Obstructed labour

Obstructed labour (dystocia)

1. Obstructed labor Nur Fadzlina Zabri

2. Definition It is failure of descent of fetal presenting part in birth cannal due to mechanical reasons in spite of good uterine contractions

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

4. Risk factors Malnutrition Previous caesarean or stillbirth, previous prolonged labour Young age of mother (under 17 years of age) Female genital mutilation Custom of early marriage Previous obstructed labour

5. Causes Fault in the passage Fault in the passenger

6. Fault in the passage : (1) Bony Contracted pelvis Cephalopelvic disproportion (2) Soft tissue obstructions: Cervical dystocia due to prolapse or previous operative scarring Broad ligament fibroid Impacted ovarian tumor The non-gravid horn of a bicornuate uterus below the presenting part.

7. Fault in the passenger : Transverse lie (2) Brow presentation (3) Congenital malformations of the fetus —hydrocephalus (commonest), fetal ascites, double monsters (4) Big baby, occipito -posterior position (5) Compound presentation (6) Locked twins.

8. Morbid anatomical changes Uterus : formation of Bandl’s ring Bladder : patient fails to empty the bladder. The bladder walls get traumatized, which may lead to blood stained urine, a common finding in obstructed labor . The base of the bladder and urethra, which are nipped in between the presenting part and symphysis pubis may undergo pressure necrosis. The devitalized tissue becomes infected and later on may slough off resulting in the development of genitourinary fistula.

9. During prolonged labor, compression of soft tissues between the baby’s head and the woman’s pelvis cuts off blood flow to the bladder or rectum. As a result, tissue dies , leaving hole or fistula

10. Want big impact? Use big image. Immediate: Remote: Exhaustion Dehydration Metabolic acidosis Genital sepsis Injury to the genital tract includes rupture of the uterus Postpartum hemorrhage and shock. (1) Genitourinary fistula or rectovaginal fistula (2) Variable degree of vaginal atresia (3) Secondary amenorrhoea following hysterectomy due to rupture or due to Sheehan’s syndrome. Effects on the mother

11. Effects on the fetus (1 ) Asphyxia ( 2) Acidosis ( 3) Intracranial hemorrhage ( 4) Infection. All these lead to increased perinatal loss.

12. Prevention Antenatal detection of the factors likely to produce prolonged labor (big baby, small women, malpresentation and position). Intranatal : Continuous vigilance, use of partograph and timely intervention of a prolonged labor due to mechanical factors can prevent obstructed labor . Failure in progress of labor in spite of good uterine contractions for a reasonable period (2–4 hours) is an impending sign of obstructed labor

13. Complications Uterine rupture Fistula-faecal, urinary and its psychosocial effects Cervical and vaginal scarring and stenosis Pressure sores and contractures Foot injury Sepsis PPH, amenorrhea, infertility Fetal loss and maternal death

14. Actual treatment: Principles are : ( 1) To relieve the obstruction at the earliest by a safe delivery procedure (2) To combat dehydration and ketoacidosis (3) To control sepsis.

15. Preliminaries : Fluid electrolyte balance and correction of dehydration and ketoacidosis A vaginal swab Blood sample Antibiotic

16. Obstetric management : Before proceeding for definitive operative treatment, rupture of the uterus must be excluded. There is no place of “wait and watch”, neither any scope of using oxytocin to stimulate uterine contraction.

17. Abdominal delivery When do we use cs ( abdominal delivery ) If cephalopelvic disproportion is confirmed If precondition for instrumental delivery not fulfilled Malpresention – breech presentation Definite uterine rupture

18. Symphysiotomy - rarely used today For relatively mild obstruction If the fetus is alive & cervix is fully dilated Episiotomy If the cause of obstruction is tight peritoneum Instrumental delivery If the fetus is alive , and the cervix is fully dilated and if the head is at the level of ischial spine or below. Forceps Vacuum

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