A Research Report submitted to the Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, South Africa, in partial fulfilment of the requirements for the Degree of Master of Public Health - Maternal and Child Health Submitted: August 2014 / Introduction: A partograph is a tool that is used to monitor progress of labour, and its correct use and appropriate interpretation can assist in early identification of complications of labour. The aim of this study was to assess if and how the partograph was used at Mulanje District Hospital in Malawi. Methods: This was a retrospective review of records of women who delivered at the Mulanje District hospital from the 1st to the 30th of September, 2010. A total of 360 women’s files were reviewed. Data was collected from the delivery register, theatre register, case files and partograph charts. A Chi-square was used for statistical analysis and a p value of < 0.05 was considered significant. Results: The partographs were available in 93.3% (336/360) of women’s files. Forty eight percent (162/336) of women’s files had partographs with all three sections of labour monitoring documented, but only 10% (16/162) of the partographs had information correctly and completely filled in on each parameter of the three components of the partograph. Forty percent (64/162) of women delivered after crossing the action line, and 67.2% (43/64) who delivered after crossing the action line were referrals, while 32.8% (21/64) were women who came to the hospital in labour. Almost 40.6% (26/64) of women who crossed the action line suffered immediate adverse outcomes. There was no significant difference in maternal outcomes (post partum haemorrhage, ruptured uterus and maternal deaths) and foetal outcomes (low Apgar score of 5/10 or less at 1 minute and 5 minutes, fresh still births and deaths within 24 hours) between women that were from the primary care health centres and those that reported to the hospital in labour. The study found that 57.8% (37/64) of women who crossed the action line had spontaneous vertex delivery, almost 38% (24/64) delivered by caesarean section and 4.7% (3/64) delivered by assisted vacuum extraction. There was a significant difference in mode of delivery after v crossing the action line. More caesarean sections were performed on women from the primary care health centres as compared to those that came to the hospital in labour: 44.2% (19/43) vs 23.8% (5/21), p=0.049. Conclusion and Recommendation: Although partographs were available in women’s files, the partograph data were not completed adequately. While progress of labour was frequently documented, maternal and foetal condition were incompletely documented. Effective interventions such as in-service training, regular supportive supervision, regular audits of records of women in labour and intensification of use of guidelines for labour management are required to strengthen the use of the partograph for women in labour. Further research is recommended to highlight barriers for correct use of the partograph

Habilitationsschrift. / Bibliographical foot-notes.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfilment of the requirements for the degree of Master of Public Health in the field of Hospital Management July, 2014 / BACKGROUND: The World Health Organization (WHO) has acknowledged the importance of maternal care and listed it as part of its Millennium Development Goals (MDGs). The 5th goal is focused on improving maternal health by reducing the maternal mortality rate by 75% by 2015. South Africa has aligned itself with the MDGs. The Gauteng Department of Health and Social Development has also embraced the MDGs and decided to improve its maternal health services. It has decided to target Intra-partum period for interventions to improve maternal health because intra-partum period is associated with a high rate of perinatal death from intra-partum hypoxia (4.8 per 1000 births) (National Department of Health, 2000), as well as a significant number of maternal death (8.7%) (NCCEMD, 2007). This study was planned to systematically study the clinical procedure performed during the intra-partum period at the Heidelberg Hospital (a semi - rural district hospital in the Lesedi Sub – district of Sedibeng District in Gauteng Province). AIM: To describe the clinical procedures and factors related to these procedures and maternal and neonatal health outcomes for the mothers admitted and delivered in the Maternity unit at Heidelberg hospital during one year period (1st April 2010 to 31st March 2011) METHODOLOGY: The setting of this study was the Maternity unit of the Heidelberg Hospital. A cross sectional study design was used based on retrospective review of routinely collected data for 12 months (2010 April 1st to 2011 March 31st). No intervention was done as a part of this study. The study variables included different clinical procedures (such as normal vaginal delivery, assisted vaginal delivery, caesarean section, evacuation of uterus, caesarean hysterectomy), socio-demographic profile of patients (such as age, gender, ethnicity, medical aid), clinical profile (such antenatal diseases, booking status, intra-partum complications, postpartum complications) and maternal and perinatal outcomes. RESULTS: The study found highest number of deliveries (78.6%) were normal vertex deliveries and a very few (1%) assisted and breech deliveries. The caesarean section rate was high (20.4%) as compared to the normal national target (12, 5%). Fetal distress and CPD was the main indications for caesarean section. The majority of women who delivered at Heidelberg Hospital maternity came from poor socio-economic class, mostly single, teenagers, and unemployed. They were the most vulnerable group in the Society. The majority of women were booked and referred from PHC clinic where they were booked for antenatal check-up. Pregnancy induced hypertension was the commonest obstetric problem encountered during antenatal period. Most women who delivered at Heidelberg hospital during the period were discharged without complications, no maternal deaths were reported. There were 8.1% preterm deliveries but a relatively high still birth rate which is of concern. CONCLUSION: The study was the first of its kind to be done at Heidelberg Hospital and the Sedibeng Health District. The study systematically analysed routinely collected data and identified high risk patients, who would require special attention. This study would hopefully assist the Hospital Management to realise the high rate of CS and to develop appropriate measures to reduce unnecessary C/S being done, and to strengthen referral systems. In addition, further study is necessary at clinic level in the sub-district to identify work-loads in the feeder clinics.

by Ip Wan Yim. / Thesis (M.Phil.)--Chinese University of Hong Kong, 1995. / Includes bibliographical references (leaves 65-85). / ACKNOWLEDGEMENTS / ABSTRACT --- p.ii / TABLE OF CONTENTS --- p.iv / LIST OF TABLES --- p.vi / LIST OF FIGURES --- p.vii / Chapter CHAPTER 1. --- INTRODUCTION --- p.1 / Anxiety and labour --- p.3 / Reducing anxiety in labour --- p.8 / Social support and labour --- p.11 / Husband support --- p.16 / Chapter CHAPTER 2. --- METHODOLOGY / Null hypotheses --- p.25 / Research design --- p.26 / Setting --- p.26 / Sample --- p.27 / Instruments --- p.28 / Procedure --- p.32 / Chapter CHAPTER 3. --- RESULTS / Sample characteristics --- p.35 / Comparison of treatment and control groups --- p.39 / Intercorrelations between obstetrical outcome measures --- p.46 / Husbands support --- p.47 / Chapter CHAPTER 4. --- DISCUSSION / Preference and importance rating for husband's presence --- p.52 / "Effect on anxiety, pain, length of labour and dosage of analgesic" --- p.53 / Intercorrelations between the obstetrical outcome measures --- p.56 / Mothers' perception of husbands support and obstetric outcome measures --- p.57 / Mothers' ratings of husbands support and duration of husband's presence --- p.59 / Chapter CHAPTER 5. --- CONCLUSION AND RECOMMENDATIONS / Childbirth education --- p.62 / Clinical management of labour --- p.63 / Research --- p.63 / REFERENCES --- p.65 / APPENDICES / Chapter A. --- Pre-Test Questionnaire --- p.86 / Chapter B. --- The Chinese Version Of STAI FormX-1 In Pre-Test Questionnaire --- p.88 / Chapter C. --- The Chinese Version of STAI FormX-2 In Pre-Test Questionnaire --- p.89 / Chapter D. --- Post-Test Questionnaire --- p.90 / Chapter E. --- The Cinese Version of STAI Form X-1 In Post-Test Questionnaire --- p.93 / Chapter F. --- The Cinese Version of STAI Form X-l In Post-Test Questionnaire --- p.94 / Chapter G. --- Consent Form --- p.95 / Chapter H. --- Letter Of Request For Approval --- p.96 / Chapter I. --- The Original Version Of The STAI Form X-l --- p.97 / Chapter J. --- The Original Version Of The STAI Form X-2 --- p.98

Diss. (sammanfattning) Umeå : Umeå universitet, 2006. / Härtill 4 uppsatser.

Thesis (M.S.)--University of Wisconsin--Madison, 1981. / Typescript. eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 63-65).

Thesis (Ph. D.)--University of Washington, 1999. / Vita. Includes bibliographical references (leaves 60-71).

Thesis (M.Arch.)--University of Hong Kong, 1996. / Includes special report study entitled : Management on materials handling systems : improvement on the operatio & services of an independent perinatal care centre. Includes bibliographical references. Also available in print.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfilment of the requirements for the degree of Master of Medicine in Obstetrics and Gynaecology MMed (O&G) Johannesburg, October 2014 / Background Grand multiparous women, defined as women who have had five or more deliveries, have historically been considered to be at risk for maternal and fetal complications. Over the years, these complications have been attributed to physiological changes as a result of high parity, maternal age, age-related medical conditions and socioeconomic status. Recent research has indicated a strong relationship between access to health care, especially in the antenatal phase, and outcomes. This work aimed to describe maternal, obstetric and fetal complications occurring in GM women, to determine their attendance at antenatal clinic, to review their modes of delivery and to identify any demographic characteristics related to GMP. Methods This was a prospective, descriptive study undertaken at Chris Hani Baragwanath Academic Hospital, a tertiary and regional hospital situated in Soweto that serves approximately two million people within its jurisdiction. In excess of 23 000 deliveries take place there each year. The labour ward attends mostly to high-risk women and approximately 20 % low-risk walk-ins. Another 10 000 births are conducted at midwife obstetric units in Soweto. This study surveyed a sample of pregnant women presenting at Chris Hani Baragwanath and the referring midwife obstetric units who had had five or more viable deliveries, including the current birth, and was conducted over four months in 2011. Results A total of 122 women were included with 124 deliveries as there were two twin pregnancies. Detailed data were available for 98 of these women. The study group were largely of advanced maternal age and were generally healthy. The attendance rate at antenatal care was high (91.35%). Antepartum and postpartum complications were infrequent and there were no intensive care unit admissions or maternal deaths. The CS rate was high (32.79 %), with more emergency CSs performed than elective CSs. The majority of the emergency CSs performed was as a result of fetal distress. There were four stillbirths (3.23%), and 25 (20.16%) of infants weighed <2500g at birth. Conclusion This study showed good maternal and fetal outcomes in a group of GM women who have access to and who largely attended antenatal care facilities. The results, albeit from a small sample, do not support traditional views that GM women are at risk of poor outcomes due to advanced maternal age, physiological changes as a result of high parity or low socioeconomic status. GM women who are generally healthy and are afforded access to adequate health care facilities should have good pregnancy outcomes.

The increasing use of Point of Care (POC) ultrasound presents a challenge in providing efficient training to new POC ultrasound users. In response to this need, we have developed an affordable, compact, laptop-based obstetric ultrasound training simulator. It offers freehand ultrasound scan on an abdomen-sized scan surface with a 5 degrees of freedom sham transducer and utilizes 3D ultrasound image volumes as training material. On the simulator user interface is rendered a virtual torso, whose body surface models the abdomen of a particular pregnant scan subject. A virtual transducer scans the virtual torso, by following the sham transducer movements on the scan surface. The obstetric ultrasound training is self-paced and guided by the simulator using a set of tasks, which are focused on three broad areas, referred to as modules: 1) medical ultrasound basics, 2) orientation to obstetric space, and 3) fetal biometry. A learner completes the scan training through the following three steps: (i) watching demonstration videos, (ii) practicing scan skills by sequentially completing the tasks in Modules 2 and 3, with scan evaluation feedback and help functions available, and (iii) a final scan exercise on new image volumes for assessing the acquired competency. After each training task has been completed, the simulator evaluates whether the task has been carried out correctly or not, by comparing anatomical landmarks identified and/or measured by the learner to reference landmark bounds created by algorithms, or pre-inserted by experienced sonographers. Based on the simulator, an ultrasound E-training system has been developed for the medical practitioners for whom ultrasound training is not accessible at local level. The system, composed of a dedicated server and multiple networked simulators, provides synchronous and asynchronous training modes, and is able to operate with a very low bit rate. The synchronous (or group-learning) mode allows all training participants to observe the same 2D image in real-time, such as a demonstration by an instructor or scan ability of a chosen learner. The synchronization of 2D images on the different simulators is achieved by directly transmitting the position and orientation of the sham transducer, rather than the ultrasound image, and results in a system performance independent of network bandwidth. The asynchronous (or self-learning) mode is described in the previous paragraph. However, the E-training system allows all training participants to stay networked to communicate with each other via text channel. To verify the simulator performance and training efficacy, we conducted several performance experiments and clinical evaluations. The performance experiment results indicated that the simulator was able to generate greater than 30 2D ultrasound images per second with acceptable image quality on medium-priced computers. In our initial experiment investigating the simulator training capability and feasibility, three experienced sonographers individually scanned two image volumes on the simulator. They agreed that the simulated images and the scan experience were adequately realistic for ultrasound training; the training procedure followed standard obstetric ultrasound protocol. They further noted that the simulator had the potential for becoming a good supplemental training tool for medical students and resident doctors. A clinic study investigating the simulator training efficacy was integrated into the clerkship program of the Department of Obstetrics and Gynecology, University of Massachusetts Memorial Medical Center. A total of 24 3rd year medical students were recruited and each of them was directed to scan six image volumes on the simulator in two 2.5-hour sessions. The study results showed that the successful scan times for the training tasks significantly decreased as the training progressed. A post-training survey answered by the students found that they considered the simulator-based training useful and suitable for medical students and resident doctors. The experiment to validate the performance of the E-training system showed that the average transmission bit rate was approximately 3-4 kB/s; the data loss was less than 1% and no loss of 2D images was visually detected. The results also showed that the 2D images on all networked simulators could be considered to be synchronous even though inter-continental communication existed.