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OBSTRUCTED LABOUR – Dr.

Wanjala
DURING LABOUR
DEFINITION:- • The upper segment actively contracts and retracts
Labour is said to be obstructed when there is absence of While the lower segment is relatively passive
progress in the presence of strong uterine contractions. • The upper segment contracting almost instantly and
retracting becomes hard and its walls become very
ABSENCE OF PROGRESS much thicker and shorter as it forces fetus down and
• Failure of the cervix to dilate draws the lower segment and cervix up.
• Failure of the presenting part of the • As times goes on more and more of the fetus is
• Fetus to descent the birth canal driven down into the relaxing lower segment which
becomes dangerously and will rupture if urgent help
ETIOLOGY is not given.
MATERNAL CONDITIONS • The uterine contractions usually increase in force
• Contracted pelvis or deformity of the pelvis
and frequently often accompanied by strong bearing
• Turmours of the uterus or ovary – Fibromyomata
efforts. The mother becomes exhausted usually
of lower uterine segment
restless and haggard. Pains are severe and
• Tumours of rectum or bladder
continuous and her tongue and lips becomes dry and
• Tumours of pelvic bones
discoloured; the pulse rate is 120/minute or over.
• Pelvic kidney
The temperature also rises.
• Stenosis of cervix or vagina
• Obstruction always occurs in the cavity or just below
• Congenital Septum of vagina
the pelvic bring serious obstruction at the pelvic
• Contraction ring of uterus
outlet is uncommon. Death of the fetus results
compression of the placental site circulation.
FETAL CONDITIONS
• The vagina and vulva are oedematous and the birth
• Malposition of the fetus
canal feels hot and dry. The oedematous cervix may
o Persistent posterior position of the occiput
be felt below the presenting part and a large caput
(very common)
and marked moulding of cranial bones are felt.
o Deep transverse arrest of the fetal head

Cephalopelvic disproportion
• Malpresentation of the fetus
• A large pelvis may be inadequate for a very large
o Breach presentation
baby.
o Face presentation
• A small baby can negotiate a small pelvis
o Brow presentation • Extreme cases of cephalopelvic disproportion can
o Shoulder presentation sometimes be identified as the onset of labour.
o Compound presentation • In others a trial or test of labour is required
o Locked twins • In a trial of labour the conclusion that labour cannot
continue normally is reached before full dilatation.
• Congenital abnormalities of the fetus
o Large fetus MANAGEMENT OF OBSTRUCTED LABOUR
o Hydrocephulas
o Hydrop fetalis • IV line for Rehydration
o Fetal abdominal tumors or ascites o (a) X match blood
o (b) Haemogram
CLINICAL PICTURE o (c) Urea/Electrolyte
• The patient is exhausted by pain and the demands of • Catheterize the bladder if the urine is blood stained
overworking the uterus. – remember to have continuous bladder drainage for
• Pulse rate rise 10 days postnatally.
• Temperature may also rise • Arrange for delivery of the baby by c/s to relieve the
• The upper part of the uterus is hard obstruction.
• The lower part (segment) is tender and distended • Give antibiotics – broadspectrum.
• The line of junction between the two areas is clearly
visible on the abdominal wall as an oblique groove or
furrow “The retraction Ring”.
• in obstructed labour the presenting part has become
arrested inspite the strong contractions.
• There is over thickening of the upper segment and
over thinning of the lower segment
• The pathological retraction ring or “bandis ring” is
diagnostic
• Prepare for laparatomy. At laboratory two options
may be looked:-
1. After delivery of the fetus who may be dead or alive
RUPTURE OF THE UTERUS 1 and the placenta. You may proceed to repair the
uterus .
Position of the rupture 2. Or do subtotal hysterectomy
• Commonly occurs obliquely at the junction of the
upper and lower uterine segments. Clean the peritoneal cavity with warm saline to remove
• Occasionally the uterus splits vertically through the meconium.
lateral point of uterine vessels.
RUPTURE OF THE UTERUS 2
Rapture Of The Uterus Can Be Considered At Three Periods Rupture of the Uterus is a dangerous complication of
o Rupture of the uterus during pregnancy pregnancy.
• Occur in uterus previous scar, especially
classical i.e. previous c/s or hysterotomy INCIDENCE
• Previous perforation of the uterus by an IUCD • The reported incidence varies from 1:93
this leaves weak area of scar confinements to 1:8741
• Previous myomectomy scar • The average is around 1:2000 Increase of the
incidence may be blamed on :-
o Rupture of the uterus during ordinary labour (i) more frequent use of cesarean section scarred
• Misuse of oxytocic drugs uterus
• High parity (ii) careless administration of oxytocic drugs
• Cervical scarring after amputation of uterus or (iii) inadequate professional care during labour
cone biopsy (iv) none-recognition of an obstructed labour
• Unrecognized injury to the uterine wall due to
previous delivery TYPES OF RUPTURE
• Manual removal of placenta (I) Complete rupture - when all the layers of the
• Fetal death in the uterus uterus
(II) Incomplete rupture - whole myomectrium But
o Rupture Of The Uterus After Protracted Labour peritoneum covering the uterine remains intact
• Common predisposing causes includes:- (III) The Serosa and part of the external myomectrium
 Cephalepelvic disproportion are torn but laceration does not extend into the cavity
 Malpresentation
 Hydrocephalus SITE AND TIME OF THE RUPTURE
• Trauma from unskilled attempts at delivery • Tears that take place during pregnancy are more
often in the upper segment of the uterus, at the site
Classical Symptoms and Signs. of previous operation or injury
• Feeling of something giving way • During labour the rupture is usually in the lower
• Cessation of uterine contractions segment - may extend into the uteririe vessels -
• Alteration in the shape of the abdominal swelling causing profuse haemorrhage
• Haemorrhage and collapse • Tears in the anterior or posterior walls of the uterus
• Epidural block may mask the symptoms usually extends transversely or obliquely.
• Rupture of the uterus may occur during pregnancy,
• Fetal parts may be much more palpated after the
normal labour or difficult labour or may follow
fetus has been extruded into peritoneal cavity
labour. Those happening before onset of labour are
usually dehiscences of cesarean section scars
Three chief causes of death are:-
• Haemorrhage
CLASSIFICATION
• Shock
1. Spontaneous Rupture of the Normal Uterus
• Sepsis
Coexisting complications toxaemia or anaemia may be • Occur during labour
contributory factors • More common in the lower segment of the uterus
• Result of mismanagement
MANAGEMENT OF RUPTURED UTERUS • Etiologic Factors
o Multipavity
• IV line for rehydration o Cephalopelvic disproportion
• Resuscitate the patient o Abnormal presentation (brow, breach,
• Blood for urgent Haemogram, Urea and Electrolytes transverse lie)
and Group Xmatch blood o Improper use of oxytocin
Usually associated with scar of previous cesarean section

2) Usual Variety
2. Traumatic Rupture ♦ Picture develops over period of a few hours, signs
• Caused by ill adversed and poorly excecuted operative and Symptoms
vaginal deliveries ♦ Abdominal pain
• Etiologic Factors ♦ Vomiting
o Version and Extraction ♦ Faintness
o Difficult forces operation ♦ Vaginal bleeding
o Forceful breech extraction ♦ Rapid pulse rate
o Craviotomy ♦ Pallor
o Excessive manual pressure on fundus of the
♦ Tenderness on palpation
uterus
♦ Absence of the fetal heart
♦ Hypotension and shock
3. Postcesarean Rupture
• most common may occur before or during labour
3) Violent Rupture
• Upper segment scars rupture more often than lower
♦ Is apparent almost immediately
segment incisions. There is no accurate way of
♦ Usually a hard uterine contraction is followed by
predicting the behaviour of a uterine scar. All cesarean
section scars present a hazard. sensation of something having given way and a sharp
pain in the lower abdomen
4. Rupture Following Trauma other than cesarean ♦ Contractions Cease
• Previous myomectomy ♦ Patient becomes anxious
• Too vigorous curettage ♦ There is change in the character of pain
• Perforation during curettage ♦ Fetus may be palpated easily presenting part no
• Mannual removal of an adherent placenta longer at the pelvic Orim
• Hydalidiform mole ♦ Fetal movements cease
• Cornual resection for ectopic pregnancy ♦ Fetal heart not heard
• Hysterotomy ♦ Shock ------ complete collapse

5. Silent Bloodless Dehiscence of a previous cesarean scar 4) Rupture with delayed diagnosis
• A complication of lower segment cesarean incisions ♦ Condition not diagnosed until patient is in a process
part or all of incision may be involved of gradual deterioration
• Usually peritoneum of the is intact ♦ Unexplained anaemia
• these windows are due to failure of the original ♦ A palpable haematoma develops in the broad
incision to heal ligament
♦ Signs of peritoneal irritation
CLINICAL PICTURE ♦ Patient may go into shock, either gradually or
This variable and depends on many factors. suddenly e.g. when haematoma ruptures
• Time of occurrence ♦ Diagnosis may be made at autopsy
• Cause of rupture
• Degree of the rupture (Complete or incomplete) DIAGNOSIS
• Position of the rupture • Easy diagnosis with classical picture
• Extend of rupture • In atypical cases, the diagnosis may be difficult
• Amount of intraperitoneal spill • A high suspicion index is important
• Size of the blood vessels involved and amount of bleeding • Palpatory findings may be pathognomonic
• Complete or partial extrusion of the fetus and placenta • Fetal heart beat absent in most cases
from the uterus • Abdominal scan may show fetus lying in the peritoneal
• Degree of retraction of the myometrium cavity with uterus to one side.
• General condition of the patient
TREATMENT
• Must be prompt in keeping with patients condition
On clinical basis there are four groups:-
1) Silent or Quiet rupture • Resuscitation
• Laparotomy performed and bleeding controlled as quickly
♦ A rising pulse pallor and slight vaginal bleeding
as possible
♦ Patient complains of some pains
♦ Contractions may go one , Cervix fails to dilate MATERNAL MORTALITY
• Reported maternal death rate ranges from 3 to 40%
• Spontaneous rupture of the uterus is responsible for the
largest number of deaths. The lowest death rate is
associated with post cesarean ruptures.
• Main causes of death are
o shock and blood loss
o Sepsis and paralytic ileus

Prognosis for the mother depends:-


• Prompt diagnosis and treatment (the interval between
rupture and surgery being important)
• The amount of haemorrhage and the availability of blood
• Sepsis
• The type and site of the rupture

Mortality can be lowered by:-


• Early diagnosis
• Immediate laparotomy
• Blood transfusion
• Antibiotic
• Reduction or elimination of traumatic operative
deliveries
• Better management of prolonged or obstructed labour

FETAL MORTALITY
• Fetal mortality is high ranges 30 – 85%
• Most fetuses die from separation of the placenta
• Fundal rupture where the fetus has been extruded into
the abdominal cavity has highest mortality

PREGNANCY AFTER RUPTURE OF THE UTERUS


The risk of repeat rupture is:-
• Least when the scar is confined to the lower segment
• Greater if the scar extends into the upper segment
• Greatest in women whose original rupture occurred
following cesarean section

MANAGEMENT
Cesarean section should be performed before the scar is
subjected to stress:-
• Scar in lower segment: C/s at 38 weeks
• Scar in upper segment: C/s at 36 weeks.