Society of obstetrics and gynecology of Nigeria – Clinical practice guidelines: Guidelines for the prevention of cervical cancer Oliver C Ezechi, Babasola O Okusanya, Chris O Aimakhu, Olubukola A Adesina, Aigbe G Ohihoin, Hadiza A Usman, Odidika U Umeora, Rotimi Akinola, Rose Anorlu, Atiene Sagay, Bala Audu, Olusola B Fasubaa, Adekunle Oguntayo, Olutosin Awolude, Michael Ezeanochie, Adegboyega Fawole, Munirdeen Ijaiya, Azubuike Onyebuchi, Lamaran Dattijo, Osayande E Osagie, Adetokunbo Fabanwo, Faye Iketbuson, Bukola Fawole, Bose Afolabi, Chris Agbogoroma, Habib Sadauki, Anthony Okapani, Ibrahim Yakasai, Josiah Muthir, Patrick Okonta Tropical Journal of Obstetrics and Gynaecology 2019 36(2):161-164 Clinical practice guidelines have been developed by professional societies globally. Each guideline although based on published scientific evidence reflected each country's socioeconomic peculiarities and unique medical environment. The Society of Obstetrics and Gynaecology of Nigerian has published guidelines in other clinical areas; however, this is the first edition of practice guidelines for the prevention of cervical cancer. The Guidelines Committee was established in 2015 and decided to develop the first edition of this guideline following Delphi pool conducted among members which selected cervical cancer prevention as the subject that guideline is urgently needed. These guidelines cover strategies for cervical cancer prevention, screening, and management of test results. The committee developed the draft guideline during a 2-day workshop with technical input from Cochrane Nigeria and Dr. Chris Maske, Lancet Laboratories, South Africa. The recommendations for each specific area were developed by the consensus, and they are summarized here, along with the details. The objective of these practice guidelines is to establish standard policies on issues in clinical practice related to the prevention of cervical cancer.

Obstetric morbidity and mortality: Exploration of the use of Maternal Early Warning Scores (M-EWS) for recognition and escalated timely interventions in acute obstetric emergencies in Nigeria AO Isemede, JA Unuigbe Tropical Journal of Obstetrics and Gynaecology 2019 36(2):165-169 Severe Obstetric Emergencies: Use of Maternal Early Warning Scores (M-EWS) in Nigeria. Maternal Early Warning Scores (M-EWS) is a patient illness severity scoring system that aids tracking and timely escalation of acutely deteriorating obstetric patients. M-EWS has been demonstrated to reduce substandard care, obstetric complications, and maternal mortality in the United Kingdom and a number of other countries. Background: Successes in the prevention of maternal mortality attributed to this tool in the United Kingdom where it is in established use coupled with high potential for its usefulness in other countries prompted the inclusion of the M-EWS in the post 2015 United Nations Sustainable Development Goals for the 193 member nations. Aims: We set out to explore the availability of M-EWS for the recognition and escalated timely interventions in obstetric emergencies in Nigeria and a desire for its application. Methods: A combination of SurveyMonkey (online) and paper-based questionnaires distributed to clinicians of all teams and grades involved in obstetric care was used. Results: In all, 76 responses (17 online and 59 paper-based questionnaire) were received out of 30 e-mails and 70 paper-based questionnaires. Nineteen (25%) clinicians reported use of a physician-specific calling system but none had the M-EWS in use. Three respondents (4%) were not certain whether M-EWS would be welcomed in their service, but 73 (96%) welcomed the introduction of the M-EWS. Conclusion: This survey shows the lack of M-EWS in obstetric practice in Nigeria and strong desire for its introduction. Consequently, some collaborative work aimed at refining this tool for the Nigerian obstetric environment has commenced.

Awareness, attitude and use of labor analgesics by pregnant women at State Specialist Hospital, Akure RS Omotayo, O Akinsowon, SE Omotayo Tropical Journal of Obstetrics and Gynaecology 2019 36(2):170-176 Background: Pain relief during labor has always been associated with myths and controversies. Several groups of people think that God has made this process painful and no interference should be done in it. In the present civilization, there is no circumstance where it is considered acceptable for a person to experience severe pain, amenable to safe intervention while under a physician's care. Objective: This study assessed the level of awareness of pregnant women about labor analgesia and factors preventing them from having analgesia in labor. Study Design: This study is a descriptive cross-sectional study. Methodology: Questionnaires were used to obtain information on awareness, attitude and use of labor analgesia from pregnant women at the booking clinic visit. Three hundred (300) consenting pregnant women were recruited into the study including provision for attrition. Data were analyzed with the Statistical Package for Social sciences (SPSS) 20. Proportions were calculated for independent variables while crosstabulation was done for related variables to find P value for statistical significance. Results: Level of awareness of labor analgesia was 21%. Majority of the respondents (70.3%) believe that among all health professionals, it is doctors that should inform them about labor analgesia. Only 4.4% had used labor analgesic in their previous deliveries. About 81% of respondents desire labor analgesia in their next delivery. Among factors analyzed, only severity of last labor had significant influence on the patient's desire for analgesia in their next delivery (P value = 0.026). Conclusion: The awareness rate of pregnant women about labor analgesia is very low. Therefore, all efforts must be made to ensure that discussions about labor analgesia are commenced as early as at the booking visit to improve on pregnant women's awareness about labor analgesia and help their acceptability and choices. Attitude towards labor analgesia is not influenced by type of facility where the delivery took place suggesting possibility of socio-cultural influence of the people in the area of study on the practice of labor analgesia.

Outcome of induction of labor with prostaglandin E1 25 mg vaginal tablet – A retrospective study G Puliyath, A Balakrishnan, L Vinod, H Hameed Tropical Journal of Obstetrics and Gynaecology 2019 36(2):177-182 Context: Labor induction with prostaglandin E1 (PGE1) vaginal tablet results in shorter induction delivery interval and decreased rate of failed induction of labor and reduced caesarean section rate. However, higher doses may be associated with uterine hyper stimulation. It is therefore necessary to determine the safe dose of PGE1 for labor induction. Aims: To assess the maternal and neonatal outcome with use of 25 mg vaginal misoprostol for induction of labor. Settings and Design: A retrospective analysis conducted in an obstetric department of a tertiary care teaching institute. Materials and Methods: The sample consists of women with singleton term pregnancy, with Bishop's score <6 compared with women with spontaneous onset of labor. Statistical Analysis Used: Statistical significance was assessed at 5% level of significance. Chi-square test, with correction for continuity where applicable, was carried out to compare proportions across subgroups or between induction and spontaneous onset groups. Results: The rate of vaginal delivery was higher among spontaneous onset group compared with induction group (χ2 (1) = 30.3, P < 0.001). The induction delivery interval of vaginal delivery was less than 24 h in 91.85% of women. Neonatal intensive care unit admission frequency was similar among both groups (χ2 (1) = 0.14, P = 0.704). The induction group was with less frequency of meconium staining than the control group (χ2 (1) = 8.05, P = 0.0046). Conclusion: Our study showed a higher rate of vaginal delivery with induction delivery interval less than 24 h in a majority of women with better neonatal and maternal outcomes.

Twin pregnancies at federal medical centre Katsina: A 5 year review Abdulfattah Mohammed Lawal, Ojonigwu Dadi Atabo-Peter, Aisha Abdurrahman Tropical Journal of Obstetrics and Gynaecology 2019 36(2):183-188 Background: Multiple gestation is associated with higher risk of maternal complications in the antenatal, intrapartum, and postpartum periods compared with singleton pregnancies, as well as higher risk for perinatal morbidity and mortality. Objective: The objective of this study was to determine the incidence and obstetric outcomes of twin deliveries in Federal Medical Centre Katsina. Methods: It is a retrospective study of twin deliveries over a 5-year period from January 1st 2010 to December 31st 2014 conducted at the Federal Medical Centre Katsina (FMCK), Katsina state. Results: There were 172 cases of twin deliveries out of 9,947 deliveries giving an overall twinning rate of 17.3 per 1,000 deliveries. There were three cases of triplet delivery during this period. The most common complication was preterm delivery which occurred in 40.1% of cases. The mode of delivery was vaginal in 64.5% while 35.5% had caesarean section. Emergency caesarean section for delivery of both babies was carried out in 24.42% while elective caesarean section for both babies accounted for 8.72%. Combined vaginal and abdominal delivery occurred in 2.33% of deliveries. The stillbirth rate was 81.4 per 1,000 births. There were 11 (6.4%) and 17 (9.9%) stillbirths among the first and the second babies respectively. Babies that had normal birth weight constituted 42.2%. The male to female ratio was 1:1.15. Conclusion: The rate of twin deliveries in our centre is high. There is also associated high rate of maternal complications and adverse perinatal outcomes.

A comparison of oral versus vaginal misoprostol for induction of labor at term, at the Ahmadu Bello University Teaching Hospital, Zaria S Umar Hauwa, SO Shittu, Hajaratu Umar-Sulayman, BM Audu Tropical Journal of Obstetrics and Gynaecology 2019 36(2):189-195 Background: The comparison of same,equal and low dose of misoprostol by the oral and vaginal routes for induction of labour at term requires further elucidation. Objective: To compare the efficacy and safety of 25 micrograms (ug) of oral misoprostol with 25ug vaginal misoprostol for induction of labor at term. Methods: A randomised control trial that involved 169 consented women with indication for induction of labor. A total of 85 women had oral misoprostol while 84 women had vaginal misoprostol. The oral misoprostol dose (25ug) was repeated every 2 hours, while the vaginal dose (25ug) was repeated every 6 hours for a maximum duration of 24 hours or when need arose for intervention. Data was analysed using SPSS version 20. Results: The mean induction-delivery interval was significantly shorter (18.48 +/- 2.01 vs. 22.82 +/- 2.50, P = 0.00), with more vaginal deliveries (88.2% vs. 85.7%, P = 0.00) in the oral group compared to the vaginal group respectively. The cardiotocographic abnormalities in the vaginal group were significantly higher than the oral group (8.3% vs. 1.2%, P = 0.03). There were more foetal distress and meconium stained liquor in the vaginal group but not statistically significant.

Misoprostol versus oxytocin in preventing postpartum hemorrhage: A randomized controlled trial OO Owa, AS Lemadoro, BA Temenu, JA Ayeyemi, OM Loto Tropical Journal of Obstetrics and Gynaecology 2019 36(2):196-199 Objective: To compare low dose sublingual misoprostol with the standard 10 IU of intramuscular oxytocin in active management of third stage of labor. Materials and Methods: A total of 104 women with term pregnancy were randomized to receive either 200 μg misoprostol sublingually or 10 IU oxytocin intramuscularly after vaginal delivery. Primary outcome measured was mean blood loss and incidence of primary postpartum hemorrhage (PPH). Secondary outcome measured included duration of third stage of labor, side effects of drugs and need for additional oxytocics to treat life-threatening hemorrhage. Results: A total of 104 women with term pregnancy in two groups of 52 were studied. The mean blood loss with sublingual misoprostol and oxytocin groups was 320.58 ± 244.12 vs. 253.27 ± 171.74 ml; P = 0.11. There was no significant differences between the misoprostol and oxytocin groups with regard to the incidence of PPH (19.2% vs. 13.5% respectively; P = 0.43). More women in the misoprostol group experienced side effects compared with those in oxytocin group; however, the difference was not statistically significant (P = 0.26). The mean duration of third stage of labor was similar and the difference was statistically not significant (6.65 ± 3.47 vs. 6.08 ± 3.07 minutes) (P = 0.38), as well as need for additional oxytocics (13.5% vs. 5.8% P = 0.18) misoprostol and oxytocin, respectively. Conclusion: Sublingual misoprostol has similar efficacy to standard intramuscular oxytocin in preventing PPH following vaginal birth. Misoprostol at 200 μg with its thermostability may be an effective alternative to intramuscular oxytocin in active management of third stage of labor.

Determinants and outcomes of elective and emergency caesarean section at a tertiary hospital in Abakaliki, Southeast Nigeria: A 6-year review Obiora Godfrey Asiegbu, Uzoma Vivian Asiegbu, Emmanuel Johnbosco Mamah, Chidebe Christian Anikwe, Onwe Emeka Ogah, Ugochukwu Uzodimma Nnadozie Tropical Journal of Obstetrics and Gynaecology 2019 36(2):200-205 Background: Despite its increasing acceptance as a safe alternative to vaginal delivery, caesarean section (CS) in developing countries continue to be associated with maternal and fetal morbidity and mortality. Objectives: This study was aimed at evaluating the indications, outcomes and factors associated with increased CS at the Federal Teaching Hospital, Abakaliki. Methods: This was a six year retrospective study covering 2012 to 2017. Case notes of patients were identified and retrieved from the records unit of the hospital. Information extracted include sociodemographic variables, indications and types of CS performed and the complications. These data were entered into a personal computer and analysed with Epi Info version 7. Results: These were presented using tables and percentages. A p-value of 0.05 was considered significant. In 6 years, 11,215 women were delivered, 2405 (21.4%) had emergency CS while 1445 (12.9%) had elective CS; giving a CS rate of 34.3%. The most common indication for emergency CS was cephalopelvic disproportion (22.0%) while previous caesarean section (27.7%) formed the major indication for elective CS. Severe birth asphyxia was recorded in 17.2% and 4.2% of babies delivered by emergency and elective CS respectively. Booking status, parity and patient's age had statistically significant association with the chance of having a CS. Maternal and perinatal deaths were recorded in 2.6% and 5.0% for emergency CS compared to 1.0% and 0.2% for elective CS. Although lifesaving, CS, due to an existing condition or complication in the patient, may be associated with an increase in maternal and fetal morbidities and mortalities. Conclusion: There was a higher burden of complication with emergency CS due to its associated determinants. Adequate training of healthcare personnel on ways of minimizing complications against the backdrop of an existing problem and an efficient referral system will help reduce these morbidities and mortalities.

Outcomes of induction of labor with mature and premature amniotic fluid optical density (AFOD): A preliminary case control study Hemmanur Samartha Ram, IS Samyuktha, Vasudeva Nagasree Tropical Journal of Obstetrics and Gynaecology 2019 36(2):206-211 Background: Onset of spontaneous labor occurs on completion of fetal functional maturity at amniotic fluid optical density (AFOD) value 0.98 ± 0.27 (Mean ± SD). All three events occurring together at any time from 35 to 42 weeks indicate individual term for each fetus. Babies born with AFOD ≤0.40 are functionally premature and develop varying degrees of respiratory distress syndrome (RDS). In this study, we tested the hypothesis, labors with AFOD 0.98 ± 0.27 are functionally mature with well-established labor cascades and may respond well t o induction. On the other hand, labors with AFOD ≤0.40 are functionally premature with poorly established labor cascades and may not respond well t o induction. Methods: In this gestational age and parity-matched case control study, cases consisted of 36 uncomplicated singleton laboring women who delivered normally with premature (≤0.40) AFOD values. Controls consisted of 36 similar laboring women who delivered normally with mature AFOD (0.98 ± 0.27) values. Uncentrifuged fresh AF samples collected at amniotomy were used for OD measurement with colorimeter at 650 nm. Women were assigned to groups based on AFOD values. In both groups, labor was induced with vaginal T. Misoprostol 25 mcg 6 hourly up to 4 doses. Labor outcome measures; Bishop score at induction, induction- delivery intervals (IDI), induction failures, number of T. Misoprostol required, presence of fetal distress, RDS, and NICU admission days were recorded in both groups and compared. Results: Median Bishop scores at induction in cases and controls were 5.0 (IQR 4.25--6), 7.0 (IQR 6--8), respectively. Median IDI in cases and controls were 18 h (IQR 12.25--21.5 h) and 7.0 h (IQR 5--9.5 h), respectively. Number of induction failures in cases and controls were 8 and 0, respectively. Outcomes of Induction of labor with…. Statistically significant differences observed in all these outcomes between groups (P = 0.00) favoring inductions with mature AFOD. Conclusion: Labor induction with mature AFOD value was successful in all women with shorter IDI and with better perinatal outcomes.

Maternal death surveillance and response system in Northern Nigeria S Ochejele, J Musa, MJ Abdullahi, P Odusolu, DI Attah, G Alobo Tropical Journal of Obstetrics and Gynaecology 2019 36(2):212-217 Introduction: The maternal death surveillance and response (MDSR) responds to MDG 5 and Sustainable development goal 3. It was designed to achieve this goal by obtaining and strategically using information to guide public health actions and monitoring their impact. Objective: To determine the burden and avoidable causes of maternal mortality in midwives service scheme (MSS) communities in Northern Nigeria. Methodology: This was a cross-sectional study using baseline MDSR data on confidential enquiry into maternal deaths in all health facilities and their host communities under the MSS in Northern Nigeria from July 1st to December 31st, 2011. Results: The MMR was 181/100,000 live births. Most (80.9%) of the deaths were due to direct obstetric complications with obstetric hemorrhage and eclampsia accounting for 66.6% of the deaths. Most deaths occurred postpartum (93.6%) with the first 48 h accounting for 85.1% of cases. At presentation, 76.5% were in critical conditions. The TBAs conducted 50.0% of the deliveries. Delays in decision making contributed to 51 (63.8%), delay in arriving at the facility accounted for 48 (60.0%), financial constraints 28 (35.0%), unsafe traditional practice 27 (33.8%), and use of traditional medicines 22 (27.5%). The TBA failed to refer early in 42 (52.5%), failed to recognize dangers signs in 27 (33.8%). Stillbirths occurred in 22.2% of cases. Conclusion: Most maternal deaths in Northern Nigeria are preventable. Operational research using the MDSR is very useful in determining the causes and designing appropriate response to maternal deaths at the community level in Nigeria.