1.4 management of constriction ring of the uterus using isoxuprine m. barker and j.v. laursen_2

8/3/2019 1.4 Management of Constriction Ring of the Uterus Using Isoxuprine m. Barker and j.v. Laursen_2

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10 S.A. TYDSKRIF VIR OBSTETRIE EN GINEKOLOGIE 1 Junie 1968symptoms such as hot flushes and atrophic vaginitis, buttheir prophylactic use in the prevention of age ing has asyet to be established. Early enthusiasm fo r long-termexogenous oestrogen therapy has resulted in the suggestionthat condi tions such as osteoporosis and myocard ia l infarction may be prevented. I t has, however, not yet beenshown that these changes are the direct resul t of withdrawal of endogenous oestrogens and are preventable byappropriate oestrogen therapy.With regard to progesterone administration. Kistner'states that as yet there is no evidence that progesteroneplays any significant role in the physiology of the menopause.Several questions urgently require answers.I. Is the climacteric a normal physiological stage in thelife of the human female, or is it a simple resul t of ovarian

failure and oestrogen deficiency?2. Are the manifes ta tions of ageing directly related to

diminution of circulating sex hormones?3. Can the administrat ion of exogenous oestrogen orother sex hormones prevent the manifestations of ageing?4. Are the oestrogens at present available for administ ra tion equivalen t in effect to circulating endogenousoestrogens?5. Does long-term oestrogen administration result in anincreased incidence of breast or uterine carcinoma?6. Do oestrogens have a direct effect on the psychological state and sense of well- be ing in the postmenopausalpatient?To these ends the development of more precise diagnostic techniques and methods of evaluation is vital.Wilson's' description of the probable fate of the non

treated elderly f emal e a s being one of hypertension, atherosclerosis, flabby breasts, dowager's hump, atrophic genitals and a vapid cow-l ike feel ing cal led a 'negative state'would app ea r t o be an overstatement of the case. How-

ever, there is some reason to be lieve that the administration of oestrogens or other sex hormones may no t onlyalleviate menopausal symptoms, but will have some reaeffects on ageing processes in the postmenopausal woman

SUMMARYEvidence for the cur rent concept tha t the climacteric is aresult of hormone deficiency is critically appraised. There is ayet no proof that long-term oestrogen therapy to the postmenopausal female is of any major benefit in the preventionof coronary occlusive disease or osteoporosis. Further controlled investigation into the use of natural oestrogens, particularly their effect on ageing, is an urgent necessity.

I wish to thank Prof. D. A. Davey, head of the Departmenof Obstetrics and Gynaecology of the Univers ity of CapeTown, for his constructive crit icism during the preparation othis review.REFERENCES

1. JefIcoate, T. N. A. (1967): Principles of Gynaecology, 3rd ed .. p. 112London; Butterworths.2. Lewis, T. L. T. (1964): Progress i n Cli ni ca l Obs te tr ic s and Gynaecology, 2nd ed.. p. 460. London: J. & A. Churchill.3. Kistner, R. W. (1968): s. Afr. J. Obstet. Gynaec .. 6. 1.4. Wilson. R. A. and Wilson, T. A. (1963): J. Arner. Geriat. Soc .le 347.5. Davis, M. E. il l Marcus. S. L. and Marcus, C. C.. eds. (1967): Advances i n Obs te tr ic s and Gynaecology, vo!. 1, p. 419. Baltimore:\Villiams & Wilkins.6. GreenhiH, J. P., ed. (1967): Yearbook of Obs!ecrics and G)'"aecolog)"1967 - 1968. p. 472. Chicago: Year Book Medical Publishers.7. Pick, R.. Stamler, J., Rodbard, S. and Katz, L. N. (1952): Circulation. 6, 276.8. Oliver, M. F. and Boyd. G. S. (1959): Lancet. 1, 690.9. Snajderrnan. M. and Oliver. M. F. (1963): Ibid., 1, 962.10. Leading Article (1966): Ibid., 2, 96.11. Veterans Administration Coopera t ive S tudy of Atherosclerosis (1966):Circulation. 33 , suppl. 2.12. Parrish. H. M., Carr, C. A., Hall, D. G. and King, M. T. (!967):Arner. J. ObSlet. Gynec .. 99 , 155.13. Symposium on Estrogen and the Menopausa l Woman ( 1966 ): Bul lSloane Hosp. Worn. N.Y., 12. 99.14. WaHach. S. and Hennernan. P. H. (1959): J. Arner. Med. Assoc.171, 1637.15. Albright, F. , Smith, P. H. and Richardson. A. M. (1941): Ibid .116, 2465.16. Kretzschrnar. W. A. and SlOddard, F. J. (1964): Chn. ObSletGynec .. 7, 451.17. Young. C. M. . Blondin. J. . Tensuan, R. and Fryer. J. H. (1963):Ann. N.Y. Acad. Sci., HO, 589.

MANAGEMENT OF CONSTRICTION RING OF THE UTERUS USING ISOXUPRINE*M. BARKER. M.B., CH.B. (BIRMINGHAM) AND J. V. LARSEN, M.B., CH.B. (CAPE TOWN), Charles John.son MemorialHospital, Nqutu, Zululand, Natal

A constriction ring of the uterus 'represents an area ofi nt en se local activity" in an organ in wh ich the normalpolarity of contractions is disturbed. The usual site ofsuch a ring is at the junction of the upper and lowersegments.Because the Bantu patient tends to go into labour withthe presenting part well above the brim of the pelvis,such a constriction ring, even in vertex presentations,usua lly f orms bel ow the presenting part, thus confiningthe foetus to the upper segment of the uterus. When thisoccu rs , it gives r ise to a d is tinc t c linica l picture, generallyfirst recognized because of the failure of the presentingpart to engage with the brim of the pelvis, in spite ofgood contractions. Indeed, palpation during a contractionwill often reveal that the presenting part moves up, awayfrom the pelvic 'brim, and th e examiner's h and c an alwaysbe comfortably pressed against the abdominal wall be-*Date received: 28 Sepremben 1967.

tween the vertex and the symphysis pubis , the vertexmaking no attempt to push past it to engage with thebrim. Vaginal examination is necessary to confirm thediagnosis, and usually reveals a more or less dilatedcervix, an empty lower segment, and a constriction ringholding the present ing part out of the lower segmentThere is no relationship between this cond ition andBandl's ring.In this uni t, where the incidence of constriction ring of

the u te ru s in vertex presentations during a I-year period(1966 - 1967) was 8 cases in 1,509 deliveries (0'53%)special interest i n t reatment was aroused by the failureof more conventional methods to relax the r ing beforefoetal distress supervened. The caesarean sections thusnecessitated were technically difficult, and resulted in poorscars because the upper segment had so often to beencroached upon in order to del iver the foetus througha tight ring. Fo r these. reasons it was decided to study the


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TABLE 11. STATUS AT TIME OF DIAGNOSIS

S.A. JOURNAL OF OBSTETRICS AND Gv 'AECOLOGV

The following cases seem to us to be worth describingin detail.

Results of the treatment are tabulated in Tables I, I land Ill. The constrict ion rings were relieved completely

11

1V 3* hrs. later

Summary of treatment

Isoxuprine } IMPethilorfanIsoxuprine 5 mg. IMIsoxuprine 10 mg. IMIsoxuprine 5 mg.Pethilorfan 100 mg.lsoxuprine 5 mg. IMPethilorfan lOO rng.Isoxuprine 10 mg. IM 6 hrs. laterPethilorfan 100mg. IMIsoxuprine 10 mg. IM + IV fl 'dPethilorfan 100 mg. UI sBoth repeated 12 hrs. laterIsoxuprine 10 mg. } IMPethilorfan 100 mg.Pethilorfan lOO mg. } IMChlorpromazine 25 mg.Isoxuprine 10 mg. IM 7 hrs. later

Yes

No

Probably

YesYesYes

YesYes

TABLE I. SUMMARY OF ANTE 'ATAL F INDINGSEsrimared period ObstetricalAge in of geslQlion conjugate Shape of brimPatient years Parity (weeks) (estimated) (CIIl.) oj"pehis

I 23 I 38 10 Android2 26 2 40 9'5 GynaecoidJ 26 5 40 12 Gynaecoid4 34 3 38-40 105 Platypelloid5 28 4 40 10 Android6 16 0 38 11 Gynaecoid7 26 4 40 10 Android8 30 I (LSCS) 40 10'5 Android

Each case was then handled on its merits. I f thecons tr ic tion ring wa relieved. the ver tex descended intothe lower segment within an hour of giving isoxuprine,and gross disproportion did not then become apparent.t he pat ient was allowed to proceed with labour in thenormal way, and vaginal del ivery was awaited . I f theconstriction ring appeared to have been improved, butthe vertex remained high. it was sometimes conside redwise to rupture the membranes if these were intact, eitherhalf an hour after the first injection of isoxuprine orshortly after the drug was repeated. The mother wasthen instructed to bear down briefly between two con-tractions while the ring was relaxed, the observer's handbeing kept in the vagina to assess the result of thismanoeuvre, and to make sure the cord did not prolapse.In more recent cases, not included in this series, in whomthe cervix was sufficiently dilated to admit one of thesmaller cups of the vacuum extractor, and in whom thering disappeared completely between but was still evidentduring contractions, we have used this instrument t o bringthe vertex down against the cervix, where it was heldduring one or two cont ra ct ions befo re t he vacuum wa,released.

in 6 ou t of 8 cases. In one further case it was probablyrelieved, but this was not confirmed vaginally. There wasonly I failure.

Constriction ring relieved?

RupturedIntact

RupturedRuptured

RupturedIntactIntact

IntactStaTe of membranes

At The time of diagnosis

I June 1968

Patiell1 Duration of labour Dilation ofcervix(hours) (cm.)10 4 5

2 15 53 6 4 5

4 4 1 55 5i 36 19 37 8 458 6 3

effect of i oxuprine (Duvadilan-Philips-Duphar, Amster-dam) in these cases.

MATERIALS AND METHODSOur unit is s ituated in a rural area, where methods ofcommunication are poor. Because of this, t he major ityof our patients spend the final "2 or 3 weeks in theantenatal ward in the hospital grounds. thus usuallyreaching the labour ward fairly early in the course of thefirst stage. The s tandard of care is reasonably high, asevidenced by a maternal mortality rate of 0'66/1,000(spontaneous ruptur e o f a left cardiac ventri cle in ear lypuerperium), and a perinatal mortality rate of 43'3/1,000,dur ing the period under discussion. All patients. with onlyone exception, were Zulus or Basutos.Each patient had the usual investigations during the

antenatal per iod, including est imat ion of haemoglobin,the Wassermann reaction and a clinical pelvic assess-ment. Facil it ies fo r radiological assessment were no tavailable. Inpat ients, unless ill, were seen twice weeklyfor routine antenatal examinations by a medical officer.

Only cases with vertex presentation were included inthis series, because the prognosis fo r vaginal delivery ift he ri ng could be relieved was so much better. Limitingthe discussion in this way also removes other factorswhich would interfere in the assessment of the assistancethis treatment gave to the surgeon in p e r f o r ~ i n g suchcaesarean sections as became necessary. All caesareansections were performed under local anaesthesia.

As soon as a constriction ring of the uterus was sus-pected on abdominal examination, the diagnosis wasconfirmed by vaginal examination by one of us. Thet reatment then instituted consisted of isoxuprine, 5 mg.or 10 mg. given by the intramuscular or intravenous route,with or without Pethilorfan 100 mg., generally givenintramuscularly. One patient (case 5), was given Pethilorfan only, wi th the intention of administering isoxuprinelater if this proved necessary. Another (case 8) was givenPethilorfan, 100 mg., and chlorpromazine, 25 mg., bothintramuscularly, followed later by i soxupr ine when therewas no improvement in the condition.


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12 S.A. TYDSKRIF VIR OBSTETRIE E r GINEKOLOGIETAilLE I l l . SUMMARY OF RESULTS OF TREATMENf

1 Junie 1968

MaTernal side-effects possiblyWeight ofbaby Puerperium atTribuTable 10 isoxuprine6 lb. 6 oz. Normal None6 lb. 11 oz. Normal Urinary retention 12 hrs. postpartumTrealmem- IndicaTionsPaTient deliveryimerral Type ofdelhery for LSCS Blood loss1 13 hrs. 10 min. Spontaneous 60 ml.2 2 hrs. 30 min. LSCS Disproportion. 450 ml.Foetal distress3 18 hrs. 45 min. Spontaneous 300 ml.4 10 hrs. 45 min. LSCS Unrelieved 450 ml.constriction ring

5 7 hrs. 30 min. Spontaneous 10 record6 12 hrs. Spontaneous 450 ml.7 5 hrs. LSCS Foetal distress 900 ml.8 9 hrs. LSCS Disproportion 400 ml.

8 lb. 3 oz.6 lb. 12 oz.71b. 13 oz.7 lb. 4!- oz.7 lb. 11 oz.5 lb. 151 oz.

ormallormalNormalormalModeratesepsisormal

Twitching (transitory)Urinary retention 24 hrs. postpartum'oneRecords incomplete'oneNone

CASE REPORTSCase IC.M., aged 23 years, para. 1, gravida 2, with a negat ive

Wassermann reaction, and a haemoglobin concentrationof 115 G /100 ml., presented in the l abou r ward soonafter sunrise, having been in labour since about midnight.He r general condit ion was good, with a blood pressu re of100/70 mm.Hg. Abdominal palpation revealed a highmobile vertex as the present ing part. Uterine contractionswere poor and incoordinate in type . Foeta l heart r ate was140/min. Vaginal examination confi rmed a const rict ionring about the junction of the upper and lower segments,well above a 4-5-cm. dilated cervix. The ver tex wasresting on this ring. Membranes were intact. Pethilorfan,lOO mg., and isoxuprine, 5 mg., were given by the intramuscular route. Contractions became weaker, bu t thevertex descended into the lower segment, and vaginalexamination carried ou t 6 hours later confirmed that theconstriction ring had disappeared. She gave birth to amale infan t with an Apgar rating of 9, weighing 6 lb.6 oz., 13 hours after the isoxuprine injection. The puerper ium was normal.Case 3A.B., aged 26 was a para. 5, gravida 6, and had had oneabortion at 16 weeks. Her last baby had weighed 9 lb. 5 oz.,and had been delivered by vacuum ext ract ion. She was admitted to the labour ward in good condition, having beenin labour for about 6 hours. Her blood pressur e was110/70 mm.Hg. Abdominal palpation revealed a high mobile vertex presentation. The foetal heart was within normalrange. Vaginal examination revealed a 4-5-cm. dilatedcervix with a sausage of membranes pro trud ing throughthis from a constriction ring 2 inches h igher up, whichadmitted 2 fingers only. Isoxuprine, 10 mg., was administered by the intramuscular route. Three hours later thecervix had progressed to almost full dilation, but theconstriction ring remained unchanged. Isoxuprine, 5 mg. ,and Pethilorfan, 100 mg., were administered intravenously,and the membranes were ruptured. The patient subsequently had some mild twitchings. with a blood pressureof 110 /70 mm.Hg. Two hours after the second dose ofisoxupr ine, t he const ri ct ion r ing had disappeared , andcontractions were very weak. The cervix had closed downto 3 cm. dilation and was now only partially effaced.but was well applied to the presenting part . Within a fewhours contractions became established again, and 12 hourslater she delivered an 8 lb. 3 oz. infant with an Apgarrating of 10. Blood loss was 300 ml. The puerperium wasuneventful.

Case 4M.S., aged 34 years, was a para 3, gravida 4, with anegative Wassermann reaction, and a haemoglobin concentration of 115 G /100 mI. She was first seen when shehad been in labour fo r 4 hours. Her general condit ion wasgood, and her blood pressure was within the normalrange. On abdominal palpation, the vertex was present ingand was high and mobile. Contractions were irregular andfairly strong. Vaginal examination confirmed a const rict ion ring of the uterus well above a 15-cm. di la ted cervixand seemingly at the junction of the upper and lowersegments. The membranes were intact. The patient wasgiven a simple enema. I soxup rine , 5 mg., and Pethilorfan,100 mg., were administered intramuscularly. Seven hourslater the uterus had become even more abnormal in action,an additional constriction ring having formed at the levelof the neck of the foetus. Findings on vaginal examinationwere unchanged. Isoxuprine, 10 mg., was given intramuscularly, and Pethilorfan, 100 mg., by slow intravenousinjection, with no improvement in the first const rict ionring, although the second ring disappeared. Lower-segmentcaesarean sect ion was decided upon 12 hours aft er thediagnosis had been made, before foetal distress supervened. Operation, performed under local anaesthesia, revealed sufficient lower segment to make the procedurefeasible, but the upper segment had to be entered in theleft-hand corner of the incision in order to deliver thebaby. The Apgar rating was 9, and the weight 6 lb. 12 oz.Blood loss was about 450 mI. The puerperium was complicated in the first 24 hours by urinary retention necessitating catheterization and drainage for 12 hours.In retrospect , it seems likely that if intravenous isox

uprine had been used when the condition was first diagnosed, and membranes had been ruptured when relaxationhad occurred, better results might have been obtained.However, the second dose of isoxuprine did relax t he r ingaround the neck of the foetus , making delivery of thebaby relatively easy once the primary ring had been cut.

ISOX PRINEIsoxuprine (Duvadilan) has the following structural formula: > CH) C1H) >o \. ) CHOH- tH-NH-cH-CHP


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S.A. JOURNAL OF OBSTETRICS A D GYNAECOLOGYJune 1968gested that the effect in humans may be regulated tosome degree by oxytoc in levels!

The effect on the human parturient uterus was investi-gated by Karim: and may be summarized as follows:(a) Reduction in the tone of the uterus.(b) Reduction in the f requency of contractions.(c) Reduction in the amplitude of contractions. Thiseffect was of shorter durat ion than the effect on

the tone of the uterus, thus giving 'greater efficiency of the uterus for delivery'. This in turn ledto more rapid dilation of the cervix in 25% of hiscases.In patients in premature labour, isoxuprine has been

found capable of stopping contractions; but in the par-turient uterus at term, when low oxytocinase levels arepresent, the ch ief effect appears to be on the tone ofthe u te rus, cor rect ing abnormal patterns of contraction,bu t not stopping the labour.Karim was able to show that i soxupr ine does no tcause postpartum haemorrhage:Given int ravenously, in undiluted form, the drug actsalmost immediately, bu t 10 mg. given in this way willp roduce a cer ta in inc idence of side-effects. By the int ra -muscular route, the drug acts within 5 minutes, andmaintains its act ion fo r one hour; side-effects are rare.Subsequent to this series, it has become ou r practice togive 5 mg. in travenously and 5 mg. intramuscularly atthe same t ime, in an effort to minimize side-effects , whilegetting the benefit of a rapid onset of action.In all the cases in this series, the reduc tion in tone ofthe uterus and in the frequency and duration of contractions was a very noticeable result of the injection.

It was during this period of uterine tranquilli ty that thever tex passed through t he const ri ct ion ring and applieditself to the cervix. The moment this had occurred, thepattern of labour became more normal, contractions becoming stronger and more frequent, and the cervixd ila ted in the normal way.The side-effects encountered by Karim included a tran-sient, and usually unimport an t, d rop in materna l bloodpressure, and a rise in maternal and foetal heart rates.More important effects inc luded occasiona l cases ofdiplopia, tr emors and urinary retention. All these effe:t:;were transitory:Table II I illustrates the side-effects we encountered. Onepatient had transient twitching an hour af te r he r seconddose of isoxuprine; her blood pressure and urine werenormal at the time. Two patients developed urinary retention after caesarean section, bu t the significance of this,in the presence of postoperative pain, is difficult toassess.Postpartum blood loss was norma l in all cases except

one in whom a branch of both uterine arter ies was cu tduring caesarean section, resulting in a total loss ofabout 900 m!.

DISCUSSIONFrom this series of cases, several interesting facts emerge.This is a cond it ion found chief ly in multiparous patients.The single primiparous patient in this series is the onlycase we have had in this unit, and so we suspect that theincidence in first pregnancies is, in fact , lower than thisseries suggests. The condition usually seemed to be present

13

from an ear ly s tage during t he labour. Cases 1, 2 and 6were seen initially by junior members of staff who weremisled by fairly weak contractions and failure of descentof the vertex, into thinking that the patients were not inestablished labour, and the diagnosis was therefore delayed.

Ruptured membranes were not by any means a constant feature, 50% of these pat ients having intact mem-branes at the time of diagnosis. Th is is in contrast to theexperience of others in obstetrics dealing only withWhites.'The success of treatment does not seem to dependgreatly upon the sta te of the cervix or the duration of

labour at the time it is instituted, but rather upon thedegree of disruption of normal uterine polarity, as thesingle failure in this series seems to suggest.Insurmountable cephalopelvic disproportion was presentin 2 of the cases, a much higher incidence than in thegeneral obstetrical population in this area (about 10%).Of the cases requi ring caesarean section, well-formedlower segments were present in cases 2 and 8, the operat ions were technical ly easy and the su rgeon expected thescars to be good . In case 7, l abour had to be interrupted

before enough time had elapsed for a good lower segment to be formed, but it was still possible t o obt ain agood lower-segment scar. Only in case 6, in whom thering persisted, was it necessary to cut into the uppersegment at the le ft-hand end of the incision in order todeliver the baby. These findings are in marked contrastto those of Bourne, who states that 'it is essential tomake a vertical incision through the ring' in order todel iver the baby safely.Only in one case (case 6) was maternal distress afeature.

CONCLUSIONSWhile we accept t ha t ruptu re of the uterus due to aconstriction ring is a very unlikely event, and t he con-dit ion is ' reversible with heavy sedat ion and the lapse oftime',' it was all too often ou r exper ience with othermethods of treatment that, a ft er many anxious hours, adifficult caesarean section was the only safe means ofdelivering a distressed foetus. Frequently it was necessaryto extend the incision i nto the upper segment in order todel iver the head through a tight const ricti on ring, andsometimes one had the unpleasant experience of the vertexfloating away ou t of reach, necessitating internal versionand b reech extracti on i n an already dangerously tightuterus.With its ability to relax a constriction ring andallow the vertex to descend into the lower segment ,isoxuprine seems to be a useful drug in the managementof this difficult condition. At best it ensures a spontaneousvaginal delivery, and at worst a technically eas;er, andtherefore safer, caesarean section.Best results are obtained when active measures areemployed to prevent the recurrence of the constrictionring as the effect of the isoxuprine wears off.

There was no foetal loss or morbidity in this series,and only one case of significant maternal distress.

SUMMARYA suggested method of m a n a ~ e m e n t of a con triction ringof the uterus in vertex presentations, incorporating the use of


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THE INVESTIGAnON OF BACTERIURIA IN PREGNANCY*HERMAN A. VAN COEVERDEN DE GROOT, M.B., CH.B. (CAPE TOWN), M.R.C.O.G., DENNIS A. DAVEY, M.B., B.S.(LOND.), PH.D., M.R.C.O.G. , ARDERNE A. FORDER, M.B. , CH.B. (CAPE TOWN), M.MED. (PATH.) AND S. T. TREZISE.M.B., CH.B. (CAPE TOWN), M.R.C.O.G., Fro m the D ep artm en ts of Obstetrics and Gynaecology and Bacteriology,

Groote Schllllr Hospital, and University of Cape Town

S.A. TVDSKRIF VIR OBSTETRIE EN GlNEKOLOOm4isoxuprine, is discussed with reference to a small series inBantu patients. Treatment was successful in 6 out of 8 cases,with a further probable success and only one failure. Therewas no serious maternal or foetal morbidity.

We wish to thank Dr. E. A. Barker, Medical Superintendentof the Charles Johnson Memorial Hospital, for permission touse hospital records, and Mrs. A. Reynoldson and Sister J.Conway for their valuable assistance.

Since the studies of Kass,'" routine screening for asymptomat ic bacteriur ia by means of bacterial counts has becomean accepted part of ant enat al care. Dixon and Brant'stated that the value of bacterial counts in the detect ionof pyelonephritis of pregnancy had been overemphasized.Most writers, however, agree with Williams et at.' that therelationship between bacteriuria and acute and chronic pyelonephrit is seems beyond doubt a nd that the preventionof these condi tions is sufficient reason to make routinescreening for bacteriuria essential.In prac ti ca lly all t he published work the specimens of

urine used for bacter ia l counts and for cultural examination have been midstream urine collections. Sleigh et al.'and Williams et al.' stressed the importance of the technique of midstream urine collection and of the carefulhandling of the specimens, but this has received littlemention in other articles.Before embarking on a programme of routine screeningfor bacteriuria, i t was decided to investigate the importanceof the technique of mids tream collection on bacter ialcounts in the urine. Two series of patients were investigated.In the first series, no special instructions were given regarding the method of midst ream urine collec tion, or ofhandling of the urine specimens. which were del ivered tothe laboratory by the usual hospital service. In the secondseries, str ict c ri te ri a were laid down for the method ofcollection and for the transport of the specimens to thelaboratory, with particular attention to the technique ofvulval cleansing, and the efficiency of two cleansing agents.

MATERIALS At.... ! ) METHODSAll the pa ti ent s were healthy, pregnant females with noevidence of urinary tract infection. No postpartum caseswere included.In the first series, 78 midstream specimens of urine werecol lected from pat ients a ttending the Antenatal Clinic a tthe Peninsula Maternity Hospital, and sent to the Bacte

riology Laboratory in Groote Schuur Hospi ta l by the usualhospital service.In the second series, 87 midstream specimens of urinewere collected dur ing the morning f rom ward patients in

the Groote Schuur Maternity Block. The method of collection was as fol lows :The patient stood ast ride the toilet and held her labia

'Paper presented at the 46th Sou th Afr ic an Med ical Congress (M.A.S.A.),Durban. July 1967.

I Junie 1968REFERENCES

1. Donald. 1. ((959): Practical Obstetrical Problems, 2nd ed., p. 375.London: L1oydLuke.2. Lish. P. N.. Dungan. K. W. and Pet ers. E . L. ((960): J. Pharmacal.3. ~ : ~ d J c h k e : . - . d . 2 9 H 1 9 a l ~ d Ciblis, L. A. ( (9 61 ): Ame r. J . Obs te !. Gynec.,82. 5. .4. Kar im . M . (1963): J . Obs re !. Gynaec. Brit. Cwlth. 70, 6.5. Bishop. H. and Won te ry , B. (1961): J. Ame r. Med . A ss oc .. 178. 812.6. Bourne. A. W. (959): A Synopsis 0/ Obsretrics and GynaecologL12th ed., p. 231. Bristol: John Wright & Sons.

apart. The nurse collecting the specimen, then swabbedthe vulva with 3 separate sterile cottonwool swabs, soakedin eit her 0'5% aqueous chlorhexidine or sterile normalsaline. Half the pat ients were swabbed with the first andthe other hal f with the second solution. The patient thencommenced to pass urine and the nurse collected not lessthan 10 ml. from the middle of the stream into a cleanplast ic container with a clip-on lid. The container was thenlabelled and delivered immediately by the house surgeonto the laboratory in the hospi ta l. Care was taken that thepatient had not passed urine for at least 4 hours beforethe collection of the specimen.In the laboratory each urine specimen from both serieswas treated as follows:(a) A semi-quanti tative count was carried out asdescribed by Leigh and Wil liams: In principle, a measured

area of blotting paper is used as a vehicle for transferringa constant aliquot of urine to the surface of a culturemedium. From the number of colonies on the inoculatedarea the number of organisms in the urine may be calculated.(b) Wet preparations and Gram-stained smears wereexamined microscopically, and if pus cells or organismswere noted in the 2 preparations, the urine was culturedby plat ing onto a MacConkey agar p la te and Har tl ey agaror blood-agar plate.

RESULTSFirst SeriesOf the 78 specimens, only 5 ( 6 ' 5 ~ ~ ) failed to show anybacterial growth on culture. Sixty-eight (87%) were obviously contaminated as shown by either a heavy vaginalflora on microscopic examination of Gram-stained smearsor by a quant itat ive bacterial count of more than 100,000organisms per m!. with a mixed growth of microorganismson the cul tu re plates. The remaining 5 specimens (65{,)had a count o f more than 100,000 organisms per m\. wi tha pure growth on cu lture, but the findings on microscopyshowed that these too were probably contaminated. Nineteen of the urines were a day old when received at thelaboratory and all were heavily contaminated.Second SeriesOf the 87 urines. 44 (51 O ~ showed no growth on culture.Thirty-five (40%) were contaminated as shown by either ascanty vaginal flora on examination of Gram-stainedsmears and no growth using the semi-quanti ta tive tech-

1.4 management of constriction ring of the uterus using isoxuprine m. barker and j.v. laursen_2

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