MUDHA GARBH

Presented by:

Dr. Diksha Khathuria Joshi

Dr.Diksha Khathuria Joshi

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Dr.Diksha Khathuria Joshi

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Entymology

• ew<+ “kCn eqg~ /kkrq ls cuk gS A
• laKkfoghu ,ewfPNZr~ ,foiFkxkeh ,fn”kkfoghu A
• “kkfCnd vFkZ % vkylh A
• vkpk;Z HkkofeJ % #/n xfr A
• e/kqdks’kdkj % O;kLkDr~ xfr ;k vLkkekU; xfr A

Dr.Diksha Khathuria Joshi

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Dr.Diksha Khathuria Joshi

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Definitions given by Sushruta and Vaghbhata shows similarity with OBSTRUCTED LABOUR AS......

• foo~~~`/n xHkZ – Exaggerated growth – macrosomia / fetal ascitis / hydrocephalus / congenital tumours.
• vlE;d~ vkxr ;k vusd/kk izfriUu – Malpresentations and Malpositions.
• viR;iFk es vuqizkIr gks vfujL;eku ;k vlE;d~ viR;iFk es izkIr xHkZ -- Abnormal passage / inadequate pelvis.
• viku ok;q ossSxq.; -- Abnormal uterine contractions or uterine inertia.

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���Last two Gatis of Mudhagarbha are Asadhya�i.e. –�

• • Hasta-pada-shirodaya

(obstructed labour due to faulty presentation)

• • One foot in yoni & other in

anus (remote effects of undiagnosed

obstructed labour)

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Probable Modern Correlation Of MUDHA GARBHA

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OBSTRUCTED LABOUR

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�� � DEFINITION � � � �

• LABOR IS SAID TO BE OBSTRUCTED WHEN THERE IS ABSENCE OF PROGRESS OF LABOR IN THE PRESENCE OF STRONG UTERINE CONTRACTIONS
• ABSENCE OF PROGRESS

*FAILURE OF CERVIX TO DILATE

*FAILURE OF DESCENT OF

PRESENTING PART

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World wide

• Prevalence is 2-8%
• 1 -2% of referral cases in developing country.
• Maternal mortality rate is 8%

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Epidemiology

Causes of obstructed labour

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Powers

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Cervix Before labor

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Cervix in labor

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Causes of obstructed labour

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Powers

Passage

� Maternal causes (fault in passage) �

1. Contracted pelvis/Inadequate Pelvis.
2. Pelvic tumor:- fibroid, ovarian tumor
3. Tumor of rectum, bladder or pelvic bone.
4. Abnormality in uterus & vagina:-stenosis in Cx. & vagina, contraction ring in uterus, vaginal septum, rigid perineum.

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Inadequate

Pelvis

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Causes of obstructed labour

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Powers

Passage

Passenger

� Fault in Passenger

FETAL CONDITIONS

MALPOSITION OF THE FETUS

POPP(VERY COMMON)

DTA

MALPRESENTATION OF THE FETUS

BREECH/FACE/ BROW PRESENTATION

SHOULDER PRESENTATION

COMPOUND PRESENTATION

LOCKED TWINS

CONGENITAL ABNORMALITIES OF THE FETUS

LARGE FETUS

HYDROCEPHALUS

HYDROPS FETALIS

FETAL ASCITIS/TUMORS

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Fetal ascitis Hydrocephalus

Causes of obstructed labour

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Shoulder Dystocia

Causes of obstructed labour

Shoulder dystocia is called if shoulders cannot be delivered with gentle traction

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Locked conjoined twins

Causes of obstructed labour

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Malposition

Malpresentation

Causes of obstructed labour

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Diagnosis

• Partograph will recognize

impending obstruction early

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• history of-prolonged labour and -the labour pain become severe and frequent with -bearing down.

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Clinical features

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• Features of maternal distress i.e.

Exhaustion & keto acidosis

• Dehydration : dry tongue

and cracked lips.

• Tachycardia >100/m
• Raise temperature
• Scanty blood stained urine.

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General examination

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* 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.

* The foetus:

>foetal parts cannot be felt easily.

>FHS are absent or show foetal distress due to interference with the utero-placental blood flow.

• Distended urinary bladder.

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Abdominal examination

Clinical features

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Bandel’s ring

The retraction ring (bandl’s ring) is seen and felt between the tonically contracted upper segment of the uterus and the distended , tender and stretched lower segment.

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Vaginal examination

* Vulva: is oedematous.

* Vagina: is dry and hot.

* Cervix: is fully or partially dilated, oedematous and hanging.

• The membranes: are ruptured.
• Foul smelling meconium

*The presenting part: is high and not engaged or impacted/jammed in the pelvis.

If it is the head it shows excessive moulding and large caput.

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Excessive moulding and large caput

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Remote Maternal Effects Of Obstructed Labour

• If patient survives-genitourinary fistula or recto vaginal fistula
• •Variable degree of vaginal atresia
• •Secondary amenorrhoea following hysterectomy due to rupture or Sheehan’s syndrome.

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Complications

• Fetal:-
• Immediate:-
• -Birth trauma
• -Birth asphyxia
• Foetal distress
• Meconium aspiration syndrome
• Still birth
• Neonatal death

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• Late:-
• -Cerebral palsy
• - Mental retardation

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UTERINE RESPONSE TO OBSTRUCTION

• PRIMI GRAVIDA – THERE IS DIMINISHING CONTRACTILITY LEADING TO UTERINE INERTIA

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• MULTI GRAVIDA –THE CONTRACTILITY IS MAINTAINED WITH RISK OF UTERINE RUPTURE

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PREVENTION OF OBSTRUCTED LABOR

• ANTENATAL PERIOD- DETECTION OF FACTORS LIKELY TO PRODUCE PROLONGED LABOR-BIG BABY ,SMALL WOMEN,MALPRESENTATION AND MALPOSITION.
• INTRANATAL PERIOD-EARLY DETECTION OF ABNORMAL PROGRESS OF LABOR
• LABOR IS SAID TO BE PROLONGED WHEN DURATION OF 1^st &2^nd STAGE IS MORE THAN 18 HOURS
• PARTOGRAM ALLOWS EARLY IDENTIFICATION AND DIAGNOSIS OF PATHOLOGICAL LABOR

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Components of the partograph

• Part 1 : fetal condition ( at top )
• Part 2 : progress of labour ( at middle )
• Part 3 : maternal condition ( at bottom )
• Outcome : ………………

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One of the main functions of the Partograph is to detect early deviation from normal progress of labor

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Partograph

Partograph

• Alert line- it starts at the end of latent phase {3cm cervical dilatation} and ends with full dilatation of cervix {10cm} in 7 hours i.e,. 1cm/hr dilatation rate.
• Action line- it is drawn 4 hours to the right of Alert line.

An interval of 4 hours is allowed to diagnose delay in active phase and then appropriate intervention is done.

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Moving to the right of alert line

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• warning sign-when the tracing moves to the right of the alert line.
• Transfer the woman from health center to hospital
• Danger sign- reach the action line.
• Decision regarding the mode of delivery is to be made.
• Patient is to be reassesed

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Prolonged latent phase

• If a woman is admitted in labor in the latent phase ( less than 3 cm dilatation ) and remains in the latent phase for next 8 hours
• Progress is abnormal and she must be transferred to a hospital for a decision about further action

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�Prolonged Active phase

• In the active phase of labor , plotting of cervical dilatation will normally remain on or to the left of the alert line
• But some cases will move to the right of the alert line and this warns that labor may be prolonged
• This will happen if the rate of cervical dilatation in the active phase of labor is less then 1 cm / hour
• A woman whose cervical dilatation moves to the right of the alert line must be transferred and managed in a hospital with adequate facilities for obstetric intervention unless delivery is near
• at the action line , the woman must be carefully reassessed for why labor is not progressing and a decision made on further management

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Secondary arrest of cervical dilatation

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• Abnormal progress of labor may occur in cases with normal progress of cervical dilatation, then followed by secondary arrest of dilatation

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Secondary arrest of head descent

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• Abnormal progress of labor may occur with normal progress of descent of the fetal head, then followed by secondary arrest of descent of fetal head

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AIMS OF MANAGEMENT

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• TO TREAT DEHYDRATION
• TO CONTROL SEPSIS
• TO RELIEVE THE OBSTRUCTION
• TO DELIVER THE BABY

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Management

1. General management :-
1. NPO & i/v fluid start immediately.
2. Bladder evacuation and catheterisation should be done.
3. Parenteral antibiotics.
4. Intake output chart should be strictly maintain.
5. Urine should be examine for albumin & acetone.
6. Blood should be send for grouping and cross matching.

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B. Obstetric management :-

1. During 1^st stage:-
1. Role of oxytocin :- hypotonic uterine contraction
2. Role of sedation :- incase of incordinate uterine contraction, liberal use of inj. Pethidine 75mg and inj. Phenargan 25mg IM may lead to spontaneous correction.
3. Role of ARM:- hypotonic uterine contraction
4. Role of ventouse:-POPP and fetal distress
5. Role of c/s:- contracted pelvis, big baby, mal presentation, mal position, severe fetal distress.

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B. During 2^nd stage:-

1. Role of episiotomy:- rigid perineum
2. Role of forceps:- fetal distress, DTA, POPP, cord prolapse in living baby.
3. Role of ventouse:-DTA, OAP,OPP.
4. Role of c/s:- contracted pelvis, big baby, mal presentation, mal position, severe fetal distress.
5. Role of destructive operation :- craniotomy, decapitation, evisceration.

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Episiotomy

• May facilitate or allow room for delivery.

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Active management of 3^rd stage of labor.

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CONTROLLED CORD TRACTION

• Panic
• Pulling (on the head)
• Pushing (on the fundus)
• Pivoting (sharply angulating the head, using the coccyx as a fulcrum)

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Avoid the P’s

Description of Lakshnas of Asadhya mudhagarbh as per Modern

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Garbhkosha prasang or Rupture of Uterus

• Caused by a tear in the wall of the uterus, when the uterus can’t stand the pressure exerted on it.
• Predisposing Factors-
• •Vertical scar
• •Multiple Gestation
• •Prolonged labor
• •Obstructed labor
• •Faulty presentation
• •Traumatic Maneuvers
• •Faulty use of oxytocin

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Signs and Symptoms

• Abdominal pain and tenderness
• –Chest pain between the scapula or on inspiration
• –Hypovolemic shock caused by hemorrhage
• –Signs associated with impaired fetal oxygenation
• –Absent fetal heart tones , cessation of uterine contractions
• –Palpation of fetus outside the uterus

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MANAGEMENT

• Resucitation
• laprotomy
• •Hysterectomy -subtotal
• •Repair

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Yoni Samvarana or Cervical Dystocia

• Cervical dystocia: Difficult labor and delivery caused by mechanical obstruction at the cervix.
• •Dystocia comes from the Greek "dys" meaning "difficult, painful, disordered, abnormal" + "tokos" meaning "birth."

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• Cervical dystocia is nothing but a complication arising during laborthat causes difficulty in delivery because the cervix is obstructed.
• •This abnormal condition of labor is a result of the ineffectual dilation of the cervix ,though quite a rare condition, it can lead to serious difficulties to the mother and the baby.
• •A cervical dystocia basically happens at the external os. The complete cervical canal is consumed, and then often thinned out. The external os however, remains incompletely dilated or even closed at times.

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Causes

• 1.Inefficient Uterine Contractions
• •2.Malpresentation, malposition
• •3.Spasm of cervix

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• Treatment-delivery by cessarian section is preferred.

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Makkala or Uterine Tetany

• Pronounced retraction occurs involving whole of uterus up to level of internal os.
• •So, the physiological differentiation between active upper segment and passive lower uterine segment of uterus is lost.
• •No thinnig of lower segment of uterus occurs.
• •The uterine contraction ceases and the whole uterus undergoes a sort of tonic muscular spasm holding the foetus inside.
• •Treatment- cs section preferred

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Yoni Bharnsha or Prolapse

• There is marked hypertrophy and oedemaof cervix and first degree becomes second degree, cystocele and rectocele become pronounced and there is aggravation of stress incontinence.
• •Vaginal discharge may be copious and decubitus ulcer may develop when the cervix remains outside the interoitus.
• •Incarceration might occur if uterus fails to rise above the pelvis by 16thweak of pregnancy.

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Management of Prolapse during Labour

• Bed rest complete
• •Intravaginal plugging soaked with glycerine and acriflavine
• •Prophylactic antibiotics
• •Manual stretching of cervix or pushing up of cystocele or rectocele.
• •Cessarian section –if cx.is undilated, thick or edematous and/ or head is high up.

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General Principles of management of Mudha Garbha

• Jarayu-patana+Sanshamana chi.
• Mantrachikitsa
• Shalyakarma

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• Jarayu Patana-using langli ,dhuma, basti, local applications
• Mantra chikitsa-
• Chyavana mantra
• Maatangi vidya

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Udarapatana in MUDHAGARBHA

• cLrekjfoiUuk;k% dqf{k% izLiUnrs ;fn A

rR{k.kkTtUedkys ra ikVf;Roks/njsn~ fHk’kd~ AA ( Lkq fu 8/14)

• CkfLr}kjs foiUuk;k% dqf{k% izLiUnrs ;fn A

tUedkys rr% “kh?kza ikVf;Roks/njsfPN”kqe~ AA (v l “kk 4/52)

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Post Operative Management after extraction of Mudha Garbha

• AparaPatana
• •Abhyanga
• •Yoni Sneha pichu
• •VataghnaYogas for 10 days
• •Snehapana for 3, 5 or 7 days (depending on Prakruti)
• •Asava or Arishtapana at night
• •Pathya-for 4 months

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Differential diagnosis

* Constriction ring [ does not change it’s position]

* Full bladder [excluded by catheterisation]

* Fundal myoma [ not rising and no signs of obstruction]

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CONCLUSION

• OBSTRUCTED LABOR REMAINS AN IMPORTANT CAUSE OF MATERNAL AS WELL AS FETAL MORBIDITY & MORTALITY
• EARLY RECOGNITION & TIMELY MANAGEMENT OF PROLONGED LABOR/ OBSTRUCTED LABOUR CAN SIGNIFICANTLY IMPROVE MATERNAL & FETAL OUTCOME

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THANKS

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