|Year : 2018 | Volume
| Issue : 3 | Page : 117-121
Prevalence, risk factors, and outcomes of obstructed labor at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
Babagana Bako, Emmanuel Barka, Abubakar A Kullima
Department of Obstetrics and Gynaecology, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria
|Date of Web Publication||4-Oct-2018|
Dr. Babagana Bako
Department of Obstetrics and Gynaecology, University of Maiduguri Teaching Hospital, P. M. B 1414, Maiduguri, Borno State
Introduction: Obstructed labor is a common cause of feto-maternal morbidity and mortality in Maiduguri, Nigeria. This study aimed to determine the prevalence, causes, risk factors, and outcome of obstructed labor at the University of Maiduguri Teaching Hospital (UMTH). Materials and Methods: This was a retrospective observational study of all cases of obstructed labor managed from January 2012 to December 2014 at the UMTH, Maiduguri, Nigeria. For each case, the next woman who delivered without obstruction was used as a control. Data were analyzed for sociodemographic variables, labor, delivery and postdelivery events using SPSS version 20.0. The Chi-square test and odds ratio (OR) were used and statistical significance set at P < 0.05. Results: The prevalence of obstructed labor was 2.13%. Cephalopelvic disproportion, persistent occipitoposterior position, and malpresentation were seen in 65.37%, 16.58%, and 11.71%, respectively. The risk factors were teenage pregnancy (χ2: 26.96, P < 0.0001, OR: 4.44, 95% confidence interval [CI]: 2.45–8.05), nulliparity (χ2: 50.70, P < 0.0001, OR: 4.63, 95% CI: 2.99–7.15), illiteracy (χ2:53.91, P < 0.0001, OR: 5.26, 95% CI: 3.31–8.33), and unbooked status (χ2: 113.26, P < 0.0001 OR: 11.9, 95% CI: 7.24–19.61). Complications were observed in 37.56% of the women with obstructed labor. The common morbidities were wound sepsis, ruptured uterus, and puerperal sepsis, seen in 16.59%, 13.17%, and 7.81%, respectively. The case fatality rate was 0.98% and perinatal mortality was 34.15%. Conclusion: Obstructed labor is common in Maiduguri. We recommend amelioration of the risk factors through advocacy, girl child education, and public enlightenment on the need for antenatal care and hospital delivery, identification, and referral of high-risk patients.
Keywords: Maiduguri, morbidity, mortality, obstructed labor, prevalence, risk factors
|How to cite this article:|
Bako B, Barka E, Kullima AA. Prevalence, risk factors, and outcomes of obstructed labor at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria. Sahel Med J 2018;21:117-21
|How to cite this URL:|
Bako B, Barka E, Kullima AA. Prevalence, risk factors, and outcomes of obstructed labor at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria. Sahel Med J [serial online] 2018 [cited 2019 Nov 20];21:117-21. Available from: http://www.smjonline.org/text.asp?2018/21/3/117/242748
| Introduction|| |
Obstructed labor is a labor in which progress has come to a complete halt in the presence of good and adequate uterine contractions. Progress here refers to cervical dilatation and descent of the presenting part. Obstructed labor remains an important cause of not only maternal death but also short- and long-term disabilities., It is almost nonexistent in the developed countries where good antenatal care and supervised delivery are the norm. However, it has particular impact in developing countries where mechanical problems during labor are common and availability of functioning health services are sparse. Obstructed labor is one of the five major causes of maternal morbidity and mortality in developing countries.,
In most Sub-Saharan countries, women are traditionally expected to give birth at home, and if complication arises, there is often delay in accessing health-care services. This may be due to delay in making the decision to seek for medical care, the delay in reaching the facility, or the delay in offering of medical services while the patient is already in the facility. Inadequately developed health-care systems including poor infrastructure, poor transportation, and poor obstetric services are also major contributors to obstructed labor.,
The management involves resuscitating the patient, parenteral broad-spectrum antibiotics, and relieved the obstruction. The method for relieved the obstruction depends on the cause of the obstruction and the extent of complications., Improper management of obstructed labor may result in severe complications leaving the mother with lifelong disabilities. These are related to unrelieved pressure on the bladder, rectum, and lumbosacral trunk of the sacral plexus and to the method of delivery of the fetus.
This study was to determine the prevalence, causes, risk factors, and outcome of obstructed labor.
| Materials and Methods|| |
Study design and setting
A 3-year retrospective study of all cases of obstructed labor managed at the Department of Obstetrics and Gynaecology, University of Maiduguri Teaching Hospital (UMTH) was conducted. Cases were identified using the delivery registration records, operation theater records, and patients case notes recovered from the medical record department.
The hospital is located in Maiduguri, the Borno state in Northeastern geopolitical zone of Nigeria. It serves as a referral center for the sates in northeastern Nigeria including Borno, Yobe, Adamawa, Taraba, Gombe, and Bauchi as well as the neighboring countries like Cameroon, Niger, and Chad. The department undertakes an average of 3000 deliveries annually. There are three antenatal clinics per week and the booking policy is unrestricted. All high-risk patients and primigravidas have routine clinical pelvimetry at 36 weeks and labors are routinely monitored on partograph.
Two hundred and fifteen women were managed with obstructed labor from January 1, 2012 to December 31, 2014. Only 205 cases were retrieved and another 205 women who delivered immediately after a case of obstructed labor were also studied. The cases with obstructed labor were classified as obstructed labor group (OLG). While those that delivered after an obstructed labor case and did not suffer obstructed labor were termed no-OLG (NOLG). Data were retrieved and analyzed for sociodemographic variables, labor, delivery, and postdelivery events. The data were entered on an Excel spreadsheet, imported on SPSS Statistics for Windows, Version 20.0. (IBM Corp., Released 2011. Armonk, NY), statistical package, and simple frequency tables generated. The Chi-square test and odds ratio (OR) were used for categorical variables and assess risk factors with level of significance set at P < 0.05.
Diagnosis of obstructed labor
The criteria used for diagnosing obstructed labor in this study was admission into the hospital with a pregnancy of a gestational age of 28 weeks or more and having a clinical diagnosis of obstructed labor in the patient folder.
Permission to access obstetric records was obtained from the hospital management on July 17, 2015.
| Results|| |
During the study period, there were 10,109 deliveries at the UMTH. Of these, 215 were complicated by obstructed labor giving the prevalence of 2.13%. Two hundred and five cases were retrieved given a retrieval rate of 95.35%. During the same period, a total of 175 (10.02%) of cesarean deliveries were performed because of obstructed labor.
The mean age and parity of the patients were 25.12 ± 5.53 and 2.18 ± 2.61, respectively. [Table 1] shows the sociodemographic characteristics of the 205 women with OLG and the NOLG. Teenage pregnancy was found to be more common among the OLG compared to the NOLG (27.3% vs. 7.8%) and the difference was statistically significant (χ2: 26.96, P < 0.0001, OR: 4.44, 95% confidence interval [CI]: 2.44–8.05). In the OLG, 55.12% were nulliparous compared to 20.96% in the NOLG (χ2: 50.70, P < 0.0001, OR: 4.63, 95% CI: 2.99–7.15). Parturients who were illiterate accounted for 50.2% of those that had obstructed labor. This was significantly higher than 16.1% found in the NOLG. One hundred and thirty-two (64.4%) of those that had obstructed labor were unbooked, in the NOLG, only 27 (13.2%) were unbooked (χ2: 113.26, P < 0.0001 OR: 11.9, 95% CI: 7.24–19.61). There was no statistical difference between the OLG and the NOLG with regard to employment (χ2: 0.02, P = 0.88, OR: 1.04, 95% CI: 0.59–1.81).
The causes of obstructed labor are summarized in [Table 2]. The most common cause of obstructed labor was cephalopelvic disproportion which occurred in 65.37% of cases. Thirty-four (17.07%) cases were as a result of persistent occipitoposterior position, and malpresentation was found in 11.72% of cases. Congenital abnormalities were seen in 3.9%, (six had hydrocephalus and two had abdominal tumors).
Cesarean section delivery was performed on 80.98% of the women with obstructed labor, however, only 3.90% of the NOLG had cesarean section (χ2: 379.47, P < 0.0001). Other methods of delivery in women with obstructed labor included laparotomy (14.14%) and destructive delivery (4.88%) as shown in [Table 3].
Maternal complications were observed among 37.56% (77/205) of the women with obstructed labor compared to 4.39% (9/205) in women without obstructed labor (χ2: 73.88, P < 0.0001, OR: 7.56, 95% CI: 5.24–9.56). [Table 4] shows the maternal outcome and morbidities associated with obstructed labor. There were 2 cases of maternal death, giving a case fatality rate of 0.98%. The common morbidities observed in this study were wound sepsis, ruptured uterus, and puerperal sepsis, in 16.57%, 13.17%, and 7.81%, respectively. In patients with obstructed labor, the duration of hospital stay ranged from 4 to 44 days with an average of 9.08 days, however in the NOLG, the range was 1 day to 10 days with an average of 1.68 days
Of the 205 cases of obstructed labor, 59 (28.78%) babies were delivered with an Apgar score of <7 at 5-min compare to 22 (10.73%) of the NOLG (χ2: 116.89, P < 0.0001) [Table 5]. Seventy perinatal deaths (34.15%) were recorded in patients that had obstructed labor as against 5 (2.4%) in the NOLG.
| Discussion|| |
The prevalence of obstructed labor of 2.13% in this study is <2.7% reported in Enugu, but it is higher than 0.8% observed in Kano, Nigeria. This may be because of the unrestricted antenatal enrolment and delivery policy of the hospital, which has encouraged many low-risk women to come for antenatal care and delivery, thereby increasing the total number of normal deliveries. In addition, most of the women with cephalopelvic disproportion (CPD) are detected either during antenatal or early in labor and appropriate measures undertaken before the labor gets obstructed.
Teenage pregnancy and nulliparity are associated with obstructed labor in this study, this is because of early marriage in our society, with its resultant high prevalence of adolescent mothers, who go into pregnancy and labor with immature pelvises., Pregnancy in adolescence imposes great physiologic burden on girls, which is often worsened by poor dietary intakes and failure to use antenatal care optimally. The increased extraction from the adolescent mothers of nutrients (e.g., iron, folic acid, calcium, and essential amino acids) when there are inadequate stores will result in deficiency and its consequent complications. Since adolescents are still growing, the implications of deficiency are restricted growth, contracted pelvis, and feto-pelvic disproportion that may result in obstructed labor. This is responsible for why there is high prevalence of obstructed labor among teenage nulliparas.
We found high occurrence of obstructed labor among unbooked and illiterate women, probably because they have an aversion to Western-oriented programs like antenatal care and hospital delivery. Similar observation has been made in Uganda, Ethiopia, and India.,, Public enlightenment and health education, entrenching compulsory basic education in the community, and incorporation of reproductive health education in schools curriculum may help the woman to make better health-related choices. Cultural barriers can also be overcome with good education and women empowerment as studies have shown that, women who had Western education are less likely to engage in early marriage and childbearing,, they are also more likely to utilize available antenatal care and delivery services.,,
Similar to previous studies conducted in Uganda, Ethiopia, and India,,, CPD was the major cause of obstructed labor in this study and the fact that most (85.37%) of the babies delivered in the study weighted <4000 g buttresses that contracted pelvis was the cause of the CPD rather than foetal size. Emergency cesarean section which is usually indicated when the fetus is alive was the most common intervention done to relieve obstructed labor, and this is similar to reports from Uganda and Enugu Nigeria., The increased use of cesarean section in this study is because of its perceived safety and that most of the parturients (73.66%) with obstructed labor had live fetuses at presentation. Furthermore, in some studies, the risk of developing complications with either lower segment cesarean section or destructive operation is not statistically significant. All but one of the destructive operations performed were craniotomies, probably because it is easier to performed and evisceration and decapitation may be too mutilating and may not be acceptable in our society because of social and cultural factors.
Sepsis and uterine rupture were the common morbidities in our study and a similar report has also been made in Ethiopia and India., This may be due to the late arrival to the hospital after onset of labor, as most cases (98.05%) arrived more than 12 h after the onset of labor. The reason being that majority of the population live in rural areas, with a high illiteracy rate, restricted health-care facilities with an underlying synergistic background of anemia, malnutrition, infection, and unregulated fertility., Consequently, a large majority of patients reach hospital too late with features of complicated obstructed labor. The other reason could be that a significant proportion (44.87%) of the patients with obstructed labor in our study were multiparous ladies, who are at increased risk of uterine rupture. This is reflected by the fact that 86.21% of the parturient who had ruptured uterus are grand multiparous and the remaining had at least one previous delivery. Two women died from obstructed labor compared to none in the NOLG. The case fatality rate of 0.98% is comparable to the report from Uganda and Bangladesh,, but lower than the studies from Enugu and Gombe, Nigeria., This may be due to the punctilious emergency obstetric care services that are rendered in these hospitals.
The study also showed obstructed labor to be one of the major causes of poor perinatal outcome. The perinatal deaths observed in this study is higher compared to studies reported at Uganda and Enugu,, but it is lower than other studies from Kano, Ethiopia, and India.,, The poor fetal outcome and perinatal deaths were as a result of prolonged labor as all cases of obstructed labor presented more than 12 h after the onset of labor and 61.42% of the perinatal deaths and 57.63% of birth asphyxia were associated with duration of labor of more than 24 h before presentation. The delay in seeking medical health is multifactorial, but lack of finance may be an important factor in addition to poor communication network.
Health insurance is not yet available to all the populace; therefore, most people have to pay for health care from their pockets at service delivery points. This means that if the woman cannot afford initial hospital deposits, she may not receive the necessary medical care. This calls for urgent intervention by governmental and nongovernmental organizations to prevent these obstetric neglect and fetal wastages by providing accessible and affordable health-care delivery services. It is on record that the democratic government of the Borno state has launched a policy of free maternal and child health care for over a decade, but it has not been gazetted and the policy is poorly funded as such only a few women have benefitted from it. There is a need for better policy formulation and implementation on the side of government. In addition, a more sustainable policy of health insurance for all the populace will go a long way in alleviating the menace of obstructed labor.
| Conclusion|| |
The prevalence of obstructed labor is 2.13% and it remains as an important cause of feto-maternal morbidity and mortality in Maiduguri. It commonly follows CPD and the risk is higher for illiterate women, unbooked mother, and teenage primigravidas while the common complications are sepsis and uterine rupture. Much can be done at the moment, by advocacy, girl child education and public enlightenment for women to avail themselves for proper antenatal care and hospital delivery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Agboola A. Problems of labour. In: Agboola A, editor. Textbook of Obstetrics and Gynaecology for Medical Students. 2nd
ed. Lagos: Heinemann Educational Books Plc.; 2006. p. 442-51.
Obed SA. Obstructed labour. In: Kwawukume EY, Emuveyan EE, editors. Comprehensive Obstetrics in the Tropics. 2nd
ed. Dansoman: Asante & Hittscher Printing Press Limited; 2002. p. 77-83.
Mahler H. The safe motherhood initiative: A call to action. Lancet 1987;1:668-70.
World Health Organization. Maternal Mortality Ratios and Rates: A Tabulation of Available Information. 3rd
ed. Geneva: WHO; 1991. p. 5.
Kyomuhendo GB. Low use of rural maternity services in Uganda: Impact of women's status, traditional beliefs and limited resources. Reprod Health Matters 2003;11:16-26.
Kabakyenga JK, Östergren PO, Turyakira E, Mukasa PK, Pettersson KO. Individual and health facility factors and the risk for obstructed labour and its adverse outcomes in South-Western Uganda. BMC Pregnancy Childbirth 2011;11:73.
Thaddeus S, Maine D. Too far to walk: Maternal mortality in context. Soc Sci Med 1994;38:1091-110.
Nwogu-Ikojo EE, Nweze SO, Ezegwui HU. Obstructed labour in Enugu, Nigeria. J Obstet Gynaecol 2008;28:596-9.
Granja AC, Machungo F, Bergstrom S. Avoidability of maternal death in Mozambique: Audit and retrospective risk assessment in 106 consecutive cases. Afr J Health Sci 2000;7:83-7.
Konje JC, Ladipo OA. Nutrition and obstructed labor. Am J Clin Nutr 2000;72:291S-297S.
Omole-Ohonsi A, Ashimi AO. Obstructed labour – A six year review in Aminu Kano teaching hospital, Kano, Nigeria. Nig Med Pract 2007;51:59-63.
Omole-Ohonsi A, Mohammed Z. Emergency hysterectomy in Kano, Northern Nigeria. Med Rev 2005;12:4-6.
Obed JY, Mairiga A. Outcome of subsequent labour after primary caesarean section for arrest disorders in teenage pregnancies. Trop J Obstet Gynaecol 2004;21:36-9.
Fantu S, Segni H, Alemseged F. Incidence, causes and outcome of obstructed labor in Jimma university specialized hospital. Ethiop J Health Sci 2010;20:145-51.
Ritu GS, Kumar P. Obstructed labour: Incidence, causes and outcome. Int J Biol Med Res 2012;3:2185-8.
Barns T. Obstetric mortality and its causes in developing countries. Br J Obstet Gynaecol 1991;98:345-8.
Khan S, Roohi M. Obstructed labour: The preventable factors. J Pak Med Assoc 1995;45:261-3.
Melah GS, El-Nafaty AU, Massa AA, Audu BM. Obstructed labour: A public health problem in Gombe, Gombe state, Nigeria. J Obstet Gynaecol 2003;23:369-73.
Chama C, Mairiga A, Geidam A, Bako B. An assessment of policies and programs for reducing maternal mortality in Borno State, Nigeria. Afr J Reprod Health 2010;14:49-54.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]