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Obstetrics

Obstructed Labour

Failure of labour to progress despite adequate uterine contractions, usually due to mechanical factors (cephalopelvic disproportion, malpresentation) or ineffective contractions (rarely the primary cause if obstruction present). A major cause of maternal and perinatal morbidity/mortality.

Also known as: Failure to Progress

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Referral and warning signs

When to refer

Urgent Referral to Hospital (H/RR) as soon as obstructed labour suspected (progress crossing Alert/Action line). Transfer with IV fluids, +/- antibiotics.

Red flags

  • Progress crossing Action Line
  • Arrest of dilatation/descent
  • Fetal distress
  • Maternal exhaustion/infection
  • Bandl's ring / Impending rupture signs

Signs and symptoms

  • Labour prolonged (>12-18h).
  • Poor progress on Partograph (crossing Alert/Action line, lack of descent).
  • Strong contractions initially, may become ineffective/tetanic later.
  • Maternal exhaustion, dehydration, ketosis, tachycardia, fever.
  • Signs of CPD: High presenting part, excessive moulding/caput.
  • Fetal Distress: Abnormal FHR, Meconium.
  • Impending Rupture Signs: Constant lower abdominal pain, tenderness over lower segment, Bandl's ring, haematuria.

Risk factors

  • Cephalopelvic Disproportion (CPD).
  • Malpresentation (breech, transverse).
  • Malposition (OP, deep transverse arrest).
  • Fetal abnormalities (hydrocephalus).
  • Primigravida.
  • Previous difficult delivery.

Diagnosis

Clinical assessment

Diagnosis via Partograph monitoring: Slow/arrested dilatation or descent despite adequate contractions. Assess for cause (CPD, malpresentation).

Investigations

  • Partograph monitoring.
  • Abdominal palpation.
  • Vaginal examination.
  • Assess maternal/fetal condition.

Diagnostic criteria

Labour progress right of Action Line, or arrest of progress in active phase with adequate contractions.

Management

Non-pharmacological management

  • Early Recognition and Referral.
  • Supportive care (IV hydration, manage exhaustion).
  • Continuous monitoring.
  • Emotional support.

Pharmacological treatment

  • Antibiotics if labour/ROM prolonged.
  • Oxytocin CONTRAINDICATED if obstruction suspected.
  • Analgesia.
  • Definitive Management (Hospital): Caesarean Section (for confirmed obstruction). Instrumental Delivery (very select cases, full dilatation, no CPD). Symphysiotomy (rare, destructive).

Monitoring

Monitor Partograph, maternal vitals, FHR, signs of rupture pending definitive management.

Complications

  • Maternal: Uterine rupture, PPH, Sepsis, Obstetric fistula (VVF/RVF), Nerve damage, Exhaustion, Death.
  • Fetal/Neonatal: Distress/asphyxia, Trauma, Sepsis, Stillbirth/Death.

Prevention

  • Good ANC (identify risks).
  • Partograph use.
  • Skilled birth attendance.
  • Timely referral.
  • Appropriate oxytocin use.

Patient education

  • Explanation of poor progress.
  • Need for urgent referral.
  • Likely need for C/S.
  • Risks of delay.

Uganda-specific notes

Major cause of mortality/fistula. Partograph use and timely referral critical. Transport challenges significant.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 16, Section 16.4.3

For learning and professional reference. Use current local guidance and clinical judgement.

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