Prolonged & Obstructed Labor Rupture Uterus

Prolonged Labor when combined duration of first and second stage of labor (excluding latent phase) is more than 18hrs in primi and >12hrs in multiparous women, is called prolonged labor. Second stage is defined prolonged when it is >2hrs in primi & >1 hr. in multi.

The prolongation denotes either delay in cervical dilatation and/or inadequate descent of presenting part. Incidence of prolonged labor:- - 8% in primigravda - 2% in multigravida

Causes of Prolonged Labor Fault in any one or combination of basic elements involved in labor - Fault in power - Fault in passage - Fault in passenger

Fault in power -Abnormal or Inadequate uterine contraction - Incoordinate uterine contraction - Inability to beardown Fault in passage - Full bladder - Contracted pelvis - Pelvic tumor (e.g.fibroid)

Fault in passenger -Malposition (op), Malpresentation (Face) - Congenital anomaly of fetus (hydrocephalus) - Deflexed head with poor uterine contraction Others - Injudious early administration of sedative and analgesic before actual labor begins

Dangers of Prolong Labor Fetal – The fetal risk increased due to combined effect of hypxia & infection  Intra uterine hypoxia  Low Apgor score at birth  Infection  Intracranial hemorrage  ↑ fetal morbidity & mortality

Maternal Risks- Maternal distress Postpartum Hemorrhage Trauma to genital tract- cervical tear - Rupture uterus - ↑ operative delivery Puerperal sepsis / Subinvolution Undue stretching of the perineal muscles – which may cause prolapse later ↑ Morbidity and Mortality

- Use partography in all labor to diagnose abnormality early and timely intervention, optimally by alert and action line. - Early detection of factors producing prolong labor and appropriate timely treatment. Prevention of prolonged labor

Treatment Evaluate maternal and fetal condition from history, general examination and obstetrical examination and start supportive resuscitation. If there is Fetal Distress in 1 st stage of labor, CPD, Malpresentation or failed augmentation → CS If inefficient uterine contraction → Augmentation of labor by ARM and oxytocin.

Obstructed Labor Definition – Labor is said to be obstructed when inspite of good uterine contraction the progress of labor comes to standstill due to mechanical obstruction. Incidence – 1-5% in referral hospital

Causes of obstructed labor Important Common causes are:-  Contracted Pelvis and CPD  Malpresentation ( Shoulder, braw, mentoposteriar)  Malposition ( DTA, OP ) Less Common causes are:-  Fetal anomalies – Hydrocephalus, fetal ascitis, conjoined twin.  Soft tissue tumor –fibroid, ovarian  Scarred cervix from previous amputation

Course of Labor in Obstructed labor During labor uterine contraction increases in intensity, duration and frequency to overcome obstruction With each contraction some retraction of upper segment occur → Upper segment becomes progressively thicker and shorter (tonic contraction) The passive lower segment progressively stretches and become thinner to accommodate the fetus driven from upper segment

A circular groove is formed between the active upper segment and passive distended lower segment called pathological retraction ring (Bandle’s Ring) In primigravida → further uterine contraction ceases and uterus subsequently becomes inert. In multigravida → the uterus continue to contract vigrously.there is progressive rise of Bandle’s Ring upward and ultimately lower segment rupture if baby is not delivered promptly.

Clinical features of obstructed labor  Patient is in agony due to continuous pain & restless  Features of exhaustion – Tachycardia - Perspiration - Dehydration - Ketoacidosis, L. respiration  P/A Examination - Bladder may be full - Bandle’s Ring is visible - Upper segment of uterus hard tonically contracted & tender - Lower segment distended & tender - Fetal parts may not be well defined - FHS usually absent or bradycardia

 P/V Examination - Edematous Vulva - Hot and Dry vagina - Offensive vaginal discharge - Cervix almost fully dilated - Membranes are absent - Presenting part may be impacted in pelvis - Cause of obstructed labor is reveals

Prevention  Antenatal detection of high risk pregnancy likely to produce prolong labor such as big size baby, short stature women, CPD, malpresentation & malposition.  Routine Partography and timely intervention of a prolonged labor due to mechanical factor can prevent obstructed labor.

Treatment of obstructed labor  Correction of dehydration and acidosis with 1-3 liter NS or RL infusion.  Vaginal swab to be taken for C/S  Arrange blood in anticipation of PPH.  Broad Spectrum antibiotic  Obstetrical Management

Obstetrical Management  If baby alive (rare ) → CS  If baby is dead - Destructive operation is an option if obstetrician Experience - Otherwise do CS - After Every case of operative vaginal delivery → *vaginal, cervical tear and rupture uterus must be excluded. *Oxytocin must be given * Indwelling catheter for 7-10 days

Effects of Obstructed Labor  Fetus - Asphyxia - Intracranial hemorrhage - Infection - ↑Perinatal Loss  Mother Immediate Remote - exhaustion - Genital urinary fistula - Dehydration - rectovaginal fistula - Metabolic acidosis - Variable degree of v.atresia - Genital sepsis - Secondary Amenorrhea due - Injury to G.T. Hysterectomy or Sheehan’s syndrome - PPH & Shock - ↑ M. Morbidity & Mortality

Rupture Uterus  Rupture of uterus is giving way of gravid uterus or dissolution in continuity of uterine wall any time after 28 weeks of gestation with or without expulsion of fetus  Rupture of the uterus is one of the most dramatic serous obstetric Emergency.  Incidence – Widely varies 1 in 200 to 1in 1800 deliveries

Aetiology of Rupture Uterus  Spontaneous Rupture - Obstructed Labor - Fundal Pressure in grand multipara - Uterine malformation  Scar Rupture - Rupture of CS Scar→ L.S.C.S , U.S.C.S- 4-9% -Uterine scar following operation on uterus *Myomectomy *Metroplasty * Hysterotomy * D&C

 Iatrogenic -Injudicious administration of oxytocin - Use of prostaglandin - Internal version - Destructive operations - Difficult Forceps delivery - M.R.P.  Over all most common cause of uterine rupture is separation of previous c.s. scar  But in developing country obstructed labor with feto-pelvic disproportion is still one of the common cause of rupture uterus

Types of Rupture Uterus  Complete Rupture- when uterine cavity communicate directly with peritoneal cavity. - Spontaneous rupture is more often complete.  Incomplete Rupture- when uterine cavity is separated from peritoneal cavity by visceral peritoneum or broad ligament. - Traumatic is usually incomplete  Scar Dehiscence - When there is separation of previous scar with intact peritoneum.

Site of Rupture Lower segment – Most common occurs in previous CS, obstructed labor, which may extent to lateral site & extends upward. Upper Segment – Occurs in previous classical CS, Previous scar in upper segment & other muscular pathology.

Diagnosis Rupture During Pregnancy Typically - Acute abdominal pain - Features of shock & intrabdominal hemorrhage - Easily palpable fetal parts - Absent fetal heart sound - Contracted uterus is felt on one side Atypically - Incomplete rupture producing localized abdominal pain & tenderness -Frank signs of hemorrhage & shock develop slowly - It may confuse with accidental hemorrhage

Rupture in Labor H/o vigorous uterine contraction followed by sudden bursting pain→ cessation of L. pains Signs of internal hemorrhage depending on severity → Shock, abdominal tenderness, guarding P/A → Fetal parts are easily palpable together with hard retracted uterus can be felt. Vaginal Examination - Reveals bleeding through the cervical os - Recession of presenting part in complete rupture - Cervix hangs like a curtain - Hematuria may be present

Management I.V. line, Antibiotics, Arrange blood Laparotomy along with blood transfusion when the ∆ of rupture uterus is made In case of ruptured C.S. scar, low parity, women & rupture wound is clear cut, condition stable →Repair Patient with high parity, edges of rupture are ragged and irregular, anatomy is distorted →Hysterectomy to be.

Causes of Mortality Hemorrhage Shock Sepsis Mortality in intacted uterus rupture is more than scarred uterus Mortality is more (3%) in classical scar than lower segment scar rupture (1%).