Nutrition and obstructed labor13

Justin C Konje and Oladapo A Ladipo

KEY WORDS
Obstructed labor, cephalopelvic disproportion,
supplementation, intergenerational effects

INTRODUCTION
Nutrition is important in reproduction, including the safe delivery of infants. Philpott (1) and Moller and Lindmark (2) showed
that failure to achieve a normal delivery was directly related to the
height of the mother, which is influenced by nutritional status in
childhood and adolescence. Flattening of the pelvis is generally
associated with a height < 152 cm (3). Other factors that can cause
poor or distorted pelvic growth are rickets in infancy and childhood and osteomalacia in adolescence and adulthood (4). Early
studies of the African pelvis showed that although the brim of the
pelvis has a normal female shape, it is markedly smaller in all its
diameters, and the resulting disproportion between the fetal head
and the maternal pelvis (cephalopelvic disproportion) is a major
indication for cesarean delivery due to obstructed labor (5).
Obstructed labor occurs when the passage of the fetus through
the pelvis is mechanically obstructed. When it is not diagnosed
quickly, or when it is improperly managed, obstructed labor is
associated with significant complications. It is a major cause of
maternal mortality, accounting for 15 deaths/1000 live births
(69). In Bangladesh, for example, obstructed labor was found
to be the third most common cause of maternal mortality in one
study (10) and the most important cause of mortality in another
(11). In addition to its effects on maternal mortality, obstructed
labor can be a significant contributor to infant perinatal morbidity and mortality (6).
The prevalence of obstructed labor varies from one country to
another, but it is more common in developing countries (12)

because of the lack of adequate health care delivery facilities,

poor nutrition, poverty (13), and socioeconomic and cultural factors that oppose orthodox antenatal care and delivery (14). In
developing countries, the incidence of obstructed labor is difficult
to estimate, primarily because of poor data collection procedures
and secondarily because most of the reported studies are based on
data from large, tertiary hospitals. Nevertheless, reported incidences vary from 12/100 deliveries in Nigeria (6, 15) to
3/100 deliveries in India (16). Estimates of these incidences are
independent of cesarean delivery rates because most obstructed
labors in developing countries were (4)and are stillbeing
treated by destructive operative deliveries (see below) rather than
by cesarean delivery (JC Konje unpublished observation, 1998).
In cultures where child marriage is common and pregnancy
occurs soon after menarche, obstructed labor can be common
because young adolescent girls may not have achieved their
maximal growth potential and thus start childbearing with an
inadequate pelvis (17). Obstructed labor can also occur in subsequent pregnancies in which maternal nutrient deprivation may
result in a distorted pelvis, or in women prone to pelvic fractures
and other acquired pelvic deformities (4). Nutrient deficiencies
such as calcium, vitamin D, folic acid, iron, and zinc deficiencies
interact in combination with various biological and biosocial
factors to determine the prevalence of obstructed labor (4). This
article discusses the potential role of nutrition in the origins of
obstructed labor and possible preventive nutritional measures.

ETIOLOGY
The most common cause of obstructed labor is disproportion
between the fetus head and the mothers pelvis. Occasionally,
however, obstruction is secondary to malpresentation, malposition, and fetal abnormalities, especially in women who deliver at
home unattended, or with the help of an untrained midwife (6).

1
From the University Department of Obstetrics and Gynaecology, Leicester Royal Infirmary, Leicester, United Kingdom, and the Department of
Obstetrics and Gynaecology, University of Wales College of Medicine, Heath
Park, United Kingdom.
2
Presented at the meeting Iron and Maternal Mortality in the Developing
World, held in Washington, DC, July 67, 1998.
3
Reprints not available. Address correspondence to JC Konje, University
Department of Obstetrics and Gynaecology, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX, United Kingdom. E-mail: justin.konje@gyn.obs.msmail.lri-tr.trent.nhs.uk.

Am J Clin Nutr 2000;72(suppl):291S7S. Printed in USA. 2000 American Society for Clinical Nutrition

291S

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ABSTRACT
Obstructed labor is one of the most common
preventable causes of maternal and perinatal morbidity and
mortality in developing countries. Among the common causes
are cephalopelvic disproportion, malpresentation, and malposition. Recognizing the causes of obstructed labor is important if
the complications are to be prevented. Adequate prevention,
however, can be achieved only through a multidisciplinary
approach aimed in the short term at identifying high-risk cases
and in the long term at improving nutrition. Early motherhood
should be discouraged, and efforts are needed to improve nutrition during infancy, childhood, early adulthood, and pregnancy.
Improving the access to and promoting the use of reproductive
and contraceptive services will help reduce the prevalence of this
complication.
Am J Clin Nutr 2000;72(suppl):291S7S.

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The availability of ultrasound for detection of obstructed labor

reduces the prevalence of malpresentation complications, but
this is not often an option for most women in developing countries. Although there are many other causes of obstructed labor
(1823), their contribution is small compared with that secondary to disproportion, and they are nonnutritional in origin.
Short stature

Calcium
Even after growth in height has stopped, there is a continuous
need to lay down calcium in bone to maintain bone structure and,
therefore, the shape of the pelvis. Calcium deficiency affects the
bony pelvis. Severe deficiency causes rickets in children and
causes osteomalacia in adults. Unlike rickets, which affects bones
before the closure of the epiphyses, osteomalacia causes decalcification of fully formed bones. Osteomalacia is seldom seen in first
pregnancies unless rickets in childhood has been followed by persistent vitamin D deficiency in puberty (4). Osteomalcia can
develop after several pregnancies and worsens without treatment
(4). Osteomalacia in women is more common in rural and economically deprived areas where lactation by the already nutritionally deprived women is prolonged and, additionally, the interval
between pregnancies is not long enough to allow for replenishment of calcium stores (4). Although Brunvand et al (40) reported
that vitamin D deficiency, which can cause osteomalacia and subsequent maternal pelvic deformities, is common in Karachi, it was
not associated with obstructed labor. What is uncertain is the
severity of vitamin D deficiency in these communities. Mild deficiencies alone are not enough to cause osteomalacia.
Defective calcium absorption or poor bioavailability are causes
of vitamin D deficiency and, therefore, osteomalacia (41), which
may cause pelvic deformities and subsequently obstructed labor.
In fact, Chaim et al (42) observed a few cases of pelvic deformities of the osteomalacia type in Bedouin women who consumed
large quantities of raghif, an unleavened bread with a high content of phytic acid. Insufficient dietary intake of vitamin D compounded by inadequate exposure to sunlight, which reduces the
synthesis of vitamin D from cholecalciferol in the skin, are other
factors that can cause osteomalacia. Vitamin D deficiency often
occurs in situations in which calcium intake or bioavailability is
also precarious because this enhances the metabolic inactivation
of vitamin D (43).

The demand for both energy and nutrients is increased during

pregnancy. For well-nourished women, only a small amount of
additional energy is required because the body adapts to the
increased energy demands and becomes more energy efficient by
reducing physical activity and lowering the metabolic rate. It is
only during the last trimester of pregnancy that average-sized,
well-nourished women require an extra <849 kJ/d (44). Research
on pregnancy weight gain in women with normal prepregnancy
weight showed that high gestational weight gain increases birth
weight (45). Studies of white and Asian women, who are at a high
nutritional risk in the West Midlands, England, and in Indonesia,
showed that protein-energy supplementation during pregnancy
did not significantly affect birth weight and length (46, 47). Similarly, Kramer (48) concluded that prenatal protein-energy supplementation proffered little benefit to either mothers or infants.
Other studies, however, have shown that protein-energy supplementation of pregnant women at risk of delivering a low-birthweight infant enhanced intrauterine growth (4953).
Garner et al (54) suggested that interventions to increase birth
weight could be hazardous to women because they could lead to
more mechanical difficulties in labor in areas where access to the
proper care might not be available. Few data are available to support this hypothesis. Prenatal supplementation (60 mg Fe and
250 mg folate, with or without 15 mg Zn) in Peru produced no
effect on birth weight or head circumference (55). Goldenberg et
al (56), however, found that daily supplementation with 25 mg
Zn in early pregnancy for women with relatively low plasma zinc
concentrations was associated with greater infant birth weights
(126 g; P < 0.03) and head circumferences (0.4 cm; P < 0.02).
This effect was greater in women with a body mass index
< 26 (expressed in kg/m2), in whom birth weight was 248 g
higher (P = 0.005) and head circumference was 0.7 cm larger
(P = 0.007). Ceesay et al (52) found a small (3.1 mm) but statistically significant (P < 0.01) increase in head circumference with
daily high-energy supplementation (4.3 MJ), which translated
into an increase of only 1.5 mm in diameter, which is unlikely to
increase the prevalence of cephalopelvic disproportion.
Secular studies of birth weight showed an increase across generations with no reported adverse effects (57), presumably
because other secular changes in maternal proportions also occur
and this increase in fetal size does not create cephalopelvic disproportion. Li et al (58) found that mean birth weights of infants
born to Southeast Asian parents who were born outside the
United States increased annually by <18 g (95% CI: 11, 25 g)
between 19081981 and 1986. A similar secular change of birth
weight during the same period was not observed for infants of
US-born Asian mothers. This, the authors suggest, shows that
migration from their native countries to the United States had a
positive effect on the birth weight of infants born to these mothers. Secular changes in birth weight were also observed in Asians
living in England (59). Infants of migrant Pakistanis were 139 g
heavier and those of migrant Indians 25 g heavier in 1978 than
they had been 10 y earlier, reinforcing the concept that environmental factors play an important role in intrauterine growth.
Despite the absence of any negative effect of supplementation
on obstructed labor, the situation may be different for women
whose skeletaland, therefore, pelvicgrowth was restricted
during childhood and early adolescence but whose general food
intake increased later. Abitbol et al (60) reported that mothers
born and raised outside of the United States (with narrow pelvic

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Many studies that examined anthropometric measures as predictors of fetomaternal disproportion provided evidence that the
shorter a woman is, the more likely is significant disproportion
between the fetus and the maternal pelvis, which results in
obstructed labor (2431). Although maternal height can predict
the risk of obstructed labor, it is also an index of a womans general health and nutritional status from her childhood, in which
genetic factors play a major role. Thus, the obstetric significance
of a particular height needs to be related to the patients own
genetic background (2, 33). This is exemplified by the various
cutoff points that have been identified in different studies as
being associated with or predicting an increased risk of
obstructed labor. For example, associations have been identified
for heights 150153 cm in Ghana (27, 33), < 155 cm in Burkina Faso (29), < 156 cm in Denmark (34), 150 cm in Kenya
(35), < 146 cm in Tanzania (36), and < 140 cm in India (37);
cesarean deliveries were predicted by a height < 160 cm in Zimbabwe (38) and 157 cm in the United States (39).

Macronutrient intake and weight gain in pregnancy

NUTRITION AND OBSTRUCTED LABOR

dimensions) who eat a high-protein diet and receive adequate
prenatal care after migrating as adults to the United States give
birth to relatively large infants. This results in a marked cephalopelvic disproportion and severe dystocia, which frequently leads
to cesarean delivery. Observations from the United Kingdom
(JC Konje, unpublished observations, 1999) show that fetomaternal disproportion is more common in first-generation than in second-generation minority groups. These effects are more marked in
women who are shorter and by inference more growth retarded.

PREVENTION
Breaking the intergenerational cycle of growth failure
An intergenerational cycle of ill health and growth failure has
been described in which undernutrition in childhood leads to
small body size in adulthood. The critical periods are the
intrauterine period, early childhood, and adolescence.
Intrauterine growth
Genetic and environmental influences affect maternal height
and prepregnancy weight, both of which are important determinants of birth size (67). Malnourished women (ie, women who
are short, underweight, do not gain sufficient weight during
pregnancy, or are anemic) are more likely to deliver intrauterinegrowth-restricted or low-birth-weight infants (6870). Low birth
weight and intrauterine growth restriction are not independent
because birth weight is affected by intrauterine growth and gestation age; thus, both conditions need to be optimized to reduce

the prevalence of low birth weight. Prentice (71) reviewed foodsupplementation programs targeted at pregnant women and concluded that supplementation during late pregnancy can have a
significant beneficial effect on birth weight in women who are
genuinely at risk as a result of an inadequate home diet. The
effect of food supplements will depend most likely on the nutritional status of the woman, which is multifactorial, and few good
intervention studies have been conducted. Efforts to reverse
intrauterine growth restriction have been disappointing and at
times risky (72). Nevertheless, Strauss (72) agrees with Prentice
(71) that energy supplementation in undernourished populations
may be of significant benefit.
The concept of altering food and energy supplementation to
influence intrauterine growth and therefore reduce fetal size and
obstructed labor as proposed by Rush (73) is not justified. This
is not only because of the multifactorial nature of fetal growth,
but also because embarking on such a policy is not only unethical, it is also scientifically flawed. Having access to nutrition
education during pregnancy is a fundamental human right and to
not promote adequate food intake just because women are short,
to theoretically reduce the risk of obstructed labor, is unacceptable in our contemporary world. There is epidemiologic evidence linking intrauterine growth and adult diseases such as
diabetes mellitus, ischemic heart attack, and early death from
stroke and hypertension (74). Deliberately withholding nutrition
education or food supplementation during pregnancy may indirectly condemn offspring in future generations to these complications. There is insufficient justification on the basis of available evidence for such programmatic action.
Maternal micronutrient status may also affect the status of
young offspring. A longitudinal study in Malawi among HIVseropositive mothers showed that maternal vitamin A deficiency
was related to linear growth of children after adjustment for confounding factors. At 1 y of age, children of vitamin Adeficient
mothers were shorter than children of nondeficient mothers (75).
Ramakrishnan et al (76) examined the intergenerational
effects of growth by using data from 14 studies of middle-class
populations in developed countries. Overall, for every 100-g
increase in maternal weight at the time of birth, child birth
weight increased by 1020 g. In a prospective analysis of data
from Guatemala, Ramakrishnan et al (76) found that child birth
weight increased by 29 g for every 100-g increase in maternal
birth weight, which was almost double that reported for developed countries. Child birth weight increased by 53 g per 1-cm
increase in maternal birth length, but this was reduced to 38 g/cm
after maternal height and prepregnancy weight were controlled
for, which the authors suggested was due to the intergenerational
effects of maternal birth size. Child birth length also increased
by 0.2 cm per 1-cm increase in mothers birth length and by
0.1 cm per 100-g increase in maternal birth weight, although the
former was not significant after adult size was controlled for.
Growth in childhood
The most striking effects of the intrauterine environment on
childhood growth are seen in children with intrauterine growth
restriction, who remain significantly lighter and shorter than
their peers (72). There is some tendency for catch-up growth in
low-birth-weight children, but the deficits can persist even up to
1214 y of age (77, 78); children at greatest risk of long-term
stunting were low-birth-weight infants who were also severely
stunted during infancy. The potential for catch-up growth in a

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CONSEQUENCES OF OBSTRUCTED LABOR

Once obstructed labor has been diagnosed, the obstruction
must be relieved. The method of relief will be determined by various factors, including the state of the mother, the state of the
fetus, associated complications, and the environment. The initial
steps should be adequate resuscitation of the mother by rehydration and intravenous provision of fluids and energy, and, when
infections are thought to have supervened, antibiotics. Immediately thereafter, the fetus must be delivered. When the fetus is
alive, a safe delivery for both the mother and the fetus must be the
option. When the fetus is dead, most women in developed countries will be offered a cesarean delivery. In developing countries,
management should aim to reduce complications and simultaneously ensure that the woman and her family maintain some
confidence in the health care facility. Often, this may mean a
destructive operation rather than a cesarean delivery. This is
important because women with obstructed labor often avoid hospitals in the first instance because of fear of cesarean delivery (3).
Moreover, performing a cesarean delivery that does not result in
a live baby will further reinforce a womans fears and result in her
delivering at home in subsequent pregnancies, which increases
the risk of uterine rupture and possibly maternal mortality (61).
If improperly managed, obstructed labor is associated with
very severe complications. 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. Some of the
more common complications that can be considered nutritionally
relevant are high perinatal morbidity and mortality (62), infections of the uterus and the urinary tract (6), maternal mortality
(10, 11, 6365), and secondary amenorrhea (66).

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Adolescent growth
Brabin and Brabin (94) looked at adolescence, which is an
intense anabolic period during which requirements for all nutrients increase. They suggested that the process of catch-up
growth may increase nutritional risk because it reduces stores of
critical micronutrients such as iron and vitamin A. On the basis
of studies showing improved growth after iron supplementation,
Brabin and Brabin also postulated that iron is an essential nutrient for skeletal growth and that deficiency may limit growth during adolescence. Similarly, on the basis of data from Swedish
adolescents that showed an association between serum retinol
and puberty stage, they suggested that vitamin A is important for
sexual maturation and that deficiency can cause menstrual irregularities, such as menorrhagia, and thus contribute to anemia.
Ilich-Ernst et al (95) performed a longitudinal study to look at,
among other things, the simultaneous effect of growth and
menarche on iron stores in adolescent girls. They found that the
adolescent growth spurt and menstrual losses adversely affected

iron stores in girls with low iron intakes (< 9 mg/d). Delayed
puberty has been reported in low-birth-weight children (96, 97),
although Bhargava et al (98) documented an earlier onset of
menarche in these children in a longitudinal study.
Pregnancy in adolescence imposes an even greater physiologic burden on girls, which is often worsened by poor dietary
intakes and failure to use antenatal care optimally. Increased
extraction from the adolescent parturient of nutrients (eg, iron,
folic acid, and essential amino acids) when there are inadequate
stores will result in deficiency and its consequent complications.
Because adolescents are still growing, the implications of deficiency are restricted growth and fetopelvic disproportion that
may result in obstructed labor.
Although a considerable amount of work has been invested in
supplementing preschool children, few data are available to indicate whether food or micronutrient supplementation of girls during the rapid preadolescent growth phase can increase attained
height, which could ultimately contribute to reducing maternal
morbidity and mortality from obstructed labor.
Improved health
Growth in length is also compromised by common childhood
infections, particularly diarrheal diseases in early childhood
(99, 100). Infants with sustained Helicobacter pylori infection
also grow less well than do children without the infection
(101). Single and multiple helminthic infections have been
shown to be associated with growth retardation (86) and catchup growth has occurred in preschool-aged children after
deworming (102, 103). Deworming school-aged children was
also shown to improve physical growth (104). The adverse
effects of chronic and acute infections on linear growth may
result from micronutrient malnutrition or the induction of the
acute phase response and production of proinflammatory
cytokines that can affect long bone growth (99).
In some societies, a large number of adolescents are sexually
active, resulting in a high prevalence of sexually transmitted diseases (105), such as HIV (106, 107), syphilis, and chlamydia
(108). Some of these diseases are more prevalent in undernourished and immunocompromised individuals. Improved nutrition
may, therefore, enhance growth not only directly but also indirectly by improving the immunologic status of adolescents.
To improve the health of women of reproductive age, health
care providers need to be trained to identify women at high risk
of obstructed labor (and other pregnancy complications) and the
factors that can diminish this risk. Improving the utilization of
health care facilities during pregnancy, especially in areas with
early adolescent marriage, and the introduction of nutrition education and supplementation programs could reduce the prevalence of obstructed labor.

CONCLUSIONS
Obstructed labor remains a common cause of maternal morbidity and mortality in developing countries. However, the
prevalence and incidence rates are unknown. Even in developed
countries, intervention often occurs before labor becomes
obstructed; thus, it is difficult to determine true incidence and
prevalence rates. Eliminating obstructed labor will be difficult
unless adequate data on prevalence become available; to this
end, a better definition of an acceptable international standard
for the diagnosis is needed, probably under the auspices of the

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cohort of Filipino children aged 212-y was greatest for children

with greater growth potential, ie, those with taller mothers,
longer length and lower ponderal index at birth, and less severe
stunting during early infancy (78).
Poor food intake in early childhood is known to affect longterm physical growth (79, 80). The effects of single micronutrient
supplementation on growth were also studied. Vitamin A supplementation had no effect on linear growth for preschool boys and
girls in randomized supplementation trials in Indonesia (81),
India (82), and the Sudan (83). The situation of linear growth
with iron is equivocal. Among iron-deficient children (1.513 y
of age), growth was improved after 815 wk of iron supplementation (8487), although Gershoff et al (88) and Migasena et al
(89) did not confirm these findings. Angeles et al (87) attributed
the improvement in growth to reduced morbidity after iron supplementation. Allen (90) suggested that these mixed results may
reflect the short duration of the interventions. Alternatively, the
treatment effect may occur only if the child was initially anemic.
Brown et al (91) conducted a meta-analysis of 25 zinc intervention trials of children 013 y of age (mean: 3.6 y). Zinc supplementation had a significant effect on height (0.22 SD units),
and the effects were greatest for the children who were the most
zinc deficient or the most growth stunted. A randomized, controlled trial among rural Zimbabwean schoolchildren, however,
found no effect of zinc supplementation on growth (92). Only
one study was found that looked at the effect of multiple
micronutrient (ie, vitamins A, C, D, E, K, B-12, B-6, niacin, thiamine, riboflavin, folic acid, pantothenic acid, iodine, iron, zinc,
copper, manganese, and fluoride) supplementation on the growth
of children aged 814 mo in a double-blind, community-based,
randomized trial (93). Treatment was administered under supervision 6 d/wk over 12 mo. Final length in the supplemented
group was 0.6 cm greater than in the placebo group after background variables were controlled for. Nevertheless, the effect
was lower than expected for catch-up growth, which led the
authors to suggest that supplementation with more than the
apparently deficient nutrients is required. Allen (90), in her summary of a review of nutrient deficiencies and linear growth faltering, noted that single nutrient supplementation has not had the
effect on growth that would be expected if that nutrient were limiting. She too suggested that multiplerather than single
growth-limiting nutrient deficiencies coexist in children.

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World Health Organization. For example, a clear distinction has

to be made between prolonged labor (resulting from inertia) and
obstructed labor (which is mechanical). In this regard, there is
the need to reeducate midwives, physicians, and all health care
personnel. Population-based studies in different geographic
zones will provide the necessary data on the prevalence rate of
this complication of pregnancy. This can be achieved only
through cooperation among governments; voluntary agencies;
and primary, secondary, and tertiary care providers. A more
effective means of assessing prevalence may be hospital
cesarean delivery rates for failure to progress in labor due to disproportion. Such data, however, are likely to be biased toward
urban areas and possibly the middle and upper classes. Nevertheless, these data can help to improve the standardization of
data collection and provide a better understanding of the magnitude of the problem for programmatic action.
A major cause of obstructed labor is fetomaternal disproportion. Intergenerational cycles of chronic undernutrition, which
may include calcium deficiency, are responsible for this in a large
proportion of cases. Because of this, it may take more than one
generation to overcome the effects of childhood disadvantage; the
most effective way to reduce the incidence of obstructed labor is,
therefore, to adopt measures to improve the health and nutrition
of children during their rapid periods of growth, ie, infancy, early
childhood, and adolescence. This means that an efficacious policy would be one that included effective interventions initiated
from as early as infancy to beyond the conventional preschool
years. Such programs must not only concentrate on nutrients that
enhance skeletal growth but also aim to improve the general
nutrition of the infant, child, and adolescent girl. Interventions
should include infection control, the provision of hematinics, and,
in some situations, calcium supplements.
Efforts must be made to increase the awareness of the importance of good health, especially during the adolescent period,
including the need for a balanced diet and the elimination of
infections in early childhood that commonly exist in malnourished children. Such infections potentiate the effects of nutrient
deprivation on growth. Policies that encourage formal education
of young women, delay the age of marriage, and promote family
planning and contraceptive use may result in the age of first
pregnancy being delayed and, therefore, increase the chance of
girls completing adolescent growth.
For women who are undernourished and who have not
achieved their full growth potential (ie, have a small pelvis),
macro- and micronutrient supplementation may be important for
fetal growth. Intrauterine growth can influence child and adolescent growth, and the effect is intergenerational. For this reason, it
is likely to take a few generations to achieve secular changes in
growth that will reduce and possibly even eliminate obstructed
labor. There may be some justification in trading a transient
increase in cesarean delivery for disproportion to future reduction
in stunted growth and thus the eventual elimination of obstructed
labor. However, the theoretical fear of increased obstruction can
be obviated by the inclusion of an education program that encourages women in rural communities to accept orthodox health care
and by a simultaneous increase in the number in health care centers and personnel in such communities.

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