OBSTRUCTED LABOUR

-Is defined as the failure of descent of the presenting part

despite having good uterine contractions.
-It is attributed to mechanical obstruction resulting from
abnormality in the passage (pelvis) or the passenger
(fetus).
-Obstructed labour is a major contributor to maternal
mortality
 CAUSES OF OBSTRUCTED LABOUR

• Cephalopelvic disproportion common cause

• Contracted pelvis
• Big baby
• Deformed pelvis e.g. poliomyelitis
• Abnormal presentations & positions
-Brow presentation
-Face presentation
-Shoulder presentation
-Breech presentation (big breech)
-Occipito-posterior position
-Compound presentation e.g. head with an arm
• Fetal abnormalities:Hydrocephalus,Locked twins (
1st breech, 2nd cephalic )
• Soft tissue abnormalities: Tumors e.g. fibroids in
the lower segment of uterus or cervix, Cervical
stenosis ( trauma to the cervix e.g. due to an illegal
abortion) ,Transverse vaginal septum
• Predisposing factors
• Adolescence pregnancies
• Short stature
• Culture that encourages early marriages
 CLINICAL FEATURES

• Mothers who are unbooked

• H/O of prolonged labour
• Early rupture of membranes
• H/O poor past obstetrical e.g. Past still birth, difficult
labor, past neonatal death
• Early signs
• Presenting part doesn’t enter the pelvic brim despite
of good uterine contractions
• Cervical dilatation is slow described as a hanging
empty sleeve
• Early rupture of membranes or formation of
elongated sack of fore waters.
• Late signs (usually happen in a poorly
managed or neglected labour)
• O/E – Mother is unkempt, Dehydrated, ketotic
(acetone smell from her breath) tongue is
furred, in pain and is anxious
Clinical signs
• pyrexia, tachycardia
• Urinary output is poor plus or minus
hematuria
• Fetal distress
• Uterus is moulded around the fetus, fails to
relax between contractions
• Bandl’s ring (saucer like depression) Presence of
this ring is indication of obstruction and it is an
indication for urgent surgical intervention, as the
uterus may be just minutes away from being
ruptured.
• Uterine exhaustion (contractions cease for a
while)
V/E :
• Vagina is hot and dry
• Presenting part is high and immovable
• Excessive moulding
• Large caput
 In untreated case the possible outcomes are:

• Secondary uterine inertia from uterine exhaustion

• Generalized spasm or tonic contraction of the uterus,
where the uterus makes one last effort to overcome
the obstruction.
• Rupture of the uterus, often as a result of tonic
contractions.
 MANAGEMENT OF OBSTRUCTED
LABOUR
• Management includes prevention of obstructed labour
• Prevention of obstructed labour
• Primary prevention:
• Accessible health systems
• Prevent malnutrition in the girl child this is done
through health education
• Poverty eradication
• Secondary Prevention
• Proper ANC all mothers at risk of obstructed labour
must be referred for hospital delivery
• Assessment of risk e.g. pelvic assessment done to all
primegravidas at 36weeks
• Prevent post maturity and induce labour in minor
degree of CPD at 38 weeks
• Tertiary Prevention:
• Proper monitoring of labour progress, condition of
the mother and the fetus by use of a partogram
 In a maternity centre

• This should not happen in a maternity centre but if

the mother reports with it do the following;
• Arrange for referral immediately meanwhile do the
following
• Observations; TPR,B.P,FHR
• Rescuscitate the mother
• Antibiotics e.g. ampicillin 1g stat
• I.M pethidine 50-100mg to reduce on the pain
• Empty the bladder
• Counsel the mother and relatives
• Accompany the mother and relatives with a written
document about the mother and care given
 In the Hospital
• Admit the mother in a warm bed and send for a
doctor mean while;Put I.V fluids e.g. normal saline
• Antibiotics
• Empty the bladder by catheterization and test urine
• Take off blood for HB, group and cross match
• Clean the mother with warm water
• The mainstay treatment is CAESAREAN SECTION
• Make the mother to consent
• Inform theatre staff
• Destructive operation can be done if the fetus is
already dead
 Post-delivery care

• Good nursing care

• Continued monitoring of temperature, pulse, BP and
urine output & colour
• Monitor for abdominal distension
• Continue with antibiotics
• Bladder drainage for at least 10days
• Check for nerve damage (obstetric palsy) where the
mother gets a foot drop and rehabilitate appropriately
e.g. physiotherapy
• Counsel the mother if had a still birth or
hysterectomy in case of un repairable ruptured uterus
• Bear in mind the possibility of PPH
• Counsel the patient in regard to future pregnancies
 Complication of obstructed labour:
• Maternal:
• Prolonged compression of the tissues causing trauma
to the bladder, VVF, RVF common in primegravidas,
• Sepsis post operatively
• Amenorrhea due to severe infection
• Rupture of the uterus common in multiparous.
• Heamorrhage
• nerve damage (mother gets a foot drop)
• Social impact i.e. staying in labour for so long, loss of
a baby, loss of the uterus
• Maternal death
 Fetal:

• Fetal distress
• Asphyxia at birth
• Cerebral damage
• Neonatal pneumonia caused by ascending infection
and meconeum aspiration
• Neonatal death
• flesh still birth
 Rupture of the Uterus
• Defn: When there is a tear or cut in the uterus. It is
one of the obstetric emergencies
• Causes
1. Weak previous caesarian section scar
2 .Trauma during operative manipulation per vagina
3. The unwise use of oxytocic drug
4. Obstructed labour
Types of rupture
- Incomplete rupture the myometrium and
endometrium are ruptured and the perimetrium
remains intact.
- Complete rupture all uterine layers are torn.
 Threatened uterine rupture

• Obstructed descend of fetal presenting part,

prolonged labor
• Appearance of pathologic retraction ring
• Mother shows distress, rapid breathing and heart rate,
unbearable pain
• Urination difficulty, hematuria
• Fetal heart rate change or unclear
 Incomplete rupture- may be gradual in onset or silent
and only found after delivery or during C/S
• More common in previous scar
• May manifest in as a cause of PPH after vaginal birth
• If Shock during 3rd stage is more severe compared to
the amount of blood loss or mother not responding to
RX given, consider incomplete rupture
 Complete uterine rupture

• At the point of rupture, patient experiences sudden

abdominal tearing pain, uterine contraction ceases,
temporary relieve of abdominal pain
• Following blood, amniotic fluid, fetus going into the
abdominal cavity, abdominal pain progressively
worsen
• Patient presents with rapid breathing, paleness, weak
pulse, decreasing blood pressure etc shock
manifestations
• Tenderness and rebound tenderness throughout
abdomen
• Fetal parts and small uterine body may be easily
palpable under abdominal wall, disappearing of fetal
movement and fetal heart
• Vaginal examination: may have fresh bleeding,
originally dilated cervix becomes smaller, ascend of
fetal presenting part, if site of rupture is low, may be
able to palpate uterine wall rupture per vaginal
 Signs of rupture of the uterus

• Maternal tachycardia
• Scar pain and tenderness
• Abnormal fetal heart rate and pattern
• Fetal heart sound may be lost
• Poor progress in labour
• Uterine contractions may be lost
• Fetus palpable in the abdomen
• Vaginal bleeding
• Maternal collapse & shock depends on blood loss
 Management of a ruptured uterus in the hospital

1. Blood group and cross match

2. Put Intravenous drip
3. Get patient to sign consent form
4. Give pre medication e.g. Abcs
5. Carry out doctor’s order
• Hysterectomy will be done : big tear, irregular tear
or obvious infection, perform subtotal hysterectomy.
If tear extends to cervix, perform total
hysterectomy
• or repair of the uterus depending on the extent
of trauma & the mother’s condition
• Postoperative care is the same with other
postoperative cases
 Prevention

• Build more efficient and comprehensive antenatal

care
• Patients of high risk should be admitted 1-2 weeks
before expected date of delivery
• Strengthen observation ability of doctors and
midwives, pick up abnormality during labour
promptly
• Strict indication of usage of oxytocin