obstructed labour is one where in spite of good uterine contractions,the progressive descent of presenting part is arrested due to mechanical obstruction.
One of the challenging aspect of obstetrics !!
2. OBSTRUCTED LABOUR
Definition- obstructed labour is one where in spite of good uterine
contractions,the progressive descent of presenting part is arrested
due to mechanical obstruction.
Either due to factors in the fetus or in the birth canal or both,so
that further progress is almost impossible without assistance.
Incidence – about 1-2 % in referral hospitals (in developing
countries). It contributes to 8% of all maternal deaths in the world.
6. •Fetal hazards- dystocia due to CPD, shoulder dystocia,brachial
plexus injury, asphyxia ,birth trauma,meconium aspiration.
•Maternal hazards- soft tissue injury ,PPH, puerperal sepsis.
•Prophylactic early induction and elective caesarean section.
7. HYDROCEPHALUS
• Excessive accumulation of CSF in the ventricles resulting
in enlargement of the skull.
• 0.5-1.5 litre
• 1 in 2000 deliveries and 5% recurrence
• Head circumference >5o cm
• Head is high up cannot be pushed down in pelvis. FHS high
up.
• USG- fontanelle and suture wide,ventriculomegaly,thin
vault bones, dangling choroids sign .
8. •p/v- gaping sutures and fontanelle, crackling sensation on pressing
•Dangers- dystocia is inevitable ,fetal prognosis is poor
•Diagnosed mostly in later half of pregnancy
•Principle – decompress the head
•Cephalocentesis – p/v or usg guided through the abdominal approach ,
using a wide bore 17 G needle.
•Breech(30%) – perforation and decompression through sub–occipital
region
•During caesarean delivery – drain CSF by needle before incision of
uterus in diagnosed cases
•MTP cannot be done after 20 weeks
•Prognosis- use of ventriculoamniotic shunt is limited
9. ANENCEPHALY
•Deficient development of vault of skull and brain tissue
•Pituitary gland is hypoplastic or absent, atrophic adrenal glands
•70% females
•Diagnosis- increased alphafetoprotein in amniotic fluid, USG- absent
cranial vault, angiomatous brain tissue,associated hydramnios.(10 weeks)
p/a- unable to palpate the head
•Complications- hydramnios(70%),malpresentation – face and
breech,postmaturity, shoulder dystocia,obstructed labour head and
shoulders try to engage together because of short neck
•Indication for termination irrespective of gestation age as it is
incompatible with life
10. Iniencephaly- failure of formation of cervical and thoracic vertebra and
base of skull with abnormal formed brain tissue.
11. Enlargement of fetal abdomen-
• Ascitis, distended bladder, enlargement of
kidneys by tumor,umbilical hernia can cause
dystocia .
• USG findings of ascitis – Buddha position
• Decompression of abdomen with wide bore
needle
Neck tumor ,neck masses and cord around neck
• Congenital goiter , bronchocele,cystic hygroma,
Thoracic lymphangioma
14. Transverse lie
•Long axis of fetus perpendicular to maternal spine
•Dorsoanterior is most common (60%)
•Dorsoposterior – chances of fetal extension and arm prolapse with cord
prolapse
•Formation of pathological retraction ring and obstructed labour
15.
16. Neglected shoulder presentation-
•Series of complication that may arise out of shoulder presentation when
labour is left uncared.
•Impacted shoulder lead to obstructed labour , rupture of uterus with
clinical evidence of dehydration ,ketoacidosis , shock ,haemorrhage
,peritonitis and sepsis.
•Marked increase in the fetal loss is due to cord prolapse,tonic
contractions and rupture uterus.
•Management – aims at prevention of condition by managing the
shoulder presentation in early labour. First resuscitation of mother
followed by delivery of the baby.
•In cases of rupture- laparotomy followed by delivery through caesarean
section
17. FACE PRESENTATION-
•Variety of cephalic presentation with complete extension of head
•Denominator is mentum and most common is LMA
•Engaging diameter – fully extended –submentobregmatic(9.5cm)
partially extended –submentovertical(11.5cm)
18. •Mentoposterior (20-25%)- anterior rotation occurs in only 20-30%
cases rest, incomplete anterior rotation, nonrotation or short posterior
rotation occurs.
•No possibility of spontaneous delivery in persistent mentoposterior
position as short neck cannot clear off the total length of the sacrum .the
thorax is thrust in resulting the bregmaticosternal diameter (18cm)to
occupy pelvis and cause obstruction.
19. BROW PRESENTATION-
•Variety of cephalic presentation when head lies in between full
extension and full flexion.
•Engaging diameter is mentoverticle (14cm).
•Leads to obstructed labour,prolonged labour and uterine rupture.
•There is no mechanism of labour in an average size baby with normal
pelvis.
21. SHOULDER DYSTOCIA-
•Defined to describe the wide range of obstetric maneuvers to deliver the
fetus after the head has been born and gentle traction has failed to deliver
the shoulders. (0.1-1%)
22. •Previous shoulder dystocia
•Macrosomia ,postmaturity
•Diabetis and obesity
•Induced labour , prolonged 1ST ans 2ND stage
•Secondary arrest of labour
•Anencephaly , fetal ascites
•Mid pelvic instrumental delivery
•Multiparity
23. COMPLICATIONS –
Fetal- asphyxia, brachial plexus injury due to stretch, humerus fracture
clavicle fracture or sternocleidomastoid hematoma.
25. Diagnosis –
1. Definite recoil of the head back against the perineum (turtle neck sign)
2. Inadequate spontaneous restitution
3. Plethoric fetal face
4. Failure of shoulder to descent
26. MANAGEMENT –
According to ACOG –
• It cannot be predicted or prevented because
accurate measures to do so do not exist .
• No evidence that any method is superior
than other in releasing impacted shoulder
and reduce chance of injury.
• Risks and benefits of vaginal and caesarean
delivery depends on factors like estimated
wight,gestational age,maternal diabetes
,previous history of dystocia, congenital
anomalies etc.
27. McROBERTS maneuver-
Abduct and hyperflex
• Decrease in angle of pelvic
inclination.
• Increases AP diameter of pelvis.
• Successful in 90% (RCOG 2012)
29. Rubin’s II
consists of inserting the fingers of one hand vaginally
behind the posterior aspect of the anterior shoulder of
the fetus and rotating the shoulder toward the fetal
chest. This motion will adduct the fetal shoulder girdle,
reducing its diameter.
30. Wood ‘s cork screw maneuver – (DONE UNDER GA)
Place at least two fingers (index and middle) on the anterior aspect of the fetal
posterior shoulder
Apply pressure to abduct/extend the posterior shoulder and rotate the fetal body
180°
After 90° the practitioner may need to switch hands in order to complete the full
180° turn
This movement rotates the anterior shoulder from under the symphysis pubis and
releases the impaction (shoulder dystocia)
31.
32. Extraction of the posterior arm
Arm is swept
across chest and
delivered by gentle
traction.
33. “ALL FOURS”
Increases pelvic dementions
Downward traction on posterior
shoulder
• Symhysiotomy and cleidotomy are
rarely done
35. FAULT IN THE PASSAGE-
•Bony obstructions – cephalopelvic disproportions, contracted pelvis
,asymmetrical and obliquiely contracted pelvis or secondary contracted
pelvis .
•Anatomical definition – essential diameters of one or more plane are
shortened by 0.5cm
•Disparity in relation to head and pelvis is known as CPD
39. Bladder
•Bladder becomes abdominal organ , compression of urethra between the
presenting part and symphysis pubis.
•Earliest sign of obstructed labour is “unable to empty the bladder”.
•Trauma to bladder wall leads to hematuria
•Base of the bladder and urethra gets nipped in between the presenting
part and symphysis pubis and undergoes pressure necrosis. Devitalized
tissue gets infected and slough off resulting in genitourinary fistulas.
40.
41. Effect of obstructed labour on mother-
Immediate effects
•Exhaustion due to constant pain and agony
•Dehydration due to increased muscular activity without adequate fluid
•Metabolic acidosis (lactic acid and ketones)
•Genital sepsis due to rupture ,repeated p/v and manipulations
•Injury to genital tract and rupture of uterus
•PPH and shock
•Death due to – sepsis, shock and metabolic changes
43. Effects on the fetus –
•Asphyxia ; prolonged 1st stage – hypertonic uterine contractions without relaxation
in between interferes with the uteroplacental circulation leads to fetal distress .
•Acidosis due to fetal hypoxia and maternal acidosis
•Intracranial hemorrhage due to supermoulding and tentorial tear or traumatic
deliver
•Infections
•Perinatal loss
44. Clinical features-
•Features of maternal distress
•h/o prolonged labour
•Severe frequent pain and bearing down
•Exhaustion
•signs of dehydration,dry tongue and sunken eyes
•Tachycardia
•raised temperature
•Scanty concentrated urine
• blood tinged urine
45. Per abdomen examination-
•Uterus tonically contracted may be hard and tense
•Fetal parts palpated with difficulty
•FHS may or may not be heard , it is irregular and presence of
bradycardia
•Formation of bandl’s ring felt at the junction of upper uterine segment
and lower uterine segment
•Bladder can be palpated abdominally
46. •in case of uterine rupture – tender abdomen ,fetal parts felt
easily ,baby in peritoneal cavity ,FHS may be absent,flanks dull
due to hemoperitonium .
•In primigarvida or multigravida obstructed labour lead to “three
tumour abdomen” : distended bladder , upper segment of uterus
, lower segment of uterus separated by pathological retraction
ring.
47. On per vaginal examination-
•Vulva is swollen ,edematous
•Dry hot vagina
•Offensive and purulent discharge
•Cervix fully dilated or hanging like a curtain
•Presenting part – excessive moulding amd jammed large caput.
49. PREVENTION –
•Adequate good nutrition from childhood period would help to achieve
genetically predetermined height and help in prevention of nutritional
deficiency chances of the maternal pelvis.
•Universal antenatal care protocol
•Regular antenatal visits – obstetrician can anticipate obstruction and
prolong labour by detailed history and by identification of the risk factors
•Intranatally – monitoring of labour by skilled staff
•Use of partograph, continuous vigilance and timely intervention
50. MANAGEMENT –
Principle of treatment
•To relieve the obstruction at the earliest by safe delivery procedure
•To combat dehydration and ketoacidosis
•To control sepsis
51. Immediate management –
•Treat dehydration and shock by fluid resuscitation - 1 lit RL or DNS
rapidly (x3) till dehydration and ketosis is corrected then 1 lit 4-6 hrs
•Severe tonic contractions prevented by tocolysis ( terbutaline sc)
•Blood sampling – blood group typing ,cross
matching,LFT,KFT,cbc,urine for ketone and urine r/m
,sr.electrolytes,blood culture sensitivity.
•High vaginal swab is taken and sent for culture and sensitivity.
53. OBSTETRICAL MANAGEMENT –
•Before proceeding for definitive operative treatment ,rupture of
uterus must be excluded.
•There is no place for “wait and watch”
•Do not use oxytocin to stimulate contractions
•Vaginal delivery-
1. Destructive operations like craniotomy, evisceration,decapitation
and cleidotomy have historical importance and no place in modern
obstetrics.
2. If the head is low and vaginal delivery is not risky then forceps
extraction can be done in live fetus
54. 3. There is no place for internal cephalic version .
4. After delivery of baby explore uterus and lower genital tract for tears
and rupture.
•Caesarean delivery-
1. If obstructed labour is detected early and with good fetal condition
the it gives best results.
2. Desperate attempt to save the moribund baby often leads to
disastrous consequences
3. Brow ,mentoposterior ,placenta previa
4. Dead fetus with impending rupture
55. • active management of third stage of labour
•Continuous bladder draining for 3-7 days to prevent genitourinary
fistulas.
•Management of sepsis- inj ampicillin 2g 6hrly or inj ceftriaxone 1g +
Inj gentamycin 5mg /bw (gram neg) and inj metronidazole (anerobes)
Less severe cases – ampi+genta
Hydrocortisone 200-400 mg stat iv followed by 100-200mg 4 hrly
Dopamine infusion ( hypovolemic shock)
Tetanus prophylaxis
56. •Laprotomy repair is done in cases of ruptured uterus- recent rupture,
clean wound and margins, tear not too large ,preservation of
fertility,little or no sepsis.
•TAH/subtotal hysterectomy -severe infected uterus, tear with necrotic
edges,tear extending to vagina,future cervical ca concerns, spontaneous
obstructive rupture.
•Analgesia
•Breast care
58. Explain the condition and counsel
•Repaired rupture and CS- always hospital delivery
•Total /subtotal hysterectomy- amenorrhoea and infertility
•Severe postpartum infections – possible ectopic in next pregnancies amd
need for regular antenatal visits
