Prolonged and obstructed labor

Prolonged labor and obstructed labor

1. PROLONGED AND OBSTRUCTED LABOR Binod Chaudhary MBBS 4 th Batch, CMC

2. L abor Series of events that take place in the genital organs in an effort to expel the viable products of conception out of the womb through the vagina into the outer world. First stage start of the true labor pain to full dilatation of the cervix (10 cm) latent phase (primi-8hrs, multi-4hrs) active phase (primi-4hrs, multi-2hrs)

3. Second stage from full dilatation of the cervix to the expulsion of the fetus . P ropulsive phase E xpulsive phase duration- primi =2 hours multi = 30 minutes

4. Third stage from expulsion of the fetus to the expulsion of the placenta Phase of placental separation Phase of placental descent Phase of placental expulsion Duration- 15 minutes ( primi and multi) 5 minutes in active management Fourth stage Upto 1 hours of delivery of placenta

5. Prolonged labor

6. Labor is said to be prolonged when the combined duration of the first and second stage is more than the arbitrary time limit of 18 hours. WHO- labor is considered to be prolonged when the cervical dilatation rate is less than 1 cm/ hr and descent of the presenting part is <1 cm/ hr for a period of minimum 4 hours observation .

7. Prolonged latent phase P rimi >20 hrs and multi >14 hrs C auses: unripe cervix, malposition and malpresentation , CPD, PROM W orrisome to the patient but donot endanger mother and fetus

8. Causes of prolonged labor First stage (@3P) Fault in power A bnormal uterine contraction (uterine inertia or inco -ordinate uterine contraction) b. Fault in passage C ontracted pelvis C ervical dystocia Pelvic tumor F ull bladder

9. c. Fault in the passenger Malposition or malpresentation Congenital anomalies of the fetus (hydrocephalus) d. Others – early administration of sedatives and analgesics before active labor

10. 2. Second stage Fault in the power Uterine inertia I nability to bear down E pidural analgesia C onstriction ring b. Fault in the passage CPD, android pelvis, contracted pelvis U ndue resistance (spasm or old scarring) S oft tissue pelvic tumor

11. c. Fault in the passenger Malposition M alpresentation Big baby Congenital malformation of the baby

12. Diagnosis Prolonged labor is not a diagnosis but it is the manifestation of an abnormality. First stage duration >12 hours cervical dilatation- <1 cm/ hr ( primi ) <1.5 cm/ hr (multi) Second stage duration >2 hrs ( nullipara ), >1 hrs (multipara) [ if regional analgesia is given then one hour is permitted in both groups ]

13. Dangers Fetal Hypoxia Intrauterine infection Intracranial stress or hemorrhage Increased operative delivery

14. 2. Maternal Distress Postpartum hemorrhage Trauma to the genital tract Increased operative delivery Puerperal sepsis Subinvolution

15. Treatment

16. Prevention Antenatal or early detection Use of partograph Selective and judicious augmentation Change of posture in labor , avoidance of dehydration in labor and use of adequate analgesia for pain relief

17. Treatment Principle- “The sun should not set twice in women in labor ” Evaluate carefully to find out Cause of prolonged labor (m/c inadequate uterine activity in nulliparous; cephalopelvic disproportion in multiparous) Effect on the mother Effect on the fetus

18. Preliminaries Correct fluid and electrolyte imbalance Control of infections (ampicillin, metronidazole, ceftriaxone) Emptying the bladder (catheterization) Emptying the stomach Blood cross matching

19. First stage delay Vaginal examination and clinical pelvimetry done Uterine activity suboptimal Secondary arrest (Careful using oxytocin) Amniotomy and oxytocin infusion (5U in 500 ml RL Effective pain relief ( im pethidine or RA) Cesarean section

20. Second stage delay provided the FHR is reassuring and vaginal delivery is imminent, short period of expectant management is reasonable if not, appropriate assisted delivery, vaginal (forceps, ventouse ) or abdominal ( cesarean ) should be done. Note: difficult instrumental delivery should be avoided

21. Obstructed labor

22. Obstructed labor is one where in spite of good uterine contractions, the progressive descent of the presenting part is arrested due to mechanical obstruction. Result due to factors in the fetus or in the birth canal or both

23. Causes: Fault in the passage C ephalopelvic disproportion Contracted pelvis Cervical dystocia Cervical or broad ligament fibroid Impacted ovarian tumor Non gravid horn of bicornuate uterus

24. b. Fault in the passenger T ransverse lie B row presentation C ongenital malformations (hydrocephalus, ascites , double monsters) B ig baby, occipitofrontal position C ompound presentation L ocked twins

25. Morbid anatomical changes Uterus Formation of bandl’s ring Gradual increase in intensity, duration and frequency of contraction. Relaxation becomes less and less Ultimately, a state of tonic contraction develops

26. b. Bladder Becomes abdominal organ Compression of urethra b/w presenting part and symphysis pubis→urinary retention Trauma →blood stained urine Pressure necrosis of the bladder and urethra→ genitourinary fistula

27. Clinical features Maternal condition Mother is in agony, exhausted, sepsis appear early Abdominal examination Uterus tense and tender Fetal parts easily felt Distended bladder due to retention or edema Retraction Ring may be felt FHS usually absent “Three tumor abdomen” evident

28. Vaginal examination Lower segment pressed by forcibly driven presenting part Edematous vulva (cannula sign) and cervix Severe caput and moulding Ring not felt vaginally Descent of presenting part absent

29. Anticipation of Obs. Labor during ANC Short stature particularly in primes <150 cm Large fetuses >4 kg Obvious pelvis/spinal deformities Gynetresia (at least one pelvic exam be done at ANC) Uterine myomas in lower segment or cervix Abnormal lie Severe degree of overlap at pelvic brim

30. Dangers Mother Immediate Exhaustion Dehydration Metabolic acidiosis Hypoglycemia Genital sepsis Injury to the genital tract includes rupture of the uterus Postpartum hemorrhage and shock

31. b. Remote Genitourinary fistula or rectovaginal fistula Variable degree of vaginal atresia Secondary amenorrhea 2 . Fetus Asphyxia Acidosis Intracranial hemorrhage Infection

32. Treatment

33. P rinciples To relieve the obstruction at earliest by a safe delivery procedure Pain relief To combat dehydration and ketoacidosis To control sepsis Correct hypoglycemia Correct electrolyte imbalance

34. 1. Prevention Same as prolonged labor 2. Initial assessment of the patient Pallor, pulse, blood pressure, dehydration Fundal height, fetal lie, presentation and heart rate, state of the uterus and bladder Level of presenting part, cervical dilatation, caput formation and moulding Do pelvic assessment and note the measurement and the presence of infected liquor Access urine Blood group and cross matching

35. 3. Resuscitate the patient Iv fluids at least 3 l Give dextrose saline for hypoglycemia initially then ringers lactate Oxygen if fetal distress or maternal distress 4. Control infection Give broad spectrum iv antibiotics Stat dose of Ampicillin 1g and chloramphenicol

36. 5. Check if the fetus is alive and decide mode of delivery 6. Empty bladder with self retaining catheter

37. Obstetric management No place of “wait and watch”, neither any scope of using oxytocin to stimulate uterine contraction Before proceeding for definitive operative treatment, rupture of the uterus must be excluded Decide best method to relieve the obstruction with least hazards to the mother

38. Vaginal delivery If baby dead, destructive operation (craniotomy, decapitation, evisceration and cleidotomy ) is best choice If baby living and head is low down and vaginal delivery not risky→forceps extraction After delivery, explore uterus and lower genital tract to exclude uterine rupture or tear

39. Cesarean delivery Done if the case is detected early with good fetal outcome. In late case, desperate attempt to do a C/S to save the moribund baby more often leads to disastrous consequents Symphysiotomy Alternate to risky cesarean In case of established obstruction due to outlet contraction with vertex presentation having good FHS

40. Post delivery care Continue monitoring of temperature, pulse, BP, urine output and colour Monitor abdominal distension Continue antibiotics Continuous bladder drainage for at least 10 days Check for perineal nerve damage and rehabilitate accordingly Bear in mind possibility of secondary PPH Counseling for future pregnancies and deliveries

41. Thank you!!!