A mother in obstructed labour is in great pain, anxiety, and distress. In the bustle of treating her, don’t forget to comfort 8and reassure her. If her baby is already dead, tell her. If you don’t, she may blame you for his death, and not come to hospital when she is pregnant next time. Many of the steps and complications are the same as for rupture of the uterus, so see Section 18.17.
Vaginal delivery is often possible, but try to avoid a difficult one. Learn to predict when it is going to be difficult, so that you can avoid a ’failed vacuum’, and do a Caesarean section or a symphysiotomy (18.6, M 22.7) to begin with, especially when there is fetal distress. An operative vaginal delivery is absolutely contraindicated if her uterus has already ruptured—do a laparotomy. Often, you will not know if it has ruptured or not, so do all vaginal operations for the relief of obstructed labour in the theatre, with a set of laparotomy instruments ready for instant use.
Caesarean section has a limited role, and is likely to be a serious risk, so don’t do it lightly. It is mainly indicated: (1) when a baby is alive and his mother is in reasonable condition. (2) When a destructive operation on a dead baby would be dangerous, because his head is mobile 3/5, or more, high above her pelvic brim (rare). Try not to section her, if she cannot be sure of adequate care in her next delivery, or if your skills and facilities for doing so safely are not good. If you have to section her, Section 18.8 will help you to decide on the most suitable method.
A destructive operation (M 22.10) is indicated when her baby is dead, her cervix is fully dilated or nearly so, the presenting part is fixed in her pelvis, and her uterus has not ruptured, and is in no danger of doing so. Usually, you can be fairly sure that a uterus is not going to rupture. If you are in any doubt, the only way to find out is to do a laparotomy, and see if there is a rupture. If you don’t find one, close her abdomen and deliver her vaginally.
