Decision-to-delivery interval and obstetric outcomes of emergency caesarean sections in a Nigerian teaching hospital

Prolonged Decision-to-Delivery interval (DDI) is associated with adverse maternal-foetal outcomes following emergency Caesarean section (EmCS). Objectives: To determine the DDI, predictive factors, and the foeto-maternal outcomes of patients that had EmCS in a Nigerian Teaching Hospital. Methods: A descriptive study of all EmCS performed at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria, from 1st June 2020 to 31st May 2021, was conducted. Relevant data were extracted from the documentations of doctors, nurses and anaesthetists using a designed proforma. The data obtained were analysed using the IBM SPSS Statistics for Windows, version 25. Results: The median (IQR) DDI was 297 (175-434) minutes. Only one patient was delivered within the recommended DDI of 30 minutes. The most common cause of prolonged DDI was delay in procuring materials for CS by patients' relatives(s)/caregiver(s) (264, 85.2%). Repeat CS (AOR = 4.923, 95% CI 1.09-22.36; p = 0.039), prolonged decision-to-operating room time (AOR = 8.22, 95% CI 1.87-8.66; p<0.001), and junior cadre of surgeon (AOR = 25.183, 95% CI 2.698-35.053; p = 0.005) were significant predictors of prolonged DDI. Prolonged DDI > 150 minutes was significantly associated with maternal morbidity (p = 0.001), stillbirth (p = 0.008) and early neonatal death (p = 0.049). Conclusion: The recommended DDI of 30 minutes for CS is challenging in the setting studied. To improve foetomaternal outcomes, efforts to reduce the DDI should be pursued vigorously, using the recommended 30 minutesas a benchmark.

Maternal near-miss and death among women with rupture of the gravid uterus: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey.

OBJECTIVE: To investigate the burden of maternal near-miss and death due to rupture of the gravid uterus, the indicators of quality of care, and avoidable factors associated with care deficiencies for ruptured uterus in Nigerian tertiary hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy, childbirth or puerperal complications. METHODS: Cases of severe maternal outcome [SMO: maternal near-miss (MNM) or maternal death (MD)] following uterine rupture were prospectively identified over 1 year. MAIN OUTCOME MEASURES: Incidence of SMO, indicators of quality of care, and avoidable factors associated with deficiencies in care. RESULTS: There were 91 724 live births and 3285 women with SMO during the study period. SMO due to uterine rupture occurred in 392 women: 305 MNM and 87 MD. Uterine rupture accounted for 11.9, 13.3, and 8.7% of all SMO, MNM, and MD, respectively. SMO, MNM, and intra-hospital maternal mortality ratios due to uterine rupture were 4.3/1000 live births, 3.3/1000 live births, and 94.8/100 000 live births, respectively. Mortality index (% of MD/SMO) was 22.2%, and MNM:MD ratio was 3.5. Avoidable factors contributing to deaths were related to patient-orientated problems, especially late hospital presentation and lack of insurance to cover life-saving interventions. Medical personnel problems contributed to care deficiencies in one-third of women who died. CONCLUSION: Uterine rupture significantly contributes to SMO in Nigerian tertiary hospitals. Strategies to improve maternal survival should address avoidable institutional factors and include community-based interventions to encourage skilled attendance at birth and early referral of complications. TWEETABLE ABSTRACT: Uterine rupture remains an important cause of maternal death in Nigerian tertiary hospitals.

When getting there is not enough: a nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country.

OBJECTIVE: To investigate the burden and causes of life-threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals. DESIGN: Nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy, childbirth and puerperal complications. METHODS: All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) were prospectively identified using the WHO criteria over a 1-year period. MAIN OUTCOME MEASURES: Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO). RESULTS: Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near-misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre-eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life-threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes (IQR: 21-215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non-availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care. CONCLUSIONS: Improving the chances of maternal survival would not only require timely application of life-saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care. TWEETABLE ABSTRACT: Of 998 maternal deaths and 1451 near-misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.

Combined Oral Contraceptive Pills: Profile of Acceptors in a Tertiary Hospital in South-South Nigeria.

BACKGROUND: Combined oral contraceptive pills were the first contraceptive method to provide sexual freedom of choice for women through reliable, personal and private control of fertility. They are the most widely used hormonal contraceptives and also the most popular non-surgical method of contraception. OBJECTIVE: To review the profile of acceptors of combined oral contraceptive pills at the University of Uyo Teaching Hospital, Uyo. METHODOLOGY: An 8 year review of all clients that accepted combined oral contraceptive pills in the family planning clinic. RESULTS: There were 1,146 new contraceptive acceptors during the period of study out of which 309 (27.9%) accepted the pills. Majority of the clients were between 20 and 29 years of age (54.0%), were multiparous (72.8%), Christians (99.7%) and 61.2% had tertiary level education. Two hundred and fifty-five women (82.5%) desired to use combined oral contraceptive pills to space births while 7.8% wanted to limit child bearing. There was a high discontinuation rate among the women (45.0%) and out of these 87.9% of the clients changed to other contraceptive methods. All the clients commenced their pills within seven days of menstruation and only the low dose monophasic preparations were available in the family planning unit and thus were given to the clients. CONCLUSION: Women who accept to initiate combined oral contraceptive pills in our center are young, well educated, multiparous women who want to space their pregnancies. However, due to the high discontinuation rate among the clients, there is need for further studies evaluating reasons for the high discontinuation rate, exploring interactions between clients and providers' and also providers' attitude towards combined pills in our environment.

Spontaneous heterotrophic pregnancy with tubal rupture and delivery of a live baby at term: a case report.

BACKGROUND: Heterotopic pregnancy is the coexistence of intrauterine and extrauterine gestations. It is associated with significant maternal morbidity and mortality particularly in low resource settings. Spontaneous heterotopic pregnancy is very rarely seen with documented incidence of 1 in 30,000 pregnancies. We present the first case of heterotopic pregnancy managed in our center with the delivery a live female baby at term. METHODS/RESULT: The case of a 25 year nulliparous lady who presented in our center with lower abdominal pains, amenorrhoea and an ultrasound report confirming an intrauterine, pregnancy is presented. Examination revealed mild right iliac fossa tenderness, cervical motion tenderness and a bulky uterus. A trans-vaginal ultrasound scan confirmed a right fimbrial ectopic gestation. A right salpingectomy was performed. The patient subsequently had an uneventful antenatal period and spontaneous vaginal delivery of a live female baby at term. We also review literatures on heterotopic pregnancy and its management. CONCLUSION: Spontaneous heterotopic pregnancy a potentially fatal condition though rare can occur in our environment. Clinicians should maintain a high index of suspicion in all patients presenting with amenorrhoea and abdominal pains even if an intrauterine pregnancy has been confirmed and a thorough evaluation of the adnexae using a trans-vaginal ultrasound scan should be routinely performed in such cases.

Inevitable myomectomy during caesarean section: a case report.

Myomectomy during Caesarean section is conventionally reserved for pedunculated myomas. When fibroids located in the lower uterine segment are encountered in pregnancy, due to fear of haemorrhage, obstetricians would prefer to perform a classical Caesarean section even with its high risk of subsequent uterine rupture and avoid the fibroids. We hereby present a case where removal of intra-mural fibroids in a 34-year old primigravida though inevitably performed, was successful.

Contraceptive Practice in a Tertiary Hospital in South-South Nigeria

Background: The high maternal and infant mortality in sub-Saharan Africa has been associated with unplanned pregnancy; high parity and short birth intervals. Use of effective contraceptive methods significantly reduce maternal and infant mortality and improved quality of life. This study determines the contraceptive practice among clients in a tertiary hospital. Method: The record cards of all clients that accepted contraceptive methods in the family planning clinic at the University of Uyo Teaching Hospital; Uyo over a 7-year period were reviewed. Results: There were 1094 new contraceptive acceptors during the study period. The modal age group of the clients was 25 - 34 years (59.3); majority of the clients were multiparous (59.8); christians (99.6) and 71.0had at least secondary school education. The most commonly accepted contraceptive methods were the intrauterine contraceptive device (45.0) and oral contraceptive pills (28.1); while clinic personnel (63.1); and friends and relatives (20.1) were the most common sources of information on contraception. Conclusion: Intrauterine contraceptive device and oral contraceptive pills were the most frequently accepted methods of contraception. We advocate increase in the contraceptive options including implants. The print and electronic media should be more involved in the awareness programs on contraception

A review of t the prevalence and rate of utilisation of measures offered to HIV-positive women during delivery in a tertiary hospital in South-South Nigeria

Background: Vertical or mother-to-child transmission of HIV which accounts for over 90 of paediatric HIV infection is increasingly becoming a major mode of transmission in developing countries. Aim: To determine the prevalence of HIV infection among pregnant women that deliver at the University of Uyo Teaching Hospital and also review the interventions they are offered when they present in labour. Methods: The case records of all HIV positive patients who delivered between 1st July 2005 and 31st December 2007 were reviewed. Results: There were 2;851 deliveries out of which 188 patients were HIV positive giving a prevalence of 6.6. The modal age group of the HIV-positive patients was 26-30 years (40.4). Most (68.6) of the patients were multiparous and 89.3of them had regular antenatal care in the hospital. HIV was diagnosed in the antenatal clinic in 71.8of the patients. Most (72.3) of them had a single dose of nevirapine in labour while 5.8received highly active anti-retroviral therapy. About 63.8of the patients had spontaneous vertex delivery while 33.5were delivered by Caesarean section. All the babies had single doses of nevirapine within 72 hours of birth. Most (84.0) of the mothers chose to feed their babies exclusively with breast milk substitutes. There were 3 maternal (1.6) and 16 (8.5) perinatal deaths.Conclusion: The prevalence of HIV infection among women who deliver in our hospital (6.6) is relatively high. The treatment of HIV positive pregnant women in labour with respect to the prevention of mother-to-child transmission fell short of acceptable standards in some of our patients. Efforts should be made to ensure the adoption of anti-retroviral therapy as recommended in the Nigerian national guidelines

Reasons for preference of delivery in spiritual church-based clinics by women of south-south Nigeria.

OBJECTIVES: To investigate the various reasons for patronizing the spiritual church-based clinics by women from South-South Nigeria. DESIGN: Forty seven spiritual church-based clinics were studied between 1st February 2003 and 31st July 2003. SETTING: Forty seven spiritual church-based clinics in both Akwa Ibom and Cross River State in South-South Nigeria. PATIENTS: Two thousand and sixty three pregnant women who were regular attendants of the spiritual church-based clinics. RESULTS: Various reasons for preferring church delivery included: Spiritual protection against satanic attacks and safe delivery in 975 (36.8%) lack of funds in 629 (30.5%), harsh attitude of health workers in 249 (12.1%), convenience in 212 (10.3%), faith in God and previous delivery in church 83 (4.0%) each help and good care guaranteed in 48 (2.35). CONCLUSION: It is suggested that the spiritual churches with interest in obstetric care establish properly staffed and well equipped health clinics as an annex to the church.

Profile of intrauterine contraceptive device acceptors at the University of Uyo Teaching Hospital, Uyo, Nigeria.

BACKGROUND: Use of modern contraceptive methods has been shown to reduce unwanted pregnancy, high parity and maternal mortality. Intrauterine contraceptive devices which are among the safest and most effective reversible contraceptives available, are particularly suitable for women in developing countries as they are affordable, convenient to use, do not require re -supply visits and are very cost-effective. The aim of this study is to determine the socio-demographic characteristics of intrauterine contraceptive device acceptors, the pattern of insertions and complications at the University of Uyo Teaching hospital, Uyo. METHOD: The record cards of all clients who had intrauterine contraceptive device inserted at the family planning clinic over a six-year period were reviewed. RESULTS: During the study period, there were 852 new contraceptive acceptors out of which 39.7% accepted the intrauterine contraceptive device. The modal age group of the clients was 25-29 years (32.5%). Acceptance of intrauterine contraceptive device was most common among multiparous clients (65.1%). Majority of the acceptors were married (90.0%), Christians (98.8%) and 72.8% had at least secondary school education. Clinic personnel (65.7%) and friends/relatives (21.3%) were the most common sources of information on contraception. Most (93.5%) of the clients had their intrauterine contraceptive devices inserted within 7 days of menstruation. Lower abdominal pain (5.5%) and vulval/vaginal itching (5.3%) were the most common complications. CONCLUSION: The acceptors of intrauterine contraceptive devices in our center were young, multiparous and educated women. Increasing mass media involvement in the dissemination of accurate information about intrauterine contraceptive devices to the general populace, the introduction of postpartum and post-abortal intrauterine contraceptive device insertions and the encouragement of our grandmultiparous women to accept intrauterine contraceptive device would lead to an increase in its acceptance and use.

Profile of intrauterine contraceptive device acceptors at the University of Uyo Teaching Hospital, Uyo, Nigeria

Background: Use of modern contraceptive methods has been shown to reduce unwanted pregnancy; high parity and maternal mortality. Intrauterine contraceptive devices which are among the safest and most effective reversible contraceptives available; are particularly suitable for women in developing countries as they are affordable; convenient to use; do not require re-supply visits and are very cost-effective. The aim of this study is to determine the socio-demographic characteristics of intrauterine contraceptive device acceptors; the pattern of insertions and complications at the University of Uyo Teaching hospital; Uyo. Method: The record cards of all clients who had intrauterine contra- ceptive device inserted at the family planning clinic over a six-year period were reviewed. Results: During the study period; there were 852 new contraceptive acceptors out of which 39.7accepted the intrauterine contraceptive device. The modal age group of the clients was 25-29 years (32.5). Acceptance of intrauterine contraceptive device was most common among multiparous clients (65.1). Majority of the acceptors were married (90.0); Christians (98.8) and 72.8had at least secondary school education. Clinic personnel (65.7) and friends/relatives (21.3) were the most common sources of information on contraception. Most (93.5) of the clients had their intrauterine contraceptive devices inserted within 7 days of menstruation. Lower abdominal pain (5.5) and vulval/vaginal itching (5.3) were the most common complications. Conclusion: The acceptors of intrauterine contraceptive devices in our center were young; multiparous and educated women. Increasing mass media involvement in the dissemination of accurate information about intrauterine contraceptive devices to the general populace; the introduction of postpartum and post-abortal intrauterine contraceptive device insertions and the encouragement of our grandmultiparous women to accept intrauterine contraceptive device would lead to an increase in its acceptance and use

Misconception of emergency contraception among tertiary school students in Akwa Ibom State, South-south, Nigeria.

OBJECTIVE: To assess the degree of awareness and use of emergency contraception among tertiary school students inAkwa Ibom State, Nigeria. DESIGN: A self-administered questionnaire survey. SETTING: The Akwa Ibom State Polytechnic, Ikot Osurua, located on the outskirts of Ikot Ekpene local government area between 1stApril 2002 and 31st April 2002. SUBJECTS: 1,000 randomly selected female students ofthe Akwa Ibom State polytechnic, Ikot Osurua RESULTS: The students were aged between 16 and 43 years. Five hundred and eighty-nine (68.5%) of the respondents had heard of products that could be used as emergency contraceptives. However, only 49 (5.7%) of the respondents had practised some form of emergency contraception, which was most commonly practised by those between 16 and 25 years (71.4%). Menstrogen (30.6%), gynaecosid (24.5%), and quinine (14.3%) were the most common medications used for emergency contraception. Patent medicine dealers (40.9%) and friends/course mates (29.7%) were the most common sources of knowledge about emergency contraception. CONCLUSION: This study shows that awareness and use of emergency contraception by our youths is low. Community enlightenment about emergency contraception using specifically designed programmes, the formation of reproductive health clubs in our tertiary institutions and training of peer group educators in all our communities are advocated. Patent medicine dealers in our communities should have basic training in modern contraceptive methods and periodic evaluation should be carried out to assess their knowledge and practice of emergency contraception.

Current concepts in contraception.

BACKGROUND: Worldwide, contraceptive use has increased substantially over the past two decades. The increased demand for wider choices of contraceptive methods has resulted in extensive research and rigorous clinical trials. This has led to improvements on existing contraceptive methods and also the development of several new, more effective and acceptable methods with fewer side effects. Thus, this article presents a review of existing literature on recent developments on existing contraceptive methods. It also reviews recently developed contraceptive methods currently in use worldwide. METHODS: Relevant literature was reviewed using manual library search, electronic sources such as CD-ROMS and internet articles. CONCLUSION: More effective methods of contraception which are generally safer and easier to administer are increasingly being developed. Hopefully, as they increasingly become available in our environment, they will lead to and increase in acceptance and use of contraception by our women.

Caesarean section in the management of singleton breech delivery in Calabar, Nigeria.

OBJECTIVE: To establish the role of Caesarean section in reducing perinatal mortality following singleton breech delivery in the University of Calabar Teaching Hospital, Calabar. METHOD: The case notes of all patients who had singleton breech delivery between 1st January 1991 and 31st December 2000 were studied. RESULTS: The incidence of singleton breech delivery was 1.4% and 37.1% of the breech deliveries were by Caesarean section. Feto-pelvic disproportion and footling breech presentation were the most common indications for Caesarean section (50.0%). Most of the breeches delivered by emergency Caesarean section (55.0%) were in unbooked patients while the booked ones were mostly delivered by elective Caesarean section (80.0%). There was a statistically significant decrease in perinatal mortality in primigravid breeches ((p = 0.018) and in fetuses estimated to weigh above 3.5 kilograms (p = 0.0005) following Caesarean section. CONCLUSION: This study shows that Caesarean section plays a very important role in the management of breech presentation in our environment. We advocate elective Caesarean section of all primigravid breeches and those whose fetuses are estimated to weigh above 3.5 kilograms.

Spousal communication in contraceptive decisions among antenatal patients in Calabar, south eastern Nigeria.

BACKGROUND: The objective of this study was to determine how many women in Calabar urban community actually discuss with their spouses about family planning, how their spouses view family planning and how that affects their usage of family planning facilities. METHOD: The study was conducted using a structured questionnaire which was administered by house officers and medical students on one thousand consecutive patients who attended antenatal care during the study period Seven hundred patients met the inclusion criteria for the study. RESULT: Fifty six percent of the respondents in the study have never discussed family planning with their spouses. About 15% of the respondents have the same view on family planning with their husbands while 11% of the women themselves do not want family planning even though their husbands wanted it. CONCLUSION: Communication between couples about family planning should be encouraged. Whereas women have common meeting points like antenatal clinics to learn more about contraceptives and family planning, the men rarely have such opportunities. They will therefore benefit from discussing with their spouses who are opportuned to learn from the various clinics. Spousal communication should therefore be emphasized in these clinics where contraception and family planning are taught.

Awareness, attitude and practice of contraception among secondary school girls in Calabar, Nigeria.

BACKGROUND: Adolescents are disposed to unprotected sexual activity and as a consequence, there is an increasing incidence of unwanted pregnancy among adolescent school girls in Nigeria. This study was carried out to assess the awareness, attitude and use of contraceptives among secondary school girls in Calabar, Nigeria and to determine how attitude affects its use. METHODS: Data was obtained using self administered semi-structured questionnaires distributed to 480 secondary school girls out of which 450 were properly filled and returned. These were analysed using percentages and chi-square was used to test for significance. RESULTS: The study revealed that contraceptive awareness was high. The main sources of contraceptive information were books/magazines (37%) and friends (26%). Three hundred and thirty-three (74%) girls had a negative attitude (misconceptions) towards contraceptives, while 117 (26%) girls said contraceptives were essential/useful. Sixty-six girls (14.7%) admitted that they were currently sexually active and 42 (9.3%) of them used contraceptives. There was a statistically significant association between positive attitude/beliefs and use of contraceptives (P < 0.05). CONCLUSION: We recommend the provision of accurate contraceptive information to dispel these misconceptions and the establishment of adolescent reproductive health services which should be strictly confidential to encourage acceptability and optimum utilization.