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Background: There is no consensus on the preferred time to remove urethral catheter post caesarean section. Aim: To compare rate of significant bacteriuria and urinary retention following 8-h (study) and 24-h urethral catheter removal (control) post elective caesarean section. Methods: A randomized controlled trial of eligible participants that underwent elective caesarean section under spinal anaesthesia between March 2019 and November 2019 was conducted. Participants (150 in each arm) were randomly assigned (1:1 ratio) to either 8-h or 24-h group. Primary outcome measures included rates of significant bacteriuria 48-h post-operatively and acute urine retention 6-h post urethral catheter removal. Analysis was by Intention-to-treat. ( www.pactr.org:PACTR202105874744483 ) Results: There were 150 participants randomized into each arm and data collection was complete. Significant bacteriuria was less in 8-h group (3% versus 6.0%; risk ratio (RR): 0.85 CI: 0.60 to 5.66; p = 0.274), though not significant. Acute urinary retention requiring repeat catheterisation was significantly higher in 8-h group (11(7.3%) versus 0(0.0%); RR: 0.07; CI: 0.87 to 0.97; p = 0.001). Mean time until first voiding was slightly higher in 8-h group (211.4 ± 14.3 min versus 190.0 ± 18.3 min; mean difference (MD): 21.36; CI: −24.36 to 67.08; p = 0.203); but patient in this group had a lower mean time until ambulation (770.0 ± 26.1 min versus 809 ± 26.2 min; MD: −38.8; CI: −111.6 to 34.0; p = 0.300). The 8-h group were significantly more satisfied (82/150 (54.7%) versus 54/150 (36.0%); p = 0.001) Conclusions: An 8-h group was associated with significant clinical satisfaction and acute urine retention compared to 24-h removal. The timing of urethral catheter removal did not affect rate of significant bacteriuria and other outcomes

Introduction: Reproductive Health is a concept that caters for the complete health of humans from conception to the grave. Currently, the concept has undergone an expansion of its scope beyond the elimination of mortality and physical morbidity: Methods: Issues such as respect for women’s autonomy; rights, preferences, dignity and right to informed choice, as well as shared decision-making process were brought under the spotlight. The quality of reproductive health services available in a nation reflect on the overall health of the citizens and assesses the relationship between the three key components of health care, including the Client, Healthcare providers, and the relationship between the two. Indeed, the technical aspect of medical practice (diagnosis and treatment) is as important as the human, physical and the contextual setting in which the health care service is rendered. Developing countries like Nigeria must start to look beyond addressing morbidity and mortality in quantitative forms and consider the mental and psychological wellbeing of their citizens as well. Outcome: The Structures, Processes and Outcomes of reproductive health care in Nigeria were critically appraised, and suggestions for improvement were made as appropriate in this article.

Background: The procedure of vaginal hysterectomy is a fast disappearing art. This study looks at 14 years' experience of vaginal hysterectomy in Ile-Ife, Nigeria. Objectives: To determine and compare the rate, indications, and complications of vaginal hysterectomy over a 14-year period at Ile-Ife, Nigeria. Methods: The medical records of patients managed with vaginal hysterectomies performed from 1st January 2005 to 31st December 2018 were reviewed. The demographics and indications for vaginal hysterectomy were extracted. Data were analyzed using Statistical Package for Service Solutions – IBM version 22. Frequencies and percentages were calculated and associations compared where applicable using Chi-square with level of significance set at

Background: Episiotomy is a deliberate surgical incision of the perineum with the aim of increasing the vulval outlet to facilitate childbirth. However, it could be associated with some complications, such as pain, hemorrhage, and wound infection. It is a surgical procedure that requires adherence to basic surgical principles of providing adequate analgesia. Aim: To determine the efficacy of magnesium sulphate (MgSO4) as an adjunct to local anesthetics for analgesia during episiotomy repair among women that had vaginal delivery at Usmanu Danfodiyo University Teaching Hospital Sokoto, Sokoto, Nigeria. Subject and Methods: This was a single-blind randomized clinical trial. Pregnant women who had episiotomy during the study period were randomized into two groups. Those in Group A had xylocaine administered alone, whereas those in Group B had xylocaine + MgSO4 administered for repair of episiotomy. Pain was assessed by numeric rating scale at commencement of the repair, at 2 and 6 h after the repair. Patient's level of satisfaction, request for additional analgesia, and side effects were also assessed. Results: The pain score in the xylocaine + MgSO4 group was lower throughout the period of assessment. There was no significant difference in the pain scores between the two groups at 0 and 6 h. However, there was significant difference in the mean pain scores between the two groups at 2 h (P

Labour and its management constitute one of the most important elements of obstetrics and the prevention of maternal and/or perinatal morbidity and mortality. In practice, while it is important to avoid meddlesome obstetrics, well-timed and correctly deployed obstetric interventions are unarguably lifesaving. Modern day obstetric practice is therefore about achieving and maintaining that safe balance between a hands-off approach which avoids meddlesomeness, and outright interventionism. Building from a rich historical perspective, this chapter explores the various modern approaches to labour management and provides a detailed analysis of the current best available evidence on the subjects of active management of labour, the partograph, as well as the identification and management of abnormal labour.

Key Clinical Message Our aim is that urologists, gynecologists, nephrologists, and general practitioners will be reminded that diagnosis of renal malignancies sometimes require a high index of suspicion as they may remain asymptomatic in advanced stages; even as they can also rarely co‐exist with and cause peculiar challenges in pregnancy.

Choricarcinoma co-existing with pregnancy is rare often misdiagnosed with great potential for hemorrhagic complications and death. We present a case of a 34-year-old woman diagnosed with choriocarcinoma in her 3rd pregnancy with vaginal and pulmonary metastasis. Her first episode of vaginal bleeding was in the third trimester which was misdiagnosed. She had spontaneous vaginal delivery at 34 weeks of a healthy neonate. She was refered to gyneoncology unit of our hospital 5 weeks into puerperium from a nearby State hospital due to continouos vaginal bleeding and a growth from the postero-lateral wall of the lower third of the vagina. She had five courses of EMA-CO regimen. Her beta-human chorionic gonadotropin (hCG) has fallen from pretreatment value of 168,266 mIU/ml to

Background: Infertility is a major public health problem in developing countries where pelvic inflammatory disease due mainly to Chlamydia trachomatis and Neisseria gonorrhea infection have been implicated. The role of Chlamydia serology in predicting tubal factor infertility (TFI) has been demonstrated by many researchers elsewhere. However, there are limited data in our environment. This prospective cross-sectional study aims to determine the usefulness of Chlamydia Serology as a screening tool for TFI at Federal Medical Centre, Bida, North Central Nigeria.Methods: 125 women with infertility who met the inclusion criteria were enrolled into the study. Relevant information on their socio-demographic characteristics, gynaecological symptoms and risks factors for infertility were obtained. Participants had Hysterosalpingography (HSG) as part of their fertility work-up while 5ml of venous blood was withdrawn to check for Immunoglobulin G antibody to Chlamydia trachomatis using rapid test kits. The HSG findings were correlated with the result of Chlamydia serology. Data was analyzed using the computer software, Statistical Package for Social Science (SPSS) version 20. The level of significance (p value) was set at 0.05.Results: A total of 120 infertile women completed the study, 5 had incomplete investigations and were excluded from the analysis. The prevalence of TFI was 47.5%, while that of positive chlamydia serology was 36.5%. The prevalence of chlamydial seropositivity was 59.6% for patients with TFI but 15.9% for non-TFI. There was a significant association between positive chlamydia serology and TFI p< 0.05. The study revealed moderate sensitivity 59.6%, and negative predictive value 69.7% but high specificity 84.1% and positive predictive value of 77.2%. In this study the odds for diagnosing tubal infertility was 7.8.Conclusions: Chlamydia serology is useful in predicting TFI and should be incorporated in the routine work up for infertility.

Objective: To assess the impact of training on use of the partogram for labor monitoring among various categories of primary health care workers. Methods: Fifty-six health workers offering delivery services in primary health care facilities were trained to use the partogram and were evaluated after 7 months. Results: A total of 242 partograms of women in labor were plotted over a 1-year period; 76.9% of them were correctly plotted. Community health extension workers (CHEWs) plotted 193 (79.8%) partograms and nurse/midwives plotted 49 (20.2%). Inappropriate action based on the partogram occurred in 6.6%. No statistically significant difference was recorded in the rate of correct plotting and consequent decision-making between nurse/midwives and the CHEWs. Conclusion: Lower cadres of primary health care workers can be effectively trained to use the partogram with satisfactory results, and thus contribute towards improved maternal outcomes in developing countries with scarcity of skilled attendants.

A cross-sectional study was carried out among 134 antenatal clinic attendees in a Nigerian tertiary hospital to assess pregnancy-related sexual beliefs and changes in sexual frequency and response. Information was collected through a semi-structured questionnaire, and analysed by SPSS. Only 15% of women believed that religious, social or cultural reasons prevented sexual intercourse in pregnancy. Frequency of sexual intercourse decreased in pregnancy in 37.4% of the respondents, remained unaltered in 46.1% and increased in 16.5%. Age, marriage duration and gestational age were not associated with change in the pattern of coital frequency in pregnancy, but education was significantly associated. Sexual responsiveness diminished in approximately half of our respondents in terms of arousal (54.5%), orgasm (48.5%), pleasure (43.7%) and satisfaction (51.4%). The changes were not associated with pregnancy duration. We concluded that sex in pregnancy is well accepted in our environment, and health workers should promote sexual health and well-being in pregnancy.

Objectives: Clinical outcomes following the exclusive use of autotransfusion in the management of ruptured ectopic pregnancy are reviewed. Methods: A MEDLINE search (1966–2002) for relevant articles documenting the exclusive use of autotransfusion, and data collection and analysis was made. Results: There were 21 studies, 16 from developing and five from developed countries, involving 632 cases of ruptured ectopic pregnancies. Hypovolemic shock with significant hemoperitoneum (>500 ml) was the most common complication. The procedure was performed completely manually in developing countries and with the help of a device in developed countries. The mean volume of autotransfused blood was over 1000 ml, with mean hemoglobin levels ranging from 6 to 12.5 g/dl. Mean posttransfusion hemoglobin levels were higher than pretransfusion levels. There was one death, thought to be due to pulmonary embolism, and nine major and minor complications. Conclusions: Autotransfusion is useful in the management of ruptured ectopic pregnancy.

The occupational health hazards among health-care workers in an obstetrics and gynaecology unit were investigated. A total of 78 pretested questionnaires were administered to the doctors, nurses and ward orderlies in the unit of Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. The common occupational health hazards were work-related stress (83.3%), needle-stick injuries (75.6%), bloodstains on skin (73.1%), sleep disturbance (42.3%), skin reactions (37.2%) assault from patients (24.3%) and hepatitis (8.9%). Nearly half of the staff used diazepam, lexotan or alcohol to cope with the stress of work. A greater percentage of doctors compared to nurses and ward orderlies used safety precautions such as gloves, facemasks and aprons. All the staff employed regular handwashing after various procedures. However no category of staff adopted regularly proper disposal of needles and sharps into separate puncture-resistant containers. About 59% of the staff recap used needles. The implications of the findings were discussed and recommendations made appropriately.

This is a prospective study that examined the nature of emergency obstetric admissions in a Nigerian university hospital in association with such factors as late referrals and misdiagnoses and their contribution to maternal and perinatal morbidity/mortality. The study comprised 144 consecutive emergency obstetric admissions to the hospital over a 6.5-month period. An incidence of 13.6% emergency admissions was recorded. Despite the proximity of the hospital to the parturients, most of them laboured in substandard facilities within the community. Referrals to the university hospital were made only after prolonged delay and onset of complications. Obstetric haemorrhage (24.6%) was the most common cause for referral followed by labour disorders (19%) and hypertensive disorders (8.4%). Thirteen maternal deaths occurred, giving a maternal mortality ratio of 6.2%, while perinatal mortality rate was 461 per 1000 births. Twelve of the maternal deaths were in women living within 5 km of the hospital. There was a caesarean section rate of 50.9%, a 4.8% incidence of diagnostic laparotomy, a 9% incidence of emergency hysterectomy and 44% of emergency blood transfusions. Misdiagnoses of clinical conditions were made by the referring centres in 68% of cases, which contributed to the high maternal morbidity and mortality. Patient attitude was the main cause of non-use of teaching hospital facilities (fear of operation in 32% of cases, dissuasive advice from friends in 27.4% and negative staff attitude in 7%). A need for and type of programme that will promote increased utilisation of modern maternal health services in the community are discussed.

This is a 5-month prospective study to determine the decision emergency caesarean delivery interval in a Nigerian tertiary hospital, the factors responsible for the delays and the consequent maternal and perinatal complications. One hundred and thirty-four emergency caesarean deliveries were analysed and the main indications were failure to progress/ prolonged labour (35.4%), previous caesarean-section/failed trial of scar (27.9%), cephalopelvic disproportion (26.8%), fetal distress (19.5%), pre-eclampsia/eclampsia (15.3%) and obstructed labour/ruptured uterus (14.7%). The mean decision-caesarean delivery interval was 4.4 +/- 4.2 (SD) hours (range 0.5-26 hours), median 3.2 hours and mode 2 hours. Bottlenecks within the maternity unit were responsible for delays in 31.7% of cases. Unavailability of paediatrician (19.6%), non-availability of anaesthetic coverage (13.6%), unreadiness of the operation theatre (11.9%) and seeking second opinion (6.4%) were other major causes of delay. There were 15 perinatal deaths, five of whom were directly linked to the delays i.e. a perinatal mortality rate of 3.7%. Four maternal deaths were directly attributable to delay, a maternal mortality rate of 3%. Other direct consequences of the delays were severe haemorrhage (10.3%), uterine rupture (2.3%) and disseminated intravascular coagulopathy (1.5%). Suggestions on how to minimise delays in emergency services and overall improvement in quality assurance control are discussed.

This is a review of the problems of cervical cancer in Nigeria, typified by data from a tertiary hospital over a 9-year period. Of 146 cases of cervical cancer studied, 79% presented in advanced stages, peak age incidence was between 40 and 70 years, mean 54.5 +/- 12.4 (SD) years. Squamous cell carcinoma was predominant (97% of cases). Presentation was typical: mainly abnormal vaginal bleeding, vaginal discharge and postmenopausal bleeding. Low socioeconomic status (90%) and high parity (83%) were prominent features. Treatment and outcome were poor because of late presentation, lack of radiotherapy facilities and inadequate surgical procedures. Comparison with previous Nigerian studies reveal a continued lack of improvement over the years as regards preventative strategies and adequate treatment facilities. Suggestions on cervical cancer control measures for developing countries like Nigeria are given.

This study analysed the reproductive morbidity associated with 91 cases of retained placenta at the Obafemi Awolowo University Hospital in Nigeria. The incidence of retained placenta in the hospital was 1.4% of all deliveries. Over 42% of the patients were admitted in haemorrhagic shock; 56.5% were anaemic, 10.6% severely; 17% had puerperal sepsis while 67% of the women received blood transfusions. There was one maternal death (1%). Unbooked patients (74%) constituted the largest proportion of cases while inappropriate management of the third stage of labour featured in many of the patients. Retained placenta was treated with manual removal in 90% of cases. Properly supervised delivery is an important component in efforts to reduce the incidence of morbidity associated with retained placenta in Nigeria.

To determine the influence of multiple contraceptive counselling sessions during antenatal care on use of modern postpartum contraception.A total of 216 eligible pregnant women were randomised into antenatal and postnatal counselling groups. The 'Antenatal group' received one-to-one antenatal contraceptive counselling on several occasions while the 'Postnatal group' received a single one-to-one contraceptive counselling session at the sixth week postnatal check, as is routinely practised. All participants were contacted six months postpartum by telephone or personal visit, and questioned about their contraceptive use, if any.More women who had multiple antenatal contraceptive counselling sessions used modern contraceptive methods than those who had a single postnatal counselling session (57% vs. 35%; p = 0.002). There was also a significantly more frequent use of contraception among previously undecided patients in the Antenatal group (p = 0.014).Multiple antenatal contraceptive counselling sessions improve the use of modern postpartum contraception.

Abortions performed by persons lacking the requisite skills or in environments lacking minimal medical standards or both are considered unsafe. It is estimated that over 20 million unsafe abortions are performed annually and about 70 000 women die globally as a result, with the majority occurring in the developing world. This study aims to determine the sociodemographic factors involved in complicated unsafe abortions.The study is a four-year retrospective evaluation of all cases of complicated unsafe abortions managed at the Niger Delta University Teaching Hospital, Okolobiri, Bayelsa state, Nigeria between January 1, 2007 and December 31, 2010.The incidence of unsafe complicated abortions over the study period was 4.10% of total deliveries and contributed 14.0% of gynaecological admissions: 34.92% occurred in adolescents less than 20 years of age, of which the majority (55.55%) were secondary school students. There were 55.45% of patients who were nulliparae, 60.32% were unemployed and 69.80% were unmarried. A total of 87.30% had never used any form of contraceptive. Abortion mortality rate was 256/100 000 deliveries and the case fatality was 4.76%. It constituted 30.0% of all gynaecological deaths and 17.64% of maternal deaths during the study period. The commonest cause of death was septicaemia (66.66%).Unfavourable sociodemographic factors are major determinants of the high incidence of unsafe abortion in the Niger Delta despite strict abortion laws. Concrete measures must be put in place to address these, as unsafe abortion and its complications are a major cause of maternal morbidity and mortality in the environment.

On November 20, 1989, the United Nations General Assembly adopted the Convention on the Rights of the Child after about a decade of deliberations between major stakeholders, including other United Nations agencies and Heads of Government of member states as well as Non-Governmental organisations (United Nations, 1989). In the World Summit for Children, which held a year later in 1990, world leaders further affirmed the need to promote earliest possible ratification and implementation of the Convention on the Rights of the Child, work for optimal growth and development in childhood, devise methods to eradicate hunger and globally attack poverty among other commitments, irrespective of race, age, colour, language, religion, socio-economic class or other considerations (United Nations, 1990).

To compare the safety and effectiveness of vaginal misoprostol 25 μg with those of 50 μg in induction of labor.One hundred and sixty eligible women of low parity with indications for induction of labor at term were enrolled for the study. The subjects were randomized into two groups of vaginal misoprostol 25 µg and 50 µg dose regimens. Maternal characteristics, labor and newborn outcome were compared.The total duration of labor was significantly shorter in the 50 µg group (8.24 ± 1.5 h) than 25 µg group (9.09 ± 2.7 h), p = 0.02. Oxytocin augmentation was significantly higher in the 25 µg group (18.75%) than in the 50 µg group (7.5%), p = 0.04. The indications for caesarean section were significantly different, (p = 0.02) between the two groups although the incidence was similar. The intrapartum adverse effects like fetal distress, meconium stained liquor, and tachysystole were significantly higher in the 50 µg group, p = 0.003. Similarly, the postpartum adverse effects such as cervical and vaginal tears were significantly higher in 50 µg group, p = 0.01.The two dose regimens were both effective in induction of labor, but 50 µg dose regimen resulted in significantly shorter duration of labor but with higher rate of labor complications than the 25 µg dose regimen.

To determine whether rectally administered misoprostol can induce intestinal motility compared with oxytocin infusion when used to prevent primary postpartum hemorrhage after cesarean delivery.In a prospective randomized double-blind study in Nigeria, 218 parturients undergoing cesarean delivery who had risk factors for primary postpartum hemorrhage were enrolled between July 1, 2010, and March 31, 2011. Participants received 600 μg of rectal misoprostol or 20 intravenous units of oxytocin for 4 hours after surgery. The primary outcome was time until passage of flatus. Adverse effects, need for additional analgesic, and length of hospital stay were also assessed.The misoprostol group had a significantly shorter mean postoperative interval to passage of flatus (20.27 ± 7.77 hours versus 38.34 ± 10.98 hours; P0.001) and commencement of regular diet (21.08 ± 7.69 hours versus 39.13 ± 10.94 hours; P0.001). Gastrointestinal adverse effects were more frequent, albeit not significantly, in the misoprostol group: nausea, 6.4% versus 1.8%; vomiting, 7.3% versus 2.8%; and abdominal distension, 3.7% versus 2.8%. The need for additional analgesic was the same in the 2 groups.After cesarean delivery, rectal misoprostol had the added benefit of inducing intestinal motility. Misoprostol might be considered in a clinical setting where postoperative ileus is anticipated.

SummaryAnalyses of semen samples from 346 male patients whose wives were investigated for infertility were performed over 6 years. The results showed that the gross male contribution to infertility based on sperm density was 46 per cent. Twelve per cent of the patients were azoospermic. Sperm quality was generally poor; 42-1 per cent (128 patients) had poor sperm motility and in 43-8 per cent (133 patients) there was significant abnormal sperm morphology. There was also a high incidence of necrospermia (53-3 per cent) occasioned by genital tract infections. Attention should be paid to sperm quality in the overall assessment of semen analysis and routine semen culture and sensitivity tests should be an integral part of semen analysis in infertility clinics.

SummarySixty cervical circlage operations, mostly by the McDonald method, were performed in 52 pregnant patients. Diagnosis of cervical incompetence was based on the history and characteristics of previous pregnancy losses and findings in the current pregnancy. Of the 60 pregnancies, 9 (15 per cent) ended in abortions; preterm labour occurred in 10 cases (17 per cent) and term deliveries in 41 cases (68 per cent). Complications following the procedure were minimal. No difference was found in pregnancy outcome with respect to the suture material used (Mersilene tape or silk suture).

We conducted a review of eight ureteric injuries associated with major gynecologic surgery in seven patients over an 11-year period. Our low incidence of 0.36% is comparable with other reports. Diagnosis was made either intra-operatively or postoperatively. Immediate ureteric repair is advocated for all injuries discovered intra-operatively. Attention to preventive measures both before and during gynecological operations will reduce the incidence of ureteric injuries.

Background: Until recently, family planning researchers and service providers had focused almost exclusively on women. Men are often seen as uncooperative and uninterested in family planning or reproductive health. Objective: To investigate the contraceptive knowledge, attitude and practice among married market men. Design: A cross-sectional survey. Setting: llesa Main Market, Osun State, Nigeria. Subjects: Four hundred and fifty married market men were interviewed between November 2000 and January 2001. Main Outcome Measures: Level of awareness and utilisation, reasons for non-use, influence of socio-demographic variables. Results: All the men were aware of family planning and 60.9% are currently using a form of contraception with their spouse. Reasons for non-contraceptive use by 39.1% of the respondents include: family size not yet complete, religious opposition, afraid of contraceptive failure, still searching for a male sex. Christianity and education were significantly associated with contraceptive use and knowledge (p< 0.05). Conclusion: Men favour contraceptive use in Nigeria. Involving men by family planning providers is a winning strategy with benefits to both men and women. East African Medical Journal Vol.80(7) 2003: 357-360

This is a 5-month prospective study to determine the decision emergency caesarean delivery interval in a Nigerian tertiary hospital, the factors responsible for the delays and the consequent maternal and perinatal complications. One hundred and thirty-four emergency caesarean deliveries were analysed and the main indications were failure to progress/ prolonged labour (35.4%), previous caesarean-section/failed trial of scar (27.9%), cephalopelvic disproportion (26.8%), fetal distress (19.5%), pre-eclampsia/eclampsia (15.3%) and obstructed labour/ruptured uterus (14.7%). The mean decision-caesarean delivery interval was 4.4 +/- 4.2 (SD) hours (range 0.5-26 hours), median 3.2 hours and mode 2 hours. Bottlenecks within the maternity unit were responsible for delays in 31.7% of cases. Unavailability of paediatrician (19.6%), non-availability of anaesthetic coverage (13.6%), unreadiness of the operation theatre (11.9%) and seeking second opinion (6.4%) were other major causes of delay. There were 15 perinatal deaths, five of whom were directly linked to the delays i.e. a perinatal mortality rate of 3.7%. Four maternal deaths were directly attributable to delay, a maternal mortality rate of 3%. Other direct consequences of the delays were severe haemorrhage (10.3%), uterine rupture (2.3%) and disseminated intravascular coagulopathy (1.5%). Suggestions on how to minimise delays in emergency services and overall improvement in quality assurance control are discussed.

Prolactin and oxytocin are among hormones associated with lactation. Oxytocin released from the posterior pituitary during breastfeeding is known to cause myoepithelial contraction of the breast tissues thereby promoting milk let-down and ejection. Additionally, oxytocin stimulates uterine contraction during breastfeeding causing 'afterbirth pains' and facilitating postpartum uterine involution. It is possible therefore that breastfeeding continued into a new pregnancy could, by oxytocin effect on the uterus, lead to abnormal uterine contractions, unintended abortion, impaired uteroplacental blood flow in latter pregnancy, intrauterine growth retardation, premature contractions/premature labour, low birth weight or in extreme cases intrauterine death. Eckford and Westgate (1997) recently reported placental abruption associated with breastfeeding in pregnancy progressing to fetal distress, emergency delivery and early neonatal death. We have had occasion to counsel women who discover and unplanned pregnanc...

Objective: To determine the decision-intervention interval in ruptured uterus with a view of overhauling the management strategy thereby improving the maternal and perinatal outcome. Design: Cross-sectional survey based on secondary data done between 1990-1999. Setting: Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria. Subjects: One hundred and two consecutive women who had uterine rupture. Results: The decision-surgical intervention interval ranged from 30 minutes to 4.5 hours. The major reason for delay was unavailability of compatible blood (88.2%), followed by lack of electricity (4.9%), unsterile instruments (3.9%), waiting for ambulance to get senior obstetricians (2.9%), delay in arrival of anaesthetist (1.9%) and neonatologists (1.9%). The peri-natal mortality rate (PNMR) was 843 per 1000 total births and maternal mortality rate (MMR) 4902 per 100,000 births. Conclusion: The maternal and perinatal outcome in uterine rupture would be improved by early diagnosis and avoidance of preoperative delay through availability of essential obstetric services.

Context: There are conflicting reports on the concentration of plasma lipid fractions in pregnant Nigerians. Objectives: This study compares the plasma lipid levels in non-pregnant normotensive women with those in normotensive pregnant women and hypertensive pregnant women in the second and third trimesters and at three days postpartum. Study Design: Hypertensive women numbering 75, aged between 20 and 39 years were selected from the clinics of the Obstetrics and Gynaecology Department, Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC). A comparable group of 75 normotensive pregnant women and 25 normotensive women who were not pregnant were also recruited. Plasma total cholesterol (TC), high-density lipoprotein cholesterol (HDLC), low density lipoprotein cholesterol (LDLC) and triglyceride (TG) were assayed for all the patients, using established enzymatic methods. Results: In the 2nd trimester, plasma TG, HDLC and TC were significantly higher and LDLC lower in normotensive pregnancy than in non-pregnant women (p < 0.001). In the same period, plasma TG, HDLC and TC were lower and LDLC higher in hypertensive pregnant women than in their normotensive counterparts and the non-pregnant (p < 0.001). This pattern was also evident in the 3rd trimester. The blood pressure levels dropped to different extents and all the plasma lipids were reduced to similar levels in both the normotensive and hypertensive groups at 3 days postpartum. Conclusion: There is hyperlipidaemia in normal pregnancy with significantly lower LDLC and higher HDLC compared to the non-pregnant. There is elevated LDLC and lower HDLC in hypertensive pregnant women. There is a noticeable decline in plasma lipid levels by the 3rd day postpartum. Key Words: Triglycerides, Lipoproteins, Cholesterol, Hypertension, Pregnancy. [Trop J Obstet Gynaecol, 2003, 20: 119-122]

Context: Caesarean section is widely embraced and utilized in the developed countries, but among the Yoruba of Western Nigeria the operation is treated with suspicion, and aversion, misconceptions, fear, guilt, misery and anger are often associated with the procedure. Objective: To investigate the beliefs and perceptions of pregnant women at Ilesa, South-western Nigeria about caesarean section. Design, Setting and Subjects: A cross-sectional survey carried out at Wesley Guild Hospital, Ilesa, Nigeria from 1st October 2000 to 31st December, 2000. The study group comprised of 400 consecutive pregnant women seen at the antenatal clinic during the study period. Main Outcome Measures: Proportion of women supporting or opposing caesarean sections, the reasons for their views and possible response if caesarean section becomes indicated during their current pregnancies. Results: Out of the 400 women studied, 210 (52.5%) women supported caesarean section while 190 (47.5%) were opposed to it. Increasing maternal age was significantly associated with support for caesarean section (P Conclusion: More pregnant women supported caesarean section than were opposed to it. Due to the importance of caesarean section in modern obstetric practice, there is need for better education of the community on its indications and benefits for achieving safe motherhood. Key Words: Caesarean Section, Childbirth, Attitudes, Beliefs. [Trop J Obstet Gynaecol, 2003, 20: 141-143]

Context: Medical audit in healthcare has a goal to monitor and upgrade the standard of health care in a setting. Whether a client will accept, use effectively and continue to practice contraception depends on the quality of services rendered. Objective: To assess the quality of our family planning services as perceived by our clients. Design, Setting and Subjects: A cross-sectional survey of clients at three family planning clinics in Ife-Ijesha Administrative Health Zone coordinated by the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife between 1st April and 31st August 2000. The study group consisted of 490 clients. Main Outcome Measures: Technical competence of providers, client/provider relations; mechanisms to encourage continuity, constellation of services offered and client satisfaction. Results: More than half (52.2%) of clients felt satisfied with the competence of the provider, 94.6% were satisfied with the client-provider relationship. Measures to encourage continuity were maintained in 90.8% of clients. There is a high level (94%) of client satisfaction with overall services rendered while 36.7% received other information apart from family planning services. Conclusion: Our clients were satisfied with the quality of family planning services being rendered. However there is need for improvement in the counselling of women before vaginal examination/ procedures. Literature should be provided to educate clients about what to expect during specific procedures. The common side effects of all methods should be fully explained to clients. Key Words: Family Planning, Contraception, Service Quality, Audit [Trop J Obstet Gynaecol, 2003, 20: 28-31]

SummarySeventy-one cases of emergency obstetric hysterectomy were performed in 13 years in Ile-Ife, Nigeria, representing an incidence of 1 in 448 deliveries (2–2 per 1000). Rupture of the gravid uterus was the major indication, followed by uncontrollable haemorrhage. There was an associated high maternal morbidity (90 per cent), maternal mortality (11 per cent) and fetal loss (75 per cent). Relevant contributory factors were no antenatal care, increased maternal age and grand multiparity. Good antenatal care and labour supervision will reduce the rate of emergency obstetric hysterectomy and its attendant hazards.

Ectopic pregnancies can be very difficult to diagnose at initial admission. This paper reviewed the morbidity and mortality associated with misdiagnosis of ectopic gestation over a 15-year period (1985-99) at Ile-Ife, Nigeria. There were 380 confirmed ectopic pregnancies of 35 857 live births, giving an incidence of 10.5 per 1000 live births. Of the 380 cases, 38 (10%) were misdiagnosed initially at presentation. Mistaken diagnoses include pelvic inflammatory diseases, cholera, acute appendicitis, typhoid enteritis, incomplete septic abortion, uterine fibroid with menorrhagia, malaria, gastroenteritis, peptic ulcer and intestinal obstruction. There were five maternal deaths among the 38 misdiagnosed cases compared to two maternal deaths among the 342 initially correctly diagnosed cases. Significant morbidity included prolonged hospital stay, increased hospital costs and an enterocutaneous fistula. To improve the chances of correct diagnosis at initial admission, accurate menstrual and sexual history should be obtained. Facilities for improved diagnosis such as serum beta HCG and transvaginal ultrasonography should be provided. Colleagues from other specialities should be educated to increase their suspicion of ectopic pregnancy in any woman of childbearing age and perform the appropriate investigations.

This study investigates the prevalence and determinants of contraceptive practice in Ile-Ife, Nigeria. A prospective study of 500 rural women in the reproductive age group was conducted between April to June 1999 in the Igboya health district of Ife central local government area of Osun State. A comprehensive contraceptive promotion and distribution had been carried out in this area by the University Teaching Hospital, the State Ministry of Health and many non-governmental organisations in the past 10 years. It is therefore expected that the contraceptive awareness and use in this environment would be high. Unfortunately, although all the respondents (100%) were aware of contraception and 78% were sexually active, only 18.8% used contraception. A majority of the non-users gave no reasons for failure to use contraception. Among reasons given by others include fear of side effects, no need for contraception, not married, religion, need for more children and student status. The most common contraceptive method among users was intrauterine contraceptive device followed by pills, condoms and injectable contraceptives. Factors which were significantly associated with utilisation of contraception were availability of family planning services, parity, knowledge of contraception and child spacing (P0.05). Religion, literacy level, attitudes of family planning providers and distance to family planning services were not found to be significant (P0.05). Recommendations that will improve wide contraceptive usage are preferred.

Not all pregnant women who decide to seek care at a medical facility in Nigeria arrive in time to be treated. Some die while trying to get there. Data on such deaths are, however, scarce. In this study, conducted over a 5-year period (1995-99), when any pregnant woman was brought in dead into the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria, the relatives were interviewed immediately to discover the immediate and remote causes. Reasons given for late presentation include: inability to obtain transportation in time (41.7%), inability of the health-care staff to detect an obstetric emergency early enough and refer to an appropriate centre (33.3%), inability of the referring hospital to perform an emergency caesarean section (33.3%), fear of caesarean section (25%), unwillingness of drivers to travel by night (25%) and no money to pay for hospital costs (16.7%). Causes of death include eclampsia, ruptured uterus, severe postpartum haemorrhage, severe antepartum haemorrhage, sickle cell anaemia with crises and road traffic accidents. Prevention of 'brought-in' maternal deaths requires social transformation, overhauling the health-care delivery services and improving the socio-economic status of the population.

As a result of reports of reduced birthweight in neonates of mothers with hemoglobin AS (Hb-AS) in other populations, we compared birthweights in 57 Hb-AS primigravidas in Nigeria with 60 controls who were sickle negative. There was no statistically significant difference in mean birthweight or placental weight between the groups. This finding may be due to development of resistance against malaria infection by Hb-AS women in this population.

The concentration of copper and zinc was determined by atomic absorption spectrophotometry in 26 normal Nigerian women at term and their newborn babies. Cord zinc was significantly greater than maternal zinc. In contrast, cord copper was lower than maternal copper. There was only a weak correlation between cord copper and maternal copper but none between cord zinc and maternal zinc. There was no correlation between maternal and cord zinc and neonatal birthweight. However, an inverse correlation was found between maternal and cord copper and neonatal birthweight. These results indicate that: (1) zinc has no effect on fetal growth in Nigerian women but (2) copper may have a negative effect on fetal growth.

Summary Thirty-three cases of ruptured ectopic pregnancies treated by emergency autologous blood transfusion were compared with 85 cases treated by homologous blood. The postoperative outcome was satisfactory and the duration of hospital stay was similar in both groups. However, the quantity of blood transfused in those who received autologous blood was significantly higher than in those transfused with homologous blood (P 0.02). Because of this experience we advocate greater use of intra-operative blood salvage and autotransfusion, even when banked homologous blood is available, in the management of ruptured ectopic pregnancy.

A 75 g oral glucose tolerance test was performed in 127 normal Nigerian women between 24 and 28 weeks of pregnancy. The glucose response at fasting, 1, 2 and 3 h were studied. At 2 h, the glucose level at 2-SD and 4-SD above the mean were less than the criteria of abnormality recommended by the World Health Organisation: 6.5 mmol/l vs. 8 mmol/l for impaired glucose tolerance and 8.0 mmol/l vs. 11.0 mmol/l for gestational diabetes mellitus. The area under the glucose response curve correlated best with the glucose levels at 2 h during the OGTT (y = 4.3 + 1.8x, r = 0.862). The 75-g OGTT interpreted with the WHO criteria appear not to be appropriate for use in pregnant women in Nigeria.

The effect of illegal abortion on subsequent reproduction was studied in 46 Nigerian women who gave a history of illegal termination of pregnancy. There was a statistically significant increase in the incidences of premature rupture of membranes, premature labour and low birth weight when compared to 53 primigravida who gave no such history of abortion. The perinatal mortality was also significantly higher in the abortion group. In contrast, pre-eclampsia was less common in the abortion group. These findings indicate that illegal abortion has adverse effects on pregnancy outcome in Nigerian women.Researchers compared data on 46 women with a history of illegal induced abortion with data on 53 women with no previous pregnancy to examine the effect of previous abortion(s) on subsequent pregnancy outcome. All 99 women delivered at the Obafemi Awolowo University Teaching Hospital in Ile-Ife, Nigeria, during January 1984-December 1988. The type of illegal induced abortion was dilatation and curettage (DC) which tends to cause cervical incompetence. Controls were more likely to suffer from preeclampsia than cases (11.3% vs. 2.1%; p 0.05). Women with a history of induced abortion were more likely than the controls to suffer premature rupture of fetal membranes and preterm labor (23.9% vs. 1.8%, p 0.001 and 32.6% vs. 9.4%, p 0.0001, respectively). Gestational age was shorter in the study group than in the control group (median, 36 vs. 39 weeks; p 0.01). Cases were more likely than controls to have smaller newborns (2.2 vs. 2.8 kg; p 0.01) and more low birth weight newborns (41.3% vs. 17%; p 0.01). Perinatal mortality was 23.9% in the study group compared to 1.8% in the control group (p 0.001), mainly due to prematurity. Gestational age at termination did not effect the risks of premature rupture of membranes, preterm labor, low birth weight, or perinatal mortality. These findings show that illegal abortion has adverse effects on outcome of subsequent pregnancies. Physicians should determine whether a pregnant woman has had an illegal abortion. If so, they should monitor her for cervical incompetence so they can treat it early. Clinicians performing abortions should use vacuum aspiration rather than DC to reduce the likelihood of premature labor and perinatal death in subsequent pregnancies.

Endometrial and follicular development were investigated by ultrasound in 25 normally cycling women who received clomiphene citrate and human menopausal gonadotrophin to induce multiple follicular development for in vitro fertilization. Ultrasonic determination of endometrial thickness and reflectivity grading and follicular number were correlated with daily concentrations of estradiol (E2) and progesterone (p) in peripheral serum. Serum E2 showed a better positive correlation with endometrial thickness than with total number of developing follicles. There was a significant inverse correlation between endometrial thickness and plasma p concentration. The E2 value per follicle and E2/p ratio were both weakly correlated respectively with endometrial thickness. These data indicate that ultrasound determination of endometrial thickness is a useful ultrasonic parameter for monitoring ovarian function for in vitro fertilization. However, endometrial thickness should always be combined with total number of developing follicles, in order to reach decisions concerning timing of oocyte recovery.

Total glycosylated haemoglobin (HbA1) was measured in 16 healthy non-pregnant Nigerian women and in three groups of healthy women at various times during pregnancy. There was a statistically significant decrease in HbA1 in the first trimester. The values progressively increased thereafter and by term, the values were comparable to those in non-pregnant controls. The values were identical to those reported for caucasian women at similar stages of pregnancy.

Seventy-four women with complications of induced abortion were studied prospectively at the Obafemi Awolowo University, Nigeria. Twenty of the women were interviewed privately to elicit confidential information and also to determine their attitudes to contraception and to the Nigerian national abortion law. The results showed that abortion is prevalent in all classes of women and in married as well as unmarried women. There were 13 maternal deaths, accounting for 35% of the maternal mortality in the hospital during the period. Sepsis was the most common cause of death, and most of the abortions complicated by sepsis had been performed by medical practitioners. Interviews with the women revealed that most of them had knowledge of contraception but were unwilling to use it because of wrong information. Most women did not know that abortion is illegal in Nigeria, but felt that it should be. Measures that could be of value in reducing abortion-associated maternal mortality in Nigeria include training and retraining of physicians in the management of abortion and of abortion complications, family planning education of all fertile women, provision of confidential family planning services and liberalization of the abortion law.All consecutive women admitted for complications of induced abortion at the Obafemi Awolowo University, Nigeria, from November 1988 through December 1989 were studied and interviewed. The interviews, conducted at the end of the stay by the staff member with most rapport with the women, asked about the abortion method, abortionist, cost patient's socioeconomic background, knowledge and practice of contraception, and knowledge and attitude toward the Nigerian abortion law. The 74 admissions accounted for 12% of all gynecological admissions. The patients ranged in age from 15 to 49, mean 22.8 years, and parity from 0 to 8, median O. 42% were ever married. 80% were Christians. The abortions were performed in 32% of cases by medical practitioners, 27% by non-medical persons, and 19% were self-induced. Self-induction methods included coat hangers, injections, ingestion of strong alcohol or tablets, instillation of native pessaries, potash, or gunpowder vaginally. Complications included sepsis (84%), hemorrhage (51%), uterine perforation (8%), cervical laceration (4%), septic shock (4%), perforation of gut or bladder, pelvic abscess, and psychosis. Treatment was broad spectrum antibiotics in all cases, evacuation of retained products in 76%, laparotomy in 7%, and hysterectomy in 2 cases. Hospital stay ranged from 1 to 60 days (mean 9.8). There were 13 maternal deaths (18%), or 35% of total maternal deaths in the hospital in this period. Sepsis was the cause of all deaths except one from hemorrhage. 54% of the fatal abortions were done by medical personnel, although none were obstetricians. In interviews of 20 subjects, it was learned that the majority of their abortionists were physicians, and costs ranged from $2 to 25 (US). All 20 women knew about effective contraception, but did not use it because they feared side effects, disliked the lack of privacy in clinics, and could not afford private providers. Only 4 knew that abortion is illegal in Nigeria, and only 2 thought it should be legalized, because they believed it is immoral. Contrary to common opinion, these women included married as well as single women, and the deaths were caused by physicians as well as lay abortionists.

A 12-month prospective study of 120 consecutive hysterectomy and 12 myomectomy specimens received at the histopathology laboratory of the Obafemi Awolowo University Teaching Hospitals was undertaken to determine the occurrence of adenomyosis. The observed incidence was 9.8%. Adenomyosis was commonest in multiparous women in the fifth decade of life. The principal presenting complaint was abnormal uterine bleeding. The average dimension of a typical affected uterus was 10 x 7 x 6 cm weighing an average of 175 g. Diagnosis was mostly post-operative. This study shows that adenomyosis uteri is not uncommon in Nigerians.

A retrospective review of pregnancies complicated by preterm premature rupture of membranes (PPROM) in 149 women of low socioeconomic status in Nigeria was undertaken. Delivery occurred within 24 h of onset of symptoms in 51 of these women (immediate delivery group), whereas 98 patients were managed conservatively. The mean length of gestation was higher in the conservatively managed group and the perinatal mortality was correspondingly lower. In contrast, there was a slightly increased incidence of puerperal febrile morbidity in the conservative group. These data suggest that conservative management can be selectively employed in PPROM occurring in women of low socioeconomic status.