obstructed labor and prolonged labor

1. Nirsuba Gurung
MN II (Women health development)

2. Background
Obstructed labor is one of the
indicator of maternal health
care quality services and still
prevalent in developing
countries like Nepal

3. Global epidemiology
In 2013 it resulted in 19,000
deaths down from 29,000
deaths in 1990

4. Obstructed labour is associated with a
high perinatal mortality and
morbidity (fetal and newborn deaths,
and disease and disability occurring
around the time of the birth)
Obstructed labour remains an important
cause of not only maternal death but also
short- and long-term disability

5. Obstructed labour comprises one of the
five major causes of maternal 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 a maternal mortality rate
as high as 410/100,000 live births

7. Labor
Labor: Series of events
that take place in the
genital organs in an
effort to expel the
viable products of
conception out of the
womb through the vagina
in to the outer world is
called labour

8. Definition
Labor is a physiologic process during
which the products of conception (ie, the
fetus, membranes, umbilical cord, and
placenta) are expelled outside of the
uterus.

9. Labor is achieved with changes in the
biochemical connective tissue and with
gradual effacement and dilatation of the
uterine cervix as a result of rhythmic
uterine contractions of sufficient
frequency, intensity, and duration
Labor is a clinical diagnosis. The onset of
labor is defined as regular, painful uterine
contractions resulting in progressive
cervical effacement and dilatation.

10. Normal labour (Eutocia)
Normal labour is callled when it is
fulfilling the following criteria;
Spontaneous in onset and at term
With vertex presentation
Without undue prolongation
Natural termination with minimal aid
Without having any complications
affecting the health of the mother
and/or baby

11. Abnormal labour (Dystocia)
Any deviation from definition of normal
labour is called abnormal labour.
Thus a labour other than vertex
presentation or having some
complications even with vertex
presentation affecting the course nature
of termination or adversely affecting
the nature of termination or adversely
affecting the maternal and/or fetal
prognosis is called an abnormal labour

12. Stages of labour
First Stage of Labour
The first stage is the longest and most
variable stage. It starts from the onset
of true labour pains and ends with full
dilatation of the cervix. It is also
termed as the “cervical stage” or
“dilatation stage” of labour
Its average duration is 12 hours in
primigravida and 6 hours in multipara

13. Early or latent phase
The latent phase is early, slow part of
labour, which begins with the onset of
regular contractions and last until cervix
is dilated 4 cm.
It is prior to active phase of first stage
of labour.

14. It may last 6-8 hours in the first time
mother (primigravida); the cervix dilates
0-4 cm and cervical canal shortens from
3 cm long to less than 0.5 cm long.
The uterine contractions occur about
every 10-15 minutes and lasts bout 15-20
seconds
The contractions become progressively
more rhythmic and stronger

15. Cervical effacement

16. Active phase
During this phase, the cervix dilates 4-8
cm and is characterized by rapid cervical
dilatation and descent of the presenting
fetal part.
Contractions will be about 3-4 minutes
apart, lasting 40 to 60 seconds.
Woman may have a tightening feeling in
pubic area and increasing pressure in
back

17. The transition phase:
Transition is the most difficult phase of
labor, and fortunately, the shortest,
lasting from 30 minutes to two hours.
The cervix is opening the last few
centimeters, from 8 to 10 centimeters.
The pain may be intense, as the cervix
stretches and the baby descends into
the birth canal.

18. Second stage of labor
It starts from full dilatation of cervix
(not from rupture of membrane) and
ends with expulsion of the fetus from
the birth canal. It has two phases. Its
average duration is 2 hours in
primigravida and 30 minute in
multigravida

19. The propulsive phase: Starts from full
dilatation up to the descent of the
presenting part to the pelvic floor
Expulsive phase: It is distinguished by
maternal bearing down effort and ends
with delivery of the baby

20. The contractions become more frequent
and, longer (60-90 seconds) and
stronger.
During this phase, the woman may
exhibit decreased ability to cope with
her contractions and pain. Often, woman
becomes very restless and frequently
changing position

21. Stage of labour
Characteristics First Stage Second
Stage
Latent
Phase
Active
Phase
Transition
al Phase
Primigravida
Multipara
Cervical dilatations
Contraction
 Frequency
 Duration
 Intensity
8-10 hours
6-8 hours
0-4 cm
10-15 min
15-30 sec
Begin mild
and become
moderate
6 hours
4 hours
4-8 cm
2-3 min
30-45 sec
Begin moderate
and become
strong
1-2 hours
30 min to 1
hour
8-10 cm
1-2 min
60-95 sec
Strong
1-1 1/2 hours
20-30
minutes
2-3 min
60-90 se
Strong

23. Third stage of labor
Third stage of labour is referred as
placental stage.
It begins after birth of the baby and
end with expulsion of placenta and
membrane (after births).
It lasts up to 30 min with average length
10-15 minutes in both multi and primi.
The duration is reduced to 5 minutes in
active management.

24. Fourth Stage of Labour
It is the stage of observation for at
least one hour after expulsion of the
placenta.
During this period, general condition of
the woman and the behaviors of the
uterus are to be carefully watched.

25. Factors Affecting Labour
1. Passenger
Size of the fetal head
Fetal presentation
Fetal lie
Fetal attitude
Fetal position
Station
Engagement

26. 2. Passageway
Bony pelvis
Soft tissues
3. Power
Primary power
Secondary powers

27. Primary & secondary powers combine to
expel fetus and placenta from uterus
Primary (involuntary) forces:
contractions of uterine muscle fibers
Secondary (voluntary) forces: use of
abdominal muscles during second stage
of labor to facilitate descent & delivery
of fetus

28. Obstructed labour
Obstructed labour is the failure of the
fetus to descend through the birth
canal, because there is an impossible
barrier (obstruction) preventing its
descent despite strong uterine
contractions.
The obstruction usually occurs at the
pelvic brim, but occasionally it may occur
in the pelvic cavity or at the outlet of
the pelvis

29. Prolonged labour
Prolonged latent phase of labour: when
true labour lasts for more than about 8
hours without entering into the active
first stage.
Prolonged active phase of labour: when
true labour takes more than about 12
hours without entering into the second
stage.

30. Prolonged second stage of labour:
Multigravida mother: when it lasts for
more than 1 hour.
Primigravida mother: when it lasts for
more than 2 hours

31. Causes of obstructed labor
Passenger
Head:
● Large fetal head (big for that pelvis)
● Hydrocephalus (brain surrounded by
fluid, which makes the skull swell)

32. Twin pregnancy:
● Locked twins (locked at the neck)
● Conjoined twins (fused together with
some shared organs)

33. Presentation and position:
● Brow, face, shoulder
● Persistent malposition

34. Powers:
Inadequate power, due to poor or
uncoordinated uterine contractions, is a
major cause of prolonged labour.
Either the uterine contractions are not
strong enough to efface and dilate the
cervix in the first stage of labour, or
the muscular effort of the uterus is
insufficient to push the baby down the
birth canal during the second stage

35. Passage
The birth canal is the passage, so labour
may be prolonged if the mother’s pelvis
is too small for the baby to pass
through(CPD)
the pelvis has an abnormal shape,
if there is a tumour or
other physical obstruction in the pelvis.

36. Clinical features
Obstructed labour is more likely to occur
if:
 The labour has been prolonged (lasting
more than 12 hours)
 The mother appears exhausted, anxious
and weak
 Rupture of the fetal membranes and
passing of amniotic fluid was premature
(several hours before labour began)

37.  The mother has abnormal vital signs:
fast pulse rate, above 100 beats/minute;
low blood pressure; respiration rate
above 30 breaths/minute; possibly also a
raised temperature.
 Concentrated urine, which may contain
meconium or blood.

38. Abdominal examination:
Strong uterine contraction
Bandls' ring

39. Pervaginal examination:
Vulval and cervical edema
Hot , dry and foul smelling vagina
poor cervical effacement
blood mixed urine

40. Effect to mother
Effects on mother:
Maternal distress
Postpartum heamorrhage
Trauma to genital tract
Increased operative delivery
Shock

41. Effects to fetus:
Hypoxia
Intrauterine infection
Intracranial hemorrhage
Increased operative delivery

42. Diagnosis
Prolonged labour is not a diagnosis but it
is the manifestation of an abnormality
which leads to alteration in normal
progress of labour.

43. History
General examination
Abdominal examination
Pervaginal examination
Fetal heart sound

44. Differential diagnosis
Constriction ring.
Full bladder.
Fundal myoma

45. Complication
Fistula
Postpartum haemorrhage (you will learn
about this in Study Session 11 in this
Module)
Slow return of the uterus to its pre-
pregnancy size
The small intestine becomes paralyzed
and stops movement (paralytic ileus)
Sepsis (widespread infection throughout
the body)
Death

47. Complications of obstructed
labour for the newborn
Neonatal sepsis
Convulsions (fits)
Facial injury
Severe asphyxia (life-threatening lack of
oxygen)
Death.

48. Management
Preventive
Antenatal :
Detection of factors likely to produce
prolonged labour(big baby, small women,
malpresentation)
Intrapartum :
Careful observation,
proper assessment,
Use of partograph
early detection and management of
the causes of obstruction.

49. Definitive management
PRINCIPLE:
to relieve the obstruction at earliest by
a safe delivery procedure
to combat dehydration and ketoacidosis
to control sepsis and PPH

50. Management
Preliminaries :
Fluid and electrolyte balance and
correction of dehydration
A vaginal swab is taken and send for
culture and sensitivity test
Blood sample sent for grouping and
cross matching
Antibiotic:

51. Obstretric management
There is no place for wait and watch
after the diagnosis of obstructed
labor
C-section : gives the best result
Symphysiotomy: Alternative to risky
C-section

52. Activity intolerance related to fatigue
secondary to pain at incision site and
blood loss during surgery
Risk for infection in incisional site
related to open wound

53. Discharge teaching
Follow up visit: she should visit to the
doctor as per adviced
Nutrition: she was advised to take
nutritious diet. She should take iron
richer diet, high in protein and high
minerals, vitamins, carbohydrates for
rapid wound healing.
Patient was advised to drink atleast 2-3
liters of water in a day. And was advised
to drink one glass of fluid after each
breast feeding

54. Personal hygiene and perineal hygiene
She was advised for regular intake of
medicines
Rest and sleep: need of adequate rest
of sleep
Postnatal exercise

55. Making habit of doing exercise.
she adviced not to lift heavy loads for 6-
8 weeks after surgery
she was adviced to come for follow up if
following signs appear
Heavy vaginal bleeding
Foul smelling vaginal discharge
Severe abdominal distension and / or
pain not relieved by painkillers
High fever
Pain when passing urine
Inability to pass urine

56. Infromal health teaching
Breast feeding technique
Exclusive breast feeding
Newborn care
Immunization
Family planning

58. Reference
Dutta, D.C. Textbook of Obstetrics ,5th edition (2009),
New Central Book Agency, India.
Black, J.M., Jacobs, E.M., Luckman and Sorensen (1993).
Medical and Surgical Nursing: A Psychophysiologic
Approach, (4th Ed). WB Sounders Company, USA.
Julia, G. B. (1995). Nursing Theories- The Base for
Professional Nursing Practice , (3rd ed). Norwalk, Appleton
and Lange.