Browsing by Author "Fawcus, Susan R"

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    Adverse perinatal events observed in obese pregnant women in the Metro West Region
    (2014) Gadama , Luis Aaron; Horak, Tracey Anne; Fawcus, Susan R
    Background. Obesity is increasing globally and is defined as a Body Mass Index (BMI) over 30 kgms/m². It’s prevalence in the Metro West Maternity service is unknown. Objective .To assess the prevalence of obesity and determine its association with adverse perinatal and maternal outcomes among pregnant women in the Metro West Region, Cape Town, South Africa Study Design. This was a retrospective observational study that compared perinatal outcomes in women with normal pregnancy BMI to outcomes in women with high pregnancy BMI. Setting. Mitchells Plain and Guguletu Midwife Obstetric Units, Mowbray Maternity Hospital and Groote Schuur Hospital, Metro West Region, Cape Town, South Africa Population. A total of 970 pregnant women divided into BMI groups that had their first antenatal booking visit between January and April 2011. Methods. A list of folder numbers was compiled from the antenatal booking registry at the two MOUs. From the list, maternal folders were then traced through the CLINICOM tracking system, MOU delivery registers, antenatal clinic transfer registers and labour ward transfer registers to find place of delivery or outcome of pregnancy. Maternal and perinatal characteristics were then extracted from the folders into the data collection sheet and data was analysed by STATA. Descriptive statistics included proportions with percentages and median with interquartile ranges. Inferential statistics included Chisquared tests, Fisher Exact tests, Kruskal Wallis test, univariate and multivariable logistic regressions. Main outcome measures. Perinatal outcomes (stillbirth, macrosomia, shoulder dystocia, 5 minute Apgar Score less than 7, congenital abnormalities) observed in obese and morbidly obese compared to normal BMI pregnant women.
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    An audit of uterotonic use for the prophylaxis and treatment of haemorrhage at caesarean delivery at Mowbray Maternity Hospital, Cape Town, South Africa
    (2018) Pheto, Peloentle; Fawcus, Susan R; Petro, Gregory
    Obstetric Haemorrhage is the leading cause of maternal death globally (1) and the third leading cause of death in South Africa (2). Concern has been expressed in South Africa that bleeding associated with caesarean delivery (CD) accounts for one-third of haemorrhage deaths and this has increased over the last ten years (3). The underlying cause of bleeding at CD is commonly uterine atony, and the majority of the CDs were performed at district hospitals (2,3,4). The Saving Mothers Reports describe inadequate use and documentation of uterotonics to prevent or treat bleeding at CD and have promoted the development of a standardised national protocol. While there is international agreement on the dosage and administration route for oxytocin to prevent OH after vaginal delivery, there is lack of consensus or standardisation of protocols for its prophylactic use at CD, with marked differences between country and facility protocols. Anaesthetists are concerned about the hypotensive effect of high dose intravenous boluses of oxytocin, particularly in women under spinal anaesthesia, and some maternal mortalities in the United Kingdom have been partially attributed to this (5). Hence it is important to balance safety with efficacy by promoting the lowest effective doses to minimise side effects but enable uterine contraction. Aim: The aim of this study was to perform a clinical audit of the documented use of uterotonics at CD at MMH to see how it adheres to the national protocol; and as a secondary outcome to measure the rate of haemorrhage at CD. Methods: This was a retrospective folder review of women who delivered by CD at MMH during the months of June and July 2017, including both elective and emergency operations. Information was obtained from women’s folders kept in the medical records department, using especially designed data extraction sheets. Data analysis was by simple descriptive statistics. Results: Three hundred and nineteen (319) folders from the study period were interrogated. This included 239 emergency CDs (75%) and 80 elective CDs (25%). They were all performed by obstetric registrars or medical officers with 89% being done under spinal anesthesia. Prophylactic oxytocin boluses at CD were given in 302 (94.7%) women but there was no documentation of its use in 17 (5.3%). One of the 302 women had a high dose IV bolus (7.5 IU) but the remainder had boluses below 5 IU. There were 75 women (23.5%) patients who received the national recommended dose of 2.5 IU IVI while 227 (71.1%) received alternative low dose boluses which were all less than 5 IU. The dose most commonly given was 3 IU; to 169 patients (53%) as a single or divided dose. There was wide variation in the dosage of prophylactic infusions with only 18 (5.6%) patients receiving the recommended intraoperative 7.5 IU infusion, while 221 (66.5%) received alternate infusion doses. Only 49 (15%) were discharged from theatre recovery to the postnatal ward with a prophylactic infusion running. In total 65 (20.4%) of the women received a 20 IU oxytocin infusion but it was unclear whether this was for prophylaxis or treatment. No intramuscular doses of oxytocin or syntometrine were given for prophylaxis. Among the 319 CDs, 13 (4.1%) had documented blood loss over 1000 ml and 24 (7.5%) had uterine atony reported by the surgeon. The most common treatment was 20 IU infusion followed by misoprostol (13 women), syntometrine (three women) and tranexamic acid (one woman). Additional surgical measures required were B-Lynch compression suture for one, and haemostatic sutures for two. There were no re-look laparotomies or hysterectomies during the study period and there were no major morbidity or mortalities from either CD or from anaesthetic complications. Discussion: Low dose bolus oxytocin and infusion is widely used at CD post fetal delivery at MMH, although the dose of 3 IU was most commonly used in contrast to the recommended 2.5 IU in the national protocol. There was variation in the usage and dosage of prophylactic oxytocin infusion. The rate of PPH in the subjects was low (4.1%) with the low dose prophylactic regimens used, suggesting that they were effective, although this may also have been contributed to by the skill of the surgeons. Consensus is needed among anaesthetists and standardisation of protocols on oxytocin prophylaxis at CD, particularly for training doctors working in district hospitals. Repeating this audit in district hospitals where there are higher CD case fatality rates would be important to shed light on practice in such facilities and improve healthcare delivery.
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    An analysis of the caesarean section rate at Mowbray Maternity Hospital using Robson's Ten group Classification System by Tracey Anne Horak.
    (2012) Horak, Tracey Anne; Fawcus, Susan R
    Includes synopsis. Includes bibliographical references.
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    Clinical officers in Malawi : expanding access to comprehensive emergency obstetrics care
    (2009) Chilopora, Garvey Chipiliro; Fawcus, Susan R
    Clinical officers perform much of major emergency surgery in Malawi, in the absence of medical officers. The aim of this study was to validate the advantages and disadvantages of delegation of major obstetric surgery to non-doctors.
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    Clinical Officers in Malawi: Expanding access to comprehensive emergency obstetric care
    (2009) Chilopora, Garvey Chiliro; Fawcus, Susan R
    Background: Clinical officers perform much of major emergency surgery in Malawi, in the absence of medical officers. The aim of this study was to validate the advantages and disadvantages of delegation of major obstetric surgery to non-doctors. Methods: During a three month period, data from 2131 consecutive obstetric surgeries in 38 district hospitals in Malawi were collected prospectively. The interventions included caesarean sections alone and those that were combined with other interventions such as subtotal and total hysterectomy repair of uterine rupture and tubal ligation. All these surgeries were conducted either by clinical officers or by medical officers. Results: During the study period, clinical officers performed 90% of all standard caesarean sections, 70% of those combined with subtotal hysterectomy, 60% of those combined with total hysterectomy and 89% of those combined with repair of uterine rupture. A comparable profile of patients was operated on by clinical officers and medical officers, respectively. Postoperative outcomes were almost identical in the two groups in terms of maternal general condition = both immediately and 24 hours postoperatively - and regarding occurrence of pyrexia, wound infection, wound dehiscence, need for re-operation, neonatal outcome or maternal death. Conclusion: Clinical officers perform the bulk of emergency obstetric operations, including complicated procedures, at district (level 1) hospitals in Malawi. The postoperative outcomes of their procedures are comparable to those of medical officers. Clinical officers constitute a crucial component of the health care team in Malawi for saving maternal and neonatal lives given the scarcity of physicians.
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    Comparability of an innovative Doppler ultrasound fetal heart rate monitor to a pinard fetal stethoscope using cardiotocography as a standard to assess the fetal heart rate in singleton pregnancies during labour at Mowbray Maternity Hospital
    (2013) Chinula, Lameck; Fawcus, Susan R; Woods, David
    Almost four million babies die in the first four weeks of life per year worldwide, most from preventable causes. In addition a million babies die during labour and delivery (Lawn J et al., 2005). In South Africa, ‘intrapartum hypoxia and birth trauma’ are among the top three causes of perinatal deaths. Severe intrapartum hypoxia is often preventable with appropriate maternal and fetal monitoring in labour. However, this remains a challenge in under-resourced settings, due to difficulties that accompany the use of a Pinard Fetal Stethoscope (PFS) which include user-dependence and lack of evidence based standardisation in taking measurements with it. Although intermittent fetal heart monitoring is as effective as continuous electronic monitoring in low risk labours (Banta DH and Thacker, 2001), the search is for reliable, robust and cheaper fetal monitoring devices. The innovative crank powered Doppler Ultrasound Fetal Heart Rate Monitor (DUFHRM) developed by Power-free Education and Technology is robust, cheaper and designed for use even in settings with no or erratic access to mains electricity and replaceable batteries, and overcomes some of the challenges that come with the use of PFS (Banta DH and Thacker, 2001). The aim of the study was to assess the accuracy of Fetal Heart Rates (FHRs)taken with the DUFHRM compared to FHRs taken with a PFS using a Cardiotocography (CTG) as a standard fetal heart rate monitoring device. This was a comparative diagnostic study conducted at Mowbray Maternity Hospital, a public sector maternity hospital in Cape Town during 2012. Women with singleton pregnancies in the active phase of the first stage of labour, who had consented to participation, were enrolled in the study. Paired readings of FHRs were taken with a DUFHRM and a PFS, by two midwives and also with a CTG during the active phase of the first stage of labour before and after two preferably consecutive uterine contractions. The midwives were blinded to the CTG measurements by silencing the CTG and turning it away from their view. The FHRs taken with a PFS were done over a 60 second period in accordance with the guidelines from professional bodies (ACOG, 1995, RANZCOG, 2002, RCOG, 2001a, Liston R et al., 2002) The DUFHRM and CTG readings were made at the start and end of each 60 second period of PFS monitoring. The proportion agreement of FHRs taken with a DUFHRM to FHRs recorded with a CTG, and the proportion agreement of FHRs taken with a PFS to FHRs recorded with a CTG were determined and compared using McNemar Exact Significance Probability test (mcc).
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    The effect of HIV infection on the incidence and severity of post-partum haemorrhage
    (2012) Chilopora, Garvey Chipiliro; Fawcus, Susan R
    Postpartum haemorrhage (PPH) accounts for more than 75% of maternal deaths from obstetric haemorrhage. In South Africa, maternal mortality resulting from postpartum haemorrhage has persistently been shown to be higher in HIV positive compared to HIV negative women. It is unknown whether the incidence of PPH is higher in HIV positive women; and/or whether HIV positive women have more severe bleeding and suffer greater morbidity as a result of PPH. The aim of the study was to investigate the effect of HIV infection on the incidence and severity of PPH. All women delivering at Mowbray Maternity and Groote Schuur Hospital in 2009 who had PPH were identified through a manual search of labour ward and operating theatre records. The women were categorized according to their HIV status as HIV positive, negative and untested. Data was also obtained on HIV status of the whole delivery population at these two hospitals. For women with PPH, data regarding background characteristics:- blood loss; cause of PPH and management provided; severity of and morbidity from PPH was analysed by comparing the HIV positive with the HIV negative group. Severity was assessed in terms of blood loss alone. Morbidity on the other hand was a composite assessment of blood loss, need for blood products, interventions required and complications of the PPH. Data was also collected on CD4 counts and treatment provided although the study was not powered to investigate these factors as associations.
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    The effect of HIV status on perinatal outcome at Mowbray Maternity Hospital and referring MOUs
    (2011) Kennedy, Deon; Fawcus, Susan R
    Background: 33,4 Million people were living with the Human Immune Deficiency virus by the end of 2009 with sub-Saharan Africa the most affected region. Maternal HIV infection is the leading cause of maternal and child morbidity and mortality in South Africa. A meta-analysis of world literature suggests a clear association between HIV infection and perinatal mortality. Aims and Objectives: To study the effect of HIV status on perinatal outcome at Mowbray Maternity Hospital (a secondary level hospital in Cape Town, South Africa.) and its catchment MOUs. Specific aims: 1) To compare the perinatal mortality rate in the group of HIV exposed with the HIV negative group and the untested group. 2) To determine where possible, the primary obstetric cause of adverse outcome and compare this in HIV exposed to the HIV negative and the untested group. 3) To compare the incidence of Neonatal Encephalopathy in the group of HIV exposed with the HIV negative group and the untested group. Methods: The study was a retrospective descriptive and comparative audit. All deliveries at MMH and its referral midwife obstetric units from January 2008 to December 2008 were audited with respect to HIV status and other demographic data. All deliveries with perinatal mortality and or neonatal encephalopathy were identified and analyzed in detail. Results: There was a total of 18 870 deliveries at the units being studied. The number of deliveries to HIV positive mothers were 3259 (17,2 %). The stillbirth rate in the HIV positive population for the units being studied was 17,1 per 1000 deliveries. In the HIV negative population this rate was 8,3 per 1000 deliveries. The odds ratio was 2,07 [CI, 1.5-2.8] with a p-value of <0,0001. The neonatal death rate in the HIV positive population was 4,6 per 1000 deliveries, this as opposed to a rate of 3,1 per 1000 in the HIV negative population. The odds ratio was calculated as 1,46 [ CI, 0.8-2.6] with a p-value of 0,26. The perinatal mortality rate in the HIV population was 21,7 per 1000 deliveries. In the HIV negative population this rate was 11,7 per 1000 deliveries. The odds ratio was 1,91 [CI, 1.4-2.5] with a p-value of <0,0001. A comparison of the pattern of primary obstetric cause for perinatal mortality showed that infection, intra uterine growth restriction and ante partum haemorrhage were significantly more common as a cause for perinatal death in the HIV positive population. The risk of neonatal encephalopathy in the HIV exposed population was 4,9 per 1000 deliveries as opposed to 2,07 per 1000 deliveries in the HIV negative group. Comparing the two groups found an odds ratio of 2,36 [CI, 1.28- 4.35] with the p-value 0,008. The untested group of patients is shown in this study to be at particularly high risk of adverse perinatal outcome. This consists mostly of mothers who have had no antenatal care in the index pregnancy. Discussion: The perinatal mortality rate in the group of HIV exposed mothers was significantly higher than the HIV negative group due to a higher stillbirth rate. The lack of difference in neonatal death rate could be due to the high standard of neonatal care at the hospital. There was no significant difference in demographic data between the HIV positive and negative groups. Conclusion: Parturients who were infected with HIV were at significantly increased risk of perinatal mortality. Infection, intra uterine growth restriction and antepartum haemorrhage were significantly more common obstetric causes for mortality in the HIV infected population. The risk of neonatal encephalopathy was also significantly higher in the HIV positive population.
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    External cephalic version for breech presentation at term : missed opportunities?
    (2014) Membe, Gladys Chikumbutso; Fawcus, Susan R; Kennedy, Deon
    Background External Cephalic Version (ECV) is the manipulation of the baby, through the mother’s abdomen to a cephalic presentation. ECV is typically performed antenatally, in women with a breech presentation who are not in labour, at or near term, to improve their chances of having a normal vaginal delivery. ECV is one of the few obstetric interventions for which there is evidence that its use leads to a fall in caesarean section rates. ECV is an intervention that gives women another option, prior to considering caesarean section. Objective: To evaluate whether there were missed opportunities for performing ECV in women that had caesarean sections for breech presentation at term, and to determine the reasons why ECV was not offered or attempted for women with breech presentation, who had a caesarean section for that reason.
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    Maternal near miss audit in Metro West Maternity services
    (2015) Enyeribe Iwuh, Ibezimako Augustus; Fawcus, Susan R; Schoeman, Leann
    Background: A near miss occurs when a pregnant woman experiences a severe life threatening complication during pregnancy or up to 42 days after the end of the pregnancy and survives. The near miss rate is defined as the number of near misses per 1000 live births. In 2011, World Health Organization (WHO) produced a useful tool for identifying near misses according to composite criteria which include the occurrence of a severe maternal complication together with organ dysfunction and/or specified critical interventions. The ratio of maternal near miss cases to maternal deaths and the mortality index both reflect the quality of care provided in a maternity service Maternal deaths have been audited in the Metro West maternity service for many years but there has been no routine monitoring or evaluation of maternal near misses. Aim of study: The study aim was to perform a near miss audit in Metro West, specifically (a) measuring the near miss rate, the maternal mortality ratio and the mortality index, (b) performing an in-depth investigation of the associated demographic, clinical and health system factors of the near miss cases, and (c) providing input into the development of an on -going system of auditing near misses cases in Metro West. Methods: A retrospective observational study conducted over 6 months between mid- March 2014 to mid -September 2014. This service includes 9 level one maternity facilities which refer all complicated maternal cases to two secondary hospitals, New Somerset (NSH) and Mowbray Maternity (MMH); or to the tertiary hospital, Groote Schuur Maternity Center (GSH). All cases of near miss managed at the three hospitals were identified weekly by the author with the assistance of onsite health providers. These cases included near misses that occurred at level one facilities and were referred on to one or more of the three hospitals. Strict criteria were used to ascertain a case as a near miss according to the WHO near miss definitions. The folders of all the near misses were reviewed and relevant data entered into a data collection form which was adapted from the WHO near miss data form. In addition, these identified folders were reviewed by two senior obstetric specialists to confirm adherence to the WHO inclusion criteria for near miss classification, and also to determine avoidable factors in the management of the near miss cases. Maternal deaths occurring during the same time period of the Near Miss audit were identified from monthly mortality meetings and the ongoing maternal mortality audit system in Metro West. Results: 112 near miss cases and 13 maternal deaths were identified, giving a total of 125 women with severe maternal outcomes. There were a total of 19,222 live births in Metro West facilities. The Maternal mortality ratio (M MR) was 67.6 per 100,000 live births and the maternal near miss rate was 5.83 per 1000 live births. The maternal near miss to death ratio was 8.6:1 and the mortality index was 10.4% Hypertension, obstetric hemorrhage and pregnancy related sepsis were the major causes of the near miss cases accounting for 50(44.6%), 38(33.9%), and 13 (11.6%) of near misses respectively. These three conditions all had low mortality indices; 1.9%, 1.9% and 0 for hypertension, pregnancy related sepsis and hemorrhage respectively. Less common conditions were, medical /surgical conditions, non-pregnancy related infections and acute collapse, accounting for 7 (6.3%), 2 (1.8%), and 2 (1.8%) of near misses respectively. Although these numbers were small, these three conditions accounted for more maternal deaths with mortality indices of 66.7 %, 33.3% and 33.3% for non- pregnancy related infections, medical /surgical conditions, and acute collapse respectively. There were 25 (22.3%) of the near miss cases who were HIV positive. The majority of near misses 99(88.4%) had antenatal care. Analysis of avoidable factors showed that, the most common problems were lack of antenatal clinic attendance (11.6%) and inter-facility transport problems (6.3%). For health provider related avoidable factors, the highest number of avoidable factors were identified at level 2 (38.2%), followed by level one (25.9%) and level 3 (7.1%). The most common factors were problem recognition, monitoring and substandard care Discussion and Conclusions: The near miss rates and maternal mortality ratio in Metro West were lower than for some other developing countries, but higher than rates in high income countries. The mortality index was low for direct obstetric conditions such as hypertensive disorders, obstetric hemorrhage and pregnancy related sepsis, reflecting good quality of care and referral mechanisms for these conditions. The mortality indices for non-pregnancy related infections, medical/surgical conditions and acute collapse were much higher and, suggest that medical problems may need more focused attention. Ongoing near miss audit would be valuable for Metro West but would require identification and monitoring systems to be institutionalized.
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    Non-elective caesarean sections in the Khomas Region, Namibia: implications for midwifery practice
    (2014) Shikwambi, Hilma Inoukapo Taukondjele; Clow, Sheila; Fawcus, Susan R
    Women who undergo caesarean section (CS) are likely to have a repeat CS in a subsequent pregnancy, thus increasing the CS rate in the country, which is not ideal in a resource constrained setting. The occurrence of high maternal mortality among women who have nonelective CS is usually due to indications for prior CS such as fetal distress, obstructed labour and eclampsia. In developing countries, there is a high rate of maternal deaths associated with major operative complications. This study was a retrospective, descriptive quantitative, clinical audit. The purpose was to identify the reasons for non-elective CS in two hospitals namely, the Windhoek Central hospital and Intermediate Katutura hospital, and the implications for Midwifery clinical practice. The research question was: What are the indications and intrapartum care factors for non-elective CS in the two hospitals, and what are the implications for Midwifery practice? The population consisted of records of women who had given birth by CS between 1st January 2012 and 30th June 2012 in the two hospitals. All available records of women who had non-elective CS during the study period were reviewed. Data was collected with individual data collection sheets and analysed using Statistica 11 software. A total of 838 records were reviewed. The CS rate was 1264/5296 (23.9%), the rate of nonelective CSs was 912/5296 (17.2%), and the proportion of non-elective CS was 912/1264 (72.2%). A total of 171/838 (20.4%) women were HIV positive. Seventy per cent (634/838) women had a CS for the first time, of which 290/634 (45.7%) were multigravida. Records were grouped according to Robson’s classification, a mutually exclusive and totally inclusive classification of CS. The Robson group making the largest contribution was nulliparous women with a single cephalic pregnancy, at greater than or equal to 37 weeks gestation in spontaneous labour (group 1) with 213/838=25.4%. Problems with the progress of labour were the most common reason why women had non-elective CSs during the study period. The study findings highlighted a high number of primary CS in low risk women with poor assessment of maternal wellbeing and progress of labour. Limited documentation of Midwifery intervention and care was noted suggesting inadequate Midwifery care. Training is required to render evidence based care.
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    Preference for mode of delivery in a low risk population in Cape Town, South Africa
    (2015) Naudé, Nadia; Horak, Tracey Anne; Fawcus, Susan R
    Introduction: Over the past few decades there has been an increase in caesarean section rates that has been well documented in many developed countries. The impact of this cannot be ignored as several studies have shown higher risks of maternal morbidity and mortality with caesarean section as compared to vaginal births. The reasons behind it are complex, with maternal request frequently being cited as a major contributor. A growing body of evidence shows that relatively few women would actually prefer to deliver by caesarean section. Caesarean section on request is not routinely offered in the public health care sector in South Africa, and is therefore unlikely to contribute significantly to the overall caesarean section rate. In the South African context very few studies examining women's preference for mode of delivery exist. Aims and Objectives: The primary aim of our study was to determine women's preference for mode of delivery during the third trimester of pregnancy in a low risk population. The secondary outcome was to describe the major reasons for their preferred mode of delivery. Methodology: We conducted a cross-sectional descriptive study of pregnant women attending antenatal care at two midwife obstetric units (MOUs) in Gugulethu and Mitchell's Plain in the Western Cape. Women were recruited during the third trimester of pregnancy and women over the age of 18, with a singleton low risk pregnancy, planning to deliver at the MOU, were eligible for inclusion. Two trained interviewers conducted an interview-based questionnaire regarding women's preference for mode of delivery. Data on demographic and socio-economic characteristics were also collected. We also described the major reasons behind women's preferred mode of delivery. Results: Of the 195 women that participated in our study, 160 (82.1 %) indicated a preference for vaginal delivery. This compared to only 5 (2.6 %) of the study participants who preferred a caesarean delivery, and 30 women (15.4 %) who were unsure about their preferred mode of delivery. Of the group preferring caesarean section, all five women (100 %) cited 'fear of vaginal birth' as the major reason for preferring a caesarean section. Of the 195 women that participated in our study, 106 (54.4 %) did not believe that women should be given the right to request a caesarean section in the absence of a medical indication, 14 women were unsure (7.2 %) and 75 of them believe that women should have the right to request a caesarean (38.5 %). Conclusion: The need for maternity services that are more women-centred has arisen, with an increasing emphasis on maternal choice and birth satisfaction. Our study contributed to the mounting body of evidence that the majority of women prefer to have a vaginal delivery. In the small group preferring caesarean section, 'fear of vaginal birth' was the major reason behind their preference. There were a considerable number of women in our study population who were unsure about their preference. This indicates a need for improved antenatal education. Knowledge about women's preference and the reasons they regard as important will aid health care providers in counselling patients appropriately regarding the risks and benefits of both delivery methods and thereby enable women to make an informed decision about their preferred mode of delivery.
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    A quality of care assessment of the management of obstetric haemorrhage in the Peninsula Maternal and Neonatal Services
    (2009) Adams, Tracey; Fawcus, Susan R
    In South Africa obstetric haemorrhage is the third most common cause of maternal deaths. In addition to maternal mortality audits, quality of care audits using criterion based audit methodology provides useful information. The aim of this study was to audit the management of all women with severe obstetric haemorrhage in the Peninsula Maternal and Neonatal Services in order to improve management. A descriptive retrospective audit was conducted during the period August 2006 to August 2007 using a criterion based audit methodology. Cases of severe obstetric haemorrhage were identified prospectively. Folders were reviewed and data collection sheets utilized to: 1. Describe the demographics and causes of obstetric haemorrhage in the Peninsula Maternal and Neonatal Services, 2. Measure the case fatality ratio, 3. Describe the management of women with severe obstetric haemorrhage with reference to that prescribed in the South African National Guidelines (2002-2004), 4. Score the management provided by the Peninsula Maternal and Neonatal Services using a shorter checklist devised from the National Guidelines.
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    A retrospective review of surgical site infection following caesarean section at Mowbray Maternity Hospital
    (2016) Sonntag, Kim; Horak, Tracey Anne; Fawcus, Susan R
    Introduction: Pregnancy related sepsis is a major cause of maternal mortality and morbidity in South Africa. Caesarean section (CS) is the most important risk factor in the development of puerperal infection, and surgical site infection (SSI) after CS increases maternal morbidity as well as medical costs. Mowbray Maternity Hospital (MMH), is a secondary level, public maternity hospital. The caesarean section rate at MMH has increased considerably over the last fifteen years, and the perception has been that there have been increasing numbers of patients developing SSI post-CS. This study was designed to look more closely at the incidence of SSI and to describe the patients identified with SSI. Methods: This was a retrospective observational study. Cases of severe SSI, as defined by the Centres for Disease Control and Prevention (CDC), following CS at MMH from December 2011 to December 2014 were identified. Following ethical approval, patient records were sourced, data collected and analysed using Stata and Statistica. Results: In the 3-year study period, 14982 CS were performed with 98 patients identified with severe SSI. Folders were retrieved for 96 patients, with 2 patients' folders missing and 29 patients with a missing maternity case record (MCR). The overall incidence of severe SSI was 0.65%, with an incidence of 0.88% in Year 1, 0.90 in Year 2 and 0.70 in Year 3. Of the cases, 79 (80.6%) had been in labour, 16 (16.3%) patients had had prolonged rupture of membranes (PROM) and 32 (32.7%) had prolonged labour, with a median of 5 vaginal examinations. An emergency CS was performed in 90 (91.8%) patients, 7 (7.2%) had an elective CS and 1 (1.0%) patient had this data missing. Deep incisional SSI was diagnosed in 74 (75.5%) patients and 24 (24.5%) patients were identified with organ/space SSI. Intravenous (IV) antibiotics was the main treatment in all 96 cases, with 23 (23.5%) patients requiring a wound debridement, 17 (17.2%) a laparotomy, which proceeded to a hysterectomy in 12 (12.3%) patients. In the majority of cases, no organism was cultured, Whereas multiple organisms were cultured in 16 cases, of which 12 were identified as MRSA, and 18 as Klebsiella pneumoniae. There were no maternal deaths or Intensive Care Unit (ICU) admissions. Discussion and Conclusion: The incidence of severe SSI is in keeping with other institutions, with the lowest incidence being found in Year 3, which may be explained by the change in referral population and/ or the full implementation of the Best Care Always (BCA) bundles of care. Of the 98 patients with severe SSI, 80.6% had been in labour, 32.7% had prolonged labour and 91.8% had an emergency CS performed. These are all factors which are known to increase the likelihood for development of post-CS SSI.
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    Review of Late Preterm birth at Mowbray Maternity Hospital
    (2018) Chambers, Kate Melanie; Horak, Tracey Anne; Fawcus, Susan R; Petro, Gregory
    Introduction: Preterm births are common in all obstetric hospitals and present multiple challenges to both the obstetrician and the paediatrician. Preterm delivery is an important cause of perinatal morbidity and mortality, and places significant psychosocial stress on all involved. Late Preterm Birth (LPTB) is an important topic with many consequences for mother, child and society. It would be of interest to quantify the problem of late preterm birth at Mowbray Maternity Hospital (MMH); quantifying the deliveries into spontaneous versus medically indicated, and to explore the reasons and outcomes for each category. Aims and Objectives: To review the causes, indications for, and outcomes (maternal and neonatal) of all late preterm births delivered at Mowbray Maternity Hospital. Methods: This was a retrospective descriptive study, conducted at Mowbray Maternity Hospital, between January 1 st 2016 and March 31 st 2016. The study population, consisting of 231 patients, includes all deliveries at MMH during the above time period, which fit the inclusion criteria of a gestational age (GA) of between 34⁺⁰ and 36⁺⁶ weeks. All data pertaining to the patient’s previous history, risk factors and current pregnancy were captured and analyzed using Stata. This study was approved by the UCT Ethics Committee (HREC) and institutional approval was obtained from Mowbray Maternity Hospital. All information was treated with confidentially and in accordance with the Helsinki Declaration. Results: During the study period, 1st January 2016 and 31st March 2016, there were a total of 2342 deliveries. Of these deliveries 36 (1.5%) were found to have a GA < 28 weeks (these included those that were categorised as miscarriages); 24 (1%) were between 28 – 31⁺⁶ weeks; 56 (2.4%) were between 32 – 33⁺⁶ weeks and 1833 (78.2%) had a GA above 37 weeks. 162 (6.9%) folders were missing and therefore GA was not calculated, leaving 231 (9.9%) deliveries of late preterm infants. Of the 231 patients included, 64 (27.7%) were noted to have a poor obstetric history, 38 (16.5%) had a history of a previous preterm delivery. Gestational age was calculated by Early Ultrasound Scan (EUS) in 44.2% of cases; Late Ultrasound Scan (LUS) in 36.4 % of cases; Last Normal Menstrual Period (LNMP) in 14.3% of cases and booking palpation in 5.12% of cases. At least one maternal characteristic associated with preterm labour was seen in 131 (56.7%) of the included patients. There were 20 (8.7%) sets of twins. Of the 231 patients, 129 (55.8%) presented in spontaneous labour and 102 were delivered late preterm for medical reasons; this included 70 (30.3% of 231) who had labour induced and 32 (13.9% of 231) who were delivered via caesarean section despite not being in labour for reasons that prevented an Induction of Labour (IOL)/vaginal birth. There were 251 babies delivered in the late preterm category, and of these, 250 (99.6%) were born alive, with 1 Early Neonatal Death (ENND) and 1 macerated stillborn. Of the 251 newborns, 63 (25.1%) were admitted to at least one of the neonatal wards during their hospital stay. Of these, 64.1% spent time in the High Care Unit (HCU), 28.1% spent time in the Neonatal Intensive Care Unit (NICU) and 68.8% spent time in Kangaroo Mother Care (KMC) unit (majority of these newborns had been in either HCU or NICU prior to KMC). Of the 63 neonates admitted to a neonatal ward; there were 37 (36.3%) from the 102 mothers delivered for medical reasons and 26 (20.2%) from the 129 mothers who had presented in spontaneous labour. The overall correlation between gestational age calculated by EUS/LUS/LMNP and Ballard score was calculated as 37%. The average length of stay in the hospital for the newborns, whether admitted or with mom, was 4.96 days. Discussion and Conclusion: Late Preterm Birth accounts for 9.9% of all births and 66.6% of all preterm births at Mowbray Maternity Hospital. This is a substantial proportion of MMH deliveries, putting pressure on already strained resources. This pressure is confounded by the fact that 25.1% of these neonates are admitted to a neonatal ward. 44.2% of these births are medically initiated and this should give cause for thought as to whether our protocols that govern certain medical conditions in pregnancy could possibly be altered to prolong pregnancies and reduce the incidence of Late Preterm Birth.
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    The use of uterine compression sutures in the management of patients with severe postpartum haemorrhage in a regional obstetric hospital
    (2017) Muavha, Dakalo Arnold; Allie, Saalih; Fawcus, Susan R; Petro, Gregory
    Background: Postpartum haemorrhage (PPH) is a direct leading cause of maternal death in developing countries including South Africa, and atonic uterus is responsible for up to 80% of cases of postpartum haemorrhage. The introduction of the uterine compression suture (UCS) by C B-Lynch revolutionised the conservative surgical management of postpartum haemorrhage. Its use is simple, does not require special training and reduces the need for hysterectomy. Many small studies have been conducted in different parts of the world on its effectiveness but no published studies have been found from Africa. To understand the unique challenges in developing countries, especially those in Africa, it would be relevant to establish if uterine compression sutures are beneficial in a low resource setting for the management of PPH. Accordingly, the aim of the present study was to audit the use of uterine compression suture (UCS) in our regional hospital, with a focus on the circumstances in which it was used and its success rate in treating postpartum haemorrhage. Methods: This was a retrospective folder review study of all women who had a UCS inserted to treat obstetric haemorrhage in Mowbray Maternity Hospital during the period between January 2010 and June 2016, following ethical approval from the UCT HREC and Mowbray Maternity Hospital's management. Cases were identified from theatre registrars and a designated UCS book. Patients' records were retrieved and data collected and analyzed using the Excel spreadsheet software. Results: During the 6.5-year study period, there were 132, 612 deliveries in the population served by Mowbray maternity Hospital, of which 102,261 (78%) were by normal vaginal delivery and 30,351 (22%) by caesarean section. A total of 150 UCS cases were identified giving a rate of 0.87 UCS per 1000 deliveries (at MMH and its referral MOUs). Of the 150 cases, 115 (77%) patient files could be retrieved for further analysis. UCS was performed more commonly after ceasarean section (107; 93%) than after vaginal delivery (8; 7%) The majority were performed by obstetric registrars (73; 63.4%) compared to 21 (18.3%) performed by consultants and by medical officers. The UCS was successful in stopping haemorrhage without the need for hysterectomy in 107 (93%) of all analyzed cases. Among the 8 failures, all required a hysterectomy and one woman died. The majority of UCS (50%) were performed in cases with estimated blood loss over 1000 mls, with 20.9% having blood loss more than 2000mls. Of note, 13.9% had an estimated blood loss (EBL) less than 500 mls (the majority of which were performed by medical officers). Short term morbidity of UCS cases included blood transfusion (42%), admission to ICU (8.7%), post ceasarean section sepsis (9.6%), and prolonged hospital stay (46.1%). Discussion and conclusion: This study is one of the largest case series and the first done in an African setting. Our success rate of 93% is similar to other previously reported published studies with similar low rates of short term morbidity. Our study confirmed that the success of the UCS is achievable even in low-resource environments and that UCS can be safely performed by surgeons with different levels of surgical expertise (medical officers as well as registrars and consultants).