OBSTRUCTED LABOR

DR SEEMA MEHTA

MS,FICOG,FICMCH

ASSOCIATE PROFESSOR

DEPT. OF OBST. & GYNAE

S.M.S. MEDICAL COLLEGE

JAIPUR

INTRODUCTION�

• IMPORTANT CAUSE OF MATERNAL DEATH
• CAUSES SIGNIFICANT SHORT & LONG TERM MATERNAL MORBIDITY
• RESULTS IN SIGNIFICANT PERINATAL MORBIDITY & MORTALITY

�� � � � � 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

� ETIOLOGY

MATERNAL CONDITIONS

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• CONTRACTED PELVIS OR DEFORMED PELVIS
• TUMORS OF UTERUS OR OVARY
• TUMORS OF RECTUM OR BLADDER
• TUMORS OF PELVIC BONES
• VAGINAL SEPTUM

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� ETIOLOGY

FETAL CONDITIONS

MALPOSITIONOF THE FETUS

POP(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

� DIAGNOSIS

HISTORY

• PROLONGED LABOR
• HANDLING BY UNTRAINED DAI

GENERAL EXAMINATION

• EXHAUSTED/DEHYDRATED/RESTLESS
• PULSE RATE INCREASED
• TEMP USUALLY RAISED

� DIAGNOSIS

PER ABDOMINAL EXAMINATION

• STRONG & FREQUENT UTERINE CONTRACTIONS
• UPPER PART OF UTERUS IS HARD & TENDER
• LOWER PART OVER DISTENDED & TENDER
• BANDL`S RING
• NON DESCENT OF PRESENTING PART INSPITE OF GOOD UTERINE CONTRACTIONS
• FHS MAY BE PRESENT(FD)/ABSENT(IUFD)

� DIAGNOSIS

PER VAGINAL EXAMINATION

• VULVA -EDEMATOUS
• VAGINA –HOT & DRY
• CERVIX-PARTLY DILATED, THICK &EDEMATOUS
• LARGE CAPUT AND MARKED MOULDING OF CRANIAL BONES
• PELVIS SEEMS INADEQUATE FOR THE BABY

EFFECTS OF OBSTRUCTED LABOR

ON MOTHER

IMMEDIATE:-EXHAUTION

-DEHYDRATION

-METABOLIC ACIDOSIS

-GENITAL SEPSIS

-INJURY TO GENITAL TRACT

-RUPTURE

-PPH & SHOCK

REMOTE:- -GENITO URINARY FISTULA

-RECTO VAGINAL FISTULA

ON FETUS

-BIRTH ASPHYXIA

-INTRACRANIAL HAEMORRHAGE

-INFECTION

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

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 )
• Pqrt 11 : progress of labour ( at middle )
• Part 111 : maternal condition ( at bottom )
• Outcome : ………………

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

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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

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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MANAGEMENT

AIMS

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

MANAGEMENT

� -IV LINE FOR RAPID INFUSION OF RINGER LACTATE

-BLOOD TAKEN FOR CROSS MATCH

-BASE LINE INVESTIGATIONS-CBC,ELECTROLYTE

-VAGINAL SWAB FOR C/S

-ANTIBIOTICS

-S/R CATHETERISATION

OBSTETRIC MANAGEMENT

• EXCLUDE UTERINE RUPTURE
• NO PLACE FOR WAIT & WATCH
• VAGINAL DELIVERY:

#when fetus is dead/congenitally malformed- destructive operation & vaginal delivery is the best choice

# exploration of uterus & lower genital tract should be done.

• CAESARIAN SECTION:

# when fetus is alive, CS gives best results

# sometimes to prevent rupture, CS is to be performed in dead fetus

S/R CATHETER SHOULD BE KEPT FOR TWO WEEKS

CONCLUSION

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

THANKS