Risk factors for retained placenta in southwestern Nigeria.

INTRODUCTION: This study aimed to determine the incidence of, and identify independent risk factors to retained placenta in Ile-Ife, southwestern Nigeria. METHODS: This was a prospective case-control study involving 120 women with retained placenta after vaginal birth at the Obafemi Awolowo University Teaching Hospital, Ile-Ife, southwestern Nigeria over a period of seven years. Two consecutive normal deliveries after each retained placenta served as controls. Following a bivariate analysis, a multivariate logistic regression model was constructed in order to define independent risk factors for retained placenta while controlling for confounding variables. RESULTS: During the study period, there were 120 cases of retained placenta, and the total number of deliveries was 6,160, making the incidence 1.9 percent. Independent risk factors associated with retained placenta include non-use of antenatal care (odds-ratio [OR] 22.71, 95 percent confidence interval [CI] 10.5-49.12, p-value is less than 0.000), previous retained placenta (OR 15.22, 95 percent CI 3.30-70.19, p-value is less than 0.000), previous caesarean section (OR 12.00, 95 percent CI 2.05-70.19, p-value is less than 0.006), maternal age 35 years or more (OR 7.10, 95 percent CI 1.5-32.40, p-values is less than 0.012), grand multiparity (OR 6.63, 95 percent CI 1.88-23.40, p-value is less than 0.003), previous dilatation and curettage (OR 4.44, 95 percent CI 1.69-11.63, p-value is less than 0.002), preterm delivery (OR 3.12, 95 percent CI 1.12-8.68, p-value is less than 0.029) and placenta weight less than 501 g (OR 2.91, 95 percent CI 1.34-6.32, p-value is less than 0.007). CONCLUSION: Women with identifiable risk factors should be targeted for the prevention of retained placenta. There is a need for the training of birth attendants in the proper conduct of delivery and third stage of labour to prevent placenta retention and postpartum haemorrhage.

Pregnancy outcome in nulliparous women aged 35 or older.

Our objective was to examine pregnancy outcome in women age 35 and over. We compared pregnancy delivery complications in 207 women aged 35 years and older with 219 control women aged 25 - 29 years. Data was collected retrospectively and stratified by parity. Results of statistical analysis showed that the older women differed significantly in (1) antepartum factors (previous pregnancy experience, chronic and pregnancy-induced hypertension, maternal and gestational diabetes, placenta previa) (2) intrapartum factors (malpresentations, fetal disproportions, abnormal labour, caesarean and operative vaginal delivery) (3) neonatal outcomes (birth asphyxia, prematurity, low birth weight, neonatal intensive care unit admissions). However, birth trauma and perinatal mortality did not differ between the two groups. We concluded that pregnancies in older women are prone to complications, but when managed accordingly the overall perinatal outcomes were good.

Outcome of term breech by intended mode of delivery.

BACKGROUND: The optimal mode of delivery for the term breech fetus is undetermined. METHODS: Over a 10-year period, the outcome of 157 planned caesarean sections and 265 trials of vaginal delivery for the matured, selected, singleton breech presentation were compared. RESULTS: The perinatal mortality among the planned vaginal group was not statistically different from the planned caesarean group (3.0% vs 0.6%, p = 0.102), so was the incidence of birth asphyxia (9.4% vs 4.5%, p = 0.06), admission into neonatal intensive care unit (13.6 vs 7.6%, p = 0.063) and neonatal birth injury (3.4% vs 0.6%, p = 0.072). The overall maternal morbidity was 28% in the planned caesarean group, and 9% in the planned vaginal group, p = 0.025. CONCLUSION: Given appropriate selection criteria and management protocol, the outcome from elective caesarean section might not be better than that from planned vaginal delivery.

Female genital mutilation: an analysis of 522 cases in South-Western Nigeria.

This study was conducted at three teaching hospitals in South-Western Nigeria. Paturients were examined to find out if they had had female genital mutilation. Those who did were given a self-administered questionnaire. Results show that all the patients had either Type I (69%) or Type II (31%) mutilation (using WHO classification). The average age at which the procedure was performed was 6.9+/-2.9 years, with 4% of women having the procedure performed in pregnancy. The majority of the procedures were performed by medically untrained personnel (89%). Up to 67% of the women reported complications following the procedure. Severe pain and bleeding were the most common (69%) of the complications reported. The most common reason given for the procedure is cultural/traditional (63%). About a fifth of the women want their female child to undergo female genital mutilation. This study highlights the need for further interventions aimed at discouraging the practice of female genital mutilation.

Ultrasonic measurement of biparietal diameter and femur in foetal age determination.

Our objective was to verify ultrasonic measurement of biparietal diameter and femur in foetal age determination in the second and third trimester of pregnancy. The prospective cross sectional study was carried out at the ultrasound department of Aberdeen Maternity Hospital Scotland. The study population consisted of 716 pregnant Scottish (Caucasian) women who were certain of their gestational ages and had their gestational ages confirmed in the first trimester by ultrasound. The findings revealed: (1) Linearity through out pregnancy using the femur length measurements while that of the biparietal diameter demonstrated poor correlation after 32 weeks of gestation. (2) The standard deviation and the correlation coefficient of the femur length measurements were 0.0042 and 0.9920 respectively while the corresponding values for biparietal diameter were 0.0045 and 0.9850 respectively. (3) The standard error for femur length estimate was 0.2251 as against 0.3009 for biparietal diameter estimate. The results suggest that femur length measurement is a more reliable index of late third trimester gestational age prediction than biparietal diameter.

Risk factors of placenta accreta in Ile-Ife, Nigeria.

Our objective was to identify the independent risk factors of placenta accreta. The hospital records of 44 pregnancies complicated by placenta accreta, and 1371 controls over a 10-year period were reviewed. Univariate analysis was followed by multivariate logistic regression analyses with adjustment for potentially confounding variables to determine the statistically significant independent predictors of placenta accreta (p <.05). The following factors were associated with placenta accreta: maternal age of at least 35 years (P =.004), gravidity = 5 (P =.004), placenta praevia (P <.001), previous uterine curettage (P =.006) and previous caesarean delivery (P =.014). However, when examined with a multivariate model, only placenta praevia (Odds Ratio [OR] 49.3; 95% confidence interval [95% CI] 13.1, 119.0) and maternal age = 35 (OR 2.7; 95% CI 1.3, 7.9) reached a significant association. Independent risk factors of placenta accreta include placenta praevia and maternal age 35 and over.

Mortality and morbidity associated with misdiagnosis of ectopic pregnancy in a defined Nigerian population.

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

The role of membrane stripping in prevention of post-term pregnancy: a randomised clinical trial in Ile-lfe, Nigeria.

This study was carried out to evaluate the efficacy and safety of membrane stripping at term in reducing the incidence of post-term (41 weeks or greater) pregnancies. One hundred and thirty-seven pregnant women at 38 weeks gestation were randomised to receive either membrane stripping (69) or gentle cervical examination (68). Women who received stripping had earlier delivery (4.8 vs. 12.1 days; P<0.001) and less incidence of delivery at 41 weeks or greater (3% vs. 16%; P=0.009). No statistically significant difference was noted in incidence of premature rupture of membranes, clinical evidence of chorioamnionitis, intrapartum characteristics and perinatal outcome. We conclude that membrane stripping is a safe method to reduce the incidence of post-term pregnancy.

Occupational health hazards among health care workers in an obstetrics and gynaecology unit of a Nigerian teaching hospital.

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

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.

Ureteric injuries following pelvic operations.

BACKGROUND: Iatrogenic injuries to the ureter are hazardous complications of pelvic operations, causing severe morbidity and even mortality. OBJECTIVE: To present our 10 years experience in the management of such ureteric injuries. DESIGN: A retrospective study carried out between January 1990 and December 1999. SETTING: Two busy health institutions, namely Ife State hospital and Wesley Guild Hospital, both of the Obafemi Awolowo University (OAU) Teaching Hospitals Complex, Ile-Ife, Nigeria. RESULTS: The incidence of iatrogenic injury was 0.4%. Ureteral transection was the commonest lesion (58%). Ureteroneocystostomy was performed in 70% of the operated cases. Those diagnosed at the time of injury and treated with end-to-end anastomosis had the best results. CONCLUSION: The proper identification and, when necessary, isolation of the ureter during operations in which there is a risk is crucial in reducing the incidence of ureteral injuries.

Determinants of mission house delivery among booked patients in a Nigerian teaching hospital.

This study examines the determinants of Mission House Delivery among booked patients in Ile-Ife, Nigeria. During the 12 months of the study (1 May 199930 April 2000) 196 booked patients at Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife who delivered at mission houses were analysed. All ages and parity groups, educational level and social classes were involved. The majority (73%) were of low socio-economic class. The reasons for mission house delivery included financial constraints (41%), fear of possible caesarean section (46%), industrial action by health-care workers (39%), transport difficulty at night (26%), previous deliveries in mission houses (16%) and communal feud (12%). Four maternal deaths occurred (MMR 978/100 000 births) and 20 perinatal deaths (PNMR 118/1000 total births). Reduction of hospital user fees, provision of transportation and efficient telecommunication facilities at all times, conflict resolution and proper remuneration of health care workers are urgent needs to be addressed. Legislation against delivery in unsafe places and establishment of appropriate facilities by churches interested in maternity services is highly recommended.

Obstetric fistula: evaluation with ultrasonography.

Twenty-two patients with 24 fistulae were examined prospectively with real-time sonography. Sonographic findings were compared with those of intravenous urograms and correlated with the findings at examination under anesthesia and at surgery. Various genital abnormalities not revealed by intravenous urography were demonstrated by sonography preoperatively. These included cervical injuries, vesicovaginal fistula showing "flat tire" sign and hourglass deformities, and identification of the site, size, and course of fistulae in seven (29%) of the cases. However, the demonstration of the fistulae by sonography is poor relative to that of examination under anesthesia, in which 21 (87%) of the fistulae were identified. The factors responsible for the difficulty in demonstrating the fistulae on sonography, which included size and multiplicity, are discussed. Sonography is complementary to examination under anesthesia in preoperative evaluation of the patients with obstetric fistulae in general and in those with previous unsuccessful repairs in particular.

Socioeconomic barriers to safe motherhood among booked patients in rural Nigerian communities.

This study examines the socioeconomic barriers to safe motherhood in booked patients in the Ife-Ijesha health administrative zone, Nigeria. During the period of study (January 1998 to December 1998), 161 booked patients of Ife State Hospital, Ile-Ife and Wesley Guild Hospital, Ilesha presented with an avoidable obstetric emergency, Seventeen (10.6%) presented during the antenatal period, while 89 (55.3%) and 55 (34.2%) presented in labour and postpartum respectively. The patients presented with obstetric complications such as obstructed labour (24.2%), postpartum haemorrhage (21.1%), puerperal sepsis (24.2%), imminent eclampsia and eclampsia (15.5%), retained second twin (9.3%). Three maternal deaths occurred (MMR 1467/100 000 births) and the perinatal mortality rate was 290/1000 total births. The adduced reasons for late presentation included, financial constrains (85.1%), poor access to hospital/transportation difficulties (33.5%), objection to hospital admission by relatives (23.0%), aversion to caesarean section (21.7%) and attitude to hospital staff (8.1%). The patients were of the opinion that reducing the economic burden associated with hospital fee, provision of transportation, encouraged family support and reduction of operation rate would lead to reduction in late presentation.

Uncomplicated Caesarean section: is prolonged hospital stay necessary?

BACKGROUND: Caesarean section among the Yoruba of western Nigerian is surrounded by a lot of fears, miseries, aversion, guilt and misconceptions for reasons varying from the desire by women to have a natural vaginal birth, fear of surgery, morbidity and deaths from the operation and prolonged hospital stay. OBJECTIVE: To examine issues of reduced hospital stay following Caesarean section with a view of making the operation more acceptable and proffering solution to some of the problems faced by women when Caesarean section is indicated. DESIGN: A prospective case control study. SETTING: Wesley Guild Hospital, Ilesha, Nigeria from 1st July, 1997 to 30th June, 1998. SUBJECTS: One hundred consecutive patients who had uncomplicated Caesarean section, randomised into two groups of short (three days) and prolonged (seven to eight days) hospital stay respectively. MAIN OUTCOME MEASURES: Observations of patients in both groups were made by an independent observer on day seven post-operation and the main outcomes measured included: wound infection rates, ability to maintain erect posture, mood changes, neonatal sepsis rate, immunisation rate of the neonates and average hospital bills. RESULTS: The findings revealed that wound infection rates of six per cent and ten per cent among the short and prolonged hospitalised patients respectively are not significantly different. Patients with short stay have better erect posture, lower incidence of depressive mood, lower neonatal sepsis rate, lower hospital bill and are more satisfied with early home discharge. CONCLUSION: Embracing the concept of early home discharge after Caesarean section in uncomplicated cases may remove some of the psychological upsets and economical impediments associated with the operation and make the operation more acceptable.

Sociodemographic factors in mental disorders associated with infertility in Nigeria.

The mental status of 37 female patients with infertility and that of 37 healthy controls was evaluated using General Health Questionnaire, Present State Examination, and clinical assessment. An interview schedule, designed to elicit information on sociodemographic, psychiatric predisposing, and obstetric factors, was also administered. A significantly higher proportion (29.7%) of the patients was found to have diagnosable psychopathology, mainly depressive episode and generalized anxiety disorder. Compared with the control group, the infertile women experienced poorer marital relationships, had a significant family history of infertility, were more negatively predisposed to child adoption. and had a greater history of surgery and induced abortion. Polygamy was found to have a close association with psychopathology in the sample of infertile women. The implications of these findings and ways of improving the mental status of the infertile woman are discussed.

Umbilical cord prolapse: a clinical study of 60 cases seen at Obafemi Awolowo University Teaching Hospital, Ile-Ife.

The incidence of umbilical cord prolapse at Obafemi Awolowo University teaching hospital complex, Ile-Ife over a ten year period was 0.42% (one in 240 deliveries). The incidence was observed to be higher among the unbooked patients (76.7%). Analysis of the 60 cases reveals that multiparity, unengaged presenting part from cephalo-pelvic disproportion, prematurity, prelabour spontaneous rupture of membranes, breech presentation, and multiple pregnancy were the major contributory factors. The perinatal mortality (36.7%) was significantly higher than that of the hospital which was 8% (P < 0.05). The perinatal mortality rate was higher among the unbooked patients (86.4%). Caesarean section gave better results except when the cervix was fully dilated. Early resort to Caesarean section, proper and adequate antenatal care and properly supervised hospital delivery is recommended.