Obstructed labour. .ppt

Obstructed labour

1. Lecture 31
Obstructed labour
Shoulder dystocia

2. Obstructed Labor

3. Definition
It is the arrest of vaginal delivery of the fetus due to
mechanical obstruction.
Incidence :- 1 -2% of referral cases in developing
country.

4. Etiology
Maternal causes
Bony obstruction : e.g.
Contracted pelvis.
Tumors of pelvic bones.
Soft tissue obstruction :
Uterus : impacted subserous pedunculated fibroid,
constriction ring opposite the neck of the fetus.
Cervix : cervical dystocia.
Vagina : septa, stenosis, tumors.
Ovaries : impacted ovarian tumors.

5. Fetal causes
Malpresentations and malpositions : e.g.
Persistent occipito-posterior and deep transverse arrest,
Persistent mento-posterior and transverse arrest of the face
presentation.
Brow,
Shoulder,
Impacted frank breech.
Large sized fetus (macrosomia).
Congenital anomalies : e.g. Hydrocephalus, Fetal ascites and Fetal
tumours.
Locked and conjoined twins.

7. 7

8. Diagnosis
Impending rupture uterus (excessive uterine contraction and
retraction).
The uterus undergoes excessive contractions and retractions of US
with thinning of LS with formation of a groove between them
(pathologic retraction or Bandle's ring).
If delivery is delayed, rupture uterus occurs.

9. History :
Prolonged labor,
Frequent and strong uterine contractions,
Rupture membranes.
General examination : It shows signs of maternal distress as : exhaustion, high
temperature (38ºC), rapid pulse, and signs of dehydration : dry tongue and
cracked lips.

10. Abdominal examination :
The uterus :
Is hard and tender,
Frequent strong uterine contractions with no relaxation in between
(tetanic contractions).
Rising retraction ring is seen and felt as an oblique groove across the
abdomen.

11. The fetus :
Fetal parts cannot be felt easily.
FHS are absent or show fetal distress due to interference with the utero-
placental blood flow.

12. Vaginal examination :
Vulva : is edematous.            
Vagina : is dry and hot.
Cervix : is fully or partially dilated, edematous and hanging.
The membranes : are ruptured.
The presenting part : is high and not engaged or impacted in the
pelvis. If it is the head it shows excessive moulding and large caput.
The cause of obstruction can be detected.

13. Complications
Maternal :
Maternal distress and ketoacidosis.
Rupture uterus.
Necrotic vesicovaginal fistula.
Infections as chorioamnionitis and puerperal sepsis.
Postpartum haemorrhage due to injuries or uterine atony.

14. Fetal :
Asphyxia.       
Intracranial haemorrhage from excessive moulding.
Birth injuries.
Infections

15. Management
Preventive measures : Careful observation, proper assessment, early
detection and management of the causes of obstruction.
Curative measures : Cesarean section is the safest method even if
the baby is dead as labor must be immediately terminated and any
manipulations may lead to rupture uterus.

16. Soft Tissue Obstruction

17. Cervical cancer in pregnancy
Incidence :
Very rare 1 :10.000 because :
The mean age of cancer cervix is 45-50 years.
The associated infection prevents conception.

18. Effect of invasive carcinoma on pregnancy and labor :
Abortion and preterm labor : due to haemorrhage, infection and
general health affection.
Cervical dystocia, obstructed labor, cervical laceration.
Puerperal sepsis.

19. Effect of pregnancy and labor on invasive carcinoma :
Rapid growth : as young patients tend to have a rapidly growing
tumors.
Rapid spread : if vaginal delivery is allowed.

20. (I) Early pregnancy :
Wertheim’s operation or
Hysterotomy followed by radiotherapy.
(II) Late pregnancy :
Upper segment cesarean section followed by either Wertheim’s
operation (cesarean hysterectomy) or radiotherapy.
Management

21. Fibroids in pregnancy
Incidence : 1%.
Effect of Fibroid on Pregnancy and Labour :
Abortion : particularly in submucous myomas due to :
- Distortion of the uterine cavity,
- Affection of the decidual development,
- Affection of the vascular supply to the implanted ovum.
Incarceration : of retroverted gravid uterus in case of posterior wall fibroid.
Malpresentation.
Nonengagement.
Torsion of the uterus : very rare in subserous fundal myoma.
Premature labor.
Prolonged labor : Inertia may be present due to interference with normal uterine
contractions.

22. Adherent placenta if implanted on a submucous myoma.
Obstructed labor : In cervical myoma or pedunculated subserous myoma
impacted in the pelvis.
Postpartum haemorrhage : due to
- Interference with uterine retraction,
- Increased vascularity.
Inversion of the uterus : rare.
Puerperal sepsis.
Subinvolution of the uterus.

23. Effect of Pregnancy and Labor on Fibroid :
Increase in size : due to
- Edema and increased vascularity,
- Hypertrophy of the uterine muscles.
Softening : due to edema and increased vascularity.
Red degeneration.
Torsion of a pedunculated myoma.
Internal haemorrhage : from rupture of a surface vein.
Infection : supervenes bruising during labor.
Extrusion : of submucous myoma may rarely occur in puerperium.

24. Management
(A) During pregnancy :
No treatment is indicated in the majority of cases.
(B) During labor :
Myoma not causing dystocia : vaginal delivery
Myoma causing dystocia : cesarean section is indicated by expert
obstetrician, but myomectomy is contraindicated.
(C) Postpartum :
Give prophylactic antibiotic and guard against postpartum haemorrage.
 

25. Ovarian tumours with pregnancy
Incidence: 1:1500. The commonest is simple serous cyst followed by dermoid cyst.
Effect Of Ovarian Tumours On Pregnancy and Labour
Abortion and preterm labour in large and complicated tumours.
Pressure symptoms.
Malpresentations and nonengagement.
Obstructed labour: if a pedunculated tumour is impacted in the pelvis.
Effect of Pregnancy and Labour on Ovarian Tumours
Torsion: is the commonest complication particularly in pedunculated tumours that lie above
the
pelvic brim. It is more common during puerperium than pregnancy due to; lax abdominal wall,
large intra-abdominal space after birth allows free mobility of the tumour.
Haemorrhage. 3- Rupture. 4- Infection. 5- Rapid growth.

26. Management
(A) During pregnancy
(I)Cyst less than 6 cm in diameter : is left and followed up by periodic examination and
ultrasound as it is usually a functional corpus luteum cyst.
(II) Cyst of 6 cm or more in diameter:
Discovered in the first half of pregnancy: is removed after the 12th week when the
placenta is formed so there is less liability for abortion.
Discovered in the second half of pregnancy: is left to be removed in the first week of
puerperium.
(III) Complicated or malignant tumours:
are removed immediately irrespective of the duration of pregnancy.

27. (B) During Labour
(I) If the tumour lies above the pelvic brim- causing no obstruction:
vaginal delivery is allowed and tumour is removed in the first week in
puerperium.
(II) If the tumour is impacted in the pelvis - causing obstruction :
caesarean section with immediate removal of the tumour is done.
(C) During puerperium
Tumours discovered for the first time should be removed immediately for
fear of torsion.

28. SHOULDER DYSTOCIA

29. DEFENITION
Shoulder dystocia can be defined
as failure of the shoulders to
spontaneously traverse the pelvis
after delivery of the fetal head

31. Incidence
It occurs in 0.2 to 2 percent of births and can be a devastating
obstetric emergency.

32. pathophysiology
The fetal biacromial
diameter normally enters
the pelvis at an oblique
angle with the posterior
shoulder ahead of the
anterior one, rotating to
the anterior-posterior
position at the pelvic
outlet with external
rotation of the fetal head

33. the anterior shoulder can then slide
under the symphysis pubis for
delivery

If the fetal shoulders remain in an
anterior-posterior position e during
descent or descend simultaneously
rather than sequentially into the
pelvic inlet, then the anterior
shoulder can become impacted
behind the symphysis pubis and/or
the posterior shoulder may be
obstructed by the sacral
promontory .
Then you get the dreaded “Turtle
Sign
pathophysiology

34. Oh crap, Turtle Sign!

35. Risk factors
Maternal
Abnormal pelvic anatomy
Gestational diabetes
Post-dates pregnancy
Previous shoulder dystocia
Short stature
Obesity, BMI >30
Fetal
macrosomia LGA > 4000 gm
Male Sex
Labor related
Assisted vaginal delivery (forceps or vacuum)
Protracted active phase of first-stage labor
Protracted second-stage labor

36. Complications 
Fetal
Fractures ex : clavicle or humerus, in 18 to 26 %
Erb’s palsy : although 80% resolve by 18 months
Perinatal ashphyxia
Neonatal death
Maternal
Postpartum hemorrhage
Vaginal & cervical lacerations
Puerperal infection

37. The goal of management is to prevent fetal
asphyxia, while avoiding physical injury (eg, Erb's
palsy, bone fractures).

38. These maneuvers are designed to do one of three
things:
›Increase the functional size of the bony pelvis through
flattening of the lumbar lordosis and cephalad rotation of
the symphysis (i.e., the McRoberts maneuver)
›Decrease the biacromial diameter, the breadth of the
shoulders, of the fetus through application of suprapubic
pressure.
›Change the relationship of the biacromial diameter
within the bony pelvis through internal rotation
maneuvers.

39.  HELPERR mnemonic 
“H” call fo Help 

40. H E LPERR mnemonic
“E” evaluate for episiotomy 

41. HE L PERR mnemonic
“L” Legs (the McRoberts maneuver) 

44. HEL P ERR mnemonic
“P” Pressure (Suprapubic) 

47. HELP E RR MNEMONIC
ENTER" MANEUVERS
11 . .Rubin II Rubin II
At vaginal At vaginal examination apply pressure as indicated. If examination apply pressure as indicated. If
shoulders move into the oblique diameter, attempt deliveryshoulders move into the oblique diameter, attempt delivery . .
22 . .Rubin II + Woods corkscrew maneuverRubin II + Woods corkscrew maneuver
If unsuccessful, add the Woods corkscrew maneuver and If unsuccessful, add the Woods corkscrew maneuver and
continue rotation in the same direction. Use both hands and continue rotation in the same direction. Use both hands and
apply pressure as indicated. If shoulders now move into the apply pressure as indicated. If shoulders now move into the
oblique, attempt delivery. If this is unsuccessful, continue oblique, attempt delivery. If this is unsuccessful, continue
rotation 180 degrees and deliverrotation 180 degrees and deliver..
33 . .Reverse Woods corkscrew maneuver Reverse Woods corkscrew maneuver
If the last maneuver is unsuccessful, change to reverse If the last maneuver is unsuccessful, change to reverse
Woods corkscrew maneuver. Slide fingers down to back Woods corkscrew maneuver. Slide fingers down to back
of posterior shoulder and attempt 180-degree rotation of posterior shoulder and attempt 180-degree rotation
in the opposite directionin the opposite direction . .

50. HELPE R R MNEMONIC

“R” Remove the posterior arm 

52. HELPER R mnemonic
“R” Roll the patient on all fours position 

53. Other extreme maneuvers 
Zavanelli's maneuver, which involves pushing the fetal head back in
with performing a C section. or internal cephalic replacement followed
by Cesarean section
intentional fetal clavicular fracture which reduces the diameter
of the shoulder girdle that requires to pass through the birth
canal.
maternal symphisotomy, which makes the opening of the birth
canal laxer by breaking the connective tissue between the
two pubic bones facilitating the passage of the shoulders