Introduction: Induction of labour is commonly performed in clinical practice. Increasing rates of induction of labour worldwide has led to debate on whether elective induction improves the outcomes or simply leads to increased complications and healthcare costs. Maternal and neonatal complications and increased caesarean section (CS) rates associated with induction of labour are related to a variety of factors influencing the methods of induction. Misoprostol has been the drug of choice for induction of labour in developing countries for almost a decade. Different misoprostol regimens are used for induction of labour in different health facilities. New Somerset Hospital uses the standard protocol for induction of labour using misoprostol that the Western Cape Government adopted. This protocol has however not been audited. The main objective of the study was to determine the maternal and fetal outcomes of inductions of labour performed at New Somerset Hospital. Methods: This was a retrospective study conducted at New Somerset Hospital. We reviewed a random sample of medical records of patients who underwent induction of labour from 01 January 2014 to 31 December 2014. Ethics committee approval was granted by the Human Research Ethics Committee of the Faculty of Health Sciences of UCT. A total of 88 folders were sampled from 1029 women who had induction of labour. Results: There were a total of 6514 deliveries in 2014 of which 1029 had induction of labour, giving an induction rate of 15.8%. A total of 86 patients were included in the study. The mean age of the patients was 28.9 years (SD±6.586) with an age range of 16 to 44 years. The average gestational age at the time of induction of labour was 39.5 weeks with a range 35 to 42.6 weeks and 14.0% of the patients were HIV positive. The three main indications of induction of labour were hypertension in pregnancy (40.7%), prolonged pregnancy (27.9%) and pre-labour rupture of membranes (8.1%). Overall, 50 patients (58.1%) had vaginal delivery and 36 patients (41.9%) had caesarean delivery. There was a significant association between mode of delivery and time to delivery. Patients who delivered within 24 hours of commencement of induction of labour were more likely to have had a vaginal delivery (p = 0.005). The three main indications for caesarean delivery were fetal heart rate changes (n=30; 72.0%) followed by failed induction of labour (n=9; 21.0%) and cephalopelvic disproportion (n=3; 7.0 %). In terms of maternal outcomes, 2 patients (2.3%) had hyperstimulation of the uterus, 6 patients (7.0%) had postpartum hemorrhage, 8 patients (9.3%) had vaginal tears and 5 patients (5.9%) had an episiotomy performed during delivery. The mean birth weight was 3262.1g (SD±503.77) with a range of 1925 to 4515 grams. At five minutes the means Apgar score was 9.8(SD ± 0.62) with range of 6 to 10. A total of 38 babies (44.3%) had meconium stained liquor documented at delivery, three babies (3.4%) required neonatal resuscitation upon delivery. There were 10 (11.6%) babies that were admitted to NICU. Conclusion: In this study we found that the prevalence of induction of labour was 15.8%. Hypertension in pregnancy, prolonged pregnancy and pre-labour rupture of membranes are the three common indications for induction of labour. Successful vaginal delivery was achieved in 51.0% of the study population. The caesarean delivery rate was high, mostly due to CTG changes The current induction of labour protocol using oral misoprostol is associated with acceptable maternal and fetal outcomes.

Includes abstract. Includes bibliographical references (leaves 50-55).

INTRODUCTION: Cervical cancer is the second commonest cancer in South Africa and the commonest amongst Black females with a Lifetime Risk (LR) of 1:35. In South Africa the problem has been compounded by the HIV epidemic as well as a lack of resources and infrastructure to offer an adequate screening and treatment programme. Cone biopsies are one of the diagnostic and sometimes therapeutic modalities used to assess and treat cervical precursors and cervical cancer. Unfortunately, cone biopsy of the cervix remains a morbid procedure often performed on young women in the reproductive age group and has resultant complications. OBJECTIVE: To audit the demographics, indications, histology and post cone management and outcome of women requiring cone biopsies of the cervix, at Groote Schuur Hospital Colposcopy Clinic between 1st April 2010 and 31st October 2013. METHODS: A group of women attending the colposcopy clinic, and requiring cone biopsies between 1st April 2010 and 31st October 2013 were identified from a computerized database, known as the Hygiena Database. Women who had an incomplete dataset were excluded. Folder review and review of the National Health Laboratory Services was also conducted. Patient demographics, indications, cone histology and follow up at 4-6 months, 10-12 months and > 12 months were analysed. Age, parity, HIV status, CD4 count, ARV status and cone margin involvement were included in the univariate and multivariate analysis to determine predictors of persistent disease RESULTS: Three hundred and seventy six cone biopsies were performed during the study period, with a mean age of 42.3 years, mean parity of 2. The majority of women [56,7% (213/376)] were HIV positive. The final histology indicated that 65,2% (246/376) of the women had high-grade disease (CIN 2/3 or HSIL) and 12,5% (47/376) had microinvasion. Ectocervical margins were clear in 57,6% (212/368) of cases and endocervical margins were clear in 54,6% (201/368) of specimens. Fifty-one cancers were detected during the study period. In the multivariate analysis age 40-49yrs (RR 1.4, 95% CI 1.01-2.0: p=0,043), ectocervical margin involvement with CIN 2/3 (RR 1.8, 95% CI 1.1-3.0: p-0.017) and endocervical margin involvement with CIN 2/3 (RR 1.5, 95% CI 1.04-2.3; p=0,031) and microinvasion ( RR 2.4, 95% CI 1.4-4.3; p=0.003) were all predictors of persistent disease. CONCLUSION: The use of cone biopsy is a valid diagnostic and sometimes therapeutic procedure at Groote Schuur Hospital with significant detection of high grade disease and cervical cancer. Women aged 40-49 years and positive cone margins are strong predictors of persistent disease. Improved compliance and a reduction in positive margins are two areas that need to be addressed to improve the current treatment programme. Use of cone biopsy as surgical therapy for early stage cancer appears promising but needs further study.

Introduction: Preterm births are common in all obstetric hospitals and present multiple challenges to both the obstetrician and the paediatrician. Preterm delivery is an important cause of perinatal morbidity and mortality, and places significant psychosocial stress on all involved. Late Preterm Birth (LPTB) is an important topic with many consequences for mother, child and society. It would be of interest to quantify the problem of late preterm birth at Mowbray Maternity Hospital (MMH); quantifying the deliveries into spontaneous versus medically indicated, and to explore the reasons and outcomes for each category. Aims and Objectives: To review the causes, indications for, and outcomes (maternal and neonatal) of all late preterm births delivered at Mowbray Maternity Hospital. Methods: This was a retrospective descriptive study, conducted at Mowbray Maternity Hospital, between January 1 st 2016 and March 31 st 2016. The study population, consisting of 231 patients, includes all deliveries at MMH during the above time period, which fit the inclusion criteria of a gestational age (GA) of between 34⁺⁰ and 36⁺⁶ weeks. All data pertaining to the patient’s previous history, risk factors and current pregnancy were captured and analyzed using Stata. This study was approved by the UCT Ethics Committee (HREC) and institutional approval was obtained from Mowbray Maternity Hospital. All information was treated with confidentially and in accordance with the Helsinki Declaration. Results: During the study period, 1st January 2016 and 31st March 2016, there were a total of 2342 deliveries. Of these deliveries 36 (1.5%) were found to have a GA < 28 weeks (these included those that were categorised as miscarriages); 24 (1%) were between 28 – 31⁺⁶ weeks; 56 (2.4%) were between 32 – 33⁺⁶ weeks and 1833 (78.2%) had a GA above 37 weeks. 162 (6.9%) folders were missing and therefore GA was not calculated, leaving 231 (9.9%) deliveries of late preterm infants. Of the 231 patients included, 64 (27.7%) were noted to have a poor obstetric history, 38 (16.5%) had a history of a previous preterm delivery. Gestational age was calculated by Early Ultrasound Scan (EUS) in 44.2% of cases; Late Ultrasound Scan (LUS) in 36.4 % of cases; Last Normal Menstrual Period (LNMP) in 14.3% of cases and booking palpation in 5.12% of cases. At least one maternal characteristic associated with preterm labour was seen in 131 (56.7%) of the included patients. There were 20 (8.7%) sets of twins. Of the 231 patients, 129 (55.8%) presented in spontaneous labour and 102 were delivered late preterm for medical reasons; this included 70 (30.3% of 231) who had labour induced and 32 (13.9% of 231) who were delivered via caesarean section despite not being in labour for reasons that prevented an Induction of Labour (IOL)/vaginal birth. There were 251 babies delivered in the late preterm category, and of these, 250 (99.6%) were born alive, with 1 Early Neonatal Death (ENND) and 1 macerated stillborn. Of the 251 newborns, 63 (25.1%) were admitted to at least one of the neonatal wards during their hospital stay. Of these, 64.1% spent time in the High Care Unit (HCU), 28.1% spent time in the Neonatal Intensive Care Unit (NICU) and 68.8% spent time in Kangaroo Mother Care (KMC) unit (majority of these newborns had been in either HCU or NICU prior to KMC). Of the 63 neonates admitted to a neonatal ward; there were 37 (36.3%) from the 102 mothers delivered for medical reasons and 26 (20.2%) from the 129 mothers who had presented in spontaneous labour. The overall correlation between gestational age calculated by EUS/LUS/LMNP and Ballard score was calculated as 37%. The average length of stay in the hospital for the newborns, whether admitted or with mom, was 4.96 days. Discussion and Conclusion: Late Preterm Birth accounts for 9.9% of all births and 66.6% of all preterm births at Mowbray Maternity Hospital. This is a substantial proportion of MMH deliveries, putting pressure on already strained resources. This pressure is confounded by the fact that 25.1% of these neonates are admitted to a neonatal ward. 44.2% of these births are medically initiated and this should give cause for thought as to whether our protocols that govern certain medical conditions in pregnancy could possibly be altered to prolong pregnancies and reduce the incidence of Late Preterm Birth.

Background: Clinical officers perform much of major emergency surgery in Malawi, in the absence of medical officers. The aim of this study was to validate the advantages and disadvantages of delegation of major obstetric surgery to non-doctors. Methods: During a three month period, data from 2131 consecutive obstetric surgeries in 38 district hospitals in Malawi were collected prospectively. The interventions included caesarean sections alone and those that were combined with other interventions such as subtotal and total hysterectomy repair of uterine rupture and tubal ligation. All these surgeries were conducted either by clinical officers or by medical officers. Results: During the study period, clinical officers performed 90% of all standard caesarean sections, 70% of those combined with subtotal hysterectomy, 60% of those combined with total hysterectomy and 89% of those combined with repair of uterine rupture. A comparable profile of patients was operated on by clinical officers and medical officers, respectively. Postoperative outcomes were almost identical in the two groups in terms of maternal general condition = both immediately and 24 hours postoperatively - and regarding occurrence of pyrexia, wound infection, wound dehiscence, need for re-operation, neonatal outcome or maternal death. Conclusion: Clinical officers perform the bulk of emergency obstetric operations, including complicated procedures, at district (level 1) hospitals in Malawi. The postoperative outcomes of their procedures are comparable to those of medical officers. Clinical officers constitute a crucial component of the health care team in Malawi for saving maternal and neonatal lives given the scarcity of physicians.

Introduction: Pregnancy related sepsis is a major cause of maternal mortality and morbidity in South Africa. Caesarean section (CS) is the most important risk factor in the development of puerperal infection, and surgical site infection (SSI) after CS increases maternal morbidity as well as medical costs. Mowbray Maternity Hospital (MMH), is a secondary level, public maternity hospital. The caesarean section rate at MMH has increased considerably over the last fifteen years, and the perception has been that there have been increasing numbers of patients developing SSI post-CS. This study was designed to look more closely at the incidence of SSI and to describe the patients identified with SSI. Methods: This was a retrospective observational study. Cases of severe SSI, as defined by the Centres for Disease Control and Prevention (CDC), following CS at MMH from December 2011 to December 2014 were identified. Following ethical approval, patient records were sourced, data collected and analysed using Stata and Statistica. Results: In the 3-year study period, 14982 CS were performed with 98 patients identified with severe SSI. Folders were retrieved for 96 patients, with 2 patients' folders missing and 29 patients with a missing maternity case record (MCR). The overall incidence of severe SSI was 0.65%, with an incidence of 0.88% in Year 1, 0.90 in Year 2 and 0.70 in Year 3. Of the cases, 79 (80.6%) had been in labour, 16 (16.3%) patients had had prolonged rupture of membranes (PROM) and 32 (32.7%) had prolonged labour, with a median of 5 vaginal examinations. An emergency CS was performed in 90 (91.8%) patients, 7 (7.2%) had an elective CS and 1 (1.0%) patient had this data missing. Deep incisional SSI was diagnosed in 74 (75.5%) patients and 24 (24.5%) patients were identified with organ/space SSI. Intravenous (IV) antibiotics was the main treatment in all 96 cases, with 23 (23.5%) patients requiring a wound debridement, 17 (17.2%) a laparotomy, which proceeded to a hysterectomy in 12 (12.3%) patients. In the majority of cases, no organism was cultured, Whereas multiple organisms were cultured in 16 cases, of which 12 were identified as MRSA, and 18 as Klebsiella pneumoniae. There were no maternal deaths or Intensive Care Unit (ICU) admissions. Discussion and Conclusion: The incidence of severe SSI is in keeping with other institutions, with the lowest incidence being found in Year 3, which may be explained by the change in referral population and/ or the full implementation of the Best Care Always (BCA) bundles of care. Of the 98 patients with severe SSI, 80.6% had been in labour, 32.7% had prolonged labour and 91.8% had an emergency CS performed. These are all factors which are known to increase the likelihood for development of post-CS SSI.

Artificial insemination with donor sperm is a widely accepted form of treatment for severe male factor infertility. The introduction of quarantined, cryopreserved semen and the associated reduction in cycle fecundity when compared to fresh semen necessitated the development of strategies to improve the performance of frozen sperm. A prospective randomised clinical trail was undertaken in the Reproductive Medicine Unit at Groote Schuur Hospital to compare intrauterine insemination with intracervical insemination in a therapeutic donor insemination program with cryopreserved semen. The method of insemination was alternated in successive cycles in each patient after intitial randomised selection. Forty three patients underwent 61 intracervical insemination cycles and 48 intrauterine insemination cycles. Strict cycle control was exercised and the timing and frequency of insemination followed a specific protocol. Eighteen clinical pregnancies occurred following eleven intrauterine insemination cycles (22.9% per cycle) and seven intracervical insemination cycles (11.5% per cycle). Treatment outcome was influenced by patient age, the severity of the male factor and endometriosis. Most pregnancies followed insemination with 15 to 25 million motile sperm. Sperm fecundity differed amongst donors. The findings of our study and the current literature suggest that intrauterine insemination improves cycle fecundity in therapeutic donor insemination cycles with frozen donor sperm.

Includes bibliographical references.

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 / Introduction: Over the past few decades there has been an increase in caesarean section rates that has been well documented in many developed countries. The impact of this cannot be ignored as several studies have shown higher risks of maternal morbidity and mortality with caesarean section as compared to vaginal births. The reasons behind it are complex, with maternal request frequently being cited as a major contributor. A growing body of evidence shows that relatively few women would actually prefer to deliver by caesarean section. Caesarean section on request is not routinely offered in the public health care sector in South Africa, and is therefore unlikely to contribute significantly to the overall caesarean section rate. In the South African context very few studies examining women's preference for mode of delivery exist. Aims and Objectives: The primary aim of our study was to determine women's preference for mode of delivery during the third trimester of pregnancy in a low risk population. The secondary outcome was to describe the major reasons for their preferred mode of delivery. Methodology: We conducted a cross-sectional descriptive study of pregnant women attending antenatal care at two midwife obstetric units (MOUs) in Gugulethu and Mitchell's Plain in the Western Cape. Women were recruited during the third trimester of pregnancy and women over the age of 18, with a singleton low risk pregnancy, planning to deliver at the MOU, were eligible for inclusion. Two trained interviewers conducted an interview-based questionnaire regarding women's preference for mode of delivery. Data on demographic and socio-economic characteristics were also collected. We also described the major reasons behind women's preferred mode of delivery. Results: Of the 195 women that participated in our study, 160 (82.1 %) indicated a preference for vaginal delivery. This compared to only 5 (2.6 %) of the study participants who preferred a caesarean delivery, and 30 women (15.4 %) who were unsure about their preferred mode of delivery. Of the group preferring caesarean section, all five women (100 %) cited 'fear of vaginal birth' as the major reason for preferring a caesarean section. Of the 195 women that participated in our study, 106 (54.4 %) did not believe that women should be given the right to request a caesarean section in the absence of a medical indication, 14 women were unsure (7.2 %) and 75 of them believe that women should have the right to request a caesarean (38.5 %). Conclusion: The need for maternity services that are more women-centred has arisen, with an increasing emphasis on maternal choice and birth satisfaction. Our study contributed to the mounting body of evidence that the majority of women prefer to have a vaginal delivery. In the small group preferring caesarean section, 'fear of vaginal birth' was the major reason behind their preference. There were a considerable number of women in our study population who were unsure about their preference. This indicates a need for improved antenatal education. Knowledge about women's preference and the reasons they regard as important will aid health care providers in counselling patients appropriately regarding the risks and benefits of both delivery methods and thereby enable women to make an informed decision about their preferred mode of delivery.