OBSTRUCTED LABOR is an emergency that poses significant risk to the life of both mother and fetus. A condition usually associated with low socioeconomic status puts much burden on the fragile health care delivery in subsaharan Africa

1. OBSTRUCTED
LABOR/EMERGENCY C-
SECTION
CASE PRESENTATION BY:
DR.EMMANUEL ALI ADAMU
COLLEGE OF MEDICAL SCIENCES
UNIVERSITY OF MAIDUGURI, NIGERIA

2. CASE SUMMARY
BIODATA
• Name: Mrs. J.S
• Hospital no; 300556
• Age:19yrs
• Tribe: Kanuri
• Religion: Islam
• Occupation: H/wife
• Marital status: Married
• Address: Konduga LGA
• Booking status: Unbooked
• Parity : primigravida
• LMP: ? 9/12
• DOA; 12/01/19
• DOD: 26/01/19

3. History
PRESENTIG COMPLAINT
 Labour pain of 24 hours duration
HISTORY OF PRESENTING COMPLAINT
 Patient was apparently well until about 24 hours prior to
presentation when she developed lower abdominal pain of
gradual onset, associated increase in frequency.
 6 hours later she noticed sudden gush of clear fluid from the
vagina which soaked her wrapper and non foul smelling. This
was not associated with vaginal bleeding.

4. History cont.
• She had several vaginal examinations and labored for
14 hours at home without progress despite fundal
pressure performed by an untrained TBA and
ingestion of herbal concoctions.
• She presented to PHC where she was augmented for
3 hours and finally referred by an NGO (PUI) to this
hospital.
• There was no history of instrumentation. There was
no associated vaginal bleeding, no fever, no dizziness
or fainting attacks.

5. History of index pregnancy
• Pregnancy was spontaneously conceived desired,
unplanned but suspected by missed period and early
morning nausea and vomiting. The pregnancy was
not confirmed with USS
• Shebooked at PHC and had 2 uneventful visits. She
received 2 doses of TT, IPT and was placed on
heamatinics.
• She perceived first fetal movement at about 5
months of pregnancy. The pregnancy had been
uneventful until the time she went into spontaneous
labour.

6. GYNAE HX
• 14K5/28D0M0
• Not aware of modern family planning, pap
smear or self breast examination and was
adequately counseled

7. PAST MED/ DRUG. Hx
• She is not a known diabetic, hypertensive,
SCDx or asthmatic.
• There is no history of hospitalization
• No previous surgery or blood transfusion, no
known drug allergy.

8. FAMILY AND SOCIAL Hx
• No family hx of diabetes, hypertension or
heart disease.
• No family history of multiple gestation
• Married in a monogamous setting to a small
scale farmer with no formal education
• Not gainfully employed.
• She neither smoke nor ingest alcohol

9. EXAMINATION
General physical Examination
• Young woman, anxious in painful distress,
moderately dehydrated, exhausted, febrile(
axillary temp of 38.9oC), not pale, not
jaundiced, acynosed, no pedal oedema.
• Height: 1.50m, weight : 56kg

10. Abdomen:
• Her abdomen was uniformly enlarged and
moves with respiration, umbilicus is everted,
SFH is 38cm, a singleton fetus lying
longitudinal, presenting cephalic, in ROP,
Descent 2/5th palpable per abdomen, FHR
100b/minutes.

11. Vaginal Examination
• Edematous vulva
• Vagina dry and hot
• Cervix was fully dilated and membranes
absent
• Caput +++, Moulding severe
• Station 0.

12. Cardiovascular System:
• PR :106 bpm
• BP: 120/80mmHg
• HS: S1, S2 only

13. Respiratory system:
• RR 24cpm
• Clear lung fields

14. ASSESSMENT
Prolonged obstructed labour secondary to
malposition with fetal distress.

15. Management
• She was admitted into labour ward and planed for an
emergency caesarean section.
• The condition was explained to her and she
consented to the operation.
• An IV access was secured with 16G cannula and
blood sample was taken for PCV, grouping and cross
matching, electrolytes, urea and creatinine.
• An indwelling Foleys urethral catheter was inserted
which drained concentrated urine and sample was
taken for urinalysis.

16. Management cont.
• intravenous fluid Normal saline 1L was given fast,
and then continued on 5% Dextrose saline to
alternate with Ringer’s lactate at the rate of 1L 8
hourly.
• Antibiotics were commenced with IV metronidazole
500mg and IV Ceftriaxone 1g stat.
• IM pentazocine 30mg stat was also given for
analgesia.
• IM tetanus toxoid 0.5mls stat and anti tetanus serum
1500 IU was given after a test dose.
• The anaesthetist, neonatologist and theater staff
were informed.

17. INVESTIGATION AND RESULTS
• PCV - 35%
• Blood group - O Rhesus D. Positive
• Bicarbornate - 16mmol/liter (low) normal range 20 –
30mmol/1
• Urea- 6.8mmo1/liter (raised) Normal range 2.5-
5.8mmo1/1
• Other electrolytes and creatinine were within normal
range.
• Urinalysis - Albumin ++
- Glucose negative
• She had two unit of fresh blood cross-matched and kept
in the blood bank.

18. SURGICAL FINDINGS
• Clean pelvis
• Thinned out lower uterine segment
• Oedematous bladder
• Foul smelling meconium stained liqour

19. SURGICAL FINDINGS CONT.
• A live male neonate delivered cephalad in
right occipito posterior position, with APGAR
score of 4 and 7 in the 1st and 5th minute
respectively and weight of 2.9kg
• Anterofundal placenta
• Normal ovaries and tubes
• Estimated blood loss was 400mls

20. POSTOPERATIVE PERIOD
• Her immediate postoperative period was satisfactory.
• She was placed on intravenous fluid 5% Dextrose saline to
alternate with Ringer’s lactate 1 L 8 hourly for 24 hours,
intravenous Ceftriaxone 1g 12 hourly & intravenous
metronidazole 500mg 8 hourly for 48 hours and
intramuscular Pentazocine 60 mg 6 hourly for 24 hours.
• Her vital signs were monitored quarter hourly.
• An indwelling Foleys catheter was left insitu for 14 days.

21. POST-OP MANAGEMENT CONT.
• On the second day post operation, her condition and
vital signs were stable.
• The fluid input-output was adequate.
• Bowel sounds had returned and she commenced graded
oral feeds which she tolerated
• Intravenous fluid was discontinued.
• On the 3rd post-operative day, antibiotics were converted
to orals.
• She was continued on tablets Cefuroxime 500mg 12
hourly for 7 days, tablets metronidazole 400mg 8 hourly
for 5 days and Diclofenac potassium 50mg 8 hourly for 5
days.
• She was also placed on haematinics.

22. POST-OP MANAGEMENT
• Her post operation packed cell volume was 30
%.
• On the 7th post-operative day, her vital signs
remained stable, the wound had healed well
and stitches were removed.
• The urethral catheter which was draining clear
urine was removed on the14th post-operative
day and she was discharged home to be seen in
the postnatal clinic after 4 weeks.

23. POST NATAL CLINIC
• She was well and had no complaint. Her general
condition was satisfactory. She was neither pale
nor febrile to touch and her blood pressure was
110/80 mmHg.
• The abdominal examination revealed a
pfannestiel’s scar which healed by primary
intention, abdomen was soft and not tender. The
spleen, liver and kidneys were not palpably
enlarged and uterus was not palpable.
• Vaginal examination revealed a healthy looking
cervix and well-involuted uterus.

24. POST NATAL CLINIC CONT.
• The baby weighed 5.4 kg and was fully
immunized for age. The mother was counseled
on exclusive breast feeding and completion of
her baby’s immunization.
• She was advised to book for antenatal care in
her subsequent pregnancies. She was then
discharged from the clinic and referred to the
Family Planning Clinic.

25. SUMMARY
• Patient is a 19yr old unbooked primigravida at
39weeks of gestation admitted with complaint
of labour pain of 24 hours duration. She was
evaluated and managed as a case of
obstructed labor who had emergency C-
section and was delivered of a live male
neonate who is alive and well and had an
uneventful follow up.

26. OBSTRUCTED LABOR
DISCUSSION

27. OUTLINE
• Definition
• Epidemiology
• Risk factors
• Clinical presentation
• Investigations
• Treatment
• Complications
• Prevention
• Conclusion

28. DEFINITION
• Obstructed labor is a labor in which progress
has come to a complete halt in the presence of
good and adequate uterine contractions.
Progress here refers to cervical dilatation and
descent of the presenting part.
• This may result either due to factors in the fetus
or in the birth canal or both, so that further
progress is almost impossible without
assistance.

29. EPIDEMIOLOGY
• Worldwide incidence is 2-8% of all
pregnancies accounting for 8% of maternal
mortality
• About 65 million women worldwide have
obstruted labor each year and 2-5% of them
develop VVF and RVF
• In Africa, it varies ranging from 0.4-3.4/100
births in Nigeria

30. EPID. CONT…
• Accounts for 13% of MM in Uganda(according to
international alliance for HIV/AIDS in Uganda)
• In Nigeria;
In Maiduguri, according to a 3-year retrospective
study of all cases of obstructed labor managed at the
department of O&G UMTH between Jan. 1st 2012 to Dec.
31st 2014 ,215 cases of obstructed labor were found out
of 10,109 deliveries giving a prevalence of 2.13%(B. Bako,
E. Barka and A.A Kullima 2014)

31. EPID. CONT…
• It is <2.7% reported in Enugu
>0.8% observed in Kano

32. RISK FACTORS
MATERNAL FACTORS

33. FETAL FACTORS
• Macrosomia
• Congenital anomalies;hydrocephalus
• Malpresentation
• Malposition
• Cephalopelvic disproportion

34. CAUSES OF OBSTRUCTED LABOR

35. CLINICAL PRESENTATION
• The patient usually presents with prolonged
labor having severe and continuous pain.
• Abdominal examination reveals the uterus to
be somewhat smaller in size, tense and tender.
• Fetal parts are neither well defined, nor is the
fetal heart sound audible.
• Vaginal examination reveals jammed head with
big caput, dry and edematous vagina.

36. INVESTIGATIONS
• USS
• FBC, EUCr, Urinalysis, Group and cross match 2
units of blood
• Blood culture to rule out sepsis
• Identify the underlying cause

37. TREATMENT
• ACTUAL TREATMENT: The underlying principles are
(1) to relieve the obstruction at the earliest by a safe delivery
procedure,
(2) to correct dehydration and ketoacidosis,and
(3) to control sepsis.
• Preliminaries:
(1) Fluid electrolyte balance and correction of dehydration and
ketoacidosis are done by rapid infusion of Ringer’s solution; at
least 1 liter is to be given in running drip. At least 3 liters of
fluid is required to correct clinical dehydration.

38. TREAT. CONT…
(2) A vaginal swab is taken and sent for culture and sensitivity
test.
(3) Blood sample is sent for group and cross matching and a
bottle of blood should be at hand prior to any operative
intervention.
(4) Antibiotic: ceftriaxone 1 g IV is administered.
(5) IV infusion, metronidazole is given for anaerobic infection..
• Obstetric management: Before proceeding for definitive
operative treatment, uterus rupture must be excluded. There
is no place of “wait and watch”, neither is any scope of using
oxytocin to stimulate uterine contraction.

39. • Vaginal delivery: The baby is invariably dead in most of
the neglected cases and destructive operation is the best
choice to relieve the obstruction. If, however, the head is
low down and vaginal delivery is not risky, forceps
extraction may be done in a living baby.
• Cesarean section: If the case is detected early with good
fetal condition, cesarean section gives the best result.
• Symphysiotomy: can be done in a case of established
obstruction due to outlet contraction with vertex
presentation having good FHS.

40. COMPLICATIONS
MATERNAL

41. COMPLICATIONS CONT..
FETAL

42. PREVENTION
• Primary;
Ensuring adequate nutrition especially at puberty
Advocacy, girl child education and public
enlightenment for women to avail themselves for
proper antenatal care and hospital delivery.
Awareness on the effects of early marriage
• Secondary;
Antenatal care
Intrapartum monitoring using partograph
• Tertiary;
Early intervention

43. CONCLUSION
• The prevalence of obstructed labor is high and it remains
as an important cause of feto-maternal morbidity and
mortality. It commonly follows CPD and the risk is higher
for illiterate women, unbooked mother, and teenage
primigravidas while the common complications are
sepsis and uterine rupture.
• Much can be done at the moment, by advocacy, girl
child education and public enlightenment for women to
avail themselves for proper antenatal care and hospital
delivery.

44. BIBLIOGRAPHY
• Babagana Bako, Emmanuel Barka, Abubakar A.
Kullima,Prevalence, risk factors, and outcomes of obstructed
labor at the University of Maiduguri Teaching Hospital,
Maiduguri, Nigeria ;Department of Obstetrics and Gynaecology,
University of Maiduguri Teaching Hospital, Maiduguri, Borno
State, Nigeria 2014
• DC Dutta’s OBSTETRICS including Perinatology and Contraception
8TH ED.
• OBSTRUCTED LABOR; RISK FACTORS & OUTCOME AMONG
WOMEN DELIVERED IN A TERTIARY CARE HOSPITAL ;Dr. Shazia
Rahman Shaikh1, Dr. Khalida Naz Memon2, Dr. Gulzar Usman3