Thesis (M.P.H.)--University of Hong Kong, 2005.

Introduction Maternal volume depletion at the time of caesarean section plays a role in ma- ternal and fetal outcome. Measuring uid volume status currently requires invasive monitors. It would be useful to determine biochemical measurements which would accurately determine uid volume status in these patients. We investigated the di erence in biochemical parameters of participants presenting for elective and urgent caesarean section at Chris Hani Baragwanath Hospital and made inferences about their uid volume status. We also sought to de- termine whether this difference in biochemical parameters if present could be linked to a potential difference in the intra-operative haemodynamic course as well as fetal outcome between the two groups. Method This was a prospective open-label observational cross-sectional pilot study. The sample was 54 participants, 27 elective and 27 urgent cases. Blood and urine samples were taken at the red line. Parameters from the blood samples were haematocrit, haemoglobin, sodium, urea, creatinine and plasma osmolality. Parameters from the urine samples were sodium, creatinine, osmolality and specific gravity. Intra-operatively, all participants received a standard spinal anaesthetic. Vari- ables measured intra-operatively were systolic, diastolic and mean arterial blood pressure, heart rate, highest level of block achieved as well as 1 and 5 minute Apgar scores of the newborn. The primary outcome variable was hypotension (mean arterial drop of more than 15% from the baseline). The secondary outcome variable were the Apgar scores of the infants. Results Urine specific gravity showed a trend towards statistical significance (mean, median, standard deviation for elective, urgent): 1.01, 1.010, 0.01 and 1.02, 1.015, 0.01 p = 0:06. The other biochemical parameteres displayed higher p- values. The average relative blood pressure change was -11,7% (median, standard de- viation) (-12.4, 11.1) for the elective group and -15.1% (-14.9, 15.1) for the urgent group p = 0:36. The relative blood pressure change to end point of study was -9.6% (-9, 12.7) for the elective group and -15.4% (-17, 17.6) for the urgent group p = 0:17. When comparing baseline blood pressure and heart rate measurements to the 10 minute end point measurements; 15 participants expe- rienced hypotension in the urgent group compared to 9 in the elective group p = 0:17. When comparing baseline blood pressure measurements to the av- erage at 2, 4, 6, 8, and 10 minute intervals; 13 participants from the urgent group experienced hypotension compared to 9 participants in the elective group p = 0:40. The average Apgar scores at 1 min were 8.89 (9,0.32) for the elective group and 8.37 (9,0.93) for the urgent group p = 0:01. Conclusion This was a pilot study and as such statistical signi cance between variables was not expected. However possible trends were identified to guide future investiga- tions. The higher incidence rate of hypotension in the urgent group showed such a trend towards signi cance as well as the higher urine specific gravity in the urgent group. We also noted that Apgar scores differed significantly between elective and urgent cases.

No description available.

M.Cur. (Midwifery and Neonatal Nursing) / The purpose of this study is to determine the experiences of parents prior to, during and following an unplanned caesarean section. Parents who experience this event have mixed emotions. The related occurrences may influence their behaviour and consequently their relationships with their spouses, themselves and their environment. These interact with each other continually and thus need to be looked at in context. The "Nursing of the Whole Person Theory' ensures a wholistic approach to the parents. Unstructured, in-depth interviews held with five mothers and five fathers, respectively, on day three post-delivery, were transcribed and analyzed. At six weeks a follow-up semistructured questionnaire was answered by these same respondents and analyzed. The experiences of the parents were then compared. A literature control was undertaken in order to determine what the conclusions of other researchers in this field are. The results of the literature search were compared to that of the present study and conclusions reached. Recommendations concerning nursing practice, education and further study were made at the end of the study, including a listing of the limitations affecting the study.

Introduction There is concern that C-section rates are increasing in the public health sector in South Africa and wide variation has been reported between districts, provinces and hospitals. This study is a comprehensive analysis of C-section rates in all public sector hospitals during 2000/01- 2008/09 by facility, district and province. It aims to inform decision makers in maternal health services of the trends and patterns occurring in C-section rates in South African public sector hospitals. Variation in C-section rates is described to highlight the differences in care that pregnant women receive in different parts of the country and to illustrate where inequity of resource allocation is occurring, as well as highlighting possible data quality problems. Methodology This is a descriptive study using quantitative methods of analysis on secondary data obtained from the National Department of Health’s routinely collected data specific to Caesarean sections in the DHIS. C-section averages are weighted by taking the number of deliveries per facility and level into consideration. Results 1. Wide variation is noted between individual facilities, between and within provinces and districts and within the different levels of hospitals in 2008/09. The mean weighted C-section rate ranges from 17.2% in District Hospitals to 40.7% in Specialised Maternity Hospitals. A 3.7 fold difference between the highest and lowest district average C-section rates is seen for District Hospitals. Within provinces, average District Hospital C-section rates vary by as much as 3.5 fold between districts. Interdistrict variation in Regional Hospitals shows a 3.3 fold difference between the lowest and highest average district rates. Among the eight National Central Hospitals there is a 2.5 fold difference between the highest (79.7%) and lowest (31.7%) facility C-section rates. Nationally a total of 23 District Hospitals had C-section rates below 5% and nine hospitals of varying levels had rates of over 50% 2. Caesarean Section rate trends, 2000/01 – 2008/09 are increasing. Nationally the average C-section rate in South Africa increased by 6.3 percentage points from 18.1% in 2000/01 to 24.4% in 2008/09, with an average annual compounded growth rate of 3.8%. Bivariate linear regression analysis confirms there is a positive linear relationship between time (year) and C-section rate (p<0.001). All levels of hospitals showed an increasing trend over the nine years, (p<0.001), with the rate in Provincial Hospitals having increased by the highest amount (1.40%) year on year and District Hospitals, the least (0.48%). Trends within certain districts and individual hospitals however, show a decline. 3. A strong relationship between level of deprivation and C-section rate exists when adjusting data for provincial variation Bivariate linear regression analysis revealed no association between the level of deprivation of the population at district level and the mean C-sections rate per district (p=0.130). Multiple regression analysis adjusted for the effect of province, reveals a significant association (p=0.044). A negative association between the DI (p=0.006) and Csection rate is seen in eight out of nine provinces. 4. Data quality of C-sections and deliveries in the DHIS needs improving Data quality in the DHIS leaves uncertainty in some instances whether C-section rate trends are a true reflection or not. The C-section rate indicator on its own is unable to inform on the full spectrum of emergency obstetric care. The definition of C-section rate for primary health care currently only considers deliveries in District Hospitals. The national C-section rate for primary health care in the country however, reduces from 17.2% to 13.2% when including the deliveries which take place in CHCs. Conclusions The quality of data relating to C-sections (number of births, C-sections and hospital categorisation) in the DHIS needs to be improved in order to enable accurate monitoring and should include deliveries and C-sections which take place in Community Health Centres to allow for a more accurate reflection of C-section rate in primary health care. The C-section rate indicator on its own is insufficient to adequately inform on the full spectrum and quality of the provision of emergency obstetric care in South Africa. Including additional indicators to the DHIS, such as the UN process indicators, could improve on the current knowledge and monitoring of the provision of emergency obstetric care in South Africa. The wide variation in C-section rates seen among District Hospitals and the C-section rates between and within districts and provinces, suggest inequity in resource allocation and irregular service delivery patterns. Reasons and solutions for these wide differences need to be found, which are likely to be unique to each district and province. Further studies are needed to investigate the access of poorer women, especially those in remote rural areas to emergency obstetric care services.

A research report submitted to the Faculty of Medicine, University of Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Anaesthesia. / Spinal anaesthesia for Caesarean section is associated with an unacceptably high incidence of hypotension despite the administration of an intravenous fluid preload and the use of uterine displacement. The theoretical benefits of preventing hypotension as opposed to treating it as it occurs are the avoidance of considerable maternal discomfort, a reduced risk of serious cardiovascular or respiratory depression and the avoidance of transient foetal asphyxia. The use of prophylactic intramuscular ephedrine prior to spinal anaesthesia has been recommended but not well studied. The advantages of the intramuscular route for ephedrine administration are its simplicity and its favourable pharmacokinetic profile. Cardiovascular support is sustained throughout the surgery and into the post operative period. Opposition to the use of intramuscular ephedrine in the prevention of hypotension is based on two studies in which spinal anaesthesia was not used [1,2]. These studies showed an unacceptably high incidence of hypertension, a deleterious effect on foetal gas exchange and a lack of efficacy when intramuscular ephedrine was used in epidural and general anaesthesia respectively. This research report describes a randomised, double blind, interventional study designed to assess the safety (prevalence of hypertension, tachycardia or foetal compromise) and efficacy (prevalence of hypotension) of 37,5mg of ephedrine given prior to spinal anaesthesia for Caesarean section. Forty patients who had given informed consent were entered into the study. Blood pressures and pulse rates were recorded for 90 minutes after ephedrine administration, samples of umbilical venous blood were collected and Apgar scores assessed. This study found that giving 37,5mg of intramuscular ephedrine prior to spinal anaesthesia was safe from a maternal point of view in that it was not associated with reactive hypertension or tachycardia. When the ephedrine was given 10 minutes prior to induction of the spinal the technique proved to be effective in reducing the incidence and severity of hypotension. When used in the above manner the technique was not associated with foetal depression or acidosis. / WHSLYP2016

published_or_final_version / abstract / toc / Clinical Psychology / Master / Master of Social Sciences

Thesis (M.Med.Sc.)--University of Hong Kong, 2003. / Also available in print.

Thesis (M.S.)--University of Wisconsin--Madison, 1980. / Typescript. eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 63-65).

A Thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Doctor of Philosophy. 14th October 2016 in Johannesburg / Poorly controlled pain following caesarean section surgery can have a debilitating effect on the physical and emotional well being of a woman during the post-operative period. Good intra-operative anaesthetic management during caesarean section surgery is requisite to improve post-operative analgesia, and thereby contribute to the well being of the patient. In South Africa (SA) there are currently no national obstetric anaesthesia practice guidelines. Anaesthetic service providers therefore rely on knowledge acquired during their anaesthetic training and recommendations from international guidelines (which may not be applicable in SA). In order to establish a reference standard of anaesthetic care for obstetric patients in SA, a semi-structured interview was conducted with the heads of department and/or their representatives from the eight anaesthesiology academic departments in SA in 2012. The experts provided recommendations on the intra-operative anaesthetic management of patients for elective and emergency caesarean sections, as well as the post-operative monitoring and analgesic management of these patients. The recommendations were based on the experts’ understanding of the uniquely local healthcare environment in SA. Following the establishment of the SA reference standard, a national survey of anaesthetic service providers was conducted in 2014 to establish what the practises are in South Africa for caesarean section anaesthetics. Ninehundred- and-thirty-three survey responses were analysed, which equated to a 58% response rate. The majority of anaesthesia providers (97.8%) perform single shot spinal anaesthesia for caesarean sections. Thirty percent of respondents chose to use Quincke spinal needles, despite the increased risk of this needle causing post-dural puncture headaches (PDPH). The preferred local anaesthetic drug was 0.5% bupivacaine with dextrose, and fentanyl was the most commonly used additive agent, as opposed to common international practice, which advocates morphine. The survey also revealed that 58% of doctors work in hospitals that do not have a post-operative monitoring protocol for patients following caesarean section surgery. This contrasts to recommendations suggested by the national experts regarding patient monitoring requirements. A clinical trial was then conducted to compare the analgesic efficacy of two different doses of intrathecal morphine (50μg and 100μg) with 25μg fentanyl. Patients in both morphine treatment groups had significantly lower postoperative opioid requirements than patients in the fentanyl group. The pain numerical rating scale (NRS) scores were however not statistically different and there was also no difference in the side effects profile or emotional parameters measured, between the groups. This study highlights the differences in the recommended practise of obstetric anaesthesia in SA compared to other countries and demonstrates how obstetric anaesthesia is practised in SA. The final component of this study has demonstrated how international best practices can be easily implemented in SA to improve the anaesthetic care of the obstetric patient. / MT2017