Peritoneal closure or non-closure at caesarean section.

At caesarean section, the closure or non-closure of the parietal and/or the visceral peritoneum has short-term and long-term advantages and disadvantages. The majority of reports have compared double closure vs double non-closure, non-closure of the parietal, or non-closure of the visceral parietal, with special emphasis on operation time, febrile morbidity, and duration of hospital stay. The present study compares the three methods in 692 consecutive caesarean sections in a South African rural hospital, with special emphasis on wound sepsis, operation time and febrile morbidity. The prevalence of wound sepsis and febrile morbidity was 4.9% and 2.5%, respectively. The only significant difference between the three groups was that double closure resulted in the longest operation time.

Revising the primigravid partogram: does it make any difference?

OBJECTIVE: To investigate the distribution of the rate of cervical dilatation of primigravid labour and its deviation from the standard partogram. DESIGN: Retrospective observational study. SETTING: South African district hospital serving an indigent rural population. POPULATION: Expectant management of labour of healthy nulliparous women in active labour, at term, with a singleton pregnancy and cephalic presentation. METHODS: Audit of 1,595 partograms of spontaneous primigravid labour. The standard partogram's alert line was replaced by a customised alert line based on the lowest 10th centile of the rate of cervical dilatation of the study population and an alert line representing the 10% slowest labours. The action line was placed parallel and 4 h to the right of the alert lines. MAIN OUTCOME MEASURE: The distribution of labours left to and on the respective alert lines, and right to the action lines. RESULTS: The lowest 90th centile of the customised alert line yielded a rate of cervical dilatation of 0.860 cm/h. Three quarters of labours evolved left to the revised alert line as opposed to 56.1% left of the standard alert line [Odds ratio (OR) 0.49, 95% confidence interval (CI) 0.42-0.56]. The mean rate of cervical dilatation of the 10% slowest labours was 0.535 +/- 0.076 cm/h (P < 0.0001), and 95.7% of labours evolved left to the corresponding alert line (OR 8.40, 95% CI 6.44-11.0). CONCLUSION: The alert line representing the mean of the 10% slowest labours leads to an unrealistic distribution of labour on the partogram. A revised alert line based on the lowest 10th centile of the local population is more representative and should perhaps be used in the management of labour.

Neonatal outcome after caesarean birth for fetal distress and/or meconium staining in a South African rural setting.

The aim was to evaluate the effect of caesarean delivery on the neonatal outcome after labour with fetal distress and/or meconium staining (MS). We audited 199 caesarean sections performed for non-reassuring fetal condition (NRFC) and/or MS in a rural regional hospital. The 1 and 5 min Apgar scores were compared with those of 33 vaginal births after labour with MS. There were five neonates out of 232 (2.2%) with an Apgar score <7 at 5 min; one died early, neonatally. In the caesarean section group for NRFC, there were two fresh stillbirths and one early neonatal death, a perinatal mortality of 15.1/1,000 births. The 5 min Apgar score was not statistically significantly affected by the mode of delivery. Caesarean delivery does not improve the neonatal outcome when the amniotic fluid is meconium stained.

Efficacy of a single misoprostol regimen in the first and second trimester termination of pregnancy.

A total of 273 women underwent termination of pregnancy (TOP) with a single regimen of misoprostol (400 microg orally and 800 microg vaginally), without mifepristone. A total of 98 (35.9%) were first trimester and 175 (64.1%) second trimester gestations. Of these women, 189 (69.2%) responded to a single administration of misoprostol and 84 (30.8%) required between two and six administrations of misoprostol. The medical TOP was complete in 90.8% of all cases. A surgical intervention was needed in 23 (27.4%) of those requiring repeated administrations of misoprostol vs only two (1.1%) of those responding to a single administration. Age, parity and gestational age did not affect the response rate to the misoprostol regimen. The need for a D&C was related to the response to misoprostol: most D&Cs were needed in cases of repeat administrations of misoprostol. This study shows the feasibility of medical TOP in the developing world. It has the great advantage of significantly reducing the need for surgical termination where the required skills are scarce.

A comparison of women's, providers' and ultrasound assessments of pregnancy duration among termination of pregnancy clients in South Africa.

OBJECTIVE: To compare providers' and women's estimates of duration of pregnancy with ultrasound estimates for determining medical abortion eligibility. DESIGN: Cross-sectional study. SETTING: Public termination of pregnancy (TOP) services in three provinces. SAMPLE: A total of 673 women attending the above services for TOP. METHODS: Women participating in a medical abortion feasibility study in South Africa provided estimates of pregnancy duration and date of last menstrual period (LMP). Each woman also had clinical and ultrasound exams. We compared estimates using the four methods, calculating the proportion of women in the 'caution zone' (< or = 8 weeks gestation by woman or provider estimate and > 8 weeks by ultrasound). MAIN OUTCOME MEASURES: Mean gestational age by each method; difference between provider and LMP estimates and ultrasound estimates; and percentage of women in the 'caution zone'. RESULTS: Women's estimates of pregnancy duration were 19 days fewer than ultrasound estimates (95% CI = -27 to 63). Mean provider- and LMP-based estimates were two (95% CI = -30 to 35) and less than one day(s) (95% CI = -46 to 51) fewer than ultrasound estimates. Comparing provider and ultrasound estimates, 15% of women were in the 'caution zone'; this fell to 12% if estimates of 9 weeks or fewer were considered acceptable. CONCLUSIONS: Provider estimates of gestational age were sufficiently accurate for determining eligibility for medical abortion. LMP-based estimates were also accurate on average, but included more extreme differences from ultrasound estimates. Medical abortion could be provided in TOP facilities without ultrasound or with ultrasound on referral.

Anaemia and pregnancy outcomes in a South African rural population.

The purpose of this study was to evaluate whether the booking haemoglobin (Hb) did affect the mode of delivery or the birth weight. A total of 3,214 booking Hb was available from 1,628 primiparas and 1,586 multiparas. A total of 507 had a caesarean section and 2,707 a spontaneous vaginal delivery (SVD). Moderate and severe anaemia were defined, respectively as an Hb of <10 and <8 g/dl. There were only 112 women with recorded evidence of iron and folate supplementation. The overall prevalence of anaemia was 19.7%. Multigravidas with SVD had a 22.5% prevalence of booking Hb <10 vs 14.2% in primigravidas (p < 0.0001). The prevalence of severe anaemia was similar for all subgroups. Simple regression analysis showed no significant correlation between the booking Hb and pregnancy outcome in terms of birth weight or mode of delivery. However, booking visit anaemia could predispose to caesarean delivery. Documented iron and folate supplementation did not appear to result in different pregnancy outcomes.

The partogram's result and neonatal outcome.

The aim was to investigate to what extent low Apgar scores are linked to the partogram's result and, more specifically, if the action line should be set 3 rather than 4 h parallel and right to the alert line. Some 24.0% of all labours evolved left to the alert line and 26.3% of the labours right to the alert line crossed the 4-h action line. An Apgar score of

Mode of delivery after one cesarean section.

OBJECTIVES: To investigate labor patterns and mode of delivery of aginal births after cesarean (VBAC) versus unsuccessful trial of labor after cesarean (TOLAC) in a South African district hospital, and the influence of the indication for the primary cesarean section (C-section) on the subsequent mode of delivery. METHODS: Retrospective audit of the partogram of 202 VBAC and 382 repeat C-section. There were 108 elective repeat cesarean deliveries (ERCD) and 274 emergency repeat C-sections after unsuccessful TOLAC. The indication of the primary C-section was known in 127: 43 (33.9%) VBAC and 84 (66.1%) repeat C-sections. RESULTS: The indication for the primary C-section in terms of recurrent/non-recurrent did not affect the subsequent mode of delivery (chi(2)=3.5; P=0.06; OR 0.49, 95% CI 0.23-1.04). The indication of the primary C-section in terms of dysfunctional/non-dysfunctional labor did not reoccur in the same parturients (chi(2)=0.01; P=0.91; OR 0.94, 95% CI 0.35-2.55). CONCLUSION: Dysfunctional labor accounted for most primary and repeat emergency C-sections, but not as a recurrent condition in the same parturients.

The multigravid partogram--should it be customised?

Multigravid labour is conducted according to an alert line and an action line derived from primigravid spontaneous labour. Although it is widely recognised that multigravid labour is significantly faster than primigravid labour, the standard of care for both is the 'usual-care' partogram. A series of 1398 partograms of spontaneous multigravid labours resulting in vaginal delivery was audited. Retrospectively, the labours were graphed on a usual-care and on a customised partogram. The customised alert line was built to represent the rate of cervical dilataion of the lower 90 per cent. (after excluding the 10 per cent of very rapid labours.) The effect of putting the action line 2, 3 or 4 hours behind the alert line on the relative distribution of labours was tested. The results indicate that the norms of the usual-care partogram do not reflect the facts of multigravid labour.

Opportunistic testing of medically underserved women for cervical cancer in South Africa.

OBJECTIVE: To determine the yield of opportunistic Pap smears taken in an unscreened and medically underserved population in the Transkei Region of South Africa. STUDY DESIGN: Cross-sectional study of 22,160 cervical cytology specimens from an unscreened population attending gynecologic outpatient clinics between January 1990 and December 1996. RESULTS: The overall prevalence of atypical squamous cells of uncertain significance (ASCUS), low grade squamous intraepithelial lesions (LSIL) and high grade squamous intraepithelial lesions (HSIL) was, respectively, 34.7%, 8.3% and 2.4%. The ASCUS: SIL ratio was 3:1. The prevalence of invasive squamous cell carcinoma was 1.6%. The yield of opportunistic Pap smears was 10.7% including only LSIL and HSIL. CONCLUSION: The pathologic process of precursor lesions of cervical cancer appears to start at an early age since > 20% of cases are diagnosed before the age of 30 years. In the absence of a national screening program, opportunistic testing of medically underserved women needs to be maintained and encouraged.

Customised gravidogram and fetal growth chart in a South African population.

OBJECTIVE: To investigate whether gravidograms and fetal growth curves should be customized, i.e. tailor made for a specific ethnic group. METHODS: A cross-sectional study of 800 pregnant Xhosa women attending antenatal care in the Eastern Cape Province (South Africa). The data measured was used to compare the correlation between the symphysis-fundus height measurement (SFHM) and the sonographic estimate of gestational age (SEGA), as well as the intra-uterine fetal growth curve with existing gravidograms and fetal growth charts. RESULTS: There was a good correlation between the SFHM and the SEGA: r = 0.91 (P < 0.0001). The correlation between the SFHM and the sonographic estimate of fetal weight (SEFW) yielded a correlation coefficient (r) of 0.40 (P < 0.0001). The correlation between the SEFW and SEGA resulted in a r = 0.97 (P < 0.0001). The customized gravidogram and fetal growth chart followed the general trend seen in their Caucasian equivalents. CONCLUSION: The comparison of our customized gravidogram and intra-uterine fetal growth curve with similar charts established in Caucasians does not show any significant difference.

The relation between height, foot length, pelvic adequacy and mode of delivery.

OBJECTIVE: To investigate the value of maternal height and foot length as predictors of pelvic adequacy and to evaluate the influence of body components' proportions on the mode of delivery. METHODS: Retrospective study of the anthropometry of women having normal vertex deliveries (NVD), caesarean sections (CS) and vaginal birth after caesarean (VBAC). RESULTS: NVD patients were taller, had a longer vertebral column, longer lower limbs and longer feet than CS and than VBAC patients. The anthropometric measurements of VBAC patients yielded values intermediate between CS and NVD patients. The ratios of height to any of the other measured variables (vertebral column, lower limb and foot length) were similar in the three groups indicating that the body proportions were the same. CONCLUSION: Maternal height and foot length are of limited value as predictors of pelvic (in-)adequacy. The anthropometric features of women delivered by CS only are similar to those of women having a vaginal birth after Caesarean.

Spinal block caesarean section in parturients with pregnancy-induced hypertension.

The objective of this work was to determine whether parturients with pregnancy-induced hypertension (PIH) are at higher risk of post-spinal hypotension at caesarean section. This was an observational study of 24 women with PIH undergoing caesarean section under spinal analgesia with 0.5% hyperbaric bupivacaine, compared with 24 matched normotensive parturients receiving a spinal block for caesarean section. The mean intra-operative systolic arterial pressure (SAP) was similar with and without PIH (p = 0.38). The mean percentage decrease in SAP of baseline was more with PIH (16.2%) than in the controls (0.5%) (p < 0.001). The number of episodes of severe hypotension (SAP decrease to < or = 80% of baseline and < 90 mmHg) (p = 0.80) as well as the magnitude (p = 0.31) of severe hypotension was similar in both groups. There was no difference in the evolution of diastolic arterial pressure and maternal pulse rate between cases and controls. Maximum levels of upper sensory blockade were similar. Foetal and maternal outcome was similar with and without PIH. The decrease in SAP is less on an absolute scale but more on a percentile basis with PIH at caesarean section under spinal analgesia than in normotensive patients. The difference, however, is not clinically sufficient to discourage spinal analgesia for caesarean section with a low dose (1.5 ml, 7.5 mg) of 0.5% hyperbaric bupivacaine in parturients with PIH.

Prevention of post-spinal hypotension at elective cesarean section by wrapping of the lower limbs.

OBJECTIVE: To investigate whether wrapping and/or elevation of the legs prevents post-spinal hypotension at cesarean section (CS). METHODS: 82 parturients in a community hospital were randomly allocated to one of 4 groups: raising, wrapping, raising and wrapping of the legs and no intervention. The outcome measures were the upper level of blockade, pulse rate and arterial systolic pressure (SAP). Statistical evaluation included paired and unpaired t-test, contingency table analysis and repeated measures analysis of variance. RESULTS: The SAP remained significantly higher with wrapping; elevation did not add any benefit. The number of episodes of severe hypotension (defined as a SAP decrease > or = 20% of baseline and < 100 mmHg) was significantly reduced by wrapping (15.8% of cases) as compared to controls (45.5%)(chi2 = 11.02; P = 0.012). Elevation alone did not prevent hypotension (chi2 = 0.76; P = 0.38). CONCLUSION: Wrapping of the legs at spinal block for Cs is recommended to reduce hypotension.