OBSTRUCTED LABOUR Question Mrs Muntu Mubaya Ngoni 33 years old, para 6 gravida 7 was admitted to the labour ward at 07.00 hours this morning with a history of being in labour for 3 hours at home. Her general condition was good and on examination, cervical dilatation was 4 cm with a normal vertex presentation. After 4 hours the cervix is 6 cm dilated. Pulse is 80 beats per minute, foetal sounds 138 per minute and regular. a). Explain the term Obstructed labour. 10% b). What would lead you to suspect that there's obstructed labour 20% c). Describe the continuing management of Mrs Mubaya’s labour following the last vaginal examination. 50% d). i. List the five (5) possible causes of Obstructed Labour? 5% ii. State the five (5) possible complications of Obstructed Labour 15%

a) Obstructed labor is defined as the failure of the presenting part of the fetus to descend through the birth canal despite strong uterine contractions, due to a mechanical barrier that prevents further progress. This can lead to prolonged labor and potential harm to both mother and baby. b) You would suspect obstructed labor based on the following signs: • Slow or absent progress of labor: For a multiparous woman like Mrs. Mubaya (para 6), cervical dilation of only 2 cm in 4 hours (0.5 cm/hour) is significantly slower than the expected rate (typically >1 cm/hour in the active phase). • Failure of descent of the fetal presenting part despite adequate uterine contractions. • Formation of a pathological retraction ring (Bandl's ring): A visible or palpable ridge across the abdomen, indicating impending uterine rupture. • Maternal exhaustion: Signs such as increasing pulse rate, dehydration, ketosis, or fever. • Fetal distress: Abnormal fetal heart rate patterns (e.g., decelerations, bradycardia, tachycardia). • Excessive molding or caput succedaneum on the fetal head during vaginal examination. c) The continuing management of Mrs. Mubaya’s labor following the last vaginal examination (6 cm dilated after 4 hours) would involve: Step 1: Re-evaluation and Diagnosis Confirmation • Plot her labor progress on a partograph immediately to visually assess the rate of cervical dilation and fetal descent against the alert and action lines. • Perform a thorough vaginal examination to re-assess cervical dilation, effacement, station of the presenting part, position of the fetal head, and to clinically evaluate pelvic adequacy. • Assess the strength, frequency, and duration of uterine contractions. • Re-check maternal vital signs (pulse, blood pressure, temperature, respiratory rate) and fetal heart rate to ensure well-being. Step 2: Supportive Care • Ensure adequate hydration by establishing an intravenous (IV) line and administering crystalloids (e.g., Ringer's lactate) to prevent dehydration and ketosis. • Provide pain relief as needed. • Ensure the bladder is empty (consider catheterization if she is unable to void or if the bladder is distended). • Offer emotional support and reassurance to Mrs. Mubaya. Step 3: Intervention Based on Findings • If the partograph shows arrest of labor (no further progress) or protracted labor (slow progress) and there is no evidence of mechanical obstruction (e.g., cephalopelvic disproportion, malposition), consider oxytocin augmentation to improve uterine contractions, with careful monitoring. • If cephalopelvic disproportion (CPD) or a malpresentation (e.g., persistent occiput posterior, brow presentation) is suspected or confirmed, or if there is no progress despite adequate contractions, prepare for Cesarean section. • If fetal distress develops at any point, immediate delivery, usually by Cesarean section, is indicated. Step 4: Continuous Monitoring • Continue plotting all parameters on the partograph (cervical dilation, fetal descent, contractions, maternal vital signs, fetal heart rate, urine output). • Monitor fetal heart rate continuously or every 15-30 minutes. • Monitor maternal vital signs every 1-2 hours. • Perform vaginal examinations only when necessary, typically every 2-4 hours, to assess progress. • Monitor for signs of impending uterine rupture (e.g., Bandl's ring, severe abdominal pain, sudden cessation of contractions). d) i. Five (5) possible causes of Obstructed Labour: 1. Cephalopelvic disproportion (CPD): The fetal head is too large to pass through the maternal pelvis. 2. Malpresentation or malposition: Such as brow presentation, face presentation (mentum posterior), transverse lie, or persistent occiput posterior. 3. Fetal anomalies: E.g., hydrocephalus, conjoined twins, large fetal tumors. 4. Maternal soft tissue obstruction: E.g., cervical dystocia, large uterine fibroids in the lower segment, ovarian tumors, or a full bladder/rectum. 5. Contracted pelvis: An abnormally small or misshapen maternal pelvis. ii. Five (5) possible complications of Obstructed Labour: 1. Uterine rupture: Due to prolonged, strong contractions against an unyielding obstruction. 2. Postpartum hemorrhage (PPH): Caused by uterine atony (exhaustion of the uterine muscle) or trauma to the birth canal. 3. Maternal infection: Such as chorioamnionitis or puerperal sepsis, due to prolonged rupture of membranes and repeated vaginal examinations. 4. Fistula formation: Vesicovaginal or rectovaginal fistulas can develop due to prolonged pressure on maternal soft tissues. 5. Fetal distress, asphyxia, or stillbirth: Due to prolonged compression of the fetal head, cord, or placenta, leading to oxygen deprivation. That's 2 down. 3 left today — send the next one.