Abnormal Uterine Action

Abnormal  Uterine  Action

Page 1

INTRODUCTION

Normal labour is characterized by coordinated uterine contractions associated by progressive dilatation of cervix ( more than 1 cm/hr) and descent of the fetal head.

Page 2

DEFINITION

Any deviation of the normal pattern of uterine contractions affecting the course of labour is designated as disorder or abnormal uterine action.

Page 3

ETIOLOGY

• Advance age of mother. • Prolonged pregnancy. • Over distension of uterus due to twins or   hydromnios. • Psychological factors. • Contracted pelvis. • Malpresentation. • Injudicious administration of sedatives analgesics   and oxytotics. • Premature attempt at vaginal delivery or   instrumental vaginal delivery under light   anesthesia.                                               Page 4

CLASSIFICATION

A.Over-efficient uterine action • Precipitate labour: in absence of obstruction • Excessive contraction and retraction: in   presence of obstruction B.Inefficient uterine action • Hypotonic inertia • Hypertonic inertia           * Colicky uterus

* Hyperactive lower uterine segment

• Constriction (contraction) ring C.Cervical dystocia

Page 5

PRECIPITATE LABOUR

• A Labour is called precipitate when the   combined duration of the first and   second stage of labour is less then two   hours. • Labour is short as the rate of cervical   dilatation is 5cm/hr. more in nulliparous   women.

Page 6

ETIOLOGY

• It is more common in multiparous when    there are: * strong uterine contractions * small sized baby * roomy(no plenty of space) pelvis * minimal soft tissue resistance

Page 7

COMPLICATIONS

• Maternal-

Extensive laceration of the cervix, vagina and perineum(to the extent of complete perineal tear) PPH due to uterine hypotonia Inversion of uterus Uterine rupture Infection  Amniotic fluid embolism

•

Fetal-

 Intra cranial stress and hemorrhage Birth injuries

Page 8

MANAGEMENT

• Patient who had previous precipitate   labour should be hospitalized before   expected date of delivery as she is more   prone to repeated precipitate labour. • the uterine contractions may be   suppressed by administering Mgso4   during contractions.

Page 9

• Episiotomy: to avoid perineal lacerations   and intracranial haemorrhage. • Induction of labour by low rupture of   membrane. • Delivery of head should be controlled &   careful conduction of delivery may be   done.

Page 10

EXCESSIVE UTERINE CONTRACTION AND    RETRACTION

• This type of uterine contraction is   predominantly due to obstructed labour

Page 11

Physiological Retraction Ring

• It is a line of demarcation between the upper and lower   uterine segment present during normal labour and cannot   usually be felt abdominally.

Pathological Retraction Ring (Bandl’s ring) * It is the rising up retraction ring during obstructed labour

due to marked retraction and thickening of the upper uterine   segment while the relatively passive lower segment is   markedly stretched and thinned to accommodate the foetus. *The Bandl’s ring is seen and felt abdominally as a   transverse groove that may rise to or above the symphysis   pubis.

Page 12

Page 13

CLINICAL FEATURES

• Patient is suffering from continuous pain and   discomfort and become restless • Feature of exhaustion and keto acidosis are   evident • Abdominal palpation reveals

– Upper segment is hard and tender and lower   segment is distended and tender – Pathological retraction ring is placed obliquely   between the umbilicus and symphysis pubis and   rises upward in course of time – Round ligament may be felt on either side

Page 14

– Fetal parts not well defined – F.H.S. is usually absent

• Internal examination reveals

– Vagina dry and hot, discharge is offensive – Cervix fully dilated – Membranes are absent – Cause of obstructed labour

Page 15

MANAGEMENT

• Internal inversion is contraindicated • Correction of dehydration and keto   acidosis by infusion of ringer’s solution • Adequate pain relief • Parenteral antibiotic • Cesarean delivery is done majority of the   cases

Page 16

UTERINE INERTIA (hypotonic activity)

• Uterine inertia is a common type of disordered   uterine contractions and may complicate any   stage of labour. • The intensity of uterine contraction is diminished   duration is shortened, good relaxation in between   contractions and the intervals are increased. • General pattern of uterine contraction of labour is   maintained but intrauterine pressure during   contraction hardly rises above 25 mm

Page 17

• Patient feels less pain during uterine   contractions. • Less hardening of the uterus during contraction • Uterus become relaxed after the contraction. • Internal examination reveals:-       a.Over dilatation of cervix.       b.Associated presence of contracted pelvis,        malposition, deflexed head or        Malpresentation.       c.Membranes usually remains intact.

Page 18

DIAGNOSIS

Effect on the Mother and           Fetus

• Mother: maternal exhaustion

• Fetus: fetal distress.

Page 19

MANAGEMENT

Contemplating vaginal delivery A.General measures:

1.To keep up the moral of the patient. 2.Posture of the patient is changed (left lateral position)   supine position is avoided. 3.To empty the bladder by catheterization if needed. 4.To maintain the hydration by infusion of RL solution. 5. Adequate pain relief by intramuscular pethedine 100mg

Page 20

B. Active measures: • acceleration of uterine contraction by lower   rupture of membrane followed by Oxytocin   drip. • Oxytocin is to be continued till 1 hr after   delivery. • if cervical dilatation remains unsatisfactory   and fetal distress appears, caesarian            section should be done.

Page 21

HYPERTONIC UTERINE INERTIA  (Inco-ordinate Uterine Action)

• the hypertonic state of uterus arises   from any of the conditions such as   spastic lower uterine segment ,colicky   uterus , contraction , constriction ring   or generalized uterine contraction of   the uterus and all the states are   collectively called incordinate uterine   action

Page 22

TYPES

• Colicky uterus: incoordination of the   different parts of the uterus in   contractions. • Hyperactive lower uterine segment: so   the dominance of the upper segment is   lost.

Page 23

CLINICAL FEATURES

The condition is more common in primigravidae and  characterised by:

• Labour is prolonged.

• Uterine contractions are irregular and more painful. The   pain is felt before and throughout the contractions with   marked low backache often in occipito-posterior position. • High resting intrauterine pressure in between uterine   contractions detected by tocography (normal value is 5-10   mmHg). • Slow cervical dilatation . • Premature rupture of membranes. • Foetal and maternal distress.

Page 24

MANAGEMENT

A. General measures: as hypotonic inertia. B. Medical measures:

– Analgesic and antispasmodic as pethidine. – Epidural analgesia may be of good benefit.

C. Caesarean section is indicated in:

– Failure of the previous methods. – Disproportion. – Foetal distress before full cervical dilatation.

Page 25

CONSTRICTION (CONTRACTION) RING

• It is a persistent localized annular spasm   of the circular uterine muscles. • It occurs at any part of the uterus but   usually at junction of the upper and lower   uterine segments. • It can occur at the 1st, 2nd or 3 rd stage   of labour.

Page 26

ETIOLOGY

Unknown but the predisposing factors are: * Malpresentations and malpositions. * Clumsy intrauterine manipulations under    light anaesthesia. * Improper use of oxytocin e.g.        > use of oxytocin in hypertonic inertia.        >IM injection of oxytocin.

Page 27

DIAGNOSIS

• The condition is more common in   primigravidae and frequently preceded by   colicky uterus. • The exact diagnosis is achieved only by   feeling the ring with a hand introduced into   the uterine cavity.

Page 28

COMPLICATION

• Prolonged 1st stage: if the ring occurs at   the level of the internal os. • Prolonged 2nd stage: if the ring occurs   around the foetal neck. • Retained placenta and postpartum   haemorrhage: if the ring occurs in the 3rd   stage (hour- glass contraction).

Page 29

Pathological Retraction          Ring

Occurs in prolonged 2nd stage.

Always between upper and lower uterine segments.

Rises up.

Felt and seen abdominally.

The uterus is tonically retracted, tender and the foetal parts cannot be felt.

Constriction Ring

Occurs in the 1st, 2nd or 3rd stage.

At any level of the uterus.

Does not change its position.

Felt only vaginally.

The uterus is not tonically retracted and the foetal parts can be felt.

Maternal distress and foetal distress or death.

Relieved only by delivery of the foetus.

Maternal and foetal distress may not be present.

May be relieved by anaesthetics or antispasmodics.

Page 30

www.freelivedoctor.com

MANAGEMENT

• In the 1st stage: Pethidine may be of   benefit. • In the 2nd stage: Deep general   anaesthesia and amyl nitrite inhalation are   given to relax the constriction ring: • In the 3rd stage: Deep general   anaesthesia and amyl nitrite inhalation are   given followed by manual removal of the   placenta.

Page 31

CERVICAL DYSTOCIA

• Failure of the cervix to dilate within a   reasonable time in spite of good   regular uterine contractions.

Page 32

TYPES

A. Functional (primary): > In spite of the absence of any organic   lesion and the well effacement of the   cervix, the external os fails to dilate. > This may be due to lack of softening of the   cervix during pregnancy or cervical spasm   resulted from overactive sympathetic tone

Page 33

B. Organic (secondary) due to: > Cervical scarring related to previous   amputation, cone biopsy, extensive   cauterisation or obstetric trauma. > Organic lesions as cervical myoma or   carcinoma.

Page 34

COMPLICATIONS

• Annular detachment of the cervix:   surprisingly the bleeding from the cervix is   minimal because of fibrosis and avascular   pressure necrosis leading to thrombosis of   the vessels before detachment. • Rupture uterus. • Postpartum hemorrhage: particularly if   cervical laceration extends upwards   tearing the main uterine vessels.

Page 35

MANAGEMENT

A. Organic dystocia: > Caesarean section is the management of   choice. B.Functional dystocia:  Pethidine and antispasmodics: may be   effective  Caesarean section: if medical treatment   fails or foetal distress developed.

Page 36

PREMATURE RUPTURE OF

MEMBRANES

(PROM)

Page 37

Definition

PROM is defined as the rupture of the chorioamniotic membrane before the onset of labor

Page 38

Incidence

PROM occurs in about

10%~15% of all delivery PROM is associated with 10% of term pregnancy

Page 39

Cause of PROM

 Trauma (abdominal striked intensely)  Sexual intercourse(particularly in the late

gestational weeks)  Vaginal infection   due to  bacteria 、 virus 、 TOXO 、 CMV 、 HPV and  HSV,et al

 Smoking

Page 40

 Other :

Prior PROM A short cervical length Prior preterm delivery Bleeding in early pregancy

Page 41

Mothers: (1) Infection : intrauterine                 puerperal (2) Placental abruption (3) Preterm delivery

Page 42

Infants: (1) Preterm Baby and their Complications :     (RDS / Fetal and Neurologic dysfunction      Intracranial hemorrhage) (2) neonatal pneumonia 、 sepsis (3) Pulmonary hypoplasia and fetal   compression syndrone (4) Prolapse or compression of umbilical cord (5) Abruptio placenta

Page 43

Clinical manifestation

(1) Fluid passing through the vagina   suddenly, and then small amounts of fluid   flow through the vagina intermitently,   particularly when the increased of   abdorminal pressure (cough,sneeze,et al)

Page 44

(2) Free flowing amniotic fluid

(3) Fever / heart rate of mother and     infants ↑ / WBC and CRP ↑/ Uterine     tenderness on palpation

Page 45

Vaginal speculum exam.:     leakage of amniotic fluid (2) PH determination of vaginal fluid (3) The “fern” test (4) Aminoscopy

Diagnosis

(1)

Page 46

Management

PROM at term: (1) Awaiting the onset of spontaneous labor for 12-24h (2) Termination of pregnancy after 24 hours

PROM before term:   Termination of pregnancy (1) Evidence of fetal pulmonary maturation (2) Evidence of inturine infection

Page 47

Expectant therapy Indication : (1) Evidence of fetal pulmonary inmaturation (2) Without evidence of inturine infection Management: (1)To enhance fetal pulmonary maturation (2) Antibiotic (3) Tocolysis