Obstructed labour

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Obstructed labour
Other namesLabour dystocia
Illustration of a deformed female pelvis - angular distortion Wellcome L0038229.jpg
Illustration of deformed pelvises. A deformed pelvis is a risk factor for obstructed labour
Specialty Obstetrics
Complications Perinatal asphyxia, uterine rupture, post-partum bleeding, postpartum infection [1]
CausesLarge or abnormally positioned baby, small pelvis, problems with the birth canal [2]
Risk factors Shoulder dystocia, malnutrition, vitamin D deficiency [3] [2]
Diagnostic method Active phase of labour > 12 hours [2]
Treatment Cesarean section, vacuum extraction with possible surgical opening of the symphysis pubis [4]
Frequency6.5 million (2015) [5]
Deaths23,100 (2015) [6]

Obstructed labour, also known as labour dystocia, is the baby not exiting the pelvis because it is physically blocked during childbirth although the uterus contracts normally. [2] Complications for the baby include not getting enough oxygen which may result in death. [1] It increases the risk of the mother getting an infection, having uterine rupture, or having post-partum bleeding. [1] Long-term complications for the mother include obstetrical fistula. [2] Obstructed labour is said to result in prolonged labour, when the active phase of labour is longer than 12 hours. [2]

Contents

The main causes of obstructed labour include a large or abnormally positioned baby, a small pelvis, and problems with the birth canal. [2] Abnormal positioning includes shoulder dystocia where the anterior shoulder does not pass easily below the pubic bone. [2] Risk factors for a small pelvis include malnutrition and a lack of exposure to sunlight causing vitamin D deficiency. [3] It is also more common in adolescence as the pelvis may not have finished growing by the time they give birth. [1] Problems with the birth canal include a narrow vagina and perineum which may be due to female genital mutilation or tumors. [2] A partograph is often used to track labour progression and diagnose problems. [1] This combined with physical examination may identify obstructed labour. [7]

The treatment of obstructed labour may require cesarean section or vacuum extraction with possible surgical opening of the symphysis pubis. [4] Other measures include: keeping the women hydrated and antibiotics if the membranes have been ruptured for more than 18 hours. [4] In Africa and Asia obstructed labor affects between two and five percent of deliveries. [8] In 2015 about 6.5 million cases of obstructed labour or uterine rupture occurred. [5] This resulted in 23,000 maternal deaths down from 29,000 deaths in 1990 (about 8% of all deaths related to pregnancy). [2] [6] [9] It is also one of the leading causes of stillbirth. [10] Most deaths due to this condition occur in the developing world. [1]

Cause

The main causes of obstructed labour include a large or abnormally positioned baby, a small pelvis, and problems with the birth canal. [2] Both the size and the position of the fetus can lead to obstructed labor. Abnormal positioning includes shoulder dystocia where the anterior shoulder does not pass easily below the pubic bone. [2] A small pelvis of the mother can be a result of many factors. Risk factors for a small pelvis include malnutrition and a lack of exposure to sunlight causing vitamin D deficiency. [3] A deficiency in calcium can also result in a small pelvis as the structures of the pelvic bones will be weak due to the lack of calcium. [11] A relationship between maternal height and pelvis size is present and can be used to predict the possibility of obstructed labor. This relationship is a result of the mother's nutritional health throughout her life leading up to childbirth. [1] Younger mothers are also at more risk for obstructed labor due to growth of the pelvis not being completed. [11] Problems with the birth canal include a narrow vagina and perineum which may be due to female genital mutilation or tumors. [2] All of these factors lead to a failure in the progress of labor.

Evolution

Obstructed labor is more common in humans than any other species and continues to be a main cause of birth complications today. [12] Modern humans have morphologically evolved to survive as bipeds, however, bipedalism has resulted in skeletal changes that have consequently narrowed the pelvis and the birth canal. [13] The combination of increased brain size and changes in pelvic structure are the major contributors of obstructed labor in modern humans. It is also common for obstructed labor in humans to be caused by the fetus' broad shoulders. However, morphological shifts in pelvic structure still account for the inability of a fetus to effectively pass through the birth canal without major complications [14]

Other primates have a wider and straighter birth canal that allows a fetus to pass through more effectively. [15] Mismatch between birth canal size and infant cranial width and length due to bipedal locomotion requirements have often been referred to as the obstetric dilemma, since compared to other great apes, modern humans have the greatest disproportion between infant cranial size and birth canal size. [16] Shrinking of upper extremities and curvature of the spine have also affected the way modern humans give birth. Quadruped apes have longer upper limbs that allow them to reach down and pull their fetus out of the birth canal unassisted. [14] Other primates also have a wider and straighter birth canal that allows a fetus to pass through more effectively. [15] Modern human's shorter upper extremities and evolution of bipedal locomotion may have placed a premium on assistance during labor. For this reason, researchers argue that assisted labor may have evolved with bipedalism. [14] Obstructed labor has been documented as a complication of childbirth since the field of obstetrics originated. For over 1,000 years obstetricians have had to forcibly remove obstructed labor fetuses to prevent the death of the mother. [17]

Prior to the existence of the cesarean section, fetuses that were obstructed had a low survival rate. [17] Even in the 21st century, if obstructed labor is left untreated, it could result in mother and infant death. [16] Although surgical removal of the fetus is the preferred method of managing obstructed labor, manual removal using medical tools is also common. [15]

Diagnosis

Obstructed labour is usually diagnosed based on physical examination. [7] Ultrasound can be used to predict malpresentation of the fetus. [11] In examination of the cervix once labor has begun, all examinations are compared to regular cervical assessments. The comparison between the average cervical assessment and the current state of the mother allows for a diagnosis of obstructed labor. [1] An increasingly long time in labor also indicates a mechanical issue that is preventing the fetus from exiting the womb. [1]

Prevention

Access to proper health services can reduce the prevalence of obstructed labor. [11] Less developed areas have inadequate health services to attend to obstructed labor, resulting in a higher prevalence among less developed areas. Improving nutrition of female, both before and during pregnancy, is important for reducing the risk of obstructive labor. [11] Creating education programs about reproduction and increasing access to reproductive services such as contraception and family planning in developing areas can also reduce the prevalence of obstructed labor. [18]

Treatment

Before considering surgical options, changing the posture of the mother during labor can help to progress labor. [18] The treatment of obstructed labour may require cesarean section or vacuum extraction with possible surgical opening of the symphysis pubis. [4] Caesarean section is an invasive method but is often the only method that will save the lives of both the mother and the infant. [18] Symphysiotomy is the surgical opening of the symphysis pubis. This procedure can be completed more rapidly than Caesarean sections and does not require anesthesia, making it a more accessible option in places with less advanced medical technology. [18] This procedure also leaves no scars on the uterus which makes further pregnancies and births safer for the mother. [1] Another important factor in treating obstructed labor is monitoring the energy and hydration of the mother. [11] Contractions of the uterus require energy, so the longer the mother is in labor the more energy she expends. When the mother is depleted of energy, the contractions become weaker and labor will become increasingly longer. [1] Antibiotics are also an important treatment as infection is a possible result of obstructed labor. [11]

Prognosis

If cesarean section is obtained in a timely manner, prognosis is good. [1] Prolonged obstructed labour can lead to stillbirth, obstetric fistula, and maternal death. [19] Fetal death can be caused by asphyxia. [1] Obstructed labor is the leading cause of uterine rupture worldwide. [1] Maternal death can result from uterine rupture, complications during caesarean section, or sepsis. [18]

Epidemiology

In 2013 it resulted in 19,000 maternal deaths down from 29,000 deaths in 1990. [9] Globally, obstructed labor accounts for 8% of maternal deaths. [20]

Etymology

The word dystocia means 'difficult labour'. [1] Its antonym is eutocia (Ancient Greek : εὖ, romanized: eu, lit.  'good' + Ancient Greek : τόκος, romanized: tókos, lit.  'childbirth') 'easy labour'.

Other terms for obstructed labour include difficult labour, abnormal labour, difficult childbirth, abnormal childbirth, and dysfunctional labour.[ citation needed ]

Other animals

The term can also be used in the context of various animals. Dystocia pertaining to birds and reptiles is also called egg binding.[ citation needed ]

In part due to extensive selective breeding, miniature horse mares experience dystocias more frequently than other breeds.[ citation needed ]

Related Research Articles

<span class="mw-page-title-main">Caesarean section</span> Surgical procedure in which a baby is delivered through an incision in the mothers abdomen

Caesarean section, also known as C-section or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen. It is often performed because vaginal delivery would put the mother or fetus at risk. Reasons for the operation include obstructed labor, twin pregnancy, high blood pressure in the mother, breech birth, shoulder presentation, and problems with the placenta or umbilical cord. A caesarean delivery may be performed based upon the shape of the mother's pelvis or history of a previous C-section. A trial of vaginal birth after C-section may be possible. The World Health Organization recommends that caesarean section be performed only when medically necessary.

Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgical field.

<span class="mw-page-title-main">Childbirth</span> Expulsion of a fetus from the pregnant mothers uterus

Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million human births globally. In the developed countries, most deliveries occur in hospitals, while in the developing countries most are home births.

<span class="mw-page-title-main">Stillbirth</span> Death of a fetus before or during delivery, resulting in delivery of a dead baby

Stillbirth is typically defined as fetal death at or after 20 or 28 weeks of pregnancy, depending on the source. It results in a baby born without signs of life. A stillbirth can often result in the feeling of guilt or grief in the mother. The term is in contrast to miscarriage, which is an early pregnancy loss, and Sudden Infant Death Syndrome, where the baby dies a short time after being born alive.

<span class="mw-page-title-main">Obstetric fistula</span> Hole that develops in the birth canal as a result of childbirth

Obstetric fistula is a medical condition in which a hole develops in the birth canal as a result of childbirth. This can be between the vagina and rectum, ureter, or bladder. It can result in incontinence of urine or feces. Complications may include depression, infertility, and social isolation.

<span class="mw-page-title-main">Maternal death</span> Aspect of human reproduction and medicine

Maternal death or maternal mortality is defined in slightly different ways by several different health organizations. The World Health Organization (WHO) defines maternal death as the death of a pregnant mother due to complications related to pregnancy, underlying conditions worsened by the pregnancy or management of these conditions. This can occur either while she is pregnant or within six weeks of resolution of the pregnancy. The CDC definition of pregnancy-related deaths extends the period of consideration to include one year from the resolution of the pregnancy. Pregnancy associated death, as defined by the American College of Obstetricians and Gynecologists (ACOG), are all deaths occurring within one year of a pregnancy resolution. Identification of pregnancy associated deaths is important for deciding whether or not the pregnancy was a direct or indirect contributing cause of the death.

Obstetrical bleeding is bleeding in pregnancy that occurs before, during, or after childbirth. Bleeding before childbirth is that which occurs after 24 weeks of pregnancy. Bleeding may be vaginal or less commonly into the abdominal cavity. Bleeding which occurs before 24 weeks is known as early pregnancy bleeding.

<span class="mw-page-title-main">Large for gestational age</span> Medical condition

Large for gestational age (LGA) is a term used to describe infants that are born with an abnormally high weight, specifically in the 90th percentile or above, compared to other babies of the same developmental age. Macrosomia is a similar term that describes excessive birth weight, but refers to an absolute measurement, regardless of gestational age. Typically the threshold for diagnosing macrosomia is a body weight between 4,000 and 4,500 grams, or more, measured at birth, but there are difficulties reaching a universal agreement of this definition.

<span class="mw-page-title-main">Shoulder dystocia</span> Birthing obstruction complication

Shoulder dystocia is when, after vaginal delivery of the head, the baby's anterior shoulder gets caught above the mother's pubic bone. Signs include retraction of the baby's head back into the vagina, known as "turtle sign". Complications for the baby may include brachial plexus injury, or clavicle fracture. Complications for the mother may include vaginal or perineal tears, postpartum bleeding, or uterine rupture.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

The obstetrical dilemma is a hypothesis to explain why humans often require assistance from other humans during childbirth to avoid complications, whereas most non-human primates give birth unassisted with relatively little difficulty. This occurs due to the tight fit of the fetal head to the maternal birth canal, which is additionally convoluted, meaning the head and therefore body of the infant must rotate during childbirth in order to fit, unlike in other, non-upright walking mammals. Consequently, there is an unusually high incidence of cephalopelvic disproportion and obstructed labor in humans.

Maternal health is the health of women during pregnancy, childbirth, and the postpartum period. In most cases, maternal health encompasses the health care dimensions of family planning, preconception, prenatal, and postnatal care in order to ensure a positive and fulfilling experience. In other cases, maternal health can reduce maternal morbidity and mortality. Maternal health revolves around the health and wellness of pregnant women, particularly when they are pregnant, at the time they give birth, and during child-raising. WHO has indicated that even though motherhood has been considered as a fulfilling natural experience that is emotional to the mother, a high percentage of women develop health problems and sometimes even die. Because of this, there is a need to invest in the health of women. The investment can be achieved in different ways, among the main ones being subsidizing the healthcare cost, education on maternal health, encouraging effective family planning, and ensuring progressive check up on the health of women with children. Maternal morbidity and mortality particularly affects women of color and women living in low and lower-middle income countries.

<span class="mw-page-title-main">Maternal–fetal medicine</span> Branch of medicine

Maternal–fetal medicine (MFM), also known as perinatology, is a branch of medicine that focuses on managing health concerns of the mother and fetus prior to, during, and shortly after pregnancy.

<span class="mw-page-title-main">Obstetrical forceps</span> Medical instrument used for the delivery of a baby

Obstetrical forceps are a medical instrument used in childbirth. Their use can serve as an alternative to the ventouse method.

<span class="mw-page-title-main">Vaginal delivery</span> Delivery through the vagina

A vaginal delivery is the birth of offspring in mammals through the vagina. It is the most common method of childbirth worldwide. It is considered the preferred method of delivery, with lower morbidity and mortality than caesarean sections (C-sections).

An asynclitic birth or asynclitism are terms used in obstetrics to refer to childbirth in which there is malposition of the head of the fetus in the uterus, relative to the birth canal. Asynclitic presentation is different from a shoulder presentation, in which the shoulder is presenting first. Many babies enter the pelvis in an asynclitic presentation, and most asynclitism corrects spontaneously as part of the normal birthing process.

<span class="mw-page-title-main">Shoulder presentation</span> Medical condition

A shoulder presentation is a malpresentation at childbirth where the baby is in a transverse lie, thus the leading part is an arm, a shoulder, or the trunk. While a baby can be delivered vaginally when either the head or the feet/buttocks are the leading part, it usually cannot be expected to be delivered successfully with a shoulder presentation unless a cesarean section (C/S) is performed.

An obstetric labor complication is a difficulty or abnormality that arises during the process of labor or delivery.

Obstetric medicine, similar to maternal medicine, is a sub-specialty of general internal medicine and obstetrics that specializes in process of prevention, diagnosing, and treating medical disorders in with pregnant women. It is closely related to the specialty of maternal-fetal medicine, although obstetric medicine does not directly care for the fetus. The practice of obstetric medicine, or previously known as "obstetric intervention," primarily consisted of the extraction of the baby during instances of duress, such as obstructed labor or if the baby was positioned in breech.

<span class="mw-page-title-main">Prolonged labor</span> Medical condition

Prolonged labor is the inability of a woman to proceed with childbirth upon going into labor. Prolonged labor typically lasts over 20 hours for first time mothers, and over 14 hours for women that have already had children. Failure to progress can take place during two different phases; the latent phase and active phase of labor. The latent phase of labor can be emotionally tiring and cause fatigue, but it typically does not result in further problems. The active phase of labor, on the other hand, if prolonged, can result in long term complications.

References

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  8. ↑ Usha K (2004). Pregnancy at risk : current concepts. New Delhi: Jaypee Bros. p. 451. ISBN   9788171798261. Archived from the original on 2016-03-04.
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  12. ↑ AbouZahr C (2003-12-01). "Global burden of maternal death and disability". British Medical Bulletin. 67 (1): 1–11. doi: 10.1093/bmb/ldg015 . PMID   14711750.
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