Obstructed labor Obstructed labor Defn Failure to progress

Obstructed labor.

Obstructed labor Defn - Failure to progress due to mechanical problems—a mismatch between fetal size(the size of the presenting part of the fetus) and the mother’s pelvis. • Inspite of good uterine contractions, the progressive descent of the presenting part is arrested due to mechanical obstruction My=>failure of descent of presenting part due to mechanical obstruction despite adequate uterine contraction.

Obstructed labor… • The most famous account of obstructed labor is the case of Princess Charlotte of England who died after delivering a 9 -pound stillborn Baby following 50 hours of labor. • Three months later Sir Richard Crofts, the Princess’s obstetrician, unable to bear the responsibility of the death of the heir to the British throne committed suicide. This has historically been referred to as “The Triple Obstetric Tragedy”. • It illustrates the grave consequences of obstructed labor involving the infant, the mother and the doctor

Obstructed labor… • It is an absolute condition, further progress is impossible w/out assistance • It is an out come of a neglected and mismanaged labor. Incidence -Depends on factors • Incidence of CPD in the community • The availability and quality of ANC and intrapartum care (obstetric care) • Account for 8% of maternal death globally ü This entirely preventable labour complication carrying a very high maternal and neonatal morbidity and mortality is an indicator of the inadequacy and poor quality of obstetric care.

Causes of obstructed labour • CPD - faults in the pelvis -faults in the fetus • Mal presentation and mal position - Breech (impacted, large breech) -Transverse lie, Brow presentation, Mentp, Occipit Post. • Impacted shoulder • Tight perineum esp in primipravida.

Causes of obstructed labour • Abnormalities of vagina - Transverse or longitudinal septa - scarring from caustic traditional medication • Abnormalities of Ux - myoma -Congenital malformation

Clinical presentation Hx • Prolonged labor often extending to days rather than hours. • Prolonged Rom • Painful contractions eventually might cause Ux hypotonia or rupture • Fever

Clinical presentation P/E • Exhausted , tired anxious (by severe pain, lack of sleep) • Dehydrated and acidotic- due to muscular activity in absence of intake • Rapid pulse & often febrile • Hypotension or shock ( septic or hemorrhagic due to infection or Ux rupture) • Distended hypoactive bowels due to electrolyte deficit

Clinical presentation… • Hypotonic or hypertonic Ux contractions depending on the progress of labor • The cause of the obstruction may be evident on abdominal examination (abnormal lie, big baby etc. . ) =>In the presence of Ux rupture ü the abdomen will be tender, ü fetal parts are easily felt, ü lie and presentation may be difficult to detect as the baby has been displaced into the peritoneal cavity.

Clinical presentation…. =>In multiparous woman and in aprimigravid Pt with advanced obstructed labor three tumor abdomen may be evident ( bladder, lower and upper Ux segments separated by pathological Bandls ring). ü Full bladder due to uretral obstruction by Px ü Bandls ring during cervical dilatation

. =>Sepsis is more common in primigravid women, and uterine rupture in parous women. • Sepsis results from the prolonged state of an open cervix often with ruptured membranes impairing natural, mechanical barriers to ascending infection from the vagina. #The major immediate causes of death in obstructed labour are sepsis and haemorrhage from uterine rupture.

Clinical presentation…. PV edematous vulva (kanula sign) and Cx. ü Foul smelling meconium stained liquor, severe caput and moulding ü The Cx may or may not be fully dilated and the station may be high or low depending on the level of obstruction ü Catheterization is often difficult b/s of the impacted presenting part necessitating inserting of two fingers behind symphysis pubis to pass F. Catheter.

Management A. Resuscitation -If delivery is not imminent or likely to be so shortly, resuscitation is the first step before facilitating transfer of the Pt to higher institution. • In H/L admit the Pt straight to the delivery unit or operating theater • Update HCt, blood group & RH type, WBC

Management… • Start IV fluid and correct shock, dehydration, acidosis and electrolyte deficits (crystalloids or colloids). • v/s should be checked regularly ü O 2; 5 li/min if there is fetal distress or maternal distress. • Broad spectrum Abx-risk of septic shock

Management… • Insert F. catheter into the bladder • Avoid metal catheter-devitalized urethra is very easy to be injured • If C/S planned empty stomach with NGT =>If Ux rupture is strongly suspected , prepare 2 unit of blood.

Management… B. Operative delivery – Obstructed labor has to be relieved w/out delay v. Choice of the operative intervention should depend on; Ø Fetal condition (dead or alive) Ø Station or descent of the presenting part Ø The presence or absence of evidence of imminent or overt Ux rupture Ø Fetal presentation

Management… Ø Extent of cervical dilatation Ø The cause of obstruction # Episiotomy =>May be the only intervention required in a Pt with the presenting part in the Perineum. • This is often the case when obstruction is due to tight perineum • Obstructed labor due to CPD at the out level eg. OP could be effected by generous episiotomy

Management… # Vacuum and Forceps Delivery -No definite CPD -Descent not more than 1/5 above brim -Other conditions forceps and vacuum are met -The procedure preferably should be a lift out never be a difficult procedure -The fetus must be alive

Management… # C/S Indicated if • The fetus is alive and exceptional conditions for instrumental delivery are not satisfied • The fetus is dead and conditions for vaginal operative deliveries are not met • Repeat C/S almost always required • Next baby is larger, sepsis during peurperium produce weak scar

C. Destructive operations 1. Craniotomy Destructive operation for cephalic presentation if • The fetus is dead • The head is the presenting part • 2/5 or less of the head is above the brim (Head should be fixed) • The cervix is fully dilated • No uterine rupture or imminent rupture

2. Destructive delivery for transverse lie Decapitation The fetal neck is divided & the body & head are delivered separately Evisceration( Embryotomy) Fetal chest or abdomen is opened & all intestinal organs are removed. The trunk collapses & delivery becomes easier Preconditions The same with that of craniotomy Cleidotomy Reduction of the size of the shoulder girdle after delivery of the head ü Indicated in shoulder dystocia & dead fetus

. Rx after relieve of obstruction 1. IV therapy for 24 hrs - correction of DHN with electrolyte imbalance 2. Abx for at least 5 days - puerperal sepsis inevitable 3. Keep catheter for 10 -14 days

Complications of obstructed labor – – – – Rupture of uterus & its sequele Intrpartum/puerperal sepsis, Infertility Lower genital tract injuries (VVF, RVF etc. ) Osteitis pubis Urinary incontinence Peripheral nerve injury-foot drop Amenorrhea Fetal Asphyxia Cerebral birth trauma Clotting defect Contracture and stenosis of vagina, Dysparunia Peritonitis with abscess formation Atonic PPH, Psychological trauma

Fistula - is more common in the primigravid. =>In primigravid if a mechanical obstruction to labour exists, the uterine contractions gradually weaken and then stop. BUT, in multiparous women , contractions continue until delivery or uterine rupture occurs. VVF- mainly result from the ischaemic necrosis of vaginal and bladder tissues, trapped between the fetal head and the mother’s pubic symphysis during prolonged, obstructed labour. RVF- less common B/S of absence of maternal bony surface in close proximity, posteriorly.

Prevention • Good obstetric care (ANC, intrapartum care) Ø obstructed labor should never occur • Risk assessment(ANC) - past Hx of difficult deliveries - short stature - mal presentation , big baby - pelvic assessment antenataly for selected pts - use of partograph during labor help in recognition of slow cervical dilatation to predict and detect mechanical problems

Ruptured uterus • Is a life threatening situation • Peak incidence is in the 3 rd & 4 th pregnancies • Anterior rupture is common & the tear is often L-shaped. • The bladder is often torn & extend sometimes in to the vagina.

Dx ü Palpation of the abdomen causes severe pain ü Often vaginal bleeding ü The shape of the uterus changes & fetal parts may be easily palpable ü Lie and presentation difficult(displaced to peritoneal cavity) ü Sudden circulatory collapse, mostly shock develops slowly ü Cessation of contraction

Mx • • • Improve circulation rapidly Prepare immediately > 2 units of blood Give broad spectrum antibiotics Catheterize the patient Insert N-G tube Laparotomy • Repair + tubal ligation or, • Hysterectomy