Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 6  |  Issue : 2  |  Page : 146-150  

Fetomaternal outcome in obstructed labor in a peripheral tertiary care hospital


1 Department of Gynaecology and Obstetrics, Swasthya Bhawan, Kolkata, West Bengal, India
2 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
3 Department of Gynaecology and Obstetrics, B. S. Medical College, Bankura, West Bengal, India

Date of Web Publication10-Apr-2013

Correspondence Address:
Arunima Chaudhuri
Krishnasayar south, Borehat, Burdwan - 713 102, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.110301

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  Abstract 

Background: Obstructed labor is the leading cause of hospitalization, comprising up to 39% of all obstetric patients in developing countries. It is the single most important cause of maternal death and is one of the three leading causes of perinatal mortality. Objectives: To study the different parameters of obstructed labor cases, like its frequency, etiology, management, and complications. This will help to formulate a positive strategy to prevent obstructed labor and its consequences. Materials and Methods: 313 patients admitted with features of obstructed labor were studied. By clinical examination, diagnosis of cephalopelvic disproportion, malposition, malpresentation, obstruction in birth canal, overdistended bladder, hematuria, rupture of uterus, and supermolding of fetal head was done. Screening for maternal exhaustion, dehydration, genital sepsis, pyrexia, rupture of uterus, postpartum hemorrhage, vesico-vaginal fistula, and shock was carried out. Deaths as a consequence of obstructed labor were noted. Diagnosis of asphyxiated or dead fetus or neonatal death was done. Mode of delivery and time interval between referral, admission, intervention done, and related feto-maternal outcome were noted. Statistical analysis was done using Epi Info software. Results: Majority of the patients (87.86%) were from low socioeconomic group, 88.82% were from rural areas, 16.16% were illiterate, and 27.79% were unbooked. The commonest cause of obstructed labor was cephalopelvic disproportion (55.59%). Other causes were malposition (23%), malpresentation (18.21%), fetal congenital abnormality (1.28%), myoma (0.32%), and non-dilatation of cervix (1.60%). The commonest mode of delivery was cesarean section (85.94%). Instrumental deliveries formed 9.58%. Destructive operation was done in 1.92% cases. Rupture uterus was seen in 8 (2.56%) cases, out of which hysterectomy was done in 5 cases and repair in 3 cases. The common maternal complications were sepsis [pyrexia 49.8%, urinary tract infection (UTI) 10.9%, wound infection 7.7%] and post-partum hemorrhage (PPH; 33.9%). Other complications were rupture uterus (2.56%), subinvolution (9.3%), shock (2.2%), bladder injury (1.9%), hysterectomy (1.6%), broad ligament hematoma (1.28%), maternal death (1.6%), vesico-vaginal fistula (VVF; 0.6%), and rectovaginal fistula (RVF; 0.3%). Perinatal mortality rate was 71/313 (22.68%), still birth rate was 57/313 (18.21%), and live birth rate was 256/313 (81.79%). Perinatal morbidity (in 198 cases) was most commonly due to birth asphyxia (29.68%), jaundice (16.80%), septicemia (14.84%), and meconium aspiration syndrome (9.77%). Incidence of PPH, still birth, perinatal mortality, and cesarean section was significantly higher among multiparous women. Conclusions: Cephalopelvic disproportion is the commonest cause of obstructed labor, and proper antenatal care, early diagnosis, and timely intervention may result in decrease in incidence of morbidity and mortality.

Keywords: Maternal mortality, obstructed labor, perinatal mortality


How to cite this article:
Mondal S, Chaudhuri A, Kamilya G, Santra D. Fetomaternal outcome in obstructed labor in a peripheral tertiary care hospital. Med J DY Patil Univ 2013;6:146-50

How to cite this URL:
Mondal S, Chaudhuri A, Kamilya G, Santra D. Fetomaternal outcome in obstructed labor in a peripheral tertiary care hospital. Med J DY Patil Univ [serial online] 2013 [cited 2021 Sep 17];6:146-50. Available from: https://www.mjdrdypu.org/text.asp?2013/6/2/146/110301


  Introduction Top


Obstructed labor continues to plague thousands of women each year, accounting for about 8% of all maternal deaths in developing countries like India. [1] It is the leading cause of hospitalization, comprising up to 39% of all obstetric patients in developing countries. [2] Obstructed labor is the single most important cause of maternal death and is one of the three leading causes of perinatal mortality [3] with the case fatality rate of 87%-100%. [4] Maternal mortality ranges between 1% and 13%, and perinatal mortality between 74% and 92%. [5],[6] It is found to be directly or indirectly responsible for about half of all maternal deaths, affecting mainly primigravida and grand multipara. [7],[8] Maternal deaths occur as a result of ruptured uterus as well as genital sepsis in women having undergone cesarean section done for obstructed labor. [6],[9]

Each year, 210 million women become pregnant, of whom 20 million experience pregnancy-related illness and 500,000 die as a result of the complications of pregnancy or childbirth. [10] In 1987, the World Health Organization (WHO) launched the Safe Motherhood Initiative, which aimed to reduce maternal morbidity and mortality by 50% by the year 2000. The initiative did not succeed, but maternal health continues to be a major focus of WHO effort. The current WHO initiative [11] is to reduce maternal mortality to 75% of the 1990 level by 2015. If this is to be successful, the problem of obstructed labor will need to be addressed effectively.

Maternal mortality from obstructed labor is largely the result of ruptured uterus or puerperal infection, whereas perinatal mortality is mainly due to asphyxia. Significant maternal morbidity is associated with prolonged labor, since both post-partum hemorrhage and infection are more common in women with long labor. Obstetric fistulas are long-term problems. Traumatic delivery affects both mother and child. [10],[11]

The present study was conducted to detect the presentation, management, and the various complications of obstructed labor cases in a peripheral tertiary care center, so that early intervention strategies may decrease the incidence of morbidity and mortality.


  Objectives Top


To study the different parameters of obstructed labor cases like its frequency, etiology, management, and complications. This will help to formulate a positive strategy to prevent obstructed labor and its consequence.


  Materials and Methods Top


This observational prospective study was carried out in the Department of Obstetrics and Gynaecology in a tertiary care hospital in West Bengal on 313 patients after taking permission from the ethical committee in a time period of 1 year.

Inclusion criteria

Patients with features of obstructed labor attending the obstetric emergency or developing obstructed labor in the institution were included in this study.

Procedure

Detailed history regarding age, socioeconomic status, parity, previous obstetric history, past history, antenatal care, duration of labor, details of referral history and management given were recorded. General examination was done. By clinical examination (per abdominal and per vaginal), diagnosis of cephalopelvic disproportion, malposition, malpresentation, obstruction in birth canal, overdistended bladder, hematuria, rupture of uterus, supermolding of fetal head, and Bandl's ring was made. [12],[13],[14]

Diagnosis of maternal exhaustion, dehydration, genital sepsis, pyrexia, rupture of uterus, post-partum hemorrhage (PPH), vesico-vaginal fistula, and shock was done. Any death occurring as a consequence of obstructed labor was noted. Diagnosis of living or asphyxiated or dead fetus or neonatal death was done by taking Apgar score at 5 min following birth. Mode of delivery (vaginal, cesarean section, destructive operations), time interval between referral, admission, intervention done at tertiary care center and related feto-maternal outcome were noted. Vaginal swab cultures of mother for infected cases were carried out. [12],[13],[14]

Parameters by which the obstructed labor was diagnosed were analyzed. The management including the mode of delivery was written in detail. The complications and maternal, fetal, and neonatal outcome as described in the parameters were recorded. All the information was recorded in a predesigned proforma. Outcome and complications of Lower segment Cesarean Section (LSCS) were recorded. Statistical analysis was done using Epi Info software (Version 3.5.1) after proper arrangement of all data in tabular form. P value <0.05 was considered as significant and <0.01 as highly significant.


  Results Top


Majority of the patients (87.86%) were from low socioeconomic group, 88.82% were from rural areas, 16.16% were illiterate, and 27.79% were unbooked. The commonest cause of obstructed labor was cephalopelvic disproportion (55.59%). Other causes were malposition (23%), malpresentation (18.21%), fetal congenital abnormality (1.28%), myoma (0.32%), and non-dilatation of cervix (1.60%). The commonest mode of delivery was cesarean section (85.94%). Instrumental deliveries formed 9.58%. Destructive operation was done in 1.92% cases. Rupture uterus was present in 8 (2.56%) cases, out of which hysterectomy was done in 5 cases and repair in 3 cases. The common maternal complications were sepsis [pyrexia 49.8%, urinary tract infection (UTI) 10.9%, wound infection 7.7%] and PPH (33.9%). Other complications were rupture uterus (2.56%), subinvolution (9.3%), shock (2.2%), bladder injury (1.9%), hysterectomy (1.6%), broad ligament hematoma (1.28%), maternal death (1.6%), vesico-vaginal fistula (VVF) (0.6%), and rectovaginal fistula (RVF) (0.3%). Perinatal mortality rate was 71/313 (22.68%), still birth rate was 57/313 (18.21%), and live birth rate was 256/313 (81.79%). Perinatal morbidity (in 198 cases) was most commonly due to birth asphyxia (29.68%), jaundice (16.80%), septicemia (14.84%), and meconium aspiration syndrome (9.77%). Incidence of PPH, still birth, perinatal mortality, and cesarean section was significantly higher among multiparous women [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11],.
Table 1: Magnitude of obstructed labor


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Table 2: Distribution of age and parity of patients


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Table 3: Demographic profile


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Table 4: Duration of labor in referral and institutional cases


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Table 5: Causes of obstructed labor


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Table 6: Different modes of delivery


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Table 7: Different maternal complications due to obstructed labor


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Table 8: Perinatal morbidity and mortality in 198 live births


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Table 9: Apgar score


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Table 10: Parity wise comparison of mode of delivery


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Table 11: Parity wise comparison of complications of obstructed labor


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  Discussion Top


The incidence of obstructed labor in the present study was 1.64%, which was lower than the incidence of obstructed labor was 12.2%. reported by Fantu et al, [15] 2.7% reported by Ikojo et al., [16] 3.3% reported by Gessessew et al., [17] 2.1% reported by Menon et al. [18] in a study conducted at Liaquat University of Medical and Health Sciences at Sindh, Pakistan, 4% reported by Melah et al. [19] in a study conducted at the Specialist Gombe Hospital (SHG), Gombe State, over a period of 5 years, and 3.2% reported by Aboyeji et al. [20] in a study conducted in University of Ilorin, Nigeria; but higher than 0.56% reported (Checked) by Adhikari et al. [21] in their study from India, 0.8% reported by Omole-ohonsi et al. in a study conducted in Aminu Kano Teaching Hospital (AKTH), and 1.27% reported by Dafallah et al. [22] in a study conducted in a teaching hospital in Sudan. This decreasing trend in incidence is probably a reflection of improvement in antenatal and intranatal care.

In the present study, the common causes of obstructed labor were found to be cephalopelvic disproportion (55.59%), malposition (23%), and malpresentation (18.21%).

Fantu et al in Ethiopia [15] the causes of obstructed labor were cephalo-pelvic disproportion in 67.6% and malpresentation in 27.9%. The commonest maternal complications observed were uterine rupture in 45.1% and sepsis in 39.3% with complications. Forty-five point eight percent of fetuses were born alive and all had low first minute APGAR score

In Sudan, Dafallah et al. [20] showed that 57% cases suffered from cephalopelvic disproportion. In a study in Enugu, Nigeria, by Nwogu-ikojo et al., [16] they showed that the cause of obstructed labour was cephalopelvic disproportion in 56.6% cases. A study conducted in University of Ilorin, Nigeria, by Aboyeji et al. [18] showed that the commonest cause of obstruction was fetopelvic disproportion in 56.7% of cases.

Obstructed labor being a grave condition, there is no place for wait and watch policy. Most cases (85.94%; 269/313 multiplied by 100) were terminated by LSCS while destructive operations accounted for 1.92% in this study. Konje et al., [21] from Ibadan, performed LSCS in 82%. A study from India by Adhikari et al. [22] showed that 63.27% were delivered by LSCS and 36.73% by destructive operations.

Regional anesthesia was used in 58% of the cases of LSCS and for all cases of destructive operation.

In a study conducted at Ethiopia, Gessessew et al. [17] showed that cesarean section was performed in 88 of the 195 cases (46.1%), craniotomy in 31 (16.2%), instrumental delivery in 27 (14.1%), hysterectomy in 28 (14.6%), and repair of ruptured uterus in 17 (8.9%), among 5980 hospital deliveries during the study period. A study in Enugu, Nigeria, by Nwogu-ikojo et al. [16] showed the most common intervention was LSCS. In the present study, the incidence of LSCS was slightly high, the incidence of destructive operation was low, and the incidence of instrumental delivery was also low (9.58%). Incidence of rupture uterus was also low (2.56%) as compared to other studies.

Maternal mortality in the study group was 5/313 (1.60%). All deaths occurred following rupture uterus. Maternal mortality rates in other studies were higher than those reported by Adhikari et al. [19] (2.04%), and Nwogu-ikojo et al. [16] (3.3%). Melah et al. [17] suggested that puerperal sepsis was the most frequent morbidity. Aboyeji et al. [18] showed that the common complications included wound infection (34.3%) and genital sepsis (31.3%). In the present study, the common maternal complications included pyrexia (49.8%), PPH (33.9%), UTI (10.9%), subinvolution (9.3%), and wound infection (7.7%).

Perinatal mortality reported in various studies are as follows: 38%, Neena et al. [22] 71.3%, Dafallah et al. [20] 27.1%, and Nwogu-ikojo et al. [16] 30%. In the present study, perinatal mortality rate was 71/313 (22.68%), still birth rate was 57/313 (18.21%), and live birth rate was 256/313 (81.79%). Perinatal morbidity (in 198 cases) was most commonly due to birth asphyxia (29.68%), jaundice (16.80%), septicemia (14.84%), and meconium aspiration syndrome (9.77%).

Limitations of the study

In the present study, 77% referral cases of obstructed labor came from remote and low socioeconomic areas. Increased number of institutional cases of obstructed labor (23%) was due to lack of proper monitoring system and partogram. Most of the patients (88.82%) came from rural areas, 16.61% patients were illiterate, 87.86% patients were of low socioeconomic status, and 27.79% cases were unbooked.


  Conclusions Top


Poor referral system, low socioeconomic status, illiteracy, and inadequate antenatal care services ANC services produce many cases of obstructed labor. The common mode of delivery is cesarean section. Destructive operations are done only in those cases of cephalo pelvic disproportion CPD with fetal death, but they are not frequently practiced because of their immediate and remote complications. Early recognition of obstructed labor cases and immediate safe abdominal or vaginal instrumental delivery can decrease the incidences of maternal and perinatal morbidity and mortality.

 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]



 

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