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    Correlating cardiotocography, apgar score and cord blood ph after caesarean section for fetal distress at Rahima Moosa mother and child hospital
    (2018) Ashley, Tshikanda Khathutshelo
    Background Fetal distress is one of the most common indications for emergency caesarean section in both developed and developing countries. Intrapartum fetal monitoring was designed with the hope of reducing the prevalence of cerebral palsy and early detection of fetal hypoxia. The most commonly used method of intrapartum fetal surveillance is cardiotocography (CTG). The use of umbilical cord artery blood gases can provide important information about the acid-base status of the newborn. The aim of this study was to correlate intrapartum CTG findings with the outcome of the newborns in terms of umbilical cord pH and Apgar scores, in women who underwent caesarean sections for fetal distress at term and were in labour, and thus to evaluate the accuracy of CTGs. Methods This study included 99 women with term singleton pregnancies, who were in labour and underwent caesarean section for fetal distress. CTG tracings were interpreted by a senior obstetrician as normal, non-reassuring or abnormal. The senior obstetrician interpreted these CTGs without knowledge of the acid-base statuses of the newborns. Umbilical artery blood was taken immediately after birth in a heparinized syringe and was analysed in less than 30 minutes. A pH of < 7.1 was taken as acidosis and a pH of ≥7.1 was taken as normal. Results The age range was 18-46 years. The number of women with gestational age of 42 weeks or more was 8 (8%). The interval between end of CTG and birth ranged from 21 to 352 minutes. Three women had a hypertensive disorder and none had diabetes mellitus. The birth weight range was 2125-4240 g. The median Apgar score at 1 minute was 9 (range 1-9), and at 5 minutes was 10 (range 7-10). No infants required admission to the neonatal intensive care unit, none developed hypoxic-ischaemic encephalopathy, and none died. The CTG interpretation found 9 normal, 21 non-reasuring and 69 abnormal tracings.The cord blood pH correlated well with the lactate level (r=-0.82; p<0.001), and also with the base deficit (r=-0.78; p<0.001). The Apgar scores at 1 minute and 5 minutes also correlated well with the pH (both r=0.44 with p<0.001). When the Apgar score at 5 minutes was <9 (n=7), mean pH was 7.04, and when it was ≥9, the mean pH was 7.22 (p<0.001). Following fetal distress in the latent phase of labour, the mean pH was 7.23, while after the active phase of labour, the mean pH was 7.1 (p=0.017). Normal, non-reassuring and abnormal fetal heart rate (FHR) patterns were followed by cord blood pH values of 7.19, 7.21 and 7.21 respectively p=0.879). Conclusion: The predictive value of CTGs for neonatal encephalopathy was zero in this series, although the sample size of was small, given the rarity of neonatal encephalopathy. The neonatal outcome may however have been modified (improved) by the performance of caesarean section. There was a good correlation between Apgar scores and cord blood pH. Within this group of 99 infants delivered for suspected fetal distress, different fetal heart rate patterns could not be related to neonatal outcome. The study confirms the low predictive value of CTG tracings in the diagnosis of neonatal acidaemia and prediction of poor neonatal outcome, but cannot exclude the possibility that a proportion of infants may have benefited from caesarean section following CTG monitoring.
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    The association between mode of delivery and early adulthood overweight or obesity in an urban South African birth cohort
    (2018) Sogunle, Eniola Olufunmilayo
    Background Obesity is an important public health problem and rates have reached epidemic proportions in many countries. South Africa has one of the highest rates of obesity in Africa, with about 38% of the population (and about 44% of adults) estimated to be overweight or obese in 2013. Caesarean section (CS) as a mode of child delivery has been reported to be associated with a low bacterial richness that predisposes infants to being overweight or obese; this early life deprivation is presumed to persist to adulthood. The aim of this study was to determine if mode of delivery is a predictor of early adulthood overweight or obesity. Methods This was a retrospective analysis of data that was collected from a prospective cohort study (Birth to Twenty Plus) established in 1990. A total of 889 young adults aged 21-24 years were included in the analysis. Pearson’s chi-square and Kruskal-Wallis tests were used to assess associations between covariates and BMI categories, and prevalence of overweight or obesity among young adults, across mode of delivery categories. Multiple logistic regression models were fitted to examine the association between mode of delivery and early adulthood overweight or obesity. Results Of the 889 participants, 793 (89.2%) were delivered vaginally, 24 (2.7%) were delivered by assisted VD, and 72 (8.1%) were delivered through CS. The numbers of overweight and obese young adults were 175 (19.7%) and 106 (11.9%), respectively. Caesarean section was significantly associated with obesity in young adults, after adjusting for potential confounders (OR 1.99, 95% CI 1.00–3.94, p=0.049). However, no significant association was observed for overweight + obese combined. Conclusion Caesarean section was statistically associated with early adulthood obesity but not overweight + obesity combined. Mothers and physicians should, however, reduce the use of CS as a delivery procedure unless entirely required. This is due to the higher odds of obesity in later life, the potential biological link between CS and obesity, and the statistically significant associations reported.
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    Maternal mortality due to sepsis after caesarean section at Chris Hani Baragwanath Hospital from 1997-2014
    (2017) Dlamini, Zandile Barbara
    Background Pregnancy related sepsis is one of the leading direct causes of preventable maternal morbidity and mortality. Evidence shows that caesarean section increases the risk of developing sepsis threefold compared to vaginal deliveries. Maternal death from sepsis after caesarean section can be prevented by proper monitoring of patients from the antenatal period, during labour and delivery and by early recognition and aggressive treatment of puerperal sepsis. This study was conducted to determine the frequency of maternal death from sepsis after caesarean section at Chris Hani Baragwanath Academic Hospital, and to identify associated factors including the role of HIV infection. Methods This was a retrospective descriptive study of maternal death due to sepsis after caesarean section at Chris Hani Baragwanath Academic Hospital from January 1997 to December 2014. Maternal death records of women who died of sepsis after caesarean section were obtained from the maternal death data base in the Department of Obstetrics and Gynaecology at the hospital. Results There were 108 299 caesarean sections performed during the study period, and 24 women died from sepsis after caesarean section from 1997 to 2014. These deaths made up 3.6% of the 661 maternal deaths at the hospital in this period. Three women presented as referrals, and 21 had their operations done at Chris Hani Baragwanath. The frequency of maternal death from sepsis after caesarean section at the hospital was 0.02% or 19.4/100 000 caesarean sections. The mean age of the women was 28.8 years, with three (12.5%) less than 20 years of age. Twenty women (83.3%) had emergency caesareans. The most common indication for caesarean section was Prolonged labour (50%). Sixteen (66.7%) women were HIV-infected. Twenty women (83.3%) required surgical intervention for puerperal sepsis after caesarean section. Conclusion On average, one to two women die each year at Chris Hani Baragwanath Academic Hospital from puerperal sepsis associated with caesarean section. This study showed that sepsis after caesarean section was more commonly observed with emergency than with elective procedures, and that prolonged labour was the most frequently associated obstetric indication. HIV infected women were more susceptible to death from sepsis after caesarean section, compared with HIV uninfected women. Obstetricians and midwives need to be skilled in the prevention, identification and treatment of life-threatening sepsis after caesarean section.
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    The anaesthetic management of patients undergoing caesarean section surgery and its impact on post-operative analgesia
    (2016) Chetty, Sean
    Poorly controlled pain following caesarean section surgery can have a debilitating effect on the physical and emotional well being of a woman during the post-operative period. Good intra-operative anaesthetic management during caesarean section surgery is requisite to improve post-operative analgesia, and thereby contribute to the well being of the patient. In South Africa (SA) there are currently no national obstetric anaesthesia practice guidelines. Anaesthetic service providers therefore rely on knowledge acquired during their anaesthetic training and recommendations from international guidelines (which may not be applicable in SA). In order to establish a reference standard of anaesthetic care for obstetric patients in SA, a semi-structured interview was conducted with the heads of department and/or their representatives from the eight anaesthesiology academic departments in SA in 2012. The experts provided recommendations on the intra-operative anaesthetic management of patients for elective and emergency caesarean sections, as well as the post-operative monitoring and analgesic management of these patients. The recommendations were based on the experts’ understanding of the uniquely local healthcare environment in SA. Following the establishment of the SA reference standard, a national survey of anaesthetic service providers was conducted in 2014 to establish what the practises are in South Africa for caesarean section anaesthetics. Ninehundred- and-thirty-three survey responses were analysed, which equated to a 58% response rate. The majority of anaesthesia providers (97.8%) perform single shot spinal anaesthesia for caesarean sections. Thirty percent of respondents chose to use Quincke spinal needles, despite the increased risk of this needle causing post-dural puncture headaches (PDPH). The preferred local anaesthetic drug was 0.5% bupivacaine with dextrose, and fentanyl was the most commonly used additive agent, as opposed to common international practice, which advocates morphine. The survey also revealed that 58% of doctors work in hospitals that do not have a post-operative monitoring protocol for patients following caesarean section surgery. This contrasts to recommendations suggested by the national experts regarding patient monitoring requirements. A clinical trial was then conducted to compare the analgesic efficacy of two different doses of intrathecal morphine (50μg and 100μg) with 25μg fentanyl. Patients in both morphine treatment groups had significantly lower postoperative opioid requirements than patients in the fentanyl group. The pain numerical rating scale (NRS) scores were however not statistically different and there was also no difference in the side effects profile or emotional parameters measured, between the groups. This study highlights the differences in the recommended practise of obstetric anaesthesia in SA compared to other countries and demonstrates how obstetric anaesthesia is practised in SA. The final component of this study has demonstrated how international best practices can be easily implemented in SA to improve the anaesthetic care of the obstetric patient.
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    Re-evaluation of the role of intramuscular ephedrine as prophylaxis against hypotension associated with spinal anesthesia for Caesarean section
    (1997) Webb, Adrian Arthur
    Spinal anaesthesia for Caesarean section is associated with an unacceptably high incidence of hypotension despite the administration of an intravenous fluid preload and the use of uterine displacement. The theoretical benefits of preventing hypotension as opposed to treating it as it occurs are the avoidance of considerable maternal discomfort, a reduced risk of serious cardiovascular or respiratory depression and the avoidance of transient foetal asphyxia. The use of prophylactic intramuscular ephedrine prior to spinal anaesthesia has been recommended but not well studied. The advantages of the intramuscular route for ephedrine administration are its simplicity and its favourable pharmacokinetic profile. Cardiovascular support is sustained throughout the surgery and into the post operative period. Opposition to the use of intramuscular ephedrine in the prevention of hypotension is based on two studies in which spinal anaesthesia was not used [1,2]. These studies showed an unacceptably high incidence of hypertension, a deleterious effect on foetal gas exchange and a lack of efficacy when intramuscular ephedrine was used in epidural and general anaesthesia respectively. This research report describes a randomised, double blind, interventional study designed to assess the safety (prevalence of hypertension, tachycardia or foetal compromise) and efficacy (prevalence of hypotension) of 37,5mg of ephedrine given prior to spinal anaesthesia for Caesarean section. Forty patients who had given informed consent were entered into the study. Blood pressures and pulse rates were recorded for 90 minutes after ephedrine administration, samples of umbilical venous blood were collected and Apgar scores assessed. This study found that giving 37,5mg of intramuscular ephedrine prior to spinal anaesthesia was safe from a maternal point of view in that it was not associated with reactive hypertension or tachycardia. When the ephedrine was given 10 minutes prior to induction of the spinal the technique proved to be effective in reducing the incidence and severity of hypotension. When used in the above manner the technique was not associated with foetal depression or acidosis.
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    Factors associated with high caesarean section rates in Bertha Gxowa Hospital
    (2014-08-27) Inyang-Otu, Ukeme Sunday
    BACKGROUND: Bertha Gxowa hospital, like other district hospitals in South Africa offers Caesarean section as an essential obstetric service to pregnant women. Caesarean section rates have been increasing worldwide, giving cause for concern because of increased maternal and perinatal morbidity and mortality associated with high Caesarean section rates. This study aims to describe factors associated with high Caesarean section rates in Bertha Gxowa hospital. The researcher hypothesized that associated factors could be identified, and if demographic obstetric and non obstetric factors are described in relation to the context in which the Caesarean sections took place, it should be possible to identify significant modifiable factors. It is hoped that the findings of this study will help to shape local obstetric policy and practice, and lead to improved maternal and perinatal health. METHODS: This study utilized a quantitative cross sectional descriptive design. Patient records were reviewed to obtain information on Caesarean deliveries performed between January and December 2011. Demographic, obstetric and non obstetric factors were described. Pearson’s Chi-square, Fisher’s exact and Student t tests were used as tests of association between independent variables and Caesarean section. A logistic regression model was used to describe risk factors associated with Caesarean section. RESULTS: The results show that increasing parity was associated with Caesarean section (P = 0.004). Eighty six percent of the Caesarean sections were emergency Caesarean sections and 65% were primary Caesarean sections. The commonest obstetric indications were fetal distress, previous Caesarean section, cephalopelvic disproportion, poor progress and malpresentation. Women belonging to Robson classes 1 and 5 had more Caesarean sections than other classes. There was a significant association between Medical Officers and Caesarean section (P=0.001). There was no significant association between patient’s demand, HIV status, Medical Officers’ experience and Caesarean section. CONCLUSION: Obstetric indications contributed more to the high Caesarean sections in Bertha Gxowa hospital than non obstetric factors. The Caesarean section rates may be reduced if obstetric protocols are implemented for certain classes of patients. LEVEL OF EVIDENCE: III
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    An analysis of theatre utilization at Sekororo District Hospital
    (2014-02-26) Ramodise, Kgaugelo Betrets
    BACKGROUND – District hospitals provides level of care services that are part of the basic service package for district hospitals. Services applicable to district hospitals’ operating theatres include performance of elective and emergency surgical procedures. A study was conducted at Sekororo district hospital to evaluate the functioning of the operating theatre system. AIM: To describe the profile of patients, theatre down time and theatre throughput efficiencies at the district hospital for the period 1 April 2009 – 31 March 2011. METHODOLOGY: This was a cross sectional study based on a retrospective record review. The study setting was Sekororo District Hospital Operating Theatre. The population included records of all operations performed in the theatre during the study period. Theatre utilization was calculated as well as patient throughput to assess the internal operational efficiencies. The throughput of elective and emergency cases were compared. RESULTS: A total of 702 cases were performed during the study period. The majority of cases performed in the operating theatre were maternity cases (caesarean sections). Maternity cases accounted for 602 cases. The most common indication for caesarean sections (CS) is Cephalo-pelvic Disproportion (CPD) (49.2%). For the maternity cases, the majority were emergency cases (84.33%), and 15.67% elective cases. Theatre utilization for this period was 3% (3.6% for 2009/10 and 3.2% for 2010/11). There was a statistically significant difference (p<0.01) between the average throughput for emergency and elective cases – 25 minutes for emergency cases (confidence interval 20-35 minutes) versus 62.5 minutes for elective cases (confidence interval 38.75 – 78.75 minutes). CONCLUSION: The theatre utilization rate is extremely low for this study period. Patient throughput is much more efficient for emergency cases. Further studies are required to determine resource allocation to the operating theatre that resulted in the low theatre utilization.
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    Caesarean section deliveried in public sector hospitals in South Africa, 2001-2009.
    (2013-04-05) Monticelli, Fiorenza
    Introduction There is concern that C-section rates are increasing in the public health sector in South Africa and wide variation has been reported between districts, provinces and hospitals. This study is a comprehensive analysis of C-section rates in all public sector hospitals during 2000/01- 2008/09 by facility, district and province. It aims to inform decision makers in maternal health services of the trends and patterns occurring in C-section rates in South African public sector hospitals. Variation in C-section rates is described to highlight the differences in care that pregnant women receive in different parts of the country and to illustrate where inequity of resource allocation is occurring, as well as highlighting possible data quality problems. Methodology This is a descriptive study using quantitative methods of analysis on secondary data obtained from the National Department of Health’s routinely collected data specific to Caesarean sections in the DHIS. C-section averages are weighted by taking the number of deliveries per facility and level into consideration. Results 1. Wide variation is noted between individual facilities, between and within provinces and districts and within the different levels of hospitals in 2008/09. The mean weighted C-section rate ranges from 17.2% in District Hospitals to 40.7% in Specialised Maternity Hospitals. A 3.7 fold difference between the highest and lowest district average C-section rates is seen for District Hospitals. Within provinces, average District Hospital C-section rates vary by as much as 3.5 fold between districts. Interdistrict variation in Regional Hospitals shows a 3.3 fold difference between the lowest and highest average district rates. Among the eight National Central Hospitals there is a 2.5 fold difference between the highest (79.7%) and lowest (31.7%) facility C-section rates. Nationally a total of 23 District Hospitals had C-section rates below 5% and nine hospitals of varying levels had rates of over 50% 2. Caesarean Section rate trends, 2000/01 – 2008/09 are increasing. Nationally the average C-section rate in South Africa increased by 6.3 percentage points from 18.1% in 2000/01 to 24.4% in 2008/09, with an average annual compounded growth rate of 3.8%. Bivariate linear regression analysis confirms there is a positive linear relationship between time (year) and C-section rate (p<0.001). All levels of hospitals showed an increasing trend over the nine years, (p<0.001), with the rate in Provincial Hospitals having increased by the highest amount (1.40%) year on year and District Hospitals, the least (0.48%). Trends within certain districts and individual hospitals however, show a decline. 3. A strong relationship between level of deprivation and C-section rate exists when adjusting data for provincial variation Bivariate linear regression analysis revealed no association between the level of deprivation of the population at district level and the mean C-sections rate per district (p=0.130). Multiple regression analysis adjusted for the effect of province, reveals a significant association (p=0.044). A negative association between the DI (p=0.006) and Csection rate is seen in eight out of nine provinces. 4. Data quality of C-sections and deliveries in the DHIS needs improving Data quality in the DHIS leaves uncertainty in some instances whether C-section rate trends are a true reflection or not. The C-section rate indicator on its own is unable to inform on the full spectrum of emergency obstetric care. The definition of C-section rate for primary health care currently only considers deliveries in District Hospitals. The national C-section rate for primary health care in the country however, reduces from 17.2% to 13.2% when including the deliveries which take place in CHCs. Conclusions The quality of data relating to C-sections (number of births, C-sections and hospital categorisation) in the DHIS needs to be improved in order to enable accurate monitoring and should include deliveries and C-sections which take place in Community Health Centres to allow for a more accurate reflection of C-section rate in primary health care. The C-section rate indicator on its own is insufficient to adequately inform on the full spectrum and quality of the provision of emergency obstetric care in South Africa. Including additional indicators to the DHIS, such as the UN process indicators, could improve on the current knowledge and monitoring of the provision of emergency obstetric care in South Africa. The wide variation in C-section rates seen among District Hospitals and the C-section rates between and within districts and provinces, suggest inequity in resource allocation and irregular service delivery patterns. Reasons and solutions for these wide differences need to be found, which are likely to be unique to each district and province. Further studies are needed to investigate the access of poorer women, especially those in remote rural areas to emergency obstetric care services.
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    Biochemical parameters of patients presenting for elective and urgent caesarean sections at Chris Hani Baragwanath Hospital
    (2012-01-17) Nethathe, Gladness Dakalo
    Introduction Maternal volume depletion at the time of caesarean section plays a role in ma- ternal and fetal outcome. Measuring uid volume status currently requires invasive monitors. It would be useful to determine biochemical measurements which would accurately determine uid volume status in these patients. We investigated the di erence in biochemical parameters of participants presenting for elective and urgent caesarean section at Chris Hani Baragwanath Hospital and made inferences about their uid volume status. We also sought to de- termine whether this difference in biochemical parameters if present could be linked to a potential difference in the intra-operative haemodynamic course as well as fetal outcome between the two groups. Method This was a prospective open-label observational cross-sectional pilot study. The sample was 54 participants, 27 elective and 27 urgent cases. Blood and urine samples were taken at the red line. Parameters from the blood samples were haematocrit, haemoglobin, sodium, urea, creatinine and plasma osmolality. Parameters from the urine samples were sodium, creatinine, osmolality and specific gravity. Intra-operatively, all participants received a standard spinal anaesthetic. Vari- ables measured intra-operatively were systolic, diastolic and mean arterial blood pressure, heart rate, highest level of block achieved as well as 1 and 5 minute Apgar scores of the newborn. The primary outcome variable was hypotension (mean arterial drop of more than 15% from the baseline). The secondary outcome variable were the Apgar scores of the infants. Results Urine specific gravity showed a trend towards statistical significance (mean, median, standard deviation for elective, urgent): 1.01, 1.010, 0.01 and 1.02, 1.015, 0.01 p = 0:06. The other biochemical parameteres displayed higher p- values. The average relative blood pressure change was -11,7% (median, standard de- viation) (-12.4, 11.1) for the elective group and -15.1% (-14.9, 15.1) for the urgent group p = 0:36. The relative blood pressure change to end point of study was -9.6% (-9, 12.7) for the elective group and -15.4% (-17, 17.6) for the urgent group p = 0:17. When comparing baseline blood pressure and heart rate measurements to the 10 minute end point measurements; 15 participants expe- rienced hypotension in the urgent group compared to 9 in the elective group p = 0:17. When comparing baseline blood pressure measurements to the av- erage at 2, 4, 6, 8, and 10 minute intervals; 13 participants from the urgent group experienced hypotension compared to 9 participants in the elective group p = 0:40. The average Apgar scores at 1 min were 8.89 (9,0.32) for the elective group and 8.37 (9,0.93) for the urgent group p = 0:01. Conclusion This was a pilot study and as such statistical signi cance between variables was not expected. However possible trends were identified to guide future investiga- tions. The higher incidence rate of hypotension in the urgent group showed such a trend towards signi cance as well as the higher urine specific gravity in the urgent group. We also noted that Apgar scores differed significantly between elective and urgent cases.