CHAPTERS CONTRIBUTED

PROLONGED AND OBSTRUCTED LABOR

Normal labor usually progresses in a predictable fashion once the diagnosis of labor has been made. The progress of labor is evaluated primarily through estimates of cervical dilatation and descent of the fetal presenting part i.e., by using a partogram. In developing countries the focus of a partogram in managing labor, is on preventing maternal and fetal death related to prolonged labor, whereas in developed countries the focus is on earlier identification and management of dystocia in order to offer interventions and avoid cesarean sections. Dystocia (poor progress of labor) in women accounts for approximately 50 percent of all primary cesarean sections. Poor progress of labor is a sign of an underlying pathology. If the causative pathology can be identified, specific management can be employed. Though this is not always possible in clinical practice, proper understanding of the problem will go a long way in reducing the morbidities associated with prolonged labor.

Labor is considered obstructed when the presenting part of the fetus cannot progress into the birth canal in spite of strong uterine contractions, due to mechanical obstruction. There is usually a mismatch between fetal size, or more accurately, the size of the presenting part of the fetus, and the mother’s pelvis. Some malpresentations, especially a brow presentation or a shoulder presentation, will also cause obstruction. The obstruction can only be alleviated by means of an operative delivery: either cesarean section or other instrumental delivery (forceps, vacuum extraction or symphysiotomy).

Neglected obstructed labor is a major cause of both maternal and neonatal morbidity and mortality. The incidence of obstructed labor is 4.6 percent of all live births globally. Obstructed labor is common in developing countries. It accounts for 11.4 percent of maternal deaths in the Eastern part of India. Approximately 8% of all maternal deaths in developing countries are due to obstructed labor. This figure is an underestimation of the problem, because deaths due to obstructed labor are often classified under other complications associated with obstructed labor such as sepsis, postpartum hemorrhage or ruptured uterus. Obstructed labor is responsible for 80 percent of genito-urinary fistulae in developing countries. Delayed management of obstructed labor causes fistulae in surviving women, which if not treated, may make them social outcasts for the rest of their lives. This may also lead to constant depression, many physical illnesses, and infections. 

 

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