7.2 Obstructed labour

Active labour which lasts longer than 24 hours, sometimes several days.

7.2.1 Diagnosis

– Dehydration.

– 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.

7.2.3 Complications

– Uterine rupture.
– Uterine infection, septicaemia, peritonitis.
– Compression injuries to the bladder and rectum, leading to the formation of fistulae.
– High maternal and foetal mortality.

7.2.4 Management

– 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.

– Antibiotic therapy for prolonged rupture of membranes or a rupture of unknown duration (Chapter 4, Section 4.9) and for chorioamnionitis (Chapter 11, Section 11.4.2).

– 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.

For more information on vaginal fistulae, see: Guiding principles for clinical management and programme development Obstetric Fistula. World Health Organization,  Geneva 2006.