Obstructed Labour at a Remote Health Centre
You are the only midwife on duty at a primary health centre 45 km from the nearest general hospital. A 19-year-old primigravida at 38 weeks has been in labour for 18 hours. The partograph shows cervical dilatation stuck at 8 cm for four hours, moulding of +2, and a fetal heart rate of 108 beats per minute. Her bladder is distended. The centre has no theatre, no blood bank, and one ambulance shared with three facilities; the driver says it will take at least two hours. The family wants her to deliver 'the traditional way', and the accompanying traditional birth attendant has already suggested giving her an oxytocin injection to 'speed things up'. The midwife's standing order permits IV fluids and referral but not augmentation in obstructed labour.
1. Identify the clinical red flags and state the immediate actions within your scope.
Read the worked answer
The red flags are prolonged labour, arrest of cervical dilatation at 8 cm for four hours, significant moulding (+2), a fetal heart rate of 108 beats per minute, and a distended bladder. In a primigravida, this pattern suggests obstructed or dysfunctional labour with risk of uterine rupture, vesicovaginal fistula, sepsis, fetal hypoxia and stillbirth. The fetal heart rate is below the normal range and requires close monitoring and urgent delivery at a facility with theatre and blood.
Immediately call for help and organise transfer. Insert an IV cannula and start normal saline or Ringer's lactate as ordered, take blood for grouping and cross-matching if possible, and catheterise the bladder to relieve obstruction and monitor urine output. Position the woman on her left side, give oxygen if available, monitor maternal vital signs, contractions and fetal heart rate, and keep her nil by mouth. Do not give oxytocin, do not apply fundal pressure, and do not attempt a vaginal delivery. Record everything on the partograph. Contact the receiving hospital, request the ambulance, and prepare to accompany the woman. These actions buy time and reduce harm while definitive care is arranged.
2. Explain how you would manage the family's refusal, the traditional birth attendant's suggestion and the referral.
Read the worked answer
Listen to the family's concerns without dismissing them. Explain in plain language that the baby is not descending, the cervix has stopped opening, the baby's heartbeat is low and the bladder is full, and that these are signs that vaginal delivery is dangerous. Explain that oxytocin in this situation can tear the womb and kill both mother and baby. Be firm that you will not give it. Acknowledge the traditional birth attendant's experience but state clearly that this is an obstructed labour and that her suggestion is unsafe. Invite her to help persuade the family to transfer rather than confront her publicly.
If the family refuses referral, explore the reasons: cost, transport, fear, or pressure from relatives. Involve the woman herself, since she is an adult and her consent matters, and document her wishes. Contact the officer in charge, the local government health authority or a community leader if delay continues. If the woman becomes unable to consent and her life is at risk, act in her best interests under emergency principles and continue arranging transfer. Do not discharge her home. Record the refusal, the advice given, the names of those present and the time. Continue supportive care and monitoring while arrangements proceed.
3. Document and communicate the transfer, and identify the follow-up and reporting requirements.
Read the worked answer
Write a referral letter containing the woman's details, gestation, labour onset, partograph findings, cervical dilatation, moulding, fetal heart rate, bladder catheterisation, IV fluids given, drugs administered, allergies, vital signs, and the reason for referral. Include the family's initial refusal and the advice given if relevant. Record the time the ambulance was requested, the estimated arrival time, the escort's name and the receiving facility. Hand over by telephone to the receiving midwife or doctor and confirm who will receive her. Send copies of the partograph and referral note with her and keep a duplicate.
After transfer, follow up by telephone to confirm arrival and outcome, and document the feedback. Report the case through the facility's referral and incident system, including the ambulance delay and the lack of theatre and blood. If a maternal or perinatal death occurs, follow the maternal death review process honestly. Use the case for staff learning on obstructed labour, partograph use and emergency transfer. Report any unsafe practice by the traditional birth attendant only through the appropriate local channels, and ensure the woman receives postnatal follow-up and counselling about future births.