Abnormal uterine action

Abnormal uterine action

1. Abnormal uterine action Mrs. U SREEVIDYA Msc . NURSING, Associate Professor, Apollo college of nursing, CHITTOOR

2. Normal uterine action Normal labour is characterized by coordinated uterine contractions(interval gradually shortens and intensity gradually increases) associated with progressive dilatation of the cervix (Normal labour is associated with cervical dilatation ≥ 1cm \ hour in a nulliparous woman ) descent of the fetal head.

3. u p p e r p o l e  Pol a ri t y o f ut e r u s : W h en contracts lower pole relax  Pacemakers : Two pace ma k e r s are eac h c o r n ua o f the ut e r u s c o nt r a c ti o n in co -o r d i n at e d s i tu a ted at generating manner  Pattern of contraction : uterine contraction starts at cornua and propagate towards lower uterine segment with decrease in duration and intensity as it moves away from the pacemaker

4. Parameter of uterine action  Basal tone : 5- 20 mm Hg  Peak pressure : 60 -80 mm Hg  Frequency of contraction :adequate uterine contractions are 1 in every 3 mints lasting for about 45 sec with good relaxation in between

5. Assessment of contraction  Abdominal palpation  Tocodynamometer :with the help of external tra n sducers  Intrauterine pressure catheter

6. Abnormal uterine action  Any deviation of the normal pattern of uterine contractions affecting the course of labour is designated as disordered or abnormal uterine action.

7.  Overall labour abnormalities occur in about 25% of the nulliparous women  AND 10% OF MULTIPAROUS WOMEN. Incidence:

8. ETI O LO G Y  Prevalent in primi with advancing age of the mother  Prolonged pregnancy  Ov e r dis t en s ion of t h e ut e rus d u e t o twi n s and or p ol yhydramnios  Psychologic factor  Contracted pelvis, malpresentation and deflexed head. All these lead to ill fitting of the presenting part into the lower uterine segment. This probably results in inhibition of the local reflex which is needed to produce effective contraction of the upper segment.

9.  Full bladder and loaded rectum reflexly inhibit uterine contraction  Injudicious administration of sedatives, analgesics and oxytocics  Premature attempt of vaginal delivery or attempted instrumental vaginal delivery under light anaesthesia.

10. a. Over-efficient uterine action Precipitate labour: in absence of obstruction E x cessi v e c o n t r action and r e t r action: in p r esen c e o f obstruction b.Inefficient uterine action Hypotonic inertia Hypertonic inertia Colicky uterus Hyperactive lower uterine segment >Constriction (contraction) ring Generalised tonic uterus c.Cervical dystocia Classification of abnormal uterine activity

11. PRECIPITATE LABOUR

12. PRECIPITATE LABOUR Definition A labour lasting less than 3 hours. Combined duration of 1 st and 2 nd stage of labour is < 2 hours. Rate of cervical dilatation greater than 5cm/H in primipara & 10 cm/H in multipara. Due to combined effect of hyperactive uterine contractions and diminished soft tissue resistance

13. It is more common in multipa rou s when there are: strong uterine contractions, small sized baby, roomy pelvis, minimal soft tissue resistance. A e tiology

14. Complications Maternal: * Lacerations of the cervix, vagina and perineum. *Shock. *Inversion of the uterus. *Postpartum haemorrhage : due to, >no time for retraction, lacerations. * Sepsis due to: lacerations, inappropriate surroundings.

15. Complications Foetal : >Intracranial haemorrhage due to sudden compression and decompression of the head. >Foetal asphyxia due to: *strong frequent uterine contractions reducing placental perfusion, *lack of immediate resuscitation. > A vulsion of the umbilical cord. >Foetal injury due to falling down.

16. Management Before delivery : Patient who had previous precipitate labour should be hospitalized before expected date of delivery as she is more prone to repeated precipitate labour.

17. Management cont.. During delivery: Inhalation anaesthesia: as nitrous oxide and oxygen is given to slow the course of labour. Tocolytic agents: as ritodrine (Yutopar) may be effective. Episiotomy: to avoid perineal lacerations and intracranial haemorrhage.

18. EXCESSIVE UTERINE CONTRACTION AND RETRACTION ( TONIC UTERINE CONTRACTION AND RETRACTION )

19. 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.

20. 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 umbilicus. Clinical picture: is that of obstructed labour with impending rupture uterus. Obstructed labour should be properly treated otherwise the thinned lower uterine segment will rupture.

21. TONIC UTERINE CONTRACTION AND RETRACTION PATHOLOGICAL ANATOMY OF UTERUS: Contraction increases in intensity ,duration and frequency with decreased relaxation in between Retraction continues Progressive thinning & elongation of lower uterine segment / Development of circular groove b/n upper and lower segment-called BANDL’S RING .

22. In primigravidae further retraction ceases in response to obstruction and labour comes to a stand still-a state of exhaustion. In multiparae retraction continues with progressive dilatation and thinning of lower uterine segment Bandl’s ring moves towards the umblicus Rupture of lower uterine segment Fetal jeopardy and death

23. Clinical features • • • • • Patient is anxious looking Features of exhaustion and ketoacidosis Upper uterine segment is tender and hard Lower uterine segment distended and tender Groove is seen between the two.

24. T R E A TM EN T • • • Correction of dehydration & ketoacidosis Adequate pain relief Parenteral antibiotics EXCLUDE RUPTURE OF UTERUS Caesarean delivery in majority of cases

25. HYPOTONIC UTERINE INERTIA

26. Uterine inertia Dystocia: abnormal or difficult labour . It is characterized by slow progress or arrest of labour . Definition of uterine inertia: The uterine contractions are infrequent, weak, inefficient and of short duration.  Uterine contraction: the intensity is diminished; duration is shortened; good relaxation in between contractions and the intervals are increased. General pattern of uterine contractions of labour is maintained but intrauterine pressure during contraction hardly rises above 25mm Hg

27. Etiology  Elderly primi gravida  Anemia or other chronic illnes s  Hypertensive state in pregnancy a s i n twin or  Over d i ste n sion o f uterus such polyhydraminous  Malpresentation and malposition  Full bladder  Uterine fibroid  Premature induction of labou r Nervous and emotional as anxiety and fear. Improper use of analgesics. Unknown but the following factors may be incriminated:

28. T ypes  Primary inertia :weak uterine contrations from the begin n ing  Secondary inertia :interia developed after a period of good contraction probably as the result of contracted pelvis as protective mechanism .

29. Sign s and symptom s  1.Patient feels less pain and discomfort during uterine contraction  2.Hand placed over the uterus during uterine contraction reveals less hardening of the uterus.  3.Uterine wall is easily in tena ble at the contractions .  4.Uterus becomes relaxed after the contraction; fetal parts are well palpable and fetal heart rate remains good.

30. Diagnosis Internal examination reveals;  Poor dilatation of the cervix  Membranes usually remain intact  Cervix well applied to the presenting part  Associated presence of contracted pelvis, malposition, deflexed head or malpresentation may be evident.

31. Complication s Effect s on mother:  Prolonged labor  Maternal distress, dehydration and psychological depression  Increased risk for infection  Increased risk of PPH  Subinvolution

32. Fetal complication membrane  F e t a l d i str e ss if ruptures early

33. Manag e ment  Careful evaluation of the case is to be done:  T o b e sure th a t t he p a ti e nt is in tr u e labour  To exclude cephalopelvic disproportion or malpresentation  To plan out the management protocol

34. Detected in first stage: Place of caesarean section:  Presence of contracted pelvis  Malpresentation  Evidences of fetal or maternal distress In these cases where vaginal delivery is found unsafe and fetal condition remains good, caesarean section may be preferred.

35. Vaginal delivery  General measures:  To keep up the morale of the patient  To empty the bowel by enema and bladder by encouraging the patient to empty at intervals, failing which catheterization is to be done  To maintain nourishment by infusion of 5% dextrose  Adequate sedation is ensured by intramuscular Pethidine 100 mg

36. Active measures  Acceleration of uterine contraction can be brought about by low rupture of the membranes followed by Oxytocin drip if not contraindicated. An infusion of 2 unit of Oxytocin dissolved in 500ml 5% dextrose is started. The drip rate should be slow at first and is to be gradually increased until effective contractions are set up. Close watch of the maternal and fetal conditions and nature of uterine contractions is mandatory. The drip is to be continued till 1 hour after del i v er y; unsatisfactory and \ or fetal I f , ho w e ve r , cervical dilatati o n distress rema i ns ap p ears, Caesarean section is the best alternative.

37. Detected in second stage  If the case is first seen at this stage, careful evaluation of the case is to be done to exclude contracted pelvis, malpresentation and to determine station of the head in relation to ischial spines and fetal condition.

38. Place of caesarean section  In presence of contracted pelvis or malpresentation where vaginal delivery is found unsafe and fetal condition ca e sar e an re m a i ns good, s e ction ma y be preferred even at this stage.

39. Vaginal delivery  Head low down – Forceps or ventouse delivery  Head not sufficiently low down  · Stimulation of uterine contraction by oxytocin drip or  Ventouse extraction. Difficult forceps should be avoided  Craniotomy – If the baby is dead

40. Third stage  Active management of the third stage is advocated

41. HYPERTONIC UTERINE INERTIA (Uncoordinated Uterine Action)

42. T ypes 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.

43. HYPERTONIC UTERINE ACTION  It is defined as either a series of single contractions lasting 2 minutes or more or a contraction frequency of five or more in 10 minutes.Uterine hyperstimulation may result in a b n o r ma l it i e s , fet a l hear t r a te uter i ne r u pt u r e , or placental abruption

44. Example  Spastic lower uterine segment  Colicky uterus  Asymmetrical uterine contraction  Constriction ring  Generalised tonic contraction All these states are collectively called as incordinate uterine action

45. In co-ordinate uterine action  Strong and painful uterine contraction  High frequency  Slow cervical dilatation  Two pole of uterus doesn’t functions rhythmically

46. Clinical feature s  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.

47. Management  CPD- C/S  Vital monitoring  I/V therapy  I/O charting  FH S every 15 min  Partograph  Fetal distress-C/S

48. Colicky uterus  Various parts of uterus contracts independently Hyperactive lower uterine segment  Fundal gradient is lost , reverse gradient of the uterine activity starts from the lower uterine segment goes toward fundus and cervix

49. CO N STRI C TION ring (CONTRACTION) RING  It is a persistent localised 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.

50. Aetiolo g y Unknown but the predisposing factors are:  Malpresentations and malpositions.  Premature rupture of membrane  Premature attempt of instrumental delivery l i ght  Intr auterine mani p ulations under anaesthesia.  Improper use of oxytocin e.g.  use of oxytocin in hypertonic inertia.  IM injection of oxytocin.

51. Diagnosis  The c o nd i ti o n is more c o mmon in pr i mig r avid a e and frequently preceded by colicky uterus.  The e x act diagno s is i s ac h ieved o nly by fee l ing the ring with a hand introduced into the uterine cavity. Complications  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).

52. Clinical feature s  Mother becomes tired and restless due to continue pain and discomfort  Features of maternal distress and keto-acidosis  Abdominal palpation  Upper segment hard ,uniformly convex and tender  Retraction ring obliquely placed between umblicus and symphysis pubis  Fetal part may not be well defined  FHS usually absent  Vaginal examination  Dry hot vagina with offensive discharge  Cervix fully dilated  Causes of obstruction is revealed

53. DIFFERENCE BETWEEN CONSTRICTION RING AND RETRACTION RING CONSTRICTION RING RETRACTION RING Natu r e It is a manifestation of localised inco-ordinated uterine contraction. It is an end result of tonic uterine contraction and retraction Cause Undue irritability of the uterus. Following obstructed labour Situation Usually at the junction of upper At the junction of upper and and lower segment but may occur lower segment. The position in other places. The position does progressively moves upwards not alter. Uterus Upper segment contracts and retracts with relaxation in between lower segment remains thick and loose. Upper segment is tonically contracted with no relaxation The wall becomes thicker, lower segment becomes distended and thinned out

54. M a tern a l condition Almost unaffected unless the labour is prolonged Maternal exhaustion, sepsis appear early A b d o m inal Examination o Uterus feels normal and not tender o Fetal parts are easily felt o FHS is usually felt Uterus is tense and tender Not easily felt Ring is felt as a groove placed obliquely V aginal examination The lower segment is not pressed by the presenting part Ring is felt usually above the head Features of obstructed labour are absent o Lower segment is very much pressed by the forcibly driven presenting part o Ring cannot be felt vaginally o Features are present End result Maternal exhaustion is a late o Maternal exhaustion and feature sepsis appear early Fetal anoxia usually appear late o Fetal anoxia and even death o Chance of uterine rupture is are usually early absent o Rupture uterus in multi gravidae is common

55. Management  Provide supportive therapy  Analgesic and sedation  Hydration  Prophylactic antibiotic  Definitive treatment  Destructive surgery if fetus is dead  Fetus alive-C/S

56. Management  E x c lude m a l presentatio ns , malpositi o n and disproportion.  In the 1s t s tag e : P eth i dine , morphine may b e of beneficial .  In the 2n d s tage : D e ep gener a l an a esthe s ia and amyl nitrite inhalation are given to relax the constriction ring:  I f the ring i s rela x ed, the foetus i s d e liver e d immediately by forceps.  If the ring does not relax, caesarean section is carried out with lower segment vertical incision to divide the ring.  In the 3rd stage: Deep general anaesthesia and amyl nitrite inhalation are given followed by manual removal of the placenta

57. GENERALIZED TONIC CONTRACTION (UTERINE TETANY)  In this condition pronounces retraction occurs involving whole of the uterus upto the level of internal os. Thus there is no physiological differentiation of the active upper segment and the passive lower segment of the uterus. As there is no thinning of the lower segment, there is no chance of rupture of the uterus. The uterine contraction ceases and the whole uterus undergoes a sort of tonic muscular spasm holding the fetus inside (active retention of the fetus)

58. C a uses  Failure to overcome the obstruction by powerful contractions of the uterus  Injudicious administration of oxytocics  Irritation caused by repeated unsuccessful attempt of instrumental delivery

59. Clinical Features  The pa t i e nt is in prolo n ged la b or ha v ing s e v e re an d c o nt i n u o u s p a in . Abd o min a l e x ami n at i on r e v e ls the uter u s to be s o m e wh a t s m a l l er in s iz e , te n se and we l l Fetal nor p a rts is t he a r e ne i th e r fetal hear t sou n d tender. d e fi n e d , audible. V a g i n al e x ami n at i on r e v e a l s j am med hea d wi t h b i g capu t; dr y and oedematous vagina.

60. Mana g ement  Correction of dehydration and keto acidosis: by rapid infusion of Ringer’s solution  Antibiotics : To control infection  Adequate pain relief Tocolytic agents for e.g terbutalin 0.25mg S.C. Caesarean delivery is done in majority of cases.

61. CERVICAL DYSTOCIA Definition Failure of the cervix to dilate within a reasonable time in spite of good regular uterine contractions.

62. T ypes  Organic (secondary) due to:  Cervical stances as a sequel to previous amputation, cone biopsy, extensive cauterisation or obstetric trauma.  Organic lesions as cervical myoma or carcinoma.  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 or excessive fibrous tissue .

63. Etiology  Ineffective uterine contractions  Malpresentation, Malposition (abnormal relationship between the cervix and the presenting part)  Spasm (contractions) of the cervix

64. Manag e ment  Organic dystocia:  Caesarean section is the management of choice.  Functional dystocia:  Pethidine and antispasmodics: may be effective.  Caesarean section: if  medical treatment fails or  foetal distress developed.

65. Thank You