Obstructed LabourDone by: House officer Salsabil A.

Academic year 2014/2015

USTH

Definition of Obstructed labour

(Dystocia)• Definition: The word dystocia is derived from the Greek root ”Tókos”

which means ”childbirth” thus dystocia meansdifficult labour.

• The World Health Organization (WHO) defines obstructed labour as the labour in which “the presenting part of the fetus cannot progress into the birth canal, despite strong uterine contractions .”

Epidemiology of Dystocia

• In the United States, 8-11% of all deliveries are complicated by an abnormal first stage of labor. Dystocia accounts for 12% of all deliveries in women without a previous CS history, and causes 60% of cesarean deliveries.

• Obstructed labour accounts for one fifth of all maternalmortality and morbidity causes in developing countries.

• In the years of 1990 and 2010, this condition accounted for 19,000 and 11,000 deaths respectively.

• Literature reviews suggests that in many countries maternalmortality due to dystocia is as prevalent today as it was 30 years ago.

Epidemiology continued

• A community based retrospective studyconducted in Ghana found that out of 324 maternal deaths, 26% was contributed to obstructed labour.

• Another study made in Guinea-Bissau, usingverbal autopsies, found that 19% out of 350 maternal deaths was due to obstructed labour.

Epidemiology continued

• In Uganda a study of 2006 found that 22% of all maternal deaths was due to obstructed labour

• Globally it accounts for 8% of all maternaldeaths annually.

• The WHO has set a goal to reduce the incidenceof obstructed labour related maternal mortalityby the year 2015 with 75%

Predisposing Factors to Dystocia

• Maternal causes:- Rickets during growth causing osteomalacia leading to

contracted pelvis- Polio like illness causing bone deformities affecting the

structure of the hip- Short stature (<150 cm)- Female genital mutilation- A serious RTA damaging normal pelvic anatomy- Vaginal stenosis or tumour- Rigid perineum- Pelvic tumour

Predisposing Factors to Dystocia

• Fetal causes:

- Macrosomia, either generalised or localised

- Large fetal head (Hydrocephalus) or othercongenital fetal anomalies

- Locked or conjoined twins

- Non longitudinal fetal lie, eg transverse or oblique

- Erect position of fetal head instead of flexed

Pathophysiology of Dystocia• Normal uterine contraction physiology:• The purpose of uterine contractions is to deliver the fetus and the

placenta, and thus does not mind any obstructive event.

• The whole process of delivery comprises a series of contractionsoccuring in a regular pattern. Each contraction lasts for about 60 seconds and can reach a pressure of 50 mmHg.

• Every contraction requires a huge amount of ATP to allow the smooth muscles of the uterine cavity to contract.

• The whole process of muscle contraction can be summerized in this process called the ”cross-bridge cycle”:

- Depolarisation signal Calcium influx into the cells (due to ionchannel opening) Activation of Myosin Light Chain Kinase(Which phosporylates myosin) Muscle contraction (due to cross-briding of actin with myosin)

Pathophysiology of Dystocia

• The cross-bridge cycle consumes ATP, and the hydrolysisof this constituent will produce acids.

• The maternal body of a healthy pregnant can sustaincontracting for house to deliver the fetus. But when the hours becomes days, this will lead to depletion of the metabolic reserves, and thus ATP levels will become low.

• There will be in lactic acid production (mainly due to the inability to excrete protons) this will ultimatelylead to diminished uterine contractility Obstructed labour!

Clinical Features of Dystocia

The patient has been labouring for more than 12 hours without anyprogress to delivery.

Clinical Featires of Dystocia-The patient is in distress and maybe exhausted-The Urinary bladder might be full but inable to evacuate itscontents-The patient is dehydrated, and her urine might be bloodstained.

Clinical Features of Dystocia

The membranes are ruptured and amniotic fluid might be stained with meconium

Clinical Features of Dystocia

Palpation of gravid abdomen may reveal unusalshapes and fetal parts can not be felt. There mightbe a high retration ring (Bandl’s ring)

Clinical Features of Dystocia

The FSH are either absent or there might be fetal distress with accelerations and decelerations.

Evaluation of a Woman with Dystocia

• Hours of labour progress and vaginal examination?

• Bleeding? Liquor colour?

• Fetal activity?

• Uterine consistency?

• Any tetanic contractions?

Evluation of a Woman with Dystocia

• Examination:

- There is usually an edematous and swollen vulva

- The cervix is fully dilated to palpation

- The presenting fetal part may be moulded or obstructed in the pelvis

- Check for the position of the head and colour of the liquor

- The vagina is dry and there may be purulentdischarge

Managment of Dystocia

• Fluid replacement as the patient is most likely to be dehydrated

• Plot every single change regarding the deliveryon a partogram

• Administer tocolytics to prevent contractionsthat may render the condition worse

• Take CBC, and cross matching for eventual C/S

Managment of Dystocia

• Important essential steps to be taken:

- Broad spectrum antibiotic administration

- Vital signs check every 15 minutes

- Catheterization to determine the amount of urine output and colour

Managment of Dystocia

• Obstetric interventions:- Attempting vaginal delivery: Done when head is low

or the fetus is dead, usually by forceps extraction.- Administration of oxytocin, unless there are strong

uterine contractions and any enhancement canaffect the fetal life.

- Cesarean section: Done for alive fetus with impaction and is usually the managment of choicefor obstructed labour in general

- The remaining third stage of labour should be aidedactively

Complications of Dystocia

• Maternal complications:

- Vesicovaginal fistula

- Vesicorectal fistula

- Uterine rupture

- Maternal distress

- Puerperal sepsis

- Post partum hemorrhage

- Shock

Complications of Dystocia

Complications of Dystocia

• Fetal complications:

- Fetal asphyxia

- Fetal death

- Congenital infections such as pneumonia and septicemia

- Intracranial hemorrhage due to excessive headmoulding

- Acidosis

Prevention of Dystocia

• Community education about this phenomenon

• Proper ANC visits to ensure fetal and maternalwellbeing during the progress of pregnancy and to assess for any riskfactor to obstructed labour

• Assessment of the risk factors: eg. pelvic outletstructure or fetal size

•Thank You