Obstructed Labour & Prolonged Labour

Determinants of Successful Labour ► Adequate Power (uterine contractions) ► Adequate Passage (maternal pelvis) ► Adequate Passenger (fetal size) DEFINITION OF PROLONGED LABOUR When labour tends to be prolonged for more than 18 hours both in primigravida and multigravida women

Causes ►Fault in passenger ►Fault in power : ►Fault in passage ►Fault in passenger ►Fault in power : ▪ Hypotonic Uterine Dysfunction (inertia) ►Can be 2ry to Epidural analgesia or Chorioamnionitis ▪ Hypertonic / Incoordinate Uterine function

Diagnosis History: 1.Age 2.Parity 3.Duration of labour 4.Duration of membrane rupture 5.Whether the patients was handle outside the hospital 6.Whether she was treated with oxytocin drugs 7.Previous history of difficult labour, instrumental delivery or stillbirth

Abdominal examination: 1. Contour of the uterus 2. Presentation & position 3. Tenderness 4. Frequency, intensity & duration of uterine contraction 5. Lower segment distended 6. Distension of the bladder

Vaginal examination: - The vulva usually swollen and edematous. - The vaginal is dry, hot and occasionally offensive and purulent discharge - The cervix is almost fully dilated - The presenting part is extremely moulded and jammed in the pelvis - There is usually large caput formation

Management A. General management : 1. NPO & i/v fluid start immediately 2. Bladder evacuation. 3. Parenteral antibiotics. 4. Intake output chart should be strictly maintain 5. Blood should be send for grouping and cross matching

Obstetric Management During 1st stage: 1. Role of oxytocin : hypotonic uterine contraction Role of sedation : incordinate uterine contraction use of narcotics may lead to spontaneous correction Role of amniotomy in correction of hypotonic uterine contraction 4. Role of cesarean section: contracted pelvis, big baby, malpresentation, malposition, severe fetal distress

During 2nd stage: 1. Role of episiotomy: rigid / tight perineum 2. Role of instrumental delivery (Forceps or Vacuum): in case of fetal distress, 3. Role of cesarean section: contracted pelvis, big baby, malpresentation, malposition, and severe fetal distress

Complications Fetal: Immediate: - Birth trauma - Birth asphyxia - Fetal distress - Meconium aspiration syndrome - Stillbirth - Neonatal death ! Late: - Cerebral palsy - Mental retardation Maternal: Immediately: -Maternal distress -Maternal injury -PPH -Puerperal sepsis -Maternal death Late:- -Urinary fistula -Vaginal stenosis -Secondary infertility

Obstructed labour ►Definition : defined as labour where there is poor or no progress of labour in spite of good uterine contraction! ►Incidence :- 1 -2% of cases in developing country

Causes ►Maternal condition (fault in the passage): 1. Contracted pelvi 2. Abnormal pelvis: android, anthropoid 3. Pelvic tumor: fibroid, ovarian tumor 4. Tumor of rectum, bladder or pelvic bone 5. Abnormality in uterus & vagina: scarring in cervix, vaginal septum, rigid perineum

fetal causes Big baby Big head, hydrocephalus Deflexed head, brow and face mentoposterior. Oblique or transverse lie

Diagnosis ►Partograph will recognize impending obstruction of labour early ►Careful general, abdominal and vaginal examination can detect if labour is slow or no progress

General examination: Features of maternal distress Dehydration Tachycardia >100/m Raise temperature Scanty urine

Abdominal examination : -The retraction ring might appear and felt between the tonically contracted upper segment of the uterus and the distended lower segment - Distended urinary bladder

Vaginal examination: - The vulva usually swollen and edematous - The vaginal can be dry and hot - The cervix is almost fully dilated or hanging like a curtain - The presenting part is extremely moulded and jammed in the pelvis - There is usually large caput formation

Complication Maternal: ! -Rupture of uterus -Urogenital fistula -Rectovaginal fistula -Postpartum hemorrhage -Puerperal sepsis -Shock -Maternal death Fetal: -Intra uterine asphyxia -Intracranial hemorrhage -Neonatal infection -Metabolic Acidosis -Fetal death

Management ►Preventive: - Proper assessment of pregnant woman during ANC - Regular ANC visit - Proper assessment in early labour to - Use of Partogram - Prompt and appropriate treatment

Obstetric Management 1. Delivery of fetus: a. Vaginal delivery: if head is low and vaginal delivery is not risky, forceps extraction may be done b. Caesarean section: 2. Active management of 3rd stage of labour 3. Continuous bladder drainage for 2-3 days to prevent any urogenital fistula