This study aimed to establish reference values for heart rate frequency and variability indices in preterm neonates admitted to a neonatal intensive care unit of a tertiary care hospital during their first week of life. In this retrospective cohort study, the Generalized Additive Models for Location Scale and Shape framework was employed to establish reference values for heart rate indices across time-domain, frequency-domain and nonlinear-domain in neonates considering gestational age, postnatal age, sex and birth weight. Heart rate tracings of 594 neonates (45% female; median gestational age at birth 29⁰ (IQR 26⁶-30⁵); 38% birth weight <p10, 6% birth weight >p90) were analyzed. Reference values were established for 25 heart rate indices. Nearly all heart rate indices were significantly influenced by gestational age, postnatal age and sex. Baseline heart rate decreased with gestational age, increased with postnatal age and was higher in females. Heart rate standard deviation increased with gestational age and postnatal age and was lower in female. Inclusion of birth weight significantly improved model fit for all HRV indices. This study highlights the importance of considering gestational and postnatal age, sex and birth weight when interpreting neonatal heart rate frequency and variability in preterm neonates. These findings support the need for personalized approaches for neonatal monitoring and interpretation. Future research should validate these values in larger, more diverse populations, including additional clinical factors such as neonatal complications and medication administration, to determine their clinical relevance.

Objective: Grasping force control is crucial for safe laparoscopic surgery. However, force feedback is limited as haptic information on grasping strength and tissue stiffness is mostly lost due to internal instrument backlash and friction. This increases tissue trauma risk as excessive grasping forces can lead to (postoperative) complications. This study aims to develop a grasping force feedback providing add-on for a laparoscopic grasper and to validate its impact on skills acquisition in basic laparoscopic skills training. Method: The ShaftFlex, a shaft-based grasping force measurement system providing feedback was designed as an add-on for standard reusable instruments. It consists of a compliant element deflecting proportionally to the applied grasping force, and a Hall sensor measuring that deflection. Influence on skills acquisition was evaluated in a comparative study where novices were divided into a Feedback and No feedback group, performing five training trials of a silicon torus transfer boxtrainer task. Afterwards, both groups performed a post-training task without feedback. Grasping force, time to completion and number of errors were measured. Results: There was a significant difference in mean grasping force between groups for all training trials and the post-training trial. In the Feedback group, there was no significant increase in grasping force when feedback was removed. Conclusions: The ShaftFlex working principle provided a feasible, sustainable method to measure grasping forces exerted by a laparoscopic grasper, enabling immediate haptic feedback. It potentially enhances objective skill assessment, providing feedback on training performance. In a clinical context, the ShaftFlex might be useful in surgery where delicate tissue is grasped.

Shock is a life-threatening condition marked by inadequate tissue perfusion and oxygen supply, leading to organ failure if not rapidly addressed. Clinical management of shock involves detecting and correcting altered macro hemodynamic parameters. However, these parameters may not accurately reflect microcirculatory alterations or abnormalities in oxygenation. A resuscitation strategy focused on peripheral perfusion, which can be non-invasively monitored, may allow for earlier shock detection and treatment, potentially reducing mortality. This literature review aims to study the available technologies found in literature and in patents to non-invasively monitor peripheral perfusion. PRISMA method was employed to systematically select or exclude articles and patents, resulting in 44 studies and 21 patents included in the review. The found technologies were classified based on the sensing principle in light (reflected, transmitted, or scattered), Doppler effect, temperature, and skin mottling. Combining the monitorization of microcirculatory with macrocirculatory parameters has the potential to have an accurate prognosis value for shock and other diseases. However, the various technologies that have been developed to monitor peripheral perfusion require further research and testing in diverse conditions.

Introduction: Preterm infants’ growth is typically monitored through weight, body length (BL) and head circumference (HC). However, 3D cranial volume (CrV) is considered a more accurate indicator of brain growth than 2D HC. The PreemieScanner is a novel 3D measuring device that simultaneously measures BL, HC and CrV. Its clinical usability was tested in a simulated NICU setting. Materials and methods: Three extremely low birth weight (ELBW; BW < 1,000 gram) dolls with Optiflow breathing systems, (tubes positioned either at the front or back of the head) were used. Nurses conducted scan sessions and marked anatomical landmarks on 3D PreemieScanner images. As control, nurses measured HC manually with a standard measuring tape. Key outcomes were: (1) Measurement success rate, (2) Precision—percentage within clinically allowed limits, ±0.4 cm for BL, ±0.3 cm for HC, ±12 ml for CrV, and 3) accuracy—mean or median measurement error (MME) relative to the ground truth. Results: Thirty-five scan sessions resulted in 100% successful measurements for BL and HC; 80% for CrV. BL MME −3.3% (p < 0.001); 40% (42/105) within precision limits. HC MME (Optiflow-front) 0.0% (p = 0.63); 89% (51/57) within limits. HC MME (Optiflow-back) −0.4% (p = 0.91). 93% (43/46) within limits. MME HC measuring tape, (Optiflow-front) −0.8% (p < 0.001), 88% (50/57) within limits, and MME (Optiflow-back) −1.1% (p < 0.001), 83% (40/48) within limits. MME CrV (Optiflow-front) −1.8% (p = 0.01), 86% (31/36) within limits, MME CrV (Optiflow-back) −1.3% (p < 0.001), 98% (45/46) within limits. Conclusions: The PreemieScanner is a reliable, comprehensive device for measuring BL, HC and CrV in ELBW infants. It integrates smoothly into routine care with minimal disturbance. HC measurements demonstrated higher accuracy and precision than traditional tape method. CrV measurements, with 93% within precision limits, can be regarded as acceptable, enabling development of CrV growth reference charts, enhancing clinical growth monitoring.

Annually, 14-41 per 100 000 infants get mildly to lethally injured or severely disabled through violent shaking. The incidence and mortality of inflicted head injury by shaking trauma (IHI-ST) are highest in the early months and decrease with age. This may partly be due to the age-related physical characteristics of infants. Younger, smaller infants are more vulnerable owing to their size and material properties. In addition, from basic biomechanics, it is expected that larger or heavier infants may be more difficult to fiercely shake and will exhibit different motion patterns when being shaken violently. Therefore, the aim of this study was to compare the kinematics of shaking a smaller versus a larger infant dummy. We recorded the kinematics of two dummies, representing a 6-week-old and a 1-year-old, while they were violently shaken by volunteers. We found that participants induced higher head and torso accelerations when shaking the 6-week-old, than with the 1-year-old dummy. Moreover, higher peak sagittal angular accelerations coincide with smaller radii of rotation in the 6-week-old than in the 1-year-old. Because it has been suggested in the literature that sagittal angular acceleration of the head is an important mechanism in inducing the injuries associated with IHI-ST; the results of this study show that shaking a smaller/younger infant is more likely to cause the kinematics possibly responsible for IHI-ST.

Endovascular intervention is a minimally invasive method for treating cardiovascular diseases. Although fluoroscopy, known for real-time catheter visualization, is commonly used, it exposes patients and physicians to ionizing radiation and lacks depth perception due to its 2D nature. To address these limitations, a study was conducted using teleoperation and 3D visualization techniques. This in-vitro study involved the use of a robotic catheter system and aimed to evaluate user performance through both subjective and objective measures. The focus was on determining the most effective modes of interaction. Three interactive modes for guiding robotic catheters were compared in the study: 1) Mode GM, using a gamepad for control and a standard 2D monitor for visual feedback; 2) Mode GH, with a gamepad for control and HoloLens providing 3D visualization; and 3) Mode HH, where HoloLens serves as both control input and visualization device. Mode GH outperformed other modalities in subjective metrics, except for mental demand. It exhibited a median tracking error of 4.72 mm, a median targeting error of 1.01 mm, a median duration of 82.34 s, and a median natural logarithm of dimensionless squared jerk of 40.38 in the in-vitro study. Mode GH showed 8.5%, 4.7%, 6.5%, and 3.9% improvements over Mode GM and 1.5%, 33.6%, 34.9%, and 8.1% over Mode HH for tracking error, targeting error, duration, and dimensionless squared jerk, respectively. To sum up, the user study emphasizes the potential benefits of employing HoloLens for enhanced 3D visualization in catheterization. The user study also illustrates the advantages of using a gamepad for catheter teleoperation, including user-friendliness and passive haptic feedback, compared to HoloLens. To further gauge the potential of using a more traditional joystick as a control input device, an additional study utilizing the Haption Virtuose robot was conducted. It reveals the potential for achieving smoother trajectories, with a 38.9% reduction in total path length compared to a gamepad, potentially due to its larger range of motion and single-handed control.

Background: Laparoscopic surgery requires a complex set of motor skills. Currently, basic laparoscopic skills training is performed in a static environment, while intraoperatively, abdominal tissue is often moving. The aim of this study was to develop a dynamic training platform and evaluate its impact on laparoscopic skills acquisition in a box trainer. Methods: The Dynamic Laparoscopic Platform (DyLaP) includes a moving base which has been intergrated with the Lapron box trainer and the ForceSense objective measurement system. Dynamic training was evaluated in a comparative study where novices were divided into a static and dynamic training group, performing six training trials of a peg transfer task with the DyLaP. Afterwards, both groups performed a dynamic exam task. Task manipulation (force) and instrument efficiency (path length and time) were measured. Results: Participants (n = 12) exhibited a significant difference (p < 0.05) in time, path length, and maximum force between the static and dynamic groups in the first trial. Learning curves were most prevalent in the dynamic group. Conclusions: The DyLaP can be used to provide a challenging and realistic training environment. From the comparative peg transfer study, it can be concluded that dynamic training significantly affects laparoscopic skill acquisition. More research is needed to evaluate dynamic training effects in force-based training tasks.

Background: Preoperative planning of patients diagnosed with pancreatic head cancer is difficult and requires specific expertise. This pilot study assesses the added value of three-dimensional (3D) patient models and computer-aided detection (CAD) algorithms in determining the resectability of pancreatic head tumors. Methods: This study included 14 hepatopancreatobiliary experts from eight hospitals. The participants assessed three radiologically resectable and three radiologically borderline resectable cases in a simulated setting via crossover design. Groups were divided in controls (using a CT scan), a 3D group (using a CT scan and 3D models), and a CAD group (using a CT scan, 3D and CAD). For the perceived fulfillment of preoperative needs, the quality and confidence of clinical decision-making were evaluated. Results: A higher perceived ability to determine degrees and the length of tumor–vessel contact was reported in the CAD group compared to controls (p = 0.022 and p = 0.003, respectively). Lower degrees of tumor–vessel contact were predicted for radiologically borderline resectable tumors in the CAD group compared to controls (p = 0.037). Higher confidence levels were observed in predicting the need for vascular resection in the 3D group compared to controls (p = 0.033) for all cases combined. Conclusions: “CAD (including 3D) improved experts’ perceived ability to accurately assess vessel involvement and supports the development of evolving techniques that may enhance the diagnosis and treatment of pancreatic cancer”.

Objective: Navigation through tortuous and deformable vessels using catheters with limited steering capability underscores the need for reliable path planning. State-of-the-art path planners do not fully account for the deformable nature of the environment. Methods: This work proposes a robust path planner via a learning from demonstrations method, named Curriculum Generative Adversarial Imitation Learning (C-GAIL). This path planning framework takes into account the interaction between steerable catheters and vessel walls and the deformable property of vessels. Results: In-silico comparative experiments show that the proposed network achieves a 38% higher success rate in static environments and 17% higher in dynamic environments compared to a state-of-the-art approach based on GAIL. In-vitro validation experiments indicate that the path generated by the proposed C-GAIL path planner achieves a targeting error of 1.26±0.55mm and a tracking error of 5.18±3.48mm. These results represent improvements of 41% and 40% over the conventional centerline-following technique for targeting error and tracking error, respectively. Conclusion: The proposed C-GAIL path planner outperforms the state-of-the-art GAIL approach. The in-vitro validation experiments demonstrate that the path generated by the proposed C-GAIL path planner aligns better with the actual steering capability of the pneumatic artificial muscle-driven catheter utilized in this study. Therefore, the proposed approach can provide enhanced support to the user in navigating the catheter towards the target with greater accuracy, effectively meeting clinical accuracy requirements. Significance: The proposed path planning framework exhibits superior performance in managing uncertainty associated with vessel deformation, thereby resulting in lower tracking errors.

Laparoscopic surgery offers significant benefits to patients in low-resource settings compared to open surgery such as faster recovery, less pain, and lower infection rate. However, there exist significant barriers to the safe introduction of laparoscopy such as high costs and limited availability of trained staff. Low- and middle-income country (LMIC) hospitals suffer from higher post-surgical infection which might be due to the limited facilities for the sterile reprocessing of laparoscopic instruments. To design a solution to this issue, a detailed understanding of local settings was needed. Therefore, this research applied a context-driven design approach, based on the Roadmap for Design of Surgical Equipment for Safe Surgery Worldwide. Over several design phases, the need for a reprocessing device was established. An analysis of the sterile reprocessing of laparoscopic instruments led to a list of context-specific design requirements. These were translated to a final conceptual design of a laparoscopic instrument cleaner using a waterfall design method. Finally, a usability study of the loading system of the device was conducted with nurses in four Indian hospitals. A root-cause analysis of the usability study showed that the device was not intuitive enough to use for Indian nurses. A redesign of the loading system was made to improve its ease of use. The design process used in this study can be used as an example for designers wanting to address the critical issue of context-specific medical devices worldwide, or more specifically, the sterile supply of surgical instruments in resource-constrained environments.

Peripheral autonomic nerve function (ANF) impairment (ANFI) can be one of the first indicators for leprosy or leprosy neuropathy. However, within leprosy, hardly any ANF assessment methods are used in current practice. Skin temperature could be a proxy measure to assess ANF. Therefore, this research aims to explore whether low-cost infrared (IR) video thermography can be used as an ANF assessment tool by measuring the skin temperature response (STR) of human hands before, and after applying a cold pressor test (CPT). A protocol was defined to perform a baseline measurement, apply CPT, and record the resulting STR curve during 15 minutes. An IR video camera connected to a mobile phone was selected as sensor. A setup was developed to immobilize the position of the hands and fingers relative to the camera. A Python script was developed to extract the hand palm skin temperature STR curve from an IR video for 12 ulnar and median innervated regions of interest (ROI) in 1s intervals. A Matlab script was developed to post-process the raw temperature data into filtered data. This data is used to calculate key metrics that describe the STR curve. This approach was evaluated on technical accuracy and precision by comparing IR data for 3 cameras to a reference sensor. The variability caused by the observer analyzing the data was studied by analyzing the same video 5 times by 2 observers. The subject variability was studied by enrolling 7 subjects into a pilot, testing them daily for 5 consecutive days. The results show a high mean Interclass correlation of 0.94 between the 3 IR cameras and the reference sensor. Bland-Altman plots show a mean accuracy of +0.090°C between the cameras and the reference, and a variation between −1.30 and +1.50°C. High agreement was shown between observers analyzing the data. The pilot test showed high variability in STR curve within subjects. Although the general shape of the STR was similar, the location of the steep increase in recovery varied strongly within and between subjects. This study shows that a low-cost, portable IR camera can be used to measure STR of human hands after CPT. A pilot study showed high subject variability for repeated testing of the STR curve. Future research is needed to establish its value in assessing ANF in leprosy patients or other systemic and local neuropathies and traumatic nerve conditions.

Negative Pressure Wound Therapy (NPWT) is a treatment that promotes healing of chronic wounds. Despite high prevalence of chronic wounds in Low- and Middle-Income Countries (LMICs), NPWT devices are not available nor affordable. This study aims to improve chronic wound care in LMICs by presenting the Wound Care (WOCA) system, designed for building, testing and use in LMICs. Design requirements were formulated using input from literature, ISO standards, and wound care experts. The WOCA design was developed to provide safe, portable, user-friendly and affordable NPWT to patients in LMICs. The design features an adjustable operating pressure ranging from −75 to −125 mmHg, a battery for portability, a 300 ml canister, overflow protection, and system state alarms. An Arduino controls the pressure and monitors the system state. Three prototypes were developed and built in Nepal, and their performance was evaluated. Pressure control was 125 ± 10 % mmHg, internal leakage was 7.5 ± 4.3 mmHg/min, reserve capacity was 189 ± 16.9 ml/min, and overflow protection and alarm systems were effectively working. Prototype cost was approximately 280 USD. The WOCA demonstrates to be a locally producible NPWT device that can safely generate a stable vacuum. Future research will include clinical trials situated in LMICs.

Background: The Veress Needle (VN) is commonly used in establishing pneumoperitoneum in laparoscopic surgery. However, severe vascular and/or visceral complications can occur due to overshoot at the insertion of the VN in the abdominal cavity. In order to investigate whether the new VeressPLUS needle (VN+) could improve safety, the learning curve of this needle was compared to that of a conventional VN, under standardized conditions. Methods: In total, 26 residents and med students, without prior Veress needle experience, were recruited and randomly assigned to VN or the VN+ group. A learning curve plateau phase recognition model was developed and used to determine the learning curve of the participants who used either the VN or the VN+ needle on two Thiel-embalmed human cadavers. Insertion of the needles was done in a systematic way in the upper abdomen and insertion depth was measured under direct laparoscopic vision. At the end of the learning curve, the number of participants that reached a safe insertion depth between 5 and 15 mm was compared. Results: On average, it took the VN group 8 trials to reach and establish the plateau phase of the learning curve. The VN+ group showed no learning curve at all. At the 8th trial, a significant difference (p < 0.002) in average insertion depth was found in favor of the VN+ (mean: 5.4 mm SD 1.4) compared to the VN (mean: 12.7 mm SD 6). In the VN group and VN+ group, 46% versus 8% exceeded the safe insertion depth of 10 mm at the end of the learning curve. Conclusion: This study indicates that for novices, there is no learning curve for the VN+, when compared to VN. Moreover, in all cases, the insertion depths were significantly reduced (with more than 50%) while using the VN+ when compared to the VN.

Since the introduction of robot-assisted laparoscopic surgery, efforts have been made to incorporate force sensing technologies to monitor critical components and to provide force feedback. The advanced laparoscopic robotic system (AdLap RS) is a robotic platform that aims to make robot technology more sustainable through the use of the fully reusable shaft-actuated tip-articulating (SATA) instruments. The SATA instrument driver features electronics and sensors exposed to the sterile environment, which complicate the sterilisation process. The aim of this study was to develop and validate smart sensing in stepper motors using the back electromotive force in a newly developed Smart SATA Driver (SSD), eliminating the need for sensors in the sterile environment. Methods: The stepper drivers were equipped with TMC2209 ICs featuring StallGuard technology to measure back EMF. The tip was actuated up until a set StallGuard threshold value was reached, at which the resulting tip force was measured. This cycle was repeated ten times for a range of threshold levels. A regression analysis with a power series model was used to determine the quality of the fit. Results: The SSD is capable of exerting tip forces between 2.4 and 8.2 N. The back EMF force test demonstrated a strong correlation between obtained StallGuard values and measured tip forces. The regression analysis showed an R-squared of 0.95 and a root Mean squared error of 0.4 N. Discussion: The back EMF force test shows promise for force feedback, but its accuracy limits real-time use due to back EMF fluctuations. Future improvements in motor stability and refining the back EMF model are needed to enable real-time feedback. Conclusion: The strong correlation during the back EMF force test shows its potential as a low-budget method for detecting motor stalls and estimating tool–tissue forces without the need for sensors in laparoscopic instruments.

This systematic review explores machine learning (ML) applications in surgical motion analysis using non-optical motion tracking systems (NOMTS), alone or with optical methods. It investigates objectives, experimental designs, model effectiveness, and future research directions. From 3632 records, 84 studies were included, with Artificial Neural Networks (38%) and Support Vector Machines (11%) being the most common ML models. Skill assessment was the primary objective (38%). NOMTS used included internal device kinematics (56%), electromagnetic (17%), inertial (15%), mechanical (11%), and electromyography (1%) sensors. Surgical settings were robotic (60%), laparoscopic (18%), open (16%), and others (6%). Procedures focused on bench-top tasks (67%), clinical models (17%), clinical simulations (9%), and non-clinical simulations (7%). Over 90% accuracy was achieved in 36% of studies. Literature shows NOMTS and ML can enhance surgical precision, assessment, and training. Future research should advance ML in surgical environments, ensure model interpretability and reproducibility, and use larger datasets for accurate evaluation.

Background: To validate whether the SATA-LRS, a novel reusable articulating laparoscopic instrument, fits surgical practice, a pre-clinical study was performed. Methods: Thirteen medical doctors used the instrument in a laparoscopic endoscopic inguinal hernia repair (TEP)-like task inside a cadaver. A set of sensors on the instrument handle detected motion and articulation of the instrument tip. Data from the sensors and video recordings were used to assess the amount and type of movement of the instrument and the time spent on tasks. questionnaire was used to gain insight into the participants’ perception of the contextual factors. Results: There was no difference between task time and instrument tip velocities when using articulation (or not) and all participants used articulation at least half of the task time. Instrument-handle movement, indicating the user’s hand and arm movement, was significantly reduced when using articulation. The questionnaire indicated strong acceptance of the instrument and the experimental setup, and a desire to use the instrument in surgery by most participants. Conclusions: The added articulation feature of the SATA-LRS instrument was deemed beneficial by the participants, showed no increased handling complexity or time spent on the task and was used frequently when enabled, indicating intuitiveness.

Background: The steep radiation dose gradients in cervical cancer brachytherapy (BT) necessitate a thorough understanding of the behavior of afterloader source cables or needles in the curved channels of (patient-tailored) applicators. Purpose: The purpose of this study is to develop and validate computer models to simulate: (1) BT source positions, and (2) insertion forces of needles in curved applicator channels. The methodology presented can be used to improve the knowledge of instrument behavior in current applicators and aid the development of novel (3D-printed) BT applicators. Methods: For the computer models, BT instruments were discretized in finite elements. Simulations were performed in SPACAR by formulating nodal contact force and motion input models and specifying the instruments’ kinematic and dynamic properties. To evaluate the source cable model, simulated source paths in ring applicators were compared with manufacturer-measured source paths. The impact of discrepancies on the dosimetry was estimated for standard plans. To validate needle models, simulated needle insertion forces in curved channels with varying curvature, torsion, and clearance, were compared with force measurements in dedicated 3D-printed templates. Results: Comparison of simulated with manufacturer-measured source positions showed 0.5–1.2 mm median and <2.0 mm maximum differences, in all but one applicator geometry. The resulting maximum relative dose differences at the lateral surface and at 5 mm depth were 5.5% and 4.7%, respectively. Simulated insertion forces for BT needles in curved channels accurately resembled the forces experimentally obtained by including experimental uncertainties in the simulation. Conclusion: The models developed can accurately predict source positions and insertion forces in BT applicators. Insights from these models can aid novel applicator design with improved motion and force transmission of BT instruments, and contribute to the estimation of overall treatment precision. The methodology presented can be extended to study other applicator geometries, flexible instruments, and afterloading systems.

Collision feedback about instrument and environment interaction is often lacking in robotic surgery training devices. The PoLaRS virtual reality simulator is a newly developed desk trainer that overcomes drawbacks of existing robot trainers for advanced laparoscopy. This study aimed to assess the effect of haptic and visual feedback during training on the performance of a robotic surgical task. Robotic surgery-naïve participants were randomized and equally divided into two training groups: Haptic and Visual Feedback (HVF) and No Haptic and Visual Feedback. Participants performed two basic virtual reality training tasks on the PoLaRS system as a pre- and post-test. The measurement parameters Time, Tip-to-tip distance, Path length Left/Right and Collisions Left/Right were used to analyze the learning curves and statistically compare the pre- and post-tests performances. In total, 198 trials performed by 22 participants were included. The visual and haptic feedback did not negatively influence the time to complete the tasks. Although no improvement in skill was observed between pre- and post-tests, the mean rank of the number of collisions of the right grasper (dominant hand) was significantly lower in the HVF feedback group during the second post-test (Mean Rank = 8.73 versus Mean Rank = 14.27, U = 30.00, p = 0.045). Haptic and visual feedback during the training on the PoLaRS system resulted in fewer instrument collisions. These results warrant the introduction of haptic feedback in subjects with no experience in robotic surgery. The PoLaRS system can be utilized to remotely optimize instrument handling before commencing robotic surgery in the operating room.

It is estimated that in Africa 30,000-130,000 new cases arise annually and a total of 3 million women suffer from untreated vesicovaginal fistulas (VVFs) in Low- and Middle-Income Countries (LMICs) worldwide. A VVF is an abnormal communication between the bladder and vagina that can result in urine leakage through the vagina. This does not only lead to physical but also psychological problems. In LIMCs, the most common cause of a VVF is obstructed labour. Early childbearing (before full pelvic growth is achieved), poor socioeconomic status, low literacy rate, malnourishment, inadequately developed infrastructure for health care for pregnant women and lack of access to emergency obstetric services are factors that impact the high rate of cases in LIMCs. Some of the consequences are stigmatization and social isolation, because obstructed labour is often seen as a punishment from God and patients are abandoned by their families because of the smell of urine. [...]