Obstructed Labour.pptx

Overview of the diagnosis and management of Obstructed labour in a low resource setting

1. OBSTRUCTED LABOUR Dr. M. TENO 28th July 2023

2. Outline Review of Pelvic Anatomy and normal Labour D efinition Predisposing factors Pathophysiology C lincal features Complications Management References

3. Review: Pelvic Anatomy

4. Review: Pelvic Anatomy Three parts: Pelvic Inlet Pelvic Cavity Pelvic outlet

5. Clinically Orientated Anatomy 6 th Ed < 90° > 90° (M) pelvis: narrow (F) pelvis: wide

6. Comparison between male & Female pelvis Bony pelvis Male Female General structure Thick/heavy Thin/light Pelvic inlet Heart-shaped, narrow Oval & round, wide Pelvic outlet small large Pubic arch and suprapubic angle Narrow < 90 o Wide > 90 o Obturator foramen round Oval acetabulum large small

7. Types of pelvis William’s Obstetrics – 22 nd Edition

8. Movements of the Fetal head during Labour

9. Definitions (WHO) Term Definition Prolonged Labour Labour prolongs > 24hrs, i.e Prolonged Latent phase > 8hrs Prolonged Active phase > 12hrs Obstructed Labour Despite uterine contractions, failure of fetal head descend through the pelvic cavity due to an “obstruction” or “barrier” that prevents its descent. Obstruction can occur at: P elvic brim P elvic cavity P elvic outlet Cephalopelvic disproportion (CPD) O ccurs when there is a discrepancy between the fetal head and pelvis. Therefore, it is difficult for the fetus to pass through the pelvis.

10. Obstructed labour

11. Predisposing Factors Maternal Factors Short Stature (<150cm) Cephalopelvic Disproportion (CPD) Polio like illness affecting the pelvic structure and causing bone deformities Hisotry of rickets disease which causes osteomalacia and contracted pelvis Abnormalities of reproductive tract: stenosis of Cervix or vagina, tight perineum, pelvic tumour

12. Predisposing Factors Fetal Factors Macrosomia Congenital anomalies: hydrocephalus, fetal ascites Locked or con-joined twins Malpresentation or deflexion Brow Shoulder

13. Vertex Sinciput Brow Face Normal fetal head flexion during labour Deflexed positions that can cause Obstructed Labour

14. Pathophysiology of Obstructed Labour Cx dilates slowly or not at all, because fetal head cannot decend and put pressure on it Cx becomes edematous and labour is prolonged Mother becomes ketoacidotic and dehydrated When all amniotic fluid has drained, uterine contractions force the fetus into the lower segment Lower segment stretches and thins

15. Clinical Features of Obstruction Maternal Features Labouring > 12hrs Delay in Cx dilatation Mother is distressed and exhausted Bandl’s Ring Bloody urine or difficulty passing urine despite full bladder Edematous or swollen vulva Vagina is dry + purulent discharge

16. Clinical Features of Obstruction Fetal Fatures Meconium stained amniotic fluid (sign of fetal compromise or distress) Fetal heart rate deceleration (<120bpm) or acceleration (>160bpm) No fetal head descent during labour Fetal scalp: caput and moulding

17. Fetal Head Descent and moulding

18. Complications

19. Complications Maternal Complications Fistula: vesicovaginal or vesicorectal Uterine Rupture Post partum Haemorrhage M aternal Distress Shock Puerperal Sepsis Fetal Complications Fetal asphyxia F etal death Intracranial haemmorrhage 2 O moulding Acidosis Congenital infections: pneumonia, sepsis

20. What is a fistula? A communication between two hollow structures When fetal head is stuck in the pelvis, it subjects portions of the bladder, Cx , Vagina and rectum to excessive pressure. Also impairs circulation and oxygenation to these tissues  necorosis and ultimately a fistula forms

21. Types of Fistulae

22. Management

23. Management Plot every women’s labour on a partogram Establish whether labour is obstructed or not Collect FBE and x-match Administer tocolytics: prevents contractions that may entail further complications Insert an IDC: determine output and colour of urine Cover with broad spectrum antibiotics Establish the mode of delivery/obstetric intervention

24. Obstetric Interventions Vaginal delivery or instrumental delivery : when head is low or fetus is dead Destructive delivery: preferably when fetus is dead and when vaginal delivery is difficult. Emergency C/Section: when fetus is alive

25. References Mola & Maurice King. Primary Mother Care and Population (second Edition). 2014. University of Papua New Guinea Press, PNG. World Health Organization. Maternal Health and Safe Motherhood Programme . Education material for teachers of midwifery : midwifery education modules. Midwifery Educ Modul. 2nd ed. 2008;6.