Disorders of uterine contraction, precipitate labor, premature labor and prolonged labor

Disorders of uterine contraction, precipitate labor, premature labor, and prolonged labor

1. Disorders of Uterine Contraction, Precipitated Labour, Premature Labour & Prolonged Labour

2. DISORDERS OF UTERINE CONTRACTION Problems with the Powers

3. Regular interval Interval gradually shortens Intensity gradually increases Discomfort in the back and abdomen Associated with cervical dilatation Discomfort not relieved by sedation Review of Normal Uterine Action

4. Any deviation from normal pattern of uterine contractions affecting the normal course of labour is designated as disordered or abnormal uterine contraction. Over all labour abnormalities occur in 25% nulliparous and 10% multiparous . Abnormal Uterine Action

5. Types of Abnormal Uterine Contraction

6. First birth specially with advancing age of the mother Prolonged pregnancy Over distention of the uterus Psychological factor Contracted pelvis, mal-presentation and deflexed head Etiology for Abnormal Uterine Action

7. Injudicious administration of sedatives, analgesics and oxytocics Premature attempt at vaginal delivery or attempted instrumental vaginal delivery under light anesthesia Cervical rigidity Massively obese clients Continued….

8. Weak, infrequent and ineffective uterine contractions Intensity is diminished Duration is shortened Good relaxation in between contractions and the intervals are increased. Uterine Inertia (Hypotonic Inertia)

9. General factors: Primi-gravida especially elderly. Anemia, chronic illness, antepartum hemorrhage Hypertensive states with pregnancy. Local factors: Over distension of the uterus Anomalies in development of the uterus Mal-presentations and mal-position Full bladder or rectum. Uterine fibroids Induction of premature labour. Etiology

10. 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. Clinical Features

11. In the 1st stage : Nervousness, anxiety, exhaustion 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. Complications of Uterine Inertia

12. Proper diagnosis Exclusion of cephalo -pelvic disproportion and mal-presentations Oxytocin stimulation: To increase the strength, frequency and duration of the uterine contractions. Close observation of the mother & the fetal well being. Assessment of efficiency of uterine contractions Management

13. 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 the conditions are suitable for vaginal delivery. Caesarean section: if fetal distress occurs before full dilatation of the cervix. Continued…

14. 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 Two pole of uterus doesn’t functions Inco-Ordinate Uterine Action ( Hypertonic Uterine Action)

15. Labour is prolonged Uterine contractions are irregular and more painful High resting intrauterine pressure in between uterine contractions detected by tocography Slow cervical dilatation Premature rupture of membranes Fetal and maternal distress   Clinical Features

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

17. 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 Spastic Lower Segment

18. Patient is agony with unbearable pain referred to the back. Bladder is frequently distended; distension of stomach and bowels are visible. Premature attempts to bear down. 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 Diagnosis

19. Internal examination may reveal: Cervix which is thick, edematous hangs loosely like a curtain; not well applied to the presenting part Inappropriate dilatation of the cervix 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. Continued….

20. Caesarean section-most common. Prior correction of dehydration and ketoacidosis Conservation approach with adequate pain relief.   * NO OXYTOCIN AUGMENTATION Management

21. It is a persistent localized annular spasm of the circular uterine muscles . Constriction (Contraction) Ring

22. It occurs at any part of the uterus but usually at junction of the upper and lower uterine segments around a constricted part of the fetus usually around the neck in cephalic presentation. It can occur at the any stage of labour and is usually reversible and complete. Continued….

23. Etiology is unknown but the predisposing factors are: Malpresentations and malpositions Premature rupture of membrane 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 . Predisposing Factors

24. 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. Features

25. Diagnosis

26. Complications

27. Management

28. This type of uterine contraction is predominately due to obstructed labor. 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. As a result of lower segment thinning and concomitant upper segment thickening. Tonic Uterine Contraction and Retraction ( Bandl's Ring, Pathological Retraction Ring)

29. 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   Progressive thinning & elongation of lower uterine segment Development of circular groove between upper and lower segment-called BANDL’S RING . Continued….

30. Continuous pain, discomfort, restlessness. Features of exhaustion and ketoacidosis 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. Cervix fully dilated. Membranes are absent. Cause of obstructed labour is revealed. Clinical features

31. Correction of dehydration and keto -acidosis by infusion of Ringer's solution. Adequate pain relief. Parenteral antibiotic is given. Caesarean delivery is done in majority of the cases. Rupture of uterus must be excluded before attempting destructive operation. Treatment

32. Difference between Constriction Ring and Pathological Retraction Ring

33. Cervical Dystocia 1. Organic (secondary) Due to: Cervical stances as a sequel to previous amputation, cone biopsy, extensive cauterization or obstetric trauma. Excessive scarring or rigidity of cervix from previous operation or disease. Post delivery. Organic lesions as cervical myoma or carcinoma. 2. Functional (primary): In spite of the absence of any organic lesion and the well effacement of the cervix, the external Os fails to dilate. Due to: lack of softening of the cervix during pregnancy or cervical spasm resulted from overactive sympathetic tone or excessive fibrous tissue. Insufficient uterine contraction. Malpresentation and malposition . Failure of the cervix to dilate within a reasonable time in spite of good regular uterine contractions

34. 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. Management

35. 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.  Continued….

36. 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). Generalized Tonic Contractions (Uterine Tetany)

37. Causes

38. 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 Clinical Features

39. 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 : to manage hypercontractility ( tachysystole ) induced by oxytocics . Caesarean delivery is done in majority of cases. Management

40. PRECIPITATE LABOUR

41. 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.  It is due to strong coordinate uterine contractions 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. Definition

42. Contributor Factors

43. 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. Signs

44. 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. Diagnosis

45. FOR MOTHER Increased risk of tearing and laceration of the cervix and vagina Predisposing to postpartum hemorrhage and sepsis Atonic Uterus: due to uterine exhaustion Hemorrhaging from the uterus or vagina Shock following birth which increases recovery time Delivery in an unsterilized environment such as the car or bathroom Risks of Precipitate Labour and Delivery

46. 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 Continued…

47. 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 any injury and manage accordingly. 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.   Management

48. PRETERM LABOUR

49.   Preterm labor is defined as the presence of contractions of sufficient strength and frequency to effect progressive effacement and dilatation of the cervix between 20 and 37 weeks’ gestation. (American College of Obstetricians and Gynecologists, 2003) Definition

50. Etiology and Risk Factors

51. Continued…..

52. The two most promising markers currently available are: 1. Fetal fibronectin levels 2. Ultrasound assessment of cervical length. Fetal fibronectin ( fFN ) testing :   It is an extracellular glycoprotein secreted by the chorionic tissue at maternal-fetal interface. 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 weeks can provide important marker of preterm labour Prediction of Preterm labour

53. 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. Continued….

54. PRIMARY PREVENTION :  Smoking cessation . Nutritional counseling . Lower workload for women with stressful jobs SECONDARY PREVENTION :   Self-measurement of the vaginal pH for B.V. Cervix length measurement by TVS . The accepted cutoff value for cervix length is ≤ 25 before GW 24 ). Cerclage and complete closure of the birth canal. Progesterone supplementation. Prevention of Premature Labor

55. Management Inhibition of uterine contractions with tocolysis . 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 for signs of hypoxia during labour, preferably by continuous 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. Caesarean section : only for obstetric indications.

56. PROLONGED LABOUR

57. 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. Definition

58. Causes

59. 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 rate of descent if the presenting part is < 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. Diagnosis

60. Dangers

61. 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. Prevention

62. 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. Treatment

63. 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. Continued….

64. Any query???