2. OUTLINE
• Prevention
• Specific treatment
– Resuscitation and monitoring of life endangering conditions
– Relief of Obstruction
• Vaginal
• Abdominal
• Postoperative care
3. A. Prevention
• Good nutritional supply? since childhood.
• Avoid early marriage?
• Emergency obstetric Care
• Universal ANC is outdated
• Monitor labor using partograph?
• Promote family planning? services
• Maternal waiting area (MWA)? for high risk mothers in remote
area
• Elective caesarean delivery? when indicated
4. B. Specific Treatment
The initial management of OL and ruptured uterus involves two
concurrently on going activities:
Resuscitation and monitoring of the life endangering conditions such
as
• Shock
• Sepsis
Identifying the cause of OL? and other complications and Intervening
accordingly
5. Resuscitation (ABC) and Monitoring
− Shock Treat with ongoing resuscitation
− Dehydration Fluid and electrolyte replacement
If the woman is not in shock but she is dehydrated and ketotic, give 1
liter of ringers lactate or (DNS) rapidly and repeat (x3) till dehydration
and ketosis are corrected. Then reduce to 1 liter in 4–6 hours.
− Monitor closely
Keep an accurate record of all intravenous fluids infused, drugs given,
vital signs and urinary output.
6. − Sepsis
In Severe cases the following antibiotic regimen can be used:
• Ampicillin 2 g every 6 hours (QID) or ceftriaxone and
• Gentamicin 5 mg/ body weight every 24 hours IV (adjusted with renal
status)
• Metronidazole 500 mg IV every 8 hours, Clindamycin or
Chloramphenicol
In Less severe cases, ampicillin and gentamicin may be adequate.
− Analgesics can be given while resuscitating and preparing her for
operative delivery.
There is no reason to withhold anti-pain treatment in a woman with
obstructed labor which developes peritonitis.
7. − Other Medications given
Crystalline penicillin 2 mega units IV Q 2 hourly (For infections by gas-
forming organisms).
Hydrocortisone initial dose 200-400 mg IV followed by 100-200 mg IV,
4 hourly (If there is septic shock).
Titrated infusion of Dopamine (for hypovolemic shock with low urine
out put and not corrected with IV fluids)
Tetanus prophylaxis??
TAT 1500 units
8. Preparation before intervention
o Empty bladder
o Empty stomach with NG tube
o Laboratory tests required for preoperative assessment and evaluation:
− Hemoglobin/ Hct
− Blood group (ABO, Rh) prepare 2 units.
− Urine analysis
− Renal function tests (especially with decreased urine output)
− Blood culture and sensitivity
− Others test depending on individual clinical findings
10. Caesarean Delivery
Indications
Alive fetus with incomplete cervical dilatation or high station.
Alive fetus with Brow or Mentoposterior face position.
Alive or dead fetus with evidence of imminent uterine rupture.
Dead fetus with unmet criteria for destructive/ instrumental delivery.
Placenta Previa Totalis is one criteria.
Complications
Less safe in small rural hospitals where most of obstructed labor have to be dealt with.
Risk of Hemorrhage.
Risk of Injury to bladder and ureter.
Risk of rupture for women who come to hospitals as a last resort. So for subsequent Px she might
not come.
Risk of Reproductive failure.
11. Laparotomy
Simple repair of ruptured uterus (with or without tubal ligation).
• Clean wound, lower segment transverse incision (Prev. C/S).
• Recent rupture.
• Tear is not too large, clean edge.
• Preservation of fertility or menstruation if needed.
• Little or no infection.
• Easy procedure.
Total abdominal hysterectomy/ Subtotal hysterectomy
• Severe infection of uterus
• Rupture compromising blood supply of uterine muscle
• Extensive tear with Necrotic edges
• Tears difficult to stitch such as posterior tears and extension into the vagina
• Rupture after prolonged labor
• Future cervical cancer concern
12. Forceps Delivery
Indications
Alive fetus and head < 1/5 above pelvic brim. ( Well Engaged)
Mild-moderate moulding.
OT or OP position with no or minimal CPD. (Incomplete rotation + Minor disproportion)
Complications
Posterior rupture of Uterus or Colporrhexis (Tearing of vagina) due to “Boot-Scrapper effect”
Bladder neck injury
Inc. distortion of already moulded fetal head likely to produce Tentorial Tear.
Contraindications
Dead fetus
Pelvic Tumors
Mentoposterior Face or a Brow Presentation. B/c Impacted head can’t be flexed for delivery
13. Vacuum Extraction
Indication
Same as Forceps but its benefit
–Easier to apply b/c there is no need to define exact position of head,
nor to rotate it.
–Doesn’t occupy space b/n fetal head and pelvic side walls.
–Laceration of Vagina is less
Complications and Contraindications
Same as Forceps
One useful function over Forceps is to complete delivery after
symphysiotomy.
14.
15. Symphysiotomy
Indications
Done for Gross CPD as a cause of Obstructed Labor in a patient with no Previous Obstetric Care.
Complication
Serious urinary and Locomotory disabilities.
Pubic pain and Back pain.
Contraindications
Dead fetus.
Previous C/S.
Extreme degree of contraction of pelvis (TC< 6cm).
Breech, Brow or mento-posterior face presentation.
Preexisting locomotor disturbance (Hip joint d/s).
Gross Obesity.
16. Destructive Delivery
Indication
Dead fetus
Fully dilated cervix and
No evidence of rupture or imminent rupture.
2/5 or less of his head must be above the brim (Impacted Head)
His mother's cervix must be at least 7 cm dilated, and preferably fully dilated.
Her uterus must be unruptured, and not in imminent danger of rupturing.
Caution
If she is a multiparous with a dead fetus, and has been in labour for a long time, her lower
segment will be very thin. She can only be saved by Caesarean section; any destructive
operation, except Craniotomy, will rupture it.
17. Management of Obstructed Labor
General Measures Obstruction relief
Resuscitation Vaginal Route
Oxygen Operative Delivery
Antibiotics Destructive Delivery
Catheterization Abdominal Route
Pain relief Caesarean Delivery
NG tube drainage of gastric Laparotomy – Uterine
contents repair or Hysterectomy
Hemogram and blood as
necessary
17
19. C. Postoperative care and follow up
Intensive resuscitation and monitoring should be continued till condition (K+ corrected)
improves.
Puerperal Sepsis is almost Inevitable so Antibiotics IV till fever free for 2-3 days and continue
coarse PO.
Close monitoring to identify complications early (e.g., Peritonitis; Abscess).
Bladder drainage for 5-7 days by indwelling catheter.
Blood transfusion.
Investigation including blood and urine culture and sensitivity as indicated.
Analgesics including pethidine.
Breast care for those with stillbirths or neonatal deaths.
Fistula care and follow-up:
Women with fistula are kept in the hospital until infection is controlled. They should get
informed about when and where they can have the fistula repair.
Usually, the fistula repair is undertaken 2-3 months after delivery.
20. Explain condition and Counsel on future pregnancy
o Repaired uterine rupture without tubal ligation or CS:
Always hospital delivery.
o Total or sub-hysterectomy or tubal ligation:
Amenorrhea and Infertility.
o Severe postpartum infection:
Possibility of ectopic pregnancy in future pregnancy and
Need for early check up if pregnant;
Infertility(one child syndrome)
21. Bibliography
• Obstructed Labour Chapter 11 by J.B.Lawson
• Management Protocol On Selected Obstetrics Topics; FMOH
January, 2010
• Dr. Asheber Gaym- Concise best short note book, 2009
• World Health Organization; Education material for teachers
of midwifery: midwifery education modules. – 2nd ed. 2008
22. Thank
You
”Obstructed labor? Definitely!
Head won't budge an inch!”
Notas del editor
When Obstruction is diagnosed it must be relieved immediatelyHowever the effects of the preceding prolonged labor must be at least partially rectified.
Nutritional Supply--Rickets…Contracted PelvisEarly Marriage--Immature PelvisPelvic Ass. Remote from term--For Untested PelvisPartograph--Early recognition of CPD.Family Planning--For Preconceptional CounselingMWA--To deal with Shock, SepsisElective C/S If she has Severe CPD
Causes of obstructed labour Cephalopelvic disproportion (small pelvis or large fetus) Abnormal presentations, e.g.- brow- shoulder- face with chin posterior- after coming head in breech presentation Fetal abnormalities, e.g.- hydrocephalus*- locked twins* Abnormalities of the reproductive tract, e.g.- pelvic tumour*- stenosis of cervix or vagina**tight perineum.*** Rarer causes.** This may be associated with scarring caused by female genitalmutilation.
If the patient is in shock (hemorrhagic or septic), treat shock aggressively With the ongoing resuscitation, preparation for operative interventions (e.g., Preparing cross matched bloods, organizing the OR), has to be undertaken so that measures to stop bleeding or removal of septic focus (e.g., hysterectomy for ruptured uterus) are done as soon as possible. Whenever there is ongoing bleeding (as in ruptured uterus), laparotomy should not be delayed till patient is resuscitated out of shock.Crystalloid Rx for dehydration.
Give antibiotics if there are signs of infection, or the membranes have been ruptured for 12 hours or more. In severe cases with OL for days,If the womandelivered by caesarean section or had laparotomy, continue antibiotics until the woman is fever-free for 48 – 72 hours.
Tissue anoxia and Necrosis favor activation of tetanus spores.
Emptying Bladder—Metal catheter should never be used before delivery b/c the devitalized urethra is easy to injure.Empty stomach—Before anesthesia to prevent aspiration.
CAUTION ! Don't use an oxytocin drip if there are signs of obstruction. On the correct indications, you can use it for delay If there is obstruction or delay, don't use Kielland's forceps, or try internal version. Never do an operative vaginal delivery if her uterus has already ruptureddo a laparotomy. You may not know if it is ruptured or not, so do all vaginal operations in an Operation Theatre, with a set of laparotomy instruments ready for instant use.
Lower Segment transverse scar only ruptures during labor.Upper Segment classical scar ruptures @ anytime during the last trimester.
Pfannenstiel Incision is the choice of incision for C/S or Hysterectomy.If Cervix is intact—Subtotal HysterectomyRelative ease of procedure than total hysterectomyHigh subtotal hysterectomy preserves menstruationMay also preserve sexual pleasureIf Cervix Removed—Total Hysterectomy
NEVER If Ux Rupturedb/c we remove the tamponading effect of fetus.Very limited place in the management b/c the stage of obstruction is reached after tremendously powerful expulsive efforts have failed So additional traction with forceps will usually not complete the delivery unless Brute Force is Used.Tarnier’s axis traction forceps invented for obstructed labor are Obsolete now by LUST C/S“Trial Of Forceps” Done in an operating theatre with everything ready for C/S
Even More limited use in Management of Obstructed labor
Enlargement of pelvis by dividing the symphysis pubis. Joint separation shuld not exceed 2.5 cm; this enlarges the pelvis by 25%.Wide Episiotomy in all cases.Extreme degree of pelvic contracture--True Conjugate <6cm or Very large fetus >4kgScarred Ux shuld not be expected to withstand the extra strain required to overcome disproportion.
Craniotomy--Simpsons Perforator for impacted head with greatest diameter below BrimMorris’s Craniotomy Forceps for impacted head with greatest diameter above BrimCleidotomy—Embryotomy ScissorsDecapitation—Ramsbotham’sdecapitating hook for impacted shoulder presentation
Explain both to her and to her relatives that it could have been prevented by adequate obstetric care.