View source for Obstructed labour

{{short description|Complication during childbirth}} 
{{cs1 config|name-list-style=vanc|display-authors=6}}
{{Infobox medical condition (new)
| name            = Obstructed labour
| synonyms        = Labour dystocia
| image           = Illustration of a deformed female pelvis - angular distortion Wellcome L0038229.jpg
| caption         = Illustration of deformed pelvises. A deformed pelvis is a risk factor for obstructed labour
| field           = [[Obstetrics]]
| symptoms        =
| complications   = [[Perinatal asphyxia]], [[uterine rupture]], [[post-partum bleeding]], [[postpartum infection]]<ref name=BMJ2003/>
| onset           =
| duration        =
| causes          = Large or abnormally positioned baby, small [[pelvis]], problems with the birth canal<ref name=WHO2008S1/>
| risks           = [[Shoulder dystocia]], [[malnutrition]], [[vitamin D deficiency]]<ref name=WHO2008S2/><ref name=WHO2008S1/>
| diagnosis       = [[Active phase of labour]] > 12 hours<ref name=WHO2008S1/>
| differential    =
| prevention      =
| treatment       = [[Cesarean section]], [[vacuum extraction]] with possible [[symphysiotomy|surgical opening of the symphysis pubis]]<ref name=WHO2008S6/>
| medication      =
| prognosis       =
| frequency       = 6.5 million (2015)<!-- incidence table --><ref name=GBD2015Pre/>
| deaths          = 23,100 (2015)<ref name=GBD2015De/>
}}
<!-- Definition and symptoms -->
'''Obstructed labour''', also known as '''labour dystocia''', is the baby not exiting the pelvis because it is physically blocked during [[childbirth]] although the [[uterus]] contracts normally.<ref name=WHO2008S1/> Complications for the baby include [[Perinatal asphyxia|not getting enough oxygen]] which may result in death.<ref name=BMJ2003/> It increases the risk of the mother getting an [[puerperal infection|infection]], having [[uterine rupture]], or having [[post-partum bleeding]].<ref name=BMJ2003>{{cite journal | vauthors = Neilson JP, Lavender T, Quenby S, Wray S | title = Obstructed labour | journal = British Medical Bulletin | volume = 67 | pages = 191–204 | date = 2003 | pmid = 14711764 | doi = 10.1093/bmb/ldg018 | doi-access = free }}</ref> Long-term complications for the mother include [[obstetrical fistula]].<ref name=WHO2008S1/> Obstructed labour is said to result in [[prolonged labour]], when the active phase of labour is longer than 12 hours.<ref name=WHO2008S1/>

<!-- Causes and diagnosis -->
The main causes of obstructed labour include a large or abnormally positioned baby, a small [[pelvis]], and problems with the birth canal.<ref name=WHO2008S1/> Abnormal positioning includes [[shoulder dystocia]] where the anterior shoulder does not pass easily below the [[pubic bone]].<ref name=WHO2008S1/> Risk factors for a small pelvis include [[malnutrition]] and a lack of exposure to sunlight causing [[vitamin D deficiency]].<ref name=WHO2008S2>{{cite book|title=Education material for teachers of midwifery : midwifery education modules|date=2008|publisher=[[World Health Organization]] (WHO)|location=Geneva [Switzerland]|isbn=978-92-4-154666-9|pages=38–44|edition=2nd|url=http://whqlibdoc.who.int/publications/2008/9789241546669_4_eng.pdf?ua=1|url-status=live|archive-url=https://web.archive.org/web/20150221002801/http://whqlibdoc.who.int/publications/2008/9789241546669_4_eng.pdf?ua=1|archive-date=2015-02-21}}</ref> It is also more common in [[adolescence]] as the pelvis may not have finished growing by the time they give birth.<ref name=BMJ2003/> Problems with the birth canal include a narrow vagina and perineum which may be due to [[female genital mutilation]] or [[tumors]].<ref name=WHO2008S1/> A [[partograph]] is often used to track labour progression and diagnose problems.<ref name=BMJ2003/> This combined with physical examination may identify obstructed labour.<ref name=WHO2008S3>{{cite book|title=Education material for teachers of midwifery : midwifery education modules|date=2008|publisher=[[World Health Organization]] (WHO)|location=Geneva [Switzerland]|isbn=978-92-4-154666-9|pages=45–52|edition=2nd|url=http://whqlibdoc.who.int/publications/2008/9789241546669_4_eng.pdf?ua=1|url-status=live|archive-url=https://web.archive.org/web/20150221002801/http://whqlibdoc.who.int/publications/2008/9789241546669_4_eng.pdf?ua=1|archive-date=2015-02-21}}</ref>

<!-- Management and epidemiology-->
The treatment of obstructed labour may require [[cesarean section]] or [[vacuum extraction]] with possible [[symphysiotomy|surgical opening of the symphysis pubis]].<ref name=WHO2008S6/> Other measures include: keeping the women hydrated and [[antibiotic]]s if the [[amniotic membrane|membranes]] have been ruptured for more than 18 hours.<ref name=WHO2008S6>{{cite book|title=Education material for teachers of midwifery : midwifery education modules|date=2008|publisher=[[World Health Organization]] (WHO)|location=Geneva [Switzerland]|isbn=978-92-4-154666-9|pages=89–104|edition=2nd|url=http://whqlibdoc.who.int/publications/2008/9789241546669_4_eng.pdf?ua=1|url-status=live|archive-url=https://web.archive.org/web/20150221002801/http://whqlibdoc.who.int/publications/2008/9789241546669_4_eng.pdf?ua=1|archive-date=2015-02-21}}</ref> In Africa and Asia obstructed labor affects between two and five percent of deliveries.<ref>{{cite book|last1=Usha|first1=Krishna |title=Pregnancy at risk : current concepts|date=2004|publisher=Jaypee Bros.|location=New Delhi|isbn=978-81-7179-826-1|page=451|url=https://books.google.com/books?id=gadYMLeYXOkC&pg=PA451|url-status=live|archive-url=https://web.archive.org/web/20160304220911/https://books.google.ca/books?id=gadYMLeYXOkC&pg=PA451|archive-date=2016-03-04}}</ref> In 2015 about 6.5 million cases of obstructed labour or [[uterine rupture]] occurred.<ref name=GBD2015Pre>{{cite journal | vauthors = Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A, etal | collaboration = GBD 2015 Disease and Injury Incidence and Prevalence Collaborators | title = Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015 | journal = Lancet | volume = 388 | issue = 10053 | pages = 1545–1602 | date = October 2016 | pmid = 27733282 | pmc = 5055577 | doi = 10.1016/S0140-6736(16)31678-6 }}</ref> This resulted in 23,000 maternal deaths down from 29,000 deaths in 1990 (about 8% of all [[maternal deaths|deaths related to pregnancy]]).<ref name=WHO2008S1>{{cite book|title=Education material for teachers of midwifery : midwifery education modules|date=2008|publisher=[[World Health Organization]] (WHO)|location=Geneva [Switzerland]|isbn=978-92-4-154666-9|pages=17–36|edition=2nd|url=http://whqlibdoc.who.int/publications/2008/9789241546669_4_eng.pdf?ua=1|url-status=live|archive-url=https://web.archive.org/web/20150221002801/http://whqlibdoc.who.int/publications/2008/9789241546669_4_eng.pdf?ua=1|archive-date=2015-02-21}}</ref><ref name=GBD2015De>{{cite journal | vauthors = Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A, etal | collaboration = GBD 2015 Mortality and Causes of Death Collaborators | title = Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015 | journal = Lancet | volume = 388 | issue = 10053 | pages = 1459–1544 | date = October 2016 | pmid = 27733281 | pmc = 5388903 | doi = 10.1016/s0140-6736(16)31012-1 }}</ref><ref name=GDB2013>{{cite journal | title = Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013 | journal = Lancet | volume = 385 | issue = 9963 | pages = 117–71 | date = January 2015 | pmid = 25530442 | pmc = 4340604 | doi = 10.1016/S0140-6736(14)61682-2 | author1 = <!--staff writer--> }}</ref> It is also one of the leading causes of [[stillbirth]].<ref>{{cite journal | vauthors = Goldenberg RL, McClure EM, Bhutta ZA, Belizán JM, Reddy UM, Rubens CE, Mabeya H, Flenady V, Darmstadt GL | title = Stillbirths: the vision for 2020 | journal = Lancet | volume = 377 | issue = 9779 | pages = 1798–805 | date = May 2011 | pmid = 21496912 | doi = 10.1016/S0140-6736(10)62235-0 | hdl = 11336/192198 | s2cid = 26968628 | hdl-access = free }}</ref> Most deaths due to this condition occur in the [[developing world]].<ref name=BMJ2003/>

==Cause==
The main causes of obstructed labour include a large or abnormally positioned baby, a small [[pelvis]], and problems with the birth canal.<ref name=WHO2008S1/>  Both the size and the position of the fetus can lead to obstructed labor. Abnormal positioning includes [[shoulder dystocia]] where the anterior shoulder does not pass easily below the [[pubic bone]].<ref name=WHO2008S1/> A small pelvis of the mother can be a result of many factors. Risk factors for a small pelvis include [[malnutrition]] and a lack of exposure to sunlight causing [[vitamin D deficiency]].<ref name=WHO2008S2/> A deficiency in calcium can also result in a small pelvis as the structures of the pelvic bones will be weak due to the lack of calcium.<ref name="Konje_2000">{{cite journal | vauthors = Konje JC, Ladipo OA | title = Nutrition and obstructed labor | journal = The American Journal of Clinical Nutrition | volume = 72 | issue = 1 Suppl | pages = 291S–297S | date = July 2000 | pmid = 10871595 | doi = 10.1093/ajcn/72.1.291s | doi-access = free }}</ref> A relationship between maternal height and pelvis size is present and can be used to predict the possibility of obstructed labor. This relationship is a result of the mother's nutritional health throughout her life leading up to childbirth.<ref name="BMJ2003" /> Younger mothers are also at more risk for obstructed labor due to growth of the pelvis not being completed.<ref name="Konje_2000" /> Problems with the birth canal include a narrow vagina and perineum which may be due to [[female genital mutilation]] or [[tumors]].<ref name=WHO2008S1/> All of these factors lead to a failure in the progress of labor.

=== Evolution ===
Obstructed labor is more common in [[human]]s than any other species and continues to be a main cause of birth complications today.<ref>{{cite journal | vauthors = AbouZahr C | title = Global burden of maternal death and disability | journal = British Medical Bulletin | volume = 67 | issue = 1 | pages = 1–11 | date = 2003-12-01 | pmid = 14711750 | doi = 10.1093/bmb/ldg015 | doi-access = free }}</ref> Modern humans have morphologically evolved to survive as bipeds, however, [[bipedalism]] has resulted in skeletal changes that have consequently narrowed the pelvis and the birth canal.<ref>{{cite journal | vauthors = Sigmon BA | title = Bipedal behavior and the emergence of erect posture in man | journal = American Journal of Physical Anthropology | volume = 34 | issue = 1 | pages = 55–60 | date = January 1971 | pmid = 4993117 | doi = 10.1002/ajpa.1330340105 }}</ref> The combination of increased brain size and changes in [[Pelvis|pelvic]] structure are the major contributors of obstructed labor in modern humans. It is also common for obstructed labor in humans to be caused by the fetus' broad shoulders. However, morphological shifts in pelvic structure still account for the inability of a fetus to effectively pass through the birth canal without major complications <ref name = "Rosenberg_2002">{{cite journal | vauthors = Rosenberg K, Trevathan W | title = Birth, obstetrics and human evolution | journal = BJOG | volume = 109 | issue = 11 | pages = 1199–206 | date = November 2002 | pmid = 12452455 | doi = 10.1046/j.1471-0528.2002.00010.x | s2cid = 35070435 }}</ref>

Other primates have a wider and straighter birth canal that allows a fetus to pass through more effectively.<ref name = "Dunsworth_2015">{{Cite journal |last1=Dunsworth |first1=Holly |last2=Eccleston |first2=Leah |date=2015-10-21|title=The Evolution of Difficult Childbirth and Helpless Hominin Infants |journal=Annual Review of Anthropology |volume=44 |issue=1 |pages=55–69 |doi=10.1146/annurev-anthro-102214-013918 |s2cid=24059450 |url=https://digitalcommons.uri.edu/cgi/viewcontent.cgi?article=1006&context=soc_facpubs |doi-access=free }}</ref> Mismatch between birth canal size and infant cranial width and length due to bipedal locomotion requirements have often been referred to as the obstetric dilemma, since compared to other great apes, modern humans have the greatest disproportion between infant cranial size and birth canal size.<ref name = "Wittman_2007">{{cite journal | vauthors = Wittman AB, Wall LL | title = The evolutionary origins of obstructed labor: bipedalism, encephalization, and the human obstetric dilemma | journal = Obstetrical & Gynecological Survey | volume = 62 | issue = 11 | pages = 739–48 | date = November 2007 | pmid = 17925047 | doi = 10.1097/01.ogx.0000286584.04310.5c | s2cid = 9543264 }}</ref> Shrinking of upper extremities and curvature of the spine have also affected the way modern humans give birth. Quadruped apes have longer upper limbs that allow them to reach down and pull their fetus out of the birth canal unassisted.<ref name = "Rosenberg_2002" /> Modern human's shorter upper extremities and evolution of bipedal locomotion may have placed a premium on assistance during labor. For this reason, researchers argue that assisted labor may have evolved with [[bipedalism]].<ref name = "Rosenberg_2002" /> Obstructed labor has been documented as a complication of childbirth since the field of [[obstetrics]] originated. For over 1,000 years obstetricians have had to forcibly remove obstructed labor fetuses to prevent the death of the mother.<ref name = "Drife_2002">{{cite journal | vauthors = Drife J | title = The start of life: a history of obstetrics | journal = Postgraduate Medical Journal | volume = 78 | issue = 919 | pages = 311–5 | date = May 2002 | pmid = 12151591 | pmc = 1742346 | doi = 10.1136/pmj.78.919.311 }}</ref>

Prior to the existence of the cesarean section, fetuses that were obstructed had a low survival rate.<ref name = "Drife_2002" /> Even in the 21st century, if obstructed labor is left untreated, it could result in mother and infant death.<ref name = "Wittman_2007" /> Although surgical removal of the fetus is the preferred method of managing obstructed labor, manual removal using medical tools is also common.<ref name = "Dunsworth_2015" />

==Diagnosis==
Obstructed labour is usually diagnosed based on physical examination.<ref name=WHO2008S3/> Ultrasound can be used to predict malpresentation of the fetus.<ref name="Konje_2000" /> In examination of the cervix once labor has begun, all examinations are compared to regular cervical assessments. The comparison between the average cervical assessment and the current state of the mother allows for a diagnosis of obstructed labor.<ref name="BMJ2003" /> An increasingly long time in labor also indicates a mechanical issue that is preventing the fetus from exiting the womb.<ref name="BMJ2003" />

==Prevention==
Access to proper health services can reduce the prevalence of obstructed labor.<ref name="Konje_2000" /> Less developed areas have inadequate health services to attend to obstructed labor, resulting in a higher prevalence among less developed areas. Improving nutrition of female, both before and during pregnancy, is important for reducing the risk of obstructive labor.<ref name="Konje_2000" /> Creating education programs about reproduction and increasing access to reproductive services such as contraception and family planning in developing areas can also reduce the prevalence of obstructed labor.<ref name="Hofmeyr_2004" />

==Treatment==
Before considering surgical options, changing the posture of the mother during labor can help to progress labor.<ref name="Hofmeyr_2004">{{cite journal | vauthors = Hofmeyr GJ | title = Obstructed labor: using better technologies to reduce mortality | journal = International Journal of Gynaecology and Obstetrics | volume = 85 | pages = S62-72 | date = June 2004 | issue = Suppl 1 | pmid = 15147855 | doi = 10.1016/j.ijgo.2004.01.011 | s2cid = 6981815 }}</ref> The treatment of obstructed labour may require [[cesarean section]] or vacuum extraction with possible [[symphysiotomy|surgical opening of the symphysis pubis]].<ref name=WHO2008S6/> Caesarean section is an invasive method but is often the only method that will save the lives of both the mother and the infant.<ref name="Hofmeyr_2004" /> Symphysiotomy is the surgical opening of the symphysis pubis. This procedure can be completed more rapidly than Caesarean sections and does not require anesthesia, making it a more accessible option in places with less advanced medical technology.<ref name="Hofmeyr_2004" /> This procedure also leaves no scars on the uterus which makes further pregnancies and births safer for the mother.<ref name="BMJ2003" /> Another important factor in treating obstructed labor is monitoring the energy and hydration of the mother.<ref name="Konje_2000" /> Contractions of the uterus require energy, so the longer the mother is in labor the more energy she expends. When the mother is depleted of energy, the contractions become weaker and labor will become increasingly longer.<ref name="BMJ2003" /> Antibiotics are also an important treatment as infection is a possible result of obstructed labor.<ref name="Konje_2000" />

== Prognosis ==
If [[cesarean section]] is obtained in a timely manner, prognosis is good.<ref name="BMJ2003" /> Prolonged obstructed labour can lead to [[stillbirth]], [[obstetric fistula]], and [[maternal death]].<ref>{{Cite journal| first1 = Carmen | last1 = Dolea | first2 = Carla | last2 = AbouZahr |date=July 2003|title=Global burden of obstructed labour in the year 2000|url=https://www.who.int/healthinfo/statistics/bod_obstructedlabour.pdf|journal=Evidence and Information for Policy (EIP), World Health Organization}}</ref> Fetal death can be caused by asphyxia.<ref name="BMJ2003" /> Obstructed labor is the leading cause of uterine rupture worldwide.<ref name="BMJ2003" /> Maternal death can result from uterine rupture, complications during caesarean section, or sepsis.<ref name="Hofmeyr_2004" />

==Epidemiology==
In 2013 it resulted in 19,000 maternal deaths down from 29,000 deaths in 1990.<ref name=GDB2013/> Globally, obstructed labor accounts for 8% of maternal deaths.<ref>{{cite journal | vauthors = Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF | title = WHO analysis of causes of maternal death: a systematic review | journal = Lancet | volume = 367 | issue = 9516 | pages = 1066–1074 | date = April 2006 | pmid = 16581405 | doi = 10.1016/s0140-6736(06)68397-9 | s2cid = 2190885 }}</ref>

==Etymology==
The word ''dystocia'' means 'difficult labour'.<ref name=BMJ2003/> Its [[antonym]] is ''eutocia'' ({{langx|grc|εὖ|eu|good}} + {{langx|grc|τόκος|tókos|childbirth}}) 'easy labour'.

Other terms for obstructed labour include difficult labour, abnormal labour, difficult childbirth, abnormal childbirth, and dysfunctional labour.{{cn|date=January 2024}}

==Other animals==
The term can also be used in the context of various animals. Dystocia pertaining to birds and reptiles is also called [[egg binding]].{{cn|date=January 2024}}

In part due to extensive selective breeding, miniature horse mares experience dystocias more frequently than other breeds.{{cn|date=January 2024}}

Most [[brachycephalic]] dogs require [[caesarean section]]s to decrease risk of mortality for both the bitch and puppies.<ref>{{cite journal |last1=Flintoff |first1=Marcus |title=Babies on board: brachycephalic caesarean |journal=The New Zealand Veterinary Nurse |date=March 2024 |volume=30 |issue=109 |pages=14–18 }}</ref> In the [[Boston Terrier]], [[French Bulldog]], and the [[Bulldog]] more than 80% of births require caesarean sections.<ref>{{cite journal|last1=Evans|first1=Katy M.|last2=Adams|first2=Vicki J.|year=2010|title=Proportion of litters of purebred dogs born by caesarean section|journal=Journal of Small Animal Practice|volume=51|issue=2|pages=113–8|doi=10.1111/j.1748-5827.2009.00902.x|pmid=20136998}}</ref>
<gallery>
File:Miniature Horse Dystocia.jpg|Assisted delivery: miniature horse dystocia. Note the position of the head.
File:Miniature Horse Dystocia. Note the position of the head.jpg|Miniature horse dystocia. Note the position of the head.
</gallery>

== References ==
{{reflist|colwidth=32em}}

== Further reading ==
{{Medical condition classification and resources
 | DiseasesDB     = 4025
 | ICD10          = {{ICD10|O|64}} – {{ICD10|O|66}}
 | ICD9           =
 | ICDO           =
 | OMIM           =
 | MedlinePlus    =
 | eMedicineSubj  = med
 | eMedicineTopic = 3280
 | MeshID         = D004420
}}
* {{cite book|title=Education material for teachers of midwifery : midwifery education modules|date=2008|publisher=[[World Health Organization]] (WHO)|location=Geneva [Switzerland]|isbn=978-92-4-154666-9|edition=2nd|url=http://whqlibdoc.who.int/publications/2008/9789241546669_4_eng.pdf?ua=1}}

{{Women's health|state=collapsed}}
{{Pathology of pregnancy, childbirth and the puerperium}}

[[Category:Complications of labour and delivery]]
[[Category:Wikipedia medicine articles ready to translate]]
[[Category:Midwifery]]

[[it:Taglio cesareo#Distocia]]