This document discusses obstructed labor and uterine rupture. It defines obstructed labor as failure of fetal descent in the birth canal due to mechanical reasons despite contractions. Obstructed labor is caused by factors like contracted pelvis, malpresentations, or large baby size. Clinical presentation includes prolonged labor, fever, and abdominal tenderness in uterine rupture. Management involves resuscitation, antibiotics, and relieving obstruction through episiotomy, instruments, cesarean, or destructive operations depending on factors like fetal status and cervical dilation. Complications can include uterine rupture, fistula, sepsis and death if not properly managed. Prevention relies on good obstetric services and risk assessment.

1. Obstructed labor and uterine
rupture
Yibrah Berhe, MD
January, 2012 G.C.

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. 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. 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. 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. Causes
2- Large sized fetus ( macrosomia).
3- Congenital anomalies :
- Hydrocephalus.
- Fetal Ascites.
- Fetal tumors.
4- Locked and conjoined twins.

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. “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!!!!!!!!!!!!!!!!