OBSTRUCTED

LABOUR
Definition
Obstructed labor is one where in spite of good uterine contractions, the
progressive descent of the presenting part is arrested due to
mechanical obstruction.
Causes
1. Fault in the passage
• Bony: Cephalopelvic disproportion and contracted
pelvis.
• Soft tissue obstructions: cervical dystocia, cervical or
broad ligament fibroid or impacted ovarian tumor
2. Fault in the passenger
• Transverse lie
• Brow presentation
• Congenital malformations of the fetus—hydrocephalus, fetal ascites
• Big baby, occipitoposterior position
• Compound presentation
• Locked twins.
Anatomical changes
• Uterus
 There is gradual increase in intensity, duration and frequency of uterine
contraction. The relaxation phase decreases & develops tonic contraction. But
retraction continues. A circular groove encircling the uterus is formed
between the active upper segment and the distended lower segment, called
Bandl’s ring.
 In primigravidae, further retraction ceases in response to obstruction and
labor comes to a stand still—a state of uterine exhaustion.
 But in multiparae, retraction continues with progressive circumferential
dilatation and thinning of the lower segment. There is progressive rise of the
Bandl’s ring, moving nearer and nearer to the umbilicus and ultimately, the
lower segment ruptures
• Bladder: The bladder becomes an abdominal organ and due to
compression of urethra between the presenting part and symphysis
pubis, the patient fails to empty the bladder. The bladder walls get
traumatized, which may lead to blood stained urine. The base of the
bladder and urethra, which are nipped in between the presenting part
and symphysis pubis, may undergo pressure necrosis. The devitalized
tissue becomes infected and later on may slough off resulting in the
development of genitourinary fistula.
Effects on mother
• Immediate
 Exhaustion due to constant agonizing pain and anxiety
 Dehydration
 Metabolic acidosis due to accumulation of lactic acid and ketones
 Genital sepsis
 Rupture of the uterus which may be spontaneous in multiparae or may be traumatic
following instrumental delivery
 PPH and shock may be due to atonic uterus
• Remote
 genitourinary fistula or rectovaginal fistula
 vaginal atresia
 secondary amenorrhea following hysterectomy or due to Sheehan’s syndrome
Effects on foetus
• Asphyxia results from tonic uterine contraction that interferes with
the uteroplacental circulation or due to cord prolapse, especially in
shoulder presentation
• Acidosis due to fetal hypoxia and maternal acidosis
• Intracranial hemorrhage
• Infection
• All these lead to increased perinatal loss.
Clinical features
• The patient is in agony from severe and continuous pain.
• Features of exhaustion and ketoacidosis
• On abdominal examination
 uterus is smaller in size, tense and tender.
 Fetal parts are neither well defined, nor is the fetal heart sound audible.
 Distended bladder
• On vaginal examination
 dry and edematous vagina with offensive and purulent discharge
 Cervix is almost fully dilated
Treatment
• Principle of treatment
 Relieve obstruction → combat dehydration & ketoacidosis → control sepsis
• Preliminary treatment
 Fluid electrolyte balance and correction of dehydration
 Vaginal swab - culture and sensitivity test
 Blood sample - group and cross matching
 Antibiotic - ceftriaxone 1g iv
 Metronidazole iv for anaerobic infection
• Obstetric management
 Vaginal delivery - for dead foetus, destructive operation is done. If the head is low down and
vaginal delivery is not risky, forceps extraction may be done in a living baby.
 Cesarean section - if case detected early, c-section gives best results. But in late cases, even c-
section cannot save the baby. The baby is either delivered stillborn or dies due to neonatal sepsis.
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