An Overview of the Ethical Issues in Assisted Reproductive Technology Practices in Nigeria

Assisted reproductive technology (ART) is becoming a popular method of treating infertility in Nigeria however the practice still remains largely unregulated leaving room for unethical practices and/or with possible financial exploitation of the infertile couple thereby compounding their misery. There is an urgent need for widespread adoption of proper ethical guidelines and regulation in the provision of ART services in the country for the protection of both the providers and the clients.

A Nested Case Control Study of Serum Fasting Lipid Profiles in Pre-Eclamptic Primigravidas in Ile-Ife, Nigeria

BACKGROUND

Pre-eclampsia contributes significantly to both maternal and perinatal morbidities and mortalities. One of the identified pathophysiology of pre-eclampsia is deranged serum lipid profile of which some components have been found to be elevated early in pregnancy in women destined to develop pre-eclampsia.

OBJECTIVE

To compare the serum fasting lipid profiles of pre-eclamptic primigravidas with normal primigravidas at week 20, 28 ad 34.

METHODS

We conducted a nested case-control study at Obafemi Awolowo University, Ile-Ife between November 2016 and April 2018. A cohort of 290 primigravidas was recruited at week 20 and followed up until delivery. Serum fasting lipid profiles were quantified at weeks 20, 28 and 34 for all participants. Twenty four women that developed pre-eclampsia were compared with 48 women that had normal pregnancy. Data were analysed with SPSS version 22. We used a linear mixed-effect regression model with random intercept and slope. Significance was established using p<0.05.

RESULTS

Serum lipid profiles showed average weekly increase in both groups. Primigravidas that developed pre-eclampsia had a weekly increase of 0.2(SE0.14) mmol/l in serum total cholesterol more than those with normal pregnancies.(p<0.001) Serum low density lipoprotein also showed a differential weekly increase of 0.1(SE0.05)mmol/l in primigravidas that developed pre-eclampsia over primigravidas with normal pregnancies.(p<0.001).

CONCLUSION

The average weekly increase in serum total cholesterol and low density lipoprotein were higher significantly in primigravidas that developed pre-eclampsia when compared to the control group. These findings depicted an association between serum lipid profile and pre-eclampsia among the primigravidas.</P>.

A prospective study of severity of complications associated with use of misoprostol and other abortion methods in South West Nigeria

OBJECTIVES

To assess the severity of complications following misoprostol used to induce abortion compared with other methods among women admitted for postabortion complications.

METHODS

A cross-sectional study of women who presented with complications of induced abortion at nine secondary and tertiary hospitals in South West Nigeria between April 1, 2013 and May 31, 2014. Face-to-face interviews were conducted and information on the current admission was extracted from patient records. Associations between abortion method used and severity of abortion complications were evaluated using χ² and Fisher exact tests.

RESULTS

Of 522 women included in the study, 177 reported an induced abortion: 41 women (23.2%) had used misoprostol at the first attempt to induce abortion, whereas 79 (44.6%) women had undergone surgical abortion. Occurrence of fever (P=0.06), bleeding (P=0.3), and lower abdominal pain (P=0.32) was not significantly different between the misoprostol and surgical abortion/other methods groups. Severe complications were rare with misoprostol, but more common among women in the surgical abortion/other methods group. Maternal mortality occurred only among women in the surgical abortion/other methods group.

CONCLUSION

Use of misoprostol for induced abortion was associated with fewer complications and no maternal mortality compared with surgical abortion/other methods.

Narratives of women presenting with abortion complications in Southwestern Nigeria: A qualitative study

Unsafe abortion continues to impact negatively on women’s health in countries with restrictive abortion laws. It remains one of the leading causes of maternal mortality and morbidity. Paradoxically, modern contraceptive prevalence remains low and the unmet need for contraception continues to mirror unwanted pregnancy rates in many countries within sub-Saharan Africa. This qualitative study assessed women’s knowledge; their expectation and experiences of the methods employed for abortion; and their health care-seeking decisions following a complicated abortion. Women who presented with abortion complications were purposively sampled from seven health facilities in south-west Nigeria. In-depth interviews were conducted by social scientists with the aid of a semi-structured interview guide. Coding schemes were developed and content analysis was performed with WEFTQDA software. Thirty-one women were interviewed. Misoprostol was used by 16 women; 15 women used other methods. About one-fifth of respondents were aged ≤ 20 years; almost one-third were students. Common reasons for terminating a pregnancy were: “too young/still in school/training”; “has enough number of children”; “last baby too young” and “still breastfeeding”. Women had little knowledge about methods used. Friends, nurses or pharmacists were the commonest sources of information. Awareness about use of misoprostol for abortion among women was high. Women used misoprostol to initiate an abortion and were often disappointed if misoprostol did not complete the abortion process. Given its clandestine manner, women were financially exploited by the abortion providers and only presented to hospitals for post-abortion care as a last resort. Women’s narratives of their abortion experience highlight the difficulties and risks women encounter to safeguard and protect their sexual and reproductive health. To reduce unsafe abortion therefore, urgent and synergized efforts are required to promote prompt access to family planning and post-abortion care services.

Uterine artery Doppler velocimetry in hypertensive disorder of pregnancy in Nigeria

Aim of the study

To evaluate the value of uterine artery Doppler indices and waveform pattern in predicting fetuses at risk for intrauterine growth restriction in hypertensive disorders of pregnancy.

Materials and methods

This was a prospective cross-sectional study including 80 pregnant subjects with hypertensive disorders of pregnancy and two control groups. Uterine artery Doppler sonography was performed in all study participants. Uterine artery Doppler indices across the groups were compared using the analysis of variance (ANOVA) while the presence of prediastolic notch was analyzed with the Chi Square test.

Results

For the hypertensive disorders of pregnancy group, resistivity index > 0.66 had a sensitivity of 50.0%, specificity of 69.1% and a positive predictive value of 22.2% for predicting intrauterine growth restriction. The odds ratio was 2.2 with a 95% confidence interval of 0.6–7.8. The presence of prediastolic notching had a sensitivity of 100.0%, specificity of 96.0% and a positive predictive value of 80.0% for predicting intrauterine growth restriction. The odds ratio was 22.7 with a 95% confidence interval of 7.5–68.5.

Conclusion

Uterine artery Doppler sonography is useful for predicting fetuses at risk for intrauterine growth restriction in hypertensive disorder of pregnancy. Prediastolic notching is more sensitive and more specific than uterine artery resistivity index in predicting fetuses at risk of intrauterine growth restriction in established hypertensive disorder of pregnancy.

Clinical correlates of leiomyoma estrogen and progesterone receptors among Nigerian women

OBJECTIVE

To compare the expression of estrogen receptor α (ERα) and progesterone receptor (PR) in myometrium and leiomyomata tissue, and to correlate their expression with symptoms of uterine leiomyomata.

METHODS

In a cross-sectional study, intraoperative biopsy samples of leiomyomata and adjacent myometrial specimens were obtained from premenopausal women with uterine leiomyomata treated at a center in Nigeria between September 2013 and August 2014. Immunohistochemistry for ERα and PR expression was performed on the samples. The immunoscores of both receptors were correlated with the size and symptoms of the leiomyomata.

RESULTS

Among 60 pairs of samples, leiomyomata had a higher mean expression of ERα (H-score 193.42±64.55 vs 153.29±69.13; P=0.01) and PR (214.86±66.56 vs 171.53±63.53; P<0.001) than did myometrial tissues. The tumor diameter correlated negatively with the immunoscores of both receptors irrespective of age, parity, and body mass index, but this was only significant for PR (ρ=-0.44; P<0.001). Downregulation of PR on leiomyomata was predicted to occur at a diameter of 11cm. Menorrhagia, dysmenorrhea, and infertility occurred independently of steroid-receptor expression.

CONCLUSION

Leiomyomata seem to depend on steroid hormones, but only during early tumor development. This could have implications for the selection of patients for medical management, especially with steroid-receptor modulators.

Comparison of short versus long term antibiotic prophylaxis in elective caesarean section at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria

AIMS AND OBJECTIVES

This study was to determine any significant difference between the incidence of infectious morbidity with the use of a 24 hour antibiotics regimen compared to a 7-day course of antibiotics following elective caesarean section using a cheap and easily available combination of Ampicillin/Cloxacillin and Metronidazole.

PATIENTS AND METHODS

Two hundred patients planned to have elective caesarean section for various indications and who satisfied the inclusion criteria were enrolled in the study in two groups of 100 patients each between the period of January to June 2010. Patients were randomized to receive either Ampiclox as 4 intravenous doses of 1g stat and 500 mg each 6 hourly and Metronidazole as 3 intravenous doses of 500 mg each 8 hourly both for 24 hours or same combination intravenously for 48 hours and subsequent oral use for 5 days.

RESULTS

The mean maternal age, parity, gestational age and indication for caesarean section were similar in the two groups of participants. There was no statistical difference in the incidence of febrile morbidity (17%/18%, p=0.852), urinary tract infection (6%/4%, p=0.196), wound infection (4%/3%, p=0.056) and endometritis (3%/2%, p=0.367). The mean cost of antibiotics per patient (N730/$4.65) in the short term prophylaxis group was half that of the long term prophylaxis group (N1, 540/$9.81).

CONCLUSION

There was no difference in the incidence of infection related morbidity when short term prophylactic antibiotics was used at elective caesarean section compared to long term prophylactic antibiotics.

Influence of multiple antenatal counselling sessions on modern contraceptive uptake in Nigeria

OBJECTIVE

To determine the influence of multiple contraceptive counselling sessions during antenatal care on use of modern postpartum contraception.

METHOD

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.

RESULTS

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).

CONCLUSION

Multiple antenatal contraceptive counselling sessions improve the use of modern postpartum contraception.

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.

Uterine Leiomyomata in South Western Nigeria: a clinical study of presentations and management outcome

BACKGROUND

Uterine leiomyoma is remarkably common, however only a subset of women have their fibroids clinically detected, symptomatic, or warrant surgical treatment. Its removal is commonly associated with complications. To prevent or control the occurrence of this complication requires the understanding of the factors associated with the complications.

OBJECTIVE

To evaluate the sociodemographic, clinical characteristics, management outcome and its determinants in southwestern Nigeria.

METHODS

Study was carried out at two large tertiary hospitals in the south west region of Nigeria. Retrospective review of case records of all surgically managed cases of uterine leiomyoma over a period of 25 years. One hundred and fifty nine women with uterine leiomyoma seen and managed surgically in South-Western Nigeria were the participants.

RESULTS

The common presenting complaints were menstrual irregularities (47.7%), abdominal swelling (39.1%) and infertility (31.9%). The average uterine size at presentation was 15±9.7 weeks. The majority (79.9%) of the women presented with multiple leiomyomata. The commonest anatomical position of the nodules were multiple positions and intramural in 707(60.9%) and 172(14.8%) respectively. Myomectomy was performed in 54.7% of cases. Postoperative complications occurred in 20.9 % of cases with postoperative pyrexia (13.5%), blood loss warranting transfusion (12.8%) and postoperative anaemia (10.4%) been the most common complications.

CONCLUSION

Uterine fibroid is common in our environment and its removal is commonly associated with post-operative pyrexia, blood loss, and anaemia and wound infection. Midline incision, closure of rectus sheet with chromic catgut and myomectomy were associated with postoperative complications in this review.

The effect of caesarean section on self-esteem amongst primiparous women in South-Western Nigeria: a case-control study

OBJECTIVE

This study aims to assess the level of self-esteem of newly delivered mothers who had caesarean section (CS) and evaluate the sociodemographic and obstetrics correlates of low self-esteem in them.

METHODS

Newly delivered mothers who had CS (n = 109) and who had spontaneous vaginal delivery (SVD) (n = 97) completed questionnaires on sociodemographic and obstetrics variables within 1 week of delivery. They also completed the Rosenberg self-esteem scale. RESULTS. Women with CS had statistically significant lower scores on the self-esteem scale than women with SVD (p = 0.006). Thirty (27.5%) of the CS group were classified as having low self-esteem compared with 11 (11.3%) of the SVD group (p = 004). The correlates of low self-esteem in the CS group included polygamy (odd ratio (OR) 4.99, 95% confidence interval (95% CI) 1.62-15.33) and emergency CS (OR 4.66, 95% CI 1.55-16.75).

CONCLUSIONS

CS in South-Western Nigerian women is associated with lowered self-esteem in the mothers.

Active management of third stage of labor: evidence versus practice

OBJECTIVE

To determine the correct use of active management of third stage of labor (AMTSL) (using the full complement of existing standard definitions) and compare the outcomes of third stage of labor in women who received AMTSL (according to these definitions) with those who did not.

DESIGN

Observational, cross-sectional survey.

SETTING

Seven tertiary centers in southwest Nigeria.

POPULATION

Women undergoing non-instrumental vaginal deliveries.

METHODS

Prospective direct observations of childbirth procedures. AMTSL was defined according to Cochrane review, ICM/FIGO (International Confederation of Midwives/International Federation of Gynecology and Obstetrics), and WHO (World Health Organization) recommendations. Main outcome measures. Use of AMTSL and its components and outcome of third stage of labor.

RESULTS

There was a high rate of compliance with most of the individual components of AMTSL. The use of AMTSL varied widely with the definition applied and tended to decrease with increasing strictness of the criteria (Cochrane review: 88.9%; ICM/FIGO: 42%; WHO: 1.8%). The frequencies of adverse labor outcomes were generally low (postpartum hemorrhage (PPH): 4.9%; severe PPH: 0.8%; retained placenta: 1.9%; uterine inversion: 0.0%). Frequencies of PPH, postpartum anemia, and mean blood loss among women who received AMTSL according to the Cochrane review definition were significantly lower than for those who did not (p < 0.05). There was no significant difference between any of the outcomes for women who received AMTSL according to the ICM/FIGO definition and those who did not.

CONCLUSIONS

The survey reveals substantial definition-dependent variation in the providers' adherence to recommended AMTSL practices. The clinical implications of the current practice in this population suggest the need for randomized comparison of various AMTSL packages to determine their comparative effectiveness in the prevention of PPH.

Safety and efficacy of misoprostol for induction of labour in a semi-urban hospital setting

Most studies on the use of misoprostol for induction of labour have been carried out in well-endowed hospitals in developed countries with state-of-the-art monitoring equipment. There is need for more studies to be conducted in facilities with limited resources, if more patients are to benefit from the low cost and effectiveness of the drug. Following Ethical Committee approval, 152 women had labour induced in our maternity unit using intravaginal misoprostol. The patients were monitored clinically using the WHO model partograph with digital palpation of uterine contractions and intermittent auscultation of fetal heart with a pinard stethoscope. One hundred and thirty-five (88.8%) of the women had a vaginal delivery, while nine (5.9%) had a caesarean section for various obstetric indications. Eight cases of uterine hyperstimulation were noted but none of uterine rupture. We conclude that misoprostol can be used safely for induction of labour in less endowed hospital settings such as in developing countries, using basic clinical tools for monitoring.

Poor obstetric performance of teenagers: is it age- or quality of care-related?

We studied prospectively the effect of antenatal care on the obstetric performance of teenagers seen at a university teaching hospital over a 14-month period. When the obstetric complications among the teenagers were compared to their older counterpart, there were significantly higher complication rates, especially anaemia, preterm delivery, low birth weight and neonatal admission. After controlling for utilisation of antenatal care, significant differences were observed only in the incidence of low birth weight babies. In conclusion, this study has shown that the poor obstetric outcome of teenage pregnancy is related to non-utilisation of prenatal care rather than their biological age.

Delivery outside hospital after antenatal care: prevalence and its predictors

Over a period of 5 years (1994 - 1998), of 9519 women who booked for antenatal care at the two tertiary hospitals of the Obafemi Awolowo University Teaching Hospital Complex, Ile Ife,-Nigeria,12.8% (1220) defaulted from hospital delivery. The casenotes of these patients were retrieved from the medical records department and were sorted into two groups of defaulters and non-defaulters from hospital delivery. Information obtained from the casenotes includes sociodemographic characteristic, past obstetric and present obstetric history. Bivariate analysis revealed six potential predictors; however, following adjustment by multiple logistic regression, only history of previous delivery outside the hospital (OR = 3.13, CI = 2.06 - 4.67), planned elective caesarean section in current pregnancy (OR = 2.03, 1.66 - 2.75), caesarean section in last delivery (OR = 1.93, CI = 1.57 - 2.76) and objection to admission in the current pregnancy (OR = 1.33, CI = 1.04 - 1.65) remained as significant predictors.

Pattern and correlates of premenstrual symptomatology amongst Nigerian University students

This study aimed to evaluate the pattern and correlates of premenstrual symptomatology amongst Nigerian female undergraduates. Female University students (n = 409) completed questionnaires detailing sociodemographic, menstruation/gynecological history and personality traits. They were then rated with a checklist for premenstrual symptoms. The most frequent premenstrual symptoms were 'breast tenderness' (35.5%), 'sleeplessness' (15.6%), 'decreased interest in usual activities' (15.4%), 'lethargy/easy fatigability/lack of energy' (13.2%) and 'change in appetite' (13.2%). The prevalence of premenstrual symptomatology was 50.1% and the correlates of increasing premenstrual symptomatology included increasing age, increasing severity of menstrual pain, personality traits of neuroticism and agreeableness and increasing body mass index. Although the rate of premenstrual symptomatology in sub-Saharan African women was comparable with that in the western cultures, there may be cross-cultural differences in the pattern of presentation. Dysmenorrhoea and personality traits should be taken into consideration when planning and implementing effective strategy to manage perimenstrual problems in this region.

Active management of third stage of labour: a survey of providers' knowledge in southwest Nigeria

BACKGROUND

The disparity between current evidence and practice on active management of third stage of labour (AMTSL) demands assessment of providers' knowledge on the subject.

OBJECTIVE

To assess the level and determinant(s) of accurate knowledge of obstetric providers regarding AMTSL.

METHODS

Questionnaire-based survey of 361 labour and delivery professionals in public tertiary obstetric centres in southwest Nigeria.

RESULTS

Female nurses at different cadres accounted for most of the respondents. Majority (90.6%) of the respondents reported being aware of AMTSL as an obstetric intervention and 49.7% were aware of FIGO/ICM recommendation on AMTSL. Out of 13 potential third stage interventions, 102 respondents (28.3%) correctly and exclusively identified the components of AMTSL as defined by FIGO/ICM. Many procedures reserved for treatment of complicated third stage of labour such as manual placental removal (37.7%), blood transfusion (20.2%), bimanual uterine compression (24.7%) and uterine artery ligation (13.9%) were also selected as AMTSL components. Multivariate logistic regression analysis indicated that being in administrative position (adjusted OR: 2.68; CI 1.19-6.02) and frequent compared to rare or no consultation of books, journal and internet sources for information (adjusted OR: 2.58; CI 1.21-5.52) increased the odds of having accurate knowledge of AMTSL while being a nurse/midwife (adjusted OR: 0.15; CI 0.05-0.39), matron (adjusted OR: 0.25; CI 0.08-0.79) or intern (adjusted OR: 0.07; CI 0.01-0.29) compared to postgraduate resident doctors reduced the odds of having accurate knowledge of AMTSL.

CONCLUSION

AMTSL was a familiar but poorly understood intervention among obstetric care providers in this region. Improvement in healthcare quality and practitioners' adherence to recommended guidelines on AMTSL urgently requires educational interventions that target those who provide routine delivery care and organisation of the health care delivery system in such a way that enables providers to act on acquired knowledge.

Outcome of eclampsia at the Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife

OBJECTIVE

Eclampsia is a serious obstetric complication with attending high maternal and perinatal morbidity and mortality. There is need for periodic audit of our management of these cases so as to identify potential areas for possible intervention aimed at improving the management outcome of this pregnancy complication.

METHODS

The records of cases of Eclampsia managed at the OAUTHC Ile-Ife between January 1, 1994 and December 31, 2003 were retrospectively analysed.

RESULTS

The incidence of Eclampsia was 0.91% of total deliveries. It was highest in teenagers and young adults who are less than 25 years (1.56%), who were carrying their first pregnancy (2.64%) and were unbooked (6.3%). Headache was the commonest symptom (100%), while hypertension and fever were the commonest signs being present in 75% and 20.2% of the patients respectively. Antepartum Eclampsia accounted for 56.5% of the cases and majority was delivered by emergency caesarean section. Maternal and perinatal mortality were 8.0% and 19.1% respectively.

CONCLUSION

Provision of good quality and widespread antenatal care, improving the capacities of the hospitals to handle emergencies and intensive care unit management of all cases of Eclampsia are measures that could reduce the burden ofEclampsia in this environment.

Premenstrual dysphoric disorder amongst Nigerian university students: prevalence, comorbid conditions, and correlates

AIMS

The rate of premenstrual dysphoric disorder (PMDD) amongst sub-Saharan Africans is unknown. This study aimed to estimate the rate of PMDD amongst Nigerian undergraduates and to evaluate psychosocial correlates and comorbid psychiatric conditions.

METHOD

Female university students (n=410) completed questionnaires detailing sociodemographic, menstruation, and gynaecological history. They also completed the Big Five Personality Inventory (BFI), and the presence of PMDD and any other DSM-IV axis 1 psychiatric diagnosis was assessed with the Mini International Neuropsychiatric Interview (MINI).

RESULTS

The prevalence of PMDD was 6.1% and the correlates included older age (p=0.001), painful menstruation (p=0.006), and high score on neuroticism scale (p=0.019). Compared with participants without PMDD, participants with PMDD have significantly higher rates for the following psychiatric diagnoses: dysthymia (odds ratio [OR], 3.82; 95% confidence interval [CI], 1.68-8.69), major depressive disorder (OR, 17.00; 95% CI, 6.72-43.00), panic disorder (OR, 4.39; 95% CI, 1.35-14.30), and generalised anxiety disorder (OR, 1.21; 95% CI, 1.21-17.83).

CONCLUSION

The rate of PMDD in sub-Saharan African women was comparable to that in the western cultures. Planning and implementing an effective strategy to manage perimenstrual problems in this region should be an issue of priority.

Attitude of rural Nigerian pregnant women to antenatal HIV screening

OBJECTIVE

To assess the knowledge and attitude of rural Nigerian women to the incorporation of HIV screening as part of the routine antenatal screening test at booking.

METHODS

1 820 women were interviewed using a close ended questionnaire at the antenatal clinic of the Federal Medical Centre (FMC) Owo, Nigeria over a period of 12 months.

RESULTS

Though the majority of the women were of low socio-economic status (85.9%) with 20% having less than six years of formal education, 98.6% of them were aware and knowledgeable (89.1%) about HIV/AIDS. The majority (89.9%) of the women accept routine HIV screening as part of antenatal screening.

CONCLUSION

Based on the above findings, obstericians practicing in this locality are encouraged to incorporate HIV screening into their antenatal care.

A multicentre evaluation of the two-layered repair of postpartum perineal trauma

We set out to compare a policy of two-layered postpartum perineal repair leaving the skin unsutured with a policy of three-layered repair, which involved skin closure. Parturients who sustained a second-degree tear or an episiotomy in four Nigerian centers were randomised to have either a two-layered repair (417 women) or a three-layered repair (406 women). Fewer women in the two-layered group reported perineal pain at 48 hours (57% vs. 65%, relative risk [RR] 0.87, 95% confidence interval [CI] 0.78-0.97) and 14 days postpartum (22% vs. 28%, RR 0.77, CI 0.61-0.98). The two-layered repair was also associated with reduced risk of suture removal (6% vs. 10%, RR 0.62, CI 0.39-0.99), and less superficial dyspareunia at 3 months (6% vs. 12%, RR 0.52, CI 0.33-0.81). The rates of wound healing were similar between the two groups. Leaving the skin unsutured during postpartum perineal repair reduces perineal pain and dyspareunia.

Delivery of the impacted head of the fetus at caesarean section after prolonged obstructed labour: a randomised comparative study of two methods

Obstructed labour is a common obstetric complication in Nigeria associated with poor fetal and maternal outcome. Delivery of the fetus at caesarean section is always difficult, especially if the fetal head is impacted in the pelvis. The mode of delivery at caesarean section may occasionally compound the morbidity associated with obstructed labour. The purpose of this study was to examine and compare the morbidity and mortality associated with two methods of delivery of the impacted fetal head at caesarean section for obstructed labour (the push method and the pull (reverse breech) method). This study is a prospective study of cases of obstructed labour admitted into the labour ward of Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife between 1 June 1998 and May 31 2000. One hundred and eight women with obstructed labour at term with live fetus undergoing caesarean section were assigned randomly to either of the methods of admission. The maternal and fetal outcomes were analysed and compared between groups. Patients in the push group had statistically significant higher rates of maternal morbidity (longer operation time, more blood loss, extension of uterine incision, endometritis, longer hospital stay and higher hospital bills) than the pull method (P < 0.05). Also the fetal morbidity was worse in the push group. The 'pull' method of delivery of impacted fetal head at caesarean section for obstruction is safer and faster than the 'push' method.

Unavoidable caesarean myomectomy: A case report

Establishment of the feasibility and need to perform myomectomy during caesarean section when fibroid obstruct wound closure with associated hemorrhage has been presented. A case of a primigravida with a huge uterine fibroid located in the lower segment lifting up the uterine cavity leading to persistent transverse lie of the fetus at term is presented. An elective classical caesarean section was performed with difficulty in uterine wound closure and haemorrhage necessitating myomectomy. Haemorrhage was controlled with the use of Foley catheter tourniquet and high dose oxytocin infusion. Literature review was carried out. The mother and baby had satisfactory outcome. To conclude, life threatening situations of myomectomy with caesarean section ought to be, and can be safely performed using tourniquet and high dose oxytocin to reduce haemorrhage. The uterus in the immediate post partum period is better adapted physiologically to control haemorrhage than any other stage of a woman's life. Key Words: Classical caesarean Section, Myomectomy, caesarean-myomectomy, Haemorrhage.   doi:10.3126/njog.v2i2.1463 N. J. Obstet. Gynaecol 2007 Nov-Dec; 2 (2): 81 - 83

Caesarean myomectomy - a safe procedure: A retrospective case controlled study

Objective(s): The aim of the study is to determine whether myomectomy at the time of caesarean section leads to increase incidence of intrapartum and postpartum complications. Methods: Fourteen women, with uterine fibroids in pregnancy who were treated by caesarean myomectomy between January 2001 and June 2007, were compared retrospectively with fourteen women, without uterine fibroids who had routine caesarean section during the same period. Myomectomy for all types of myoma was performed at caesarean section after the delivery of the baby. Haemorrhage was controlled with the use of Foleys catheter tourniquet and high dose oxytocin infusion. The cases and control were analysed for age of the patient, parity, pre and post-operative haematocrit levels, duration of operation, blood loss, blood transfusions, and incidence of postpartum fever. Results: Caesarean myomectomy resulted in the mean blood loss of 589 ml (range 300-1300 ml) compared with 518 ml (range 350-850 ml) in the control group (p=0.376). The mean duration of operation was longer in the cases of caesarean myomectomy (66.8 mins) than those of the controls (56.4 mins). There were no significant differences between the two groups in the incidence of intraoperative haemorrhage, the need for blood transfusion, post partum fever, and length of hospital stay. Conclusions: This study shows that myomectomy during caesarean section is a safe procedure in experienced hands and is not as dangerous as generations of obstetricians have been trained to believe. Further research is necessary to establish the cost effectiveness of the procedure. Key words: myomectomy, cesarean section, hemorrhage      doi:10.3126/njog.v2i2.1457 N. J. Obstet. Gynaecol 2007 Nov-Dec; 2 (2): 59 - 62

A Prospective Comparison of the 30-Minute and 60-Minute Oxytocin Dose Incremental Schedules for Induction of Labor at Term

Aim: To compare the efficacy and safety of two oxytocin incremental protocols used for induction of labor in women of low parity. Method: One hundred and twenty women (120) of low parity requiring induction of labour at term were randomly assigned into the two oxytocin induction dose protocols of the 30-minute and 60-minute incremental intervals. Induction–onset of labour interval, Induction-delivery interval, Delivery outcome and perinatal outcome were compared. Results: The induction-onset of labour interval and the induction delivery interval were comparable between the 60-min group and the 30-min group. Intrapartum complications like fetal distress, uterine hyperstimulation and precipitate labour were more common in the 30-min group however, this was not statistically significant. Conclusion: Oxytocin infusion regimens of 60-min and 30-min are comparable in outcome for induction of labour. The 60-min group carries less risk to both the mother and the fetus. Keywords: Induction-delivery interval, Induction of labor, oxytocin DOI: http://dx.doi.org/10.3126/njog.v6i1.5250 NJOG 2011; 6(1): 35-40

Uterine Fibroids: A Ten Year Clinical Review in Ile-Ife, Nigeria

DOI: http://dx.doi.org/10.3126/njog.v4i2.5031 NJOG 2010 Jan-Feb; 4(2): 8-11

Caesarean Section and Perinatal Mortality in South Western Nigeria

Aim: Caesarean section carries a substantial hazard to the unborn fetus, especially if done as an emergencyprocedure. In our environment fetal loss following a caesarean delivery is usually attributed to the procedureby patients and relations who do not readily accept caesarean section as a delivery option.Method: A 10 year descriptive study of caesarean section related perinatal mortality in four tertiary hospitalsin South western Nigeria.Results: Nineteen thousand one hundred and seventy nine deliveries were conducted in the hospitalsduring the study period; five thousand one hundred and ninety five (27.1 %) of which were caesareandeliveries. Two hundred and thirty five of the caesarean deliveries were associated with perinatal death (6.9%.). Majority of these deaths were among the unbooked (73.8%), multiparous (69.0 %) patients and emergencycaesarean delivery (83.4%). Prolonged/ obstructed labour (45.4%), preeclampsia/eclampsia (18.8%) andfetal distress (11.5%), were the commonest indication for caesarean deliveries. While majority of the perinataldeath were still born (60.3%), (39.7%) were early neonatal deaths. The common causes of early neonataldeath in these patients were severe birth asphyxia (37.4 %), neonatal sepsis (22.0%) and prematurity (16.4%).Conclusion: The cause of perinatal mortality associated with caesarean delivery in our environment arepreventable with public enlightenment, provision of affordable and accessible prenatal and neonatal care,discipline, behavioural and attitudinal change of health workers, and the political will on the part of policymakers to maternal and child health delivery care more effective.DOI: 10.3126/njog.v4i1.3332Nepal Journal of Obstetrics and Gynaecology June-July 2009; 4(1): 46-48

A Randomized Clinical Trial of Misoprostol and Oxytocin for Induction of Labour

DOI: http://dx.doi.org/10.3126/njog.v5i1.5061 NJOG 2010 Jul-Aug; 5(1): 44-48

Obstetric performance in elderly Nigerian women: A comparative study

Aims: To study the obstetric outcome in Nigerian women aged 35 years and above while comparing them with younger women matched for parity, socioeconomic class and body mass index. Method: A cohort of 132 pregnant women aged 35 years and above with another 269 pregnant women aged 20-25 years matched for parity, socioeconomic class and body mass index seen at the obstetric unit of a multidisciplinary proprietary hospital in Lagos Nigeria. Results: There were statistically significant difference between the two group in incidence of chronic hypertension (P = 0.02), gestational diabetes (P = 0.05), symptomatic fibroid (P = 0.01), frequent hospitalisation (P = 0.007), caesarean section (P = 0.005), operative vaginal delivery (P = 0.042), Induction of labour (P = 0.024) premature delivery (P = 0.001), low birth weight (P = 0.021) and congenital abnormality but not in Preeclampsia, malpresentation, obstetric haemorrhage, wound infection and multiple pregnancy . Conclusion: This study demonstrated that women at 35 years and above are high-risk group and should be closely supervised during pregnancy. Keywords: Elderly, Nigerians, obstetric performance   doi:10.3126/njog.v2i1.1468 N. J. Obstet. Gynaecol Vol. 2, No. 1, p. 9 - 12 May -June 2007