12. OBSTRUCTED LABOR. This is are notes made from reliable text books at obs/gyn at Must

Obstructed labour's in obstetrics

1. Obstructed labor BAHATI FELIX 2015/MBR/060/PS SUPERVISORS: Dr.KAYONDO Dr.MARIAM

2. DEFINATION Obstructed labor is a condition in which the progressive descend of presenting part is arrested, despite adequate uterine contractions. D ue to mechanical obstruction It may be due to abnormalities of presentation ,position ,development of the fetus or abnormalities of maternal bony pelvis or birth. INCIDENCE It occurs in about 1-3% of all pregnancies in developing countries

3. CAUSES Faulty in passage (maternal causes) Bony; cephalopelvic disproportion, contracted /deformed/small pelvis are common causes .secondary contracted pelvis is common in multiparous women. Soft tissue; cervical dystocia, cervical or broad ligament fibroid, impaired ovarian tumor, rectal tumors, cervical and vaginal stenosis Full urinary bladder.

4. Fault in passenger Mal positions i.e. POP, POT and Transverse lie Abnormal presentations e.g. brow, face shoulder and breech Congenital malformations e.g. hydrocephalous, cystic hygromas and conjoined twins Fetal ascites Macrosomia

5. ANATOMICAL CHANGES Uterine changes e.g. formation of pathological retraction ring or bandl’s ring. Bladder changes ,it becomes an abdominal organ due to compression of the urethra between the presenting part and the pubis and the patient fails to empty the bladder , its walls get traumatized by the presenting part leading to a blood stained urine acommon finding in Ol .This can also result into genitourinary fistula.

6. Clinical features It presents with distension of gut (hyperkalemia) Bladder(compression Lower uterine segment There is edema of the : vulva (cannula syndrome) cervix lower uterine segment

7. Dehydration; hot and dry skin, loss of tissue turgor, oliguria, Patient is in agony Features of exhaustion and ketoacidosis Abdominal palpation shows; upper segment is hard and tender, lower segment is distended and tender Inspite of good uterine contractions, the mother spends 2-4 hrs in labor

8. Ctn…… Sepsis; purent vaginal discharge and pyrexia Tender swelling above pubic symphysis (indicating swollen bladder ) over the stretched lower uterine segment

9. Late signs of obstructed labor Mother is dehydrated ,ketotic and constant pain Pyrexia and tarchycardia Abdominal palpation will be difficult due to maternal distress with area over the lower segment being tender to touch . Urinary output is present and on insertion of catheter you notice urine concentrated with blood

10. Diagnosis Obstetric exam: the sign of obstructed labor is the bandl’s ring seen on a gravid uterus. Its seen at the level where the upper and lower segments of the uterus meet , where a firm ridge is formed running obliquely across the uterine wall. its presence is an indication for emc/s bse the uterus may just be minutes away from rupturing Vaginal examination: the vulva may be edematous and the vagina may be hot and dry.

11. Signs on a partogram Secondary arrest of the cervical dilation and descent of the presenting part with a large caput Third degree moulding Maternal and fetal distress On V/E Cervix is poorly applied on the presenting part Cx is edematous Ballooning of the lower uterine segment Formation of uterine bands

12. EFFECTS ON THE MOTHER immediate Exhaustion of the mother Dehydration Metabolic acidosis Injury to the genital tract including rupture of uterus PPH All the above lead to increased maternal mortality and morbidity esp uterine rapture, shock after pph and sepsis with metabolic changes

13. EARLY Genital sepsis

14. LATE Genitourinary fistula Rectovaginal fistula Variable degree of vaginal atresia Secondary amenorrhea following hysterectomy due to uterine rapture or due to sheehans syndrome

15. EFFECTS ON FETUS Asphyxia Acidosis Intracranial hemorrhage Infection All these lead to increased perinatal loss

16. vaginal examination Edema of the lower vagina and vulva Thick offensive vaginal discharge Per vaginal bleeding On the cervix; cephalic presentation gives a full dilatation; shoulder presentation- rim of cervix persists

17. COMPLICATIONS Maternal; ruptured uterus,maternal death,trauma to the bladder, puerperal sepsis, stenosis of the vaginal due to fibrosis, dyspareunia, osteitis pubis (infection of the pubic bone after damage to the periosteum and superficial cortex by pressure necrosis.) Fetal; asphyxia, neonatal sepsis, and death

18. PREVENTION Antenatal checkups; - detection of factors likely to produce prolonged labor e.g. big baby, small women ,malpresentations (brow,face,arm breech and transverse lie) and malposition(persistent occipital anterior and persistent occipital transverse) Intranatal; use of a partograph to monitor labor. Timely intervention of prolonged labor and development of appropriate and timely referral systems Prevent malnutrition. Health education

19. Mgt Goals To relieve the obstruction by safe delivery procedure To combat dehydration and ketoacidosis To control sepsis

20. Mgt IV fluids; Ringers lactate, 1L in a running drip at 3L in 24hrs Vaginal swab taken for culture and sensitivity to r/o infections Blood sample sent for grouping and cross matching Iv Antibiotics, ceftriaxone 1g is administered IV infusion of metronidazole 500mg

21. MODE OF DELIVERY Before deciding the mode of delivery, rule out uterine rupture There is NO place of “wait and watch” neither any scope of using oxytocin to stimulate uterine contraction There is no place for internal version in ol The following modes can be undertaken

22. CESAREAN SECTION It’s the standard mgt for O/l. If good fetal condition is detected, cesarean section is the best mode of delivery if obstructed labor is detected early

23. VAGINAL DELIVERY If fetus is dead; destructive operation is done( craniotomy(commonly used in hydrocephalus), decapitation, evisceration, cleidotomy(deliberate clavicle fracture). Resuscitate the mother before proceeding ensure empty bladder and be ready for PPH After completion of the delivery explore the uterus and the perineum for the rapture and tears respectively