2. Introduction
Modern Obstetric care has led to the virtual disappearance of
obstructed labor in developed countries,
However , in underdeveloped countries obstructed labor is not
uncommon.
Obstructed labor is one of the four leading causes of direct
maternal death.
3. DEFINITION AND
SIGNIFICANCE
Obstructed labor is failure of descent of the fetus in the
birth canal for mechanical reasons in spite of good
uterine contractions.
It accounts for about 8% of maternal deaths globally.
In Ethiopia we host the biggest fistula hospital in the
world due to obstructed labor.
Obstructed labor is an outcome of a neglected and
mismanaged labor.
4. Causes
Obstructed labor is usually an end result of improperly
managed CPD
Maternal causes:
Contracted pelvis,
Abnormal shaped pelvis,
Soft tissue obstruction
Uterus – impacted subserous pedunculated myoma,
Cervix - cervical dystocia
Vagina – septum, stenosis, or tumors
Ovaries – impacted ovarian tumors
Trauma to bony pelvis, polio, congenital deformity of
bony pelvis
5. Causes
Fetal causes:
1- Malpresentations and malpositions :
Persistent occipito-posterior and deep transverse arrest,
Persistent mento-posterior and transverse arrest of the
face presentation.
Brow presentation,
Shoulder,
Impacted frank breech.
7. CLINICAL PRESENTATION
Hx:
Prolonged labor often extending to days rather than hours
Prolonged rupture of membranes
Painful contractions (contractions eventually might cease due
to uterine hypotonia or rupture)
Fever
8. PHYSICAL FINDING
Exhausted, tired and anxious
Dehydrated and acidotic
Rapid pulse and often febrile
Hypotension or shock (septic or hemorrhagic due to infection
or uterine rupture)
Distended hypoactive bowels due to electrolyte deficit
Hypotonic or hyperactive uterine contractions depending on
the progress of labor
The cause of the obstruction may be evident on abdominal
examination (abnormal lie, big baby)
9. PHYSICAL FINDING
In the presence of uterine rupture:
The abdomen will be tender,
Fetal parts are easily felt, lie and presentation may be difficult to detect
as the baby has been displaced into the peritoneal cavity.
There will be flank dullness suggestive of hemoperitoneum.
The fetus may be distressed or dead
Distended bladder due to retention or edema
In multiparous woman and in a primigravid patient with
advanced obstructed labor the three tumour abdomen may
be evident (bladder, lower and upper uterine segments
separated by pathological Bandl’s ring.)
10. PHYSICAL FINDING
Vaginal examination will reveal edematous vulva (Cannula
sign), and cervix, foul smelling meconium stained liquor,
severe caput and moulding.
The cervix may or may not be fully dilated and the station may
be high or low depending on the level of obstruction.
Catheterization is often difficult because of the impacted
presenting part necessitating insertion of two fingers behind
symphysis pubis to pass Foley catheter.
11. MANAGEMENT
When obstructed labor is diagnosed it must be relieved with out
delay.
However the effects of the preceding prolonged labor must be
partially rectified.
Fluid and electrolyte imbalance
Control of infection
Emptying the bladder
Emptying the stomach
Crossmatching Blood
12. MANAGEMENT
RESUSCITATION:
If delivery is not imminent or likely to be so shortly,
resuscitation is the first step before facilitating transfer of the
patient to higher health institution.
In a hospital admit the patient straight to the delivery unit or
operating theatre
Update Hct, Blood group and Rh type, and white blood cell
count
Start intravenous fluid right away to correct dehydration
Vital signs should be checked regularly.
13. MANAGEMENT
Start Oxygen 6 lit/min if there is fetal distress or maternal
distress
Start broad spectrum antibiotics.
Ampicillin
Chloramphenicol and
Gentamycin. Clindamycin and Metronidazole iv are alternatives to
Chloramphenicol
Insert indwelling catheter into the urinary bladder.
If cesarean section is planned empty stomach with NGT
If uterine rupture is strongly suspected, prepare two units of
blood.
Give sometime for the patient and family before major operative
delivery and provide reassurance.
14. Operative delivery
A balanced decision should be taken on the method of delivery
and there is no place for “wait and see” policy in obstructed
labor.
The obstruction should therefore be relieved by operation
(abdominal or vaginal)
Choice of the operative intervention should depend on:
Fetal condition (dead or alive)
Station or descent of the presenting part
The presence or absence of evidence of imminent or overt uterine or
rupture
Fetal presentation
Extent of cervical dilatation
The cause of obstruction
15. Operative delivery
Vaginal:
Episiotomy
Instrumental delivery
Destructive delivery
An operative vaginal delivery should never be tried
if there is uterine rupture as it can cause:
extension of the rupture
release of the tamponade effect of the presenting part
aggravating blood loss
Explore the uterus after any vaginal operative
delivery.
16. Operative delivery
Episiotomy
Episiotomy may be the only intervention required in a patient
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 outlet level, such as due to
occiput posterior position, could be effected by generous
episiotomy.
17. VACUUM AND FORCEPS
DELIVERY
No major degree CPD
Descent not more than 1/5 above brim
Other pre-conditions for forceps and vacuum are met
The procedure preferably should be a lift out
The fetus must be alive
18. CESAREAN SECTION
Cesarean section is 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 (instrumental or destructive) are not met.
19. DESTRUCTIVE DELIVERIES
Destructive operations (craniotomy, decapitation,
evisceration and cleidotomy) are indicated if:
The baby is dead or hopelessly malformed
Descent is 2/5 or below pelvic brim
No evidence of imminent or overt uterine rupture. If
imminent uterine rupture is suspected, destructive
delivery under direct vision is indicated.
Cervix at least dilated to 8cm but preferably should be
fully dilated.
20. OTHER INTERVENTIONS
Cesarean hysterectomy (if the uterus is found severely
infected or necrotic at cesarean section)
Symphysiotomy done in some areas to deliver obstructed
labor due to borderline CPD with a live baby in cephalic
presentation
Hysterectomy is indicated if the uterus is ruptured
21. PREVENTION
Obstructed labor is preventable!!
Good obstetric service
Risk assessment: short stature, bony deformity, big baby,
malpresentation, malpositions, pelvic assessment antenatally
for selected patients
Careful assessment of labor progress with Partograph
22. COMPLICATIONS
Uterine rupture
Fistula-faecal, urinary and its psychosocial effects
Cervical and vaginal scarring and stenosis
Pressure sores and contractures
Foot injury
Sepsis
PPH, amenorrhea, infertility
Fetal loss and maternal death
23. “If a woman in the battle to reproduce her
race has ruptured her uterus , she should
be invalidated from the service, for it is
not with cripples that an army takes the
field!!” whatever!!!!!!!!!!!!!!!!
