Obstructed labor management

Beka Aberra
C1 Medical Student
Black Lion Hospital
[email protected]

1. Obstructed Labor Management By Beka Aberra C1

2. OUTLINE Prevention Specific treatment Resuscitation and monitoring of life endangering conditions Relief of Obstruction Vaginal Abdominal Postoperative care

3. A. Prevention Good nutritional supply? since childhood. Avoid early marriage ? Emergency obstetric Care Universal ANC is outdated Monitor labor using partograph? Promote family planning? services Maternal waiting area (MWA )? for high risk mothers in remote area Elective caesarean delivery? when indicated

4. B. Specific Treatment The initial management of OL and ruptured uterus involves two concurrently on going activities : Resuscitation and monitoring of the life endangering conditions such as Shock Sepsis Identifying the cause of OL? and other complications and Intervening accordingly

5. Resuscitation (ABC) and Monitoring − S hock Treat with ongoing resuscitation − Dehydration Fluid and electrolyte replacemen t If the woman is not in shock but she is dehydrated and ketotic, give 1 liter of ringers lactate or (DNS ) rapidly and repeat (x3) till dehydration and ketosis are corrected . Then reduce to 1 liter in 4–6 hours . − Monitor closely Keep an accurate record of all intravenous fluids infused, drugs given, vital signs and urinary output .

6. − Sepsis In Severe cases the following antibiotic regimen can be used: • Ampicillin 2 g every 6 hours (QID) or ceftriaxone and • Gentamicin 5 mg/ body weight every 24 hours IV (adjusted with renal status ) • Metronidazole 500 mg IV every 8 hours, Clindamycin or Chloramphenicol In Less severe cases , ampicillin and gentamicin may be adequate. − Analgesics can be given while resuscitating and preparing her for operative delivery . There is no reason to withhold anti-pain treatment in a woman with obstructed labor which developes peritonitis .

7. − Other Medications given Crystalline penicillin 2 mega units IV Q 2 hourly ( For infections by gas-forming organisms ). Hydrocortisone initial dose 200-400 mg IV followed by 100-200 mg IV, 4 hourly ( If there is septic shock ). T itrated infusion of Dopamine ( for hypovolemic shock with low urine out put and not corrected with IV fluids ) Tetanus prophylaxis?? TAT 1500 units

8. Preparation before intervention Empty bladder Empty stomach with NG tube Laboratory tests required for preoperative assessment and evaluation : − Hemoglobin/ Hct − Blood group (ABO, Rh) prepare 2 units. − Urine analysis − Renal function tests (especially with decreased urine output) − Blood culture and sensitivity − Others test depending on individual clinical findings

9. Operations to Relieve obstruction Abdominal delivery Cesarean delivery Laparotomy if Ux Ruptures deliver the fetus abdominally. Operative Vaginal delivery Forceps delivery Vacuum Extraction Symphysiotomy Destructive delivery Craniotomy Cleidotomy Decapitation

10. Caesarean Delivery Indications Alive fetus with incomplete cervical dilatation or high station. Alive fetus with Brow or Mentoposterior face position. Alive or dead fetus with evidence of imminent uterine rupture. Dead fetus with unmet criteria for destructive/ instrumental delivery . Placenta Previa Totalis is one criteria. Complications Less safe in small rural hospitals where most of obstructed labor have to be dealt with. Risk of Hemorrhage. Risk of Injury to bladder and ureter. Risk of rupture for women who come to hospitals as a last resort. So for subsequent Px she might not come. Risk of Reproductive failure.

11. Laparotomy Simple repair of ruptured uterus (with or without tubal ligation). Clean wound, lower segment transverse incision (Prev. C/S ). Recent rupture . Tear is not too large, clean edge. Preservation of fertility or menstruation if needed. Little or no infection. Easy procedure. Total abdominal hysterectomy/ Subtotal hysterectomy Severe infection of uterus Rupture compromising blood supply of uterine muscle Extensive tear with Necrotic edges Tears difficult to stitch such as posterior tears and extension into the vagina Rupture after prolonged labor Future cervical cancer concern

12. Forceps Delivery Indications Alive fetus and head < 1/5 above pelvic brim. ( Well Engaged) Mild-moderate moulding. OT or OP position with no or minimal CPD . (Incomplete rotation + Minor disproportion) Complications Posterior rupture of Uterus or Colporrhexis (Tearing of vagina) due to “Boot-Scrapper effect” Bladder neck injury Inc. distortion of already moulded fetal head likely to produce Tentorial Tear . Contraindications Dead fetus Pelvic Tumors Mentoposterior Face or a Brow Presentation. B/c Impacted head can’t be flexed for delivery

13. Vacuum Extraction Indication Same as Forceps but its benefit Easier to apply b/c there is no need to define exact position of head, nor to rotate it. Doesn’t occupy space b/n fetal head and pelvic side walls. Laceration of Vagina is less Complications and Contraindications Same as Forceps One useful function over Forceps is to complete delivery after symphysiotomy.

14. Symphysiotomy Indications Done for Gross CPD as a cause of Obstructed Labor in a patient with no Previous Obstetric Care. Complication Serious urinary and Locomotory disabilities. Pubic pain and Back pain. Contraindications Dead fetus. Previous C/S. Extreme degree of contraction of pelvis (TC< 6cm). Breech, Brow or mento-posterior face presentation. Preexisting locomotor disturbance (Hip joint d/s). Gross Obesity.

15. Destructive Delivery Indication Dead fetus F ully dilated cervix and N o evidence of rupture or imminent rupture. 2/5 or less of his head must be above the brim (Impacted Head) His mother's cervix must be at least 7 cm dilated, and preferably fully dilated. Her uterus must be unruptured, and not in imminent danger of rupturing. Caution If she is a multiparous with a dead fetus , and has been in labour for a long time , her lower segment will be very thin . She can only be saved by Caesarean section ; any destructive operation, except Craniotomy, will rupture it.

16. Management of Obstructed Labor General Measures Resuscitation Oxygen Antibiotics Catheterization Pain relief NG tube drainage of gastric contents Hemogram and blood as necessary Obstruction relief Vaginal Route Operative Delivery Destructive D elivery Abdominal Route Caesarean Delivery Laparotomy – Uterine repair or Hysterectomy 17

17. By Dr. Shiferaw Negash

18. C. Postoperative care and follow up Intensive resuscitation and monitoring should be continued till condition (K+ corrected) improves . Puerperal Sepsis is almost Inevitable so Antibiotics IV till fever free for 2-3 days and continue coarse PO. Close monitoring to identify complications early (e.g ., Peritonitis; Abscess). Bladder drainage for 5-7 days by indwelling catheter. Blood transfusion . Investigation including blood and urine culture and sensitivity as indicated. Analgesics including pethidine . Breast care for those with stillbirths or neonatal deaths. Fistula care and follow-up: Women with fistula are kept in the hospital until infection is controlled . They should get informed about when and where they can have the fistula repair . Usually, the fistula repair is undertaken 2-3 months after delivery.

19. Explain condition and C ounsel on future pregnancy o Repaired uterine rupture without tubal ligation or CS: Always hospital delivery. o Total or sub-hysterectomy or tubal ligation: A menorrhea and I nfertility. o Severe postpartum infection : P ossibility of ectopic pregnancy in future pregnancy and N eed for early check up if pregnant ; I nfertility(one child syndrome )

20. Bibliography Obstructed Labour Chapter 11 by J.B.Lawson Management Protocol On Selected Obstetrics Topics; FMOH January , 2010 Dr . Asheber Gaym- Concise best short note book, 2009 World Health Organization; Education material for teachers of midwifery: midwifery education modules. – 2nd ed . 2008

21. Thank You   ”Obstructed labor? Definitely!        Head won't budge an inch !”