Review of instrumental vaginal delivery at the Obafemi Awolowo University Teaching Hospitals Complex

Background: Instrumental vaginal delivery (IVD) is one of the signal functions of the basic emergency obstetric and newborn care. Some recent reviews point towards a sustained fall in the performance of this lifesaving procedure. With increasing caesarean section rates, institutional reviews of the practice of IVD are important to improve and sustain this art which is on the path of extinction.Objectives: To determine the IVD rate at the OAUTHC over a 5‑year period from January 2013 to December 2017 and to review the maternal and newborn outcomes.Methods: This was a retrospective review. Case records of parturients who had either forceps or vacuum delivery during the study period were retrieved and relevant information were extracted. Data analysis was done with IBM‑SPSS version 20.Results: There were 10,286 deliveries and 101 IVDs over the 5‑year period giving an IVD rate of 0.98%, with 0.41% for forceps and 0.57% for vacuum delivery. Seventy‑one case records were available for review. Mean maternal age was 27.21 ± 5.8 years and 31 (43.7%) of the parturients were primigravidae. Thirty‑nine (54.9%) were booked and 66 (93%) of the procedures were performed as emergencies. Senior residents conducted most (94.4%) of the procedures and poor maternal efforts in the second stage of labor was the most common indication (43.8%). All resulted in vaginal delivery with the most common maternal complication being genital tract laceration, most notably first and second‑degree perineal tears. Of the 66 livebirths, neonatal ward admission rate was 45.5%. There was an early neonatal death which followed a traumatic vacuum delivery.Conclusion and Recommendations: The IVD rate at OAUTHC is low, with higher preference for vacuum delivery. Appropriate case selection is evident, and poor maternal effort in second stage of labor remained the leading indication. The neonatal admission rate is high. Training and retraining of resident doctors is necessary towards increasing the conduct and ensuring better outcome.Keywords: Forceps delivery; instrumental vaginal delivery; maternal complications; neonatal outcomes; vacuum deliver

Trends in vaginal hysterectomy in a Nigerian teaching hospital: A 14-year review

Background: The procedure of vaginal hysterectomy is a fast disappearing art. This study looks at 14 years’ experience of vaginal hysterectomy in Ile‑Ife, Nigeria.Objectives: To determine and compare the rate, indications, and complications of vaginal hysterectomy over a 14-year period at Ile‑Ife, Nigeria.Methods: The medical records of patients managed with vaginal hysterectomies performed from 1st January 2005 to 31st December 2018 were reviewed. The demographics and indications for vaginal hysterectomy were extracted. Data were analyzed using Statistical Package for Service Solutions – IBM version 22. Frequencies and percentages were calculated and associations compared where applicable using Chi‑square with level of significance set at <0.05.Results: Pelvic organ prolapse accounted for 0.8% of gynecological admissions and vaginal hysterectomy accounted for 2.3% of major  gynaecological operations. The mean age was 66.1 ± 9.2 years with a mean age of menopause of 15.2 ± 7.1 years. The mean parity was 6.2 ± 1.6. Pelvic organ prolapse was the commonest indication. The mean blood loss at surgery was 314.2 ± 184.8 ml. The modal post‑operative complication was post‑operative anemia, and hypertension was the commonest comorbidity. The mean duration of surgery was 3 ± 0.9 h and the mean duration of admission was 5.4 ± 2.7 days.Conclusion: The rate of vaginal hysterectomy is on the decline. This may be due to case under reporting, limiting of family size, or low uptake of farming occupation in our society. Key words: Comorbidities; complications; incidence; indications; vaginal hysterectomy

Obstructed labour in a Nigerian tertiary health facility: a mixed-method study

Background: Obstructed labour remains a leading cause of maternal and perinatal mortality and morbidity in sub-Saharan Africa. This study aimed to determine the incidence, causes, complications and outcomes of obstructed labour at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Osun state, Nigeria.Methods: A mixed methods approach was employed for this study. A 10-year retrospective review of all cases of obstructed labour managed at the OAUTHC, between January 1, 2008, and December 31, 2017, was done. Ten in-depth interviews were conducted for some selected patients. The quantitative data was analysed using SPSS version 24, while the qualitative data was analyzed with NVivo version 12.Results: The incidence of obstructed labour was 1.99%. Most of the patients were unbooked (217, 90.4%), primigravid (138, 57.5%), and either had no formal or only primary/secondary education (120, 50%). Cephalopelvic disproportion (CPD) was the commonest cause of obstructed labour (227, 94.6%). The most common maternal complication was wound infection (48, 20%). There were three maternal deaths, giving a case fatality rate of 1.25%. The most common foetal complication was birth asphyxia (85, 34.7%). The perinatal mortality rate was 18.8 %. From the qualitative arm of the study, reasons given by parturients who suffered obstructed labour, for avoiding hospitals for delivery, included religion, finance, fear of hospitals, faith/belief in mission homes/maternity houses, and proximity.Conclusions: Obstructed labour remains an important obstetric problem in our environment, contributing significantly to the burden of maternal and perinatal mortality and morbidity.

Review of instrumental vaginal delivery at the Obafemi Awolowo University teaching hospitals complex

Background: Instrumental vaginal delivery (IVD) is one of the signal functions of the basic emergency obstetric and newborn care. Some recent reviews point towards a sustained fall in the performance of this lifesaving procedure. With increasing caesarean section rates, institutional reviews of the practice of IVD are important to improve and sustain this art which is on the path of extinction. Objectives: To determine the IVD rate at the OAUTHC over a 5-year period from January 2013 to December 2017 and to review the maternal and newborn outcomes. Methods: This was a retrospective review. Case records of parturients who had either forceps or vacuum delivery during the study period were retrieved and relevant information were extracted. Data analysis was done with IBM-SPSS version 20. Results: There were 10,286 deliveries and 101 IVDs over the 5-year period giving an IVD rate of 0.98%, with 0.41% for forceps and 0.57% for vacuum delivery. Seventy-one case records were available for review. Mean maternal age was 27.21 ± 5.8 years and 31 (43.7%) of the parturients were primigravidae. Thirty-nine (54.9%) were booked and 66 (93%) of the procedures were performed as emergencies. Senior residents conducted most (94.4%) of the procedures and poor maternal efforts in the second stage of labor was the most common indication (43.8%). All resulted in vaginal delivery with the most common maternal complication being genital tract laceration, most notably first and second-degree perineal tears. Of the 66 livebirths, neonatal ward admission rate was 45.5%. There was an early neonatal death which followed a traumatic vacuum delivery. Conclusion and Recommendations: The IVD rate at OAUTHC is low, with higher preference for vacuum delivery. Appropriate case selection is evident, and poor maternal effort in second stage of labor remained the leading indication. The neonatal admission rate is high. Training and retraining of resident doctors is necessary towards increasing the conduct and ensuring better outcome

Comparison of Pregnancy Outcomes of History-Indicated and Ultrasound-Indicated Cervical Cerclage: A Retrospective Cohort Study

Background. Cervical cerclage is the procedure of choice for preventing preterm delivery due to cervical insufficiency. The indication for its application may be based on the woman’s reproductive history, findings at ultrasound, or clinical findings on vaginal examination. Pregnancy outcomes from these indications are variable according to the available literature. Objective. To compare the effectiveness and reproductive outcomes (miscarriage, preterm birth rates, and birth weights) of McDonald’s cervical cerclage after history-indicated and ultrasound-indicated cervical cerclage in pregnant women. Methods. The retrospective cohort study was conducted at Life International Hospital Awka, Nigeria and Life Specialist Hospital Nnewi, Nigeria. Pregnant women, who had a McDonald’s cervical cerclage performed due to either history or ultrasound indication between January 1, 2011, and December 31, 2020, were included in the study. Women with multiple pregnancies and those with physical examination-indicated or emergency cerclages were excluded. The main outcome measures included the prevalence of cervical cerclage, miscarriage, and preterm delivery rates. Outcomes were compared between groups with the chi-square test, Fisher’s exact test, or Student’s t test. p value of < 0.5 was set as significant value. Results. Overall, during the study period, 5392 deliveries occurred in the study sites, of which 103 women had a history-indicated or ultrasound-indicated cervical cerclage. This resulted in a 1.91% prevalence rate for history-indicated and ultrasound-indicated cervical cerclage. Of these, 68 (66%) had history indicated, while 35 (34%) had ultrasound-indicated cerclage. There was no difference in the sociodemographic characteristics of both groups. Both groups had similar miscarriage rates: 1.18 in 1000 and 1.04 in 1000 deliveries, respectively (RR 1.160, 95% CI: 0.3824 to 3.5186, p=0.793). There was more preterm delivery in history-indicated cerclage than ultrasound-indicated cervical cerclage (26.50% vs. 17.10%; p=0.292), though the difference was not statistically significant. The ultrasound group had a higher average birthweight than the history group (2.67±0.99 vs. 2.53±0.74). However, this difference was not statistically significant. Conclusion. The effectiveness and reproductive outcomes (miscarriage, preterm birth rates, and birth weights) of pregnant women with cervical cerclage due to history-indicated and ultrasound-indicated cervical cerclage appear similar. When needed, cervical cerclage should be freely applied for cervical insufficiency, irrespective of the type of indication

Intravenous versus intramuscular oxytocin injection for preventing uterine atonic primary postpartum haemorrhage in third stage of labour: A double-blind randomised controlled trial

Objectives: To compare the efficacy and safety of intravenous and intramuscular oxytocin in preventing atonic primary postpartum haemorrhage in the third stage of labour. Methods: A double-blind randomised clinical study on consenting women without risk factors for primary postpartum haemorrhage in labour at term. Two hundred and thirty-two women were randomly allotted into intravenous ( n  = 115) and intramuscular ( n  = 117) oxytocin groups in the active management of the third stage of labour. All participants received 10 IU of oxytocin, either IV or IM, and 1 ml of water for injection as a placebo via a route alternate to that of administration of oxytocin within 1 min of the baby’s delivery. The primary outcome measures were mean postpartum blood loss and haematocrit change. Trial Registration No.: PACTR201902721929705. Results: The baseline socio-demographic and clinical characteristics were similar between the two groups ( p  > 0.05). There was no statistically significant difference between the two groups with regards to the mean postpartum blood loss (254.17 ± 34.85 ml versus 249.4 ± 39.88 ml; p  = 0.210), haematocrit change (2.4 (0.8%) versus 2.1 (0.6%); p  = 0.412) or adverse effects ( p  > 0.05). However, the use of additional uterotonics was significantly higher in the intravenous group (25 (21.73%) versus 17 (14.53%); p  = 0.032). Conclusion: Although oxytocin in both study groups showed similar efficacy in terms of preventing atonic primary postpartum haemorrhage, participants who received intravenous oxytocin were more likely to require additional uterotonics to reduce their likelihood of having an atonic primary postpartum haemorrhage. However, both routes have similar side effect profiles

Intra-operative Diagnosis of Lower Segment Scar Dehiscence in a Second Gravida After One Previous Lower Segment Cesarean Section: Should We Advocate for Routine Antenatal Uterine Scar Thickness Testing?

Background: Uterine dehiscence is a separation of uterine musculature with intact uterine serosa. It can be encountered at the time of cesarean delivery, suspected on obstetric ultrasound or diagnosed in-between pregnancies. The antenatal diagnosis may occasionally elude the Obstetricians. This particular case demonstrates an intra-operative diagnosis of uterine dehiscence with missed antenatal ultrasound diagnosis in an asymptomatic woman. Case presentation: She was a 32-year-old Nigerian second gravida who booked for antenatal care at 32 weeks of gestation following a referral from her attending Obstetrician from a neighboring state due to relocation. She had 3 antenatal visits and 2 antenatal ultrasound investigations without uterine scar thickness report. She subsequently had elective Cesarean section (CS) at a gestational age of 38 weeks plus 2 days due to persistent breech presentation on a background of a previous lower segment CS scar. There was no previous uterine curettage prior to or after the previous lower segment CS scar and there was no labor pains prior to the elective CS. The surgery was successful with intra-operative findings of moderate intra parietal peritoneal adhesions with rectus sheath and obvious uterine dehiscence along the line of the previous CS scar. The fetal outcomes were normal. Immediate post-operative condition was satisfactory and the woman was discharged on a third-day post operation. Conclusion: Obstetricians are charged to maintain a high index of suspicion when managing pregnant women with history of emergency CS in order to avert the adverse consequences of uterine rupture from asymptomatic uterine dehiscence. Based on this report, it may be useful to routinely assess the lower uterine segment scar of women with previous emergency CS using the available ultrasound facilities. However, more studies are needed before advocating for routine antenatal uterine scar thickness testing following emergency lower segment CS in low and middle-income settings

Adaptation of the Wound Healing Questionnaire universal-reporter outcome measure for use in global surgery trials (TALON-1 study): mixed-methods study and Rasch analysis

BackgroundThe Bluebelle Wound Healing Questionnaire (WHQ) is a universal-reporter outcome measure developed in the UK for remote detection of surgical-site infection after abdominal surgery. This study aimed to explore cross-cultural equivalence, acceptability, and content validity of the WHQ for use across low- and middle-income countries, and to make recommendations for its adaptation.MethodsThis was a mixed-methods study within a trial (SWAT) embedded in an international randomized trial, conducted according to best practice guidelines, and co-produced with community and patient partners (TALON-1). Structured interviews and focus groups were used to gather data regarding cross-cultural, cross-contextual equivalence of the individual items and scale, and conduct a translatability assessment. Translation was completed into five languages in accordance with Mapi recommendations. Next, data from a prospective cohort (SWAT) were interpreted using Rasch analysis to explore scaling and measurement properties of the WHQ. Finally, qualitative and quantitative data were triangulated using a modified, exploratory, instrumental design model.ResultsIn the qualitative phase, 10 structured interviews and six focus groups took place with a total of 47 investigators across six countries. Themes related to comprehension, response mapping, retrieval, and judgement were identified with rich cross-cultural insights. In the quantitative phase, an exploratory Rasch model was fitted to data from 537 patients (369 excluding extremes). Owing to the number of extreme (floor) values, the overall level of power was low. The single WHQ scale satisfied tests of unidimensionality, indicating validity of the ordinal total WHQ score. There was significant overall model misfit of five items (5, 9, 14, 15, 16) and local dependency in 11 item pairs. The person separation index was estimated as 0.48 suggesting weak discrimination between classes, whereas Cronbach's α was high at 0.86. Triangulation of qualitative data with the Rasch analysis supported recommendations for cross-cultural adaptation of the WHQ items 1 (redness), 3 (clear fluid), 7 (deep wound opening), 10 (pain), 11 (fever), 15 (antibiotics), 16 (debridement), 18 (drainage), and 19 (reoperation). Changes to three item response categories (1, not at all; 2, a little; 3, a lot) were adopted for symptom items 1 to 10, and two categories (0, no; 1, yes) for item 11 (fever).ConclusionThis study made recommendations for cross-cultural adaptation of the WHQ for use in global surgical research and practice, using co-produced mixed-methods data from three continents. Translations are now available for implementation into remote wound assessment pathways