BACKGROUND: The World Health Organization (WHO) has acknowledged the importance of maternal care and listed it as part of its Millennium Development Goals (MDGs). South Africa has aligned itself with these MDGs. The 5th goal is focused on improving maternal health by reducing the maternal mortality rate by 75% by 2015. There are a number of interventions in place to try and to achieve this goal; the provision of antenatal care is one of these interventions. Antenatal care provides the expectant mother early ongoing monitoring and risk assessment of her pregnancy. It is commonly considered fact that antenatal care improves maternal and perinatal outcomes. In spite of the provision of free maternal health services in South Africa, there are still a significant number of mothers who do not attend antenatal clinics before delivery. No formal study has been done to understand the magnitude of this problem in the Limpopo Province. In view of this, it was decided to conduct this study at the Van Velden Hospital (a rural district hospital in the Mopani District in the Limpopo Province) which has been admitting a significant number of unbooked mothers even after the introduction of free maternal health services in South Africa sixteen years ago. AIM: To compare the pregnancy outcomes (maternal and perinatal) between booked and unbooked mothers who delivered at Van Velden Hospital, a district hospital in the Limpopo Province in South Africa. METHODOLOGY: The setting of this study is the Maternity Unit at the Van Velden Hospital. A cross sectional study design was used. A retrospective record review was done and information for one year (2008/09) will be extracted from the records captured in the District Health Information System. No primary data was collected for this study. RESULTS: This is the first study that looked at broad issues pertaining to the influence of booking status on pregnancy outcomes (maternal and neonatal) at a district hospital in a rural district in the Limpopo Province and probably in South Africa. The study found a prevalence of 15.7% (range: 2.7% to 32.3%) among the study population during the 12 month study period. There were no significant differences in age, marital and employment status of the subjects. However, there were a significant number of teenage pregnancies (13.2%) among the study population, which is of concern. Interestingly, more white women were found not to book in comparison to the black women. There were no significant differences in parity, gravidity and miscarriages between the two groups. Overall, unbooked mothers were more likely to have a preterm baby. This implies antenatal booking can probably prevent preterm deliveries. This study also found unbooked mothers were more likely to have C/S than booked mothers. However, there was no significant difference between booked and unbooked mothers in terms of delivery complications. There was no significant difference between booked and unbooked mothers in terms of birth weight. Although, the babies of unbooked mothers had a significantly lower Apgar score (1 minute) than booked mothers, the difference became insignificant at 10 minutes. There was no maternal mortality during this period. All mothers were discharged home. Overall, perinatal mortality among the study population was 44/ 1000 births. This study found a significant risk of perinatal morbidity (preterm delivery and low Apgar score) among the unbooked mothers. CONCLUSION: This research was undertaken to develop a model that could be used by both the provincial and national governments to evaluate the prevalence and impact of booking status of pregnant women in rural district hospitals in South Africa.

Stabilisation and resuscitation in the delivery room is an integral part of the care of extremely premature newborns. The main task is to support essential life functions and to facilitate the adaptation of the immature organism to the extrauterine life. The current recommendations are well defined for the full term and late preterm newborns, but there is a lack of targeted recommendations for the stabilisation and resuscitation of extremely premature newborns. The research part of the submitted thesis summarises the most important results of clinical research performed in 2010-2015 at the Department of Neonatology of the Department of Gynecology and Obstetrics, VFN and First Faculty of Medicine, Charles University in Prague. The research evaluates the efficacy and side effects of the currently recommended methods of stabilisation and resuscitation of extremely premature neonates in the delivery room and presents some new and potentially useful techniques for delivery room care. A significant output of this work is the recommendation for practice, structured according to the gestational age of extremely premature newborns. The proposed guideline is based on our results of partial clinical trials and aims to improve the current level of stabilisation and resuscitation of extremely premature newborns...

Background: Delivery room management (DR) of the newly born infant should be performed according to international guidelines, but no recommendations are available for an infant’s position immediately after birth. The present study was performed to answer the following questions: 1. How often is DR-management performed in term infants in side position? 2. Is routine DR-management possible in side position? 3. Is there any benefit of side position with respect to agitation or vital parameters? Methods: Cross-sectional study of video-recorded DR-management in term newborns delivered by C-section in 2012. Videos were analysed for infant’s position, administered interventions, vital parameters and agitation. Results: 187 videos were analysed. The Main Position (defined as position spent more than 70% of the time) was “supine” in 91, “side” in 63 and “not determinable” in 33 infants. “Supine” infants received significantly (p < 0.001) more often stimulation (12.5% of the total time) than “side” infants (3.9% of time). There were no differences between both groups with regard to suctioning; CPAP was exclusively (98%) administered in supine position. Newborns on side were less agitated than those on supine. There was a trend towards a better oxygenation in “side” positioned infants (p = 0.055) and significantly (p = 0.04) higher saturation values in “left-sided” infants than “right-sided” infants at 8th minute. “Side” positioned infants reached oxygen saturation values >90% earlier than “supine” positioned infants (p = 0.16). Conclusions: DR-management is feasible in the side position in term infants. Side position seems to be associated with reduced agitation and improved oxygenation. However, it remains unclear whether this represents a causal relationship or an association. The study supports the need for a randomized controlled trial.

Background: Whereas good data are available on the resuscitation of infants, little is known regarding support of postnatal transition in low-risk term infants after c-section. The present study was performed to describe current delivery room (DR) management of term infants born by c-section in our institution by analyzing videos that were recorded within a quality assurance program. Methods: DR- management is routinely recorded within a quality assurance program. Cross-sectional study of videos of term infants born by c-section. Videos were analyzed with respect to time point, duration and number of all medical interventions. Study period was between January and December 2012. Results: 186 videos were analyzed. The majority of infants (73%) were without support of postnatal transition. In infants with support of transition, majority of infants received respiratory support, starting in median after 3.4 minutes (range 0.4-14.2) and lasting for 8.8 (1.5-28.5) minutes. Only 33% of infants with support had to be admitted to the NICU, the remaining infants were returned to the mother after a median of 13.5 (8-42) minutes. A great inter- and intra-individual variation with respect to the sequence of interventions was found. Conclusions: The study provides data for an internal quality improvement program and supports the benefit of using routine video recording of DR-management. Furthermore, data can be used for benchmarking with current practice in other centers.

Background: Delivery room management (DR) of the newly born infant should be performed according to international guidelines, but no recommendations are available for an infant’s position immediately after birth. The present study was performed to answer the following questions: 1. How often is DR-management performed in term infants in side position? 2. Is routine DR-management possible in side position? 3. Is there any benefit of side position with respect to agitation or vital parameters? Methods: Cross-sectional study of video-recorded DR-management in term newborns delivered by C-section in 2012. Videos were analysed for infant’s position, administered interventions, vital parameters and agitation. Results: 187 videos were analysed. The Main Position (defined as position spent more than 70% of the time) was “supine” in 91, “side” in 63 and “not determinable” in 33 infants. “Supine” infants received significantly (p < 0.001) more often stimulation (12.5% of the total time) than “side” infants (3.9% of time). There were no differences between both groups with regard to suctioning; CPAP was exclusively (98%) administered in supine position. Newborns on side were less agitated than those on supine. There was a trend towards a better oxygenation in “side” positioned infants (p = 0.055) and significantly (p = 0.04) higher saturation values in “left-sided” infants than “right-sided” infants at 8th minute. “Side” positioned infants reached oxygen saturation values >90% earlier than “supine” positioned infants (p = 0.16). Conclusions: DR-management is feasible in the side position in term infants. Side position seems to be associated with reduced agitation and improved oxygenation. However, it remains unclear whether this represents a causal relationship or an association. The study supports the need for a randomized controlled trial.

Background: Whereas good data are available on the resuscitation of infants, little is known regarding support of postnatal transition in low-risk term infants after c-section. The present study was performed to describe current delivery room (DR) management of term infants born by c-section in our institution by analyzing videos that were recorded within a quality assurance program. Methods: DR- management is routinely recorded within a quality assurance program. Cross-sectional study of videos of term infants born by c-section. Videos were analyzed with respect to time point, duration and number of all medical interventions. Study period was between January and December 2012. Results: 186 videos were analyzed. The majority of infants (73%) were without support of postnatal transition. In infants with support of transition, majority of infants received respiratory support, starting in median after 3.4 minutes (range 0.4-14.2) and lasting for 8.8 (1.5-28.5) minutes. Only 33% of infants with support had to be admitted to the NICU, the remaining infants were returned to the mother after a median of 13.5 (8-42) minutes. A great inter- and intra-individual variation with respect to the sequence of interventions was found. Conclusions: The study provides data for an internal quality improvement program and supports the benefit of using routine video recording of DR-management. Furthermore, data can be used for benchmarking with current practice in other centers.

Background: Since an objective description is essential to determine infant’s postnatal condition and efficacy of interventions, two scores were suggested in the past but weren’t tested yet: The Specified-Apgar uses the 5 items of the conventional Apgar score; however describes the condition regardless of gestational age (GA) or resuscitative interventions. The Expanded-Apgar measures interventions needed to achieve this condition. We hypothesized that the combination of both (Combined-Apgar) describes postnatal condition of preterm infants better than either of the scores alone. Methods: Scores were assessed in preterm infants below 32 completed weeks of gestation. Data were prospectively collected in 20 NICU in 12 countries. Prediction of poor outcome (death, severe/moderate BPD, IVH, CPL and ROP) was used as a surrogate parameter to compare the scores. To compare predictive value the AUC for the ROC was calculated. Results: Of 2150 eligible newborns, data on 1855 infants with a mean GA of 286/7± 23/7 weeks were analyzed. At 1 minute, the Combined-Apgar was significantly better in predicting poor outcome than the Specified- or Expanded-Apgar alone. Of infants with a very low score at 5 or 10 minutes 81% or 100% had a poor outcome, respectively. In these infants the relative risk (RR) for perinatal mortality was 24.93 (13.16-47.20) and 31.34 (15.91-61.71), respectively. Conclusion: The Combined-Apgar allows a more appropriate description of infant’s condition under conditions of modern neonatal care. It should be used as a tool for better comparison of group of infants and postnatal interventions.

Background: Since an objective description is essential to determine infant’s postnatal condition and efficacy of interventions, two scores were suggested in the past but weren’t tested yet: The Specified-Apgar uses the 5 items of the conventional Apgar score; however describes the condition regardless of gestational age (GA) or resuscitative interventions. The Expanded-Apgar measures interventions needed to achieve this condition. We hypothesized that the combination of both (Combined-Apgar) describes postnatal condition of preterm infants better than either of the scores alone. Methods: Scores were assessed in preterm infants below 32 completed weeks of gestation. Data were prospectively collected in 20 NICU in 12 countries. Prediction of poor outcome (death, severe/moderate BPD, IVH, CPL and ROP) was used as a surrogate parameter to compare the scores. To compare predictive value the AUC for the ROC was calculated. Results: Of 2150 eligible newborns, data on 1855 infants with a mean GA of 286/7± 23/7 weeks were analyzed. At 1 minute, the Combined-Apgar was significantly better in predicting poor outcome than the Specified- or Expanded-Apgar alone. Of infants with a very low score at 5 or 10 minutes 81% or 100% had a poor outcome, respectively. In these infants the relative risk (RR) for perinatal mortality was 24.93 (13.16-47.20) and 31.34 (15.91-61.71), respectively. Conclusion: The Combined-Apgar allows a more appropriate description of infant’s condition under conditions of modern neonatal care. It should be used as a tool for better comparison of group of infants and postnatal interventions.