Disorder of uterine contraction & precipitate labour.pptx

Nursing

1. Problems with the Powers

2. Any deviation from normal pattern of uterine contractions affecting the normal course of labour is designated as disordered or abnormal uterine contraction. O v er all labour abno r malitie s o c cu r i n 2 5% nulliparous and 10% multiparous.

3. Ab n ormal Uterine Action N ormal P olari t y Excessive C o n t r action Precipitate Labour Tonic Uterine Contraction & Retraction Ut er ine Inertia Ab n ormal Polarity Spast i c L o w er Segment Colicky Uterus Asymmetric Uterine Contraction Constriction Ring Generalized Tonic Contraction Cervical Dystocia T ype s of Abn o rm a l Uterine Contraction

4. First birth specially with advancing age of the mother Prolonged pregnancy O v er dis t ention of th e u t erus Psychological factor Contracted pelvis, mal-presentation and deflexed head

5. Injudicious administration of sedatives, analgesics and oxytocics P r emat u r e a tt empt at v ag i nal delivery or attempted instrumental vaginal delivery under light anesthesia Cervical rigidity M ass i v e l y obese clie n ts

6. Weak, infrequent and ineffective uterine contractions Intensity is diminished Duration is shortened Good relaxation in between contractions and the intervals are increased.

7. General factors: Primi-gravida especially elderly. Anemia, chronic illness, antepartum hemorrhage Hypertensive states with pregnancy. Local factors: O v er dis t e n sion of th e u t erus Anomalies in development of the uterus Mal-presentations and mal-position F ul l bladde r or r e c tum. Uterine fibroids Induction of premature labour.

8. Classi f ication of Uterine Inertia Prima r y Inertia Se c onda r y Inertia

9. Labor is prolonged On Examination: weak increase in the uterine tone uterine contractions in 10 minutes are less than 3 contractions and each lasting less than 30 seconds.

10. In th e 1st sta g e : N e r v ousnes s , anx i et y , exhaus t i o n and starvation ketoacidosis In the 2nd stage : Prolonged 2nd stage, increase liability for instrumental delivery and cesarean section. In the 3rd stage : Retention of the placenta and postpartum hemorrhage. Sub-involution of the uterus. Risks of abuse of uterine stimulants.

11. P r oper diagnosis Exclusion of cephalo-pelvic disproportion and mal-presentations Oxytocin stimulation: To increase the strength, frequency and du r at io n of th e u t eri n e c on t r actio n s . Close observation of the mother & the fetal well being. Assessmen t of ef f ic ien c y of u t er ine contractions

12. Operative interference: Artificial rupture of the membranes Operative delivery indicated if labor is prolonged beyond 24hours or if there is fetal distress at any time. One of the following may be done: Vaginal delivery by forceps if the cervix is fully dilated and th e c o n dit i o n s a r e su i tabl e f or v ag i na l del i v e r y . Caesarean section: if fetal distress occurs before full dilatation of the cervix.

13. 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. Strong and painful uterine contraction High frequency Slow cervical dilatation T w o po l e of u t erus does n ’ t f u n ctio ns

14. Labour is prolonged Uterine contractions are i r r eg ula r and mo r e painful High resting intrauterine pressure in between uterine contractions detected by tocography Slow cervical dilatation P r emat u r e rup t u r e of membranes Fetal and maternal distress

15. CPD, Fetal Distress- Caesarean Section Vital monitoring I/V therapy: correction of dehydration and ketoacidosis I/O charting FSH every 15 min Partograph

16. Uterine Contraction: Fundal dominance is lacking Reverse polarity Lower segment contractions are stronger Inadequate relaxation in between the contractions Premature bearing down Cervix loose, edematous, not well applied to the presenting part

17. Patient is agony with unbearable pain referred to the back. Bladder is frequently distended; distension of stomach and b o w els a r e v i sible. P r ematu r e a tt empts t o bea r d o w n . Abdominal palpation reveals: Uterus is tender and gentle manipulation excites hardening of the uterus with pain Uterus remains tense even after contraction passes off and as such Palpation of the fetal parts is difficult

18. Internal examination may reveal: Cervix which is thick, edematous ha n gs lo o se l y li k e a curta i n ; n ot w ell applied to the presenting part Inapp r opri a t e dilata t io n of th e c e r v i x Absence of the membrane Varying degree of caput Meconium stained liquor amnii Effect on the Fetus : Fetal distress appears early due to placental insufficiency caused by inadequate relaxation of the uterus.

19. Caesarean section-most common. Prior correction of dehydration and ketoacidosis Conservation approach with adequate pain relief. * NO OXYTOCIN A UGM E N T A TION

20. It is a persistent localized annular spasm of the circular uterine muscles .

21. I t o c cur s at a n y part of th e u t er u s bu t usual l y at jun c t i on of the uppe r a n d l o w er u t er i n e segments a r ou n d a c o n str i c t ed part of the fetus usually around the neck in cephalic presentation. I t ca n o c cu r at th e a n y sta g e of la b our and i s usual l y r e v ersible and complete.

22. Etiology is unknown but the predisposing factors are: Malpresentations and malpositions P r ematu r e rup t u r e of memb r ane Premature attempt of instrumental delivery Intrauterine manipulations under light anesthesia. Improper use of oxytocin e.g. use of oxytocin in hypertonic inertia or IM injection of oxytocin.

23. Maternal condition not affected. Fetal distress may occur Ring is not palpable during per abdomen Felt into first stage during – Caesarean Section Second stage – Forceps application Third stage – Manual removal of placenta.

24. Diagnosis is difficult. More common in primi gravida and frequently preceded by colicky uterus The exact diagnosis is achieved only by feeling the ring with a hand introduced into the uterine cavity.

25. Prolonged 1st stage if the ring occurs at the level of the internal Os. Prolonged 2nd stage if the ring o c c u r s a r ou n d the fetal neck. Retained placenta and postpartum hemorrhage if the ring occurs in the 3rd stage

26. 3rd stage: Deep general anesthesia and amyl nitrite inhalation followed by manual removal of the placenta. ring is relaxed, delivery by forceps ring does not relax, caesarean section 1st stage: Pethidine morphine 2nd stage: Deep general anesthesia and amyl nitrite Exclude malpresentations, malposition and disproportion

27. Thi s typ e of u t eri n e c o n t r action i s p r edom i na t e l y du e t o obstructed labor. Physiological Retraction Ring: It is a line of demarcation bet w een th e uppe r and l o w er u t eri n e segment p r esent during n o rma l lab o u r a n d ca n n o t us u al l y b e f elt abd o mi n al l y . As a result of lower segment thinning and concomitant upper segment thickening.

28. Pathological Retraction 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 fetus. Contraction increases in intensity ,duration and frequency with decreased relaxation in between. Retraction continues P r og r ess i v e thinn i n g & elon g ation of l ow er u t eri n e segment Development of circular groove between upper and lower segment-called BANDL’S RING .

29. Continuous pain, discomfort, restlessness. F eat u r es of exhaus t i o n and k e t oac i dos i s Abdominal palpation reveals : Upper uterine segment is tender and hard. Lower uterine segment distended and tender. Groove is seen between the umbilicus and symphysis pubis and rises upwards in course of time. Fetal part may not be well defined. F.H.S. is usually absent. Internal examination reveals: Vagina-dry and hot and the discharge - offensive. C e r v i x ful l y dila t ed. M emb r anes a r e absent. Cause of obstructed labour is revealed.

30. Correction of dehydration and keto-acidosis by infusion of Ringer's solution. A d equ a t e pai n r elie f . Parenteral antibiotic is given. Caesarean delivery is done in majority of the cases. Rupture of uterus must be excluded before attempting dest r uct i v e ope r at i o n .

31. 1. Organic (secondary) Due to: Cervical stances as a sequel to previous amputation, cone biopsy, ex t ens i v e cau t eri z at i on or obstetric trauma. E x c es s i v e scarring or rigidit y of cervix from previous operation or disease. P ost del i v e r y . Organic lesions as cervical myoma or ca r cin o ma. 2. Functional (primary): In s p i t e of th e abse n c e of a n y organic lesion and the well effa c e m ent of th e c e r vix, the external Os fails to dilate. Due to: lack of softening of the cervix duri n g p r eg n a n c y or c e r vical spasm resulted from overactive sympath e t ic t one or e x c ess i v e fibrous tissue. Insuf f icie n t u t eri n e c on t r actio n . M al p r ese n t a t ion a n d malposition. F ailu r e of th e c e r v i x t o dila t e with i n a r easona b le t i m e i n spi t e of good regular uterine contractions

32. If only thin rim of cervix left behind- it is pushed up manually during contraction. If cervix is thinned out but only half dilated – Duhrssens’s incision is given at 2’oclock and 10 o’clock position followed by forceps or ventouse extraction.

33. Organic dystocia: Caesarean section is the management of choice. Functional dystocia: Pethidine and antispasmodics: may be effective. Caesarean section: if medical treatment fails or fetal distress developed.

34. Pronounces retraction occurs involving whole of the uterus up to the level of internal Os. No physiological differentiation of the active upper segment and the passive lower segment of the uterus. 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).

35. Failure to overcome the obstruction by powerful contractions of the uterus. Injudicious administration of oxytocics Irritation caused by repeated unsuccessful attempt of instrumental delivery.

36. The patient is in prolonged labor having severe and continuous pain. PER ABDOMINAL EXAMINATION Uterus is smaller in size, tense, tender Fetal parts are not palpable Fetal heart sounds not audible PER VAGINAL EXAMINATION Dry and edematous vagina Jammed head with a big caput

37. C or r ection of de h y d r ation and k e t o acid o sis: b y r a p id infusion of Ringer’s solution Antib i otics : T o c o n t r ol i n f ection Adequate pain relief T o c o l yti c a g ents f or e.g t e r b u tali n 0. 2 5mg S . C : t o manage hypercontractility (tachysystole) induced by oxytocics. Caesarean delivery is done in majority of cases.

38. Precipitate labour refers to a labour pattern that progresses rapidly and ends with delivery occurring in less than 3 hours is typically less than 5 hours after the onset of uterine activity. I t i s du e t o st r o n g c o o r di n a t e u t eri n e c o n t r actio n s in absence of obstruction in the birth canal, and resistance of the soft tissues. The patient does not feel contractions except the last contractions during the expulsion of the fetus.

39. 1 Maternal multi parous status. 2 Small fetus 3 Relaxed pelvic and vaginal musculature 4 History of rapid labors with previous deliveries 5 A particularly efficient uterus which contracts with great strength

40. A sudden onset of intense, closely timed contractions with little opportunity for recovery between contractions. The sensation of pressure including an urge to push that comes on quickly and without warning. Often times this symptom is not accompanied by contractions as the cervix dilates very quickly.

41. It is a retrospective diagnosis as the patient is usually seen in the 2nd or 3rdstages of labor. If seen during the first stage of the labor, the Partograph will show rapid progress of cervical dilatation and effacement.

42. FOR MOTHER Increased risk of tearing and laceration of the cervix and vagina Predisposing to postpartum hemorrhage and sepsis A t o n i c U t erus: du e t o u t eri n e exhaus t i o n Hemorrhaging from the uterus or vagina Shock following birth which increases recovery time Delivery in an unsterilized environment such as the car or bathroom

43. FOR BABY Risk of infection from unsterilized delivery Potential aspiration of amniotic fluid Intracranial hemorrhage: due to rapid compression and decompression of the fetal head during delivery. Fetal injuries Avulsion (forcible separation) of the cord Neonatal sepsis

44. BEFORE DELIVERY A patient with past history of precipitate labor should be admitted to the hospital at the first perception of labor pains. DURING DELIVERY Rarely if the patient is seen during delivery, general anesthesia (inhalation by nitrous oxide and oxygen or sedation) may be given to slow down the course of delivery to prevent forcible bearing down. AFTER DELIVERY If the patient is seen after delivery: exploration of the birth canal for a n y i n ju r y a n d m a n a g e a cc o r di n g l y . Prophylactic antibiotics if delivery occurred in unsuitable conditions. Proper examination of the fetus for detection of any complications. Continuous assessment of maternal and fetal status.

45. Preterm labor is defined as the presence of contractions of sufficient strength and f r equen c y t o ef f ect p r og r ess i v e effa c ement and dilatation of the cervix between 20 and 37 weeks’ gestation. (American College of Obstetricians and Gynecologists, 2003)

46. Obstetric c om p licati o ns Demog r a p hic factors P s y chosoc i al factors P ast obs t etric history In f ecti o n Genetic factors

47. The two most promising markers currently available are: Fetal fibronectin levels Ultrasound assessment of cervical length. Fetal fibronectin (fFN) testing : It is an extracellular glycoprotein secreted by the chorionic tiss u e at ma t ernal- f etal i n t erfa c e. It acts as a biological glue which binds blastocyst to endometrium. It can be normally present in cervico-vaginal secretions up to 20-22 wks. Thus, presence of fFN between 27 to 34 w eeks ca n p ro vide im p ortant ma r k er of p r e t erm labour

48. SAMPLE : Sample is taken from the posterior fornix of the vagina. VALUES: A cut-off of 50 ng/ml is considered positive. Length of cervix: Cervix can be assessed digitally or by ultrasound. A reduction in cervical length of >6mm between 2 ultrasounds have higher risk.

49. PRIMARY PREVENTION : Smoking cessation . Nutritional counseling . L o w er w o r kload f or w omen with st r essful jo b s SECONDARY PREVENTION : Self-measurement of the vaginal pH for B.V. Cervix length measurement by TVS . Th e a cc ep t ed cu t off v alue f or c e r v i x le n g t h i s ≤ 2 5 b e f o r e GW 24 ). Cerclage and complete closure of the birth canal. Progesterone supplementation.

50. Inhibit i on of u t er in e c o n t r actio n s with t o c o ly si s . Corticosteroids to induce fetal lung maturation. Treatment of infection with antibiotics. Bed rest and hospitalization. INTRAPARTUM MANAGEMENT Monitoring : The preterm fetus should be monitored closely f or si g n s of h yp o xi a dur i n g lab o u r , p r e f e r ab l y b y c ontinuous electronic fetal monitoring. Antibiotic prophylaxis Delivery : Delivery must be conducted in the presence of expert neonatologist capable of dealing with complications of prematurity. * Ventouse is contraindicated in preterm deliveries. 1 . Ca e sa r e an se c tio n : o n l y f or o b s t et r i c indication s .

51. The labour is said to be prolonged when the combined duration of the first and second stage is more than the arbitrary time limit of 18 hrs. Latent Phase : Latent phase is the preparatory phase of the uterus and the cervix before the actual onset of labour. Normal latent phase is about 8 hours in primi gravida & 4 hours in multi gravida. Prolonged Latent Phase : A latent phase that exceeds 20 hrs in primi gravida or 14 hrs in multi gravida is abnormal.

52. U nrip e c e r vix Malposition and malpresentation Cephalopelvic disproportion Premature rupture of the membranes Abnormal uterine contraction Contracted pelvis Congenital malformation of the baby

53. FIRST STAGE: First stage of labour is considered prolonged when the duration is more than 12 hrs. The rate of cervical dilatation is < 1 cm/hr in primi and < 1.5 cm/hr in multi. The r a t e of des c ent i f t he p r es e nt i n g pa r t i s < 1 cm/ hr in primi and < 2 cm/hr in multi. SECOND STAGE: The 2nd stage is considered prolonged if it lasts for more than 2 hrs in primi, and 1 hr in multi. The diagnostic features are: Sluggish or non descent of the presenting part even after full dilatation of the cervix. Variable degrees of molding and caput formation in cephalic presentation. Identification of the cause of prolongation.

54. FETAL Hypoxia I n t r au t e r i n e infection Intracranial stress or hemorrhage Increased operative delivery MATERNAL Distress Postpartum he m or r ha g e Trauma to the genital tract Increased operative delivery Puerperal sepsis Sub-involution

55. Antenatal or early intranatal detection of the factors likely to produce prolonged labour (big baby, malpresentation or position). Use of partograph helps early detection. Selective and judicious augmentation of labour by low rupture of membranes followed by oxytocin drip. Change of posture in labour other than supine to increase the uterine contractions. Avoidance of labour dehydration. Use of adequate analgesia for pain relief.

56. First Stage Delay Vaginal examination is done to verify the fetal presentation, position and station. Clinical pelvimetry is done, if only uterine activity is sub- optimal. Amniotomy and/ or oxytocin infusion is adequate. Effective pain relief is given by IM Inj: Pethidine or by regional analgesia. Caesarean section is done when vaginal delivery is unsafe.

57. Second Stage Delay Short period of expectant management is reasonable provided the FHR is reassuring and vaginal delivery is imminent. Otherwise appropriate assisted delivery vaginal (forceps,ventouse) or abdominal (caesarean) should be done.