Evaluation of neonatal sepsis screening in a tropical area. Part II: Evaluation of intrapartum chemoprophylaxis protocol

The authors report on an analysis of a chemoprophylaxis protocol at the University Hospital of Guadeloupe in the Caribbean. This study comprised 6,060 consecutive deliveries and was initiated to assess the application of an intrapartum chemoprophylaxis protocol, evaluate the results, and try to identify possible necessary modifications to the existing protocol. Although more than 90 percent of women had at least one bacterial screening (vaginal or urinary) during the last trimester of pregnancy, approximately 75 percent of mothers who were heavily colonized group B streptococcus (GSB) at delivery were not detected by this systematic screening. As is also reported in other tropical areas where a great portion of nenonatal sepsis occurs in term babies, low birthweight was not a specific risk factor in this study when controlling for other major risk factor such as fever and premature rupture of membranes. Intrapartum chemoprophlaxis was associated wiyh an approximate three fold decrease in the risk of GBS neonatal bacteraemia among at risk deliveries. The results suggest that, in our tropical context, prolonged rupture of membranes of at least 12 hours' duration should be considered as a cause for intrapartum chemopropylaxis as it accounted for the majority of neonatal bacteraemia that escaped the existing protocol. (AU)

Ways of knowing about birth in three cultures

This article examines the concept of authoritative knowledge elaborated by Brigitte Jordan, using examples of birthing systems in Mexico, Texas, and Jamaica. We explore the linkages between the distribution of knowledge about birth and the use of technology; the valuation of biomedical and alternative ways of knowing about birth; the production of authoritative knowledge through interaction; and the relationship between authoritative knowledge and social status. In the Maya low-technology, collaborative birthing system in Mexico, the midwife and other adult women share knowledge about birth. In contrast, Spanish-speaking women undergoing cesarean delivery in a high-technology public hospital in Texas are, due to their limited English, only minimally able to interact with hospital staff. While they acknowledge the authoritative position of biomedical personnel and value technology, they protest their inability to communicate during their hopitalization. Jamaican women deliver in a formerly high-technology hospital system that is now experiencing economic austerity measures that render it increasingly dysfunctional. While use of technology is infrequent in the Jamaican case, authoritative knowledge remains vested in biomedicine. By means of three examples we respond to Jordan's call for rethinking of authoritative knowledge in high- and low-technology settings. (AU)

Factors affecting outcome of pregnancy in adolescents at the Victoria Jubilee Hospital in Kingston for the period December 1, 1995 to February 29, 1996

This study involved all the adolescents 10-19 years of age who were delivered at the Victoria Jubilee Hospital between December 1, 1995 and February 29, 1996. There was a total of 570 adolescents in the study. Teenage pregnancy is not a new phenomenon of modern times. In some countries it occurs within the framework of considerable kin and community approval. Fertility among adolescents varies from country to country. In Jamaica the fertility rate for adolescents 15-19 for 1993 was 108 per 100,000. Ninety percent of pregnancy in women under 20 years of age occur outside the formal marriage or common-law unions. The hazards of childbirth in adolescents are greater for both mother and infants than for women in their childbearing prime, age 20-29 years. There are higher incidence of prematurity and low birth weight to these babies. The purpose of the study was to deduce that preventive measures if any, may be required to improve reproductive outcome among adolescents. The method used was collection of data from adolescents' records and interviewing some of them. Of the total, 94.6 percent had normal delivery and 5.4 percent had caesarean section or other methods of delivery. There were 17.5 percent low birth weight and 20.7 percent prematurity. There was a significant association between multiparity and age of mothers. The results were generally in keeping with previous findings. The prediction of those adolescent mothers an babies at risk of poor outcomes due to pregnancy induced hypertension and other complications are particularly important in developing countries such as Jamaica. Hence, the importance of early and appropriate antenatal care and intervention are crucial. Unintended pregnancies and childbearing among adolescents are a source of increasing concern because of their impacts on the young mothers, the children and society at large. (AU)

Born before arrival (BBA) in Trinidad and Tobago: a 7-year case controlled study - abstract

328 babies were born before arrival (BBA) at Hospital over a 7-year period during which time the total number of births was 40,188. These were compared with two separated hospital delivered control groups (Control I: 302 patients of similar age and parity); (Control II: 262 patients of similar gestational age and foetal birth weight). It was found that BBA was more common in multiparous women (92.9 percent vs 75.5 percent) who had lack of antenatal care (20.1 precent vs 3.0 percent vs 3.4 percent, P<0.001) and who had a similar previous event(p<0.001). The condition was associated with a significant higher incidence of genital tract trauma (p<0.05) than in controls. Perinatal mortality was more common than in control group I but was similar to control group II, the latter because of the high risk obstetrical cases in this group. Unlike other studies, young maternal age, unmarried and distance from hospital were not significant contributing factors. Provision and uptake of antenatal care must be considered the cornerstone in the prevention of BBA and its serious consequences (AU)

Deaths associated with intrapartum asphyxia in Jamaica

The Jamaican Perinatal Mortality Survey compared all 2069 perinatal deaths occurring during the 12 months between 1 September 1986 and 31 August 1987 with 10086 survivors born in the 2 months of September and October 1986. The Wigglesworth classification identified 44 percent of the deaths as attributable to intrapartum asphyxia (IPA), and this grouping was largely confirmed by post-mortem examination where it had been carried out. About half of these babies weighed 2500g+ and death should have been largely preventable. Comparison of the 813 IPA singleton deaths with 9919 singleton survivors using logistic regression showed independent associations with maternal employment status, the number of children in the household, maternal height, whether or not the mother was trying to get pregnant, or had ever used an intrauterine contraceptive device. Medical conditions such as syphilis, untreated vaginal infection, bleeding < 28 weeks, bleeding 28+ weeks, highest diastolic and first blood pressures and eclamptic fits antenatally were all strongly associated. Mothers who commenced antenatal care in the first trimester were at reduced risk as were those who took iron during pregnancy. There were at substantial reductions in mortality in areas where better medical facilities were available. To this model, features of previous obstetric history were offered, but the only variables which entered were those relating to prior perinatal deaths and immediately preceding miscarriage and termination. Examination of specific features in the management of labour and delivery is a logical basis for the introduction of changes in practice. Caesarean section is unlikely to be apropriate but it is suggested that more active interventions in terms of use of forceps and/or vacuum extraction may be useful (Summary)

Adolescent pregnancy in Grenada

A retrospective review of adolescent deliveries (maternal age range: 12-19 years) at the maternity unit of the main General Hospital, Grenada, was undertaken for the years 1987 and 1988 using the delivery room register and hospital medical records. These mothers were compared with women who delivered during the same period but were aged between 20 and 30 years. Of the 3203 deliveries which occurred during the study period, 613 (20 percent) involved adolescents, giving a prevalence rate of one in five pregnancies. chi 2 and Fisher's exact test analyses revealed that pregnancies occurred in younger adolescents ( age less than 16 years, n = 58) carried an increased risk of preterm labour, operative delivery, prematurity, small-for gestational age infants, asphyxia and perinatal mortality when compared with the 'optimum reproductive age group'. Older adolescents (16-19 years, n = 555) had a higher risk pregnancy induced hypertension but otherwise compared well with the optimal reproductive age group. Adolescent pregnancy is very prevalent in Grenada and the reproductive outcome for young adolescents < 12 years of age is relatively poor.

Breast feeding promotion in an urban and a rural Jamaican hospital

Breast feeding promotion has been a national priority in Jamaica since the mid-1970s. Despite this effort, breast feeding rates have continued to decline there, especially in urban areas. Studies of the role of health professionals in promoting breast feeding have shown that specific practices encourage breast feeding, while others discourage it. In the context of declining breast feeding in a nation committed to promoting it, the goal of this study was to explore the relationship between specific health professional practices, mothers' breast feeding, and mothers' knowledge of breast feeding in rural and urban Jamaica. To accomplish this goal, a structured interview was administered to 113 mothers of infants age 0-6 months at one urban (n=62) and one rural (n=51) hospital, regarding (1) physician and nurse practices known to affect breast feeding, (2) mothers' own breast feeding practices, and (3) mothers knowledge of breast feeding issues. Physician and nurse visits were also directly observed to confirm responses given to the questionnaire and to assess the resources devoted to teaching mothers about breast feeding. While extensive lectures, posters and pamphlets promoting breast feeding were provided for mothers at the urban hospital, far fewer educational resources were available for mothers at the rural hospital. Overall, however, health professional practices discouraging breast feeding were observed more frequently at the urban hospital than at the rural hospital, whereas practices promoting breast feeding were more common at the rural hospital. At the rural hospital, mothers' breast feeding practices more closely approximated recommendations than at the urban hospital. Moreover, there was no difference between urban and rural mothers' knowledge about breast feeding despite the input of far greater educational resources to mothers at the urban hospital. This study suggests that merely educating mothers about feeding is insufficient. Efforts to promote breast feeding must emphasize specific health professional practices that support early initiation of breast feeding. The health policy implications of these findings are discussed. (AU)

Birth asphyxia versus the quality of obstetric care in Curacao - abstract

In order to evaluate the quality of obstetric care in Curacao, a systematic and comprehensive investigation of foetal and neonatal deaths was carried out in the 2-year period, 1984-1985. Two hundred and twenty-three (223) consecutive foetal and neonatal deaths occurred in the Island during this period. Asphyxia during labour was the principal cause of death in 35 (15.7 per cent) cases most of which occurred in term infants (25/35, 71 per cent). Intrapartum death occurred in 25 (71 per cent) cases and 10 (29 per cent) infants died in the early neonatal period. On the whole, patients' compliance with antenatal care was satisfactory. However, when the woman presented in labour, the attending physician or midwife often lacked information on the antecedents of the mother and pregnancy. In addition, inadequate intrapartum surveillance together with failure to respond appropriately to abnormalities in labour constituted the main factors which were associated with asphyxiated deaths. Moreover, asphyxial conditions were often preceded by inappropriate administration of oxytocin agents. On the basis of these findings, it is recommended to identify more clearly women whose pregnancies are considered to be at medium or high risk, to improve intrapartum surveillance and to reappraise criteria for referral to the hospital classified as level 2 (secondary care) (AU)

Intrapartum infusion of oxytocin and glucose water and neonatal jaundice

Two hundred and seventy-eight deliveries were studied prospectively to determine the association between the use of oxytocin during labour and the incidence of neonatal jaundice. Jaundice was seen significantly more often in neonates following maternal infusion of oxytocin in dextrose water (OT) or dextrose water alone (DW) as compared to those whose mothers did not receive either. No significant difference was seen in the incidence of jaundice between OT or DW groups. Mean umbilical cord serum sodium levels were significantly lower in the OT and DW group neonates who became jaundiced, as compared to the rest of the neonates in the same group and the control group. Sixty per cent of the jaundiced neonates in the OT as well as the DW group had frank hyponatremia as compared to only 8 percent in the control group. These findings support a probable causative association between hyponatremia at birth and neonatal jaundice in the deliveries following dextrose water and/or oxytocin infusion (AU)

Prolonged pregnancy: a rational approach to management

The optimum management of prolonged pregnancy is controversial. Eighty-two patients with this problem were managed prospectively. If the cervix was favourable for induction of labour, this was done. If the cervix was unfavourable, pregnancy was allowed to continue but the foetus was monitored with twice weekly non-stressed cardiotocography. A control group of 115 patients who were all induced at 42-weeks gestation was used to compare pregnancy outcome. Selective intervention resulted in reducing the induction rate by half. Pregnancies managed conservatively resulted in fewer (6.6 percent as opposed to 30 percent) Caesarean births in the induced pregnancies. More babies with higher Apgar scores at birth were born to the conservatively managed patients (AU)

Plasma arginine vasopressin response to water load during labor

To find out whether plasma vasopressin (PAVP) response to a water load during pregnancy is inappropriately high, as had been speculated, we measured PAVP by radio-immunoassay in 30 women at the time of delivery. Ten women had received infusion of aqueous glucose solution during labor for hydration (GW group); another ten received infusion of glucose solution as a vehicle for oxytocin (OT group), and ten women did not receive any intrapartum intravenous fluid therapy (controls). Serum sodium and osmolality were also determined in all the subjects. PAVP levels were significanty lower in GW (0.70) ñ 0.4 pg/ml)and OT groups (0.7 ñ 0.6 pg/ml) (P< 0.05). Significant negative correlation was seen between the amount of glucose solution infused and levels of PAVP (r = 0.61; P< 0.01). These findings suggest that during labor, the physiological relationship between serum osmolality and PAVP is intact, and that infusion of a water load in the form of aqueous glucose solution is attended by an expected lowering of PAVP. We infer that inappropriate ADH response is not the cause of water retention and hyponatremia often seen in women receiving aqueous glucose solution during labor.(AU)

Plasma zinc levels throughout pregnancy: a study in Jamaican women, with relevant aspects of nutrition

In a prospective study plasma zinc levels were determined by atomic absorption spectrophotometry in 135 Jamaican women over a two year period. A total of 1237 such determinations were made at fixed intervals throughout pregnancy. Each patient was investigated at 15, 20, 25, 30, 35 and 38 weeks gestation, in labour, and once in the early and in the late puerperium. Zinc being an essential trace element with a wide physiological role in many aspects of metabolism, supplementary studies on the relationship between zinc, folic acid, vitamin A, dietary intake in general, taste acuity and weight gain in pregnancy were undertaken. Results show that plasma zinc levels are lowered during pregnancy, moreso during the second trimester. The levels rise significantly during labour and then fall rapidly towards normal during the puerperium. Daily dietary zinc intake was of the order of 8-10 mg/day (the RDA for pregnancy being 15 mg/day) while protein intake averaged 67 g/day (the RDA being 80-90 g/day). Average weight gain in pregnancy was 12 kg. Plasma vitamin A and red cell folate levels were within normal range in all patients, indicating that there was no state of zinc deficiency interfering with the absorption of these vitamins. Clinical observations and laboratory investigations revealed no signs of any dietary deficiency among the patients. Viewed together, all the facets of this study suggest that the pattern of fall of plasma zinc in pregnancy is a normal physiological change not related to socio-economic status, parity or age. It is concluded that the lowered plasma zinc observed in pregnancy does not reflect a state of true zinc deficiency nor even a state of inadequate dietary zinc intake; it is most likely due to the heavy demand for zinc in the developing fetal tissues and by the expanding maternal blood volume (AU)

The provision of epidural analgesia during labour at the University Hospital, Jamaica April 1979 - January 1980 - abstract

Pain relief on the labour ward at the University Hospital of the West Indies is afforded mainly by the parenteral administration of narcotic analgesics frequently given in combination with a phenotheazine derivative. This paper describes the introduction of an epidural service to the University Hospital for the relief of pain during childbirth. Fifty patients were studied. The indications included elective pain relief, pre-eclampsia, cardiac disease, premature or high risk foetus and operative delivery. The contraindications to the technique were few and included patients who were unwilling to have this form of analgesia, patients with antepartum haemorrhage, and those with a history of previous uterine surgery. The local anaesthetic agent of choice was bupviacaine (marcaine), but due to limited supplies of this drug, lignocaine in combination with adrenaline was employed in the majority of cases. The local analgesic agents were injected every two hours (bupivacaine) or every 45 - 60 minutes (lignocaine) via an indwelling Teflon epidural catheter. All patients were interviewed during the postpartum period. The forceps rate was not increased and the mothers did not feel deprived of the 'feeling' of parturition in the majority of instances. Backache during the 1st and 2nd days post delivery occurred in 60 percent of these cases. Forty-five patients (90 percent) spoke highly of the procedure and requested this form of analgesia for subsequent pregnancies (AU)

Epidural analgesia during labour at the University Hospital of the West Indies

Thirty-two patients were given epidural analgesia during labour at the University Hospital of the West Indies. The majority were impressed by the quality of analgesia provided by the technique and have requested this form of pain relief for subsequent deliveries. The complications were few and transient. The advantages far outweighed the few disadvantages of the technique. It is hoped that a more frequent and widespread application of this satisfactory form of pain relief will be practised in hospitals throughout the West Indies (AU)

Pregnancy in women over the age of forty

The pregnancies of women 40 years and over who delivered at the Port-of-Spain General Hospital, Trinidad, during 1978, were reviewed in order to establish to what extent such women constitute a high-risk group. Seventy-four per cent were grandmultiparae (5 or more viable pregnancies) and the Caesarian section rate was high as 14.3 per cent. The majority of Caesarian sections (73 per cent) were performed in grandmultiparous patients. Pre-eclampsia occurred in a third of patients studied. Anaemia, pre-mature labour and post-partum haemorrhage were other common complications. In view of these findings, it is strongly recommended that greater emphasis be placed on family planning in order to eliminate parturient women beyond 40 years of age, and in particular, those who are highly parous (AU)