The students’ perceptions of the teachers’ practices in the classroom:

were adversely affected by poor socioeconomic supports. Many studies have however demonstrated little advantage in instituting active intensive care to infants born at 22 and 23 weeks gestational age because of the high morbidity and poor quality of life associated with the survival of such infants.^14-17

delivery in defined populations, is thus offered to those women in labour with intact membranes and cervical dilatation less than 5cm.⁴⁴ A review of current literature however shows that only a minority of women who go into preterm labour meet current criteria for tocolytic therapy.⁴³ Tocolytic therapy also buys time for such measures as maternal transfer to an institution with facilities for neonatal care and for corticosteroid therapy for lung maturity. Complications include maternal hyperglycaemia, hyperkalaemia, tachycardia, cardiac arrhythmias, increased intravascular volume and pulmonary oedema.⁴⁴ It also leads to fetal hyperglycaemia.⁴⁴

In those women with intact membranes and whose gestational age is between 26 and 34 weeks, especially if a delay of 48 hours can be obtained, pulmonary maturity therapy should be instituted.¹²⁶ Corticosteroid therapy requires at least 24 to 36 hours for it to be effective.¹²⁷ The incidence of neonatal respiratory distress is reduced by 40 to 60% of that found in untreated patients.¹²⁷ Crowley et al¹²⁸ has reviewed all the controlled trials on the role of exogeneous corticosteroids in preventing RDS and concluded that all the benefits were achieved without any detectable increase in the risk of maternal, fetal or neonatal infection, even in the presence of prolonged rupture of membranes. Agents that can be used include betamethasone or dexamethasone.

Premature rupture of membranes is leakage of amniotic fluid through the cervix before the onset of labour.¹²⁹ When this occurs before term, it is termed preterm premature rupture of membranes (preROM).¹²⁹ It is the leading identifiable cause of preterm delivery associated with 30 to 40% of all preterm births and contributes to perinatal morbidity and mortality.¹² Between 60 and 80% of patients

with preROM go into labour in 24 hours while an additional 15 to 25% go into active labour in 72 hours.¹³⁰ The overall objective of management is expectant until a gestational age beyond which neonatal morbidity and mortality is minimal and to achieve delivery before the mother and/or her fetus become infected.¹³¹ Thus, the initial management depends on the gestational age and the presence or absence of chorioamnionitis. With chorioamnionitis, delivery is necessary regardless of the gestational age.¹³¹ With documented fetal lung maturity after 32 weeks gestational age, delivery is recommended.¹³¹ If however fetal lung maturity is not confirmed, delivery should be guided by availability of neonatal intensive care facilities and the chances of survival at that gestational age for that institution.¹³¹ In the absence of clinical chorioamnionitis, steroids should be used to mature the lungs below 32 weeks gestational age.¹³¹ Studies have confirmed that groups treated with antibiotics do better than controls, though the use of amoxicillin- clavulanic acid combination has been associated with NEC in the infant.^132,133 The role of tocolysis is controversial but is generally discouraged especially if chorioamnionitis has not been completely ruled out.¹²⁵ A sterile speculum should be used for pelvic examination and should be minimized as much as possible.¹²⁷

The attitude of the obstetrician, in instituting or withholding active obstetric intervention, is an important variable in determining the outcome of these infants.¹²⁷ Primary causes of mortality are SPA, RDS and infection. Others include BPD, NEC, pneumothorax and IVH.¹²

When the fetus is presenting cephalic, there is no specific policy on the mode of delivery. Advocates of Caesarean section (CS) delivery propose that it helps to

reduce the incidence of hypoxia, IVH and SPA while those of vaginal delivery stress the disadvantage of CS like higher maternal morbidity and mortality and higher chances of subsequent CS delivery.¹²⁷ A review of the literature has failed to show any statistically significant difference between outcome and method of delivery in cephalic fetal presentation.^134-137 All these studies were however retrospective with its attendant limitations. Similarly, no evidence was found for routine use of forceps prophylactically in the delivery of VLBW and ELBW babies.^{138- 141} Infact, the greater percentage of studies found a worse outcome when prophylactic forceps was used.

138-140 The steel cup vacuum delivery is considered contraindicated for preterm delivery.¹²⁷ Prophylactic episiotomy, though a time honoured intervention emphasized throughout the literature, is another debatable subject in preterm delivery. Lobb and Cooke¹⁴² for example, found no evidence to support routine use of prophylactic episiotomy in preterm delivery.

In preterm babies with breech presentation, CS is routinely performed at present. A review of available literature shows that though there is no general agreement, there is overwhelming evidence in favour of CS delivery. While Kaupilla and colleagues¹⁴³ found a difference between vaginal breech extraction and CS that was not statistically significant, most other workers found a difference that was statistically significant in favour of CS.^144-147 On the other hand, while Karp and associates¹⁴⁸ supported vaginal delivery of preterm breech infants, Woods¹⁴⁹ suggested that CS should not be routine but should be individualized.

The umbilical cord should be clamped and ligated within 30 seconds of delivery of the infant with the infant positioned at the level of the maternal trunk. A

delay in clamping the cord especially with the baby malpositioned can either lead to increase in blood volume or anaemia. An increase in blood volume can lead to pulmonary oedema, intracranial haemorrhage, hyperbilirubinaemia and polycythaemia, worsening outcome.¹²