Prolonged and obstructed labor refer to complications in childbirth characterized by extended duration and mechanical obstruction despite adequate uterine contractions, respectively. Prolonged labor can lead to maternal and fetal risks such as hypoxia, infection, and increased morbidity, influenced by factors like uterine contractions, pelvic structure, and fetal positioning. Management focuses on early intervention, supportive care, and surgical options when necessary, including cesarean sections for fetal distress or obstructed labor conditions.

1. Prolonged & Obstructed Labor
Rupture Uterus

2. Prolonged Labor
• when combined duration of first and second
stage of labor (excluding latent phase) is more
than 18hrs in primi and >12hrs in multiparous
women, is called prolonged labor .
• Second stage is defined prolonged when it is
>2hrs in primi & >1 hr. in multi.

3. • The prolongation denotes either delay in
cervical dilatation and/or inadequate
descent of presenting part.
• Incidence of prolonged labor:-
- 8% in primigravda
- 2% in multigravida

4. Causes of Prolonged Labor
Fault in any one or combination of basic
elements involved in labor
- Fault in power
- Fault in passage
- Fault in passenger

5. • Fault in power -
Abnormal or Inadequate uterine contraction
- Incoordinate uterine contraction
- Inability to beardown
• Fault in passage
- Full bladder
- Contracted pelvis
- Pelvic tumor (e.g.fibroid)

6. • Fault in passenger
-Malposition (op), Malpresentation (Face)
- Congenital anomaly of fetus (hydrocephalus)
- Deflexed head with poor uterine contraction
• Others
- Injudious early administration of sedative and
analgesic before actual labor begins

7. Dangers of Prolong Labor
• Fetal – The fetal risk increased due to
combined effect of hypxia & infection
 Intra uterine hypoxia
 Low Apgor score at birth
 Infection
 Intracranial hemorrage
 ↑ fetal morbidity & mortality

8. • Maternal Risks-
 Maternal distress
 Postpartum Hemorrhage
 Trauma to genital tract- cervical tear
- Rupture uterus
- ↑ operative delivery
 Puerperal sepsis / Subinvolution
 Undue stretching of the perineal muscles – which
may cause prolapse later
 ↑ Morbidity and Mortality

9. - Use partography in all labor to diagnose abnormality
early and timely intervention, optimally by alert and
action line.
- Early detection of factors producing prolong labor and
appropriate timely treatment.
Prevention of prolonged labor

10. Treatment
• Evaluate maternal and fetal condition from history,
general examination and obstetrical examination
and start supportive resuscitation.
• If there is Fetal Distress in 1st
stage of labor, CPD,
Malpresentation or failed augmentation → CS
• If inefficient uterine contraction → Augmentation of
labor by ARM and oxytocin.

11. Obstructed Labor
• Definition – Labor is said to be obstructed
when inspite of good uterine contraction
the progress of labor comes to standstill
due to mechanical obstruction.
• Incidence – 1-5% in referral hospital

12. Causes of obstructed labor
Important Common causes are:-
 Contracted Pelvis and CPD
 Malpresentation ( Shoulder, braw, mentoposteriar)
 Malposition ( DTA, OP )
Less Common causes are:-
 Fetal anomalies – Hydrocephalus, fetal ascitis,
conjoined twin.
 Soft tissue tumor –fibroid , ovarian
 Scarred cervix from previous amputation

13. Course of Labor in Obstructed labor
• During labor uterine contraction increases in
intensity, duration and frequency to overcome
obstruction
• With each contraction some retraction of upper
segment occur → Upper segment becomes
progressively thicker and shorter (tonic contraction)
• The passive lower segment progressively stretches
and become thinner to accommodate the fetus
driven from upper segment

14. • A circular groove is formed between the active upper
segment and passive distended lower segment called
pathological retraction ring (Bandle’s Ring)
• In primigravida → further uterine contraction ceases and
uterus subsequently becomes inert.
• In multigravida → the uterus continue to contract
vigrously .there is progressive rise of Bandle’s Ring
upward and ultimately lower segment rupture if baby is
not delivered promptly.

15. Clinical features of obstructed labor
 Patient is in agony due to continuous pain & restless
 Features of exhaustion – Tachycardia
- Perspiration
- Dehydration
- Ketoacidosis, L. respiration
 P/A Examination
- Bladder may be full
- Bandle’s Ring is visible
- Upper segment of uterus hard tonically contracted & tender
- Lower segment distended & tender
- Fetal parts may not be well defined
- FHS usually absent or bradycardia

16. P/V Examination
- Edematous Vulva
- Hot and Dry vagina
- Offensive vaginal discharge
- Cervix almost fully dilated
- Membranes are absent
- Presenting part may be impacted in pelvis
- Cause of obstructed labor is reveals

17. Prevention
 Antenatal detection of high risk pregnancy likely
to produce prolong labor such as big size baby,
short stature women , CPD, malpresentation &
malposition.
 Routine Partography and timely intervention of a
prolonged labor due to mechanical factor can
prevent obstructed labor.

18. Treatment of obstructed labor
 Correction of dehydration and acidosis with 1-3
liter NS or RL infusion.
 Vaginal swab to be taken for C/S
 Arrange blood in anticipation of PPH.
 Broad Spectrum antibiotic
 Obstetrical Management

19. Obstetrical Management
 If baby alive (rare ) → CS
 If baby is dead
- Destructive operation is an option if obstetrician Experience
- Otherwise do CS
- After Every case of operative vaginal delivery →
*vaginal, cervical tear and rupture uterus must be excluded.
*Oxytocin must be given
* Indwelling catheter for 7-10 days

20. Effects of Obstructed Labor
 Fetus
- Asphyxia
- Intracranial hemorrhage
- Infection
- ↑Perinatal Loss
 Mother
Immediate Remote
- exhaustion - Genital urinary fistula
- Dehydration - rectovaginal fistula
- Metabolic acidosis - Variable degree of v.atresia
- Genital sepsis - Secondary Amenorrhea due
- Injury to G.T. Hysterectomy or Sheehan’s syndrome
- PPH & Shock
- ↑ M. Morbidity & Mortality

21. Rupture Uterus
 Rupture of uterus is giving way of gravid uterus or
dissolution in continuity of uterine wall any time
after 28 weeks of gestation with or without
expulsion of fetus
 Rupture of the uterus is one of the most dramatic
serous obstetric Emergency.
 Incidence – Widely varies
1 in 200 to 1in 1800 deliveries

22. Aetiology of Rupture Uterus
 Spontaneous Rupture
- Obstructed Labor
- Fundal Pressure in grand multipara
- Uterine malformation
 Scar Rupture
- Rupture of CS Scar→L.S.C.S-0.2-1.5, U.S.C.S- 4-9%
-Uterine scar following operation on uterus
*Myomectomy *Metroplasty
* Hysterotomy * D&C

23.  Iatrogenic
-Injudicious administration of oxytocin
- Use of prostaglandin
- Internal version
- Destructive operations
- Difficult Forceps delivery
- M.R.P.
 Over all most common cause of uterine rupture is
separation of previous c.s. scar
 But in developing country obstructed labor with feto-
pelvic disproportion is still one of the common cause
of rupture uterus

24. Types of Rupture Uterus
 Complete Rupture- when uterine cavity communicate
directly with peritoneal cavity.
- Spontaneous rupture is more often complete.
 Incomplete Rupture- when uterine cavity is separated
from peritoneal cavity by visceral
peritoneum or broad ligament.
- Traumatic is usually incomplete
 Scar Dehiscence - When there is separation of
previous scar with intact peritoneum.

25. Site of Rupture
• Lower segment – Most common occurs in
previous CS, obstructed labor, which may extent
to lateral site & extends upward.
• Upper Segment – Occurs in previous classical
CS, Previous scar in upper segment & other
muscular pathology.

26. Diagnosis
• Rupture During Pregnancy
Typically
- Acute abdominal pain
- Features of shock & intrabdominal hemorrhage
- Easily palpable fetal parts
- Absent fetal heart sound
- Contracted uterus is felt on one side
Atypically
- Incomplete rupture producing localized abdominal pain & tenderness
- Frank signs of hemorrhage & shock develop slowly
- It may confuse with accidental hemorrhage

27. Rupture in Labor
• H/o vigorous uterine contraction followed by sudden
bursting pain→ cessation of L. pains
• Signs of internal hemorrhage depending on severity
→ Shock , abdominal tenderness, guarding
• P/A → Fetal parts are easily palpable together with
hard retracted uterus can be felt.
• Vaginal Examination
- Reveals bleeding through the cervical os
- Recession of presenting part in complete rupture
- Cervix hangs like a curtain
- Hematuria may be present

28. Management
• I.V. line, Antibiotics, Arrange blood
• Laparotomy along with blood transfusion when the
∆ of rupture uterus is made
• In case of ruptured C.S. scar, low parity, women &
rupture wound is clear cut, condition stable
→Repair
• Patient with high parity, edges of rupture are
ragged and irregular, anatomy is distorted
→Hysterectomy to be.

29. Causes of Mortality
• Hemorrhage
• Shock
• Sepsis
• Mortality in intacted uterus rupture is more than
scarred uterus
• Mortality is more (3%) in classical scar than lower
segment scar rupture (1%).