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OBSTRUCTED LABOUR
2/23/2021 Dr.TADESSE G.
 Outline
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 Definition of obstructed labor

 Significance
 Etiology of OL
 Clinical presentation
 Management of OL
 Complication
 Prevention

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 Obstructed Labor
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 Obstructed Labor is defined as the labor in which

the presenting part of the fetus cannot progress into
the birth canal, despite strong uterine contractions
due to mechanical reason
Incidence
 2- 8% of deliveries in developing countries

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 Significance
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 Obstructed labor is an outcome of neglected and

mismanaged labor and is an indicator of the
inadequacy and poor quality of obstetric care
 It is almost entirely preventable labor complication
carrying very high maternal and neonatal morbidity
and mortality
 Obstructed labour is one of the five major causes of
maternal deaths which accounts for about 8% of
maternal deaths globally

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 Etiology
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 Obstructed labor is usually the end result of improperly

managed CPD which is its most common cause
 CPD (cephalo-pelvic disproportion): defined as disproportion
between the fetal head and maternal pelvis which leads to
inability of the fetus to pass through the maternal pelvis
 Gross immediate causes: the two ’P’s
 Maternal causes (fault in the passage)

 Fetal causes (fault in the passenger)

 Abnormality in the relationship b/n fetus and

mother..CPd/FPD

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 Maternal causes (fault in passage)

A. Bony obstruction: B. Soft tissue obstruction:
size and shape of pelvis  Uterus: impacted subserous
 Contracted pelvis myoma, constriction ring opposite
the neck of the fetus
 Abnormal shape of
 Cervix: cervical dystocia, stenosis
pelvis:- android,
anthropoid, congenital
 Vagina: septa, stenosis, tumours,
deformity of pelvis, rigid perineum
polio, ricketts…  Ovaries: Impacted ovarian tumours
 Tumours of pelvic bones.
 Rare causes- Tumors of bladder
and rectum, pelvic kidney …
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 Fetal causes (fault in the passenger)

A. Malpresentations and malpositions: e.g.
 Persistent occipito-posterior and deep transverse arrest,
 Persistent mento-posterior and transverse arrest of the face
 Brow, Shoulder/ transverse lie
 Impacted frank breech.
B. Large sized fetus (macrosomia).
C. Congenital anomalies: e.g. Hydrocephalus, Fetal ascites, Fetal
tumors.
D. Locked and conjoined twins.

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 Clinical Features of Obstructed Labor
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History
 Abnormally prolonged labor ( in

days than hours)

 Early ROM

 No ANC

 Pain full contractions

 Fever

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General condition of the patient

 Weak, exhausted due to sever pain and lack of sleep

 Anxious, terrified, uncontrollable

 Rapid pulse, deep and rapid respiration, pyrexia

 Dehydration nearly always present

 Dry and furred tongue, lips cracked, dry, hot and

inelastic skin
 Hypotension, circulatory collapse

 Bowel distention (acidosis , hypokalemia)

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State of the uterus

 In multipara - uterus respond by increasingly

frequent and violent contractions => tonic

contractions=>Lower segment thinned out and
elongated=>Retraction continues and stretching of
lower segment proceeds until it ruptures
 In primi, further retraction ultimately ceases and

labor usually comes to stand still with uterus in

firm spasm

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State of the bladder

 Normally displaced out of pelvis

 Catheterization difficult or impossible

 Very edematous bladder

 Scanty and highly concentrated urine, or blood stained urine

 Three tumor abdomen=> upper segment, lower segment

and edematous bladder

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Vaginal findings
 Edema of lower vagina and vulva

 Thick and offensive/purulent vaginal discharge

 Bleeding may be seen

 In cephalic presentation, full cervical dilatation

usually seen

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Fetal status
 Fetal distress/asphyxia

 Fetal death- 23% -76% may suffer perinatal death

 Even delivered alive, succumb during the 1 st

48hours from asphyxia ,birth trauma and infection

 Excessive moulding

 Big caput formation makes identification of the

presentation and position very difficult

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 Management of obstructed labor
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1. Speedy resuscitation
 Fluid and electrolyte imbalance

 Secure iv line immediately

 Rengers lactate- fluid of choice

 At least 3 liters; 1st liters as fast as possible

 Dextrose replacement is important

 Never oral replacement

 Lung bases to be examined at intervals

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 Management cont………
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 Iv antibiotics; broad spectrum

 To cover both anaerobes & aerobic bac, gm –ve & +ves
 In case of gas forming; add penicillin

 Iv corticosteroids
 Prophylactic dose of TAT-1500 units
 Tissue anoxia and necrosis favor activation of tetanus spores
 Inhalation of oxygen by face mask
 Emptying the bladder
 Emptying the stomach
 Cross-matching blood
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2. Relieve the obstruction/operative delivery

 Choice of operative delivery depends on
 Fetal condition(dead or alive)

 Station or descent

 Presence or absence of evidence of imminent or overt

uterine rupture
 Fetal presentation

 Extent of cervical dilatation

 The cause of obstruction

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 Management cont…..
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 If no –evidence of uterine rapture, imminent rapture,

sever pelvic contracture and vaginal stenosis the choice
depend on fetal status
 Alive fetus
 Promptc/s
 Symphysiotomy in cephalic presentation only- obsolete!
 Dead fetus depends on lie and presentation and also cervical
status and station
 Craniotomy
 Evisceration
 decapitation

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 Laparatomy regardless of fetal condition is done if

imminent rupture, uterine rupture, severe pelvic
contracture, severe vaginal stenosis , difficulty for
destructive delivery…etc
3. Further treatment after obstruction has been relieved
 Iv fluid

 Iv antibiotics 5-10 days

 Catheter 10 days

 Skilled obstetric care next time

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 Complications of Obstructed Labor
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 Maternal complication
Early: Late
 Maternal distress  Obstetric fistula (vvf, rvf)

 Maternal death  Vaginal stenosis&stricture

 Uterine rupture  Foot drop (sciatic,common
 Atonic PPH peroneal nerve)
 Peripartum infection  Osteitis pubis
, sepsis, peritonitis,  Ammenorrhea
septic shock  Pressure sores
 Tetanus
 Others…

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 Other complications of obstructed labor
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Osteitis pubis
 Prolonged febrile illness

 Site infection may remain obscure

 Heavy purulent vaginal discharge

 Later new bone is laid down; on x ray abnormally dense with bony

obliteration

Peripheral nerve injuries

 Locomotor disturbance

 Usually only one leg is involved

 Commonest disturbance is foot drop

 Moulded back splint and uplifting toe-spring are help full

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Fetal complication
 Fetal death
 Fetal distress/ asphyxia
 Cerebral injury
 Tentorial tear and intra cranial hemorrhage
 Fetal & neonatal infection, sepsis

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 Prevention
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 Obstructed labour is the result of multi level deficiencies in health

care delivery system so particular attention should be given to:
 Increase community awareness and education on OL
 Improve the socio-economic environment of the women.
 Increase accessibility and availability of efficacious and safe
obstetric care
 Effective health care planning starting from grassroots levels to
tertiary levels
 Establishment of an streamlined and effective referral system

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 Prevention …
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Anticipation during ANC

 Proper ANC visits to ensure fetal and maternal well being
and to assess for any risk factors of obstructed labour
 Height measurement
 Pelvic outlet structure
 Previous history of difficult labor
 Towards the end of pregnancy;
 Fetal lie
 Fetal weight estimation

 Non engagement

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 Prevention...
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Anticipation during labor

 Partograph will recognize impending obstruction
early. If the labor is slow to progress, careful
general, abdominal and vaginal examination is
necessary and early referral
 In the presence of good uterine contraction if there
is stasis of cervical dilatation over a period of 4-6
hours ;it is sign of impending obstruction

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 ‘LET US MAKE MOTHERHOOD
SAFE’ !

Thank you!

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