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Postpartum haemorrhage is the leading cause of preventable maternal mortality in South Africa. In a significant breakthrough in the management of PPH, the E-MOTIVE trial found that a multifaceted health service intervention reduced severe PPH after vaginal delivery by 60% in 78 hospitals in Nigeria, Kenya, Tanzania and SA. The E-MOTIVE approach comprises objective blood loss measurement monitored every 15 minutes during the first hour after delivery to detect PPH early and trigger a bundle of first-line treatments, including massaging the uterus, oxytocin infusion, tranexamic acid infusion, intravenous crystalloid fluids, examination for the cause, emptying the bladder and, if necessary, escalation of care. E-MOTIVE was integrated into the existing Essential Steps in Managing Obstetric Emergencies algorithm. Certain research-related elements of the trial setting cannot be replicated in routine practice. Therefore, we need to develop local strategies to ensure the essential clinical elements of the intervention are implemented. Potential strategies include incorporating the E-MOTIVE principles into national guidelines, ongoing training strategies and ensuring all facilities are equipped with necessary medication, equipment and delegations. This breakthrough intervention provides hope for women in SA, and requires a purposeful, co-ordinated implementation strategy on a national scale to reach all levels of the health service.

Background: Little is known about the outcomes of self-induced pregnancy termination after 24 weeks' gestation, as previous studies have concentrated on outcomes before 24 weeks., Objectives: To investigate the gestational age, misoprostol dosage, source of information on misoprostol, reasons for termination and outcomes of self-induced pregnancy termination after 24 weeks' gestation., Methods: A quantitative, retrospective case series observational research design was utilised. Paediatric case summaries and the Perinatal Problem Identification Programme were used to collect data. Cases of self-induced pregnancy termination using misoprostol after 24 weeks' gestation treated at a tertiary hospital in the Eastern Cape Province, South Africa, during the period 1 July 2011 - 1 January 2012 were identified and included in the study. Frequencies and proportions were used to analyse data., Results: Eighteen known cases of self-induced pregnancy termination using misoprostol after 24 weeks' gestation were treated at the hospital during the 6-month study period. Misoprostol doses ranged from 400 to 1 200 µg. Birth weight was <500 g in 1 case (6%), 500 - 1499 g in 12 (67%), 1 500 - 1 999 g in 2 (11%), >2 500 g in 1 (6%) and unknown in 1 (6%). Eleven of the babies (67%) were born alive and 5 (28%) were stillborn (1 further stillbirth (6%) was classified as an abortion, <500 g). One baby (6%) survived, and in 1 case (6%) the pregnancy continued. Eight of the 10 neonatal deaths were early and 2 were late. The major cause of neonatal death was hyaline membrane disease (n=8, 44%). Other causes were hypoxia (n=2), septicaemia (n=2), necrotising enterocolitis (n=2), pulmonary haemorrhage (n=2) and intraventricular haemorrhage (n=2). More than one cause applied in some cases. The maternal complications were manual removal of the placenta (n=2, 11%), ruptured uterus (n=1, 6%), and anaemia with blood transfusion (n=1, 6%)., Conclusions: Self-administration of misoprostol to induce pregnancy termination after 24 weeks' gestation contributes to preterm births and perinatal morbidity and mortality. The findings of this study show that there is a need to educate women on the perinatal and maternal risks associated with self-induced pregnancy termination at a late stage of gestation, availability of safe options for pregnancy termination, and contraceptive use and adherence. Healthcare workers need to be sensitive to the possibility that cases of apparent spontaneous preterm labour or birth may have been self-induced.

The World Health Organization (WHO) published guidelines for hormonal contraceptive eligibility for women at high risk of HIV in March 2017. This guidance followed from a technical consultative meeting convened by the WHO in December 2016, where all the available evidence on hormonal contraceptives and risk of HIV acquisition was reviewed. This was an expert meeting with representation from global experts in family planning and HIV management, including clinicians, epidemiologists, researchers and civil society. The guideline development group, through a consensus, made recommendations to change the medical eligibility criteria for contraceptive use from category 1 to category 2 for progestogen-only injectable contraceptives among women at high risk of HIV. There was no change in the recommendation for all other methods of hormonal contraception. The data that informed this decision are from observational studies, which have limitations; therefore, causality or association of hormonal contraception and risk of HIV acquisition have not been proven. This guidance will have an impact on countries that have a high HIV disease burden and where progestogen-only injectable contraceptives are the highest used, as in South Africa (SA). The information has to be communicated in line with the WHO's sexual and reproductive health rights principles of ensuring that all women should receive evidence-based recommendations. This will empower them to make informed choices about their reproductive needs. This article seeks to clarify the decision-making process of the WHO and how the new recommendations were formulated. It also gives SA's response to the guidance and a perspective of what informed the National Department of Health's position, taking into account the effect this will have on SA's contraceptive guidelines.

Background: Obstetric haemorrhage (OH) remains a major contributor to maternal morbidity and mortality. Blood transfusion is critical in OH management; yet, data on peripartum transfusion are lacking. A pilot study reported high rates of peripartum transfusion in a sample of South African (SA) hospitals, which was independently associated with HIV status., Objectives: To assess the incidence of peripartum transfusion in a sample of Eastern Cape, SA hospitals to evaluate generalisability of preceding study findings., Methods: Hospital chart reviews were conducted of all deliveries at three large regional hospitals from February to June 2013. Additional clinical data were collected for patients who sustained OH and/or were transfused., Results: A total of 7 234 women were enrolled in the study; 1 988 (27.5%) were HIV-positive. Of the 767 HIV-positive women with a CD4 count <350 cells/μL, 86.0% were on full antiretroviral therapy and 9.9% received drugs for prevention of mother-to-child transmission. The overall transfusion rate was 3.2%, with significant variability by hospital: Frere Hospital (1.5%), Dora Nginza Hospital (3.8%) and Cecilia Makiwane Hospital (4.6%). The number of red blood cell units per transfused patient and per delivery varied significantly by hospital. Bivariate analysis showed significant association between transfusion and HIV status. In a multivariate analysis, controlling for OH, age, mode of delivery, gestational age, parity and birthweight, this association (odds ratio 1.45; 95% confidence interval 0.78 - 2.71) was no longer significant., Conclusion: These findings confirm high rates of peripartum transfusion in SA. While this can be possibly ascribed to variability in practice and patient profile, variation in care and improvement in HIV treatment should be considered.

Delivery by caesarean section (CS) is becoming more frequent. Childbirth is an emotion-filled event, and the mother needs to bond with her baby as early as possible. Any intervention that leads to improvement in pain relief is worthy of investigation. Local anaesthetics have been employed as an adjunct to other methods of postoperative pain relief, but reports on the effectiveness of this strategy are conflicting. This review attempted to assess the effects of local anaesthetic agent wound infiltration and/or abdominal nerve blocks on pain after CS and the mother's well-being and interaction with her baby. Methods. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2009).The selection criteria were randomised controlled trials of local analgesia during CS to reduce pain afterwards. Twenty studies (1 150 women) were included. Results. Women who had wound infiltration after CS performed under regional analgesia had a decrease in morphine consumption at 24 hours compared with placebo (morphine dose -1.70 mg; 95% confidence interval (CI) -2.75 to -0.94). Women who had wound infiltration and peritoneal spraying with local anaesthetic after CS under general anaesthesia (1 study, 100 participants) had a reduced need for opioid rescue (risk ratio (RR) 0.51; 95% CI 0.38 to 0.69). The numerical pain score (0 -10) within the first hour was also reduced (mean difference (MD) -1.46; 95% CI -2.60 to -0.32). Women with regional analgesia who had local anaesthetic and non-steroidal anti-inflammatory cocktail wound infiltration consumed less morphine (1 study, 60 participants; MD -7.40 mg; 95% CI -9.58 to -5.22) compared with those who had local anaesthetic control. Women who had regional analgesia with abdominal nerve blocks had decreased opioid consumption (4 studies, 175 participants; MD -25.80 mg; 95% CI -50.39 to -5.37). For outcome in terms of the visual analogue pain score (0 - 10) over 24 hours, no advantage was demonstrated in the single study of 50 participants who had wound infiltration with a mixture of local analgesia and narcotics versus local analgesia. Conclusions. Local anaesthetic infiltration and abdominal nerve blocks as adjuncts to regional analgesia and general anaesthesia are of benefit in CS by reducing opioid consumption. Non-steroidal anti-inflammatory drugs may provide additional pain relief.

Background: Caesarean section (CS) is a very common surgical procedure worldwide. Suturing the peritoneal layers at CS may or may not confer benefit, hence the need to evaluate whether this step should be omitted or not., Objectives: To assess the effects of non-closure as an alternative to closure of the peritoneum at CS on intraoperative, immediate and later postoperative, and long-term outcomes., Search Strategy: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (November 2002) and the Cochrane Central Controlled Trials Register (October 2003)., Selection Criteria: Randomised controlled trials that compared leaving the visceral and/or parietal peritoneum unsutured at CS with suturing the peritoneum, in women undergoing elective or emergency CS., Data Collection and Analysis: Trial quality was assessed and data were extracted by two reviewers., Main Results: Nine trials involving 1811 women were included and analysed. The methodological quality of the trials was variable. Non-closure of the peritoneum reduced operating time when both layers or one layer was not sutured. For both layers, the operating time was reduced by 7.33 minutes (95% confidence interval (CI): -8.43 - -6.24). There was significantly less postoperative fever and reduced postoperative stay in hospital for non-closure of the visceral peritoneum and non-closure of both layers. There were no other statistically significant differences. The trend for analgesia requirement and wound infection tended to favour non-closure, while endometritis results were variable. Long-term follow-up in 1 trial showed no significant differences. The power of the latter study to show differences was low., Conclusions: There was improved short-term postoperative outcome if the peritoneum was not closed. Long-term studies following CS are limited, but data from other surgical procedures are reassuring. At present there is no evidence to justify the time taken and cost of peritoneal closure.

Ensuring that health professionals practise according to evidence-based standards is important since it affects the quality and cost of care patients receive. The purpose of this research was to use a focused change programme (the Better Births Initiative) to influence obstetric practice of 10 hospitals in Gauteng, South Africa. The findings show some important improvements in practice following the implementation of the BBI; providers at some sites reduced the use of enemas, shaving and episiotomy, and increased use of oral fluids and companionship during labour. Qualitative data suggest that an interactive approach to implementing evidence-based practice can influence health professionals decisions to change practice, and that good working relationships and enthusiastic staff are central to effective change.

Objectives: To compare three methods of labour induction., Design: Randomised controlled trial., Setting: Academic hospitals in Johannesburg, South Africa., Subjects: Women with intact membranes due for induction of labour., Method: Randomised, sealed opaque envelopes were used to allocate women to labour induction with extra-amniotic Foley catheter/titrated oral misoprostol solution (N = 174), titrated oral misoprostol solution alone (N = 176), or vaginal dinoprostone (N = 176). Misoprostol was dissolved in water and 20-40 g was given 2-hourly., Outcome Measures: These were failure to deliver vaginally within 24 hours, additional measures for induction or augmentation of labour, analgesia, and maternal and fetal complications., Results: In the Foley catheter group, misoprostol was required in all but 1 case. Failure to deliver vaginally within 24 hours was similar for the three groups (79/174 v. 70/176 v. 70/176 respectively). Labour augmentation, caesarean section and instrumental delivery were used somewhat more frequently in the Foley/misoprostol group than in the misoprostol alone group, but these differences were not statistically significant. More analgesia was used in the Foley catheter/misoprostol group than in the misoprostol group (64/172 v. 46/175). Side-effects and neonatal complications were similar for the three groups., Conclusions: Use of extra-amniotic Foley catheter placement showed no measurable benefits over the use of oral misoprostol alone, or vaginal dinoprostone.

Background: Calcium supplementation during pregnancy may prevent high blood pressure and preterm labour., Objective: To assess the effects of calcium supplementation during pregnancy on hypertensive disorders of pregnancy and related maternal and child adverse outcomes., Design: A systematic review of randomised trials that compared supplementation with at least 1 g calcium daily during pregnancy with placebo., Search Strategy: The Cochrane Pregnancy and Childbirth Group trials register (October 2001) and the Cochrane Controlled Trials Register (Issue 3, 2001) were searched and study authors were contacted., Data Collection and Analysis: Eligibility and trial quality were assessed. Data were extracted and analysed., Main Results: There was a modest reduction in the risk of pre-eclampsia with calcium supplementation (relative risk (RR) 0.68, 95% confidence interval (CI): 0.57-0.81). The effect was greatest for women at high risk of hypertension (RR 0.21, 95% CI: 0.11-0.39) and those with low baseline calcium intake (RR 0.32, 95% CI: 0.21-0.49). There was no overall effect on the risk of preterm delivery, although there was a reduction in risk among women at high risk of hypertension (RR 0.42, 95% CI: 0.23-0.78). There was no evidence of any effect of calcium supplementation on stillbirth or death before discharge from hospital. There were fewer babies with birthweight < 2,500 g (RR 0.83, 95% CI: 0.71-0.98). In one study, childhood systolic blood pressure > 95th percentile was reduced (RR 0.59, 95% CI: 0.39-0.91)., Conclusions: Calcium supplementation appears to be beneficial for women at high risk of gestational hypertension and in communities with low dietary calcium intake. These benefits were confined to several rather small trials, and were not found in the largest trial to date, conducted in a low-risk population. Further research is required.

Background: Misoprostol, a cheap, stable, orally active prostaglandin analogue, is effective for labour induction when administered either vaginally or orally, but uterine hyperstimulation and rupture have been reported. Previous studies of oral misoprostol for labour induction have used fixed dosages 3-6-hourly., Objectives: To develop a new method of misoprostol use for labour induction using very small, frequent, titrated oral dosages, and to pilot effectiveness., Study Design: Open clinical pilot study., Setting: Coronation Hospital, an academic hospital in Johannesburg, South Africa., Methods: We developed a method using 2-hourly titrated misoprostol doses commencing with 20 micrograms, increased after three doses to 40 micrograms. To administer such small doses we dissolved one misoprostol tablet in 200 ml water. A pilot study of this method was undertaken in 25 women with various indications for induction of labour., Results: Eighteen women (72%) delivered vaginally within 32 hours of induction and two women developed uterine hyperstimulation. The caesarean section rate was 20%., Conclusions: Women may respond to much smaller dosages of misoprostol than are currently in use. A multicentre randomised trial of this method is underway. We emphasise the dangers inherent in the current unregistered use of misoprostol in clinical practice.

Background: Misoprostol, an inexpensive, stable, orally active prostaglandin analogue, has been suggested for use in the prevention of postpartum haemorrhage. Potential side-effects, however, need to be quantified., Objective: To compare the rate of postpartum shivering and pyrexia following oral misoprostol 600 micrograms and placebo., Design: A double-blind placebo-controlled trial. Women in labour were randomly allocated to receive either misoprostol 600 micrograms orally or placebo after delivery. Conventional oxytocics were given immediately if blood loss was thought to be more than usual. Side-effects were recorded. Postpartum blood loss in the first hour was measured by collection in a special flat plastic bedpan., Setting: The labour ward of an academic hospital in Johannesburg, with 7,000 deliveries per annum., Main Outcome Measures: Shivering and pyrexia., Results: The groups were well matched. Misoprostol use was associated with more shivering (44% versus 11%, relative risk (RR) 4.03, 95% confidence interval (CI) 2.85-5.70), pyrexia > or = 37.8 degrees C (38% v. 6%, RR 6.23, CI 3.89-9.97), 1-hour systolic blood pressure > or = 140 mmHg (33% v. 25%, RR 1.32, CI 1.03-1.70), and diastolic blood pressure > or = 90 mmHg (10.5% v. 3.0%, RR 3.44, CI 1.67-7.11). There were no other significant differences. The study was not designed to be large enough to assess a difference in blood loss > or = 1,000 ml (9% v. 9.7%, RR 0.93, CI 0.56-1.53). Possible effects on blood loss may have been obscured by the lesser use of additional oxytocics in the misoprostol group (14% v. 18%, RR 0.78, CI 0.54-1.13)., Conclusions: This study has shown the association of postpartum oral misoprostol 600 micrograms with shivering, pyrexia and hypertension. The increased blood pressure, as for the trend towards increased abdominal pain, may be secondary to the uterotonic effect of misoprostol. Large randomised trials are needed to assess the effectiveness of misoprostol in the prevention of postpartum haemorrhage, against which the disadvantages demonstrated here can be weighed.

Unlabelled: Postnatal depression occurs in 10-15% of women. The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-report scale designed specifically as a screening instrument for the postnatal period. It was initially validated for use in the UK, but has subsequently been validated for other communities. It has not been validated for an African community., Objective: To determine whether the EPDS is a valid screening scale for depression in a Johannesburg community cohort., Participants and Setting: 103 women attending the postnatal clinic at Coronation Hospital, Johannesburg, South Africa., Method: The EPDS was validated against the Diagnostic and Statistical Manual (DSM-IV) criteria for depression. It was administered verbally to participants and translated into one of six South African languages where necessary., Results: A threshold of 11/12 on the EPDS identified 100% of women with major depression and 70.6% of women with minor depression. For major and minor depression combined, sensitivity was 80%, specificity 76.6%, positive predictive value 52.6% and negative predictive value 92.2%., Conclusion: The EPDS, administered verbally, is a valid screening instrument in this urban South African community.

Objective: To assess the usefulness of the can as a fetal vibro-acoustic stimulator in the clinical environment., Patients and Setting: 112 high-risk obstetric patients at Coronation Hospital, Johannesburg., Method: 161 vibro-acoustic stimulation tests with a can and 159 non-stress tests (NSTs) were performed. The results of the can test were compared with those of the NSTs and with fetal outcome at delivery., Results: The can test showed poor sensitivity (5/9). Three of the 4 false-negative results were due to placental abruption that occurred subsequent to the can test. The ability of the can test to predict a reactive NST and good fetal outcome was 94% (negative predictive value)., Conclusions: In view of the reasonable negative predictive value, the test should be evaluated further as a screening test at primary care level, where there are few or no cardiotocographic facilities.

Conventional vibro-acoustic stimulation tests require expensive vibro-acoustic stimulators and electronic monitoring equipment. Attempts to simplify the test have been made using an electric toothbrush and razor but even these simpler devices are not available in most primary care settings. We compared the sound pressure generated by a Corometrics 146 vibro-acoustic stimulator to that of an empty soft-drink can in an in vitro study. The can compared favourably to the conventional vibro-acoustic stimulator.

Selective termination in twin pregnancies with a chromosomal abnormality in one twin may be offered to prevent long-term suffering for the infant and/or the family. The procedure poses considerable risks to the remaining fetus and also to the mother, and these, together with the ethical aspects, should be discussed thoroughly with the couple. We report 2 successful cases of selective midtrimester termination by intracardiac potassium chloride injection, and recommend a management protocol for selective birth in twins with discordant chromosomal abnormalities.

Objectives: To determine the relationship between umbilical arterial catecholamine levels and fetal heart rate variability and meconium passage., Study Design: A prospective descriptive study was performed. Umbilical artery catecholamine levels were measured in 55 newborns and correlated with fetal heart rate before delivery, umbilical arterial pH, base excess and the presence of meconium-stained liquor., Results and Conclusion: The range of catecholamine levels was enormous, with very high epinephrine or norepinephrine levels in several fetuses. We were unable to demonstrate an association between high catecholamine levels and the presence of normal fetal heart rate variability despite acidaemia. We postulate that high catecholamine levels may inhibit fetal meconium passage.

A diagnostic screening programme identified a possible aetiological factor in 32 of 76 couples (42%) evaluated for recurrent spontaneous abortion (three or more consecutive abortions). The abnormalities most commonly observed were endocervical infections (18%), cervical incompetence (11%) and uterine abnormality (9%). Hypothyroidism was present in 3 women and chromosomal abnormality in 2. None were positive for lupus anticoagulant. Treatment of uterine abnormality and cervical incompetence was associated with 75% and 86% success rates, respectively, whereas treatment of infective causes resulted in a 44% successful pregnancy rate, much the same as the 42% rate that occurred in women who had not been thus treated.

An inflatable device designed to achieve controlled dilatation of the pelvic floor soft tissues before the second stage of labour in women with epidural analgesia was tested in a randomised pilot study. Assisted vaginal delivery was required in 4/14 primiparous women (29%) after use of the dilator, and 8/16 controls (50%). The concept of improving the efficiency of pelvic floor dilatation and reducing the trauma associated with childbirth was found to be worth pursuing, and potential improvements in the design of the dilator were identified.

Despite the widespread use of beta-sympathomimetic agents for preterm labour there appears to be a limited appreciation of the need for cardiovascular monitoring in the mother. Four patients in whom pulmonary oedema developed during tocolysis with hexoprenaline are described and the aetiological factors and pathogenesis of this potentially lethal complication discussed. Guidelines for the safe use of hexoprenaline in preterm labour are suggested.

The mechanism of episodes of fetal bradycardia during epidural analgesia is unknown in the majority of cases. This retrospective study considers the relationship between prolonged fetal bradycardia and epidural analgesia during labour. Of 705 cardiotocographs recorded during administration of epidural analgesia for patients in labour, 207 were suitable for analysis. Prolonged fetal bradycardia occurred after 40 of 366 (11%) initial or repeat injections of local anaesthetic into the epidural space. The peak incidence of onset of bradycardia was 5-20 minutes after administration, but occurrences continued throughout the 60-minute period studied. In 1 patient a single episode of fetal bradycardia occurred before administration of the epidural block. In all cases studied the 5-minute Apgar scores were 7 or better. It is concluded that administration of epidural analgesia is significantly associated with episodes of prolonged fetal bradycardia, but that there is usually a return to pre-epidural patterns. The fetal heart rate should be monitored during epidural block administration to confirm the return to baseline rate and normal variability. Episodes of fetal bradycardia that return to a normal pattern do not necessitate early delivery.

An ultrasensitive modification of the Tandem Icon urine test for human chorionic gonadotrophin was used by clinicians, without special training, in the evaluation of 51 women with suspected ectopic pregnancy. There were 2 false-positive results. No negative results occurred in the presence of ectopic or ongoing pregnancy. A negative result (the majority of cases) is useful for excluding the diagnosis of ectopic pregnancy. The need for observation in hospital and diagnostic surgery can be greatly reduced by the use of this test in the ward or outpatient department.

The sequence of fetal heart rate (FHR) changes recorded in a case of acute fetal haemorrhage is reported. Initial bradycardia progressed through an undulatory phase to tachycardia. Analysis of these patterns in the context of experimental data on intrinsic heart rate control suggests that the FHR was limited by availability of local myocardial energy, which at a critical level produced low-frequency FHR fluctuations. Extrapolation of this hypothesis to the pathophysiology of the true sinusoidal FHR pattern is discussed.

Two cases of sigmoid volvulus complicating pregnancy at 33 and 26 weeks' gestation are reported. The clinical presentations were strikingly similar, although the second patient presented later in the evolution of the condition and died 6 hours after surgery. Both fetuses died in utero. The reasons for suspecting sigmoid volvulus as a cause of intestinal obstruction (especially in pregnant black women) and its management are outlined.

In view of the present questioning of interventive obstetric practices such as the elective performance of episiotomy, the putative advantages of episiotomy are critically analysed. Recent prospective randomised studies support the growing body of evidence that the value of elective episiotomy is yet to be substantiated.

Conventional criteria for the prediction and diagnosis of dehiscence of a caesarean section scar during labour were prospectively evaluated. Of 70 patients selected to undergo trial of labour, scar dehiscence occurred in 2 of 35 mothers delivered vaginally and in 4 delivered by caesarean section. Conventional predictive and diagnostic criteria correlated poorly with the occurrence of scar dehiscence. These limitations should be recognised and, during trial of labour after caesarean section, emphasis should be placed on careful monitoring of maternal and fetal condition.

The value of the Accurette endometrial sampler in the cytological and histological assessment of the endometrium was studied in 42 anaesthetized patients. Satisfactory samples for cytological diagnosis of endometrial state were obtained in 23 patients out of 24 (96%), whereas endometrial specimens suitable for histological diagnosis were obtained in 23 out of 29 patients (79%). Immediately following Accurette sampling, conventional dilatation and curettage was performed. Histological diagnosis of Accurette samples correlated with that of formal curettage in all instances except in the detection of polyps. Cytological findings with the Accurette did not correlate with those of formal curettage in 2 cases. Nevertheless, interpretation of endometrial cytology, which requires specialized knowledge and experience, is shown to provide helpful information especially in cases where curettage fails to yield tissue.

The timing of umbilical cord clamping in 38 women with preterm labour was randomly assigned. Ultrasonographic evidence of periventricular/intraventricular haemorrhage (PVH/IVH), assessed blindly, was found in 77% of the group clamped early compared with 35% of those in whom clamping of the cord was delayed for 1 minute. A hypothesis to explain the possible contribution of the haemodynamic events which accompany cord clamping to the development of PVH/IVH is presented.

The finding of adenosis in the vaginal pouch of a patient with agenesis of th lower Müllerian tract suggests that not all cases of vaginal adenosis are Müllerian in origin.

"Active birth' is becoming an increasingly prominent issue in obstetric practice. The psychosocial background of current public interest in the subject is examined. Guidelines are suggested to accommodate "active-birth' practices within the hospital environment. The Johannesburg Hospital experience of the application of these guidelines in the first 100 patients admitted to the "Midwives Active Birth Unit' is reported.

Prior to artificial rupture of membranes, 498 women were questioned about obstetric and social factors including self-medication during pregnancy. Caesarean section (P less than 0,01) and low Apgar scores (P less than 0,001) were significantly more common in pregnancies complicated by fetal meconium passage. Meconium passage was more common in women who had recently taken castor oil (P less than 0,01) and possibly herbal substances called 'sihlambezo' (trend P less than 0,2). Use of laxatives or enemas and other obstetric risk factors were not associated with meconium passage.

A 30-year-old woman with von Willebrand's disease completed her third pregnancy uneventfully. She was infused during labour with fresh frozen plasma and cryoprecipitate. This is in keeping with the good outcome reported in the literature when management is appropriate and surveillance is maintained.

Reports on fluctuating fetal heart rate (FHR) patterns, which have been called sinusoidal FHR patterns in the literature, have been critically reviewed. Based on this analysis, stricter criteria are presented whereby the true sinusoidal pattern can be diagnosed and distinguished from the pseudosinusoidal pattern. A practical approach to the interpretation and management of fluctuating FHR patterns is presented.