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Obstructed labour (PowerPoint)

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					OBSTRUCTED
  LABOUR
                DEFINITION
   It is Failure of delivery of the fetus due to
    mechanical obstruction.
                        AETIOLOGY
       Maternal causes:
         Contracted pelvis.
         Soft tissue obstruction e.g. fibroid, ovarian tumors impacted in
          Douglas pouch.
         Cervical dystocia.
         Other less common causes include: contraction ring, vaginal stricture
          or septum, vulval edema, hematoma or neoplasma and rigid
          perineum.
       Fetal causes:
             Macrosomia: large fetus more than 4 kg.
             Malpresentations
             Shoulder dystocia: difficulty in delivery of the shoulders
       Locked twins: very rare
             CLINICAL PICTURE
        "Impending rupture of the uterus":

       History:
           History of a prolonged labor, inspite of the presence of good uterine
        contractions, with prolonged rupture of membranes (ROM).
       General examination:
          The patient is exhausted due to prolonged labor.
          Signs of dehydration are commonly evident; blood pressure is low,
           temperature is elevated, pulse is rapid, tongue and mucus membranes are
           dry.
       Abdominal examination:
          The uterus is hard and tender, contractions are rapid and strong.
          Pathological retraction ring = BANDL'S RING is seen and felt as a
           transverse or oblique groove across the abdomen. The ring rises with time.
          Fetal parts are difficult to palpate
          F.H.S. are inaudible or show severe distress.
    Differential diagnosis of pathological
    retraction ring:
       Full bladder (excluded by catheterization).
       Fundal fibroid (not rising - no signs of
        obstruction).
       Contraction ring.
     Pathological retraction ring                      Contraction Ring

Occurs with prolonged second stage          Occurs during any stage

Always lies between the upper and lower     At any level of the uterus
segments
Rises up                                    Does not change its position

Seen abdominally                            Not seen abdominally

The uterus is tonically retracted, tender   The uterus is not tonically retracted and
and fetal parts cannot be felt              fetal parts can be felt
The mother is distressed and the fetus is   The mother and the fetus are not
distressed or dead                          necessarily distressed
Relieved only by delivery                   May relax by antispasmodics or anesthesia
   Vaginal examination:
       The vulva becomes oedematous, and the vagina
        becomes dry.
       The cervix feels oedamatous, not well applied on the
        presenting part unless fully dilated.
       The presenting part is not engaged, pelvic caput
        succidanum commonly develops in the fetal scalp in
        vertex presentation. This is of particular importance
        as.
       The cause of obstruction is determined:
        (Disproportion, Persistent OP, Neglected shoulder
        etc….)
         COMPLICATIONS OF
        OBSTRUCTED LABOUR
   Maternal distress, exhaustion, and dehydration.
   Fetal distress, hypoxia and neonatal asphyxia.
   Prolonged rupture of membranes (with its complications).
   Intra-amniotic infection.
   Rupture uterus (overstretch of lower uterine segment).
   Injuries of birth canal: cervical, vaginal and perineal lacerations.
   Puerperal infection due to:
     - Prolonged labour with prolonged rupture of membranes.
     - Intrauterine manipulations and possible genital tract lacerations.
   Necrotic obstetric vesico-vaginal fistula (due to prolonged head
    compression).
   High perinatal mortality (neonatal asphyxia, fetal birth injuries,
    and sepsis).
            MANAGEMENT OF
          OBSTRUCTED LABOUR:
   Immediate C.S. with least possible manipulations is the safest
    choice
   Difficulties encountered during the procedure include:
      Extension of lower segment incision and subsequent injury of
       the uterine vessels
      Difficulty in extraction of the fetus due to impaction of the
       presenting part
      These problems could be avoided by dis-impaction of fetal head
       vaginally, making an adequate uterine incision and gentle
       extraction of the fetus.
   Exploration of the birth canal (under anesthesia) is essential after
    any vaginal manipulation to exclude any traumatic lesion especially
    rupture uterus.
   Forceps delivery should not be attempted as it carries a high risk of
    complications especially rupture uterus.

				
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Description: Managing prolonged and obstructed labour.