When Obstruction is diagnosed it must be relieved immediatelyHowever the effects of the preceding prolonged labor must be at least partially rectified.
Nutritional Supply--Rickets…Contracted PelvisEarly Marriage--Immature PelvisPelvic Ass. Remote from term--For Untested PelvisPartograph--Early recognition of CPD.Family Planning--For Preconceptional CounselingMWA--To deal with Shock, SepsisElective C/S If she has Severe CPD
Causes of obstructed labour Cephalopelvic disproportion (small pelvis or large fetus) Abnormal presentations, e.g.- brow- shoulder- face with chin posterior- after coming head in breech presentation Fetal abnormalities, e.g.- hydrocephalus*- locked twins* Abnormalities of the reproductive tract, e.g.- pelvic tumour*- stenosis of cervix or vagina**tight perineum.*** Rarer causes.** This may be associated with scarring caused by female genitalmutilation.
If the patient is in shock (hemorrhagic or septic), treat shock aggressively With the ongoing resuscitation, preparation for operative interventions (e.g., Preparing cross matched bloods, organizing the OR), has to be undertaken so that measures to stop bleeding or removal of septic focus (e.g., hysterectomy for ruptured uterus) are done as soon as possible. Whenever there is ongoing bleeding (as in ruptured uterus), laparotomy should not be delayed till patient is resuscitated out of shock.Crystalloid Rx for dehydration.
Give antibiotics if there are signs of infection, or the membranes have been ruptured for 12 hours or more. In severe cases with OL for days,If the womandelivered by caesarean section or had laparotomy, continue antibiotics until the woman is fever-free for 48 – 72 hours.
Tissue anoxia and Necrosis favor activation of tetanus spores.
Emptying Bladder—Metal catheter should never be used before delivery b/c the devitalized urethra is easy to injure.Empty stomach—Before anesthesia to prevent aspiration.
CAUTION ! Don't use an oxytocin drip if there are signs of obstruction. On the correct indications, you can use it for delay If there is obstruction or delay, don't use Kielland's forceps, or try internal version. Never do an operative vaginal delivery if her uterus has already ruptureddo a laparotomy. You may not know if it is ruptured or not, so do all vaginal operations in an Operation Theatre, with a set of laparotomy instruments ready for instant use.
Lower Segment transverse scar only ruptures during labor.Upper Segment classical scar ruptures @ anytime during the last trimester.
Pfannenstiel Incision is the choice of incision for C/S or Hysterectomy.If Cervix is intact—Subtotal HysterectomyRelative ease of procedure than total hysterectomyHigh subtotal hysterectomy preserves menstruationMay also preserve sexual pleasureIf Cervix Removed—Total Hysterectomy
NEVER If Ux Rupturedb/c we remove the tamponading effect of fetus.Very limited place in the management b/c the stage of obstruction is reached after tremendously powerful expulsive efforts have failed So additional traction with forceps will usually not complete the delivery unless Brute Force is Used.Tarnier’s axis traction forceps invented for obstructed labor are Obsolete now by LUST C/S“Trial Of Forceps” Done in an operating theatre with everything ready for C/S
Even More limited use in Management of Obstructed labor
Enlargement of pelvis by dividing the symphysis pubis. Joint separation shuld not exceed 2.5 cm; this enlarges the pelvis by 25%.Wide Episiotomy in all cases.Extreme degree of pelvic contracture--True Conjugate <6cm or Very large fetus >4kgScarred Ux shuld not be expected to withstand the extra strain required to overcome disproportion.
Craniotomy--Simpsons Perforator for impacted head with greatest diameter below BrimMorris’s Craniotomy Forceps for impacted head with greatest diameter above BrimCleidotomy—Embryotomy ScissorsDecapitation—Ramsbotham’sdecapitating hook for impacted shoulder presentation
Explain both to her and to her relatives that it could have been prevented by adequate obstetric care.
Obstructed Labor Management By Beka Aberra C1
OUTLINE• Prevention• Specific treatment – Resuscitation and monitoring of life endangering conditions – Relief of Obstruction • Vaginal • Abdominal• Postoperative care
A. Prevention • Good nutritional supply? since childhood. • Avoid early marriage? • Emergency obstetric Care • Universal ANC is outdated • Monitor labor using partograph? • Promote family planning? services • Maternal waiting area (MWA)? for high risk mothers in remote area • Elective caesarean delivery? when indicated
B. Specific TreatmentThe initial management of OL and ruptured uterus involves twoconcurrently on going activities:Resuscitation and monitoring of the life endangering conditions such as• Shock• SepsisIdentifying the cause of OL? and other complications and Intervening accordingly
Resuscitation (ABC) and Monitoring− Shock Treat with ongoing resuscitation− Dehydration Fluid and electrolyte replacementIf the woman is not in shock but she is dehydrated and ketotic, give 1liter of ringers lactate or (DNS) rapidly and repeat (x3) till dehydrationand ketosis are corrected. Then reduce to 1 liter in 4–6 hours.− Monitor closelyKeep an accurate record of all intravenous fluids infused, drugs given,vital signs and urinary output.
− SepsisIn Severe cases the following antibiotic regimen can be used:• Ampicillin 2 g every 6 hours (QID) or ceftriaxone and• Gentamicin 5 mg/ body weight every 24 hours IV (adjusted with renalstatus)• Metronidazole 500 mg IV every 8 hours, Clindamycin orChloramphenicolIn Less severe cases, ampicillin and gentamicin may be adequate.− Analgesics can be given while resuscitating and preparing her foroperative delivery.There is no reason to withhold anti-pain treatment in a woman withobstructed labor which developes peritonitis.
− Other Medications givenCrystalline penicillin 2 mega units IV Q 2 hourly (For infections by gas- forming organisms).Hydrocortisone initial dose 200-400 mg IV followed by 100-200 mg IV, 4 hourly (If there is septic shock).Titrated infusion of Dopamine (for hypovolemic shock with low urine out put and not corrected with IV fluids)Tetanus prophylaxis?? TAT 1500 units
Preparation before interventiono Empty bladdero Empty stomach with NG tubeo Laboratory tests required for preoperative assessment and evaluation: − Hemoglobin/ Hct − Blood group (ABO, Rh) prepare 2 units. − Urine analysis − Renal function tests (especially with decreased urine output) − Blood culture and sensitivity − Others test depending on individual clinical findings
Caesarean DeliveryIndicationsAlive fetus with incomplete cervical dilatation or high station.Alive fetus with Brow or Mentoposterior face position.Alive or dead fetus with evidence of imminent uterine rupture.Dead fetus with unmet criteria for destructive/ instrumental delivery. Placenta Previa Totalis is one criteria.ComplicationsLess safe in small rural hospitals where most of obstructed labor have to be dealt with.Risk of Hemorrhage.Risk of Injury to bladder and ureter.Risk of rupture for women who come to hospitals as a last resort. So for subsequent Px she mightnot come.Risk of Reproductive failure.
LaparotomySimple repair of ruptured uterus (with or without tubal ligation). • Clean wound, lower segment transverse incision (Prev. C/S). • Recent rupture. • Tear is not too large, clean edge. • Preservation of fertility or menstruation if needed. • Little or no infection. • Easy procedure.Total abdominal hysterectomy/ Subtotal hysterectomy • Severe infection of uterus • Rupture compromising blood supply of uterine muscle • Extensive tear with Necrotic edges • Tears difficult to stitch such as posterior tears and extension into the vagina • Rupture after prolonged labor • Future cervical cancer concern
Forceps DeliveryIndicationsAlive fetus and head < 1/5 above pelvic brim. ( Well Engaged)Mild-moderate moulding.OT or OP position with no or minimal CPD. (Incomplete rotation + Minor disproportion)ComplicationsPosterior rupture of Uterus or Colporrhexis (Tearing of vagina) due to “Boot-Scrapper effect”Bladder neck injuryInc. distortion of already moulded fetal head likely to produce Tentorial Tear.ContraindicationsDead fetusPelvic TumorsMentoposterior Face or a Brow Presentation. B/c Impacted head can’t be flexed for delivery
Vacuum ExtractionIndicationSame as Forceps but its benefit –Easier to apply b/c there is no need to define exact position of head, nor to rotate it. –Doesn’t occupy space b/n fetal head and pelvic side walls. –Laceration of Vagina is lessComplications and ContraindicationsSame as ForcepsOne useful function over Forceps is to complete delivery aftersymphysiotomy.
SymphysiotomyIndicationsDone for Gross CPD as a cause of Obstructed Labor in a patient with no Previous Obstetric Care.ComplicationSerious urinary and Locomotory disabilities.Pubic pain and Back pain.ContraindicationsDead fetus.Previous C/S.Extreme degree of contraction of pelvis (TC< 6cm).Breech, Brow or mento-posterior face presentation.Preexisting locomotor disturbance (Hip joint d/s).Gross Obesity.
Destructive DeliveryIndicationDead fetusFully dilated cervix andNo evidence of rupture or imminent rupture.2/5 or less of his head must be above the brim (Impacted Head)His mothers cervix must be at least 7 cm dilated, and preferably fully dilated.Her uterus must be unruptured, and not in imminent danger of rupturing.CautionIf she is a multiparous with a dead fetus, and has been in labour for a long time, her lowersegment will be very thin. She can only be saved by Caesarean section; any destructiveoperation, except Craniotomy, will rupture it.
Management of Obstructed LaborGeneral Measures Obstruction relief Resuscitation Vaginal Route Oxygen Operative Delivery Antibiotics Destructive Delivery Catheterization Abdominal Route Pain relief Caesarean Delivery NG tube drainage of gastric Laparotomy – Uterine contents repair or Hysterectomy Hemogram and blood as necessary 17
C. Postoperative care and follow up Intensive resuscitation and monitoring should be continued till condition (K+ corrected) improves. Puerperal Sepsis is almost Inevitable so Antibiotics IV till fever free for 2-3 days and continue coarse PO. Close monitoring to identify complications early (e.g., Peritonitis; Abscess). Bladder drainage for 5-7 days by indwelling catheter. Blood transfusion. Investigation including blood and urine culture and sensitivity as indicated. Analgesics including pethidine. Breast care for those with stillbirths or neonatal deaths. Fistula care and follow-up:Women with fistula are kept in the hospital until infection is controlled. They should getinformed about when and where they can have the fistula repair.Usually, the fistula repair is undertaken 2-3 months after delivery.
Explain condition and Counsel on future pregnancyo Repaired uterine rupture without tubal ligation or CS:Always hospital delivery.o Total or sub-hysterectomy or tubal ligation:Amenorrhea and Infertility.o Severe postpartum infection:Possibility of ectopic pregnancy in future pregnancy andNeed for early check up if pregnant;Infertility(one child syndrome)
Bibliography• Obstructed Labour Chapter 11 by J.B.Lawson• Management Protocol On Selected Obstetrics Topics; FMOH January, 2010• Dr. Asheber Gaym- Concise best short note book, 2009• World Health Organization; Education material for teachers of midwifery: midwifery education modules. – 2nd ed. 2008
Thank You”Obstructed labor? Definitely! Head wont budge an inch!”