2. DEFINTION
• OBSTRUCTED LABOUR CAN BE DEFINED AS A LABOUR WHERE
THERE IS POOR OR NO PROGRESS OF LABOUR IN SPITE OF GOOD
UTERINE CONTRACTION.
• OR AS ONE WHERE IN SPITE OF GOOD UTERINE CONTRACTIONS,
THE PROGRESSIVE DESCENT OF THE PRESENTING PART IS
ARRESTED DUE TO MECHANICAL OBSTRUCTION.
• THIS MAY RESULT EITHER DUE TO FACTORS IN THE FETUS OR IN
THE BIRTH CANAL OR BOTH, SO THAT FURTHER PROGRESS IS
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3. INCIDENCE
IN THE DEVELOPING COUNTRIES, THE PREVALENCE IS ABOUT 1–2% IN
THE REFERRAL HOSPITALS.
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4. CAUSES
MATERNAL CONDITION (FAULT IN THE PASSAGE) ;-
1)CEPHALOPELVIC DISPROPORTION
2)CONTRACTED PELVIC
3)ABNORMAL PELVIS;- ANDROID, ANTHROPOID
4)PELVIC TUMOR;- FIBROIDS IN LOWER UTERINE SEGMENT
(e.g. CERVICAL OR BROAD LIGAMENT FIBROID), OVARIAN
TUMOR, OVARIAN CYSTS IMPACTED IN POUCH OF
DOUGHLAS
5)TUMOR OF RECTUM, BLADDER OR PELVIC BONE
6)ABNORMALITY IN UTERUS AND VAGINA;- CERVICAL
STENOSIS, VAGINAL STENOSIS, CONTRACTION RING IN
UTERUS, VAGINAL SEPTUM, RIGID PERINEUM.
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5. CAUSES
FETAL CONDITION (FAULT IN THE PASSENGER);-
1) MACROSOMIC BABY
2) MALPRESENTATION e.g. BROW PRESENTATION, BREECH
3) COMPOUND PRESENTATION
4) MALPOSITION;- TRANSVERSE LIE, OCCIPITO-POSTERIOR
POSITION, MENTO POSTERIOR
5) CONGENITAL MALFORMATIONS OF THE FETUS;-
HYDROCEPHALUS (COMMONEST), FETAL ASCITIS,
CONJOINT TWINS, CORD AROUND THE NECK,
6) LOCKED TWINS.
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6. MORBID ANATOMICAL CHANGES
• UTERUS: THERE IS GRADUAL INCREASE IN INTENSITY,
DURATION AND FREQUENCY OF UTERINE CONTRACTION.
THE RELAXATION PHASE BECOMES LESS AND LESS;
ULTIMATELY A STATE OF TONIC CONTRACTION
DEVELOPS. RETRACTION, HOWEVER, CONTINUES. THE
LOWER SEGMENT, ELONGATES AND BECOMES
PROGRESSIVELY THINNER TO ACCOMMODATE THE FETUS
DRIVEN FROM THE UPPER SEGMENT (FIG. 24.5). A
CIRCULAR GROOVE ENCIRCLING THE UTERUS IS FORMED
BETWEEN THE ACTIVE UPPER SEGMENT AND THE
DISTENDED LOWER SEGMENT, CALLED PATHOLOGICAL
RETRACTION RING (BANDL’S RING). DUE TO
PRONOUNCED RETRACTION, THERE IS FETAL JEOPARDY
OR EVEN DEATH.
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7. CONTD……………………………………………
IN PRIMIGRAVIDAE, FURTHER
RETRACTION CEASES IN
RESPONSE TO OBSTRUCTION
AND LABOR COMES TO A STAND
STILL—A STATE OF UTERINE
EXHAUSTION. CONTRACTIONS
MAY RECOMMENCE AFTER A
BRIEF PERIOD OF REST WITH
RENEWED VIGOUR. BUT IN
MULTIPARAE, RETRACTION
CONTINUES WITH PROGRESSIVE
CIRCUMFERENTIAL DILATATION
AND THINNING OF THE LOWER
SEGMENT. THERE IS
PROGRESSIVE RISE OF THE
BANDL’S RING; MOVING NEARER
AND NEARER TO THE UMBILICUS
AND ULTIMATELY, THE LOWER
SEGMENT RUPTURES
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9. MORBID ANATOMICAL CHANGES
• BLADDER: THE BLADDER BECOMES AN ABDOMINAL ORGAN
AND DUE TO COMPRESSION OF URETHRA BETWEEN THE
PRESENTING PART AND SYMPHYSIS PUBIS, THE PATIENT FAILS TO
EMPTY THE BLADDER. THE TRANSVERSE DEPRESSION AT THE
JUNCTION OF THE SUPERIOR BORDER OF THE BLADDER AND THE
DISTENDED LOWER SEGMENT IS OFTEN CONFUSED WITH THE
BANDL’S RING. THE BLADDER WALLS GET TRAUMATIZED, WHICH
MAY LEAD TO BLOOD STAINED URINE, A COMMON FINDING IN
OBSTRUCTED LABOR. THE BASE OF THE BLADDER AND URETHRA,
WHICH ARE NIPPED IN BETWEEN THE PRESENTING PART AND
SYMPHYSIS PUBIS MAY UNDERGO PRESSURE NECROSIS. THE
DEVITALIZED TISSUE BECOMES INFECTED AND LATER ON MAY
SLOUGH OFF RESULTING IN THE DEVELOPMENT OF
GENITOURINARY FISTULA.
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10. DIAGNOSIS
❖PARTOGRAPH WILL RECOGNIZE IMPENDING
OBSTRUCTION EARLY. IF THE LABOUR IS SLOW TO
PROGRESS, CAREFUL GENERAL, ABDOMINAL AND
VAGINAL EXAMINATION IS NECESSARY.
❖WOMAN GIVES HISTORY OF;-
‾ PROLONGED LABOUR AND
‾ THE LABOUR PAIN BECOME SEVERE AND
FREQUENT AND
‾ BEARING DOWN.
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11. EXAMINATION
GENERAL EXAMINATION;-
FEATURES OF MATERNAL DISTRESS i.e.
EXHAUSTION (IS DUE TO A CONSTANT AGONIZING PAIN AND ANXIETY)/ ANXIOUS
PAINFUL STATE
TACHYCARDIA/ FEEBLE PULSE
DEHYDRATION (IS DUE TO INCREASED MUSCULAR ACTIVITY WITHOUT ADEQUATE
FLUID INTAKE)
RAISED TEMPERATURE
SCANTY CONCENTRATED URINE CONTAING KETONE BODIES/ BLOOD. METABOLIC
ACIDOSIS IS DUE TO ACCUMULATION OF LACTIC ACID AND KETONES
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12. PER ABDOMEN EXAMINATION;-
ON INSPECTION;
❑ TONICALLY CONTRACTED UTERUS
❑ DISTENDED URINARY BLADDER (FULL BLADDER)
❑ BANDL’S RING (THE RETRACTION RING)
ON PALPATION;
❑UTERUS IS TENDER
❑LIQUOR ALL DRAINED
❑FETAL PARTS DIFFICULT TO PALPATE
❑FHS SHOWS EVIDENCE OF FETAL DISTRESS OR EVEN ABSENT (DIFFICULT TO
AUSCULTATE/ ABNORMALITIES IN FHS)
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13. VAGINA EXAMINATION;-
❑THE VULVA IS USUALLY SWOLLEN AND EDEMATOUS
❑THE VAGINAL IS DRY, HOT AND OCCASIONALLY OFFENSIVE AND
PURULENT
❑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
❑MECONIUM DRAINING
❑IF UTERUS HAS RUPTURED, FETAL PARTS WILL BE PALPABLE IN
PERITONEAL CAVITY AND UTERUS IS FELT AS SEPARATE FIRM MASS.
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14. COMPLICATIONS OF OBSTRUCTED LABOUR
MATERNAL;-
❑UTERINE RUPTURE
❑PPH
❑VVF (GENITOURINARY FISTULA)
❑RVF (FECAL FISTULA)
❑PUERPERAL SEPSIS
❑SHOCK
❑ANNULAR DETACHMENT OF CERVIX
❑MATERNAL DEATH
FETAL;-
❖ INTRAUTERINE FETAL ASPHYXIA. (RESULTS
FROM TONIC UTERINE CONTRACTION THAT
INTERFERES WITH THE UTEROPLACENTAL
CIRCULATION OR DUE TO CORD PROLAPSE
ESPECIALLY IN SHOULDER PRESENTATION)
❖ INTRACRANIAL HEMORRHAGE. (DUE TO SUPER
MOULDING OF THE HEAD LEADING TO
TENTORIAL TEAR OR DUE TO TRAUMATIC
DELIVERY)
❖ NEONATAL INFECTION e.g. PNEUMONIA DUE TO
ASCENDING INFECTION
❖ ACIDOSIS. (DUE TO FETAL HYPOXIA AND
MATERNAL ACIDOSIS)
❖ FETAL DEATH
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15. MANAGEMENT
PREVENTIVE;-
❑PROPER ASSESSMENT OF PREGNANT WOMAN DURING ANC. .
❑REGULAR ANC VISITS. FOCUSED ANC IS RECOMMENDED.
❑PROPER ASSESSMENT IN EARLY LABOUR TO DETECT THE CAUSE, IF ANY.
❑PARTOGRAPH HAVE TO BE STRICTLY FOLLOWED.
❑PROMPT FOLLOW APPROPRIATE TREATMENT TO SOLVE THE PROBLEMS.
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16. CURATIVE;-
A. IMMEDIATE MANAGEMENT
B. GENERAL MANAGEMENT
C. OBSTETRICS MANAGEMENT;- BEFORE PROCEEDING FOR DEFINITIVE
OPERATIVE TREATMENT, RUPTURE OF THE UTERUS MUST BE EXCLUDED. A
BALANCED DECISION SHOULD BE TAKEN ABOUT THE BEST METHOD OF
RELIEVING THE OBSTRUCTION WITH LEAST HAZARDS TO THE MOTHER.
FRANTIC ATTEMPT TO DELIVER A MORIBUND BABY BY A METHOD IGNORING
THE RISK INVOLVED TO THE MOTHER IS INDEED BAD OBSTETRICS. THERE IS
NO PLACE OF “WAIT AND WATCH”, NEITHER ANY SCOPE OF USING OXYTOCIN
TO STIMULATE UTERINE CONTRACTION.
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17. A. IMMEDIATE MANAGEMENT;-
1. TWO LARGE BORE CANNULAS
2. ADMINISTER FLUIDS TO CORRECT MATERNAL
DEHYDRATION
3. BLOOD SAMPLE SEND FOR HB, GROUPING AND X-
MATCH, BED SIDE CLOTTING TIME.
4. CONTRACTION PREVENTION BY TOCOLYTIC DRUGS
5. ULTRASOUND TO CONFIRM FETAL VIABILITY
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18. B. GENERAL MANAGEMENT;-
1. QUICK ASSESSMENT OF VITAL OF MOTHER AND GENERAL
CONDITION.
2. IV FLUIDS TO CORRECT DEHYDRATION
3. BROAD SPECTRUM ANTIBIOTICS. TRIPPLE THERAPY COVER
OR USE CEFTRIAXONE 1g IV AND METRONIDAZOLE IV
4. CATHETERISATION.
5. SODIUM BICARBONATE INFUSION TO CORRECT ACIDOSIS.
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19. C. OBSTETRIC MANAGEMENT
1. DELIVERY OF FETUS;-
a. VAGINAL DELIVERY;-
⁃ (DESTRUCTIVE OPT.) DEAD FETUS
⁃ IF HEAD IS LOW AND VAGINAL DELIVERY IS NOT RISKY, FORCEPS
EXTRACTION MAY BE DONE IN A LIVE FETUS.
b. CAESAREAN SECTION;-
⁃ A LIVE FETUS
⁃ OVER DISTENDED LOWER SEGMENT WITH IMPENDING RUPTURE EVEN THE
FETUS IS DEAD.
2. ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR.
3. CONTINUOUS BLADDER DRAINAGE FOR 2-3 DAYS TO PREVENT VVF
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20. “
”
A GREAT PART, I BELIEVE, OF THE ART OF
MEDICINE IS THE ABILITY TO OBSERVE—
HIPPOCRATES
THE END
THANK YOU
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