Background: The most common major surgical procedure performed worldwide is the caesarean section (CS). Effective pain management is a priority for women undergoing this procedure, to reduce the incidence of persistent pain, (a risk factor for postpartum depression), as well as optimize maternal-neonatal bonding and the successful establishment of breastfeeding. Multimodal analgesia is the gold standard for post-caesarean section analgesia. At present, no perioperative pain management protocols could be identified for the management of patients presenting for CS at regional hospitals in South Africa. This audit aimed to review the folders of patients who underwent CS, with reference to perioperative pain management guidelines for CS. Methods: A descriptive, retrospective, cross-sectional audit was conducted. Three hundred folders (10% of the annual number of caesarean procedures performed) from New Somerset Hospital, a regional hospital in Cape Town, South Africa were reviewed. Results: The women were a mean age of 30 years (SD 6.2). Median gravidity was 3 (IQR 2-3) and parity was 1 (IQR 1-2); 52% had previously undergone a CS. In 93.3%, spinal anaesthesia was employed for CS. Pain assessment was poor, with only 55 (18%) patients having their pain assessed on the day of the operation. Analgesia was prescribed in over 98% of the patients, however, medication was only administered as prescribed in 32.6%. Non-steroidal anti inflammatory drugs (NSAIDs) were prescribed in < 1.67% of cases. None of the patients received a patient-controlled analgesia (PCA), transversus abdominis plane (TAP) block, or wound infusion catheter as supplementary strategies. Conclusions: Pain management for post-CS patient at this hospital is lacking. There is the need for the implementation of a structured assessment tool to improve administration of analgesics in these patients. In addition, the reasons for the omission of NSAIDs from the analgesia regimen requires investigation. Hospitals require post-CS pain protocols to guide management especially in resource-limited settings.

No description available.

It is a commonly held belief that a repeat caesarean section through a low vertical scar provides easier access and fewer complications than an operation through a previous Pfannenstiel incision. To test this hypothesis the records of one hundred and twenty one repeat caesarean sections were retrospectively reviewed by the author. These records were reviewed at the two large teaching hospitals of the University of the Witwatersrand, Chris Hani Baragwanath and Johannesburg General Hospital. Statistically significant findings were that older women were more likely to have had an initial midline incision. Incision to delivery times were faster via the midline (4 min) than the Pfannenstiel incision (5.5 min). Total operating times did not differ significantly. The findings do show that repeat midline incisions are faster (1.5 min) to deliver, but do not address the patient’s need for a cosmetically pleasing wound scar.

M.Med.(Anaesthesia), Faculty of Health Sciences, University of the Witwatersrand, 2011 / BACKGROUND Multiple studies have been conducted comparing the efficacy and duration of analgesia obtained from spinal anaesthesia containing local anaesthetics as well as opioids. The literature available has not considered the individual‟s HIV status as a variable. Postoperative analgesic duration and requirements in this group of patients may differ due to the occurrence of acute and chronic pain syndromes, pain arising from the disease itself, side effects of treatment for HIV infection, or opportunistic infections. Response to opioid analgesia may be altered due to previous opioid exposure, potential increase in nociception, drug interactions and emotional status. OBJECTIVES The primary objective of this study was to determine the time to post-operative analgesic request in HIV-positive and negative individuals having caesarean sections under spinal anaesthesia containing bupivacaine or bupivacaine and fentanyl. The secondary objectives of this study were to determine if factors such as height, ethnicity, level of education, CD4 count, and antiretroviral therapy impacted on the duration of analgesia obtained.

BACKGROUND: Sensory over-responsivity (SOR) is a type of Sensory Modulation Disorder (SMD), where the individual has an over-responsive behavioural reaction to non-harmful or non-threatening sensory stimulation, which is out of proportion to the stimulus. SOR can negatively impact a child’s engagement and performance in their daily life. SOR is frequently diagnosed by occupational therapists, and deep pressure is an important facet of the treatment of SOR by occupational therapists. Prior research (Alberts &amp; Ronca, 2012) indicates that the component of pressure in the vaginal birth process aids the infant’s neurophysiological adaption to extra-uterine life. This component is absent in elective caesarean section births. This study therefore set out to determine whether method of birth could be associated with SOR, as well as investigating demographic and other variables linked to SOR. It was hypothesised that there would be a higher prevalence of SOR in children aged 3-5 years born by elective caesarean section compared to those born by vaginal birth. The study objectives were: • To establish a profile (demographic and variables linked to SOR) of participants (mother-child dyads) by birth method group (CS or vaginal delivery) • To determine the prevalence of SOR by birth method • To establish if there is a statistically significant difference in SOR and birth method • To establish which variables (for example birth weight, jaundice, birth complications) are associated with SOR METHOD: A quantitative, descriptive, analytical study was conducted with a sample of 91 children between the ages of 3 years 0 months and 4 years 11 months. Children across various language, cultural and socio-economic groups were recruited and allocated to two groups based on their method of birth - vaginal delivery and elective caesarean section. Caregivers of each child completed the Short Sensory Profile 2 (SSP2) questionnaire as well as a demographic information questionnaire. The scores for SOR were calculated for each participant, and prevalence of SOR between the two birth method groups was compared. Demographic variables were tested for significance between the two groups. The variables showing a significant difference were further analysed to determine any association with SOR. RESULTS: There were 91 participants, 58 in the VB group and 33 in the CS group. Mothers in the VB group gave birth at a younger age (U = 499.0, p < .001), were of a lower income level (chi-square = 11.49, df = 2, p = .003) and more likely to be single (Fishers exact p (2-tailed) = .037). The children in the VB group were of a greater gestational age (U = 472.5, p = .001), had a shorter time period before the first breastfeed (U = 478.0, p = .006), and had fewer sleeping difficulties (Fishers exact p (2-tailed) = .003). The prevalence of SOR for the total sample was 22%. There was a significant association in SOR prevalence and birth method (Fishers exact p (2-tailed) = .034), with greater prevalence in the VB group (29%) as opposed to the elective CS group (9%). There were statistically significant associations between SOR and maternal age (U = 380.5, p = .004), marital status (Fishers exact p (2-tailed) = .003) and time after birth to the first breastfeed (U = 394.5, p = .049). CONCLUSION: There was a statistically significant difference in SOR between the two birth method groups, with higher prevalence in the VB group. This was thought to be linked to cultural and language challenges associated with the use of the SSP2, and the impact of low socio-economic circumstances on child development and the ability to regulate sensory input. Recommendations include developing and validating a culturally appropriate sensory profile questionnaire, available in the most common official languages to facilitate the accurate assessment of sensory modulation of all children living in South Africa. In addition, there is a need to test the birth method hypothesis in demographically balanced groups.

Abstract Introduction Chris Hani Baragwanath (CHB) hospital has 20 000 deliveries per annum, with 25% by caesarean section (CS). Therefore, vaginal birth after caesarean section (VBAC) is an important delivery option. We questioned the reasons for the low VBAC success following trial of labour (TOL). The primary objective was to determine the proportion of eligible patients attempting TOL and the VBAC success rate. Secondary objectives were to establish reasons for failed VBAC, predictive factors for VBAC, and maternal and neonatal morbidity and mortality. Methodology A retrospective descriptive study by record review, analysing demographic, obstetric and delivery outcome variables of women with one prior CS in a subsequent pregnancy. Results From the 340 patients eligible for VBAC, 287 (84.4%) attempted TOL and 53 (15.6%) had an elective repeat caesarean section (ERCS). VBAC success was 51.6% (148/287). Prelabour rupture of membranes and prolonged latent phase of labour resulted in 40% of failed VBAC. Successful VBAC was associated with a higher parity, lower birth weight and lower gestation (p<0.001). Positive predictors of successful VBAC were previous vaginal birth (p=0.004), previous VBAC (p=0.038), previous CS for malpresentation (p=0.012), birth weight <3500g (p=0.003), and gestation ≤ 39 weeks (p<0.001). Negative predictors were previous CS for cephalopelvic disproportion (p=0.003) and women with no prior vaginal deliveries (p<0.001). There was no maternal mortality. Complications however, included 2 uterine ruptures, 2 uterine dehiscences, 4 hysterectomies, and one intrapartum fetal death. Adverse maternal outcomes were increased with TOL compared to ERCS (p=0.038), and more so with failed compared to successful VBAC (p=0.002). Adverse neonatal outcomes were also increased with TOL compared to ERCS (p=0.048), however there was no difference in neonatal outcomes between failed and successful VBAC (p=0.420). Conclusion VBAC remains a viable option for patients with one prior CS in this setting, despite a lower VBAC success than developed countries. Failed VBAC due to prelabour rupture of membranes and prolonged latent phase of labour remains a problem.

In Canada, one in five women can now expect to deliver their baby by caesarean section. For some women, this method of delivery creates little concern, but for others, birth by caesarean causes emotional trauma that can last for years. Childbirth was historically regarded as a natural event and was undertaken with little assistance from health professionals. However, with urbanization and medical advancements, childbirth soon became a medically managed process. During the Women's Health Movement of the 1970's, women reacted to the medicalization of birth by calling attention to the emotional reactions of women following childbirth, with particular attention paid to deliveries by caesarean section. This paper discusses interviews with five women who sought the assistance of a community support and awareness group following a negative emotional response to an unplanned caesarean section. Qualitative research methods were used in order to capture the participants' unique experiences during and after childbirth. The women described feelings of fear, failure, disappointment, and loss of control. They perceived that the medical staff was generally uncaring and dismissive of their concerns. Each participant felt that the support group was instrumental in helping them to recover from the trauma of their birth experience, but also reported that they would have appreciated the opportunity to speak with a social worker following the birth. / Thesis / Master of Social Work (MSW)

Background: The role of Midwife Obstetric Units (MOUs) as lead caregivers for low risk pregnancies has been a topic of much debate in recent years. It has been suggested that MOUs are more cost effective, and have a less interventionist approach to low risk pregnancies, when compared to Consultant Obstetric Units (COUs). Objectives: The primary objective of this study was to compare intrapartum delivery procedures, methods of delivery, and maternal and neonatal wellbeing for low risk pregnancies between a MOU and a COU. The second objective was to investigate the predictors of key outcomes such as caesarean sections and perineal tears. The research was carried out at a private obstetric unit in Gauteng from January 2005-June 2006. Materials and Methods: The study design was a retrospective cohort study, by means of a record review of routinely collected data. 808 subjects (212 COU and 596 MOU patients) satisfied the criteria for a low risk pregnancy during the defined period and were included in the analysis. Results: Overall the MOU had fewer interventions than the COU, but had very similar maternal and neonatal outcomes. MOU patients were less likely to have an epidural than COU patients (p<0.001), and more likely to utilise a bath for pain relief (p<0.001). The MOU was also less likely to induce a patient than the COU (p=0.002). Primiparous patients accounted for more than 95% of the caesarean section (C/S) rate (p<0.001), with the COU performing 2.2 times more C/S on primiparous patients than the MOU. Vaginal birth in the MOU was 2.6 times more likely to be an underwater birth (UWB) than the COU (p<0.001). Positive predictors for C/S were COU care, primiparous status and induction of labour. UWB was a positive predictor for grade 1 and 2 perineal tears. There were no maternal or neonatal deaths, in either unit, during the study period. There were no significant differences between the MOU and COU for maternal morbidity indicators (tears, postpartum haemorrhage, and retained placenta) or neonatal morbidity indicators (Apgar < 7 at 5 minutes and neonatal ICU admission). Conclusion: The MOU had fewer intrapartum interventions (epidurals and induction of labour) and lower C/S rates than the COU for low risk pregnancies, yet maternal and neonatal outcomes were similar. This study suggests that the MOU can function just as effectively as the COU for low risk pregnancies. Therefore the establishment of more MOUs would have immense resource implications for both the public and private health sectors in South Africa.

Introduction Increased use of caesarean section (CS) as a mode of delivery is of concern for maternal and child health in many countries. The World Health Organization (WHO) has set guideline of population caesarean section rate between 5% - 15% for CS deliveries. Accordingly the South African National Department of Health (NDOH) has set a national target for district hospitals, that no more than 10% of all deliveries should be by CS. Standerton District Hospital experienced a sudden increase in the caesarean section rate (CSR), from 17.5% in 2004 to 30.8% in 2007. The reasons for this increase are not known. Purpose of the study This study aims to investigate factors which contributed to the sudden increase of CSR from 17.5% in 2004 to 30.8% in 2007 at Standerton District Hospital, Gert Sibande District Mpumalanga. Method A retrospective record review of 790 women who delivered at Standerton District Hospital by caesarean section from January 2004 to December 2007 was done. Fifty percent of the total number of records for each year was retrieved and to achieve this every second record was selected from the maternity and theatre registers for patients who have undergone CS. Systematic sampling selection of records of all women who have undergone CS was conducted during the identified period. Data on patient demographics, the reasons for the CS, the maternal and neonatal outcomes achieved, antenatal care profile, the employment status and the responsible medical practitioner were extracted from existing records maintained by the hospital. Analysis ascertained factors associated with increased CSR. Results The Caesarean section rate at Standerton District Hospital has increased annually since 2004. The factors contributed to the increase include medical indications, clients who are primigravida and the less experienced community service doctors who performed the CS. There was no evidence that education, high income clients, or maternal request contributed to the increase of Caesarean Section rate (CSR). The outcome of mother and baby were positive except for 1% of babies who were not alive. Robson’s group classification (classification system which defines 10 groups of women according to obstetric record, category of pregnancy, the presence of previous uterine scar, the course of labour, delivery and gestational age), revealed that groups two and four played a major role. Conclusion CSR has increased over the years and strategies needs to be developed to reduce this by having experienced doctors supervising community service doctors, training of professionals working in maternity and monitoring of labour by midwives. Recommendation Standerton District Hospital management should intensify recruitment and retention of experienced medical officers, train additional midwives on advanced courses, intensify ante natal care, establish a high risk clinic at the hospital, review hospital policies on maternal care and monitoring of compliance to mother and baby’s national and provincial policies. / Theses (M.Med.Sc.)-University of KwaZulu-Natal, Durban, 2011.

In recent decades, there has been a seemingly inexhaustible rise in the use of caesarean section (CS) worldwide. The overall aim with this thesis is to explore the effects of and reasons for an increase in the CS rate at a university hospital in Dar es Salaam, Tanzania. In Study I, we analysed time trends in CS rates and maternal and perinatal outcomes between 2000 and 2011 among different obstetric groups. In Study II, we documented the occurrence and panorama of maternal ‘near-miss’ morbidity and death, and analysed their association with CS complications. We also strived to determine if women with previous CS scars had an increased risk of maternal near-miss, death, or adverse perinatal outcomes in subsequent pregnancies. Studies III and IV explored women’s and caregivers’ in-depth perspectives on CS and caregivers’ rationales for their hospital’s high CS rate. During the study period, the CS rate increased from 19% to 49%. The rise was accompanied by an increased maternal mortality ratio (odds ratio [OR] 1.5, 95% Confidence Interval [CI] 1.2–1.8) and improved perinatal outcomes. CS complications accounted for 7.9% (95% CI 5.6–11) of the maternal near-miss events and 13% (95% CI 6.4–23) of the maternal deaths. Multipara with previous CS scars had no increased risk of maternal near-miss or death compared with multipara with previous vaginal deliveries, and a lower risk of adverse perinatal outcomes (adjusted OR 0.51, 95% CI 0.33–0.80). Both women and caregivers stated they preferred vaginal birth, but caregivers also had a favourable attitude towards CS. Both groups justified maternal risks with CS by the need to ‘secure’ a healthy baby. Caregivers stated that they sometimes performed CSs on doubtful indications, partly due to dysfunctional team-work and a fear of being blamed by colleagues.  This thesis raises a concern that maternal health, interests, and voices are overlooked through the CS decision for the benefit of perinatal outcomes and caregivers’ liability. An overuse of CS should be seen as a sign of substandard care and preventing such overuse needs to be among the key actions when formulating new targets for the post-2015 era.