Obstructed Labour
Dr. Mtumweni, MD
Learning Objectives
• By the end of this session, students are
expected to be able to:
• Define obstructed labour
• List causes of obstructed labour
• Describe clinical features of obstructed
labour
• Mention complications of obstructed
labour
• Describe management of a woman with
obstructed labour
Definition of Obstructed Labour
• A term used to indicate a labour/delivery
that progresses slowly, or with difficulty,
when there is no advance of the
presenting part despite strong uterine
contractions.
• When there is true obstructed labor it is
not possible to give birth vaginally, This
will necessitate operative delivery
• Is 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 almost impossible
without assistance.
INCIDENCE
• In the developing countries, the
prevalence is about 1–2% in the referral
hospitals.
Causes of Obstructed Labour
• Obstructed labour has a variety of potential
causes.
• These causes are generally related to the
mechanics of labour and delivery.
1. Foetal Causes (Passenger) presents difficulties
(such as
i. big baby (weight≥4Kg)
ii. hydrocephalous
iii.conjoined twins
iv.malpresentations (breech)
v. abnormal lie (transverse lie)
vi.malpositions (occiput posterior presentation, face
presentation).
vii.Fetal ascites
Fetal ascites Hydrocephalus
Conjoined twins
• Maternal Causes (Passage) presents
difficulties such as a
i. contracted pelvis (Secondary contracted
pelvis may be encountered in multiparous
women).
ii.Cephalopelvic disproportion
iii.pelvic mass (e.g. fibroids situated in the
lower uterine segment).
iv. Soft tissue obstructions
This includes
cervical dystocia
broad ligament fibroid
impacted ovarian tumor
the non-gravid horn of a bicornuate uterus
below the presenting part.
Clinical Features of Obstructed Labour
• Obstructed labour is the neglected or un-
monitored labour which presents with:
Dehydration
Maternal exhaustion and distress
Poor urinary output and blood in urine
Tender lower abdomen
Bandl’s ring (pathological retraction ring)
Foetal distress or foetal demise
Slow dilatation of the cervix and sometimes
swelling
Caput succedaneum
Excessive moulding
Note: obstructed labour can also occur with
monitored labour.
Bandl’s ring
Caput
Caput succedaneum
Caput v/s Cephalohematoma
Complications of Obstructed Labour
• Maternal Complications
Infection – chorioamionitis/puerperal fever,
sepsis, peritonitis
Obstetric fistula
Thrombo-embolism
con't
Ruptured uterus
Postpartum Haemorrhage (PPH)
Paralytic ileus
Electrolyte imbalance, ketonuria
Increased risk of operative delivery
Metabolic acidosis
NOTE: Even if the patient survives, the
following legacies may be left behind:-
Genitourinary fistula or rectovaginal fistula
Variable degree of vaginal atresia
Secondary amenorrhoea following
hysterectomy due to rupture or due to
Sheehan’s syndrome.
Foetal Complications
Body and cerebral birth injury – Birth
Asphyxia
Meconium aspiration syndrome
Convulsions
Jaundice
Neonatal sepsis
Facial Injury
Cephalohaematoma
Intracranial hemorrhage
Management of a Woman with
Obstructed Labour
1. Resuscitation
IV fluids preferably RL or NS (at least 3L IV stat)
2. Antibiotics
Intravenously (IV Ceftriaxone 1g od x 3/7 AND IV
Metronidazole 500mg tds x 3/7)
3. Urethral catheterization to monitor urine
output (Normal urine output is 0.5 - 1 ml/kg/hr)
4. Refer urgently for operative delivery
Retain urethral catheter for 10-14 days
after delivery to encourage healing of the
bladder to prevent Vesico-Vaginal Fistula
(VVF).
Continue antibiotics for seven days
(Metronidazole 400mg PO tds x 5-7 days AND Amoxillin 500 mg PO
tds x 5-7 days or Ampiclox 500mg PO tds x 5-7 days)
Care of the baby after has been born
Resuscitate the baby – suction, respiration
support, oxygenation, assist feeding,
antibiotics, etc.
The decision on the method of delivery
NB:- There is no place of “wait and
watch”, neither any scope of using
oxytocin to stimulate uterine
contraction.
•The clinician must have an ability to
give the timely proper decision on the
method of delivery considering both
the viability of the fetus and to save
the mother.
Vaginal delivery
• Recommended when:-
i. The baby is dead for destructive operation.
ii.If the baby is alive and the head is low
down, but must be assisted by vacuum
or forceps (if appropriate considering
other factors).
NB:- After completion of the delivery and
expulsion of the placenta, exploration of
the uterus and the lower genital tract
should be done to exclude uterine rupture
Cesarean section
• Cesarean section gives the best result if
decided earlier.
• If decided late the baby is either delivered
stillborn or dies due to neonatal sepsis.
Prevention of Obstructed Labour
• Prevention f obstructed labour requires a
multisectoral approach.
• Interventions include:
Prevention of teenage pregnancies
Improved use of focused antenatal care
services
Deliveries in the health facilities with
ability to provide Emergency Obstetric
Care (EmOC)
Use of partogram in labour
• During antenatal detection of the factors
likely to produce prolonged labor (big
baby, small women, malpresentation and
position).
• Intranatal: Continuous vigilance, use of
partograph and timely intervention of a
prolonged labor due to mechanical factors
can prevent obstructed labor.
• Failure in progress of labor in spite of good
uterine contractions for a reasonable
period (2–4 hours) is an impending sign of
obstructed labor.
Scenario
• Ms. E.R. presented to the labour ward with
a history of prolonged active labour.
Suddenly, she stopped experiencing any
more labour-like pain from contractions.
On examination, you find no contractions,
blood pressure 60/40mmHg, pulse rate
100 beats per minute, foetal heart rate
100 per minute and weak. The mother
looks anxiously and her skin feels cold and
moist. The mother is Gravida 8 Para 7 and
the index pregnancy is confirmed to be
twins.
References
• DC Dutta's Textbook of Obstetrics 7th
Edition
• Facilitator guide Obstetrics and
Gynaecology I - Ministry of health and
social welfare 2010
