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Obstructed labor is one of the five leading causes of maternal mortality in addition to varying maternal and fetal/neonatal morbidity and mortality.
A failure of labor management.
Almost nonexistent in developed countries but still quite common in developing ones.
Definition
Obstructed labor is when labor has come to a complete halt in the presence of adequate uterine contractions due to mechanical factors and delivery is not possible without assistance.
Note that this is not the same as Cephalopelvic disproportion in which delivery is still possible
Maternal factors:
Contracted pelvis [reduction in all pelvic dimensions] from:
- Inadequate development- malnutrition, child marriage.
- Diseases: childhood rickets, poliomyelitis
- Abnormal pelvic shapes: Android, Anthropoid, Platypelloid.
Pelvic tumors: uterine fibroid, ovarian cyst, horse-shoe shaped kidneys.
Cervical stenosis with inability of the cervix to dilate due to scarring from previous surgeries like cone biopsy, cervical amputation, cauterization of the cervix.
Vaginal abnormalities- vaginal septum.
Fetal factors:
Malpositioning- e.g. Occipito-posterior
Malpresentation- face [mentoposterior], brow shoulder, compound presentation, shoulder dystocia, breech with deflexed head, impaction or extended arms.
Congenital abnormalities- hydrocephalus
Conjoint twin
Fetal tumours
Fetal-maternal factors:
Cephalopelvic disproportion
History
- History of prolonged labor, usually with an unskilled birth attendant or misdiagnosis by a skilled personnel.
- Poor antenatal attendees.
- Pointers to some causes e.g. poliomyelitis teenage/childhood pregnancy.
Examinations
- Usually anxious, in pain, some have not slept for days.
- Dehydration- dry, furred tongue, exhaustion
- Fever
- Abdomen- contractions, fetal lie, presentation, poor descent, FHR abnormalities,
- Bladder- becomes palpable, catheterization maybe impossible, or blood stained urine
- Pelvic exam- edematous vulva, offensive vaginal discharge, ?bleeding, cervix may or may not be fully dilated, severe caput and moulding, station is usually high.
History- onset /duration of labor, history of augmentation, use of oxytocics
Examination- general state, hydration status, fever, pallor, pulse rate, BP,
Abdomen- lie, presentation, contractions, descent, FHR, estimated fetal weight
Pelvic exam- state of vulva, cervical dilatation, station, severe caput, severe moulding, pelvic assessment
Principles of management
- Resuscitation
- Correct dehydration- intravenous fluid
- Samples for investigation- PCV, Urinalysis, E/U/Cr, urine m/c/s. blood group & crossmatch
- Antibiotics- broad spectrum to take care of gram positive and gram negative bacteria and also anerobes
- Urethral catheterization
- Relieve the obstruction promptly
Fluid and electrolyte imbalance
Require rapid correction
Correct dehydration- N/Saline/ringers lactate
Do not forget calorie deficit- glucose infusion
Some may need as much as 3 liters of IVF
Control infection
Should be immediate
Intravenous Broad spectrum antibiotics
- Ampicillin/metronidazole
- Ceftriaxone/metronidazole
- Augmentin/metronidazole
- Add gentamicin once urinary output has been shown to be adequate
Urethral catheterization
To empty the bladder, get samples for investigation
Monitor urinary output hourly
Rest the bladder and promote recovery
Prevention of fistula formation
May be impossible in cases of impaction.
Empty the stomach
This may be necessary especially in cases of prolonged obstructed labor where the patient has developed ileus.
Also important in preventing aspiration during anesthesia (aspiration pneumonitis/Mendelson syndrome)
Treatment
Prompt relief of the obstruction.
Depends on:
- The state of the fetus- dead or alive
- The state of the cervix
- The skill of the doctor
- The facilities available
- The desire of the woman
Abdominal operations
Emergency cesarean section.
Commonest procedure of choice
- If fetus is alive
- If due to cervical factor and cervix is not fully dilated irrespective of the state of the fetus.
Vaginal operations
Instrumental vaginal delivery- especially in deep transverse arrest where rotation is needed. Can be forceps or vacuum delivery.
Symphysiotomy- now outdated in modern obstetric practice due to its multiple complications.
Destructive operations-
- Fetus must be dead, skillful person must be available, cervix must be fully dilated, no evidence of uterine rupture.
- Examples of such operations include—
- Craniotomy- cephalic dead fetus with descent not more than 3/5.
- Decapitation- for transverse or oblique lie
- Cleidotomy- for impacted shoulders by fracturing both clavicles.
- Embryotomy- e.g. fetus with abdominal tumors.
Care after destructive operation
- Evaluate for genital tract injuries and repair any if noted.
- Continuous bladder drainage for at least 10 days.
- Broad spectrum antibiotics
Maternal
- Uterine rupture
- PPH
- Obstetric fistula
- Puerperal sepsis
- Osteitis pubis
- Foot drop
- Acquired gynetresia
- Menstrual abnormalities
- Infertility
Fetal
- Fetal distress
- Birth asphyxia
- IUFD
- Neonatal sepsis
- HIE
- Cerebral palsy
- Intracranial hemorrhage
- Neonatal death
Pathophysiology of complications
Lactic acidosis from prolonged uterine and skeletal muscle contractions.
No calorie, so fat metabolism leading to ketones formation.
Dehydration worsens the acidotic state
Potassium is mobilized from cells to balance the equilibrium and this causes ileus.
Signs of acidosis- tachycardia, tachypnea, pyrexia.
Foot drop
A peripheral nerve injury to nerves supplying the lower limbs.
Mainly paralysis of muscles for dorsiflexion of the foot, eversion the foot or extension of the toes.
Prolonged pressure on the lumbosacral trunk by the fetal head.
Stretch injury to sciatic nerve by prolonged hyper flexion of the thighs.
Occurs as lumbo-sacral trunk passes anterior to sacro-iliac joint. L4 &L5 are closest to the bone, so they are mostly affected.
- Tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneous longus and brevis.
Manifest as failure of dorsiflexion and stamping of the foot.
Treatment- physiotherapy, some may need braces or corrective surgery.
General:
- Improvement in socioeconomic status
- Good nutrition
- Childhood immunization
- Avoid harmful cultural practices
- Encourage antenatal care and delivery in hospitals
Specific measures:
- Proper evaluation during antenatal period – rule out pelvic abnormalities/contraction, rule out fetal macrosomia.
- Monitor labor with Partograph
- Presence of skilled birth attendants at deliveries.
Obstructed labor is one of the conditions that tells us that we are not doing enough, it is a failure of our obstetric care program.
IT MUST NOT OCCUR AGAIN.
Good labor management and prompt intervention is the simplest mode of prevention
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