Complications of labour may affect the mother, baby or both. Most complications are associated with obstructed labour. Cephalopelvic disproportion (CPD) is the major cause of obstructed labour and ruptured uterus.
Maternal complications of labour include:
• Genital tract infection
• Fistula formation
• Laceration of the genital tract
• Peripheral nerve palsies
• Foot drop
Foetal/infant complications of labour may be:
• Foetal distress
• Meconium aspiration
• Hypoxia/Asphyxia
• Injuries
• Foetal death.
CEPHALOPELVIC DISPROPORTION (CPD)
(“Baby too big for pelvis or pelvis too small for baby”). CPD may be due to faults in pelvis or faults in the foetus or combination of both. The faults in pelvis may be:
• Contracted pelvis
• Deformed pelvis.
The faults in the foetus may be:
• Too large baby
• Hydrocephalus
• Foetal monsters, locked twins (rare).
CPD is the most important cause of obstructed labour. Other causes of obstructed labour are malpresentations or malpositions of the foetus, and soft tissue abnormalities of the genital tract. Obstructed labour is the commonest cause of ruptured uterus and a major cause of maternal mortality. Obstructed labour and ruptured uterus can be prevented by appropriately timed Caesarean section.
OBSTRUCTED LABOUR
Essentials of diagnosis
• The cervix fails to dilate despite good uterine contractions
• Oedema of the cervix and vulva
• The head fails to descend
• The degree of moulding increases
• Bandl's ring occurs
• Urinary retention, blood stained urine on catheterisation
• Foetal distress
• Maternal distress:
- dehydration
- fever
- tachycardia
Management - Supportive
• Resuscitation, rehydration (IV fluids), parenteral antibiotics, bladder care (empty bladder and continuous bladder drainage for at least two weeks
• Relief of obstruction: C/S or destructive operation if the foetus is dead
• Laparotomy, if there is rupture of the uterus: repair or subtotal hysterectomy.
RUPTURED UTERUS
• Is an obstetric catastrophe and should be prevented. Major causes are:
• Obstructed labour
• Previous operations on uterus (C/S, myomectomy)
• Ecbolic herbs and improper use of oxytocin
• Grand multiparity
• Perforations during evacuation of uterus or D&C are a type of ruptured uterus.
Clinical Features
Clinical features may be insidious (“quiet”) or obvious (“classical”). In classical cases the patient who was in labour complains of severe abdominal pains, has PV bleeding and goes into shock. Examination shows hypovolaemic shock with signs of intraperitoneal haemorrhage. Impending rupture of the uterus can be diagnosed by:
• Observing rise in maternal pulse (more than 100 beats per minute)
• Localised abdominal pains
• Foetal distress (irregular foetal heart, meconium stain)
• PV bleeding.
Management
• Quick resuscitation with drip, blood
• Cross-match adequate blood
• Arrange for laparotomy as soon as possible or refer
• Decision to repair the tear or remove uterus (hysterectomy) depends on extent and number of tears. Whichever is best to achieve haemostasis quickly is done.
CAESAREAN SECTION (C/S)
When properly applied C/S is an important operation in reducing maternal and perinatal mortality and morbidity.
The major indications for C/S are:
• Cephalopelvic disproportions (CPD)
• Foetal distress
• Previous C/S; 2 or more C/S or 1 C/S with CPD
• Malpresentations: breech, transverse lie
• Cord prolapse or presentation
• Antepartum haemorrhage (APH)
• Placenta praevia (major types), placental abruptions (sometimes)
• Hypertensive disease: Where induction is unlikely to succeed or is contraindicated.
Types of C/S operation
• Lower uterine segment transverse incision - routinely done nowadays because of its low morbidity and safety during subsequent pregnancies
• Classical C/S - vertical incision in upper uterine segment - done very rarely e.g. for:
- inaccessible lower segment because of tumours or adhesions
- in cancer of cervix to avoid dissemination
- impacted shoulder presentation.
Preparation for C/S and Procedure
• Catheterisation of the bladder
• Empty the stomach (if not fasted), premedicate with atropine 0.6 mg only
• Cross-match 1 -2 units, fix drip
• Anaesthesia may be general or regional, requires special skills to avoid foetal respiratory depression and maternal gastric acid aspiration. Preparation of operation field done when mother is awake to shorten induction delivery interval to 10 minutes or less
• Incision through the abdomen and uterus done quickly (but carefully) to avoid foetal respiratory depression.
Post operatively
Patient requires IV fluids for 24 hours, analgesia, and close observation. Early ambulation is encouraged, and chest and leg exercises given to prevent hypostatic pneumonia and DVT. Patient can be discharged from 4 to 7 days. Alternate stitches are removed on the sixth day and all stitches on the seventh day.
INDUCTION OF LABOUR
This is artificial initiation of the process of labour.
Indications
• Intrauterine foetal death from any cause
• Prolonged gestation (post-dates, 41 weeks and above)
• Diabetes mellitus
• Pre-eclampsia and eclampsia
• Rhesus isoimmunisation.
Technique
Generally induction is achieved by ARM and oxytocin drip as described above in active management of labour. Bishops score:
• If 7 and above, OBE then ARM and oxytocin
• If less than 7, cervical ripening is indicated. The following option is available:
- Foley's catheter (can only be used when the membranes are intact) inflated maximally and left for 8-12 hours will normally achieve ripening.
- prostaglandins F2, E2 and PGE can be used under specialised care.
OPERATIVE VAGINAL DELIVERY
The method commonly taught and used in Kenya is vacuum delivery- (ventouse). It must be performed by properly trained and experienced personnel.
Indications
Must be right to avoid maternal and/or foetal injuries
• Poor maternal effort
• Delayed second stage (within 30 minutes from full dilatation) in the absence of CPD
• Cardiac/respiratory maternal disease in second stage
• Cord prolapse in second stage.
Requirements
• Cephalic presentation
• Full cervical dilation
• Low head
• Empty bladder
• Episiotomy.
Contraindications
• CPD
• Previous scar
• Malpresentation (Breech, transverse lie, oblique, etc)
• Malpositions (Brow & face malpositions).
