Obstructed labour occurs when progress of labour stops due to mechanical factors despite adequate uterine contractions. It is a leading cause of maternal and fetal morbidity and mortality worldwide. Risk factors include cephalopelvic disproportion, malnutrition, osteomalacia, teenage pregnancy and macrosomia. Prolonged obstructed labour can result in uterine rupture, obstetric fistula, maternal death and stillbirth. Treatment involves relieving obstruction through caesarean section if fetus is alive or craniotomy/caesarean if not. Prevention strategies include good antenatal care, early referral and use of a partograph during labour.

1. OBSTRUCTED LABOUR
GOMBE STATE UNIVERSITY
College of Medical Sciences
Department of Obstetrics and Gynaecology
MODERATOR: Dr. Nuhu Teri James

2. OUTLINE
 Introduction
Significance
Definition
Epidemiology
 Aetiology
 Pathogenesis
 Clinical Presentation
 Investigations
 Management
 Complications
 Prevention
 Conclusion

3. CASE
What is your diagnosis?
What are the possible complications in this patient?
A 35-year-old G2P1 +0 A1 woman at 40 weeks 6 days presents to Gynae
Emergency of FTHG with a 5-hour history of painful contractions. Monitoring
reveals contractions every 3 minutes, and cervical examination on arrival is 3 cm
dilated, 50% effaced, and −2 station. Her pregnancy has been complicated by GDM
and 45 lb weight gain in pregnancy (BMI, 24). In her first pregnancy, she delivered
a live male fetus weighing 4.5kg by Caeserian section. You recheck her cervix 4
hours later and find that it is 4 cm dilated, 90% effaced, and -1 station. A recent
ultrasound performed at 38 weeks estimated the fetal weight at 4,200g.

4. HISTORY
• The consequences of obstructed labor can best be illustrated by the story of
Princess Charlotte of England, the only eligible heir to the British throne in 1817
• Went into labor at 42 weeks and labored for 50 hours (26 hrs. in 1st stage of labor
and 24 hrs. in 2nd stage) and delivered 4.08kg (9-pound) still-born
• The princess died 5 hrs. later ?hypovolemic shock due to PPH from uterine atony, a
direct result of her obstructed labor
• Her obstetrician, Sir Richard Crofts committed suicide 3 months later
THE ‘’TRIPLE OBSTETRIC TRAGEDY”

5. INTRODUCTION
• Every year it is estimated that worldwide, more than 500,000 women die of
complications of pregnancy and childbirth. At least 7 million women who survive
childbirth suffer serious health problems. The overwhelming majority of these
deaths and complications occur in developing countries – WHO
• Obstructed labor is the leading cause of uterine rupture worldwide, which is a
common cause of maternal death.
• Obstructed labor also causes significant maternal morbidity in the short term
(notably infection) and long term (notably obstetric fistulas).
• Fistula formation is more common in the primigravid woman and uterine rupture in
multigravida. Fetal death from asphyxia is also common.

6. INTRODUCTION
is an obstetric
emergency.
• It occurs when labour progress has
come to a complete halt in the presence
of adequate uterine contractions due to
mechanical factors and vaginal delivery
is impossible without assistance.
• Its result simply from a mismatch
between fetal size, or more accurately,
the size of the presenting part of the
fetus, and the mother’s pelvis

7. EPIDEMIOLOGY
• In United States, about 12% of all deliveries are complicated by dystocia and
accounts for 60% of all caeserian deliveries.
• A community-based retrospective survey of maternal deaths in a region of
Uganda suggests 26% of 324 obstetrics deaths is attributable to obstructed
labor.
• The prevalence of obstructed labour in Nigeria is 4.13% and it remains as an
important cause of feto-maternal morbidity and mortality

8. EPIDEMIOLOGY
• In North Eastern Nigeria, the prevalence is 3.13% commonly follows CPD and
risk is higher for illiterate women, unbooked mother and teenage primigravidas
• In a retrospective study done at SSHG, Gombe State, over a period of 5 years. The
incidence of obstructed labour was 4.0%.

9. AETIOLOGY
• These are usually remembered as:
“The powers” (uterus and soft tissue)
“The passenger” (foetus)
“The passage” (pelvis)

10. AETIOLOGY
MATERNAL
i. Malnutrition
ii. Osteomalacia
iii. Childhood rickets
iv. Teenage pregnancy
v. Abnormal pelvic shape
i. Uterine fibroid
ii. Ovarian cyst
i. Transverse/longitudinal vaginal septum

11. FETAL
i. Malposition
ii. Malpresentation
iii. Macrosomia
iv. Congenital anomalies
v. Abnormal fetus e.g Hydrocephalus
FETO-MATERNAL
i. Cephalopelvic disproportion

12. PATHOGENESIS
• There is a substantial evidence to show an association between
, as a cause of obstructed labour, and —which is
linked to pelvic size.
• There may be large deviations from normal if there had been rickets in
childhood or osteomalacia in adolescence.
• Also, teenage pregnancy may pose problems even without gross nutritional
deficiencies because the bony pelvis may not yet have achieved its full
dimensions. Different cut-off heights have been identified in different
communities to highlight an increased risk of obstetric labour, the individual
values reflecting genetic diversity

13. • Cephalopelvic disproportion may be due to a small pelvis with a normal size head,
or a normal pelvis with a large fetus, or a combination of a large baby and small
pelvis
• With continued contraction and retraction, the lower segment elongates and thins
out, while the upper segment retracts and thickens, producing a circular groove
between the upper and lower segments called
• The urethra and bladder base are trapped between the presenting part and the
pubic symphysis so that the bladder cannot be emptied.
mainly result from the ischaemic necrosis of vaginal and
bladder tissues, trapped between the fetal head and the mother’s pubic symphysis
during prolonged, obstructed labour. Recto-vaginal fistulas may also form but these
are less common

14. CLINICAL PRESENTATION
HISTORY
• Usually non-attendants or poor attendants at the ANC
• Low social class, uneducated and usually a young teenager
• History of a very prolonged labour at home-extending to days rather than hours.
• Attempted delivery at home/peripheral hospital with history of oxytocics use,
‘’Gishiri’’ cut, attempted instrumental delivery and use of herbal medication

15. CLINICAL PRESENTATION
EXAMINATION
1. General Examination
• Patient in distress and agony
• Pale, febrile and dehydrated
• Offensive liqour discharge
2. Abdominal Examination
• Enlarged bladder
• Bandl’s ring
• 3 tumor sign
• Transverse lie may be picked
• Non-reassuring FHS

16. 3. Cardiorespiratory
• Shock (↑ Pulse, ↓ Low blood pressure)
• Tachycardia
4. Vaginal Examination
• Vagina hot and dry
• Edema of the cervix and vulva (Kanula Sign)
• Vaginal discharge
• Vaginal bleeding
• Large caput succedaneum can be felt
• Moulding and Caput

18. INVESTIGATION
• Urgent PCV
• FBC
• Eucr
• GXM
• USS
• High vaginal swab or Endocervical swab
• Urinalysis
• Urine MCS
• Blood culture

19. TREATMENT
• Obstructed labor is an obstetric emergency. RESUSCITATE the patient on
presentation
• The steps below are employed for management of Obstructed Labour
Combat dehydration and acidosis
↓
Relieve obstruction
↓
Control sepsis and pain

20. Combat dehydration and acidosis
(a) Put up an IV line. Use a wide bore cannula.
(b) If the woman is shocked, give normal saline or Ringer’s lactate. Run in 1 litre as
quickly as possible, then repeat 1 litre every 20 minutes until the pulse slows to less
than 90 beats per minute, systolic blood pressure is 100 mmHg or higher.
However, if breathing problems develop, reduce to 1 litre in 4–6 hours.
(c) If the woman is not in shock but is dehydrated and ketotic, give
1 litre rapidly in 4–6 hours.

21. Combat dehydration and acidosis
• Start parenteral broad spectrum antibiotics
• Catheterize the bladder and keep an accurate record of all intravenous fluids
infused, and urinary output.

22. Relieve obstruction
is confirmed, and the fetus is alive delivery should be
by caesarean section
- delivery should be by craniotomy
- if this is not possible, delivery should be by caesarean section.
is suspected, do laparatomy

23. • Continue IVF
• Continue antibiotics
• Continue analgesia
• Continuous bladder drainage for 7-14 days
• May require blood transfusion
• Correct other electrolyte derangements
Control sepsis and pain

24. COMPLICATIONS
Maternal
• Exhaustion
• Shock
• Dehydration
• Metabolic acidosis
• ARF
• Genital injuries
• Sepsis
• Uterine rupture
• PPH
• VVF and gynaetresia
• Death
Fetal
• Fetal hypoxia
• Birth asphyxia
• Neonatal Sepsis
• CP later in life
• ICH
• Death

25. PREVENTION
• Good antenatal care
• Good referral system( early referral from lower facilities)
• Use of partograph in labour

26. CONCLUSION
• The sequelae of obstructed labour can be an enormous source of human
misery and the prevention of obstetric fistulas, and skilled treatment if they do
occur, are important priorities in regions where obstructed labour is still
common.
• Antenatal care aim to identify early problem associated with obstructed
labour and address many thus reducing the burden
• Use of Partograph during labour is unparalleled tool to prevent such
occurences
• Delivery in a hospital setting cannot be over-emphasized!

27. REFERENCES
• World Health Organization, Managing Prolonged and Obstructed labor, WHO
Library Cataloguing-in-Publication Data, 2018, Page 6-21 ISBN 978 92 4
154666 9.
• Philip N Baker. Louise C Kenny. Obstetrics by Ten Teachers 19th Edition
Minion by MPS Limited 2011 Page 123- 134 ISBN 978 0 340 983 539
• Prof. Calvin Chama (unpublished lecture note) OBG401, Obstetrics and
Gynaecology, Gombe State University
• Science Direct, Obstructed Labour and its management at
www.sciencedirect.org. Accessed on 30th March, 2021 8:45pm

28. Thanks!