TABLE OF CONTENTS
CONSENSUS STATEMENTS FROM THE 15TH CONFERENCE ON PRIORITIES IN PERINATAL CARE IN SOUTHERN AFRICA 1
EDUCATION PROGRAMMES
THE IMPACT OF THE PERINATAL EDUCATION PROGRAMME ON THE INTERPRETATION OF ANTENATAL CARDS AND PARTOGRAMS BY MIDWIVES. GB Theron 3
DOES SUCCESSFUL COMPLETION OF THE PERINATAL EDUCATION PROGRAMME RESULT IN IMPROVED OBSTETRIC PRACTICE? E le Roux 5
EVALUATION OF THE USE OF THE NEONATAL MANUAL OF THE PERINATAL EDUCATION PROGRAMME.DH Greenfield 9
TRAINING TRADITIONAL BIRTH ATTENDANTS (TBAs): THE ZIMBABWE EXPERIENCE. SP Munjanja 10
SARTORIAL ELOQUENCE. GR Howarth...... 12
LABOUR
VAGINAL PROSTAGLANDIN E2 GEL VS. INTRAVENOUS OXYTOCIN VS. EXPECTANT MANAGEMENT FOR PRELABOR RUPTURE OF MEMBRANES AT TERM. A RANDOMIZED CLINICAL TRIAL.
M Hannah...... 14
A RANDOMISED CONTROLLED TRIAL COMPARING VAGINALLY ADMINISTERED MISOPROSTOL TO VAGINAL DINOPROSTONE GEL IN LABOUR INDUCTION. P Steytler 15
MECONIUM ASPIRATION SYNDROME: IMPORTANCE OF THE MONITORING OF LABOUR. M Adhikari 17
AMNIOINFUSION IN DEVELOPING COUNTRIES. GJ Hofmeyr...... 19
PREGNANCY
DOUBLE BLIND RANDOMISED CONTROLLED TRIAL OF THE USE OF LOW DOSE DOPAMINE IN POST PARTUM PRE-ECLAMPTIC WOMEN WITH OLIGURIA. GD Mantel 20
PREGNANCY OUTCOME IN PRIMIGRAVIDAE WITH HYPERTENSIVE DISEASE. J Moodley...... 22
PERINATAL OUTCOME OF HYPERTENSIVE DISORDERS OF PREGNANCY IN BLACK SOUTH AFRICAN WOMEN. NM Rankhethoa 26
THE EFFECT OF DEXAMETHASONE ON THE IMMUNE SYSTEM OF WOMEN WITH PRETERM PREMATURE RUPTURE OF MEMBRANES: A RANDOMISED CONTROLLED TRIAL. M Funk 29
THE VALUE OF DOPPLER STUDIES OF THE MIDDLE CEREBRAL ARTERY 9MCA0 IN THE MANAGEMENT OF PREGNANCIES WITH SEVERE PLACENTAL INSUFFICIENCY. L Geerts 31
REFERRAL OF PATIENTS WITH PRELABOUR RUPTURE OF THE MEMBRANES FROM RETREAT MOU TO GROOTE SCHUUR HOSPITAL. AA Van Coeverden de Groot 33
NEONATAL INTENSIVE CARE
A COMPARATIVE PROFILE OF INFANTS VENTILATED IN TERTIARY AND PRIVATE INTENSIVE CARE UNITS IN SOUTH AFRICA. GF Kirsten 35
EXTUBATION OF VENTILATED INFANTS: DIRECT EXTUBATION FROM LOW RATES COMPARED WITH EXTUBATION FROM CPAP. JC Stephen 36
COMPARISON OF INTRAVENOUS AND ORAL IRON IN PRETERM INFANTS RECEIVING RECOMBINANT HUMAN ERYTHROPOIETIN. M Meyer 39
INFECTIONS
NOSOCOMIAL INFECTIONS IN A NEONATAL HIGH CARE AND INTENSIVE CARE UNITSD Delport....41
ANTIBIOTICS AND SUSPECTED SEPSIS IN THE NEONATE: AN AUDIT. M Adhikari...... 43
SHOULD SYMPTOMATIC CONGENITAL SYPHILITICS BE OFFERED VENTILATION? THE BARAGWANATH EXPERIENCE. CJ Hauptfleisch 45
ASYMPTOMATIC BACTERIURIA: SIGNIFICANCE AND TREATMENT DURING PREGNANCY. DR Hall 47
GENITAL INFECTIONS IN THE ETIOLOGY OF LATE FETAL DEATH : AN INCIDENT CASE-REFERENT STUDY. NB Osman 49
APPROPRIATE TECHNOLOGIES
NEW INSTRUMENTS FOR MONITORING GROWTH AND NUTRITION OF CHILDREN AND MOTHERS. HdeV Heese 50
PREVENTION OF LOW BIRTH WEIGHT INFANTS (POLO) PHASE ONE : DEVELOPING A RISK SCORE. LR Pistorius 53
BEDSIDE FETAL LUNG MATURITY TESTING. WKH Kuchenbecker...... 55
THE INTRA-UTERINE GROWTH GRAPH AND SCORE REVISITED: A PRAGMATIC CLINICAL TOOL OF FOETAL WELLBEING. PM Garde 57
PRIMARY CARE FETAL ASSESSMENT: LOW-COST FETAL ACOUSTIC STIMULATION. TA Lawrie....59
THE OXYGEN CONCENTRATOR - EVALUATION AND POTENTIAL USE IN THE NEONATE. IT Hay....61
WEIGHT GAIN & PREGNANCY HYPERTENSION - PART II. I Kennedy...... 63
COMMUNITY OBSTETRICS
ARE THERE MEASURABLE EFFECTS OF THE INTRODUCTION OF FREE MATERNAL CARE? PA Cooper66
A COMMUNITY BASED INVESTIGATION OF MATERNAL MORTALITY DUE TO OBSTETRIC HAEMORRHAGE IN RURAL ZIMBABWE. S Fawcus 68
COMMUNITY HEALTH WORKERS INVOLVED IN POSTNATAL CARE OF PATIENTS IN KHAYELITSHA. L Linley 70
PERINATAL HEALTH IN THE CHIAWELO DISTRICT OF SOWETO. EJ Buchmann...... 72
A PROSPECTIVE ANALYSIS OF ALCOHOL INGESTION IN 400 PREGNANT WOMEN IN RURAL AND URBAN AREAS IN THE WESTERN CAPE. DL Viljoen 74
HIV
VERTICAL TRANSMISSION OF HIV-INFECTION. EFFECT OF VAGINAL WASHING. A Justesen...... 76
MATERNAL AND OBSTETRICAL FACTORS IN MOTHER TO CHILD TRANSMISSION OF HIV IN SOWETO, SOUTH AFRICA. JA McIntyre 78
THE MIDWIFE'S EXPERIENCE OF A HIV-POSITIVE DELIVERY. M de Jager...... 81
MEDICAL STUDENTS AND HIV EXPOSURE. EC de Coning...... 83
POSTERS
MOU PROFILES - A COMPARISON OF THE SOCIO-OBSTETRIC PROFILES OF 2 ADJACENT MIDWIFE OBSTETRIC UNITS IN CAPE TOWN. HA van Coeverden de Groot 85
CLINICAL EVALUATION OF NORMAL UMBILICAL ARTERY DOPPLER AND PERINATAL OUTCOME.K Norman 87
MATERNAL NUTRITION AND LOW BIRTH WEIGHT. K Kyriazis...... 89
AN OVERVIEW OF PERINATAL MORTALITY IN SOUTH AFRICA. H Saloojee...... 92
UNBOOKED PATIENTS. M Mokoana...... 94
THE UNBOOKED MOTHER AT BARAGWANATH HOSPITAL AFTER THE INTRODUCTION OF FREE ANTENATAL CARE. D Dawood 96
AN EVALUATION OF THE INCIDENCE OF EPISIOTOMIES AND PERINEAL TEARS IN PATIENTS AT PELONOMI HOSPITAL. EC De Coning 98
SCREENING FOR ANAEMIA IN PREGNANCY. COMPARISON BETWEEN COPPER SULPHATE AND HAEMOGLOBINOMETER METHODS. LR Pistorius 100
ADRENALIN AS AN INOTROPE IN CRITICALLY ILL, HYPOTENSIVE NEONATES. H Saloojee...... 102
USING THE PERINATAL PROBLEM IDENTIFICATION PROGRAMME IN MIDWIFE OBSTETRIC UNITS IN CAPE TOWN. DH Greenfield 104
AUDIT ON ANTENATAL CARE BEFORE AND AFTER THE INTRODUCTION OF THE PERINATAL EDUCATION PROGRAMME AND FREE ANTENATAL CARE IN ATTERIDGEVILLE. R Pfau 106
ACCURACY OF ASSESSMENT OF CERVICAL DILATATION. M Funk...... 108
UPDATE ON THE IMPORTANCE OF TOUCH. K Hansen...... 110
THE INTERNET AND TEACHING IN PERINATAL CARE. A Kent...... 112
ANTENATAL PREDICTIVE FACTORS OF NEURODEVELOPMENTAL DELAY IN VERY LOW BIRTH WEIGHT (VLBW) INFANTS. PA Smith 114
REVIEW OF RISK FACTORS FOR THE PREDICTION OF FETAL LUNG HYPOPLASIA AND ULTRASOUND PREDICTORS THEREOF. CJM Stewart 115
POOR CORRELATION BETWEEN FETAL HEART RATE PATTERNS AND UMBILICAL ARTERY BLOOD GASES IN HIGH RISK PATIENTS DELIVERED LONG BEFORE TERM. C A Oettlé 116
SOCIAL AND EDUCATIONAL BACKGROUND OF THE TEENAGE MOTHERS AT GA-RANKUWA HOSPITAL.NJ Kekesi 117
FACTORS CONTRIBUTING TO THE MORTALITY OF VERY LOW BIRTH WEIGHT INFANTS 1500g ADMITTED TO GA-RANKUWA HOSPITAL. F Muwazi 119
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CONSENSUS STATEMENTS FROM THE 15TH CONFERENCE ON PRIORITIES
IN PERINATAL CARE IN SOUTHERN AFRICA
Delegates to the 15th Conference on Priorities in Perinatal Care in Southern Africa, held at Goudini Spa from 5-8 March 1996, adopted consensus statements on three topics which have been the subject of considerable discussion and research over the past 15 years. These conferences are the annual meetings of the Priorities in Perinatal Care Association, and are attended by a broad spectrum of rural and urban health workers with an interest in perinatal care, including midwives, neonatal nurses, neonatologists and obstetricians.
1.A patient carried antenatal record
It is in the best interest of pregnant women that they keep with them medical information of importance to their pregnancy. All health care workers should provide pregnant women with written information preferably in the form of a structured card or book. Antenatal cards should be made available to all providers of maternal care. The information should include:
Relevant history and clinical findings
Blood group
Results of other laboratory investigations, particularly syphilis screening
Results of ultrasound examination, if available
Estimated date of delivery
2.A partogram
All pregnant women should be monitored during labour using a partogram. The partogram must accompany a woman who is transferred during labour. The partogram should consist of the following sections:
The well being of the woman (blood pressure, pulse, temperature, urine output and urinalysis)
The well being of the fetus (heart rate and pattern, and colour of the liquor)
Graphical presentation of the progress of labour (cervical effacement and dilatation, decent of the presenting part, fetal position, station, caput and moulding)
The alert and actions lines
Latent and active phases of labour recorded on the same sheet
Medication, including analgesia
Both oral and intravenous fluid
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There should also be place for :
Patient's name, age, gravidity and parity
Address and telephone number of clinic
A problem list with high risk factors
Assessment of fetal size, and pelvimetry is indicated
Haemoglobin concentration, blood group and results of syphilis screening
It is essential that a relevant training course be used when partograms are introduced for the first time.
3.Treatment of newborn infants born to women with syphilis
All infants born to women who have proven or suspected syphilis during pregnancy should be treated with penicillin unless the mother has been adequately treated. Adequate maternal treatment consists of three weekly intramuscular doses of 2,4 million units of benzathine penicillin. The treatment must be completed before the last month of pregnancy. Women who have not been screened for syphilis during their pregnancy should be screened at delivery. If the mother cannot be screened for syphilis, it is recommended that the infant be regarded as at an increased risk for congenital syphilis and treated.
The choice of treatment of the newborn infant depends on the clinical examination of the infant at birth. Unfortunately radiography and immunological tests are only of limited diagnostic value.
Infants with any clinical signs of syphilis should receive 50 000 units/kg of procaine penicillin by intramuscular injection daily for 21 doses, preferably on consecutive days. Every effort must be made to keep the mother and infant together during treatment. These infants should be followed until they are thriving and all signs of syphilis have disappeared.
Infants who appear healthy with no signs of clinical syphilis should be given 50 000 units/kg of benzathine penicillin as a single intramuscular dose. No further follow-up is needed.
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THE IMPACT OF THE PERINATAL EDUCATION PROGRAMME ON THE INTERPRETATION OF ANTENATAL CARDS AND PARTOGRAMS BY MIDWIVES.
GB Theron
Department of Obstetrics and Gynaecology, University of Stellenbosch
A previous study has shown that the Perinatal Education Programme (PEP) significantly increased the cognitive knowledge of midwives concerning maternal and infant care as assessed by multiple-choice testing.1 This study assessed the ability of midwives that studied the Maternal Care Manual of PEP to correctly interpret antenatal cards and partograms. An assessment of their attitude towards their work was also made.
Methods:
A prospective controlled study was conducted in a region where PEP has not been implemented at all. A study town and 2 control towns were selected. Pretests were conducted in all 3 towns. Attitudes towards work were tested with a questionnaire. Five antenatal cards had to be interpreted by all midwives rendering antenatal care in these towns and 5 partograms by the midwives working in the labour wards. The Maternal Care Manual of PEP was subsequently studied in the study town. The Programme was introduced in the usual way and managed by a regional and local coordinators. On completion of the Programme the same tests were conducted in all 3 towns. The interpretations of the antenatal cards and partograms were marked strictly according to a preset memorandum.
Results:
A total of 40 and 53 midwives were included in the study and control towns respectively. There were no differences regarding the age, level of training and experience between the two groups. The ability to interpret findings on antenatal cards and partograms during the pretesting also did not differ between the study and control towns. The post-testing showed a significant improvement (0,001) with regards to interpretation of both the antenatal cards and the partograms (Tables I and II). The mean score with the antenatal cards improved by 32,9% and the partograms by 17,2%. There was a significant (p=0,0001) improvement in the attitude towards work in the study town with the means score improving by 24,6% (Table III). Post-tests in the control towns revealed no changes.
Discussion:
The Maternal Care Manual of PEP significantly improved midwives ability to correctly interpret information on the antenatal cards and partograms. Their attitude towards their work also improved significantly. These achievements will improve ante- and intrapartum care rendered in regions where PEP has been studied.
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Table 1Antenatal Cards (scored out of 20)
STUDY TOWNPretest / Post test / p-value*
*mean (s)8,4 (4,3)
*median9,0
*range0-15 / 15,0# (4,9)
15,0
12-19 / 0,000
CONTROL TOWN
Pretest / Post test / p-value
*mean (s)10,4 (5,0)
*median10,5
*range0-17 / 10,4 (4,7)
12,0
0-16 / 0,744
* Student's t test# Mean improvement = 33%
Table 2Partograms (scored out of 20)
STUDY TOWNPretest / Post test / p-value*
*mean (s)11,3 (3,0)
*median11,0
*range7-17 / 14,8# (3,0)
13,5
10-20 / 0,001
CONTROL TOWN
Pretest / Post test / p-value
*mean (s)8,3 (3,4)
*median8,0
*range2-17 / 9,0 (3,5)
9,5
1-19 / 0,640
* Student's t test# Mean improvement = 18%
Table 3Attitude towards work (scored out of 25)
STUDY TOWNPretest / Post test / p-value*
*mean (s)14,5 (6,4)
*median15,5
*range0-25 / 20,6# (3,6)
21,0
13-25 / 0,000
CONTROL TOWN
Pretest / Post test / p-value
*mean (s)16,7 (4,5)
*median17,0
*range6-25 / 16,0 (4,0)
16,0
4-22 / 0,646
* Student's t test# Mean improvement = 24%
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DOES SUCCESSFUL COMPLETION OF THE PERINATAL EDUCATION PROGRAMME RESULT IN IMPROVED OBSTETRIC PRACTICE?
E le Roux, RC Pattinson, W Tsaku*, JD Makin
Department of Obstetrics & Gynaecology, University of Pretoria and Kalafong Hospital, and *Mmametlhake Hospital, Mpumalanga
Objective:
To determine whether the successful completion of the Perinatal Education Programme (PEP) improves obstetric practice.
Method:
Three midwife obstetric units (MOU's) - Marapyane, Mmametlhake and Pankop clinics, in the Moretele District of Mpumalanga were included in the study. PEP was run at Marapyane and Mmametlhake and Pankop served as a control. Data was collected by analysing the obstetric files after the patient had delivered. The analysis was performed using two systems, firstly a code was given if an observation or procedure was or was not performed and whether it was correctly performed, e.g. haemoglobin measurement. The second coding system was used to assess whether or not appropriate action, where applicable, was taken.
Data was collected from all three clinics from July to October 1995, and from Marapyane in July and August 1994, 6 months before PEP was initiated. Two control groups were established; a “before” group, consisting of data collected before doing the relevant chapters in PEP, and a “during” group, where data was collected at the time of studying PEP from Pankop clinic, which did not do PEP. The antenatal part of PEP was completed by July and the chapters dealing with the partogram were dealt with at the end of August and the beginning of September. For antenatal care assessment the “before” control group consisted of data collected at Marapyane in 1994, and the “during” control group data collected at Pankop. The study group consisted of data collected at Marapyane (in 1995) and Mmametlhake Clinics. For intrapartum care the “before” control group consisted of data collected at Marapyane in 1994, and from July-August 1995, and Mmametlhake Clinic July-August 1995, i.e. before studying the intrapartum chapters in PEP, and the “during” control group data collected from Pankop Clinic. The study group consisted of data collected at Marapyane Clinic from September-November, and at Mmametlhake Clinic from September-October.
Outcome Measures:
In antenatal care, the obstetric history, syphilis testing, blood group testing, haemoglobin and uterine growth assessment were assessed along with whether appropriate action was taken. For intrapartum care, the estimated fetal weight, pelvimetry, blood pressure, urine, head above pelvis, fetal heart rate, contractions and plotting cervical dilatation as well as whether the appropriate actions were taken, were assessed.
Results:
Eight midwives went through the Obstetric Manual of PEP, all demonstrated a significant improvement in knowledge, and all but 2 scored above 80% at the final examinations. Five of
eight midwives did the course at Marapyane and three of five at Mmametlhake.
Details are given in Table 1 below.
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Table1. Totals for pre- and post- test scoring of candidates doing PEP.
Candidates / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / AllBefore / 168 / 193 / 148 / 155 / 148 / 211 / 257 / 231 / 188,8
56% / 64% / 49% / 51% / 49% / 70% / 85% / 77% / 62,9%
After / 296 / 266 / 249 / 212 / 238 / 262 / 270 / 250 / 252
92% / 88% / 83% / 70% / 79% / 87% / 90% / 83% / 84,2%
P-value / <0,001 / <0,001 / <0,001 / <0,001 / <0,001 / <0,001 / <0,05 / <0,05 / <0,001
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272 Patients case files were studied from the various clinics (Marapyane 145, Mmametlhake 60 and Pankop 67 representing 18%, 35% and 82% of deliveries respectively). There was no change in the referral patterns of any of the clinics during the study period.
The obstetric history was taken well but in no group was there a satisfactory response to a detected problem where, in only 0-12% of cases
was appropriate action taken. Syphilis testing was not performed in 18-41% of cases with significantly less testing occurring in all places in 1995. The haemoglobin was tested in only 4-15% of patients with no difference before or after PEP. Where a problem was detected in uterine growth, there was no response in 81-100% of patients and no difference before or after PEP was ascertained. See Tables 2 and 3.
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Table 2. Antenatal observations and procedures done correctly.
Key Observations / Study Group (S)n = 234 / “Before” Control (B)
n = 62 / “During” Control (D)
n = 67 / P=value
Obstetric History / 222 = 94,8% / 57 = 92% / 59 = 88% / S/B, S/D - NS
STS / 137 = 58,5% / 51 = 82% / 43 = 64% / S/B - <0.001,
S/D - NS
Bloodgrouping / 134 = 57,2% / 51 = 82% / 44 = 66% / S/B - <0.001,
S/D - NS
Haemoglobin / 22 = 9,4% / 9 = 14,5% / 3 = 4% / S/B, S/D - NS
Gestational age / 161 = 68% / 39 = 62,9% / 43 = 64% / S/B, S/D - NS
STS - Serological tests for syphilis; S/B - Study group versus “Before” control; Study group versus “During” control; NS - Not statistically significant
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Table 3. Appropriate actions taken where necessary.
Study Group / “Before” Control / “During” Control / P=ValueObstetric History / 4/33 = 12% / 0/7 = 0% / 0/6 = 0% / S/B, S/D - NS
STS / 15/82 = 18,2% / 26/36 = 72% / 7/17 = 41% / S/B - <0.001,
S/D - <0.05
Bloodgrouping / 1/66 = 1,5% / 0/5 = 0% / 1/12 = 8,3% / S/B, S/D - NS
Gestational age / 6/53 = 11,3% / 0/20 = 0% / 0/18 = 0%* / S/B, S/D - NS
STS - Serological tests for syphilis; S/B - Study group versus “Before” control; Study group versus “During” control; NS - Not statistically significant
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Estimation of fetal weight and pelvimetry was poorly performed across all groups, the uterine and fetal heart rate documentation was moderately well done in all groups and the blood pressure, head above pelvis, contractions and plotting of cervical dilatation was performed well in all groups. No differences before and after PEP were detected.
Where problems were detected, appropriate actions taken during labour improved but not significantly at Marapyane (44-79%) but no change was detected at Mmametlhake (70-67%) and there was no difference between Marapyane and Mmametlhake after PEP and Pankop (79%). See Tables 4 and 5.
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Table 4. Partogram observations and procedures correctly done.
Key observations / Study Group (S)n = 76 / “Before” Control (B)
n = 116 / “During” Control (D)
n = 42 / P-value
Estimated fetal weight / 28 = 36% / 48 = 41% / 26 = 62% / S/B - NS,
S/D - <0.01
Pelvimetry / 0 = 0% / 2 = 1,7% / 2 = 5% / S/B, S/D - NS
Bloodpressure / 63 =82,9% / 102 = 87,7% / 23 = 60% / S/B - NS,
S/D - <0.001
Urine / 43 =56,5% / 60 = 51,7% / 25 = 64% / S/B, S/D - NS
Head above pelvis / 65 = 85% / 98 = 84,4% / 25 = 64% / S/B - NS,
S/D - <0.005
Fetal heart rate / 48 = 63% / 86 = 74,1% / 10 = 26% / S/B - NS,
S/D - <0.005
Contractions / 69 = 90% / 109 = 93,9% / 33 = 85% / S/B, S/D - NS
Cervical dilatation / 73 = 96% / 113 = 97,4% / 33 = 85% / S/B - NS,
S/D - <0.005
S/B - Study group versus “Before” control; Study group versus “During” control; NS - Not statistically significant