Obstructed labor and uterine rupture

1. Obstructed Labor and Uterine
Rupture

2. Characteristic of Normal Labor
Friedman Curve

3. Abnormal Labor patterns
Abnormal Labor Diagnostic criteria
Nullipara Multipara
Prolongation disorder
Prolonged latent phase > 20 hours > 14 hours
Protraction disorder
Protracted active-phase dilatation < 1.2 cm/hr <1.5 cm/hr
Protracted descent < 1 cm/hr < 2 cm/hr
Arrest disorders
Prolonged deceleration phase > 3hours > 1hour
Secondary arrest of dilatation > 2 hours > 2 hours
Arrest of descent > 1 hour > 1 hour
Arrest of dilatation No descent in deceleration phage or
second stage

4. Why do abnormal pattern of Labor occur?
Fault in
Power Passage Passenger

5. Obstructed Labor
 Labor is considered obstructed when the
presenting part of the fetus cannot progress
into the birth canal, despite strong uterine
contractions because of insurmountable barrier
preventing its descent. WHO, 2003
 Usually occurs at the pelvic brim, but may
occur in the cavity or at the outlet.

6.  Accounts for 1-2% deliveries in referral
hospitals
 Obstructed labor accounts for 8% of all
maternal deaths in the developing world, and
plays a negligible role in all US maternal
deaths.
J Am Med Women Assoc, 2002

7. Causes of obstructed labor:
Passasge
 cephalopelvic disproportion
(small pelvis with normal
sized fetus)
 Contracted pelvis
Passage, Passenger
Power
Normal

8. Causes of obstructed labor:
Passasge
 Abnormality of bony
pelvis
Passage, Passenger
Power
Normal

9. Causes of obstructed labor:
Passasge
 abnormalities of the
reproductive tract
 pelvic tumour
 stenosis of cervix or
vagina
 tight perineum.
Passage, Passenger
Power
Normal

10. Causes of obstructed labor:
Passenger
Passage, Passenger
Power
Normal
 Cephalopelvic
disproportion (normal
sized pelvis with large
fetus)
 Abnormal lie
 Abnormal presentations,
e.g. – brow ,
shoulder, face with
chin posterior
 Abnormal position

11. Causes of obstructed labor:
Passenger
Passage, Passenger
Power
Normal
 Aftercoming head in
breech presentation
 fetal abnormalities,
e.g. – hydrocephalus
- fetal ascitis
- locked twins

12. Risk Factors for Obstructed Labor
1) early marriage and young age of mother
2) short height
3) previous prolonged labour
4) malnutrition or lack of exposure to sunlight,
resulting in rickets or osteomalacia
5) staff untrained to recognize obstructed labor
(partograph not used)
6) failure to act on risk factors and delay in referral
to higher level of care (e.g. for caesarean section)
7) long distance involved in obtaining skilled help,
lack of transport and communication
8) community distrust of health care personnel

13. Pathologic changes during Obstructed Labor
 In primigravida:
 Increasing frequency and intensity of uterine
contraction leads to state of “Uterine exhaution”→
Uterine Inertia
 In multigravida
 With tonic uterine contraction and retraction of
upper segment, the lower segment becomes
progressively thinner to accommodate fetus
 A groove is formed between active upper segment
and distended lower segment, called Bandl’s ring
 With persistent contraction and retraction→ Lower
segment rupture
Constriction Ring ( Schroeder’s
Ring): Result of incoordinate
uterine action

14. Pathologic changes during Obstructed Labor
 Compression of urethra between presenting
part and symphysis pubis, bladder gets
distended and becomes abdominal, trauma to
bladder wall and mucosa→ hematuria

15. Pathologic changes during Obstructed Labor

pressure necrosis→ fistula formation

16. Diagnosis of Obstructed Labor
1) Presence of risk factors
1) General Condition:
 Exhausted, anxious
 Tachycardia
 Blood pressure: Normal or Increased or Decreased
 Dehydrated
 Foul smelling breath ( ketotic smell)
 Scanty concentrated urine/ no urine output

17. Diagnosis of Obstructed Labor
3) Per abdomen
 Abdomen tender
 Abdominal contour
changed
 Fetal heart rate: normal
(rarely), abnormal or
absent

18. Diagnosis of Obstructed Labor
4) Local
 Vulva: edematous
 Per Vaginal:
 Vagina: hot, flushed
 Cervix: not well applied to
presenting part,
edematous
 Presenting part:
impacted, large caput
succedaneum, excessive
moulding
 Liquor: scanty or absent,
Meconium stained

19. Diagnosis of Obstructed Labor

20. Complications of Obstructed labor
Maternal:
 Maternal exhaustion
and dehydration→
metabolic acidosis
 Uterine rupture
 Postpartum
hemorrhage
 Puerperal Sepsis
 Maternal mortality
Late:
 Psychological trauma
 Genitourinary fistulae
 Vaginal stenosis
 Secondary
amenorrhea, infertility
 Neurological injury to
perineal nerve, foot
drop (compression of
lumbosacral plexus),
bladder (neurogenic
bladder)

21. Complications of Obstructed labor
Fetal:
 Excessive moulding of
fetal head→ Intracranial
hemorrhage
 Perinatal asphyxia
 Fetal death/ still birth
 Neonatal Sepsis

22. Management of obstructed labor
 Resuscitation: ABC
 Catheterization
 Arrange blood and blood products
 Arrange uterotonics
 Prepare for emergency cesarean section
 Explain the condition, plan of management and
posible complications to patient and her
relatives
 Pre-operative prophylaxis with broad spectrum
antibiotics

23. Management of obstructed labor
 Beware of bladder and ureteric injury
 Address intraoperative complication: extension
of uterine incision, atonic or traumatic PPH
 Continue broad spectrum antibiotics
postoperatively
 Continue catheter for at least 14 days
 Inspect vaginal mucosa before removing
catheter for slough, necrosis→ may need to
prolong catheter
 Counsel regarding possibility of fistula

24. Complications of Obstructed labor
Maternal:
 Maternal exhaustion and
dehydration→ metabolic
acidosis
 Uterine rupture
 Postpartum hemorrhage
 Puerperal Sepsis
 Maternal mortality
Late:
 Psychological trauma
 Genitourinary fistulae
 Vaginal stenosis
 Secondary amenorrhea
Fetal:
 Excessive moulding of
fetal head→ Intracranial
hemorrhage
 Perinatal ashyxia
 Fetal death
 Neonatal Sepsis

25. Prevention of Obstructed Labor
SAFE PREGNANCY
AND DELIVERY
Raising
Awareness
Medical Intervention
Capacity
Building
Proper
Antenatal
Care Labor
Monitoring
LSCS

26. Prevention of Obstructed Labor
Labor monitoring by
WHO partograph

27. Prevention of Obstructed Labor
 Referring and recognising women who are at
increased risk of obstructed labour.
 Women who are pregnant very young.
 Previous history of prolonged or obstructed labor.
 Antenatal care:
 Pelvimetry to rule out inadequate pelvis
 Identify women with abnormal lie, presentations and
referring to centre with emergency c-section.

28. Uterine Rupture
Full thickness disruption of uterine wall
i) Complete:
All layers of uterine wall are separated (the uterus
communicates directly with the peritoneal cavity)
ii) Incomplete:
Uterine muscle is separated but visceral peritoneum
is intact (rupture does not reach the visceral
peritoneum)
Also referred as uterine dehiscence

29. Uterine Rupture

30. Risk factors
1) Previous uterine scar
 Prior cesarean delivery
 Prior uterine rupture
 Myomectomy
 Uterine perforation
Prior Incision Estimated rate of rupture
One low transverse 0.2-0.9%
Multiple low transverse 0.9-1.8%
Low vertical 1-7%
T-shaped 4-9%
Classical 2-9%
Prior preterm CS Increased
Lower segment 2-6%
Upper segment 9-32%

31. Risk factors
2) Multiparity
3) Prolonged or obstructed labor
4) Difficult instrumental delivery
5) Intra uterine manipulation: ECV, internal
podalic version
6) Injudicious use of oxytocin
7) Fundal pressure during delivery

32. Diagnosis
 History:
 Previous uterine surgeries: LSCS, Myomectomy
 Previous history of rupture
 Obstructed labor
 Prolonged labor with difficult instrumental deliveries
 Clinical features
 Complain of sudden sharp pain with sensation of tear
inside
 Loss of labor pain, instead continuous pain
 Abdominal distension
 Per vaginal bleeding
 Hematuria

33. Diagnosis
 Patient’s condition deteriorate suddenly due to
massive blood loss
 Pale
 Tachycardia
 hypotension
 Sudden death if major vessels involved
 Abdominal examination:
 loss of uterine contour
 fetal parts easily palpable superficially
 PV examination:
 loss of presenting part ( the presenting part moves
higher)

34. Diagnosis
Alteration in fetal heart rate
 Fetal tachycardia
 Deceleration and bradycardia
 Absent fetal heart sounds

35. Management
 Resuscitation: ABC
 Catheterization
 Arrange blood and blood products
 Prepare for emergency laparotomy
 Explain the condition to patient and her
relatives, need of blood transfusion, emergency
laparotomy, possibility of hysterectomy if
rupture is irreparable, possible need of ICU
care, chances of sepsis postoperatively, risk of
mortality
 Pre-operative prophylaxis with broad spectrum
antibiotics

36. Management
 Emergency laparotomy under GA
 Midline vertical incision
 Deliver the baby and placenta
 Assess the site and size of the rupture
 Repairable: Repair
 Irreparable: Hysterectomy (Total/Subtotal)
 If the tear extends up to cervix and vagina:
Exploration of vagina and repair of tear.
 If associated bladder rupture: Repair
 If hemostasis cannot be obtained: Internal iliac
artery ligation

37. Management
 Continue broad spectrum antibiotics
 Blood and blood products ( PCV: FFP: PRP in 1:1:1)
 Continue catheter for 14 days
 Inspect anterior vaginal wall before removing
catheter: if necrotic, slough→ may need to prolong
the catheter
Contraception
 If family is complete:
 Perform tubal ligation with uterine repair
 If wants pregnancy in future:
 effective reversible contraception , at least for 5 years,
 Explain the risk of rupture in next pregnancy

38. Complications
 Hemorrhage → hypovolemic shock and its
complications (Coagulopathy, AKI), complications
related to transfusion
 Puerperal sepsis
 Maternal mortality (up to 30%)
 Perinatal mortality (10-80%)
Late complications
 Urogenital fistulae (VVF, ureteric)
 Secondary amenorrhoea, lactational failure
 Increased chances of rupture in future pregnancy

39. Prevention
1) Proper antenatal care
2) Identification of high risk patients
3) Labor monitoring
4) Judicious use of oxytocin
5) Avoid fundal pressure during labor
6) Always rule out genital tract injuries in
instrumental deliveries

40. Thank You !