MANAGEMENT OF OBSTRUCTED LABOUR

Dr A.E Edugbe

Outline

• Introduction
• Definitions
• Epidemiology
• Management

-resuscitation

-history: biodata, risk factors

-examination

-investigations

-treatment

-complications

Outline

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• Prevention: primary, secondary, tertiary
• Prognosis
• Conclusion
• References

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Outline

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Objectives

• Define obstructed labour
• Highlight the epidemiological factors
• Outline the principles of management
• Discuss the complications
• Understand the importance and means of prevention

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Objectives

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Introduction

• Obstructed labour is one of the major preventable complications of labour
• It is a significant cause of maternal and fetal morbidity and mortality, especially in the developing world
• The “triple obstetric tragedy” in 1817 perhaps best illustrates the grave consequence of obstructed labour
• It is presently almost non-existent in the developed world due to rarity of contracted pelvis and advancement in obstetric practice

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Introduction

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Definitions

• Labour is said to be obstructed when there is mechanical impediment to its progress as depicted by lack of cervical dilatation and descent of the presenting fetal part despite adequate uterine contractions
• When there is no further progress in labour despite adequate uterine contractions and delivery is impossible without intervention
• Obstructed labour is a labour in which progress has come to a complete halt in the presence of good and adequate uterine contractions

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Definitions

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Epidemiology

• Incidence varies depending on existing health measures

-Ibadan incidence 1:189 deliveries

-Gombe 4%

-Enugu 4.7%

-commoner in primigravidae

• Low socio-economic status
• Illiteracy and ignorance
• Harmful cultural practices
• Undernutrition leading to poorly-formed and contracted pelvic types
• Disease conditions in childhood and adolescence e.g. rickets, osteomalacia, poliomyelitis
• Inadequate health facilities and skilled manpower
• Under-utilization of maternity services

Epidemiology

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• Obstructed labour may arise from maternal or fetal conditions or both.
• The commonest cause is Cephalopelvic disproportion (CPD)

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Causes of obstructed labour

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• Maternal

Contracted pelvis which can be due to;

i) generally contraction of all pelvic dimensions

- malnutrition

-child marriage.

ii) disease states as in

-childhood rickets

-osteomalacia

-childhood poliomyelitis.

iii) abnormal pelvic shapes (android, anthropoid, platypelloid)

Causes of obstructed labour

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Pelvic tumours

-uterine fibroids

-ovarian cyst

- horse-shoe shaped kidneys

Cervical stenosis following scarring

-cone biopsy

-Manchester repair

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Causes of obstructed labour

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-Amputation of the cervix

-Electrocautery of the cervix

Abnormalities of the vagina;

-transverse vaginal septum

-vaginal scarring

Tight perineum especially in primigravidae

Causes of obstructed labour

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• Fetal

Macrosomia

Fetal malposition/ malpresentation

-Occipitoposterior position

-Deep transverse arrest

-face mentoposterior

-brow

-shoulder

-compound

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Causes of obstructed labour

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• Breech presentation

-fetopelvic disproportion

-extended arms

-arrested aftercoming head.

Locked twins / conjoined twins.

Fetal hydrocephalus/ hydrops fetalis

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Causes of obstructed labour

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Management

• Depends on the clinical state and the presence of complications
• Resuscitation

-ABC

-Wide-bore IV access

-Blood sample (PCV, Group and cross-match, E/U/Cr)

-Adequate rehydration (normal saline or Ringer’s lactate)

-Correct electrolyte imbalance

-Catheterize (urine sample for bacteriological studies)

-Nasogastric intubation

Management

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-Antibiotics

-Analgesics

-Anti-tetanus serum

Management

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• History

-Biodata: risk factors

-Obstetric:

ANC- Usually poor or non-attendant

prolonged labour in a spiritual home or with untrained attendant

Failed attempts at operative vaginal delivery

History

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• Examination

On general examination;

-Maternal exhaustion, painful distress, anxiety, uncooperative,

-Dehydration; inadequate fluid intake, excessive muscular activity

Skin; hot, dry & inelastic

Tongue; dry, furred with cracked lips

-Pyrexia; dehydration, genital sepsis

-Respiration; deep, rapid with acetone breath

-Rapid, thready pulse

-Urine is concentrated and scanty

Examination

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• Abdominal examination

-SFH; increased in fetal macrosomia

-Abnormal lie; transverse/oblique

-Palpation; most of the fetal head is above the pelvic brim

-“Three tumour abdomen”; distended bladder, distended tender Lower uterine segment & tonically contracted upper uterine segment above the retraction (Bandl’s) ring

-Contractions may be absent with easily palpable fetal parts (uterine rupture)

-Fetal heart rate abnormalities (distress) or absent (fetal demise)

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Abdominal examination

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• Vaginal examination usually reveals:

-Oedema of the vulva (Kanula sign) and vagina

-Thick offensive vaginal discharge

-Bleeding (uterine rupture)

-Cervix is puffy and poorly applied to the presenting part

-Cervix may not be fully dilated in primigravida (prolonged obs. labour)

-extreme moulding and caput (cephalic)

Vaginal examination

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Investigations

• Full blood count
• Group and cross-match (4 units)
• Electrolytes, Urea and Creatinine
• Urine M/C/S
• High vaginal swab for culture and sensitivity
• Blood culture
• Random blood sugar

investigations

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Treatment

• The mainstay of treatment is to relieve the obstruction after resuscitating the patient
• The options are usually operative via abdominal delivery or extraction of the fetus per vaginam
• Abdominal delivery

Emergency Caesarean Section (CS)

Laparotomy

Treatment

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• Operative Vaginal Delivery

Instrumental delivery (Forceps, Vacuum extraction)

Symphysiotomy

Destructive operations (craniotomy, decapitation, cleidotomy, embryotomy and drainage of hydrocephalic head)

Operative vaginal delivery

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Abdominal delivery

Emergency CS

Indications:

-Obstruction with live baby

-Abnormal presentation (transverse/ oblique)

-Breech with live baby

-Compound presentation

-Dead fetus with poor cervical dilatation (transverse/oblique)

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Abdominal delivery

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• Lower segment CS is preferred (unless contraindicated) for the following reasons

-It has less chances of rupture

-Less chances of causing pelvic peritonitis in infected cases.

-Less incidence of adhesive intestinal obstruction

Abdominal delivery

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• Post operative care

-Oxytocin infusion for 4-6hrs

-Indwelling catheter for 5-14 days

-Parenteral Antibiotics for 48-72hrs

-IV Fluids for 48-72hrs

-Blood transfusion when indicated.

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Post-operative care

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Operative vaginal deliveries

Forceps;

• Limited place
• Indications

-deep transverse arrest

-following craniotomy

Contraindications

-obstruction due to pelvic tumour below presenting foetal part

-Non-engaged fetal head

-Face presentation

-Brow presentation

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Operative vaginal deliveries

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• Complications
• Posterior uterine rupture (Boot scraper effect)
• Spiral vaginal laceration
• Tentorial tear (fetus)

Forceps

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• Vacuum extraction (malpositional CPD)

-Easier to apply

-Occupies no space

-Causes autorotation as well

-Less vaginal laceration

Use with caution in:

- Deep transverse arrest

Adhere to “rule of three pulls”

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Vacuum extraction

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Symphysiotomy

• Indicated for mild cephalopelvic disproportion with live baby,
• Not recommended for modern day obstetric practice
• Complications include osteitis pubis, haematoma, stress incontinence and locomotor instability

symphysiotomy

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Destructive operations

• Craniotomy (Simpson’s perforator, Mayor’s scissors, Kocher’s forceps)
• Decapitation (Blond-Heidler saw, stout scissors)
• Cleidotomy
• Embryotomy
• Decompression of hydrocephalic head (Simpson’s perforator, Drew-Smythe’s catheter, spinal needle)

-Mainly indicated to avoid caesarean scar when the fetus is dead

-Must only be performed if cervix is fully dilated

-contraindicated if uterus is ruptured or lower uterine segment balloons out from obstructed labour

Destructive operations

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Complications of obstructed labour

Obstructed labour injury complex includes:

• Uterine rupture
• Lower genital tract injury
• Obstetric fistula
• Peripheral nerve injuries
• Osteitis pubis
• Pressure sores
• Amenorrhoea

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Complications of obstructed labour

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• Puerperal sepsis
• Postpartum haemorrhage
• Fluid and electrolyte imbalance.
• Death; maternal / foetal
• Birth asphyxia
• Intracranial haemorrhage
• Trauma

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Complications of obstructed labour

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Uterine rupture

• Commonly in multiparous patients either spontaneously or following intervention
• Can occur in primips with existing uterine scars e.g. of undiagnosed uterine perforation
• Commonly ruptures anteriorly
• Transverse tear common

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Complications of obstructed labour

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Lower genital tract injury

• Occurs due to pressure necrosis on vaginal wall in prolonged obstruction
• Sepsis increases area and depth of sloughing
• Full thickness of vaginal wall may be involved
• The whole vagina may slough piecemeal or as complete cast

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Complications of obstructed labour

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Obstetric fistulae

• Urinary fistula
• Faecal fistula
• Both
• Due to pressure necrosis and subsequent sloughing of the intervening tissue
• May also result from forceps or destructive operations

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Complications of obstructed labour

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Peripheral nerve injury

• Due to persistent pressure on lumbosacral plexus by the impacted foetal head.
• Prolonged & extreme hyperflexion of maternal thighs on her trunk can cause stretch injury on sciatic nerve.
• Commonly presents as:

-numbness

-hyperaesthesia

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Complications of obstructed labour

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-foot drop

• Late presentation may involve;

-contractures

-atrophy

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Complications of obstructed labour

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Osteitis pubis

• Unrelieved obstruction leads to damage to periosteum and superficial cortex of pubic bone which become infected
• Presents with pyrexia, pubic pain and inability to walk
• Differential diagnosis: DVT

Complications of obstructed labour

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Ammenorrhoea

• Occurs from either anterior pituitary necrosis following PPH or due to extensive endometrial scarring due to endometritis following puerperal sepsis
• Psychological factor also acts via frontal lobe to cause hypothalamo- pituitary axis dysfunction
• Menstruation returns following successful VVF repair or rehabilitation in this group of patients

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Complications of obstructed labour

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Prevention of obstructed labour

Primary prevention

• Girl-child education
• Women empowerment
• Improved socio-economic status
• Improved nutrition
• Improved health services
• Prompt and early treatment of disease conditions
• Avoidance of teenage pregnancy

Prevention of obstructed labour

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Secondary and tertiary preventive measures

• Improved antenatal care services
• Adequate staffing of health facilities
• Adequate training of health personnel
• Education on utilization of ANC and delivery services
• Antenatal care facilities should be accessible to remote locations with standard protocols for early referral
• Good road networks to facilitate early presentation to hospital

Prevention of obstructed labour

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Specific preventive measures to be observed at the antenatal facilities include:

• Screening for height and shoe size
• Taking special note of previous difficult labours/deliveries
• Routine vaginal examinations at booking and at 37 weeks and clinical and x-ray pelvimetry as appropriate
• Planning elective CS for abnormal pelvic shapes and sizes
• A carefully conducted trial of labour for primigravidae with borderline pelves
• Judicious use of the partograph to monitor the progress of labour

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Prevention of obstructed labour

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Prognosis

• With early diagnosis, absence of complications and prompt appropriate intervention outcome can be good both for mother and baby
• Unfortunately most cases will present late with complications and the appropriate level of care may not be readily available giving a bleak outlook for the parturient and her baby

Prognosis

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Conclusion

• Obstructed labour is one of the most challenging emergencies for obstetricians
• This preventable labour complication with its high maternal and neonatal morbidity leaves much more to be desired of obstetric practice in the developing world
• This scourge can only be prevented by the combined efforts of obstetricians and well-meaning health administrators backed by the right political will

Conclusion

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References

(1) Oats J, Abraham S. Abnormal labour (dystocia) and prolonged labour. Llewellyn-Jones Fundamentals of Obstetrics and Gynaecology. 9^th ed. Sydney: Elsevier; 2010; 173-180.

(2) Orhue A A E. Problems Of Labour. Textbook of Obstetrics and Gynaecology for Medical Students 2^nd ed. Ibadan: Heinemann Educational Books (Nigeria) PLC; 2006; 453-465.

(3) Obed S A. Obstructed Labour. Comprehensive Obstetrics in The Tropics. Accra: Asante & Hittscher Printing Press Ltd.; 2002; 77-85.

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References

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(4) Lawson J B, Stewart D B. Obstructed Labour. Obstetrics and Gynaecology in the Tropics and Developing Countries. Hodder Arnold; 1967; 173-218.

(5) Fasubaa O B, Ezechi O C, Orji E O, Ogunniyi S O, Akindele S T, Loto O M, et al. Delivery of The Impacted Head of The Fetus at Caesarean Section After Prolonged Obstructed Labour: A Ranomised Comparative Study of Two Methods. Journal of Obstetrics and Gynaecology. 2002; 22(4): 375-8.

(6) Ozumba B C, Uchegbu H. Incidence and Management of Obstructed Labour in Eastern Nigeria. Austalian and New Zealand Journal of Obstetrics and Gynaecology. 1991; 31(3): 213-6.

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References

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Thank you