OBSTRUCTED LABOUR

Prolonged labour may precede obstructed labour especially in a primigravida and this can
be identified by monitoring labour progess on a partograph.
Definition
Obstructed labour is defined as the condition when the foetus cannot pass through the pelvis
inspite of good uterine contractions due to mechanical obstruction.
Causes of Obstructed Labour
Causes of obstructed labour are enumerated below:
(a) Cephalopelvic disproportion (CPD)
Safe passage of fetal head through the pelvis is difficult or impossible. CPD cannot be
diagnosed before 37 weeks as head would not have reached birth size before that period.
CPD could be due to
 Fetal head is large in comparison to pelvis
 Pelvis is small with normal size fetus
 Combination of small pelvis and large fetus.
With borderline CPD, the problem could be overcome during labour. Moulding of fetal head
(skull) and “give of pelvis” (relaxation of pelvic joints) enable vaginal delivery. With moderate
CPD, about 50% will need operative delivery. With severe CPD, all will need operative delivery
(100%).
(b)Abnormal presentations and position
 Occipito posterior position (10% cases) and deep transverse arrest
 shoulder
 brow
 face - mento posterior position
 breech - large fetus
(c) Fetal causes
 Abnormal presentation – Brow presentation, shoulder lie, compound presentation
 Congenital anomalies - Hydrocephalus, fetal ascitis, sacrococcygeal tumours, conjoined
twins, locked twins
 Big baby, occipitoanterior position
(d) Abnormalities of soft tissue obstruction
 Pelvic tumours such as fibroid, ovarian tumours
  Undilatable stenosis of cervix
Risk Factors for obstructed labour
 Young age < 17 years (pelvis is not fully developed) .
 Grand multigravida - (abnormal presentations common, large babies with increasing
parity, subluxation of sacroiliac joints pushing the sacral promontory forwards affecting
the AP diameter of pelvic inlet)
 Short height < 145 cms (usually associated with malnutrition and small pelvis)
 Previous caesarean section, still births and previous prolonged labour .
 Diseases such as
 Rickets
 Osteomalacia
 Poliomyelitis
 Tuberculosis of hip in childhood
 Injuries of hips, pelvis, lower limbs affecting pelvis
 Community risk factors
 No antenatal care - causes not diagnosed antenatally
 Staff untrained to recognize obstructed labour (Partogram not used).
 Long distance involved in obtaining skilled help
 Lack of transport and communication
 Traditional beliefs and practices regarding prolonged/obstructed labour
 Custom of early marriage
 Failure to act on risk factors
 Delay in referral to higher level of care for caesarean sections
 Community distrust of health care personnel.
Course of Labour
1) Early Developing Stage:
 There is misfit of presenting part to the brim and this hinders the descent of the
presenting part
 Membranes rupture early
 The presenting part is not well applied to the cervix and cervix dilates slowly or there is
no further cervical dilatation.
 Even when cervix is well dilated, it is not closely applied to presenting part and
  Hangs loose like a thick curtain. Cervix becomes edematous as woman is trying to push
down.
 In vertex presentation, a large caput succedenum is formed and moulding is excessive.
If the diagnosis is not made at this stage and early intervention instituted to deliver the
woman, she will progress to late fully developed obstructed labour.
2) Late Fully Developed Stage
 The woman looks exhausted and shows signs of maternal exhaustion. She is dehydrated,
pulse is rapid, temperature may be raised, respiratory rate may be increased.
 There is edema of vulva.
 Abdominal examination will reveal distended guts (due to electrolyte imbalance). The
upper part of uterus (upper segment) is hard, uterine wall is closely applied to the fetus as
all liquor amnii has drained out. The foetal parts mobility is restricted and fetal outline
becomes obscure.
 Bandls' ring become visible (junction of thick upper segment and thin lower segment is
well demarcated and seen as a groove between the two segments) and may rise to the
level of umbilicus.
Diagnosis
i) History - History may reveal the following points :
 Age
 Primigravida
 History of previous caesarean section, difficult forceps delivery with still birth
 Previous still birth/still births, prolonged labour
 Early rupture of membranes
 Pains may have been good at first and stopped now
ii) Clinical findings
In early cases: Abdominal exam will reveal stretching of lower uterine segment
and edematous drawn up bladder. Contractions are hypertonic. The presenting part is not
engaged. There may be fetal distress. In vertex presentation, a large caput and excessive
moulding may be seen. Though the scalp may be seen at the introitus, both poles of head
are felt on abdominal palpation.
In late cases:
General examination
  Woman looks exhausted
 Dehydration—tongue dry, fast pulse, ketonuria
 Fever
 Vulval edema
Abdominal examination
 Head felt above brim (major part) or abnormal presentation.
 Frequent strong uterine contractions
 Uterus is tonically contracted and moulded over the fetus (no
relaxation of uterus felt)
 Bandls’ ring may be seen near umbilicus and can be palpated
(normally the junction between upper segment and lower segment
is not felt/seen during labour. In normal labour it is called
retraction ring).
 Gut is distended
 Bladder is distended (the woman is unable to pass urine)
Vaginal examination
 No liquor is present
 Foul smelling meconium may be present
 Edema of vulva and vagina
 Vagina is hot and dry
 Edema of cervix, it is not well applied over presenting part and
may hang loose like a thick curtain.
 Cervix may be partially or fully dilated
 A large caput succedaneum is felt
iii) Partograph Readings
o A prolonged first stage of labour with secondary arrest
o A prolonged second stage
o Poor cervical dilation inspite of strong contractions
o Fetal distress FHR < 120/minute
o Meconuim +(? Foul smelling)
Management
i) Rehydrate the patient - Prevent and treat dehydration and ketosis.
  Start an IV line
 Use a large needle (No. 18) or cannula
 Give Ringer lactate or dextrose saline.
ii) Start antibiotics - The aim is to prevent sepsis.
Select broad spectrum antibiotic. Infection is due to multiple bacteria and flora - Gram
+ve, gram -ve and anaerobic Add metrogyl - (Penicillin with Gentamycin and metrogyl), Give
IV or 1M every 6 hours
iii) Deliver the baby
Complications of Obstructed Labour
Maternal
 Increase in operative delivery (caesarean section, forceps and vacuum deliveries)
 Rupture uterus
 PPH - atonic and traumatic
 Puerperal sepsis
 Urinary fistulas (VVF, UVF)
Fetal
 Increase in still births and neonatal deaths
 Asphyxia
 Intracranial hemorrhage
 Delayed complications - delayed milestones, convulsive disorders, mental retardation etc.
Prevention
1) Antenatal
 Risk factors mentioned earlier should be identified during antenatal care.
 Contracted pelvis and CPD and abnormal presentations are detected
2) Intranatal
 Prolonged active phase - Deviation from normal are detected at an early stage and
appropriate management can be instituted
 Non descent of head with good uterine action and satisfactory cervical dilatation indicates
CPD and requires referral.