Frere Hospital

BACKGROUND: Postpartum haemorrhage (PPH) is a common and potentially life-threatening complication of labour. Several options for preventing PPH are available, but further advances in this field are important, especially the identification of safe, easy to use and cost-effective regimens. Tranexamic acid (TA), which is an antifibrinolytic agent that is used widely to prevent and treat haemorrhage, merits evaluation to assess whether it meets these criteria. OBJECTIVES: To determine, from the best available evidence, whether TA is effective and safe for preventing PPH in comparison to placebo or no treatment (with or without uterotonic co-treatment), or to uterotonic agents. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2015) and reference lists of retrieved studies. SELECTION CRITERIA: All published, unpublished and ongoing randomised controlled trials (RCTs) evaluating the use of TA alone or in addition to uterotonics in the third stage of labour or during caesarean section (CS) to prevent PPH. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed for inclusion all the potential studies identified as a result of the search strategy. We entered the data into Review Manager software and checked for accuracy. MAIN RESULTS: Twelve trials involving 3285 healthy women at low risk of excessive bleeding undergoing elective CS (nine trials, 2453 participants) or spontaneous birth (three trials, 832 participants) satisfied inclusion criteria and contributed data to the analysis. All participants received routine prophylactic uterotonics in accordance with the local guideline in addition to TA or placebo or no intervention. Overall, included studies had moderate risk of bias for random sequence generation, allocation concealment, blinding, selective reporting and low risk of bias for incomplete data. The quality of evidence was also as assessed using GRADE.Blood loss greater than 400 mL or 500 mL, and more than 1000 mL was less common in women who received TA versus placebo or no intervention (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.42 to 0.63, six trials, 1398 women; moderate quality evidence) and (RR 0.40, 95% CI 0.23 to 0.71, six trials, 2093 women; moderate quality evidence), respectively. TA was effective in decreasing the incidence of blood loss greater than 1000 mL in women who had undergone CS (RR 0.43, 95% CI 0.23, 0.78, four trials, 1534 women), but not vaginal birth (RR 0.28, 95% CI 0.06, 1.36, two trials 559 women). The effect of TA on blood loss greater than 500 mL or 400 mL was more pronounced in the group of women having vaginal birth than in women who had CS. Mean blood loss (from delivery until two hours postpartum) was lower in women who received TA versus placebo or no intervention (mean difference MD - 77.79 mL, 95% CI -97.95, -57.64, five trials, 1186 women) and this effect was similar following vaginal birth and CS.Additional medical interventions (moderate quality evidence) and blood transfusions were less frequent in women receiving TA versus placebo or no interventions. Mild side effects such as nausea, vomiting, dizziness were more common with the use of TA (moderate quality evidence). The effect of TA on maternal mortality, severe morbidity and thromboembolic events is uncertain (low quality evidence). AUTHORS' CONCLUSIONS: TA (in addition to uterotonic medications) decreases postpartum blood loss and prevents PPH and blood transfusions following vaginal birth and CS in women at low risk of PPH based on studies of mixed quality. There is insufficient evidence to draw conclusions about serious side effects, but there is an increase in the incidence of minor side effects with the use of TA. Effects of TA on thromboembolic events and mortality as well as its use in high-risk women should be investigated further.

BACKGROUND: Rates of caesarean section (CS) have been rising globally. It is important to use the most effective and safe technique. OBJECTIVES: To compare the effects of complete methods of caesarean section; and to summarise the findings of reviews of individual aspects of caesarean section technique. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 3) and reference lists of identified papers. SELECTION CRITERIA: Randomised controlled trials of intention to perform caesarean section using different techniques. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies and extracted data. MAIN RESULTS: 'Joel-Cohen based' compared with Pfannenstiel CS was associated with: less blood loss, (five trials, 481 women; weighted mean difference (WMD) -64.45 ml; 95% confidence interval (CI) -91.34 to -37.56 ml); shorter operating time (five trials, 581 women; WMD -18.65; 95% CI -24.84 to -12.45 minutes); postoperatively, reduced time to oral intake (five trials, 481 women; WMD -3.92; 95% CI -7.13 to -0.71 hours); less fever (eight trials, 1412 women; relative risk (RR) 0.47; 95% CI 0.28 to 0.81); shorter duration of postoperative pain (two comparisons from one trial, 172 women; WMD -14.18 hours; 95% CI -18.31 to -10.04 hours); fewer analgesic injections (two trials, 151 women; WMD -0.92; 95% CI -1.20 to -0.63); and shorter time from skin incision to birth of the baby (five trials, 575 women; WMD -3.84 minutes; 95% CI -5.41 to -2.27 minutes). Serious complications and blood transfusions were too few for analysis.Misgav-Ladach compared with the traditional method (lower midline abdominal incision) was associated with reduced: blood loss (339 women; WMD -93.00; 95% CI -132.72 to -53.28 ml); operating time (339 women; WMD-7.30; 95% CI -8.32 to -6.28 minutes); time to mobilisation (339 women; WMD -16.06; 95% CI -18.22 to -13.90 hours); and length of postoperative stay for the mother (339 women; WMD -0.82; 95% CI -1.08 to -0.56 days). Misgav-Ladach compared with modified Misgav-Ladach methods was associated with a longer time from skin incision to birth of the baby (116 women; WMD 2.10; 95% CI 1.10 to 3.10 minutes). AUTHORS' CONCLUSIONS: 'Joel-Cohen based' methods have advantages compared to Pfannenstiel and to traditional (lower midline) CS techniques, which could translate to savings for the health system. However, these trials do not provide information on mortality and serious or long-term morbidity such as morbidly adherent placenta and scar rupture.

This study surveys the extent and severity of haematological and biochemical abnormalities which occurred in 265 patients with pulmonary tuberculosis, and records the haematological changes that occur with treatment. Anaemia was present in 60 per cent of patients, more frequently in males than in females. Leucocytosis with neutrophilia occurred in 40 per cent, lymphopenia in 17 per cent and monocytopenia in 50 per cent. Platelet count and erythrocyte sedimentation rate were elevated in 52 and 80 per cent respectively. Bone marrow aspiration and trephine biopsy were of limited diagnostic value. Ferritin and vitamin B12 levels were increased in 94 and 57 per cent of subjects respectively whilst serum and red cell folic acid were within normal limits in 83 per cent. The frequency of the important biochemical changes were hyponatraemia (43 per cent) and hypoalbuminaemia (72 per cent); alkaline phosphatase, aspartic transaminase and lactic dehydrogenase levels were elevated in approximately a third of patients possibly due to unsuspected dissemination. There was a close correlation between the acid-fast bacilli in sputum and abnormal values, particularly those of body weight, haemoglobin, platelet count, white cell count and erythrocyte sedimentation rate. Failure of these indices to return to normal was invariably associated with persistent excretion of acid-fast bacilli. We have shown that haematological and biochemical abnormalities in pulmonary tuberculosis are common and may be valuable aids to diagnosis. Some haematological markers also reflect response to treatment.

The 143 low- and middle-income countries (LMICs) of the world constitute 80% of the world's population or roughly 5.86 billion people with much variation in geography, culture, literacy, financial resources, access to health care, insurance penetration, and healthcare regulation. Unfortunately, their burden of cardiovascular disease in general and acute ST-segment-elevation myocardial infarction (STEMI) in particular is increasing at an unprecedented rate. Compounding the problem, outcomes remain suboptimal because of a lack of awareness and a severe paucity of resources. Guideline-based treatment has dramatically improved the outcomes of STEMI in high-income countries. However, no such focused recommendations exist for LMICs, and the unique challenges in LMICs make directly implementing Western guidelines unfeasible. Thus, structured solutions tailored to their individual, local needs, and resources are a vital need. With this in mind, a multicountry collaboration of investigators interested in LMIC STEMI care have tried to create a consensus document that extracts transferable elements from Western guidelines and couples them with local realities gathered from expert experience. It outlines general operating principles for LMICs focused best practices and is intended to create the broad outlines of implementable, resource-appropriate paradigms for management of STEMI in LMICs. Although this document is focused primarily on governments and organizations involved with improvement in STEMI care in LMICs, it also provides some specific targeted information for the frontline clinicians to allow standardized care pathways and improved outcomes.

One hundred forty-two patients with all stages of gastric carcinoma were prospectively stratified into two divisions according to T.N.M. stage following, but irrespective of the type of surgical procedure. Division I (T1-3, N1-2, M0) was randomized into a control group, and a treatment group who received 2000 rad in 8 fractions over 10 days with intravenous 5 Fluorouracil (5 F.U.) at a dose of 500 mg daily x 4 days preirradiation and then 12.5 mg/kg daily for 5 days every 28 days for six courses. Division II (T4 or M1) was randomized into three groups; a control group, a group who received radiotherapy and 5 F.U. in the same schedule as division one and a group who received Thiotepa 45 mg intravenously daily for three days and then every 28 days for 6 months. Four and one-half years after commencement of the trial 86% of the patients had died. There was no difference in survival rate between the treatment and control groups, (p greater than 0.5) in Division I or II. Survival appeared to correlate with the T.N.M. stage of disease and not therapy. Blind assessment of the quality of life showed no difference between the treatment groups and the controls. In the dose schedules used, this form of oncological therapy had no effect on survival or quality of life in patients with gastric carcinoma.

BACKGROUND: Fetal movement counting is a method by which a woman quantifies the movements she feels to assess the condition of the baby. The purpose is to try to reduce perinatal mortality by alerting caregivers when the baby might have become compromised. This method may be used routinely, or only in women who are considered at increased risk of complications in the baby. Some clinicians believe that fetal movement counting is a good method as it allows the clinician to make appropriate interventions in good time. On the other hand, fetal movement counting may cause anxiety to women. OBJECTIVES: To assess outcomes of pregnancy where fetal movement counting was done routinely, selectively or was not done at all; and to compare different methods of fetal movement counting. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library) and the reference lists of relevant papers. SELECTION CRITERIA: Randomised controlled trials. Trials were excluded where allocation concealment was inadequate and no measures were taken to prevent bias were excluded. The interventions included routine fetal movement counting, selective fetal movement counting, and studies comparing different fetal assessment methods. DATA COLLECTION AND ANALYSIS: We assessed the methodological quality of included studies and extracted data from studies. MAIN RESULTS: Four studies, involving 71,370 women, were included in this review; 68,654 in one cluster-randomised trial. All four trials compared formal fetal movement counting. Two trials compared different types of counting with each other; one with no formal instruction, and one with hormonal analysis. Women in the formal fetal movement counting group had significantly fewer visits to the hospital antenatally than those women randomised to hormone analysis (relative risk (RR) 0.26, 95% confidence interval (CI) 0.20 to 0.35), whereas there were fewer Apgar scores less than seven in five minutes for women randomised to hormone analysis (RR 1.72, 95% CI 1.01 to 2.93). There was a significantly higher compliance with the Cardiff 'count to ten' method than with the formal fetal movement counting method (RR 0.25, 95% CI 0.19 to 0.32).All other outcomes reported were non significant. AUTHORS' CONCLUSIONS: This review does not provide enough evidence to influence practice. In particular, no trials compared fetal movement counting with no fetal movement counting. Robust research is needed in this area.

BACKGROUND: During caesarean section mothers can be in different positions. Theatre tables could be tilted laterally, upwards, downwards or flexed and wedges or cushions could be used. There is no consensus on the best positioning at present. OBJECTIVES: We assessed all available data on positioning of the mother to determine if there is an ideal position during caesarean section that would improve outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 August 2012), PubMed (1966 to 20 August 2012) and manually searched the references of retrieved articles. SELECTION CRITERIA: Randomised trials of woman undergoing caesarean section comparing different positions. DATA COLLECTION AND ANALYSIS: Two review authors assessed eligibility, trial quality and extracted data. MAIN RESULTS: We identified 22 studies with a total of 857 women included. We included 11 studies and excluded 11. Included trials were of variably quality with small sample sizes. Most comparisons had data from single trials. This is a shortcoming and applicability of results is limited.The incidence of air embolism was not affected by head up versus horizontal position (average risk ratio (RR) 0.85; 95% confidence interval (CI) 0.28 to 2.57; Tau² = 0.50; I² = 74%).We found no change in hypotensive episodes when comparing left lateral tilt (RR 0.11; 95% CI 0.01 to 1.94), right lateral tilt (RR 1.25; 95% CI 0.39 to 3.99), a right lumbar pelvic wedge (RR 0.85; CI 0.53 to1.37) and head down tilt (RR 1.07; 95% CI 0.81 to 1.42) with horizontal positions. We found no change in hypotensive episodes when comparing full lateral tilt with 15-degree tilt (RR 1.20; 95% CI 0.80 to 1.79). Hypotensive episodes were decreased with manual displacers (RR 0.11; 95% CI 0.03 to 0.45), and increased with a right lumbar wedge compared with a right pelvic wedge (RR 1.64; 95% CI 1.07 to 2.53) and increased with a right lateral tilt compared with a left lateral tilt (RR 3.30; 95% CI 1.20 to 9.08).Position did not affect systolic blood pressure when comparing left lateral tilt (MD 2.70; 95% CI -1.47 to 6.87) or head down tilt (MD -3.00; 95% CI -8.38 to 2.38) with horizontal positions, or full lateral tilt with 15-degree tilt (MD -5.00; 95% CI -11.45 to 1.45). Manual displacers showed decreased fall in mean systolic blood pressure compared with left lateral tilt (MD -8.80; 95% CI -13.08 to -4.52).Position did not affect diastolic blood pressures when comparing left lateral tilt versus horizontal positions (MD-1.90; 95% CI -5.28 to 1.48). The mean diastolic pressure was lower in head down tilt (MD -7.00; 95% CI -12.05 to -1.95) when compared with horizontal positions.There were no statistically significant changes in maternal pulse rate, five-minute Apgars, maternal blood pH or cord blood pH when comparing different positions. AUTHORS' CONCLUSIONS: There is limited evidence to support or clearly disprove the value of the use of tilting or flexing the table, the use of wedges and cushions or the use of mechanical displacers. A left lateral tilt may be better than a right lateral tilt and manual displacers may be better than a left lateral tilt but larger studies with more robust data are needed to confirm these findings.

BACKGROUND: It is customary for fluids and/or food to be withheld for a period of time after abdominal operations. After caesarean section, practices vary considerably. These discrepancies raise concern as to the bases of different practices. OBJECTIVES: To assess the effect of early versus delayed introduction of fluids and/or food after caesarean section. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register (January 2002) and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001). SELECTION CRITERIA: Clinical trials with random allocation comparing early versus delayed oral fluids and/or food after caesarean section were considered. The participants were women within the first 24 hours after caesarean section. The criteria for 'early' feeding were as defined by the individual trial authors - usually within six to eight hours of surgery. DATA COLLECTION AND ANALYSIS: Trials considered were evaluated for methodological quality and appropriateness for inclusion. For dichotomous data, relative risks and 95% confidence intervals were calculated. Continuous data were compared using weighted mean difference and 95% confidence interval. Sub-group analyses were performed for general anaesthesia, regional analgesia and where anaesthesia was mixed or undefined. MAIN RESULTS: Of 12 studies considered, six were included in this review. Four were excluded and two are pending further information. The methodological quality of the studies was variable. Only one to three studies contributed usable data to each outcome. Three studies were limited to surgery under regional analgesia, while three included both regional analgesia and general anaesthesia. Early oral fluids or food were associated with: reduced time to first food intake (one study, 118 women; the intervention was a slush diet and food was introduced according to clinical parameters; weighted mean difference -7.20 hours, 95% confidence interval -13.26 to -1.14); reduced time to return of bowel sounds (one study, 118 women; -4.30 hours, -6.78 to -1.82); reduced postoperative hospital stay following surgery under regional analgesia (two studies, 220 women; -0.75 days, -1.37 to -0.12 - random effects model); and a trend to reduced abdominal distension (three studies, 369 women; relative risk 0.78, 95% confidence interval 0.55 to 1.11). No significant differences were identified with respect to nausea, vomiting, time to bowel action/ passing flatus, paralytic ileus and number of analgesic doses. REVIEWER'S CONCLUSIONS: There was no evidence from the limited randomised trials reviewed, to justify a policy of withholding oral fluids after uncomplicated caesarean section. Further research is justified.

BACKGROUND: Oligohydramnios (reduced amniotic fluid) may be responsible for malpresentation problems, umbilical cord compression, concentration of meconium in the liquor, and difficult or failed external cephalic version. Simple maternal hydration has been suggested as a way of increasing amniotic fluid volume in order to reduce some of these problems. OBJECTIVES: The objective of this review was to assess the effects of maternal hydration on amniotic fluid volume and measures of pregnancy outcome. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register were searched. Date of last search: September 2001. SELECTION CRITERIA: Randomised trials comparing maternal hydration with no hydration in pregnant women with reduced or normal amniotic fluid volume. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality were assessed by both reviewers. MAIN RESULTS: Two studies of 77 women were included. The women were asked to drink two litres of water before having a repeat ultrasound examination. Maternal hydration in women with and without oligohydramnios was associated with an increase in amniotic volume (weighted mean difference for women with oligohydramnios 2.01, 95% confidence interval 1.43 to 2.56; and weighted mean difference for women with normal amniotic fluid volume 4.5, 95% confidence interval 2.92 to 6.08). Intravenous hypotonic hydration in women with oligohydramnios was associated with an increase in amniotic fluid volume (weighted mean difference 2.3, 95% confidence interval 1.36 to 3.24). Isotonic intravenous hydration had no measurable effect. No clinically important outcomes were assessed in any of the trials. REVIEWER'S CONCLUSIONS: Simple maternal hydration appears to increase amniotic fluid volume and may be beneficial in the management of oligohydramnios and prevention of oligohydramnios during labour or prior to external cephalic version. Controlled trials are needed to assess the clinical benefits and possible risks of maternal hydration for specific clinical purposes.

The records of 273 patients with germ cell tumours of the testis referred between 1970 and July 1991 were reviewed. There were 25 (9%) black, 40 (14%) mixed race and 214 (77%) white patients. Histology showed seminoma in 53% and non-seminomatous and germ cell tumours in 47% of patients. Maldescent of the testis (MDT) was found in 30 patients--an incidence of 11% overall. MDT was present in 8 of 25 (32%) black, 7 of 40 (18%) mixed race and 15 of 214 (7%) white patients with testicular cancer. The incidence of MDT was statistically significantly higher in both black and mixed race patients compared with white patients. None of the black patients had undergone orchiopexy but 71% of mixed race and 87% of white patients had done so. This resulted in a different pattern of presentation in black compared with mixed race and white patients with MDT and testicular cancer. The mean age was 40 years for black, 32 years for mixed race and 33 years for white patients. Black patients presented with abdominal or inguinal tumours rather than scrotal tumours and they had an increased tendency to present with seminomas.

BACKGROUND: This study assesses the perceptions and acceptance of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) vaccination. It also examines its influencing factors among the healthcare workers (HCWs) in the Eastern Cape, South Africa. METHODS: In this cross-sectional study performed in November and December 2020, a total of 1308 HCWs from two large academic hospitals participated in the Eastern Cape Healthcare Workers Acquisition of SARS-CoV-2 (ECHAS) study. Validated measures of vaccine hesitancy were explored using a questionnaire. Logistic regression was used to identify the determinants of vaccine hesitancy. RESULTS: The majority were nurses (45.2%), and at risk for unfavourable Covid-19 outcome, due to obesity (62.9%) and having direct contact with individuals confirmed to have Covid-19 (77.1%). The overall acceptance of SARS-CoV-2 vaccine was 90.1%, which differed significantly by level of education. Individuals with lower educational attainment (primary and secondary education) and those with prior vaccine refusal were less likely to accept the SARS-CoV-2 vaccine. However, positive perceptions about the SARS-CoV-2 vaccine were independently associated with vaccine acceptance. CONCLUSIONS: The high level of acceptance of SARS-CoV-2 vaccine is reassuring; however, HCWs with a lower level of education and those with prior vaccine refusal should be targeted for further engagements to address their concerns and fears.

Background External cephalic version (ECV) of the breech fetus at term (after 37 weeks) has been shown to be effective in reducing the number of breech presentations and caesarean sections, but the rates of success are relatively low. This review examines studies initiating ECV prior to term (before 37 weeks' gestation). Objectives To assess the effectiveness of a policy of beginning ECV before term (before 37 weeks' gestation) for breech presentation on fetal presentation at birth, method of delivery, and the rate of preterm birth, perinatal morbidity, stillbirth or neonatal mortality. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2015) and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) of ECV attempted before term (37 weeks' gestation) or commenced before term, compared with a control group of women (in breech presentation) in which either no ECV attempted or ECV was attempted at term. Cluster‐randomised trials were eligible for inclusion but none were identified. Quasi‐RCTs or studies using a cross‐over design were not eligible for inclusion. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy. Studies were assessed for risk of bias and for important outcomes the overall quality of the evidence was assessed using the GRADE approach. Main results Five studies are included (2187 women). It was not possible for the intervention to be blinded, and it is not clear what impact lack of blinding would have on the outcomes reported. For other 'Risk of bias' domains studies were either at low or unclear risk of bias. One study reported on ECV that was undertaken and completed before 37 weeks' gestation compared with no ECV. No difference was found in the rate of non‐cephalic presentation at birth (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.64 to 1.69; participants = 102). One study reported on a policy of ECV that was initiated before term (33 weeks) and up until 40 weeks' gestation and which could be repeated up until delivery compared with no ECV. This study showed a decrease in the rate of non‐cephalic presentation at birth (RR 0.59, 95% CI 0.45 to 0.77; participants = 179). Three studies reported on ECV started at between 34 to 35 weeks' gestation compared with beginning at 37 to 38 weeks' gestation. Pooled results suggested that early ECV reduced the risk of non‐cephalic presentation at birth (RR 0.81, 95% CI 0.74 to 0.90; participants = 1906; studies = three; I² = 0%, evidence graded high quality), failure to achieve vaginal cephalic birth (RR 0.90, 95% CI 0.83 to 0.97; participants = 1888; studies = three; I² = 0%, evidence graded high quality), and vaginal breech delivery (RR 0.44, 95% CI 0.25 to 0.78; participants = 1888; studies = three; I² = 0%, evidence graded high quality). The difference between groups for risk of caesarean was not statistically significant (RR 0.92, 95% CI 0.85 to 1.00; participants = 1888; studies = three; I² = 0%, evidence graded high quality). There was evidence that risk of preterm labour was increased with early ECV compared with ECV after 37 weeks (6.6% in the ECV group and 4.3% for controls) (RR 1.51, 95% CI 1.03 to 2.21; participants = 1888; studies = three; I² = 0%, evidence graded high quality). There was no clear difference between groups for low infant Apgar score at five minutes or perinatal death (stillbirth plus neonatal mortality up to seven days) (evidence graded as low quality for both outcomes). Authors' conclusions Compared with no ECV attempt, ECV commenced before term reduces non‐cephalic presentation at birth. Compared with ECV at term, beginning ECV at between 34 to 35 weeks may have some benefit in terms of decreasing the rate of non‐cephalic presentation, and risk of vaginal breech birth. However, early ECV may increase risk of late preterm birth, and it is important that any future research reports infant morbidity outcomes. Results of the review suggest that there is a need for careful discussion with women about the timing of the ECV procedure so that they can make informed decisions.

BACKGROUND: Active management of the third stage of labour (AMTSL) consists of a group of interventions, including administration of a prophylactic uterotonic (at at or after delivery of the baby), baby, cord clamping and cutting, controlled cord traction (CCT) to deliver the placenta, and uterine massage. Recent recommendations are to delay cord clamping until the caregiver is ready to initiate CCT. The package of AMTSL reduces the risk of postpartum haemorrhage, (PPH), as does one component, routine use of uterotonics. The contribution, if any, of CCT needs to be quantified, as it is uncomfortable, and women may prefer a 'hands-off' approach. In addition its implementation has resource implications in terms of training of healthcare providers. OBJECTIVES: To evaluate the effects of controlled cord traction during the third stage of labour, either with or without conventional active management. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (29 January 2014), PubMed (1966 to 29 January 2014), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials comparing planned CCT versus no planned CCT in women giving birth vaginally. DATA COLLECTION AND ANALYSIS: Two authors assessed trial quality and extracted data using a standard data extraction form. MAIN RESULTS: We included three methodologically sound trials with data on 199, 4058 and 23,616 women respectively. Blinding was not possible, but bias could be limited by the fact that blood loss was measured objectively.There was no difference in the risk of blood loss ≥ 1000 mL (three trials, 27,454 women; risk ratio (RR) 0.91, 95% confidence interval (CI) 0.77 to 1.08). Manual removal of the placenta was reduced with CCT (two trials, 27,665 women; RR 0.69, 95% CI 0.57 to 0.83). In the World Health Organization (WHO) trial the reduction in manual removal occurred mainly in sites where ergometrine was used routinely in the third stage of labour. The non-prespecified analysis excluding sites routinely using ergometrine for management of the third stage of labour found no difference in the risk of manual removal of the placenta in the WHO trial (one trial, 23,010 women; RR 1.03, 95% CI 0.73 to 1.46). The policy of restricting the third stage of labour to 30 minutes (4057 women; RR 0.69, 95% CI 0.53 to 0.90) may have had an effect in the French study.Among the secondary outcomes, there were reductions in blood loss ≥ 500 mL (three trials, 27,454 women; RR 0.93, 95% CI 0.88 to 0.99), mean blood loss (two trials, 27,255 women; mean difference (MD) -10.85 mL, 95% CI -16.73 to -4.98), and duration of the third stage of labour (two trials, 27,360 women; standardised MD -0.57, -0.59 to -0.54). There were no clear differences in use of additional uterotonics (three trials, 27,829 women; average RR 0.95, 95% CI 0.88 to 1.02), blood transfusion, maternal death/severe morbidity, operative procedures nor maternal satisfaction. Maternal pain (non-prespecified) was reduced in one trial (3760 women; RR 0.78, 95% CI 0.61 to 0.99).The following secondary outcomes were not reported upon in any of the trials: retained placenta for more than 60 minutes or as defined by trial author; maternal haemoglobin less than 9 g/dL at 24 to 48 hours post-delivery or blood transfusion; organ failure; intensive care unit admission; caregiver satisfaction; cost-effectiveness; evacuation of retained products; or infection. AUTHORS' CONCLUSIONS: CCT has the advantage of reducing the risk of manual removal of the placenta in some circumstances, and evidence suggests that CCT can be routinely offered during the third stage of labour, provided the birth attendant has the necessary skills. CCT should remain a core competence of skilled birth attendants. However, the limited benefits of CCT in terms of severe PPH would not justify the major investment which would be needed to provide training in CCT skills for birth attendants who do not have formal training. Women who prefer a less interventional approach to management of the third stage of labour can be reassured that when a uterotonic agent is used, routine use of CCT can be omitted from the 'active management' package without increased risk of severe PPH, but that the risk of manual removal of the placenta may be increased.Research gaps include the use of CCT in the absence of a uterotonic, and the place of uterine massage in the management of the third stage of labour.

BACKGROUND: The partograph is currently the main tool available to support decision-making of health professionals during labour. However, the rate of appropriate use of the partograph is disappointingly low. Apart from limitations that are associated with partograph use, evidence of positive impact on labour-related health outcomes is lacking. The main goal of this study is to develop a Simplified, Effective, Labour Monitoring-to-Action (SELMA) tool. The primary objectives are: to identify the essential elements of intrapartum monitoring that trigger the decision to use interventions aimed at preventing poor labour outcomes; to develop a simplified, monitoring-to-action algorithm for labour management; and to compare the diagnostic performance of SELMA and partograph algorithms as tools to identify women who are likely to develop poor labour-related outcomes. METHODS/DESIGN: A prospective cohort study will be conducted in eight health facilities in Nigeria and Uganda (four facilities from each country). All women admitted for vaginal birth will comprise the study population (estimated sample size: 7,812 women). Data will be collected on maternal characteristics on admission, labour events and pregnancy outcomes by trained research assistants at the participating health facilities. Prediction models will be developed to identify women at risk of intrapartum-related perinatal death or morbidity (primary outcomes) throughout the course of labour. These predictions models will be used to assemble a decision-support tool that will be able to suggest the best course of action to avert adverse outcomes during the course of labour. To develop this set of prediction models, we will use up-to-date techniques of prognostic research, including identification of important predictors, assigning of relative weights to each predictor, estimation of the predictive performance of the model through calibration and discrimination, and determination of its potential for application using internal validation techniques. DISCUSSION: This research offers an opportunity to revisit the theoretical basis of the partograph. It is envisioned that the final product would help providers overcome the challenging tasks of promptly interpreting complex labour information and deriving appropriate clinical actions, and thus increase efficiency of the care process, enhance providers' competence and ultimately improve labour outcomes. Please see related articles ' http://dx.doi.org/10.1186/s12978-015-0027-6 ' and ' http://dx.doi.org/10.1186/s12978-015-0028-5 '.

BACKGROUND: The primary objective of postpartum haemorrhage (PPH) prevention and treatment is to reduce maternal deaths. Misoprostol has the major public health advantage over injectable medication that it can more easily be distributed at community level. Because misoprostol might have adverse effects unrelated to blood loss which might impact on mortality or severe morbidity, it is important to continue surveillance of all relevant evidence from randomised trials. This is particularly important as misoprostol is being introduced on a large scale for PPH prevention in low-income countries, and is commonly used for PPH treatment in well-resourced settings as well. OBJECTIVES: To review maternal deaths and severe morbidity in all randomised trials of misoprostol for prevention or treatment of PPH. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (11 January 2013). SELECTION CRITERIA: We included randomised trials including pregnant women who received misoprostol in the postpartum period, versus placebo/no treatment or other uterotonics for prevention or treatment of PPH, and reporting on maternal death, severe morbidity or pyrexia.We planned to include cluster- and quasi-randomised trials in the analysis, as a very large number of women will be needed to obtain robust estimates of maternal mortality but we did not identify any for this version of the review. In future updates of this review we will include trials reported only as abstracts if sufficient information is available from the abstract or from the authors. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and extracted data. MAIN RESULTS: We included 78 studies (59,216 women) and excluded 34 studies.There was no statistically significant difference in maternal mortality for misoprostol compared with control groups overall (31 studies; 11/19,715 versus 4/20,076 deaths; risk ratio (RR) 2.08, 95% confidence interval (CI) 0.82 to 5.28); or for the trials of misoprostol versus placebo: 10 studies, 6/4626 versus 1/4707 ; RR 2.70; 95% CI 0.72 to 10.11; or for misoprostol versus other uterotonics: 21 studies, 5/15,089 versus 3/15,369 (19/100,000); RR 1.54; 95% CI 0.40 to 5.92. All 11 deaths in the misoprostol arms occurred in studies of misoprostol ≥ 600 µg.There was a statistically significant difference in the composite outcome 'maternal death or severe morbidity' for the comparison of misoprostol versus placebo (12 studies; average RR 1.70, 95% CI 1.02 to 2.81; Tau² = 0.00, I² = 0%) but not for the comparison of misoprostol versus other uterotonics (17 studies; average RR 1.50, 95% CI 0.50 to 4.52; Tau² = 1.81, I² = 69%). When we excluded hyperpyrexia from the composite outcome in exploratory analyses, there was no significant difference in either of these comparisons.Pyrexia > 38°C was increased with misoprostol compared with controls (56 studies, 2776/25,647 (10.8%) versus 614/26,800 (2.3%); average RR 3.97, 95% CI 3.13 to 5.04; Tau² = 0.47, I² = 80%). The effect was greater for trials using misoprostol 600 µg or more (27 studies; 2197/17,864 (12.3%) versus 422/18,161 (2.3%); average RR 4.64; 95% CI 3.33 to 6.46; Tau² = 0.51, I² = 86%) than for those using misoprostol 400 µg or less (31 studies; 525/6751 (7.8%) versus 185/7668 (2.4%); average RR 3.07; 95% CI 2.25 to 4.18; Tau² = 0.29, I² = 58%). AUTHORS' CONCLUSIONS: Misoprostol does not appear to increase or reduce severe morbidity (excluding hyperpyrexia) when used to prevent or treat PPH. Misoprostol did not increase or decrease maternal mortality. However, misoprostol is associated with an increased risk of pyrexia, particularly in dosages of 600 µg or more. Given that misoprostol is used prophylactically in very large numbers of healthy women, the greatest emphasis should be placed on limiting adverse effects. In this context, the findings of this review support the use of the lowest effective dose. As for any new medication being used on a large scale, continued vigilance for adverse effects is essential and there is a need for large randomised trials to further elucidate both the relative effectiveness and the risks of various dosages of misoprostol.

BACKGROUND: Clinical observations indicate that mothers commonly perceive a reduction in, or absence of, the baby's movements for some days preceding a baby's death. For this reason, fetal movement monitoring is advised by caregivers and used spontaneously by mothers to assess the baby's well-being. However, it is possible that the harmful effects of interventions may outweigh the benefits of such testing. Evidence of effectiveness of fetal movement screening to improve outcomes is limited, though indirect evidence suggests a potential benefit. A secondary question is whether any specific management response to perceived decreased fetal movements (DFM) improves clinical outcome. OBJECTIVES: To determine, from the best available evidence, the effectiveness of various management strategies for DFM. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2012) and bibliographies of included studies. SELECTION CRITERIA: Randomised clinical trials comparing various management strategies for DFM, including delivery, expectant management, cardiotocography (visual and computerised), ultrasound examination including Doppler ultrasound, and fetal arousal tests (cardiotocographic or clinical). DATA COLLECTION AND ANALYSIS: Two assessors evaluated potentially eligible trials for inclusion, and extracted data onto a purpose-designed form. Where DFM was one among a number of inclusion criteria for the trial, we contacted trial authors for information on outcomes specific to the DFM subgroups. MAIN RESULTS: No randomised trials of management of DFM were found. Of 13 randomised trials of management strategies for pregnancies with risk factors for fetal compromise including DFM, data on the DFM subgroups could only be provided by the authors of one trial. The numbers were too small for meaningful analysis (there were 28 cases of DFM). AUTHORS' CONCLUSIONS: There are insufficient data from randomised trials to guide practice regarding the management of DFM. Based on the results of other systematic reviews of management strategies for women whose babies are thought to be at risk of compromise for various reasons, the following strategies show promise and may be prioritised for further research: Doppler ultrasound studies, computerised cardiotocography, and fetal arousal to facilitate cardiotocography.For settings where electronic fetal assessment methods are not available, clinical fetal arousal tests should be investigated.

OBJECTIVES: Drawing from a baseline sample of a cohort study, the study examines the extent and correlates of serostatus non-disclosure to sex partners and family members, and reasons for non-disclosure among HIV-infected pregnant women in the Eastern Cape Province, South Africa. METHODS: This longitudinal cohort study recruited 1709 pregnant women living with HIV who attended three of the largest maternity centres in the Eastern Cape, South Africa, for delivery between September 2015 and May 2016. Relevant items on demographics, serostatus awareness, disclosure to sex partners and family members, and lifestyle behaviours were obtained using structured interviews. Age-stratified binary logistic regression models were used to determine the significant correlates of non-disclosure among the participants. RESULTS: A higher rate of HIV serostatus non-disclosure to sex partners (25.6%) in comparison to family members (20%) was reported by the participants. Younger age, not living with partners and alcohol use were significantly associated with non-disclosure of HIV serostatus to sex partners. Non-disclosure of HIV serostatus to sex partners was significantly (p<0.05) associated with poor adherence to the highly active anti-retroviral therapy (HAART), failure to keep clinic appointments and high viral load at the delivery of the baby. Perceived fear of intimate partner violence, fear of rejection, guilt of not disclosing at the onset of the relationship, sex partner's non-disclosure of HIV serostatus, and guilt of unfaithfulness were some of the reasons for non-disclosure of HIV serostatus to sex partners. CONCLUSIONS: Non-disclosure of HIV serostatus is a public health concern with serious implications for both mother-to-child transmission, as well as horizontal transmission, in our setting. Strategic efforts toward ending the epidemic of HIV and AIDS in South Africa should address the sociocultural and behavioural determinants of non-disclosure.

BACKGROUND: Over the past few years, the incidence and prevalence of stroke has been rising in most African countries and has been reported as one of the leading causes of morbidity and mortality. To study this problem, we need to realize the quality and availability of stroke care services as a priori to improve them. METHODS AND RESULTS: In this study, we investigated the availability of different stroke-related services in 17 countries from different African regions. An online survey was conducted and fulfilled by stroke specialists and included primary prevention, acute management, diagnostic tools, medications, postdischarge services, and stroke registries. The results showed that although medications for secondary prevention are available, yet many other services are lacking in various countries. CONCLUSION: This study displays the deficient aspects of stroke services in African countries as a preliminary step toward active corrective procedures for the improvement of stroke-related health services.

OBJECTIVES: In 2008 the South African Children's Cancer Study Group decided to review the epidemiology, management, and chemotherapy response of HIV-positive children with malignancy. METHODS: This is a retrospective analysis of data collected from the records of HIV-positive children diagnosed with malignancy at 7 university-based pediatric oncology units serving 8 of the 9 provinces in South Africa. RESULTS: Two hundred eighty-eight HIV-positive children were diagnosed with 289 malignancies between 1995 and 2009. Age at diagnosis ranged from 17 days to 18.64 years; median 5.79 years. Of the 220 HIV-associated malignancies, there were 97 Kaposi sarcomas, 61 Burkitt lymphomas, 47 other B-cell lymphomas including 2 primary central nervous system lymphomas, 12 Hodgkin lymphomas, and 3 leiomyosarcomas. Sixty-nine patients presented with non-AIDS-defining malignancies. More than 80% presented with advanced disease. Most patients (76.7%) were naive to antiretroviral therapy; 22.2% did not have access because it only became available in public hospitals in 2004. One hundred ninety-seven children were treated with curative intent; 91 received palliative care due to advanced malignancy and/or advanced HIV disease. Nearly one third had coexisting pathology, mostly tuberculosis. Overall survival for the whole group was 33.7%, but was 57.8% for those treated with antiretroviral therapy and chemotherapy. CONCLUSIONS: The study shows more Kaposi sarcoma and fewer primary central nervous system lymphomas among HIV-positive children than that is reported in the developed world, but confirms a higher incidence of non-Burkitt B-cell lymphoma than in HIV-negative children. The high number of non-AIDS-defining malignancies underscores the prevalence of HIV-AIDS in South Africa. The overall survival should improve with universal access to antiretrovirals and earlier diagnosis.

Liver cystic echinococcosis (CE), known as hydatid disease, is caused by the tapeworm Echinococcus granulosus sensu lato. Humans are accidental hosts in this zoonotic disease process, and hepatic infection accounts for over two-thirds of all cases. Since signs and symptoms are mainly non-specific, especially in early disease, clinicians should have a low threshold to include CE as a differential diagnosis in patients with positive serology and suggestive radiological findings, especially in endemic regions. The standard management for liver CE depends on the patient’s symptoms, the radiological stage, the size and location of the cyst, the presence of complications and the treating clinicians’ expertise. In this review, we discuss the lifecycle of Echinococcus granulosus sensu lato and its epidemiology and then focus on discussing the clinical features, diagnosis and treatment options of CE of the liver.