Obstructed Labour

Definition

Obstructed labour is the failure of the fetus to descend through the birth canal, because there is an impossible barrier (obstruction) preventing its descent despite strong uterine contractions.

causes

Maternal causes

a.Bony obstruction e.g.

> Contracted pelvis.

> Tumours of pelvic bones.

b.Soft tissue obstruction:

>Uterus:impacted subserous pedenculated fibroid Constriction ring opposite the neck of the fetus.

>Cervix:cervical dystocia.

>Vagina:septa,stenosis,tumours.

>Ovaries:impacted ovarian tumours

Fetal causes:

a.Malpresentation and Malposition

e.g. persistent occipito posterior and deep transverse arrest,

persistent mento posterior and trasverse arrest of face presentation

Brow,

shoulder presentation

Impacted frank breech.

b.Large size foetus(macrosomia).

c.Congenital anomalies e.g,

hydrocephalus.

foetal ascites.

foetal tumours.

d.Locked and conjoined twins.

History

Includes prolonged labour with strong contractions and ruptured membranes.

Examination

General examinations reveal

Sometimes short mother.

Exhaustion, acetone smell in the mouth, tachycardia, hypotension, fever and signs of dehydration.

Abdominal Examination shows

Uterus

Hard and tender with strong contractions with no relaxation in between (tetanic contractions)

Rising retraction ring is seen and felt as an oblique groove across the abdomen >>> (Bandl”s ring).

The foetus:

High presenting part, sometimes transverse lie or other malpresentations.

Fetal parts difficult to palpate.

Fetal death or fetal distress.

Vaginal examinations

Vulva: is oedamatous.

Vagina: is dry and hot with bad smell vaginal discharge.

Cervix: is fully or partially dilated,oedamatous and hanging.

The membranes: are ruptured.

The presenting part: is high and not engaged or impacted in the pelvis. If it is head,it shows excessive moulding and large caput.

The cause of obstruction can be detected.

Complications of obstructed labour

Maternal complications

1-Dehydration, acidosis & electrolyte imbalance

2-Infection and septicaemia

3-Vesico-vaginal & recto-vaginal Fistula

4-Post-partum haemorrhage

5-Ruptured uterus

6-Renal failure

7-Thrombo-embolism & thrombophelibitis.

8-Broad Ligament Haematoma

9-peritonitis

10-pelvic abcess

11-Paralytic ileus

12-Pneumonia

13-Burst abdomen

Fetal complications

Fetal death

Fetal distress

Intracranial haemorrhage

Birth Asphyxia and may be cerebral palsy later on.

Septicemia

Meconium Aspiration Syndrome

Convulsion

Jaundice

Umbilical Sepsis

Facial Injury

Cephlohaematoma

Management of obstructed Labour

Principles of management are 1-correction of fluid imbalance 2-control of infection 3-rest of the bladder. 4-Relief of obstruction.

▪Admission

▪NPO

▪insert two wide bore canulla

▪Correct fluid imbalance→ one liter of normal saline or Ringer’s lactate- with high flow rate & repeat every 20 minutes, till her pulse = 90/minutes or less & her diastolic B.P= 90 mm/HG or more.

▪Insert Catheter to

1- evacuate bladder 2- to monitor output 3- to help preventing obstetric fistula formation.

▪Parenteral antibiotics to prevent or control infections (e.g. intravenous cefuroxime and intravenous or rectal metronidazole.)

▪monitor vital signs

▪monitor input & output

▪Investigations urine for albumin & acetone/CBC/ blood grouping & cross matching/ Prepare blood/ High vaginal swab for culture and sensitivity/ blood culture.

▪check fetal condition by auscultation or ultrasound

▪ Suction of gastric secretions by NGT may be needed.

▪Delivery as soon as possible, Caesarean section is safest method even if baby is dead. If head is deeply engaged

caesarean section may be difficult & if baby is dead destructive procedure of the fetus is an option.

Where the circumstances will not allow safe caesarean section symphsiotomy is done.

Chapter-6Brief account of Miscarriage & Abortion

Uterine fibroids

Ectopic pregnancy

Endometriosis

Carcinoma cervix

Brief account of Miscarriage & Abortion

Abortion is termination of pregnancy before viability.

Or termination of pregnancy before 24 weeks of gestation. Or where the fetal weight is below 500 gram (potentially non viable fetus )

Abortion can be spontaneous or induced.

Miscarriage refer to spontaneous abortion.

For details of different types of abortion refer to soft copy of lectures provided to you

Aetiology

Often no cause is found but common recognised causes include:

Abnormal fetal development. Genetically balanced parental translocation. Uterine abnormality. Incompetent cervix (second trimester). Placental failure. Multiple pregnancy. Immunological. Infections. Endocrine - eg, luteal phase deficiency, polycystic ovarian

syndrome.

Risk factors

Age: it is more frequent in women aged >30 years and even more common in those aged >35 years (due to an increased risk of random chromosomal abnormalities).

Incidence increases with the number of births. Cigarette smoking of Excess alcohol. Even low amounts . Illicit drug use. Uterine surgery or abnormalities - eg, incompetent cervix. Connective tissue disorders (systemic lupus erythematosus,

antiphospholipid antibodies - lupus anticoagulant/anticardiolipin antibody).

Uncontrolled diabetes mellitus.

Management of different types of Abortion

Threatened miscarriage is associated with painless mild bleeding. Patient is usually clinically stable. If baby is viable symptoms of pregnancy like nausea and tiredness are present. O/E normal vital signs/Abdomen is soft/fundus if palpable is consistent with date. Vaginal examinations reveal mild bleeding and closed cervical os.

Most patients can be managed at home. Rest and observation of further bleeding is that all required.

Inevitable Miscarriage

Usually presents with heavy bleeding with clots and pain. The cervical os is open. The pregnancy will not continue and without

medical or surgical intervention pregnancy will proceed to incomplete or complete miscarriage. Products of conception may be felt in cervical canal & cervix may be ballooned (usually associated with severe pain). Management include

Insert wide bore canullae

Iv fluid

CBC/Group and cross matching/urine analysis

In severe bleeding prepare blood

If gestational age more 12 weeks opt for medical termination by oxytocin

If gestational age below 12 weeks both surgical management by evacuation or medical by oxytocin can be employed

Ergometrine can be given to reduce bleeding

Anti-D Injection should be given to rhesus negative mothers

Incomplete Miscarriage

Here woman have passed some tissue but be careful as she may have passed clots. In ectopic pregnancy rarely woman pass a tissue which is a decidual cast & case may be confused as incomplete miscarriage. Os is open & some precuts may be felt or seen in vagina or cervix. Bleeding can be severe or mild. Usually there is pain or abdominal cramp.

Management include

Insert wide bore canullae

Iv fluid

CBC/Group and cross matching/urine analysis

In severe bleeding prepare blood

If bleeding is severe suction evacuation is done (it can be done by manual suction aspirator as outpatient in many patient)

Ergometrine can be given to reduce bleeding

Anti-D Injection should be given to rhesus negative mothers

Complete Miscarriage

Here bleeding is mild & pain has subsided.

Os is open & no cervical excitation (upon movement of cervix which is non specific sign of ectopic pregnancy but can occur in any condition associated with pelvic peritonitis (e.g. PID-Pelvic abcess, or intraperotineal haemorrhage e.g. Ruptured corpus luteum ). No further treatment is needed. Check that uterus is empty by ultrasound. Insure that patient is haemodynamiclly stable & haemoglobin is normal

Missed Miscarriage Her the uterus fails to expel a dead fetus.

In early pregnancy sometimes no fetal tissues are seen & and an empty gestational sac is seen in ultrasound (blighted ovum)

Sometimes associated with vaginal bleeding but there may be no bleeding. Symptoms of pregnancy have disappeared.

Uterus is less than date & in gestations beyond 16-18 weeks there is loss of fetal movements.

Options of management

Counsel patient about options give psychological support & explain risks and complications.

▪Conservative if IUFD occurred recently patient can wait for spontaneous expulsion up to 4 weeks. Check coagulation profile initially & monitor fibrongen level weekly to discover the risk of coagulopathy (rare event).

▪Medical with misoprostol +/- mifepristone priming

▪Surgical

Suction curettage in early gestation or dilation and cuuretage

Cervical priming with misoprostol in cases of closed cervical os.

Hystretomy or caesrean section if indicated

Check coagulation state-prepare fresh frozen plasma & fresh blood-correct coagulopathy before surgery incomplete expulsion/ failure of medical method/contraindication to medical method ( previous scar in advanced gestation)-severe bleeding.

Uterine fibroids

A common benign uterine tumors affecting 20-40 % of women above 35 years old. They are more common in black women. Histologically they are leiomyoma or myoma.

Sites

Subserosal Fibroids/Intramural Fibroids/Submucosal Fibroids/cervical . rarely fibroids can be in broad ligament ( intra-ligementary which may rarely cause polythycaemia and hypoglycemia.

Clinical presentation remember that most fibroids are asymptomtic & only about 10-20 % of fibroids require treatment. Symptoms include Heavy, prolonged menstrual periods (menorrhagia) and unusual monthly bleeding, sometimes with clots; this can lead to anemia

Pelvic pain and pressure

Pain in the back and legs

Pain during sexual intercourse (dyparunia)

Bladder pressure leading to a frequency of micturtion.

Pressure on the bowel, leading to constipation and bloating

Abnormally enlarged abdomen rarely polycythaemia in intraligmentary fibroids

rarely hypoglycaemia in intraligmentary fibroids

Complications of fibroids in pregnancy & labour include

1-miscarrige and preterm labour

2-malpresentations and malpostion

3-red degeneration (overgrowth- so fibroid outgrows its blood supply leading to ischaemia. Symptoms include severe localized abdominal pain nausea and vomiting. Signs localized tender mass.

Management /exclude other causes of acute abdomen/admission/i.v fluids and analgaesia. Pain usually will subside after few days. Surgery is contraindicated for fibroid during pregnancy as this may result in uncontrolled haemorrhage.

4- fundus more than date

5- IUGR

6- In labour complication include obstructed labour (cervical fibroid)-post-partum haemorrage

7-pureperal sepsis.

Options of Management include

Non intervention or conservative in asymptomatic fibroid

Myomectomy in patient who does not complete her family and still fertile.

Hysterectomy in elderly women and those who completed their family

Uterine artery embolization via interventional radiologist.

Hystroscopic resection of fibroids (small submucos).

Ectopic pregnancy implantation of fertilized ovum outside uterine cavity most are tubal (ampullary (commonest)-isthmic-fimbrial-inersitial-abdominal (rare)-ovarian (rare) & cervical (rare).

With the advent of sensitive pregnancy tests, ultrasound & laparoscopy diagnosis become easier.

Nevertheless still even in advanced world there are incidents of missing of diagnosis. No alternative to high index of clinical suspicion in order not to miss the diagnosis.

Symptoms include the triad of Amenorrhoea-abdominal pain and vaginal bleeding. Women may not be aware that she is pregnant and may think that it is prolonged period.

For further details of clinical picture and investigations please revise soft copy of lecture provided early.

Management of ectopic pregnancy

Depends on presentation, haemo-dynamic state, facilities, expertise of caring gynaecologist, state of the contralateral tube and finally if patient has completed here family or not

Most cases need surgical intervention by laparoscopy or laparotomy.

For undisturbed ectopic please refer to soft copy of lectures provided to you or your standard textbook.

Here I will discuss cases of ruptured ectopic

In all cases of ruptured ectopic laparotomy is the standard treatment.

In contradistinction to other type of bleeding where there may be a time for resuscitation before surgery, resuscitation and mobilizing to operating theatre go together in cases of ruptured ectopic. The management include

1- Resuscitation and mobilizing to operating theatre go together2- Insert 2 wide bore cannula (14-16 gauge 14= orange-16= gray)3- I.V Fluid crystalloid and colloid)4- Take blood sample for CBC-Coagulation study-RFTs and any

other needed)5- Grouping and crossmatching and prepare 4-6 units of blood.6- Transfuse blood as needed (in extreme cases give

Uncrossmatched O negative or group-specific blood7- Inform anesthesiologist and theatre team8- Do urgent laparotomy identify affected tube clamp and

remove (salpingectomy). The haemodynamic state of the woman improves dramatically once you clamp the tube

9- Anti-D injection for rhesus negative women10- Follow vital signs and haemodynamic state in ICU or

intermediate ICU or ward according to the condition

EndometriosisDefinition

The presence and growth of functioning endometrial tissue in places other than the uterus that often results in severe pain and infertility.Infertility affect 40 % of patients.

Symptoms

1/3 are asymptomatic

Symptoms include:-dysmenorrhea/Heavy or irregular bleeding/Pelvic pain/Lower abdominal or back pain

Dyspareunia Dyschezia (pain on defecation) - Often with cycles of diarrhea and

constipation/Bloating, nausea, and vomiting/Inguinal pain Pain on micturition and/or urinary frequency/Pain during exercise

Patients with endometriosis do not frequently have any physical examination findings beyond tenderness related to the site of involvement.The most common finding is nonspecific pelvic tenderness. Palpable cysts or nodules may be palpable in adnexa or pouch of Douglas. Tenderness and nodules in uterosacral ligament in per rectal examinations may be elicited

Diagnosis

Laparoscopy

Laparoscopy is considered the primary diagnostic modality for endometriosis.

Sites affected are Ovaries/Posterior cul-de-sac/Broad ligament/Uterosacral ligament/Rectosigmoid colon/Bladder/Distal ureter

Histology

Histologic demonstration of a combination of endometrial glands and stroma in biopsy specimens obtained from outside the uterine cavity is required to make the diagnosis of endometriosis.

Laboratory studies

Complete blood count (CBC) with differential - May help to differentiate pelvic infection from endometriosis, as well as to assess the degree of blood loss

Urinalysis and urine culture - If urinary tract infection (UTI) is in the differential diagnosis Cervical Gram stain and cultures - Because sexually transmitted diseases (STDs) can also

cause pelvic pain and infertility

Imaging studies

Ultrasonography - Endometriosis can be assessed by either transvaginal ultrasonography or endorectal ultrasonography

Magnetic resonance imaging (MRI)

Management

The dependence of endometriosis on the cyclic production of menstrual cycle hormones provides the basis for medical therapy. Thus, the following drugs form the mainstay of pharmacologic care:

Combined oral contraceptive pills (COCPs) Danazol Progestational agents Gonadotropin-releasing hormone (GnRH) analogues

Surgical care for endometriosis can be broadly classified as follows:

Conservative - When reproductive potential is retained e.g. Laparoscopic drainage or cystectomy. Others include ablation and nerve ablation.

Semiconservative - When reproductive ability is eliminated but ovarian function is retained-surgery involves hysterectomy and cytoreduction of pelvic endometriosis.

Radical surgery

Radical surgery involves total hysterectomy with bilateral oophorectomy (TAH-BSO) and cytoreduction of visible endometriosis. Adhesiolysis is performed to restore mobility and normal intrapelvic organ relationships.

Carcinoma cervix

Most are squamous carcinoma & around 10 % are adenocarcinoma.

For details revise your soft copy from lectures or seminars.

Risk factors include

Human papilloma virus {strong association) (specially strain 16-18) (

Early coitus age

Multiple sexual partners

Cigerate smoking

HIV infection

Family history

Combined oral contraceptive pill (small risk)

Multiparity

Failure to attend screening program.

Clinical pictures

In early stages it is asymptomatic

Later patient may develop pelvic pain.

Vaginal bleeding or contact bleeding→ postcoital/tampon insertion/speculum or vaginal examination//intermenstural bleeding.

Excessive vaginal discharge which may be or may not be smelly.

Dysparunia (painful sexual intercourse may occur).

Management in tertiary center by gyn-oncologist

The treatment of cervical cancer varies with the stage of the disease. For early invasive cancer, surgery is the treatment of choice. In more advanced cases, radiation combined with chemotherapy is the current standard of care. In patients with disseminated disease, chemotherapy or radiation. provides symptom palliation.