Prolonged and obstructed labour

Prolonged and obstructed labour

1. PROLONGED AND OBSTRUCTED LABOR

2. L abo u r 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. Propulsive phase Expulsive 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 hour of delivery of placenta

5. NORMAL LABOUR Defined as: Presence of regular painful uterine contractions becoming progressively stronger and more frequent accompanied by effacement and progressive dilatation of the cervix and decent of the presenting part. At its onset its usually accompanied by bloody mucoid vaginal discharge called show . The process culminates in expulsion of the baby and other products of conception.

6. The course of normal labour

7. 1. The 1 st stage of labour (a)the latent phase This is the period from 0 – 3 cm dilatation of the cervix. Its duration can not be easily determined but perhaps around 8 hrs.

8. (b) The active phase This is the period from 3 – 10 cm (full dilatation) dilation of the cervix . In this stage the woman is said to be in established labour . Th e ce r vix dil a t es a t the r a t e o f a bou t 1 cm/hour It may be a little faster esp. in multiparous women or little slower esp. in primigravida, giving an average duration of labour of about 12 hrs.

9. 2. The 2 nd stage of labour This is the stage from full dilatation of the cervix to the delivery of the baby. It takes 2 hour s in primigravidas 30 minutes in multigravidas

10. The 3 rd stage of labour This is the stage of labour after delivery of the baby to the delivery of the placenta and membranes. It usually takes 15 minutes

11. The 4 th stage of labour This is the stage in the first 24 hours after delivery This is the period where majority of maternal deaths occurs It needs close monitoring of the mother in the hospital esp. for PPH, Eclampsia etc..

12. Prolonged labor

13. DEFINITION: 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. According to 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.

14. Failure to progress normal childbirth process.

15. Prolonged latent phase Primi >20 hrs and multi >14 hrs Causes: unripe n cervix, malposition and malpresentation, CPD, PROM Worrisome to the patient but donot endanger mother and fetus

16. Expectant management is usually done unless there is any indication (for the fetus or mother) for expediting the delivery. Rest and Analgesic are usually given When augmentation is decided, medical methods ( oxytocin or prostaglandin) are preferred. Amniotomy is usually avoided. Prolonged latent phase is not an indication for cesarean section delivery.

17. FIRST STAGE FAULT IN POWER FAULT IN PA S SA GE FAULT IN P ASS E N G ER

18. Causes of prolonged labor First stage a. Fault in power Abnormal uterine contraction (uterine inertia or inco-ordinate uterine contraction) b. Fault in passage Contracted pelvis Cervical dystocia Pelvic tumor Full bladder

19. 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

20. SECOND STAGE FAULT IN POWER FAULT IN PA S SA GE FAULT IN P AS S EN G ER

21. 2. Second stage a. Fault in the power Uterine inertia Inability to bear down Epidural analgesia Constriction ring b. Fault in the passage CPD, android pelvis, contracted pelvis Undue resistance (spasm or old scarring) Soft tissue pelvic tumor

22. c. Fault in the passenger Malposition Malpresentation Big baby Congenital malformation of the baby

23. Diagnosis History:- Age Parity Duration of labour Duration of membrane rupture Whether the patient was handle outside the hospital Whether she was treated with oxytocic drugs outside the hospital Previous history of difficult labour, instrumental delivery or stillbirth.

24. General examination :- Height of patient Dehydration Acetone breath Pallor Raise in temperatur e Tachycardia Decrease in BP

25. Abdominal examination :- Contour of the uterus Presentation & position Tenderness of uterus Frequency, intensity & duration of uterine contraction. Lower segment distended or not. Distension of the bladder. Fetal heart sound.

26. Vaginal examination:- The vulva usually swollen and edematous. The vagina is dry, hot and occasionally offensive and purulent discharge. The cervix is almost fully dilated or hanging like a curtain. The presenting part is extremely moulded and jammed in the pelvis. There is usually large caput formation.

27. Diagnosis cont.. Prolonged labor is not a diagnosis but it is the manifestation of an abnormality. The cause of which should be detected by a thorough abdominal and vaginal examination. During vaginal examination if the finger is accomodated in between the cervix and the head during uterine contraction pelvic adequecy can be reasonably established. Intranatal imaging ( radiography, CT or MRI) is of help in determining the fetal station and position as well as pelvic shape and size.

28. FIRST STAGE Duration is > 12 hours Cervical dilatation rate < 1 cm/hr in primi and < 1.5 cm/ hr Rate of descent of presenting part is < 1 cm/hr in primi and < 2 cm/hr in multi SECOND STAGE Duration >2 hrs (nullipara), >1 hr (multipara) [ if regional analgesia is given then one hour is permitted in both groups ]

29. PUE R PER A L SEPSIS SUB I N V O LUT I ON

30. Treatment

31. Prevention Antenatal or early intranatal 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

32. Actual Treatment Careful evaluation is to be done Evaluate carefully to find out Cause of prolonged labor ( inadequate uterine activity in nulliparous , primary dysfunctional labour ; cephalopelvic disproportion in multiparous) Effect on the mother Effect on the fetus

33. Preliminaries Correct fluid and electrolyte imbalance Correction of dehydration and ketoacidosis by IV fluids in case of neglacted prolonged labour Control of infections (ampicillin, metronidazole, ceftriaxone) Emptying the bladder (catheterization) Emptying the stomach Blood cross matching

34. DEFINITIVE TREATMENT FIRST STAGE DELAY IF only uterine activity is suboptimal, Amniotomy/ oxytocin infusion Effective pain relief SECONDARY ARREST Careful use of oxytocin Cesarean section delivery

35. 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

36. SECOND STAGE DELAY Short period of expectant management is reasonable provided the FHR is reassuaring and vaginal delivery is imminent Otherwise, appropriate assisted delivery , vaginal (forceps, ventouse ) or abdominal (cesarean) should be done. Note: difficult instrumental delivery should be avoided

37. Complications Maternal:- Immediate :- - Maternal distress - Increase operative interference - Maternal injury - PPH - Puerperal sepsis - Maternal death Late :- - Urinary fistula - Vaginal stenosis - Secondary infertility Fetal:- Immediate :- -Birth trauma -Birth asphyxia - Foetal distress - Meconium aspiration syndrome - Still birth - Neonatal death Late :- -Cerebral palsy - Mental retardation

38. Obstructed labor

39. O bs t r u c t ed l a bour Definition :- obstructed labour can be define d as a labour where there is poor or no progress of labour in spite of good uterine contraction. Incidence :- 1 -2% of referral cases in developing country.

40. 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

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

42. b. Fault in the passenger Transverse lie Brow presentation Congenital malformations (hydrocephalus, ascites, double monsters) Big baby, occipitofrontal position Compound presentation Locked twins

43. Morbid anatomical changes a. 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

44. 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

45. Diagnos i s Partograph will recognize impending obstruction early. If the labour is slow to progress, careful general, abdominal and vaginal examination is necessary. Woman gives the history of:- - prolong labour and - the labour pain become severe and frequent

46. Ex a m in a t ion General examination :- Features of maternal distress i.e. Exhaustion & keto acidosis Dehydration Tachycardia >100/m Raise temperature Scanty urine

47. 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

48. BANDL’S RING

49. 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

50. Anticipation of Obs. Labor during ANC Short stature particularly in prim i <150 cm Large fetus >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

51. Dan g e r s Mother Immediate Exhaustion Dehydration Metabolic acidiosis Hypoglycemia Genital sepsis Injury to the genital tract includes rupture of the uterus Postpartum hemorrhage and shock

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

53. T r e a tme n t

54. Principles 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

55. Prevention Same as prolonged labor 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

56. 3. Resuscitate the patient I V fluids at least 3 l itres 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 C hloramphenicol

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

58. 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 .

59. 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

60. 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 mor bidu nd 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

61. 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

62. Thankyou!!!!