Prolonged labor and obstructed labor

1. PROLONGED AND OBSTRUCTED
LABOR
Binod Chaudhary
MBBS 4th Batch, CMC

2. Labor
Series of events that take place in the genital
organs in an effort to expel the viable products
of conception out of the womb through the
vagina into the outer world.
 First stage
start of the true labor pain to full
dilatation of the cervix (10 cm)
latent phase (primi-8hrs, multi-4hrs)
active phase (primi-4hrs, multi-2hrs)

3. Second stage
from full dilatation of the cervix to the
expulsion of the fetus.
Propulsive phase
Expulsive phase
duration- primi =2 hours
multi = 30 minutes

4. Third stage
from expulsion of the fetus to the expulsion
of the placenta
Phase of placental separation
Phase of placental descent
Phase of placental expulsion
Duration- 15 minutes (primi and multi)
5 minutes in active management
 Fourth stage
Upto 1 hours of delivery of placenta

5. Prolonged labor

6. Labor is said to be prolonged when the
combined duration of the first and second
stage is more than the arbitrary time limit of
18 hours.
WHO- labor is considered to be prolonged
when the cervical dilatation rate is less than 1
cm/hr and descent of the presenting part is <1
cm/hr for a period of minimum 4 hours
observation.

7. Prolonged latent phase
• Primi >20 hrs and multi >14 hrs
• Causes: unripe cervix, malposition and
malpresentation, CPD, PROM
• Worrisome to the patient but donot
endanger mother and fetus

8. Causes of prolonged labor
1. First stage (@3P)
a. Fault in power
 Abnormal uterine contraction (uterine inertia
or inco-ordinate uterine contraction)
b. Fault in passage
 Contracted pelvis
 Cervical dystocia
 Pelvic tumor
 Full bladder

9. c. Fault in the passenger
 Malposition or malpresentation
 Congenital anomalies of the fetus
(hydrocephalus)
d. Others – early administration of sedatives
and analgesics before active labor

10. 2. Second stage
a. Fault in the power
 Uterine inertia
 Inability to bear down
 Epidural analgesia
 Constriction ring
b. Fault in the passage
 CPD, android pelvis, contracted pelvis
 Undue resistance (spasm or old scarring)
 Soft tissue pelvic tumor

11. c. Fault in the passenger
 Malposition
 Malpresentation
 Big baby
 Congenital malformation of the baby

12. Diagnosis
Prolonged labor is not a diagnosis but it is the
manifestation of an abnormality.
First stage
duration >12 hours
cervical dilatation- <1 cm/hr (primi)
<1.5 cm/ hr (multi)
Second stage
duration >2 hrs (nullipara), >1 hrs (multipara)
[if regional analgesia is given then one hour is
permitted in both groups]

13. Dangers
1. Fetal
a. Hypoxia
b. Intrauterine infection
c. Intracranial stress or hemorrhage
d. Increased operative delivery

14. 2. Maternal
a. Distress
b. Postpartum hemorrhage
c. Trauma to the genital tract
d. Increased operative delivery
e. Puerperal sepsis
f. Subinvolution

15. Treatment

16. Prevention
Antenatal or early detection
Use of partograph
Selective and judicious augmentation
Change of posture in labor, avoidance of
dehydration in labor and use of adequate
analgesia for pain relief

17. Treatment
Principle- “The sun should not set twice in
women in labor”
Evaluate carefully to find out
 Cause of prolonged labor (m/c inadequate uterine
activity in nulliparous; cephalopelvic disproportion
in multiparous)
 Effect on the mother
 Effect on the fetus

18. Preliminaries
Correct fluid and electrolyte imbalance
Control of infections (ampicillin,
metronidazole, ceftriaxone)
Emptying the bladder (catheterization)
Emptying the stomach
Blood cross matching

19.  First stage delay
Vaginal examination and clinical pelvimetry done
Uterine activity suboptimal Secondary arrest
(Careful using oxytocin)
• Amniotomy and oxytocin infusion (5U in 500 ml RL
• Effective pain relief (im pethidine or RA)
• Cesarean section

20. Second stage delay
provided the FHR is reassuring and vaginal
delivery is imminent, short period of expectant
management is reasonable
if not, appropriate assisted delivery,
vaginal (forceps, ventouse) or abdominal
(cesarean) should be done.
Note: difficult instrumental delivery should be
avoided

21. Obstructed labor

22. Obstructed labor is one where in spite of good
uterine contractions, the progressive descent
of the presenting part is arrested due to
mechanical obstruction.
Result due to factors in the fetus or in the
birth canal or both

23. Causes:
a. Fault in the passage
 Cephalopelvic disproportion
 Contracted pelvis
 Cervical dystocia
 Cervical or broad ligament fibroid
 Impacted ovarian tumor
 Non gravid horn of bicornuate uterus

24. b. Fault in the passenger
 Transverse lie
 Brow presentation
 Congenital malformations (hydrocephalus,
ascites, double monsters)
 Big baby, occipitofrontal position
 Compound presentation
 Locked twins

25. Morbid anatomical changes
a. Uterus
 Formation of bandl’s ring
 Gradual increase in intensity, duration and
frequency of contraction.
 Relaxation becomes less and less
 Ultimately, a state of tonic contraction develops

26. b. Bladder
Becomes abdominal organ
Compression of urethra b/w presenting part and
symphysis pubis→urinary retention
Trauma→blood stained urine
Pressure necrosis of the bladder and urethra→
genitourinary fistula

27. Clinical features
Maternal condition
Mother is in agony, exhausted, sepsis appear
early
Abdominal examination
• Uterus tense and tender
• Fetal parts easily felt
• Distended bladder due to retention or edema
• Retraction Ring may be felt
• FHS usually absent
• “Three tumor abdomen” evident

28. Vaginal examination
• Lower segment pressed by forcibly driven
presenting part
• Edematous vulva (cannula sign) and cervix
• Severe caput and moulding
• Ring not felt vaginally
• Descent of presenting part absent

29. Anticipation of Obs. Labor during ANC
Short stature particularly in primes <150 cm
Large fetuses >4 kg
Obvious pelvis/spinal deformities
Gynetresia (at least one pelvic exam be done
at ANC)
Uterine myomas in lower segment or cervix
Abnormal lie
Severe degree of overlap at pelvic brim

30. Dangers
1. Mother
a. Immediate
Exhaustion
Dehydration
Metabolic acidiosis
Hypoglycemia
Genital sepsis
Injury to the genital tract includes rupture of the
uterus
Postpartum hemorrhage and shock

31. b. Remote
 Genitourinary fistula or rectovaginal fistula
 Variable degree of vaginal atresia
 Secondary amenorrhea
2. Fetus
a. Asphyxia
b. Acidosis
c. Intracranial hemorrhage
d. Infection

32. Treatment

33. Principles
To relieve the obstruction at earliest by a safe delivery
procedure
Pain relief
To combat dehydration and ketoacidosis
To control sepsis
Correct hypoglycemia
Correct electrolyte imbalance

34. 1. Prevention
Same as prolonged labor
2. Initial assessment of the patient
 Pallor, pulse, blood pressure, dehydration
 Fundal height, fetal lie, presentation and heart
rate, state of the uterus and bladder
 Level of presenting part, cervical dilatation, caput
formation and moulding
 Do pelvic assessment and note the measurement
and the presence of infected liquor
 Access urine
 Blood group and cross matching

35. 3. Resuscitate the patient
Iv fluids at least 3 l
Give dextrose saline for hypoglycemia initially
then ringers lactate
Oxygen if fetal distress or maternal distress
4. Control infection
Give broad spectrum iv antibiotics
Stat dose of Ampicillin 1g and chloramphenicol

36. 5. Check if the fetus is alive and decide mode of
delivery
6. Empty bladder with self retaining catheter

37. Obstetric management
No place of “wait and watch”, neither any scope of
using oxytocin to stimulate uterine contraction
Before proceeding for definitive operative
treatment, rupture of the uterus must be excluded
Decide best method to relieve the obstruction with
least hazards to the mother

38. Vaginal delivery
If baby dead, destructive operation (craniotomy,
decapitation, evisceration and cleidotomy) is
best choice
If baby living and head is low down and vaginal
delivery not risky→forceps extraction
After delivery, explore uterus and lower genital
tract to exclude uterine rupture or tear

39. Cesarean delivery
Done if the case is detected early with good fetal
outcome.
In late case, desperate attempt to do a C/S to save
the moribund baby more often leads to disastrous
consequents
Symphysiotomy
Alternate to risky cesarean
In case of established obstruction due to outlet
contraction with vertex presentation having good
FHS

40. Post delivery care
Continue monitoring of temperature, pulse, BP,
urine output and colour
Monitor abdominal distension
Continue antibiotics
Continuous bladder drainage for at least 10
days
Check for perineal nerve damage and
rehabilitate accordingly
Bear in mind possibility of secondary PPH
Counseling for future pregnancies and deliveries

41. Thank you!!!