This Note is Prepared by A OBGYN resident @ SPHMMC, Addis Ababa, Ethiopia (March 2019) For further notes, you can join us on our Telegram group @obgynsphmmc2019 Tel: +251920257863

1. Obstructed Labor - By Dr Gebresilassie
Andualem
1
Pocket Notes
Resident @ SPHMMC
By Dr Gebresilassie Andualem
Email: bjlomsecond@gmail.com
Obstructed Labor
March, 2019

2. Contents
Introduction
Incidence
Clinical Presentation and Diagnosis
Management
Complications
References
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Obstructed Labor - By Dr Gebresilassie
Andualem

3. Introduction
Definition
– failure of descent of fetus in the birth canal
• for mechanical reasons
despite good uterine contractions
a totally preventable labor complication
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It is a neglected labor & should not occur in a labor ward
Obstructed Labor - By Dr Gebresilassie
Andualem

4. Causes of OL
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CPD
Contracted
pelvis
Uterus: impacted subserous
pedunculated fibroid
Cervix dystocia, fibroid
Vagina: septa, stenosis,
tumors.
Ovaries: Impacted ovarian
tumors
• Large fetus
• Ascites, hydrocephalus
• Congenital abnormalities
• hydrocephalus, ascites or
tumor
• Locked twins
• Transverse lie
• Malpresentations
• Malpositions
Obstructed Labor - By Dr Gebresilassie
Andualem

5. Distribution of cases by cause of obstructed
labor, JUSH, Nov 2008-April 2009
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Major cause of obstructed labor identified
– Is Cephalopelvic disproportion - responsible for
67% in a Nigerian study
41.1% in an Indian study
Obstructed Labor - By Dr Gebresilassie
Andualem

6. Risks
Maternal
Malnutrition, rickets or osteomalacia
short stature
– Height <150 cm doe not have adequate
sensitivity and specificity to be used for
screening
Previous
– uterine scare
– stillbirth with prolonged labor
Care Provider related
Failure to act on risk factors
(previous scare to deliver in hospital)
Delay in referral to higher level of
care
Cultural
Young age (< 17 years)
Custom of early marriage
Female genital cutting
Socioeconomical
Lack of trained staff in recognizing
obstructed labor and its management
Lack of transport and
communication
Limited resource allocation for
reproductive health services and
programs
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Obstructed Labor - By Dr Gebresilassie
Andualem

7. Incidence
Worldwide, OL occurs in an estimated 5% of live
births and accounts for 8% of maternal deaths
Africa has the highest maternal mortality in the world
– Estimated at an average of about 1,000 deaths per
100,000 live births
Different studies in developing countries
– Incidence of OL varies
• as low as 1.3% in a Sudan study to
• as high as 7% in a retrospective study done at JUSH
– Developing countries: 1–2%
JUSH, Nov 2008-April 2009
– incidence of obstructed labor was 12.2%
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Obstructed Labor - By Dr Gebresilassie
Andualem

8. • OL Contributes to 22% of the maternal
mortality in Ethiopia
– Still this underestimation of the problem
– because deaths due to OL are often classified
under other complications such as
sepsis,
postpartum hemorrhage or
ruptured uterus
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Obstructed Labor - By Dr Gebresilassie
Andualem

9. 9
Complication Incidence (% of live
births)
% of all direct causes
Hemorrhage 10.5 28%
Sepsis 4.4 16%
Preeclampsia, eclampsia 3.2 13%
Obstructed labor 2.6 9%
Abortion 14.8 15%
Five major global direct obstetric
complications of pregnancy
Obstructed Labor - By Dr Gebresilassie
Andualem

10. Clinical Presentation and Diagnosis
History
Prolonged labor (Usually > 12 hours
Mother
– exhausted, anxious and weak
– dry tongue and cracked lips
Prolonged ROM
Hx of previous operative deliveries
Partograph
– Prolonged: FSOL /SSOL
– Cervicogram cross alert line & then action line despite
adequate uterine contractions
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Obstructed Labor - By Dr Gebresilassie
Andualem

11. Objectively
Deranged maternal VS
– Fever, Tachycardia, hypotension/shock, tachypnea
Abdomen
– 2/3 - tumor abdomen; Tenderness; Signs of fluid collection
GUS
– Foul-smelling meconium
– Edematous vulva (Cannula sign), cervix
– severe caput and molding
– cervix may or may not be fully dilated
– station may be high or low depending on the level of obstruction
– Concentrated urine, which may contain meconium or blood.
• Catheterization is often difficult because of the impacted presenting part
necessitating insertion of two fingers behind symphysis pubis to pass Foley
catheter
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Obstructed Labor - By Dr Gebresilassie
Andualem

12. Morbid Anatomical Changes
Primigravida
• In response to mechanical obstruction,
uterine contraction gradually decreases
– Uterine Inertia
– Atonic uterus: common in primigravida and
may lead to atonic PPH after delivery
Multigravida
• Uterine contraction is intense at the fundus
➔
– Upper segment: Topically contracted
– LUS – thinned out & distended
– Constriction forms bn upper contractile
portion & LUS ➔ Bandl's ring
• In multiparous woman and in a primigravid
patient with advance obstructed labor -
three tumor abdomen may be evident
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Obstructed Labor - By Dr Gebresilassie
Andualem

13. Three Tumor Abdomen
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Fully distended or/ and edematous
bladder further distending the
lower abdomen
1
1 2
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Obstructed Labor - By Dr Gebresilassie
Andualem

14. Bandl’s ring
a late sign of OL
can be seen as a depression across the abdomen at
about the level of the umbilicus
An hourglass constriction ring of the uterus
Incidence: 1 in 5000 live births
Diagnosis
– typically made at cesarean delivery
• Finding: transverse thickened muscular band can be observed
separating U & L – US of the uterus
– case reports have described predelivery diagnosis using
ultrasound
• Findings: Thinned LUS, thick UUS; a prominent ring in between
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Obstructed Labor - By Dr Gebresilassie
Andualem

15. When to suspect Uterine Rupture ?
Abdomen
– Tender
– flank dullness suggestive of hemoperitoneum
Fetus
– Fetal parts easily felt
– lie and presentation may be difficult to detect
• Because baby - displaced into the peritoneal cavity
– distressed / dead
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Obstructed Labor - By Dr Gebresilassie
Andualem

16. Differential diagnosis
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Constriction ring
Full bladder
Fundal myoma
Obstructed Labor - By Dr Gebresilassie
Andualem

17. Management
• OL is an emergency condition
• Simultaneous activities
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1) Resuscitation
• Monitor life threatening conditions (shock, sepsis)
• Antibiotics if - signs of infection prolonged ROM
2) Work-Up: CBC, B/G & Rh, Prepare blood preparation
3) Identifying the cause of OL
4) Decide on mode of delivery
• Laparotomy, CS, Instrumental, destructive ???
Obstructed Labor - By Dr Gebresilassie
Andualem

18. Standard components
• Crystalloids: RL/NS
• Catheterize
• Blood typing & Prepare Crossmatched blood
• Broad spectrum antibiotics
– Ampicillin + Gentamycin + Metronidazole
– Ceftriaxone + Metronidazole
• Obtain informed consent
• Proceed with the planned mode of delivery
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Obstructed Labor - By Dr Gebresilassie
Andualem

19. Determinants of mode of labor
• No place for "wait & see" policy in OL
but balanced decision should be taken on the method
of delivery
• Factors
Fetal condition (dead or alive)
Station (descent) of presenting part
± evidence of imminent (overt) uterine rupture
Fetal presentation
Extent of cervical dilatation
Maternal hemodynamic status
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Obstructed Labor - By Dr Gebresilassie
Andualem

20. 20
Ux - Intact & no
imminent rupture
Imminent Ux rupture
Cervix
• Not Fully dilated → CS
• Fully dilated
– RFHR + well descended presenting part
→ Instrumental delivery
– NRFHR / high station → CS
• Destructive delivery if
1. Dead fetus / malformed
2. Descent is 2/ 5 or below
3. No evidence of imminent or overt
uterine rupture
4. Cervix ≥ 8cm (preferable if fully
• Alive fetus: CS
• Dead fetus: Laparotomy fof direct vision ➔
– destructive delivery under direct vision
– If the lower segment of the uterus is
dangerously thinned out, cesarean
section is safer
• Ruptured uterus
× Destructive vaginal operation
✓ Hysterectomy: Total / Subtotal
Obstructed Labor - By Dr Gebresilassie
Andualem

21. Interventions done in cases of obstructed
labor, JUSH, Nov 2008-April 2009
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Obstructed Labor - By Dr Gebresilassie
Andualem

22. Ruptured uterus
• Destructive vaginal operation is a contraindicated
• Laparotomy ➔
– Total hysterectomy
• Extensive tear
• Necrotic edges
• Tears difficult to stitch such as posterior tears and extension into the vagina
• Grossly infected uterus
• Rupture after prolonged labor
• Future cervical cancer concern
– Subtotal hysterectomy
• Similar conditions as total hysterectomy that are related to infection and tear
• Relative ease of procedure than total hysterectomy
• High subtotal hysterectomy preserves menstruation
• May also preserve sexual pleasure
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The term subtotal hysterectomy is ambiguous and is not a preferred term
Uterine corpus
Cervix
Obstructed Labor - By Dr Gebresilassie
Andualem

23. Options of Head extraction in OL
Pull method: Reverse breech
extraction
• Advantage
– lower risk of lateral or downward
uterine incision extension, blood
loss
– shorter operative time
• U 2018 – preferred – since this
approach is best supported by
available literature
Abdominovaginal delivery ("push
method")
• both abdomen & perineum
should be prepped preoperatively
• Disadvantage
– ↑ risk of uterine incision extension
(8X)
– ↑ risk of blood loss, transfusion,
postpartum endometritis
– Longer mean operative time
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Obstructed Labor - By Dr Gebresilassie
Andualem

24. Other techniques
• Fetal head elevator, obstetrical spoon
– Obstetrical spoons
– Fetal head elevators
• Shoulders first techniques
– assistant gently push shoulder cephalad
– primary obstetrician tries to extract the fetal head
• Patwardhan's shoulders first technique
– first delivering the anterior shoulder and arm ➔ rotate the fetus and
delivering the posterior shoulder and arm
– fetal trunk, breech, and lower limbs are then successively delivered through
the incision using a combination of gentle traction on the arms, fingers
beneath the thorax, and fundal pressure
– Once the body is delivered, the head is lifted out of the pelvis in the same
manner as a reverse breech extraction
– Compared with the traditional abdominopelvic delivery technique, this
technique has been reported to reduce
• risk of uterine lacerations/extension of the incision, bladder injuries, and need for
blood transfusions
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Obstructed Labor - By Dr Gebresilassie
Andualem

25. Postoperative care and follow up
• continue antibiotics until the woman is fever-free for 48 –
72 hours ➔ continue PO
• Intensive resuscitation and monitoring
• Blood transfusion
• Analgesics
• If outcome – SB/END
– Bereavement Care
– Breast care
• Fistula care and follow-up
– kept until infection is controlled
– Usually, the fistula repair is undertaken 2-3 months after
delivery
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Obstructed Labor - By Dr Gebresilassie
Andualem

26. Bladder care
• Avoid distention & encourage urination
• Catheter
– Leave the urinary catheter in place for a minimum of 7 to
10 days (WHO) ➔
– If there is no fistula: remove the urinary catheter
– If VVF fistula is ≤ 4 cm diameter
• attempt conservative treatment
• Leave catheter for at least 4 to 6 weeks to allow fistula to heal
• Keep catheter as long as the fistula is not closed and as long as a
gradual decrease of its diameter is observed at each weekly
inspection
– If the fistula is > 4 cm diameter or conservative treatment
fails or the patient has fistula for over 3 months
• surgical treatment
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Obstructed Labor - By Dr Gebresilassie
Andualem

27. Is OL Preventable?
Skilled birth attendance
Using the partograph
birth preparedness and complication readiness
– pillars of safer labour and delivery
– Help mother to organize herself into birth preparedness
Delaying early marriage
– Researches in Ethiopia have shown that 50% of women,
especially rural women, get married on average at around
16 years, and most of them rapidly become pregnant
Improved antenatal care coverage
Early referral
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Obstructed Labor - By Dr Gebresilassie
Andualem

28. Complications
Maternal
• Necrotic vesico-vaginal
fistula
• Uterine rupture
• Postpartum hemorrhage
• Slow return of the uterus to
its pre-pregnancy size
• Shock
• small intestine becomes
paralyzed and stops
movement (paralytic ileus)
• Sepsis
• Death
Neonatal
• Intracranial haemorrhage
from excessive moulding.
• Birth injuries.
• Infections
• Severe asphyxia (life-
threatening lack of oxygen)
• Death
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Obstructed Labor - By Dr Gebresilassie
Andualem

29. 29
Prolonged compression of head against pelvic bones
1. Decreases blood supply ➔ tissue Ischemia (Fistula  pressure necrosis
2. Obstructs venous drainage → Edematous Cx, Vulva
Obstructed Labor - By Dr Gebresilassie
Andualem

30. Distribution of complications in cases of
obstructed labor, JUSH, Nov 2008-April 2009
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Obstructed Labor - By Dr Gebresilassie
Andualem

31. References
Gabbe 7th edition
Management protocol on selected obstetrics
topics (FMOH) - January, 2010
WHO recommendation on duration of bladder
catheterization after surgical repair of simple
obstetric urinary fistula, 2018
Incidence, causes & outcome of obstructed labor
in JUSH
Global burden of obstructed labor in the year
2000 (WHO) - Geneva, July 2003
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Obstructed Labor - By Dr Gebresilassie
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Obstructed Labor - By Dr Gebresilassie
Andualem