OBSTRUCTED
LABOR
Definition of obstructed labour
Obstructed labour means that, in spite of strong uterine
contraction, the foetus cannot descend because of mechanical
factors. Obstruction usually occurs at the brim, but it may occur
in the mid cavity or pelvic outlet.
Definition of (CPD): This occurs when foetal head is large in
comparison with the pelvis. Cephalopelvic disproportion may be
due to a small pelvis with a normal sized head, or a normal
pelvis with a large foetus or a combination of a large baby and
small pelvis. This means it is difficult or impossible for the foetus
to pass safely through the pelvis.
Cont……………………..
Cephalopelvic disproportion may be:
Marginal CPD, which means that the problem may be overcome
during labour. The relaxation of the pelvic joints and moulding of
the foetal skull may enable vaginal delivery.
Half of these patients will need an operative delivery.
True CPD: This means the pelvis is small or abnormally shaped
and/or foetus is unusually large or abnormal e.g. hydrocephalus.
Operative delivery will be needed.
Causes of obstructed labour
Common factors predisposing to obstructed labour include:
Cephalopelvic disproportion
Foetal macrosomia e.g. in poorly controlled diabetes mellitus in
pregnancy
Malpresentation e.g. brow, shoulder, face with mentoposterior,
breech
Foetal abnormalities e.g. hydrocephalus
Multiple gestation with locked twins
Cont……….
Abnormalities of the reproductive tract e.g. pelvic tumour,
cervical or vaginal stenosis, tight perineum and FGM/FGC
scar.
Underdeveloped pelvis e.g. adolescent pregnancy
Childhood malnutrition leading to contracted pelvis
Diagnosis of obstructed labour
History
Relevant points to find out from the woman or her family are
Her age, parity, gravidity
History of previous operative delivery
History of previous stillbirth
Duration of previous labour and outcome
Duration of current labour
Duration of ruptured membranes
Physical Examination
General examination
The following may be observed:
Signs of physical and mental exhaustion
Dehydration- dry mouth,
Acetone breath due to keto-acidosis.
Fever
Shock - rapid pulse, anuria or oligouria, cold extremities, pale
complexion, low blood pressure.
Shock may be due to a ruptured uterus or sepsis.
Abdominal examination
The foetal head may be palpable above the pelvic brim
There may be frequent and strong uterine contractions
The uterus may have gone into tetanic contractions and its
tightly moulded around the foetus
Bandl’s ring may be evident. This is when the border of upper
and lower uterine segments becomes visible and/or palpable
during labour. It is usually seen as a depression across the
abdomen at about the level of the umbilicus. This is a late sign.
The uterus may stop contracting especially in primigravidas
Signs of obstruction in Vaginal examination include:
Oedema of the vulva present, especially if the woman has been
pushing for a long time.
Foul smelling - meconium stained liquor
Absence of amniotic fluid (fluid has already drained away)
Catheterization will produce concentrated urine which may
contain blood
Hot and dry vagina
Cont…………….
Oedema of the cervix.
Incomplete dilatation of the cervix
Large caput succedaneum can be felt
May palpate a severely moulded head, or a shoulder
presentation or prolapsed arm.
Partograph reading
Examination of the partograph may reveal:
Foetal heart rate of more than 160/minute or less than
120/minute indicating foetal distress
Cont…………
Foul smelling meconium-stained liquor
Severe moulding
Severe caput formation
The rate of cervical dilatation slow or remains static in spite of
strong contraction
Maternal tachycardia and pyrexia
Scanty urine with ketonuria.
Management of Obstructed labour
a) Resuscitation of the Mother
Perform a rapid assessment of the airway, breathing and
circulation and manage as appropriate.
b) Rehydrate the patient
c) Catheterize
d) Give antibiotics
(e.) Deliver the baby or referral
Deliver the baby
Cephalo-pelvic disproportion:
If cephalo-pelvic disproportion is confirmed, delivery should be
by caesarean section
If the fetus is dead: - delivery should be by craniotomy - if this is
not possible, delivery should be by caesarean section.
Obstruction:
If the fetus is alive, the cervix is fully dilated and the head is at 0
station or below, deliver by vacuum extraction.
Cont ………..
If the fetus is alive and the cervix is fully dilated and there is
evidence of or indication for symphysiotomy for relatively minor
obstruction (if safe caesarean section is not possible) and the
fetal head is at -2 station, then delivery should be by
symphysiotomy and vacuum extraction.
If the fetus is alive but the cervix is not fully dilated or if the fetal
head is too high for vacuum extraction, referral should be made
immediately for delivery by caesarean section.
If the fetus is dead: - delivery should be by craniotomy - if this is
not possible, delivery should be by caesarean section.
Complications of obstructed labour
1.Maternal complications
Maternal death
Chorioamnionitis
Uterine rupture
Obstetric fistula
Puerperal sepsis
Neurological injury e.g. foot drop
Spontaneous symphsiotomy and/or osteitis pubis
Foetal complications
Intrauterine foetal death
Foetal distress
Foetal injury
Birth asphyxia
Neonatal sepsis
Factors associated with obstructed labour
Childhood malnutrition leading to contracted pelvis
History of previous still birth, or previous prolonged labour
Young age of mother (under 17 years)
Female genital mutilation/cutting
Some medical illnesses like diabetes mellitus
Pelvic abnormalities following childhood illnesses like polio or
pelvic injuries
