Slide gives the basic information about how to diagnose obstructed and prolonged labour cases early and it management.

1. DR. BICKEY KHADGI
OBSTRUCTED LABOR AND
PROLONGED LABOR
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2. PROLONGED LABOR
• The labor is said to be prolonged when the combined
duration of the first and second stage is more than the
arbitrary time limit of 18 hours.
• Labor is considered prolonged when the
• cervical dilatation rate is less than 1 cm/hr and
• descent of the presenting part is < 1 cm/hr for a period of
minimum 4 hours observation (WHO-1994).
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3. Stages of labour
•First stage:
• Latent Phase: Begins with the onset of labor and ends at 4 cm
cervical dilatation. (12 hrs in primi, 6 hrs in multi)
• Active Phase: Phase of Rapid dilation.
• Begins at 4 cm dilatation and ends at 10 cm.
• Minimal normal rate of cervical dilatation from 4 to 10 cm
• Nulliparous: < 1.2 cm/hr
• Multiparous: < 1.5 cm/hr
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4. Second stage
• Begins with full dilatation of the cervix and
ends with expulsion of the fetus.
• Maximum duration
• In nulliparous: 2 hours - 3 hours
• In multiparous: 1 - 2 hours
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5. Third stage
• Begins immediately after the delivery of
the fetus and ends with the delivery of the
placenta and membranes.
• Duration: Usually < 10 minutes.
• considered prolonged if > 30 minutes.
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6. Fourth Stage
Stage of observation upto 1 hour after delivery
Regular monitoring of:
• Vital signs
• Pallor
• Uterine contraction
• p/v bleeding
• Episiotomy/perineal tear sutures
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7. PROLONGED LATENT PHASE
• Mean duration of latent phase is about
• 8 hours in a primigravida and
• 4 hours in a multiparous
• A latent phase that exceeds
• 20 hours in primigravidae or
• 14 hours in multiparous is abnormal.
• The causes include—
• (1) unripe cervix
• (2) malposition and malpresentation
• (3) cephalopelvic disproportion and
• (4) premature rupture of the membranes
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8. Management
• Conservative management is usually done unless there is any
indication.
• Rest and analgesic are usually given.
• When augmentation is decided, medical methods (oxytocin or
prostaglandins ) are preferred.
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9. CAUSES OF PROLONGED LABOR
• Remember the three “Ps”
• That affect the duration of the active phase of
labor:
• Power (strength and frequency of contractions
• Passenger (size of the baby)
• Pelvis (size and shape of mother’s pelvis)
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10. Prolonged Second stage
• Sluggish or non-descent of the presenting part in
the second stage is due to:
• Fault in the power
• Fault in the passage
• Fault in the passenger:
• (1) Malposition (occipito-posterior)
• (2) Malpresentation
• (3) Big baby
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11. DIAGNOSIS
•Partograph can diagnose any
dysfunctional labor early and help to
initiate correct management.
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13. DANGERS
Fetal
(1) Hypoxia
(2) Intrauterine infection
(3) Intracranial stress or hemorrhage
(4) Increased operative delivery.
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14. Maternal
1) Distress
2) Postpartum hemorrhage
3) Trauma
4) Increased operative delivery
5) Puerperal sepsis
6) Subinvolution.
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15. TREATMENT/PREVENTION
• Antenatal or early intranatal detection of the factors likely to
produce prolonged labor
• big baby,
• small women,
• malpresentation or position.
• Use of partograph helps early detection.
• Augmentation of labor by low rupture of the membranes followed by
oxytocin drip
• Change of posture in labor other than supine to increase uterine
contractions.
• Avoidance of dehydration in labor and use of adequate analgesia for
pain relief.
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16. OBSTRUCTED LABOUR
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17. • “Obstructed labour is one where inspite of good uterine
contractions, the progressive descent of the presenting part is
arrested due to mechanical obstruction.”
• Thismay result either due to factors in the fetus or in the birth canal
or both, so that further progress is almost impossible without
assistance.
Defintion
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18. • In the developing countries, the prevalence is
about 1-2 % in the referral hospitals.
INCIDENCE
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19. CAUSES
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20. FAULTY PASSAGE
1. BONY:
 Cephalo pelvic disproportion
 Contracted pelvis
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21. 2. SOFT TISSUE OBSTRUCTION
 Cervical dystocia :
 Failure of cervix to dilate within a reasonable time
in spite of good regular uterine contraction
 Difficult labor and delivery caused by
mechanical obstruction at the cervix.
 Dystocia comes from the Greek "dys" meaning
"difficult, painful, disordered, abnormal”+ "tokos"
meaning "birth."
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22. FAULT IN PASSENGER
• Transverse lie
• Brow presentation
• Congenital malformations of the fetus:
hydrocephalus (commonest), fetal ascites.
• Big baby, occipito-posterior position
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23. IMMEDIATE:
• Exhaustion
• Dehydration
• Genital sepsis
• Injuryto the genital tract includes rupture of the uterus
• Postpartum hemorrhage and shock
• The death are due to rupture of uterus, shock and sepsis with metabolic
changes.
Effect On Mother
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24. REMOTE:
• If patient survives they may present with
complication.
1.Genito-urinary fistula or rectovaginal fistula
2.Variable degree of vaginal atresia
3.Secondary amenorrhoea
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25. • Asphyxia
• Acidosis (due to fetal hypoxia)
• Intracranial hemorrhage
• Infection
Effect on Fetus
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26. • Patient is in agony
• Features of exhaustion
• Abdominal Examination:
• Upper segment is hard and tender
• Lower segment is distended and tender.
• Fetal heart sounds are usually absent
• Membranes rupture early spontaneously
Clinical Features
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27. • Antenataldetectionoffactorproducingprolongedlabor.
• Bigbaby,
• Smallwomen
• Malpresentationand position
• Perinatal: Continuous monitor, use of partograph , to detect prolonged
labour.And useinterventionaccordingly.
• Failure in progress of labour inspite of good uterine
contraction for a reasonable period (2-4 hours ) is an
impending sign of obstructed labour.
Prevention
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28. • Theunderlying principles are
1. To relieve the obstruction at the earliest by a safe
delivery procedure.
2.To combat dehydration and ketoacidosis
3. To control sepsis
Treatment
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29. PRELIMINARIES
1. Fluid electrolyte balance and correction of dehydration
and ketoacidosis.
2.A vaginal swab tissue culture and sensitivity test
3.Blood examination
4.Antibiotic: 1g cefriaxone IV
5.Metronidazole for IV for anaerobic infection
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30. • Rule out rupture of uterus.
• Decision should be made to relieve the obstruction.
Obstetric Examination
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31. • There is no place of “wait and
watch”, neither is any scope
of using oxytocin to stimulate
uterine contraction.
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32. • Lower segment Caesarean section (LSCS):
• If the case is detected early with good fetal
condition, caesarean section gives the best
result.
• But in late or neglected cases, even if the fetal
heart sound is audible, desperate attempt to do
a casearean section to save moribund baby
more often leads to disastrous consequences.
Definitive management
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33. Thank-YOU
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