Full Opinion

USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 1 of 43 PUBLISHED UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT No. 24-7049 TRACEY EDWARDS, Plaintiff - Appellant, v. BENITA J. WITHERSPOON; ANTHONY PERRY; JAMES ALEXANDER; GARY JUNKER; ELTON AMOS; LESLIE COOLEY DISMUKES; KAVONA GILL; TAMARA BROWN; NIKITIA DIXON; TAMMY WILLIAMS; SHEIDA BRODIE; TIANNA LYNCH; LORAFAITH RAGANO, Defendants - Appellees. -------------------------------------- DISABILITY RIGHTS NORTH CAROLINA; LEGAL ACTION CENTER; NATIONAL WOMEN’S LAW CENTER; PREGNANCY JUSTICE; ADDICTION MEDICINE SPECIALISTS, Amici Supporting Appellant, Appeal from the United States District Court for the Eastern District of North Carolina, at Raleigh. James C. Dever III, District Judge. (5:21-ct-03270-D) Argued: October 22, 2025 Decided: September 10, 2026 Before DIAZ, Chief Judge, and GREGORY and BENJAMIN, Circuit Judges. USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 2 of 43 Affirmed in part, vacated in part, and remanded by published opinion. Judge Benjamin wrote the opinion, in which Chief Judge Diaz and Judge Gregory joined. ARGUED: Joseph Longley, AMERICAN CIVIL LIBERTIES UNION FOUNDATION, Washington, D.C.; Shana Hope Khader, TYCKO & ZAVAREEI LLP, Washington, D.C., for Appellant. Laura Howard McHenry, NORTH CAROLINA DEPARTMENT OF JUSTICE, Raleigh, North Carolina, for Appellees. ON BRIEF: D Dangaran, RIGHTS BEHIND BARS, Washington, D.C.; Sarah Grady, David Howard Sinkman, Amelia Caramadre, KAPLAN & GRADY LLC, Chicago, Illinois; Jaclyn S. Tayabji, Hassan A. Zavareei, TYCKO & ZAVAREEI LLP, Washington, D.C.; Daniel K. Siegel, Amika Medha Singh, ACLU OF NORTH CAROLINA LEGAL FOUNDATION, Raleigh, North Carolina, for Appellant. Jeff Jackson, Attorney General, NORTH CAROLINA DEPARTMENT OF JUSTICE, Raleigh, North Carolina, for Appellees. Jim Davy, ALL RISE TRIAL & APPELLATE, Philadelphia, Pennsylvania, for Amici Addiction Medicine Specialists. Dorianne Mason, Alison Tanner, Ma’ayan Anafi, Emily Gabos, NATIONAL WOMEN’S LAW CENTER, Washington, D.C.; Russell H. Falconer, Kathryn M. Cherry, Dallas, Texas, Raena Ferrer Calubaquib, Sanjay Nevrekar, Dillon M. Westfall, New York, New York, Robert B. Watson, GIBSON, DUNN & CRUTCHER LLP, Washington, D.C., for Amici Disability Rights North Carolina, Legal Action Center, National Women’s Law Center, and Pregnancy Justice. 2 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 3 of 43 DEANDREA GIST BENJAMIN, Circuit Judge: Tracey Edwards was incarcerated at the North Carolina Correctional Institution for Women (“NCCIW”) in Raleigh, North Carolina, when she found out she was pregnant with her second child. Edwards had a history of opioid use disorder (“OUD”) and was thus eligible to receive medication for opioid withdrawal (“MOUD”) at NCCIW pursuant to an internal policy that provided MOUD only to pregnant offenders. Edwards was induced and gave birth while in state custody. She was shackled on her way to the hospital, at various times during active labor and delivery, and while returning to NCCIW. Upon her return, Edwards was placed in the NCCIW’s inpatient medical facility and requested to continue her MOUD treatment but was denied because she was no longer pregnant. Edwards sued state and prison officials, alleging Eighth Amendment violations for the restraints used during her labor and delivery and for the denial of MOUD after she gave birth. She also alleged disability discrimination under the Americans with Disabilities Act and § 504 of the Rehabilitation Act for the prison’s denial of MOUD after pregnancy. The district court granted summary judgment in favor of the defendants on all claims. For the reasons below, we affirm in part, vacate in part, and remand for further proceedings. I. Background A. Tracey Edward’s Incarceration Tracey Edwards was convicted of a nonviolent drug offense in North Carolina and began serving a 70-month sentence at NCCIW in May 2019. [J.A. 116.] She was 3 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 4 of 43 incarcerated at NCCIW from 2019 to 2021. [J.A. 116.] NCCIW is the only state prison under the North Carolina Department of Adult Corrections (“DAC”)1 that incarcerates pregnant offenders. [J.A. 118.] During intake, she learned that she was pregnant with her second child. [J.A. 117.] Prior to her incarceration, Edwards struggled with opioid addiction and was diagnosed with OUD. [J.A. 116.] NCCIW provides treatment for OUD to pregnant offenders to protect the child. [J.A. 365–66, 570–72.] Because Edwards was pregnant, she received a daily dose of Suboxone, a Food and Drug Administration (FDA) approved medication for OUD treatment, to prevent withdrawal. [J.A. 705.] She initially received this treatment daily at an outside clinic and was shackled while transported to and from the clinic. [J.A. 705.] Later, NCCIW initiated its own in-house medication assisted treatment (“MAT”)2 program where Edwards received Suboxone treatment until she was induced. [J.A. 140, 570–72.] B. Policy Hierarchy for the DAC NCCIW employees, including the warden, officers, and medical staff, must adhere to three sets of guidelines—DAC Policies, NCCIW standard operating procedures 1 At the time of Edwards’ incarceration, NCCIW was under the North Carolina Department of Public Safety. Beginning in 2023, the North Carolina Department of Adult Corrections began operations as a separate state agency and is currently responsible for all state prisons, including NCCIW. [J.A. 118.] We use DAC for consistency. 2 NCCIW refers to its in-house program as MAT. MAT and MOUD are often used interchangeably, and both include the use of FDA-approved medications for OUD treatment, including Suboxone. [J.A. 139.] Hereinafter, we will refer to the treatment as MOUD unless we are referring to NCCIW’s specific in-house program. 4 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 5 of 43 (“SOPs”), and NCCIW post orders. [J.A. 118–19.] The three guidelines operate within a hierarchy. DAC policies, which take precedence over other directives, are mandatory guidance issued by the state that must be followed by all state prison facilities. [J.A. 118, 3075.] NCCIW SOPs are policy documents issued by NCCIW that instruct NCCIW staff on the use of techniques relevant to their jobs. [J.A. 119]. Post orders are procedures related to the specific facility where an officer is stationed. [Id.] When DAC updates a policy, the prison warden must update any corresponding SOPs and post orders. [J.A. 3075] DAC issued Policy F.1100 Transporting Offenders on September 6, 2018. F.1100 “outline[s] procedures governing the transportation of offenders outside of the institution/facility.” J.A. 504.3 Section (i) addresses transportation for pregnant offenders: (1) An offender with a clinical diagnosis of pregnancy shall not be restrained by leg, waist, or ankle restraints. Wrist restraints may be used during any internal escort or external transport. These wrist restraints shall only be applied in the front and in such a way that the pregnant offender may be able to protect herself and the fetus in the event of a fall. (2) The following offenders should not be placed in any restraints, including wrist restraints, unless there are reasonable grounds to believe the offender presents an immediate, serious threat of hurting herself, staff, or others, including her fetus or child, or that she presents an immediate, credible risk of escape that cannot be reasonably contained through other methods: (A). An offender who is in labor, which is defined as occurring at the onset of contractions; (B). An offender who is delivering her baby; . . . (D). An offender who is transported or housed in an outside medical facility for treating labor and delivery; Citations to “J.A.” refer to the joint appendix filed by the parties. The J.A. contains 3 the record on appeal from the district court. Page numbers refer to the “J.A. #” pagination. 5 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 6 of 43 (E). An offender for induction once the intravenous line has been placed and the induction medication has been started If restraints are required, they should allow for the mother’s safe handling of her infant. . . . (4) Upon medical discharge, wrist restraints shall be applied for transport back to the correctional facility. Leg restraints may be applied when there are reasonable grounds to believe the offender presents an immediate, serious threat of hurting herself, staff, or others, or that she presents an immediate, credible risk of escape that cannot be reasonably contained through other methods. (5) Waist restraints shall not be used at any time during pregnancy or post- delivery, to include transport back to the facility. J.A. 510–11 (cleaned up) (emphasis added). On February 1, 2019, NCCIW issued SOPs D.1800 Offender Restraint and H.0300 Use of Force and Restraints, which were approved by NCCIW Warden Benita Witherspoon. [J.A. 2220.] Both SOPs require an offender in the hospital to be restrained to their bed by one arm and one leg. [J.A. 518; J.A. 523.] Under D.1800, there is an exception to the general policy that an offender should not be restrained outside the facility if a “[p]regnant offender is in active labor.” J.A. 513. And H.0300 states that a “maternity offender WILL NOT have leg restraints applied” and “shall not be restrained during active labor.” J.A. 524. Active labor is not defined in the SOPs, but F.1100 defines “in labor” as “the onset of contractions.” J.A. 510. Edwards and defendants disagree about whether the SOPs conflict with F.1100 as policies related to the shackling of pregnant offenders. [see J.A. 131.] However, in March 2021, a DAC official wrote in an email stating that the SOPs “[did] not match with red 6 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 7 of 43 book4 policy in regard to pregnant offenders” and that NCCIW was notified of the issue previously. J.A. 548. Defendants further represent that “correctional staff knew to implement any exceptions for pregnant offenders outlined in F.1100.” J.A. 3060. C. Warden Witherspoon’s Actions Witherspoon was the warden at NCCIW when Edwards was incarcerated and was responsible for ensuring all SOPs and post orders complied with DAC policies. [J.A. 722, 2220, 2258.] By April 2019, DAC’s region director and Witherspoon had at least three phone calls to discuss community organizers’ concerns with NCCIW’s policies, including the shackling of pregnant offenders during hospital transport and stays. [J.A. 135, 321–22, 722,]. In these calls, it was noted that such shackling violated DAC policy. [J.A. 136, 3076]. And the region director and Witherspoon discussed updating the post orders to better comply with DAC policies regarding the use of restraints on pregnant offenders. [J.A. 722]. But no changes were made until January 2020. [Id.]. After another pregnant NCCIW offender was shackled during labor against medical advice, DAC issued the following directive on November 22, 2019: Any offender in their third trimester should not be restrained. This applies even if they are not in pre or active labor. If there is a potential serious security concern with the offender not being restrained it should be discussed with the Region Director prior to restraints being added . . . Please ensure that you notify your staff of this temporary directive. 4 We understand “red book” to be a general term for DAC and/or facility policies that are written down, often in a red book. See J.A. 2478, 2486 (discussion of “red book” in reference to DAC policies). The reference here is to DAC policies, but the general term was also used by NCCIW officers to refer to the physical red book where NCCIW SOPs and post orders were written. See J.A. 1483 (Officer Tamara Brown noting that the NCCIW red book includes its SOPs and post orders). 7 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 8 of 43 J.A. 554–55; 538–39 (emphasis added). At the time the directive was issued, Witherspoon was out of the office. [J.A. 538.] But she requested that a direct report ensure that the directive and general prison policy were discussed with prison staff. [Id.] That training did not take place, and Witherspoon took no action to ensure any training was held. [J.A. 3076–77.] Witherspoon did not update the post order for the University of North Carolina at Chapel Hill Hospital (“UNC- CH”), where Edwards’ labor and delivery took place, until after the region director provided an updated DAC policy in January 2020. [J.A. 722.] A timeline of the relevant institutional policies is below: Issuing Body Date Issued Title Key Policies DAC September 6, F.1100 • “An offender with a clinical diagnosis 2018 Transporting of pregnancy shall not be restrained Offenders. by leg, waist, or ankle restraints.” (J.A. 510–11) • “An offender who is in labor … should not be placed in any restraints.” • “Waist restraints shall not be used at any time during pregnancy or post- delivery, to include transport back to the facility.” NCCIW February 1, SOPs D.1800 • An offender should not be restrained 2019 Offender Restraint outside the facility where a (J.A. 513) “[p]regnant offender is in active labor.” H.0300 Use of • “Maternity offender WILL NOT have Force and leg restraints applied” and “shall not Restraints be restrained during active labor.” (J.A. 524) NCCIW April 20, Post Order • “Although restraints are provided for 2019 Security the maternity offender while Supervisor for transporting to and from the hospital UNC-CH during pregnancy and immediately 8 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 9 of 43 (later updated (J.A. 3345) post-partum the Offender will only be in January handcuffed from the front. The 2020) maternity Offender WILL NOT have leg restraints or waist chain applied. “ • “The Offender will not be handcuff[sic] while holding the baby, but will have one leg restrain[sic] per policy.” DAC November 22, Directive • “Any offender in their third trimester 2019 (J.A. 554–55) should not be restrained.” D. Edwards’ Labor and Delivery On December 19, 2019, NCCIW officers transported Edwards to be induced at UNC-CH. [J.A. 3114–15]. Officers Shieda Brodie, Tamara Brown, Nikita Dixon, Kavona Gill, Tianna Lynch, and Tammy Williams, and Sergeant Lorafaith Ragano (collectively, the “Officer Defendants”) were responsible for Edwards while she was in the hospital. On the way to the hospital, Edwards was handcuffed, and, upon arrival, one of her arms and one of her legs were shackled to the hospital bed. [J.A. 121–22.] Brodie monitored Edwards on December 19 from Edwards’ arrival until approximately 7:00 p.m. that evening. [J.A. 623.] Lynch monitored Edwards overnight from approximately 7:00 p.m. on December 19 to 6:00 a.m. on December 20. [J.A. 510, 623.] According to the Officer Defendants’ activity logs, Edwards was induced through her intravenous (IV) line at 8:25 p.m. and given an epidural (pain medication provided to pregnant patients) at 11:15 p.m. [J.A. 623.] According to Edwards, she was shackled by one arm and one leg even after she was induced and until she began pushing. [J.A. 167, 624–25, 2110–11.] 9 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 10 of 43 Edwards gave birth to her child at 11:04 a.m. on December 20, 2019. J.A. 117. Ragano monitored Edwards during this time. About two hours after giving birth, Edwards was transferred to the maternity ward where Ragano handcuffed Edwards to the wheelchair during the transfer and then shackled one of her arms and the opposite leg to a different bed. J.A. 625, 729–30. Dixon relieved Ragano at 7:00 p.m. on December 20 and Ragano took over once again at 7:00 a.m. on December 21. [J.A. 168.] While Edwards was in the hospital, she continued to receive Suboxone daily and was prescribed Suboxone upon discharge. [J.A. 3077.] Edwards remained in the hospital for two days where she was monitored by Ragano, Brown, Gill, and Williams. [J.A. 610–11, 613, 616–18.] She was discharged on December 22 while Williams was on duty. [J.A. 616–18.] According to Edwards, as she was transported back to NCCIW, Williams and one other officer5 restrained her by shackling her ankles together, handcuffing her, and placing a belly chain around her stomach to restrict her movements. [J.A. 123.] Prison officials did not identify Edwards to be a security or flight risk before or during the time that she was at UNC-CH. [J.A. 3076.] The parties dispute how long Edwards was shackled during her hospital stay, but the district court identified times that both parties agree she was unrestrained: when Edwards’ medical team instructed her to push, when she gave birth, for some period of time after birth, when she went to the restroom, and on at least two other occasions during 5 During Williams’ deposition, she testified that she had another person with her during this transport but did not remember which officer. J.A. 1992. 10 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 11 of 43 her stay when she was unshackled to walk with her baby in the hospital hallway. [J.A. 3073–74.] E. Edwards’ Post-Pregnancy Medical Treatment When Edwards returned to NCCIW, she was placed in the inpatient medical unit. Edwards requested MOUD, but NCCIW denied her request pursuant to its policy restricting MOUD to pregnant offenders. [J.A. 141, 636.] Edwards was instead given an oxycodone taper over nine days: 10 milligrams three times a day for three days, then twice a day for three days, and then once a day for three days. [J.A. 169.] She was also given Tylenol and ibuprofen for pain management. [Id.] Edwards experienced withdrawal symptoms including pain, diarrhea, and vomiting for several weeks after she gave birth. [J.A. 3128.] Edwards described the pain as “more painful than giving birth” and alleged that she sometimes could not eat or shower due to the intensity of her symptoms. J.A. 169. Edwards remained in the medical unit until mid- January 2020. [J.A. 141.] Dr. Elton Amos was the medical director at NCCIW during Edwards’ incarceration. [J.A. 46.] Amos supervised nine medical providers responsible for direct patient care and provided clinical oversight, including the drafting of NCCIW’s MAT provider handbook. [J.A. 353, 635–36.] The MAT handbook includes the policies and procedures for NCCIW’s MAT program and notes that Amos was responsible for preliminary approvals of MOUD medications for pregnant offenders. [J.A. 636.] Dr. James Alexander was the healthcare facility health treatment administrator at the time and was responsible for reviewing NCCIW policies, such as the MOUD policy, to ensure compliance with 11 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 12 of 43 statewide policies. [J.A. 568, 737.] Dr. Gary Junker was the behavioral health director for DAC from 2015 until 2020. Junker was responsible for mental health policies across state prisons and provided oversight for medical directors, including Amos. [J.A. 732, 1032, 2219, 2340.] F. Procedural History In April 2022, Edwards sued DAC officials under 42 U.S.C. § 1983, alleging Eighth Amendment violations for shackling her during labor and postpartum and denying her MOUD after birth, as well as disability discrimination because of her OUD under the Americans with Disabilities Act (“ADA”) and § 504 of the Rehabilitation Act (“RA”).6 Edwards moved for partial summary judgment and all of the defendants moved for summary judgment in full. The district court denied Edwards’ motion for summary judgment and granted Defendants’ motion for summary judgment, thereby dismissing all of Edwards’ claims. Edwards now appeals. She challenges the district court’s decision on three grounds: (1) the district court’s grant of qualified immunity to Witherspoon and the Officer 6 Edwards named the following defendants: James Alexander, the NCCIW healthcare facility health treatment administrator, in his personal and official capacities; Elton Amos, the NCCIW medical director, in his personal and official capacities; Todd Ishee, the secretary of the DAC, in his official capacity; Anthony Perry, the current NCCIW warden, in his official capacity for the purpose of injunctive relief; Gary Junker, the then- behavioral health director, in his personal and official capacities; and Benita Witherspoon, the former NCCIW warden, in her personal capacity. Edwards also named the seven Officer Defendants in their personal capacities. Pursuant to Federal Rules of Civil Procedure 25(d), defendants Ishee and Perry were substituted for their predecessors, former secretary Eddie Buffaloe and former warden Claudette Edwards (as of September 2025, Michelle Carlton is warden at NCCIW). 12 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 13 of 43 Defendants for Eighth Amendment violations, specifically her shackling during pregnancy, labor, and postpartum recovery; (2) the district court’s finding that there was no constitutional injury committed by DAC medical officials Alexander, Amos, and Junker for denial of postpartum MOUD; and (3) the district court’s conclusion that Edwards was not discriminated against under the ADA or RA after being denied postpartum MOUD. [J.A. 3097]. We address each in turn. We have jurisdiction under 28 U.S.C. § 1291. II. Standard of Review We review the district court’s summary judgment and qualified immunity decisions de novo. Aleman v. City of Charlotte, 80 F.4th 264, 283 (4th Cir. 2023). Summary judgment is proper “ ‘if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.’ ” Id. (quoting FED. R. CIV. P. 56(a)). All facts and reasonable inferences drawn therefrom must be viewed in the light most favorable to the nonmoving party.” Id. at 283–84. III. Eighth Amendment Shackling Claim A. Background on Shackling The shackling of pregnant offenders is controversial and dangerous. The United Nations explicitly prohibits the use of restraints “on women during [labor], during childbirth and immediately after childbirth” in its rules for the treatment of prisoners. The United Nations Standard Minimum Rules for the Treatment of Prisoners, United Nations, 13 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 14 of 43 at 15 (Dec. 2015). This is for good reason. The American College of Obstetricians and Gynecologists explains that “[p]hysical restraints interfere with the ability of clinicians to safely practice medicine by reducing their ability to assess and evaluate the pregnant patient and the fetus.” Reproductive Health Care for Incarcerated Pregnant, Postpartum, and Nonpregnant Individuals, Comm. Op. No. 830, at 30 (July 2021) [https://perma.cc/P2J9- 2N8H]. The National Commission on Correctional Health Care notes an increased risk of falls, pain during labor, and complications in postpartum from shackling pregnant prisoners. Nonuse of Restraints for Pregnant and Postpartum Incarcerated Individuals, at 2 (Dec. 2025).7 Consequently, by 2018, 22 states, the District of Columbia and the federal government had enacted legislation prohibiting or limiting the use of shackling during labor.8 Ginette G. Ferszt, et al., Where Does Your State Stand on Shackling of Pregnant Incarcerated Women?, 22 Nursing for Women’s Health 17, 18 (2018). And the Sixth, Eighth, and Ninth Circuits condemn the practice of shackling pregnant offenders who do 7 Edwards’ expert cites to an earlier version of this position statement from 2020 concluding the same, which is reaffirmed in the 2025 version cited here. 8 As of 2025, 40 states have enacted legislation restricting the use of shackles on incarcerated pregnant women. Veronica Brawley & Emma Kurant-Thoma, Use of Shackles on Incarcerated Pregnant Women, J. of Obstetric, Gynecologic, & Neonatal Nursing, Oct. 2013, at 87, https://www.jognn.org/action/showPdf?pii=S0884- 2175%2823%2900247-2 [https://perma.cc/F53K-CL4W]. Relevant here, in 2021, North Carolina passed the Dignity for Women who are Incarcerated Act, which restricts DAC employees from restraining “a pregnant female incarcerated person during the second and third trimester of pregnancy, during labor and delivery, and during the postpartum recovery period.” N.C. GEN. STAT. § 153A-229.2 (2021). 14 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 15 of 43 not present a security or flight risk. See e.g., Villegas v. Metro. Gov’t of Nashville, 709 F.3d 563, 572 (6th Cir. 2013); Nelson v. Corr. Med. Servs., 583 F.3d 522, 534 (8th Cir. 2009); Mendiola-Martinez v. Arpaio, 836 F.3d 1239, 1252–55 (9th Cir. 2016). B. Edwards’ Shackling is a Constitutional Violation With this background in mind, we begin with Edwards’ shackling claim. The district court granted qualified immunity for Witherspoon and the Officer Defendants because it found one’s “right to be free from shackling” while pregnant, during labor, and postpartum was not clearly established. J.A. 3087. It did not discuss the constitutionality of the underlying conduct. We address both issues, starting with whether shackling Edwards violated the Eighth Amendment. “[T]he qualified immunity analysis consists of two prongs: (1) whether a statutory or constitutional violation occurred, and (2) whether the right was clearly established at the time of the violation.” Benton v. Layton, 139 F.4th 281, 288 (4th Cir. 2025) (internal quotation marks omitted) (quoting Aleman, 80 F.4th at 284). Courts may address the inquiry “in whichever sequence ‘will best facilitate the fair and efficient disposition of [the] case.’ ” Pfaller v. Amonette, 55 F.4th 436, 444 (4th Cir. 2022) (quoting Halcomb v. Ravenell, 992 F.3d 316, 319 (4th Cir. 2021)). The Eighth Amendment’s prohibition of cruel and unusual punishments extends to “the treatment a prisoner receives in prison and the conditions under which [s]he is confined.” Helling v. McKinney, 509 U.S. 25, 31 (1993); U.S. CONST. amend. VIII. The Eighth Amendment “imposes [] dut[ies] on prison officials to ‘provide humane conditions of confinement . . . [and] ensure that inmates receive adequate food, clothing, shelter and 15 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 16 of 43 medical care.’ ” Scinto v. Stansberry, 841 F.3d 219, 225 (4th Cir. 2016) (quoting Farmer v. Brennan, 511 U.S. 825, 832 (1994)). To make out an Eighth Amendment claim in this context, a plaintiff must make two showings. First, that the confinement conditions inflict an “objectively, sufficiently serious” harm that “deprives prisoners of ‘the minimal civilized measure of life’s necessities.’ ” Thorpe v. Clarke, 37 F.4th 926, 933 (4th Cir. 2022) (internal quotation marks omitted in first quotation) (quoting Farmer, 511 U.S. at 834). Second, that the officers acted with a culpable state of mind showing “ ‘deliberate indifference to inmate health or safety’ because they knew of but disregarded the inhumane treatment.” Id. (quoting Farmer, 511 U.S. at 834). 1. Shackling of Pregnant Offenders is Objectively Serious To satisfy the objective prong, a deprivation must be “objectively ‘sufficiently serious.’ ” Strickler v. Waters, 989 F.2d 1375, 1379 (4th Cir. 1993) (quoting Wilson v. Seiter, 501 U.S. 294, 298 (1991)). The plaintiff must produce evidence of “ ‘a serious or significant physical or emotional injury resulting from the challenged conditions,’ or ‘a substantial risk of such serious harm resulting from . . . exposure to the challenged conditions.’ ” Scinto, 841 F.3d at 225 (alteration in original) (quoting De’Lonta v. Angelone, 330 F.3d 630, 634 (4th Cir. 2003) (De’Lonta I)). “Only an extreme deprivation” meets this burden. De’lonta v. Johnson, 708 F.3d 520, 525 (4th Cir. 2013) (De’Lonta II). We can consider the consensus of experts to prove that a prison official’s conduct poses a risk of “serious or significant physical or emotional injury.” Scinto, 841 F.3d at 225 (quoting De’Lonta I, 330 F.3d at 634). We also may take into consideration the “contemporary values concerning the infliction of a challenged sanction” as the Eighth 16 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 17 of 43 Amendment “ ‘must draw its meaning from the evolving standards of decency that mark the progress of a maturing society.’ ” Villegas, 709 F.3d at 572 (quoting Gregg v. Georgia, 428 U.S. 153, 173 (1976)). Edwards claims that two sources of evidence are sufficient to meet the objective prong. First, she points to a growing consensus within the medical community and amongst policymakers that the shackling of pregnant offenders is dangerous and harmful. Edwards adduces evidence from the United Nations Committee Against Torture, the American Medical Association, American College of Obstetricians and Gynecologists, the National Commission on Correctional Health Care, and others condemning the practice of shackling pregnant women, specifically during labor, and identifying the harms that can result from the practice. See e.g., J.A. 174, 180–81; see also Villegas, 709 F.3d at 572–75 (relying on a similar set of sources to find that shackling “poses a substantial risk of harm”). Edwards’ expert, maternal fetal medicine specialist Dr. Alison M. Stuebe, characterized the use of restraints on a pregnant woman as “psychologically devastating, dehumanizing, and painful.” J.A. 173. Steube noted that, as pregnancy impacts a person’s balance and mobility, shackling “directly increases” the risks of falls and injury to both the pregnant offender and the baby and “can cause skin breakdown, nerve damage, and fractures.” J.A. 175. Stuebe continued that shackling “interferes with medical care” as the ability for medical staff to maneuver a patient, like Edwards, is delayed by restraints putting both the 17 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 18 of 43 women and the baby’s lives at risk. Id. She also assessed that shackling increases the risks of fatal blood clots postpartum because of a reduction in movement. J.A. 175–76.9 Second, Edwards points to her labor and delivery experience. Edwards states that she was shackled by one leg and one arm for hours, even after medical staff induced her, leaving her skin “raw and red.” J.A. 167. She was unable to move around even while experiencing contractions and the shackles were only removed once doctors told her to start pushing. Id. All told, her testimony supports that she was shackled by her hand and foot for at least twelve hours from the time she was induced at 8:25 p.m. until shackles were removed so that she could push and gave birth at 11:04 a.m. the next day. J.A. 117, 623. She then says that she was again shackled with both legs together and one wrist handcuffed within an hour of giving birth as she was moved from a delivery to recovery room. J.A. 168. 9 Defendants argue, citing Williams v. Branker, that Edwards’ testimony and expert report do not rise to the level of an objectively serious injury or medical need because any discomfort from Edwards’ shackling in the hospital was just an aggravation of a preexisting condition that resulted from incarceration. See 462 F. App’x 348, 354 (4th Cir. 2012) (“The fact that the conditions to which Williams was subjected aggravated his mental illness is an unfortunate but inevitable result of his incarceration.”). But there is a key difference between Williams and the case before us. Williams centered on allegations that the plaintiff-inmate’s mental health suffered due to solitary confinement conditions that included isolation and behavioral restrictions. Id. at 354. The court concluded that where the conditions of confinement meet the minimal standards required by the Constitution, any impacts on the inmate’s mental health were an “unfortunate but inevitable result of his incarceration” that do not violate the Eighth Amendment. Id. Not so here. As we explain below, shackling a pregnant inmate during labor and post-partum, without justification, is an Eighth Amendment violation. 18 USCA4 Appeal: 24-7049 Doc: 108 Filed: 09/10/2026 Pg: 19 of 43 While this court has not opined on this exact issue, other courts condemn shackling of pregnant offenders who do not present a security or flight ris