Obstructed Labour

Failure of the presenting part to descend through the birth canal despite adequate uterine contractions, from a mechanical mismatch between the fetus and the maternal pelvis (cephalopelvic disproportion), malposition, malpresentation, or, rarely, a pelvic mass or contracted pelvis.

Remains a major cause of maternal and perinatal mortality in settings with limited access to timely cesarean section, given the risk of progression to uterine rupture, obstetric fistula (see that entry), and fetal death if unrelieved.

Prolonged labor with poor or absent progress despite strong contractions, maternal exhaustion, a Bandl's ring (a palpable, visible ridge across the lower abdomen marking the junction between the over-distended lower segment and the retracted upper segment, an ominous sign of impending uterine rupture), maternal tachycardia and pyrexia (from prolonged labor and ketosis), and, on vaginal examination, significant caput succedaneum and molding of the fetal head, and an edematous, poorly applied cervix.

This is an obstetric emergency once recognized: immediate senior obstetric involvement, IV access, and preparation for delivery
Cesarean section is the definitive management for true obstructed labor; a symphysiotomy (surgical division of the pubic symphysis) is used in some resource-limited settings without immediate cesarean access, though this is increasingly uncommon practice
Maternal resuscitation: IV fluids, correction of ketosis, and analgesia
Bladder catheterization, given the risk of bladder trauma and, if unrelieved, the pathway to obstetric fistula
Broad-spectrum antibiotics if prolonged rupture of membranes or signs of infection are present
Continuous fetal monitoring, recognizing the high risk of fetal distress and death with ongoing obstruction
Postpartum vigilance for uterine rupture (see that entry), postpartum hemorrhage, and, in the following days, obstetric fistula, given the tissue ischemia from prolonged pressure of the fetal head against the maternal pelvis

Referral: obstetric emergency requiring immediate senior obstetric and anesthetic involvement and emergency cesarean facilities.

Placental Abruption

Premature separation of a normally sited placenta from the uterine wall before delivery, causing bleeding into the decidua basalis.

Risk factors include hypertension and pre-eclampsia (the strongest association), previous abruption, trauma, smoking and cocaine use, multiple pregnancy, polyhydramnios with rapid decompression (as with membrane rupture), and preterm premature rupture of membranes.

Classically painful vaginal bleeding with a tense, tender, "woody hard" uterus, in contrast to the painless bleeding of placenta praevia.

Bleeding may be revealed (visible vaginally) or concealed (retroperitoneal, behind the placenta, with disproportionately severe systemic signs relative to visible blood loss).

Fetal distress or fetal death may be the presenting feature in severe abruption.

Uterine contractions are frequently present, and preterm labor commonly follows.

Primarily clinical, based on the pain, tenderness, and bleeding pattern; ultrasound is poor at reliably detecting abruption (retroplacental clot is visualized in only a minority of cases) but is used to assess fetal wellbeing and exclude placenta praevia as an alternative cause of bleeding.

Cardiotocography assesses fetal status.

Coagulation profile is essential, given the risk of DIC, particularly with concealed abruption or fetal death, from release of thromboplastin into the maternal circulation.

FBC, group and crossmatch, Kleihauer test (quantifies fetomaternal hemorrhage, guiding anti-D dosing).

Managed as an obstetric emergency: senior obstetric and anesthetic involvement, ABC assessment, two large-bore IV access, aggressive fluid resuscitation, and crossmatched blood
Fetal status dictates urgency: a non-reassuring or absent fetal heart rate with maternal instability warrants immediate delivery, generally by emergency cesarean unless vaginal delivery is imminent
With a live fetus and reassuring CTG, continuous fetal monitoring and expedited delivery (mode depending on gestation, severity, and cervical status)
Intrauterine fetal death with abruption: vaginal delivery is generally preferred once the mother is stabilized, given the coagulopathy risk with cesarean in this setting, unless maternal condition mandates otherwise
Correct coagulopathy aggressively with fresh frozen plasma, cryoprecipitate, and platelets as guided by coagulation results and ongoing bleeding (see Postpartum Haemorrhage entry for detailed transfusion principles)
Anti-D prophylaxis for Rh negative women, dose guided by Kleihauer result where significant fetomaternal hemorrhage is suspected
Corticosteroids for fetal lung maturation if preterm and delivery is not immediately mandated

Referral: obstetric emergency requiring immediate senior obstetric, anesthetic, and neonatal involvement.

Obstructed Labour

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management