OBSTRUCTED LABOUR Answer Booklet PART- II
Item
- Title
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OBSTRUCTED LABOUR
Answer Booklet
PART- II - extracted text
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. J.
..J.
OBSTRUCTED LABOUR
Answer Booklet
PPRT - JJ
The Wellcome Tropical Institute
CONTENTS
Unit 1: Clinical management
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Answers to Problem 1.
Answers to Problem 2.
Answers to Problem 3.
Answers to Problem 4.
Answers to Problem 5.
Answers to Problem 6.
...5
19
.33
.45
.47
.49
Unit 2: Prevention and the labourgraph
• Answers to Problem 1,
• Answers to Problem 2,
.77
.93
Unit 3: Epidemiology
• Answers to Problem 1
I
119
1
UNIT1
Management
ANSWERS TO PROBLEM 1
5
Unit 1, Problem 1
Question 1.2
Please write your 'model' referral letter. Base your letter on a case such
as that of Charity Msowoya.
Sample referral
letter
I would expect every midwife in my district to be able to write a
letter similar to the example below.
Nthunduma Maternity Unit
24th December 1987
Dear Doctor,
I received a patient at 6 a.m. Her name is Charity Msowoya
from Katumbi village, 15 km from here by footpaths only. She is
about 16 years old, speaks Bemba only and is unmarried.
Her grandmother is with her. She says she has been in labour
for 24 hours, has not eaten but has had local medicines which have
made her vomit.
Clinical findings = temperature 36°, pulse 130, blood
pressure 90/50, dry tongue.
Contractions strong and frequent, head 3/5 above the pelvic
brim, cervix fully dilated, moulding +, caput + +, and fetal heart
heard.
We have no intravenous fluids here (please send more) and I
failed to pass a catheter.
She says that she didn't come to our antenatal clinics because
the rains made the journey too difficult. I cannot persuade any
young relatives to travel with her.
The ground labourer is leaving here with this letter at 7 a.m.
Yours sincerely,
Faith Ngoma (Midwife).
P.S. Labourgraphs are out of stock here.
References B and J relate to this question.
8
Unit 1, Problem 1
Question 1.3
What pre-operative instructions do you give to prepare for this?
Pre-operative
management for
Caesarean section
• Check haemoglobin, group and cross-match donors if available.
• Catheterise - to facilitate operative delivery and to measure the
urine output.
• Intravenous fluids - 2 litres of 5% dextrose quickly to
compensate for dehydration and ketosis, then 1 litre of normal
saline to restore the ECF volume and to be running when the
anaesthetic starts - mandatory if using spinal anaesthesia.
• She is probably very frightened and apprehensive. Try to
reassure her and help her to understand what you are doing for
her and her baby. She will then be much more ready to do what
you want her to.
• Decide (if a choice is available) what will be the most
appropriate anaesthetic.
References A (Chapter 32) and B relate to this question.
10
Unit 1, Problem 1
Question 1.4
List in sequence the actions you would take.
For each action give a reason.
Do not give a technical account of the whole procedure but
concentrate on the two particular problems outlined in the boxed
statement at the top of the page.
Procedure for
Caesarean section
Action
Reason
Before opening the
uterus ask an assistant
to disimpact the head
with a gloved hand in the
vagina.
Without doing so, you may find
great difficulty dislodging and
delivering the head. If done after
opening the uterus, the baby's
shoulder may present first, causing
your further difficulties.
Open the uterus with a
pair of scissors and
create a U shaped
incision, i.e. a
transverse lower segment
incision with the
incision turning
'upwards' in a U shape.
This is to prevent further tearing
downwards towards the large uterine
vessels. These tears are difficult
to repair in themselves but in
addition may lead you to damage the
ureter in attempting the repair.
Reference B relates to this question.
12
Unit 1, Problem 1
Question 1.5
List the steps you would take to establish the cause of this fever.
Establishing causes
of fever
I will approach this problem in the same logical way as any other
clinical problem via the three stages of history, clinical signs and
special tests.
History
Ask specifically about cough, chest pain, abdominal pain, wound
pain, dysuria, urinary frequency and breast pain.
Examination
Pulse and blood pressure - in particular these may reveal that she is
septicaemic.
Lochia
Look for offensive, excessive or scanty lochia.
Respiratory rate
If raised, suggestive of pneumonia.
Chest signs
If dullness on percussion, crackles, and bronchial breathing, then
pneumonia is present (these signs depend on the stage of the
pneumonia).
Breasts
Look for a local tender area which may suggest an abscess.
Abdomen
Palpate for tenderness, either in the wound, of the uterus or
elsewhere.
Legs
Look for evidence of deep vein thrombosis.
Special tests
Urine - Microscopy; are pus cells abundant?
Blood - Look for malaria parasites.
Sputum - Gram stain: look for many Gram +ve cocci.
References A (Chapter 53) and H relate to this question.
14
Unit 1, Problem 1
Question 1.6
List the advice, explanations, instructions and any other help Charity
should be given in relation to her obstetric future.
With each piece of advice, etc. give your reason.
Advice and
follow-up
Advice etc.
Reason
A midwife should explain
to her why she needed a
Caesarean section.
Only by understanding the problem
can it be hoped that she will attend
in her next pregnancy.
She should receive a card
(of the most durable
material available)
outlining the main point
for use by maternity
staff in her next
pregnancy, e.g.
'Caesarean section for
obstructed labour due
to a contracted pelvis;
elective c.s. indicated in
next pregnancy.'
Patients cannot be relied upon to
give sophisticated histories or
or indeed even to remember the
events of two or three years ago.
I will arrange that she
attend (if she can do so)
the rural maternity unit
on the day of my next
visit there.
This will not only give me the oppor
tunity of reviewing her clinical state
but, more importantly, give me an
opportunity to reinforce the advice
given to her at the district hospital.
I will encourage her to
take the baby to the
under five clinic, run
by the midwife.
This will allow the midwife the
opportunity to get to know her and
be aware of her next pregnancy as
well as the accepted benefits to the
baby of attending the under five
clinic.
Reference H relates to this question.
16
Unit 1, Problem 1
CONCLUSION TO PROBLEM 1
As a result of this case the District Medical Officer organised a
mobile antenatal clinic near Charity Msowoya's village. She
attended that clinic in her next pregnancy and was safely delivered
by elective Caesarean section at the district hospital.
A course was organised for Traditional Birth Attendants
throughout the district with the result that from that time on any
woman labouring at home for more than 12 hours was referred to
the nearest midwife.
Study advice
How did your answers compare with mine?
If you are well satisfied with your own decisions and your
reasoning, why not try answering one of the other problems. If,
however, you feel you would like to have another opportunity to
think through these issues and problems, you will find Problem 2
interesting and useful.
17
ANSWERS TO PROBLEM 2
19
Unit 1, Problem 2
Question 2.1
List possible explanations for her failure to deliver.
Give your explanations in order of likelihood.
• The most likely cause is malpresentation, e.g. a shoulder or
brow presentation which is causing obstructed labour.
• Cephalo-pelvic disproportion is less likely because of the past
history of nine successful pregnancies. However, this can occur
where there is a fetal abnormality such as hydrocephalus.
• The least likely cause, but one that does occur, is obstructed
labour owing to an ovarian tumour or uterine fibroid obstructing
the delivery passage.
20
Unit 1, Problem 2
Question 2.2
22
What observations and actions should she now take?
Give reasons for each point you make.
Observation/Action
Reason
• Arrange urgent transfer to the
district hospital.
Vaginal delivery of the
presentation cannot
occur.
• Assess the general clinical
state: temperature, pulse,
blood pressure, state of
hydration.
She may be able to give
intravenous fluids if the
observation indicates the
need for them.
• Catheterise the woman, record
the urine volume.
The urinary outflow may
well be obstructed by the
pressure of the present
ing part. The urine
volume is part of the
assessment of fluid
balance.
• Give pethidine ..? if allowed
to do so.
Pain relief.
• Attempt to ensure two fit,
suitable adults to travel as
blood donors.
It is never easy to find
donors at the district
hospital.
• Write referral letter indicating
social and family history.
Helpful for the medical
officer to have this
knowledge to help with
decisions e.g. tubal
ligation.
• Explain to the patient the
nature of the problem.
This will relieve her
anxiety and, we hope,
will make her more
cooperative.
Unit 1, Problem 2
Question 2.3
What is the significance of these findings?
Bandl’s ring is found around the level of the umbilicus and
represents the division between the distended, stretched lower
segment and the contracted upper segment. Its significance is that
rupture of the uterus will soon occur. The normal fetal heart rate is
120 - 180/minute. A fetal heart rate of 80/minute signifies severe
fetal distress.
Reference B relates to this question.
24
Unit 1, Problem 2
Question 2.4
What problems face you ?
What do you do to resolve the problems?
Give your reasons.
I am faced with two problems.
• A very difficult lower segment to open safely. Tearing,
downwards and laterally, during delivery and involving the large
uterine vessels is very likely.
• Cutting through the large veins will result in considerable blood
loss until the baby has been delivered and the uterus contracts.
My approach will be to use the low mid-line incision to avoid
lateral tearing and haemorrhage from the veins over the lower
segment.
If you decided to perform a lower segment transverse incision then
you should enlarge the incision ’upwards' in a broad U shape so
that tearing does not continue towards the large uterine vessels.
When clamping these in a difficult case it is easy to clamp the
ureter(s) in error.
Reference B relates to this question.
26
Unit 1, Problem 2
Question 2.5
Give two arguments for tubal ligation and two against.
What would you personally decide and why?
For tubal ligation
• The woman has a large family, she will be aware that this
pregnancy has brought her close to death and so she will be
pleased to stop child-bearing.
• A grand multipara with a uterine scar is a major obstetric risk
(of ruptured uterus) in her next pregnancy. We cannot even be
sure we will see her in that pregnancy. Tubal ligation is justified
as a life- saving procedure in this case.
Against tubal ligation
• She has not given informed consent. Even if she is asked about
this while she is in labour, how can you expect her to make up
her mind rationally at such a time?
• Such a decision must be taken by the husband and wife together,
or even by the husband alone. Tubal ligation should be
postponed for a later date after a family discussion.
Personal decision
28
I would personally perform a tubal ligation. I believe that I have an
obligation as a doctor for her future well-being which overrides the
consideration of informed consent. The point made in paragraph
two above, that she may well not be seen in a future pregnancy, is
an important one. In my past experience of similar cases in grand
multiparae, such women on being told that they would no longer
become pregnant were quite overjoyed. I understand that this
reaction will vary between different societies in Africa and there is
no 'right' answer applicable everywhere.
Unit 1, Problem 2
Question 2.6
List the steps you would take to identify the cause of her problem.
• Short, relevant history asking about vomiting, bowels, dysuria,
and lochial discharge.
• Check the pulse and blood pressure - even if these have been
recorded I like to check them myself - many nurses find
difficulty in counting pulse rates over 100/min and clearly a
pulse of 150/min has much greater significance than one of
102/min.
• Examine the abdomen - palpate the non-tender area first. Look
carefully for a wound infection and check bowel sounds - if they
are absent peritonitis is probable. If present, peritonitis is still
possible and you must assess all the signs very carefully. Rectal
examination may reveal pelvic tenderness owing to a pelvic
cellulitis. Look for abdominal distension suggesting an ileus if
peritonitis is present.
• If no cause has yet been found, then look at the urine for cells
suggesting a bladder infection. The urine for microscopy should
be obtained by supra-pubic aspiration of the bladder or by
urethral catheterisation.
• Choose appropriate antibiotics, depending on what you find, and
re-examine daily to assess progress or signs of deterioration.
Reference A (Chapter 53) relates to this question.
30
M
Unit 1, Problem 2
CONCLUSION TO PROBLEM 2
In this case of a grand multipara the rural midwife's accurate
assessment and action led to a successful Caesarean section and a
live baby. Tubal ligation was performed and the husband and wife
were both grateful that her life would never again be similarly
endangered. The lower abdominal pain was the result of a wound
infection which was successfully treated.
At future antenatal classes in the woman's area her story was told
by the midwife to illustrate the problems of grand multipara and
the importance of supervised labour in a maternity unit.
31
ANSWERS TO PROBLEM 3
33
Unit 1, Problem 3
Question 3.1
How do you intend to deliver this young woman? Explain why you
choose the method you do.
Craniotomy
I will deliver the baby by doing a craniotomy. I will do so because I
want to avoid the alternatives of symphysiotomy or Caesarean
section in this situation. Caesarean section in this case would be
unnecessary and hazardous. Firstly we would have the danger of
anaesthesia in an ill patient. Secondly the risk of intra-abdominal
infection after two days of labour would be very high. With no live
baby at the end of an operative procedure the woman and her
relatives would be very unlikely to return to the hospital in the next
pregnancy which would then end in ruptured scar and certain
death.
Reference E relates to this question.
34
Unit 1, Problem 3
Question 3.2
Outline the pre-operative management before you proceed with the
delivery.
Pre-operative
management for
craniotomy
• Check the haemoglobin and cross-match two units of blood if
available.
• Inform the theatre and ask them to be ready for a possible
laparotomy.
• Correct dehydration and ketoacidosis by giving at least a litre of
5% dextrose.
• Give broad spectrum antibiotics e.g. chloramphenicol
1 g intravenously to combat the infection.
• Give pethidine 50 mg intravenously slowly for pain relief.
• Pass a nasogastric tube and empty the stomach by suction.
• Give ranitidine 150 mg orally as soon as possible and 30 ml
0.3 M sodium citrate before she goes to theatre.
Reference A (Chapter 48) relates to this question.
36
Unit 1, Problem 3
37
Unit 1, Problem 3
Question 3.3
Write down what you will say to him, explaining each step so that he
knows the reason for everything he has to do.
Procedure for
craniotomy
• Give diazepan intravenously 10-20 mg - as much as required to
make the patient drowsy and unaware of the procedure. If she is
still in some pain following the first injection of pethidine in the
ward give 25-50 g pethidine intravenously again.
• Place her in the lithotomy position, clean and drape the vulva
and perineum.
• Ask an assistant to hold one or two Sims specula in the vagina to
give you a good view of the head. It is important not to do
anything 'blind' and damage the vagina.
• Find a suture line or fontanelle with your finger and incise the
skin in this area with a cross-shaped incision.
• Now use your scissors. Keeping them closed push them between
the bones, opening and closing them as you do so to enlarge the
opening they have made.
• Brain should now extrude. Put a finger into the skull and break
up the septa to allow as much material to extrude as possible.
• Using four strong volsella forceps or Kocher, grip the bony
margins of the opening. Pull on these. If one breaks away
holding a fragment of bone take a deeper bite on the skull but
make sure you do not catch any vaginal tissue or the cervix.
• Be very careful that ragged edges of bone do not lacerate the
vagina. Traction on the forceps should result in an easy delivery
of the head.
• The rest of the delivery is in my experience usually easy. If you
find difficulty delivering the shoulders, turn them through 90°. If
this does not work then pull down the posterior arm, then turn
the fetus through 180° and pull the other arm down. The
delivery is then completed easily.
• Do a manual removal of the placenta and make sure to give
ergometrine 0.25 mg intravenously stat. This is most important
because in these cases the uterus can be atonic and a primary
post-partum haemorrhage is a strong possibility.
• You must be aware of the possibility of ruptured uterus after
any destructive procedure, although this is less likely with a
cephalic presentation than a transverse lie. After delivering the
placenta feel the uterus very carefully for any tear. Then inspect
the cervix, vagina and vulva for any tears. Repair any you find.
38
Unit 1, Problem 3
• He should have asked the theatre to prepare for a laparotomy in
case a ruptured uterus was found.
• Insert an indwelling catheter for continuous drainage of the
bladder.
• Check that the uterus is now well contracted. If it is not, run in
oxytocin 10-40 units/litre intravenously over 12 hours.
Reference A (Chapter 48) relates to this question.
39
Unit 1, Problem 3
Question 3.4
What post-operative instructions are ofparticular importance in this
case and why?
Post-operative
management of
craniotomy
• Because of the high risk of serious pelvic infection, high doses of
broad spectrum antibiotics must be continued for seven days,
e.g. chloramphenicol 500 mg six hourly.
• Because of the likelihood of pressure necrosis to the bladder
during the two days of labour, open bladder drainage must be
continued for 14 days.
• Continue intravenous fluids slowly for 24 hours as a precaution
for any rapid circulatory collapse either because of septicaemia
or because of a primary post-partum haemorrhage.
40
Unit 1, Problem 3
Question 3.5
i)
ii)
What is the likely explanation of this new problem?
Outline the main points of management of this problem over the
next few months.
Vesico-vaginal
fistula
i)
It is very likely that this patient has a vesico-vaginal fistula, a
common complication of prolonged obstructed labour in
primigravidae.
ii)
Management
• Continue bladder drainage for three weeks to help
encourage healing in a small fistula.
• Twice daily bathing of the vulva followed by application of a
barrier cream to prevent ammoniacal dermatitis.
• Treat any urinary tract infection with antibiotics.
• After three weeks remove the catheter and allow the patient
to return home. Explain to her that she must return after
three months for specialised treatment.
• See her again sooner than three months after delivery.
Ensure that her haemoglobin is at least 11 g%, that there is
no urinary tract infection (very rare when the bladder is
draining constantly through a fistula) and that
schistosomiasis, if present, has been treated. Check that the
vagina and vulva are clean. Now is the time to refer her to a
gynaecologist at a central hospital for further treatment.
References A (Chapter 55), H and K relate to this question.
42
Unit 1, Problem 3
CONCLUSION TO PROBLEM 3
Mary Mwenifumbo had a successful repair of her vesico-vaginal
fistula at the central hospital and the following year had a full-term
healthy baby delivered by elective Caesarean section at the district
hospital.
43
ANSWER TO PROBLEM 4
45
Unit 1, Problem 4
Question 4.1
Use these three papers and Driessen's notes, (Reference A, Chapter
48, pages 145-147), to construct a short list of reasons for and points
against each one of these three procedures for dealing with intra
uterine death with an arm or shoulder presentation.
For
Against
Caesarean section
• Avoids any possibility
of rupturing the uterus;
Drs Mphahlele and Van
Der Meulen delivered
all 33 of their cases
by this method.
• Breaks rule of 'no
Caesarean for a
dead baby.' Assumes
good anaesthesia
and return of
the woman in her next
pregnancy.
Decapitation
• Avoids any manipulation
of the fetus which could
damage the stretched
lower segment.
• Best procedure if neck
is easily reached.
• Can be difficult to
pass the thimble
(see Lawson) over
the neck.
• Specialised instru
ments often not
available in district
hospitals.
Evisceration
• Technically easier than
decapitation.
• Can be performed without
any special surgical
instruments (see
Dr Dutta's 41 cases of
transverse lie all
delivered this way).
• Does involve gentle
version and breech
extraction which
may cause damage
to the thin lower
segment of the
uterus.
46
ANSWERS TO PROBLEM 5
47
Unit 1, Problem 5
Question 5.1
Write down your diagnosis and your reasons for making it.
Ruptured uterus
The diagnosis is ruptured uterus, for the following reasons.
Reasons
• The history is that of obstructed labour in a multigravida. We
know that rupture of the uterus is the almost inevitable outcome
of obstructed labour which is unrelieved by an operative
delivery.
• The examination reveals no contractions. Whereas a
primigravida with obstructed labour may eventually stop
contracting this is not the case in the multigravida. The cessation
of contractions is highly suggestive of uterine rupture.
• The ease with which the fetal parts can be palpated is another
common finding in this condition.
• The absence of the fetal heart supports the diagnosis but on its
own is not diagnostic. However in this case its absence confirms,
with the other signs, the diagnosis.
Reference B relates to this question.
48
Unit 1, Problem 5
Question 5.2
Is the normal blood pressure an expected finding? Give a reason for
your answer.
Yes, the normal blood pressure is an expected finding, particularly
in an early case of uterine rupture.
The reason is because of the impacted presenting part
compressing the tom bleeding areas. The tear itself may not have
involved major vessels. However, in some cases of ruptured uterus
the picture may be more dramatic with shock in the early stages if
the large uterine vessels in the broad ligament are tom and
bleeding freely. The patient will then have a fast, thready pulse and
low blood pressure.
Reference B relates to this question.
50
Unit 1, Problem 5
Question 5.3
Explain why this problem can arise in a fourth pregnancy in a woman
who has had previous vaginal deliveries.
It is recognised that the peak incidence of rupture of the uterus is
in the third and fourth pregnancies. Professor Lawson believes that
this is due to progressive increase in the birth weight in these
pregnancies compared to the first two. In our patient’s case we can
postulate that she has a borderline pelvis; the combination of a
larger baby than she has previously had and the occipito-posterior
position which presents a large diameter (11-12 cm) compared to
10 cm in the occipito-anterior position has lead to cephalo-pelvic
disproportion as the cause of her obstructed labour.
Reference I (pages 203-210) relates to this question.
52
Unit 1, Problem 5
Question 5.4
What signs, in addition to those given for this Problem, would you
expect your junior medical assistant to look for?
List these signs in note form.
Signs before
rupture
• Shortly before rupture occurs contractions become increasingly
frequent and last longer. Finally the uterus may reach a state of
tonic uterine contraction.
• Bandl’s ring may be seen on inspection of the abdomen. It is a
contraction ring between the distended lower segment and the
contracted upper segment of the uterus. The outline of the
distended bladder may also be noted.
• On vaginal examination the cervix is usually fully dilated and the
presenting part is high.
Signs after
rupture
• When the uterus has actually ruptured the woman will complain
of severe pain which is now continuous and she will be
distressed.
• On examining the abdomen the commonest finding is of
generalised tenderness, although in some cases tenderness is
confined to the lower segment. It is often very difficult to feel
the uterus separate from the fetal parts but there is usually an
irregularity rather than the smooth surface of the uterus.
• Vaginal examination may reveal bleeding and the head which
was previously impacted may now be easily dislodged.
• Catheterisation can be easily performed whereas it is frequently
impossible or very difficult in obstructed labour. The urine may
well be blood-stained.
Reference B relates to this problem.
54
Unit 1, Problem 5
Question 5.5
Write down the pre-operative instructions to be carried out by the
nurses.
Pre-operative
management of
ruptured uterus
• Blood to be taken for haemoglobin estimation, and cross
matching of two units of blood at least.
• Start intravenous infusion of normal saline; try to give 1-2 litres
in the time available.
• Catheterise and record urine volume.
• Give a large dose of broad-spectrum antibiotic e.g.
chloramphenicol 1 g intravenously.
• Nil by mouth. Pass nasogastric tube, aspirate stomach contents
and give antacids.
• Prepare the patient for laparotomy as soon as theatre is ready.
References A (Chapter 45) and D relate to this question.
56
Unit 1, Problem 5
Question 5.6
i)
ii)
Which should he give?
Explain the reason for your decision.
Should he consider any other form of anaesthesia and why?
You should ask him to give a general anaesthetic. If the
woman's general condition is very poor, as is sometimes the
case in those who present many hours after rupture has
occurred, then you may have to proceed with local anaesthesia
and intravenous pethidine.
ii) Spinal anaesthesia should not be used because of the very
great danger of circulatory collapse in a patient who is already
hypotensive.
i)
Reference D relates to this question.
58
Unit 1, Problem 5
Question 5.7
Outline briefly how you will proceed. Write your answer as ifyou are
explaining to your assistant at the operation what you are doing, stepby-step, so that he can eventually take over from you in future cases.
Procedure for
ruptured uterus
• First of all we must decide whether we shall repair the tear or
do a sub-total hysterectomy. As we are inexperienced a simple
repair is almost always the easier procedure. Sometimes when
there is a posterior tear or a tear so extensive that the uterus is
almost detached from the cervix then there is no choice but to
do a sub-total hysterectomy.
In this case, which is an anterior tear, we shall do a repair.
• We look for any dead tissue to excise; we do not excise any
other tissue in an attempt to trim a ragged tear.
• We now gently reflect the bladder downwards with a gauze swab
to help us avoid it when suturing the tear.
• If the tear is in the lower segment and extends low and laterally,
look out for the ureter so that you can avoid it. Only put sutures
in the uterine tear when you have clearly identified the edges.
Our aim must be to avoid catching a ureter in a suture and
ligating it.
• We now repair the tear starting at the apex using continuous
chromic cat-gut number one or two. If it is difficult to start at the
apex we can start at the other end and with traction on the
suture bring the apex into a more accessible position. We use
only one layer of suture material.
• Close the peritoneum over the uterus. Abdominal drains are not
useful in cases of this nature but if the broad ligament has been
involved in the tear then we would place a drain from the broad
ligament into the vagina by leaving a small enclosed area at the
inferior end of the tear.
• We tie both fallopian tubes. This, unfortunately, is mandatory
because a repaired uterus cannot withstand a future pregnancy.
• Finally we clean out the abdomen with warm saline and close in
three layers in the usual way.
References A (Chapter 45) and D relate to this question.
60
Unit 1, Problem 5
Question 5.8
Write down the post-operative instructions which you wish the nurses
to follow on the ward.
Post-operative
management of
ruptured uterus
Post-operative instructions for ward staff:
• Record pulse and blood pressure hourly for the first six hours,
then continue with four hourly temperature, pulse and blood
pressure recordings. (We cannot expect such ideally frequent
observations if there is only one nurse running the entire
maternity unit in the hospital).
• Transfuse whole blood, if depending on estimated blood loss
and signs of shock.
• ’Drip and suck' until bowel sounds return.
• Cover with broad spectrum antibiotics for five days.
• Continuous bladder drainage with a catheter for ten days if
there is any suspicion that the bladder has been damaged.
Reference A (Chapter 45) relates to this question.
62
Unit 1, Problem 5
Question 5.9
Write down the important clinical signs you would look for when
you see her in the ward.
ii) Outline the important management steps at this stage, before
possible surgical intervention.
i)
i)
ii)
64
Check her pulse and blood pressure to assess whether the
blood loss has been large enough to affect her circulation by
making her hypovolaemic.
Correct hypovolaemia, if present, with normal saline. Cross
match blood and re-check the haemoglobin. Give
ergometrine 0.25 mg immediately via an intravenous infusion.
Arrange an examination under anaesthesia with the theatre
staff prepared for you to proceed to a laparotomy.
Unit 1, Problem 5
Question 5.10
i)
ii)
What possible alternatives are there to deal with this problem?
Which would you choose and why?
The alternatives are to resuture the wound or to do a sub-total
hysterectomy.
ii) I would choose to do the hysterectomy on the basis that I
could not be sure that secondary suturing would be more
successful than the first repair. I do not want her to undergo a
third laparotomy and indeed either she or her husband might
well not give consent for yet another operation.
i)
66
Unit 1, Problem 5
Question 5.11
Write down exactly what you will say to her. Do so in a way which
takes account of her level of knowledge and which acknowledges the
sadness she feels having lost this baby and learning that she can have
no more.
Whenever I have to explain to patients about problems such as this
I try to make sure that they understand what has happened to them
and why. Simple statements of fact are not enough. Beware of
sounding 'matter of fact' about a problem which you deal with quite
often but which for the patient is a once in a lifetime disaster. It is a
good rule never to underestimate intelligence and never to
overestimate knowledge. Uneducated people are not unintelligent
people.
I should start by talking to her about the way the hospital has
helped her. Go over the story of her labour reminding her of her
unusually long labour and severe pain. She will probably believe
that this was due to outside forces in keeping with her cultural
beliefs so do not stress your explanation of why she had obstructed
labour. Tell her that when she arrived at the district hospital the
baby was dead and that she was bleeding inside. Ask her if she
knows of women who have died in childbirth.
I would then outline the operation, how the womb was tom
apart and how two operations were required to stop her bleeding
to death. Although she has lost a baby her two children at home
have not lost their mother.
At this point it is not uncommon to be praised and thanked.
Now is the time to explain that the torn womb has been removed.
Tell her quite truthfully that she will have no more monthly periods
or ever again conceive. At the same time say that a further
pregnancy in a womb which has torn apart always ends in the same,
often fatal, way.
I should end by saying that I know how sad she must be to know
that she can have no more children but that I am also glad to see
her well again and able to go home to her children.
68
ANSWERS TO PROBLEM 6
69
Unit 1, Problem 6
Question 6.1
Prepare this talk in note form. You may find it useful to divide it into
four sections:
• The indications for symphysiotomy.
9 The procedure itself.
9 The complications and the post-operative care.
• Concluding summary stating the case for the usefulness of
symphysiotomy in the district hospital
Indications for
symphysiotomy
• Cephalo-pelvic disproportion with the head jammed deeply in
the pelvis.
• Vacuum extraction has only just failed or when it would succeed
but with great difficulty, thus endangering the baby.
• Prolonged second stage; immediate symphysiotomy is better
than first trying the vacuum extractor when the conditions make
you suspect that delivery is unlikely.
Before starting the procedure we check that certain conditions are
present and that other conditions which are contra-indications are
absent.
• The baby must be alive.
• The head is 2/5 or less palpable abdominally.
• There is no overlap of the anterior parietal eminence over the
symphysis pubis.
• The baby is not very big - severe damage to the pelvis may ensue
if the baby is large.
• The cervix is 8 cm or more dilated.
• There should be no maternal locomotor disability arising from
the spine, pelvis or legs.
• There should not be gross obesity.
• There should not be gross cephalo-pelvic disproportion and no
evidence of impending rupture.
Procedure
70
• Explain what you are doing to the patient.
• Place patient in lithotomy position with the legs abducted to not
more than 80°; two assistants must hold the legs. Greater
abduction will damage the sacroiliac joints.
• Disinfect the lower abdomen and vulva and then infiltrate
around the symphysis pubis and perineum.
• Catheterise.
• Apply vacuum extractor and pull once to check that an easy
delivery will not occur.
• Put one finger between the head and the symphysis to push the
urethra, with the catheter in it, aside.
Unit 1, Problem 6
• Incise the symphysis pubis in the mid-line as in the diagrams
below. If there is any difficulty feeling the tip of the blade with
the finger behind the pubis symphysis then you are not in the
exact mid-line. The symphysis now separates and you should be
able to place a finger in the gap. The separation should be
limited to 2.5cm.
• Make a large episiotomy.
Figure 1 Symphysiotomy
* V
Bladder
Symphysis
pubis
Cannula displaced
by finger
• Deliver using the vacuum extractor; deliver the baby 'away' from
the symphysis to avoid more strain on the urethra.
• Any bleeding from the area of the incision can be stopped by
pressure between finger and thumb. It usually stops bleeding as
soon as the baby is bom.
• Repair the skin incision over the symphysis with one suture and
then repair the episiotomy.
Complications
• Sepsis and haematoma at the operation site - both rare.
• Stress incontinence - fairly common but full control is usually
regained.
• Injury to bladder and urethra - occur if technique is faulty;
therefore a complication which should not occur.
• Pelvic instability - this can occur but is remarkably uncommon.
• Failure to effect vaginal delivery - this will only happen if the
procedure is attempted in the presence of unfavourable
conditions. If the indications are correct and there are no
adverse factors, failure will not occur.
71
Unit 1, Problem 6
Post-operative
care
• Continuous bladder drainage with a Foley catheter: for
three days if procedure uncomplicated but if any suspicion of
prolonged pressure on the bladder during labour, or if there is
blood stained urine then leave the catheter in for one to three
weeks.
• Complete bed-rest for three days; allow gentle mobilisation only
for the next few days. Most patients will walk well by the tenth
day.
• Give antibiotics using the same regimen as for a Caesarean
section.
• Analgesia as required.
Concluding summary
• Clinical decisions in district hospitals have to be made in the
light of limited resouirces both of people and equipment. A
hospital may have no intravenous fluids and sometimes even no
antibiotics. Anaesthetics may have to be administred by
unqualified assistants. The nurse who attends the operating
theatre may, by doing so, leave the maternity ward unattended.
• Symphysiotomy avoids the dangers of general and spinal
anaesthesia used for Caesarean section.
• The complications of Caesarean section are avoided.
• There is no risk of ruptured scar in future pregnancy - rural
patients can sometimes not reach the district hospital in the
rainy season.
• Symphysiotomy takes less than 15 minutes to perform. This is an
important considertion for a single District Medical Officer.
Medical ethical philosophers argue that our duty to the
individual patient may have to be balanced by our obligations to
others when we are faced with allocating scarce resources. In
this situation the District Medical Officer’s time is the limited
resource.
References A (Chapter 42), C and I relate to this question.
72
Unit 1, Problem 6
Question 6.2
74
Using the study material produce two arguments against:
i) his statement that the pelvis will be unstable following
symphysiotomy, and,
U) his recommendation of Caesarean section in all cases.
i)
Professor Philpott, the ex-Professor of Obstetrics in Nairobi,
has described his experience of over 500 symphysiotomies
(Reference C). He admits that we cannot be certain how
frequently women develop pelvic instability after
symphysiotomy but that the evidence available suggests that it
is not common. The stability of the pelvis depends on the
sacro-iliac joints; by doing a surgical symphysiotomy they are
in fact protected from a dangerous degree of separation by
controlling the abduction of the legs and by the relatively short
time that the delivery takes compared to the considerable time
for a difficult vaginal delivery.
Professor Philpott writes that symphysiotomy fell into
disrepute because of the worry about pelvic instability and
difficulty with walking as a consequence. This came about
because the operation was being done incorrectly for cases of
gross cephalo-pelvic disproportion. He feels that the operation
needs to be reinstated as an excellent procedure in developing
countries for cases of mild cephalo-pelvic disproportion.
ii)
Dr Driessen (Reference A) writes that in cases where the head
is deeply jammed in the pelvis with caput visible at the vulva.
Caesarean section will be disastrous because of tears in the
lower segment, bleeding and sepsis. In his opinion
symphysiotomy is life-saving for the mother and in his words 'a
must'.
Professor Lawson writes in his textbook (Reference I)
something that all district medical officers know only too well
that in rural areas where many people live great distances
from the hospital, Caesarean section leads to the possibility of
a ruptured scar in a subsequent unsupervised labour. This
long-term consideration should always be in our minds when
we are considering delivery by Caesarean section.
UNIT 2
Prevention
ANSWERS TO PROBLEM 1
77
Unit 2, Problem 1
Question 1.1
Write a statement defining the role of the midwife in a rural area in
the prevention of obstructed labour and its complications.
Midwife's role
The midwife's role is to prevent obstructed labour and its
complications by using her knowledge of the predisposing factors
which she can discover through taking a thorough obstetric history
and by being alert to those clinical signs found on examination
which indicate potential problems in labour. She must ensure that
all such women are seen by a senior midwife or the District
Medical Officer for a further assessment at a future date either at
her rural unit or at the district hospital if appropriate.
Reference M relates to this question.
78
Unit 2, Problem 1
Question 1.2
Produce such a protocol It should contain the risk factors that a
midwife must identify, the reason this antenatal finding is a risk factor,
and the steps she should take when she has identified the woman at
risk.
Risk factor
Reason
Action
• Previous obstetric
history of prolonged
labour or still-birth.
Both suggestive of
cephalo-pelvic
disproportion (CPD).
Refer to senior staff
for pelvic assessment.
Explain to woman
that delivery at
district hospital may
be necessary.
• Past history of vesico
vaginal fistula
Confirms severe
CPD in previous
labour
Arrange transfer to
district hospital at
36 weeks to await
elective Caesarean
section.
• Previous delivery of
large baby.
Subsequent baby can be
even larger leading to
CPD or shoulder
dyslocia even in a
woman with a good past
obstetric record.
Refer to senior staff
for assessment.
• Young girls not
physically fully
mature
High risk of CPD owing
to pelvis not fully
grown. Maternal
mortality known to be
higher in this age
group compared to
20-30 year olds.
Refer to senior staff
for assessment.
Delivery may be
planned at rural unit
if i) labour closely
supervised, ii) good
communication to
facilitate transfer to
district hospital.
• Past history of
section for prolonged
despite previous
deliveries.
Despite subsequent
vaginal deliveries
these women remain a
high risk for
obstructed labour
and ruptured scar.
Transfer at 36 weeks
to district hospital
or close by. Delivery
must take place in a
unit with operative
facilities.
80
Unit 2, Problem 1
Reason
Action
• Pelvic assessment
revealing a contracted
pelvis.
High risk of CPD.
Refer to senior staff
to confirm findings.
• Very short women, for
example those below
147 cm. (This height
varies in different
populations).
Very short women have
smaller pelvises & are
more likely to have
CPD than taller women.
Refer to senior staff
for assessment.
• Grand multipara.
At risk of abnormal
presentation e.g. arm
presentation and can
progress to obstructed
labour and ruptured
uterus in a short time.
Advise these women
to await delivery in
or near the district
hospital. Reassure
them you expect a
vaginal delivery in
most cases.
Risk factor
Reference A (Chapter 2) relates to this question.
81
Unit 2, Problem 1
Question 1.3
Produce a list for the use of all your maternity staff offive causes of
obstructed labour excluding cephalo-pelvic disproportion.
Causes of obstructed
labour excluding CPD
• Abnormal presentation: an impacted transverse lie.
• Abnormal presentation: breech, obstructed most commonly by
the arm and head together after traction on the trunk.
• Abnormal presentation: compound presentation of head and
arm; certain others which cannot be delivered - brow, face with
chin in the posterior position.
• Abnormality of the fetus, for example hydrocephalus or locked
twins.
• Tumours in the pelvis, cervical stenosis.
Reference L relates to this question.
82
Unit 2, Problem 1
Question 1.4
i)
ii)
Write down what you will say to the midwife using this example
to make sure she understands the points it illustrates.
Produce a further example with notes on the teaching points it
emphasises for you to use in practice in your district.
i)
I shall ask her what risk factors she can identify in the history
as given so far: age, because we know that in general girls of
this age are a high-risk group for cephalo-pelvic disproportion
(CPD) and the previous early neonatal death at six hours.
Although some early neonatal deaths are due to severe
congenital abnormalities, the midwife can discover if CPD was
the cause by asking about the length of the first labour. A
labour lasting more than 24 hours followed by an early death
like this is almost confirmatory of CPD.
I would then go on to discuss with the midwife the future
management. She should be able to tell me that this girl needs
to have a careful supervised trial of labour at the district
hospital with a strong possibility of an operative delivery.
ii)
The way to approach this is to choose a risk factor and
incorporate it into a case-history in such a way that the point
you want to get over is established by the midwife asking
more questions to show you that she understands. For
example, you could choose a past history of a stillbirth; many
midwives will record this and inquire no further. What you
want to know and what they must ask is: 'Was the baby alive
at the start of labour?'; 'How long was the labour?'; 'If the
baby was delivered at a district hospital was an anaesthetic
given - suggesting a destructive procedure?' These questions
provide the information which allows the midwife to infer
that the stillbirth was caused by obstructed labour.
References A (Chapter 2) and J relate to this question.
84
Unit 2, Problem 1
Make a list of the main points you wish her to understand, then for
each point outline how you will explain it to her.
Question 1.5
Explanation
Main points
• Ask all women about the length(s)
of previous labour and whether there
has been a stillbirth. We want to
see women who have laboured for more
than a day.
Long labour and stillbirths are not
the result of any wrong done by the woman
or her husband but occur because the baby
is too big for the birth passage. This
problem does not go away but happens in
each labour. Take the woman to a midwife for
her advice.
• Has the woman ever had an operation
at the time of childbirth? (This
question should identify all those
who had Caesarean section,
symphysiotomy, destructive operation
or vesico-vaginal fistula surgery).
These operations saved the woman's life
and maybe her baby's. She may die if you try
to deliver her in the village. Take the
woman to a midwife for her advice.
• All very young girls, and all older
women who have had five or more
babies.
Young girl's bodies are not ready for
childbirth; older women's bodies are
tired of bearing babies. All these women can
die or become very ill in childbirth. Take all
such women to a midwife for advice.
Reference N relates to this question.
86
Unit 2, Problem 1
Question 1.6
What steps could you take and what provision would you make to
ensure that all the women identified by midwives and TBAs
throughout the district are under your close observation at the
beginning of labour?
Accommodation for
at-risk women
The whole programme of selecting high risk women and so
preventing obstructed labour from occurring, and therefore
eliminating its sometimes dreadful complications, fails if these
women are not in the district hospital or close by at the start of
labour. It depends for its success on one practical issue: the
provision of accommodation for the waiting mothers, their relatives
who will help them in the ward after delivery and any children who
must be with them.
Buildings must be constructed on a scale to accommodate the
expected numbers; plan one room for three people for each
expected 'case'. There must be cooking areas, adequate latrines and
an area for storing firewood.
Funding can be a problem. Bureaucracy often makes it
impossible to assign any of the hospital's 'votes' to such a project
despite the fact that it is a most cost effective programme. Good
buildings can be built, however, using local materials on a 'self
help' basis with the cooperation of local leaders, churches and
politicians.
In my old district, having built this type of accommodation for
waiting mothers, as an extra inducement for its use we provided all
at-risk women with food tickets which allowed them to collect
meals for themselves from the hospital kitchen, throughout their
waiting period.
Reference M relates to this question.
88
Unit 2, Problem 1
Question 1.7
Are there any groups of women whom you would not want to go into
labour in the first place but rather deliver by Caesarean section as an
elective procedure? Make a list of these cases with an explanation for
the inclusion of each on your list.
Elective Caesarean
section
• Two or more previous Caesarean sections - ruptured scar very
likely if allowed to labour.
• One previous Caesarean section for cephalo-pelvic
disproportion - ruptured scar likely.
• One previous Caesarean section for other indications combined
with the following findings at or near term - breech, persistent
transverse lie, borderline pelvis, large baby, previous classical
section or inverted T incision - all predispose to the likelihood
of ruptured scar.
• Previous surgery for or continued presence of vesico-vaginal
fistula - confirms severe cephalo-pelvic disproportion.
Likelihood of obstructed labour. Any new fistula formed would
be very difficult to repair.
Reference A (Chapters) relates to this question.
90
Unit 2, Problem 1
CONCLUSION TO PROBLEM 1
You are now in a position to ensure that all the health workers in
the district involved with maternity work are able to identify at risk
women and to make correct decisions about their management. As
you know, some women may not be recognised as having problems
until cephalo-pelvic disproportion is identified during labour itself.
The next section of the unit will be on the labourgraph and its use
in particular for identifying abnormal labour due to cephalo-pelvic
disproportion.
91
ANSWERS TO PROBLEM 2
93
Unit 2, Problem 2
Question 2.1
Using the resource material provided with this module, write down in
note form answers to the following questions.
i) Why is the labourgraph so useful to midwives and doctors?
H) What is the gradient in cm/hour of normal cervical dilatation?
Why is this figure taken as the normal rate?
Usefulness of
labourgraph
i)
The labourgraph has been found to be an excellent way of
recording the progress of labour. It provides a visual record of
labour and is easy to use. The alert line provides a simple
screening device for abnormal labour due to cephalo-pelvic
disproportion and inefficient uterine contraction. It is
particularly helpful to midwives working on their own in rural
areas allowing them to assess and transfer patients at clearly
defined times. The labourgraph is also useful in teaching
midwives about abnormal labour.
Rate of normal
cervical dilatation
ii)
The gradient for normal labour of cervical dilation is 1 cm per
hour or faster, i.e. more than 1 cm per hour. Philpott and
Castle have taken this rate from their studies of African
primigravidae. It represents the mean rate of cervical
dilatation of the slowest 10%. They showed that by taking this
rate as the slowest rate of normal labour, abnormal labour
could best be distinguished from normal labour.
Reference P relates to this question.
94
Unit 2, Problem 2
Question 2.2
Write down a short definition of the following:
9 Alert line
9 Action line
9 Latent phase of labour
9 Prolonged latent phase of labour
9 Active phase of labour
9 Prolonged active phase of labour
9 Descent of the fetal head.
Definitions
The alert line is a line drawn on the labourgraph starting at 3 cm of
dilatation on that section of the labourgraph on which we record
the active phase of labour. It is the line which separates normal
from abnormal labour.
The action line(s) is drawn four hours to the right of the alert line
for primigravidae and three hours to the right for multigravidae. It
is called the action line because action to correct delay in the
progress of labour must be taken before the action line is reached
or at the very latest when it is reached. A doctor must see the
patient if the action line is crossed.
The latent phase of labour extends from the onset of labour until
in primigravida the cervix is 3 cm dilated and fully effaced, and in
multipara the cervix is 3 cm dilated but not necessarily fully
effaced. This phase can last up to eight hours and is recorded on
the left side of the labourgraph.
The prolonged latent phase of labour occurs if a patient who has
been admitted in labour has not progressed to the active phase
after eight hours. In rural Africa an expectant approach is best.
You may need two labourgraphs to plot out a prolonged latent
phase.
The active phase of labour begins when the latent phase ends and
continues until full dilatation of the cervix signifies the onset of the
second stage.
The prolonged active phase of labour occurs when the active phase
proceeds too slowly. Either cervical dilation occurs too slowly from
the start of the active phase and the graph lies to the right of the
alert line or cervical dilation proceeds at a normal rate, i.e. to the
left of the alert line but then at 6 cm or more progress stops - a
condition known as secondary arrest.
Descent of the fetal head is measured by abdominal palpation and
recorded on the labourgraph as a measure of the progress of
labour. This descent is measured in 'fifths' of fetal head palpable
above the pelvic brim.
Reference O relates to this question.
96
Unit 2, Problem 2
Question 2.3
Write down in note form the guidelines for the intervals between
assessments of the progress of labour.
Give reasons for the guidelines.
Assessment of the
progress of labour
• Vaginal examinations should be carried out every four hours in
primigravidae and every three hours in multiparae. The shorter
interval in multiparae is because labour progresses more rapidly
in these women.
• Vaginal examination should be performed when the membranes
rupture in addition to the other examinations to exclude
prolapse of the cord. This is particularly likely to occur when the
presenting part is high.
• If a woman wishes to push, then a vaginal assessment is made to
see whether or not she is fully dilated.
• If at the last vaginal examination the cervix was 7cm or more
dilated the next vaginal examination is brought forward to the
anticipated time of full dilatation.
• In a primigravida who is to the right of the alert line and who,
after excluding cephalo-pelvic disproportion is being stimulated
by oxytocin, vaginal examinations should be at intervals of three
hours, unless there is fetal distress when a further assessment
must be made.
Reference A (Chapter 20) relates to this question.
98
Unit 2, Problem 2
A 16-year-old primigravida who has attended antenatal clinics
arrives at a rural maternity unit at 8 a.m. in early labour.
Examination shows her to be contracting 1 in 10 minutes, the head
is palpable 4/5 abdominally and the cervix is 2 cm dilated. The
midwife performs the next vaginal examination at 12 a.m. and finds
the cervix 3 cm dilated but not fully effaced. At 4 p.m. repeat
examination reveals a fully effaced cervix, 4 cm dilated; the head is
now 3/5 palpable and she is contracting 3 in 10 minutes, each
contraction lasting about 30 seconds. The membranes have
ruptured spontaneously and the fetal heart is good. At 8 p.m. the
cervix is 6 cm dilated, the head 2/5 abdominally.
Complete the labourgraph with the information provided so far.
Question 2.4
io
A/1
/ I
- ---- 1-----
ACTIVE PHASE
LATENT PHASE
9
I
8
E
R
V
I
X
(cm)
T-7
i /
7
c
/ \/
6
J____
I
5 -
D
E
S
C
E
N
T
-1--------I
3
1-------
J___
2,
I
1
----------- -----
0
TIME
initials__
5
4
3
2
1
100
M/ P
1
2
3
4
5
6
7
8
9
10
11
12
1|3
l|4
4
1.5
16
17
18
19
20
21
22
Unit 2, Problem 2
Question 2.5
What should the management decision be at this point?
Transfer the patient as soon as possible to the district hospital. The
labourgraph must be sent with her.
102
Unit 2, Problem 2
The patient arrives at the district hospital at midnight and the
midwife reports that the head is 2/5 palpable, contractions are 3 in
10 minutes, lasting for 30 seconds and the cervix is 7cm dilated.
The pelvis, she feels is adequate and the fetal heart good.
Question 2.6
Enter this information in the labourgraph. What should the midwife
do now?
io
LATENT PHASE
A/1
ACTIVE PHASE
9
—iri
8
r“
i /
7
c
E
R
V
I
X
M/ P
/ I
<3
6
J____
I
5 -
(cm)
D
E
S
C
E
N
T
4©-
-tI—I
1--------
3
J___
2'
I
1
0
1
2
3
5
6
7
8
9
ijO
11
12
1|3
1|4
1,5
16
1|7
1|8
19
20
TIME «■■am
initials _
5
4
3
2
1
The action line has been reached; the medical officer or a senior
midwife must be called to assess the patient.
104
21
22
Unit 2, Problem 2
Question 2.7
Assume that this patient had been at the district hospital throughout
her labour (and had not started at a rural unit). What would have
been the correct management at 8 p.m. ?
If the patient had been at the hospital throughout her labour then
the assessment by a senior midwife or medical officer should have
been carried out as soon as the alert line was crossed. In this
example of a young primigravida the problem will almost certainly
be cephalo-pelvic disproportion or inefficient uterine contractions.
If the pelvis is thought to be adequate, labour should be stimulated
with oxytocin. The important point is that action should be taken
before the action line is reached if possible.
Reference Q relates to this question.
106
Unit 2, Problem 2
Question 2.8
When should the next vaginal examination be performed?
After an interval of three hours or earlier if there is evidence of
fetal distress or if the patient wishes to push.
108
Unit 2, Problem 2
Question 2.9
If the 3 a.m. vaginal examination had revealed cervical dilation of
8 cm, what decision would you have made?
Give your reasons.
At this stage with there having been strong contractions for a
number of hours and still lack of progress, the problem becomes
one of cephalo-pelvic disproportion. In this case, the descent of the
head and the cervical dilatation of 8 cm make delivery by
symphysiotomy an attractive method, providing the other
conditions are fulfilled (see Unit 1). The alternative would be
delivery by LSCS.
110
Unit 2, Problem 2
Question 2.10
Make a list of the problems rural midwives face when they want to
transfer women in labour to the district hospital For each problem try
to suggest a solution.
Problems in arranging
transfers
• Patient refuses to travel, may even abscond at this stage in
labour. Her husband may be required to give his permission.
Anticipate this problem by including it as the subject of a talk
given by the midwife to each antenatal class as part of her
health education talks.
Try to find someone in the village who has been through a
similar problem - with a successful outcome - to talk to the
woman in labour to help you persuade her to go to the district
hospital.
• Problems with actually getting a message through to the district
hospital. Someone usually has to travel with it and this can take
a long time. Problems I met were of bicycles being broken and
messengers refusing to go out after dark because of their fear of
wild animals.
Midwives may sometimes have to request transfer towards
the end of the day when they have a suspicion, rather than proof,
that labour may not progress during the night. Medical officers
need to inspect bicycles when they visit rural units and make
sure repairs are done.
• Transport may be unavailable at the district hospital. This may
be because the vehicle is out on other duties or broken down.
Vehicle breakdown, as all District Medical Officers know
only too well, is a major problem. In urgent cases, other
government departments - agriculture, police, etc. may be asked
to help out while the hospital supplies the petrol. In general the
use and movements of the hospital vehicle(s) must be firmly
controlled by the medical officer.
112
Unit 2, Problem 2
Question 2.11
i)
ii)
Write down the main point(s) each labourgraph illustrates.
What management decision should be made at the time of the
last assessment?
Labourgraph A: Gravida 3, para 2.
io
LATENT PHASE
A/1
/ I
7---- 1-----
ACTIVE PHASE
9
M/ P
I
8
I
7
7
C
E
R
V
I
X
' \/
6
5
(cm)
D
E
S
C
E
N
T
i
4
3
2
1
0
1
2
3
4
5
6
7
8
9
10
11
12
13
16
17
18
1 9
20
21
TIME
initials
X
X
5
4
3
2
1
Labourgraph *A’
i) This illustrates secondary arrest in a multiparous woman.
Labour has progressed normally to 7 cm and then despite
strong, frequent contractions for three hours there has been no
progress.
ii) The management is:
• Ata rural hospital arrange urgent transfer; this is the sort
of woman who will have a ruptured uterus.
• At the district hospital ask senior staff to assess, but really
there is no choice but to proceed to an urgent LSCS.
114
22
Unit 2, Problem 2
Labourgraph B: Primigravida
10
LATENT PHASE
A/1
/ I
-- 1--
ACTIVE PHASE
9
C
E
R
V
I
X
(cm)
l
8
“I 7
7
*
7
/ IZ
6
f
D
E
S
C
E
N
T
M/ P
i
7
I
-—Ii-------i
—
4 -
3 -
j____
i
1 -
----- ---
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
4
1,5
16
17
18
19
20
2|1__ J 2
TIME
initials
5
4
3
2
1
I
Labourgraph ’B’
i) This labourgraph is an example of how the graph is
transferred to the alert line at the third vaginal examination as
the woman is in active labour. The next vaginal examination
shows she has gone to the right of the alert line. This means
she is not progressing normally.
ii) The management is assessment by a senior midwife or doctor.
Providing the pelvis is thought to be adequate and the fetal
heart satisfactory the labour should be stimulated using
oxytocin.
115
Unit 2, Problem 2
CONCLUSION TO PROBLEM 2
You have now completed Unit 2 of this module. I hope you will put
the ideas for teaching about prevention in this field into practice in
your district.
In both Units 1 and 2 we have looked at problems relating to
obstructed labour in general terms, in a way which would apply
equally well to all doctors working in isolated conditions with poor
resources. However, you will have in your district additional
problems only to be faced by you and your co-workers. Some of
these problems will be produced by the people themselves, some
will be due to the geography of the area and some will be due to
the lack of specific resources, not only medical resources but
resources such as communication or petrol supplies. Therefore any
plans which you develop to improve the maternity service must
take account of these factors.
In the last unit of this module you will be looking at some of the
factors which directly influence the prevalence and outcome of
obstructed labour in your district. This subject is called
epidemiology. You may remember epidemiology from your student
days as less exciting than the clinical subjects. I believe that by
working through Unit 3 you will find epidemiology is all about
those matters which directly affect your daily clinical work and that
it is a vitally important subject for the District Medical Officer
organising the district’s health service.
116
UNITS
Epidemiology
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ANSWERS TO PROBLEM 1
119
Unit 3, Problem 1
Question 1.1
Write down definitions of the following terms.
9 Maternal mortality rate
• Stillbirth rate
9 Perinatal mortality
9 Birth rate.
Definitions
• Maternal mortality rate is the number of maternal deaths
occurring in pregnancy and in the puerperium up to the end of
the sixth week, per 1000 total births.
• Stillbirth rate is the number of deliveries of dead infants after
28 weeks of pregnancy, occurring during one year in every 1000
total births (live and dead births).
• Perinatal mortality is the number of stillbirths and infant deaths
in the first week of life per 1000 total births (live and dead
births). (Although some first week deaths will be due to severe
congenital abnormalities, some will be due to prolonged,
traumatic, difficult labour and therefore provide a measure of
the effectiveness of maternity care).
• The birth rate is calculated by relating the total live births in a
year to the total population and is recorded as the number of
births per 1000 population.
120
Unit 3, Problem 1
The first part of the project is to establish the prevalence of
obstructed labour and its complications in your district.
Question 1.2
Write down two reasons why this will be useful
These data will serve as a basis for comparison when the
programme to improve maternal mortality has been
implemented.
ii) The data you collect can be compared with those from other
districts. Differences may help point to particular problems in
different districts.
i)
122
Unit 3, Problem 1
Question 1,3
Write a list of the factors which could be studied in your district:
i) Factors relating to prevalence;
ii) Factors relating to outcome ofpatients with cephalo-pelvic
disproportion.
i)
1
124
•
•
•
•
Age.
Parity.
Height.
Ethnic group.
ii) • Distance from home to maternity unit.
• Distance to maternity unit from the district hospital.
• Local geographical features - terrain, seasonal weather
changes.
• Failure by health workers to identify risk factors in
antenatal period.
• Failure to use labourgraph correctly.
• Women who have not booked.
• Formal education.
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