Obstructed labor

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  • Interesting presentation. Thank you Dr. In my opinion, Obstructed Labour is not nomenclature for a single labour disorder but rather it can be considered as a Syndrome including both maternal and fetal manifestation. And In my experience, I sometimes tend to 'Grade' Obstructed labour. As Grade 0 OL (A labouring mother arriving solely with signs of CPD) Grade 1 OL (CPD + Fetal distress, MSAF, NRFHR) Grade 2 OL (Grade 1/ IUFD + Three tumour abdomen, Difficult catheterization, all other maternal manifestations such as Fever, signs of Dehydration) Grade 3 (Any of the above with signs of Imminent uterine rupture). I suggested in such a way because these clinical factors affect both the Mgt and the prognosis.I would be happy to receive any comment on my own assumed Grade of OL from you the author or from anyone in the field of Tropical Obstetrics. Modification in elaborating the grades is highly appreciable , especially in consideration of the intra-operative finding. Thanks again
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  • thanks instructor ,an interesting presentation
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  • thanks a lot
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Obstructed labor

  1. 1. Obstructed labor and uterine rupture Yibrah Berhe, MD January, 2012 G.C.
  2. 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. 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. 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. 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.
  6. 6. Causes 2- Large sized fetus ( macrosomia). 3- Congenital anomalies : - Hydrocephalus. - Fetal Ascites. - Fetal tumors. 4- Locked and conjoined twins.
  7. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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!!!!!!!!!!!!!!!!

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