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Obstructed Labor

Obstructed Labor

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Published by: khadzx on Aug 01, 2009
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06/07/2013

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OBSTRUCTED LABOUR – Dr. Wanjala
DEFINITION:-Labour is said to be obstructed when there is absence of progress in the presence of strong uterine contractions.ABSENCE OF PROGRESSFailure of the cervix to dilateFailure of the presenting part of theFetus to descent the birth canalETIOLOGY
MATERNAL CONDITIONS
Contracted pelvis or deformity of the pelvisTurmours of the uterus or ovary – Fibromyomataof lower uterine segmentTumours of rectum or bladderTumours of pelvic bonesPelvic kidneyStenosis of cervix or vaginaCongenital Septum of vaginaContraction ring of uterus
FETAL CONDITIONS
Malposition of the fetus
o
Persistent posterior position of the occiput(very common)
o
Deep transverse arrest of the fetal headMalpresentation of the fetus
o
Breach presentation
o
Face presentation
o
Brow presentation
o
Shoulder presentation
o
Compound presentation
o
Locked twinsCongenital abnormalities of the fetus
o
Large fetus
o
Hydrocephulas
o
Hydrop fetalis
o
Fetal abdominal tumors or ascitesCLINICAL PICTUREThe patient is exhausted by pain and the demands ooverworking the uterus.Pulse rate riseTemperature may also riseThe upper part of the uterus is hardThe lower part (segment) is tender and distended
The line of junction between the two areas is clearlyvisible on the abdominal wall as an oblique groove orfurrow “The retraction Ring”.in obstructed labour the presenting part has becomearrested inspite the strong contractions.There is over thickening of the upper segment andover thinning of the lower segmentThe pathological retraction ring or “bandis ring” isdiagnosticDURING LABOUR
The upper segment actively contracts and retractsWhile the lower segment is relatively passiveThe upper segment contracting almost instantly andretracting becomes hard and its walls become verymuch thicker and shorter as it forces fetus down anddraws the lower segment and cervix up.As times goes on more and more of the fetus isdriven down into the relaxing lower segment whichbecomes dangerously and will rupture if urgent helpis not given.
The uterine contractions usually increase in forceand frequently often accompanied by strong bearingefforts. The mother becomes exhausted usuallyrestless and haggard. Pains are severe andcontinuous and her tongue and lips becomes dry anddiscoloured; the pulse rate is 120/minute or over.The temperature also rises.
Obstruction always occurs in the cavity or just belowthe pelvic bring serious obstruction at the pelvicoutlet is uncommon. Death of the fetus resultscompression of the placental site circulation.The vagina and vulva are oedematous and the birthcanal feels hot and dry. The oedematous cervix maybe felt below the presenting part and a large caputand marked moulding of cranial bones are felt.Cephalopelvic disproportionA large pelvis may be inadequate for a very largebaby.A small baby can negotiate a small pelvisExtreme cases of cephalopelvic disproportion cansometimes be identified as the onset of labour.In others a trial or test of labour is requiredIn a trial of labour the conclusion that labour cannotcontinue normally is reached before full dilatation.MANAGEMENT OF OBSTRUCTED L ABOURIV line for Rehydration
o
(a)X match blood
o
(b)Haemogram
o
(c)Urea/ElectrolyteCatheterize the bladder if the urine is blood stained– remember to have continuous bladder drainage for10 days postnatally.Arrange for delivery of the baby by c/s to relieve theobstruction.Give antibiotics – broadspectrum.
 
RUPTURE OF THE UTERUS 1
Position of the ruptureCommonly occurs obliquely at the junction of theupper and lower uterine segments.Occasionally the uterus splits vertically through thelateral point of uterine vessels.Rapture Of The Uterus Can Be Considered At Three Periods
o
Rupture of the uterus during pregnancyOccur in uterus previous scar, especiallyclassical i.e. previous c/s or hysterotomyPrevious perforation of the uterus by an IUCDthis leaves weak area of scarPrevious myomectomy scar
o
Rupture of the uterus during ordinary labourMisuse of oxytocic drugsHigh parityCervical scarring after amputation of uterus orcone biopsyUnrecognized injury to the uterine wall due toprevious deliveryManual removal of placentaFetal death in the uterus
o
Rupture Of The Uterus After Protracted LabourCommon predisposing causes includes:-
Cephalepelvic disproportion
Malpresentation
HydrocephalusTrauma from unskilled attempts at deliveryClassical Symptoms and Signs.Feeling of something giving wayCessation of uterine contractionsAlteration in the shape of the abdominal swellingHaemorrhage and collapse
Epidural block may mask the symptomsFetal parts may be much more palpated after thefetus has been extruded into peritoneal cavityThree chief causes of death are:-HaemorrhageShockSepsisCoexisting complications toxaemia or anaemia may becontributory factorsMANAGEMENT OF RUPTURED UTERUSIV line for rehydration
Resuscitate the patientBlood for urgent Haemogram, Urea and Electrolytesand Group Xmatch blood
Prepare for laparatomy. At laboratory two optionsmay be looked:-1.After delivery of the fetus who may be dead or aliveand the placenta. You may proceed to repair theuterus .2.Or do subtotal hysterectomyClean the peritoneal cavity with warm saline to removemeconium.
RUPTURE OF THE UTERUS 2
Rupture of the Uterus is a dangerous complication of pregnancy.INCIDENCE
The reported incidence varies from 1:93confinements to 1:8741The average is around 1:2000 Increase of theincidence may be blamed on :-(i)more frequent use of cesarean section scarreduterus(ii)careless administration of oxytocic drugs(iii)inadequate professional care during labour(iv)none-recognition of an obstructed labourTYPES OF RUPTURE(I)Complete rupture - when all the layers of theuterus(II)Incomplete rupture - whole myomectrium Butperitoneum covering the uterine remains intact(III)The Serosa and part of the external myomectriumare torn but laceration does not extend into the cavitySITE AND TIME OF THE RUPTURETears that take place during pregnancy are moreoften in the upper segment of the uterus, at the siteof previous operation or injuryDuring labour the rupture is usually in the lowersegment - may extend into the uteririe vessels -causing profuse haemorrhageTears in the anterior or posterior walls of the uterususually extends transversely or obliquely.Rupture of the uterus may occur during pregnancy,normal labour or difficult labour or may followlabour. Those happening before onset of labour areusually dehiscences of cesarean section scarsCLASSIFICATION1. Spontaneous Rupture of the Normal Uterus
Occur during labour
More common in the lower segment of the uterus
Result of mismanagement
Etiologic Factors
o
Multipavity
o
Cephalopelvic disproportion
o
Abnormal presentation (brow, breach,transverse lie)
o
Improper use of oxytocin
 
2.Traumatic Rupture
Caused by ill adversed and poorly excecuted operativevaginal deliveries
Etiologic Factors
o
Version and Extraction
o
Difficult forces operation
o
Forceful breech extraction
o
Craviotomy
o
Excessive manual pressure on fundus of theuterus3.Postcesarean Rupture
most common may occur before or during labour
Upper segment scars rupture more often than lowersegment incisions. There is no accurate way of predicting the behaviour of a uterine scar. All cesareansection scars present a hazard.4.Rupture Following Trauma other than cesarean
Previous myomectomy
Too vigorous curettage
Perforation during curettage
Mannual removal of an adherent placenta
Hydalidiform mole
Cornual resection for ectopic pregnancy
Hysterotomy5.Silent Bloodless Dehiscence of a previous cesarean scar
A complication of lower segment cesarean incisionspart or all of incision may be involved
Usually peritoneum of the is intact
these windows are due to failure of the originalincision to healCLINICAL PICTUREThis variable and depends on many factors.
Time of occurrence
Cause of rupture
Degree of the rupture (Complete or incomplete)
Position of the rupture
Extend of rupture
Amount of intraperitoneal spill
Size of the blood vessels involved and amount of bleeding
Complete or partial extrusion of the fetus and placentafrom the uterus
Degree of retraction of the myometrium
General condition of the patientOn clinical basis there are four groups:-1)Silent or Quiet rupture
A rising pulse pallor and slight vaginal bleeding
Patient complains of some pains
Contractions may go one , Cervix fails to dilateUsually associated with scar of previous cesarean section2)Usual Variety
Picture develops over period of a few hours, signsand Symptoms
Abdominal pain
Vomiting
Faintness
Vaginal bleeding
Rapid pulse rate
Pallor
Tenderness on palpation
Absence of the fetal heart
Hypotension and shock3)Violent Rupture
Is apparent almost immediately
Usually a hard uterine contraction is followed bysensation of something having given way and a sharppain in the lower abdomen
Contractions Cease
Patient becomes anxious
There is change in the character of pain
Fetus may be palpated easily presenting part nolonger at the pelvic Orim
Fetal movements cease
Fetal heart not heard
Shock ------ complete collapse4)Rupture with delayed diagnosis
Condition not diagnosed until patient is in a processof gradual deterioration
Unexplained anaemia
A palpable haematoma develops in the broadligament
Signs of peritoneal irritation
Patient may go into shock, either gradually orsuddenly e.g. when haematoma ruptures
Diagnosis may be made at autopsyDIAGNOSIS
Easy diagnosis with classical picture
In atypical cases, the diagnosis may be difficult
A high suspicion index is important
Palpatory findings may be pathognomonic
Fetal heart beat absent in most cases
Abdominal scan may show fetus lying in the peritonealcavity with uterus to one side.TREATMENT
Must be prompt in keeping with patients condition
Resuscitation
Laparotomy performed and bleeding controlled as quicklyas possibleMATERNAL MORTALITY

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