10 S.A.

TYDSKRIF VIR OBSTETRIE EN GINEKOLOGIE 1 Junie 1968

symptoms such as hot flushes and atrophic vaginitis, but
their prophylactic use in the prevention of ageing has as
yet to be established. Early enthusiasm for long-term
exogenous oestrogen therapy has resulted in the suggestion
that conditions such as osteoporosis and myocardial in-
farction may be prevented. It has, however, not yet been
shown that these changes are the direct result of with-
drawal of endogenous oestrogens and are preventable by
appropriate oestrogen therapy.
With regard to progesterone administration. Kistner'
states that as yet there is no evidence that progesterone
plays any significant role in the physiology of the meno-
pause.
Several questions urgently require answers.
I. Is the climacteric a normal physiological stage in the
life of the human female, or is it a simple result of ovarian
failure and oestrogen deficiency?
2. Are the manifestations of ageing directly related to
diminution of circulating sex hormones?
3. Can the administration of exogenous oestrogen or
other sex hormones prevent the manifestations of ageing?
4. Are the oestrogens at present available for adminis-
tration equivalent in effect to circulating endogenous
oestrogens?
5. Does long-term oestrogen administration result in an
increased incidence of breast or uterine carcinoma?
6. Do oestrogens have a direct effect on the psychologi-
cal state and sense of well-being in the postmenopausal
patient?
To these ends the development of more precise diagnos-
tic techniques and methods of evaluation is vital.
Wilson's' description of the probable fate of the non-
treated elderly female as being one of hypertension, athe-
rosclerosis, flabby breasts, dowager's hump, atrophic geni-
tals and a vapid cow-like feeling called a 'negative state'
would appear to be an overstatement of the case. How-
ever, there is some reason to believe that the administra-
tion of oestrogens or other sex hormones may not only
alleviate menopausal symptoms, but will have some real
effects on ageing processes in the postmenopausal woman.
SUMMARY
Evidence for the current concept that the climacteric is a
result of hormone deficiency is critically appraised. There is as
yet no proof that long-term oestrogen therapy to the post-
menopausal female is of any major benefit in the prevention
of coronary occlusive disease or osteoporosis. Further con-
trolled investigation into the use of natural oestrogens, particu-
larly their effect on ageing, is an urgent necessity.
I wish to thank Prof. D. A. Davey, head of the Department
of Obstetrics and Gynaecology of the University of Cape
Town, for his constructive criticism during the preparation of
this review.
REFERENCES
1. JefIcoate, T. N. A. (1967): Principles of Gynaecology, 3rd ed.. p. 112.
London; Butterworths.
2. Lewis, T. L. T. (1964): Progress in Clinical Obstetrics and Gynae-
cology, 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. ill Marcus. S. L. and Marcus, C. C.. eds. (1967): Ad-
vances in Obstetrics 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): Circula-
tion. 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 Cooperative Study 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 Menopausal Woman (1966): Bull.
Sloane 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. ObSlet.
Gynec .. 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 Memorial
Hospital, Nqutu, Zululand, Natal
A constriction ring of the uterus 'represents an area of
intense local activity" in an organ in which the normal
polarity of contractions is disturbed. The usual site of
such a ring is at the junction of the upper and lower
segments.
Because the Bantu patient tends to go into labour with
the presenting part well above the brim of the pelvis,
such a constriction ring, even in vertex presentations,
usually forms below the presenting part, thus confining
the foetus to the upper segment of the uterus. When this
occurs, it gives rise to a distinct clinical picture, generally
first recognized because of the failure of the presenting
part to engage with the brim of the pelvis, in spite of
good contractions. Indeed, palpation during a contraction
will often reveal that the presenting part moves up, away
from the pelvic 'brim, and the examiner's hand can always
be comfortably pressed against the abdominal wall be-
*Date received: 28 Sepremben 1967.
tween the vertex and the symphysis pubis, the vertex
making no attempt to push past it to engage with the
brim. Vaginal examination is necessary to confirm the
diagnosis, and usually reveals a more or less dilated
cervix, an empty lower segment, and a constriction ring
holding the presenting part out of the lower segment.
There is no relationship between this condition and
Bandl's ring.
In this unit, where the incidence of constriction ring of
the uterus in vertex presentations during a I-year period
(1966 - 1967) was 8 cases in 1,509 deliveries (0'53%),
special interest in treatment was aroused by the failure
of more conventional methods to relax the ring before
foetal distress supervened. The caesarean sections thus
necessitated were technically difficult, and resulted in poor
scars because the upper segment had so often to be
encroached upon in order to deliver the foetus through
a tight ring. For these. reasons it was decided to study the
TABLE 11. STATUS AT TIME OF DIAGNOSIS
S.A. JOURNAL OF OBSTETRICS AND Gv 'AECOLOGV
The following cases seem to us to be worth describing
in detail.
Results of the treatment are tabulated in Tables I, Il
and Ill. The constriction rings were relieved completely
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11
1V 3* hrs. later
Summary of treatment
Isoxuprine } IM
Pethilorfan
Isoxuprine 5 mg. IM
Isoxuprine 10 mg. IM
Isoxuprine 5 mg.
Pethilorfan 100 mg.
lsoxuprine 5 mg. IM
Pethilorfan lOO rng.
Isoxuprine 10 mg. IM 6 hrs. later
Pethilorfan 100 mg. IM
Isoxuprine 10 mg. IM + IV fl 'd
Pethilorfan 100 mg. UI s
Both repeated 12 hrs. later
Isoxuprine 10 mg. } IM
Pethilorfan 100 mg.
Pethilorfan lOO mg. } IM
Chlorpromazine 25 mg.
Isoxuprine 10 mg. IM 7 hrs. later
Yes
No
Probably
Yes
Yes
Yes
Yes
Yes
TABLE I. SUMMARY OF ANTE 'ATAL FINDINGS
Esrimared period Obstetrical
Age in of geslQlion conjugate Shape of brim
Patient years Parity (weeks) (estimated) (CIIl.) oj"pehis
I 23 I 38 10 Android
2 26 2 40 9'5 Gynaecoid
J 26 5 40 12 Gynaecoid
4 34 3 38-40 105 Platypelloid
5 28 4 40 10 Android
6 16 0 38 11 Gynaecoid
7 26 4 40 10 Android
8 30 I (LSCS) 40 10'5 Android
Each case was then handled on its merits. If the
constriction ring wa relieved. the vertex descended into
the lower segment within an hour of giving isoxuprine,
and gross disproportion did not then become apparent.
the patient was allowed to proceed with labour in the
normal way, and vaginal delivery was awaited. If the
constriction ring appeared to have been improved, but
the vertex remained high. it was sometimes considered
wise to rupture the membranes if these were intact, either
half an hour after the first injection of isoxuprine or
shortly after the drug was repeated. The mother was
then instructed to bear down briefly between two con-
tractions while the ring was relaxed, the observer's hand
being kept in the vagina to assess the result of this
manoeuvre, and to make sure the cord did not prolapse.
In more recent cases, not included in this series, in whom
the cervix was sufficiently dilated to admit one of the
smaller cups of the vacuum extractor, and in whom the
ring disappeared completely between but was still evident
during contractions, we have used this instrument to bring
the vertex down against the cervix, where it was held
during one or two contractions before the vacuum wa,
released.
in 6 out of 8 cases. In one further case it was probably
relieved, but this was not confirmed vaginally. There was
only I failure.
Constriction ring relieved?
Ruptured
Intact
Ruptured
Ruptured
Ruptured
Intact
Intact
Intact
StaTe of membranes
At The time of diagnosis
I June 1968
Patiell1
Duration oflabour Dilation ofcervix
(hours) (cm.)
10 45
2 15 5
3 6 45
4 4 1 5
5 5i
3
6 19 3
7 8 45
8 6 3
effect of i oxuprine (Duvadilan-Philips-Duphar, Amster-
dam) in these cases.
MATERIALS AND METHODS
Our unit is situated in a rural area, where methods of
communication are poor. Because of this, the majority
of our patients spend the final "2 or 3 weeks in the
antenatal ward in the hospital grounds. thus usually
reaching the labour ward fairly early in the course of the
first stage. The standard of care is reasonably high, as
evidenced by a maternal mortality rate of 0'66/1,000
(spontaneous rupture of a left cardiac ventricle in early
puerperium), and a perinatal mortality rate of 43'3/1,000,
during the period under discussion. All patients. with only
one exception, were Zulus or Basutos.
Each patient had the usual investigations during the
antenatal period, including estimation of haemoglobin,
the Wassermann reaction and a clinical pelvic assess-
ment. Facilities for radiological assessment were not
available. Inpatients, unless ill, were seen twice weekly
for routine antenatal examinations by a medical officer.
Only cases with vertex presentation were included in
this series, because the prognosis for vaginal delivery if
the ring could be relieved was so much better. Limiting
the discussion in this way also removes other factors
which would interfere in the assessment of the assistance
this treatment gave to the surgeon in such
caesarean sections as became necessary. All caesarean
sections were performed under local anaesthesia.
As soon as a constriction ring of the uterus was sus-
pected on abdominal examination, the diagnosis was
confirmed by vaginal examination by one of us. The
treatment then instituted consisted of isoxuprine, 5 mg.
or 10 mg. given by the intramuscular or intravenous route,
with or without Pethilorfan 100 mg., generally given
intramuscularly. One patient (case 5), was given Pethilor-
fan only, with the intention of administering isoxuprine
later if this proved necessary. Another (case 8) was given
Pethilorfan, 100 mg., and chlorpromazine, 25 mg., both
intramuscularly, followed later by isoxuprine when there
was no improvement in the condition.
12 S.A. TYDSKRIF VIR OBSTETRIE E r GINEKOLOGIE
TAilLE Ill. SUMMARY OF RESULTS OF TREATMENf
1 Junie 1968
MaTernal side-effects possibly
Weight ofbaby Puerperium atTribuTable 10 isoxuprine
6 lb. 6 oz. Normal None
6 lb. 11 oz. Normal Urinary retention 12 hrs. postpartum
Trealmem- IndicaTions
PaTient delivery imerral Type ofdelhery for LSCS Blood loss
1 13 hrs. 10 min. Spontaneous 60 ml.
2 2 hrs. 30 min. LSCS Disproportion. 450 ml.
Foetal distress
3 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 record
6 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.
ormal
lormal
Normal
ormal
Moderate
sepsis
ormal
Twitching (transitory)
Urinary retention 24 hrs. postpartum
'one
Records incomplete
'one
None
CASE REPORTS
Case I
C.M., aged 23 years, para. 1, gravida 2, with a negative
Wassermann reaction, and a haemoglobin concentration
of 115 G /100 ml., presented in the labour ward soon
after sunrise, having been in labour since about midnight.
Her general condition was good, with a blood pressure of
100/70 mm.Hg. Abdominal palpation revealed a high
mobile vertex as the presenting part. Uterine contractions
were poor and incoordinate in type. Foetal heart rate was
140/min. Vaginal examination confirmed a constriction
ring about the junction of the upper and lower segments,
well above a 4-5-cm. dilated cervix. The vertex was
resting on this ring. Membranes were intact. Pethilorfan,
lOO mg., and isoxuprine, 5 mg., were given by the intra-
muscular route. Contractions became weaker, but the
vertex descended into the lower segment, and vaginal
examination carried out 6 hours later confirmed that the
constriction ring had disappeared. She gave birth to a
male infant with an Apgar rating of 9, weighing 6 lb.
6 oz., 13 hours after the isoxuprine injection. The puerpe-
rium was normal.
Case 3
A.B., aged 26 was a para. 5, gravida 6, and had had one
abortion at 16 weeks. Her last baby had weighed 9 lb. 5 oz.,
and had been delivered by vacuum extraction. She was ad-
mitted to the labour ward in good condition, having been
in labour for about 6 hours. Her blood pressure was
110/70 mm.Hg. Abdominal palpation revealed a high mo-
bile vertex presentation. The foetal heart was within normal
range. Vaginal examination revealed a 4-5-cm. dilated
cervix with a sausage of membranes protruding through
this from a constriction ring 2 inches higher up, which
admitted 2 fingers only. Isoxuprine, 10 mg., was adminis-
tered by the intramuscular route. Three hours later the
cervix had progressed to almost full dilation, but the
constriction ring remained unchanged. Isoxuprine, 5 mg.,
and Pethilorfan, 100 mg., were administered intravenously,
and the membranes were ruptured. The patient subse-
quently had some mild twitchings. with a blood pressure
of 110/70 mm.Hg. Two hours after the second dose of
isoxuprine, the constriction ring had disappeared, and
contractions were very weak. The cervix had closed down
to 3 cm. dilation and was now only partially effaced.
but was well applied to the presenting part. Within a few
hours contractions became established again, and 12 hours
later she delivered an 8 lb. 3 oz. infant with an Apgar
rating of 10. Blood loss was 300 ml. The puerperium was
uneventful.
Case 4
M.S., aged 34 years, was a para 3, gravida 4, with a
negative Wassermann reaction, and a haemoglobin con-
centration of 115 G /100 mI. She was first seen when she
had been in labour for 4 hours. Her general condition was
good, and her blood pressure was within the normal
range. On abdominal palpation, the vertex was presenting
and was high and mobile. Contractions were irregular and
fairly strong. Vaginal examination confirmed a constric-
tion ring of the uterus well above a 15-cm. dilated cervix
and seemingly at the junction of the upper and lower
segments. The membranes were intact. The patient was
given a simple enema. Isoxuprine, 5 mg., and Pethilorfan,
100 mg., were administered intramuscularly. Seven hours
later the uterus had become even more abnormal in action,
an additional constriction ring having formed at the level
of the neck of the foetus. Findings on vaginal examination
were unchanged. Isoxuprine, 10 mg., was given intra-
muscularly, and Pethilorfan, 100 mg., by slow intravenous
injection, with no improvement in the first constriction
ring, although the second ring disappeared. Lower-segment
caesarean section was decided upon 12 hours after the
diagnosis had been made, before foetal distress super-
vened. Operation, performed under local anaesthesia, re-
vealed sufficient lower segment to make the procedure
feasible, but the upper segment had to be entered in the
left-hand corner of the incision in order to deliver the
baby. The Apgar rating was 9, and the weight 6 lb. 12 oz.
Blood loss was about 450 mI. The puerperium was compli-
cated in the first 24 hours by urinary retention necessitat-
ing catheterization and drainage for 12 hours.
In retrospect, it seems likely that if intravenous isox-
uprine had been used when the condition was first diag-
nosed, and membranes had been ruptured when relaxation
had occurred, better results might have been obtained.
However, the second dose of isoxuprine did relax the ring
around the neck of the foetus, making delivery of the
baby relatively easy once the primary ring had been cut.
ISOX PRINE
Isoxuprine (Duvadilan) has the following structural for-
mula:
>
CH) C1H) >
Ho\. ) CHOH- tH-NH-cH-CHP <. HCl
It is postulated that the drug depresses uterine activity
by activating the beta-adrenergic receptors of the muscle
cells,' and the effect in laboratory animals was found to
be independent of hormonal status. However, it is sug-
S.A. JOURNAL OF OBSTETRICS A D GYNAECOLOGY 1 June 1968
gested that the effect in humans may be regulated to
some degree by oxytocin 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 frequency of contractions.
(c) Reduction in the amplitude of contractions. This
effect was of shorter duration than the effect on
the tone of the uterus, thus giving 'greater effi-
ciency of the uterus for delivery'. This in turn led
to more rapid dilation of the cervix in 25 % of his
cases.
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 are
present, the chief effect appears to be on the tone of
the uterus, correcting abnormal patterns of contraction,
but not stopping the labour.
Karim was able to show that isoxuprine does not
cause postpartum haemorrhage:
Given intravenously, in undiluted form, the drug acts
almost immediately, but 10 mg. given in this way will
produce a certain incidence of side-effects. By the intra-
muscular route, the drug acts within 5 minutes, and
maintains its action for one hour; side-effects are rare.
Subsequent to this series, it has become our practice to
give 5 mg. intravenously and 5 mg. intramuscularly at
the same time, in an effort to minimize side-effects, while
getting the benefit of a rapid onset of action.
In all the cases in this series, the reduction in tone of
the uterus and in the frequency and duration of con-
tractions was a very noticeable result of the injection.
It was during this period of uterine tranquillity that the
vertex passed through the constriction ring and applied
itself to the cervix. The moment this had occurred, the
pattern of labour became more normal, contractions be-
coming stronger and more frequent, and the cervix
dilated in the normal way.
The side-effects encountered by Karim included a tran-
sient, and usually unimportant, drop in maternal blood
pressure, and a rise in maternal and foetal heart rates.
More important effects included occasional cases of
diplopia, tremors and urinary retention. All these effe:t:;
were transitory:
Table III illustrates the side-effects we encountered. One
patient had transient twitching an hour after her second
dose of isoxuprine; her blood pressure and urine were
normal at the time. Two patients developed urinary reten-
tion after caesarean section, but the significance of this,
in the presence of postoperative pain, is difficult to
assess.
Postpartum blood loss was normal in all cases except
one in whom a branch of both uterine arteries was cut
during caesarean section, resulting in a total loss of
about 900 m!.
DISCUSSION
From this series of cases, several interesting facts emerge.
This is a condition found chiefly in multiparous patients.
The single primiparous patient in this series is the only
case we have had in this unit, and so we suspect that the
incidence in first pregnancies is, in fact, lower than this
series suggests. The condition usually seemed to be present
13
from an early stage during the labour. Cases 1, 2 and 6
were seen initially by junior members of staff who were
misled by fairly weak contractions and failure of descent
of the vertex, into thinking that the patients were not in
established labour, and the diagnosis was therefore de-
layed.
Ruptured membranes were not by any means a con-
stant feature, 50% of these patients having intact mem-
branes at the time of diagnosis. This is in contrast to the
experience of others in obstetrics dealing only with
Whites.'
The success of treatment does not seem to depend
greatly upon the state of the cervix or the duration of
labour at the time it is instituted, but rather upon the
degree of disruption of normal uterine polarity, as the
single failure in this series seems to suggest.
Insurmountable cephalopelvic disproportion was present
in 2 of the cases, a much higher incidence than in the
general obstetrical population in this area (about 10%).
Of the cases requiring caesarean section, well-formed
lower segments were present in cases 2 and 8, the opera-
tions were technically easy and the surgeon expected the
scars to be good. In case 7, labour had to be interrupted
before enough time had elapsed for a good lower seg-
ment to be formed, but it was still possible to obtain a
good lower-segment scar. Only in case 6, in whom the
ring persisted, was it necessary to cut into the upper
segment at the left-hand end of the incision in order to
deliver the baby. These findings are in marked contrast
to those of Bourne, who states that 'it is essential to
make a vertical incision through the ring' in order to
deliver the baby safely.
Only in one case (case 6) was maternal distress a
feature.
CONCLUSIONS
While we accept that rupture of the uterus due to a
constriction ring is a very unlikely event, and the con-
dition is 'reversible with heavy sedation and the lapse of
time',' it was all too often our experience with other
methods of treatment that, after many anxious hours, a
difficult caesarean section was the only safe means of
delivering a distressed foetus. Frequently it was necessary
to extend the incision into the upper segment in order to
deliver the head through a tight constriction ring, and
sometimes one had the unpleasant experience of the vertex
floating away out of reach, necessitating internal version
and breech extraction in an already dangerously tight
uterus.
With its ability to relax a constriction ring and
allow the vertex to descend into the lower segment,
isoxuprine seems to be a useful drug in the management
of this difficult condition. At best it ensures a spontaneous
vaginal delivery, and at worst a technically eas;er, and
therefore safer, caesarean section.
Best results are obtained when active measures are
employed to prevent the recurrence of the constriction
ring 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.
SUMMARY
A suggested method of m a n a ~ e m e n t of a con triction ring
of 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., From the Departments of Obstetrics and Gynaecology and Bacteriology,
Groote Schllllr Hospital, and University of Cape Town
S.A. TVDSKRIF VIR OBSTETRIE EN GlNEKOLOOm 14
isoxuprine, is discussed with reference to a small series in
Bantu patients. Treatment was successful in 6 out of 8 cases,
with a further probable success and only one failure. There
was no serious maternal or foetal morbidity.
We wish to thank Dr. E. A. Barker, Medical Superintendent
of the Charles Johnson Memorial Hospital, for permission to
use hospital records, and Mrs. A. Reynoldson and Sister J.
Conway for their valuable assistance.
Since the studies of Kass,'" routine screening for asympto-
matic bacteriuria by means of bacterial counts has become
an accepted part of antenatal care. Dixon and Brant'
stated that the value of bacterial counts in the detection
of pyelonephritis of pregnancy had been overemphasized.
Most writers, however, agree with Williams et at.' that the
relationship between bacteriuria and acute and chronic pye-
lonephritis seems beyond doubt and that the prevention
of these conditions is sufficient reason to make routine
screening for bacteriuria essential.
In practically all the published work the specimens of
urine used for bacterial counts and for cultural examina-
tion have been midstream urine collections. Sleigh et al.'
and Williams et al.' stressed the importance of the tech-
nique of midstream urine collection and of the careful
handling of the specimens, but this has received little
mention in other articles.
Before embarking on a programme of routine screening
for bacteriuria, it was decided to investigate the importance
of the technique of midstream collection on bacterial
counts in the urine. Two series of patients were investigated.
In the first series, no special instructions were given regard-
ing the method of midstream urine collection, or of
handling of the urine specimens. which were delivered to
the laboratory by the usual hospital service. In the second
series, strict criteria were laid down for the method of
collection and for the transport of the specimens to the
laboratory, with particular attention to the technique of
vulval cleansing, and the efficiency of two cleansing agents.
MATERIALS At..... '!) METHODS
All the patients were healthy, pregnant females with no
evidence of urinary tract infection. No postpartum cases
were included.
In the first series, 78 midstream specimens of urine were
collected from patients attending the Antenatal Clinic at
the Peninsula Maternity Hospital, and sent to the Bacte-
riology Laboratory in Groote Schuur Hospital by the usual
hospital service.
In the second series, 87 midstream specimens of urine
were collected during the morning from ward patients in
the Groote Schuur Maternity Block. The method of collec-
tion was as follows:
The patient stood astride the toilet and held her labia

'Paper presented at the 46th South African Medical Congress (M.A.S.A.),

Durban. July 1967.
I Junie 1968
REFERENCES
1. Donald. 1. ((959): Practical Obstetrical Problems, 2nd ed., p. 375.
London: L1oydLuke.
2. Lish. P. N.. Dungan. K. W. and Peters. E. L. ((960): J. Pharmacal.
3. Ciblis, L. A. ((961): Amer. J. Obste!. Gynec.,
82. 5. .
4. Karim. M. (1963): J. Obsre!. Gynaec. Brit. Cwlth. 70, 6.
5. Bishop. H. and Wontery, B. (1961): J. Amer. Med. Assoc.. 178. 812.
6. Bourne. A. W. (959): A Synopsis 0/ Obsretrics and GynaecologL
12th ed., p. 231. Bristol: John Wright & Sons.
apart. The nurse collecting the specimen, then swabbed
the vulva with 3 separate sterile cottonwool swabs, soaked
in either 0'5% aqueous chlorhexidine or sterile normal
saline. Half the patients were swabbed with the first and
the other half with the second solution. The patient then
commenced to pass urine and the nurse collected not less
than 10 ml. from the middle of the stream into a clean
plastic container with a clip-on lid. The container was then
labelled and delivered immediately by the house surgeon
to the laboratory in the hospital. Care was taken that the
patient had not passed urine for at least 4 hours before
the collection of the specimen.
In the laboratory each urine specimen from both series
was treated as follows:
(a) A semi-quantitative count was carried out as
described by Leigh and Williams: In principle, a measured
area of blotting paper is used as a vehicle for transferring
a constant aliquot of urine to the surface of a culture
medium. From the number of colonies on the inoculated
area the number of organisms in the urine may be calcu-
lated.
(b) Wet preparations and Gram-stained smears were
examined microscopically, and if pus cells or organisms
were noted in the 2 preparations, the urine was cultured
by plating onto a MacConkey agar plate and Hartley agar
or blood-agar plate.
RESULTS
First Series
Of the 78 specimens, only 5 failed to show any
bacterial growth on culture. Sixty-eight (87%) were ob-
viously contaminated as shown by either a heavy vaginal
flora on microscopic examination of Gram-stained smears
or by a quantitative bacterial count of more than 100,000
organisms per m!. with a mixed growth of microorganisms
on the culture plates. The remaining 5 specimens (65{,)
had a count of more than 100,000 organisms per m\. with
a pure growth on culture, but the findings on microscopy
showed that these too were probably contaminated. Nine-
teen of the urines were a day old when received at the
laboratory and all were heavily contaminated.
Second Series
Of the 87 urines. 44 (51 showed no growth on culture.
Thirty-five (40%) were contaminated as shown by either a
scanty vaginal flora on examination of Gram-stained
smears and no growth using the semi-quantitative tech-