OBSRUCTRCED
LABOUR
INTRODUCTION
Obstructed labour is almost
non-existent in the developed countries where good antenatal care and supervised
delivery are the norm.In contrast,antenatal coverage and supervised delivery
in developing countries are still far from satisfactory levels. In Ghana
The unsupervised deliveries
are often prolonged due to failure to recognize mechanical disorders that are
more likely to lead to obstructed labour.
DEFINITION
Obstructed labour occurs
when there is lack of progress in spite of adequate uterine contractions.Progress here refers to cervical dilatation and descent of the presenting part.
The prolongation of labour from obstructions could lead to maternal exhaustio, keto-acidosis,dehydration and infection.
CAUSES
The commonest causes of
obstructed labour is cephhalo-pelvic disproportion. General pelvic contraction
may be closely related to impairment of growth by ill health or malnutrition
during childhood and adolescence. Minor disproportion may b e combine with
occipito-posterior position when the fetus is deflexed attitude and constitute
a
Major mechanical dfficulty.
Impacted transverse lie and
breech presentation of a large fetus can also lead to obstruction The after
coming head of average sized baby presenting with breech and especially with
extended arms may be obstructed.
This often occurs when the
body of the baby is pushed out before full dilatation of the cervix. Other malpresentation like
brow,mento-posterioface. Macrosomic babies especially. When the mother is a
diabetic and other fetal anomalies like hydrocephalus and fetal ascites may
constitute mechanical barriers even in a capacious maternal pelvis.
Soft tissue abnormalities
such as fibroid, impacted ovarian tumours and stenosis of the cervix or the
vagina could obstruct labour. Rarely locked twins and double monsters cause
obstruction.
CLINICAL FEATURES
Patients who have obstructed
labour are usuaaly non-attendants or poor attendants at the antenatal clinic.
Quite often they are grandmultiparas with little or no formal education. They
have had prolonged labour with most of it being unsupervised or at a spiritual
home with an untrained birthatendannt
some of them also present with retained second twin.
Occasionally they are seen
after failed attempts at an operative vagina delivery .Most of these are due to
failure to recognise cephalo-pelvic
disproportion.
General examination reveals
a woman exhausted from lack of sleep and severe unremitting pain.
They are usually very
anxious and sometimes terrified to an
almost
uncontrollable state.
There is dehydration from
inadequate fluid intake and muscular activity. The skin is hot, dry and
inelastic ,the tongue dry and furred and lips are cracked.
The urine is scanty and
highly concentrated.
Accumulated of lactic acid
from contracting uterine and skeletal muscles leads to metabolic acidosis.
Catabolism of fat in the absence of carbohydrates also leads to increased
acidosis from the production of ketone bodies.
The patients thus present
with rapid respiration and the breath smells acetone. They are also pyrexic as
a result of dehydration and birth canal infection from multiple unsterile
vagina examinations. Vagina examination reveals oedema of the vulva and lower
vagina with thick offensive vagina discharge. Bleeding per vagina usually
indicates uterine rupture. The upper part of the vagina is hot and dry.
The cervix is puffy and
poorly applied to the presenting part.
In cephalic presentation,
there is extreme moulding and mark caput succedeneum formation.
Abdominal palpation usually
shows that most of the fetal head is still above the pelvic brim
MANAGEMENT
The diagnosis of obstructed
labour is clinical.
Before embarking on
procedures to relieve the mechanical obstructions, the effects of the prolonged
labour should be recited at least partially.
An intravenous line with a
wide bore canula is established for fluid and electrolyte imbalance correction.
Blood is taken for full blood count, grouping and cross matching against at
least 4 units of blood urea. Electrolytes and creatinine, and culture and
sensitivity if septiccaemia is suspected. Rapid infusion with normal saline or
Ringers lactate is started
Endocervical swab for
culture and sensitivity is done after which an in-dwelling foley’s urethral
catheter is passed for continuous drainage of the urine. The passage of the
foley’s catheter may be difficult due to compression of the urethra by the
presenting part. Insertion of two fingers on either side of the urethra between
the presenting part and the symphysis pubis aids in the passage of the
catheter. Naso –gastric tube is passed to empty the stomach as these patients
might have eaten or given herbal concoction at home or at a spiritual temple.
Paranteral broad-spectrum
antibiotics are administered to control infection. In some communities’ herbal
concoction, cow dung and mud are applied into the vagina when labour is
prolonged. These may contain tetanus spores. Prophylactic anti-tetanus serum
should be given in such cases.
Below is a brief outline of
the initial steps taken in the
management of obstructed labour
·
Intravenous fluid
·
Full blood count
·
Group and x-matching of 4 units blood
·
Blood urea and electrolytes
·
Serum creatinine
·
Endocervical swab for c/s.
·
Blood for c/s
·
Catheter
·
NG tube .
·
Antibiotics/and antitetanus serum/vaccine
Me of the woman who present
with obstructed our are told that the misery
they are going through is due to marital infidelity or other antisocial
activities. It is important to allay the anxieties of such patients and win
their co-operation for an active management.
Mode of Delivery
A balance decision must be
taken on the best method of delivering the patient after initiating the
resuscitation measures and the patient is in a stable condition. The
obstruction must be relieved by operative means. The option are abdominal
delivery or extraction of the fetus per vagina.
ABDOMINAL DELIVERY
The
main indications for abdominal delivery are uterine rupture, live fetus
and a surgeon unskilled in operative vaginal techniques. The surgical team
should prepare for a possible caesarean hysterectomy when undertaking abdominal
delivery in obstructed labour. Occasionally repair of the torn bladder will
also be undertaken. It is important to involve a senior obstetrician as early
as possible in cases of obstructed labour. The lower uterine segment caesaren
delivery is recommended in obstructed labour, as it is less likely to rupture
in subsequent pregnancies. Other advantages include less likely intestina;
obstruction from adhesions and in infected cases risk of general peritonitis is
considerably reduced compared to a classical section. However, classical
section may be done when the lower uterine segment is not accessible on account
of lowly placed uterine fibroids or scarring from previous operation.
OPERATIVE VAGINAL DELIVERY:
Operative
vaginal deliveries in obstructed labbour include forceps delivery, vacuum
extraction, symphysiotomy and destructive operations.
SYMPHYSIOTOMY
Symphysiotomy
is performed in cases of cephalopelvic disproportion with a vertex presentation
in a live fetus. It is performed when the descent of the head is such that at least one third
or more of the fetal head has entered
the pelvic brim and the cervical dilatation is more than 7cm. it can be done
after a failed vacuum extraction in areas without theatre facilities . this
procedure is obsolete but may be life saving.
The Technique of symphysiotomy
The symphysiotomy instrument tray.
The tray itself does not
need to be sterilized. Keep the
symphysiotomy tray separate from other delivery trays. So that it is always
ready in an emergency. Swabs, sterile
gauze in packets
10ml syringe, various
needles and a bottle of local anaesthetic.
Sterile, Warpped (No4)
Large- Size scalpel handle with size 22 or 24 scaple blades
Foley’s catheter and
Nelathon Catheter.
Other instruments as for delivery tray and vacuum extraction.
Your notes or text on how to
perform symphysiotomy.
The women is placed in lithotomy
position and two assistants position a leg each as show in figure 1, instead of
placing them in stirrups. It is very important that the assistance are very
careful not to abduct the things. Make sure that they understand that there
must always sure that understand that there must always be less than 90 degrees of angle maintained
between the thighs. Turn off any oxytocin drip for the time being if labour is
being augmented.
Have an assistant shave the
pubic hair for 3-4 centimeters square just above the clitoris. Swab the shaved
area with iodine or spirit. Inject 5-8 ml of local catheter of medium to large
size (Nelathon) into the bladder. Put on new sterile gloves, and put the index
and middle fingers of your left hand into the vagina. (the following notes on
technique refer to a right handed operation). Push the catheter (and thereby
the urethra) laterally to the patient’s right. Keep the catheter running along
the outer border of your index finger. Hook the top of your middle finger over
the top of the symphysis to protect the bladder neck, make a stab incision
about 3-4cm above the base of the clitoris down to the symphysis. Cut down
through the symphysis until you can feel the scalpel exerting pressure on your
middle finger in the vagina. Make sure
you cut in the midline groove in the symphysis with your right hand before you
begin cutting. If you cut into bone, you are not in the midline.
Cut downward, i.e. toward
yourself, and then rotate the blade 180 degrees
to cut upwards towards the patient’s abdomen. When you have completely divided the
symphysis you should be able to tap the blad through the length of the divided symphysis on to your finger in the vagina.
There is virtually no danger of cutting your finger, as there are still bends
of ligaments across the back surface of
the symphysis as well as subcutaneous tissue and vaginal skin between the blade
and your finger. The common part of the symphysis through the skin incision with a finger of your right hand. If there is still a bridge of undivided
symphysis, continue to complete the division before going on.
Ask as assistant to turn the oxytocin drip back on and h run it at about 60 drops per minute. Inject oxytocin 5IU into the IV bag if you bag if you do not have this in pace already.
Place the vacuum extractor
cup on the baby’s head posterior to the
caput if possible, and tell al the
mother to push hard with the next
contraction. Never apply the forces after symphysiotomy as you are very likely to cause serious material
injury. When she does have a contraction, pull downward away from the
synphysis. This minimizes the possibility dislocating the urethra from its
supports, you will probably hear a clunk as the posterior symphyseal ligaments tear apart and the head drops in the pelvis.
After the delivery of the
baby, tell the two assistants who are holding the things to bring the knees
together and hold them there whilst you delivers the placenta and suture the
episiotomy. This minimizes the blood loss from the symophysiotomy wound site.
Suture the symphysis skin wound with one matters suture going down deep to the
level of the symphysis.
It is kind to give your
patient a dose of IV pethidine for the suturing: by this time she is in need of
rest.
Insert a Foley’s catheter
into the bladders (to replace the Nelathon one) and allow continuous bladder
drainage for 24-48 hour. It is usually safe to remove the catheter as soon as
the urine in the bag is clears of blood. Put a loose bandage around the thighs
to keep them together as this may lead to deep venous thrombosis.
POSTOPERATIVE ORDERS.
I Broad-spectrum antibiotics
ii. Remove the foley’s catheter
when the urine is clear, usually in 24-48 hours the only reason for leaving the
accidentally cut into the bladder or urethra.
iii. Remove the bandage around the
things after 24 hours and tell the patient to move her legs around in the bed,
but not to try and get out bed for another day.
iv. Allow normal diet, and for
48-78 hours provide pain relief with pethidine or a similar opioid drug.
v. Prepare a walking frame (any
table, cot or other trolley with wheels will do) for the patient to hold on to
and walk when she first gets out of bed and try to walk] with the walking frame after
2 days. It will be a painful experience and she will feel very insecure and
unstable at first. Reassure her.
COMMON PROBLEMS ASSOCIATED
WITH
1. You cannot get the Nelathion
catheter into the bladder. This is because the head is so jammed down in the
pelvis that it has squashed the urethra. Try todislodge the catheter up the
urethra with a finger in the vagina.
2. You hit bone with your
scalpel. You are not in the midline. Check for the midline with a finger of your
right hand, and begin cutting again in the midline.
3. The symphysis does not
separate when you have finished cutting it. You have not completely divided the
symphysis. The common place to miss is
the top anterior (front) part of the symphysis. Palpate the divided symphysis
through the skin incision with a finger of your right hand to check for the
part, which you have missed.
4. you still cannot deliver the
baby. This should never happen as long as you have followed the rules for
trials of vacuum extraction, and you have in fact divided the symphysis. As
long as the baby is still alive, there is no alternative but to do a caesarean
section.
PROBLEMS IN THE IMME DIATE POSTOPERATIVE
PERIOD.
There is no doubt that
immediate postoperative period for symphysiotomy patients is just as
uncomfortable as for those who have had
caesarean section; if not more so.
Always give adequate analgesia after symphysiotomy operations: do not allow
these patients to be labeled as another vaginal delivery. They need much more
nursing assistance postoperative than the average caesarean section patient.
Because of the instability of the pelvis, symphysiotomy patients also take
longer to walk well postoperatively. Symphysiotomy she usually just needs
reassurance and support from a walking
frame; however, a broad belt pulled tight around her hips may provide added
support for a couple of days.
2. Postpartum haemorrhage is
common after symphysiotomy because most patients are primigravidae who have had
a prolonged and possibly augmented first stage, and a prolonged second stage
too. Use 0.5mg IV ergometrine after the baby is delivered and put up oxytocin
20IU in the IV bag to run at 30 drops per minute postoperatively. Massage the
uterus firm if it is not well contracted.
3. The patient is not able to
control her maturation when you take the catheter out, e. there is severe
stress incontinence. This is more common the longer you leave the catheter is
situ. Remove the catheter within 48 hours or earlier if the urine is clear.
Teach your patient to do pelvic floor exercises. The problem usually resolves
with time and exercises. Give her a course of contrimoxazola in case she has
development cystitis.
PROBLEMS OF A MORE LONG-TERM NATURE
MATERNAL DEATH IS FAR LESS COMMONLY
Associated with symphsiotomy
than with caesarean section in the comparable situation. Maternal morbidity
then is the main reason for objection to
the use of the operation by some
obstetricians. Why is it that doctors are more afraid of morbidity than mortality?
When your caesarean patient dies, you grieve about it for a short while, and
usually find reasons to justify your
actions, and the problems, which led to her demise. However, with
serious morbidly, the patient often keeps coming back to clinic, and does not let your conscience so easily forget
your involvement in the case.
The only major serious complications of symphysiotomy are
pelvic joint pain and ambulatory difficulty, and intractable urinary
incontinence. Both these complications should be extremely rare when care is
taken with technique and selection of cases.
To prevent excessive
separation of the symphysis after it has been divided and undue stress on the
sacroiliac joins, the two assistants holding the legs must be very careful to keep the knees
pointing directly at the ceiling, and the angle between the thighs less than 90
degrees.
When urinary incontinence is persistent, examination under
anaesthesia should be performed to exclude a fistula. The most likely cause is
avuncular necrosis form the prolonged obstructed labour rather than the
symphysiotomy operation. Precipitate delivery after division of the symphysis
acan cause detachment – of the urethra from the back of the pubic arch, and
this can lead to sever stress incontinence or complete urethral incontinence.
To prevent this from happening the delivery of the head should be controlled
carefully more likely to occur in multiparas. On discharge, the patient is
advised to refrain from lifting heavy weights and from hard physical work for
three months. Hospital delivery is indicated in subsequent pregnancies.
DESTRUCTIVE OPERATIONS.
Destructive operations are
not common nowadays but are indicated when the fetus is confirmed to be dead
and the operation is competent to perform the procedure. Ruptured uterus should
also be excluded. These procedures are safely performed when cervix is fully
dilated although in the hands of an experience
operation it could be done at cervical dilatations of 7.cm or more.
General anaesthesia or. Regional analgesia is required.
Destructive operations
usually performed include craniotomy, decapitation, leucotomy, embryology and
decompression of a hydrocephalic head.
CRANIOTOMY
Craniotomy is the commonest
performed destructive operation. It is indicated in a neglected and obstructed labour with a dead fetus. If the head is more than
three-fiffths palpable above the pelvis brim or if it mobile, craniotomy may be
difficult and dangerous. In such
situations caesarean section should be done. The procedure is done by first
emptying the bladder by urethral catheterization. After exposing the large
caput succedaneum of the fetus by
parting the labis. An incision of about
3cm is made on the posterior aspect of
the scalp with a Mayo Scissors. The index finger of the non-dominant hand is
inserted into the incision and moved around so as to identify the suture and
trace the fontanelle lying posteriorly.
With the index finger resting on the fonatanelle, and the
palmar surface facing upwards, the mayo scissors is then carefully directed
towards the palm of the non-dominant hand and index finger, and made to rest
with the tip of scissors touching the fontanelle. The scissor is steadied and
pushed through the fontanelle into the cavity of the skull. Through the
fontanelle into the cavity of the skull. The scissors is then opened out in a
cruciate director and the brain is evacuated with fingers. A Kocher’s forceps is now clamped on each lip of the
incised scalp, making sure then removed
from the lithotomy stirrups and placed on two stools. Two layers of bandage are
passed through the handles of the two Kocher’s
forceps, with the other end attached to chosen weight. The weight is left to han g
down gently. The body is delivered by the weight. In some cases the use of the
weights may not be necessary. After delivery, the bladder is drained
continuously for 7-10 days.
DECAPITATION:-
Decapitation is indicated in
obstructed labour when the fetus is deed with a shoulder presentation. Position
of the fetal neck, and an assistant may have to pull down an arm to give a
beter exposure of the fetal neck. The
decapitation can be done with
Blond-Heilder decapitation saw or in smaller fetuses the neck can be severed
with stout scissors. After deception, the truck of the fetus is delivered by
traction on the arm. The after-coming head is then rotated in the uterus until
the stump of the neck is pointing down the brith canal. The stump is then
grasped with a heavy volsellum and the head delivered in cases of a suspected gross disproportion, a
caesaren section should be performed.
CLEIDOTOMY.
Cleidotomy is indicated when
the shoulders are impacted in dead fetus. A pair of stout scissors is used to
cut the clavicles, starting with the more accessible one. The reduction in size
of the shoulder griddles following division of the clavicles facilitates delivery.
EMBRYOTOMY.
Embryotomy is rarely done
for an abdominal tumor or a very large fetus following craniotomy and
cleidotomy. An incision is made into the abdomen or thorax. The viscera are
then manually evacuated. It is most easily performed if the breech is
presenting.
DECOMPRESSION
Decompression of
hydrocephalic head can be done by draining the CSF of the fetus before full
dilatation of the cervix. This can be achieved vaginally b perforating the
skull with a sharp instrument like simpson’s perforator, Drews-Symthe catheter,
a spinal needle or a pair of scissors. The hydrocephalic head can also be
decompressed trans-abdominally using a spinal needle. The collapsed head is
easily delivered vaginally. It can also be done for an after coming hydrocep
halic head in breech presentation.
The use of symphysiotomy and destructive operations in
obstructed labour is declining in West African. Caesarean. Sections have become
quite safe in the sub-region with decreasing morbidity and mortality. Many
obstetricians are also expressing reservations on the use of symphysiotomy and
destructive operations even though studies have show that long-term disabling
sequelae of symphysiotomy and the destructive operation are over emphasized.
Medical officers their career and thus may fell more confident in deciding to do a caesarean operation
rather than a destructive operation. Destructive operations. Should not be
disregarded, as post-operative infective
morbidity tends to be lower than pertains in a Caesaren section for obstructed
labour in the face of overwhelming genital tract infection.
COMPLICATION OF OBSTRUCTED LABOUR.
Uterine Rupture.
The likelihood of the uterus
to rupture in obstructed labour is influenced by parity. It is rare for a
nulliparous women to rupture her uterus who rupture may have a scarred uterus
from form a silent uterine pregnancy.
Rupture of the uterus may be spontaneous from over stretched lower segment;
or induced by oxytocics or by operation for the relief of obstruction, which
further distend the vulnerable lower segment. The anterior wall is most
commonly involved in uterine rupture and the tears are more commonly transverse
than long autodial. Occasionally the tears are multiple. Uterine tears may
involve the bladder interiorly or laterally into the broad ligaments with
massive bleeding from the uterine arteries.
Relieved obstructed labour may cause severe
image to the lower genital tract. Necrosis of the interior vaginal wall may
involve the posterior wall the bladder and urethra leading to a vesico- aginal
fistula. Posteriors, sloughing may result in recto-vaginal fistula from
compression between the presenting part and the sacrum.
PERIPHERAL NERVE INJURIES
Rolonged and difficult
labour may injure the nerves upplying the lower limbs. These may be due to
rolonged pressure on the lumbo-sacral trunk by he fetal head impacted in the
pelvis and stretch injury of the sciatic nerve by prolonged and extreme hyperflexion
of the things on the trunk. The commonest presentation is foot drop.
The plantar-flexors and gluteal muscles may also be involved
Occasionally sensory loss may. Accompany
the paralysis.
OSTEITIS PUBIS.
Infection of the public bone
after damage to the periosteum and superficial cortex by pressure necrosis, which has extended unusually deep,
can cause osteitis pubis.
PRESSURE SORES.
Obstructed labour may lead
to a chronically ill patient who may be
immobile in bed. If the patient does not have frequent turning and treatment of the pressure points, sores tend
to develop. The common sites affected are the sacrum, scapulae, heels and
elbows.
AMENORRHOEA
Some patient have amenorrhoea after surviving a
prolonged and traumatic labour. This is probably due to severe endocrine upset.
The menstrual cycle return after a year
or more sometimes after the improvement
in general health, which follows the repair of associated vesico-vaginal
fistulae.
DISCUSSIONS AND CONTROVERSI ES.
The efficient management of
obstructed labour demands the full rage of nursing, medical and surgical
skills, which are Often lacking in most parts of rural areas in developing countries, obstructed labour is
a preventable calamity in obstetric practice
Good antenatal care can select at-risk patient for supervised
delivery physicians or elective Caesaren
section. The use of the partograph to monitor labour can also help to identify
patients whose labour may be difficult and thus facilitate early referral refer
to centres with facilities to handle them.
ANTICIPATION DURING ANTENATAL PERIOD.
Most of the causes of
obstructed labour can be detected during the antenatal period most short women les than 15meters tend to have small pelves. Measurement of maternal height
at the antenatal contraction for clinical pelvimetry. Women who have had prolonged difficult deliveries
usually with unfavourable outcomes would require referral for special obstetric
supervision.
During the third trimester, examination will reveal fetal
macrosmia, abnormal lis, malpresentation and malposition, abnormal lie,
malpresentationand malposition.
Ultrasound scan can also detect these abnormalities as well as pelvic tumors.
An elective caesarean section can be planned to overcome mechanical impediments
to delivery.
ANTICIPATION IN LABOUR
Competent observation in
early labour can detect the predisposing factors of obstructed labour even if they were not recognized during the
antenatal period. The use of the pantograph has been proven to prevent
prolonged labour. The graphical
notation makes it easy to detect
abnormal labour . Referral of patients when the cervical dilatation crosses the
alert line in peripheral centres and reassessment, when the action line is
crossed at the referral centres, when the WHO Partoghrahp is used, goes a long way to help take early decisions to prevent obstructed labour.
In multiparous women, the uterus reacts to obstruction by
increasingly frequent and more violent
contraction of the upper segment which
is subsequently followed by tonic contraction
Retraction continues and the lower uterine segment thinned by
circulferential dilatation in the first
stage of labour, elongates for the first
time and thus becomes progressively
thinner. Retraction of the lower segment proceeds until ruptures.
In nulliparous women, further retraction ultimately cases
and labour usually comes to a standstill
with the uterus in firm spasm. In the
early stages of obstruction palpation of the
Uterus reveals very strong frequent contractions with little relaxation in
between.
The uterus later becomes
hard, uniformly convex and tender to pressure, particularly over the distended
lower uterine segment. When the uterus ruptures, the patient’s condition
deteriorates with collapse and severe abdominal pain. In obstructed labour
extreme compression between the back of the symphysis pubis and the presenting
part prevents the patient from emptying her bladder Urethral catheterization may
be impossible.
The bladder thus forms
a tender palpable swelling above the symphysis pubis. Prolonged compression
traumatizes the bladder leading to bloodstained urine without necessarily
uterine rupture. The fetus invariably dies in obstructed labour from asphyxia dies in obstructed labour from
asphyxia due to interference with placental exchange by prolonged frequent strong uterine
contraction.
In vertex presentation
excessive molding can lead to tentorial tears and intracranial heamorrhage.
Asphyxia from umbilical cord prolapse may occur in shoulder presentation. Most
of the fetuses, which do not die in-utero usually, succumb in the early,
neonatal period from a combination of asphyxia, birth trauma and intra- uterine
infection.
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July 08, 2015
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