Abnormal labor and with good intervention

Outline
 Definition of abnormal labor (dystocia)
 Discuss classifications of abnormal labor patterns
 Outline etiologies of abnormal labor
 Discuss the diagnosis of abnormal labor
 Describe management options of abnormal labor
patterns
Saturday, February 1, 2025
2

Definition of Abnormal labor
 An abnormal labor is any labor in which the pattern of labor
progress is significantly different from accepted and recognized
patterns of labor progress in terms of cervical changes, decent
of fetal presenting part or profile of uterine contractions.
 Dystocia ( difficult labor) is often used interchangeably to
denote an abnormal labor pattern
3

4
 Dystocia (difficult labor)
• characterized by abnormally slow progress of labor
• is the most common indication for primary c/section.
• Dystocia is a consequence of faults in the five P’s operating alone or
in combination.
 Power (uterine contraction and voluntary muscular efforts)
 Passage (bony pelvis and soft tissues of the birth canal)
 Passenger (the fetus)
 Psyche
 Physician

 Mainly it arises from four distinct abnormalities that may exist singly
or in combination:
1.Abnormalities of the expulsive forces. Uterine contractions may be
insufficiently strong or inappropriately coordinated to efface and dilate
the cervix—uterine dysfunction. Also, there may be inadequate
voluntary maternal muscle effort during second-stage labor.
2.Abnormalities of presentation, position, or development of the fetus
-Passenger abnormality
3.Abnormalities of the maternal bony pelvis—that is, pelvic
contraction.
4.Abnormalities of soft tissues of the reproductive tract that form an
obstacle to fetal descent – passage abnormality
5

 Common Clinical Findings in Women with Ineffective Labor
Inadequate cervical dilation or fetal descent:
 Protracted labor—slow progress
 Arrested labor—no progress
 Inadequate expulsive effort—ineffective pushing
 Fetopelvic disproportion:
 Excessive fetal size
 Inadequate pelvic capacity
 Malpresentation or position of the fetus
 Ruptured membranes without labor
6

Classifications of abnormal labor patterns –
Four major groups
 Prolongation disorders
 Protraction disorders
 Arrest Disorders
 Precipitate labor
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Etiologies of abnormal labor – related to
one of the four P’s of labor determinants
Abnormalities of the powers
 Primary power – uterine contraction
 Secondary power – maternal expulsive efforts
Abnormalities of the passages
 Contraction of the bony pelvis –inlet, midpelvic , outlet
 Soft tissue dystocia – tumor, previa, vaginal septa etc
Abnormalities of the passenger
Psychological factors
 Often due to stress of labor affecting autonomic nervous system
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Abnormalities of the
powers(expulsive forces)
Abnormalities of the "powers" constitute uterine activity that is
ineffective in eliciting the normal progress of labor.
Ineffective uterine action characteristically falls into one of two
categories:
 Hpotonic: with a normal pattern of low-pressure
contractions
Hypertonic: with a discoordinated pattern of high-pressure
contractions.
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Abnormalities of power conti….
Studies of normal uterine activity during labor have revealed the
following characteristics:
 The relative intensity of contractions is greater in the fundus than in the
midportion or LUS (fundal dominance)
 Contractions are well synchronized in different parts of the uterus
 The frequency of contractions progresses from 1 every 3–5 minutes to
1 every 2–3 minutes during the active phase
 The duration of effective contraction in active labor approaches 60
seconds; and
 The rhythm and force of contractions are regular.
10

Abnormalities of the powers – Etiologies
 Primary uterine inertia – abnormal uterine contraction
frequencies, duration and intensity that is due to inherent
myometrial dysfunction
 Mainly affects primigravid without other additional factors
Secondary uterine inertia – causes
 Prolonged labor
 Malpresentations/ malpositions
 Epidural analgesia
 Uterine myoma
 Dehydration and electrolyte imbalances
 Fetopelvic disproportion
 Abruptio placentae with couvaliare uterus
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Diagnosis of abnormal labor patterns - Steps
Document the following parameters against time
 Uterine contraction profile
 Cervical dilatation/effacement
 Descent of fetal presentation
Compare against normal patterns for respective parity, identify
any deviations and then classify into respective abnormal patterns
 Look for specific etiology responsible for the abnormal labor
patterns by carefully assessing the four determinants of labor
progress (P’s of labor)
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Evaluation for causes of abnormal labor
patterns – Assessment of the four P’s of labor
Assessment of powers of labor – four ways
 Palpation of uterine contractions
 External tocodynamometer
 Intrauterine pressure catheter monitoring
 Maternal exhaustion, vital signs, blood glucose and evidence of
dehydration
Assessment of the passenger
 Size, number, presentation, position and anomalies of the fetus by
Leopold's palpations and ultrasonography
Assessment of the passages
 Bony pelvis – clinical pelvimetry
 Soft tissue dystocia – vaginal exam
Assessment of maternal emotional status and pain control
13

Management of abnormal labor – depends on
specific etiology diagnosed
Power abnormalities
 Uterine inertia – Augmentation
 Secondary powers failure – Instrumental assistance
Passenger abnormalities
 Often caesarean deliveries required
 Destructive deliveries in cases of fetal deaths
Abnormalities of the passages
 Often Caesarean delivery
 Episiotomy for perineal level obstruction
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Prolongation Disorders
 Only one prolongation disorder recognized
Prolonged latent phase of labor
 Definition – A latent phase lasting more than 14 hours in a
multigravida and 20 hours in a primigravida
 Lasting more than 8 hours after true labor is diagnosed
 The latent phase of labor begins with the onset of regular
uterine contractions and extends to the beginning of the
active phase of cervical dilatation.
 Challenge in diagnosis is often due to the problem in
diagnosing the exact time of onset of labor.
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 Causes of prolonged latent phase include:
Excessive sedation or sedation given before the end of the latent
phase,
Use of general anesthesia before labor enters the active phase
Labor beginning with an unfavorable cervix
Uterine dysfunction characterized by weak, irregular,
uncoordinated, and ineffective uterine contractions, and
Fetopelvic disproportion.
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 Treatment options in prolonged latent phase primarily consist of therapeutic
rest regimens or active management of labor.
 After 6–12 hours of rest with hydration, 85% of patients spontaneously enter
the active phase of labor, and further progression in dilatation and effacement
may be expected.
 10% of patients will have been in false labor and can be allowed to return
home to wait for the onset of true labor if no other indications for delivery
are present.
 In the remaining 5% of patients, uterine contractions remain ineffective in
producing dilation; in the absence of any contraindication, augmentation with
oxytocin infusion may be effective in progression to the active phase of labor.
18

 Some authorities recommend oxytocin infusion as the primary
treatment for all patients with prolonged latent phase.
 If immediate delivery is required for clinical reasons (eg, severe
preeclampsia or amnionitis), oxytocin infusion is the treatment of
choice.
 The prognosis for vaginal delivery after therapeutic measures is
excellent.
 After abnormalities in the latent phase have been corrected,
patients are not at any greater risk of developing subsequent labor
disorders than are patients who have experienced a normal latent
phase.
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Diagnosis and management of prolonged latent phase of
labor
20

Active –Phase Disorders
 Labor abnormalities are clinically divided into either:
 Slower-than-normal progress: protraction disorder or
 Complete cessation of progress: arrest disorder
 A woman must be in the active phase of labor with cervical
dilatation to at least 4 cm to be diagnosed with either of these.
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Protraction Disorders
Two protraction disorders
1.Protracted (slow rate) cervical dilatation
A cervical dilatation less than 1.2 cm/hr for nulliparas and for
multiparas it is defined as less than 1.5 cm/hr during active phase of
labor.
2. Protracted descent
Descent of the fetal presentation less than 1 cm per hour for nulliparas
and less than 2 cm per hour for multiparas
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Arrest Disorders
Defined as a complete cessation of dilatation or descent.
Three arrest disorders
1. Secondary Arrest of Cervical Dilatation
 No cervical dilatation for 2 or more hours in the active phase of labor
2. Arrest of descent
 No descent for more than 2 hours
3. Failure of descent
 No descent of fetal presentation in deceleration phase or second stage
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Management of abnormal active phase 1st stage of labor
24

Abnormalities in Second stage of labor.
Abnormalities of descent and rotation
 Definition : The median duration of 2nd
stage of labor is 50 minutes
in nulliparas and 20 minutes in multi parous.
 But arbitrary definition of prolonged 2nd
stage are 2hrs in nulliparas
& extended to 3 hrs when epidural anesthesia used; 1hr for multi
paras and extended to 2 hrs when epidural anesthesia used.

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 The duration of 2nd
stage has no relationship to perinatal out
come if fetal distress and traumatic deliveries are excluded.
 Management
 In the absence of fetal heart rate abnormality, if mother is well
hydrated & reasonably comfortable and if there is some progress
of descent or rotation regardless of how slow, there is no need
for operative delivery.

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 CPD may be apparent in second stage of labor – cesarean delivery is
indicated in the presence of clear evidence of CPD
 Evaluate uterine action and if failure of descent and rotation is due to
inadequate uterine action oxytocin augmentation should be done.
 Prolongation secondary to malpositions is managed according to
the malposition diagnosed.
 Prolongation secondary to inadequate maternal voluntary effort is
managed as follows…..
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 Appropriate encouragement & instruction
 Careful selection and timing of anesthesia not to interfere with voluntary
force.
 Allow epidural block to wear off its paralytic effect and can push to level
appropriate for out let forceps & out let vacuum delivery.
 Intervention allowed for this indication when these preconditions are met.
 For women who cannot bear due to pain which over ride the urge of bearing
down. Benefit form analgesics -N2O safe for both fetus & mother.
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Precipitate labor
Precipitate labor has been defined as delivery in less than 3 hours from onset
of contractions.
 Precipitate dilatation can be defined as cervical dilatation occurring at a rate
of 5 cm or more per hour
 Precipitate labor may result from:
Extremely strong uterine & abdominal contractions
Abnormally low resistance of the soft parts of the birth canal
Absence of painful sensations and thus a lack of awareness of vigorous
labor(rarely).
Although, the initiating mechanism for extraordinarily forceful uterine
contractions usually is not known, abnormal contractions may be associated
with administration of oxytocin.
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Maternal Effects of precipitate labor
 Maternal complications are rare if the cervix and birth canal are
relaxed.
 However, when the birth canal is rigid and extraordinary
contractions occur, uterine rupture may result.
 Extensive Lacerations of the birth canal ( cervix, vagina, vulva, or
perineum) are common.
 Furthermore, the uterus that has been hypertonic with labor
tends to be hypotonic postpartum, thereby predisposing to
postpartum hemorrhage.
30

.
Fetal and Neonatal Effects of precipitate labor
 Adverse perinatal outcomes from precipitous labor may be increased
considerably for several reasons.
 The turbulent uterine contractions, often with negligible intervals of
relaxation, prevent appropriate uterine blood flow and fetal
oxygenation, as a result, perinatal mortality is increased secondary to
possible decreased uteroplacental blood flow(hypoxia)
 Perinatal intracranial hemorrhage may result from trauma to the
fetal head pushing against unyielding maternal tissue with contractions.
 Finally, during an unattended birth, the newborn may fall to the floor
and be injured, or it may need resuscitation that is not immediately
available.
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Treatment of precipitate labor
 If oxytocin administration is the cause of abnormal contractions, it may
simply be stopped.
 The problem typically resolves in less than 5 minutes.
 The patient should be placed in the lateral position to prevent
compression of the inferior vena cava.
 If excessive uterine activity is associated with FHR abnormalities and
this pattern persists despite discontinuation of oxytocin, a beta-mimetic
such as 125–250 mcg of terbutaline or ritodrine can be given by
subcutaneous or slow intravenous injection if no contraindications are
present.
 Physical attempts to retard delivery are absolutely
contraindicated.
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Obstructed labour
Yibelu Bazezew,
October, 2016 G.C.
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Learning Objectives
 To define obstructed labor
 To list the important causes of obstructed labor
 To enumerate the immediate and late complications of
obstructed labor.
 To discuss the clinical features of obstructed labor.
 To outline the management of obstructed labor.
 To discuss the prevention of obstructed labor.
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Introduction
 Obstructed labor is failure of descent of the fetus in the birth
canal for mechanical reasons arising from either the
passage or passenger in spite of good uterine
contractions.
 Modern Obstetric care has led to the virtual disappearance of
obstructed labor in developed countries,
 However , in underdeveloped countries obstructed labor is a
common problem.
 It is one of the five leading causes of direct maternal death.
 It was estimated to be the most disabling of all maternal
conditions. Saturday, February 1, 2025
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Intro..........
 It is an absolute condition, which should be applied only when
further progress is impossible without assistance.
 It accounts for about 8% of maternal deaths globally.
 In Ethiopia we host the biggest fistula hospital in the
world due to obstructed labor.
 Obstructed labor is an outcome of a neglected and mismanaged
labor.
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Importance
 is one of the major causes of maternal and perinatal mortality
in developing countries.
 Its incidence is mainly related to
 the availability, accessibility and quality of ante partum and
Intrapartum services in the community
 to a lesser extent to the incidence of fetopelvic
disproportion in the community.
 should never occur in communities where obstetric care is
optimal even if disproportion is prevalent.
 Therefore, is considered as a sign of major failure in
obstetric care.
37

Causes
Obstructed labor is usually an end result of improperly managed
CPD.
Maternal causes:
1.Bony obstruction : e.g.
 Contracted pelvis,
 Abnormal shaped pelvis,
 Tumours of pelvic bones
2.Soft tissue obstruction
 Uterus – impacted subserous pedunculated myoma,
 Cervix - cervical dystocia
 Vagina – septum, stenosis, or tumors
 Ovaries – impacted ovarian tumors
 Trauma to bony pelvis, polio, congenital deformity of bony pelvis
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Causes
 Fetal causes:
1- Malpresentations and malpositions :
 Persistent occipito-posterior and deep transverse arrest,
 Persistent mento-posterior and transverse arrest of the
face presentation.
 Brow presentation,
 Shoulder,
 Impacted frank breech.
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Causes
2. Large sized fetus ( macrosomia).
3. Congenital anomalies :
- Hydrocephalus.
- Fetal Ascites.
- Fetal tumors.
4. Locked and conjoined twins.
40

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Diagnostic approach
 OL is an emergency condition and requires a concerted team
approach.
 A rapid assessment of any patient on first contact is essential to
identify critical patients and immediately instituting life saving
measures. Besides the prolonged labor, a woman with OL may
have life-endangering signs such as loss of consciousness,
breathing difficulty, bleeding, fever, or shock. The general
condition and vital signs (respiratory rate (RR), blood pressure
(P), pulse rate (PR) and temperature) may indicate the critical
condition of the patients
 The management should incorporate close monitoring, comprehensive
clinical evaluation and essential investigations.

History
− Age, height, gait, and any disability affecting the pelvis or lower limbs
− Gravidity, parity,
− Gestation age
 History of current labor:
-Prolonged labor often extending to days rather than hours
-Prolonged rupture of membranes
-Painful contractions (contractions eventually might cease due to uterine
hypotonia or rupture)
42

 Change of labor pain characteristics to continue generalized
abdominal pain (peritoneal irritation due to hemoperitoneum,
infection and meconium) which may be preceded by a sudden
sever pain at the time of uterine rupture (described some times as
“something gives away”).
 The woman may also give a feeling that the “fetus is moving
upwards”.
43

 Past obstetric history:
• Any complications during previous pregnancy
• Reasons for any previous operative deliveries (instrumental
deliveries , CS etc)
• Previous stillbirth or early neonatal death and cause, if known,
and whether associated with prolonged labor
 Medical history, in particular rickets, osteomalacia, or
pelvic injury
44

PHYSICAL FINDINGS
 The physical findings depend on the duration,
complications, cause of the obstruction and gravidity.
 For example, a primigravida with prolonged labor due
to CPD is prone to atonic uterus with fistula formation
while a multipara will have continued stronger
contractions till the uterus ruptures.
45

PHYSICAL FINDING
General examination
Exhausted, tired and anxious(from severe pain, lack of sleep and in
adequate diet)
Fluid and electrolyte imbalance
a. Dehydration
- Cracked lips, dry tongue
- Hot, dry and inelastic skin
- Scanty highly concentrated urine
b. Metabolic acidosis
- Ketosis (from catabolism of fat in the absence carbohydrates)
-Acidemia (accumulation of anions due to ed
↓
urine out put)
46

 Intrapartum infection
 Prolonged rupture of membrane
 Repeated digital examinations
 Manipulation (application of local medicines)
Rapid pulse and often febrile
Hypotension or shock (septic or hemorrhagic due to infection
or uterine rupture)
47

Abdominal examination
Hypotonic or hyperactive uterine contractions
depending on the progress of labor
The cause of the obstruction may be evident on
abdominal examination (abnormal lie, big baby)
Fetal parts may not be felt easily
Distended hypoactive bowels due to electrolyte
deficit (hypokalemia)
FHR (Tachycardia or bradycardia or may be absent)
Bladder often distended.
48

 In multiparous woman and in a primigravid patient with advanced
obstructed labor the three tumour abdomen may be evident
(bladder, lower and upper uterine segments separated by
pathological Bandl’s ring.)
 Bandl’s ring is a late sign of obstructed labor.
 It is the retraction ring which becomes visible and/or palpable
during labor.
 It can be seen as a depression across the abdomen at about the
level of the umbilicus.
49

 The ‘three tumor abdomen” is a
warning sign of an impending
uterine rupture.
 The three tumors are due to:
 Grossly thickened and retracted
upper uterine segment above Bandl’s
ring;
 Thinly distended lower uterine
segment bellow the ring;
 Fully distended or/and edematous
bladder further distending the lower
abdomen.
50

Vaginal examination
 Vaginal examination will reveal edematous vulva and cervix.
 Foul smelling meconium stained liquor,
 Severe caput and moulding
 The cervix may or may not be fully dilated and the station may
be high or low depending on the level of obstruction.
 Catheterization is often difficult because of the impacted
presenting part necessitating insertion of two fingers behind
symphysis pubis to pass Foley catheter and urine is blood
stained.
51

After uterine rupture
 History
Continuous and very severe abdominal pain.
Cession of uterine contraction
Vaginal bleeding
 General examination
Extremely anxious, distressed, with dehydration and shock.
Pulse and BP may be absent.
Low central venous pressure

52

 Abdominal examination
 Greatly distended, tender abdomen and uterus is difficult to feel
 Fetal parts are easily felt
 Lie and presentation may be difficult to detect as the baby has been
displaced into the peritoneal cavity.,
 Positive shifting dullness -suggestive of hemoperitoneum
 Abdominal paracentesis - frank blood
 Absent FHR
 Vaginal examination
Impacted fetal head or receded above the pelvic brim.
Catheterization – blood stained urine
53

MANAGEMENT
Treatment Plan
 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 treating accordingly
54

MANAGEMENT
RESUSCITATION:
 If delivery is not imminent or likely to be so shortly,
resuscitation is the first step before facilitating transfer of the
patient to higher health institution.
 In a hospital admit the patient straight to the delivery unit or
operating theatre
 Update Hct, Blood group and Rh type, and white blood cell
count
 Start intravenous fluid right away to correct dehydration
 Vital signs should be checked regularly.
55

Resuscitation
Fluid and electrolyte replacement
Shock, dehydration add ketotic
-Rehydration with ctystaloids of intravenous fluids and at least 1
liter should be run fast (5%D/W or DNS)
-Add 50 Ml of 50% Dextrose and NaHCO3
 Start Oxygen 6 lit/min if there is fetal distress or maternal
distress
 If the patient is in shock (hemorrhagic or septic), treat shock
aggressively.
56

With the ongoing resuscitation,preparation for operative
interventions (e.g., availing 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.
57

Start broad spectrum antibiotics.
 Give antibiotics if there are signs of infection, or the
membranes have been ruptured for 12 hours or more.
 Ampicillin
 Chloramphenicol and
 Gentamycin.
 Clindamycin and Metronidazole iv are alternatives to
Chloramphenicol
58

Control infection with
Broad spectrum antibiotics
-Ampicillin 2gm IV, QID plus Chloramphenicol 1gm IV, QID and
Gentamycin 80mg IV, TID OR
-Ceftriaxon 1gm IV, BID plus Metronidazole 500gm IV, TID AND
-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).
A titrated infusion of Dopamin for hypovolumic shock with low urine out
put and not corrected with IV fluids.
Tetanus prophylaxis -TAT 1500 units
59

MANAGEMENT
 Insert indwelling catheter into the urinary bladder.
 If cesarean section is planned empty stomach with NGT
 If uterine rupture is strongly suspected, prepare two units of
blood.
 Give sometime for the patient and family before major operative
delivery and provide reassurance.
60

Operative delivery
 A balanced decision should be taken on the method of delivery
and there is no place for “wait and see” policy in obstructed
labor.
 The obstruction should therefore be relieved by operation
(abdominal or vaginal)
 Choice of the operative intervention should depend on:
 Fetal condition (dead or alive)
 Station or descent of the presenting part
 The presence or absence of evidence of imminent or overt uterine
rupture
 Fetal presentation
 Extent of cervical dilatation
 The cause of obstruction Saturday, February 1, 2025
61

Operative delivery
 Vaginal:
 Episiotomy
 Instrumental delivery
 Destructive delivery
An operative vaginal delivery should never be tried if
there is uterine rupture as it can cause:
 extension of the rupture
 release of the tamponade effect of the presenting part
aggravating blood loss
Explore the uterus after any vaginal operative delivery.
62

Operative delivery
Episiotomy
 Episiotomy may be the only intervention required in a patient
with the presenting part in the perineum.
 This is often the case when obstruction is due to tight
perineum.
 Obstructed labor due to CPD at the outlet level, such as due
to occiput posterior position, could be effected by generous
episiotomy.
63

VACUUM AND FORCEPS DELIVERY
 No major degree CPD
 Mild-moderate moulding
 OT or OP position with no or minimal CPD
 Descent not more than 1/5 above brim
 Other pre-conditions for forceps and vacuum are met
 The procedure preferably should be a lift out
 The fetus must be alive especially for vacuum delivery
64

DESTRUCTIVE DELIVERIES
Destructive operations (craniotomy, decapitation,
evisceration and cleidotomy) are indicated if:
 The baby is dead or hopelessly malformed
 Descent is 2/5 or below pelvic brim
 No evidence of imminent or overt uterine rupture. If
imminent uterine rupture is suspected, destructive
delivery under direct vision is indicated.
 Cervix at least dilated to 8cm but preferably should be
fully dilated.
65

CESAREAN SECTION
Cesarean section is indicated if:
 The fetus is alive and exceptional conditions for instrumental
delivery are not satisfied
 Alive fetus with incomplete cervical dilatation or high station
 Alive fetus with Brow or Mentoposterior position
 Alive or dead fetus with evidence of imminent uterine rupture
 Dead fetus with unmet criteria for destructive/ instrumental
vaginal delivery Saturday, February 1, 2025
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If Ruptured uterus is exist:
 Destructive vaginal operation is a contraindication in
ruptured uterus.
 Through a subumbilical vertical skin incision, one of the
following operative procedures is undertaken for rupture of
the uterus:
Repair of uterine tear (with or without tubal ligation)
Total hysterectomy
Subtotal hysterectomy
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 Repair of uterine tear (with or without tubal ligation)
 Tear is not too large
 Recent rupture
 Edge clean and easy to see
 Little or no infection
 Preservation of fertility or menstruation is needed
 Easy procedure
68

Total hysterectomy
 Extensive tear
 Rupture compromising blood supply of uterine
muscle( Necrotic edges)
 Tears difficult to stitch such as posterior tears and
extension into the Vagina
 Grossly infected uterus
 Rupture after prolonged labor
 Future cervical cancer concern
69

 Subtotal hysterectomy
 Similar conditions as total hysterectomy that are
related to infection and tear
 Relative ease /simplicity of procedure than total
hysterectomy
 High subtotal hysterectomy preserves menstruation
 May also preserve sexual pleasure
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Postoperative care and follow up
 Intensive resuscitation and monitoring should be continued till
condition improves
 Blood transfusion
 Antibiotics IV till fever free for 2-3 days and continue with PO
 Investigation including blood and urine culture and sensitivity
as indicated
 Analgesics including pethidine
 Breast care for those with stillbirths or neonatal deaths
 Close monitoring to identify complications early (e.g., abscess)
72

,
 Explain condition and counsel on future pregnancy
Repaired uterine rupture without tubal ligation or CS: always hospital
Delivery
 Total or sub-hysterectomy or tubal ligation: infertility
 Hysterectomy: amenorrhea and infertility
 Severe postpartum infection: possibility of ectopic pregnancy in future
pregnancy and need for early check up if pregnant; infertility (one child syndrome)
 Fistula care and follow-up: Women with fistula are kept in the hospital until
infection is controlled. They should be explained about when and where they
can have the fistula repair. Usually, the fistula repair is undertaken 2-3 months
after delivery.
73

 Follow up schedule of women with OL after discharge depends
on the type of complications, operative procedure and
residence of the patient.
 It is advisable to keep patients till infection and acute
conditions are well controlled, especially in women coming
from rural and distant areas.
 Besides the basic postpartum care, the follow up care focuses on
the specific complication sustained after OL.
74

Complications
 Maternal and neonatal mortalities and morbidities are greatly increased in OL
due to complications arising from prolonged labor, mechanical effects of the
obstruction or/ and operative interventions.
Maternal complications
Infection (sepsis, abscess and peritonitis) and septic shock leading to various
organ failure (temporary or permanent)
Hemorrhage (APH, PPH)– shock and anemia
Urinary or/ and rectal fistula: more common in nullipara mainly due to
pressure necrosis of the vaginal wall entrapped between the fetal head and
bony pelvis. Some are due to operative complications used to relieve the
obstruction (e.g. bladder injury during CS or craniotomy).
−
75

Ruptured uterus: more common in multipara
Nerve injury: e.g., drop foot(sciatic and/ or common perineal
nerve palsy)
 Infertility following postpartum PID or hysterectomy
 Psychological trauma due to the painful labor experience, loss
of the baby, fistula and social isolation
 Fetal loss and maternal death
76

 Fetal complications
 Cerebral birth trauma
 Asphyxia
 Early neonatal infection
 Congenital pneumonia
 Seizure disorder ± neurological deficit
 Mental retardation
77

Quize1
1. write the management options of obstructed labour.
2.List and define the two active phase disorders.
3.Define obstructed labor.
4.How the passanger (fetus)affectes the progress of labor?
78

PREVENTION
Obstructed labor is preventable!!
 Good obstetric service including universal ANC
 Risk assessment: short stature, bony deformity, big baby,
malpresentation, malpositions, pelvic assessment antenatally for
selected patients
 Careful assessment of labor progress with Partograph (early
recognition of CPD)
 Good nutritional supply since childhood
 Avoid early marriag
 Promote family planning services
 Maternal waiting area (MWA) for high risk mothers in remote area
 Elective caesarean delivery when indicated Saturday, February 1, 2025
79

Feto-Pelvic Disproportion
Cephalopelvic Disproportion
80

Outline
 Define fetopelvic/cephalopelvic disproportion
 Discuss etiology of fetopelvic disproportion
 List steps of fetal size estimation
 Outline diagnosis of fetopelvic disproportion
 List complications of fetopelvic disproportion
81

Definitions
 Fetopelvic disproportion refers to a discrepancy between the
fetal parts and the bony pelvic dimensions through which it has
to pass during delivery.
 As the structure with large diameters and being the least
pliable, the fetal head is the fetal part often creating
disproportion with the pelvis.
82

FPD/CPD……
 Cephalic presentation is the commonest presentation makes CPD
to be the most important fetopelvic disproportion.
 Fetopelvic disproportion can however occur in other
presentations such as the breech and shoulder as well.
 Fetopelvic disproportion occurs on an individual basis;
i.e. it is an event that involves a particular fetus with a
particular pelvis.
83

FPD/CPD………
 The same pelvis that could not pass a particular fetus may easily
deliver a smaller fetus and vice versa.
 Hence, FPD diagnosis always entails the comparison b/n two
variables at the same time.
 The Dx of FPD often requires the test of labor to Dx it.
 It often cannot be accurately predicted before hand.
 The best pelvimeter is the fetal head; and the best
diagnostic method is trial of labor.

84

FPD/CPD……
 Thus CPD is often diagnosed with certainty after a trial of labor
with adequate augmentation of inefficient uterine contractions.
 Most diagnoses of CPD are often considered to be inaccurate as
nearly 90% of women whose primary indication for caesarean
section was CPD have a successful VBAC in subsequent deliveries.
85

86
Etiology of Fetopelvic Disproportion
Fetal Maternal (Contracted Pelvis)
Fetal macrosomia
Fetal malpresentations- Breech,
Face, Brow ( the same fetus which
would have been delivered had it been
a vertex, develops a disproportion in
these positions)
Fetal malpositions-
Occipitoposterior – the same fetus
which would have been delivered if in
occipitoanterior fails to be delivered
in OP positions
Fetal anomalies- hydrocephalus,
 Genetic variations in maternal
pelvic size and shape
 Pelvic fractures in childhood
 Skeletal deformities leading to
pelvic deformities- poliomyelitis;
kyphoscoliosis
 Childhood malnutrition and rickets
 Congenital pelvic abnormalities-
very rare such as Naegle’s pelvis ( one
ala of the sacrum is missing) and
Robert’s pelvis ( both ala of the
sacrum are missing)

Assessment of the Female Pelvis
General physical
exam
Clinical Pelvimetry Radiological
Pelvimetry
•History of difficult
vaginal delivery
•History of prolonged
labor
•History of operative
delivery
•History of pelvic
fracture
•Short maternal stature
•Kyphoscoliosis
•Lower extremity
deformity
•Performed at term for every mother with the
risk factors indicated in general physical exam
•Performed for every mother at admission to
labor or induction
•Assess the following:
•Diagonal conjugate- reachability of the sacral
promontory
•Pelvic side walls- convergent or divergent
•Ischial spines- prominent or flat
•Sacrum – flat, concave or convex and pushed
anteriorly
•Sub pubic arch- accommodates two fingers
•Intertuberous space- accommodates the four
knuckles
•Anteroposterior and
lateral X-ray views of the
pelvis obtained and the
various relevant
diameters measured.
Abandoned from clinical
practice as there are no
strict measurements
indicating a pelvis that
cannot deliver a fetus.
Diagnosis of CPD
involves the fetus size as
well.
87

FINDINGS INDICATING ADEQUATE PELVIS:
DATA FINDINGS
Forepelvis ( pelvic brim)
Diagonal conjugate
Symphysis
Sacrum
Side walls
Ischial spines
Interspinous diameter
Sacrosciatic notch
Subpubic angle
Bituberous diameter
Coccyx
Anterposterior diameter of outlet
Round
≥11.5 cm
Average thickness, parallel to sacrum
Hollow , average inclination
Straight
Blunt
≥ 10.0 cm
2.5 -3 finger - breadths
2finger - breadths
4 knuckles (> 8.0 cm)
Mobile
≥ 11.0 cm
88

Methods of Fetal Weight Estimation
Method Description
Maternal estimation of fetal
weight
Mother is asked to estimate if current pregnancy feels heavier
or lighter than previous babies. Weight is estimated in
reference to previous weight based on her estimate.
Clinical estimation Fetal weight estimated during abdominal exam based on the
clinician’s experience.
Johnson’s formula Estimated fetal weight= SFH in cms- 11(12) X 155 grams.
Accurate within 375 grams range.
Sonographic estimation Fetal weight is estimated by sonographic machines based on
inbuilt formulas after certain fetal biometric variables are
measured by the sonographer. Accurate to within 300 grams
range. Saturday, February 1, 2025
89

90
Estimated fetal weight greater than 4500 grams- most protocols
suggest a caesarean delivery assuming that such a large fetal weight
cannot be accommodated by even a capacious pelvis.

91
CPD
 Def: when the fetal head failed to pass through the pelvis
 Can be
 absolute: the fetal head to big to pass the normal pelvis or the
pelvis is too narrow to pass a normal sized fetus
 relative: a normal sized fetus unable to pass an adequate pelvis
as a result of abnormal attitude /position:
 persistent occiputo posterior, mentoposterior ,persistent
brow ,posterior asynclytism

Assignment
 What is asynclytism?
 Types of asynclytism
 How it can be diagnosed?
 Management of asynclytism
92

93
….CPD
 Causes are
Contracted pelvis
Big baby
Abnormal presentation
Abnormal position

94
…CPD
 Diagnosis is
 By labor abnormality after the power problem is ruled out
 Protracted or arrest disorders
 In the 1st
stage /second stage
 By signs of overt CPD
 Capute ,moulding ± meconium
 Usually in the second stage /sometimes in the late second
stage
 NB .the following could help us in suspecting possibility of CPD
but they are not a definitive method of diagnosing CPD
 Hx of prolonged labor with still birth/neonatal death,
 instrumental deliveries
 pendulous abdomen
 short women with short finger and feet
 Unengaged head /unable to do head to pelvic fitting test

Cephalopelvic disproportion tests:
 These are done to detect contracted inlet if the head is not engaged in the last 3-4
weeks in a primigravida.
(1) Pinard’s method:
 The patient evacuates her bladder and rectum.
The patient is placed in semi-sitting position to bring the foetal axis
perpendicular to the brim.
 The left hand pushes the head downwards and backwards into the pelvis while
the fingers of the right hand are put on the symphysis to detect disproportion.
95

(2) Muller - Kerr’s method:
 It is more valuable in detection of the degree of disproportion.
 The patient evacuates her bladder and rectum.
 The patient is placed in the dorsal position.
 The left hand pushes the head into the pelvis and vaginal examination
is done by the right hand while its thumb is placed over the symphysis
to detect disproportion.
96

Degrees of Disproportion:
(1) Minor disproportion:
 The anterior surface of the head is in line with the posterior
surface of the symphysis. During labour the head is engaged due
to moulding and vaginal delivery can be achieved.
(2) Moderate disproportion (1st degree disproportion):
 The anterior surface of the head is in line with the anterior
surface of the symphysis. Vaginal delivery may or may not
occur.
(3) Marked disproportion (2nd degree disproportion):
 The head overrides the anterior surface of the symphysis.
Vaginal delivery cannot occur.
97

Diagnosis of Fetopelvic Disproportion
Antepartum diagnosis
Assessment of the female pelvis at term in those at high risk for
contracted pelvis
Assessment of fetal weight at term or post term
If a diagnosis of “gross pelvic contracture” or “very large fetal
weight” i.e. > 4500 grams is made then a decision for elective
caesarean section can be made.
98

Gross pelvic contracture signifies an easily reachable sacral
promontory; highly convergent pelvic side walls; prominent
ischial spines; flat or forward sacrum; acute sub pubic arch and a
narrow intertuberous diameter that does not allow the four
knuckles. Gross contracture is a rare diagnosis.
 In most cases either a adequate; capacious or a “ suspected” or
“borderline” pelvic contracture is diagnosed in which case a trial
of labor is allowed so that labor will decide the true pelvic
capacity.
99

Suspect CPD
 Previous prolonged labor with bad obstetric history or
operative delivery
 Primigravida especially if age is less than 16 years
 True conjugate of 8 – 10 cm (borderline CPD)
 Prominent ischial spines, flat sacrum etc
 The cervicogram crossing the alert line without signs of
CPD
100

Intrapartum diagnosis
Fetopelvic or CPD is diagnosed during labor follow up by the
following:
Abnormal labor patterns such as secondary arrest of cervical dilatation
and protracted dilatation
Failure of augmentation to correct the abnormal labor
Failure of descent of presenting part particularly in late first stage or
second stage of labor
Excessive fetal head caput or molding
Plus a clinical pelvimetry indicating a contracted pelvic dimensions
101

Complications of Fetopelvic Disproportion or CPD
Maternal complications Fetal and Neonatal complications
•Prolonged labor
•Obstructed labor
•Infections- chorioamnionitis/ puerperal sepsis
•PROM
•Cord presentation/prolapse
•Other malpresentations are more common in
gross CPD due to failure of descent and
engagement of the fetal head into the pelvis
resulting in unstable lie
•Increased operative vaginal delivery
•Increased caesarean delivery
•Genital trauma
•Post partum hemmorhage
•Fetal asphyxia and distress
•Neonatal asphyxia
•Neonatal sepsis
•Increased stillbirth and neonatal mortality
•Birth trauma either following spontaneous or
operative delivery
•Malpresentations and related complications
102

Treatment plan
 C/S for gross CPD with normal fetus
 Hydrocephalus is managed by craniocentesis
 If gross CPD with normal fetus is diagnosed, elective CS is appropriate
 C/S /instrumental depending on
 the degree of CPD
 Station of the fetus
 Suspected CPD: Mild and moderate of contracted pelvis needs -trial of labor
 Plan place of delivery at a hospital (where CS service is available) or health
centre with timely referral service to a hospital.
 Conduct trial of labor using partogram
 Emergency CS is done when CPD is diagnosed after trial of labor
 Obstructed labor or ruptured uterus treat accordingly.
103

Trial o flabor to manage CPD
 It is a clinical test for the factors that cannot be
determined before start of labour as :
1. Efficiency of uterine contractions
2. Moulding of the head
3.Yielding of the pelvis and soft tissues
104

Procedure
1. Trial is carried out in a hospital where facilities for C.S is
available.
2. Adequate analgesia.
3. Nothing by mouth.
4. Avoid premature rupture of membranes by:
- rest in bed,
- avoid high enema,
- minimise vaginal examinations.
5. The patient is left for 2 hours in the 2nd stage with good uterine
contractions under close supervision to the mother and foetus.
105

Termination of trial of labour:
 Vaginal delivery: either spontaneously or by forceps if the head is
engaged.
 Caesarean section if :
 failed trial of labour i.e. the head did not engage or
 complications occur during trial as foetal distress or prolapsed
pulsating cord before full cervical dilatation.
106

Refferences
 Williams obstetrics23 edition
 CurrentOBGYN2007
 Management protocol on selected obstetrics topics (FMOH)
January, 2010
 Obstetrics Simplified Diaa M. EI-Mowafi, MD
107

Thank You!!!
108

Abnormal labor and with good intervention

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