Obstetrics obstructive labour

1. OBSTRUCTED LABOR

2. • Definition:Its one in which despite good uterine contractions, the
progressive descent of the presenting part is arrested due to
mechanical obstruction.
• CAUSES
1. Fault in the passage
2. Fault in the passenger

3. Fault in the passage(maternal condition)
• Bony
Cephalopelvic disproportion i .e small pelvis
Contracted pelvis
• Soft tissue obstruction
Cervical dystocia due to uterine prolapse or previous operative
scarring.
Cervical or broad ligament fibroid
Impacted ovarian tumor


4. Fault in the passenger(fetal factors)
• Transverse lie
• Brow presentation
• Congenital malformations of the fetus-hydrocephalus,fetal ascites
• Big baby
• Compound presentation:arm prolapse alongside the presenting part
so that the two are felt simultaneously in the pelvis
• Locked twins

5. Diagnosis of obstructed labor
Points to note during history taking include:
Her age,parity,gravidity
History of previous operative delivery
Duration of previous labor and outcome
Duration of current labor
Duration of ruptured membranes

6. Effects of obstructed labor on the mother
1.IMMEDIATE
i. Exhaustion of the mother due to constant agonising pain and anxiety
ii. Dehydration –increased muscular activity without adequate fluid intake
iii. Metabolic acidosis
iv. Injury to the genital tract ie rupture of the uterus following instrumental delivery
v. Genital sepsis-rupture of membranes due to repeated VE examination or attempted
manipulation outside
vi. Postpartum hemorrhage and shock –effects of atonic uterus or genital tract trauma

7. Maternal complications
i. Genitourinary fistula or rectovaginal fistula
ii. Neurological injury eg foot drop
iii. Maternal death

8. Effects on the fetus
i. Aspyxia –tonic uterine contraction that interfere with the
uteroplacental circulation or due to cord prolapse especially in
shoulder presentation.
ii. Acidosis –fetal hypoxia and maternal acidosis
iii. Intracranial hemorrhage-supermoulding of the head leading to
tentorial tears ,traumatic delivery
iv. Infection

9. Clinical features
i. Signs of physical or mental exhaustion
ii. Features of ketoacidosis
Abdominal Examination
i. Bandl’s ring may be present. This is when the upper and lower uterine segments becomes
visible/palpable during labor. It is usually seen as a depression across the abdomen at about the level of
the umbilicus. This is a late sign of obstructed labor mostly in primigravida.
ii. The uterus may stop contracting mostly in primigravida.
Vaginal Examination
Signs of obstruction include:
i. Oedema of the vulva,especially if the patient has been pushing for a long time
ii. Foul smelling-meconium staining liqor
iii. Absence of amniotic fluid since it has already drained away
iv. Oedema of the cervix
v. Incomplete dilatation of the cervix
vi. Large caput succedaneum can be felt
vii. May palpate a severely moulded head ,or shoulder presentation

10. Factors associated with obstructed labor
History of previous stillbirth or prolonged labor
Young age of the mother(<17 years)
Female genital mutilation
Medical illnesses eg diabetes mellitus
Pelvic abnormalities following childhood illnesses eg polio,pelvic
injuries.

11. Management of obstructed labor
1. Combat dehydration and ketoacidosis-by rapid infusion of ringers
solution/normal saline; at least 1 litre is to be given in running drip in the
fist 15 min. At least 3litres required to correct dehydration.
2. Catheterize
Insert an indwelling urinary catheter using aseptic technique and
monitor urine output
3. Control sepsis; if there are signs of infection or membranes have been
ruptured for 18 hrs or more .Give ceftriaxone 1g iv
 If a woman is delivered by caesarian section, continue
antibiotics and give metronidazole 500mg IV every 8 hours until
the woman is fever free for 48 hrs.

12. 4. Deliver the baby
Cephalo pelvic disproportion
• If CPD is confirmed, delivery should be by caesarian section
• If the fetus is dead-delivery should be by craniotomy, if this is not possible,
delivery should be done by caesarian section
Obstruction
• If the fetus is alive, the cervix is fully dilated and the head is at 0 station
or below, deliver the baby by vacuum extraction
• If the fetus is alive and the cervix is fully dilated and there is evidence of or
indication for symphysiotomy for relatively minor obstruction(if caesarian
section is not possible)and the fetal head is at -2 station, then delivery
should be by symphysiotomy and vacuum extraction

13. • If the fetus is alive but the cervix not fully dilated or if the fetal head is
too high for vacuum extraction, referral should be made immediately
for delivery by caesarian section
• If the fetus is dead-delivery should be by craniotomy. If this not
possible, delivery should be by caesarian section.
NOTE:Destructive obstetric procedures sch as craniotomy should be
performed by a competent health provider using the appropriate
equipment.