Active labour which lasts longer than 24 hours, sometimes several days.
– Possible hypovolaemic shock.
– Patient dazed, anxious, agitated, in pain.
– Imminent uterine rupture (pathological retraction ring, hourglass shape, see Chapter 3, Section 3.3).
– Amniotic infection: fever, foul-smelling amniotic fluid.
– Distended bladder.
– On vaginal examination:
- oedematous cervix;
- depending on the presentation:
- Vertex: caput that may reach the vaginal opening, but vertex itself not engaged and pelvis seems narrow;
- Breech: retention of aftercoming head;
- Transverse: neglected shoulder, prolapsed arm and hand.
– Foetus often dead or in life-threatening condition.
7.2.2 Possible causes
– Foeto-pelvic disproportion (including malpresentations and praevia obstructions).
– Pushing with an incompletely dilated cervix.
– Uterine rupture.
– Uterine infection, septicaemia, peritonitis.
– Compression injuries to the bladder and rectum, leading to the formation of fistulae.
– High maternal and foetal mortality.
– Insert an IV line (16-18G catheter), fluid resuscitation (Ringer lactate or 0.9% sodium chloride).
– Insert a urinary catheter, if it is possible without damaging the urethra. Otherwise, insert suprapubic catheter. Relieving the bladder distension is sometimes enough to produce delivery.
– Depending on the cause of the obstruction and the medical equipment available:
• The foetus is alive and viable: caesarean section.
• The foetus is non-viable or if there is no possibility of caesarean section: symphysiotomy, episiotomy and vacuum extraction.
• The foetus is dead: embryotomy.
– There is a significant risk of postpartum haemorrhage due to uterine atony: if active management of third stage labour fails, quickly perform manual removal of placenta then, administer oxytocin.
– Speculum examination: if tissue necrosis, excision under sterile conditions.
– Perineal and vulvar toilet, 2 times daily.
7.2.5 Prevention/management of vaginal fistulae
– Encourage the patient to drink 4 to 5 litres of water per day.
– Leave the urinary catheter in place for 14 days, then:
• If there is no fistula: remove the urinary catheter.
• If the fistula is ≤ 4 cm diameter, attempt conservative treatment. Leave the urinary catheter in place for at least 4 to 6 weeks to allow fistula to heal. Keep the catheter in place as long as the fistula is not closed and as long as a gradual decrease of its diameter is observed at each weekly inspection.
• If the fistula is > 4 cm diameter or the conservative treatment fails or the patient has fistula for over 3 months, refer or register the patient for surgical treatment.