Obstructed labour

1. Obstructed labour • Definition :- obstructed labour can be define as a labour where there is poor or no progress of labour in spite of good uterine contraction. • Incidence :- 1 -2% of referral cases in developing country.

2. Causes:- • Maternal condition (fault in the passage):- • Contracted pelvis • Abnormal pelvis:- android, anthropoid • Pelvic tumor:- fibroid, ovarian tumor • Tumor of rectum, bladder or pelvic bone. • Abnormality in uterus & vagina:-stenosis in cx. & vagina, contraction ring in uterus, vaginal septum, rigid perineum.

3. Foetal condition (fault in the passenger):- • Macrosomic baby • Malpresentation • Malposition:- popp, transverse lie • Malformed foetus:- hydrocephalus, foetal Ascitis, conjoint twins, cord around the neck. • Locked twins

4. Diagnosis • Partograph will recognize impending obstruction early. If the labour is slow to progress, careful general, abdominal and vaginal examination is necessary. • Woman gives the history of:- -prolong labour and -the labour pain become severe and frequent and -bearing down.

5. Examination:- General examination:- Features of maternal distress i.e. Exhaustion & keto acidosis Dehydration Tachycardia >100/m Raise temperature Scanty urine

6. Abdominal examination :- -The retraction ring (bandl’s ring) is seen and felt between the tonically contracted upper segment of the uterus and the distended , tender and stretched lower segment. • Distended urinary bladder. • FHS shows evidence of foetal distress or even absent.

9. Vaginal examination:- • The vulva usually swollen and edematous. • The vaginal is dry, hot and occasionally offensive and purulent discharge. • The cervix is almost fully dilated or hanging like a curtain. • The presenting part is extremely moulded and jammed in the pelvis. • There is usually large caput formation.

10. Management • Preventive:- • Proper assessment of pregnant woman during ANC. • Regular ANC visit. • Proper assessment in early labour to detect the cause if any. • Partograph have to strictly follow. • Prompt follow appropriate treatment to solve the problems.

11. Curative:- • Immediate management • General management • Obstetric management

12. Immediate management :- Correct maternal dehydration Contraction prevent by tocholytic drugs. Blood sample send for grouping and cross matching.

13. B. General management :- Assessment of vital of mother and general condition. IV fluid to correct dehydration. Broad spectrum antibiotics. Catheterization. Sodium bicarbonate infusion to correct acidosis.

14. C. Obstetric management:- 1. Delivery of foetus:- a. Vaginal delivery:- -(destructive opt.) dead foetus -if head is low and vaginal delivery is not risky, forceps extraction may be done in alive foetus also. b. Caesarean section:- -alive foetus -over distended lower segment with impending rupture even the foetus is dead. 2. Active management of 3rd stage of labour. 3. Continuous bladder drainage for 2-3 days to prevent VVF.

15. Complication • Maternal • Rupture of uterus • VVF • RVF • PPH • Puerperal sepsis • Shock • Maternal death Fetal -intra uterine asphyxia -Intracranial haemorrhage -Neonatal infection -Acidosis -Foetal death

16. Prolong labour

17. When labour tends to be prolonged for more than 18 hours both in primi gravida and multi gravida is called prolonged labour.

18. Causes • Fault in passage • Fault in passenger • Fault in power :- - hypotonic uterine contraction - uncoordinated uterine contraction - Constriction ring • Cervical dystocia

19. Diagnosis History:- Age Parity Duration of labour Duration of membrane rupture Whether the patients was handle outside the hospital Whether she was treated with oxytocic drugs outside the hospital Previous history of difficult labour, instrumental delivery or stillbirth.

20. B. General examination :- Height of patients Dehydration Acetone breath Pallor Raise in temperature Tachycardia Decrease in BP

21. C. Abdominal examination :- Contour of the uterus Presentation & position Tenderness Frequency, intensity & duration of uterine contraction. Lower segment distended or not. Distension of the bladder. Fetal heart sound.

22. Vaginal examination:- • The vulva usually swollen and edematous. • The vaginal is dry, hot and occasionally offensive and purulent discharge. • The cervix is almost fully dilated or hanging like a curtain. • The presenting part is extremely moulded and jammed in the pelvis. • There is usually large caput formation.

23. Management General management :- NPO & i/v fluid start immediately. Bladder evacuation. Parenteral antibiotics. Intake output chart should be strictly maintain. Urine should be examine for albumin & acetone. Blood should be send for grouping and cross matching.

24. B. Obstetric management :- During 1st stage:- Role of oxytocin :- hypotonic uterine contraction Role of sedation :- incase of incordinate uterine contraction, liberal use of inj. Pethidine 75mg and inj. Phenargan 25mg IM may lead to spontaneous correction. Role of ARM:- hypotonic uterine contraction Role of ventouse:- OPP and fetal distress Role of c/s:- contracted pelvis, big baby, mal presentation, mal position, severe fetal distress.

25. B. During 2nd stage:- Role of episiotomy:- rigid perineum Role of forceps:- fetal distress, DTA, POPP, cord prolapse in living baby. Role of ventouse:-DTA, OAP,OPP. Role of c/s:- contracted pelvis, big baby, mal presentation, mal position, severe fetal distress. Role of destructive operation :- craniotomy, decapitation, evisceration.

26. Complications • Maternal:- • Immediately:- • Maternal distress • Increase operative interference • Maternal injury • PPH • Puerperal sepsis • Maternal death • Late:- • Urinary fistula • Vaginal stenosis • Asherman’s syndrome • Secondary infertility • Fetal:- • Immediate:- • -Birth trauma • -Birth asphyxia • Foetal distress • Meconium aspiration syndrome • Still birth • Neonatal death • Late:- • -Cerebral palsy • - Mental retardation