case study of obstructed labour

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Published: 10 March 2021

Incidence, causes, and maternofetal outcomes of obstructed labor in Ethiopia: systematic review and meta-analysis

Asteray Assmie Ayenew 1

Reproductive Health volume 18 , Article number: 61 ( 2021 ) Cite this article

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Obstructed labor is a preventable obstetric complication. However, it is an important cause of maternal mortality and morbidity and of adverse outcomes for newborns in resource-limited countries in which undernutrition is common resulting in a small pelvis in which there is no easy access to functioning health facilities with a capacity to carry out operative deliveries. Therefore, this systematic review and meta-analysis aimed to estimate the incidence, causes, and maternofetal outcomes of obstructed labor among mothers who gave birth in Ethiopia.

for this review, we used the standard PRISMA checklist guideline. Different online databases were used for the review: PubMed, Google Scholar, EMBASE, Cochrane Library, HINARI, AFRO Library Databases, and African Online Journals. Based on the adapted PICO principles, different search terms were applied to achieve and access the essential articles. The search included all published and unpublished observational studies written only in the English language and conducted in Ethiopia. Microsoft Excel 16 was used for data entrance, and Stata version 11.0 (Stata Corporation, College Station, Texas, USA) was used for data analysis.

I included sixteen (16) primary studies with twenty-eight thousand five hundred ninety-one (28,591) mothers who gave birth in Ethiopia. The pooled incidence of obstructed labor in Ethiopia was 12.93% (95% CI: 10.44–15.42, I 2 = 98.0%, p < 0.001). Out of these, 67.3% (95% CI: 33.32–101.28) did not have antenatal care follow-up, 77.86% (95% CI: 63.07–92.66) were from the rural area, and 58.52% (95% CI: 35.73– 82.31) were referred from health centers and visited hospitals after 12 h of labor. The major causes of obstructed labor were cephalo-pelvic disproportion 64.65% (95% CI: 57.15– 72.14), and malpresentation and malposition in 27.24% (95% CI: 22.05–32.42) of the cases. The commonest complications were sepsis in 38.59% (95% CI: 25.49–51.68), stillbirth in 38.08% (95% CI: 29.55–46.61), postpartum hemorrhage in 33.54% (95% CI:12.06– 55.02), uterine rupture in 29.84% (95% CI: 21.09–38.58), and maternal death in 17.27% (95% CI: 13.47–48.02) of mothers who gave birth in Ethiopia.

This systematic review and meta-analysis showed that the incidence of obstructed labor was high in Ethiopia. Not having antenatal care follow-up, rural residency, and visiting hospitals after 12 h of labor increased the incidence of obstructed labor. The major causes of obstructed labor were cephalo-pelvic disproportion, and malpresentation and malpresentation. Additionally, the commonest complications were sepsis, stillbirth, postpartum hemorrhage, uterine rupture, and maternal death. Thus, promoting antenatal care service utilization, a good referral system, and availing comprehensive obstetric care in nearby health institutions are recommended to prevent the incidence of obstructed labor and its complications.

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Plain english summary

Labor is considered obstructed when the presenting part of the fetus cannot progress into the birth canal, despite strong uterine contractions. The most frequent cause of obstructed labor is cephalo- pelvic disproportion, a mismatch between the fetal head and the mother's pelvic brim. The fetus may be large to the maternal pelvic brim, such as the fetus of a diabetic woman, or the pelvis may be contracted, which is more common when malnutrition is prevalent. Some other causes of obstructed labor may be malpresentation and malposition of the fetus (shoulder, brow, or occipito- posterior positions). In rare cases, locked twins or pelvic tumors can cause obstruction. To the best of my knowledge, no systematic review was conducted to estimate the national prevalence of obstructed labor. Therefore, this systematic review and meta-analysis aimed to estimate the incidence, causes, and maternofetal outcomes of obstructed labor among mothers who gave birth in Ethiopia. Sixteen (16) primary studies with twenty-eight thousand five hundred ninety-one (28,591) mothers who gave birth in Ethiopia were included. The pooled incidence of obstructed labor) mothers who gave birth in Ethiopia was 12.93%. Out of these, 67.3% did not have antenatal care follow-up, 77.86% were from the rural range, and 58.52% were referred from health centers and visited hospitals after at least 12 h of labor. The major causes of obstructed labor were cephalo-pelvic disproportion 64.65%, and malpresentation and malposition in 27.24% of the cases. The commonest complications were sepsis in 38.59%, stillbirth in 38.08%, postpartum hemorrhage in 33.54%, uterine rupture in 29.84%, and maternal death in 17.27% of mothers who gave birth in Ethiopia. Thus, promoting antenatal care service utilization, a good referral system, and availing comprehensive obstetric care in nearby health institutions are recommended to prevent the incidence of obstructed labor and its complications.

Introduction

Obstructed labor is defined as a failure of the fetal presenting part to descent in the birth canal due to mechanical reasons, despite having adequate uterine contraction [ 1 , 2 ]. It is diagnosed when the duration of labor is prolonged, a laboring mother became unable to support herself or unable to move her lower extremities, with deranged vital signs, distended bladder, Bandle’s ring formed in the lower uterine segment, fetal distress or death, edematous vulva, big caput, significant molding, foul-smelling and thick meconium-stained amniotic fluid [ 3 ]. Neglected obstructed labor (OL) is a major cause of both maternal and newborn morbidity and mortality. The obstruction can only be alleviated by means of operative delivery, either cesarean section or other instrumental delivery (forceps, vacuum extraction, or simphysiotomy) [ 4 ].

Globally, at least 585,000 women die each year from complications of pregnancy and childbirth. More than 70% of all maternal death is due to five major complications: hemorrhage, infection, unsafe abortion, hypertensive disorders of pregnancy, and obstructed labor [ 5 ]. Among these etiologies, obstructed labor is one of the most common causes of maternal illness and death in sub-Saharan Africa and Southeast Asia. Worldwide, obstructed labor occurs in an estimated 5% of pregnancies and accounts for an estimated 8% of maternal deaths. The majority of the maternal deaths occurred in the poor, illiterate, hard-to-reach women who are living in rural areas with limited or no access to skilled birth attendants [ 6 ].

It is an indicator of inadequacy and poor quality of obstetric care, and immediate cause of maternal and prenatal morbidity and mortality due to uterine rupture, complications of cesarean delivery, postpartum hemorrhage, anesthesia complications, puerperal sepsis, asphyxia, and brain damage. Moreover, neglected obstructed labor resulted from poverty and prohibiting high cost of maternal care in hospitals, ignorance, illiteracy, obstructed transportation, socio-cultural belief to achieve vaginal delivery at all cost, late referrals, and aversion to caesarean delivery and hospital delivery especially after a previous caesarean operation [ 7 ].

The fetus dies first, followed by the death of the mother that puts the lives of other children in the family in jeopardy. Many parturient women die undelivered and delivered by postmortem cesarean delivery [ 8 ]. The few women with intra uterine infection and fetal deaths that managed to reach the hospital alive, the tip of the iceberg, were usually delivered by cesarean operations because of lack of the skills to perform the simpler fetal destructive vaginal operations, and this is associated with the gamut of complications [ 5 , 9 ]. The risk of maternal death after abdominal delivery in such a septic condition can be very high [ 10 ].

Other complications of abdominal delivery include sepsis and septic shock, anemia, blood transfusion, wound infection, and burst abdomen, prolonged hospital stay, high cost of care, infertility, aversion to hospital delivery, and caesarean delivery in a subsequent pregnancy, obstetric fistulas, abandonment, and even divorce. Complications that have been attributed directly to fetal destructive vaginal operations include uterine rupture in 2.6–9.1% of cases, postpartum hemorrhage in 4.5%, and cervical and vaginal lacerations in 1.3% [ 11 ].

Maternal mortality arising from destructive operations in the management of neglected obstructed labor ranged from 0 to 2.7% when compared to 7.5% for abdominal delivery [ 11 , 12 ]. Certainly, fetal destructive operation is safer than abdominal delivery in neglected obstructed labor with fetal demise provided the uterus has not ruptured and is not at the verge of rupture.

Maternal and perinatal mortality and morbidity associated with obstructed labor are almost totally prevented in developed countries because of improved nutritional status, wide health coverage, adequate transportation and communication system, availability of trained health personnel, optimal antenatal and intrapartum care, and other related factors [ 13 ].

In most sub-Saharan countries including Ethiopia, women are traditionally expected to give birth at home and consequently delay their health care seeking in childbirth, even if complications arise. Moreover, women are often marginalized in decision making regarding where and when to seek care [ 14 ]. Unofficial financial demands from health workers prevent women from badly needed maternal health services. Inadequately developed health care systems including poor infrastructure, poor transportation and poor obstetric services are also major contributors to obstructed labor [ 15 ].

Obstructed labor has different magnitudes in different developing countries ranging from 2 to 8%. When we come to Africa some research finding showed that the magnitude of obstructed labor was more than the above determined once; In Uganda and Ethiopia, the magnitude of obstructed labor was described as 10.5% and 12.2% respectively [ 2 , 16 ]. In Ethiopia, despite different strategies to reduce morbidities and mortalities, among the 412 maternal deaths per 100,000 live births annually, 19.1% happened due to obstructed labor [ 17 , 18 ].

Apart from maternal deaths, obstructed labor had different maternal outcomes such as uterine rupture, postpartum hemorrhage, puerperal sepsis, bladder injury, Vesico-Vaginal fistula (VVF), recto-vaginal fistula (RVF), and fetal outcomes including birth asphyxia, stillbirth, neonatal jaundice, and umbilical sepsis [ 3 , 19 , 20 ]. By far, the most severe and distressing long-term condition following obstructed labor is obstetric fistula which causes serious social issues of divorce, separation from religious exercises, detachment from their families which can worsen poverty, and malnutrition [ 20 ]. Despite these severe complications, the prevalence of obstructed labor is still high in Ethiopia ranging from 3.3% in Tigray region [ 21 ] to 34.3% in Oromia region [ 22 ]. Therefore, the aim of this systematic review and meta-analysis was to estimate incidence, causes, and maternofetal outcomes of obstructed labor among mothers who gave birth in Ethiopia.

This systematic review and meta-analysis were conducted to estimate incidence, causes, and maternofetal outcomes of obstructed labor among mothers who gave birth in Ethiopia. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guideline [ 23 ] (Additional file 1 ).

Searching strategy

First, the PROSPERO database and database of abstracts of reviews of effects (DARE) ( http://www.library.UCSF.edu ) were searched to check whether published or ongoing projects exist related to the topic. The literature search strategy, selection of studies, data extraction, and result reporting were done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 24 ]. We searched PubMed, Google Scholar, EMBASE, Cochrane Library, HINARI, AFRO Library Databases, and African Online Journal databases for all available studies using the following terms: "obstructed labor", "prolonged labor", "obstetric complications", "childbirth", "labor abnormalities", "factors", and "Ethiopia". The search string was developed using "AND" and "OR" Boolean operators. Searching terms were based on adapted PICO principles to search through the above-listed databases to access all relevant articles. For unpublished studies, the official website of Ethiopian's University research repository online library (University of Gondar and Addis Ababa University) were used. The searching period was from September 1/2020 to November 30/2020.

Inclusion and exclusion criteria

All observational studies reporting the incidence of obstructed labor and/or associated factors in Ethiopia were included in this review. Both unpublished and published research articles, conducted in English language were included. Whereas duplicated studies, case reports, qualitative studies, anonymous reports, articles without full text, and abstract and editorial reports were excluded from the study.

Operational definition

Obstructed Labor: also known as labor dystocia, is a failure to progress due to mechanical problems—a mismatch between fetal size, or more accurately, the size of the presenting part of the fetus, and the mother’s pelvis, although some malpresentation, notably a brow presentation or a shoulder presentation. it is diagnosed when the duration of labor > 24 h, a laboring mother became unable to support herself or unable to move her lower extremities, with deranged vital signs, distended bladder, Bandle’s ring formed in the lower uterine segment, fetal distress or death, edematous vulva, big caput, significant molding, foul-smelling and thick meconium-stained amniotic fluid [ 3 , 25 ].

Causes of obstructed labor

The commonest cause of obstructed labor is craniopelvic disproportion (CPD). This could arise as a result of reduced pelvic dimension from childhood, maternal malnutrition, infection, poliomyelitis, deformity, sickle cell disease, or in teenagers increased diameter of the presenting part, such as malposition and malpresention. These include brow presentation, compound presentation, occipto-posterior, and mento-posterior in face presentation and congenital malformation (hydrocephalus, fetal ascites, and double monsters) [ 26 , 27 ].

Complications of obstructed labor

Apart from maternal death, obstructed labor had different maternal outcomes such as uterine rupture, postpartum hemorrhage, puerperal sepsis, Vesico-Vaginal fistula (VVF), recto-vaginal fistula (RVF), and fetal outcomes including birth asphyxia, stillbirth, neonatal jaundice, and umbilical sepsis. Women who experience obstructed labor for a prolonged time can be complicated with fistulas. Besides their physical wounds, serious social issues of divorce, separation from religious exercises, detachment from their families which can worsen poverty, and malnutrition are the major problems of obstructed labor [ 3 , 19 , 20 ].

Cephalopelvic disproportion (CPD)

Is an inadequate size of the maternal pelvis, compared to the fetal head, which prevents the fetus from passing through the pelvic cavity during delivery, and causes obstructed labor [ 28 ].

Quality assessment

After collecting the findings from all databases, the articles were exported to Microsoft Excel spreadsheet. The methodological quality of each study (sampling strategy, response rate, and representativeness of the study), comparability, and outcome were checked using the NOS tool. Newcastle–Ottawa Quality Assessment Scale (NOS) for cross-sectional, and case–control studies was used to assess the methodological quality of a study, and to determine the extent to which a study has addressed the possibility of bias in its design, conduct, and analysis [ 29 ]. All included articles scored (NOS) 7 and more can be considered as “good” studies with low risk (Additional file 2 ).

Data extraction

Microsoft Excel (2016), and Stata version 11.0 (Stata Corporation, College Station, Texas, USA) software were used for data entry and analysis, respectively. The data was extracted by using a standardized Joanna Briggs Institute (JBI) data extraction format. During data extraction; the name of the author, sample size, publication year, study design, prevalence, response rate, population outcome, study site, and different contributing factors were included. Moreover, the incidence, and outcomes of obstructed labor with 95% CI and associated factors were collected [ 30 ].

Statistical analysis

As the test statistic showed significant heterogeneity among studies (I 2 = 98.0%, p < 0.05) the Random-effects model was used to estimate the DerSimonian and Laird's pooled effect [ 31 ]. Cochran’s Q chi-square statistics and I 2 statistical test was conducted to assess the random variations between primary studies [ 32 ]. In this study, the heterogeneity of included studies was interpreted as an I 2 value of 25% = low, 50% = moderate, and 75% = high [ 33 ]. In case of high heterogeneity, subgroup analysis and sensitivity analyses were run to identify possible moderators of this heterogeneity. Potential publication bias was assessed by visually inspecting funnel plots and objectively using the Egger’s test (i.e. p < 0.05) [ 34 ]. To account for any publication bias, we used the trim-and-fill method, based on the assumption that the effect sizes of all studies are normally distributed around the center of a funnel plot. The meta-analysis was performed using the Stata version 11.0 (Stata Corporation, College Station, Texas, USA) software. Finally, for all analyses, P < 0.05 was considered statistically significant.

Study selection and data extraction

The search strategy identified 80 articles from PubMed, 60 articles from Google Scholar, 45 articles from Cochrane Library, 10 articles from African Journals Online, 7 articles from Ethiopian’s University online library, and 2 articles from manual search. Of which, 134 were excluded due to duplication, 35 through review of titles and abstracts. Additionally, 44 full-text articles were excluded for not reporting the outcome variable and other reasons. Finally, 16 articles were included to analyze the incidence, outcome, and associated factors of obstructed labor (Fig. 1 ).

Flow chart of study selection for systematic review and meta-analysis of obstructed labor among mothers who gave birth in Ethiopia

Study characteristics

In this review, 16 relevant studies were included with a sample size of 28,951. Among sixteen studies thirteen were cross sectional [ 1 , 14 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ] and three case-controls [ 46 , 47 , 48 ] in study design. Regarding the geographical area, six from Oromia [ 14 , 35 , 36 , 40 , 41 , 47 ], four [ 3 , 37 , 39 , 42 ] from Southern Nation Nationalities and People (SNNPR), and four [ 1 , 38 , 43 , 48 ] from Tigray region, two studies [ 45 , 46 ] were from Amhara region. Among the included studies the largest sample size was 13,425 [ 41 ], whereas the smallest was 90 [ 48 ] (Table 1 ).

Incidence of obstructed labor in Ethiopia

Primarily, all three case–control [ 46 , 47 , 48 ] studies were not considered in the incidence estimation, because they did not report the incidence of obstructed labor, but all studies were included in factor analysis. The pooled incidence of obstructed labor is presented on a forest plot (Fig. 2 ). Therefore, the estimated incidence of obstructed labor among mothers who gave birth in Ethiopia was 12.93% (95% CI: 10.44 – 15.42, I 2 = 98.0%, p < 0.001).

Forest Plot for the pooled incidence of obstructed labor among mothers who gave birth in Ethiopia, 2020

Publication bias

The funnel plot was assessed for asymmetry distribution of the prevalence of obstructed labor among mothers who gave birth in Ethiopia (Fig. 3 ). Egger's regression test showed a p-value of 0.259 with no evidence of publication bias.

Funnel plot with 95% confidence limits of the pooled incidence of obstructed labor among mothers who gave birth in Ethiopia, 2020

Sensitivity analysis

This systematic review and meta-analysis showed that the point estimate of its omitted analysis lies within the confidence interval of the combined analysis. Therefore, trim and fill analysis was no further computed (Fig. 4 ).

Sensitivity analysis of the pooled incidence of obstructed labor among mothers who gave birth in Ethiopia, 2020

Subgroup analysis

Subgroup analysis was employed with the evidence of heterogeneity. In this study, the Cochrane I 2 statistic was 98.0%, P < 0.001, shower the presence of marked heterogeneity. Therefore, subgroup analysis was done using the study region and sample size. As a result, obstructed labor was high in Southeastern Ethiopia 15.14% (95% CI: 11.61–18.66), regarding sample size, the highest incidence was in the study with the sample size less than 1000 [16.93% (95% CI: 10.92–21.14)] (Figs. 5 and 6 ).

Subgroup analysis of the pooled incidence of obstructed labor among mothers who gave birth in Ethiopia based on the study region, Southeastern Ethiopia

Subgroup analysis of the pooled incidence of obstructed labor among mothers who gave birth in Ethiopia based on sample size

Risk factors for the incidence of obstructed labor

The association between not having antenatal care follow-up, rural residency, referred from health centers and visited hospitals after at least 12 h of labor with obstructed labor was carried out.

A total of six articles were included to identify the association between referred from health centers and visited hospitals after at least 12 h of labor and obstructed labor. Mother’s referred from health centers, and visited hospitals after at least 12 h of labor develop obstructed labor by 58.52% than mothers who visited hospitals in short hours of labor (58.52%, 95% CI: 35.73–82.31).

A total of five articles were included to identify the association between rural residency and obstructed labor. Mother’s residency (as defined as rural and urban) was significantly associated with obstructed labor. Mother’s from rural areas were more likely to have obstructed labor than those (women) from urban areas, 77.86% (95% CI: 63.07–92.66).

Moreover, four studies showed a significant association between not having antenatal care follow-up and obstructed labor. Mother’s who did not have antenatal care follow-up were 67.3% more likely to develop obstructed labor (67.3%, 95% CI: 33.32–101.28) compared to mothers who had antenatal care follow-up (Table 2 ).

Additionally, the two major causes of obstructed labor were cephalo-pelvic disproportion 64.65% (95% CI: 57.15–72.14), and malpresentation and malposition in 27.24% (95% CI: 22.05–32.42) of the cases (Figs. 7 and 8 ).

Cephalo-pelvic disproportion as a major cause of obstructed labor among mothers who gave birth in Ethiopia

Malpresentation and malposition as a major cause of obstructed labor among mothers who gave birth in Ethiopia

Materno-fetal complications following obstructed labor in Ethiopia.

Following obstructed labor, different adverse maternal and neonatal complications were reported. Sepsis, stillbirth, postpartum hemorrhage, uterine rupture, and maternal death were the most common complications following obstructed labor (Table 3 ).

Obstructed labor is a life-threatening obstetrical complication associated with significant maternal as well as fetal morbidity and mortality. Early recognition and immediate intervention are important to prevent associated complications and to improve maternal and fetal outcomes [ 21 ]. Several interventions, such as the utilization of the partograph to monitor labor and provision of emergency obstetrical care services have been proposed to reduce the incidence of obstructed labor, and its squeal. However, the prevalence remains high in the developing countries [ 49 ].

The purpose of this review was to assess the incidence, mernofetal outcome, and associated factors of obstructed labor by reviewing the findings of available primary studies. The pooled incidence of obstructed labor in Ethiopia was 12.93%. The result higher than the studies conducted in India [ 50 ] 1.9%, Pakistan [ 51 ] 2.1%, Nigeria [ 52 ] 4.7%, and Uganda 10.5% [ 53 ]. The possible reason might be poor ANC follow up, high homebirth prevalence, teenage pregnancy, low socioeconomic status, poor infrastructure, and poor referral system in Ethiopia [ 54 , 55 , 56 ].

This study also elucidated that, 67% of the obstructed labor cases did not have ANC follow-up during pregnancy. The result is supported by studies conducted in Pakistan [ 57 ], and Nigeria [ 20 ]. This might be the fact that not having antenatal care during pregnancy may decrease women knowledge about their pregnancy condition like multiple pregnancies, big baby, fetal anomalies, and other risk factors for obstructed labor. Moreover, women who don’t have antenatal care are prone to home childbirth, poor awareness about birth preparedness and complication readiness plan, and danger signs of pregnancy which in turn increase the risk of obstructed labor.

Among mothers who had obstructed labor, 77.86% were from rural areas. The result is in line with studies conducted in Uganda [ 53 ] and Bangladesh [ 57 ]. This could be due to women residing in rural areas, health facilities are distant, and accesses to information about institutional deliveries are limited. This might result in a delay to decide for seeking health care as early as possible and delay in reaching a health facility which contributes a lot to the occurrence of obstructed labor.

Additionally, 58.52% of mothers who had obstructed labor were referred from health centers and visited hospitals after at least 12 h of labor. The result is supported by studies conducted In Ghana [ 58 ] and Eastern Uganda [ 59 ]. This could be explained as women might be referred after a long time of stay at the lower level facilities either due to lack of transportation, lack of infrastructure, poor decision of health care providers, and refusal of families which promote the occurrence of obstructed labor.

The main obstetric causes of obstructed labor in this review were cephalopelvic disproportion accounted for 64.65%. The result is supported by studies in Uganda [ 53 ], Nigeria [ 5 ], and India [ 50 ]. This could be explained as the prevalence of CPD is high in Ethiopia, where girls are small in stature, grow up malnourished, marry at a young age, and become pregnant before their pelvis is fully grown [ 60 ]. Additionally, a cross-sectional study of obstetric fistula patients in Ethiopia revealed that the mean ages at the first marriage and at the delivery that caused the fistula were 14.7 and 17.8 years respectively [ 61 ]. Indeed, 13% of the girls surveyed in the study in 2016 between 15 and 19 years of age had begun childbearing, including 1.6% of 15 year-olds, 4.4% of 16-year-olds and 13% of 17 year-olds [ 62 ]. Malposition and malpresentation were also responsible for 27.4% of obstructed labor, which was consistent with a study conducted at Pakistan Public Sector University [ 63 ].

Sepsis was the commonest maternal complication of obstructed labor accounted for 38.08% of cases. The result is in line with studies conducted in Uganda [ 53 ], India [ 50 ], Eastern Nigeria [ 52 ], and the United States [ 64 ]. Additionally, postpartum hemorrhage resulted in 33.54% of obstructed cases. The result is supported by studies in Norway [ 65 ] and Le Ray et al. [ 66 ].

Uterine rupture resulted in 29.84% of obstructed cases. The result is supported by the study conducted in Uganda [ 67 ], Dar es Salaam, and the USA [ 68 ]. The reason for this could be during obstructed labor there is an impossible barrier (obstruction) preventing its descent despite strong uterine contractions, which increases the risk of uterine rupture.

This review revealed that obstructed labor results stillbirth 38.59% of cases. The result is in line with studies in Boston, Massachusetts, United States [ 64 ], and Pakistan [ 51 ]. The possible reason might be obstructed labor is when the baby does not exit the pelvis during childbirth due to being physically blocked, despite the uterus contracting, resulted in the baby not getting enough oxygen which may result in death. Moreover, as labor is obstructed, the fetal head impacts on the soft tissue of the pelvic floor, pinning the bladder base and the urethra against the pelvic bone. In the absence of any intervention, this condition may last for several days; the fetus may die and the results stillbirth.

Maternal death has also resulted in 17.27% obstructed labor cases in Ethiopia. The result is supported by a systematic review in Sub-Saharan Africa [ 69 ], Uganda [ 53 ], and Eastern Nigeria [ 52 ]. This shocking figure is certainly an underestimation of the problems, because deaths due to obstructed labor are often classified under other complications (such as sepsis, postpartum hemorrhage or ruptured uterus). This could be explained by obstructed labor results, dehydration, exhaustion, fistula, uterine rupture, sepsis, postpartum hemorrhage, anemia, and shock which all could result in maternal death.

Since it is the first systematic review and meta-analysis, it is taken as a strength. The included articles were restricted to the English language only; this is a limitation of the study as it missed studies published in local languages. Additionally, one of the limitations of this systematic review is the credibility of the unpublished and non-peer-reviewed publications included in this review.

This study revealed the high incidence of obstructed labor and its complications in Ethiopia. Not having antenatal care follow-up, rural residency, and referred from health centers and visited hospitals after at least 12 h of labor were contributing factors for the incidence of obstructed labor. Additionally, the major causes of obstructed labor were cephalo-pelvic disproportion and malpresentation and malposition. Sepsis, stillbirth, postpartum hemorrhage, uterine rupture, and maternal death were the commonest complications of obstructed labor among mothers who gave birth in Ethiopia. Therefore, to prevent the incidence of obstructed labor; promoting ANC service utilization during pregnancy, improving the referral system, and infrastructure to reach health faculty that had a capacity to manage obstructed labor is recommended. Moreover, it is better to promote institutional service utilization for the prevention and early management of obstructed labor and its complications.

Availability of data and materials

The data sets generated during the current study are available from the corresponding author on reasonable request.

Abbreviations

Addis Ababa

Confidence Interval

Cepalo-Pelvic Disproportion

Adjusted Odds Ratio

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Southern Nation Nationality and Peoples Representative

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Ayenew, A.A. Incidence, causes, and maternofetal outcomes of obstructed labor in Ethiopia: systematic review and meta-analysis. Reprod Health 18 , 61 (2021). https://doi.org/10.1186/s12978-021-01103-0

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Risk factors for obstructed labour in Eastern Uganda: A case control study

Affiliations.

1 Department of Obstetrics and Gynaecology, Mbale Regional Referral and Teaching Hospital, Mbale, Uganda.
2 Department of Obstetrics and Gynaecology, Busitema University Faculty of Health Sciences, Mbale, Uganda.
3 Department of Paediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
4 Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
5 Africa Centre for Systematic Reviews and Knowledge Translation, Makerere University College of Health Sciences, Kampala, Uganda.
6 Sanyu Research Unit, University of Liverpool, University of Liverpool/Liverpool Women's Hospital, Liverpool, England, United Kingdom.
7 Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda.
8 Centre for Intervention Science and Maternal Child Health (CISMAC), Centre for International health, University of Bergen, Bergen, Norway.
9 School of Statistics and Planning, College of Business and Management Sciences, Makerere University, Kampala, Uganda.
PMID: 32040542
PMCID: PMC7010384
DOI: 10.1371/journal.pone.0228856

Introduction: Obstructed labour (OL) is an important clinical and public health problem because of the associated maternal and perinatal morbidity and mortality. Risk factors for OL and its associated obstetric squeal are usually context specific. No epidemiological study has documented the risk factors for OL in Eastern Uganda. This study was conducted to identify the risk factors for OL in Mbale Hospital.

Objective: To identify the risk factors for OL in Mbale Regional Referral and Teaching Hospital, Eastern Uganda.

Methods: We conducted a case control study with 270 cases of women with OL and 270 controls of women without OL. We consecutively enrolled eligible cases between July 2018 and February 2019. For each case, we randomly selected one eligible control admitted in the same 24-hour period. Data was collected using face-to-face interviews and a review of patient notes. Logistic regression was used to identify the risk factors for OL.

Results: The risk factors for OL were, being a referral from a lower health facility (AOR 6.80, 95% CI: 4.20-11.00), prime parity (AOR 2.15 95% CI: 1.26-3.66) and use of herbal medicines in active labour (AOR 2.72 95% CI: 1.49-4.96). Married participants (AOR 0.59 95% CI: 0.35-0.97) with a delivery plan (AOR 0.56 95% CI: 0.35-0.90) and educated partners (AOR 0.57 95% CI: 0.33-0.98) were less likely to have OL. In the adjusted analysis, there was no association between four or more ANC visits and OL, adjusted odds ratio [(AOR) 0.96 95% CI: 0.57-1.63)].

Conclusions: Prime parity, use of herbal medicines in labour and being a referral from a lower health facility were identified as risk factors. Being married with a delivery plan and an educated partner were protective of OL. Increased frequency of ANC attendance was not protective against obstructed labour.

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Labour and Delivery Care Module: 9. Obstructed Labour

Study session 9. obstructed labour, introduction.

Obstructed labour is a totally preventable labour complication. One of your major roles as a skilled birth attendant is to prevent the occurrence of obstructed labour in women in your community. It is highly prevalent in the rural areas of Ethiopia, particularly among women who are in labour at home for a long time.

Obstructed labour is associated with a high perinatal mortality and morbidity (fetal and newborn deaths, and disease and disability occurring around the time of the birth). It contributes to 22% of the maternal mortality in Ethiopia. This shocking figure is certainly an underestimation of the problem, because deaths due to obstructed labour are often classified under other complications (such as sepsis, postpartum haemorrhage or ruptured uterus).

In this session, you will learn how to identify the clinical signs of prolonged and obstructed labours and determine the best management. Delayed management of obstructed labour often causes fistula in surviving women, which if not treated, may make them outcasts from their community for the rest of their lives.

Learning Outcomes for Study Session 9

When you have studied this session, you should be able to:

9.1 Define and use correctly all of the key words printed in bold . (SAQs 9.2 and 9.3)

9.2 List the main causes of obstructed labour and describe how each factor contributes to the development of this complication. (SAQ 9.1)

9.3 Describe the clinical signs of obstructed labour and the common maternal and fetal complications that result from uterine obstruction. (SAQ 9.3)

9.4 Describe the management of obstructed labour and ways of preventing it through your actions. (SAQ 9.3)

9.5 Explain how social changes at community level could affect the risk of obstructed labour occurring. (SAQ 9.4)

9.1 Defining obstructed labour

Obstructed labour is the failure of the fetus to descend through the birth canal, because there is an impossible barrier (obstruction) preventing its descent despite strong uterine contractions. The obstruction usually occurs at the pelvic brim, but occasionally it may occur in the pelvic cavity or at the outlet of the pelvis. When labour is prolonged because of failure to progress, there is a high risk that the descent of the fetus will become obstructed. There is no single definition of prolonged labour , because what counts as ‘too long’ varies with the stage of labour (see Box 9.1).

Box 9.1 When is labour classed as prolonged in the different stages of labour?

Prolonged latent phase of labour : when true labour lasts for more than about 8 hours without entering into the active first stage.
Prolonged active phase of labour : when true labour takes more than about 12 hours without entering into the second stage.
Multigravida mother: when it lasts for more than 1 hour.
Primigravida mother: when it lasts for more than 2 hours.

Although labour can be classed as ‘prolonged’ at any stage, you should note that obstructed labour most commonly develops after the labour has entered into the second stage.

9.2 Causes of obstructed labour

As indicated above, obstructed labour is generally a second stage phenomenon, in women whose labour is prolonged. Why labour becomes prolonged or obstructed may be due to one of the ‘Ps’ (as midwives and obstetricians call them): ‘powers’, ‘passenger’ and ‘passage’.

Powers : Inadequate power, due to poor or uncoordinated uterine contractions, is a major cause of prolonged labour. Either the uterine contractions are not strong enough to efface and dilate the cervix in the first stage of labour, or the muscular effort of the uterus is insufficient to push the baby down the birth canal during the second stage.
Passenger: The fetus is the ‘passenger’ travelling down the birth canal. Prolonged labour may occur if the fetal head is too large to pass through the mother’s pelvis, or the fetal presentation is abnormal.
Passage: The birth canal is the passage, so labour may be prolonged if the mother’s pelvis is too small for the baby to pass through or the pelvis has an abnormal shape, or if there is a tumour or other physical obstruction in the pelvis.

Table 9.1 summarises the mechanical causes of ‘passenger’ and ‘passage’ failure.

Table 9.1 Causes of passenger and passage failures that lead to prolonged and possibly obstructed labours.
Passenger	Passage
: ● Large fetal head (big for that pelvis) ● Hydrocephalus (brain surrounded by fluid, which makes the skull swell) : ● Brow, face, shoulder ● Persistent malposition : ● Locked twins (locked at the neck) ● Conjoined twins (fused together with some shared organs)	: ● Contracted (due to malnutrition) ● Deformed (due to trauma, polio) : ● Tumour in the pelvis ● Viral infection in the uterus or abdomen ● Scars (from female circumcision)

The mechanical causes of prolonged and obstructed labour shown in Table 9.1 can be grouped into various categories: cephalopelvic disproportion; malpresentations and malpositions; or an abnormality in the fetus or the mother which obstructs the birth canal. We will look at each of these in turn in more detail.

9.2.1 Cephalopelvic disproportion (CPD)

Cephalic (pronounced ‘seff-ah-lik’) is from a Greek word meaning ‘the head’. Disproportion tells you that the size of the fetal head is different from the size of the mother’s pelvic brim.

C ephalopelvic disproportion (CPD) means it is difficult or impossible for the fetus to pass safely through the mother’s pelvis due either to a maternal pelvis that is too narrow for that fetal head, or a large fetal head relative to that mother’s pelvis (see Figure 9.1, and think back to the anatomy of the maternal pelvis and fetal skull which you learned in Study Session 6 of the Antenatal Care Module). The small (or contracted) pelvis in developing countries like Ethiopia is generally due to malnutrition in childhood persisting into adult life. Cephalopelvic disproportion cannot usually be diagnosed before the 37th week of pregnancy because before then the baby’s head has not reached birth size.

9.2.2 Abnormal presentations and multiple pregnancies

A womans pelvis is too small for her baby’s head.

Persistent malpresentation or malposition are other major causes of obstructed labour.

Can you distinguish between these two terms and recall some abnormal fetal presentations and malpositions from Study Session 8?

Malpresentation is any presentation other than vertex (the top of the baby’s skull is the presenting part). The most common malpresentations are breech (the baby’s buttocks and/or its feet present first), and shoulder when it engages ‘shoulder first’. Malposition is when the baby is ‘head down’ (cephalic presentation), but the vertex is in the wrong position relative to the mother’s pelvis. Two of the most common malpositions result in face and brow presentations.

You also learned about multiple pregnancies in Study Session 8. Labour can be obstructed by locked twins (the two babies are ‘locked’ together at their necks when the first twin is in breech presentation and the second twin is in cephalic presentation), or conjoined twins (twins fused at the chest, head or any other site).

9.2.3 Fetal abnormalities

Some fetal abnormalities result in a fetus with an abnormally large head diameter, for example, hydrocephalus, which is due to excessive accumulation of fluid around the baby’s brain.

9.2.4 Abnormalities of the reproductive tract

A possible cause of obstructed labour is if the mother has a tumour (growth or swelling of tissue) in her pelvic cavity, or a scarred birth canal due to a severe type of female genital mutilation (‘female circumcision’). Or she may have a tight perineum (the area between the vulva and the anus), which does not stretch in order to allow the baby to pass through.

Female genital mutilation is the subject of Study Session 5 in the Module on Adolescent and Youth Reproductive Health .

9.3 Clinical signs of obstructed labour

A key sign of an obstructed labour is if the widest diameter of the fetal skull remains stationary above the pelvic brim because it is unable to descend. You should be able to detect this by careful palpation of the mother’s abdomen as the uterus relaxes and softens between contractions. However, if the uterus has gone into tonic contraction (it is continuously hard) and sits tightly moulded around the fetus, it will be very difficult to feel whether the fetus is making any progress in the birth canal. Palpation will also be very painful for the woman . In this case you will have to rely more on other signs for your diagnosis, listed below.

9.3.1 Assessment of clinical signs of obstruction

Obstructed labour is more likely to occur if:

The labour has been prolonged (lasting more than 12 hours)
The mother appears exhausted, anxious and weak
Rupture of the fetal membranes and passing of amniotic fluid was premature (several hours before labour began)
The mother has abnormal vital signs: fast pulse rate, above 100 beats/minute; low blood pressure; respiration rate above 30 breaths/minute; possibly also a raised temperature.

You should assess a woman with this labour history b y doing a vaginal examination. Any of the following additional signs would suggest the presence of obstruction:

Foul-smelling meconium draining from the mother’s vagina.
Concentrated urine, which may contain meconium or blood.
Oedema (swelling due to collection of fluid in the tissues) of the vulva (female external genitalia, including the labias), especially if the woman has been pushing for a long time. Vagina feels hot and dry to your gloved examining finger because of dehydration.
Oedema of the cervix.
A large swelling over the fetal skull can be felt ( caput , Study Session 4).
Malpresentation or malposition of the fetus.
Poor cervical effacement (look back at Figure 1.1 in the first study session); as the result the cervix feels like an ‘empty sleeve’.
Bandl’s ring may be seen ( Figure 9.2 ).

9.3.2 Bandl’s ring

Bandl’s ring is the name given to the depression between the upper and lower halves of the uterus, at about the level of the umbilicus. It should not be seen or felt on abdominal examination during a normal labour (Figure 9.2a), but when it becomes visible and/or palpable (Figure 9.2b) Bandl’s ring is a late sign of obstructed labour. Above this ring is the grossly thickened, upper uterine segment which is pulled upwards (retracted) towards the mother’s ribs. Below the Bandl’s ring is the distended (swollen), dangerously thinned, lower uterine segment. The lower abdomen can be further distended by a full bladder and gas in the intestines.

(a) Normal shape of pregnant abdomen during labour, in a woman lying on her back; (b) Bandl’s ring in the abdomen of a woman with obstructed labour.

9.3.3 Evidence from the partograph

You will remember from Study Session 4 that the partograph is a key tool in detecting an abnormal or prolonged labour. Obstructed labour is revealed by recordings on the partograph of the rate of cervical dilatation (which, as you know, should progress at a rate of at least 1 cm per hour) and the rate of fetal he ad descent. Figure 9.3(a) shows a partograph record of a normal labour with progressive cervical dilatation and fetal head descent. However in Figure 9.3(b) you can quickly see that there is evidence of a prolonged first or second stage of labour because:

the cervical dilatation measurement has crossed the ‘Alert line’ and if no action is taken it will cross the Action line, despite strong uterine contractions; the fetal head is not descending.

(a) Normal cervical dilatation and fetal head descent recorded on a partograph. (b) Cervical dilatation has stopped and the record line has crossed the Action line.

In Figure 9.3(b), how many hours after recordings began on the partograph did cervical dilation stop progressing?

The cervix stopped dilating 4 hours after the partograph record began.

In the partograph shown in Figure 9.3(b), how much time has passed since there was any sign of cervical dilatation?

The partograph shows that there was no increase in cervical diameter for the previous two and a half hours.

9.4 Management of obstructed labour

There are several things that you can do to try to relieve the obstruction if the record of cervical dilatation reaches the Alert line on the partograph, and before it approaches the Action line. The details of these procedures were taught in the Antenatal Care Module (Study Session 22) and your practical skills training, so we will only refer briefly to them here.

If the woman has signs of shock (fast pulse and low blood pressure), prepare to give her an intravenous infusion of N ormal Saline or Ringer’s L actate to rehydrate her. Use a large (No. 18 or 20) cannula. Infuse her with 1 litre of fluids, with the flow rate running as quickly as possible, then repeat 1 litre every 20 minutes until her pulse slows to less than 90 beats per minute, and her diastolic blood pressure (when the heart relaxes after a beat) is 90 mmHg or higher.
If you think the obstruction may be due to a very full bladder, prepare to drain it by inserting a catheter. Clean the perineal area and catheteri s e the mother’s bladder to drain the urine into a closed container. Relieving this obstruction may be enough to allow the baby to be born. Note that catheteri s ation of the bladder in a woman with obstructed labour is usually very difficult, because the urethra is also obstructed by the deeply engaged baby’s head.

A health worker refers a pregnant woman in labour to the hospital.

9.5 Complications resulting from obstructed labour

The complications of uterine obstruction for the mother and for the fetus or newborn can be very serious. Remember that uterine obstructions happen mainly because of a prolonged labour at home that was not well managed and which was not referred quickly enough. The commonest complication affecting the mother is the formation of a fistula.

9.5.1 Fistula

Fistula is an abnormal opening (usually as a result of ruptured tissues) between the:

Vagina and the urinary bladder
Vagina and rectum
Vagina and urethra (the tube bringing urine from the bladder to the opening in the vulva)
Vagina and ureter (the tube bringing urine from each kidney to the bladder).

A woman is walking along and experiences a fistual leak.

As a result of the fistula, urine or faeces get into the vagina and exit in an uncontrolled way. A woman with a fistual can leak urine or faeces while walking, or doing any daily activities, and the waste stains her clothes and creates a bad smell (Figure 9.5). Because of these effects, her husband and family may stigmatise her or make her an outcast. You can also imagine what continuously leaking urine or faeces means at a personal level. Other consequences of fistula may include constant depression, and many physical illnesses and infections of the reproductive tract, bladder and kidneys, which may even result in the woman taking her own life.

Obstructed labour is responsible for about 20% of all cases of fistula formation (see the research study reported in Figure 9.6).

Clinical expert-based estimation of progression of prolonged labour to stillbirth and obstetric fistula development in high-risk sub-Saharan African countries

Other rare causes of fistula are congenital malformation (abnormal communication, usually between the rectum and vagina, found at birth), infection (specifically tuberculosis), trauma, forceful sexual intercourse (rape), and early age sexual intercourse.

9.5.2 Other common complications of obstructed labour

To summarise briefly, unless it is well managed, obstructed labour can also lead to the following complications in the mother:

Postpartum haemorrhage (you will learn about this in Study Session 11 in this Module)
Slow return of the uterus to its pre-pregnancy size
Shock (low blood pressure and fast pulse rate)
The small intestine becomes paralyzed and stops movement (paralytic ileus)
Sepsis (widespread infection throughout the body)

Complications of obstructed labour for the newborn can include:

You will learn in detail about complications affecting the newborn in the Modules on Postnatal Care and Integrated Management of Newborn and Childhood Illness

Neonatal sepsis
Convulsions (fits)
Facial injury
Severe asphyxia (life-threatening lack of oxygen)

9.6 Prevention of obstructed labour

There are several things that a skilled birth attendant can do to prevent a prolonged labour from becoming obstructed. Additionally, certain cultural changes would also make a significant difference to the circumstances that increase the risk of obstructed labour. We now look briefly at these factors.

9.6.1 Skilled birth attendance

As we said at the beginning, obstructed labour is a major cause of maternal death worldwide, and especially in developing countries like Ethiopia. The most important intervention that could prevent this toll of death and disability is having the services of a skilled attendant at the birth. So a really important part of your role as a rural health worker is to teach the people in your community (men as well as women) about the importance of getting skilled care at every delivery. Encourage the women to come to you for advice and maintain close links with the health centres or hospital (if there is one) in your area to facilitate quick and efficient referral in cases of emergency.

9.6.2 Using the partograph

The best diagnostic tool for identifying prolonged labour is to plot the stages of labour on the partograph, at the same time as regularly assessing fetal and maternal condition (see also Study Session 4). The partograph record will give you an early warning if labour may be prolonged to the point where an obstructed uterus seems likely and referral is essential. So always remember to use it when attending any delivery.

What are the two things you must do to minimise the chances of a woman who is in labour developing a fistula?

The two things you should do are:

Closely monitor the progress of labour using the partograph to check that the record of cervical dilatation stays on or to the left of the Alert line.
Urgently refer the mother to a health facility if she has an obstruction (the record of cervical dilatation is approaching the Action line on the partograph), with pre-referral IV fluid infusion or bladder catheteri s ation if appropriate.

9.6.3 Birth preparedeness and complication readiness

As you learned in the Antenatal Care Module (Study Session 13), birth preparedness and complication readiness are the pillars of safer labour and delivery. So assist your community to organise themselves into birth preparedness teams, which have the leadership, knowledge, funding and transport to transfer mothers to the nearest health facility if there is an emergency such as obstructed labour.

9.6.4 Nutritional education

It is also important to intervene in the underlying factors that increase the risk of obstructed labour. As we said earlier, a major cause of obstructed labour is a small pelvis, which is mostly the result of poor nutrition during childhood persisting into adult life. Thus it is important to improve childhood nutrition through health education, especially for girls, to reduce the risk of prolonged and obstructed labour in later life.

9.6.5 Delaying early marriage

Early marriage is the subject of a study session in the Module on Adolescent and Youth Reproductive Health.

Another issue is early marriage. Researches in Ethiopia have shown that 50% of women, especially rural women, get married on average at around 16 years, and most of them rapidly become pregnant. This group of very young mothers is at especially high risk of obstructed labour because the pelvis has not grown sufficiently to accommodate the baby’s head. In your discussions with women, their partners and community leaders you can point out these risks of early marriage, and try to persuade them of the importance of delaying the first birth until after the woman is 18. As part of this, you will need to promote contraception (family planning methods) as a way of delaying the first pregnancy among these very young women. If unwanted pregnancy occurs, it is also important to counsel about safe abortion services (as described in the Antenatal Care Module, Part 2, Study Session 20).

Summary of Study Session 9

In Study Session 9 you have learned that:

Obstructed labour is failure of descent of the fetus through the birth canal (pelvis) because there is an impossible barrier (obstruction) preventing its descent in spite of strong uterine contractions.
Causes of obstructed labour are c ephalopelvic disproportion (CPD), abnormal presentations, fetal abnormalities and abnormalities of the maternal reproductive tract.
Causes of prolonged labour are abnormali ty in one or more of the three ‘P s ’ : p ower, p assenger and p assage.
The best diagnostic tool for you to identify prolonged labour is the partograph.
The clinical features of obstructed labour include mother stay in labour for more than 12 hours, exhausted and unable to support herself, deranged vital signs, dehydrated, Bandl’s ring formation in the abdomen, bladder f ull above the symphysis pubis, big caput and big moulding, may be edematous vaginal opening.
Common maternal complications of obstructed labour include sepsis, paralytic ileus, postpartum haemorrhage, fistula formation.
Common fetal complications of obstructed labour are severe asphyxia, neonatal sepsis and death.
Early referral can save the life of the woman and the baby in case of obstructed labour.

Self-Assessment Questions (SAQs) for Study Session 9

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 9.1 (tests Learning Outcome 9.2)

Write down what you understand by the three ‘Ps’ and how they cause obstructed labour.

The three ‘Ps’ (powers, passenger and passage) are a shorthand way of describing the main causes of obstructed labour. After you have checked your answers with ours (below), re-read Section 9.2 for more detail about the causes.

Powers refers to the strength of the uterine contractions – too weak or uncoordinated and the baby is not pushed down the birth canal.
Passenger refers to the baby – if the head is too big or deformed, or if the position or presentation is wrong, the baby will not be able to pass down the birth canal.
Passage refers to the birth canal – if it is too small or deformed, or has blockages from tumours or scars, the baby will not be able to pass smoothly.

SAQ 9.2 (tests Learning Outcome 9.1)

Write down what you understand by the following terms:

a. Perinatal mortality and morbidity
b. Prolonged latent phase of labour
c. Prolonged second stage of labour
d. Malposition
a. Perinatal mortality and morbidity - fetal and newborn deaths, and disease and disability occurring around the time of the birth.
b. Prolonged latent phase of labour - when true labour lasts for more than about 8 hours without entering into the active first stage.
c. Prolonged second stage of labour - when it lasts for more than 1 hour (for multigravida mothers) and more than 2 hours (primigravida mothers).
d. Malposition - when the baby is ‘head down’ but the vertex (the top of the baby’s skull) is in the wrong position relative to the mother’s pelvis.
e. Caput - a large central swelling on the fetal skull.
f. Fistula — an abnormal opening (usually resulting from a tear) between the vagina and the urinary bladder (or the rectum or urethra or ureter).

Read Case Study 9.3 and then answer the questions that follow it.

Case Study 9.1 Tadelech’s story

Tadelech lives in Mekit Woreda. The journey from village to city can take days, and she lives far from even a health post. Tadelech is 25 years old and has already delivered two children safely in the village. This is her third pregnancy. Contractions started at 40 weeks of gestation. After two days of labour Tadelech is carried on a home-made stretcher to your health post. When you examine Tadelech, finds two swellings (masses) over the abdomen, with a depression between them at about the level of the woman’s umbilicus (belly button). You also find that the baby’s head is not engaged (it is just above the pelvic brim). On vaginal examination, you estimate that Tadelech’s cervix is 8 cm dilated and the station of the fetal head is –3. Tadelech’s vagina is hot and dry and she has oedema of the vulva.

SAQ 9.3 (tests Learning Outcomes 9.1, 9.3 and 9.4)

a. From the case study what signs do you find that indicate prolonged or obstructed labour?
b. How do you manage Tadelech’s condition?
It is clear that while Tadelech has been in the active first stage of labour for some time (dilated cervix of 8 cm), but she may actually be in a prolonged active phase of labour (when true labour lasts for more than about 8 hours without finally entering the second stage). Since you have not been monitoring her labour up to this point, you cannot be absolutely sure whether her cervix is dilating slowly, or if dilatation has completely ceased and the labour is not progressing at all.
The two swellings (masses) above and below the depression in her abdomen known as Bandl ’s ring indicate an obstructed labour.
Furthermore, at -3 the baby’s head is not engaged, and remains above the pelvic brim; this indicates that it is not descending as you would expect it to do after Tadelech has been in labour for two days.
The hot and dry vagina and oedema (swelling due to collection of fluid in the tissues) of the vulva are further signs of a potential obstruction.
Explain this calmly to her and her family.
Activate the birth preparedness plan to get her transferred to a health facility as quickly as possible, together with her birth companion.
Tadelech’s vital signs suggest she is in shock: she has a fast pulse rate and low blood pressure). Her hot and dry vagina indicates dehydration. You begin treating her for shock and dehydration by giving her an intravenous infusion (see Section 9.4) and keeping it working during the trip to the higher health facility.
If the obstruction appears partly to be caused by an overfull bladder which the woman cannot empty in the normal way, you drain this using a catheter.

SAQ 9.4 (tests Learning Outcome 9.5)

How can you reduce the risks of a prolonged and obstructed labour for women giving birth at home?

You can reduce the risks of obstructed labour by:

Teaching the importance of good childhood nutrition to ensure that girls’ pelvic bones have the best chance of developing to the normal size for safe delivery.
Promoting family planning and discouraging early marriage and especially pregnancy at less than 18 years of age.
Explaining the importance for the safety of the mother and baby of having a skilled care attendant at all deliveries.
Assisting your community in organising birth preparedness teams so that in an emergency they can get the mother to the nearest health facility as quickly as possible.
Always using a partograph to monitor the progress of labour.

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Obstructed Labour: A Preventable Tragedy but Still a Long Way to Go In Developing Countries

2015, International Journal of Health Sciences and Research

Background: Obstructed labour is a major cause of both maternal and newborn morbidity and mortality in developing countries. This study was conducted in order to determine the burden of obstructed labour in our setup so that effective measures could be taken to prevent it. Objective : To review the incidence, socio-demographic details, causes and fetomaternal outcome of obstructed labour in the Department of Obstetrics & Gynecology, UP Rural Institute of Medical Sciences & Research, Saifai, Etawah, Uttar Pradesh, India. Method: A retrospective review during the period from January 2013 to April 2015 was done and all the details of the patients admitted with the diagnosis of obstructed labour were noted. Results: Out of 12,223 deliveries reviewed, 199 or 1.63% had obstructed labor. Majority of the patients were unbooked, primigravidas, illiterate and belonged to low socio-economic status and rural area. The commonest cause of obstructed labour was cephalopelvic disproportion (72.3%)....

Related Papers

Rokeya Khatun

IJAR Indexing

Background: Obstructed labour is the condition that results from failure of descent of the fetal presenting part in the birth canal for mechanical reasons inspite of good uterine contractions. It remains an important cause of maternal and perinatal morbidity and mortality in developing countries. Materials and Methods: A hospital based cross sectional study was conducted over a period of one and a half years in which 120 cases of obstructed labour were evaluated after applying preselected inclusion and exclusion criteria. Detailed history including that of sociodemographic profile, medical history and obstetric history was taken from every patient. Maternal outcome in the form of mode of delivery and complications was noted. Fetal condition was also evaluated. Results: The study revealed that obstructed labour was common in illiterate women mostly from rural areas (87.5%) of low socioeconomic status (88.4%). Majority were primigravidas (49.2%) with mean age 30.5+3.29 . Most cases were due to cephalopelvic disproportion (62.5%). Majority were delivered by caesarean section(87.5%).The most common complication was abdominal distension(51.7%) followed by postpartum hemorrhage(37.5%).There was no maternal death. There were 108 live births(90%) out of which 8 (7.4%) died in neonatal period. Obstructed labour was a significant cause of low apgar scores at 5 minutes of birth(34.2%). Conclusion: Obstructed labour is still a great contributor of maternal and perinatal mortality in developing world. Sociodemographic and health facility factors were strongly associated with the outcome. Our aim should be universal and inexpensive good obstetric care to avoid it and prompt diagnosis and timely intervention in established cases to improve the outcome.

IOSR Journals

Introduction: Obstructed labor continues to plague thousands of women each year, accounting for about 8% of all maternal deaths in developing countries like India. It is the leading cause of hospitalization, comprising up to 39% of all obstetric patients in developing countries. Obstructed labor is the single most important cause of maternal death and is one of the three leading causes of perinatal mortality with the case fatality rate of 87%-100%. Jharkhand. All patients admitted with obstructed labour were included in the study. Detailed history regarding age, socioeconomic status, parity, previous obstetric history, past history, antenatal care, duration of labour, details of referral and management were recorded. During admission, the general condition of mother was assessed as well as fetal lie, presentation, position and heart sounds were recorded. Results: During the one year study period, there were total of 8456 deliveries of which 145 cases were diagnosed to have obstructed labour, incidence being 1.71%. Maximum cases were in age group of 19-24 years (64.4%). 86.5% of the patients were from rural areas and 78.2% of the patients were unbooked. The commonest cause of obstructed labour was cephalopelvic disproportion (55%). Other causes were Malposition (22.9%), Malpresentation (17.9%), foetal congenital abnormality (1.38%), Myomas (0.83%), others (0.83%). 4 (1.11%) cases of previous caesarean section came in advanced stage of obstructed labour and resulted in rupture uterus. Conclusion: Obstructed labour continues to be a major cause of maternal and perinatal morbidity in low income countries and accounts for approximately 8% of maternal deaths globally. The common mode of delivery is by caesarean section. Poor referral system, low socioeconomic status, inadequate antenatal care services lead to many cases of obstructed labour. They are further compounded by poor road connectivity resulting in delayed specialized care.

Annals of international medical and dental research

Journal of Shaheed Suhrawardy Medical College

Gulshan Ara

Background: Obstructed labour continues to be a major cause of maternal and perinatal morbidity in low income countries even in 21 st century. If detected and managed early, which will give a healthy mother and baby. Materials and Methods: 90 patients admitted with feature of obstructed labour were studied. Detailed history included age, antenatal checkup , sociodemographic factors, referral history, obstetric history, features of obstruction, intrapartum events were recorded. Condition of patients, mode of delivery, preoperative and postoperative complications, maternal and fetal outcomes was recorded. Results: Out of 90 cases of Obstructed labour, majority of the patients were from low (82.2%) socioeconomic group, 80% of the patients were from rural areas and 76.7% of patients were unbooked and 62.2% patients were primigravida. The commonest cause of obstructed labour was cephalopelvic disproportion (67.8%) followed by Malpresentation & Malposition (17.8%). The commonest mode of delivery was cesarean section (86%). Instrumental deliveries were conducted in 2% of cases. Destructive procedures were done in 2%. Rupture uterus was seen in 4 cases (5.7%) out of which repair was done in all 4 cases. The common maternal complications were PPH (50.0%), pyrexia (28.5%), genital tract sepsis (8.6%), shock (4.3%) and vesico-vaginal fistula (2.9%). Perinatal mortality was 4/90 (4.4%) and livebirth rate was 86/90 (95.6%). Perinatal morbidity was most commonly due to birth asphyxia (61.6%), meconium aspiration syndrome (19.2%), jaundice (15.4%) and septicemia (3.8%). Conclusion: Poor referral system, low socioeconomic status and inadequate antenatal care services lead to increased number of obstructed labour even today. Early recognition of obstructed labour and immediate safe abdominal or vaginal delivery can decrease the incidence of maternal and perinatal morbidity and mortality

International Journal of Multidisciplinary Research and Analysis

Elizabeth Nionzima

Obstructed labour is a common preventable causes of both maternal and perinatal morbidity and mortality in developing countries affecting 3-6% labouring women globally and accounts for an estimated 8% of maternal deaths in Sub-Saharan Africa and South Asia. Objective: To determine the prevalence and outcome of obstructed labour in the Gynaecology and Obstetrics Department at a tertiary hospital in Northern Uganda. Method: This was a retrospective chart review of pregnant women admitted in labour and delivered by caesarean section from 1st January 2016 to 31st December 2017 at a Lira Regional Referral Hospital, a tertiary institution in Lango Sub region. Data was analysed using Statistical Package for Social Sciences version 16.0. Results: A total of 808 medical charts of mothers with obstructed labour were retrieved, evaluated and included in this review out of 12,189 deliveries during the study period, giving a prevalence of 6.6%. Majority (77%; 622/808) mothers admitted with diagn...

Temesgen Getaneh

Background Globally, obstructed labour accounted for 22% of maternal morbidities and up to 70% of perinatal deaths. It is one of the most common preventable causes of maternal and perinatal mortality in low-income countries. However, there are limited studies on the determinants of obstructed labor in Ethiopia. Therefore, this study was conducted to assess determinants and outcomes of obstructed labor among women who gave birth in Hawassa University Hospital, Ethiopia. Methods A hospital-based case-control study design was conducted in Hawassa University Hospital among 468 women. All women who were diagnosed with obstructed labour and two consecutive controls giving birth on the same day were enrolled in this study. A pretested data extraction tool was used for data collection from the patient charts. Multivariable logistic regression was employed to identify determinants of obstructed labor. Results A total of 156 cases and 312 controls were included with an overall response rate o...

Mohamed Abdi Jimale

GREEN HOPE UNIVERSITY , Mohamed Abdi Jimale

Obstructed labour as strong uterine contractions without descending of the foetus through the pelvis due to obstruction that usually occurs at the pelvic brim, in the cavity, or at the outlet of the pelvis(Yeshitila et al., 2021). of the study will assess prevalence and characteristics of obstructed labour among pregnant women attending Banadir maternity and child hospital indicators of the study are to Assess the prevalence of obstructed labour in Banadir maternal and child hospital. to describe the characteristics of obstructed labour in Banadir maternal and child hospital. This study is descriptive, cross-sectional survey on hospital-based study to assess prevalence of obstructed labour among pregnant women attending at Banadir hospital. Methodology: A descriptive survey was chosen as it provides an accurate representation and characteristics of the obstructed labour mothers in Banadir hospital. The study will assess the Demographic characteristics (Age, Marital status, Education and Occupation) and also the study will assess factors associated obstructed labour (Cephalopelvic disproportion, Partograph, Distance, ANC Follow up(visits), Height, BMI and Three Delays Model. Finding: the results indicate that out of the total respondents,200, 96 individuals (4.80%) reported not having experienced Obstructed labour, while 104 individuals (52.0%) reported having experienced Obstructed labor. Therefore, the majority of the respondents were those who reported having experienced (Girma et al., 2022) the prevalence of OL was 51 (16%). 33(66%), malpresentation 11 (22%), and mal-position 7 (12%) were reported by the clinicians as the causes of OL.

International journal of health sciences

Nootan Dayal

Introduction: Labour is considered abnormal when the presenting part of the foetus cannot progress in to the birth canal, despite strong uterine contractions which leads to various maternal or foetal complications. Obstructed labour accounts for about 8% of all maternal deaths in developing countries like India. Obstructed labour is the single most important cause of maternal death and is one of the leading causes of perinatal mortality. Materials and methods: This prospective study of obstructed labour was conducted from September 2021 to May 2022 (9 months) in the Department of obstetrics and Gynaecology of M.G.M Medical College, Jamshedpur. All patients admitted with obstructed labour were included in the study. Detailed history regarding age, socioeconomic status, parity, previous obstetric history, past history, antenatal care, duration of labour, details of referral and management were recorded. During admission, the general condition of mother was assessed as well as fetal li...

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Risk factors for obstructed labour in Eastern Uganda: A case control study

Contributed equally to this work with: Milton W. Musaba, Grace Ndeezi, Justus K. Barageine, Andrew Weeks, Julius N. Wandabwa

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Department of Obstetrics and Gynaecology, Mbale Regional Referral and Teaching Hospital, Mbale, Uganda, Department of Obstetrics and Gynaecology, Busitema University Faculty of Health Sciences, Mbale, Uganda, Department of Paediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda

Roles Conceptualization, Funding acquisition, Investigation, Supervision, Writing – original draft, Writing – review & editing

Affiliation Department of Paediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda

Roles Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Writing – review & editing

Affiliations Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda, Africa Centre for Systematic Reviews and Knowledge Translation, Makerere University College of Health Sciences, Kampala, Uganda

Affiliation Sanyu Research Unit, University of Liverpool, University of Liverpool/Liverpool Women’s Hospital, Liverpool, England, United Kingdom

Roles Conceptualization, Funding acquisition, Investigation, Methodology, Writing – review & editing

¶ ‡ These authors also contributed equally to this work.

Affiliations Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda, Centre for Intervention Science and Maternal Child Health (CISMAC), Centre for International health, University of Bergen, Bergen, Norway

Roles Formal analysis, Software, Writing – review & editing

Affiliation School of Statistics and Planning, College of Business and Management Sciences, Makerere University, Kampala, Uganda

Roles Data curation, Formal analysis, Software, Writing – review & editing

Affiliation Africa Centre for Systematic Reviews and Knowledge Translation, Makerere University College of Health Sciences, Kampala, Uganda

Roles Conceptualization, Funding acquisition, Investigation, Methodology, Resources, Writing – review & editing

Roles Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – review & editing

Affiliation Department of Obstetrics and Gynaecology, Busitema University Faculty of Health Sciences, Mbale, Uganda

Milton W. Musaba,
Grace Ndeezi,
Justus K. Barageine,
Andrew Weeks,
Victoria Nankabirwa,
Felix Wamono,
Daniel Semakula,
James K. Tumwine,
Julius N. Wandabwa

Published: February 10, 2020
https://doi.org/10.1371/journal.pone.0228856
Peer Review
Reader Comments

Introduction

Obstructed labour (OL) is an important clinical and public health problem because of the associated maternal and perinatal morbidity and mortality. Risk factors for OL and its associated obstetric squeal are usually context specific. No epidemiological study has documented the risk factors for OL in Eastern Uganda. This study was conducted to identify the risk factors for OL in Mbale Hospital.

To identify the risk factors for OL in Mbale Regional Referral and Teaching Hospital, Eastern Uganda.

We conducted a case control study with 270 cases of women with OL and 270 controls of women without OL. We consecutively enrolled eligible cases between July 2018 and February 2019. For each case, we randomly selected one eligible control admitted in the same 24-hour period. Data was collected using face-to-face interviews and a review of patient notes. Logistic regression was used to identify the risk factors for OL.

The risk factors for OL were, being a referral from a lower health facility (AOR 6.80, 95% CI: 4.20–11.00), prime parity (AOR 2.15 95% CI: 1.26–3.66) and use of herbal medicines in active labour (AOR 2.72 95% CI: 1.49–4.96). Married participants (AOR 0.59 95% CI: 0.35–0.97) with a delivery plan (AOR 0.56 95% CI: 0.35–0.90) and educated partners (AOR 0.57 95% CI: 0.33–0.98) were less likely to have OL. In the adjusted analysis, there was no association between four or more ANC visits and OL, adjusted odds ratio [(AOR) 0.96 95% CI: 0.57–1.63)].

Conclusions

Prime parity, use of herbal medicines in labour and being a referral from a lower health facility were identified as risk factors. Being married with a delivery plan and an educated partner were protective of OL. Increased frequency of ANC attendance was not protective against obstructed labour.

Citation: Musaba MW, Ndeezi G, Barageine JK, Weeks A, Nankabirwa V, Wamono F, et al. (2020) Risk factors for obstructed labour in Eastern Uganda: A case control study. PLoS ONE 15(2): e0228856. https://doi.org/10.1371/journal.pone.0228856

Editor: Calistus Wilunda, African Population and Health Research Center, KENYA

Received: November 20, 2019; Accepted: January 23, 2020; Published: February 10, 2020

Copyright: © 2020 Musaba et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: Survival Pluss Project at Makerere University. Funded by NORHED under NORAD. UGA-13-0030, Prof. James K. Tumwine. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Obstructed labour (OL) occurs when the foetal presenting part fails to descend despite adequate uterine contractions[ 1 ]. The global prevalence varies from 2–8%, being highest in low resource settings and almost none existent in high resource settings[ 1 , 2 ]. In Uganda, 8% of all maternal deaths (MDs) and 90% of perinatal deaths due to birth asphyxia are directly attributed to OL[ 3 ]. Almost three quarters of the MDs due to primary postpartum haemorrhage(PPH) and sepsis have OL as an underlying cause[ 4 , 5 ]. Limited or no access to quality emergency obstetric care services in low resource settings contributes to the high number of adverse obstetric outcomes[ 6 ].

Prevention of OL requires a multidisciplinary approach aimed in the short term at identifying high risk cases. In the long term,improving incomes at the level of the household would promote access to better nutrition, education and healthcare for the girl child [ 1 , 7 ]. Current evidence shows that access to skilled care during pregnancy and childbirth can mitigate adverse maternal and perinatal outcomes associated with OL[ 8 ]. In this regard, risk profiling during antenatal care (ANC) and intrapartum maternal fetal surveillance using a partogram are key interventions for early detection and management.

In Uganda, the utilisation of maternity services has improved with more than 90% for the first ANC visit, 60% for at least four ANC visits and facility births are at 73%[ 9 ]. Unfortunately, these improvements have not translated into a significant reduction in morbidity and mortality[ 9 ]. In addition, the known risk factors for OL have a poor predictive value that makes primary prevention difficult[ 10 – 12 ]. Parity, place of residence and age were significantly associated with OL after a review of patient records in six health facilities of western Uganda [ 2 ]. In Mbale Hospital, anecdotal evidence suggests that OL is the most common indication for primary emergency caesarean section and a cause of significant morbidity and mortality. The risk factors for OL and its associated obstetric sequel are usually context specific[ 13 ]. Currently, no epidemiological study has documented the risk factors for OL in Eastern Uganda. This study identified the risk factors for OL in Mbale Regional Referral and Teaching Hospital, Eastern Uganda. We hypothesised that increased frequency of ANC attendance (<4 versus ≥ 4 visits) was protective of OL.

Materials and methods

Study setting.

We conducted this study in the labour suite of Mbale regional referral Hospital in Eastern Uganda. This hospital, serves 14 districts in the Elgon zone with an estimated population of 4 million people. This is a government run, not-for-profit, charge-free, 470-bed hospital with 52 maternity beds. Annually, about 12,000 childbirths occur in this hospital with a caesarean section rate of 35% and nearly 500 mothers have OL. About two thirds of these mothers with OL are referrals in active labour from the lower health units.

Study design

Unmatched case control design with incidence density sampling of the controls admitted in the same delivery suite.

Study population

All patients admitted to the labour suite in active labour at term (≥ 37 weeks of gestation) were screened. A Medical Officer or Obstetrician diagnosed OL using the American College of Obstetricians and Gynecologists (ACOG) guideline for arrest of labour [ 14 ] and local protocols. A case was defined as; a cervical dilatation ≥ 6cm with ruptured membranes, having adequate contractions lasting > 4hrs with no change in cervical dilatation in the first stage of labour. For the second active stage of labour, arrest was defined as a delay of > 2 hours for the nullipara and > 1 hour for the multipara with adequate uterine contractions. In addition, a case had to have any two of the following obvious signs of severe obstruction: caput formation, Bandl’s ring, sub-conjunctival hemorrhages and edematous vulva.

Controls were women admitted to the labour suit within the same 24-hour period in active labour without obstruction.

Sample size and sampling

We used the formula described by Fleiss with a continuity correction to estimate the sample size[ 15 ]. The exposure factor was the proportion of pregnant women who attended < 4 ANC visits. We enrolled 270 cases and 270 controls based on the following assumptions: two-sided 95% confidence level, power of 95%, ratio 1:1 to detect an odds ratio of at least 2 for the risk of OL among pregnant women who attended < 4 ANC visits as the main exposure variable[ 16 – 18 ]. We further assumed that controls were like any other pregnant woman in Uganda who attended at least 4 ANC visits (60%) according to the Uganda demographic and health survey [ 9 ].

We consecutively enrolled all eligible incident cases between July 2018 and February 2019. We used simple random sampling to select one control from a list of admissions in active labour immediately after enrolling each case. Before recruitment, all respondents gave us written informed consent and pregnant adolescents below the legal age of 18 years were taken as emancipated minors[ 19 ]. We used unique study numbers issued at enrolment to identify each respondent.

Inclusion criteria

Cases were women with OL carrying singleton, term pregnancies in cephalic presentation. Controls were women in active labour without obstruction carrying singleton, term pregnancies in cephalic presentation.

Exclusion criteria

We excluded women with other obstetric emergencies such as antepartum haemorrhage, Pre-eclampsia and eclampsia (defined as elevated blood pressure of at least 140/90 mmHg, urine protein of at least 2+, any of the danger signs and fits), premature rupture of membranes and intrauterine fetal death. We also excluded all women from outside the Hospital catchment area of 14 districts as either cases or controls.

Study variables

The socio-demographic factors highlighted in the literature to predispose women to OL were the participant’s age, marital status, occupation, level of education, the occupation and education level of the spouse as well as distance to the nearest health facility and the place of residence[ 10 , 12 , 17 , 20 , 21 ]. The obstetric factors were gravidity, number of ANC visits, having a delivery plan in place, a history of being referred from a lower health facility and use of herbal medications during labour[ 16 , 17 ]. Physical examination included the respondent’s height and fetal birth weight. Our main exposure was the number of ANC visits attended as indicated on the ANC card, the other covariates were considered as confounders.

Data collection

We used an interviewer-administered questionnaire running on an open data kit (ODK) platform. Trained research assistants (RA’s) who are qualified midwives administered the questionnaire to all participants in the local dialect. We blinded all the RA’s to the hypothesis of the study. Available records such as the antenatal cards, facility registers and case report files were reviewed by the RA’s to crosscheck some of the verbal responses. The principal investigator (PI) would, on a daily basis access and review the data from the Google Aggregate server for completeness.

Data management

The data was uploaded to a password protected server to which only the PI or his designee had access. Assisted by a statistician, the data was downloaded into an excel spreadsheet and exported to Stata version 14 for further cleaning and analysis.

Data analysis

Baseline socio-demographic, physical and obstetric characteristics of the cases and controls were compared, to identify any differences. Normality of the continuous variables was tested for using the Shapiro-Wilk test. We summarised continuous variables using means and standard deviations. Whereas frequencies and percentages were used for the categorical variables. We used logistic regression (LR) to estimate Odds ratios, and 95% confidence intervals to examine the association between the number of ANC visits (< 4 Vs ≥ 4) and the different socio-demographic, physical and obstetric covariates in bivariable and multivariable analysis. We included all factors that are known to confound the relationship between the frequency of ANC attendance and OL in the multivariable LR model, based on biological plausibility. In order to control for potential residual confounding due to factors that we had not previously hypothesized to be confounders, we also included those variables for which bivariable analysis returned a p-value equal to or less than 0.25. We reasoned that a cut-off of 0.25 would allow us to test the effect of any factors previously not known to have a confounding effect on the relationship between OL and the frequency of ANC attendance, without including those factors that were reasonably least likely [ 22 ]. Multicollinearity between explanatory variables was assessed using the variance inflation factor (VIFs), and they were all less than 1.5.

In the final adjusted multivariable model, we included all the statistically significant covariates (being a referral, a history of using herbal medicines, having a delivery plan, prime parity and partner education level). Confounding was considered present, if the difference between the crude and adjusted OR was ≥ 10 percentage points[ 23 , 24 ].

Ethical considerations

The Makerere University School of Medicine Research and Ethics Committee (#REC REF 2017–103) and the Uganda National Council for Science and Technology (HS217ES) approved the protocol. The Mbale Hospital Research and Ethics Committee (MRRH-REC IN-COM 00/2018) gave us administrative clearance. The hospital protocols were followed in management emergencies during the study.

Characteristics of the study population

The respondents were generally young with a mean age of 24.5± 6 years, of average stature with a mean height of 160±8.2 cm and gave birth to babies of normal birth weight with a mean of 3.3± 0.4 Kg. Almost all (99%) respondents attended at least one ANC visit, mostly (96%) in public health facilities. Two-thirds (68%) of the respondents had no delivery plan in place. Majority of respondents resided in rural areas (84%) with no formal employment (89%) and almost one-half (44%) had used herbal medications during labour. The cases were younger (mean age 23.5±5.9 Vs 25.4±5.9), P-value <0.001 and shorter (159±8.2 Vs 161.4±7.4), P-value 0.011 than the controls ( Table 1 ).

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https://doi.org/10.1371/journal.pone.0228856.t001

Factors associated with OL

Maternal age, height, marital status, level of education, occupation and place of residence as well as the spouse’s level of education and occupation were associated with OL. Obstetric factors such as prime parity, presence of an abnormal fetal heart rate, use of herbal medications in labour and history of being referred were associated with OL.

The odds of obstructed labour among referred women were 10 [crude odds ratio (COR) 9.69: 95% CI 5.79–16.21)] times the odds of obstructed labour among the women not referred. We found no association between OL and the number of ANC visits (COR 1.01, 95% CI: 0.73–1.41). The fetal birth weight among cases was 3.30±0.45 and 3.36±0.41 among controls and was not associated with OL. The odds of obstructed labour among married women was 0.6 times (COR 0.59 (0.35–0.97) the odds of obstructed labour among unmarried women ( Table 2 ).

https://doi.org/10.1371/journal.pone.0228856.t002

After adjusting for confounding ( Table 3 ), these factors were independently associated with OL: having a partner with post primary education (AOR 0.57 95% CI: 0.33–0.98), being a referral from a lower health facility (AOR 6.80, 95% CI: 4.20–11.00), prime parity (AOR 2.15 95% CI: 1.26–3.66), use of herbal medicines in labour (AOR 2.43 95% CI: 1.50–3.64), having a delivery plan (AOR 0.56 95% CI: 0.35–0.90) and a fetal heart rate < 120 beats per minute (AOR 10.78 95% CI: 1.21–96.11).

https://doi.org/10.1371/journal.pone.0228856.t003

We conducted a case control study using incidence density sampling to identify risk factors for OL in Mbale Hospital. We found that increased frequency of ANC attendance (< 4 Vs ≥ 4 ANC visits) was not protective against OL, contrary to our postulation. The risk factors for obstructed labour were prime parity, use of herbal medicines in labour, being a referral from a lower health facility, as well as having a low fetal heart rate (<120 beats per minute) at enrolment. Having a delivery plan in place, an educated male partner and being married were protective of OL.

In this study, almost all the participants attended at least one ANC visit, which made the cases and controls similar on this particular characteristic. For instance, 43.3% of the cases and 43.5% of the controls attended four or more ANC visits. Despite this high level of utilisation of ANC services in mostly government public health facilities, being a referral from a lower health facility in active labour was independently associated with OL, implying that the quality of care at the lower health facilities may be substandard[ 25 ]. This could be attributed to the existing mismatch between the low staffing levels and high patient turnover that is common at public health facilities in Uganda[ 25 , 26 ]. Therefore, it is not surprising that OL was not associated with the frequency of ANC attendance in the current study. In a case control study among obstetric fistula patients in western Uganda, Barageine et al found no association between ANC attendance and obstetric fistula (a direct consequence of prolonged OL) [ 13 ]. On the contrary, several descriptive studies done in Nigeria and Ethiopia have found none utilisation of ANC services to be associated with OL[ 27 , 28 ]. It is likely that the effect of increased frequency ANC on OL is small and therefore another study with lager sample to study the effect of timing and number of individual ANC visits on OL, since it is known that frequent ANC visits especially in the last trimester prevents adverse obstetric outcomes[ 29 ]. The occurrence of OL and its squeal is influenced by delays due to a none functional referral system such as duration of labour before arrival to a health facility and taking > 4 hours to travel to a health facility for care [ 12 , 30 , 31 ]. The current study did not investigate the delays associated with OL, which was a limitation. Nonetheless, our finding of the odds of obstructed labour among referred women being seven times the odds of obstructed labour among non-referred has important implications because OL is an emergency that needs to be relieved in its early stages to prevent the associated morbidity and mortality. For public health, it may be a pointer to the lack of capacity to manage abnormal labour at district level hospitals and county level health centre IV’s to offer emergency obstetric services closer to the community as it was envisioned in the governments’ decentralisation plan[ 32 ]. Most of the patients were sent without clear documentation and specific diagnosis of obstructed labour. Sixty percent of the women with OL had used herbal medications in labour compared to 29% of the controls. Very often, when labour is not progressing well there is a high tendency to use local herbs in an attempt to quicken the process[ 33 , 34 ]. Referral to larger health facility is usually a last resort when everything else has failed[ 35 ]. So, it is not surprising that the odds of OL were two times higher among women with a positive history of having used herbal medications compared to those with a negative history.

The odds of obstructed labour were two times higher among the prime paras compared to the multiparous women in our study. Several studies have reported similar findings [ 2 , 12 , 36 ]. In our setting, many first time mothers are also young and it is possible that a link exists between prime parity and maternal age[ 2 , 11 , 12 ]. Although the current study was not powered to study this relationship, we know that young girls are prone to OL because they have an under developed pelvic cavity [ 2 , 13 , 37 ]. In addition, they have limited access to quality maternity services due to social and economic disadvantages and the fact that they usually conceive outside formal marriage. A prospective study involving only teenagers or prime paras would be necessary to resolve this contradiction.

Contrary to findings from similar low resource settings, the participants height, education level, occupation, distance to the nearest health facility with emergency obstetric care services and the occupation of the spouse were not identified as risk factors for OL [ 2 , 10 – 13 , 36 ]. Although, having an educated spouse (at least post primary level) and a delivery plan in place was protective of OL. Our findings are in agreement with the thinking that the known risk factors for OL have a poor predictive value, which makes primary prevention difficult[ 2 , 10 , 12 , 36 ]. This underscores the importance of having each child birth supervised by a skilled birth attendant. Although, the discrepancy might also be because we adopted an analytical approach to identify independent risk factors, while the earlier studies were mostly descriptive in nature to identify associated factors.

Fetal size was not a risk factor for OL. It is known that carrying a big baby (> 4kg) is a risk factor for OL because it increases the likelihood of cephalopelvic disproportion which is a common cause of OL [ 12 , 13 ]. In this study, the mean fetal birth weight was 3.33 kg and there was no significant difference between cases and controls on this characteristic. Ndibazza et al reported a mean fetal birth weight of 3.17 kg among 2,507 pregnant women recruited in a clinical trial in central Uganda [ 25 ], which is similar to our findings. In addition, most of the participants in this study were small with a mean body weight of 62 kg and no significant differences between cases and controls.

Post hoc power calculations suggest that our study may have been underpowered to detect a clinically important difference between the frequency of antenatal care visits (< 4 Vs ≥ 4 ANC visits) and OL even if the difference had been there ( S1 File ). For now, our results need to be interpreted with caution until they are validated by larger studies powered to detect small differences. However, conducting post hoc power calculations of this type may not be helpful as this can easily be seen from the confidence intervals that show an imprecise estimate and there is a huge body of statistical evidence that calculating a post hoc power is logically flawed ( S3 File ).

Methodological considerations

In this study, we used incidence density sampling to identify controls. This strategy helped us to minimise selection bias but we could not assess the effect of time/ duration that has been highlighted as a risk factor in several other studies[ 12 ].

The RA’s were well trained and blinded to the main hypothesis of the study to minimise information bias arising from paying more attention to the cases during the interviews. We triangulated the sources of information by supplementing the verbal responses with a review of the participant’s case notes.

In this hospital-based study, most of the patients were referrals so the findings might not be a true representation of the picture in the Elgon sub-region. It would be interesting to compare the referred cases with controls selected from the same referring health facility, which was beyond the scope of this study. These results may be generalizable to other regional referral hospitals in Uganda because the health care delivery system is uniformly organised across the country.

Prime parity, being a referral and history of using herbal medicines in labour were identified as risk factors for OL. On the other hand, having a delivery plan in place and an educated partner (at least post primary level) were found to be protective of OL. We found no association between the frequency of ANC attendance and the risk of OL.

Supporting information

S1 file. post hoc power calculations..

https://doi.org/10.1371/journal.pone.0228856.s001

S2 File. Dataset RFOLMUK.

The data set is in Stata format 14 and includes all variables analysed for this manuscript.

https://doi.org/10.1371/journal.pone.0228856.s002

S3 File. Post hoc power calculations rebuttal.

https://doi.org/10.1371/journal.pone.0228856.s003

Acknowledgments

We thank the study participants for accepting to be part of the study and the research midwives for working tirelessly to accomplish this task namely Ms. Auma Prosscovia, Ms. Nandutu Sarah Waterah, Mrs. Atim Ketty Ojwar, Ms. Alibo Elizabeth, Ms. Sarah Talyewoya and Ms. Jessica Muduwa.

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Supreme Court Imperils an Array of Federal Rules

A foundational 1984 decision required courts to defer to agencies’ reasonable interpretations of ambiguous statutes, underpinning regulations on health care, safety and the environment.

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Adam Liptak

Reporting on the Supreme Court since 2008

The decision is the latest upending longstanding precedents.

The Supreme Court swept aside a longstanding legal precedent on Friday, reducing the power of executive agencies and endangering countless regulations by transferring power from the executive branch to Congress and the courts. Chief Justice John G. Roberts Jr., writing for the majority, said that “agencies have no special competence” and that judges should determine the meaning of federal laws.

The precedent, Chevron v. Natural Resources Defense Council , is one of the most cited in American law, underpinning 70 Supreme Court decisions and roughly 17,000 in the lower courts. Critics of regulatory authority immediately hailed the decision, suggesting it could open new avenues to challenge federal rules in areas ranging from abortion pills to the environment.

The court has now overturned major precedents in each of the last three terms: on abortion in 2022, on affirmative action in 2023 and now on the power of administrative agencies. In a dissenting opinion, Justice Elena Kagan said the ruling amounted to the Supreme Court’s latest judicial power grab. “A rule of judicial humility,” she wrote, “gives way to a rule of judicial hubris.”

Here’s what else to know:

What is Chevron deference? It is the principle from the Supreme Court’s 1984 ruling that gave regulatory agencies leeway to interpret laws that Congress had left vague. When Congress passes a law, it cannot anticipate all the ways that the economy, the nation and the world will change. If regulators had only the powers that Congress explicitly gave them, many regulations would be vulnerable to legal challenges. The ruling could have broad implications for the regulation of food and drugs , the banking and financial sector , taxation , as well as conservative activists’ targeting of medication abortion and rights for transgender people .

A major goal of the conservative legal movement: Friday’s ruling undoes a precedent that empowered executive branch agencies, which many conservatives have come to believe are dominated by liberals under both parties’ administrations — a critique often described as “the deep state.” Elizabeth Murrill, the Republican attorney general of Louisiana who has taken a leading role in lawsuits against the Biden administration’s environmental regulations, said Chevron deference had been “wildly abused by this administration more than any other.” Read about conservatives’ view of the precedent.

The White House reaction: Karine Jean-Pierre, the White House press secretary, said Friday’s decision was the latest example of the Supreme Court siding with Republican-backed special interests to block “common-sense rules that keep us safe, protect our health and environment, safeguard our financial system, and support American consumers and workers.”

Supporters of regulatory oversight criticized the decision: Critics of the decision said it would empower the courts, not Congress, to dictate policy. “Getting rid of Chevron deference says, you know what? The courts will be the decider of how to interpret these laws instead of experts who are knowledgeable in the field,” said Senator Jeff Merkley, Democrat of Oregon, who sits on the Senate Environment and Public Works Committee.

The case started with fishermen: The court heard two almost identical cases, Loper Bright Enterprises v. Raimondo, and Relentless v. Department of Commerce. Both cases involved a 1976 federal law that requires herring boats to carry federal observers to collect data used to prevent overfishing.

Under a 2020 regulation interpreting the law, owners of the boats were required not only to transport the observers but also to pay $700 a day for their oversight. Fishermen in New Jersey and Rhode Island — backed by two conservative organizations that decry the “administrative state” — sued, saying the 1976 law did not authorize the relevant agency, the National Marine Fisheries Service, to impose the fee.

Charlie Savage

The decision is the latest blow to regulatory agencies.

Overturning the Chevron deference precedent is just the latest in a series of ringing blows the Supreme Court’s Republican-appointed conservative bloc has delivered to the ability of regulatory agencies to impose rules on powerful business interests, advancing a longstanding goal of the conservative legal movement and the donors who have funded its rise .

Just yesterday, the majority struck down the ability of agencies to enforce their rules via in-house tribunals before technical-expert administrative judges. Instead, it ruled, agencies must sue accused malefactors in federal court before juries.

Advancing and entrenching that idea, the court has struck down an E.P.A. rule aimed at limiting carbon pollution from power plants , and barred the Occupational Safety and Health Administration from telling large employers they must either have their workers vaccinated against the Covid-19 virus or have them undergo frequent testing.

And in a 2020 ruling , the five Republican appointees then on the Supreme Court struck down a provision of the law Congress enacted to create the Consumer Financial Protection Bureau that had protected its head from being fired by a president without a good cause, like misconduct.

Karine Jean-Pierre, the White House press secretary, said Friday’s decision was the latest example of the Supreme Court blocking “common-sense rules that keep us safe, protect our health and environment, safeguard our financial system, and support American consumers and workers.”

The court has not always gone as far as libertarians wanted, however. Earlier this term, the court rejected a challenge to the way the Consumer Financial Protection Bureau is funded. Striking it down would have opened the door to lawsuits to nullify every regulation and enforcement action it has taken in its 13 years of existence, including ones concerning mortgages, credit cards, consumer loans and banking.

While overturning Chevron is now the capstone victory for the conservative legal movement’s assault on the administrative state, it may not be the end of the story. More extreme opponents of regulation hope the court will someday embrace a sweeping version of the so-called nondelegation doctrine.

Under that vision, the Constitution does not allow Congress to delegate any of its legislative authority to executive branch agencies. If so, all regulations should be struck down because the only way society can impose a legally binding rule on business interests is if Congress manages to specifically enact one via statute.

Read the Court’s Decision to Overrule the Chevron Doctrine

The ruling sweeps aside a legal precedent that required courts to defer to the expertise of federal administrators in carrying out laws passed by Congress.

Deborah B. Solomon

Karine Jean-Pierre, the White House press secretary, called the Supreme Court’s ruling “another deeply troubling decision that takes our country backwards” and the latest decision by the court to side with Republican-backed special interests and block commonsense rules on health, the enviroment and worker protection.

She said in a statement that President Biden had directed his legal team to work with the Justice Department and other lawyers “to review today’s decision carefully and ensure that our administration is doing everything we can to continue to deploy the extraordinary expertise of the federal workforce to keep Americans safe and ensure communities thrive and prosper.”

Coral Davenport

The Chevron decision is the latest major blow in a yearslong coordinated strategy to weaken the authority of what conservative activists call the “administrative state.” One big step came two years ago, with the Supreme Court decision in West Virginia vs. E.P.A., sharply curtailing the agency’s authority to regulate climate-warming pollution from power plants. That ruling essentially told regulators to stay in their lane and not attempt broader interpretations of the law.

The Chevron decision advances that precedent, essentially applying it to all regulations, large and small. Together, experts say that the two rulings could mean that more government regulations are struck down or scaled back by the courts, and that government agencies could be more timid or restrained in writing new rules.

Christina Jewett

Utah geared up for a fight in anticipation of the court’s ruling.

The possibility of new limits on the regulatory power of the federal government had already spurred one state to identify regulations ripe for a challenge.

A law passed in Utah directs agriculture and environmental agencies to identify federal rules carried out in the state that might be vulnerable under a ruling that limits the Chevron precedent. The analyses are due at the start of 2025 and the law says the state attorney general will issue his own report by midyear to declare his plans for possible lawsuits.

Sean D. Reyes, the Utah attorney general, has made well known his distaste for the Chevron precedent, which gives federal agencies leeway to interpret laws that Congress left vague. In a news release, he called the standard “one of the greatest threats to individual liberty.”

“For far too long, it has been wielded by big government proponents, unaccountable federal bureaucrats, and activist courts to destroy the freedoms of hard-working Americans and rob local control from our states,” he said in a statement in August.

Mr. Reyes signed on with about two dozen other Republican attorneys general to a friend-of-the-court brief decrying the onus on small businesses, the vast costs and the volume of regulations, which they said vastly outpace the number of laws passed by Congress, though that has been on a downward trend for decades.

Utah is not entirely alone in its war room crouch, said Gary Feldon, an attorney with Hollingsworth who noted Utah’s work in a recent article anticipating the ruling.

“I don’t know that anybody is doing it quite as systemically as the state of Utah seems to be, but industry and businesses are certainly aware that we are on the edge of a major shift,” Mr. Feldon said. “And the savvy among them are making sure that they’re in position to take advantage of it now.”

In addition to cutting back on the power of executive agencies, the Supreme Court on Friday issued decisions in two other closely watched cases: upholding a city’s laws aimed at banning homeless residents from sleeping outdoors and ruling that federal prosecutors had overstepped in using an obstruction law to prosecute a Jan. 6 rioter .

Teddy Rosenbluth and Roni Caryn Rabin

The ruling is likely to stymie public health initiatives, experts said.

The Supreme Court decision overturning the so-called Chevron doctrine is likely to hamstring the federal government’s public health efforts and invite waves of litigation from parties opposed to regulations aimed at safeguarding Americans, scientific and legal experts said.

By gutting federal agencies’ power to interpret ambiguous laws and fill in gaps in statutes, forcing them instead to defer to protracted judicial or legislative processes, the ruling also could prevent regulators from acting quickly and creatively in the face of a catastrophic emergency, such as climate change or another deadly pandemic.

“We anticipate that today’s ruling will cause significant disruption to publicly funded health insurance programs, to the stability of this country’s health care and food and drug review systems, and to the health and well-being of the patients and consumers we serve,” several of the nation’s largest health organizations, including the American Public Health Association and the American Cancer Society, said in a joint statement on Friday.

Federal officials will feel a “chilling effect” that will slow regulations in areas in which they do not have explicit authority, said Dr. Reshma Ramachandran, co-director of the Yale Collaboration for Regulatory Rigor, Integrity and Transparency, an initiative that studies medical product evaluations and coverage in order to improve patient outcomes.

Instead of hiring more scientific and technological experts, federal agencies will have to arm themselves with lawyers, she predicted.

Zachary L. Baron, director of the Health Policy and the Law Initiative at the O’Neill Institute at Georgetown Law in Washington, said one result of the ruling “is likely to be an increase in litigation and an increase in uncertainty.”

“It seems like, as Justice Kagan wrote in her dissent, the court is flipping the script today, giving more authority to courts and judges and less authority to federal agencies and the expertise that they have,” Mr. Baron said.

Today’s ruling is one in a string of court decisions in recent years in which the court has given itself “more and more power over every significant policy dispute, and closing the door on agency experts that have been working on these issues for years,” he said.

Indeed, Justice Elena Kagan’s dissent offered an example of the type of detailed scientific question judges may now face in court: When does an alpha amino acid polymer qualify as a protein?

“I don’t know many judges who would feel confident resolving that issue,” she wrote. “(First question: What even is an alpha amino acid polymer?)”

The Food and Drug Administration, she added, has scores of experts who could “collaborate with each other on its finer points, and arrive at a sensible answer.”

The Chevron doctrine has its roots in public health: a 1984 Supreme Court case involving air pollution. At issue was the Environmental Protection Agency’s interpretation of an ambiguous provision in the Clean Air Act that affected companies subject to pollution controls.

The court determined that federal agencies should receive “deference” for reasonable interpretations of gaps or ambiguities in the statutes that Congress could not have anticipated when it crafted the laws.

The court gave federal agencies leeway because of their subject matter and scientific expertise, experience and political accountability.

Now that this authority has been curtailed, public health agencies simply may regulate less, a goal long sought by proponents of a smaller federal government and companies eager to pursue unfettered growth.

“If agencies know that everything they do that is not perfectly aligned with a statute will be scrutinized by the court, they will be less likely to promulgate expansive rules or swift rules,” said Selina Coleman, a health care partner at Reed Smith, a large law firm.

Other experts also predicted an explosion in litigation and uncertainty. The ruling will “signal to industry and aggressive state attorneys general to open the floodgates to more litigation to block federal regulatory efforts,” Mr. Baron said.

Moving public health decisions from federal agencies to Congress and the courts will lead to “incoherence, chaos and endless litigation,” said Paul Billings, national senior vice president of public policy at the American Lung Association.

The Supreme Court and lower courts have already chipped away at the authority of regulatory bodies to make public health decisions. Many such rulings were handed down during the coronavirus pandemic.

In November 2021, the Supreme Court upheld an injunction that barred the Centers for Disease Control and Prevention from enforcing a national moratorium on evictions from rental housing, despite fears that a wave of such displacements would exacerbate the spread of Covid-19.

In January 2022, the Supreme Court ruled that the Occupational Safety and Health Administration could not require large businesses to vaccinate their employees against Covid. In April 2022, a federal judge in Florida struck down a C.D.C. mandate that required passengers to wear masks on public buses, trains and planes.

Today’s Supreme Court decision will task Congress with spelling out exactly what agencies like the C.D.C. can and cannot do, several observers said. “Nobody has any confidence that Congress can get its act together to do that,” said Dr. Georges C. Benjamin, executive director of the American Public Health Association.

“I think the decision as written solidifies employment for lawyers and judges, and undermines the authority of experts,” he added.

Other scientists also expressed doubt that Congress or the judiciary could remain abreast of constantly evolving scientific evidence. “To keep up with that pace of change, even for a medical or scientific professional, is very challenging,” said Karen Knudsen, chief executive of the American Cancer Society.

Consumer advocates are calling the decision a travesty that could upend the rules and regulations Americans depend upon for their safety.

“It’s going to affect everything from airbags in peoples’ cars to the quality of the food they feed their families and the water they drink,” said Stephen Hall, legal director of Better Markets, which pushes for tougher regulation. “This decision threatens to return the United States to the 1910s when the government had very limited ability to protect the health, safety, and welfare of America.”

Alan Rappeport

The ruling could undermine the Treasury Department and the I.R.S.

The Supreme Court’s knockdown of Chevron deference could complicate the ability of the Treasury Department and the Internal Revenue Service to craft federal regulations that are central to President Biden’s economic agenda.

The Treasury Department is responsible for implementing major pieces of legislation such as the Inflation Reduction Act, including determining who qualifies for billions of dollars worth of tax credits. At the same time, the I.R.S. has vast leeway to administer the tax code. The agency has faced criticism recently for its decision to halt some pandemic relief tax credits to businesses because of concerns about fraud and delaying collection of new taxes on digital wallet transactions.

“Taxpayers are likely to challenge the validity of dozens of tax regulations and those challenges are much more likely to prevail,” said Robert J. Kovacev, a lawyer at the firm Miller & Chevalier who specializes in tax litigation and represents businesses engaged in disputes with the tax agency. “For years the I.R.S. has issued regulations expanding its power and restricting tax benefits that Congress intended taxpayers to receive.”

The ruling will also present new challenges as the Biden administration rolls out its alternative energy credit regulations, Mr. Kovacev said, because the I.R.S. will not be able to take for granted that courts will defer to its regulations.

The Tax Policy Center said in an analysis last fall that such a Supreme Court decision would make it harder for an agency such as the I.R.S. to write rules to address industries that are quickly evolving, such as cryptocurrencies, and that it would be more difficult to fill in the gaps for Congress when lawmakers rush to write tax legislation.

Critics of the tax agency said on Friday expressed optimism the ruling would limit its powers.

“Today’s decision will level the playing field for taxpayers and government agencies,” said Joe Bishop-Henchman, executive vice president at the National Taxpayers Union Foundation. “Unreasonable I.R.S. interpretations will no longer automatically win in court, which is as it should be, and reasonable interpretations will still have the force of law.”

Treasury Department and the I.R.S. did not immediately have a comment.

Former top Trump officials are gloating about the overturning of the Chevron doctrine. Mandy Gunasekara, who served as chief of staff at the E.P.A. during the Trump administration and has helped write Project 2025 , a policy blueprint for a next Republican administration, wrote on the social media site X, that the era of “trust the experts” had ended. She called it a “great day for our constitutional integrity and the American people.”

Chris Cameron

House Republican leadership praised the Supreme Court ending the Chevron doctrine. “House Republican committees will be conducting oversight to ensure agencies follow the Court’s ruling,” Speaker Mike Johnson wrote in a joint statement with Representatives Steve Scalise and Tom Emmer.

Elizabeth Dias

Conservative Christian activists see Chevron as major win to push their causes.

Conservative Christian activists and lawyers are celebrating the Chevron decision as a significant win for their ambitions to target medication abortion and rights for transgender people.

Anti-abortion activists see the ruling as a critical tool to fight the Food and Drug Administration, especially after the court rejected their bid to undo the F.D.A.’s approval of a medication abortion drug earlier in June. “Getting rid of Chevron is the first domino to fall,” Kristi Hamrick, a strategist for Students for Life, said in a statement.

They see the decision as a new precedent as they seek to bring a future case against the F.D.A. to the Supreme Court. Ms. Hamrick said such a case was likely to get a better reception “when the F.D.A. is no longer given the benefit of the doubt.”

The Alliance Defending Freedom, the conservative Christian legal advocacy group that argued against the F.D.A.’s approval of the abortion pill and lost, also praised the ruling.

Federal agencies “frequently disrespect Americans’ most cherished principles — including religious freedom and the sanctity of life,” said Julie Marie Blake, senior counsel at A.D.F. “Now, the court has wiped away a major roadblock that prevented Americans from holding government officials accountable.”

A.D.F. had filed an amicus brief in the case on behalf of Christian Employers Alliance, a group that defends freedoms for Christian businesses. The brief criticized a range of federal agencies, including the Department of Education and Health and Human Services, for what it said was the agencies’ efforts on “ending women’s sports” to imposing “radical gender ideology” to “forcing employers to pay for puberty blockers, cross-sex hormones and amputating healthy organs.”

Now, the brief’s argument looks like a road map for what lawyers may want to pursue with Chevron gone.

Business groups are cheering the Chevron decision. The National Federation of Independent Business, which represents small businesses, said the Supreme Court’s ruling will allow companies “to breathe a sigh of relief.”

“For 40 years, Chevron deference has allowed administrative agencies to enact regulations with little accountability,” Beth Milito, Executive Director of NFIB’s Small Business Legal Center, said in a statement. “Abandoning Chevron will hold agencies accountable and level the playing field in court cases between small businesses and administrative agencies.”

Democrats, anticipating Chevron’s demise, gave E.P.A. more power in recent climate law.

The Biden administration has been preparing for the overturn of Chevron, knowing that conservative activists have pushed cases like this, and that the majority of justices on the Supreme Court were expected to look favorably on it.

That’s why two years ago the White House worked with congressional Democrats to squeeze through legislation that could help protect the Environmental Protection Agency’s authority to craft climate change regulations, even if the Chevron doctrine was struck down.

Climate change rules could be particularly vulnerable to legal attack in a post- Chevron world. That’s because the E.P.A. wrote them under the authority of the 1970 Clean Air Act, a sweeping law that directs the agency to regulate all pollutants that endanger human health.

But the legislators of 1970 did not specify anywhere in the law that carbon dioxide emissions, the chief cause of climate change, should be regulated. It doesn’t even mention climate change.

Democrats changed that in the 2022 Inflation Reduction Act, a law chiefly focused on spending billions of dollars on clean energy technology to fight climate change. But the law amends the Clean Air Act to define the carbon dioxide produced by the burning of fossil fuels as an “air pollutant.”

That language, according to legal experts as well as the Democrats who worked it into the legislation, explicitly gives the E.P.A. the authority to regulate greenhouse gases and to use its power to push the adoption of wind, solar and other renewable energy sources.

The specificity of that legal language should protect E.P.A.’s authority to regulate carbon dioxide pollution by limiting their emission from tailpipes and smokestacks.

However, opponents of the rule — chiefly, the fossil fuel industry — are still expected to use the demise of the Chevron doctrine to attempt to weaken the specifics of those rules.

Overturning Chevron is just the latest in a series of ringing blows the Supreme Court’s Republican-appointed conservative bloc has delivered to the ability of regulatory agencies to impose rules on powerful business interests, advancing a long-standing goal of the conservative legal movement and the donors who have funded its rise . Here are some previous steps:

In recent years, the Republican majority has also made it easier to sue agencies and get their rules struck down, including by advancing the so-called major questions doctrine. Under that idea, courts should nullify economically significant regulations if judges decided Congress was not clear enough in authorizing them. Advancing and entrenching that idea, the court has struck down an E.P.A. rule aimed at limiting carbon pollution from power plants , and barred the Occupational Safety and Health Administration from telling large employers they must either have their workers vaccinated against the Covid-19 virus or have them undergo frequent testing.

Overturning the Chevron decision has been a major goal of the conservative legal movement.

After taking aim at abortion and affirmative action, the conservative legal movement set its sights on a third precedent: Chevron v. Natural Resources Defense Council .

The 1984 decision, one of the most cited in American law but largely unknown to the public, bolstered the power of executive agencies that regulate the environment, the marketplace, the work force, the airwaves and countless other aspects of modern life. Overturning it was a key goal of the right and is part of a project to demolish the “administrative state.”

The decision rejecting Chevron threatens regulations covering — just for starters — health care, consumer safety, government benefit programs and climate change.

Chevron — and bear with me here, this will hurt only for a minute — established the principle that courts must defer to agencies’ reasonable interpretations of ambiguous statutes. The theory is that agencies have more expertise than judges, are more accountable to voters and are better able to establish uniform national policies.

“Judges are not experts in the field, and are not part of either political branch of the government,” Justice John Paul Stevens wrote in 1984 for a unanimous court (though three of its justices recused for reasons of health or financial conflict). Justice Stevens later said of the opinion , which was easily his most influential, that it was “simply a restatement of existing law.”

The decision was not much noted when it was issued. “If Chevron amounted to a revolution, it seems almost everyone missed it,” Justice Neil Gorsuch, the harshest critic of the doctrine on the current court, wrote in 2022 , saying that courts had read it too broadly.

At first, conservatives believed that empowering agencies would constrain liberal judges. So the Reagan administration, which had interpreted the Clean Air Act to allow looser regulations of emissions, celebrated the decision.

Justice Stevens, rejecting a challenge from environmental groups, wrote that the Environmental Protection Agency’s reading of the statute was “a reasonable construction” that was “entitled to deference.”

The head of the E.P.A. when the regulation was issued? Anne Gorsuch, Justice Gorsuch’s mother.

Most surprisingly, given its current bad odor with the right, Chevron was at least initially championed, celebrated and elevated by Justice Antonin Scalia, a revered conservative figure who died in 2016 . “In the long run Chevron will endure and be given its full scope,” he wrote in a law review article in 1989, adding that this was so “because it more accurately reflects the reality of government.”

What, then, accounted for the decision’s place on the conservative hit list? After all, as the case itself demonstrates, it requires deference to agency interpretations under both Republican and Democratic administrations.

The answers are practical, cultural and philosophical. Business groups on the whole remain hostile to regulation. Many conservatives have come to believe that executive agencies are dominated by liberals under both parties’ administrations — the shorthand for this critique is “the deep state.” And some on the right have become hostile to the very idea of expertise.

The majority opinion by Justice Roberts notes: “Chevron’s presumption is misguided because agencies have no special competence in resolving statutory ambiguities. Courts do.” Justice Elana Kagan, in a fiery dissent, disagreed and predicted “large-scale disruption,” as judges are called upon to answer questions that expert agencies have been entrusted to handle.

Ken Bensinger

Conservative pundits, already celebrating last night’s debate, are now in a mood of downright jubilation after the Supreme Court’s rulings today rolling back the power of regulatory agencies and overturning the Justice Department’s use of an obstruction statute in the January 6 criminal cases. “Huge, huge 24 hours for Donald Trump/GOP WOW,” wrote Megyn Kelly, the right-wing podcaster and former Fox anchor.

Stacy Cowley and Emily Flitter

The ruling will embolden challenges against financial regulators.

The end of Chevron deference is a boon for banking lobbyists, who have in recent years intensified their pushback against the agencies that oversee them — especially the Consumer Financial Protection Bureau, one of the industry’s most aggressive regulators.

The consumer bureau’s interpretations “may now be subject to heightened attack and may require far more justification than formerly was the case,” said Joseph Lynyak, a partner at Dorsey & Whitney who specializes in financial regulation.

While the decision will complicate regulators’ jobs, its effects will likely seem familiar to them. Losing the Chevron deference will amplify a shift already underway in the lower courts, which have in recent years been receptive to lawsuits challenging financial regulators’ actions. The U.S. Court of Appeals for the Fifth Circuit, in particular — and the federal courts under its purview — has been a major roadblock, preventing the bureau from imposing credit card late fee limits and expanding its interpretation of anti- discrimination laws .

One recent action that may now be ripe for a challenge is the bureau’s decision that Buy Now, Pay Later lenders are credit card providers, giving buyers a right to dispute charges and demand refunds.

“Because this interpretive rule pushes the envelope past existing law into pure agency interpretation, it will be an attractive target for industry challenge,” said Erin Bryan, another partner at Dorsey & Whitney.

In addition to the C.F.P.B., trade groups representing banks have sued other federal bank regulators, including the Office of the Comptroller of the Currency and the Federal Reserve. They have challenged those regulators over a host of rules, from a sweeping anti-redlining regulation to one requiring banks to disclose detailed data about their small business loans.

Outside advocacy groups have also gotten into the habit of suing the regulators, though the bulk of their activity took place during the Trump administration, when proponents of stricter financial regulation felt that government officials were unlawfully loosening rules on banks and other firms. Their preferred appeals circuit was the Ninth; they often filed federal court cases in the Northern District of California, where they expected judges to treat their arguments favorably.

Both sides won rulings by judges who declined to defer to the regulators.

“A court can always avoid getting to the Chevron deference in the first place by saying that a statute is not ambiguous, and that’s what happens the vast majority of the time,” said Randy Benjenk, a partner at Covington & Burling who focuses on financial regulation.

“In practice it’s been rare for a judge to conclude that a statute is ambiguous and defer to an agency’s interpretation of law. Judges routinely reach their own interpretations that contradict the agencies. That’s true in courts nationwide, whether in Texas, California or anywhere else.”

The oversight of food, drugs and tobacco is expected to be a target.

The Food and Drug Administration, which oversees a vast swath of items people use every day, is expected to see an increase — perhaps an onslaught — of lawsuits following the Supreme Court’s decision on Friday.

“This is disastrous for public health. This is disastrous for the critical role of science-based regulatory agencies,” said Mitch Zeller, a former F.D.A. associate commissioner and tobacco division director. “Chevron has worked well for half a century and makes a lot of sense.”

Challenges could range from whether tainted spinach can be traced back to a farm to the very core of the F.D.A.’s decisions on whether drugs are safe and effective enough to be sold in the United States.

“F.D.A. has always been called the gold standard for product approval throughout the world,” said Perham Gorji, a partner at the law firm DLA Piper and former deputy chief counsel at the F.D.A. “Less deference to F.D.A. is going to obviously change what’s available in terms of products that are available here in the United States.”

The agency employs about 18,000 people, many of whom are doctors or have advanced degrees in biostatistics, chemistry and toxicology. Given the complexity of some scientific decisions the agency makes, attorneys who focus on the F.D.A. said initial challenges might focus on areas in which the F.D.A. exerts policy clout, including some that touch on drug pricing.

Chad Landmon, an attorney with Axinn who leads the F.D.A. practice group, predicted that early lawsuits could stem from a mix of problems companies face.

“I think companies are going to be much more aggressive and generally are going to be looking for opportunities to challenge the F.D.A.,” Mr. Landmon said.

Others expect a broad onslaught from tobacco companies regulated by the agency. “I would expect the tobacco industry to target every aspect of the F.D.A.’s regulatory infrastructure,” said Desmond Jensen of the Public Health Law Center. The agency decides which e-cigarettes are authorized for sale and can reject new cigarettes that could attract new smokers.

Limits on Chevron are widely thought to favor industry, but the reality could be more complex if advocacy groups gear up, said Nick Shipley, a former lobbyist for BIO and PhRMA and the founder of Cronus Consulting. He cited the group that challenged the F.D.A.’s approval of abortion medications .

“Industry,” he said, “could be caught in the crossfire.”

While the Chevron decision could imperil the standing of hundreds of recent and future regulations, Chief Justice Roberts was careful to write in his opinion that the decision is not retroactive.

Justice Roberts wrote that it does “not call into question prior cases that relied on the Chevron framework. The holdings of those cases that specific agency actions are lawful — including the Clean Air Act holding of Chevron itself — are still subject to statutory stare decisis despite our change in interpretive methodology.”

Coral Davenport , Christina Jewett , Alan Rappeport , Margot Sanger-Katz , Noam Scheiber and Noah Weiland

Here’s what the Chevron ruling could mean in everyday terms.

The Supreme Court’s decision on Friday to limit the broad regulatory authority of federal agencies could lead to the elimination or weakening of thousands of rules on the environment, health care, worker protection, food and drug safety, telecommunications, the financial sector and more.

The decision is a major victory in a decades-long campaign by conservative activists to shrink the power of the federal government, limiting the reach and authority of what those activists call “the administrative state.”

The court’s opinion could make it easier for opponents of federal regulations to challenge them in court, prompting a rush of new litigation, while also injecting uncertainty into businesses and industries.

“If Americans are worried about their drinking water, their health, their retirement account, discrimination on the job, if they fly on a plane, drive a car, if they go outside and breathe the air — all of these day-to-day activities are run through a massive universe of federal agency regulations,” said Lisa Heinzerling, an expert in administrative law at Georgetown University. “And this decision now means that more of those regulations could be struck down by the courts.”

The decision effectively ends a legal precedent known as “Chevron deference,” after a 1984 Supreme Court ruling. That decision held that when Congress passes a law that lacks specificity, courts must give wide leeway to decisions made by the federal agencies charged with implementing that law. The theory was that scientists, economists and other specialists at the agencies have more expertise than judges in determining regulations and that the executive branch is also more accountable to voters.

Since then, thousands of legal decisions have relied on the Chevron doctrine when challenges have been made to regulations stemming from laws like the 1938 Fair Labor Standards Act, the 1970 Clean Air Act , the 2010 Affordable Care Act and others.

In writing laws, Congress has frequently used open-ended directives, such as “ensuring the rule is in the public interest,” leaving it to agency experts to write rules to limit toxic smog, ensure that health plans cover basic medical services, ensure the safety of drugs and cosmetics and protect consumers from risky corporate financial behavior.

But that gave too much power to unelected government officials, according to conservatives, who ran a coordinated, multiyear campaign to end the Chevron doctrine. They believe the courts, not administrative agencies, should have the power to interpret statutes. The effort was led by Republican attorneys general, conservative legal activists and their funders, several with ties to large corporations, and supporters of former President Donald J. Trump.

“Overturning Chevron was a shared goal of the conservative movement and the Trump administration. It was expressed constantly,” said Mandy Gunasekara, who served as chief of staff at the E.P.A. under President Trump and has helped write Project 2025 , a policy blueprint for a next Republican administration. “It creates a massive opportunity for these regulations to be challenged. And it could galvanize additional momentum toward reining in the administrative state writ large if the administration changes in November.”

Still, Jonathan Berry, who served as a senior Labor Department official under Mr. Trump, noted that overturning the Chevron doctrine itself “doesn’t immediately blow anything up.”

Rather, Mr. Berry said, the fate of the regulations will be determined by what happens when they start moving through the courts without the protection of Chevron. “The mystery is exactly how much of this stuff goes down,” Mr. Berry said.

Here is a look at how the decision might affect various government agencies.

The Environmental Protection Agency

Environmentalists fear that the end of the Chevron doctrine will mean the elimination of hundreds of E.P.A. rules aimed at limiting air and water pollution, protecting people from toxic chemicals and, especially, tackling climate change.

Over the past six months, the Biden administration has issued the most ambitious rules in the country’s history aimed at cutting climate-warming pollution from cars , trucks , power plants and oil and gas wells . Without those rules, it would very likely be impossible for President Biden to achieve his goal of cutting greenhouse gas emissions in half by the end of the decade, which analysts say all major economies must do to avoid the most deadly and catastrophic impacts of global warming.

All of the Biden climate rules have already been the target of lawsuits that are winding their way through the courts.

Legal experts say that the reversal of Chevron will not remove E.P.A.’s foundational legal obligation to regulate climate-warming pollution: that was explicitly detailed in a 2007 Supreme Court decision and in 2022 legislation passed by Democrats in anticipation of challenges to that authority.

But the specific regulations — such those designed to cut car and truck pollution by accelerating the transition to electric vehicles, or to slash power plant pollution with the use of costly carbon capture and sequestration technology — could now be more legally vulnerable.

The result would quite likely be that stringent climate rules designed to sharply reduce emissions could be replaced by much looser rules that cut far less pollution. Experts say that could also be the fate of existing rules on smog, clean water and hazardous chemicals.

Labor Agencies

The elimination of the Chevron deference could affect workers in a variety of ways, making it harder for the government to enact workplace safety regulations and enforce minimum wage and overtime rules.

One recent example was in April, when the Biden administration raised the salary level below which salaried workers automatically become eligible for time-and-a-half overtime pay, to nearly $59,000 per year from about $35,000, beginning on Jan. 1. Business groups have challenged the Labor Department’s authority to set a so-called salary threshold and such challenges will have far better odds of success without the Chevron precedent, experts said.

The shift could also rein in protections for workers who publicly challenge the policies of their employers, according to Charlotte Garden, a professor of labor law at the University of Minnesota. The National Labor Relations Board often concludes that a single worker has the right to protest low pay or harassment or attendance policies without being disciplined or fired. But the relevant law refers to “concerted activities,” meaning the protection may now apply only to groups of employees who stage such protests, not individuals, Professor Garden said.

Food and Drug Administration

The Food and Drug Administration flexes significant power when it sets the standards for how new drugs must be studied and whether they are safe and effective before they are approved for use. Attorneys who worked at the agency said that companies chafing at that high bar for approvals might now challenge those regulations. Others said legal challenges could ultimately affect drug prices.

Challenges are also expected in the agency’s tobacco division, which authorizes the sale of new cigarettes and e-cigarettes with the intent to protect public health. “I would expect the industry to attack the F.D.A.’s authority to do premarket review at all,” said Desmond Jenson, deputy director of the commercial tobacco control program at the Public Health Law Center.

Others noted the Chevron decision could have a chilling effect, compelling the F.D.A. to proceed quite carefully, given the potential for litigation, if it moves forward with proposals to ban menthol cigarettes or make them less addictive by slashing nicotine levels.

Abortion opponents say the ruling could work in their favor as they seek to bring another case against the Food and Drug Administration’s approval of an abortion medication to the Supreme Court, which rejected their effort to undo the agency’s approval of the drug this month.

Kristi Hamrick, a strategist for Students for Life of America, an anti-abortion organization, said in a statement that such a case was likely to get a better reception “when the F.D.A. is no longer given the benefit of the doubt.”

Health Care

The court’s ruling could affect how Medicare, Medicaid and Affordable Care Act insurance plans are administered, health law experts said, as opponents gain an opportunity to challenge how these huge programs operate.

The health care system is governed by elaborate regulations covering how hospitals operate, what providers are paid for medical services and how insurance companies are monitored by the government. Much of that regulation is grounded in interpretation of laws that date back decades. Major industries could be affected if rules are changed.

“There’s an awful lot of regulation that flies under the radar that’s just about making sure the trains run on time,” said Nicholas Bagley, a law professor at the University of Michigan.

Rachel Sachs, a health law expert at the Washington University School of Law in St. Louis, said that the complex set of rules devised and governed by the Department of Health and Human Services and the Centers for Medicare and Medicaid Services could be challenged in new ways.

“There’s a lot of work to do in that process,” she said. “And therefore there are a lot of opportunities for challengers to pick at specific choices that C.M.S. and H.H.S. are making in the interpretation of these rules.”

The Supreme Court decision will require Congress to specify exactly what agencies like the C.D.C. can and cannot do, several analysts said. “Nobody has any confidence that Congress can get its act together to do that,” said Dr. Georges C. Benjamin, executive director of the American Public Health Association.

The Biden administration has written health regulations anticipating a world without the Chevron deference, said Abbe R. Gluck, a health law expert at Yale Law School who served in the White House at the beginning of Mr. Biden’s term. For that reason, she thinks litigation over the most recent rules may be less influenced by this change than challenges concerning some older regulations.

“The Supreme Court has not relied on Chevron in quite a few years,” she said. “So the federal government, including H.H.S., has become accustomed to drafting regulations and making its interpretation arguments as if Chevron did not exist.”

“They’ve already adjusted,” Ms. Gluck said.

Treasury and the Internal Revenue Service

The Treasury Department and the Internal Revenue Service both have broad mandates to interpret legislation when they write rules and regulations and enforce the tax code.

Since the Inflation Reduction Act passed in 2022, the Treasury Department has been racing to roll out regulations related to billions of dollars of clean energy tax credits that provide huge incentives for things such as the manufacturing of batteries or the purchase of electric vehicles. The Treasury Department has received pushback from some lawmakers who contend that it has not followed the intent of the law.

Although Congress creates the tax code through legislation, the I.R.S. has wide latitude in how the tax laws are administered. Accounting experts have suggested that the court’s ruling could complicate the agency’s ability to administer the tax code without specific direction from Congress.

A recent example is how the agency last year delayed enforcement of a contentious tax policy that would require users of digital wallets and e-commerce platforms to report small transactions. The new provision was introduced in the tax code in 2021 but was strongly opposed by lobbyists and small businesses.

The I.R.S. received criticism from some lawmakers for delaying the policy, but the agency defended its decision by arguing that taxpayers needed a longer transition period before the measure should be enforced to avoid a chaotic tax season.

Elizabeth Dias , Teddy Rosenbluth and Roni Rabin contributed reporting.

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Analysis of the heterogeneous coordination between urban development levels and the ecological environment in the chinese grassland region (2000–2020): a case study of the inner mongolia autonomous region, share and cite.

Wang, Y.; Yang, Y. Analysis of the Heterogeneous Coordination between Urban Development Levels and the Ecological Environment in the Chinese Grassland Region (2000–2020): A Case Study of the Inner Mongolia Autonomous Region. Land 2024 , 13 , 951. https://doi.org/10.3390/land13070951

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Column: A Supreme Court ruling may help Jan. 6 rioters. Here’s why it’s less likely to help Trump

Police and rioters face off across barricades in front of the Capitol.

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The Supreme Court’s decision in Fischer vs. United States, which came down among a bevy of blockbuster opinions Friday, was much anticipated for its potential impact on the prosecutions of hundreds of Jan. 6 rioters as well as former President Trump, who was charged under the same law. The court’s ruling was largely of a piece with the conservative justices’ proclivity for narrowing criminal laws they perceive as imprecise and likely to trap the unwary. The majority opinion by Chief Justice John G. Roberts Jr. contends that the Justice Department’s position on the obstruction statute at hand would “criminalize a broad swath of prosaic conduct.”

The decision is of course good news for Joseph Fischer, a Jan. 6 defendant who moved to dismiss one of the charges against him. Fischer barged into the Capitol on that day and was also charged with assaulting a federal officer, among other offenses. But the court held that he could not be charged under a federal law against obstructing an official proceeding for joining the melee that delayed the certification of the 2020 presidential election, ruling that the law is limited to conduct affecting the integrity or availability of records that could be evidence in an official proceeding.

For the record:

10:00 a.m. June 29, 2024 An earlier version of this article incorrectly indicated that Joseph Fischer could get “another trial.” Fischer has not been tried in the case.

Trump will certainly try to argue that the court’s decision also requires dismissal of two counts against him under the same law in the federal Jan. 6 case. Many of the rioters were, like Fischer, charged under the statute and could benefit from the ruling as well. But the decision isn’t likely to favor the majority of the marauders, and it’s even less likely to help Trump.

FILE - The indictment against former President Donald Trump is photographed on Friday, June 9, 2023. A pretrial conference Tuesday, July 18, to discuss procedures for handling classified information will represent the first courtroom arguments in the case before U.S. District Judge Aileen Cannon since Trump was indicted five weeks ago. (AP Photo/Jon Elswick, File)

Litman: This is Judge Aileen Cannon’s big gamble in the Trump classified records case

A new report underscores how far the Florida-based federal judge has gone in ignoring the advice and criticism of others in the legal community.

June 24, 2024

In the case of the rioters, a study in Just Security persuasively suggests that even if the statute is unavailable to charge them in the wake of the Fischer decision, the government can still prosecute the same conduct in other ways.

The ruling probably won’t be useful to Trump for another reason.

The lawyerly debate in Fischer comes down to the meaning of the word “otherwise.” Following a section of the law that prohibits altering or mutilating a record, the law goes on to criminalize conduct that “otherwise obstructs, influences or impedes any official proceeding.“ The question is whether the law thereby applies to any obstruction of an official proceeding or only to acts that affect the integrity or availability of records to be used in the proceeding.

Hunter Biden, accompanied by his wife, Melissa Cohen Biden, arrives to federal court on hearing there is a verdict, Tuesday, June 11, 2024, in Wilmington, Del (AP Photo/Matt Rourke)

Litman: A jury was right to find Hunter Biden guilty. It’s the prosecutor who was wrong

President Biden’s son was singled out for an unusual indictment by special counsel David Weiss, a former U.S. attorney under Donald Trump.

June 11, 2024

But Trump’s alleged conduct certainly affected the integrity or availability of records, namely the valid slates of presidential electors. His purported scheme was designed to undermine the legal impact of those slates and replace them with fraudulent certificates forged at the behest of his inner circle.

Justice Ketanji Brown Jackson’s concurring opinion in the case underscores this point. After endorsing the majority’s understanding of “otherwise,” she concludes that Fischer might still be charged under the statute because the “official proceeding” in question “plainly used certain records, documents, or objects — including, among others, those relating to the electoral votes themselves.”

Jackson’s hypothetical analysis concerns Fischer himself, but it seems she also means it to encompass the conduct of the former president. While Trump is not alleged to have destroyed or altered a document, he is alleged to have “otherwise” impaired the legal effectiveness of the certificates.

The dissenting opinion in the case, authored by Justice Amy Coney Barrett and joined by Justices Sonia Sotomayor and Elena Kagan, is an interesting postscript. Barrett argues that the government’s reading of the text of the statute might be expansive but is in keeping with its plain meaning. The opinion is among those suggesting Barrett, a Trump appointee, is staking out the center of the court in certain important cases.

But the most pressing question raised by this decision and the presidential immunity opinion expected Monday is whether they will undermine the various criminal charges against the former president. The bottom line in this case is that it shouldn’t, and I don’t think it will. Trump will surely move to dismiss the charges on this basis, but I expect U.S. District Judge Tanya Chutkan to reject that argument, which would allow the case to proceed as charged — unless, of course, the defendant returns to the White House and makes the entire prosecution go away.

Harry Litman is the host of the “Talking Feds” podcast and the Talking San Diego speaker series. @harrylitman

Supreme Court throws out obstruction charges lodged against hundreds of Jan. 6 rioters

June 28, 2024

FILE - In this Wednesday, Jan. 6, 2021, file photo, violent rioters storm the Capitol, in Washington. New details from the deadly riot of Jan. 6 are contained in a previously undisclosed document prepared by the Pentagon for internal use that was obtained by the Associated Press and vetted by current and former government officials. (AP Photo/John Minchillo, File)

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Risk factors for obstructed labour in Eastern Uganda: A case control study

Milton w. musaba.

1 Department of Obstetrics and Gynaecology, Mbale Regional Referral and Teaching Hospital, Mbale, Uganda

2 Department of Obstetrics and Gynaecology, Busitema University Faculty of Health Sciences, Mbale, Uganda

3 Department of Paediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda

Grace Ndeezi

Justus k. barageine.

4 Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda

5 Africa Centre for Systematic Reviews and Knowledge Translation, Makerere University College of Health Sciences, Kampala, Uganda

Andrew Weeks

6 Sanyu Research Unit, University of Liverpool, University of Liverpool/Liverpool Women’s Hospital, Liverpool, England, United Kingdom

Victoria Nankabirwa

7 Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda

8 Centre for Intervention Science and Maternal Child Health (CISMAC), Centre for International health, University of Bergen, Bergen, Norway

Felix Wamono

9 School of Statistics and Planning, College of Business and Management Sciences, Makerere University, Kampala, Uganda

Daniel Semakula

James k. tumwine, julius n. wandabwa, associated data.

All relevant data are within the manuscript and its Supporting Information files.

Introduction

To identify the risk factors for OL in Mbale Regional Referral and Teaching Hospital, Eastern Uganda.

Conclusions

Materials and methods

Study setting.

Study design

Unmatched case control design with incidence density sampling of the controls admitted in the same delivery suite.

Study population

Controls were women admitted to the labour suit within the same 24-hour period in active labour without obstruction.

Sample size and sampling

Inclusion criteria

Exclusion criteria

Study variables

Data collection

Data management

Data analysis

Ethical considerations

Characteristics of the study population

Characteristic	Cases	Controls	Total
Characteristic	n = 270 (100%)	n = 270 (100%)	N = 540 (100%)
	23.5 (5.9)	25.4 (5.9)	24.5 (6.0)
less than 20	80 (29.6)	42 (15.6)	122 (22.6)
20 to 29	147 (54.4)	165 (61.1)	312 (57.8)
30 and above	43 (15.9)	63 (23.3)	106 (19.6)
	159 (8.2)	161 (7.4)	160 (8.2)
less than 150	46 (17.0)	22 (8.2)	68 (12.6)
150 and above	224 (83.0)	248 (91.9)	472 (87.4)
	64.1 (10.1)	65.3 (9.3)	64.7 (9.8)
	3.30 (0.5)	3.36 (0.4)	3.33 (0.4)
less than 2.5	6 (2.2)	2 (0.7)	8 (1.5)
2.5 to 3.5	166 (61.4)	134 (49.6)	300 (55.6)
>3.5	98 (36.3)	134 (49.6)	232 (43.0)
	138 (13.7)	136 (8.4)	136 (15.2)
less than 120	15 (5.6)	2 (0.7)	17 (3.2)
120 to 160	240 (88.9)	264 (97.8)	504 (93.3)
above 160	15 (5.6)	4(1.5)	19 (3.5)

Not Married	46 (17)	29 (10.7)	75 (13.9)
Married	224 (83.0)	241 (89.3)	465 (86.1)

Primary	139 (51.5)	99 (36.7)	238 (44.1)
Post primary	131 (48.5)	171 (63.3)	302 (55.9)

House wife	176 (65)	164 (61)	340(63)
Peasant farmer	40 (15)	21 (8)	61 (11)
Salary earner	31 (12)	28 (10)	59 (11)
Retail business	23 (9)	57 (21)	80 (15)

Rural	239 (89)	212 (79)	451 (84)
Urban	31 (12)	58 (22)	89 (17)

< 5 km	205 (75.9)	221 (81.8)	426 (78.9)
≥ 5 km	65 (24.1)	49 (18.2)	114 (21.1)

Primary	126 (46.7)	74 (27.4)	200 (37)
Post primary	144 (53.3)	196 (72.6)	340 (63)

Peasant farmer	177 (65.6)	143 (53)	320(59.3)
Retail business	44 (16.3)	58 (21.5)	102(18.9)
Income earner	49 (18.2)	69 (25.6)	118(21.9)

Prime gravida	150 (55.6)	79 (29.3)	229 (42.4)
Gravida 2 to 4	85 (31.5)	151 (55.9)	236 (43.7)
Gravida 5+	35 (13.0)	40 (14.8)	75 (13.9)

< 4 ANC visits	153 (56.7)	152 (56.5)	305 (56.6)
≥ 4 ANC visits	117 (43.3)	118 (43.5)	234 (43.4)

Public health facility	261 (96.7)	258 (95.5)	518 (96.1)
Private health facility	9 (3.3)	12 (4.5)	21 (3.9)

Yes	79 (29.3)	93 (34.6)	172 (31.9)
No	191 (70.7)	177 (65.4)	368 (68.1)

Yes	161 (59.6)	79 (29.3)	240 (44.4)
No	109 (40.4)	171 (70.7)	300 (55.6)

Yes	184 (68.2)	45 (16.7)	229 (42.4)
No	86 (31.9)	225 (83.3)	311 (57.6)

Public health facility	174 (95)	40 (89)	214 (94)
Private health facility	10 (5.4)	5 (11.1)	15 (6.5)

Abbreviations: cm, centimetre; km, kilometre; kg, kilogram; bpm, beats per minute; ANC, antenatal care; SD, standard deviation.

* Values are given as mean ±SD or number (percentages) unless stated otherwise

Factors associated with OL

Characteristic	Crude OR	95% CI	P- Value
	0.05	0.08 - 0.03	0.000
less than 20	2.14	1.38–3.30	0.001
20 to 29	1
30 and above	0.77	0.49–1.20	0.243
	0.03	0.05 - 0.01	0.011
less than 150	1.78	0.83–3.82	0.137
above 150	1
	0.01	0.03 - 0.00	0.142
	0.34	0.74 - 0.05	0.088
less than 2.5	2.42	0.48–12.19	0.284
2.5 to 3.5	1
above 3.5	0.59	0.42–0.83	0.003
	0.02	0.00 - 0.03	0.040
less than 120	14.24	1.85–109.6	0.011
120 to 160	1
above 160	4.11	1.34–12.54	0.013

Married	0.59	0.35–0.97	0.037
Not Married	1

Post primary	0.55	0.39–0.67	0.001
Primary	1

House wife	1
Peasant farmer	1.77	1.00–3.14	0.048
Salary earner	1.03	0.59–1.79	0.912
Retail business	0.38	0.22–0.64	0.000

Rural	0.48	0.30–0.77	0.003
Urban	1

≥ 5 km	1.43	0.94–2.18	0.093
<5 km	1

Primary	0.43	0.30–0.62	0.000
Post primary	1

Peasant farmer	1
Retail business	0.61	0.39–0.96	0.033
Paid employee	0.57	0.37–0.88	0.011

Prime gravida	3.37	2.31–4.94	0.000
Gravida 2 to 4	1
Gravida 5+	1.55	0.92–2.63	0.100

< 4 ANC visits	1.01	0.73–1.41	0.933
≥ 4 ANC visits	1

Public health facility	1.38	0.55–3.42	0.493
Private health facility	1

Yes	0.79	0.55–1.13	0.196
No	1

Yes	3.65	2.45–5.42	0.000
No	1

Yes	9.69	5.79–16.21	0.000
No	1

Public health facility	1.00	0.20–4.96	1.000
Private health facility	1

Abbreviations: cm, centimetre; km, kilometre; kg, kilogram; bpm, beats per minute; ANC, antenatal care; SD, standard deviation; CI, confidence interval.

* logit coefficients.

Characteristic	Adjusted OR	95% CI	P- Value

less than 20	0.9	0.48–1.70	0.747
20 to 29	1
30 and above	0.93	0.47–1.82	0.822

above 150	1
Less than 150	1.08	0.41–2.86	0.875

less than 120	10.78	1.21–96.11	0.033
120 to 160	1
above 160	2.37	0.62–9.01	0.205

less than 2.5	1.95	0.23–16.71	0.541
2.5 to 3.5	1
above 3.5	0.95	0.606–1.49	0.818

Not Married	1
Married	0.92	0.47–1.78	0.796

Post Primary	0.65	0.38–1.13	0.127
Primary	1

House wife	1
Peasant farmer	1.25	0.56–2.76	0.341
Salaried	1.50	0.68–3.31	0.318
Retail business	0.80	0.42–1.55	0.514

Rural	1.77	0.89–3.54	0.104
Urban	1

≥ 5 km	0.94	0.45–1.97	0.870
<5 km	1

Post Primary	0.57	0.33–0.98	0.042
Primary	1

Peasant farmer	1
Retail business	1.44	0.73–2.84	0.291
Paid employee	1.19	0.68–2.10	0.537

Prime gravida	2.15	1.26–3.66	0.005
Gravida 2 to 4	1
Gravida 5+	0.80	0.36–1.748	0.573

< 4 ANC visits	0.95	0.61–1.48	0.821
≥ 4 ANC visits	1

Yes	0.56	0.35–0.90	0.017
No	1

Yes	2.34	1.50–3.64	0.000
No	1

Yes	6.80	4.20–11.00	0.000
No	1

Methodological considerations

Supporting information

The data set is in Stata format 14 and includes all variables analysed for this manuscript.

Acknowledgments

Funding Statement

Survival Pluss Project at Makerere University. Funded by NORHED under NORAD. UGA-13-0030, Prof. James K. Tumwine. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data Availability

PLoS One. 2020; 15(2): e0228856.

Author response to previous submission

20 Nov 2019

Submitted filename: response to the reviewers.docx

Decision Letter 0

PONE-D-19-32285

Risk factors for obstructed labour in Eastern Uganda: a case control study.

Dear Dr Musaba,

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Reviewer #1: In this study, the authors conducted a case-control study to explore the risk factors for obstructed labour (OL) in Eastern Uganda. This study is of great public health importance. Overall, the study was well planned and conducted, analysis was correctly performed, results carefully discussed and manuscript nicely written. The authors also addressed the study limitations. Several issues:

1) The full name of an abbreviation should be given at the first appearance. For example, Introduction section, 1st paragraph, Line 63, “PPH”.

2) Introduction, 2nd paragraph, Line 67, what do you mean by “improving nutrition of the girl child…?”

3) Results section, 1st paragraph, Line 199, “159±8.2 Vs 1161.4±7.4”, please check height is correctly presented.

4) The result for the main hypothesis is negative. There is the issue of multiple comparisons, so the conclusions should be drawn with caution.

5) The presentations of Table 2 and Table 3 should be improved. The reference category usually should be consistent, either at the top or at the bottom.

6) Typos and grammatical errors need to be checked and corrected.

Reviewer #2: While the study presents the results of original research, the statistics and other analyses still need to be described in more sufficient detail to know whether they were performed to a high technical standard. The conclusions need to be presented in a more robust fashion and provide more explanation of what the data support and results show.

Even though the article is presented is written in standard English, it could be improved with additional copy-editing for correct grammar usage. Revisions would be easier to track if authors had highlighted or underlined changes in the text.

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Reviewer #2: No

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Author response to Decision Letter 0

20 Jan 2020

20th/01/2020

Dr. Calistus Wilunda

Dear Dr. Calistus Wilunda

Re; Response to reviewers’ comments and resubmission of revised manuscript ID PONE-D-19-20983

Thank you for taking off time to review and provide feedback on this manuscript. Please receive the revised copy with specific responses and changes summarized in the table below.

Reviewers comment Response to comment Line number

Academic editor

Please include post hoc power calculations to show the extent to which the study was powered to examine the link between the factors assessed and obstructed labour. This is in the light of the fact that this study was not well powered to assess the link between ANC attendance and the outcome. You can include this information as a supplementary file. Thank you so much for the comment. We agree with the reviewer that most likely we did not have power to detect a difference between the frequency of antenatal care visits (< 4 Vs ≥ 4 ANC visits) and obstructed labour even if the difference had been there. This can easily be seen from the confidence intervals that show an imprecise estimate. The post hoc power calculations have been done for all the variables studied; referral status, use of local herbs, having a delivery plan, number of ANC visits, prime parity, occupation of the spouse, education level of spouse, distance from the nearest health facility, place of residence, occupation of the spouse, participants level of education, marital status, fetal birth weight and height of respondent.

We however agree with a huge body of statistical evidence that calculating a post hoc power is logically flawed for the reasons highlighted in supplement 3

Included as a separate file name post hoc power calculations (S1).

Lines 284 to 289, page 17.

Included as a separate file Post hoc power calculations rebuttal (S3)

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. We have updated all these accordingly and feel that the manuscript meets PLOS ONE’s style requirements. NA

We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Thank you for the guidance, after consultations with the sponsor of the study and the Makerere University School of Medicine Research and Ethics Committee (SOMREC), we have uploaded the minimal anonymized data set necessary to replicate study findings as Supporting Information file (S2 file. Dataset RFOLMUK) NA

In this study, the authors conducted a case-control study to explore the risk factors for obstructed labour (OL) in Eastern Uganda. This study is of great public health importance. Overall, the study was well planned and conducted, analysis was correctly performed, results carefully discussed and manuscript nicely written. The authors also addressed the study limitations. Several issues: Thank you for the feedback. NA

The full name of an abbreviation should be given at the first appearance. For example, Introduction section, 1st paragraph, Line 63, “PPH”. Thank you for the observation, this has been written out in full as postpartum hemorrhage. Line 56, page 4.

Introduction, 2nd paragraph, Line 67, what do you mean by “improving nutrition of the girl child…?” This has been elaborated further in the manuscript Lines 61-63, page 4.

Results section, 1st paragraph, Line 199, “159±8.2 Vs 1161.4±7.4”, please check height is correctly presented. Thank you for the observation, this has been corrected in the manuscript to “159±8.2 Vs 161.4±7.4”, Line 183, page 9.

The result for the main hypothesis is negative. There is the issue of multiple comparisons, so the conclusions should be drawn with caution. This limitation has been highlighted in the discussion section Line 233 to 236, page 15

The presentations of Table 2 and Table 3 should be improved. The reference category usually should be consistent, either at the top or at the bottom. All the tables have been reviewed and revised Table 1: Line 185 to186, page 9 to 11

Table2: Line 200 to201, page 11 to 12

Table 3: Line 209 to 210, page 13 to 14.

Typos and grammatical errors need to be checked and corrected. These have been checked and corrected throughout the document NA

Reviewer 2;

While the study presents the results of original research, the statistics and other analyses still need to be described in more sufficient detail to know whether they were performed to a high technical standard. The conclusions need to be presented in a more robust fashion and provide more explanation of what the data support and results show. The statistical analysis has been described in more detail and the data set is attached.

We have also added a post hoc power calculation.

Discussed the power limitations in more detail

Line 150 to 171, page 8 and 9.

Supplement file S1.

Even though the article is presented is written in standard English, it could be improved with additional copy-editing for correct grammar usage. This has been done throughout the document NA

Revisions would be easier to track if authors had highlighted or underlined changes in the text Sorry for the inconvenience, we have included a revised copy of the manuscript with track changes. Throughout the document.

Dr. Musaba W. Milton

Department of Obstetrics and Gynaecology

Mbale Regional Referral Hospital/ Busitema University

Submitted filename: response to the reviewers2.docx

Decision Letter 1

27 Jan 2020

PONE-D-19-32285R1

Dear Dr. Musaba,

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Reviewer #1: All comments have been addressed

2. Is the manuscript technically sound, and do the data support the conclusions?

3. Has the statistical analysis been performed appropriately and rigorously?

4. Have the authors made all data underlying the findings in their manuscript fully available?

5. Is the manuscript presented in an intelligible fashion and written in standard English?

6. Review Comments to the Author

Reviewer #1: The authors have addressed all my concerns after the revision.

I suggest accept the manuscript for publication.

7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files.

Acceptance letter

30 Jan 2020

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Obstructed labour
(PDF) Obstructed labour due to bladder stone: Case report
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Determinants of obstructed labour and its adverse outcomes among women who gave birth in Hawassa University referral Hospital: A case-control study
The dependent variable of this study was obstructed labour. Whereas, the independent variables were categorized as socio-demographic factors, obstetric, health facility and fetal factors. ... A case control study". Globally, obstructed labour accounted for 12% of maternal death and most of the maternal morbidity and perinatal mortality. It is ...
Obstructed labor and its effect on adverse maternal and fetal outcomes
Perinatal morbidity and mortality due to obstructed labor . Fourteen studies [31,32,49-51,88-93] reported an incidence of perinatal death in women with obstructed labor, and the forest plot in Fig 6 shows the rate of perinatal death among women with obstructed labor was 26.4% (26.4 (95% CI 15.18, 37.7), I 2 = 95.6%, p <0.001) (Fig 6).
Incidence, causes, and maternofetal outcomes of obstructed labor in
Whereas duplicated studies, case reports, qualitative studies, anonymous reports, articles without full text, and abstract and editorial reports were excluded from the study. ... Factors for obstructed labor Number of studies Model Status of heterogeneity Prevalence (95% CI) I 2 (%) P-value; Rural residency: 5: Random: Marked: 77.86% (95% CI ...
Incidence, causes, and maternofetal outcomes of obstructed labor in
Obstructed labor is defined as a failure of the fetal presenting part to descent in the birth canal due to mechanical reasons, despite having adequate uterine contraction [1, 2].It is diagnosed when the duration of labor is prolonged, a laboring mother became unable to support herself or unable to move her lower extremities, with deranged vital signs, distended bladder, Bandle's ring formed ...
Determinants of obstructed labour and its adverse outcomes among ...
Background Globally, obstructed labour accounted for 22% of maternal morbidities and up to 70% of perinatal deaths. It is one of the most common preventable causes of maternal and perinatal mortality in low-income countries. However, there are limited studies on the determinants of obstructed labor in Ethiopia. Therefore, this study was conducted to assess determinants and outcomes of ...
Determinants of obstructed labour and associated outcomes in 54
Retrospective observational study. Setting. A total of 54 referral-level hospitals across the six geopolitical regions of Nigeria. Population. Pregnant women who were diagnosed with obstructed labour during childbirth and subsequently underwent an emergency caesarean section between 1 September 2019 and 31 August 2020. Methods
Incidence, causes, and maternofetal outcomes of obstructed labor in
Background: Obstructed labor is a preventable obstetric complication. However, it is an important cause of maternal mortality and morbidity and of adverse outcomes for newborns in resource-limited countries in which undernutrition is common resulting in a small pelvis in which there is no easy access to functioning health facilities with a capacity to carry out operative deliveries.
Determinants of obstructed labour and its adverse outcomes ...
Therefore, this study was conducted to assess determinants and outcomes of obstructed labor among women who gave birth in Hawassa University Hospital, Ethiopia. Methods: A hospital-based case-control study design was conducted in Hawassa University Hospital among 468 women. All women who were diagnosed with obstructed labour and two consecutive ...
(PDF) Determinants of obstructed labour and its adverse outcomes among
Methods A hospital-based case-control study design was conducted in Hawassa University Hospital among 468 women. All women who were diagnosed with obstructed labour and two consecutive controls ...
Prevalence, causes, and factors associated with obstructed labour among
Background Obstructed labour is a type of abnormal labour that is one of the causes of obstetric complications such as maternal and fetal mortality and morbidity. Early detection is the key to reducing complications. Objective This study aimed to assess the prevalence, causes, and factors associated with obstructed labor among mothers who gave birth at public health facilities in Mojo Town ...
Prevalence, causes, and factors associated with obstructed labour among
was identified as a factor decreasing the risk of obstructed labour. Conclusion The prevalence of obstructed labour in this study was higher than in the majority of previous similar local and global studies. In this study setting, cephalo-pelvic disproportion, mal-pre-sentation, and mal-position were found to be the causes of obstetric labour.
PDF OBSTRUCTED LABOR;
economic class. Only 4.55% of the women in obstructed labor were the booked cases. All the cases of obstructed labor were at full term. Cesarean section was done on 90.90% women. Not a single maternal mortality was reported among women enrolled in the study as obstructed labor. Conclusion: Neglected obstructed labor is a major public health ...
Determinants of obstructed labor among women attending intrapartum care
A Hospital-based unmatched case-control study was conducted from March 1stto August 30, 2017. Cases were women whose labor was obstructed (n = 270), and controls were women whose labor was not obstructed (n = 540). ... respectively. 8 Moreover, based on a 2014 study, obstructed labor was a cause of 36% of maternal deaths. 9 Furthermore, studies ...
A hospital-based unmatched case-control study
Methods: A Hospital-based unmatched case-control study was conducted from March 1stto August 30, 2017. Cases were women whose labor was obstructed (n = 270), and controls were women whose labor was not obstructed (n = ... study, obstructed labor was a cause of 36% of maternal deaths.9 Furthermore, studies from Hawassa,10 Suhul,11 and Adama ...
Obstructed labor and its association with adverse feto-maternal outcome
For example, the JBI critical appraisal tool has eleven items to assess cohort studies, ten items to assess case-control studies, ... Huda N, Romanzi L, et al. Toward a complete estimate of physical and psychosocial morbidity from prolonged obstructed labour: a modelling study based on clinician survey. World Health Org Bull. 2020;5(7):e002520.
Risk factors for obstructed labour in Eastern Uganda: A case control study
Abstract. Introduction: Obstructed labour (OL) is an important clinical and public health problem because of the associated maternal and perinatal morbidity and mortality. Risk factors for OL and its associated obstetric squeal are usually context specific. No epidemiological study has documented the risk factors for OL in Eastern Uganda.
(PDF) A Clinical Study of 100 Cases of Obstructed Labour and Its
We present a clinical study of 204 cases of obstructed labour admitted over a period of 5 years between 1991-92 and 1996-97 in a rural institute in central India. They constituted 1.9% of births.
PDF Case 3: Obstetric Fistula
Case 3: Maternal M&M (Obstetric fistula) Sarah is an 18-year old mother, expecting her second child. She lives with her family in Kondoa, in rural Tanzania. Growing up, Sarah and her two sisters never attended school ... Global Burden of Disease Study suggested that obstructed labour aﬀ ects at least 7 million women every year, 6·5 million ...
Full article: The pathway of obstructed labour as perceived by
Recent studies reported that obstructed labour is the second largest direct cause (22%) of maternal mortality in the country Citation 19 Citation 21. In south-western Uganda the prevalence of obstructed labour in six hospitals was recently estimated to be around 10% Citation 22. There exists a knowledge gap on the communities' understanding ...
Labour and Delivery Care Module: 9. Obstructed Labour
The following signs in Tadelech's case study suggest both prolonged and obstructed labour: It is clear that while Tadelech has been in the active first stage of labour for some time (dilated cervix of 8 cm), but she may actually be in a prolonged active phase of labour (when true labour lasts for more than about 8 hours without finally ...
(PDF) Obstructed Labour: A Preventable Tragedy but Still a Long Way to
Obstructed labour is the single most important cause of maternal death and is one of the leading causes of perinatal mortality. Materials and methods: This prospective study of obstructed labour was conducted from September 2021 to May 2022 (9 months) in the Department of obstetrics and Gynaecology of M.G.M Medical College, Jamshedpur.
Risk factors for obstructed labour in Eastern Uganda: A case control study
Introduction Obstructed labour (OL) is an important clinical and public health problem because of the associated maternal and perinatal morbidity and mortality. Risk factors for OL and its associated obstetric squeal are usually context specific. No epidemiological study has documented the risk factors for OL in Eastern Uganda. This study was conducted to identify the risk factors for OL in ...
Risks of adverse obstetric outcomes among female survivors of
In our multivariable analyses we used a complete case approach to deal with missing data. ... Obstructed labour due to malposition and malpresentation of fetus (ICD10: O64) Observed (%) SIR (95% CI) ... The study was funded by Children with Cancer UK (grant numbers 20457 and 17247), The Brain Tumour Charity (grant number GN-000624) and the ...
Supreme Court Imperils an Array of Federal Rules
The case started with fishermen: The court heard two almost identical cases, Loper Bright Enterprises v. Raimondo, and Relentless v. Raimondo, and Relentless v. Department of Commerce.
Prevalence, causes, and factors associated with obstructed labour among
The prevalence of obstructed labour in this study was higher than in the majority of previous similar local and global studies. In this study setting, cephalo-pelvic disproportion, mal-presentation, and mal-position were found to be the causes of obstetric labour. ... Risk factors for obstructed labour in Eastern Uganda. A case control study ...
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Labour has pledged to put 13,000 more officers on the beat to boost detection rates for high volume crimes such as theft and burglary. The pledge involves hiring 3,000 new officers and 4,000 ...
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Boosting renewable energy growth through responsible value chains: A case study from China; Economic evolution and global impact. In some respects, this builds on its earlier narrative. For years, economists debated when - not if - China would outpace the US economy as it consistently returned growth rates of between 8% and 10%.
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Risk factors for obstructed labour in Eastern Uganda: A case control study
In this study, the authors conducted a case-control study to explore the risk factors for obstructed labour (OL) in Eastern Uganda. This study is of great public health importance. Overall, the study was well planned and conducted, analysis was correctly performed, results carefully discussed and manuscript nicely written.

Incidence, causes, and maternofetal outcomes of obstructed labor in Ethiopia: systematic review and meta-analysis

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Introduction

Searching strategy

Inclusion and exclusion criteria

Operational definition

Causes of obstructed labor

Complications of obstructed labor

Cephalopelvic disproportion (CPD)

Quality assessment

Data extraction

Statistical analysis

Study selection and data extraction

Study characteristics

Incidence of obstructed labor in Ethiopia

Publication bias

Sensitivity analysis

Subgroup analysis

Risk factors for the incidence of obstructed labor

Availability of data and materials

Abbreviations

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Labour and Delivery Care Module: 9. Obstructed Labour

Learning Outcomes for Study Session 9

9.1 Defining obstructed labour

Box 9.1 When is labour classed as prolonged in the different stages of labour?

9.2 Causes of obstructed labour

9.2.1 Cephalopelvic disproportion (CPD)

9.2.2 Abnormal presentations and multiple pregnancies

9.2.3 Fetal abnormalities

9.2.4 Abnormalities of the reproductive tract

9.3 Clinical signs of obstructed labour

9.3.1 Assessment of clinical signs of obstruction

9.3.2 Bandl’s ring

9.3.3 Evidence from the partograph

9.4 Management of obstructed labour

9.5 Complications resulting from obstructed labour

9.5.1 Fistula

9.5.2 Other common complications of obstructed labour

9.6 Prevention of obstructed labour

9.6.1 Skilled birth attendance

9.6.2 Using the partograph

9.6.3 Birth preparedeness and complication readiness

9.6.4 Nutritional education

9.6.5 Delaying early marriage

Summary of Study Session 9

Self-Assessment Questions (SAQs) for Study Session 9

SAQ 9.1 (tests Learning Outcome 9.2)

SAQ 9.2 (tests Learning Outcome 9.1)

Case Study 9.1 Tadelech’s story

SAQ 9.3 (tests Learning Outcomes 9.1, 9.3 and 9.4)

SAQ 9.4 (tests Learning Outcome 9.5)

Obstructed Labour: A Preventable Tragedy but Still a Long Way to Go In Developing Countries

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Risk factors for obstructed labour in Eastern Uganda: A case control study

Introduction

Conclusions

Materials and methods

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