Prevalence and Outcome of Obstructed Labour at a Tertiary Institution

Obstructed labour is a common preventable causes of both maternal and perinatal morbidity and mortality in developing countries affecting 3-6% labouring women globally and accounts for an estimated 8% of maternal deaths in Sub-Saharan Africa and South Asia. Objective: To determine the prevalence and outcome of obstructed labour in the Gynaecology and Obstetrics Department at a tertiary hospital in Northern Uganda. Method: This was a retrospective chart review of pregnant women admitted in labour and delivered by caesarean section from 1st January 2016 to 31st December 2017 at a Lira Regional Referral Hospital, a tertiary institution in Lango Sub region. Data was analysed using Statistical Package for Social Sciences version 16.0. Results: A total of 808 medical charts of mothers with obstructed labour were retrieved, evaluated and included in this review out of 12,189 deliveries during the study period, giving a prevalence of 6.6%. Majority (77%; 622/808) mothers admitted with diagnosis of obstructed were referred in from peripheral facilities. Over half (53.4%) of the women were in the age group of 20 to 29 years. Over 53%, were prime gravidae and were twice more likely to undergo C/S due to obstructed labour than multigravidas (OR 1.8; 95% CI 1.5-2.2). Only 49.2% had documented cause of obstructed labour, with Cephalo-pelvic disproportion being most common (17.5%), malposition/mal-presentation (14.6%), and macrosomia (3.6%). Partograph was used in only 46.6% (374) women who had obstructed labour. The commonest maternal complication observed were Sepsis (11%), PPH (5.2%), uterine rupture (4%) and burst abdomen (3%) which led to prolonged hospital stay and loss of fertility to some. Mode of delivery in the 808 reviewed charts was caesarean section, 90.3% of babies were born alive, while 8.5% (69) were born dead, (1.2%) had early neonatal, and 40.2% were referred Paediatric Neonatal Intensive Care Unit (NICU) because of low APGAR score. Conclusion: The prevalence of obstructed labour among women delivered by Caesarean section was high compared to the global average. Majority of the women were referrals from the peripheral health centres and associated with life threatening complications and even death. Young age and prime gravida is associated with obstructed labour and high caesarean section rates. The obstruction in multigravida could be due to secondary cephalo-pelvic disproportion as majority of the babies were in normal range weight. Low use of Partograph to monitor labour was evident among women who had obstructed.

Vesico-Salpingo Fistula Masquerading as Hydrosalpinx with Neurogenic Bladder - An Interesting Case Report

A fistula is an abnormal connection between two luminal structures of different epithelium. The majority of urological fistulas in developed countries are consequences of iatrogenic injury most commonly laparoscopic hysterectomies, or from radiotherapy in the treatment of pelvic cancers.1 Contrary to this, most obstetric fistulas in developing countries result from obstructed labour during childbirth.2 Common factors that contribute to obstructed labour in developing countries are delayed presentation after trial labour at home, cephalopelvic disproportion and poor nutrition. Due to prolonged compression by head on the pelvic tissues there happens ischemic necrosis of vagina, bladder neck, and urethra3 called obstructed labour complex. Necrosis and fibrotic healing lead to fistula formation with adjacent structures. The vesicovaginal fistula was the most frequent one (78 %) and the common site involved was trigone (51 %) and based on the level it could be a high or low fistula. Others are vesicouterine fistula, vesicourethral fistula, vesicoureteral fistula and rarely vesico-salpingo fistula. During the acute phase of fistula, tissue oedema, hypovascularity, infection, and nonviable tissue hinder proper tissue healing and hence delayed repair is done after 3 months. Recent literature advises early repair for simple fistulas to reduce patient morbidity and delayed repair of complex fistula, multiple fistulas, infected fistulas, post-radiotherapy, fistula due to foreign bodies, immunocompromised patients, hypoproteinaemia patients, urosepsis patients. 4 Fistula repair is preceded by contrast evaluation of ureter and bladder by CT –IVU and cystogram or MRI followed by cystoscopy or retrograde pyelography. Apart from fistula closure, bilateral ureteric implantation may be needed if ureters are close to the fistula. 5 Abdominal hysterectomy is done in uterovesical fistulas. Huge fistulas close to the bladder neck cannot be repaired without compromising continence hence bladder neck closure is done with the Mitrofanoff procedure. 6 A vesico-salpingo fistula is an abnormal epithelial-lined communication between the urinary bladder and the fallopian tube. This rare type of urogenital fistula has only 7 previously published cases in the literature.

Obstructed labour in a Nigerian tertiary health facility: a mixed-method study

Background: Obstructed labour remains a leading cause of maternal and perinatal mortality and morbidity in sub-Saharan Africa. This study aimed to determine the incidence, causes, complications and outcomes of obstructed labour at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Osun state, Nigeria.Methods: A mixed methods approach was employed for this study. A 10-year retrospective review of all cases of obstructed labour managed at the OAUTHC, between January 1, 2008, and December 31, 2017, was done. Ten in-depth interviews were conducted for some selected patients. The quantitative data was analysed using SPSS version 24, while the qualitative data was analyzed with NVivo version 12.Results: The incidence of obstructed labour was 1.99%. Most of the patients were unbooked (217, 90.4%), primigravid (138, 57.5%), and either had no formal or only primary/secondary education (120, 50%). Cephalopelvic disproportion (CPD) was the commonest cause of obstructed labour (227, 94.6%). The most common maternal complication was wound infection (48, 20%). There were three maternal deaths, giving a case fatality rate of 1.25%. The most common foetal complication was birth asphyxia (85, 34.7%). The perinatal mortality rate was 18.8 %. From the qualitative arm of the study, reasons given by parturients who suffered obstructed labour, for avoiding hospitals for delivery, included religion, finance, fear of hospitals, faith/belief in mission homes/maternity houses, and proximity.Conclusions: Obstructed labour remains an important obstetric problem in our environment, contributing significantly to the burden of maternal and perinatal mortality and morbidity.

Incidence and determinants of perinatal mortality among women with obstructed labour in eastern Uganda: a prospective cohort study

Background In Uganda, the incidence and determinants of perinatal death in obstructed labour are not well documented. We determined the incidence and determinants of perinatal mortality among women with obstructed labour in Eastern Uganda. Methods Between July 2018 and September 2019, 584 with obstructed labour were recruited and followed up to the 7th day postnatal. Information on maternal characteristics, obstetric factors and laboratory parameters was collected. Each patient received the standard perioperative care. We used a generalized linear model for the Poisson family, with a log link and robust variance estimation to determine the association between the exposure variables and perinatal death. Results Of the 623 women diagnosed with obstructed labour, 584 met the eligibility criteria. There were 24 fresh still births (FSB) and 32 early neonatal deaths (ENND) giving an FSB rate of 43.8 (95% CI 28.3–64.4) deaths per 1000 total births; early neonatal death rate of 58.4 (95% CI 40.3–81.4) deaths per 1000 and an overall perinatal mortality rate of 102.2 (95% CI 79.4–130.6) deaths in the first 7 days of life. A mother being referred in active labour adjusted risk ratio of 2.84 (95% CI: 1.35–5.96) and having high blood lactate levels at recruitment adjusted risk ratio 2.71 (95% CI: 1.26–4.24) were the determinants of perinatal deaths. Conclusions The incidence of perinatal death was four times the regional and national average. Babies to women referred in active labour and those with high maternal blood lactate were more likely to die.

Sub-Saharan African Women’s Views and Experiences of Risk Factors for Obstetric Fistula: A Qualitative Systematic Review

Background: Obstetric fistula, also known as vesico vagina fistula (VVF), is a hole between the birth canal and the bladder or rectum caused by prolonged, obstructed labour. VVF may cause sufferers to experience chronic urinary and/or faecal incontinence, and the burden of continuing foul odour. Obstetric fistula is primarily caused by prolonged obstructed labour, which is brought about by a range of causes. Recently, it has been proposed that women’s groups and fistula survivors should suggest interventions to reduce or resolve the incidence of VVF. Objective: The objective of this review was to summarise what is reported about women’s own views and experiences of the risk factors underlying the causes of obstetric fistula. Methods: A systematic approach outlined in the Joanna Briggs institute Manual for Evidence synthesis was followed for this review, articles published within the last 11 years from 2011 to 2021 were selected against several criteria and critically appraised using JBI Critical Appraisal checklist for qualitative studies. Results: Nine studies were retained for inclusion in this review, the data were then synthesised into five themes: (1) Cultural beliefs and practices impeding safe childbirth, (2) Lack of woman’s autonomy in choices of place to birth safely, (3) Lack of accessibility and social support to safe childbirth, (4) Inexperienced birth attendants and, (5) Delayed emergency maternal care (childbirth).Conclusions. This review highlights the complexity of risk factors predisposing women to the known causes of obstetric fistula. It also illuminates the absence of women’s voices in the identification of solutions to these risks. Women are most directly affected by VVF. Therefore, their knowledge, views and experience should be considered in the development and implementation of strategies to address the issue. Exploring women’s views on this issue would enable the identification of gaps in maternity care provision, which would be of interest to community and health service leaders as well as policy makers in Sub-Saharan Africa.

Living with obstetric fistula for ten years: a delayed diagnosis and review of pertinent surgical technique

Obstructed labour is a common cause of vesicovaginal fistula in the developing world. Those fistulae occurring after labour and its complications is called obstetric fistula. We report a case of complex obstetric fistula in a 32 y woman who was having continuous leakage of urine since last 10 y following caesarean section for obstructed labour. A successful fistula repair was done with transvaginal approach with Latzko technique and interposition with Martius flap.

Bladder hematoma as an unusual cause or consequence of obstructed labour

Bladder hematoma is a rare complication but also an unusual mechanical cause of obstructed labour, whose incidence in India is 1-2%. The most common reason for intraluminal urinary bladder hematoma is trauma, but it can occur with cystitis, pelvic malignancy and irradiation. A large hematoma may mimic a neoplastic mass on imaging. We reported a first case of bladder hematoma as a cause or result of obstructed labour in a multipara where the diagnosis was made intraoperatively. This bladder complication also became the indication for classical caesarean section, the technique which is almost obsolete nowadays, where the indication for classical caesarean section was obligatory.

Paperless partogram: a simple clinical tool in effective labour management

Background: Maternal mortality is unacceptably high, about 830 women die from pregnancy or child birth related complications around the world every-day. Prolonged and obstructed labour is one of the major causes of maternal and perinatal mortality and morbidity worldwide. In developing countries like India, around 5% of total maternal deaths are caused by prolonged and obstructed labour. The purpose of the present study is to evaluate the role of paperless partogram in management of labour, identification of abnormal labour and early intervention to prevent the maternal and perinatal morbidity. The objective of this study was to assess the role of paperless partogram in labour monitoring and decision-making in overburdened Indian labour room setup and to evaluate the outcome of the cases.Methods: A prospective study was conducted at a tertiary care hospital, Kurnool, Andhra Pradesh, between January 2020 to March 2020. A total of 300 pregnant mothers in established labour who fulfilled the inclusion criteria, were included in the study after taking informed consent.Results: In our study, of all the pregnant women 23 crossed the alert ETD but 16 had delivered vaginally and 2 by caesarean section before action ETD and 5 women crossed the action ETD. Among the 5 who crossed action ETD 3 delivered vaginally and 2 had cesarean section. Majority, of the women who crossed the alert and action ETDs were primigravidae.Conclusions: From our study, it is concluded that paperless partogram was effective and user friendly in management of labour and prevention of abnormal or prolonged labour.