Obstructed Labor and Management in Obstetrics

Complication of Labor
Type of Abnormal Labor

1. OBSTRUCTED LABOUR

2. DEFINITION “ Obstructed labour is one where inspite of good uterine contractions , the progressive descent of the presenting part is arrested due to mechanical obstruction .” This may result either due to factors in the fetus or in the birth canal or both, so that further progress is almost impossible without assistance.

3. INCIDENCE In the developing countries , the prevalence is about 1-2 % in the referral hospitals.

4. CAUSES

5. FAULT IN PASSAGE 1. BONY Cephalo pelvic disproportion and contracted pelvis are the common causes. Secondary contracted pelvis may be encountered in multiparous women.

6. 2. SOFT TISSUE OBSTRUCTION This includes cervical dystocia due to prolapse or previous operative scarring, cervical or broad ligament fibroid, impacted ovarian tumor or the non-gravid horn of a bicornuate uterus below the presenting part.

7. FAULT IN PASSANGER Transverse lie Brow presentation Congenital malformations of the fetus- hydrocephalus ( commonest), fetal ascites, double monsters Big baby, occipito-posterior position Compound presentation Locked twins

8. EFFECTS ON THE MOTHER IMMEDIATE: Exhaustion Dehydration Metabolic acidosis Genital sepsis Injury to 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.

9. REMOTE: Even if the patient survives, the following legacies may be left behind: Genito-urinary fistula or rectovaginal fistula Variable degree of vaginal atresia Secondary amenorrhoea following hysterectomy due to rupture or due to Sheehan's syndrome (pitutary gland damage during childbirth)

10. EFFECTS ON THE FETUS Asphyxia Acidosis Intracranial heamorrhage Infection All these lead to increased perinatal loss.

11. CLINICAL FEATURES Patient is in agony Features of exaustion On abdominal examination:- upper segment is hard and tender, lower segment is distended and tender.

12. PREVENTION Antenatal detection of the factors likely to produce prolonged labor. ( big baby, small women, malpresentation and position) Intranatal: Continuous vigilence, use of partograph and timely intervention of a prolonged labour due to mechanical factors can prevent obstructed labour.

13. Failure in progress of labour inspite of good uterine contractions for a reasonable period ( 2-4 hours) is an impending sign of obstructed labour.

14. ACTUAL TREATMENT The underlying principles are: To relieve the obstruction at the earliest by a safe delivery procedure. To combat dehydration and ketoacidosis To control sepsis

15. PRELIMINARIES Fuild electrolyte balance and correction of dehydration and ketoacidosis. A vaginal swab tissue culture and sensitivity test Blood examination Antibiotic: 1 g cefriaxone IV Metronidazole for IV for anaerobic infection

16. OBSTETRIC MANAGEMENT Before proceeding for definitive operative treatment, rupture of the uterus must be excluded. A balanced decision should be taken about the best method of relieving the obstruction with least hazards to the mother. Frantic attempt to deliver a moribund (dying) baby by a method ignoring the risk involved to the risk involved to the mother is indeed bad obstetricss.

17. There is no place of “wait and watch”, neither is any scope of using oxytocin to stimulate uterin contraction.

18. VAGINAL DELIVERY Baby is invariably dead in most of the neglected cases and destructive operation is the best choice to relive the obstruction. If however, the head is low down and vaginal delivery is not risky, forceps extraction may be done in a living baby . There no place of internal version in obstructed labour.

19. After complition of the delivery and expulsion of the placenta, exploration of the uterus and the lower genital tract should be done to exclude uterine rupture or tear.

20. CESAREAN SECTION If the case is detected early with good fetal condition , cesarean section gives the best result. But in late or neglected cases , even if the fetal heart sound is audible, desperate attempt to do a cesarean section to save moribund baby more often leads to disastrous consequences

21. Not infrequently, the baby is either delivered stillborn or dies neonatal sepsis . The postoperative period of the mother also becomes stormy and at times, ends fatally .

22. SYMPHYSIOTOMY The place of symphysiotomy has to be duly considered in the developing countries as an alternative to risky cesarean section. This can be dine in a case of eshtablished obstruction due to outlet contraction with vertex presentation having good FHS .