The Perinatal Conferences are held under the auspices of theDepartment of Obstetrics and Gynaecology, University of Pretoriaand sponsored by Abbott Laboratories SA (Pty) Ltd

Proceedings : 16th Priorities in Perinatal Care

Editor's Note:

An editorial board was appointed to look at the papers in this year's Proceedings. Where there were marked errors in the papers these were referred back to the author for correction. If, however, these were not corrected the paper has been printed in its original form. The editors thus accept no responsibility for any mistakes found. If corrections were suggested by the editorial board and these did not in any way affect the meanings intended in the paper, these changes were made without contacting the author. We apologise if this causes offence but, in view of the amount of administrative work involved in contacting the relevant authors, it was felt this was the easiest course to follow.

Proceedings : 16th Priorities in Perinatal Care

TABLE OF CONTENTS

CONSENSUS STATEMENTS

ANTENATAL SCREENING FOR SYPHILIS. SD Delport............................................................1

DISCUSSION DOCUMENT. NEONATAL ETHICS. DE Ballot...................................................3

CONTINUING EDUCATION

STAFF TRAINING FOR PERINATAL AUDIT. S Bergström.......................................................6

THE IMPACT OF THE MATERNAL CARE MANUAL OF THE PERINATAL EDUCATIONPROGRAMME ON THE PRACTICAL SKILLS OF MIDWIVES. GB Theron....................10

SUCCESS WITH THE PERINATAL EDUCATION PROGRAMME. D Woods.............................12

PREPARING AND MAINTAINING SYSTEMATIC REVIEWS - THE SA COCHRANE CENTRE(SAFRICC). C Nikodem............................................................................................14

PROMOTING EVIDENCE-BASED PRACTICE IN DEVELOPING COUNTRIES - THE WHO REPRODUCTIVE HEALTH LIBRARY. GJ Hofmeyr.....................................................17

HIGHER EDUCATION RESOURCE ORGANISATION (HERO). D Woods...............................19

LABOUR

SUBAPONEUROTIC HAEMORRHAGES - A PREVENTABLE PERINATAL PROBLEM. H Saloojee.............................................................................................................................................20

INTRAPARTUM FETAL DEATHS AT BARAGWANATH - HOW PREVENTABLE? EJ Buchmann,.............................................................................................................................................22

VAGINAL MISOPROSTOL FOR INDUCTION OF LABOUR. S Bergström................................25

MISOPROSTOL FOR THIRD STAGE OF LABOUR MANAGEMENT: A DOUBLE BLIND, PLACEBO CONTROLLED CLINICAL TRIAL. L Rose...............................................................28

THE USE OF DEXATHASONE IN WOMEN WITH PRETERM PREMATURE RUPTURE OF MEMBRANES: A MULTICENTRE, PLACEBO CONTROLLED RANDOMISED CONTROLLED TRIAL.

The DEXIPROM Study Group..............................................................................................31

FETAL AND INFANTS GROWTH

FETAL GROWTH AND LOW BIRTH WEIGHT IN MOZAMBICAN PREGNANT WOMEN.NB Osman................................................................................................................34

GROWTH AND DEVELOPMENT OF VERY LOW BIRTHWEIGHT INFANTS TO AGE FIVE YEARS.

PA Cooper................................................................................................................36

MINIMAL ENTERAL FEEDING : AN IMPORTANT ROLE FOR MILK IN THE GUT. SJ Newell....39

IS EARLY DISCHARGE OF PREMATURE BABIES SAFE? M Mokhachane.............................42

MATERNAL NUTRITION AND LOW BIRTH WEIGHT. K Kyriazis...........................................45

Proceedings : 16th Priorities in Perinatal Care i

ANTENATAL CARE

CAN DOPPLER FLOW STUDIES EXPLAIN THE PRESENCE OF OLIGOHYDRAMNIOS IN POST TERM

PREGNANCIES? S Morris.........................................................................................47

THE VALUE OF ROUTINE HEART AND LUNG AUSCULTATION IN ANTENATAL CARE.E Divanovic..............................................................................................................50

AN INVESTIGATION OF ANTENATAL PATIENTS REPORTING REDUCED FETAL MOVEMENTS.A Theron..................................................................................................................52

FETAL VIBRO-ACOUSTIC STIMULATION WITH A CAN: A CLINICAL STUDY. M de Jager......54

INFECTIONS

TRANSMISSION OF HIV FROM MOTHER TO CHILD, STRATEGIES FOR PREVENTION.GE Gray....................................................................................................................57

PERINATAL HIV: A NEW PERSPECTIVE. THE PRETERM NEONATE - AN EMERGING PROBLEM.

M Adhikari................................................................................................................62

BACTERIAL VAGINOSIS, LOW BIRTH WEIGHT INFANTS AND PERINATAL DEATHLR Pistorius..............................................................................................................64

HIDDEN PREGNANCY WASTAGE ATTRIBUTABLE TO SYPHILIS IN RURAL SOUTH AFRICA.D Wilkinson..............................................................................................................67

THE ANTENATAL PREVALENCE AND SEROCONVERSION RATE OF SYPHILIS IN THE TYGERBERG

HOSPITAL AREA: 1993 VS 1996. GB Theron..........................................................69

EPIDEMIOLOGY

SCREENING FOR CERVICAL NEOPLASIA DURING PREGNANCY. IS IT WORTHWHILE?HS Cronje.................................................................................................................72

THE NORTHERN CAPE SAFE MOTHERHOOD NEEDS ASSESSMENT. JA McIntyre..............74

PROSPECTIVE RISK OF STILLBIRTH COMPARED TO CONVENTIONAL STILLBIRTH RATES FOR THE ATTERIDGEVILLE POPULATION. GR Howarth..........................................77

PROFILE OF A MOU : WORKLOAD, PROBLEMS AND OUTCOMES. DH Greenfield..............78

WOMEN WHO BOOK LATE IN PREGANCY. D Roussot........................................................80

HYPERTENSION

HYPERHOMOCYSTEINAEMIA IN ABRUPTIO PLACENTAE. AA Carolissen............................83

DOES BETAMETHASONE TREATMENT, TO ENHANCE FETAL LUNG MATURITY IN PATIENTS WITH

SEVERE PROTEINURIC HYPERTENSION LESS THAN 34 WEEKS' GESTATION, HAVE ANY ADVERSE EFFECTS ON THE BASELINE VARIATION AND OTHER PARAMETERS OF THE FETAL HEART? G van Rensburg................................................................85

Proceedings : 16th Priorities in Perinatal Care ii

ORAL KETANSERIN IN MILD MIDTRIMESTER HYPERTENSION - A RANDOMISED CONTROLLED ....................................................................................................TRIAL.

DW Steyn...........................................................................................................................87

POSTERS

THE CONFIDENTIAL ENQUIRY INTO MATERNAL DEATHS - THE MATERNAL DEATH NOTIFICATION FORM. E Retief................................................................................89

MATERNAL MORBIDITY : A DEFINITION FOR A MATERNAL "NEAR MISS". GD Mantel.......91

THE EFFECT OF THE PERINATAL PROBLEM IDENTIFICATION PROGRAMME IN THE WITBANK

DISTRICT IN 1996. D Kotzé.....................................................................................93

THE IMPORTANCE OF LOCAL AUDIT. M Muller.................................................................. 98

SEEKING SALEABLE SOLUTIONS: RESULTS OF A REGIONAL PERINATAL AND MATERNAL MORTALITY AUDIT. RC Pattinson......................................................................... 101

A TEN YEAR REVIEW OF BLOOD CULTURE ISOLATES FROM THE NEONATAL UNIT OF GA-RANKUWA HOSPITAL 1987-1996. M Driessen.....................................................104

SCREENING FOR PREGNANCY BACTERIURIA. ET Bvuma.................................................106

PREVENTION OF REPEAT ABRUPTIO PLACENTAE. L Schoeman......................................108

Proceedings : 16th Priorities in Perinatal Care iii

CONSENSUS STATEMENTS

ANTENATAL SCREENING FOR SYPHILIS

SD Delport, RC PattinsonDepartment of Paediatrics & Child Health and Obstetrics & Gynaecology, Kalafong Hospital and University of Pretoria

Near patient screening for syphilis should be performed in all pregnant women. This implies performing a screening test in the clinic (on site) or in a nearby laboratory so that the results are available before women leave the clinic or consulting room.1. All pregnant women should be

screened for syphilis at the time their pregnancy is diagnosed.

Motivation:1.1 Many women seek antenatal

care late during pregnancy.1.2 The screening test for syphilis

is easy to perform, quick and cheap.

1.3 Similarly the treatment of maternal syphilis is cheap and prevents congenital syphilis - the cause of 10% of perinatal deaths.

2. Results of the screening test should be reacted on and given to women before they leave the clinic or the

consulting room. Women with a positive test must be treated immediately.

Motivation:2.1 Women may not return for a

2nd visit due to social and financial constraints.

2.2 Immediate counselling and treatment can be offered. (Patients should not be referred to STD clinics).

2.3 Any delay in treatment increases the risk of fetal death.

3. The results of positive screening tests performed on site must be verified in a laboratory and a titre determined. The titre must be documented on the motherhood card. A treponemal test (TPHA or FTA-ABS) should be performed if resources permit.

Motivation :3.1 A baseline titre of a screening

test is necessary to determine success of treatment (a declining follow-up titre) or a reinfection, and increasing follow-up titre).

Proceedings : 16th Priorities in Perinatal Care 1

3.2 A positive treponemal test in addition to a positive screening test rules out a false positive screening test.

Screening tests for syphilis1. Rapid plasma reagin (RPR)

testCan be performed without specialised equipment and will identify all women with RPR titres > 1:16. Negative results need not be verified in a laboratory.

2. Venereal Disease Research Laboratory (VDRL) testSophisticated and more sensitive than an RPR test. Not a suitable test for on-site testing.

Proceedings : 16th Priorities in Perinatal Care 2

DISCUSSION DOCUMENT : NEONATAL ETHICS

DE Ballot, PA Cooper

The following is a report of a discussion regarding neonatal ethics, held amongst health care workers involved in neonatal care. The problem of selecting patients for neonatal intensive care was discussed previously at the 10th Conference on Priorities in Perinatal Care. At that time it was generally agreed that a birth weight cutoff of 1000g for neonatal intensive care should be applied. It was felt that neonatal admission policies and ways of rationing tertiary care due to limited resources should be reviewed.There was general agreement that limited health resources in South Africa necessitate the selection of neonates for intensive care. It was felt that a set of general principles could be recommended, but that specific categories should be determined by the individual departments and regions.

A Selection criteria for ICUPossible methods include:

i) Selection on the basis of anticipated outcome (mortality/ functional and utilisation of resources

Factors which could be considered include:- Birthweight- Gestational age- Severity of illness- Severe congenital anomalies- Chromosomal anomalies- Birth asphyxia

Problems:- It is difficult to prognosticate

at the time of admission. Severity of illness scores e.g. CRIB, SNAP, NTISS seem attractive means for patient selection but these were not designed for this purpose. It is also impossible to accurately predict individual outcome. Many of the scores are cumbersome and require an initial period of admission and treatment.

- Selection of patients may create a self-fulfilling prophecy - sick babies do badly.

ii) Selection on the basis of "worth"Factors which could be considered include:- Precious baby- Poor obstetric history- Uncaring mother, unwanted pregnancy- Unbooked mother- Poor socio-economic

circumstancesProblems:- This is a value judgement,

which is influenced by an individual's frame of reference.

- These categories of patient often do not correlate with outcome.

- The baby is disadvantaged because of the mother's actions.

iii) Selection on the basis of response to therapyIn this circumstance all babies would be resuscitated and treated for a limited period of time (e.g. 72 hours). Patients would then be assessed and ICU support would be withdrawn in those who were not responding adequately to treatment. Severity of illness scores could be useful in assessing these patients.

Problems:- Specific criteria for withdrawal

of treatment are required (see below).

- Duration of treatment must be specified.

- Withdrawal of treatment appears more aggressive than not starting tertiary care.

- There would be a substantially

increased demand for ICU facilities.

- Would parents cope?iv) Maternal HIV infection

Neonates who have acquired HIV infection from their mothers have a poor prognosis and could be a category of patients denied tertiary care. However, there is no single reliable test to diagnose infection in the neonate at birth at present.

B Withdrawal of therapyAnother means to reduce pressure on ICU beds is aggressive withdrawal of ICU support in those patients with a poor prognosis. This is currently practised in most units but is less well defined than selection of patients for admission. Patient categories include:- Severe birth asphyxia- Severe congenital anomalies- Chromosomal anomalies- Severe intraventricular haemorrhage/ leucomalacia- End stage renal failure- Multi-organ failure- Severe bronchopulmonary dysplasiaIf response to therapy is to be used as a means of selecting

patients (A iii), other parameters, e.g. oxygen requirement at 72 hours would have to be incorporated into criteria for terminating therapy.

DiscussionIt was generally agreed that the best method in our circumstances is to have selection criteria for initial ICU admission. Birth weight is a reasonable criterion for this purpose and most units are using a birth weight cutoff. The 1000g cutoff is widely applied, although cutoffs varied between 900 and 1250 grams. Birth weight remains preferable to gestational age as accurate assessment of gestational age is often unavailable. Studies on neonatal outcome have shown that birth weight and gestational age are closely related.It was agreed that other factors in addition to birth weight could be considered including:- Maternal booking status- Obstetric history and

intervention (e.g. in vitro fertilisation)

- Interference in the pregnancy- Unwanted pregnancy- Outborn babies- General condition of the baby

(asphyxia, severity of illness,

need for resuscitation)It was suggested that instead of an absolute 1000g cutoff, a graded approach could be used:- <900 - no ICU support- 900 to 1200g - selective

admission of babies to ICU (see above)

- >1200g - ICU admissionIt was generally felt that all babies should be initially resuscitated and then assessed for ICU admission. The decision to withhold ICU support should be made at senior level. It was emphasised that those babies who are denied ICU admission would still receive level 2 care, including warmth, oxygen, nutrition and antibiotic therapy.It was agreed that active withdrawal of ICU support in patients with poor prognosis is appropriate. This decision should be made by the medical and nursing staff caring for the baby in conjunction with the parents. The ultimate decision, however, should remain the responsibility of the medical staff and not the parents. Ethics committees may help to review the options but would not take the ultimate decision to withdraw therapy.It was suggested that actual practices regarding NICU admission

and withdrawal of therapy should be formally evaluated by means of a questionnaire. The results would be made available and would form part of the general guidelines.The public sector is usually unable to provide support to those parents in the private sector who run out of

funds. It would therefore seem appropriate for private practitioners to be made fully aware of policies in public sector hospitals and to agree to refer to public sector hospitals patients who conform to these policies.

STAFF TRAINING FOR PERINATAL AUDIT

S BergströmDivision of International Health Care (IHCAR), Karolinska Institutet, Stockholm, Sweden

1. The concept of auditIn its original sense audit implies a critical review of events, particularly economic events. It has been defined as "a numerical review by an outside investigator directed at, among other things, the prevention of fraud"(1). Clinical audit does not aim at the prevention of fraud but aims at detecting mismanagement and degree of avoidability of adverse outcomes of clinical management.The retrospective scrutiny of clinical events, the re-view, is an action close to "re-search". Clinical audit can rightly be considered an action-orientated research, aiming at operationalising findings in order to

correct mismanagement, and to improve norms with a focus on avoidability issues.

2. Perinatal auditUnfortunately, much of perinatal audit exercises tend to focus more on fetal/neonatal outcome than on maternal outcome. It should be underscored, however, that more than half of all maternal deaths in most studies occur in the perinatal period, from the 28th week till the end of the 7th day postpartum. The word "perinatal" alludes only to the period surrounding birth, and does not exclude the mother or the fetus/newborn. Strictly speaking, perinatal mortality, should be specified to be "perinatal fetal/infant mortality" or "perinatal maternal mortality". Audit activities in the perinatal period should therefore cover both maternal and fetal/ neonatal events.Initially most of perinatal audit

efforts should be geared towards auditing deaths, which in itself is an obvious priority. However, it is equally relevant to audit and equally interesting to define the most severe morbidity occurring in the perinatal period both for the mother and the fetus/ newborn, the category of events that we can call "near misses". Apart from such severe morbidity it may also be useful and instructive to include all forms of significant and measurable morbidity among women and newborns in order to gradually improve management and quality of care.

3. "The mailbox syndrome"A well-known phenomenon in most low-income countries is the reasonable and conventional demand from health authorities, ministries and various health authorities to the lower levels that they deliver health statistics for central accumulation of data. Collecting data from peripheral levels of health care without their proper "digestion" on the spot where they can be registered has been said to constitute "the mailbox syndrome". The delivery of collected data to a central authority, like the Ministry of Health, may "legitimise" exportation of data to next higher

level instead of importing data to quality-assuring and quality-improving staff activities within the health unit, where the data were elaborated and collected. The latter activities precisely constitute audit, implying visualisation of clinical events for internal consumption, digestion and contemplation. Even if the need for these data in central authorities is perfectly legitimate, a still more important and operation-orientated utilisation is, obviously, in the health unit generating the data. This is particularly important as concerns perinatal data, since the outcome of two individuals is involved.

4. Prerequisites for perinatal auditA complete and high quality data collection procedure on a daily basis is a sine qua non for a successful perinatal audit. These daily collection activities should be followed by regular, weekly or fortnightly summaries of data for careful case-by-case scrutiny aiming at avoidability analyses. This may concern death, severe morbidity or other important perinatal events. Whereas these steps in the audit procedure could be prepared by a responsible individual, the proper

avoidability discussion should follow from a plenary discussion where all health staff involved are present.Since all forms of audit aim at analysing avoidability, by which mismanagement is in focus, it may appear threatening to staff involved. It has, however, being said rightly that "clinical audit should be carried out as an internal activity, for the benefit of the group and should be under local control". Encouraging participation in and real commitment to audit activities depend upon recognising and managing health staff responses. There are several useful principles that can guide the management of audit groups to constructive working relations. Such principles may comprise the following:1) Emphasis on local control.2) Reasonably ambitious and

achievable objectives.3) Emphasis on the value of

present and past practice.4) Identification of current review

activities.5) Acknowledgement of

participants' concerns.It is very important for the proper function of an audit process that the audit itself is not threatening to anyone present. The audit should not produce anxiety adrenaline

release and tachycardia.It has rightly been said that "good leaders are not authoritarian, nor are they shrinking violets. They believe in forging consensus and then helping everyone share in the implementation" (1). The importance of "fostering" co-operation (2) cannot be underscored enough. The following quotation gives a succinct description of some core elements in a good perinatal audit (2): "Co-operation and understanding cannot be taken for granted within groups. Constructive interaction often needs to be nurtured. This requires skilled contributions especially from those who hold leadership responsibilities (such as chair persons). Key activities include:1) Listening carefully to others'

ideas and reservations.2) Encouraging and praising

others' contributions.3) Summarising and clarifying

progress during discussions.4) Identifying similarities and

compromises during disagreements.

5) Mediating between those with different perspectives.

6) Relieving tensions through humour or creating breaks.

7) Managing participation so that

everyone is involved.A socially skilled chair person may sometimes perform many of these function for a group. But more commonly effective meetings depend upon the majority of participants contributing to these management activities."

5. Problems in staff training for perinatal audit

In most settings a confidential audit is to be preferred. Depending on the spirit of the unit and the needs on the spot there may be some advantages in a non-confidential perinatal audit. In Maputo such an audit has been practised for many years with conspicuously good results (3). If non-confidentiality is applied, the above demands on the chairperson are still more vital. In any audit activity, however, confidential or non-confidential, there may be disruptive problems: "An important advantage of a person-orientated approach to manage meetings is that it tends to minimise attention- and control-seeking behaviour. Nevertheless, groups often have to deal with the expression of anxieties and unmet needs. Those who continue to feel threatened by audit may resist a sharing control or block progress.

Some may seek attention from the group by being aggressive towards others or may try to focus proceedings upon their particular interests. Those who feel anxious in group meetings may withdraw or divert attention towards other topics. Common disruptive problems include members who:1) Devalue others' expertise and

work practices.2) Reject others' ideas and

proposals without acknowledging their value.

3) Blame or intimidate others.4) Distract discussion into

personal interest or previously discussed issues.

5) Block progress by refusing to compromise.

6) Display cynicism or indifference.

7) Withdraw by non-attendance or non-participation.

8) Encourage conflict between others.

Ignoring these difficulties may be effective when the issues involved are trivial or the group's life is likely to be short. However, in the longer term they are likely to result in reduced motivation or the fragmentation of groups (2).

6. Perinatal audit training at

various professional levelsSmaller health units may be able to "afford" less confidentiality due to the simple reason that perinatal events and the individuals responsible for them may be known to all involved. In bigger units there may be more reason for confidentiality since the chair person may have difficulties in maintaining a good spirit in a group, where the members are not very well acquainted with each other.Alluding to "level" of audit we may wish to refer not only to the hierarchical level of health unit (smaller or bigger units) but also to professional levels. Clinical audit is presumably most often performed by doctors but it is highly meaningful also to distinguish a perinatal audit of midwifery care. It may even be meaningful to discuss midwifery care separately addressing specific nursing care problems in perinatal care.

7. Prerequisites for staff training

A good staff spirit produced by proper staff involvement guided by the principles mentioned above, place the ground for efficient staff training. A key concept in successful staff training is the willingness of the

responsible clinician to delegate responsibility. It is vital that the quality of data, quality of registers and quality of archives are improved by such responsibility delegation. The process of feedback of data to staff is fundamental for the staff training procedure. The examples of good and bad audit habits may form cornerstones in staff training. The sustainability of the feedback system is also of utmost importance. If staff is not encouraged to share the valuable aspects of perinatal audit, sustainability is hardly probable. The basis of "fostering co-operation" is to also show appreciation. Perinatal audit should not imply identification only of mismanagement but also identification of good and laudable perinatal management.Staff ethics and staff spirit are empirically much enhanced by sustained attention to that principle.

THE IMPACT OF THE MATERNAL CARE MANUAL OF THE PERINATAL EDUCATION PROGRAMME ON THE PRACTICAL SKILLS OF MIDWIVES

GB TheronDepartment of Obstetrics and Gynaecology, University of Stellenbosch

Objective : This study assessed whether practical skills of midwives who studied the Maternal care Manual of the Perinatal Education Programme (PEP) improved significantly.

Methods : A prospective controlled study was conducted in a region where PEP has not been implemented at all. A study town and 2 control towns were selected. Fourteen practical skills were evaluated. Midwives rendering antenatal care were evaluated on 2 skills each and those working in the labour wards on 4 skills (pretests). All midwives rendering antenatal care in these towns and midwives working in the labour wards of the 3 hospitals were tested. The Maternal Care Manual of PEP was subsequently studied in the study town. On completion of the programme the same skills were again evaluated (post tests).

Outcome Measures : The ability to correctly perform practical skills scored strictly according to a preset memorandum.

Results : A total of 31 and 36 midwives were included in the study and control towns respectively (Table I). There were no differences regarding the age, level of training and experience between the 2 groups. The mean percentages obtained in the pre-tests did not differ between the study and control towns (Table II). The post tests showed a significant (p=0,0000) improvement of 35,8% in the study town and no change in the control towns (Table II). A stratified analysis was done on the midwives involved with antenatal care only and those working in labour wards of the hospitals. The skills of the antenatal care midwives in the study town improved significantly (p=0,0000) with 44,3% with no change in the control towns (Table III). the skills of the labour ward midwives in the study town also improved significantly (p=0,0000) with 29,9% with no change in the control towns (Table IV).

Conclusion : The practical skills of

both midwives rendering antenatal care and those working in the labour ward that studied the Maternal Care Manual of PEP improved significantly. This is of particular importance because practical skills are not tested as part of the examination taken on completion of the programme.

Table I MidwivesStudy town

Control towns

Total

Antenatal care

22 16 38

Labour ward 12 23 35

Total 34 39 73

Table II Percentages scored assessing skillsStudy town: pretest post test p-value*

- mean (s)- median

48,8 (33,9)50,0

85,4 (23,7)100,0 0,0000

- mean improvement = 36,6%

Control towns pretest post test p-value*

- mean (s)- median

48,6 (31,2)50,0

49,7 (32,3)50,0 0,99

*Kruskal-Wallis H

Table III Antenatal care midwives - percentages scoredStudy town: pretest post test p-value*

- mean (s)- median

46,7 (36,9)38,8

91,0 (17,0)100,0 0,0000

- mean improvement = 44,3%

Control towns pretest post test p-value*

- mean (s)- median

42,3 (33,2)33,3

33,0 (25,3)29,2 0,08

*Kruskal-Wallis H

Table IV Labour ward midwives - percentages scoredStudy town: pretest post test p-value*

- mean (s)- median

50,8 (31,2)50,0

80,7 (27,5)100,0 0,0000

- mean improvement = 36,6%

Control towns pretest post test p-value*

- mean (s)- median

51,7 (30,0)50,0

56,9 (32,5)57,1 0,12

*Kruskal-Wallis H

SUCCESS WITH THE PERINATAL EDUCATION PROGRAMME

D WoodsDepartment of Paediatrics and Child Health, University of Cape Town

IntroductionThe Perinatal Education Programme is a distance-learning course which enables doctors and nurses to improve their management of pregnant women and newborn infants. The Programme consists of a Maternal Care manual and a Newborn Care manual which address all the common and important clinical problems in perinatal care. Participants study at home and then meet regularly in small groups to discuss the lessons learned and to practice the clinical skills described in the course. A formal tutor is not necessary. Each course costs R100 and the manuals are produced and distributed at cost by an education trust.

AimThe aim of this study was to describe and identify which nurses had been awarded certificates for successfully completing one or both manuals of the Perinatal Education Programme.

MethodData was collected from the

questionnaire which is routinely included with the end-of-course examination papers. Descriptive analyses were then performed.

ResultsCurrently 15 000 manuals have been distributed in Southern Africa. Of these, 7 762 manuals have been used by nurses in South Africa. Most nursing participants take a year to study a manual. They then have the option to write a multiple choice examination and successful candidates are awarded a certificate. To date 1 543 Maternal Care and 1 838 Newborn Care certificates have been awarded in South Africa. Of these candidates, 789 have obtained both certificates. Therefore 3 242 certificates have been awarded to the recipients of 7 762 manuals (41,8%).While many certificates have been awarded in Western Cape (956), Gauteng (883), Eastern Cape (410), Northern Cape (249) and KwaZulu/Natal (233) provinces, fewer certificates have been awarded in Northern (166), North West (123), Mpumalanga (128) and Free State (94) provinces.Most certificates were awarded to professional nurses (2 337) but many enrolled nurses (74) and nursing

assistants (62) have also successfully completed one or both manuals.Most successful candidates worked in state hospitals and clinics (1937) but certificates were also awarded to nurses in the private sector (592), nursing colleges (30) and universities (13). A further 20 nurses were self-employed. The most common languages of successful candidates were Afrikaans (1029), English (692), Xhosa (195), South Sotho (116), Zulu (97), North Sotho (62) and Venda (19).

ConclusionThe Perinatal Education Programme is achieving its goal of enabling many South African nurses to further their own education. It is being used in all provinces although less so in the three northern-most provinces where the Programme needs to be actively promoted. Not only professional nurses but non-professional nurses are also successfully using the Programme in all sectors of health care. While the manuals are available in only English and Afrikaans, they are being used by nurses from all the major language groups.This innovative model of continuing education is effective, accessible,

appropriate to the needs of the country, cheap, and financially sustainable. It does not require a tutor and participants do not have to leave their places of employment to join a course. Similar programmes are needed in other fields of health care, especially child health and psychiatry.Further information on the Perinatal Education Programme is available from the Perinatal Education Trust, P O Box 34502, Groote Schuur, 7937.

PREPARING AND MAINTAINING SYSTEMATIC REVIEWS - THE SA COCHRANE CENTRE (SAFRICC)

C Nikodem, J Volmink, J Hofmeyr(Acknowledge Ian Chalmers for assistance)

Archie Cochrane (1972) remarked; "It is surely a great criticism of our profession that we have not organised a critical summary, by speciality or subspeciality, updated periodically, of all relevant randomised controlled trials." Cochrane's thinking forms the basis for a health care system that is based on Effectiveness and Efficiency on which clinical decisions are made.How can we take one small step of care to make a giant change in health care? BY USING EVIDENCE-BASED MEDICINE WHERE AVAILABLE."The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research" (Sackett et al; 1997). Every year, more than 2 million research articles are published in more than 20 000 biomedical journals. This is impossible for the health care giver or policy maker to absorb. Thus we have to rely on reviews of the literature.

The problem with traditional reviews is that:Insufficient care is taken to minimise bias (systematic error) and random error (the play of chance) and this can lead to dangerously misleading conclusions. Systematic reviews are scientific summaries of existing research evidence which enable us to cope with the large volume of original research. It separates critically important information from insignificant or unsound data and helps us deal with apparently conflicting evidence from primary studies.The Cochrane Library (CL) is one of the most powerful single sources of systematic reviews providing evidence about the effects of health care. It is an electronic database and is updated quarterly. The Cochrane Collaboration was founded in October 1993. It is an international organisation that aims to help people to make well-informed decisions about health care by preparing, maintaining and ensuring the accessibility of systematic reviews of the effects of health.How does the Cochrane collaboration work?Reviewers:Cochrane reviewers are dedicated people who have a specific interest

in a specific field of health care. They prepare and maintain reviews voluntarily, on a regular basis and are bound by a Code of Conduct for avoiding potential conflict of interest. The code of conduct states that the performance of a Cochrane review "must be free of any real or perceived bias introduced by the receipt of any benefit in cash or kind, and hospitality, or any subsidy derived from any source that may have or be perceived to have an interest in the outcome of the review" (Cochrane News No 8, 1996: 7).South Africa has it's own Cochrane Centre (SAFRICC), situated at the MRC in the Western Cape, Jimmy Volmink is the director. CC's share responsibilities for helping to support those contributing or wishing to contribute to the collaboration. SAFRICC's responsibilities are:

maintaining a register of systematic reviews;maintain a register of people who have expressed interest in contributing to the Cochrane Collaboration;help to establish CRG's;maintain a register of all registered RCT's, thus facilitate the first face of data collection for the reviewers;

provide software to reviewers;organise awareness presentations and workshops on how to prepare protocols and systematic reviews.

The eight principles of the Cochrane Collaboration:CollaborationAvoiding duplicationBuilding on enthusiasm of individualsKeeping up-to-dateMinimising biasEnsuring relevanceEnsuring accessEnsuring qualityWhat is so special about a Cochrane Systematic review?Follows a standard format (Revman)

Rigorous peer review and quality assurance. Availability on computerised database called Cochrane database of Systematic Reviews. Available on disks, CD ROM or Internet. Updated quarterly.

Minimising bias by:Identifying all relevant studies that meet prespecified criteria. Including published and unpublished studies as well as non-English literature. Assessment of relative methodological strengths of studies included in the review.

Control of random error (the play of

chance)Most trials in medicine are small and may have insufficient power to detect a significant effect. Meta-analyses can be used to synthesize the results of similar studies to produce summary estimates of effects.Sensitivity analyses are done.

Why mainly randomised trials?The RCT is able to balance known and unknown characteristics by ensuring that the division of the subjects into two groups is done by an absolutely unbiased method independent of human choice. The best randomisation is obviously a double blind controlled trials by means of computer generated randomization from a distance source. We acknowledge this is not always possible, but should always be the aim. When RCT's are not available other trials may be used by reviewers, but this is clearly stated.How can you participate in the Cochrane Collaboration?Express your interest to SAFDRICCJoin a review groupJoin another Cochrane entityHandsearch a journalIdentify sources of fundingMain important issueDisseminate and apply the findings

of reviewsBase your clinical decisions on evidence-based medicine.Furthermore, involve other authorities such as health ministries, universities, research councils, health care givers and users of health care facilities to use the best available sources for decision making.

PROMOTING EVIDENCE-BASED PRACTICE IN DEVELOPING COUNTRIES - THE WHO REPRODUCTIVE HEALTH LIBRARY

GJ HofmeyrDepartment of Obstetrics and Gynaecology, Coronation Hospital and University of the Witwatersrand

Most health interventions have the potential both, to be of benefit and to do harm. Their use is based on balancing the potential benefits and risks. Most potential benefits are likely to be known, whereas adverse effects may be quite unexpected, and sometimes come to light purely by chance. The most reliable method available for assessing benefits and those potential risks which can be identified or predicted, is the randomised control trial. The strength of this methodology is that it minimises clinical bias. It is important to keep in mind the possibility of adverse effects which have not been predicted, and are therefore not measured as outcomes in clinical trials.The most reliable method available for assessing the results of randomised clinical trials is the systematic review. The essence of this methodology is an exhaustive, worldwide search for all published and unpublished trials of a particular

intervention, to minimise the effect of publication bias, language bias and the very poor pickup rates of electronic searches. This can be achieved only with an enormous international collaborative effort, as it involves, among other initiatives, systematic handsearching of journals throughout the world.The Cochrane Collaboration is a worldwide collaboration of scientists with the primary objective of providing up to date information to clinicians on the best evidence on which to base clinical interventions, in the form of an electronic database, the Cochrane Library. The Cochrane Collaboration is very much geared towards practice in a well-resourced environment, in terms of the studies reviewed, the orientation of most authors and the cost and computer requirements for the electronic database. There are few (if any) review group editors, other than the author, from developing countries.The objective of the WHO Reproductive Health Library (1) is to make information from the Cochrane Library available to health workers in under-resourced environments in an appropriate and affordable way. The editors and commentary authors are experts

working in, or with previous experience of working in under-resourced areas. We have selected priority subjects in reproductive health, and asked experts to write commentaries on the original Cochrane Library reviews to indicate their relevance to, and application in, an under-resourced health care setting. The database, on a single disk requiring a fairly low level PC to run it, will be distributed free of charge to about 20 000 health workers in developing countries, as well as being freely available on the Internet. The first issue is due in July 1997. The Library will be updated and expanded annually, to eventually include about 80 topics. Feedback from users will be encouraged.Anyone wishing to be included on the RHL mailing list should contact Dr Metin Gulmezoglu, RHK Coordinator, UK Cochrane Centre, Summertown Pavilion Middle Way, Oxford OX2 7LG;Fax: 0944 1865 516311;Email: mgulmezoglo@cochrane.co.uk.

HIGHER EDUCATION RESOURCE ORGANISATION (HERO)

A Kent, D WoodsDepartment of Obstetrics and Gynaecology, and Paediatrics and Child Health, University of Cape Town

The Higher Education Resource Organisation Project (HERO) aims at providing medical officers and general practitioners with an opportunity to benefit from continuing health education through the media of computers. Using the Internet, both urban and rural practitioners can obtain access to academic support in various forms without having to leave their practices or places of employment. The vision of HERO is to provide continuing medical education which has not been met by conventional methods of further education such as congresses, workshops and discussion groups.As the first step to achieve this goal, it is proposed to adapt the Maternal Care Manual of the Perinatal Education Programme so that it can be made accessible via the Internet. It is hoped that this method of education may be more acceptable to doctors than the current practice of using manuals. At previous Priorities meetings it has been repeatedly stated that a major

obstruction to improving the care of mothers and infants through the use of the Perinatal Education Programme has been the reluctance of doctors to participate in the Programme.Surveys have shown that general practitioners are enthusiastic about the use of the electronic media to obtain new knowledge as well as diagnostic and management protocols.During the coming year HERO will become a reality. With its successful implementation in South Africa, and possibly further afield, other education courses could be introduced. In addition literature surveys and a consultation service will be developed. The cost of such a service would be met by the participants. Professional organisations such as the Medical Association of South Africa are supporting the project.Further information on HERO can be obtained from Dr Athol Kent, Medical Association House, Central Square, Pinelands, 7430 or hero@ct.lia.net.

SUBAPONEUROTIC HAEMORRHAGES - A PREVENTABLE PERINATAL PROBLEM

H Saloojee, A Violari

IntroductionSubaponeurotic haemorrhage (SAH) is a potentially life-threatening emergency in neonates. It presents acutely and may be difficult to distinguish from a caput soon after birth. Bleeding occurs in the loose connective tissue of the subaponeurotic space and large amounts of blood can be extravasated causing hypovolaemic shock, anaemia and death. The cause/s of SAH remains an enigma, despite it being observed regularly in many African settings. This study investigated aetiological factors associated with the occurrence of the problem.MethodA retrospective, descriptive survey of all babies with an SAH admitted to the neonatal unit at Baragwanath Hospital from 1 January to 31 December 1995

was made. The diagnosis of a SAH, as made by the attending doctor (medical officer/registrar), was accepted. However, in most instances, a neonatologist confirmed the diagnosis. Statistical analysis was performed using the EpiInfo 6.0 statistical package.Results and DiscussionSeventy one babies with an SAH severe enough to require admission were identified. This equated to an incidence of 4.4 per 1 000 deliveries. A literature review in 1980, by Plauche, reported 123 cases of SAH with an incidence between 0.4-5.9 per 1000 deliveries.SAH predominantly occurred in term, nulliparous pregnancies with a strong male predominance (2.3:1). Risk factors for the development of SAH are shown in Table 1.

Table 1 Difference between study population and general Baragwanath populationCriterium Study (n=71)

%Bara (n=498)

%p value

Term 86 __ __Male 70 50 0.002Nulliparous 63 29 < 0.001

Vacuum 35 1 < 0.001Asphyxia 31 0.7 < 0.001Meconium stained liquor

22 25 NS

Caesarean section 33 23 NS

The role of the ventouseTwenty five babies (35%) had a vacuum extraction attempted. Of these, 11 (44%) failed and required a caesarean section. In previous studies, 49-97% of SAH have been associated with vacuum deliveries. Thus, factors other than the application of the ventouse appear to be important in our setting.The role of asphyxiaTwenty-two neonates (31%) were asphyxiated at birth using strict criteria to define asphyxia. Neonatal encephalopathy was diagnosed in 30% of the babies. Only 5 of the asphyxiated babies also had a vacuum cup applied, indicating that asphyxia and the use of the vacuum are independent risk factors for the development of SAH. Of the 24 babies who had a blood gas taken soon after birth, 25% had a pH <7.0, 58% had an HCO3 <15 and 55% a base deficit >10. Postulated mechanisms to explain the association between SAH and perinatal asphyxia include the propensity of severe asphyxia to result in both a coagulopathy and an increased fragility of blood vessels.

Bleeding diathesisSeventeen babies had a clotting profile (PI, PTT) done, a third of which were grossly abnormal. more than half the babies received fresh frozen plasma, while 11 neonates (15%) required a blood transfusion to compensate for a precipitous drop in haemoglobin.MortalityThere was a significant mortality rate (8%). Nevertheless, this is lower than that reported in the literature. This can be explained by the increased awareness and vigilance of medical practitioners locally about the diagnosis, risks and management of SAH because of the more frequent occurrence of the problem. The need for NICU care (for inotropic support or ventilation) and the size of the SAH best predicted death (Table II).Table II Risk factors for death

in babies with SAHRisk factor

Number

Died

Positive predictive value (%)

Inotrope use

6 4 67

Ventilation

9 4 44

Large SAH

8 3 38

Asphyxia 21 5 24

Vacuum 25 4 16ConclusionThe use of the Ventouse device and perinatal asphyxia were identified as significant risk factors for the development of SAH. The rate of encephalopathy and death were alarmingly high. We believe that the prevention of SAH lies in the early recognition and management of problematic partum events and the selective and careful use of the Ventouse device.

INTRAPARTUM FETAL DEATHS AT BARAGWANATH - HOW PREVENTABLE?

EJ Buchmann, V NaranDepartment of Obstetrics and Gynaecology, Chris Hani Baragwanath Hospital, Soweto and University of Witwatersrand, Johannesburg

The still birth of a term fetus always raises queries about the standard of obstetric care in the unit concerned. Among stillbirths of babies weighing 2,5kg or more at Baragwanath Hospital in 1996, the most frequent cause was labour-related asphyxia. We have observed that many of these deaths resulted from a shortage of facilities rather than from medical negligence or omission. This audit was undertaken to investigate the causes of labour-related stillbirths of babies near term and to note any avoidable factors, whether patient, administration or medical staff related.MethodsWe undertook the review of all fresh stillbirths in 1996, of birthweight 2.5kg and more, delivered at Baragwanath

Hospital, where the cause of death had been noted in the Perinatal Problems Identification Programme as 'labour related asphyxia'. Maternal case notes were examined in detail. Descriptive statistics and qualitative analysis were undertaken.ResultsThere were 24 deaths that satisfied the above criteria, eleven resulting from first stage labour asphyxia and four from second stage asphyxia. Six deaths followed uterine rupture and three were caused by cord prolapse. Table I shows patient-related avoidable factors. Table II shows the influence of failure of fetal monitoring. Table III lists mother where Caesarean section (CS) had been booked and death resulted from the absence of facilities at the time. The time elapsed between decision to do CS and delivery is shown. Other avoidable factors are shown in Table IV.

Table I Patient came too lateAge Para Problem Mode Comment

16 0 Breech VD Half born in ambulance

23 1 Cord Prolapse CS Transverse lie already dead

19 0 Cord Prolapse NVD Baby already dead

Age Para Problem Mode Comment

22 3 Labour asphyxia NVD Unbooked, baby already dead

23 1 Cord Prolapse NVD Baby already dead

Table II Patient not monitoredAge Para Problem Mode Comment

37 1 1st stage asphyxia NVD Last child 1978, 14 ANC visits

29 0 1st stage asphyxia NVD Clinic referral, meconium

34 4 1st stage asphyxia CS Busy day, no CTG

31 3 Ruptured uterus Lap 3 Prev CS with pain

Table III No theatre facilities (n=9)Age Para Reason for CS Time to

CS (min)Mode Comment

21 0 360 CS Patient forgotten in CS queue

23 0 CPD 450 CS Power failure

23 0 260 NVD Postdates, meconium

28 2 FD Prev CS 120 Lap Ruptured uterus

31 1 CPD 150 Lap Ruptured uterus

29 2 CPD 240 Lap Ruptured uterus

34 3 CPD 160 NVD

22 3 2 Prev CS 195 Lap Ruptured uterus

27 1 FD 110 CS Staff reluctant at change-over

Table VI Other avoidable factorsAge Para Problem Mode Comment

20 0 2nd stage asphyxia CS Failed vacuum CPD

35 3 2nd stage asphyxia CS Failed vacuum CPD

28 0 2nd stage asphyxia NVD Fetal bradycardia ignored

28 2 1st stage asphyxia V/E Partogram misinterpreted

34 4 1st stage asphyxia V/E Referral partogram ignored

33 5 1st stage asphyxia NVD Fetal distress missed on CTG

ConclusionMost deaths were caused by patient (arrived too late) factors and administrative impediments (no Caesarean section facilities). The latter is a disturbing problem, as there is little hope for improvement in the near future. On average, twelve Caesarean sections are performed daily at our hospital. Two theatres should be available around the clock to prevent formation of operating list queues; although two theatres exist in our labour ward, there is only sufficient staff to activate one at a time. Planned staff and budget cuts do not allow for any expansion of our services. Clinicians on labour ward duty are faced with difficult decisions when several Caesarean sections need to be done simultaneously. Judicious cuts in Caesarean section rates are necessary, with prioritisation of mothers in Caesarean section queues. The efficiency of the theatre procedures can also be improved. The provincial government has been informed of this desperate situation.

VAGINAL MISOPROSTOL FOR INDUCTION OF LABOUR

S BergströmDivision of International Health Care Research (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden

IntroductionThe number of appropriate obstetric drugs available to stimulate uterine action is quite limited. This is particularly true in low-income countries, where current budgetary constraints limit the availability of uterotonic drugs. The problems related to such drugs concern not only drug costs but also adverse climatic conditions and poor storage conditions. Variable quality of low cost preparations of uterotonic drugs, like oxytocin and ergot alkaloids may make the situation still more problematic.It has rightly been said that"oxytocin is the most dangerous drug in obstetrics", a fact related to the adverse outcomes for the mother (risk of uterine rupture) and for the foetus (risk of intrauterine asphyxia) in case of overdosage. In low-income countries overburdened delivery wards with infusions running without adequate control by midwives with poor motivation due to extremely low salaries, add to the problem of oxytocin use.

In Maputo, around 1990, our interest was attracted by a prostaglandin E1

analogue used for the treatment of peptic ulcer, misoprostol (trade name Cytotec®). It was first given attention as a potential abortifacient, since we found that, after vaginal application, it quite remarkably softened the cervix (1,2). We found that abortion could be induced in around 90% of cases so treated and the currently prevailing routine in Maputo is now to medicate all abortion seeking women with vaginal misoprostol and sublingual methylergometrine tablets (3).Misoprostol has been considered safe in the management of peptic ulcer disease for more than a decade (4). The drug undergoes metabolism quickly after its absorption, several metabolites are formed and no non-metabolised drug can be detected in the urine. The presumably active metabolite in plasma is misoprostol acid, which is formed very soon after medication. Studies on oral use of medication shows that misoprostol acid can be detected in the circulation within two minutes and it has also been shown that the peak plasma level in the circulation is achieved within 15 minutes. In the literature a few adverse side effects have been registered as with other

prostaglandin agents, misoprostol does not seem to have any

hypertensive effects. It may be slightly hypotensive.

The uterotonic effects of misoprostol increase gradually after administration to reach a peak at 30 minutes after medication and the intrauterine pressure decreases gradually after that. The initiation of uterine activity may occur as early as 10 minutes after administration.

Induction of labour with misoprostol in women at high riskIn Maputo vaginal misoprostol for induction of labour has been gradually introduced, and is now a routine, which has substituted oxytocin by and large. We have focused our interest on the following categories of high risk obstetric patients for induction of labour.1. Late foetal death2. Grand multiparity3. Previous Caesarean section4. Prelabour rupture of

membranes5. PreeclampsiaOur pilot experiences of labour induction in women with late foetal death made us perform a comparative study of misoprostol and oxytocin in 156 women receiving 800g misoprostol vaginally or oxytocin infusion according to an

established routine, respectively. A dose of 100g or less was required by 81% of misoprostol-treated women and all women were successfully induced at a maximum dosage of 800g. No uterine ruptures or other severe maternal morbidity occurred in either group. The tangible advantage of misoprostol over oxytocin was noted above all in the ease of administration and the cost. The oxytocin routine is a least 20 times more expensive than the misoprostol regime (8,9).In grand multiparous women we have used misoprostol in a study comprising 134 women in need of induction of labour with a parity ranging from 5 to 10. there was not a single uterine rupture and no severe maternal morbidity occurred.In women with previous Caesarean section we have carried out a pilot study comprising 57 such women compared with 57 women left to undergo spontaneous trial of scar. These groups are not strictly comparable but the results indicate that there is a small and clinically fairly insignificant risk of scar rupture, which, under prevailing circumstances, is less than or similar

to the corresponding risk when oxytocin infusion is used. Fifty percent of otherwise normally performed repeat Caesarean sections could be prevented by the use of misoprostol. The dosage used here was a quarter of a 200g tablet, which obviously does not imply a very careful exact dosage, and was sufficient but may be too high a dose to be optimal. A careful dose-finding study of this group of patients is underway.In women with prelabour rupture of membranes we found that there is no increased risk of uterine hyperstimulation after vaginal misoprostol (50g) in these cases as compared with cases with intact membranes. This category of women often in need of induction of labour can be managed with this medication without any increased risk in comparison with oxytocin.In women requiring induction because of preeclampsia 50g misoprostol vaginally was used, in an attempt to see whether or not this high risk patient category could benefit from misoprostol treatment. We found no increased foetal risk or maternal risk compared with routine oxytocin stimulation. In this high risk category of patients the optimum dosage with a tablet

preparation (better than a quarter of a 200g tablet) awaits evaluation.

ConclusionsThe pharmaceutical producer of misoprostol (Searle Ltd) has hitherto not shown any interest in supporting our research and the non-availability of drug preparations below the 100g tablet is a major current drawback to further research. Vaginal or per oral preparations of misoprostol - in doses lower than those available today - for various obstetric and gynaecological indications should quickly be made available, since misoprostol is a most promising and appropriate drug with significant benefit at a low cost.

MISOPROSTOL FOR THIRD STAGE OF LABOUR MANAGEMENT: A DOUBLE BLIND, PLACEBO CONTROLLED CLINICAL TRIAL

GJ Hofmeyr, M de Jager, L Rose, VC Nikodem, T Lawrie

IntroductionAccording to the World Health Organisation 500 000 maternal deaths occur annually and 99% occur in developing countries. Postpartum complications are a major cause of maternal mortality, even in developed countries. Prophylactic oxytocic administration in the form of oxytocin and/or ergometrine is widely practised in the prevention of postpartum haemorrhage (PPH). A 40% reduction in PPH has been associated with this routine use of oxytocic administration. The use of these agents in areas with limited access to medical facilities is problematic: Oxytocin needs refrigerated storage and skilled personnel, syringes and needle for administration and ergometrine may be dangerous in women with undiagnosed hypertension or cardiac disease.Misoprostol is a prostaglandin analogue which is remarkably inexpensive, stable for storage, rapidly absorbed orally and has been

shown to be an effective myometrial stimulant. Most research has concentrated on the effectiveness in inducing uterine contractions at various stages of pregnancy.ObjectiveTo test the hypothesis that misoprostol administration orally reduces blood loss after delivery.

MethodDouble-blind randomised control methodology was used. Women in labour at Coronation Hospital were asked to participate in the study if they met the inclusion criteria: Age > 18yrs, no major obstetric complication, written informed consent, no oxytocin IV therapy for induction or augmentation at the time of the delivery. Baseline observations were recorded, name, hospital number, parity.At the time of the delivery a timer was started. Absence of bleeding from an episiotomy or large perineal tear was confirmed. The next randomised opaque container with two misoprostol or placebo tablet was opened and the tablets given to the patient within one minute of birth. The first 70 patients were asked to chew the tablets, and from number 71 the patients were asked to swallow the tablets with a little bit

of water. One minute after birth, and once liquor stopped draining, all the wet towels were removed and a flat bedpan and linen saver were placed under the patient. Spontaneous delivery of the placenta was awaited. If blood loss exceeded 500ml, syntocinon or syntometrine were given and active management commenced. If the placenta was retained after 30 minutes, uterine contraction was checked, if poorly contracted, an oxytocic was given and active management instituted. All blood and clots were scooped into a measuring cyclinder, linen saver was weighed and the weight noted in grams. The method of delivery of the placenta, time after birth

and the completeness of the placenta and membranes were noted. If an oxytoxic was given, the dose, time and type was noted. One hour after the birth, additional linen savers and sanitary towels were weighed and noted. Side effects e.g. nausea, diarrhoea and any other complications and additional comments were noted. The perineal outcome and the weight of the baby were recorded.

ResultsBaseline Data

Misoprostoln 98

PlaceboN 98

Mean SD Mean SD pAge 26.1 6.2 26.4 5.6 0.73Weight 3054g 424.1 3046g 560.0 0.82Parity 1.3 1.4 1.5 1.2 0.61

Perineal TraumaMisoprostol Placebo

None/Minor 67 71Major 27 23

Blood loss

Patients 1-70Mean

Misoprostol: 602mls

Placebo 573mls

Patients 71-188 (Oral use)Misoprostol

Placebo RR 95%CI p

n 59 59Mean: Blood loss (SD)

377(248.3)

514(408.6)

0.18

Blood loss >1000ml

2(3.4%)

8(13.6%)

0.25 0.06-1.13 0.098

Oxytocic needed

3(5.1%)

11(18.6%)

0.27 0.08-0.93 0.046

Side effectsMisoprostol

Placebo RR 95%C p

Shivering 11(18.6%)

1(1.7%)

11.0 1.47-82.5 0.006

Other (Abd pain, dizzy)

2(3.4%)

7(11.9%)

0.29 0.06-1.32 0.16

None of the patients received a transfusion.

DiscussionThis is an interim report of a study which is still in the early stages with small numbers so far recruited. The absorption of misoprostol across the buccal mucosa is not as rapid as we anticipated and as shown by the results should rather be administered orally. Then there is also the possibility of other routes for example rectally that we are looking at.

THE USE OF DEXATHASONE IN WOMEN WITH PRETERM PREMATURE RUPTURE OF MEMBRANES : A MULTICENTRE, PLACEBO CONTROLLED RANDOMISED CONTROLLED TRIAL

The DEXIPROM Study Group

Objective: To assess the effect of dexamethasone in women with preterm premature rupture of membranes (PPROM) on the prevalence of maternal sepsis, neonatal respiratory distress syndrome (RDS), perinatal mortality and neonatal sepsis.

Method : A double blind, randomised controlled trial was performed on women with PPROM and fetuses 28-34 weeks gestation or clinically estimated between 1000 - 2000g if the gestational age was unknown. Women entered into the trial received dexamethasone 24mg IMI, or placebo in divided doses 24 hours apart. All women received ampicillin and metronidazole and hexaprenaline if contractions were present in the first 24 hours, and were managed expectantly.

Outcome measures : The maternal outcome measures were clinical chorioamnionitis and postpartum sepsis. For the baby, perinatal death, respiratory distress syndrome, mechanical ventilation, necrotising enterocolitis, and neonatal infection within 72 hours were the outcome measures.

Results : Ninety-five women who delivered 98 babies were randomised to the dexamethsone group and 94 women who delivered 94 babies to the placebo group. The groups were well balanced. (See Table 1). There was a non significant trend for more women in the dexamethasone group to deliver in the first 24 hours.A comparison of the outcomes between the two groups is shown in Table 2. It has been well established that the major effect of corticosteroids occurs after 24 hours. For this reason a sub-analysis was performed comparing the outcome of mothers and infants who delivered more than 24 hours after admission to the study.

Table 1 Demographic data of the Dexamethasone and Placebo Groups

Dexamethasone Placebo

Number:

Dexamethasone PlaceboMothersBabies

9598 (3 twins)

9494

Hospitals (mothers):KalafongPretoria AcademicTygerbergSomersetGroote SchuurPelanomi

317

27127

14

257

26168

12

AgeParityGravidity

27 + 62 + 23 + 2

28 + 61 + 23 + 2

On admission to trial

Gestational age 31,1 + 2,25 30,4 + 2,12

Estimated weight 1577 + 341 1559 + 350

Contractions present 16 (17%) 12 (13%)

Cervical dilation:0123?

481677

20

501683

17

Table 2 Comparison between outcomes of mothers and infants in the Dexamethasone and Placebo Groups

Dexamethasone Placebo OR (95% CI)

Clinical chorioamnionitis

10 (11%) 9 (10%) 1,1 (0,39-3,16)

Endometritis 3 (3%) 7 (7%) 0,4 (0,07-1,81)

Perinatal deaths 4 (4%) 10 (11%) 0,36 (0,01-1,30)

Respiratory distress 28 (29%) 22 (23%) 1,31 (0,65-2,6)

Mechanical ventilation

13 (13%) 15 (16%) 0,79 (0,32-1,88)

NEC 6 (6%) 8 (9%) 0,7 (0,21-2,34)

Neonatal infection <72hrs

9 (9%) 10 (11%) 0,86 (0,3-2,34)

Subanalysis:Delivery > 24 hours n=69 n=78

Clinical chorioamnionitis

9 (13%) 8 (10%) 1,3 (0,43-4,02)

Dexamethasone Placebo OR (95% CI)Endometritis 3 (4%) 5 (6%) 0,66 (0,01-3,36)

Perinatal deaths 1 (1,4%) 7 (9%) p=0,044

Respiratory distress 17 (24%) 21 (27%) 0,87 (0,39-1,94)

Mechanical ventilation

7 (10%) 13 (17%) 0,55 (0,18-1,6)

NEC 4 (6%) 8 (10%) 0,53 (0,13-2,07)

Neonatal infection <72hrs

6 (9%) 8 (10%) 0,84 (0,24-2,88)

No women developed severe sepsis or required a hysterectomy. This does not exclude the possibility of such an adverse event occurring, however, further statistical analysis reveals that the greatest likelihood (95% confidence interval) of a hysterectomy having to be performed for a woman having dexamethasone in the presence of PPROM is 3/100, for this study, and for the 8/1000 for the literature.

Conclusion : The trend towards improved perinatal outcome without any adverse events for the women. When combined by meta-analysis with previous trials, (See Table 3), corticosteroids were associated with a significant decrease in perinatal mortality and RDS without any significant adverse effect to the mother or baby.

Table 3 Summary analyses of the use of corticosteroids in PPROMDexamethasone Placebo OR (95% CI)

Maternal ComplicationsChorioamnionitisEndometritis

46/38336/235

54/37624/231

0,81 (0,51-1,30)1,57 (0,86-2,87)

Perinatal ComplicationsRespiratory DistressNeonatal InfectionNecrotising EnterocolitisPerinatal Death

145/69439/4388/306

22/446

201/65135/41816/29638/433

0,57 (0,44-0,74)1,05 (0,37-3,02)0,46 (0,17-1,21)0,53 (0,30-0,95)

The DEXIPROM Study Group: Project leader RC Pattinson, Statistician JD Makin, Pretoria University M Funk, SD Delport, P MacDonald; Stellenbosch University, K Norman, G Kirsten; Cape Town University C Stewart, D Woods, E Coetzee, P Smith, J Anthony; Free State University M Schoon.

FETAL GROWTH AND LOW BIRTH WEIGHT IN MOZAMBICAN PREGNANT WOMEN. A prospective cohort study

NB Osman, K Challis, M Cotiro - Dept Obstetrics and Gynaecology, Central Hospital, MaputoS Bergström, Dept Obstetrics and Gynaecology, Akademiska Hospital, Uppsala

IntroductionIn most developing countries, LBW (low birth weight) deliveries constitute a major contributor to perinatal deaths, so research focusing upon the aetiology of LBW is a research priority.Information on gestational age is seldom accurate in developing countries and hence, an adequate assessment of birthweight related to gestational age is difficult to carry out.The fetal growth monitoring by symphysis-fundus (SF) measurements have been documented to predict SGA (small for gestational age) remarkably well. Their usefulness is hampered by the non existence of local SF graphs in most developing countries.

Objectives1. To identify in a group of 800

pregnant women, those who give birth to newborns being small for gestational age

(SGA); adequate for gestational age (AGA); large for gestational age (LGA) and monitor the perinatal mortality and morbidity in each group.

2. To establish the first symphysis-fundus growth chart in Maputo.

3. To assess the women's own estimation of her gestational age.

4. To outline potential operational measures in order to reduce the incidence of LBW.

HypothesesThe following hypotheses will be subject to confirmation or rejection:1. SGA and LGA newborns, run a

higher risk of perinatal death than AGA.

2. In a LBW group, SGA proportion is higher in Mozambique than in Sweden.

3. One explanation for SGA, is recent infections.

Study DesignProspective cohort study of 800 pregnant women from 2 suburban antenatal clinic in Maputo.

MethodologyAt the first visit, ultrasound

examination of biparietal diameter was performed as well as a

complementary questionnaire regarding socio-economic factors.

The subsequent visits were every 2-3 weeks and careful measurements of SF distance were carried out as well as all parameters of antenatal care.During the delivery time, a blood sample was taken for malaria, haemoglobin and serological test.The newborns were controlled until 7 days postpartum.

Some Preliminary ResultsNine hundred and twelve women entered in the study.The drop-out rate was 10% concerning birth weight. Regarding laboratory results the missing cases were higher due to logistical problems.The mean age was 23, and para - 0 was 41.6%, para 1-3 was 40,6% and para 4> was 17.8%.

Thirteen percent never went to school and 79% were household workers. Gestational Age: Preterm - 21%; term - 76%; Post term 3%. The mean gestational age at first antenatal control was 16 weeks by LMP and was 16w + 5d by ultrasound estimation. The mean birth weight was 2909grams. The LBW rates was 14% and the stillbirth rate was 5%. One case of maternal death has been registered. The caesarean section rate was 7% and vacuum extraction rates was 0.5%. The mean haemoglobin value was 10.8 g/l. The prevalence of malaria was 5% and 10% had positive VDRL or RPR.

GROWTH AND DEVELOPMENT OF VERY LOW BIRTHWEIGHT INFANTS TO AGE FIVE YEARS

PA CooperDepartment of Paediatrics, University of the Witwatersrand

Long term outcome of very low

birthweight infants in developed countries has been well studied, but few data are available from developing countries and, in particular, from African communities.A follow-up study was thus commenced in 1990 to document the long term outcome of very low birthweight infants discharged from Baragwanath Hospital. The success of this study rested largely on the efforts of Mrs ZM Sefuba who was responsible for ensuring follow-up.A stratified sample of infants <1500g at birth surviving to hospital discharge were enrolled, and consisted of three groups:Group 1 : consisted of 49 infants 1000-1499g at birth who required mechanical ventilation;Group 2 : consisted of 39 infants 1000- 1499g at birth who did not require ventilation;Group 3 : consisted of 25 infants <1000g at birth.Follow-up during the first year of life was previously described at the Priorities in Perinatal Care

Conference in 1993, and is summarised in Table 1.Of those with handicap one infant from group 3 was blind as a result of retinopathy of prematurity while the other nine infants had some form of cerebral palsy. Cerebral palsy and poor developmental scores as measured by the Bayley scales of infant development were associated with the finding of periventricular leukomalacia as diagnosed by cranial sonar during the later neonatal period. Higher maternal education and improved intrauterine growth on the other hand were associated with better Bayley scores.

Follow-up to age five yearsPolitical unrest and the geographical mobility of the families made subsequent follow-up extremely difficult and only 58% of surviving infants could be followed to the age of five years as shown in Table 2.

Growth to Age 5

The majority of group 3 infants were growth retarded at birth and were smaller in the early months of life, but no significant intergroup differences were noted after 6 months of age. The mean weight and length/height percentiles are

shown in Table 3 where it can be seen that, while the mean weight-for-age percentile has steadily declined up to the age of 5 years, the mean length/height percentile has increased after the age of 1 year. The reason for these trends is

not clear, but undernutrition during infancy did not seem to be a limiting factor in that weight percentiles exceeded length/height percentiles until the age of 3 years.Neurological Follow-upOf the nine cases of cerebral palsy diagnosed at one year, one infant subsequently died, while of the remainder, three were assessed as having mild handicap at the age of 5 years and five had a major handicap. Two infants thought to be normal at one year were subsequently diagnosed as having mild cerebral palsy but neither had significant handicap (1 minimally impaired and 1 with mild disability).

Conclusions1. Long term follow-up in an

urban black community is difficult, with a significant drop-out rate over time.

2. Growth in head circumference in the early weeks/months after birth is the best predictor of later growth in childhood.

3. Catch-up in length/height appears to be occurring in this cohort, but they remain underweight as a group.

4. Neurological examination at 1 year of age appears to be a very good predictor of later handicap.

Table 1 Outcome at 1 yearGroup 1 Group 2 Group 3

Number enrolled 49 39 25Died after discharge 7 5 3Lost to follow-up 6 4 2Followed to one year 36 30 20Normal examination 27 34 18Suspect 1 1 0Handicapped 8* 0 2p=0.005 compared with Group 2*

Table 2 Follow-up to Age 5Group 1 Group 2 Group 3 All*

Enrolled 49 39 25 100%1 year 36 30 20 88%3 years 27 26 11 66%5 years 20 23 13 58%* Expressed as a % to those known to be alive (15 deaths in the first year and 1 subsequently)

Table 3 Mean Weight and Length/Height for Age PercentilesAge Weight for age Length/Height for age

(mean percentile) (mean percentile)3 months 33.3 15.31 year 19.2 14.43 years 17.8 18.85 years 13.5 24.3

MINIMAL ENTERAL FEEDING : AN IMPORTANT ROLE FOR MILK IN THE GUT

SJ NewellNeonatal Medicine & Gastroenterology, St James's University Hospital, Leeds, UK

In the preterm infant, dramatic improvement in neonatal mortality has turned attention upon avoidance of morbidity highlighting the importance and urgency of nutritional care. Growth is rapid and the consequences of malnutrition are severe. Intrauterine growth rates may be achieved only if high demands for calories, protein, minerals and vitamins are met. Failure to do so is associated with poor growth, anaemia, metabolic bone disease, short stature and adverse effects upon subsequent neurodevelopmental outcome and intelligence.The fetus begins swallowing liquor around 16 weeks gestation but mature gastrointestinal motility is not achieved until around 34 weeks gestation. The preterm infant has diminished digestive capacity and frequently presents with the consequence of immature motility, the clinical picture of poor milk tolerance. The majority of pre-term infants however can be successfully fed, preferably expressed breast milk

from their mother. This paper concerns infants in whom enteral nutrition cannot be achieved or in whom it is contraindicated. In these infants parental nutrition (PN) is often necessary. The single commonest indication for PN is prematurity and low birth weight. In the infant who is receiving PN, is it worthwhile giving any milk?Minimal enteral feeding (MEF), also known as trophic feeding and gut priming, is the provision of small, nutritionally inconsequential amounts of milk given while nutrition is provided parenterally. A survey of feeding practice in the UK revealed increased use of enteral feeds during ventilation, reflecting use of MEF. Randomised controlled trials of MEF have reported improved maturation of gastrointestinal motility, more ordered patterns of gastro-duodenal motility and, in the small intestine, a more mature pattern of migrating motor activity. MEF results in lower gastric residual volumes, more rapid tolerance of enteral feeds, improved growth, a lesser need for phototherapy, reduced metabolic bone disease and earlier full nipple feeding from breast or bottle. Putative mechanisms underlying these observations include trophic factors in the milk, the presence of

nutrients in the gut lumen providing mucosal nutrition, and the surges of

gut hormones that follow feeds.

We have recently conducted the largest prospective randomised study to date of MEF in the sick preterm infant. Consecutive available infants whose parents gave consent were recruited on the NICU at St James's University Hospital. Infants were birth weight <1750g, in need of ventilation for a period of over 48 hours, in whom there was no evidence of congenital or acquired gastrointestinal disease.During intensive care, all infants received PN while half were randomised to receive MEF. MEF comprised expressed breast

milk or low birth weight formula as intragastric bolus feeds at 0,5 or 1.0 mls per hour depending on birth weight below or above 1kg. At the end of the period of intensive care, nutritive enteral feeds were introduced according to the unit protocol and parenteral nutrition reduced accordingly.

Table 1

Subjectsmedian and interquartile range

MEF Control

Number 48 52

Gestation 28 (27-30) 28 (26-30)

Birth Weight (kg) 1.1 (0.9-1.4) 0.94 (0.8-1.3)

CRIB score 4 (3-6.5) 5 (3-8)

Lactase activity was measured in fluid aspirated from the proximal bowel. Stool chymotrypsin was measured. Gut transit was determined by using a non absorbable dye. Gastric emptying used an ultrasound technique. Sepsis was defined by clinical features confirmed by positive

cultures in blood, urine or CSF.The study confirmed clinical advantage in improved gastrointestinal motility and tolerance of feeds with more rapid gut transit (Table 2). It showed induction of

lactase activity, which has previously been denied in humans. Gastric emptying at 4ml/kg/feed showed no difference. MEF reduced days on PN and length of hospital stay. This was not explained by differences between the study groups. The role

of gut bacteria in sepsis is well established in intensive care. MEF may reduce bacterial translocation. Data concerning gut colonisation is being analysed. There were no major complications or adverse effects attributable to MEF.

Table 2 ResultsVariable Minimal

enteral feedingEnteral starvation p

small intestinal lactase : sucrase activity ratio*

2.9 1.1 <0.05

chymotrypsin no effect ns

whole gut transit time* 49 min 96 min <0.05

half gastric emptying time* 40 min 38 min ns

days of PN 20 days 25 days <0.05

days to full enteral feeds (165ml/kg/day)

23 days 30 days

days in hospital 68 days 78 days <0.05

total number of episodes of proven sepsis

24 63 <0.05

NEC 1 2 ns

death 6 10 ns

* median, at end of the study period prior to the introduction of nutritive milk feeds.

If an infant is not given enteral feeds, parenteral nutrition is given. We conclude that, in this group, if there is not contraindication, MEF should be given.

IS EARLY DISCHARGE OF PREMATURE BABIES SAFE?

M Mokhachane, H Khuzwayo, H SaloojeeDepartment of Paediatrics, Baragwanath Hospital and University of the Witwatersrand

IntroductionAt the neonatal unit at Baragwanath

Hospital, 22% of all admissions weigh below 1500g.Premature babies awaiting weight gain stay in hospital for 4-6 weeks.This group of babies are responsible for a large part of both the workload and the expenditure of any neonatal unit.

Earlier discharge may have important advantages for parents and the health service.

Aims* To establish if it is safe to

discharge premature babies at a weight of 1650g.

* To monitor their outcome for three months after discharge.

Outcomes* Growth* Mortality* Morbidity

Methods* Randomised controlled trial.* Enrolment over a 10 month

period.* Premature babies randomised

on admission to low care ward into one of two groups: Group 1 (cases) - discharge at weight > 1650g; Group 2 (controls) - discharge at weight > 1800g (usual hospital discharge weight).

* Examined at one and three months after discharge.

* Monitored: - weight gain- hospital admissions- outpatient visits

ResultsSample demographicsMother* Booking - 73% had antenatal

visits* Housing - 22% lived in shacks* Education - 70% attended high

school* Marital status - 81% single* 18% would have liked to stay

longer in hospitalBaby* Ventilation - 21% ventilated* Feeding at 3 months - 8%

solely breastfed; 8% formula fed; 69% both.

Table 1 Demographics on EntryCases (n=62)Mean (+ sd)

Controls (n=58)Mean (+ sd) p-value

Birthweight (grams)

1333(+ 200)

1324(+ 229) 0.82

Gestational age (weeks)

31.2(+ 1.7)

31.2(+ 2.2) 0.92

Maternal age(years)

26.8(+ 7.0)

26.4(+ 5.9) 0.75

Parity (no) 1.52(+ 1.5)

0.95(+ 0.9) 0.01

Family Income(US dollars)

R17812$4453

R15413$3853 0.61

Table 2 Discharge DataCases (n=62)Mean (+ sd)

Controls (n=58)Mean (+ sd) p-value

Weight (grams) 1704+ 72)

1846(+ 67) <0.001

Gestational age (weeks)

35.9(+1.7)

36.8(+ 2.5) 0.06

Duration of stay (days)

33.9(+ 12.8)

38.8(+ 16.8) 0.08

Pre-discharge weight gain (grams/day)

10.5(+ 4.3)

14.2(+ 6.5) <0.001

Table 3 Morbidity and MortalityCases (n=62)Mean (+ sd)

Controls (n=58)Mean (+ sd) p-value

Outpatient visits (no)

0.53(+ 0.83)

0.40(+ 0.57) 0.36

Hospital admissions (no)

0.16(+ 0.45)

0.08(+ 0.27) 0.29

Deaths (no) 1 3 0.27

* Morbidity - gastroenteritis; bronchopneumonia; HIV related; Repair of hernias.

Conclusion* Discharge at 1650g is as safe

at 1800g.

* Weight gain similar at three months.

* Morbidity is the same in the two groups.

* Advantages not only to health service but also to family.

Recommendations* Discharge babies home at

1650g (1700g) if home circumstances appropriate.

* Transfer to a community clinic or district hospital for easier access by family.

MATERNAL NUTRITION AND LOW BIRTH WEIGHT

K Kyriazis, RC Pattinson, B Demyttinare, J Makin, O Ransome, J v/d Vyver, A Grobler, H Vermaak, L Delport: Kalafong Hospital

At Kalafong Hospital 77% of all perinatal deaths come from low birth weight (LBW) babies which comprise 12% of all deliveries.Does maternal nutrition play a role in low birth weight? Should mothers' diets be supplemented?

HypothesisThe delivery of LBW babies from medically normal black urban women is commonly associated with under nutrition.

Study Design and Methods- Case-control study- Cases, 53, (1000-2499g)

Controls, 56, (> 2 500g)- On all patients -

Anthropometric measurements; 24 hour diet recall; biochemical analysis of

maternal blood.

Results* Demographic data showed no

difference between the 2 groups regarding age, parity, gravidity, education and occupation.

* Anthropometric measurements post partumLBW CONTROLS P-VALUE

Mass (kg) 62 (47-94,2) 71 (50-130) 0,001

Length (m) 24 (15-42) 26 (16-40) 0,08

BMIUnderweight 2% 2% 0,00039

Healthy 74% 35% CR 5,38

Overweight 24% 63% CL 1,98 - 14

Dietary History - amounts/24 hoursNo differences in quantity of food eaten.

* Dietary History - data presented as < 80% of RDALBW CONTROLS P-value

Total fat 19% 49% 0,008

Carbohydrates 58% 31% 0,023

Calcium 29% 55% 0,02

* Biochemical parameters of maternal blood.No difference found.

Mother of LBW Babies1. Were not underweight.2. Took in significantly more fat

and calcium but less carbohydrates than the control group.

3. Are not early identifiable using clinical methods such as anthropometric measurements or dietary history.

ConclusionMaternal undernutrition is not commonly associated with LBW babies in our population and supplementation does not appear to make any sense.

CAN DOPPLER FLOW STUDIES EXPLAIN THE PRESENCE OF OLIGOHYDRAMNIOS IN POST TERM PREGNANCIES

L Geerts, S Morris, D Grove Ultrasound Unit, Department of Obstetrics and Gynaecology,

University of Stellenbosch

ObjectiveOur purpose was to determine whether patients with clinically suspected postterm pregnancies and oligohydramnios differ in their fetal and umbilical blood flow distributions from those with normal amniotic fluid volumes.

Study DesignThe study was a prospective analytical study on pregnant patients in the urban area served by Tygerberg Hospital. Between February and September 1996 all patients with a clinically estimated gestational age of 42 or more weeks on clinical grounds were recruited for this study. The patients were managed according to a standard protocol. All patients with a medical contra-indication for the continuation of pregnancy were excluded from the study. Pulsed-wave Doppler imaging was used prospectively to determine the resistance index (RI) and the pulsatility index (PI) in the fetal middle cerebral (MCA) and umbilical arteries (UA) in 166 consecutive patients. The amniotic fluid index (AFI) and deepest amniotic fluid pool were measured by ultrasonography to evaluate fetal

wellbeing. The patients were managed conservatively with weekly re-evaluation if the CTG was reactive or non-reactive with good beat-to-beat variability or a negative stress test and if the largest pool diameter of amniotic fluid was larger than 3cm on ultrasound. If the test results were abnormal, termination of pregnancy took place. The results of the Doppler flow studies on the UA and MCA were kept blind, because Doppler is not part of our present management protocol. On ultrasound examination 3 perpendicular diameters of the largest pool of amniotic fluid were measured. The AFI was determined by the four-quadrant method.The PI and RI were measured on the UA and MCA on 3 consecutive cardiac cycles by means of pulsed waved Doppler on gray scale imaging. Poor perinatal outcome was defined as:* Fetal distress* 5 Minutes APGAR scores of <7* Active resuscitation* Admission to the neonatal ICU* Meconium aspiration syndrome* Major morbidity* Long term sequelae

Results

A total of 164 patients were recruited for the study with a mean age of 25,06 years, a median gravidity of 2,2 and parity of 1. The average clinical gestational age at delivery was 43,1 weeks and the babies weighed an average of 3324,4g.Table 1 Pregnancy Outcome

N %

InductionCaesarean sectionsSGAComplicationsMajor - fetal distress

- shoulder impaction- meconium aspiration- convulsions- apnea- congenital abnormality

56211113221111

34,112,76,77,9

Table 2 Outcome according to amniotic fluid volumeAFI<5cm AFI >5cm Significance

NGA at delivery (w)Birth weightInductionFor oligohydramnios

- dates- maternal- poor CTG- other

NVDVacuum deliveryForceps deliveryCaesarean sectionIntrapartum fetal distressSGAComplicationsMajorDays in hospital

4142,8 (42-44)

3157,8 +465,535330101

331070

520

5,0 (1-9)

12343,2 (42-48)

3369,8 + 516,92184522

9883

142

6115

2,3 (1-5)

p=0,02p=0,001

p>0,05

p>0,05

p>0,05p>0,05

When comparing the RI of the UA and MCA between the group with

oligohydramnios and the group with normal amniotic fluid volume, no

significant difference was found. The same was true when comparing the PI values. When looking at the ratio of UA/ MCA in both groups, no

difference was found, not for the RI or the PI values.

ConclusionWe could not demonstrate a correlation between oligohydramnios and redistribution of blood flow in pregnancies clinically suspected to be postterm. Of note is the higher incidence of smaller babies in the group with oligohydramnios. The findings of this study do not support the hypothesis of fetal blood redistribution with decreased urine production as the etiology of oligohydramnios. Other physiological processes may be responsible, such as simple correlation with fetal size or maturation of the renal tubuli with increased reabsorption. With the present management protocol we have a good perinatal outcome with very few complications occurring and most were unrelated to postmaturity. There were no mortalities.

THE VALUE OF ROUTINE HEART AND LUNG AUSCULTATION IN ANTENATAL CARE

E Divanovic, E Buchmann

IntroductionIt is widely accepted that routine heart and lung auscultation (HLA), as a part of complete physical examination, should be performed at the first antenatal visit because it might detect occult heart disease or pulmonary conditions. Textbooks and clinical management guidelines disagree on the necessity for routine HLA. The Perinatal Education Programme does not include HLA as an essential part of the routine antenatal physical examination. The policy at Baragwanath Hospital and attached clinics is that HLA should be performed and special courses to train midwives in HLA are provided. No studies have been performed to evaluate this policy.

Objective of the studyTo determine the detection rate of heart and lung disease in asymptomatic pregnant women with no history of heart or lung disease.

MethodsWe performed a descriptive study by reviewing the files of all mothers that delivered at Baragwanath Hospital or were referred there postpartum, in September and October 1996. We looked for the following details: previous history of heart or lung

disease, findings of routine heart and lung examination, the person who performed the examination, findings on subsequent examinations and final diagnosis.

ResultsRecords of 3191 patients were reviewed. The results are presented in Table 1-5.

Table 1 History of heart diseaseHistory

NumberValve replacement 7Rheumatic heart disease 4Congenital heart disease 3Cardiomyopathy 1Atrial fibrillation 6

Table 2 History of lung diseaseHistory

NumberAsthma 39Previous TB 13Pneumonectomy 1

Table 3 Person performing the examination

Midwife 50%Doctor 18%Advanced midwife 7%Unknown 7%Not done 13%No records 5%

Table 4 New cases of heart disease

Referred by Number Heart diseaseMidwife 4 1Doctor 6 1

Table 5 New cases of lung disease

Referred by Number Lung diseaseMidwife 0 0

Doctor 0 0

In all cases when the examiner considered the findings of heart and lung examination to be abnormal, patients were referred to specialist clinic at the hospital for further evaluation.Only two new cases of heart disease were diagnosed in this group of 3191 patients. One patient referred by a midwife was diagnosed to have mixed aortic valve disease and another, referred by a doctor, was diagnosed to have mitral stenosis. In both patients, the pregnancy, labour and puerperium were uneventful. There were no maternal deaths related to heart or lung disease in this study group of patients.Detection rates for heart disease in asymptomatic mothers with no history were 1 in 1600, and for lung disease, zero.

Limitations of the studyA randomised controlled trial or community intervention study comparing two different protocols would have been better, but to show the difference (P<0.05) with a power of 80%, more than 12 000 patients per group would be needed. Because an uneventful pregnancy

does not exclude cardiac abnormalities, we could have missed some occult disease. As this study was performed in an urban area we are not certain that our findings would be applicable in rural regions of South Africa.

ConclusionsBased on the results of this study, we conclude that history taking is of utmost importance, and that most of the cases of heart and lung disease would be detected this way. Taking into account the very low detection rate, effort and probable costs involved, we believe that it is not worthwhile to train midwives specifically for heart and lung examinations. We also believe that it is not worthwhile to refer patients (asymptomatic pregnant mothers with no history of heart or lung disease) to be examined at the hospital if no staff able to perform heart and lung auscultation are available.At the same time we believe that if the ANC staff are trained to perform heart auscultation they should do so because some cardiac conditions will be detected and for reason of possible patient satisfaction. We

were not able to prove the same benefit for lung auscultation.AN INVESTIGATION OF ANTENATAL PATIENTS REPORTING REDUCED FETAL MOVEMENTS

A TheronDepartment of Obstetrics and Gynaecology, Tygerberg Hospital

Introduction : The Cochrane Database of Perinatal Trials recommends that routine fetal movement counting and recording is unnecessary. Whether this holds true in a developing country is uncertain. The following aspects of fetal movements were investigated in this study:1. Evaluate a change from

recording to awareness.2. Compare counting with

electronic monitoring.3. Follow-up for further

complications and outcome.

Method : Three groups of 100 consecutive patients each, were included in the study. All these patients were referred because they reported or experienced reduced fetal movements. Group one were referred during the period that all antenatal patients routinely recorded fetal movements on charts. Group two subsequent to the abandoning of this routine. Both these groups had

to manually record fetal movements at the clinic. Group three had their fetal movements counted electronically. All the patients had cardiotocography (CTG's). Their fetal movements were counted until satisfactory CTG patterns were recorded.

Results : The number of patients included in Groups one, two and three were 98, 94, 97 respectively. These groups were comparable with regards to age, gravidity, parity and the gestational age at booking (Table 1). Intra-uterine deaths (IUD's) were diagnosed in 1 patient in Group one, 2 in Group two and 1 in Group three. Of the remaining patients 29 in Group one and 25 in group two manually recorded less than 4 fetal movements (Table 2). Only one patient in Group one, none in Group two and one in Group three had less than 4 fetal movements recorded electronically. Two patients in Group one and 2 in Group 3 had positive stress tests with none in Group two. One additional patient in Group three had a non-reactive CTG with poor variability. One patient in Group one was induced and had a normal vertex delivery the next day and in

Group three one positive stress test improved on subsequent testing and the patient was discharged. The remaining three patients that had positive stress tests had to be delivered the same day for fetal

distress. A further 19 (6,5%) patients later developed complications that may be related to placental insufficiency (Table 3).

Discussion : These results indicate that: (1) Routine fetal movement counting is unlikely to improve care, but that awareness of the importance of adequate fetal movements must be stressed among all patients. (2) IUD's must be excluded when patients report reduced fetal

movements. (3) All obstetric services require a strategy to ensure that fetal wellbeing is present if patients report a reduction in fetal movements.

Table 1 Summary dataGroup 1 2 3 p-value*

numberAge (SD)

9825.7 (6.0)

9424.9 (6.7)

9725.7 (6.42)

0.98

Grav: 2.43(1.4)

2.40(1.4)

2.3(1.4)

0.75

Para: 1.2(1.2)

1.3(1.3)

1.1(1.3)

0.62

Mean:

Gestational age at first visit (SD)

35.76(3.7)

35.23(3.7)

36.14(3.6)

0.23

Gestational age at delivery

39.94(2.3)

39.02(2.6)

39.38(2.2)

0.03

* ANOVATable 2 Fetal movements recorded by patients in the clinic (first

visit)Group 1 2 p-value*

Fetal movements> 4 (%)< 4Total:

68 (70)29 (30)

97

67 (73)25 (27)

92

0.77

* Chi-squareTable 3 Summary of complications due to placental insufficiency

Fetal distress 14Induction: IUGR and abnormal doppler 1

Abnormal doppler and CTG 1IUGR, abnormal doppler and APH 1(Cord complications and fetal distress 2)Total: 19

FETAL VIBRO-ACOUSTIC STIMULATION WITH A CAN: A CLINICAL STUDY

GJ Hofmeyr, T Lawrie, M de Jager, A da PonteCoronation & Baragwanath Hospitals, University of the Witwatersrand

IntroductionVibro-acoustic stimulation has been shown to decrease the false positive rate of non-stress tests (NST's) and equivocal biophysical profiles, and to be comparable to the NST as a predictor of poor fetal outcome when performed within seven days of delivery. Fetal movement in response to vibro-acoustic stimulation is considered to be a marker of fetal wellbeing and is used as a screening procedure in places where cardiotocography is unavailable. However, conventional vibro-acoustic stimulators are not available in most primary care settings. The use of auscultation to detect fetal heart rate accelerations as part of a clinical fetal arousal test has not to our knowledge been reported.

Subjects and MethodsA cohort of 112 antenatal patients at Coronation Hospital were enrolled in a prospective study. Participants were high-risk patients of at least 27

weeks gestation, in whom antenatal fetal heart rate testing had been requested. Women were excluded from the study if they were in labour. Age, parity and the reason for non-stress testing was recorded. Before performing the can test the fetal heart rate (FHR) was auscultated for at least one minute with a Pinard stethoscope and a baseline FHR recorded as the number of beats in a 30-second epoch. The empty soft-drink can was then placed with its base halfway between the symphysis pubis and the umbilicus of the patient and steadied with the middle finger and thumb on the top rim of the can. The opener ring was then depressed about half a cm with the tip of the index finger and released, allowing it to spring back upwards, thereby emitting a vibro-acoustic stimulus. Auscultation of the FHR was immediately resumed and recorded for the subsequent two 30-second epochs. During auscultation, the examiner would lightly rest one hand on the women's abdomen to feel for fetal movement. An acceleration was considered to have occurred if the FHR in either 30-second epoch increased by 5 beats or more above the baseline value recorded. If neither an acceleration nor objective movement was evident

after one stimulus, the can test was repeated up to three times.NST's were assessed independently by a researcher who was blind to the can test results. NST's were classified as reactive or non-reactive. Can tests were classified as positive if no FHR acceleration or objective movement was felt, and negative if either or both FHR acceleration or objective movement was felt. Mode of delivery, birth weight, gestation of the baby and the 5-minute Apgar score was recorded at delivery.Results of the can test were compared to the NST's and fetal outcome. Perinatal outcome was assessed in terms of the 5-minute Apgar score and, in 45 of the subjects analysed, cord arterial blood gas analysis. A 5-minute Apgar score of < 7 or a pH of < 7.20 was taken to reflect perinatal compromise.

ResultsAnalysis was limited to 85 women who delivered within 7 days of doing

the test. The gestation of the fetuses at the time of doing the tests ranged from 27-42 weeks and the reasons for doing an NST included IUGR (27), pre-eclampsia (37), poor obstetric history (5), gestational diabetes (16), decreased fetal movement (4), post-term (4), chronic hypertension (5), undiagnosed APH (6), and polyhydramnios (1). Auscultated FHR acceleration without objective fetal movement was detected in 15 of the 63 true negative, and 1 of the false negative tests. The ability of the can test to predict a reactive NST and a good fetal outcome was 94% (negative predictive value). The percentage of non-reactive NST's and bad outcomes identified by the can test was 56% (sensitivity) with a positive predictive value of 28%. Specificity (percentage of reactive NST's and/or good outcomes identified) was 83%.

Conclusion

The can was effective in eliciting a fetal response in 67/85 (79%) of fetuses studied. On the basis of this and our invitro study it would seem reasonable to use a can for fetal arousal during electronic FHR testing, if no electronic stimulator is

available. The clinical test failed to predict bad outcomes in four out of nine patients. Three of these patients had placental abruptions in the 48 hours following the can test, two of which resulted in stillborn babies. In the fourth case

polyhydramnios was present, and the NST was reactive with variable decelerations thought to be due to cord compression. The cord pH at delivery was 7.16 but the baby was clinically well. The poor sensitivity of the can test related mainly to occurrence of placental abruption following the test, a shortcoming common to conventional FHR testing. The three patients who had placental abruptions also had pre-eclampsia and, in a primary care setting, would be referred to hospital for management.We have shown that the can test is effective in eliciting a fetal response, and that auscultation for FHR accelerations is feasible as an adjunct to the clinical fetal arousal test. In view of the reasonable negative predictive value, the can test should be investigated as a screening test in low-risk women in a primary care setting.

TRANSMISSION OF HIV FROM MOTHER TO CHILD, STRATEGIES

FOR PREVENTION

JA McIntyre, GE GrayDepartment of Obstetrics and Gynaecology and the Perinatal HIV Research Unit, Baragwanath Hospital and the University of the Witwatersrand

HIV infection continues to increase rapidly in the developing world, especially in Africa and Asia. In many African centres, over 30% of pregnant women are infected with HIV and it is estimated that almost one million women with HIV infection will become pregnant in 1996. Three hundred thousand of their children are likely to be infected. Mother-to-child transmission of HIV-1 is the main mode of acquisition of HIV infection for children, responsible for around 20% of all new infections in African countries. Estimates of the rates of transmission differ around the world, although, as more results become available from well designed studies, there is more consistency in the figures. The rate of transmission is affected by a number of factors of which breastfeeding may be the most important determinant of the differing data. From the evidence obtained in prospective studies, the approximate rates are 15-20% in Europe, 15-30% in the USA and 25-35% in Africa.Epidemiology of mother to child

transmission of HIV-1Mother to child transmission of HIV can occur antenatally, during labour and delivery or in the postpartum period. The risk of transmission is higher in women with advanced HIV infection, evidenced by markers such as low CD4 counts and P24 antigenaemia. Transmission is also higher in women who are in the seroconversion phase of the disease. These findings point to increased viral load as a major determinant of transmission risk, and this is confirmed by more recent studies using quantitative HIV PCR.Transmission in utero has been demonstrated in abortion specimens from as early as 8 weeks and is thought to occur by invasion of the virus through the villous stroma into the fetal circulation via Hofbauer cells or by invasion of the syncitiotrophoblast. While it is not know what proportion of infection occurs at which stage of pregnancy, there is increasing evidence that the majority of mother to child transmission takes place during labour and delivery. Evidence for transmission during labour includes the higher risk of infection to first born twins shown in the International Registry of HIV Exposed Twins, where 35% of first born vaginally

delivered twins were infected compared with 15% of second vaginally born twins. The rates for transmission in twins delivered by Caesarean section were 16% and 8% respectively. The increased risk of transmission is also suggested in cases of prolonged rupture of membranes and appears to be related to the time during which the baby is in contact with cervical and vaginal secretions. Evidence from prospective studies in Europe and in South Africa suggests that caesarean section may reduce the rate of transmission by half, although a randomised controlled trial has not yet been completed.Breastfeeding carries an additional risk of transmission for women known to be HIV positive during pregnancy, estimated at 14% from European studies. A similar difference has been shown in preliminary results of a South African study (Gray G, personal communication). The risk of infection from breast milk in women who seroconvert while breastfeeding is thought to be in the region of 30%.

Interventions to reduce mother to child transmissionThe availability of more evidence about transmission risks and

mechanisms has led to a number of interventions designed to reduce mother to child transmission. Some of these should be part of the routine care of HIV positive pregnant women, while others are still in the experimental phase and practitioners should watch for results over the next few years. It seems likely that a set of effective possible interventions will be developed, from which each centre will have to decide what is feasible and affordable for their own situation.

AntepartumEarly diagnosis of maternal infection will allow for discussion about and the option of termination of pregnancy, in those countries where this is available. This decision should be made by the mother and her partner, without directive counselling on the part of the health care worker.The relationship between high viral load and an increase in mother to child transmission suggests that interventions which reduce viral load may help to reduce transmission. Zidovudine (AZT, Retrovir) is the drug most used for this indication. The ACTG076 study undertaken in the USA and France was a randomised, placebo controlled trial

in which asymptomatic HIV positive women with CD4 counts above 200/mm3 in the study group received Zidovudine (100mg 5 times daily) starting between 14 and 34 weeks of pregnancy (median 26 weeks), intravenous zidovudine during labour and the neonate received zidovudine syrup 2mg/kg, 4 times daily for 6 weeks. The women did not breastfeed. The trial was stopped when preliminary analysis showed a reduction in the risk of mother to child transmission associated with zidovudine use from 25.5% (40 infected children) in the placebo arm, to 8,3% (13 infected children) in the treatment arm, a highly significant reduction of 67.5%. Based on these results, the CDC in the United States and other bodies have issued guidelines suggesting that pregnant HIV positive women should be offered zidovudine therapy, although there remains a need for long term follow up of the infants to rule out late drug related complications. The expensive dosage regime used in ACTG076 will probably be unaffordable for most developing countries. The World Health Organisation has embarked upon a multicentre trial in Africa, using short course of zidovudine and 3TC in combination, to determine the

efficacy of this regime, and other studies in the Ivory Coast are investigating short term use in late pregnancy of zidovudine alone.Reports from Malawi linking low Vitamin A levels in HIV positive mothers to an increased risk of infection of the children have led to suggestions that Vitamin A administration may help prevent mother to child transmission. Several randomised controlled trials of Vitamin A supplementation are in progress.A randomised trial of passive immunisation (Hyperimmune Intravenous Immunoglobulin (HIVIG) in women on antiretroviral therapy was stopped after an interim analysis showed no difference in transmission rates. A phase I trial is in progress in Uganda in women not treated with zidovudine. However, this intervention would be costly and it may be difficult to obtain immunoglobulin. Active immunisation could potentially induce a long-lasting maternal and possibly infant immunity and preliminary trials have started.

IntrapartumPossible interventions to reduce the risk of intrapartum infection include: elective caesarean section delivery;

anti-retroviral therapy (to mother and/or child); disinfection of the birth canal and passive and active immunisation (to mother and/or child). Routine management of labour in HIV positive women should include avoidance of invasive monitoring; avoidance of episiotomy, unless clinically indicated; and forceps delivery rather than vacuum extraction.Elective caesarean section delivery may reduce transmission by decreasing the exposure of the baby to blood or cervical secretions, and reducing the risk of transmission from microtransfusion of maternal blood during uterine contractions. While some evidence from prospective trials supports this, suggesting a reduction of 50%, it has not been proven and a larger randomised controlled trial of mode of delivery is in progress.Disinfection of the birth canal during labour with antiseptics or antiviral agents could provide an inexpensive means of prevention of transmission. Chlorhexidine (widely used in Hibitane® Vaginal Cream) and Benzylkonium Chloride have been suggested as appropriate safe antiviral compounds. A study in Malawi showed no difference in overall transmission rates with or

without vaginal cleansing in labour with a 0.25% solution of Chlorhexidine, although there was a significant reduction in those women with membranes ruptured for more than four hours. Vaginal disinfection during labour, if proved to be effective, would be the "first prize" in finding a method for prevention of transmission. As a very inexpensive management, it would be possible to use it for all women, regardless of HIV status or in areas where testing is unavailable.

PostpartumWhile very few HIV infected women will breast feed in developed countries, the opposite is true in the developing world. Provision of formula feeds could have a major impact on the rate of mother to child transmission, even possibly reducing this by half. In developing countries, the problems of malnutrition, water supply, cost of formula feeds and lack of hygienic conditions must be considered and individual advice given to each patient according to her situation. There is a risk of late postnatal transmission through breastmilk after six months and early weaning may be considered as a modification of breastfeeding

practice to avoid this. Women should be given all the necessary information to make a decision about

infant feeding and supported in their choice.

Table 1 Interventions to reduce transmission from mother to childINTERVENTIONS FURTHER RESEARCH

REQUIREDANTEPARTUM 1. Termination of pregnancy

2. AZT administration from antepartum period to postpartum

3. Avoid cordocentesis, amniocentesis, placental biopsy

1. Short course antiretrovirals: AZT or AZT & 3TC.

2. Vitamin A administration

3. HIVIG given to mother4. Active immunisation

INTRAPARTUM 1. Elective caesarean section2. Avoid fetal scalp electrodes

and scalp blood sampling3. Avoid prolonged rupture of

membranes and prolonged labour.

4. No routine episiotomies

1. Antiretroviral therapy: AZT or AZT/3RC during labour only.

2. Vaginal disinfection (Chlorhexidine or benzylkonium chloride)

POSTPARTUM 1. No breast feeding, if safe formula feeding possible.

2. Advise condom use for negative women at risk of infection while breast feeding, as rate of transmission after seroconversion is higher.

1. Antiretrovirals after birth to mother or child.

2. HIVIG given to child.3. Withdrawal of

colostrum

PERINATAL HIV: A NEW PERSPECTIVE. THE PRETERM NEONATE - AN EMERGING PROBLEM

T Pillay, M Adhikari HM Coovadia, Department of Paediatrics & Child Health, University of Natal

IntroductionKwaZulu Natal is at the epicentre of the HIV epidemic in South Africa; the prevalence rate of infection in women attending the antenatal clinic at King Edward VIIIth Hospital, Durban is 23% (Department of Virology, University of Natal - unpublished data) and the vertical transmission rate 34%. Neonates born to these HIV infected mothers have thus far had uneventful neonatal courses. Recently a number of ill neonates born to HIV infected mothers have been seen at the neonatal unit of King Edward Hospital. This report documents the clinical profiles of such mother-neonate pairs.

MethodSince April 1996 the clinical and laboratory details were documented of all ill neonates born to HIV infected mothers.

ResultsSixteen ill neonates and their HIV infected mothers were evaluated.

Maternal detailsThe mean maternal age was 21.4 years with 7 (44%) being primigravida. Seven (44%) were unbooked and 31% of these mothers had clinical signs of infection in the perinatal period (tuberculosis in 3, pneumonia in 1, cervical warts in 1). Obstetric complications occurred in 6. Pregnancy-induced hypertension in 4, eclampsia in 1 and puerperal psychosis in 1. Three mothers had experienced previous pregnancy losses (1 abortion, 1 stillbirth and 1 neural tube defect).The neonatal details revealed the mean birth weight was 1.68kg (range 1.1-3.02), mean gestational age 33 (30-40), 87% of the babies were light for dates and only two of these babies were born at term. Thirteen (81%) of these neonates were delivered vaginally.Diagnoses at birth were respiratory distress in 6, pneumonia in 3, hypotension requiring inotropic support in 2, hepatosplenomegaly and lymph nodes in 1 and 3 babies were well.Cranial ultrasound were performed in 13 of the 16 babies. Abnormalities were detected in 11 of the babies, these included bilateral grade III intraventricular haemorrhages (IVH) in 3, grade II

IVH in 2, dense echogenic basal ganglia in 2, cerebral oedema and

dense thalami in 1 and 2 scans were normal.

Nine babies suffered multiple infections; these recurrent infections occurred intermittently with more than 48 hours between episodes. These infections included congenital syphilis in 7, cytomegalovirus (CMV) infection in 4 - 2 are on treatment with gancyclovir,1 was diagnosed at autopsy and 1 serologically. In 4 babies tuberculosis was considered and proven in 3 by positive gastric aspirates in 2, positive endotracheal aspirate along with post mortem liver and lung biopsy in 1 and the 4th is on isoniazid prophylaxis. Candida infection was diagnosed in 4 - 1 at autopsy and 3 on positive cultures from the blood and urine. One developed herpes and 2 necrotising enterocolitis. Blood cultures were positive for bacteria in 3 and 3 had positive bacterial endotracheal cultures.In 7 mother and baby pairs the mean and standard deviation of the CD4 and CD 8 counts were 543 cells/mm3 (264) for the mothers and 764 cells/mm3 (280) for the babies, 1022 cells/mm3 (86) for mothers and 775 cells/mm3 (1008) for babies respectively.Ventilation. Of 9 babies who were

ventilated 7 died. Six babies were not ventilated and 3 died. The mean duration of ventilation was 6.5 days (range 1-17 days).Mortality. Ten (63%) babies died, all of a pulmonary cause. The survival time was a mean of 27 days (range 1-103) and 7 (70%) died within 17 days.

DiscussionThis picture of ill, low birth weight, light for dates infants with a high mortality born to HIV positive mothers is a new clinical picture at King Edward Hospital. Growth retardation has been described in babies born to HIV infected mothers in Malawi and low birth weight infants in Rwanda.The question of whether to ventilate these babies poses a major ethical dilemma. Since there are no guidelines on this issue it was decided not to include the maternal HIV status where known in the decision-making process for admission to intensive care.

Previous to this period the majority of babies born to HIV positive mothers were full term babies who had an uneventful neonatal course. The picture is changing and may reflect a different stage of the epidemic. Transmission occurs in 50-60% during labour and delivery. However this group may reflect in utero transmission.A prospective study is under way to correlate in greater detail the clinical course, nature of the infections during the clinical course, typing of the strain of HIV in mother and baby. The question of whether to ventilate these tiny ill babies will be addressed as well.

BACTERIAL VAGINOSIS, LOW BIRTH WEIGHT INFANTS AND PERINATAL DEATH

LR Pistorius, RC Pattinson, M Funk, GR HowarthDepartment of Obstetrics and Gynaecology, University of Pretoria and Kalafong Hospital

IntroductionBacterial vaginosis is associated with preterm labour and preterm prelabour ruptured membranes. In our setting, patients commonly book in the second half of pregnancy and it is difficult to assess gestational age accurately. Low birth weight is a useful substitute parameter, although it is related to preterm delivery as well as intrauterine growth retardation. We undertook a community-based study to evaluate the association between bacterial vaginosis, low birth weight and perinatal death.

MethodsOne thousand consecutive pregnant women from Atteridgeville who visited Kalafong Hospital for their first antenatal visit before thirty weeks gestation, were included in a cohort study. Bacterial vaginosis was diagnosed in patients by means of the amine test and the presence of clue cells. The attending medical

staff performed the amine test by dropping 10% potassium hydroxide solution onto a sample of vaginal secretions on a wooden spatula, and sniffing a few centimetres above it. Release of a pungent fishy odour was interpreted as a positive amine test. One of the investigators (MF) examined a wet mount smear of vaginal secretions with a phase contrast microscope. Coccabacilli covering more than 20% of epithelial cells were considered diagnostic of the presence of clue cells. No treatment was instituted when bacterial vaginosis was diagnosed. The correlation between the amine test and presence of clue cells was calculated. After delivery, the study patients' infants' birth weight and perinatal survival were retrieved from a computerised obstetric register with aid of the hospital number. The causes of perinatal death for infants with a birth weight above 499g were classified by means of a weekly perinatal audit by obstetricians, neonatologists, and nursing staff. The relative risks for low birth weight and perinatal death in patients with bacterial vaginosis were calculated, with the Taylor series 95% confidence intervals utilising Epi Info 6 (World Health Organisation 1994).

Permission for the study was granted by the Ethics Committee of the University of Pretoria, and oral informed consent was obtained from each patient before inclusion into the study. The study was supported with a grant from the Stimulation Fund of the University of Pretoria.

ResultsThe perinatal outcome of 463 patients with known microscopy results, and 524 patients with known amine test results were available for analysis. (One thousand patients entered into the cohort analysis. Patients were unavailable for analysis due to the following: fifty patients who had a gestational age at booking above thirty weeks. Eight patients were not pregnant. Seventy five patients were referred to Kalafong Hospital after treatment at antenatal clinics elsewhere. In 206 patients no amine test was done, in 278 patients no microscopy was done due to logistical mishaps. Prior to delivery, 104 patients were lost to follow-up. Twenty three patients aborted an infant with birthweight below 500g.) The correlation between the amine test by multiple observers and the microscopy by a single observer has been published previously. A positive amine test

was significantly associated with the delivery of a low birth weight infant, and with perinatal death. The presence of clue cells was also significantly associated with the delivery of a low birth weight infant, and with perinatal death (Table 1). There was no significant difference in perinatal outcome between the patients on whom the amine test of microscopy was done and the patients where these tests were omitted (Table 2).

DiscussionIt has previously been shown that the amine test is a robust test for bacterial vaginosis. The current study confirmed this association. The current study also demonstrated that both the amine test and the presence of clue cells on wet mount microscopy were significantly associated not only with the delivery of a low birth weight infant, but also with perinatal death. There was a trend toward a stronger association with these measures of adverse perinatal outcome when both tests were positive. In a setting where resources are limited, and staff are not trained to perform microscopy, the amine test may be a useful test for bacterial vaginosis in pregnancy. The amine test may also be useful to

classify a patient at risk of delivering a low birth weight infant, or suffering a perinatal loss. Whether a policy of screening for bacterial vaginosis with the amine test, and treating patients with a positive amine test with appropriate antimicrobial therapy, does reduce the low birth weight rate and perinatal mortality rate, needs prospective evaluation.

Table 1 Association between presence of clue cells and a positive amine test with low birth weight and perinatal deathLow birth weight rate if test positive

Low birth weight rate if test negative

Relative risk for low birth weight & p value (chi square)

Perinatal mortality if test positive

Perinatal mortality if test negative

Relative risk for perinatal death & p value (chi square)

Amine test

Clue cells

Both amine test and clue cells positive

23%(28/123)

24%(27/112)

28%(22/78)

15%(62/411)

15%(51/350)

15%(54/367

1.5(1.01-2.3)

0.041.7

(1.07-3.3)0.021.9

(1.3-3.0)0.004

73/1000(9/123)

80/1000(9/112)

103/1000(8/78)

27/1000(11/411)

34/1000(12/350)

30/1000(11/367)

2.7(1.2-6.5)

0.012.3

(1.01-5.4)0.043.4

(1.4-8.2)0.004

Table 2 Association between performance of the amine test of wet mount microscopy with low birth weight and perinatal deathLow birth weight rate if test performed

Low birth weight rate if test omitted

Relative risk & p value (chi square)

Perinatal mortality if test performed

Perinatal mortality if test omitted

Relative risk & p value (chi square)

Amine test

Clue cells

17%(90/444)

17%(78/384)

13%(27/179)

14%(39/239)

1.3(0.9-1.9)

0.211.2

(0.8-1.7)0.30

37/1000(20/514)

45/1000(21/441)

44/1000(9/197)

28/1000(8/270)

0.9(0.4-1.9)

0.701.6

(0.7-3.5)0.26

HIDDEN PREGNANCY WASTAGE ATTRIBUTABLE TO SYPHILIS IN RURAL SOUTH AFRICA

D Wilkinson

I would like to start by acknowledging my co-workers on this project: Sister Marlene Sach who has run a mobile clinic service throughout the Hlabisa district for 30 years, and Cathy Connolly, a biostatistician with the MRC in Durban.The aim of this study was to describe the epidemiology, risk factors for, and impact on pregnancy outcome of syphilis in pregnant women in the Hlabisa health district. Hlabisa is a rural part of KwaZulu Natal; blood is taken at booking and an RPR is done in the local hospital and returned to the clinic 1-2 weeks later.I will focus on the impact on pregnancy outcome and our subsequent response to the results of the study. The full report of this work was published in the Journal "Tropical Medicine and International Health" in January this year.We constructed a retrospective cohort of 200 pregnant women (50 with syphilis and 150 without) and studied the relationship between syphilis status (active syphilis defined as RPR+/TPHA+) and pregnancy outcome (defined as live

birth, still birth and perinatal death).Pregnancy outcome was available for 187 (94%) of women, 45 with syphilis and 142 without. Of the 8 perinatal deaths identified, 6 were in women with syphilis; 4 were stillbirths and 4 were early neonatal deaths. All 4 stillbirths occurred in women with syphilis (p<0.001). The odds ratio (adjusted for other measured exposures) for an adverse pregnancy outcome was 11.8 (95% CI: 2.0-67.4, p=0.006) in those women with syphilis compared to those women without syphilis. Other risk factors such as age, gravidity and marital status showed no association with pregnancy outcome.Although all women that booked for antenatal care were screened for syphilis, not all were fully treated. Of the 45 women with syphilis and a known outcome, only 22 (49%) received all 3 recommended doses of penicillin.Five of the 6 PND occurred in women who received 0 or 1 dose of penicillin. Women who had 0 or 1 dose of penicillin had a greater risk of perinatal death than those who received 2 or 3 doses (OR 19.4, 95% CI, 1.7-944.6, p=0.005). The mean number of doses received in those with syphilis and a perinatal death was 0.8 and in those with syphilis

and a live birth was 2.2 (p=0.02).Women were incompletely treated for 2 reasons: the delay between diagnosis and start of treatment, and a failure to return for subsequent clinic visits.

ConclusionsThere is a considerable hidden mortality from syphilis in pregnant women - even when all women are screened it is not reasonable to assume that all are being treated adequately.We estimated that in Hlabisa, the PAR% (the proportion of perinatal deaths due to syphilis among all women in Hlabisa is 27%). The PAR% is a very useful public health measure - it tells us by how much we could reduce the total PNMR if we can ensure that all women are screened and treated for syphilis.I just want to stress this - in this small antenatal service all women are screened for syphilis at booking - despite this many are not adequately treated, and this failure may account for around 25% of the total PNM in the district.The potential impact of on-site syphilis screening and immediate treatment is clearly considerable.

THE ANTENATAL PREVALENCE AND SEROCONVERSION RATE OF SYPHILIS IN THE TYGERBERG HOSPITAL AREA: 1993 VS 1996

M Smith, GB TheronMRC Perinatal Mortality Research Unit, Department of Obstetrics and Gynaecology, University of Stellenbosch and Tygerberg Hospital

IntroductionSyphilis remains an important cause of perinatal morbidity and mortality in the Tygerberg Hospital (TBH) area. Increased concern about a possible rise in the prevalence of syphilis in antenatal patients, with a simultaneous rise in sero-conversion rate, necessitated an audit of the current screening and treatment protocol in these patients. An increase in seroconversion rate would require rescreening later in pregnancy.

MethodThis cross-sectional descriptive study

included 918 women consecutively registered for antenatal care in the TBH area, sampled proportionally to clinic size, during a two month period (Feb - March 1996). All patients were serologically screened for syphilis at the first visit to an antenatal clinic as well as at delivery. From these results the prevalence and rate of seroconversion was determined. Demographic data and data on socio-economic status was also collected. Results were compared with a similar audit completed in 1993.

ResultsThe prevalence of syphilis in booked patients was 8.5% (73/862). Unbooked patients constituted 6% of the total and the prevalence in this group was 19.6% (11/56). Table 1 describes these two groups. The seroconversion rate during pregnancy was 0.67% (5/744).

Table 1 Descriptive data of Seropositive GroupBooked Unbooked

TOTAL 73 11

Mean age (SD) 27.4 (6.3) 26.7 (6.4)

Unmarried (%) 52 (71.2) 9 (81.0)

Unemployed (%) 28 (38.4) 7 (63.6)

Primigravida (%) 17 (23) 3 (27.2)

Booked Unbooked

Mean gestation (weeks)Booking (SD) 21.9 (7.5)

Delivery (SD) 38.0 (2.7) 34.2 (4.4)

Number of antenatal visitsMedian (Range) 6 (1-15) 0

In the seropositive group delivering at TBH, the 28 (43%) patients having decreased titres at delivery and 21 (32.3%) with unchanged titres had a normal neonatal outcome. Neonatal outcome in patients with increased titres despite sufficient treatment (n=16) was as follows: 13 babies were normal with no clinical or serological signs of syphilis, 1 was normal with clinical signs of syphilis (snuffles), 1 intrauterine death (IUD) and 1 early neonatal death were due to congenital syphilis.In patients delivering unbooked (n=11), 4

had a normal neonatal outcome with no clinical or serological signs of syphilis, 3 babies had clinical signs of syphilis (snuffles x 2, skin desquamation x 1), one IUD and one early neonatal death due to congenital syphilis. Two early neonatal deaths in this group were due to prematurity. The five mothers who sero-converted during pregnancy all had a normal neonatal outcome (no clinical or serological signs of syphilis).Table 2 shows a comparison of results of the two audits.

Table 2 Prevalence and seroconversion rates: 1993 vs 19961993 1996

Prevalence: Booked patients%p-value

66/8038.2%0.92*

73/8628.5%

Prevalence: Unbooked patients%p-value

4/4017.5%0.31*

11/5619.6%

Seroconversion rate

p-value

2/6110.32%0.46#

5/7440.67%

* Chi-square # Fisher's exact test

ConclusionsResults of the two studies indicate that the prevalence of syphilis remained stable during a four-year period. While still low, the sero-conversion rate during pregnancy doubled during the four-year period, but the normal neonatal outcomes of these babies indicate that re-screening later in pregnancy is not indicated. Screening should still take place at delivery. Although the prevalence of syphilis remained high, management of patients requiring treatment is sufficient. Re-infection may be a problem as shown in patients with rising titres. On-site screening would possibly have benefited 2 patients that booked late and delivered elsewhere. Both had only one visit. The unbooked patient group with untreated syphilis remain the major source of neonates with congenital syphilis.

SCREENING FOR CERVICAL NEOPLASIA DURING PREGNANCY. IS IT WORTHWHILE?

HS Cronje, E van Rensburg, I Niemand, BF Cooreman, E Beyer, P Divall*Departments of Obstetrics and Gynaecology and Cytology*, University of the Free State

IntroductionAntenatal visits present a unique opportunity of screening on average, a younger population for cervical neoplasia. Unfortunately, however, the Pap smear (cytology) has proved less sensitive in pregnant patients, resulting in controversy as to whether cervical screening should be implemented in pregnancy. In Pretoria, for example, 5,4% of all smears prove to be positive, whilst a mere 0,8% of pregnant women of the same population group, actually test positive (personal account).

ObjectivesIt is the aim of this trial to study, in detail, screening in pregnancy with particular

reference to cytology and then to formulate an acceptable screening policy.

Patients and MethodsThis study utilised the facilities and services of the antenatal clinic, Pelonomi Hospital. The n=842 women, constituting this sample, were routinely screened as part of their first antenatal visit, utilising the three methods i.e. cytology (aided by the Cytobrush®), cervicography (using the Cerviscope®, NTL) and the acetic acid test (AAT). All screening tests were executed by the same registered nurse (EvR).

ResultsThe average age was 27 years (minimum 15 and maximum 40). In total, 12,5% of these patients smoked. The proportion of positive results, obtained utilising each method, set out in Table 1 together with a similarly obtained set of results for non-pregnant patients.

Table 1 Proportion of positive results utilising various screening methods

Positive cases (%)

Screening method

Pregnant (n=842)

Non-pregnant* (n=6000)

P-value

Cytology 0.9 1.7 0.1052

Cervicography 5.9 4.5 0.9040

AAT** 13.7 17.7 0.7259

* Results of, as yet unpublished study, executed in a comparable population.** AAT= acetic acid test

The kappa statistic was used to determine the measure of agreement between tests. Cervicography versus cytology produced a kappa value of 0,01. In the case of cervicography and the AAT, the calculated value was 0,2 and regarding cytology and the AAT, it was a mere 0,01.

DiscussionIt would therefore seem that pregnancy, in no way affects the proportion of positive cases diagnosed by cervicography and the AAT. But, with regards to cytology we find a definite decrease (although not statistically significant) of positive cases.Furthermore, we find the measure of agreement, particularly between cytology and the other tests, to be negligibly small and therefore conclude that cytology alone cannot be utilised for screening pregnant patients.By combining screening tests, eg. cervicography and cytology, the sensitivity increases by at least 30% and as much as 52% with the further addition of speculoscopy (specialised form of the AAT).

ConclusionCytological screening in pregnancy is

not considered cost effective and we therefore recommend the implementation of a combination of methods. Cervicography appears to be an excellent choice. A minimum age (e.g. 30 years) should also be considered as factor to improve cost effectiveness. Intensive research is, however, required to determine the cost effectiveness of the various combinations of screening methods.

THE NORTHERN CAPE SAFE MOTHERHOOD NEEDS ASSESSMENT

JA McIntyre*, M Govender, P Pillay, C Madikane# Department of Obstetrics and Gynaecology, Baragwanath Hospital and University of the Witwatersrand, Department of Health & Welfare, Northern Cape

IntroductionThe World Health Organisation (WHO) has produced a rapid assessment methodology for country or provincial use to assess the availability of essential maternity services. The assessment measures the available resources and standard of care against the guidelines set out in "The Mother-Baby Package : Implementing safe motherhood in countries". The Mother-Baby package provides a minimum structured approach with model survey forms, pre-programmed data entry and analysis routines provided for local adaptation. The methodology is particularly useful for

South African provinces in this time of re-structuring and re-organisation, to establish a baseline level of services and to identify priority areas for improvement. In 1996 the Northern Cape Province undertook such an assessment in collaboration with the Department of Obstetrics and Gynaecology, Baragwanath Hospital, the World Health Organisation, and the MRC. Funding for the assessment was provided by the World Health Organisation, ODA and the Northern Cape Department of Health and Welfare.

Objectives1. To assess the standards of

safe motherhood/maternity care in the Northern Cape Province.

2. To determine the availability of equipment and staff in maternity services in the Northern Cape.

MethodsThe WHO Safe Motherhood Needs Assessment methodology, was utilised for the core design of the assessment. This provides a framework for a rapid assessment of services, designed to be undertaken by local investigators within a short period of time. The assessment tool

has modules for the assessment of the management of facilities, nurse/midwife interviews, antenatal client exit interviews, antenatal record review, normal delivery and complicated delivery record review and a district health team interview. The methodology was adapted by a

multidisciplinary reference team from the Northern Cape Province to fit local needs and conditions. A sample of health facilities ranging from Primary Health Care services to referral hospital was developed using the health regions of the Northern Cape. The sampling frame was calculated according to delivery numbers and population in the six regions.Data collection was undertaken across the province by thirty specially trained staff, seconded from the provincial services, over a period of three weeks. This included site visits and equipment inspection, interviews with mothers and service providers and record review. Data entry for completed questionnaires was undertaken at the Medical Research Council and the data analysed using the Epi-Info programmes included in the WHO Assessment modules.

ResultsThe baseline data available from health department records showed 18107 births in public facilities in 1995, with an average of 211 deliveries per delivery bed and a ratio of antenatal visits to deliveries of 0.19.Antenatal care was available at all

the community health centres but at only 29% of the hospitals. Only half of the hospitals and 83% of the health centres offering maternity care are able to do syphilis testing. Tetanus toxoid was available at all the community health centres, but only 21% of the hospitals. Family planning services were available at 50% of the community health centres and all the hospitals. STD treatment services were present at 50% of hospitals and 83% of community health centres. The majority of women attend antenatal clinics in the second trimester (70%) with only 20% of women attending before this. Only two of ten warning signs in pregnancy (headache and bad smelling discharge) were known by more than 50% of women at interview.Only two of the community health centres had delivery facilities for normal deliveries and 88% of the hospitals. Assisted delivery and caesarean sections could be performed at 85% of hospitals and 71% of the hospitals had blood transfusion facilities.Equipment levels were adequate in 93% of facilities but 14% of hospitals did not have adequate neonatal resuscitation equipment. Record keeping, both for individual patients

and patient registers, was less satisfactory. Only one of the two community health centres which did deliveries kept a delivery register, and only one of the 14 hospitals had an antenatal clinic register. Although 92% of the hospitals had partograms available, correct use was uncommon. On examination of

a sample of labour and delivery records, 37% had substandard recordings of vaginal examinations, 72% had unacceptable recordings of fetal heart, blood pressure and birthweight, 86% had substandard recording of the condition of the baby.

Only 52% of staff had attended a delivery and 24% had managed a postpartum haemorrhage within the previous six months and many identified a need for in-service education. Almost one quarter of the staff had never received any family planning training (23%) and 22% had last had training in family planning more than 5 years previously.The Northern Cape is a large province with a relatively widespread population. One third of the facilities were more than 50km from their referral centre. Despite the large distances in this province, referral logistics were satisfactory. In 80% the total transfer time (including waiting for transport) is under 2 hours.

ConclusionsThe Mother-Baby package identifies key elements of maternity care, which can be regarded as a minimum standard of care. As such,

the level of service identified is lower than many parts of South Africa would accept as a minimum standard and less demanding than the standards established by the PEP programme and other local guidelines. The assessment methodology allows for a rapid evaluation of services, based upon the Mother-Baby package, but adapted to suit local conditions. In this assessment, the adaptation was carried out by a multidisciplinary provincial team. This in itself was a valuable exercise, identifying potential problems areas and possible solutions even before the start of the data collection.The assessment has identified priority areas for action for the provincial administration. Staff education, particularly on labour management and labour complications is essential, while the introduction of standardised patient records will help correct some of the

problems. The poor record keeping at the hospitals and clinics will have to be addressed as part of the introduction of patient retained records. Syphilis testing and treatment is a priority. Equipment and drug supply logistics are functioning well, as is the transport system between centres.The involvement of provincial health care workers in the collection of data was very successful. For many of them, this was their first exposure to "research". The identification of problems and of successful innovations in the health centres they visited enabled them to reconsider their own services and ways in which these could be improved.The assessment was seen as a valuable way to involve staff in the upgrading of the facilities, and will provide a baseline for the provincial administration, to chart improvements.PROSPECTIVE RISK OF STILLBIRTH COMPARED TO CONVENTIONAL STILLBIRTH RATES FOR THE ATTERIDGEVILLE POPULATION

GR Howarth, LR Pistorius, GH de Wet, RC Pattinson

IntroductionConventional stillbirth rate for a specific weight category is expressed

as: Number of stillbirths in weight category Number of deliveries in weight category

The problem with utilising this ratio is that it is not meaningful to assess the risk of stillbirth to a fetus as those fetuses at risk of stillbirth are not included in the denominator.

The prospective risk of stillbirth is expressed asNumber of stillbirths at or beyond a weight categoryNumber of deliveries at or beyond that weight category

The advantage of utilising the prospective risk of stillbirth is that one can ascertain the risk of stillbirth to particular weight categories of fetuses while still in utero.

Methods : Computerised statistics of our obstetric database were collected over a period of 42 months and 18 036 deliveries were included. All stillbirths were identified and conventional stillbirth rates were compared to prospective risk of stillbirth rates.

ResultsConventional S/B Rate Prospective risk of S/B

500-999g 610/1000 37/10001000-1499g 209/1000 24/10001500-1999g 103/1000 16/10002000-2499g 41/1000 11/10002500-2999g 15/1000 14/10003000-3499g 7/1000 8/10003500-3999g 10/1000 12/10004000-4499g 15/1000 19/10004500-4999g 20/1000 50/1000>5000g 250/1000 250/1000

Conclusion: Prospective risk of stillbirth differs from conventional stillbirth rate. Utilising prospective risk of stillbirth allows the obstetrician to assess the risk of stillbirth of a specific pregnancy, thus facilitating obstetric decision making. Ideally prospective risk of stillbirth should be calculated for different types of common obstetric pathology, for example preeclampsia, thus facilitating decision making in specific pathologies.PROFILE OF A MOU : WORKLOAD, PROBLEMS AND OUTCOMES

DH Greenfield, KB SundgrenDepartments of Paediatrics and

Obstetrics, UCT

IntroductionIn order for primary health care to

work, there needs to be back-up from the level 2/level 3 facilities, while the providers of secondary/tertiary care need to know what are the numbers and problems of referred patients. This is also important for knowing what is appropriate in-service training for the primary care staff to be able to cope effectively with the problems they face.

Guguletu Midwife Obstetric Unit (MOU) provides primary perinatal care for people in a mainly Xhosa speaking area within the Central Substructure of the Cape Town Metropolitan Council.

MethodsData on antenatal care (bookings, attendances and transfers), labour ward deliveries and transfers, infant and postnatal maternal transfers, and perinatal mortality were collected for Guguletu MOU for the period 1/1/95 - 31/12/96.

Results

Antenatal CareBooked patients 8 485Clinic attendances 28 520Transferred to hospital 1 603

(81.9% of booked patients)

The average attendances are a booking visit and 3 further clinic visits.

Labour WardDeliveries - at MOU 5 503

- transferred to hosp 1 647

7 150

Method of delivery in transferred patientsCaesarean section 26.4Vacuum extraction 9.6Forceps 2.2Vaginal breech 2.8Twins 1.2

42.2

Main Reasons for Transfers %Prev. C/Ss 29.6Hypertensive disease 11.5Malpresentation at 36/52 11.7Gravida 5 or more 12.3Assoc. medical complications 11.5

76.6

Main Reasons for transfer in labourInadequate progress

1st stage2nd stage 30.0

Hypertensive disorder 21.2Preterm labour 10.3Fetal distress 8.9Prolonged rupture of

membranes 6.777.1

138 (8.4%) of these mothers required tertiary care.

There were 29 vaginal breech and 22 twin deliveries at the MOU.53% of the mothers transferred in labour were primigravidae compared with 28% of MOU deliveries being primigravidae.Infants transferred Main Reasons for transferLive born infants 5 548 %Babies referred 241 (4.4%) Low birth weight

33.2Respiratory distress

17.8Asphyxia 14.1Neonatal jaundice 13.7

78.8

66 (27.4%) of these babies required admission to an intensive care unit.

Postnatal transfers Main Reasons for transferTransferred 112 (2% of deliveries %

PPH13.4

Retained placenta

37.4Hypertensive disorder

14.3Suturing perineum 19

84.1

Perinatal Mortality Birthweight > 499gHosp MOU Total

Total deliveries 1647 5503 7150SB 49 93 142

Rate/1000 29.8 16.9 19.9NND 42 32 74

Rate/1000 26.3 5.9 10.3Perinatal deaths 91 125 216

PNMR 55.3 22.7 30.2

Approximately 1/3 of all the perinatal deaths were between 500g and 1000g birth weight.Conclusions58% of booked patients at Guguletu MOU only needed primary care. Primigravidae are a high risk group in labour.2/3 of women are referred because

of one of:* problems in a previous

pregnancy or labour.* hypertensive disease* prolonged labour

* maternal medical conditionsAlthough most of the work involves normal patients, the staff have to be able to deal with very ill patients. This has implications for the support and education needed at a primary care level.

WOMEN WHO BOOK LATE IN PREGANCY

D Roussot, E Buchmann, J McIntyre, JM RussellDepartment of Obstetrics and Gynaecology, Chris Hani Baragwanath Hospital and University of Pretoria

The introduction of free antenatal care in South Africa in 1994 has been followed by a fall in the numbers of unbooked emergencies presenting at maternity units. While more mothers are now using antenatal care facilities, many women still book in the second half of their pregnancies, despite obvious potential benefits. The aim of this study is to investigate the reasons for late antenatal attendance of pregnant women at Chris Hani Baragwanath Hospital and its associated clinics.

MethodsA case control study was undertaken which consisted of structured interviews by two experienced research midwives. The sample

comprised 200 consecutive first time antenatal clinic attenders, 100 at Chris Hani Baragwanath Hospital and 50 each at two midwife obstetric units (Chaiwelo and Koos Beukes). One hundred mothers who booked after 28 weeks of pregnancy made up the case group and were compared with 100 who booked before or at 24 weeks, the control group. Questions were asked to assess demographic and socioeconomic factors, obstetric risk factors, pregnancy awareness and the mother's view of antenatal care. These interviews were carried out in the mothers' home language at the antenatal clinic before the women were assessed by doctors or midwives and given their health education talks or leaflets. This took place during July and August 1996. The interview results were analysed using the Epi-Info 6.04 statistical package.

Results

The mean ages of late and early bookers were 27.6 and 28.6 years respectively (p=0.24), and the mean parities were 2.0 and 1.8 (p=0.69). Frequencies of certain characteristics of late and early bookers are shown in Table 1. A comparison of means of numerical answers is shown in Table II. Table III compares previous obstetric histories. When previous miscarriage, preterm delivery and perinatal death were combined, we found 25 late and 43 early booking mothers with poor obstetric histories (odds ratio 0.44; 95% confidence interval 0.23-0.84). Table IV shows reasons given for late booking.

Table I Characteristics of late and early bookersLate n=100

Early n=100

Odds ratio

95% confidence interval

Nulliparous mother 17 20 0.82 0.38-1.77

Parity > 4 12 6 2.14 0.71-6.72

Unplanned pregnancy 58 34 2.68 1.45-4.96

Lives in informal settlement 42 28 1.86 0.99-3.51

Education Standard 8 or less 63 59 1.18 0.64-2.18

Unemployed 76 70 1.36 0.69-2.67

Consulted private doctor 46 47 0.96 0.53-1.74

Consulted traditional healer 7 5 1.43 0.39-5.41

Table II Associations with late and early booking (mean)Late n=100

Early n=100

p-value

Mothers' first awareness of pregnancy (weeks) 10.0 8.7 0.78

Mothers' idea of when to book (weeks) 14.8 12.8 0.006

Time taken to get to clinic (minutes) 32 29 0.52

Cost of transport to clinic (Rand) 3.52 3.50 0.49

Table III Frequencies of previous obstetric risk factorsRisk factor Late

n=100Earlyn=100

Odds ratio 95% confidence interval

Caesarean section

28 23 1.30 0.66-2.59

Miscarriage 14 21 0.61 0.27-1.36

Preterm delivery

15 22 0.63 0.28-1.37

Perinatal death 4 11 0.34 0.09-1.20

Table IV Reported reasons for late bookingReason Number

Lack of knowledge of early booking 25

Living in other provinces, came to Gauteng for delivery 19

Working or at school 16

Money or transport problems 11

No reason given 3

Others 3

ConclusionIn this study population, late booking is not associated with poverty, education, employment status or increasing distance from the clinic facility. Women with poor obstetric histories understandably book earlier in their pregnancies, reflecting their own concern or following the advice of previous caregivers. Mothers with unplanned pregnancies tend to book late and must be considered to be a high-risk social group, not only for their pregnancies but also for childrearing. A large percentage of mothers attend private practitioners before booking for antenatal care. There needs to be a greater awareness of the value of antenatal care, both in the community and among general practitioners, so that early booking can become the established norm as it is in developed countries.

HYPERHOMOCYSTEINAEMIA IN ABRUPTIO PLACENTAE

AA Carolissen*, HJ Odendaal*, DW Steyn*, EP Owen+, DP Human+, PH Harley+

* Department of Obstetrics and Gynaecology, University of Stellenbosch and MRC Perinatal Mortality Research Unit, Tygerberg Hospital+ Department of Chemical Pathology, University of Cape Town Medical School, Groote Schuur Hospital, Cape Town

IntroductionAbruptio placentae still contributes significantly to maternal and perinatal morbidity and mortality. The incidence rate of abruptio placentae at Tygerberg Hospital is 1.6% with a perinatal mortality of 523/1000. Abruptio placentae causes 25-34% of intrauterine deaths among patients in the lower socioeconomic group in South Africa. Antepartum haemorrhage, including abruptio placentae, was responsible for 25.5% of the total perinatally related wastage in the area serviced by Tygerberg Hospital in 1993/94. Numerous risk factors for abruptio placentae have been identified. Recently, hyperhomocysteinaemia has been identified as a risk factor for placental vasculopathy. Steegers-Theunisen et al found a prevalence of 25% of hyperhomocysteinaemia in patients

with previous placental abruptions or recurrent spontaneous abortions, while Goddijn-Wessel et al found hyperhomocysteinaemia in 31% of women with a history of placental vasculopathy (abruption or infarction) compared to 9% in the control group.There are different pathways of homocysteine metabolism and each pathway has regulatory factors, cofactors and enzymes, with folic acid, vitamin B6 and vitamin B12 playing integral roles.The purpose of this study was to establish the prevalence of hyperhomocysteinaemia in women where the pregnancy was complicated by abruptio placentae in our population.

Patients and MethodsA case-control study was undertaken where twenty-one patients in whom the pregnancy was complicated by abruptio placentae were compared with 17 normal controls. Patients were recruited into the study group if the index pregnancy was complicated by abruptio placentae at a gestation of > 28 weeks or when the estimated birthweight was > 1000grams if the gestation was unknown.Fasting blood levels were done for

renal and liver functions, vitamin quantitations (red blood and serum folate, B6, B12) and total homocysteine. Peak homocysteine levels were repeated 6 hours after a standardised methionine loading test.

ResultsThere was no difference with regard to age, gravidity, parity, and bodyweight between the study and control groups. There was a statistically significant difference as regards the mean gestational age (32.5 weeks in the study group: 38.4 weeks in the controls) and the mean birthweight (1728g in the study group; 3052g in the controls).The mean baseline total homocysteine level in the study group was 8.0mol/l (range = 3.4-16.5) compared to 4.8mol/l (range 2.8-8.2) in the control group. This difference was statistically significant (p=0.0013). The mean peak total homocysteine level in the study group was 30.8mol/l (range=15.4-106.1) compared to 20mol/l (range=11.4-16.5) in the control group (p=0.012). Hyperhomocysteinaemia was diagnosed when the baseline and/or peak total homocysteine level exceeded the mean value of the

controls by two standard deviations. Therefore, hyperhomocysteinaemia occurred in 9/21 (43%) patients in the study group, and in 1/17 (6%) in the controls.There was no statistically significant difference between the study and control groups with regard to vitamin quantitations (folate, B12, and B12).

DiscussionMean baseline and peak total homocysteine levels in patients who had abruptio placentae were significantly higher than that of the control group. The prevalence of hyperhomocysteinaemia using the parameters of baseline and peak total homocysteine in the study group was 43% and 24% respectively, with an overall prevalence of 43%. These results confirm European results of the prevalene of approximately 30%.What is also of note is that by using peak levels, no additional patients with enzyme or metabolic block

rather than a nutritional deficiency is the underlying pathology in hyperhomocysteinaemia and abruptio placentae, although nutritional supplementation may overcome such an enzymatic block, even in the absence of a deficient status. The difference in gestational age and birthweight in the two groups may reflect management protocol as patients with abruptio placentae are delivered expeditiously, often at preterm.Hyperhomocysteinaemia has been identified as a possible risk factor for abruptio placentae in our study population, larger studies are needed to confirm this finding and to establish whether antenatal and preconceptional values also correlate with abruptio placentae.DOES BETAMETHASONE TREATMENT, TO ENHANCE FETAL LUNG MATURITY IN PATIENTS WITH SEVERE PROTEINURIC HYPERTENSION LESS THAN 34 WEEKS' GESTATION, HAVE ANY ADVERSE EFFECTS ON THE BASELINE VARIATION AND OTHER PARAMETERS OF THE FETAL HEART?

G van Rensburg, DW Steyn, HJ OdendaalDepartment of Obstetrics and Gynaecology, University of Stellenbosch Medical School, Tygerberg Hospital

Introduction : Conservative management of selected patients

with severe proteinuric hypertension leads to an improved neonatal outcome without any detrimental effects for the mother. Frequent fetal heart rate monitoring (four times daily) is necessary due to the high incidence of abruptio placentae in these patients and it may contribute to early diagnosis of fetal distress in these patients. It has been shown that neonatal outcome in patients with non-reactive fetal heart rate patterns is the same as patients with reactive patterns,

unless the beat-to-beat variation is less than five beats per minute. Therefore, the beat-to-beat variation, is the main component of evaluation used at Tygerberg Hospital. It was shown by Derks et al that betamethasone, which is routinely administered to these patients, may reduce the beat-to-beat variation for as much as two days after administration. It was thus necessary to investigate if such an effect could be demonstrated in our patients treated in the special care obstetric ward.

Objective : To examine the effects of maternal betamethasone administration on fetal heart variation and other parameters of

the fetal heart in patients with severe proteinuric hypertension less than 34 weeks' gestation - a retrospective, descriptive study.

Design : Fifteen patients on nineteen occasions were included in the analysis. All of them were admitted to the special care obstetric ward and managed conservatively with bed rest, antihypertensive treatment and close maternal and fetal monitoring. Fetal monitoring was done with the Sonicaid system 8000 four times daily. Betamethasone 12mg was routinedly administered twice 24 hours apart. Gestational age ranged from 28 to 34 weeks.

Results : It took a significantly longer time to reach the Dawes/Redman criteria after betamethasone administration, especially on day 2 (p=0,03) compared to day 0 (the day betamethasone was given). There was a significant drop in the MMR on day 1 (p=0,001) and day 2 (p<0,0001) which returned to normal of day 3. A significant reduction in short term variation was found on day 1 (p=0,0009) and day 2 (p=0,0002) as well as a significant reduction in the best-to-beat

variation on day 1 (p=0,009) and day 2 (p=0.0009) returning to normal values on day 3. We also found a trend towards significant reduction in the amount of accelerations >10 beats/minute on day 1 (p=0,067) and significantly more time was spent in low variation on day 1 (p=0,03) and day 2 (p=0,03), which returned to day 0 levels on day 3.

Conclusions : Maternal betamethasone administration causes a significant but transient

reduction in the baseline variability and other parameters of the fetal heart. Although this effect is not a sign of fetal distress, knowledge of it is important when assessing the fetal condition. The effect may be due to a glucocorticoid receptor mediated process in the fetal brain. Dexamethasone has been reported to have the opposite effect on the fetal heart rate variation and we advise that a randomised controlled trial is necessary for further research.

ORAL KETANSERIN IN MILD MIDTRIMESTER HYPERTENSION - A RANDOMISED CONTROLLED TRIAL

DW Steyn, HJ OdendaalDepartment of Obstetrics and Gynaecology, Tygerberg Hospital and the University of Stellenbosch and the MRC Unit for Perinatal Mortality

BackgroundPre-eclampsia is associated with extensive endothelial cell damage and platelet activation, resulting in a reduction of vasodilator prostaglandins and an increased release of thromboxane A2 and serotonin, both potent vasoconstrictors. Injury of endothelial cell serotonin-1 receptors leaves the serotonin-2 receptor mediated vasoconstriction and platelet aggregation relatively unopposed. We investigated the role of ketanserin, a selective serotonin-2 receptor antagonist, to decrease the incidence of pre-eclampsia in patients with mild to moderate midtrimester hypertension.

MethodsA double blind randomised placebo controlled trial was performed. Patients with a diastolic blood pressure value before 20 weeks gestation persistently between 80 and 109 mm Hg received either

ketanserin or a similar looking placebo. Both groups received 75mg aspirin per day.

ResultsSixty nine patients were recruited in each leg. In the ketaserin group a statistically significant reduction occurred in the total incidence of pre-eclampsia according to the ISSHP definition (2 vs 13), with less cases of pre-eclampsia before 34 weeks gestation (1 vs 5) (Table 1). There were significantly fewer cases of severe hypertension (6 vs 17) in the ketanserin group (Table 2). There were significantly fewer cases with neonatal morbidity (Table 3) and also a trend to less perinatal mortality (1 vs 6).

ConclusionsThe addition of ketanserin to aspirin in patients with mild to moderate midtrimester hypertension was associated with improved pregnancy outcome. These findings need to be confirmed in larger studies in different populations.

Table 1 The distribution of the occurrence of pre-eclampsia according to the definition of the International Society for the Study of Hypertension in Pregnancy (ISSHP) and the definition used in the Clasp study

Gestational age (weeks)

KETANSERIN PLACEBO

ISSHP CLASP ISSHP CLASP

< 28 0 0 0 1

28 - 29 0 0 1 1

30 - 31 0 0 2 1

32 - 33 1 0 2 0

34 - 35 0 0 2 1

36 - 37 0 0 3 2

38 - 39 1 1 3 0

2 1 13 6

Table 2 The distribution of complications associated with hypertension in the two study groups. The numbers in brackets represent the percentage of patients in the subgroup who developed the particular complication

Ketanserin Placebo p

Antenatal drugs requiredOralParenteralParenteral (intrapartum)Any antenatal drugsSevere hypertensionPre-eclampsia developing on oral medicationPerinatal losses on oral medication

11 (16)3 (4)2 (3)

13 (19)6 (9)1 (9)

0

23 (33)11 (16)

5 (7)28 (41)17 (25)12 (52)

4 (17)

0.030.0480.440.010.020.02

0.28

Table 3 A comparison of perinatal outcome in the two study groups

Ketanserin Placebo p

Gestation at birth (weeks)Losses before 28 weeksDeliveries 28 to 34 weeksBirth weight (g)Morbidity among survivorsApgar score at 1 minute

37.611

307429

36.229

2791129

0.021

0.0090.030.010.55

Apgar score at 5 minutesNeonatal days in hospital

102

102

0.550.81

THE CONFIDENTIAL ENQUIRY INTO MATERNAL DEATHS - THE MATERNAL DEATH NOTIFICATION FORM

E Retief

Obtaining information of maternal deaths is critical in determining the public health of a country and necessary to design appropriate interventions to reduce maternal mortality. This implies that preventable causes of maternal deaths should be identified.The Department of Health is committed to identifying preventable causes of maternal deaths. Presently there is not sufficient reliable information on the number of maternal deaths that occur in the country which can be used to identify the extent of the problem. To ensure that preventable causes of maternal deaths be identified and addressed in the future, all maternal deaths therefore should be notified. A confidential enquiry into the maternal deaths that occurred, should be conducted by the National Committee.A notification form for maternal deaths has also been developed and distributed to the provinces. The aim of this form is to obtain relevant and reliable information on a maternal death. It is designed so

that the health history of the mother can be investigated. The maternal death notification form must be completed for all deaths, including abortions and ectopic gestation related deaths, in pregnant women or within 42 days after termination of pregnancy irrespective of the duration or site of the pregnancy. The form should be completed within 7 days of a maternal death. The original form remains at the institution where the death occurred and the copy is sent to the person responsible for maternal health in the relevant province. A copy of the patient's file must also accompany the form.Guidelines for completing the maternal death notification form have been developed to ensure that relevant and reliable information can be obtained.The Department of Health established a National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) to evaluate all reported maternal deaths. The NCCEMD is tasked with making recommendations, based on the confidential study of maternal deaths to the Department of Health. The implementation of the recommendations could possibly contribute to the reduction of

maternal deaths. The information obtained for the confidential enquiry will only be available to specific health professionals, provincial

assessors and the members of the National Committee for Enquiries into Maternal Death (NCCEMD).

By defining the problem using the four features (see Table 1), the Minister of Health, the Provinces, Regions and Districts will be able to address the problem. Where diseases cannot be prevented, research energies can be driven in that direction to try and solve the problem. Where problems in the health system are identified, these can be addressed and rectified.

The process used is called the ICA Solution audit system. This system has been successfully used to bring down the perinatal mortality in various regions in South Africa and is incorporated in the Perinatal Problem Identification Programme.

The process is summarised by the diagram below:

Maternal Death

Sent

Report completed within 7 days

ProvincialAssessor

ProvincialMCWH

Returned within 30 days

Death notified and a unique number given

Provincial Assessor's report sent

NCCEMDSecretariat

NCCEMD

Report

Distrbuted to Provinces, who distribute information to Regions and Districts

All basic datadestroyed

MATERNAL MORBIDITY : A DEFINITION FOR A MATERNAL "NEAR MISS"

GD Mantel*, E Buchmann**, RC Pattinson* H Rees***Departments of Obstetrics and Gynaecology, University of Pretoria* and University of the Witwatersrand**, Reproductive Health Research Unit***

Objective : To develop a user friendly audit system for maternal health co-ordinated by a referral hospital, which will identify missed opportunities for intervention at all levels of a health care system in a defined community.Design : A descriptive study : a pilot over 10 months.Setting : Kalafong and the Pretoria Academic Hospitals.Intervention : A "near miss" describes a patient with an acute organ system dysfunction, which if not treated appropriately could result in death. Medical documentation was made of all pregnant or puerperal women fitting the definition of a maternal "near miss" as well as all maternal deaths.Outcome measure : Determine the primary obstetric factors and the main organ system dysfunction in pregnant women who fit the definition of a "near miss". Missed opportunities in each case were identified with respect to the health

care worker, the administration and the patient herself.Results : 113 "Near Miss" patients were identified, with the most common reason being hypotension requiring 5 or more units of packed cells or fresh frozen plasma for resuscitation in 36 cases. This was followed by 31 cases requiring an emergency hysterectomy and 20 cases in which a clinical diagnosis of pulmonary oedema, necessitating intravenous furosemide, was made. The most common primary obstetric problems were hypertensive disorders in 31 cases, haemorrhage (ante- & post partum) in 24 cases and 25 cases of sepsis (abortion and pregnancy related sepsis). The most common complicating factors were hypovolaemic shock in 47 cases, fluid overload in 22 cases and septic shock in 22 cases. There were 21 maternal deaths at these hospitals over the same time period. These cases had the same primary obstetric causes as the maternal "near misses".Proportionately there were more respiratory or cerebral dysfunction amongst the pregnant women who died as compared to those with severe morbidity. Missed opportunities by health care workers were identified in 68 cases.

Breakdown in the health care administration was identified in 21 cases, while there were patient

orientated mistakes in only 17 incidents.

Conclusions : This pilot study identified 5 times as many cases of severe maternal morbidity than there were cases of maternal mortality (113 versus 21 cases respectively). The underlying primary obstetric factors and the complicating factors appear to be similar between cases of severe morbidity and mortality. 60% of these cases could possibly have been avoided.

THE EFFECT OF THE PERINATAL PROBLEM IDENTIFICATION PROGRAMME IN THE WITBANK DISTRICT IN 1996

D Kotzé, R ChegwiddenWitbank Hospital

ObjectiveTo analyse the effect of the Perinatal Problem Identification Programme in a clearly defined health district.

Method

AREA - Witbank district which includes

Hlananikhalhle, Kwaguqa community and referrals, Kwaguqa other areas, Witbank community, Witbank other areas and Ogies.STUDY PERIOD - 1 January to 31st December 1996

DATA COLLECTED - Patient records, monthly meetings and feedback

ResultsSummarised in the following tables.

Perinatal Mortality - Witbank District

Table 1 Comparison of the Witbank District's Perinatal Care Indices from January to June and July to December 1996

January - June July - December p

Total deliveries 2161 1981

Total live births 2092 1930

Total deaths 94 61 0.038

Stillbirths 69 51 NS

Neonatal deaths 25 10 0.032

Perinatal Mortality Rate

43.5 30.8

Stillbirth rate 31.9 25.7

Neonatal Death Rate

12.0 5.2

Low birth weight rate (%)

11.5 10.8

Perinatal Care Index

0.26 0.35

Table 2 Comparison of the Witbank District's Primary Obstetric Cause of Death from January to June and July to December 1996

CAUSE January - June July - December

p

N Rate/1000 deliveries

N Rate/1000 deliveries

Unexplained intrauterine death Due to lack of informationTruly unexplained

26188

12,020128

10,1 NS

Intrapartum Asphyxia 7 3,2 7 3,5 NS

Trauma (Breech del/ruptured uteri) 4 1,9 3 1,5 NS

InfectionSyphilisOther

1183

5,1761

3,5 NS

Spontaneous preterm delivery 16 7,4 7 3,5 NS

Antepartum Haemorrhage 15 6,9 4 2,0 NS

Hypertensive Conditions 10 4,6 3 1,5 NS

Fetal Abnormalities 5 2,3 5 2,5 NS

Primary Intrauterine Growth Impairment

_ _ 4 2,0 NS

Maternal Diseases _ _ 1 0,5 NS

Total 94 43,5 61 30,4 0,038

Table 3 Comparison of the Witbank District's Final cause of Neonatal Death from January to June and July to December 1996

CAUSE January - June July - December

p

N Rate/1000 deliveries

N Rate/1000 deliveries

Asphyxia and birth trauma 12 5,7 4 2,1 NS

Prematurity related 10 4,8 4 2,1 NS

Infection 1 0,5 _ _ NS

Congenital Abnormalities 2 1,0 2 1,0 NS

Total 25 12,0 10 5,2 0,032

Table 4 Comparison of the Witbank District's occurrence of

avoidable factors from January to June and July to December 1996

AVOIDABLE FACTOR January - June July - December p

N % of assessable deaths

N % of assessable deaths

Health personnel relatedAntenatal CareIntrapartum CareNeonatal CareReferral

42181446

45,2 37171046

51,7 NS

Patient Orientated 32 34,4 22 37,9 NS

Administrative Related 20 21,5 10 17,2 NS

DiscussionThe perinatal mortality rate for the year for babies weighing more than 1000g was 38.5 per 1000 deliveries. There was a significant reduction in deaths in the second six months of the year when compared to the first (30,4 as opposed to 43,5).Avoidable factors presented in more than half the deaths, but there was a 50% decline in avoidable factors relating to

intrapartum care in the second six months.The major antenatal problem identified was inadequate syphilis screening.Intrapartum complications included asphyxia, birth trauma and breech deliveries.

Maternal syphilis serology of perinatal deaths : Witbank district1 January 1996 to 31 June and 1 July to 31 December 1996

1 January - 30 June 1996 1 July - 31 December 1996

RPR/VDRL positive 8,8% of deaths 12,9% of deaths

RPR/VDRL negative 28,1% of deaths 50,0% of deaths

RPR/VDRL not done 63,2% of deaths 35,7% of deaths

Results not available 0,0% of deaths 1,4% of deaths

ConclusionThe introduction of the Perinatal Problem Identification Programme has been associated with a significant decline in the perinatal mortality rate. Awareness of the problem has been increased by holding workshops, discussion groups & in service education sessions. Interest has been stimulated. Staff from all clinics and the referral hospital are now involved. Work is still in progress on the solutions to the identified problems.

THE IMPORTANCE OF LOCAL AUDIT

M Muller

ObjectiveTo compare the perinatal problems in two well defined health districts - Middelburg and Lydenburg - over a period of 12 months.

MethodPPIP (Perinatal Problem Identification Programme) was introduced in the districts through:- Monthly meetings to allocate

causes and analyse avoidable factors.

- Bimonthly feedback and continuing medical education for Middelburg and Lydenburg District.

ResultsIn Middelburg Districts 182 deaths were studied, and in Lydenburg 99 deaths.The causes of death were classified into primary obstetrical causes and final causes of death.Perinatal mortality defined babies >1000g.

Primary obstetrical causes of deaths

Middelburg district% No

Lydenburg district% No

Spontaneous preterm labour 21,3 30 17,7 14

Intrapartum asphyxia 8,5 12 21,5 17

Hypertensive disorders 12,8 18 7,6 6

Infections 9,9 14 8,9 7

Antepartum Haemorrhage 5,7 8 8,9 7

Others 41,8 59 35,4 28

TOTAL 100 141 100 79

Final causes of death

Prematurity related 39,6 21 25,8 8

Asphyxia and birth trauma 22,6 12 41,9 13

Infection 18,9 10 12,9 4

Others 18,9 10 19,4 6

TOTAL 100 53 100 31

The most common neonatal cause of death in Middelburg District was spontaneous preterm labour 21,3%, and in Lydenburg: intrapartum asphyxia 21,5%.

Maternal Syphilis serology of perinatal deathsMaternal syphilis serology

Middelburg district (%) Lydenburg district (%)

RPR Positive 16,2 6,1

RPR Negative 31,9 2,0

RPR Not done 51,9 89,9

Results not available 0 2,0

Avoidable factors:Middelburg district Lydenburg district

Patient 45 22

Administrative Problems 14 13

Medical PersonnelANCIntrapartumNeonatal careReferrals

12327

14

8271119

Major problems in Middelburg and Lydenburg district were:Medical Personnel:- Intrapartum care - due to the

fact that fetal distress was not detected because the partogram was not used, or was used incorrectly, fetus was not monitored or signs were interpreted incorrectly.

- Neonatal care - inadequate neonatal resuscitation and management plan.

- Delay in referring patients for secondary/tertiary treatment

especially in Lydenburg district.

Administrative Problems:Most were due to personnel not sufficiently trained to manage the patients and syphilis screening was not done.Patient problems:Mostly unbooked patients and delay in seeking medical attention during labour, maybe because of lack of transport.

DiscussionTo address the problems in

Middelburg and Lydenburg districts; tailor-made protocols based on the PEP maternal and neonatal manuals

are being drafted, and each will be applicable for its own district.

At present, the major problem in the Middelburg district is neonatal care, and in Lydenburg district: intrapartum care. Since the programme was introduced, medical and nursing personnel are becoming more aware of problems and shortcomings and are seeking solutions to these problems.The rapid RPR test was introduced in the districts and personnel are starting to use it to great effect.Personnel involved in maternal and child care are busy doing the PEP programme in order to update themselves and draft policies applicable to each district.Workshops, formal and informal lectures, and discussions are given on a continuing basis, to improve antenatal, intrapartum and neonatal care.

ConclusionIt is important to note the causes of death are different in each district as are the problems. Thus each district needs such an audit if it wishes to identify and solve its maternal and infant health care problems. Therefore, define the problem before proclaiming the solution.

SEEKING SALEABLE SOLUTIONS: RESULTS OF A REGIONAL PERINATAL AND MATERNAL MORTALITY AUDIT

RC Pattinson, Department of Obstetrics and Gynaecology, University of Pretoria and Kalafong HospitalM Muller, Development Officer, Middelburg and Lydenburg DistrictsD Kotze, Chief Professional Nurse, Witbank Hospital

IntroductionThe Perinatal Problem Identification Programme (PPIP) is a simple perinatal mortality audit programme that analyses all perinatal deaths in an area and gives a series of perinatal care indices, the causes of perinatal deaths and defines at what level there has been a breakdown in perinatal care. The system has been computerised on a user friendly programme using the ICA Solution audit system. PPIP was developed at and by the Obstetrics and Gynaecology Department of the University of Pretoria, and had been tested in the Pretoria health region. The programme was originally developed to promote perinatal mortality meetings in rural and non-academic secondary hospitals. However, after its beneficial effect was noted in the Pretoria Region, it was thought suitable to test PPIP as

a perinatal audit system for a district, region and even province. With this in mind, a project was started in the 3 districts of the HIghveld Region of Mpumalanga.ObjectiveTo field test the Perinatal Problem Identification Programme (PPIP) in a large health region, and to measure its impact, if any.

MethodTwo local "research assistants (MM and DK) were appointed by the regional health authority to collect the data and run the programme with the assistance of RCP. It was thought essential the health authority "employ" local people so that if the project was successful, PPIP could continue. Running PPIP has become part of the job description of these two health workers. The process followed is given below:1. Monthly data analysis

meetings for all districts with MM and DK.

2. Monthly perinatal mortality and feedback meetings in the Witbank district.

3. Bimonthly perinatal mortality meetings and continuing medical education sessions for Middelburg and Lydenburg

Districts. The difference between Witbank and Middelburg and Lydenburg districts was for geographical

reasons.

Results

During 1996 there were 8019 deliveries of babies more than 1000g and 318 babies died. The Perinatal Mortality Rate (PNMR) for the whole region for 1996 was 39.6/1000 deliveries. From January to June it was 43.8 and from July to December 35.4. This represents almost a

20% reduction in mortality and is significant, p<0.01. The low birth weight rate was 12% in the first six months and 10.8% in the second six months.

Table 1 Primary Obstetric Cause of DeathCause n % of

totalRate/1000 deliveries

Unavoidable Unexplained intrauterine deathsCongenital abnormalities

8821

27,86,6

11,02,6

Mostly avoidable

Intrapartum abnormalitiesTrauma (breech and ruptured uteri)Infections

381234

11,73,8

10,8

4,61,54,2

Sometimes avoidable

Spontaneous preterm deliveryHypertensive conditionsPrimary intrauterine growth impairmentMaternal diseases

553063

6,99,51,60,9

17,43,70,60,4

Mostly unavoidable

Antepartum Haemorrhage 31 9,8 3,9

Total 318

100 39,6

Note: If the unavoidable deaths are excluded, intrapartum asphyxia, trauma and infections account for 40,1% of deaths

Table 2 Final Cause of Neonatal deathCause n % of

totalRate/1000deliveries

Asphyxia and birth trauma 38 39,6 4,9

Prematurity related 36 37,5 4,6

Infections 9 9,4 1,2

Congenital abnormalities 14 14,6 1,8

Total 96 100 12,4

The neonatal mortality rate per weight category is as follows:

Weight category NMR/1000 deliveries

1000-1499g 458

1500-1999g 131

2000-2499g 27

2500g+ 4

Table 3 Avoidable FactorsAvoidable factor n % of assessable

deaths

Health Personnel RelatedAntenatal CareIntrapartum CareNeonatal CareReferral related

18652642341

61,0

Patient Orientated 100 32,8

Administrative Related 53 17,4More than one avoidable factor can be present per case

Discussion The way forward. Seeking saleable solutions1. Areas of improvement that do

not require extra funding* Development of appropriate

individualised management protocols for the clinics, level 1 and level 2 hospitals for each district that the health workers (from clinics and hospitals, doctors and nurses) and management buy into. Protocols to be based on the Perinatal Education Programme.

* Establishing a referral pattern which is adhered to.

* Training in the protocols.* Audit to see that what was

agreed upon is occurring.

2. Areas of improvement that will require extra funding

* Antenatal screening for syphilis

* Transport* Appropriate staffing* Population education

Conclusions* PPIP functioned well in the

region and is a suitable audit programme for health authorities to use to identify

problems in maternal and neonatal care.

* Audit is not enough and specific processes need to be introduced to alter the way maternal and neonatal care is practised.

A TEN YEAR REVIEW OF BLOOD CULTURE ISOLATES FROM THE NEONATAL UNIT OF GA-RANKUWA HOSPITAL 1987-1996

M Driessen, M Mawela, F MuwaziDepartment of Paediatrics and Child Health, Medunsa

The total number of blood cultures taken in the Neonatal Unit at Ga-Rankuwa Hospital was reviewed over the last 10 years from 1987 to 1996. An average of

1 748 blood cultures were taken each year (range 1044-2229). The average positive cultures were 17,8% (range 7.6% - 24.9%) (Table 1).The six most common organisms that were isolated from the blood cultures for each year are summarised in Table 2.The trend observed in the incidence of the most common organisms are illustrated in Table 3.

Table 1Year Total blood

culturesPositive blood

cultures% Positive blood

cultures

1987 1 044 192 18,3

1988 1 427 312 21,8

1989 1 843 454 24,6

1990 1 879 437 23,2

1991 2 146 532 24,9

1992 2 229 380 17

1993 2 003 313 15,6

1994 1 749 244 14

1995 1 591 165 10,4

1996 1 570 120 7,6

Table 2 Common organisms isolated from blood cultures1987 % 1988 % 1989 % 1990 % 1991 %

Staph epi 36Klebsiella 16.7E.Coli 11.5Staph aureus

11.5Streptococci

8.3Enterobacter 2

Staph epi 29.8Fungi 14.5Klebsiella 14.4Streptococci

7.4Staph aureus

5.1E.Coli 3.5

Staph epi 31.3Fungi 14.5Streptococci

9.9Klebsiella 6.8Staph aureus

4.2Corynebacte-rium 3.7

Staph epi 46.7Streptococci

10.5Klebsiella 8Fungi 6.9Bacillus 5.3E. Coli 5

Staph epi 51.3Streptococci

10.9Klebsiella 9.6Fungi 7.1Staph aureus 5E. Coli 3.2

1992 % 1993 % 1994 % 1995 % 1996 %

Staph epi 46,8Streptococci

13.1Fungi 10.5Klebsiella 8.7Coryne bacterium 4.5E.Coli 3.2

Staph epi 47.9Klebsiella 14Streptococci

11.8Bacillus 6Staph aureus

3.8Fungi 3.5

Staph epi 49.1Streptococci

18.1Klebsiella 9.8E. Coli 6.6Staph aureus

3.7Bacillus 3.7

Staph epi 49Streptococci

17.6Klebsiella 6.7E.Coli 5.5Staph aureus 3Enterobacter 3

Staph epi 45Klebsiella 17.5Streptococci

12.5E. Coli 7.5Staph aureus

5.8Enterobacter

4.2

Comments1. This was a retrospective study

and positive blood cultures were not correlated with clinical signs of sepsis in the infants.

2. Sepsis due to commensual species has become an increasing problem in the neonatal ICU. However, the high incidence of Staph epidemidis

suggests contamination during blood sampling and not always sepsis. It is necessary to study the real incidence of sepsis due to Staph. epidermidis in neonates.

3. It would be of great value to compare the incidence and trends of isolates from our hospital to those of other institutions.

SCREENING FOR PREGNANCY BACTERIURIA

LR Pistorius, ET BvumaDepartment of Obstetrics and Gynaecology, University of Pretoria and Kalafong Hospital

IntroductionAsymptomatic bacteriuria in pregnancy is associated with acute

pyelonephritis and preterm labour. These complications are reduced by treating patients with bacteriuria. A programme of screening and treatment is cost effective where the

prevalence exceeds 2%. Urine culture remains the gold standard for diagnosing asymptomatic bacteriuria but is not always logistically possible.A simple and less expensive screening method is required. Local

studies have demonstrated low sensitivity for reagent strip testing for detecting bacteriuria in pregnancy. The current study was undertaken to confirm this and also to test the feasibility of inoculating a urine sample at the antenatal clinic.

Table 1 Literature reports on urine dipstick testing for pregnancy bacteriuriaCulture positive

Culture negative

Sen (%) Spe (%) PPV (%) NPV (%)

N+ 216 42 41 99 84 96

N- 316 7231 (36-45) (99-100) (79-88) (95-96)

L+ 166 396 58 90 30 97

L- 121 3489 (52-64) (89-91) (26-34) (96-97)

L+ or N+ 248 467 72 90 35 98

L- or N- 95 4056 (67-77) (89-91) (31-38) (97-98)N = nitrite; L = leukocyte esterase; L+ or N+: either leukocyte esterase or nitrite positive; L- and N-: both leukocyte esterase and nitrite negative)Prevalence=7.9%

MethodsA study was designed to test urine dipstick on fresh and old urine samples. All patients attending the first antenatal visit at the Pretoria West Midwife Obstetric unit and the community clinics at Atteridgeville

were enrolled into the study. Oral consent was obtained. A clean catch urine specimen was tested using Multistix 9 (Ames Multistix, Bayer Diagnostics) reagent strip. A platinum loop was used to inoculate 0.001ml of urine onto MacConkey and blood agar plates in the clinic.

The inoculated plates and the remaining urine sample were sent to a central laboratory within 6 hours where the procedure was repeated. Patients with a positive nitrite test and a positive culture were repeated. We aim to enrol 580 patients.

ResultsInterim results after 157 patients are as follows:

Table 2 Urine dipstick testing for pregnancy bacteriuria: comparing dipsticks on fresh urine, with positive culture on both fresh and old urine samples

Culture positive

Culture negative

Sen (%) Spe (%) PPV (%) NPV (%)

N+ 5 5 26 96 50 91

N- 14 133 (10-51) (91-99) (20-80) (84-95)

L+ 12 48 63 65 20 93

L- 7 90 (39-83) (57-73) (11-33) (85-97)

L+ or N+ 14 49 74 65 22 95

L- or N- 5 89 (49-90) (56-72) (13-35) (88-98)N = nitrite; L = leucocyte esterase; L+ or N+: either leukocyte esterase or nitrite positive; L- and N-: both leucocyte esterase and nitrite negative)Prevalence=12.1%

ConclusionThe results so far fit in with the 95% confidence intervals of the available literature data. The prevalence is 12.1%. Reagent strip testing appears to have an acceptable sensitivity and specificity as a screening method. The study will continue to evaluate the role of reagent strip testing as a screening test for asymptomatic bacteriuria in pregnancy.

PREVENTION OF REPEAT ABRUPTIO PLACENTAE

L Schoeman, DW Steyn, HJ OdendaalDepartment of Obstetrics and Gynaecology, University of Stellenbosch

Abruptio placentae (AP) is the major cause of perinatal mortality at Tygerberg Hospital. Patients with a history of two or more previous

episodes are considered to be at a particularly high risk of recurrence in a subsequent pregnancy.

Aim : To determine if early admission with intensive fetal monitoring and elective delivery decreases the risk of recurrence in patients with a history of recurrent AP.

Methods : Patients with at least two documented previous episodes of AP received antenatal care at the special care obstetric unit and were offered admission to the special care ward at 28 weeks gestation. The fetal heart rate was monitored four times daily and betamethasone administered weekly. Delivery was considered at 34 weeks gestation unless otherwise indicated earlier.

Results : Thirty six patients were followed up in thirty nine pregnancies over nine years. Five of the 36 patients had three previous documented episodes of abruptio placentae.Maternal outcome : The median age for mothers admitted was 30 years (22-44) with gravidity of 4 (3-

7) ad parity of 3 (2-6). On average they had one live child at home (0-2). The median gestation for admission to the Special Care Ward was 29 weeks (26-38) and the average duration of antenatal admission was 28 days (2-50). The median gestation at delivery was 33 weeks (28-36). Twenty four patients were delivered by caesarean section and fifteen vaginally. Nine patients had at least two previous caesarean sections in early pregnancies.Thirty one patients were delivered electively, one patient was delivered for suspected abruptio placentae and six patients for fetal reasons. Only one pregnancy was terminated for maternal reasons. (This patient had severe hypertension with superimposed pre-eclampsia).

Seven deliveries took place before 34 weeks gestation, one for abruptio placentae, five for fetal distress and one electively at 32 weeks gestation after an amniocentesis revealed a favourable LS ratio. Only one case of repeat abruptio placentae occurred. Decelerations were noted on routine fetal monitoring at 28 weeks gestation. At caesarean section 35% abruptio placentae was noted. The fetus weighed 1295g with Apgar scores of 5, 8 and 9. The baby required ventilation and spent three

days in neonatal intensive care.Fetal outcome : Thirty nine infants were delivered with a mean birthweight of 2147g + 507 (1230-3970). Three neonates, only one of which was delivered electively, were admitted to neonatal intensive care and made uneventful recoveries. Two of these infants were ventilated for one and four days respectively. One early neonatal death following elective delivery at 34 weeks occurred. This infant weighed 1920g and died on day three of necrotising

enterocolitis and fulminating septicaemia.

ConclusionAbruptio placentae is an important pregnancy complication in the population served by Tygerberg Hospital. Antepartum haemorrhage, including placental abruption, is responsible for 25,5% of the total perinatally related wastage (TPRW) in the area served by Tygerberg Hospital.Patients with a history of two previous episodes of abruptio placentae are reported to have a 25% risk of recurrence. Since most cases of perinatal mortality due to abruptio placentae are stillbirths, hospitalisation of patients at the highest risk could possible be of benefit provided that the condition be recognised early. Intensive fetal monitoring may play a role in this regard as it has been established that fetal distress due to abruptio placentae often occurs before the condition can be recognised clinically.The expected recurrence rate for abruptio placentae for this group of

patients as predicted in the literature is 25% which would amount to 9 or 10 recurrences in 39 cases and the equivalent related perinatal mortality about five or six deaths. We had one case of abruptio placentae. This is statistically lower than an expected number of nine (p=0.02). The single perinatal death in our study is possibly not directly related to management protocol. Whichever way one considers this, one death is not statistically significant from the expected five deaths. Even if this was the case, it would not be conclusive proof that our management is optimal.A randomised control trial where patients with two proven episodes of abruptio placentae are randomly allocated to either hospitalisation at 28 weeks gestation with intensive fetal monitoring and elective delivery or no routine admission with elective delivery at 38 weeks gestation as in the case of one previous abruptio placentae, would be the preferred method to evaluate management of these patients.

We were able to identify 39 cases of patients with two previous abruptio placentae over a course of eight years. It may be

impossible to accumulate enough patients for a randomised control trial, except over a long period of time.