OBSTRUCTED LABOUR

This is a sad story about the failure of a labour to progress. It is not for those, who are faint hearted. Why does the progress of a normal labour get blocked? It is if the baby is too big for the size of the mother, or is it lying in a funny abnormal position; however the most common cause in the developing world is a distorted or small pelvis. This often happens because of poor nutrition from child hood causing problems such as rickets or in adolescent girls resulting in bone deformities called Osteomalacia. This causes not only a deformed pelvis, but deformed bodies. Often culturally more attention is placed to the nutrition of boys than the girls, and if there is not enough to feed everybody the girls suffer. Sometimes the mother is too young and not fully developed. In spite of many efforts by WHO, in some countries the maternal mortality remains as high as 410 deaths per 100,000 births due to obstructed labour and besides maternal deaths this causes long term severe maternal morbidity by way of vesico vaginal fistulas. There are half a million women in the world with fistulas, mainly in Africa and India. The college of obstetricians and gynaecologists is working very hard to prevent them happening by preventing   obstructed labour, better maternal care during labour, and also curing the fistulas in large numbers. The story I am going to tell you in this post is of one such girl.  I will have more stories about obstructed labour in some of my future posts.

This was in 1968, a very young girl named Renu aged 17 was brought to the hospital by her husband and brother on a home bed (CHARPAI).

She was in strong labour for some hours. She had not been able to walk for two years. Her thighs and legs were totally folded over her abdomen. She obviously was pregnant; and according to her mother in law almost full term. She had never seen a doctor or even a midwife. I wondered how the groom married her. He seemed a bit simple, or had she become disabled recently. Her pelvis was so narrow I was unable to insert even one finger and even the rectal examination was not of much help. I wondered how she had even become pregnant. She had to have a caesarean section (C.S) to have this baby delivered. 

There are two types of C.S, a lower uterine section, when a transverse cut is made on the lower part of the uterus, this is a safer C.S, as it is less likely to be torn or as we call it ruptured in the next labour. The other C.S. is called a classical C.S, this is a long cut made in the upper part of the uterus. This is a more risky procedure as it is likely to rupture more often ( 4% to 9% as compared to lower uterine scar which is less than 1%). Once a woman has had a classical scar, she must always have a hospital delivery by C.S.  In this case I had to do to a classical C.S.as I could not reach the lower part of the uterus due to the extremely narrowed pelvis. To add to my sadness when I pulled out the baby it was grossly abnormal weighing only 2.2lbs. It was what we call an anencephaly, this means that a part of the babies brain and skull failed to develop.

This is incompatible with life, so we did not revive the baby. There are many stories for anencephalic babies living for a while. The longest reported baby lived for 3 years. I once worked in an hospital in the UK, the sister in charge of the maternity ward did not allow us to let an anencephalic baby to be treated how we normally would have treated them. This one particular baby lived for 11 days. These days diagnosis of an anencephaly is made early on with an ultrasound, all women are offered an abortion, which most of them have. In 2012 about 208 terminations were performed in England and Wales.  Neural tube defects occur 1 in 1000, in the western world, were as it can be 5 in 1000 in developing worlds. The recurrence rate can be 4-5%, if there is a previous history of having had two such babies the risk raises to 13%.

Main reason for this to happen is poor nutrition and folic acid deficiency. In the western world this had been prevented by generous use of folic acid. In this case we could see the poor nutritional effect on the mother as well as the baby. We had lots of instructions for the family before they went home. Firstly we advised contraception for at least, 5 years. Regular visits to the village health centre, vitamin D, calcium, milk, eggs, and a high protein diet, regular physiotherapy, massage and plenty of sunshine. The next pregnancy must be supervised, and must be by C.S. in a hospital. Renu’s health could be improved if she was taken care of seriously. I found out that all this happened because of ignorance and carelessness rather than poverty. Unfortunately   I was unable to follow her case as I had to leave the country.