7.2 Obstructed labour

Active labour which lasts longer than 24 hours, sometimes several days with insurmountable barrier preventing the foetal descent.

7.2.1 Diagnosis

– Patient dazed, anxious, agitated, in pain
– Dehydration and possible hypovolaemic shock
– Possible distended bladder
– Imminent uterine rupture (pathological retraction ring, hourglass shape, see Chapter 3, Section 3.3)
– Frequent amniotic infection (fever, foul-smelling amniotic fluid)

On vaginal examination:
– Oedema of the 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).
– Pushing with an incompletely dilated cervix.

7.2.3 Complications

– Uterine rupture.
– Intrauterine 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 Foley 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 (Chapter 9, Section 9.7).
– Antibiotherapy for prolonged rupture of membranes or a rupture of unknown duration (Chapter 4, Section 4.9) or for intrauterine infection (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 (Chapter 9, Section 9.2) then, administer oxytocin (Haemorrhage due to uterine atony, Table 7.2).
– 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 daily.
– Leave the Foley catheter in place for 14 days, then:
• If there is no fistula: remove the Foley catheter.
• If the fistula is ≤ 4 cm diameter, attempt conservative treatment. Leave the Foley 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: Obstetric Fistula - Guiding principles for clinical management and programme development. World Health Organization, Geneva 2006.