    safety     of        whether amnioinfusion has a meaningful effect on
amnioinfusion. Although a causal relationship has              this outcome.
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   such   complications      could   result    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.
confirmed by aspiration of amniotic fluid before
infusion is commenced.                                         DOUBLE BLIND RANDOMISED CONTROLLED
                                                               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.       The results may or           WITH OLIGURIA
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.     The use of dopamine for oliguria has             during the trial are given in Table 2.
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               Placebo group
                                                                    n=20                         n=20

 Median fluid input for the 6 hours prior to trial in mls             900                          950              p=0.419
 (range)                                                         (700 to 3150)                (720 to 1320)

 Median urine output for the 6 hours prior to trial in                125                         81.5              p=0.29
 mls (range)                                                      (60 to 360)                  (18 to 285)

 Median fluid bolus pre-trial in mls (range)                         300                           300
                                                                 (180 to 600)                  (200 to 600)

 Median fluid balance pre-trial in mls (range)                      +1248                        +1371
                                                                (-180 to +3100)              (-240 to +4005)

 Median fluid input for the 6 hours of the trial in mls              720                           720
 (range)                                                         (450 to 910)                  (450 to 720)

 Median urine output for the 6 hours of the trial in                  344                          135              p=0.0023
 mls (range)                                                     (10 to 2760)                  (30 to 700)

 Median fluid balance for the 6 hours of the trial in                +343                         +543              p=0.004
 mls (range)                                                    (-2310 to +710)          (+200 to +690)

mls = millilitres. + = positive. - = negative. Statistical significance determined using the Mann-Whitney U Test.

Table 2. Complications before and during the trial.                        Conclusions
                          Dopamine group        Placebo group              After excluding hypovolaemia clinically, the use of
                              n=20                   n=20
                                                                           low dose dopamine in a labour setting significantly
 Placental abruption               2                      1
                                                                           improved the urine output in post partum pre-
 Eclampsia                         0                      3
                                                                           eclamptic women with oliguria who had not
 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                        1                      0
 haemorrhage

 pulmonary oedema                  0                      1

 Trial drug overdose               0                      1




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
Introduction                                                               early onset pre-eclampsia (EOPE) i.e. pre-


                                                                    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.     Patients who were not delivered were
late    onset     pre-eclampsia     i.e.   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       and   fetal   morbidity and   mortality.
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
                                                                     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       in the antenatal period were
managed by standard methods.                  Primigravid            performed in 78% of hypertensive patients and were
patients with a history of co-existing medical                       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)           Controls (n=144)                 p-Value

 Age (years)                               20.1 (15-43)                   20.1 (14-32)                      NS

 Antenatal care
 "Booked"                                     94.0                             96.0


                                                                22
 "Unbooked"                                     6.0                                4.0                            NS

 Placing of Antenatal Care
 Clinic                                        74.0                               71.0
 Hospital                                      26.0                               29.0                            NS

 Initial Blood Pressure
 Systolic (mean) mmHg                     113.2 (90-200)                      108.7 (90-160)                     0.011
 Diastolic (mean) mmHg                    71.3 (60-120)                        67.4 (60-90)                      0.004
(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%.              The method of
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.
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            hypertensive   primigravidae   with

                                                                23
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        GROUP A (N=189)                                                                                 GROUP B (N=148)
 women (n=345)

                     APROTEINURIC                     MODERATE                        SEVERE
                      (n=63)                           (n=47)                          (n=83)
                     Mean(SD)                         Mean (SD)                      Mean (SD)

 Age (years)             26              (6)              24             (6)            23               (6)              24                 (6)

 Parity                  2               (2)               1             (2)             1               (1)              1                  (1)

 Gestational age         36              (3)              35             (4)            33               (4)              31                 (3)
 (weeks)

 Antenatal care*        57*          (93%)#               41*          (93%)#           68*          (82%)#             101*            (69%)#

                                                 #
 * = patients received antenatal care;               = patients did not attend antenatal clinic;               = no statistical difference

Group     A    consisted       of    189       patients         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               the               control                  group




                                                                       26
(a proteinuric group = 2; control group = 26;                                 (hypertensive 2.30kg vs control 1.65kg: p=0.0001:
p=0.007).      The birthweights in the hypertensive                           Table 2).
group were greater than those in the control group
Table 2 Obstetric and Neonatal Data

 CATEGORY                 APROTEINURIC               MODERATE                  SEVERE                  TOTAL             CONTROL
                              n=63                     n=47                     n=83                   n=189              n=148

 Caesarean Section                  33                    25                       65                    123                 32

 Normal vaginal                     30                    22                       23                    75             124 (9 pairs
 delivery                                                                                                                 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                                 The control group had a higher frequency of
Ballard's      score.          Women          with   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              Moderate                   Severe                   TOTAL                 CONTROLS
                (n=63)                    (n=47)                     n=83)                                          n=157*
               Mean(SD)                  Mean(SD)                   Mean(SD)                 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    confirms    previous     reports   that
hypertensive    disorders     are   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.       CRP was determined by lazer
*Department of Immunology, University of Pretoria                  nephelometry and 11-6 and TNF- by photometric
                                                                   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.    Concerns that corticosteroids might                   for continuous data, while categorical data were
                                                                                         2
increase susceptibility to intrauterine infection, or              analysed using the x - test or Fisher's exact test.
delay its recognition, could however not be
substantiated by the available trials.                             Results
                                                                   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         patients        with preterm            Significantly higher leucocyte counts (13.08+4.02vs.
                                                                                    9
premature rupture of membranes.                                    10.24+2.31 x 10 /l; p=0.03) and neutrophil counts
                                                                                                     9
                                                                   (9.86+3.64 vs. 6.93+3.25 x 10 /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
                                                                                    9
with confirmed premature rupture of membranes,                     3.54+2.21 x 10 /l in the dexamethasone group,
                                                                                                 9
between 28 and 34 weeks of gestation, participated                 compared to -0.08+2.52 x 10 /l in the placebo group
in this double blind randomised controlled trial.                  (p=0.002). The change in neutrophil counts was
                                                                                                           9
Patients with clinical evidence of infection or an                 2.82+1.94 and -0.62+3.58 x 10 /l respectively
indication for immediate delivery were excluded.                   (p=0.009). No significant differences were detected
Dexamethasone       24    mg     or        placebo    was          between the groups in levels of CRP, 11-6 or TNF-
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.        Spontaneous       labour,         suspected         groups.
chorioamnionitis,   occurrence        of    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           OF        PREGNANCIES      WITH          monochorionic twin pregnancy or incomplete results
SEVERE PLACENTAL INSUFFICIENCY.                               were excluded. Analysis was repeated for fetuses
                                                              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
Background:                                                   poor fetal outcome (death or major morbidity).

Blood flow redistribution occurs in severe placental
insufficiency    due      to     increasing   cerebral        Results:
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.          The mean
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
                                                              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%).      Fetal distress

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
                                                              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)).             Patients        Doppler study.

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.         The PI-UA/MCA ratio indicated                high ratio was also associated with a higher risk for
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
REFERRAL OF PATIENTS WITH PRELABOUR                                             hospital.
RUPTURE        OF    THE      MEMBRANES       FROM
RETREAT        MOU       TO    GROOTE      SCHUUR             Patients and Methods
HOSPITAL.                                                     This retrospective pilot study, covered the period
                                                              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.           The
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,    or   even     a   repeat   speculum           had been correctly referred but did not have PROM
examination, in the hospital.        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
Objectives                                                            (68)
To establish in patients referred from the MOU with           *       Speculum examination (39)
a diagnosis of PROM:                                          *       Digital vaginal examination (4)
          1.     The percentage who had this                  In many patients several diagnostic features were
                 diagnosis confirmed in the hospital.         present.
          2.     The methods used to diagnose                 Confirmation of PROM in hospital was by means of
                 PROM, both in the MOU and in the             *       A doctor's statement to that effect in the
                 hospital.                                            folder.
          3.     The prevalence of unnecessary                *       Detecting ferning on microscopy of vaginal
                 speculum      examination    in   the                fluid.
*         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
A   COMPARATIVE           PROFILE        OF   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
                                                               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.    Incomplete information exists on the            ventilated in private and academic NICUs.

profile and outcome of infants ventilated at tertiary
hospitals in this country.         No information is           Conclusion:
available from private institutions.                           Academic and private NICUs each have unique
                                                               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
EXTUBATION        OF    VENTILATED         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.
                                                                      Group 1: extubation immediately from a
JC Stephen, VA Davies, AD Rothberg, DE Ballot                         low rate.
Dept.    of   Paediatrics,    University    of   the                  Group 2:    extubation after 1 to 3 hours
Witwatersrand.                                                        CPAP.
                                                                      Group 3: extubation after 12 to 24 hours
Introduction:                                                         CPAP.

CPAP (continuous positive airway pressure)                   Post-extubation chest x-rays were done within 24

improves functional residual capacity, decreases             hours to exclude atelectasis.       Infants were re-

post-extubation atelectasis, prevents apnoea and             intubated   if   respiratory acidosis,   atelectasis,

stabilises the chest wall.    CPAP may be given              recurrent apnoea or stridor occurred.

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
Aim:                                                         current successful extubation rate (P2 value)

1.      To ascertain current practices of extubating                                                       = 0,75

        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
        postal questionnaire.                                Results of the Survey:
2.      To conduct a prospective randomised study            The results of the survey of extubation practices at
        comparing      pre-extubation   CPAP     with        various NICUs in South Africa are shown in Table 1.
        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:           EXTUBATION PRACTICES AT                       atelectasis. Direct extubation from a low rate is a
NICUs                                                            reasonable alternative to pre-extubation CPAP and
No CPAP 1-3 hrs 3-12 hrs                12-24 hrs                may be useful where limited physical and financial
Kalafong            KEH      Garden City          BARA
Tygerberg           GSH      Morningside          JHB            resources necessitate shorter ICU stays in
Sandton             Flora    Park Lane
At most centres, VLBW infants are given longer CPAP.             ventilated newborns.

The reported failed extubation rates at the various
centres are shown in Table 2.                                    Table 3:            COMPARISON OF HOSPITAL
                                                                                     RESULTS
                                                                                     JHB     BARA
Table 2:           FAILED EXTUBATION RATES AT                                         %         %              p
                                                                 Number              51      49                NS
                   NICUs                                         Male:female         1:1.8   1 : 1 . 2 NS
         2%        Flora                                         Group 1             33      37                NS
         5%        Garden City, Park Lane                        Group 2             35      31                NS
         7%        KEH                                           Group 3             31      32                NS
         100%      GSH                                           Birth wt <1250g     16      24                NS
                   BARA                                          Failed extubation   17      17                NS
                   Sandton, Morningside                          Atelectasis          3       2                NS
         20%       VLBW Sandton, Morningside                     Aminophyllin        52      54                NS
         40%       Tygerberg                                     Dopamine            46      51                NS
                                                                 Pancuronium         25      35                NS
                                                                 Dexamethasone       15       4                <0.05
Results:                                                         Surfactant          37       9                <0.01
The extubation groups and the 2 hospital groups
                                                                 Table 4:            RESULTS      OF        EXTUBATION
were comparable in terms of entry criteria. (Table                                   STUDY
3).                                                                                  FAILED EXTUBATION
                                                                                     No      Yes               p
193 infants were enrolled, of which 13 of 68 in group                                %        %
                                                                 Number              83      17
1 (19%) failed extubation, compared to 13 of 64                  Male:female         1:1.8 1:1.0               NS
                                                                 Group 1             81      19                NS
group 2 (20%) and 7 of 61 in group 3 (12%).                      Group 2             80      20                NS
                                                                 Group 3             88      12                NS
There was no significant difference between the                  Birth wt <1501g     72      28
                                                                 Birth wt >1501g     92       8                <0.0001
groups in failed extubation rates or atelectasis rates,          Pancuronium         16      19                NS
                                                                 Surfactant          22      27                NS
or between the two hospitals Table 4).               (The        Dopamine            12      22                <0.1
                                                                 Dexamethasone       15      37                <0.05
different rates or surfactant and dexamethasone                  Daminophyllin        8      25                <0.01
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
Table 5:              RESULTS OF INFANTS
                                 < 1501g <1501g              >1501g         TOTAL
TOTAL                            87               103                 190
Failed extubation                24                 8                  32
% Failed extubation        28              8                 17             p=0.000
% Dexamethasone            37             15                 17             p=0.03
% Dopamine                       23               11                  17              p=0.04




                                                        38
COMPARISON OF INTRAVENOUS AND ORAL                            an intravenous group (IV) who received parental
IRON    IN   PRETERM        INFANTS RECEIVING                 iron sucrose (Venofer, Vifor) at a dose of
RECOMBINANT HUMAN ERYTHROPOIETIN                              6mg/kg/week of elemental iron, or an oral group
                                                              (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.           Infants received a formula

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%.                    Other

substrate     supplementation      during    rHuEpo           requirements were stable respiratory status ie not

administration.        In 3 recent trials iron was            on IPPV and requiring <40% oxygen, tolerating full

supplemented orally in a dose of 2-6mg/kg/day of              feeds,     and     absence     of   infection   or    major

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.           Tests included a

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.     Serum ferritin values and percentage

low ferritin levels.    Despite increasing oral iron          hypochromic cells were log-transformed.

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.     Two patients in the IV group were             2/39, or 5% was lower than the prevalence of 13%
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.      There was however, a                    (15% in the present study) may, however,
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                 2.      IV iron sucrose is safe and efficacious in
increase in absolute reticulocyte counts.      Mean                  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.
           3
(1000/mm ) 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 27-
                                                            33 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
preventable cause of perinatal morbidity and                        vSCS
mortality in South Africa. In June 1994 free               *        mean maternal age = 24 years (28% were
antenatal care was introduced in South Africa.                      teenagers).
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
ventilation.                                               Table 1:           Morbidity data in ventilated
                                                                              congenital syphilitics.
Aims                                                                OUTCOME                             %

The aims of this study were to:                            Hepatitis ( ALT/AST)                        73
                                                           Platelets < 100 000               49
(i)      assess the mortality and morbidity of             WCC > 30 000                                 42
                                                           IVH                                          33
         ventilated SCS (vSCS).                            Feeding intolerance               33
                                                           PDA                                          24
(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
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:
                                                               treatment of an easily preventable disease.
*           need for vasopressors 82% ppv
*           IVH                        74% ppv
*           acidosis (pH<7.2)          71% ppv
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                Control             Significance
                             (n=64)             (n=151)
PTL/PPRROM
(22w<x<34w)                  7                  5                   p=0,03 (Fisher)
Pyelonephritis               3                  2                   NS

Table 2:         OUTCOME OF PREGNANCY IN CLEARED VERSUS PERSISTED SUBGROUPS OF
                 ASYMPTOMATIC BACTERIURIA
Outcome:         Persisted            Cleared             Significance
                             (n=31)             (n=33)
PTL/PPROM
(22w<x<34w)                  5                  2                   NS
Pyelonephritis               3                  0                   NS




                                                              47
Table 3:             TREATMENT MODALITIES IN THE CLEARED AND PERSISTED SUBGROUPS OF
                     ASYMPTOMATIC BACTERIURIA
                          Persisted (n=31)   Cleared (n=33)
Dose of first drug
Single                    10                 17        63%cured
Multiple                  21                 16        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:
Women with prelabour fetal death in the third             Journal of Tropical Paediatrics 1995; 41: 258-266.
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     % of patient with    Relative risk for low    Sensitivity     Specificity   Positive     Proportional
score    high risks           birth weight (95%                                      predictive   attributable risk
                              confidence intervals                                   value

Creasy           23.6                    2.0             38.1%           79.1%        25.0%              19.0%
                                      (1.3-3.0)

POLO             31.1                    3.5             61.2%           74.3%        30.6%              43.6%
                                      (2.4-5.1)


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                        -      5 for hyaline membrane disease
amniocentesis were observed for the need for                      -       1 for congenital pneumonia
ventilation.                                                      2   Neonates were not ventilated due to extreme
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           Specificity           Predictive Value       Predictive Value
                                                     %                           of                     of
                              %
                                                                           immature test           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
PM Garde                                                       technique is demonstrated in detail in the Holistic
                                                               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 pre-
                                                               elampsia, 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              *       an observation/bonding/copying education


                                                          57
        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.   The index finger then generated the
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.
or razor instead of the purpose-built vibro-acoustic
stimulator.   Even these simpler devices are not            The results favourably compared to the
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.   Clinical details of participants are              by the can test. The NST incorrectly diagnosed
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
THE OXYGEN CONCENTRATOR -                                     At 2 litres flow per minute for 10 hours per day
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.     The        pharyngeal catheter. Locke and Wolfson showed

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:                                    4.      An intervention study of the proposed
1.       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
                                    1
                   decrements of /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)      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                PE         ChrHT
Wt Group
Gain                 7                   1          8
Spurt                16                  1          17
50 Cent              1                   6          7
Poor                 1                   5          6
                     25                  13         36
Strong clustering of PE in Spurt group




                                                         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                7                   19                    12
           Spurt               32                  57                    38
           50 Cent             39                  12                    26
           Poor                22                  12                    24
                               100%                100%                  100%
1.         NoHPT clustered in Spurt & 50th C Groups
2.         PE strongly clustered in Spurt Group
3.         ChrHPT also greatest in Spurt group - (Not in 1993)

Table 3 Distribution of BP Groups

Distribution of Wt groups
                    Gain n=28             Spurt n=93         50C n=54 Poor n=39
BP Group
          NoHPT              21                     28                   59                46
          PE                 61                     55                   20                28
          ChrHPT             17                     17                   20                26
                             100%                   100%                 100%              100%

1.         Steady gain group -   PE Dominant
2.         Spurt Group -         PE also dominant
3.         50th Centile -        "NoHPT' Dominant - (Not in 1993)
4.         Poor Gain             ChrHPT Group Dominant

Table 4 2x2 Tables of PE x Wt Spurt                                               spurt.
               ("EPIINFO")

           Wt Spurt                                                       Conclusions
           Y        N
PE                                                                        1.      Weight changes in pregnant women
Y          51        41          92
N          42        86          128                                              should still always be recorded and on
           93        127         220
                                                                                  graphs, not in tables.
Odds Ratio                       2.55
95% Confidence Limit             1.41<OR<4.63                             2.      Many patients who develop PE show a
Risk Ratio                               1.69
95% Confidence Limit             1.24<OR<2.30                                     tendency to gain excessive wt and many
P (TAYES) = 0.001
Sensitivity=55%
                                                                                  also put on a spurt late in pregnancy that
Specificity=63%                                                                   commonly heralds the onset of HPT.
Summary of our Findings                                                   3.      It is important to pay close attention to the
1.         PE patients are on average, heavier at                                 pattern of wt gain of potential PE patients.
           booking than non PE patients.                                  4.      It remains to be seen whether such action
2.         They are significantly more likely than                                can alter the outcome of PE in these
           normal patients to show excessive gain or                              patients.
           a wt spurt.                                                    'WATCH WEIGHT CHANGES during pregnancy"
3.         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
4.         The mean onset of HPT is 5 wks after                           Gerhard Theron for his advice and help.
           start of Wt spurt.
5.         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.    The policy was          Johannesburg Hospital:
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

                 Maternal mortality per              Stillbirths   Neonatal Deaths per
                 per 100 000 births        per 1000 births         per 1000 live births
1990                       44,6                      23,1                               12,4
1991                       30,2                      22,4                               11,5
1992                       65,8                      19,8                               12,8
1993                       62,1                      25,7                               11,2
Jan-June 1994              54,1                      25,7                               11,1
July-Dec 1994              72,3                      26,1                               10,4
Jan-June 1995              42,6                      23,1                               11,3




                                                           67
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
                      #                x
S Fawcus*, M Mbizvo , G Lindmark ,                        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
                X                  ^
Zimbabwe, University Uppsala,          University         haemorrhage due to ruptured uterus. 14 women
UMEA                                                      died from postpartum haemorrhage (2 ruptured
                                                          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
COMMUNITY HEALTH WORKERS INVOLVED                          II        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
L Linley, D Hewitson, G Derbyshire, B Wright, T                     about health in the postnatal period.
Mshumpden
                          +
Neonatal Service GSH , SACLA Health Project,              Participants:
                                                          I         Community-chosen Community Health
Khayelitsha MOU
                                                                     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

III       From anecdotal evidence, postnatal                         been completed by 36 CHWs and 5 of the

          health awareness and education seemed                      MOU staff.

          largely inadequate in the community.             *         Statistics are kept
                                                                     (a)      by the MOU: of (i) patients

Aim :     To improve postnatal follow-up and                                  referred to the CHWs; (ii) patients

          primary intervention where indicated                                seen at the MOU for postnatal

          through :                                                           checks.

I         Providing postnatal follow-up at home            (b)       by the CHWs: of the patients they see

Details recorded include name of patient, address                    the service is currently underway.
of patient, name of CHW and his or her co-
ordinator, 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
*         Evaluation of community satisfaction with        approximately 45% in 1994 to more than 60%


                                                      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.
EJ Buchmann                                                  Table 1 Labour complications n=2009
Department of Obstetrics and Gynaecology,                     Complication                          Number        Percent
Baragwanath Hospital and the University of the
Witwatersrand                                                 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
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
of Soweto about nine kilometres from                          Clinic delivery, referred              312          15
                                                              postpartum
Baragwanath. All births, where mothers gave
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

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
recognised in the classic case, but can vary                     AGE IN YEARS         NUMBER OF PATIENTS

considerably according to the amount and timing                         < 20              48           12%
                                                                       20-30              248          62%
of maternal alcohol ingestion, maternal nutrition                      31-40              57           14%
                                                                        > 40              47           12%
and health, other substance abuse, generic
                                                                       TOTAL              400          100%
factors and concomitant medicinal drug use.
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
Table 2 Pattern of Drinking                                 investigations will ascertain the exact risk factors
                        QUANTITY         PERCENTA           and true prevalence of FAS in disadvantaged
                       CONSUMED          GE
                                                            communities in the Western Cape.
 Occasional            <5 units/week         19.6%
 Moderate             5-10 units/week         5.8%
 Mod. Binges           5-10 units/occ        10.0%
 Heavy               11-20 units/week         6.0%
 Heavy Binges          > 10 units/occ         4.2%
 Very Heavy           > 20 units/week         0.4%
        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
          1           2             3             2
RJ Biggar , TE. Taha , A Justesen , PG Miotti ,            follow up at least once within 12 weeks, 27.4%
                  3             3           3
LA Mtimavalye , R Broadhead , G Liomba ,                   were HIV infected (PCR). There was no
              3            1
JD Chipangwi , J Goedert .                                 difference in overall HIV transmission between the
1
National Cancer Institute, Bethesda, USA                   non-intervention babies (27.9%): "intent to treat"
2
Johns Hopkins/College of Medicine Research                 analysis.   This did not change when only those
Project, Blantyre                                          who would have been washed in the control
3
Queen Elizabeth Central Hospital, Blantyre,                phase and those who were actually washed
Malawi                                                     during the intervention were considered (26.4%
                                                           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).    This decrease

labour. The newborn was also washed with the               was independent of the HIV status of the women.

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
                                 non-interv.  interv.
"intent to treat"        27.9%          26.9%         NS
"eligible to wash"
          and                    26.4%             25.3%           NS
"actual wash"
ROM 0 - 4 hours                  25.0%             28.2%           NS
          > 4 hours              38.8%             24.4%           p=0.02



Table 2 Influence of vaginal washing on postpartum sepsis
                                 non-interv.             interv.
Admission to SCBU                 19.7%            17.4% p=0.03
Neonatal sepsis
(as % of admissions                9.2%            4.7%            p-0.005*
to SCBU)
Neonatal deaths (/1000)
        total                     37.6%            29.4% p=0.07
        infectious causes          7.5%                   2.5%              p=0.01
Maternal postpartum sepsis
(as % of women with post-         14.2%             5.7% p=0.03**
partum morbidity)
* OR = 0.49, 95% CI 0.30 - 080            ** OR = 0.36, 95% CI 0.12 - 0.91




                                                      77
MATERNAL AND OBSTETRICAL FACTORS IN                         HIV at Baragwanath.
MOTHER TO CHILD TRANSMISSION OF HIV IN
SOWETO, SOUTH AFRICA                                        Objectives:
                                                            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,
Johannesburg, South Africa.                                 Method:
                                                            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
                                                                    3                               3
attending this clinic were enrolled into a                  per mm with a mean of 544 per mm in the whole
prospective follow-up study to determine the                group. In mothers who transmitted HIV to their
                                                                                                              3
factors influencing mother to child transmission of         children the mean CD4 count was 536 per mm


                                                       78
(Range 55-2542) and in non-transmitters the
                          3
means was 548 per mm (Range 68 - 1959).                    Conclusions
                                  3
CD4 counts of below 200 per mm 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
                                                                                                        3
was a non-significant trend towards a higher               have low CD4 counts (below 200 per mm ), which
transmission rate with CD4 counts less than 200            would classify them as having AIDS by the 1993
        3
per mm (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
MEDICAL STUDENTS AND HIV EXPOSURE                          10,2%, L&B measurement 38,7% versus 16% and
                                                           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

Results                                                    the rest partially correct.

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 post-
contamination 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
CAPE TOWN                                                   Patients and Methods
                                                            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
2.      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


                                                       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                  37
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)*          1767 (725)
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

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
                               < 75th centile                                        75 - 95th centile
IUD                            n=2                                                   n=1
Reason:                        * Unknown, macerated, 40w, 1900g                      * Diabetic, cord around neck 38w, 2760g
                                 no Doppler for 5w
                               * 100% abruptio, 38w, 2650g

LNND                           n=1                                                   n=1
                               * PET, prematurity, 30w, 1195g                        * PET, prematurity, 32w, 775g
Congenital Abnormality
                               n=3                                                   n=1
                               * anencephaly                                         * Trisomy 18
                               * tricuspid atresia, hypoplastic ventricle
                               * caudal regression syndrome




                                                                     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-
                                                                  study populations divided by birth mass
32)/446 which means 50.8% fewer tests. Use of
                                                                   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
                                                                  exclusion criteria:
sample which is 5 (encl PET)/187. However the
                                                                           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
                                                                  Measures
management of the suspected growth retarded
                                                                           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
                                                                   2
assessment of mother and baby           by length sq i.e.: BMI =kg/l
        urea, creatinine, total                Statistical workup done with Mann
        protein albumin, pre-                   Whitney U test unless otherwise
        albumin, cholesterol                    specified.
        retinol binding protein,               Data expressed as medians (range)
        transferrien, Vit B6 Vit
        B12, folic acid and
        homocysteine




                                   88
Table 1 Demographic data
                       Group 1          Group 2      p Value
                       1000-2500g       > 2500g
 Population                   53            56
 number
 Age years                 24 (15-42)   26 (16-40)     0.5
 Parity                     1 (0-5)       1 (0-5)     0.34
 Gravity                    1 (1-6)       2 (1-6)     0.54
 Number of                  13,2%          23%
 antenatal visits
 Education
  presecondary              13,2%         23%
  secondary                  73%          71%
  post                       5,6%          1%
  secondary                  7,5%         3,5%
  unknown
 Occupation
  Light                      66%           73%
  Medium                     24%          20,7%
  Heavy                      5,6%          3,7%
  Unknown                    3,7%          1,8%
Table 2 Maternal Results
                                                                  Group one                Group two               p Value
                                                                 1000-2500g                 > 2500g
 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
 Body mass index
 *       healthy                                                    75.6%                    36.5%                 0.00039
 *       overweight                                                 24.3%                    63.5%                 OR 5.38
                                                                                                                  CL 1.98-14
 Dividing overweight into:
 *           overweight                                              60%                      40%                    0.43
 *           obese and very obese                                    40%                      60%                 OR 2.307
                                                                                                                  CL 0.44-12
 (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
 Pre-albumin (mg/l)                                             144.5 (71-312)            161 (81-213)               0.61
 Retinol binding protein (mg/l)                                                                                   Chi square
            < 10                                                    13.5%                    15.6%                    NS
            > 30                                                     16%                      56%
            >10 <30                                                  81%                      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)               0.74
 B12 (pmol/l)                                                                                                     Chi square
          >1440                                                     10.5%                     0%                      NS
          1-200                                                     34.2%                    61.7%
          200 - 1440                                                55.2%                    38.2%
 Folic acid (nmol/l)                                                                                              Chi square
            >5                                                      92.1%                    88.4%                    NS
            <5                                                       7.9%                    11.5%
                                                                            1.     The population served by Kalafong
Conclusion
                                                                                   Hospital is not underweight.

                                                                    89
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
AN OVERVIEW OF PERINATAL MORTALITY IN                        5.       Genetic factors and the incidence of
         SOUTH AFRICA                                                 congenital abnormalities.
                                                             6.       The health status of the population as a
H Saloojee, K Kalian                                                  whole.
Department of Paediatrics and Obstetrics and                 7.       The organisation and standards of
Gynaecology, Baragwanath Hospital                                     obstetric and paediatric care.


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,

2.       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

3.       The frequency of preterm and posterm                evidence of life 24 hours after birth it should be

         deliveries.                                         considered as a livebirth.

4.       The number of LBW and VLBW babies.                  It is the authors' recommendation that Lawson's


                                                        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       PNMR       SB         ENM          SB/ENM
                                    s
 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                         21
 1 Military              91-3       1 650           18.1       7.8        10.3         0.7
*Includes deaths 500-999 grams                   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                               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                   SB=stillbirths, ENM=early neonatal mortality




                                                                92
UNBOOKED PATIENTS                                            labour ward and ante-natal clinic.
                                                             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
2.         To identify the possible socio-economic           included age, language, parity, schooling,
           characteristics leading to being unbooked.        previous booking status, previous delivery, marital
3.         To identify reasons why some people do            status, residence, financial status and social
           not book.                                         problems.
                                                             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

 1994-1995

 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%




                                                        93
Table 2 AFTER

                                                                     PERCENT

 YEAR/MONTH                 BOOKED              UNBOOKED             BOOKED                    UNBOOKED

 1995-1996

 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%


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
the study period.                                                      Exercise for pregnant women
                                                                       Clinic should be opened on Saturdays
In reviewing the unbooked and booked groups                            Health Education
                                                                       Good attitude of the staff
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

Table 3                                                                do anything about it.
WHY UNBOOKED?                                                  2.      Intervention should be at National and
Has just moved to Alexandra                      = 9/25
No money, not aware of free health services      = 7/25                Provincial level.
Still planning to book                           = 5/25
Knew that they would be referred to hospital,                  3.      Education, advertisement of free health
refusing to go                                   = 2/25
Psychosocial problems                            = 3/25
                                                                       services and the implementation of the
                                                                       patient retained card at National level.
WHY IS IT IMPORTANT TO BOOK?
To check if I have problems                     = 18/25        4.      Success of patients retained cards.     The
To check well being of baby                     = 3/25
To check both the mother and baby               = 6/25                 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
Baragwanath Hospital and University of the                  Table 1 Gestational ages of the cases and
Witwatersrand                                                              controls
                                                             Gestational age groups       Unbooked     Booked
                                                                                          n=112        n=112
Introduction
                                                                      21-24 weeks             10          10
With the introduction of free maternity services,
                                                                      25-28 weeks             20          20
the rate of unbooked mothers has decreased by
                                                                      29-32 weeks             14          14
half to ten percent at Baragwanath Hospital. This
                                                                      33-36 weeks             18          18
study was designed to describe characteristics of
                                                                    37 - 40> weeks            50          50
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     32(29%)    47(42%)     P=0.036
                                                             Unemployed       70(63%)    86(77%)     P=0.020
Table 2 Maternal Characteristics
                                                             Income
                   Unbooked   Booked    Statistical          <R500p.m.        79(71%)    86(77%)     N/S
                   n=112      n=112     Significance         Literate         99(88%)    91(81%)     N/S
                                                             Smoking          16(14%)    7 (6%)      p=0.046
                                                             Married          19(17%)    40(36%)     p=0.001
 Age               26,4 yrs   26,0yrs   N/S


                                                       95
 Live in Soweto       59(53%)     67(60%)   N/S
N/S = not significant                                         Table 5 Perinatal mortality and morbidity
                                                                                      Unbooked    Booked       p
Table 3 Reasons for not booking n=112                                                 n=112       n=112

                                  Number    Percentage         Stillbirth rate           205         241       N/S
                                                               Early neonatal death       9           9        N/S
 Intended to book                 10        9                  rate
                                                               Perinatal mortality       214         250       N/S
 Too lazy                         15        13                 rate
                                                               Birth weight <2500g     62 (54%)    52(46%)     N/S
 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.
                                                              Patients with poor obstetrical history book at
Table 4 Maternal problems                                     Baragwanath Hospital. Perinatal outcomes were
                           Unbooked    Booked     p
                           n=112       n=112                  similarly poor in both groups, mostly associated
                                                              with complications resulting in preterm birth.
 Previous C/S              12(11%)     15(13%)    N/S
 Hypertension              15(13%)     20(20%)    N/S         Syphilis as a cause of perinatal death was
 Eclampsia                 4 (3.6%)    2 (1%)     N/S
 Abruptio                  4 (3.6%)    2 (1%)     N/S         however more frequent in the unbooked group of
 Preterm Labour            31 (28%)    32(29%)    N/S
 Wasserman-reaction        22(28%)     14(13%)    N/S         mothers.
 positive


                                                              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
Hospital                                                     Results
                                                             There were five patients with haemoglobin level
Introduction                                                 below 10g%, as estimated by the Coulter method.

Anaemia in pregnancy can be caused by the                     Both the copper sulphate method and 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.            All
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
                                                               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
(<6hrs) or sustained.                                          Conclusion:
                                                               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
morbidity and mortality.                                           Conclusions
                                                                   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

                            500-999g 1000-1499g      1500-1999g           2000-2499g       >2500g           Total
Spont. preterm labour       54                16              4                                                     74

Infections
- Syphilis                  5                7                 8                   11               6               37
- AFIS                      4                2                 3                   5                9               23

APH
- Abruptio             8            6                9                    10               10               43
- Other                                      1                                     1                                2

Idiopathic IUGR             1                3                 12                  4                                20

GPH                         3                                  2                   2                3               10

Fetal abnormality           1                6                 4                   6                9               26
Intra partum hypoxia
- labour related                                               1                   3                48              52
- other                                      1                 1                   1                5               8
IUD - unexplained
- fresh                     1                1                 1                   2                2               7
- macerated                 22               8                 9                   11               20              70

Table 2 Final causes of Neonatal Death
                            500-999g 1000-1499g      1500-1999g           2000-2499g       >2500g           Total
Premature related           29                13              2                                                     43



                                                         103
Asphyxia            1                    1                 2               4       24       32

Infection
- syphilis                                         1                  2        1                 4
- other                                                               1        1        4        6

Congenital abnormality          1                  1                  3        5        9        19

Table 3 Avoidable Factors
Patient Related                                                       62
          *         Inadequate antenatal care              40
          *         Delay in seeking help                  17
          *         Other                                  5

Medical Personnel Related                                             45
         *         Deficient monitoring in labour
                   (fetal distress/progress of labour)     23
         *         Delay in referral/getting expert help   7
         *         Other                                   15

Administrative Problems                                               6
          *         Transport                      6




                                                                104
AUDIT ON ANTENATAL CARE BEFORE AND                          general.
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
R Pfau, RC Pattinson, J Makin                               Kalafong unavailable Hb results were reduced
                                                            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
intervention.                                                Results
                                                             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 intra-
observer variation. The danger of
misclassification of progress of labour still
remains due to random error and inter-observer
variation.




                                                   108
UPDATE ON THE IMPORTANCE OF TOUCH                           functioning.
                                                            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 HIV-
                                                            exposed 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
A Kent                                                                    possibility.
Department of Obstetrics and Gynaecology,
University of Cape Town                                           3.      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.     There are a number of                        by students.
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
           standardised, updated and made                         4.      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-
2.         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)
Antenatal predictive factors for poor long term           had predictive value for disability.
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
Aim of study : To establish if there were any             were able to predict poor outcome.
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
CJM Stewart, SK Tregoning, *H Wainwright                   poor predictive value.
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

Aim                                                         knowledge of menstruation and 11 could explain

1.       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

2.       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

Results                                                     adolescents.


                                                      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 full-
time 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
Recommendation                                               *        minimum appropriate FiO2 before 12
A multidisciplinary approach to teenage health                        hours
care involving physicians, educators, family                 -        maximum appropriate FiO2 before 12
planners, social workers and behavioural                              hours
scientists.                                                  *        admission temperature
                                                             *        was antenatal care received
                                                             *        congenital syphilis

                                                       117
*               born inside or outside Ga-Rankuwa
                                                                Mortality           400   157   39,3
                Hospital
                                                                No antenatal care   400   197   49,3
*               CRIB score
                                                                Born outside Ga-    400   69    17,3
*               outcome (discharged or demised)                 Rankuwa Hospital

                                                                Hypothermic on      400   331   82,8
                                                                admission (<36oC)
Results
                                                                Syphilis serology   345   34    9,9
A total of 1572 neonates were admitted during the               positive
study period, of whom 400 had a birthweight of <
                                                                Congenital          396   8     2
1500g, comprising 25,45% of all admissions.                     abnormalities

Table 1

    Mortality                Number of infants   Nr   %
                             < 1500g




                                                          118
Table 2
                                                Mean               Standard      Range          Total no of infants
                                                                   deviation                    < 1500g

 Birth weight (grams)                                 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)
                                  o
-       hypothermia (temp <36 C) 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

								
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