The efficacy of magnesium sulphate as an adjunct to local anaesthetics for perineal pain relief after episiotomy.

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 < 0.001). There was no significant difference in the level of satisfaction, request for additional analgesia, and side effects between the two groups. CONCLUSION: Both xylocaine alone and xylocaine with MgSO4 provide adequate perineal pain relief during episiotomy repair. MgSO4 improves the analgesic effect of xylocaine at 2 h after episiotomy repair without any significant side effect.

An unusual presentation of choriocarcinoma co-existing with pregnancy, successful delivery, and treatment: A case report and literature review.

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 <5 mIU/ml by the 5th course and the metastaic lesion regressed. She however developed WHO Stage III Oral Mucositis (with Oroesophageal Candidiasis) due to the side effects of chemotherapy which was co-managed successfully with the oral medicine specialist. She was subequently discharged home with follow-up visits. The quantitative beta-hCG has remained undetectable during her follow-up visits. Choriocarcinoma co-existing with pregnancy is rare, diagnosis often missed and confused with antepartum hemorrhage. Early and correct diagnosis can be life saving. High index of suspicion is needed to make the diagnosis. The role of chemotherapy and close follow-up with quantitative beta-hCG assays are key to survival.

OSCE: DESIGN, DEVELOPMENT AND DEPLOYMENT.

BACKGROUND: OSCE - Objective Structured Clinical Examination - as an examination format was developed by Harden and colleagues in 1975 as an answer to the oft-criticised traditional long case clinical examination which was judged to have low psychometric properties. Since then it has received wide acceptance globally as an objective form of assessing clinical competences both at the undergraduate and post graduate levels. Despite this wide acceptability and usage, many medical institutions in the West African sub region are yet to embrace this reality. However there has been a renaissance of interest in the past decade within the sub region such that medical assessments at both undergraduate and postgraduate levels are increasingly adopting the OSCE system. A lot of training and capacity building need to be done. It is in the light of this that a comprehensible and moderately comprehensive document has been developed for the benefit of medical teachers and examiners in the West African sub region. AIM: This document aims to provide the medical teachers and examiners in the West African sub region a valuable, easily understood OSCE document that will facilitate their understanding and use of OSCE as an assessment tool, based on wide experience of use, capacity building and establishment of the format in medical schools and postgraduate institutions in the sub region. METHODOLOGY: A widespread relevant literature search using different search platforms was conducted to identify published works, monograms and workshop manuals that met the aim and objectives targeted. RESULTS: Out of numerous publications, most of which highlighted the works of the original authors of OSCE, others qualitatively comparing the OSCE and traditional examinations, a few others quantitatively comparing OSCE and the traditional examination and yet others examining aspects of cost and security, this document is a distillate of all the above, such that the reader is well engaged to obtain a balanced coverage of the subject. CONCLUSION: An OSCE document comprehensively but compactly presented is made available for trainers and examiners in West African sub region and which easily serves as a reference document to facilitate and improve the quality of OSCE assessments in the sub region.

Sociodemographic determinants of complicated unsafe abortions in a semi-urban Nigerian town: a four-year review.

BACKGROUND: 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. SUBJECTS AND METHODS: 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. RESULTS: 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%). CONCLUSION: 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.

Accuracy of intra-partum prediction of birth weight using maternal anthropometric parameters.

AIMS AND OBJECTIVES: This study aimed at predicting foetal birth weight using various clinical methods and to determine which of the methods is the most accurate in this population. SUBJECTS AND METHODS: Parturients of all parities admitted into the labour ward of OAUTHC, Ile-Ife at term for delivery were recruited for this study. They had their symphysiofundal height, abdominal circumference at the umbilical level, height and weight measured. The body mass index was then calculated. The birth weight was calculated from these measurements using four clinical formulae. The weights of the babies were measured after delivery and compared with the individual estimated birth weights. RESULTS: There were 400 women who met the inclusion criteria during the time of this study. Three of the methods [Johnson's Rule, Ojwang's Rule and 5% maternal weight] overestimated the birth weight while 10% BMI underestimated the birth weight significantly. CONCLUSION: There is a strong correlation between the birth weights predicted by the various clinical methods and the actual birth weight. The accuracy of the methods can be improved by using the derived modified formulae.

Sociodemographic determinants of complicated unsafe abortions in a semi-urban Nigerian town: a four-year review / Determinantes sociodemográficas de abortos inseguros complicados en un poblado semiurbano de Nigeria: una revisión de cuatro anos

BACKGROUND: 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. SUBJECTS AND METHODS: 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. RESULTS: 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%). CONCLUSION: 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 ofmaternal morbidity and mortality in the environment.

ANTECEDENTES: Los abortos realizados por personas que no poseen las habilidades requeridas o en circunstancias en las quefaltan las normas médicas mínimas, o ambas, son considerados inseguros. Se estima que se realizan encima de 20 millones de abortos inseguros anualmente y aproximadamente 70 000 mujeres mueren globalmente como resultado, presentándose la mayoría de estos casos en el mundo en vías de desarrollo. Este estudio se propone determinar los factores sociodemográficos involucrados en los abortos inseguros complicados. SUJETOS Y MÉTODOS: El estudio es una evaluación retrospectiva de cuatro anos de todos los casos de abortos inseguros complicados tratados en el Hospital Docente Universitario de Niger Delta, Okolobiri, estado de Bayelsa, Nigeria, entre el 1ero de enero de 2007y el 31 de diciembre de 2010. RESULTADOS: La incidencia a lo largo del periodo de estudio fue 4.10% y contribuyó el 14.0% de los ingresos ginecológicos: 34.92% ocurrieron en los adolescentes de menos de 20 anos de edad, de los cuales la mayor parte (55.55%) eran estudiantes de escuela secundaria. Hubo 55.45% pacientes nulí-paras, 60.32% desempleadas y 69.80% solteras. Un total de 87.30% nunca había usado contraceptivo alguno. La mortalidad por aborto fue 256/100 000 partos, y la fatalidad de casos fue 4.76%. Ello constituyó el 30.0% de todas las muertes ginecológicas. La causa más común de las muertefue la septicemia (66.66%). CONCLUSIÓN: Los factores sociodemográficos desventajosos constituyen determinantes principales de la alta incidencia del aborto inseguro en Niger Delta, a pesar de sus estrictas leyes en contra del aborto. Deben tomarse medidas concretas para abordarlos, ya que el aborto inseguro y sus complicaciones constituyen una de las mayores causas de morbosidad maternal y mortalidad en el ambiente.

Evaluation of health workers' training in use of the partogram.

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.

Changes in sexual practices and responses among ante-natal clinic attendees in a Nigerian teaching hospital.

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.

Autotransfusion for ruptured ectopic 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.

Contraceptive practice among married market men in Nigeria.

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.

Decision-intervention interval in ruptured uteri in Ile-Ife, Nigeria.

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.

Prevalence and determinants of contraceptive practice in a defined Nigerian population.

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 (P < 0.05). Religion, literacy level, attitudes of family planning providers and distance to family planning services were not found to be significant (P > 0.05). Recommendations that will improve wide contraceptive usage are preferred.

Brought-in maternal deaths in south-west Nigeria.

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.

Emergency obstetric admissions: late referrals, misdiagnoses and consequences.

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.

Decision-caesarean delivery interval in a Nigerian university hospital: implications for maternal morbidity and mortality.

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.

Cervical cancer--a neglected health tragedy.

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.

Retained placenta: a cause of reproductive morbidity in Nigeria.

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.

The effect of a depressed economy on the utilisation of maternal health services: the Nigerian experience II.

This study follows an earlier one on the effect of the depressed Nigerian economy on the utilisation of maternal health services. Since then, there has been an observed and continued deterioration in maternal health service utilisation. The present study compares service utilisation within three time periods: pre-Structural Adjustment Programme (SAP) period of 1980-84; 1985-89 and 1990-94, revealing a continued decline in antenatal bookings, obstetric admissions and hospital deliveries with figures well below the pre-SAP levels. Maternal and perinatal morbidity have maintained a disproportionate upward trend. Specifically, perinatal mortality, obstructed labour and anaemia increased by two-, three- and six-fold respectively in the decade between the pre-SAP period and 1990-94 time period. Maternal mortality ratio of 9.3 per 1000 births is a 1.5 increase over pre-SAP level. The findings indicate a continuation over unsafe reproductive life among Nigerian women with bleak prospects into the 21st century and call for urgent change in government policy.