Browsing by Author "Fawcus, Susan"
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- ItemOpen AccessA descriptive retrospective audit of the obstetric conditions which occur in mothers of babies with neonatal encephalopathy at Mowbray Maternity Hospital in 2016(2019) Dietrich, Liesl Bertha Kay; Fawcus, Susan; Linley, LucyIntroduction: Neonatal encephalopathy (NE) is an important condition which may result in mortality or severe and permanent morbidity placing much strain on busy under-resourced health care services, parents and families, and the greater community. There is much debate on its aetiology; whether it is caused by antepartum conditions or intrapartum obstetric complications (known as sentinel events); and the relative contribution of intrapartum hypoxia. Unlike perinatal mortality, NE rates are not routinely audited by maternity facilities. At Mowbray Maternity Hospital, a formal audit was conducted in 2008, which measured the NE rate, focussed on obstetric factors associated with NE and identified avoidable factors in the care provided. It was thought to be of clinical value to repeat this audit to identify whether there were any trends in rates and the pattern of obstetric factors. Aims and objectives: The aim was to describe the obstetric factors occurring in patients who delivered neonates at MMH, diagnosed with NE. Specifically, it was planned to determine the NE rate, to describe obstetric factors occurring in these patients and to assess the avoidable factors related to the patients, health system and clinical management. Methodology: This was a retrospective descriptive study which included patients whose neonates were diagnosed with NE and were born at MMH in 2016. The diagnosis of NE was made according to the MMH NE protocol where NE is defined as a voltage suppression in amplitude-integrated electroencephalography (aEEG) or seizures; or clinical seizures or dystonic movements; or moderate to severe clinical signs of NE as defined by Shankaran and a level of consciousness which is decreased with abnormal tone. The neonates’ names were retrieved from a NE register in the neonatal unit and the corresponding mothers’ folders retrieved. Data on relevant obstetric and clinical management factors were collected from the folders using a data collection tool developed in the Western Cape and all cardiotocographic tracings were assessed by the researcher. Ethics approval was granted by the University of Cape Town Human Research Ethics Committee (UCT HREC) prior to the commencement of the study. STATA 14 was used for the analysis. Results: In 2016, 53 neonates with NE were identified out of 9,702 live births (LB) at MMH. The NE rate was 5.5 per 1000 LB. Of the 53 neonates, 48 maternal patient files were retrieved and analysed. There were 58% who had been referred to MMH from the midwife obstetric units (MOUs), and 42% fully managed at MMH. All patients were booked for 14 antenatal care, the mean age was 27.5 years and 50% were nulliparous. The mean gestational age at delivery was 39 weeks. The majority (87.5%) experienced labour, spontaneous in 72.9% and induced in 14.6%. Antenatal complications occurred in 77.1%, the most frequent being prolonged pregnancy (25%) hypertensive disorders (18.8%), antepartum haemorrhage (8.3%) and prelabour rupture of membranes (8.3%). Obstetric problems in labour included prolonged second stage of labour (25% of patients who had a second stage of labour); multiple vaginal examinations (28.6%) and prolonged first stage of labour (17.9%). Fetal monitoring at the MOUs was done according to protocol in 70% of patients in the latent phase but only 12.5% of those in the active phase of labour. At MMH, all patients in labour had Cardiotocograph (CTG) monitoring with 90.6% of CTGs being pathological and 6.3% suspicious, as assessed by the researcher. Meconium stained liquor occurred in 40.5% of patients. The mode of delivery was normal vertex, (27.1%), Caesarean sections (58.3%) and assisted vaginal delivery (14.6%). Most CS (71.4%) were done for pathological CTGs. Sentinel events occurred in 15 (31.3%) patients; approximately two-thirds occurring intrapartum and one- third antenatal. Sentinel events included shoulder dystocia (10.4%), prolonged second stage of labour (10.4%), abruptio placenta (6.3%), cord prolapse (2.1%) and eclampsia (2.1%). Of the 37 (68.7%) without a sentinel event, 75.8% had a pathological CTG. Considering avoidable factors, there was an ambulance delay in 42.9%, and a delay in accessing theatre for 53.6% of patients requiring a CS. Poor quality CTG tracing and monitoring occurred in 20.8% of patients; and for 34.4%, the researcher identified an abnormal CTG but it was not detected by the attendant health care workers. Discussion and conclusion: The NE rate for MMH is 5.5 per 1000 LBs, this is higher than the 3.7 found in the previous 2008 MMH study, despite a higher CS rate. Possible reasons for the increase include changes in case ascertainment, increased workload with same staff component, or a shift from perinatal hypoxic mortality to morbidity, notably NE. This NE rate compares with other lower resource settings and the previous MMH audit, as does the high proportion of intrapartum obstetric sentinel events. This is in contrast to findings from high resource settings. Areas for service improvement include regular and ongoing intrapartum care training, including fetal heart monitoring, for medical and nursing staff; and addressing the health system issues identified.
- ItemOpen AccessAdvanced abdominal pregnancy: diagnosis, evaluation and surgical management in a resource constrained setting(2022) Elijah, Regis; Fawcus, Susan; Moja, Letticia M; Godi, Nthandho PIntroduction Advanced abdominal pregnancy (AAP) is a pregnancy of over 20 weeks gestation, with a foetus living, or showing signs of having once lived and developed, in the mother's abdominal cavity. It is a rare obstetric complication associated with high maternal and perinatal morbidity and mortality. The question of whether to leave the placenta in or to remove it has been the subject of debate. When such cases present outside high resource settings, where a multi-disciplinary approach may not be possible, there are many challenges to effective treatment. The management of this rare but serious complication of pregnancy at Rob Ferreira Hospital (RFH), a rural provincial tertiary hospital, in Mpumalanga, was investigated. Methods This was a retrospective observational study of patients with AAP identified from theatre registers from January 2011 to January 2018 at RFH. Data was collected on patient demographics, diagnostic challenges, preoperative evaluation, and surgical management particularly of the placenta, and outcomes. Delivery data for RFH was retrieved from the provincial database. Results There were 26 cases of AAP identified, for which 21 folders could be retrieved from the registry. The incidence of AAP was 66.2 per 100, 000 deliveries. Abdominal pain was a presenting complaint in 100% of patients. Ultrasound scan (USS) accuracy, prior to surgery, was eventually 90.5%. However, for 61.9% the diagnosis of AAP was missed at initial USS and for 33% of these, AAP was only diagnosed after failed attempts at induction of labour (IOL). AAP was diagnosed intra-operatively in 9.5%, for a supposed caesarean delivery and 19 (94.7%) were diagnosed pre-operatively. Intra-operatively, 36.8% patients had placental site bleeding for which partial placental removal was 2 necessary in 71.4%. This group had more adverse maternal outcomes. For 73.7% of patients there was no bleeding from placental bed and the placenta was left in situ; but 7.1% required relook laparotomy for haemorrhage. There was one maternal death. Overall neonatal survival rate was 14.3% and pregnancy loss rate was 71.4%. Conclusion This study shows that planned management of AAP in a resource constrained setting with tailored approach and management, can be performed without compromising maternal outcomes. However, poor outcomes occurred when pre-operative diagnosis was not made and AAP was discovered during emergency CS, emphasising the importance of antenatal diagnosis. USS and a high index of suspicion remains the best diagnostic tool. From this study it appears safe to leave the placenta undisturbed unless it can be safely removed, or the patient is already bleeding from the placental site. There were very low neonatal survival rates, and this needs to inform counselling of patients with AAP.
- ItemOpen AccessAn audit of caesarean sections performed for suspected fetal distress at Mowbray Maternity Hospital in 2018(2022) Moreri-Ntshabele, Badani; Fawcus, Susan; Kadwa, K; Petro, GregoryBackground The cardiotocograph (CTG) is used for fetal monitoring antenatally and in labour, to detect potential fetal hypoxia and thus prevent perinatal morbidity and mortality. An abnormal CTG influences decisions clinicians make in terms of timing and mode of delivery, as the type of abnormality may warrant immediate delivery by caesarean section (CS). However caesarean section rates are increasing worldwide and in South Africa, and ‘fetal distress' is one of the common indications. The increased CS rate also increases the risk of maternal morbidity and mortality. At Mowbray Maternity Hospital, weekly review meetings show that ‘pathological CTG' and ‘non reassuring CTG' accounted for the majority of emergency CS. Therefore, this study was undertaken to see if ‘fetal distress' is being over-diagnosed leading to unnecessary CS, or to affirm that the CS are correctly indicated for this diagnosis. Hence an investigation of caesarean sections done for ‘fetal distress in 2018 was performed in order to audit emergency CS performed at MMH for abnormal CTG tracings. Methods A retrospective observational study with a comparative component was performed. The PASS 2022 software was used to calculate the sample size. The calculation was made for proportions of agreement using a kappa statistic which was calculated to be 114 cases. The study population was derived from the institutional theatre register, in which patients, who had an emergency CS for an abnormal CTG or ‘fetal distress', between 01 January 2018 and 31 March 2018 were included. The CTGs were interpreted by the two obstetric specialistts (experts) and this was compared with the original interpretation made by the attending doctor. In addition, the independent experts assessed the appropriateness of the decision for CS. Data was also obtained on co-existing obstetric conditions, and perinatal and maternal outcomes. Ethics approval for the study was attained from the University of Cape Town Human Research Ethics Committee (UCT HREC) and facility approval from MMH. Results Ninety cases were identified from the study period and analysed. The attending doctor assessed 22 (24.4%) CTGs as suspicious and 68 (75.6%) as pathological, whereas the experts assessed 7 (7.8%) as normal, 22 (24.4%) as suspicious and 61 (67.8%) as pathological. There was overall agreement in CTG interpretation between the experts and the attendant doctor for 61 cases (67.8%). The reliability of this agreement was measured using Cohen's Kappa and was 0.247 (CI 0.153-0.341). This is a ‘fair' level of agreement. A further analysis showed that there was a higher proportion of agreement with pathological CTGs and a lower proportion of agreement for suspicious CTGs which accounted for 52 (57.8%) and 9 (10%) cases, respectively. A review of the medical records showed that 69 (77%) of patients had one or more co-existing obstetric condition such as prolonged pregnancy, hypertensive disorders, prolonged rupture of membranes and meconium-stained liquor etc. When considering these obstetric factors as well as the CTG, the experts assessed 16 women (17.8%) to have had unnecessary caesarean sections. In terms of neonatal outcomes, the mean five-minute APGAR was 8, and only 3 babies had a five-minute APGAR which was less than 7. Twelve babies (13.3%) babies were admitted to the neonatal unit and of those, 4 (4.4%) were admitted for low Apgar scores. The commonest maternal complication was PPH which affected 8.9% of the patients. Conclusion The inter-observer agreement in CTG interpretation at MMH was fair, which is comparable to other studies done in the world, with agreement on the indication for CS of 82.2%. The agreement in CTG interpretation was high with pathological CTGs and poor with suspicious CTGs. A second opinion for CS for abnormal CTG may reduce the number of unnecessary CS especially for suspicious CTGs. A normal CTG tends to affirm good fetal wellbeing, however an abnormal CTG does not always mean that there is fetal compromise, therefore the clinical condition must be evaluated together with the CTG to make an appropriate decision with regards to timing and mode of delivery.
- ItemOpen AccessAn audit of peripartum hysterectomies at Groote Schuur hospital, 2014 -2019(2024) Adjei, Alfred; Fakier, Ahminah; Fawcus, SusanBACKGROUND Peripartum hysterectomy is a major surgical procedure performed in the se ng of life-threatening haemorrhage and uterine sepsis unresponsive to conserva ve measures. The opera on is considered one of the major interven ons in obstetrics and carries high maternal morbidity and mortality, mostly due to the reasons for which it is done. An audit of peripartum hysterectomies was performed at Groote Schuur Hospital during 1999-2003, which showed the main indica ons were uterine sepsis and obstetric haemorrhage. The problem of uterine sepsis was at a me when there was a high rate of HIV infec on with no treatment available for mothers.The introduc on of an retrovirals for pregnant women was commenced in the Western Cape in 2001 with the use of single dose Nevirapine during labour or prior to caesarean sec on. Currently, all pregnant women living with HIV are immediately provided with lifelong treatment regardless of CD4 count and adherence reinforced during the antenatal visits. It is thus of interest to repeat this audit twenty years later to evaluate if there is any difference in indica ons and outcomes. OBJECTIVES 1.To determine the incidence, indica ons, and complica ons associated with peripartum hysterectomy at Groote Schuur Hospital (GSH), New Somerset Hospital (NSH) and Mowbray Maternity Hospital (MMH) 2. To compare study results with a similar study conducted between 1999 to 2003 at Groote Schuur Hospital METHODOLOGY A retrospec ve descrip ve audit of peripartum hysterectomies was performed at GSH, NSH AND MMH for the years 2015-2019. Peripartum hysterectomy was defined as hysterectomy performed within 24 hours of delivery or within the same hospital admission or within 6 weeks of delivery. Pa ents who had peripartum hysterectomies during this period were iden fied from the labour ward and gynaecology theatre register, and data retrieved from their files. All sta s cal analysis was performed by using SPSS version 27.0.0.0 (IBM, Armonk, NY, USA).
- ItemOpen AccessAntenatal care an investigation of the time interval between the confirmation of pregnancy diagnosis and commencement(2018) Moshokwa, Molatelo Linneth; Fawcus, SusanIntroduction This study aimed to investigate the time interval between the confirmation of pregnancy diagnosis and the commencement of antenatal care at the Metro West district of Cape Town, and to explore reasons for delays between the confirmation of pregnancy and the first antenatal booking. Methods A cross sectional descriptive study was conducted in September 2015 at Vanguard MOU, in which 120 pregnant women were interviewed at their first antenatal visit, using a structured questionnaire. Subjects were grouped into those with a short time interval (less than 60 days) between confirmation of pregnancy diagnosis and booking, and those with a long time interval (more than 60 days). The two groups were compared. The study hypothesis was that income would be a significant determinant of this time interval. The data were divided into descriptive and categorical variables. A logistic regression analysis was conducted to determine the association between independent variables and the dependent variable (time interval). Results The average gestational age at confirmation of pregnancy was 10.75 ± 5.88 weeks and the average gestation at booking was 18.27 ± 7.27 weeks. The mean time interval between confirmation of pregnancy diagnosis and first antenatal visit was 7.50 ± 6.63 weeks. Seventy- three (60.83%) reported a short time interval (SI) while 47 (39.17%) reported a long time interval (LI). The prevalence of late booking (defined as booking at or after 20 weeks) in the total study sample was 38.30%. There was a significant association between late attendance and LI with 70.21% of the LI group attending late, as compared to 17.81% of the SI group (OR 10.88; 95% CI 4.23-28.43). The time interval was significantly influenced by the women’s type of residence, the perception of the women regarding knowledge of the timing of antenatal care, and perception of the timing of pregnancy complications. It was not influenced by monthly income, thus refuting our hypothesis. Previous obstetric complications did not influence the time interval. Private confirmation of pregnancy by a general practitioner or home pregnancy test was significantly associated with a long interval; 37 (78.7%) in the LI group compared to 43 (59.9%) in the SI group, (p= 0.016). Reasons for the delay in booking were mostly related to poor understanding by women of the role of antenatal care and the ideal time of booking. Discussion and Conclusion Even though some women confirm their pregnancy as early as three weeks, there were notable delays in booking for their first antenatal visit, thus delaying antenatal care. However, the time delays seemed shorter than found in the previous Cape Town study, and compared to other studies in Africa. Many women perceived antenatal care to be curative rather than preventive. It is suggested that the site where women confirm their pregnancy (pharmacy, general practitioner or family planning clinic) should refer women immediately for antenatal booking. Also antenatal care sites should offer pregnancy testing services so that booking could occur after pregnancy is confirmed on the same day and at the same site.
- ItemOpen AccessAudit Of Peri-Operative Care As Part Of The Enhanced Recovery Model For Caesarean Delivery(2022) Blumenthal, Abigail; Fawcus, Susan; Horak, TraceyIntroduction Mowbray Maternity Hospital (MMH) is a secondary level hospital serving a large population with low socioeconomic status. Around 10000 deliveries are done per year of which 40-50% are delivered by caesarean section (CS). There is much literature on peri-operative care for caesarean sections, under the model of fast-track surgery also known as Enhanced Recovery After Surgery (ERAS). ERAS protocols have antenatal, intra-operative and post-operative components. This audit aimed to evaluate how successfully MMH adheres to local and international guidelines for peri-operative care around elective caesarean section according to the ERAS model. It is hoped this will form the first step in a quality-improvement intervention resulting in better quality, evidence-based care appropriate for the low-resource setting. Materials & Methods: Women were invited to participate in the study in MMH postnatal ward between 24 and 48 hours after elective CS. Once consented, a structured questionnaire and data collection sheet was used to interview women and remaining details were obtained from the patient record. This covered four aspects of ERAS programmes: 1. peri-operative hydration and nutrition 2. peri-operative analgesia 3. time interval postoperatively until removal of intravenous lines and urinary catheterisation 4. time interval until first mobilisation The initial planned sample size was 50 women however after the start of the covid pandemic when in-person interviews were no longer possible, a folder audit was undertaken of the remaining files. A decision was made to therefore increase the sample size to increase the value of the data obtained from the folder audit given that there was to be more limited data from patient interviews. Anonymised data was entered into a secure online database using REDCap (Research Electronic Data Capture system). Data entry was verified by double entering all data. In total 75 folders were reviewed, of which 35% were interviewed face-to-face. Findings The audit showed that 92% of patients received exactly the same number of doses (four 10mg doses) of morphine post-operatively with more variation in the dosing of simple oral analgesics and no use of NSAIDs. It showed that 85% of patients had high pain scores (3 or more out of 5) in the first 24 hours post caesarean section but 85% also reported they were mildly or very happy with their pain management post-operatively. The audit highlighted that many patients were nilper-os for prolonged periods of time peri-operatively; on average 23 hours without food and 19 hours without oral fluid. Drips and catheters were removed on average at 12.5 hours post- operatively; and mobilisation occurred on average at 12 hours with few delays; the standard deviation was less than 1 hour. Conclusions The audit confirmed that Mowbray Maternity Hospital has good adherence to certain ERAS protocols. It confirmed that most patients were happy with their pain control despite often reporting high levels of pain. However, it highlighted several deficiencies such as poor use of regular simple oral analgesia and the lengthy duration of time for which many patients were fasted which could impact on general satisfaction with care, not to mention possible negative effects on tissue healing.
- ItemOpen AccessMid-upper arm circumference: a surrogate for body mass index in pregnant women?(2015) Fakier, Ahminah; Fawcus, Susan; Petro, GregoryBackground: Nutrition in pregnancy has important implications for both the mother and the fetus, hence the importance of an accurate assessment at the booking visit. Body mass index is currently the gold standard for measuring body fatness. However, pregnancy associated weight gain and oedema, as well as late booking in our population setting, questions the reliability of using the BMI to assess body fat or nutritional state in pregnancy. Mid upper arm circumference has been used for many decades in children under the age of five, to assess malnutrition. Many studies have shown a strong correlation between MUAC and BMI in the adult population. MUAC is a much simpler anthropometric measure to take as it eliminates the need for height charts, scales and calculations. One of the other main advantages of using MUAC is that there is minimal change in the MUAC during pregnancy, which may be a better indicator of pre-pregnancy body fat and nutrition. Objectives: To assess if there is a correlation between the mid upper arm circumference and body mass index in pregnant woman booking in the Metro West area. Methods: This was a cross sectional study of women booking at four MOUs in the Metro West area. Anthropometric measurements namely height, weight and MUAC were carried out on pregnant women booking for the first time in four midwives obstetrics units in Metro West area, Cape Town, South Africa. The participants were divided into two groups, early gestational age group for patients who booked less than twenty weeks, and a late gestational age group for those who booked more than twenty but less than thirty week Results: The results showed that there is a strong correlation between MUAC and BMI in pregnant women up to thirty weeks gestation. The correlation was calculated at 0.92 for the entire group. A regression analysis showed that there is a statistical difference in the mathematical relationship between BMI and MUAC, between the two groups (EGG and LGG). MUAC of 27cm and 31cm had sensitivities and specificities of more than 80% for identifying pregnant women as overweight and obese respectively. Conclusion: The MUAC correlates strongly with BMI in pregnancy up to a gestation of thirty weeks in women in Metro West maternity services. In a low resource settings, the simpler MUAC measurement to assess nutritional status and screen women who are at risk for potential adverse pregnancy outcomes could reliably be substituted for BMI estimation.
- ItemOpen AccessTrial of Labour or Elective Repeat Caesarean Section in Women who have had one previous caesarean section: An assessment of women's attitudes, knowledge and preferences(2020) Ahmed, Tasneem; Petro, Gregory; Fawcus, SusanINTRODUCTION Caesarean section (CS) is one of the most frequently performed major abdominal surgeries in the world. There has been a global increasing trend in CS rates over the past three decades, particularly in women who have had one previous CS. Vaginal birth after caesarean section (VBAC) is a safe option and is still strongly recommended by all international authorities with success rates ranging from 60% to 80%. However, women's preference for VBAC vs elective repeat caesarean section (ERCS) remains very poorly understood in South Africa (SA) as very few studies have addressed women's preference for mode of delivery. Repeat caesarean delivery (CD) is reported as the single largest contributor to the escalating CS rate worldwide. So why do women choose repeat CD? Evidence suggests that fear, health care worker influence, social stigma, cultural practise and religious beliefs can significantly influence the attitude toward CS. South African data remains limited and we are yet to ascertain how women make their choice and what drives their specific preferences. The rationale behind this study therefore was to gain better insight into why the women in Cape Town choose VBAC or ERCS and to ascertain to what extent their knowledge, attitude and preferences influence their choice. In so doing, we were able to highlight key findings in order to attempt to reduce the increasing CS rate in our country. AIMS AND OBJECTIVES The primary objective was to explore women's knowledge, attitudes and preferences for VBAC or ERCS after one previous CS, from 36 weeks gestation, attending antenatal care at Mowbray Maternity Hospital (MMH) and New Somerset Hospital (NSH). The secondary outcome was to describe the major reasons for their preferred mode of delivery. METHODOLOGY A prospective descriptive study was conducted over four months, of pregnant participants with one previous lower uterine segment caesarean section (LUSCS), attending antenatal care at MMH and NSH. Participants were recruited from 36-41weeks gestation. Participants over the age of 18 years with one previous LUSCS were eligible for inclusion. Participants with a medical indication for CS were excluded. An interview-based questionnaire, previously 11 adapted for use in a Cape Town antenatal population regarding women's knowledge, attitudes and preferences for mode of delivery was conducted at a routine antenatal visit. In addition, basic obstetric and socio-demographic data was abstracted from their folders. A descriptive analysis of participants' preferences for mode of delivery was completed, with subgroup comparisons. The Fisher's Exact test was used in all the statistical analyses that involved categorical variables whilst continuous variables were analysed using t-tests. RESULTS The study included 100 participants who were eligible for VBAC. Of the participants, 51% preferred ERCS whilst 49% preferred VBAC. Married couples and those in co-habiting relationships, more frequently chose VBAC compared to single participants, who more frequently chose ERCS. Participants were greatly influenced by the opinion of the HCW, particularly if ERCS was suggested, they were likely to choose a CS (p=0.001). If a previous history of long or obstructed labour was reported, participants were inclined to choose ERCS. Fear was identified as a major determinant as 78.4% cited fear of vaginal birth as their reason for preferring a CS. History of previous CS (88.2%) and fear of the risks associated with VBAC were the main reasons cited for their preference. In the group who preferred VBAC, 89.8% were of the perception that VBAC would allow them to recover faster and 87.7% desired to be home sooner therefore, favouring their choice. Whether or not the participants had a previous vaginal delivery or VBAC, it did not affect their preference for mode of delivery in a statistically significant manner. CONCLUSION This study which explored knowledge, attitudes and preferences of women who had had one previous CS, concerning their preference for mode of delivery, is one of the first to be done in South Africa. Despite all participants being medically eligible for VBAC, only 49% preferred this option, the remaining 51% preferring ERCS. Significant determinants of their choice were unstable relationships, influence of the doctor, concern about uterine rupture and fear of labour and unpredictability. Knowledge of the complications of ERCS and VBAC was very limited. This information is useful to design further research to improve understanding of these issues and to design services in a way to overcome the identified problems. In particular, women must be provided non-biased evidence-based information in order to foster a relationship of trust with the health care worker, in assisting her to make an informed decision. Similarly improving respectful competent care of women in labour with better attention to alleviating labour pain, will assist in reducing fear.