J Am Board Fam Pract: first published as 10.3122/jabfm.5.3.333 on 1 May 1992. Downloaded from Dystocia Caused By Chronic Fecal Impaction

W. Phillip Smith, M.D., M.Ed., and Paul D. Mozley, M.D.

Dysfunctional labor resulting from fecal impac­ The patient was a poorly nourished, but well tion is a rare occurrence.1-4 All of the previously developed, gravid woman who was anxious and published cases resulted in vaginal delivery after uncooperative and was in early labor. Her tem­ disimpaction. We repon the first case of obstruc­ perature was 37°C (98.6°F), pulse rate 92 beats tion of labor secondary to massive chronic fecal per minute, respirations 221min, blood pressure impaction and megacolon that required Cesarean 142180 mmHg. On abdominal examination the section. fundal height was 36 em with the vertex in the left iliac fossa. Fetal hean tones, with a rate of 130 to case Report 140 beats per minute, were monitored externally. The patient, a 19-year-old gravida 2 para 1, was Uterine contractions were palpated and moni­ admitted to our hospital on 31 October 1990. By tored externally every 3 minutes. The patient was history of last menstrual period she was 42 weeks' extremely uncooperative during pelvic examina­ gestational age. She complained of the onset of tion. The external genitalia appeared normal. labor pain 3 hours before admission to the hospi­ Digital examination of the vagina revealed that tal. The patient's prenatal care consisted of two the cervix could not be palpated. A large mass in prenatal visits to an outlying health department. the rectum could be palpated through the poste­ Her medical history revealed chronic constipa­ rior vagina. The presenting pan of the fetus could tion since early childhood, requiring multiple not be felt. There was anal incontinence of soft hospitalizations, yet the patient and her family stool, and hard stool could be palpated on rectal were unaware of a specific diagnosis or of any rec­ digital examination. ommendations for definitive treatment. Chronic Consultation was obtained with a senior obstet­ constipation and fecal incontinence had persisted ric faculty member and a general surgeon. It was into adulthood. It was reponed that numerous believed the patient had chronic megacolon physicians had attempted to perform pelvic ex­ of undetermined cause, that she was in early aminations and Papanicolaou smears but had labor, and that fecal impaction was preventing http://www.jabfm.org/ been unable to do so because of her abnormal descent of the fetus and possibly dilatation of the colon. The prenatal history also noted that the cervix. patient had been hospitalized in psychiatric Epidural anesthesia and disimpaction were of­ hospitals, but again a specific diagnosis was not fered to the patient, which she adamantly refused. known. Review of the prenatal social history After discussing the risk, Cesarean section fol­ showed that she had at times been homeless lowed by disimpaction under general anesthesia on 28 September 2021 by guest. Protected copyright. during her pregnancy. She had smoked one pack was offered to the patient, to which the patient of cigarettes per day during her pregnancy but was agreeable. denied use of alcohol or recreational drugs. At Cesarean section the uterus was deviated to The above history was confirmed by family mem­ the -left and twisted over a massive colon that bers present at the time of hospitalization. measured at least 12 em in diameter and was filled They also reponed that the patient had a pro­ with mushy material believed to be feces. This found fear of physicians, which was confirmed by dilatation of the colon extended from the rectum our observations. to the splenic flexure. The cervix rested well above the inlet to the pelvis. The baby was de­ livered without incident with Apgar scores of 7 Submitted 28 June 1991. From the Departments of Family Medicine and Obstetrics and and 8 at 1 and 5 minutes, respectively. After Gynecology, The University ofAlabama, College of Community closure of the uterus the abdomen was explored, Health Sciences, Tuscaloosa. Address reprint requests to W. revealing a dilated colon, which extended from Phillip Smith, M.D., The University of Alabama, College of the rectum to the splenic flexure; estimated di­ Community Health Sciences, Box 870376, Tuscaloosa, AL 35487-0376. ameter was 20 em. After closure of the abdomen

Dystocia and F eal bnpaction 333 J Am Board Fam Pract: first published as 10.3122/jabfm.5.3.333 on 1 May 1992. Downloaded from the patient underwent disimpaction of a huge feces with progress of labor and subsequent vagi­ amount of stool. nal delivery. A psychiatrist who saw their patient Postoperatively, the patient developed a fever in consultation noted that she was "hostile, some­ and after appropriate cultures was treated with what retarded and possibly schizophrenic." Holt antibiotics. On the 3rd postoperative day the pa­ and Hendricks suggested that Rambo's patient, tient refused further treatment and left the hospi­ who had "the lower bowel filled with putty-like tal against medical advice. She did not return for fecal material, " had also ingested clay. follow-up care. With our patient, there was no opportunity to attempt disimpaction of the fecal mass because of Discussion the patient's refusal and rejection of regional an­ Rambo1 was first to report dystocia resulting from esthesia. Disimpaction under general anesthesia, fecal impaction in this century; however, he de­ then allowing recovery with subsequent continu­ scribed a case reported in 1886 in which the pa­ ation of labor, was also considered. The patient, tient, a multipara with a rectovaginal fistula, gave however, also refused this option, and there was birth vaginally after removal of "an impacted mass uncertainty that disimpaction would be successful of feces as large as a child's head."P 812 Rambo's enough to allow descent, thus possibly subjecting patient had a fecal impaction that completely the patient to a second general anesthetic. Upon blocked the pelvis, and the cervix could not be exploring the abdomen after Cesarean section, it felt. The presenting head was in the left iliac fossa. was thought that even if disimpaction had been Vaginal delivery was accomplished after removal attempted, there could not have been successful of 1780 g of feces. reduction of the mass to accomplish vaginal Etzel, et al.2 reported a patient, gravida 2, para delivery. 1, who had "neglected prenatal care because she Common features in the case reports of fecal had a fear of physicians." The woman had been in impaction dystocias include elevation of the pre­ labor with rupture of the membranes for 3 days. senting part and obstruction of descent, difficulty A pathologic retraction ring was present in the in reaching the cervix on vaginal examination, a uterus and uterine rupture was feared. The au­ mass palpable through the posterior vagina, psy­ thors stated that "when all attempts to obtain chiatric history, fear of physicians, lack of patient cooperation from the patient had failed, compul­ cooperation, and possibly clay ingestion. Vaginal sory methods were utilized" to accomplish dis­ delivery may be possible if evacuation of the im­ http://www.jabfm.org/ impaction. A stillborn infant in breech position paction is accomplished. was delivered vaginally. Grasby and Higgins3 reported a 19-year-old primigravida who presented with almost continu­ References ous uterine contractions and a mass palpated 1. Rambo ww. Dystocia due to fecal impaction resem­ bling a pelvic tumor. AmJ Obstet Gyneco11927; 14: through the posterior vaginal wall. Rectal exami­

812-3. on 28 September 2021 by guest. Protected copyright. nation confirmed impacted feces the size of a fetal 2. Etzel CA, DeMedio MT, Journey RW, Dystocia head. The fecal mass was disimpacted under gen­ caused by fecal impaction. Am J Obstet Gynecol eral anesthesia and a cyanosed infant was de­ 1954; 68:725-6. livered vaginally. 3. Grasby EDY, Higgins BK. Megacolon in pregnancy 4 causing dystocia. J Obstet Gynaecol Br Emp 1955; Holt and Hendricks reported a case of fecal 62:912-3. impaction secondary to ingestion of clay, in which 4. Holt WA, Hendricks CH. Dysfunctional labor due enemas resulted in removal of 1200 grams of hard to fecal impaction. Obstet Gyneco11969; 34:502-5.

334 JABFP May-June 1992 Vol. 5 No.3