Background: The management of late preterm prelabour rupture of membranes (PPROM) is associated with an increased risk of neonatal prematurity related morbidity due to many obstetric care guidelines which favour delivery at 34 weeks or immediately upon diagnosis of ruptured membranes after 34 weeks gestation. However, expectant management of this group of patients (i.e delayed delivery) between 34+0 and 36+6 weeks of gestation is associated with an increased risk of neonatal and maternal infectious morbidities. Aim of Study: The aim of this study was to evaluate the impact of the latency period on maternal and neonatal outcomes in late preterm prelabour rupture of membranes in a regional perinatal service in Cape Town, South Africa. The latency period was defined as the time from rupture of membranes to the time of delivery. In addition, we sought to investigate whether immediate induction of labour in the absence of overt signs of infection or fetal compromise should be prioritised in women who present with late preterm prelabour rupture of membranes. Methods: This was a retrospective cohort study carried out over a period of two years in two secondary level hospitals of the Metro West area of Cape Town. The subjects were low risk HIV negative women with singleton pregnancies with ruptured membranes in the late preterm period. Maternal and neonatal outcomes were studied between two latency periods, namely short latency (< 48 hours) and long latency period (≥ 48 hours) after ruptured membranes. Results and Conclusion: There were no significant differences in maternal and neonatal outcomes between the two groups of latency periods when latency was defined as the time from ruptured membranes to delivery. The study favoured a delayed induction thereby improving neonatal outcomes by decreasing the complications of prematurity. There were more adverse maternal outcomes, including an increase likelihood of augmentation of labour and more operative delivery along with its major risk, that of obstetric haemorrhage, were noted in the short latency period group. Therefore, a delayed induction policy appeared to be more appropriate. Preterm delivery places the newborn at risk of prematurity. Therefore, the risk of prematurity must be balanced with the risks of intrauterine infection and antepartum haemorrhage, the two major complications of expectant management if delayed induction is to be adopted. Proper monitoring of both the pregnant woman and fetus is essential when expectant management is carried out to avoid these adverse maternal and neonatal outcomes.

Includes bibliographical references. / Objective: To compare the analgesic efficacy of Paracervical Block (1% lidocaine) with procedural sedation (Midazolam/Fentanyl) in the surgical management of incomplete/ missed miscarriages. Study design: An efficacy trial with a naturally occurring control group who received what is standard practice. The study compared two methods of analgesia. The study group received paracervical block and the control group received procedural sedation. The study ran over two consecutive months (December 2012/January 2013). Setting: Groote Schuur Hospital, a level three hospital situated in Cape Town, South Africa. Population: All women between 18 and 55 years of age that were admitted to Groote Schuur Hospital requiring a uterine evacuation following either a spontaneous incomplete or a missed miscarriage that were not excluded by any of the exclusion criteria. Methods: Over the two month period recruited participants (those patients who fit the inclusion criteria and were agreeable to participate) were allocated to either the control group (month 1) or the intervention group (month 2), depending on which month they had the uterine evacuation. Data was collected from the uterine evacuations of the recruited participants over the two month study period. Main outcome measure: The participants perceived pain during and after uterine evacuation (10 minutes and two hours), scored by the participant on an eleven point numerical pain scale. Secondary outcomes were the surgeons’ satisfaction with the analgesia, duration of procedure and complications/ side effects of the two methods of analgesia under study. Results: A total of 111 participants were recruited over the study period, 57 in the control group and 54 in the intervention group. The average pain score during the procedure was lower in the Paracervical block group compared with the procedural sedation group, but this difference was not statistically significant at a 5% level (t=-1.8495, p=0.0671). For the Paracervical block group, the ‘’pain during” mean and the standard deviation (SD) were 5.56 and 2.50 respectively, whilst for the Procedural sedation group, the mean and SD were 6.49 and 2.81 respectively. Conclusion: Paracervical block using 1% lidocaine is an effective and safe alternative to procedural sedation in the surgical management of incomplete/missed miscarriages.

Background The United Nations (UN) aims to reduce the maternal mortality ratio (MMR) and improve access to reproductive health services. Caesarean sections (CS) are known to be associated with a raised mortality rate by a factor of 2.8 in addition to the raised morbidity rate (OR 3.1; 95% CI 3.0-3.3) compared to vaginal deliveries (VD). Globally, there has been a concerning trend in the caesarean section rate (CSR), rapidly increasing since the 1970’s, with some countries reporting CS rates as high as 40.5%. South Africa has a CSR of 25.7%, which is higher than the suggested rate by the World Health Organization (WHO) of 15%; a rate above which the WHO suggests no maternal and fetal benefit exists. Robson introduced a universal classification system for caesarean sections with 10 totally inclusive and mutually exclusive groups. Horak made use of the ten group classification system (TGCS) to calculate the CSR at Mowbray Maternity Hospital (MMH) and its referring midwife obstetric units (MOU) for 2009, and reported it as 20.7%. Since the completion of her study, the referral routes to MMH have changed and the management of HIV-associated illnesses has markedly improved. A period of 7 years has elapsed and it was thought to be an optimal time to repeat a review of the CSR and compare it with the rates from 2009. Objectives The study aims to calculate the CSR for MMH from January 2016 to June 2016. Analyses of the CSR within each Robson group will be done and compared to the rates from 2009. This will allow us to make recommendations, if appropriate, aimed at reducing the CSR. Methods A retrospective, observational study was performed at MMH in Cape Town. Data was collected from birth registers for January 2016 – June 2016. All women who delivered, including all caesarean sections and vaginal births, were entered into the study, provided the newborn was viable with a birth weight >500g. Parameters were recorded onto an electronic and password-protected Microsoft Excel® spreadsheet and were used to classify deliveries according to the Robson Classification system. To allow for comparison with Horak’s study, deliveries at MMH for January 2009 – June 2009 were selected and analyzed. All the data was analyzed with STATA software and presented in various graphical formats. Ethics approval was obtained from University of Cape Town’s Human Research Ethics Committee (HREC Ref: 539/2016). Results There were 4727 deliveries from January to June 2016, of which 2472 were vaginal births and 2255 were caesarean sections, giving rise to a CSR of 47.70% (95% CI 46.28- 49.13). Of all the caesarean sections performed, 62.7% were primary caesarean sections and 37.3% were repeat caesarean sections. Nulliparous women, compared to multiparous women without a history of a prior CS, were at higher risk for a CS if in spontaneous labour (OR 2.02; 95% CI 1.71-2.38) and if induced (OR 2.75; 95% CI 2.13- 3.53). Group 5 (women with a previous CS), with a CSR of 85.34% (95% CI 82.82-87.61) made the greatest contribution to the overall CSR. The overall CSR from January to June 2009 was 44.10% (95% CI 42.63-45.57), calculated from 4379 deliveries. There was a statistically significant increase in the CSR of 3.60% from 2009 to 2016. A similar significant increase was observed in the respective CS rates of Group 1 (5.59%), Group 2 (11.63%) and Group 10 (8.73%). Group 4 was the only group with a statistically significant decrease of 4.48% in its CSR. An additional 308 labour inductions were performed in 2016, however, women in 2016 were statistically significantly less likely to be successful in a vaginal delivery (OR 0.67; 95% CI 0.55-0.81 p<0.001) compared to women in 2009. Conclusion A CSR of 47.70% is acceptable for a secondary level hospital such as MMH. This figure is elevated, but appropriate, as the referral units that perform only low risk vaginal deliveries are excluded. A surge in the number of repeat caesarean sections performed and lower success rates for labour inductions were mostly responsible for the rise. Primary caesarean sections performed on patients directly result in a higher risk patient profile in the future, coupled with more repeat caesarean sections in subsequent pregnancies. This is supported by a 17.5% prevalence of previous CS in women in 2009 as opposed to the 20.79% of women with a prior CS in 2016. This study shows that a CS in the index pregnancy has sizeable effects on the care of a woman in subsequent pregnancies. This places more strain on the health system and ultimately affects service delivery to all patients. Theoretically it is possible to explore changes in management to curb the ever-increasing CSR, but one has to consider if such changes is acceptable and appropriate to the setting of MMH and the population it serves.

Breastfeeding is considered a public health concern due to increased maternal/infant mortality and morbidity rates associated with persistent low rates in breastfeeding. Providing early breastfeeding education for women with diabetic, pregnancy-induced hypertension and multiple gestations can result in higher persistence rates and a decrease in maternal and infant mortality and morbidity rates. This quality improvement project provided early prenatal breastfeeding education for women with diabetes, pregnancy-induce hypertension and multiple gestations at a private clinic in Long Beach, Southern California. Evidence-based literature reviews were conducted through CINAHL and Medline (2009-2014). The descriptive study used for the project was made up questionnaires including 5 pre-survey questions completed by prenatal women prior to education and another 5 post-survey questionnaires after the education. Postnatal women were given 10 pre-survey questions before the education and a 10 post survey questions after the education. Variables included low and high income, level of education, and previous breastfeeding experience. Out of 100 targeted women, a total number (n) of 54 questions from a questionnaire were completed (54 %). These include 21 completed (21%) 5 pre- and 5 post-survey questions and 33 completed (33%) 10 pre and 10 post-survey questions. Early prenatal breastfeeding education increased maternal knowledge, intent and promoted self-efficacy. Providing early breastfeeding education is vital to decrease maternal-infant morbidity and mortality rates and promote positive social change.

Midwifery has existed for thousands of years, and midwives have been providing care to women and birthing people in both medical and non-medical settings. Physicians specializing in obstetrics and gynecology and midwives are both able to care for pregnant women and birthing people, but do so in differing ways. When examining the distribution of women’s health providers across different areas of the United States, there seems to be a disparate number of midwives in urban areas. Given the rising maternal mortality rates in the United States and focus on equitable care and expanding access to care, I sought to explore the role of midwifery in urban settings, and midwives’ role in mitigating adverse outcomes in vulnerable populations. Amidst time spent in numerous maternity wards within the same urban area, I’ve noticed different versions of how midwifery care is implemented, as well as distribution of this care. This thesis will discuss the role of midwives generally, and how midwives are integrated into care in urban settings. I will then discuss the geographic imbalance of midwifery care, how midwives can and do assist to mitigate health disparities, and how midwives improve maternal and neonatal health outcomes. Lastly, I will discuss how patients in urban settings view midwifery care and my view and recommendations on what the future of midwifery care should look like integrated into urban settings. / Urban Bioethics

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