Unit III.pptxbbbbbbbbbbbbbbbbbbbbbbbbbbbbb

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1. Unit III: Abnormal Labour

2. Abnormal Labour It is a condition in which the presentation of the fetus is constantly changed even beyond 36 th week of pregnancy when it should have been established.

3. Abnormal Labour It is a condition in which the presentation of the fetus is constantly changed even beyond 36 th week of pregnancy when it should have been established.

4. EXCESSIVE UTERINE CONTRACTION AND RETRACTION

5. EXCESSIVE UTERINE CONTRACTION AND RETRACTION

6. 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.

7. 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 (see later). * Obstructed labour should be properly treated otherwise the thinned lower uterine segment will rupture.

8. HYPOTONIC UTERINE INERTIA

9. HYPOTONIC UTERINE INERTIA Definition The uterine contractions are infrequent, weak and of short duration.

10. Aetiology Unknown but the following factors may be incriminated: General factors: > Primigravida particularly elderly. > Anaemia and asthenia. > Nervous and emotional as anxiety and fear. > Hormonal due to deficient prostaglandins or oxytocin as in induced labour . > Improper use of analgesics.

11. A etiology Local factors > Overdistension of the uterus. > Developmental anomalies of the uterus e.g. hypoplasia. >Myomas of the uterus interfering mechanically with contractions. >Malpresentations, malpositions and cephalopelvic disproportion. The presenting part is not fitting in the lower uterine segment leading to absence of reflex uterine contractions. >Full bladder and rectum.

12. Types Primary inertia: weak uterine contractions from the start. Secondary inertia: inertia developed after a period of good uterine contractions when it failed to overcome an obstruction so the uterus is exhausted.

13. Clinical Picture * Labour is prolonged. * Uterine contractions are infrequent, weak and of short duration. * Slow cervical dilatation. * Membranes are usually intact. * The foetus and mother are usually not affected apart from maternal anxiety due to prolonged labour . * More susceptibility for retained placenta and postpartum haemorrhage due to persistent inertia. * Tocography : shows infrequent waves of contractionswith low amplitude.

14. Management General measures > Examination to detect disproportion, malpresentation or malposition and manage according to the case. > Proper management of the first stage (see normal labour ). Prophylactic antibiotics in prolonged labour particularly if the membranes are ruptured. Amniotomy: a.Providing that; > vaginal delivery is amenable, >the cervix is more than 3 cm dilatation and > the presenting part occupying well the lower uterine segment

15. Management Amniotomy : b. Artificial rupture of membranes augments the uterine contractions by: >release of prostaglandins. reflex stimulation of uterine contractions when the presenting part is brought closer to the lower uterine segment. Oxytocin: Providing that there is no contraindication for it, 5 units of oxytocin ( syntocinon ) in 500 c.c glucose 5% is given by IV infusion starting with 10 drops per minute and increasing gradually to get a uterine contraction rate of 3 per 10 minutes.

16. Management Operative delivery a.Vaginal delivery: by forceps, vacuum or breech extraction according to the presenting part and its level providing that, > cervix is fully dilated. > vaginal delivery is amenable. b .Caesarean section is indicated in: > failure of the previous methods. > contraindications to oxytocin infusion including disproportion. > foetal distress before full cervical dilatation.

17. HYPERTONIC UTERINE INERTIA (Uncoordinated Uterine Action)

18. 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. Clinical Picture 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.

19. Management > General measures: as hypotonic inertia. > Medical measures: Analgesic and antispasmodic as pethidine . Epidural analgesia may be of good benefit. > Caesarean section is indicated in: Failure of the previous methods. Disproportion. Foetal distress before full cervical dilatation.

20. CONSTRICTION (CONTRACTION) RING

21. CONSTRICTION (CONTRACTION) RING Definition * 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 .

22. A 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 .

23. 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.

24. 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).

25. Pathological Retraction Ring Constriction Ring Occurs in prolonged 2nd stage. Occurs in the 1st, 2nd or 3rd stage. Always between upper and lower uterine segments. At any level of the uterus. Rises up. Does not change its position. Felt and seen abdominally. Felt only vaginally. The uterus is tonically retracted, tender and the foetal parts cannot be felt. The uterus is not tonically retracted and the foetal parts can be felt. Maternal distress and foetal distress or death. Maternal and foetal distress may not be present. Relieved only by delivery of the foetus . May be relieved by anaesthetics or antispasmodics.

26. Management Exclude malpresentations , malposition and disproportion. 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.

27. PRECIPITATE LABOUR

28. PRECIPITATE LABOUR Definition A labour lasting less than 3 hours. Aetiology It is more common in multiparas when there are: * Strong Uterine Contractions, * Small Sized Baby, * Roomy Pelvis, * Minimal Soft Tissue Resistance.

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

30. 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. >Avulsion of the umbilical cord. > Foetal injury due to falling down.

31. 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 . 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 .

32. Management 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 .

33. CERVICAL DYSTOCIA

34. CERVICAL DYSTOCIA Definition Failure of the cervix to dilate within a reasonable time in spite of good regular uterine contractions. Varieties a.Organic (secondary) due to: > Cervical stances as a sequel to previous amputation, cone biopsy, extensive catherisation or obstetric trauma. > Organic lesions as cervical myoma or carcinoma

35. Varieties b.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. 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 haemorrhage : particularly if cervical laceration extends upwards tearing the main uterine vessels.

36. 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.

37. PROLONGED LABOUR

38. Introduction Traditionally labour is prolonged if it exceeds 24 hours. When labour is activity managed, It is termed prolonged if delivery is not imminent after 12 hrs of established labour . NB. The sun should not set twice in woman in labour . Normal progress of labor ; Effective uterine contractions and cervical changes leading to progressive effacement and dilatation of the cervix, rotation of the fetus and descent of the presenting part, the birth of the baby and expulsion of the placenta and membranes and the control of bleeding.

39. - ‘failure to progress’ based on the rate of cervical dilatation/hour or the labor is ‘prolonged’ when it exceeds the number of hours considered to be normal for a nulliparous or multiparous woman. - prolonged labour as one that exceeds 18 hrs in primiparous women. -Dystocia: a difficult or slow labour and thus includes both failure to progress and prolonged labour .

40. -Interventions to correct dystocia included 1-ARM 2- oxytocin 3-or a combination of both. 4- If these means fail an instrumental 5- or operative delivery C\S

41. - Expected out come with prolonged labour : 1-the risk of obstructed labour 2- uterine rupture 3- maternal and fetal morbidity and mortality. 4-increase risk of infection with prolonged rupture of membranes, 5- postpartum haemorrhage as a result of an atonic uterus.

42. The first Stage The latent phase considered prolonged over 20hrs in primigravidae or over 14 hrs in multigravidae . Primary dysfunctional- labour progress in active phase of labour is slow and the cervix dilate less than 1 cm on hour. Secondary arrest:- After normal progress in early labour , cervical dilation is arrested in active phase.

43. Cause in 1st stage 1) In-efficient uterine contraction (Power) is the most common cause of prolonged labour . The cervix dilates slowly or not at all. 2) Pelvic abnormalities (Passage). A contracted pelvis and pelvic tumors prevent normal progress in labour .

44. Cont… 3) The fetus (Passenger):- a large fetus malpostion of the occiput of malpresentation inhibit the progress of labour . 4) Psychological cause:- Abnormally tense or apprehensive women tend to have prolonged labors. The primigravidae more often affected than multigravidae

45. the passages : causes that a delay in the progress of labor. -trauma to the pelvis. - the impact of a full rectum -full bladder - fibroids - A malpresention

46. *as labour continues the smooth muscle uses up its metabolic reserves and becomes tired. - signs of ketosis due to continues contraction - Any change to the strength, length or frequency of contractions will affect progress and is indicative of inefficient uterine action. -It is important that the woman and her partner are closely involved to enable informed consent to be given for any procedures as artificial rupture of the membranes or an oxytocin infusion if the membranes are ruptured.

47. - A full assessment should take place to ensure the decision to augment labour is based on sound and accurate clinical findings. The midwife's role in caring for a woman in prolonged labour -A prolonged labour leads to increased levels of stress, anxiety and fatigue and increases the risk of infection, postpartum haemorrhage and emergency caesarean section NB-Raised adrenalin levels as a result of fear, anxiety or pain can impact negatively on uterine activity and slow progress in labour

48. Management When progress in labour is slow the cause must be identified week uterine action man be rectified with a syntocinon infusion Caesarian section if no progress despite good uterine contraction Obvious disproportion or malpresentation of the fetus indicate the need for operative deliveries.

49. -Managing labour should start with 1-appropriate antenatal education. 2-Advice on suitable food and drink to eat in the early stages of labour to maintain energy levels 3-positions and activities to encourage a forward rotation of the head if there is op. 4-An upright position might help to facilitate more effective contractions or an alternative position might help to improve pelvic diameters when the position of the baby is posterior

50. 5- maintain hydration, to encourage voiding 6- and to suggest non-pharmacological ways to relieve pain. 7-Recognition and detection of abnormal progress in labour 8-An abdominal examination can provide vital information about the labour with regard to the lie, presentation, position and descent of presenting part 9- the length, strength and frequency of contractions whereby any change in the pattern of the contractions should be 10 -On VE the midwife is assessing the presence and degree of moulding of the fetal skull, the presence and position of caput succedaneum in relation to sutures and fontanelles and the dilatation of the cervix noting any thickening and its application to the presenting part.

51. 11-Any changes to the colour of the liquor if the membranes have previously ruptured 12- CTG , fetal heart rate will give some indication as to how the fetus is coping with the progress of labour . 13-Psychological as well as physical support is important -The management of prolonged labour is a collaborative effort involving the woman and her partner, the midwife, obstetrician, and anaesthetist . 14- an ARM has been done to augment labour at appropriate time before oxytocin infusion 15- An assessment will be made 2–4 hrs after ARM or commencing oxytocin to ascertain the likelihood of a successful vaginal birth.

52. - signs of successful : 1- optimal contractions of four each 10 min lasting >40 s, 2- the woman is pain free 3-well hydrated 4- empty bladder Never augment labour in multiparae or in women with prior caesarean section because of the very real risk of hyper stimulation and uterine rupture.

53. Delay in the second stage of labour -The second stage of labour can be divided into 1-a passive (pelvic) phase 2- and active ( perineal ) phase. - Delay in this stage of labour may be due to: 1- malposition causing failure of the vertex to descend and rotate 2-ineffective contractions due to a prolonged first stage 3- large fetus and large vertex 4-absence of the desire to push with epidural analgesia.

54. -Time limits in second stage; *- range from 30 min to 2 hrs for multiparae *-1–3 hrs for nulliparae - avoid the encouragement of premature bearing down efforts -the effect of epidural analgesia on the desire to push in the second stage. -The active phase when the mother is bearing down is the most critical time.

55. -When a diagnosis of delay in the second stage has been made the case is referred to the obstetrician for review and assessment. -intervention could be by an instrumental or operative delivery.

56. Nursing Care Maternal condition : She may be exhausted, dehydrated and ketotic and may be suffering severe pain Encourage and reassure the mother- Help to adopt a comfortable position Adequate analgesia should be offered because it will enable her to rest. Administer IV infusion Empty bladder regularly

57. Cont… Test urine for ketoses Record intake and out put Allow sips of water If membrane ruptured 24 hours before high vaginal swab is taken for culture and sensitivity and antibiotic is started

58. Fetal Condition: Monitor the fetal heart beat Observe amniotic fluid (meconium) Avoid aspiration at delivery