Prolonged Obstructed Labor Rupture Uterus Prolonged Labor when

Prolonged & Obstructed Labor Rupture Uterus

Prolonged Labor • when combined duration of first and second stage of labor (excluding latent phase) is more than 18 hrs in primi and >12 hrs in multiparous women, is called prolonged labor. • Second stage is defined prolonged when it is >2 hrs in primi & >1 hr. in multi.

• The prolongation denotes either delay in cervical dilatation and/or inadequate descent of presenting part. • Incidence of prolonged labor: - 8% in primigravda - 2% in multigravida

Causes of Prolonged Labor Fault in any one or combination of basic elements involved in labor - Fault in power - Fault in passage - Fault in passenger

• Fault in power -Abnormal or Inadequate uterine contraction - Incoordinate uterine contraction - Inability to beardown • Fault in passage - Full bladder - Contracted pelvis - Pelvic tumor (e. g. fibroid)

• Fault in passenger -Malposition (op), Malpresentation (Face) - Congenital anomaly of fetus (hydrocephalus) - Deflexed head with poor uterine contraction • Others - Injudious early administration of sedative and analgesic before actual labor begins

Dangers of Prolong Labor • Fetal – The fetal risk increased due to combined effect of hypxia & infection Ø Ø Ø Intra uterine hypoxia Low Apgor score at birth Infection Intracranial hemorrage ↑ fetal morbidity & mortality

• Maternal Risksü Maternal distress ü Postpartum Hemorrhage ü Trauma to genital tract- cervical tear - Rupture uterus - ↑ operative delivery ü Puerperal sepsis / Subinvolution ü Undue stretching of the perineal muscles – which may cause prolapse later ü ↑ Morbidity and Mortality

Prevention of prolonged labor - Use partography in all labor to diagnose abnormality early and timely intervention, optimally by alert and action line. - Early detection of factors producing prolong labor and appropriate timely treatment.

Treatment • Evaluate maternal and fetal condition from history, general examination and obstetrical examination and start supportive resuscitation. • If there is Fetal Distress in 1 st stage of labor, CPD, Malpresentation or failed augmentation → CS • If inefficient uterine contraction → Augmentation of labor by ARM and oxytocin.

Obstructed Labor • Definition – Labor is said to be obstructed when inspite of good uterine contraction the progress of labor comes to standstill due to mechanical obstruction. • Incidence – 1 -5% in referral hospital

Causes of obstructed labor Important Common causes are: § Contracted Pelvis and CPD § Malpresentation ( Shoulder, braw, mentoposteriar) § Malposition ( DTA, OP ) Less Common causes are: § Fetal anomalies – Hydrocephalus, fetal ascitis, conjoined twin. § Soft tissue tumor –fibroid , ovarian § Scarred cervix from previous amputation

Course of Labor in Obstructed labor • During labor uterine contraction increases in intensity, duration and frequency to overcome obstruction • With each contraction some retraction of upper segment occur → Upper segment becomes progressively thicker and shorter (tonic contraction) • The passive lower segment progressively stretches and become thinner to accommodate the fetus driven from upper segment

• A circular groove is formed between the active upper segment and passive distended lower segment called pathological retraction ring (Bandle’s Ring) • In primigravida → further uterine contraction ceases and uterus subsequently becomes inert. • In multigravida → the uterus continue to contract vigrously. there is progressive rise of Bandle’s Ring upward and ultimately lower segment rupture if baby is not delivered promptly.

Clinical features of obstructed labor Ø Patient is in agony due to continuous pain & restless Ø Features of exhaustion – Tachycardia - Perspiration - Dehydration - Ketoacidosis, L. respiration Ø P/A Examination - Bladder may be full - Bandle’s Ring is visible - Upper segment of uterus hard tonically contracted & tender - Lower segment distended & tender - Fetal parts may not be well defined - FHS usually absent or bradycardia

Ø P/V Examination - Edematous Vulva - Hot and Dry vagina - Offensive vaginal discharge - Cervix almost fully dilated - Membranes are absent - Presenting part may be impacted in pelvis - Cause of obstructed labor is reveals

Prevention Ø Antenatal detection of high risk pregnancy likely to produce prolong labor such as big size baby, short stature women , CPD, malpresentation & malposition. Ø Routine Partography and timely intervention of a prolonged labor due to mechanical factor can prevent obstructed labor.

Treatment of obstructed labor Ø Correction of dehydration and acidosis with 1 -3 liter NS or RL infusion. Ø Vaginal swab to be taken for C/S Ø Arrange blood in anticipation of PPH. Ø Broad Spectrum antibiotic Ø Obstetrical Management

Obstetrical Management Ø If baby alive (rare ) → CS Ø If baby is dead - Destructive operation is an option if obstetrician Experience - Otherwise do CS - After Every case of operative vaginal delivery → *vaginal, cervical tear and rupture uterus must be excluded. *Oxytocin must be given * Indwelling catheter for 7 -10 days

Ø Fetus Effects of Obstructed Labor - Asphyxia - Intracranial hemorrhage - Infection - ↑Perinatal Loss Ø Mother Immediate Remote - exhaustion - Genital urinary fistula - Dehydration - rectovaginal fistula - Metabolic acidosis - Variable degree of v. atresia - Genital sepsis - Secondary Amenorrhea due - Injury to G. T. Hysterectomy or Sheehan’s syndrome - PPH & Shock - ↑ M. Morbidity & Mortality

Rupture Uterus Ø Rupture of uterus is giving way of gravid uterus or dissolution in continuity of uterine wall any time after 28 weeks of gestation with or without expulsion of fetus Ø Rupture of the uterus is one of the most dramatic serous obstetric Emergency. Ø Incidence – Widely varies 1 in 200 to 1 in 1800 deliveries

Aetiology of Rupture Uterus Ø Spontaneous Rupture - Obstructed Labor - Fundal Pressure in grand multipara - Uterine malformation Ø Scar Rupture - Rupture of CS Scar→L. S. C. S-0. 2 -1. 5, U. S. C. S- 4 -9% -Uterine scar following operation on uterus *Myomectomy *Metroplasty * Hysterotomy * D&C

Ø Iatrogenic -Injudicious administration of oxytocin - Use of prostaglandin - Internal version - Destructive operations - Difficult Forceps delivery - M. R. P. Ø Over all most common cause of uterine rupture is separation of previous c. s. scar Ø But in developing country obstructed labor with feto-pelvic disproportion is still one of the common cause of rupture uterus

Types of Rupture Uterus Ø Complete Rupture- when uterine cavity communicate directly with peritoneal cavity. - Spontaneous rupture is more often complete. Ø Incomplete Rupture- when uterine cavity is separated from peritoneal cavity by visceral peritoneum or broad ligament. - Traumatic is usually incomplete Ø Scar Dehiscence - When there is separation of previous scar with intact peritoneum.

Site of Rupture • Lower segment – Most common occurs in previous CS, obstructed labor, which may extent to lateral site & extends upward. • Upper Segment – Occurs in previous classical CS, Previous scar in upper segment & other muscular pathology.

Diagnosis • Rupture During Pregnancy Typically - Acute abdominal pain - Features of shock & intrabdominal hemorrhage - Easily palpable fetal parts - Absent fetal heart sound - Contracted uterus is felt on one side Atypically - Incomplete rupture producing localized abdominal pain & tenderness - Frank signs of hemorrhage & shock develop slowly - It may confuse with accidental hemorrhage

Rupture in Labor • H/o vigorous uterine contraction followed by sudden bursting pain→ cessation of L. pains • Signs of internal hemorrhage depending on severity → Shock , abdominal tenderness, guarding • P/A → Fetal parts are easily palpable together with hard retracted uterus can be felt. • Vaginal Examination - Reveals bleeding through the cervical os - Recession of presenting part in complete rupture - Cervix hangs like a curtain - Hematuria may be present

Management • I. V. line, Antibiotics, Arrange blood • Laparotomy along with blood transfusion when the ∆ of rupture uterus is made • In case of ruptured C. S. scar, low parity, women & rupture wound is clear cut, condition stable →Repair • Patient with high parity, edges of rupture are ragged and irregular, anatomy is distorted →Hysterectomy to be.

Causes of Mortality • • Hemorrhage Shock Sepsis Mortality in intacted uterus rupture is more than scarred uterus • Mortality is more (3%) in classical scar than lower segment scar rupture (1%).