July 1, 2011

   

   

Introduction Definition Incidence Presentation, lie, position of Fetus and satges of labour Risk Factor Cause Diagnosis & prevention Management & complication

It is failure of descent of fetal presenting part in birth cannal due to mechanical reasons . It usually occurs at the pelvic brim, but ocassionally it may ocur in the cavity or the outlet. The passage can be a cause when it has abnormal shape or size and the passenger can be the cause when large, malpositioned or presenting congenital anomalies.

Of 5980 hospital deliveries in our country during the year 2003 only 195 i.e 3.3% were admitted for obstructed labour . With common cause of obstructed labor being CPD followed by malpresentation. The mean duration of labour was 45hrs .

Together with hemorrhage, infection and hypertensive disorders of pregnancy, Obstructed Labour Is the major cause of maternal and prenatal mortality in developing countries like Ethiopia. Genital Fistula, Stress Incontinence, PID, seconadry ammenorhea and uterine rupture are some of its complications.

y Labour is the period between regular uterine

contraction till expulsion. Terms in Labour y Fetal lie- relation of long axis of fetus to that of the mother. It can be transverse or vertical.
y Featl presentation- the portion of the fetal body that

is formost within birth cannal or in close proximity to it. e.g cephalic, breech
y Fetal habitus- a characterstick posture fetus assumes

during let month pregnancy

y Fetal position- relation of an arbitrarily choosen

portion of fetal presenting part to rt or lt, anterior or posterior side of maternal birth cannal. Stages of labour y 1st stage- is concerned with cervical dilatation. a) latent phase- the time till dilitation of 3-5 cm b) active phase- dilitation of cervix 5-10 cm in presence of uterine contraction y 2nd stage- begins with completion of dilitation and ends with delivery, 3rd is removal of placenta.

y Engagement. y Descent y Internal rotation y Extension y External rotation y expulsion

y Dystocia- means difficult labor and is characterized

by abnormally slow progress of labor.

y Generally, abnormal labor is common whenever there

is disproportion between the presenting part of the fetus and the birth canal.
y So the d/c b/n dystocia(abnormal labor) and

obstructed labour is the former is difficulty in labour, while the later is failure to descent due to mechanical reasons.

y malnutrition y previous caesarean or stillbirth, previous y y y y

prolonged Labour young age of mother (under 17 years of age) female genital mutilation Custom of early marriage Previous obstructed labour

y Maternal
A. Bony obstruction - constructed pelvis - tumors of pelvic bones B .Soft tissue obstruction - uterus; impacted subserous peduculated fibroid - cervix- cervical dystocia - vagina- septa, stenosis ,tumors - ovaries- impacted ovarian tumors

 Any contraction of the pelvic diameters that

diminishes the capacity of the pelvis can create obstructed labour.  This can be:
 Pelvic inlet  Mid pelvis Pelvic outlet

Contracted inlet:if
 AP(conjugate ) diameter:<12cm  Transverse diameter:<13cm  Diagonal conjugate:<12.5cm  Obstetric conjugate:<10.5cm

or

y When both the AP and transverse diameters are

contracted, the obstruction is much greater than when only one is contracted.
y In women with contracted pelvis ,face and

shoulder presentations are in countered 3 x more frequently, and cord prolapse 4-6x more.
y In contacted pelvis, arrested head in the pelvic

inlet ,the entire force exerted by the uterus acts directly on the portion of the membrane that contact the dilating cervix.

y This finding is more common than inlet contraction y It frequently causes transverse arrest of the fetal

head which potentially can lead to a difficult midforceps operation or to cesarean delivery Hence; the midpelvis is likely contracted when the sum of the transverse and posterior sagittal diameters of the midpelvis normal, 10.5 plus 5 cm, or 15.5 cm falls to 13.5 cm or below.

 we can say pelvic out let is contracted when the

transverse diameter is <8cm

y The transverse line divide the outlet in to anterior and

posterior triangles.

y So, diminished transverse diameter with narrowing of

anterior triangle must inevitably force the fetal head posteriorly. the fetus increases=>laceration

y With contracted outlet the down ward force of descent of

y A .Uterus y impacted subserous pedunculated fibroid on out side

of the uterus ,mainly during pregnancy grow with the uterus and the baby, as a result, the uterus becomes cramped and crowded ,affecting not only the the development of the baby ,but also impairs the labour of term pregnancy.
y B.

Cervix mechanical obstruction of the cervix

y C. vagina ; vaginal septum

.This can be longitudinal or transverse. . Can result in blockage of normal menstrual flow and cause primary Amenorrhea,and difficulty in labour and delivery.

vaginal stenosis
Which can cause: . difficulty in labour, .long term problems in sex .pain during physical examination

y D. Ovaries ;

ovarian tumors must grow sufficient size to be caught by the pelvic brim when the ovaries ought to rise in to the abdomen with the developing womb. y Months later , when the fetus fully developed ,the mass be big enough to cause an obstruction.

Fetal causes
A. Malpresentation and malposition -persistent occiput- posterior and deep transverse arrest -persistent mentum- posterior and transverse arrest of the face -brow presentation -shoulder presentation -breech presentation Complete Incomplete Frank

B. Large size fetus(macrosemia) C. Congenital anomalies  e.g Hydrocephalus Distended fetal abdomen
. distended bladder

. ascites . enlargement of kidney or liver D. Locked and conjoined twins

This may be normal in early labour,and approximately 10 20% of fetuses at onset of labor.

y 75 % of the vertex rotate from the posterior position

to anterior position and deliver as Occiputanterior. position and deliver as Face to Pubis.

y 5 % of the vertex continue labour in Posterior

 20% will end as deep transfers arrest and need to be

delivered

by vacuum rotation by rotational forceps by Cesarean Section

y Most occiput-posterior presentation at delivery are the

result of malrotation of occiput-anterior position during labour.

Transverse Lie
y At this transverse lie, the long axis of the fetus is

approximately perpendicular to that of the mother, and the shoulder is usually positioned over the pelvic inlet. The head occupies one illiac fossa, and the breech the other. y Result in shoulder presentation.

y With this presentation, the head is hyper-extended so that

the occiput is in contact with the fetal back and the chin(mentum)is presenting.

y The fetal head may present with the chin(mentum)

anteriorly or posteriorly, relative to the maternal symphysis pubis.

y Many mentum posterior presentations convert

spontaneously to anterior even in late labour.

y If not , the fetal brow(bregma) is pressed against the

maternal symphysis pubis=OL

Lt mento-ant

Rt mento-ant

Rt mento-post

Longitudinal lie. Face presentation. Left and right anterior and ri posterior positions.

y Rare presentation y The portion of the fetal head b\n the orbital ridge

and anterior fontanel present in the pelvic inlet.

y Except the fetal head is small or the pelvis is

unusually large ,engagement of the fetal head. and subsequent delivery cant takes place as long as brow presentation persists=OL

y Brow presentation is not suitable for

vaginal delivery because of the large longitudinal diameter.

y Is longitudinal lie in which the fetus head occupies

the fundus of utetrus. y It can be:= - Complete breech : both the hips and knees are flexed. - Incomplete breech: extension of one or more hips. -Frank breech : hips are flexed and knees are extended..

y An extremity prolapse alongside the presenting part ,

both present simultaneously.

y It implies fetal growth >4-4.5kg regardles of the

gestational age.
y macrosomia was associated with longer first and

second stages of labor, a greater need for oxytocin therapy, and a greater risk for cesarean delivery.

Hydrocephalus: y is a macrocephally from excessive accumulation of CSF ,this may prohibit vaginal delivery.
y Normal fetal head circumstance =b\n 32-38cm y With hydrocephalus >50cm,up to 80 cm y Fluid volume is b\n 500-1500ml,but as much as

5000ml can be held.

y If the head circumstance is <36cm,vaginal delivery

may be permitted.

y In most cases , hydrocephalic head must be reduced in size

to deliver it. y Even with CS delivery ,desireble to remove CSF.

Fetal abdominal distension:

Enlargement of the fetal abdomen to cause obstructed labour is usually the result of :- greatly distended bladder - fetal ascites -enlargement of kidneys and liver y The edematous fetal abdomen ay attain such proportions that spontaneous delivery is impossible.
y

y The abnormalities are sonographically diagnosed

before delivery , to decide weather or not to perform CS delivery.

y Fetal tumors: -Omphalocele -Meningomyocele

In identifying the problems of obstructed

labour,it is essential to consider

History Physical examination and The partograph.

History
y Relevant points to find out from the woman, her

family or the health care worker are: y Her age y Height, gait, and any disability affecting the pelvis or lower limbs y Medical history, in particular rickets, osteomalacia, or pelvic injury y Any history of circumcision

Reasons for any previous operative deliveries(if she had any) y Previous stillbirth or early neonatal death and cause, if known y Any complications during pregnancy y length of time in labour so far
y

In the partograph if line of cervical dilatation cross the alert or action lines contractions increased in frequency and duration, or stopped etc.

y Pattern of uterine action so far, e.g.

y If membranes have ruptured, how long ago did

it rupture and is there any meconium-staining or foul smell?

Physical examination General condition y In cases of obstructed labour there will be

signs of physical and mental exhaustion. y Some or all of the following signs and symptoms may also be observed: y Maternal and/or fetal distress y Dehydration and ketoacidosis (sunken eyes, thirsty, dry mouth, dry skin ) y Fever (raised temperature) y Abdominal pain which may be continuous

y Shock(Shock may be due to a ruptured uterus or sepsis) Manifested by 1.Vital sign derangements -Rapid, weak pulse (100 /minute or more) -Rapid respiratory rate (>30 per minute ) -lowblood pressure (systolic <90 mmHg), 2.Diminished urinary output, 3.Cold clammy skin, pallor, 4.Anxiousness, confusion, or unconsciousness.

Abdominal examination  Signs of obstructed labour that may be revealed by an abdominal examination are:
y The widest diameter of the fetal head can be felt above

the pelvic brim because it is unable to descend; y Frequent, long and strong uterine contractions that may stop because of uterine exhaustion then the contractions restart with renewed intensity y The uterus become tightly molded around the fetus that can be felt during abdominal palpation

y Bandl s ring may be seen -Bandl s ring is a late sign of obstructed labour.

 In fetoscope examination fetal heart may not be heard

in severe cases of obstructed labour because the fetus dies from anoxia.

The signs of obstruction that must be looked for in vaginal examination are
y oedematous cervix which is poorly applied to

the presenting part

y secondary arrest of cervical dilatation and descent

of the presenting part in the presence of good contractions

y vagina hot and dry y a large caput succedaneum

yexcessive moulding of fetal head yballooning of the lower uterine segment yformation of palpable or visible retraction ring ymaternal and fetal distress.

 Obstructed labour may also be revealed if the

recordings on the partograph indicate:

y A prolonged first or second stage of labour which is

evident because cervical dilatation will cross first the alert line and then , if no action is taken, will cross the action line despite a history of strong uterine contractions.

Preventing obstruction depends on:

1. Good nutrition starting in childhood, so that

mothers reach their genetically determined height, and pelvic size. 2. Universal antenatal care, so that obstructed labour can be anticipated from a mother's history, and any risk factors can identified. 3. The monitoring of labour by skilled staff, so that she can be referred at the first sign of danger, before she obstructs.

Basic principles
y Aim of management, is to save life and prevent further

damage. y Working quickly and according to priorities so that urgent things are done first. y Must be relieved with out delay y Operative delivery is always needed to relieve the obstruction

y Preventive y Curative

y Preventive

y Carful observation y Proper assessment y Early detection & Management of the cause

of obstruction
"By using partograph

Resuscitation 2. Preintervention preparation 3. Relief of obstruction 4. Postintervention care

1.

1. Resuscitation
Should be started as soon as diagnosis is made

y Fluid & electrolyte replacement

y Infuse crystalloids (5% dextrose in saline with 50% glucose) y Monitor the urine output

y Control infection
y If there is any sign of infection or the membranes have been

ruptured
" Ampicillin 2g every 6 hours, and
"

Gentamicin 5 mg/body weight IV every 24 hours.

2. Preintervantion preparation
y Catheterize the bladder y Empty the stomach y Determine the blood group & haemotocrit

y Abdominal delevery
y When do we use cs ( abdominal delivery)

y If cephalopelvic disproportion is

confirmed y If precondition for instrumental delivery not fulfilled y Malpresention breech presentation y Definite uterine rapture

y complication of abdominal delivery

y Infection - peritonitis y Organ damage - Bladder & urethra y Scar on the uterus with risks uterine rupture y bleeding

y Craniotomy
y If the fetus is dead

y Symphysiotomy - rarely used today

y For relatively mild obstruction y If the fetus is alive & cervix is fully dilated

y Episiotomy
y If the cause of obstruction is tight peritoneum

y Instrumental delivery
y If the fetus is alive, and the cervix is fully dilated and

if the head is at the level of ischial spine or below.

y Forceps y Vacuum

y 4. postintervention care

y Increase the fluid replacement to prevent

dehydration y Contineous bladder drainage y Antibiotics

y Obstructed labour may result in serious

consequences to either or both simultaneously, y Maternal effects include; intrapartum infection, uterine rupture, pathological retraction ring, pelvic floor injury and postpartum lower extremity nerve injury. y Fetal effects include; caput succedaneum and fetal head molding.

y After membrane rupture, bacteria enter the amniotic

fluid, traverse the amnion, and invade decidua and chorionic vessels. y Fetal pneumonia, caused by aspiration of infected amniotic fluid, is another serious consequence. y Digital cervical examinations following membrane rupture introduce vaginal bacteria into the uterus. y These examinations should be limited during labor, especially when dystocia is suspected.

y Abnormal thinning of the lower uterine segment

creates a serious danger during prolonged labor. y When the disproportion between the fetal head and pelvis is so pronounced that there is no engagement or descent, the lower uterine segment becomes increasingly stretched, and rupture may follow.

y The most common type is the pathological retraction

ring of Bandl, an exaggeration of the normal retraction ring. y It is often the result of obstructed labor, with marked stretching and thinning of the lower uterine segment.

y When the presenting part is firmly wedged into the

pelvic inlet but does not advance for a considerable time, tissues of the birth canal lying between it and the pelvic wall may be subjected to excessive pressure. y vesicovaginal,vesicocervical, or rectovaginal fistulas. y Formerly, when operative delivery was deferred as long as possible, such complications were frequent, but today they are rarely seen.

y During childbirth the pelvic floor is exposed to direct

compression from the fetal head as well as to downward pressure from maternal expulsive efforts. y There is accumulating concern that such effects on the pelvic floor during childbirth lead to urinary and anal incontinence and to pop. y The anal sphincter is torn in 3 to 6 percent of deliveries. y Studies also indicate that abnormal pelvic bony architecture is associated with pelvic floor disorders later in life.

y Such injuries may manifest as foot drop, which can be

secondary to injury at the level of the lumbosacral root, lumbosacral plexus, sciatic nerve, or common peroneal nerve. y Components of the lumbosacral plexus cross the pelvic brim and can be compressed by the fetal head or by forceps. y Fetal macrosomia and malpresentations (occiput posterior) predispose women to foot drop. y The most common mechanism of injury, however, is external compression of the peroneal nerves usually caused by inappropriate leg positioning in stirrups especially during a prolonged second stage of labor.

y If the pelvis is contracted, during labor a large caput

succedaneum frequently develops on the most dependent part of the fetal head.
i.e. Caput succedaneum: Swelling of the fetal scalp due to pressure from the cervix. The swelling may be exaggerated in obstructed labour.

y The caput may reach almost to the pelvic floor

while the head is still not engaged.

y Factors associated with molding included nullparity,

oxytocin labor stimulation, and delivery with a vacuum extractor. y Previously considered an overlapping of the parietal bones, ultrasonographic evidence shows molding to be an unbending or straightening of the parietal bones in combination with an inward movement of the occipital and frontal bone apices . y These investigators further described a locking mechanism by which the free edges of the cranial bones are forced into one another, preventing further molding and providing protection for the fetal brain.

y Alternatively, when the distortion is marked, molding

may lead to tentorial tears, laceration of fetal blood vessels, and intracranial hemorrhage. y Analyzed nine neonates born with asymptomatic subdural hemorrhages and found that three followed normal vaginal deliveries. y studies indicate that severe molding could lead to fatal subdural hemorrhage as a result of tears involving the dura mater septa, especially the tentorium cerebelli. Such tears were observed in both normal and complicated deliveries.

y Fetal skull bones mold more readily when they are

imperfectly ossified. This important feature may explain the differences observed in the course of labor when two apparently similar cases initially present with identical measurements of the pelvis and the fetal head. y Skull fractures occasionally are encountered, usually following forcible attempts at delivery. The skull also may fracture with spontaneous delivery or even with cesarean delivery . y The fractures are either a shallow groove or a spoonshaped depression just posterior to the coronal suture.

 Separation of the muscular wall of the uterus usually occurs during labor occasionally happen during the later weeks of

pregnancy

During pregnancy weak scar after previous operations on the uterus History of cesarean section (vaginal birth after csection) myomectomy excision of a uterine septum previous perforation of uterus(D&C, hysteroscopy, forceps delivery

During labor: uterine hyper-stimulation(oxytocin with pitocin induction or augmentation of labor) obstructed labor(macrosomia, fetopelvic dispropotion) intrauterine manipulation( manual removal of an adherent placenta) forcible dilatation(cervical tear) a weak scar(C-section or other operations)

 Incomplete rupture complete rupture depending on whether the peritoneal coat is torn

through or not

1. Rupture of scar be gradual that symptom is very slight in incomplete rupture abdominal pain wrongly attributed to the onset of labor severe pain and shock occurs in complete (suddenly pain) fetal distress bleeding in vagina

2.Spontaneous rupture during obstructed labor prolonged labor violent uterine actions, *pathologic retraction ring disporpotion, malpresentation(transverse lie) fetal distress a sharp, tearing pain in lower abdomen pulse rapid blood pressure fall fetus may be felt in the abdominal cavity

3. Rupture by oxytocin drugs: be follow the administration of oxytocin the danger is less if the drug is given as a dilute intravenous drip given in an increasing fashion

y Prognosis has a high mortality peri-natal morbidity is high

 Women s general condition must be improved y

giving morphome, blood transfusion,glucose solution) immediate laparotomy hysterectomy wide-spectrum antibiotics

y Gabes text book of gyne & obs. y Williams text book of obs. y Mid wifery education module-2nd Edition by WHO y Ethiop.J.Health Dev. 2003; 17(3)2.175-180 y Current Diagnosis & Treatment in OBS & GYN