INTRODUCTION Caesarean section (CS) is one of the most frequently performed major abdominal surgeries in the world. There has been a global increasing trend in CS rates over the past three decades, particularly in women who have had one previous CS. Vaginal birth after caesarean section (VBAC) is a safe option and is still strongly recommended by all international authorities with success rates ranging from 60% to 80%. However, women's preference for VBAC vs elective repeat caesarean section (ERCS) remains very poorly understood in South Africa (SA) as very few studies have addressed women's preference for mode of delivery. Repeat caesarean delivery (CD) is reported as the single largest contributor to the escalating CS rate worldwide. So why do women choose repeat CD? Evidence suggests that fear, health care worker influence, social stigma, cultural practise and religious beliefs can significantly influence the attitude toward CS. South African data remains limited and we are yet to ascertain how women make their choice and what drives their specific preferences. The rationale behind this study therefore was to gain better insight into why the women in Cape Town choose VBAC or ERCS and to ascertain to what extent their knowledge, attitude and preferences influence their choice. In so doing, we were able to highlight key findings in order to attempt to reduce the increasing CS rate in our country. AIMS AND OBJECTIVES The primary objective was to explore women's knowledge, attitudes and preferences for VBAC or ERCS after one previous CS, from 36 weeks gestation, attending antenatal care at Mowbray Maternity Hospital (MMH) and New Somerset Hospital (NSH). The secondary outcome was to describe the major reasons for their preferred mode of delivery. METHODOLOGY A prospective descriptive study was conducted over four months, of pregnant participants with one previous lower uterine segment caesarean section (LUSCS), attending antenatal care at MMH and NSH. Participants were recruited from 36-41weeks gestation. Participants over the age of 18 years with one previous LUSCS were eligible for inclusion. Participants with a medical indication for CS were excluded. An interview-based questionnaire, previously 11 adapted for use in a Cape Town antenatal population regarding women's knowledge, attitudes and preferences for mode of delivery was conducted at a routine antenatal visit. In addition, basic obstetric and socio-demographic data was abstracted from their folders. A descriptive analysis of participants' preferences for mode of delivery was completed, with subgroup comparisons. The Fisher's Exact test was used in all the statistical analyses that involved categorical variables whilst continuous variables were analysed using t-tests. RESULTS The study included 100 participants who were eligible for VBAC. Of the participants, 51% preferred ERCS whilst 49% preferred VBAC. Married couples and those in co-habiting relationships, more frequently chose VBAC compared to single participants, who more frequently chose ERCS. Participants were greatly influenced by the opinion of the HCW, particularly if ERCS was suggested, they were likely to choose a CS (p=0.001). If a previous history of long or obstructed labour was reported, participants were inclined to choose ERCS. Fear was identified as a major determinant as 78.4% cited fear of vaginal birth as their reason for preferring a CS. History of previous CS (88.2%) and fear of the risks associated with VBAC were the main reasons cited for their preference. In the group who preferred VBAC, 89.8% were of the perception that VBAC would allow them to recover faster and 87.7% desired to be home sooner therefore, favouring their choice. Whether or not the participants had a previous vaginal delivery or VBAC, it did not affect their preference for mode of delivery in a statistically significant manner. CONCLUSION This study which explored knowledge, attitudes and preferences of women who had had one previous CS, concerning their preference for mode of delivery, is one of the first to be done in South Africa. Despite all participants being medically eligible for VBAC, only 49% preferred this option, the remaining 51% preferring ERCS. Significant determinants of their choice were unstable relationships, influence of the doctor, concern about uterine rupture and fear of labour and unpredictability. Knowledge of the complications of ERCS and VBAC was very limited. This information is useful to design further research to improve understanding of these issues and to design services in a way to overcome the identified problems. In particular, women must be provided non-biased evidence-based information in order to foster a relationship of trust with the health care worker, in assisting her to make an informed decision. Similarly improving respectful competent care of women in labour with better attention to alleviating labour pain, will assist in reducing fear.

Premature ovarian insufficiency (POI) is a clinical syndrome defined by loss of ovarian activity before the age of 40. It is characterized by menstrual disturbance (amenorrhoea or oligo-(amenorrhoea), raised gonadotrophin concentrations and low oestradiol levels. The diagnosis is confirmed by detection of raised serum follicle stimulating hormone and low oestradiol levels. POI can occur spontaneously, but it may also result from genetic defects, chemotherapy, radiotherapy or surgery. Oestrogen deprivation as a result of POI has serious implications for female health. In particular, bone mineral density, cardiovascular health, neurological systems and sexual health, may be impacted. The challenge posed by this important condition is the absence of standardized diagnostic criteria and management guidelines within our clinical practice. There are no local data about the causes and prevalence of POI in South Africa or adherence to international recommendations for management. The aim of this study was to review the women who have presented to our gynaecological endocrine service with POI and to assess their diagnosis and presentation. Based on this information we plan to adjust, where necessary, our current protocol of investigations. Methods: The study was conducted at the Gynaecological Endocrine clinic, at Groote Schuur Hospital (GSH), South Africa over a period of 11 months (June 2016 to May 2017). It was a retrospective folder review of women diagnosed with POI from 1983 to date. Ethics approval was granted by the Human Research Ethics Committee of the Faculty of Health Sciences of UCT [HREC REF:315/2016] and further permission to access patient records was given by the Hospital committee. A total of 442 patients with the diagnosis of POI were identified using the card index system in our Gynaecological Endocrine Clinic. Clinical folders and microfilms were reviewed and information transferred to a template. The data were then entered using a Microsoft Excel spreadsheet and analysed. A total of 303 patients aged less than 40 presenting with primary or secondary amenorrhoea/oligo-menorrhoea of at least 6 months’ duration with serum FSH concentrations of >25mIU/mL on at least two occasions were evaluated. Comparison between groups was done using the t-test with a p-value of less than 0.05 being considered significant. Results A total of 369 patients with POI were identified in our clinic and we were able to review 303 of these clinical records (66 missing). Patients were aged 12-40 years at the initial visit. Serum levels of FSH, LH and oestradiol were similar in patients with primary and secondary amenorrhoea. Chromosomal abnormalities were more likely in the 38 patients with primary amenorrhoea (57.6%) than in those with secondary amenorrhoea (23.6%). Of 237 patients who presented with secondary amenorrhoea, more complained of symptoms of oestrogen deficiency (78.2%) and had been pregnant before diagnosis (53.2%) than those with primary amenorrhoea (p<0.001). Immune disturbances were present in 4.6% patients, mostly in women with secondary amenorrhoea. The most common karyotype in the 38 patients with primary amenorrhoea was 45X0 (n=18). Of the patients with primary amenorrhoea 4 had gonadal dysgenesis. After completing investigations, the cause was not identified in 36.3% (n=110) of the patients, followed by genetic causes 20.8% (n=63), chemo/RT 9.6% (n=29), iatrogenic 5.0% (n=15) and autoimmune causes 4.6% (n=14). Investigations were incomplete in 22.8% n=72) of the women due to failure to continue follow-up. Conclusion: It is important to offer a comprehensive assessment to women with POI to establish the cause and institute appropriate treatment. Counselling on long term management and fertility options is essential. Many women do not complete investigations after receiving the initial diagnosis and greater awareness of POI needs to be developed, along with increased education of women planning fertility later in life, particularly if they are at risk of POI. Women with POI have unique needs that require special attention and our clinical services need to address these.

Twin pregnancies are associated with greater fetal and neonatal morbidity and mortality compared to singleton pregnancies. It has been shown in a large multicentre randomised control trial by Barrett et al, that this risk is not significantly changed by planned mode of delivery in a twin pregnancy with a cephalic presenting first twin. This study was undertaken to assess the outcome of cephalic-presenting twin gestations according to planned mode of delivery in the local context of secondary level hospitals in the Metro West Cape Town Health District. Methods: This was a retrospective cohort study of twin deliveries at Mowbray Maternity Hospital and New Somerset Hospital over a 12 month period, starting from 1 January 2013 until the 31 December 2013. Study subjects included all twin deliveries with a cephalic presenting first twin, gestational age > 28w and 0 days, with no contraindication to vaginal delivery. The primary outcome was to document fetal and neonatal outcome according to the planned mode of delivery. Secondary outcomes included maternal outcomes and associations for combined delivery. Result: A total of 124 cases were identified. 95 had a planned vaginal delivery, and 29 had a planned caesarean section. In the planned vaginal delivery group, 61.1% delivered vaginally and 38.9% delivered via caesarean section. Nine of these caesarean sections were combined deliveries. The planned caesarean section group had a caesarean section rate of 93.1%. Two cases delivered vaginally. There was no statistical difference in the composite neonatal score between the two groups (21.1% and 29.3%, in the planned vaginal delivery and planned caesarean section groups respectively, p=0.092). There was also no significant differences in maternal outcomes between the two groups. Conclusion: The results of this study are in keeping with the findings of the Twin Birth Study. It showed no statistically significant difference in neonatal and maternal outcomes of twin gestations, with a cephalic presenting first twin, with respect to planned mode of delivery. A trial of vaginal birth is therefore a feasible option in our setting.

Obstetric Haemorrhage is the leading cause of maternal death globally (1) and the third leading cause of death in South Africa (2). Concern has been expressed in South Africa that bleeding associated with caesarean delivery (CD) accounts for one-third of haemorrhage deaths and this has increased over the last ten years (3). The underlying cause of bleeding at CD is commonly uterine atony, and the majority of the CDs were performed at district hospitals (2,3,4). The Saving Mothers Reports describe inadequate use and documentation of uterotonics to prevent or treat bleeding at CD and have promoted the development of a standardised national protocol. While there is international agreement on the dosage and administration route for oxytocin to prevent OH after vaginal delivery, there is lack of consensus or standardisation of protocols for its prophylactic use at CD, with marked differences between country and facility protocols. Anaesthetists are concerned about the hypotensive effect of high dose intravenous boluses of oxytocin, particularly in women under spinal anaesthesia, and some maternal mortalities in the United Kingdom have been partially attributed to this (5). Hence it is important to balance safety with efficacy by promoting the lowest effective doses to minimise side effects but enable uterine contraction. Aim: The aim of this study was to perform a clinical audit of the documented use of uterotonics at CD at MMH to see how it adheres to the national protocol; and as a secondary outcome to measure the rate of haemorrhage at CD. Methods: This was a retrospective folder review of women who delivered by CD at MMH during the months of June and July 2017, including both elective and emergency operations. Information was obtained from women’s folders kept in the medical records department, using especially designed data extraction sheets. Data analysis was by simple descriptive statistics. Results: Three hundred and nineteen (319) folders from the study period were interrogated. This included 239 emergency CDs (75%) and 80 elective CDs (25%). They were all performed by obstetric registrars or medical officers with 89% being done under spinal anesthesia. Prophylactic oxytocin boluses at CD were given in 302 (94.7%) women but there was no documentation of its use in 17 (5.3%). One of the 302 women had a high dose IV bolus (7.5 IU) but the remainder had boluses below 5 IU. There were 75 women (23.5%) patients who received the national recommended dose of 2.5 IU IVI while 227 (71.1%) received alternative low dose boluses which were all less than 5 IU. The dose most commonly given was 3 IU; to 169 patients (53%) as a single or divided dose. There was wide variation in the dosage of prophylactic infusions with only 18 (5.6%) patients receiving the recommended intraoperative 7.5 IU infusion, while 221 (66.5%) received alternate infusion doses. Only 49 (15%) were discharged from theatre recovery to the postnatal ward with a prophylactic infusion running. In total 65 (20.4%) of the women received a 20 IU oxytocin infusion but it was unclear whether this was for prophylaxis or treatment. No intramuscular doses of oxytocin or syntometrine were given for prophylaxis. Among the 319 CDs, 13 (4.1%) had documented blood loss over 1000 ml and 24 (7.5%) had uterine atony reported by the surgeon. The most common treatment was 20 IU infusion followed by misoprostol (13 women), syntometrine (three women) and tranexamic acid (one woman). Additional surgical measures required were B-Lynch compression suture for one, and haemostatic sutures for two. There were no re-look laparotomies or hysterectomies during the study period and there were no major morbidity or mortalities from either CD or from anaesthetic complications. Discussion: Low dose bolus oxytocin and infusion is widely used at CD post fetal delivery at MMH, although the dose of 3 IU was most commonly used in contrast to the recommended 2.5 IU in the national protocol. There was variation in the usage and dosage of prophylactic oxytocin infusion. The rate of PPH in the subjects was low (4.1%) with the low dose prophylactic regimens used, suggesting that they were effective, although this may also have been contributed to by the skill of the surgeons. Consensus is needed among anaesthetists and standardisation of protocols on oxytocin prophylaxis at CD, particularly for training doctors working in district hospitals. Repeating this audit in district hospitals where there are higher CD case fatality rates would be important to shed light on practice in such facilities and improve healthcare delivery.

To evaluate the efficacy of acupuncture in refractive OAB. The primary aim was to evaluate the effect on frequency, nocturia and urge urinary incontinence. The secondary aim was to evaluate the effect of the response on self-perceived quality-of-life.

BACKGROUND: In vitro fertilization in assisted reproduction requires controlled ovarian stimulation with exogenous gonadotrophins and oocyte maturation before ultrasound guided aspiration. GnRH-agonists have been utilized as an alternative to hCG for oocyte maturation prior to follicle aspiration. GnRH-agonist triggers are proven to lower ovarian hyperstimulation syndrome risk, a condition that can be life threatening. Lower pregnancy rates have been reported in the literature with the GnRH-agonist trigger, leading to recommendations of elective embryo cryopreservation, delayed transfer and increased costs to the patient. AIM: To determine if intensive luteal phase support of GnRH-agonist triggered cycles with intramuscular progesterone and oral oestrogen can result in similar pregnancy rates when comparing fresh embryo transfer outcomes with those of hCG triggered cycles. STUDY DESIGN, SIZE, DURATION: The study was a retrospective analysis of 279 fresh embryo transfers in autologous IVF cycles, which took place over the period of one year at Cape Fertility Clinic in Cape Town. RESULTS: Biochemical (49.40% vs 41.84%), clinical (43.37% vs 36.22%) and ongoing pregnancy rates (37.35% vs 33.16%) were higher in the GnRH-agonist triggered arm in comparison to the hCG triggered arm, respectively. Miscarriage rates were similar at 24.29% in the GnRH-agonist arm, versus 20.73% in the hCG triggered arm. None of the results were statistically significant. CONCLUSION: Similar pregnancy rates can be achieved with both hCG and GnRH-agonist triggered IVF cycles by supporting the GnRH-agonist triggered luteal phase with intensive intramuscular progesterone support.

Background: Menopause is a universal event and today most women are reaching the age when menopause occurs. Very little research has been done in South Africa about the perimenopausal period, particularly with regard to quality of life (QoL). The Utian Quality of Life Scale (UQOL) was designed to determine the QoL in peri- and postmenopausal women, and not just to measure their symptoms. The aim of this study was to validate the UQOL in a local urban population in State sector hospitals in Cape Town. Methods: This was a prospective, cross-sectional study. Participants were recruited from the Mature Women's Clinic at Groote Schuur Hospital (GSH), and Gynaecology Out Patient Departments (GOPD) at GSH and New Somerset Hospital (NSH). Four questionnaires were administered- a demographics questionnaire, the UQOL, the WHOQOL-BREF and the Greene Climacteric Scale. Women were contacted telephonically after 3-14 days for retest of the questionnaires to establish reliability. Results: Fifty two participants were initially recruited and 49 were retested. Results showed that the UQOL is a valid instrument with which to measure QoL in our study population. The test-retest reliability was good, with only 2 questions having significantly different answers (p-value < 0.05). Internal consistency (Cronbach's alpha) was >0.7 for the occupational domain of the UQOL only. The health, emotional, and sexual domains had alpha values of 0.673 and 0.691 and 0.634 respectively, which are acceptable. The Cronbach's alpha for the health domain improved to 0.739 when question 8 was removed from the health domain. Construct validity was demonstrated by a statistically significant correlation between the domains of the UQOL and the WHOQOL-BREF. Secondary factor analysis confirmed the domain structure of the UQOL. The scores from the domains seem to indicate that perceived QoL in our study population is not significantly impaired, with the sexual domain showing the most negative impact on QoL. The WHOQOL-BREF demonstrated good internal consistency in our study population. Conclusions: The UQOL is a valid instrument to measure QoL related to the menopause in our patients. No questions were deleted from the original scale. Further research is needed in Afrikaans and Black African languages. The sexual experiences of peri- and post-menopausal women should also be explored. Menopause did not seem to adversely affect QoL in the women who participated in this study. The WHOQOL-BREF is a good tool to measure general QoL in our study population.

Includes bibliographical references / Background: Nutrition in pregnancy has important implications for both the mother and the fetus, hence the importance of an accurate assessment at the booking visit. Body mass index is currently the gold standard for measuring body fatness. However, pregnancy associated weight gain and oedema, as well as late booking in our population setting, questions the reliability of using the BMI to assess body fat or nutritional state in pregnancy. Mid upper arm circumference has been used for many decades in children under the age of five, to assess malnutrition. Many studies have shown a strong correlation between MUAC and BMI in the adult population. MUAC is a much simpler anthropometric measure to take as it eliminates the need for height charts, scales and calculations. One of the other main advantages of using MUAC is that there is minimal change in the MUAC during pregnancy, which may be a better indicator of pre-pregnancy body fat and nutrition. Objectives: To assess if there is a correlation between the mid upper arm circumference and body mass index in pregnant woman booking in the Metro West area. Methods: This was a cross sectional study of women booking at four MOUs in the Metro West area. Anthropometric measurements namely height, weight and MUAC were carried out on pregnant women booking for the first time in four midwives obstetrics units in Metro West area, Cape Town, South Africa. The participants were divided into two groups, early gestational age group for patients who booked less than twenty weeks, and a late gestational age group for those who booked more than twenty but less than thirty week Results: The results showed that there is a strong correlation between MUAC and BMI in pregnant women up to thirty weeks gestation. The correlation was calculated at 0.92 for the entire group. A regression analysis showed that there is a statistical difference in the mathematical relationship between BMI and MUAC, between the two groups (EGG and LGG). MUAC of 27cm and 31cm had sensitivities and specificities of more than 80% for identifying pregnant women as overweight and obese respectively. Conclusion: The MUAC correlates strongly with BMI in pregnancy up to a gestation of thirty weeks in women in Metro West maternity services. In a low resource settings, the simpler MUAC measurement to assess nutritional status and screen women who are at risk for potential adverse pregnancy outcomes could reliably be substituted for BMI estimation.

Includes bibliographical references. / Introduction: This study aimed to assess reproductive knowledge and use of contraception in women of reproductive age with cardiac disease or chronic hypertension attending outpatient clinics. Methods: This was a prospective descriptive study. Women aged between 18 and 45 years attending cardiac or hypertension clinics at Groote Schuur Hospital, Khayelitsha and Mitchells Plain Day Hospitals were recruited. The study tool was an administered questionnaire which included social, demographic and medical information, knowledge about their condition and the contraceptive history. Results: Two hundred women were interviewed, 100 with cardiac disease and 100 with chronic hypertension. Among the 84 cardiac and 90 hypertensive women who had previously been pregnant, there were 193 and 262 pregnancies respectively. Of these participants, 72% cardiac and 70% hypertensive women reported at least one unplanned pregnancy. Unemployed hypertensive women were more likely to have unplanned pregnancies (81%), than their employed counterparts (65%) (p<0.03). In the cardiac group employment did not affect planning of pregnancies. Forty cardiac and 46 hypertensive women were married. Married women in both groups had more planned pregnancies (46% cardiac, 43% hypertensive) in contrast to 10 Out of 200 women, only 2 were unaware of any contraceptive methods. One hundred and fifty eight participants were using modern contraceptive methods. None of the women accessed contraception at their routine medical clinics and less than half had received contraceptive advice there. Conclusion: This study showed that many pregnancies among participants with medical conditions were unplanned, and there was poor knowledge about the impact of their medical condition on pregnancy. There is an unmet need for reproductive health education in women with medical conditions, and ideally this should be part of the holistic care of any woman with a significant medical condition.

Includes bibliographical references. / Background. Obesity is increasing globally and is defined as a Body Mass Index (BMI) over 30 kgms/m². It’s prevalence in the Metro West Maternity service is unknown. Objective .To assess the prevalence of obesity and determine its association with adverse perinatal and maternal outcomes among pregnant women in the Metro West Region, Cape Town, South Africa Study Design. This was a retrospective observational study that compared perinatal outcomes in women with normal pregnancy BMI to outcomes in women with high pregnancy BMI. Setting. Mitchells Plain and Guguletu Midwife Obstetric Units, Mowbray Maternity Hospital and Groote Schuur Hospital, Metro West Region, Cape Town, South Africa Population. A total of 970 pregnant women divided into BMI groups that had their first antenatal booking visit between January and April 2011. Methods. A list of folder numbers was compiled from the antenatal booking registry at the two MOUs. From the list, maternal folders were then traced through the CLINICOM tracking system, MOU delivery registers, antenatal clinic transfer registers and labour ward transfer registers to find place of delivery or outcome of pregnancy. Maternal and perinatal characteristics were then extracted from the folders into the data collection sheet and data was analysed by STATA. Descriptive statistics included proportions with percentages and median with interquartile ranges. Inferential statistics included Chisquared tests, Fisher Exact tests, Kruskal Wallis test, univariate and multivariable logistic regressions. Main outcome measures. Perinatal outcomes (stillbirth, macrosomia, shoulder dystocia, 5 minute Apgar Score less than 7, congenital abnormalities) observed in obese and morbidly obese compared to normal BMI pregnant women.