INTERNATIONAL MEDICAL AND TECHNOLOGICAL UNIVERSITY (IMTU)

OBSTRUCTED LABOUR
DATE: 9th JULY 2012 Rajabu N. MD(UDSM), Resident(OB/GY) IMTU.

CONTENTS
I. II. III. IV. V. VI. VII. VIII. INTRODUCTION DEFINITION OF LABOUR OBSTRUCTED LABOUR CAUSES OF OBSTRUCTED LABOUR CLINICAL PRESENTATION COMPLICATIONS MANAGEMENT PREVENTION

INTRODUCTION
Obstructed labour is one of the most common preventable causes of Maternal and Perinatal Morbidity and Mortality in developing countries. The prevalence of obstructed labour varies from one country to another but it is more common in developing countries, because of Lack of adequate heath and care delivery facilities Poor Nutrition Poverty Socioeconomic and cultural factors

In developing countries, the incidence of obstructed labour is difficult to estimate because of: Poor data collection procedures Most of the reported studies are based on data from tertiary Hospitals
EXAMPLES: 1 2/100 deliveries in Nigeria 3/100 deliveries in India MUHIMBILI NATIONAL HOSPITAL(MNH ) YEAR 2005 Total deliveries : 11,377 Obstructed Labour : 1343 11.8% MODE OF DELIVERIES SVD 119 8.9% LSCS 1193 88.8% LCVE 29 2.2%

FETAL OUTCOME
Alive and Well Admitted in the Ward Neonatal Deaths SBM SBF Unknown TOTAL 78 1148 40 17 49 11 1343 5.84% 85.5% 3.0% 1.3% 3.6% 0.8%

Maternal Deaths associated with obstructed Labour

PPH Eclampia Anaesthetic Others HIV / AIDS 1 2 1 1 1 16.75 33.3% 16.7% 16.7% 16.7%

FEMALE BONY PELVIS

DEF: Ring of bones through which the fetus must pass during delivery

TYPES:

I. True pelvis below pelvic brim - It is of obstetrical significance

II. False pelvis above the pelvic brim

COMPONENTS OF PELVIC BONES

4 Bones 2 Innominate bones Parts Ilium - Ischium - Pubis Sacrum 5 Fused bones Coccyx 4 Fused bones

4 Joints

2 Sacral Iliac joints Symphysis pubis Sacral Coccygeal joint

3 Passages
- Pelvic brim inlet - Pelvic cavity - Pelvic outlet

PELVIC BRIM
Between the False Pelvis and True Pelvis Oval in Shape Boundaries Antheriorly Upper part of symphysis pubis Laterally Upper margin of pubic bone and Ilial Pectineal Line, Pectineal eminence and Ala of Sacrum Posteriorly Sacral Promontory

DIAMETERS
Vary in shape and height of a woman. 5 Diameters 1. Antero Pasterior Diameter True conjugate From the sacral promontory to the inner aspect of the upper border of symphysis pubis =11cm 2. Diagnal Conjugate From sacral promontory to the inner aspect of the lower border of the symphysis pubis = 12.5cm True conjugate = Diagonal Conjugate 1.5cm =11cm 3. Transverse diameter Widest point between two Ilial Pectineal lines = 13.5cm 4. Oblique diameter From sacral Iliac joint on one side to the Ilial Pectineal Eminence or the opposite side-= 12cm 5. Sacral Cotyloid diameter From the sacral Promontory to the Ilial pectineal eminence = 9.5cm

PELVIC CAVITY
Between pelvic brim and outlet Circular in shape Curved BOUNDERIES Anteriorly : Inner aspect of the symphysis pubis Laterally : - Pubic bone - Obturator fascia - Inner aspect of Ischial bone Pasteriorly : Junction between the second and third sacral vertebral DIAMETERS - Antero Posterior 12cm - Transverse 12cm

PELVIC OUTLET
Below the Pelvic Cavity Shape Diamond BOUNDERIES - Anteriorly - Laterally - Posteriorly

Pubic Arch. Ischial Tuberosities Tip of Coccyx Sacrum Ligaments joining the ischial tuberosities

DIAMETERS
Antero Posterior diameter - Lower border of symphysis pubis to the tip of sacrum 13.5cm Transverse diameter - Between Ischial Spines 11cm Oblique diameter - Mid point of the pubic arch to the mid point of sacral spinous ligament in the opposite side 12cm

PELVIC ANGELS
PELVIC INCLINATION Angle of inclination that the pelvic planes makes with the horizontal in erect position - With Pelvic brim 60 - With Pelvic outlet 25

PELVIC AXIS
Imaginary curved line showing the pathway which the centers of the fetal head follow during its passage through the pelvis. Obtained by taking several AP diameters and joining their centers.

FEMALE PELVIC BONES

CLASSIFICATION BY CALDWELL - MOLOY I. GYNAECOID PELVIS - Most favourable for vaginal delivery - Occurs in over 50% of women PELVIC INLET - Shape Oval - Transverse diameters > AP diameter CAVITY - Curved sacrum - Round Cavity Walls OUTLET - Ischial spines not prominent - Sub pubic arch wide > 90 - Pubic bone shallow

ANTHROPOID PELVIS
Found in approximately 85% of black women and 1/5 of white women PELVIC INLET - Shape Oval - AP > Transverse CAVITY - Curved sacrum Inclined posteriorly - Deep Pelvis

OUTLET Ischial spines not prominent Sub pubic arch narrow III. ANDROID PELVIS - Male like pelvic - Found in roughly 15% of black women and 1/3 of white women INLET Heart Shaped Widest part at the back of pelvis CAVITY Straight Sacrum Convergent pelvic wall Diameter decreasing from above downwards

OUTLET Ischial spines prominent Sub pubic angle narrow < 70 Both AP, transverse diameters are smaller
IV. PLATPELLOID PELVIS Rare Less than 3% of all women INLET - Decreased AP diameter - Widest transverse diameter CAVITY - Sacrum Short and broad - Pelvic walls diverge OUTLET Sub pubic arch wide and rounded

LABOUR DEF: Regular PROGRESSIVE, painful uterine contractions increasing in intensity and frequency, accompanied by descent of the presenting part, effacement and dilatation of the cervix, completed by expulsion of the products of conception. Labour is expected to PROGRESS in an orderly and predictable manner.

Careful observation of the mother and fetus during labour will allow early detection of abnormalities. So that appropriate management can be directed toward reducing the frequency of adverse outcome. Normal labour has been divided into three stages. First stage From onset of labour to full dilat Second stage Full dilatation to delivery Third stage Delivery of placenta and its products

First stage subdivided into 2 phases Latent phase onset of labour 3cm dilat Active phase 3cm dilatation Delivery

Abnormal duration of these stages and Phases is commonly mean ABNORMAL LABOUR

MECHANISM OF LABOUR
DEF: Series of changes in the ATTITUDE and POSITION of the fetus that permits it to PROGRESS through the irregular shaped pelvic cavity THE CARDINAL MOVEMENTS I. ENGAGEMENT: When the widest transverse diameter of the fetus, BIPARIETAL has passed the plane of the inlet II. DESCENT - In occiput position, the longest diameter of the fetus head AP enters the normal pelvis inlet in transverse diameter - If the sagittal suture is equidistant from the sypmphysis, and sacral promontory. The head is entering the inlet in synclitic manner

DEGREE OF ASYNCLITISM
1. 2. Anterior parietal bone presentation - Sagittal suture is in posterior segment of inlet Posterior parietal bone presentation - Sagittal suture is in anterior segment of inlet

The degree of descent is gauged by the STATION of the presenting part, its relationship to the plane of ischial spines STATION O: The lowest point of the presenting part is at the level of ischial spines

Above ischial spines Below ischial spines +

III.

FLEXION
During the late pregnancy the fetal head usually lies in the pelvic inlet in a partialy flexed attitude. The purpose of flexion is to substitute the suboccipito bregmatic diameter of the fetus 9.5cm for the suboccipitofrontal diameter 11cm.

IV. INTERNAL ROTATION Rotation of the long axis of the fetal head from the transverse diameter begin at the level of Ischial spines, completed when the presenting part reaches the lower pelvis
V. EXTENSION - The upper half of the pelvic canal is directed posteriorly toward the sacrum - The lower half is directed anterioly making a canal a curved tube. The course of descent of the presenting part must change to conform to the pelvic curve.

VI. RESTITUTION AND EXTERNAL ROTATION Rotation of the head of fetus 45 to the RT or LT of the midline in relation to the back and shoulders occiput rotates in the direction of fetal back. Shoulders descent and rotate within the pelvis the occiput rotate further externally.

OBSTRUCTED LABOUR
DEF: Failure of labour to PROGRESS despite of good uterine contractions. ABNORMAL LABOUR PATTERNS I. Prolonged latent phase For primigravida in more than 20hrs, normal 8-12 hrs - For Multigravida in more than 14hrs, 6-8 hrs - No progress from latent to active phase II. Protraction disorders - Prolonged active phase of labour Cervical dilatation < 1cm / hr for Primigravida < 1.5cm/hr for Multigravida Arrest disorders. Secondary Arrest - No more progress in the active phase - No cervical dilatation for more than 2 hrs - No progress in the second stage

III.

CAUSES OF OBSTRUCTED LABOUR

I. MECHANICAL FACTORS

1. Passage a. Bone Pelvis - Contracted pelvis - Pelvic deformities - Fracture of pelvic bones - Poliomylitis - Rickets - Abnormalities of pelvis - Android - Plat pelloid

b. Uterus Double uterus c. Vagina Vaginal stenosis - Congenital stenosis - Surgical Stenosis d. Cervix Cervical stenosis - Congenital stenosis - Surgical Stenosis
2. PASSENGER i. Big baby ii. Malpresentation Breech, Face,Brow, Compound iii. Malposition POPP, iv. Abnormal lie- Transverse, Oblique lie v. Locked Twins vi. Congenital abnormalities of the fetus - Hydrocephalus - Conjoined Twins - Fetal Ascites

II. OTHER FACTORS a. POWER - For the fetus to be pushed through the birth canal need sufficient power created by the uterus and by accessory muscles used during the second stage of labour. - Causes of insufficient strength of the uterus 1. Maternal exhaustion 2. Excessive anaesthesia 3. Neuro muscular disorders 4. Maternal Medical conditions - Previous stroke - Cardiciac diseases - Diabetes Mellitus b. PSYCHIC

CLINICAL PRESENTATION
I. HISTORY A. i. Maternal age < 16 years High risk of CPD ii. Parity Primigravida iii. Mutligravida History of obstructed labour iv. Birth weight of all children B. POST ORTHOPAEDIC HISTORY 1. History of motor traffic accident To R/O Pelvic Trauma 2. Any disease of the spine, hip, TB Pelvis, Polio, rickets. C. Previous History of Cervical or Vaginal Surgery

II.
A.

GENERAL PHYSICAL EXAMINATION BEFORE LABOUR

(i) Height <150cm (ii) Abnormal Gait, Kyphosis, Scoliosis (iii) Size of the Mother and Appearance 1. Leopards manouvers Malpresentation Size of the fetus Twin pregnancy Abnormal lie 2. Any abdominal mass Any bone or tissue abnormality

B.

C.

DURING LABOUR
A. HISTORY: 1. History of prolonged labour in previous 2. Duration of labour 3. Onset of Labour 4. PROM Occurs early in obstructed labour GENERAL PHYSICAL EXAMINATION 1. Appearance - Mother is tired, Anxious restless exhausted, dehydrated, in severe pain - Maternal pulse -T

B.

2. P/A:- Presenting part is high fixed at the level of obstruction - Uterus is hard and tender - Bandls Ring - Distended urinary bladder 3. PVE: - Dry and oedematous vagina and vulva - Caput and moulding - Thick meconium if there is element of fetal distress

COMPLICATIONS
I. MATERNAL 1. Fluid and electrolytes imbalance Dehydration 2. Hypoglycemia 3. Maternal distress 4. Metabolic acidosis a. Accumulation of lactic acid produced by contracting muscles of the uterus b. Reduced food intake Carbohydrates Hypoglycemia Calories Catabolism of fats with production of ketone Bodies keto acidosis Acetone smell

5. Infections Pueperial sepsis 6. PPH due to uterine atony from exhaustion 7. VVF and RVF Mechanical obstruction
Vascular supply Ischaemia Necrosis Fistula

8. Ruptured uterus 9. High Perinatal morbidity and mortality in improperly managed obstructed labour

II. FETAL
1. 2. 3. 4. 5. Fetal distress Aspiration of meconium IUFD Multiple fetal injuries cp High Neonatal Morbidilty and Mortality

BASE LINE INVESTIGATIONS 1. B/G and Cross Matching 2. Serum electrolytes 3. Urine urinalysis - Culture and sensitivity 4 HB Level
38

MANAGEMENT
I. TREATMENT TO RELIEVE OBSTRUCTION A. 1. RESUSCITATION - Correction of dehydration by IVF - Correction of Hypoglycemia 2. Catheterization 14 days prevent VVF 3. Control infection By Broad Spectrum antibiotics 4. Input output 5. Monitor vital signs 6. Blood Transfusion if necessary B. MODE OF DELIVERY 1. If fetus alive emergency LSCS 2. If fetus dead destructive delivery

PREVENTION
A. DURING ANTEPATRUM PERIOD Good health before conception include a significant reduction in maternal and fetal morbidity and mortality Antepartum care promotes patient education and facilitates ongoing risk assessment and the development of an individualized patient management plan Routine ANC visits to effectively identify problems in maternal and fetal well being. Balanced diet, adequate nutrition during infancy, childhood, early adulthood and pregnancy Vit D, Calcium, Folic Acid, Iron, Zinc. Early motherhood should be discouraged Family planning and contraception for young age women to delay pregnancy Proper vaccinations during childhood The cost effectiveness standard tests should be done on each pregnancy.

- B/G and Rh factor, VDRL, RBG, urinalysis, B/S MPS, Hb Levels OBS- USS Education for Primary health care provider and traditional birth attendants for early referral of at least pregnant mothers.
DURING INTRAPARTUM PERIOD - Proper History taking - Closing monitoring of the progress of labour - Appropriate and accurate charting of partogram - Early diagnosis of abnormalities of labour appropriate decision and quick action NB: ANY WOMAN IN LABOUR IS AT RISK

B.

THE GOAL SAFE AND HEALTHY DELIVERY FOR BOTH MOTHER AND CHILD

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