Obstructed Labor

OBSTRUCTED LABOUR – Dr. Wanjala DURING LABOUR DEFINITION:Labour is said to be obstructed when there is absence of progress in the presence of strong uterine contractions. ABSENCE OF PROGRESS • Failure of the cervix to dilate • Failure of the presenting part of the • Fetus to descent the birth canal ETIOLOGY MATERNAL CONDITIONS • Contracted pelvis or deformity of the pelvis • Turmours of the uterus or ovary – Fibromyomata of lower uterine segment • Tumours of rectum or bladder • Tumours of pelvic bones • Pelvic kidney • Stenosis of cervix or vagina • Congenital Septum of vagina • Contraction 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 head •

Malpresentation of the fetus o Breach presentation o Face presentation o Brow presentation o Shoulder presentation o Compound presentation o Locked twins

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Congenital abnormalities of the fetus o Large fetus o Hydrocephulas o Hydrop fetalis o Fetal abdominal tumors or ascites

CLINICAL PICTURE • The patient is exhausted by pain and the demands of overworking the uterus. • Pulse rate rise • Temperature may also rise • The upper part of the uterus is hard • The lower part (segment) is tender and distended

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The line of junction between the two areas is clearly visible on the abdominal wall as an oblique groove or furrow “The retraction Ring”. in obstructed labour the presenting part has become arrested inspite the strong contractions. There is over thickening of the upper segment and over thinning of the lower segment The pathological retraction ring or “bandis ring” is diagnostic

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The upper segment actively contracts and retracts While the lower segment is relatively passive The upper segment contracting almost instantly and retracting becomes hard and its walls become very much thicker and shorter as it forces fetus down and draws the lower segment and cervix up. As times goes on more and more of the fetus is driven down into the relaxing lower segment which becomes dangerously and will rupture if urgent help is not given.

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The uterine contractions usually increase in force and frequently often accompanied by strong bearing efforts. The mother becomes exhausted usually restless and haggard. Pains are severe and continuous and her tongue and lips becomes dry and discoloured; the pulse rate is 120/minute or over. The temperature also rises.

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Obstruction always occurs in the cavity or just below the pelvic bring serious obstruction at the pelvic outlet is uncommon. Death of the fetus results compression of the placental site circulation. The vagina and vulva are oedematous and the birth canal feels hot and dry. The oedematous cervix may be felt below the presenting part and a large caput and marked moulding of cranial bones are felt.

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Cephalopelvic disproportion • A large pelvis may be inadequate for a very large baby. • A small baby can negotiate a small pelvis • Extreme cases of cephalopelvic disproportion can sometimes be identified as the onset of labour. • In others a trial or test of labour is required • In a trial of labour the conclusion that labour cannot continue normally is reached before full dilatation. MANAGEMENT OF OBSTRUCTED LABOUR •

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IV line for Rehydration o (a) X match blood o (b) Haemogram o (c) Urea/Electrolyte Catheterize the bladder if the urine is blood stained – remember to have continuous bladder drainage for 10 days postnatally. Arrange for delivery of the baby by c/s to relieve the obstruction. Give antibiotics – broadspectrum.

• RUPTURE OF THE UTERUS 1 Position of the rupture • Commonly occurs obliquely at the junction of the upper and lower uterine segments. • Occasionally the uterus splits vertically through the lateral point of uterine vessels. Rapture Of The Uterus Can Be Considered At Three Periods o Rupture of the uterus during pregnancy • Occur in uterus previous scar, especially classical i.e. previous c/s or hysterotomy • Previous perforation of the uterus by an IUCD this leaves weak area of scar • Previous myomectomy scar o

Rupture • • • • • •

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of the uterus during ordinary labour Misuse of oxytocic drugs High parity Cervical scarring after amputation of uterus or cone biopsy Unrecognized injury to the uterine wall due to previous delivery Manual removal of placenta Fetal death in the uterus

Rupture Of The Uterus After Protracted Labour •

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Common predisposing causes includes: Cephalepelvic disproportion  Malpresentation  Hydrocephalus Trauma from unskilled attempts at delivery

Classical Symptoms and Signs. • Feeling of something giving way • Cessation of uterine contractions • Alteration in the shape of the abdominal swelling • Haemorrhage and collapse

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Epidural block may mask the symptoms Fetal parts may be much more palpated after the fetus has been extruded into peritoneal cavity

Three chief causes of death are:• Haemorrhage • Shock • Sepsis Coexisting complications toxaemia or anaemia may be contributory factors MANAGEMENT OF RUPTURED UTERUS •

IV line for rehydration

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Resuscitate the patient Blood for urgent Haemogram, Urea and Electrolytes and Group Xmatch blood

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Prepare for laparatomy. At laboratory two options may be looked:After delivery of the fetus who may be dead or alive and the placenta. You may proceed to repair the uterus . Or do subtotal hysterectomy

Clean the peritoneal cavity with warm saline to remove meconium. RUPTURE OF THE UTERUS 2 Rupture of the Uterus is a dangerous complication of pregnancy. INCIDENCE

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The reported incidence varies from 1:93 confinements to 1:8741 The average is around 1:2000 Increase of the incidence may be blamed on :more frequent use of cesarean section scarred uterus careless administration of oxytocic drugs inadequate professional care during labour none-recognition of an obstructed labour

TYPES OF RUPTURE (I) Complete rupture - when all the layers of the uterus (II) Incomplete rupture - whole myomectrium But peritoneum covering the uterine remains intact (III) The Serosa and part of the external myomectrium are torn but laceration does not extend into the cavity SITE AND TIME OF THE RUPTURE • Tears that take place during pregnancy are more often in the upper segment of the uterus, at the site of previous operation or injury • During labour the rupture is usually in the lower segment - may extend into the uteririe vessels causing profuse haemorrhage • Tears in the anterior or posterior walls of the uterus usually extends transversely or obliquely. • Rupture of the uterus may occur during pregnancy, normal labour or difficult labour or may follow labour. Those happening before onset of labour are usually dehiscences of cesarean section scars CLASSIFICATION 1. 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

Usually associated with scar of previous cesarean section

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Usual Variety ♦ Picture develops over period of a few hours, signs and Symptoms ♦ Abdominal pain ♦ Vomiting ♦ Faintness ♦ Vaginal bleeding ♦ Rapid pulse rate ♦ Pallor ♦ Tenderness on palpation ♦ Absence of the fetal heart ♦ Hypotension and shock

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Violent Rupture ♦ Is apparent almost immediately ♦ Usually a hard uterine contraction is followed by sensation of something having given way and a sharp pain in the lower abdomen ♦ Contractions Cease ♦ Patient becomes anxious ♦ There is change in the character of pain ♦ Fetus may be palpated easily presenting part no longer at the pelvic Orim ♦ Fetal movements cease ♦ Fetal heart not heard ♦ Shock ------ complete collapse

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Rupture with delayed diagnosis ♦ Condition not diagnosed until patient is in a process of gradual deterioration ♦ Unexplained anaemia ♦ A palpable haematoma develops in the broad ligament ♦ Signs of peritoneal irritation ♦ Patient may go into shock, either gradually or suddenly e.g. when haematoma ruptures ♦ Diagnosis may be made at autopsy

Traumatic Rupture Caused by ill adversed and poorly excecuted operative vaginal deliveries Etiologic Factors o Version and Extraction o Difficult forces operation o Forceful breech extraction o Craviotomy o Excessive manual pressure on fundus of the uterus

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Postcesarean Rupture most common may occur before or during labour Upper segment scars rupture more often than lower segment incisions. There is no accurate way of predicting the behaviour of a uterine scar. All cesarean section scars present a hazard.

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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 • Hysterotomy

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Silent Bloodless Dehiscence of a previous cesarean scar • A complication of lower segment cesarean incisions part or all of incision may be involved • Usually peritoneum of the is intact • these windows are due to failure of the original incision to heal

CLINICAL PICTURE This 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 placenta from the uterus • Degree of retraction of the myometrium • General condition of the patient On 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 dilate

DIAGNOSIS • 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 peritoneal cavity with uterus to one side. TREATMENT • Must be prompt in keeping with patients condition • Resuscitation • Laparotomy performed and bleeding controlled as quickly as possible MATERNAL MORTALITY

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Reported maternal death rate ranges from 3 to 40% Spontaneous rupture of the uterus is responsible for the largest number of deaths. The lowest death rate is associated with post cesarean ruptures. Main causes of death are o shock and blood loss o Sepsis and paralytic ileus

Prognosis for the mother depends:• Prompt diagnosis and treatment (the interval between rupture and surgery being important) • The amount of haemorrhage and the availability of blood • Sepsis • The type and site of the rupture Mortality can be lowered by:• Early diagnosis • Immediate laparotomy • Blood transfusion • • •

Antibiotic Reduction or elimination of traumatic operative deliveries Better management of prolonged or obstructed labour

FETAL MORTALITY • Fetal mortality is high ranges 30 – 85% • Most fetuses die from separation of the placenta • Fundal rupture where the fetus has been extruded into the abdominal cavity has highest mortality PREGNANCY AFTER RUPTURE OF THE UTERUS The risk of repeat rupture is:• Least when the scar is confined to the lower segment • Greater if the scar extends into the upper segment • Greatest in women whose original rupture occurred following cesarean section MANAGEMENT Cesarean section should be performed before the scar is subjected to stress:• Scar in lower segment: C/s at 38 weeks • Scar in upper segment: C/s at 36 weeks.