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This paper describes traditional obstetric care among women of the Igbo tribe in Nigeria. It also discusses the role of traditional birth attendants, antenatal care, management of delivery complications, postnatal care and traditional community practices surrounding birth. There are no special agencies responsible for the care of the pregnant women in the traditional Igbo community. 2 categories of indigenous midwives are recognized: those who have developed a special interest in maternity care and conduct delivery only for close relatives and friends; and the herbalist-cum-midwife, usually a male, who is a professional medical practitioner. Most pregnant women in the Igbo community receive no formal antenatal care. There are several strong food and behavioral taboos associated with pregnancy. Certain foods are believed to cause long, difficult labor. The traditional midwife is only summoned when delivery is considered imminent. Factors which contribute to the high mortality rates include an almost complete absence of antenatal attention, ignorance of the most elementary principles of hygiene, delivery in an unsanitary environment, the long wait for the placenta to be born before the cord is cut, the use of unsterile razors for that purpose, and the subsequent nonaseptic care of the umbilical cord stump. Neonatal tetanus, pneumonia and bronchitis are major causes of child loss in Nigeria. The indigenous midwife is frequently helpless when complications such as perinatal hemorrhage, abnormal delivery, obstructed labor, or cord prolapse are encountered. Some herbal medicines used by indigenous midwives to augment labor in countries such as Uganda and Malawi have oxytocic properties. Herbal potions are also used by the Igbo traditional midwife to induce labor and to treat ailments such as generalized bodily edema. The plants used in such preparations should be analyzed pharmacologically. The benefits of ambulation during labor have been recognized. It should be encouraged.
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PMID:Childbearing among the Igbos of Nigeria. 287 77

The case records of 20 horses with tetanus referred to the Ontario Veterinary College-Veterinary Teaching Hospital between 1970 and 1990 were reviewed. The fatality rate was 75%. There was a strong association with previous vaccination and survival (P = .03). Most of the animals had been injured an average of 9 days (range 2 to 21 days) prior to development of clinical signs. Hyperesthesia and prolapse of the third eyelid were the most common clinical signs. Treatment regimens varied during hospitalization; however, all horses received parenteral penicillin, tranquilizers, tetanus toxoid, and antitoxin. Five of the nonsurviving animals were given intrathecal tetanus antitoxin. One animal had seizures as a complication of intrathecal treatment. The prognosis was best for horses that (1) had been vaccinated prior to the injury, (2) responded to the phenothiazine tranquilizers, and (3) did not rapidly (over 24 to 48 hours) become recumbent. Considering the species susceptibility, potential for contaminated wounds, and the increased survival of vaccinated horses, yearly revaccination is recommended.
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PMID:Tetanus in the horse: a review of 20 cases (1970 to 1990). 804 76

In this study, the aim was to assess perinatal and neonatal mortality and morbidity in randomly selected villages of Oriya, Nagola, Rampur, and Chandokha in Aligarh District of Uttar Pradesh State, India. The population of 7541 received poor health services. A visit to all households within an 8 km distance netted 212 pregnant women between May 1987 and April 1988. Women were followed for a year; assessment included a routine clinical history and a general physical and obstetrical examination. Visits to the home included routine blood and urine tests. Cooperative mothers received a tetanus vaccine; calcium, iron, and folic acid tablets were distributed monthly during prenatal checkups. Daily visits were made during the postpartum period (6 weeks). Women were interviewed and information collected on their attitude, knowledge, and practice of existing health services and infant health. The results showed that transportation was an impediment to use of primary health services. Travel distance by foot to a bus stop was about 1-2 km. Considerable time was spent waiting for buses. 93% of the 212 illiterate and unaware of health care facilities. None of the women had used prenatal care in their prior pregnancies. There were 204 live births, of which 72.05% had complications within 6 weeks of the delivery. The conditions were conjunctivitis neonatorum (42.9%), "loose motions" (18.4%), and scabies/pyoderma (12.9%). 57% of the complications were due to poor hygiene or ignorance of the untrained Dai or female attendant. 10.9% of the cases were unavoidable. There were 17 perinatal deaths of which 5 were stillbirths (after 28 weeks gestation) and 12 were deaths at 1 week of age. 11 deaths were males (91.7/1000 total births) and 6 were females (67.4/1000 total births). The total rate was 81.3/1000 total births. There were 3 breech birth deaths, 2 from congenital defects, 2 from prematurity, a cord prolapse, a jaundice case, and fetal distress. 2 died of asphyxia neonatorum of unknown causes. The neonatal death rate was 63.7/1000 live births which is typical for rural areas in India. A community approach to health care, improvements in women's education, and grass roots level health personnel are recommended.
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PMID:High perinatal and neonatal mortality in rural India. 847 93

The receptivity of 212 pregnant women in rural Uttar Pradesh, India, to prenatal services provided at their homes was assessed during a May 1987 to April 1988 longitudinal study. The women, from four randomly selected villages, were assessed every month until completion of the neonatal period. Receptivity to doorstep prenatal services was calculated by developing a weighted score based on time when prenatal services began, frequency of visits accepted, number of doses of tetanus toxoid immunization accepted, and place of and person attending the delivery. Of the 212 women, 17% had poor, 75.9% had moderate, and 7.1% had high receptivity to the prenatal services. The pregnancies resulted in 5 stillbirths and 12 neonatal deaths before one week, for a perinatal mortality rate of 81.3/1000. 3 of the 8 infants who were in breech presentation died, 2 infants died from congenital defects, 2 from prematurity, 1 from cord prolapse, 1 from jaundice, 1 from fetal distress, and 2 from unknown causes. Another neonate died of meningitis. The perinatal mortality rates were 90.9, 86.9, and 0/1000 births in women with poor, moderate, and high receptivity scores, respectively. The inverse relationship between maternal care receptivity and the mortality rates was statistically significant. The poor receptivity to home-based prenatal care results from ignorance, illiteracy, and poverty and from a deeply rooted confidence in traditional birth attendants. This study also revealed that anemia persisted in 62.2% of these women even after iron and folic acid supplementation. This study highlights the importance of providing health education to pregnant women to increase their receptivity to maternal care services.
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PMID:Maternal care receptivity and its relation to perinatal and neonatal mortality. A rural study. 863 4

Anorectal disorders are commonly encountered in the practice of emergency medicine. Most can be diagnosed and treated in the emergency department setting. Almost all anorectal disorders once diagnosed and treated in the emergency department need appropriate follow-up to ensure adequacy of treatment, for further possible diagnostic procedures (e.g., endoscopy, biopsy), or for definitive treatment. Hemorrhoids are the most prevalent anorectal disorder and are the most common cause of hematochezia. Treatment is dependent on the degree of hemorrhoid prolapse and symptoms. Most cases can be treated by conservative medical treatment (e.g., dietary changes, sitz baths) or nonsurgical procedures (e.g., rubber band liagation, infrared coagulation). Surgical excision of symptomatic thrombosed external hemorrhoids is indicated if within 48 to 72 hours of pain onset. Anal fissures are one of the most common causes of anorectal pain. They are most frequently idiopathic, and most are located in the posterior midline of the anal canal. Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics. If the anal fissure becomes chronic and is not responsive to medical therapy, a lateral sphincterotomy of the internal anal sphincter is the surgical procedure of choice. Pharmacologic treatment (botulinum toxin or nitroglycerin ointment) to decrease internal anal sphincter tone has shown promise in the treatment of anal fissure. Anorectal abscesses are categorized into four types: perianal, ischiorectal, intersphincteric, and supralevator. Most are idiopathic and contain mixed aerobic-anaerobic pathogens. Fistula formation varies from 25% to 50% and is much more common with gut-derived organisms (e.g., E. coli, B. fragilis). Definitive treatment for an anorectal abscess is timely surgical incision and drainage to prevent more serious complications (e.g., serious infection, extension of the abscess). Anal carcinomas are infrequent, the majority of them being squamous cell or epidermoid carcinomas. The emergency physician must maintain a high index of suspicion and obtain a biopsy of suspicious lesions in order not to miss the diagnosis of a cancer. The most common presenting complaint of anal tumors is rectal bleeding. Combination chemotherapy and radiotherapy have shown promising results in the treatment of anal canal tumors. Bacterial, viral, and protozoal infections can be transmitted to the anorectum via anoreceptive intercourse. Such infections must be considered when a patient presents with rectal pain or discharge, tenesmus, or rectal or perineal ulcers. Proctosigmoidoscopy and rectal cultures may be necessary to determine the cause. Potential rectal complications of HIV infection include infectious diarrhea, acyclovir-resistant strains of HSV2, Kaposi's sarcoma, lymphoma, and squamous cell carcinoma. Rectal injuries may result from penetrating or blunt trauma, iatrogenic injuries, or foreign bodies. Rectal injury should be suspected when a patient presents with low abdominal, pelvic, or perineal pain or blood per rectum after sustaining trauma or undergoing an endoscopic or surgical procedure. Tetanus prophylaxis, intravenous antibiotics, and surgical intervention are indicated in all but superficial rectal tears.
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PMID:Anorectal disorders. 892 68

Safe motherhood will require a multi-faceted strategy of improving girls' education and employment opportunities, providing primary and reproductive health care for women, taking a high risk approach with referral for all at-risk pregnant women, and including maternal mortality as part of the quality of life index. The World Health Organization in 1986 reported that 99% of maternal mortality occurred in developing countries: 640 per 100,000 live births in Africa, 420/100,000 in Asia, 270/100,000 in Latin America, 100/100,000 in Oceania, 450/100,000 in developing countries on average, and 30/100,000 in developed countries. The chances of maternal death ranges in the extremes from 1/9850 in northern Europe to 1/21 in Africa. In India, the chance of maternal mortality was estimated at 1/18; the surviving also might suffer from perineal tears, genital infections, uterovaginal prolapse, and vesico-vaginal fistula. Direct obstetric causes include those directly related to pregnancy, labor, and the postpartum period. Indirect causes include those resulting from previous existing diseases that were aggravated by the pregnancy. 75% of maternal mortality was caused by hemorrhage, obstructed labor, infection, eclampsia, and abortion. Proper handling could prevent maternal mortality in an estimated 63-80% of direct causes and 88-98% of all causes. Risk factors for postpartum hemorrhage include multiparity, age over 35 years with stretched uterus, and slight episodes of bleeding. Treatment must be immediate and sustained with oxytocic drugs and plasma expanders; the means of referral to an equipped facility must be available to women with hemorrhage. Risk factors for obstructed labor include very young age, height below 145 cms, previous prolonged labor or stillbirth, and previous cesarean, abnormal presentation, or labor progression. Delivery for these women must be in a facility offering trained doctors and well-equipped operating rooms. Prevention of infection is possible with pre-sterilized delivery kits, antibiotics in kits or within facilities, cleanliness of hands and delivery areas, and maternal tetanus immunization. Identification of edema in pregnancy would prevent eclampsia. Abortion complications could be prevented with safe and early practices and women's control over fertility.
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PMID:Maternal mortality and morbidity in the developing countries like India. 1228 6

A 29-year-old man with a history of dental restoration procedure was referred for a left Bell's palsy. At the emergency department, he complained instead of deteriorating unilateral ptosis and dysphagia. Incidentally, trismus was also noted. He was diagnosed with cephalic tetanus, which rapidly progressed to generalized tetanus. Ptosis is an unusual presenting complaint of tetanus. In this case, we attempt to explain how facial weakness, ptosis, and cephalic tetanus are all related. We also highlight the key aspects of tetanus in relation to the emergency physician.
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PMID:An unusual cause of 'ptosis'. 1739 89

A 77-year-old man non-immunized to tetanus suffered head trauma on the right side when he tumbled from a height of approximately 2m. Five days later, he experienced difficulty in opening his mouth and developed right ptosis. He was referred to our hospital 2 days post-ictus. The patient suffered trismus, and developed right Horner's syndrome with in a week. Symptoms due to multiple cranial nerve palsies were observed: right inferior oblique muscle weakness, reduced right corneal reflex, right facial palsy, dysphagia, and abnormal tongue movements. Neuroimages (computed tomography, magnetic resonance imaging, and angiography) of the basal skull and internal carotid arteries revealed no abnormalities. From the symptoms associated with his infected head wound and clinical follow-up, we suggested that he had cephalic tetanus. We subsequently conducted the following treatments: debridement of the wound, intravenous infusion of antitetanus human immunoglobulin (AHI), intrathecal AHI infusion, and systemic administration of benzylpenicillin. His condition improved with these treatments, and without any complications such as autonomic nervous system dysfunction or classical tetanic spasms. This case suggests that we should consider the possibility of cephalic tetanus when we observe a patient with cranial nerve palsy associated with injury.
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PMID:[Dysfunction of multiple cranial nerves in cephalic tetanus--case report]. 1969 89

Magnesium sulfate administered as an intravenous infusion is considered safe. However, there have been concerns about the neuromuscular blocking properties of magnesium that can cause respiratory insufficiency. We report a patient with mild tetanus who, after being started on magnesium infusion, developed progressive respiratory insufficiency, proximal muscle weakness and ptosis. On discontinuation of magnesium infusion, the muscular weakness improved and respiration became normal. The safety of magnesium sulfate infusion for the management of tetanus needs to be re-evaluated.
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PMID:Progressive muscle weakness with respiratory insufficiency in a young patient with tetanus during magnesium sulfate infusion. 2086 66

Cephalic tetanus is defined as a combination of trismus and paralysis of one or more cranial nerves. Cranial nerves III, IV, VI, VII, and XII may be affected, but the facial nerve is most frequently implicated. A 64-year-old female visited hospital for left ptosis followed by facial palsy after a left forehead abrasion in a car accident. At nine days post injury, left ptosis developed, left facial palsy developed twelve days post injury, and at fifteen days post injury, trismus and dysphagia developed. The following day, there was progression of symptoms to generalized tetanus, such as dyspnea and generalized rigidity. Videofluoroscopic swallow study showed penetration and aspiration. We report a case of cephalic tetanus with ptosis, facial palsy, and dysphagia, which progressed to generalized tetanus.
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PMID:A case of cephalic tetanus with unilateral ptosis and facial palsy. 2250 53


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