A THREE YEARS RETROSPECTIVE ANALYSIS OF PREVALENCE, CAUSES, OUT COME AND COMPLICATION OF OBSTRUCTED LABOUR AT AYIDER REFERRAL HOSPITAL

MEKELE TOWN, TIGRAY, ETHIOPIA, 2000-2002E.C.

BY:
ESETE BERHAN

ADVISOR: DR.MULUGETA DESTA

OBSTETRICIAN) (GYECOLOGIST AND

MARCH, 2011
MEKELE, ETHIOPIA

A THREE YEARS RETROSPECTIVE ANALYSIS OF PREVALENCE, CAUSES, OUT COME AND COMPLICATION OF OBSTRUCTED LABOUR AT AYIDER REFERRAL HOSPITAL MEKELE TOWN, TIGRAY, ETHIOPIA, 2000-2002E.C.

BY:
ESETE BERHAN

RESEARCH WILL BE SUBMITTED TO A MEDICINE DEPARTMENT COLLEGE OF HEALTH SCIENCE, MEKELE UNIVERSITY IN PARTIAL FULFILMENT OF THE REQURMENT FOR THE MASTERS DEGREE IN INTEGRATED EMERGENCY SURGERY AND GYN/OBS.

ABSTRACT

Obstructed labour is an important cause of maternal deaths in communities in which under nutrition in childhood is common resulting in small pelvis in women, and in which there is no easy access to functioning health facilities with the capability of carrying out operative deliveries. Obstructed labour also causes significant maternal morbidity in the short term (notably infection) and long term (notably obstetric fistulas). Fetal death from asphyxia is also common. There are differences in the behavior of the uterus during obstructed labour, depending on whether the woman has delivered previously. The pattern in primgravid women (typically diminishing contractility with risk of infection and fistula) may result from tissue acidosis, whereas in parous women, contractility may be maintained with the risk of uterine rupture. Ultimately, tackling the problem of obstructed labour will require universal adequate nutritional intake from childhood and the ability to access adequately equipped and staffed clinical facilities when problems arise in labour. These seem still rather distant aspirations. In the meantime, strategies should be implemented to encourage early recognition of prolonged labour and appropriate clinical responses. The sequelae of obstructed

labour can be an enormous source of human misery and the prevention of obstetric fistulas, and skilled treatment if they do occur, are important priorities in regions where obstructed labour is still common(1)

OBJECTIVE The main objective of the study is to assess the prevalence, causes outcome and complication of obstructed labour at Ayder referral hospital, eastern zone, Tigray, Ethiopia METHODOLOGY A hospital based descriptive study will be conducted in the selected hospital. Data will be collected using structured questionnaire and processed using scientific calculator. WORK PLAN AND BUDGET This research will be conducted from 1/9/2003 to 30/09/2003 and the total budget to run this study is 10,000Birr.

AKNOWLEDGMENT

My deepest gratitude goes to my advisor Dr. Mulugeta Desta (gynecologist and obstetrician)

for his commitment to give his advice during my proposal building.

TABLE OF CONTENT Page Abstract-------------------------------------------------------------------------------------------Acknowledgment-------------------------------------------------------------------------------Table of content--------------------------------------------------------------------------------List of tables-------------------------------------------------------------------------------------List of abbreviations---------------------------------------------------------------------------CHAPTER ONE: -----------------------------------------------------------------------------------1. Introduction and statement of the problem-----------------------------------------CHAPTER TWO 2. Literature review----------------------------------------------------------------------------------

CHAPTER THREE 3. Significance of the study----------------------------------------------CHAPTER FOUR 4. Objective------------------------------------------------------------------4.1 General objective------------------------------------------------------------------------4.2 Specific objective------------------------------------------------------------------------CHAPTER FIVE 5. Methods and Materials ------------------------------------------------5.1 Study areas and facility -----------------------------------------------------------------5.2 study period------------------------------------------------------------------------------5.3 Study design -------------------------------------------------------------------------------5.4 Study variables---------------------------------------------------------------------------5.4.1 Dependent variable----------------------------------------------------------5.4.2Independent variable--------------------------------------------------------------5.5population and sample-------------------------------------------------------------------

5.2.1target population--------------------------------------------------------------------5.2.2sampled population-----------------------------------------------------------------5.2.3Study population----------------------------------------------------------------------

5.6 Sampling technique and Sample size determination --------------------------5.6.1 Sampling technique ----------------------------------------------------------------5.6.2 Sample size determination------------------------------------------------------5.7 Data collection technique-------------------------------------------------------------5.8 plan for data analysis and processing-----------------------------------------------5.9 Data quality assurance------------------------------------------------------------------5.10 Ethical consideration-----------------------------------------------------------------5.11 Plan for utilization and dissemination of the study---------------------------5.12 Operational definition-----------------------------------------------------------------CHAPTER SIX 6. Work plan--------------------------------------------------------------------CHAPTER SEVEN 7.Budget proposal-------------------------------------------------------CHAPTER EIGHT 8.APPENDICES 8.1Annex-1 Questionnaire------------------------------------------------------------------

8.2Annex-2 Master sheet---------------------------------------------------------------------CHAPTER NINE: 9. Reference----------------------------------------------------------

LIST OF TABLES
Table1: project work plan for studing on prevalence, causes, out come and complication of obstructed labour in the year 2000- 2002 at Ayder referral hospital Tigray, Ethiopia Table2: Budget summary for studing on prevalence, causes, out come and complication of obstructed labour in the year2000- 2003E.C at Ayder referral hospital Tigray, Ethiopia E.C Table 3: shows the mode of delivery and the total number of deliveries in the year 20002002 E.C at Ayder referral hospital, Tigray, Ethiopia. Table 4: shows the total number of obstructed labour and the causes of obstruction in the year2000- 2002 E.C at Ayder referral hospital, Tigray, Ethiopia. Table 5: shows booking status of the client and obstructed labour in the year2000- 2002E.C at Ayder referral hospital, Tigray, Ethiopia. Table 6: shows distribution of maternal age and parity by mode of deliveries in the year2000- 2002 E.C atAyder referral hospital, Tigray, Ethiopia. Table 7 : shows mode of delivery and obstructed labour in the year2000- 2002 E.C atAyder referral hospital, Tigray, Ethiopia.

Table 8: shows common causes of obstructed labour, in the year 2000-2002 E.C at Ayder referral hospital, Tigray, Ethiopia. Table 9: shows perinatal out come of obstructed labour in the year 2000-2002E.C at Ayder referral hospital, Tigray, Ethiopia.

LIST OF ABBREVATIONS CPD=Cephalo pelvic Disproportion C/S=Cesarean Section SVD=Spontaneous vertex deliveries

WHO=world health organization

CHAPTER ONE: INTRODUCTION

Each year, 210 million women become pregnant, of whom 20 million will experience pregnancy-related illness and 500,000 will die as a result of the complications of pregnancy or childbirth . In 1987, the World Health Organization (WHO) launched the Safe Motherhood Initiative, which aimed to reduce maternal morbidity and mortality by 50% by the year 2000. The initiative did not succeed but maternal health continues to be a major focus of WHO effort. The current WHO initiative is to reduce maternal mortality to 75% of the 1990 level by 2015. If this is to be successful, the problem of obstructed labour will need to be addressed effectively. Obstructed labour remains an important cause of not only maternal death but also short- and long-term disability. It has particular impact in communities in which mechanical problems during labour are common and availability of functioning relevant health services is sparse. Obstructed labour comprises one of the five major causes of maternal
3, 4 2

mortality and morbidity in developing countries , . The number of maternal deaths as a result of obstructed labour and/or rupture of the uterus varies between 4% and 70% of all maternal deaths, amounting to 5 a maternal mortality rate as high as 410/100,000 live births . The literature suggests that in many countries, maternal mortality due to this cause is almost as prevalent today as it was 30 years ago. Maternal mortality from obstructed labour is largely the result of ruptured uterus or puerperal infection, whereas perinatal mortality is mainly due to asphyxia. Significant maternal morbidity is

associated with prolonged labour, since both post-partum haemorrhage and infection are more common in women with long labours. Obstetric fistulas are long-term problems. Traumatic delivery affects both mother and child . obstructed labor may produce injuries to multiple organ systems. The best known, and most common, of these injuries is obstetric fistula formation. When obstructed labor is unrelieved, the presenting fetal part is impacted against the soft tissues of the pelvis and a widespread ischemic vascular injury develops that results in tissue necrosis and subsequent fistula formation. Unlike the postsurgical vesicovaginal fistula, however, which is usually the result of focal trauma to otherwise healthy tissues, the obstetric fistula is the result of a "field injury" to a broad area. The field injury that is produced by obstructed labor may result in multiple birth-related injuries in addition to (or instead of) a vesicovaginal fistula. Focusing simply on the "hole" between the bladder and the vagina ignores the multifaceted nature of the injury that many of these patients have sustained. These injuries may include total urethral loss, stress incontinence, hydroureteronephrosis, renal failure, rectovaginal fistula formation, rectal atresia, anal sphincter incompetence, cervical destruction, amenorrhea, pelvic inflammatory disease, secondary infertility, vaginal stenosis, osteitis pubis, and footdrop. In addition to their physical injuries, women who have experienced prolonged obstructed labor often develop serious social problems, including divorce, exclusion from religious activities, separation from their families, worsening poverty, malnutrition, and almost unendurable suffering. Isolated almost exclusively to the developing world, particularly Africa, this problem has not received the international attention that it deserves, from either a medical or a social standpoint. Obstructed labor
injury complex: obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world.
Obstet Gynecol Surv. 1996 Sep;51(9):568-74. Addis Ababa Fistula Hospital, Ethiopia.

The term obstructed labour indicates a failure to progress due to mechanical problemsa mismatch between fetal size, or more accurately, the size of the presenting part of the fetus, and the mothers pelvis, although some malpresentations, notably a brow presentation or a shoulder presentation (the latter in association with a transverse lie) will also cause obstruction. Pathological enlargement of the fetal head, as in hydrocephalus, may also (though rarely) obstruct labour. Difficult labour may also be associated with an occipito-posterior position of the fetal head and with ineffective uterine contractions (the latter often described as dysfunctional labour). These different causes of dystocia (difficult labour) may co-exist.

CHAPTER TWO 2. LITERATURE REVIEW

A retrospective analysis of all deliveries that occurred at Jimma hospital, south western Ethiopia from September 1990 to May 1999 was conducted to determine the incidence, maternal and perinatal outcome, sociodemographic and clinical characteristics of mothers with obstructed

labor. Seven percent (945/13,425) of the deliveries were complicated with obstructed labor with an overall increasing trend noted during the study period. Sixty seven percent of the cases were primigravida and grand multiparous mothers. Fourteen percent of obstructed labor occurred among teenage pregnant mothers. Forty four percent of the cases had no antenatal care while 35.1% had antenatal care. Cephalopelvic disproportion (CPD) was responsible for 80.6% of the cases, malpresentations accounting for the remainder, shoulder presentation being the commonest (11.5%). Fifty eight percent of the CPD cases were among the primigravida but para two to four mothers were not immune accounting for 25.7% of the cases, the rest being grand multipara, (15%). Fifty seven percent of the ruptured uterus cases were para two to four mothers while primigravids accounted for 7.2%. Maternal mortality was 9.1% while 62.1% of the perinates died with only 12.5% of the neonates having normal first minute apgar scores. Obstructed labor was the commonest cause of maternal and perinatal mortality at the hospital during the study period responsible for 45.5% and 37.4% of the deaths respectively. Any attempt to reduce maternal mortality at the hospital must comprehensively address the issue of obstructed labor, identify risk groups of mothers for this peripartum complication and design preventive strategies.(1) Obstructed labor at a district
hospital. Asheber Gaym Ethiopian Medical Journal (2002) Volume: 40, Issue: 1, Pages: 11-18 1.

In easter Nigeria over a five year period (1985-1989) 527 cases of obstructed labour were recorded while 11,299 deliveries were conducted giving an incidence of 4.7%. The majority of the patients (59%) were primigravidae. The incidence of obstructed labour was much higher for the unbooked patients (33%) than for the booked patients (1.7%). Cephalopelvic disproportion was the greatest cause of obstructed labour (67%), while Caesarean section was the main method of delivery (85%).

The leading complications of obstructed labour were puerperal sepsis (57%), post partum haemorrhage (15%), uterine rupture (14%), and genital tract laceration (14%). A maternal mortality rate of 32 per 1000 and a perinatal mortality rate of 294 per 1000 were recorded. Education of primary health providers and traditional birth attendants on the dangers of obstructed labour and the need for early referral is suggested to reduce the incidence of this condition. Governmental assistance is also required to improve existing health facilities so that antenatal and delivery services will be affordable to all pregnant women in the society. (2)

Apply Incidence and management of obstructed labour in eastern Nigeria. Aust N Z J Obstet Ozumba BC, Uchegbu H. Gynaecol. 1991 Aug; 31(3):213-6.

The medical files of 42 patients presented with obstructed labour to Kassala hospital ,in sudan over a period of 1 year were reviewed. The incidence of obstructed labour was 0.9%. The majority of these patients were primigravidae (52.4%), illiterate (69%), of rural residence (90.5%) and unbooked (64.3%) emergencies. Caesarean section was the mode of delivery in 95.2% and the rest (4.8%) were delivered by forceps. Ruptured uterus (14.3%) and vesico-vaginal fistulae (4.8%) were the main complications among these patients. There were 4.8% and 35.7% maternal and perinatal mortality, respectively. Thus, in this setting obstructed labour constitutes a major

threat to both mother and fetus. Maternal and perinatal outcomes of

obstructed labour in Kassala hospital, Sudan. journal of the Institute of Obstetrics and Gynaecology, 30(4), 376-377.

A criterion based audit of the management of obstructed labour was conducted in 8 hospitals in three districts in Malawi. Management practices were: (a) assessed by a retrospective review of 44 cases notes, and (b) compared with local standards established, by a multidisciplinary team, based on the Malawi Ministry of Health guidelines and World Health Organisation manuals. Gaps in current practice were identified, reasons discussed, and recommendations made and implemented. A reaudit (41 case notes) was conducted 3 months later. There were significant improvements in the attainment of four standards: draining of urinary bladder (70.5 vs. 90.2%; P = 0.022), administration of broad spectrum antibiotics (72.7 vs. 90.2%; P = 0.039), commencement of Caesarean section within 1 hour or delivery of the foetus within 2 h of diagnosis (38.6 vs. 61.0%; P = 0.023), and maintaining an observation chart (45.5 vs. 61.0%; P < 0.001). However, there was no significant change in two standards: securing an intravenous line and hydrating the patient (95.5 vs. 97.6%; P = 0.804), and typing and cross-match of blood (77.3 vs. 63.4%; P = 0.197). There was a reduction in case fatality rate (9.1 vs. 2.4%; P = 0.361) and perinatal mortality (18.8 vs. 12.2%, P = 0.462). Criterion based audit can improve the management of obstructed labour in countries with limited resources.

Obstructed labour was the second most common cause of perinatal death in Addis Ababa, Ethiopia, being responsible for 9.1 perinatal deaths/1000 births. Most obstructed labours were due to cephalopelvic disporportion. There was a ninefold increase in the perinatal death rate when the patients were anaemic but most perinatal deaths were due to delays in seeking available obstetrical care. Formal education of the patients had little influence on the death rates but the informal education that comes with prolonged urban residence had a markedly favourable effect. Use of prenatal medical services and adequate income also had a favourable influence Epidemiological features of perinatal death due to obstructed labour in Addis
Ababa. by R L Naeye, A Dozor, N Tafari, S M Ross British journal of obstetrics and gynaecology (1977) Volume: 84, Issue: 10, Pages: 747-750

CHAPTER FOUR 4. OBJECTIVES 4.1GENERAL OBJECTIES A three year retrospective analysis on the the prevalence, causes, outcomes and complication of obstructed labour at Ayder referral hospital in the year 2000- 2002 at Ayder referral hospital Tigray, Ethiopia 4.2SPECIFIC OBJECTIVE 4.2.1 To assess the prevalence of obstructed labour 4.2.2To identify the common cause of obstructed labour 4.2.3 To determine the mode of delivery in obstructed labour 4.2.4To assess the fetal out come 4.2.5to identify early complication of the mother

CHAPTER-FIVE: METHODOLOGY 5.1 STUDY AREA AND FACILITY

5.2 STUDY PERIOD The study will be on three year retrospective analysis of cesarean section from. 5.3 STUDY DESIGN Instutional based retrospective descriptive study will be conducted using available records to assess the prevalence, causes, out come and complication of obstructed labour at Ayder referral hospital in the year 2000- 2002E.C ,Tigray, Ethiopia

5.4 STUDY VARIABLES 5.4.1Dependent variables Prevalence of obstructed labour

Causes of obstructed labour

Feto-maternal out come Early complication 5.4.2 Independent variables Age Parity Fetal weight Fetal sex Mode of delivery Apgar score

.5POPULATION AND SAMPLE 5.1 Target population All mothers admitted to Gyn/obs department of Ayder referral hospital in the year 2000- 2002 E.C Tigray, Ethiopia 5.2 Sampled population All deliveries conducted at Ayder referral hospital in the year 2000- 2003 E.C Tigray, Ethiopia 5.3 Study population All obstructed labour conducted at Ayder referral hospital in the year 2000- 2002 E.C Tigray, Ethiopia

5.6. SAMPLING TECHNIQUE AND SAMPLE SIZE

5.6.1 SAMPLING TECHNIQUE Non-probability sampling method is used to selectAyder referral hospital from this Purposeful sampling strategy will be used to undergo this study.

5.6.2 SAMPLE SIZE During this study al obstructed labour conducted from September to September 2000-2002will be included and all data will be collected from their card after their card number is DR registration book .

5.7. DATA COLLECTION TECHNIQUE A structured open and closed ended questioner will be prepared to assess the prevalence, causes, outcomes and complication of obstructed labour at Ayder referral hospital to card

5.8. PLAN FOR DATA ANALYSIS AND PROCESSING Data will be analyzed by spss and using scientific calculator. Frequency, measure of central tendency and chi-square test will be calculated. Presence or absence of association and strength of association will be evaluated between dependent and independent variables. Statistical significance will be considered at p0.05 (that is CI of 95%).

5.9. DATA QUALITY ASSURANCE To increase the quality of data trained investigators from the hospital staff will be used and checked daily.

5.10. ETHICAL CONSIDERATION Formal letter that clarify about the study will be requested from the department of medicine, Ayder CHS .Then, letter will be asked from the medical director to card and record room workers, to delivery room and operation room for their cooperativeness.

5.11 PLANS FOR UTILIZATION AND DISSEMINATION OF STUDY RESULTS The study findings will be disseminated either by submitting written research report or presentation with concerned bodies.

5.12 OPERATIONAL DEFINITION

CHAPTER SIX: RESEARCH WORK PLAN . Table1: project work plan for studing on prevalence, causes, out come and complication of obstructed labour in the year 2000- 2003 at Ayder referral hospital Tigray, Ethiopia

NO_

ACTIVITIE

RESPONS IBILITY

MAR CH

APRIL

MAY JUNE

JULY

AUGUT

Topic selection 1 2 First draft proposal writing and submission to advisor

Writing of second draft proposal and submission to department Data collection Writing of first draft of the research
Writing of second draft of the research and submission to advisor

4 5

7 8

Submission of final research result Research result presentation

CHAPTER SEVEN 7. BUDGET PROPOSAL BUDGET SUMMARY

Budget summary for studing on prevalence, causes, out come and complication of obstructed labour in the year2000- 2002E.C at Ayder referral hospital Tigray, Ethiopia

No-

Item

Total price Birr 3000

cents 00

Stationary materials

Computer graphic

2000

00

Computer rent Perdiem for data collector transportation Contingency Grand total

2000 5000

00 00

4 5 6 7

1500 500 14,000

00 00 00

BUDGET BREAK DOWN

CHAPTER EIGHT 8.APPENDICES

8.1Annex-1: Questioner

This questioner is prepared by postgraduate student of Integrated emergency surgery and Gyn/obs, Medicine department, College of health science, Mekele university to collect a three year retrospective Analysis on the prevalence, causes, out come and complication of obstructed labour in the year2000- 2002E.C at Ayder referral hospital Tigray, Ethiopia Name of data collector Date of questioner filled..

Part1: Identification and socio-demographic data 1.1Name of the mother 1.2 Age, Sex 1.3Card number 1.4Adress: Woreda, Kebele 1.5Referral a. yes b. no 1.5.1 If yes from where? a. health center b. hospital c.home 1.6 time of admition.time of interventione

Part-2: General obstetrical activities 2.1Gravida., Para..... Abortion------------ Still birth 2.2what was the gestational age(by weeks)? ............... 2.3 how long the labour stay(in hrs).. 2.3 Does she pass liqure a.yes b.no 2.3.1 if yes is it before labour a.yes b.no 2.3.2if its before specify the time 2.4Booking status a. booked b. none booked

c. unknown 2.5Is there documented chronic illness? a. yes b. no 2.6If yes, what is that? a. Diabetes mellitus b. Hypertension c. Congestive heart failure d.others (specify 2.7What was the HIV sero status of the women? a. non reactive b. reactive c. not tasted

2.8At arrival what was the physical findings a. any vls derangement a.yes. b.no Ifyes specify. b.tumer abdomain a.yes. b.no.. c.edematous vulv a.yes. b.no.. 2.9what was cervical statusa. a.Cx dilatation.not documented b..station not documented. c. caput . not documented.. d..molding. not documented. e..type of liquer. not documented. 2.10 what was the cause for obstructed labor I. Malpresentation a. yes no if yes A, Brow presentation B,Face presentation

C,Transverse lie D,Breech presentation a. footling b. big baby(weight >3500 g.m) E. Parietal bone presentation a.anterior asynclitism.. b. posterior asynclitisam. F. others(specify ).

II.MAL POSITION a. deep transverse arrest b. persistent ociput posterior III. Contracted pelvis yes.. no IV Macrosomia (weight >5000g.m)yes .. no.. V. Other (specify) -----------------------------

3. what was the intervention done? 3.1.1instrumental delivery 3.1.1Vacum.. 3.1.2forceps 3.1.3destructive delivery a. Craniotomy ----------------b. Evisceration ---------------c. Cleidotomy ----------------d. Decapitation --------------e. Cranicentesis 3.1.4c/s.. 3.2What was the type of abdominal incision? a. midline b pfannensteil c. misgaveladach d. others(specify)---------------3.3 how was the intera op finding of the ux a. intact b.ruptured.. 3.4What was the type of uterine incision? a. LUSTC/S b. Classical c/s c. Low vertical c/s d. Inverted T c/s e. J-type c/s f. Extra peritoneal c/s

.3.5 What was the fetal out come? a. alive b. dead c. congenital malformed(type----------------) 3.5.1 What was the fetal tone? a. single b. twin c. >twin 3.5.2 What was the fetal sex? a. male, female b. male, female c. male, female 3.5.3What was the fetal weight? -------------------

3.5.4 What was the Apgar score at first and fifth minute? a. ------ and----- b. -----3.6What was the maternal out come? a. good b. with complication c. dead 3.7 If maternal complication; 3.7 .1 When was the complication? a. intra operative b. <24 hours of operation c. >24 hours post operative 3.7 .2was the complication? a. hemorrhage b. anesthesia related c. trauma to nearby structures d. sepsis e. fistula f. wound infection g. wound dehiscence h. throb embolic disease i. others(specify)--------------3.7.3If hemorrhage; what was the cause? a. uterine atony b. trauma(iatrogenic) c. adherent placenta d. coagulation disorder e. others(specify)----------3.7 4 If trauma to nearby structure; which one is the affected organ? a. ureteral injury or ligation b. bladder c. bowel d. uterine laceration e. others(specify)-------------3.7 .5If sepsis what was the identified cause? a. endomyometritis b. wound site infection c. others(specify)-------------3.7.6 What was done? a. hysterectomy b. blood transfusion c. repair of the injured organ d. antibiotic e. resuscitation with crystalloids f. others(specify)----------------3.7.7 If she was transfused how many units of blood? ------------------3.7.8 If mother is dead; 3.78.1 When was it happen? a. intra-operative b. <2 hour of operation c,<24 hour of operation d.>24 hour of operation

Part-4Assessing the prevalence

4.1Total number of deliveries conducted from 2000-2002e.c at Ayder referral hospital are ---4.2 From this A. total SVD are -------------------B. total instrumental deliveries are----------a) Vacuum --------------b) Forceps ---------------C. total destructive deliveries----------------a) Craniotomy ----------------b) Evisceration ---------------c) Cleidotomy ----------------d) Decapitation --------------e) Cranicentesis -------------D. total c/s--------------------a) LUSTc/s ----------------------b) Classical c/s ------------------c) Inverted-T c/s -----------------d) J-type c/s ----------------------e) Low vertical c/s --------------f) Extra peritoneal c/s -----------E .Total number of obstructed cases..

8.2Annex-2: Master sheet

shows the mode of delivery and the total number of deliveries in the year 2000-2002 E.C at Ayder referral hospital, Tigray, Ethiopia.

Referances 1.

5.2 STUDY PERIOD

5.3 STUDY DESIGN

5.4 STUDY VARIABLES 5.4.1Dependent variables

5.4.2 Independent variables

5.5 POPULATION AND SAMPLE 5.1 Target population

5.2 Sampled population

5.3 Study population

5.6. SAMPLING TECHNIQUE AND SAMPLE SIZE 5.6.1 SAMPLING TECHNIQUE