Obstetrics and Gynaecology Forum - Volume 21, Issue 4, 2011
Volume 21, Issue 4, 2011
Author Zephne M. Van Der SpuySource: Obstetrics and Gynaecology Forum 21, pp 1 –2 (2011)More Less
In 1965 Professor Sir Dugald Baird delivered a lecture entitled "A Fifth Freedom?" at University College, London, which was subsequently published in the BMJ. He referred to the four "essential freedoms" which had been formulated by Franklin D Roosevelt, then President of the USA, in a speech on 6 January 1941.
Author S.T. JefferySource: Obstetrics and Gynaecology Forum 21, pp 8 –11 (2011)More Less
A vaginal delivery has a profound impact on the pelvic floor with the potential for significant functional sequelae. There is an increasing trend among obstetricians to perform a caesarean section to preserve pelvic floor function. This in turn has contributed to an increasing caesarean section rate, both in South Africa and internationally. What impact does vaginal delivery have on pelvic floor dysfunction and can we prevent these problems by resorting to an abdominal delivery? When it comes to preventing urinary incontinence, caesarean section has been shown to be protective; reducing the risk by about 50%, but the effect appears to dissipate with time. For faecal incontinence, caesarean delivery has only a marginal impact with one study showing that 167 caesarean sections need to be done to prevent one case of faecal incontinence. Forceps delivery appears to double the risk of faecal and urinary incontinence compared to normal vaginal delivery.
In terms of sexual function, caesarean section is associated with a sensation of better vaginal tone for both partners but no difference in any other parameters. Vaginal delivery is significantly associated with pelvic organ prolapse, with the risk rising with increased vaginal parity. Caesarean section is strongly protective against the development of prolapse. This should be viewed in the context of an increased mortality rate for elective caesarean section, with one study showing this to be about 3.6 times that of vaginal delivery. Every women embarking on a caesarean delivery to protect her pelvic floor should be counselled by her obstetrician about the limitations and risks of this procedure.
Author A.P. KentSource: Obstetrics and Gynaecology Forum 21, pp 13 –16 (2011)More Less
Death rates from cancer are falling in almost all countries. It is tempting to attribute these encouraging trends equally to, screening, early detection and better treatments. There is a great deal of scientific research being invested in these endeavours and all are rigorously scrutinised. Screening has an intuitive attraction and is often emotionally championed to be "the responsible thing to do". Recent work has questioned the scope and role of screening in three major fields of Women's Health namely cervical cytology, mammography and ovarian cancer detection. If gynaecologists are to be advocates for women's health then they must be sure that correct, evidence-based information is distributed. What was true about screening 7 years ago is not necessarily true today and the present "facts" may not be true in the future. Vested interests in the promotion of screening do exist and the well-woman visit needs to be able to prove that all its steps are in the woman's interests. This article raises new evidence about screening and argues for the evaluation in all screening on a benefits/harms ratio and then the choice being agreed by the care-giver and patient. As the evidence changes, so do our prejudices come under scrutiny. Are we prepared to objectively review our position in the light of new data?
Author E. BeraSource: Obstetrics and Gynaecology Forum 21, pp 17 –21 (2011)More Less
Preterm birth continues to be a global public health burden. Most neonatal deaths occur as a result of prematurity, and among those who survive, a substantial proportion develop disability during childhood. Preterm birth usually follows spontaneous preterm labour, preterm prelabour rupture of membranes, or iatrogenic preterm delivery. Short-term tocolysis is generally indicated to arrest labour in order for corticosteroids to be given, or for the woman to be transferred to a higher level of neonatal care. Hexoprenaline was the cornerstone of such therapy in South Africa for many years. A wide variety of tocolytic drugs have been in clinical use around the world, yet the evidence that they confer benefit to the infant remains open to debate. Some tocolytic drugs may possibly be harmful. In this review the evidence for efficacy and safety of the various commonly used tocolytic drugs will be scrutinized, in particular their effect on infant health and maternal safety. Data on newer agents will also be reviewed, and future directions for tocolytic therapy will be explored.
Author K. BrouardSource: Obstetrics and Gynaecology Forum 21, pp 22 –29 (2011)More Less
Due to the associated social stigma, most women experiencing symptoms of anal incontinence (AI) do not seek medical assistance or volunteer their symptoms when consulting a healthcare provider for other conditions. As gynaecologists, we regularly have contact with women who could be experiencing AI, particularly those with urinary incontinence or pelvic organ prolapse, those who have undergone pelvic radiotherapy or women following childbirth. Although most of the investigations and specific management for patients with AI will be performed by other members of the multidisciplinary healthcare team (e.g. colorectal surgeons, dieticians, occupational therapists, physiotherapists) we have an important role to play in identifying these patients and referring them appropriately.
Uterine artery pseudoaneurysm as a cause of secondary postpartum haemorrhage following a caesarean section : case reportAuthor L.A. KennethSource: Obstetrics and Gynaecology Forum 21, pp 31 –34 (2011)More Less
Postpartum haemorrhage (PPH) is a major direct cause of maternal mortality worldwide, and primary PPH accounts for most of these deaths. Secondary PPH is not usually as catastrophic and certainly less frequent but may still cause significant morbidity, and if not appropriately managed, can also lead to maternal death. The common causes of secondary PPH include subinvolution of the placental site, retained products of conception and endometritis. Rare causes such as uterine or cervical neoplasms as well as vascular abnormalities including uterine artery pseudoaneurysm, should be excluded, especially in patients not responding to uterotonics and antibiotics. Traditionally the treatment of uterine artery pseudoaneurysms would warrant a surgical approach, but recently selective uterine artery embolization (UAE) has become the treatment of choice. Ultrasound-guided thrombin injection of these vascular anomalies has also been successfully used in appropriate cases. With the availability of these uterine-preserving techniques, clinicians should perhaps consider UAE in the haemodynamically stable patient before resorting to surgery.