The utility of clinical care pathways in determining perinatal outcomes for women with one previous caesarean section; a retrospective service evaluation

<p>Abstract</p> <p>Background</p> <p>The rising rates of primary caesarean section have resulted in a larger obstetric population with scarred uteri. Subsequent pregnancies in these women are risk-prone and may complicate. Besides ensuring standardised management, care pathways could be used to evaluate for perinatal outcomes in these high risk pregnancies. We aim to demonstrate the use of a care pathway for vaginal birth after caesarean section as a service evaluation tool to determine perinatal outcomes.</p> <p>Methods</p> <p>A retrospective service evaluation by review of delivery case notes and records was undertaken at the Aga Khan University Hospital, Nairobi, Kenya between January 2008 and December 2009</p> <p>Women with ≥2 previous caesarean sections, previous classical caesarean section, multiple gestation, breech presentation, severe pre-eclampsia, transverse lie, placenta praevia, conditions requiring induction of labour and incomplete records were excluded. Outcome measures included the proportion of eligible women who opted for test of scar (ToS), success rate of vaginal birth after caesarean section (VBAC); proportion on women opting for elective repeat caesarean section (ERCS) and their perinatal outcomes.</p> <p>Results</p> <p>A total of 215 women with one previous caesarean section were followed up using a standard care pathway. The median parity (minimum-maximum) was 1.0<abbrgrp><abbr bid="B1">1</abbr><abbr bid="B2">2</abbr><abbr bid="B3">3</abbr><abbr bid="B4">4</abbr></abbrgrp>. The other demographic characteristics were comparable. Only 44.6% of eligible mothers opted to have a ToS. The success rate for VBAC was 49.4% with the commonest (31.8%) reason for failure being protracted active phase of labour. Maternal morbidity was comparable for the failed and successful VBAC group. The incidence of hemorrhage was 2.3% and 4.4% for the successful and failed VBAC groups respectively. The proportion of babies with acidotic arterial PH (< 7.10) was 3.1% and 22.2% among the successful and failed VBAC groups respectively. No perinatal mortality was reported.</p> <p>Conclusions</p> <p>Besides ensuring standardised management, care pathways could be objective audit and service evaluation tools for determining perinatal outcomes.</p

Perspectives on the practice of vaginal birth after caesarean section in East Africa

Background: The increasing Caesarean section rates being observed in most facilities will ultimately result in a larger proportion of women with previous scar. Choices need to be made by both the patient and the health worker between attempted vaginal birth after Caesarean section (VBAC) and Elective Repeat Caesarean section (ERCS). Both practices are associated with perinatal risks and benefits that call for certain objectivity and prudence in decision making especially where resources are scarce. Objective: To determine perceptions on the practice of vaginal birth after Caesarean section among maternity service providers in East Africa. Design: A semi-qualitative cross sectional survey using self-administered questionnaires. Setting: The study was undertaken among delegates attending a regional obstetrics and gynaecology conference in Mombasa, Kenya. Subject: Sixty-three consenting delegates were interviewed Results: A majority (69.8%) of the respondents were consultants and midwives working in government facilities. Fifty-eight out of the 63 respondents offered VBAC in their institutions despite acknowledging sub-optimal antenatal preparation. The main concerns identified were; deficiencies in healthcare delivery systems, inadequate human resources, lack of unit guidelines, inappropriate maternal education and inappropriate foetal monitoring tools. Conclusion: The practice of vaginal birth after Caesarean section was perceived to be sub-optimal with many existing deficiencies that need urgent action to ensure the safety of mothers and newborns. We therefore recommend that unless these concerns raised by maternity providers are addressed then the practice of VBAC in the region should not be encouraged

Routine late trimester ultrasound for the detection ofsmall-for-gestational-age and growth-restricted fetus inlow-risk pregnancy: a randomised controlled trial

Objectives: To compare the proportion of small-for-gestational-age and fetal growth-restricted fetuses detected in women offered a routine growth ultrasound to those either offered selective or no ultrasound in the third trimester. Methods: An open-label randomised control trial was conducted at the Aga Khan University Hospital, Nairobi. Eligible women were randomised into either the intervention or control group. Women in the intervention arm had a mandatory third trimester ultrasound for fetal growth performed between 36 weeks 0 days to 37 weeks 6 days. Those in the control group had a selective growth scan done if the clinician suspected abnormal fetal growth. The women were then followed up for delivery outcomes. Analysis was on an intention to treat basis. Results: A total of 278 women were recruited into the study with an overall completion rate of 88%. A majority of the women (67.8%) were primiparous. The overall detection rate of small-for-gestational-age and fetal growth-restricted fetus in the intervention groups was 10.9% (95%CI 4.9-16.9) with numbers needed to treat (NNT) of 9. The detection rate for fetal growth restriction was 3.6 (95%CI -0.28-7.5) and for small for gestational age was 4.5 (95% CI 0.29-8.8). The perinatal outcomes were similar between the two study groups. Conclusions: Compared to selective third-trimester ultrasound, rou-tine growth ultrasound for all low-risk women increased the detection rate of small-for-gestational-age and growth-restricted fetuses

Successful pregnancy outcome following laparoscopic myomectomy: case report

Laparoscopic myomectomy is now widely used as an alternative to laparotomy in the management of symptomatic uterine fibroids. The advantages of this minimal access approach outweigh those of the open techniques. The pregnancy outcomes between the two methods have been studied and are comparable, but there still exists a lot of scepticism locally concerning this. It is against this background that we present a 31 year old nulliparous lady who had a two year history of primary infertility secondary to multiple uterine fibroids, the largest being fundal and measuring 6.6cm. She underwent a successful laparoscopic myomectomy in November, 2006 and conceived spontaneously in February 2007. Her antenatal follow up was uneventful. She delivered a live male, 2,650 grams by Caesarean section in October, 2007 and had an unremarkable peuperium. With the availability of proper equipment, instruments, and adequately developing skills, laparoscopic myomectomy is feasible locally and with proper patient selection could result in favourable outcome as it is elsewhere

Caesarian section rates and perinatal outcome at the Aga Khan University Hospital, Nairobi

Background: There has been a persistent rise in the rate of Caesarean sections over the years.Whether this rise is the cause of the decline in infant mortality and improved neonatal outcome still remains debatable. Objective: To compare the Caesarian section rate and the perinatal outcome at the Aga Khan University Hospital for the years 2001and 2004. Design: Retrospective study. Setting: The Aga Khan University Hospital, Nairobi. Main outcome measures: The total Caesarian section rates, their indication and the perinatal outcome. Results: The overall Caesarian section rate was 20.4% in 1996,25.9% in 2001and 38.1% in 2004.The rate among patients managed by their private obstetricians was 27.1% in 1996, 30.8% in 2001and 41.7% in 2004.Whilst among general patients, it was 14.7%,21.5% and 34.5% over the same period. The main indication for emergency Caesarian section was foetal distress, while that for elective Caesarian section was a previous uterine scar. The overall perinatal mortality rate improved from 25.2 per 1,000 births in 2001to 14.0 per 1,000 births in 2004 (P\u3c 0.001, 95%CL 8.58-30.62).The early neonatal mortality rate was 12.8 per 1,000 live births in 2001compared to 10.8 per 1,000 live births in 2004 (p=0.08, 95%CI 9.84-13.76). Conclusion: There has been a significant increase in Caesarian section rate over the years. Being a referral unit dealing with many high-risk patients some of whom are supervised elsewhere and with a significant ratio of private patients, the high rate of Caesarean section at the Aga Khan University Hospital is expected.The rise could also be due to early detection of foetal compromise and improved diagnostic facilities leading to timely intervention. However, there has been a significant improvement in the neonatal outcome over the same period of time. Whether this is an effect of the high Caesarean section rate is debatable and calls for further research to correlate the two

The satisfactory growth and development at 2 years of age of the INTERGROWTH-21st Fetal Growth Standards cohort support its appropriateness for constructing international standards.

Background: The World Health Organization recommends that human growth should be monitored with the use of international standards. However, in obstetric practice, we continue to monitor fetal growth using numerous local charts or equations that are based on different populations for each body structure. Consistent with World Health Organization recommendations, the INTERGROWTH-21st Project has produced the first set of international standards to date pregnancies; to monitor fetal growth, estimated fetal weight, Doppler measures, and brain structures; to measure uterine growth, maternal nutrition, newborn infant size, and body composition; and to assess the postnatal growth of preterm babies. All these standards are based on the same healthy pregnancy cohort. Recognizing the importance of demonstrating that, postnatally, this cohort still adhered to the World Health Organization prescriptive approach, we followed their growth and development to the key milestone of 2 years of age. Objective: The purpose of this study was to determine whether the babies in the INTERGROWTH-21st Project maintained optimal growth and development in childhood. Study Design: In the Infant Follow-up Study of the INTERGROWTH-21st Project, we evaluated postnatal growth, nutrition, morbidity, and motor development up to 2 years of age in the children who contributed data to the construction of the international fetal growth, newborn infant size and body composition at birth, and preterm postnatal growth standards. Clinical care, feeding practices, anthropometric measures, and assessment of morbidity were standardized across study sites and documented at 1 and 2 years of age. Weight, length, and head circumference age- and sex-specific z-scores and percentiles and motor development milestones were estimated with the use of the World Health Organization Child Growth Standards and World Health Organization milestone distributions, respectively. For the preterm infants, corrected age was used. Variance components analysis was used to estimate the percentage variability among individuals within a study site compared with that among study sites. Results: There were 3711 eligible singleton live births; 3042 children (82%) were evaluated at 2 years of age. There were no substantive differences between the included group and the lost-to-follow up group. Infant mortality rate was 3 per 1000; neonatal mortality rate was 1.6 per 1000. At the 2-year visit, the children included in the INTERGROWTH-21st Fetal Growth Standards were at the 49th percentile for length, 50th percentile for head circumference, and 58th percentile for weight of the World Health Organization Child Growth Standards. Similar results were seen for the preterm subgroup that was included in the INTERGROWTH-21st Preterm Postnatal Growth Standards. The cohort overlapped between the 3rd and 97th percentiles of the World Health Organization motor development milestones. We estimated that the variance among study sites explains only 5.5% of the total variability in the length of the children between birth and 2 years of age, although the variance among individuals within a study site explains 42.9% (ie, 8 times the amount explained by the variation among sites). An increase of 8.9 cm in adult height over mean parental height is estimated to occur in the cohort from low-middle income countries, provided that children continue to have adequate health, environmental, and nutritional conditions. Conclusion: The cohort enrolled in the INTERGROWTH-21st standards remained healthy with adequate growth and motor development up to 2 years of age, which supports its appropriateness for the construction of international fetal and preterm postnatal growth standards

Laparoscopic management of an ovarian ectopic pregnancy: case report

Ovarian pregnancy is a rare variant of ectopic gestation.The diagnosis is often made at surgery and requires histological confirmation. The condition has not been reported locally and its diagnosis is easily missed. A case of an ovarian ectopic pregnancy in a 41year old para 1+ 1with secondary infertility is reported. The patient presented with lower abdominal pain and vaginal bleeding at six weeks gestation with a semm B-hCG of 79.12mlU/L. An ultrasound showed a complex left adnexal mass. She underwent a diagnostic and operative laparoscopy. A left oophorectomy was performed due to difficulty in achieving haemostasis

Reminder Systems for Self uterine massage in the prevention of postpartum blood loss

Background: Uterine massage may significantly reduce post partum blood loss and could be patient-driven. Objective: To assess the effectiveness of an alarm reminder system for self uterine massage in the prevention of post partum blood loss. Design: A random controlled trial. Setting: Meru District Hospital, Kenya. Subjects: One hundred and twenty seven (127) women were randomly assigned to a 15 minute alarm reminder system (71) and non-alarm (56) control arm during the fourth stage of labour. Results: Uterine massage compliance was better in the alarm group compared to the non-alarm group ( Average massage of seven and two in two hours respectively P-value Conclusion: Uterine massage compliance is remarkably increased by the use of an alarm reminder

A randomised controlled trial of the effect of laryngeal mask airway manometry on postoperative sore throat in spontaneously breathing adult patients presenting for surgery at a university teaching hospital

Background: Laryngeal mask airways (LMAs) are widely used in anaesthesia and are considered to be generally safe. Postoperative sore throat (POST) is a frequent complication following LMA use and can be very distressing to patients. The use of an LMA cuff pressure of between 30 and 32cm of H20 in alleviating post-operative sore throat has not been investigated. Objective: To compare the occurrence of POST between the intervention group in which LMA cuff pressures were adjusted to 30-32cm of H20 and the control group in which only monitoring of LMA cuff pressures was done, to compare the severity of POST between the two study groups and to compare the LMA cuff pressures between the two study groups. Methods: Eighty consenting adult patients scheduled to receive general anaesthesia with use of an LMA were randomized into two groups of 40 patients each. Intervention group: LMA airway cuff pressures were adjusted to 30 to 32cm of H20. Control group: Only had LMA cuff pressures monitored throughout the surgery. All patients were interviewed postoperatively at two, six and twelve hours. Data of their baseline characteristics, occurrence and severity of POST was collected. If POST was present; a Numerical Rating Scale (NRS) was used to assess the severity. Cuff pressures between the two study groups were also determined. Results: The baseline demographic characteristics of the participants were similar. The use of manometry to limit LMA AMBU\uae AuraOnce\u2122 intracuff pressure to 30-32cm H2O reduced POST in surgical patient\u2019s by 62% at 2 hours and 6 hours (Risk Ratio 0.38 95%CI 0.21-0.69)in the intervention group. The median POST pain score in the intervention group was significantly lower than the control group with scores of 0 at 2, 6 and 12 hours post operatively. Routine practice of LMA cuff inflation by anesthesiologists is variable, and the intracuff pressures in the control group were higher than in the intervention group. (P&lt;0.001) Conclusion: Among this population, reduction of LMA AMBU\uae AuraOnce\u2122 intracuff pressure to 30-32cm H2O reduces the occurrence and severity of POST. The LMA cuff pressures should be measured routinely using manometry and reducing the intracuff pressures to 30-32 cm of H20 recommended as best practice. DOI: https://dx.doi.org/10.4314/ahs.v19i1.47 Cite as: Waruingi D, Mung\u2019ayi V, Gisore E, Wanyonyi S. A randomised controlled trial of the effect of laryngeal mask airway manometry on postoperative sore throat in spontaneously breathing adult patients presenting for surgery at a university teaching hospital. Afri Health Sci. 2019;19(1). 1705-1715. https://dx.doi. org/10.4314/ ahs. v19i1.4

Umbilical cord hemangioma and pseudocyst with favorable fetal outcome

Umbilical cord hemangiomas are rare neoplasms of vascular origin, commonly found in the free section of the umbilical cord proximal to placental insertion. They are associated with an increased risk of fetal mortality. We present a rare co- occurrence of an umbilical cord hemangioma and a pseudocyst managed conservatively, with favorable fetal outcome despite the interval increase in size, decreased caliber of the umbilical arteries, and fetal chest compression