Uterine inertia

1. UTERINE INERTIA
BY UMOH EMMANUEL

2. DEFINITION
abnormal relaxation of the uterus during labor,
causing a lack of obstetric progress, or after
childbirth, causing uterine hemorrhage.
Can be associated with dystocia

3. CLASSIFICATION
HYPOTONIC INERTIA :
 a. Primary Uterine inertia
 b. Secondary inertia
HYPERTONIC INERTIA:
 a. Colicky Uterus
 b. Hyperactive lower uterine segment

4. PRIMARY UTERINE INERTIA
Is characterized by inefficient contractions from
the very beginning of labor, the contractions are
usually weak and short, while the pauses
between them are long. Frequent, but ineffective
contractions may also occur.
Usually occurs in general asthenia conditions,
endocrine disorders, infantilism, malformation of
the genitalia( uterus bicornuate and unicornus),
myoma of the uterus and obesity.

5. 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.

6. CONTD.
LOCAL FACTORS :Overdistension of
the uterus in multiple pregnancy and
polyhydroamnions
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.

7. Uterine inertia often results in premature
discharge of the amniotic fluid in the absence
amnion which stimulates the nerve elements of
the uterine cervix and intensifies the uterine
contraction.
Primary inertia may last to the second stage of
labor to become responsible for ineffective
abdominal contractions, labor thus becomes
markedly prolonged.
This can lead to complications such as: fetal
asphyxia, considerable bleeding in the placental
and early puerperal period.

8. CLINICAL PICTURE OF HYPOTNIC
INERTIA
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
contractions with low amplitude.

9. MANAGEMENT
Usually difficult to manage, but one principle is to find the
cause and treat the cause if possible.
Schemes used:
SCHEME 1 (KURDINOVSKIY AND SHTEIN)
Castor oil, 50-60g per os; a cleansing enema in 2hrs, Quinine
0.2g six times at 30min interval after enema. 15 mins later,
the 3
rd
,4
th
, 5
th
and 6
th
dose of quinine follows pituitrin
injections( subcutaneously 0.25ml 4 times).
If the membranes are intact, 40,000-50,000units of folliculin
or sinestrol intramuscularly may be given at the beginning
of labor.
Folluculin and sinestrol increases sensitivity of the uterus to
quinine, pituitrine and other uterine stimulants. Castor oil
is given in an hour after the administration of folliculin,
then given are cleansing enema, quinine and pituitrin.

10. SCHEME TWO( A.P NIKOLAEV)
Castor oil , 60g per os, then (in an hr), quinine,
five 0.2g doses at 30minutes interval. After the
5
th
admission of quinine, a cleansing enema is
given followed by an intravenous injection of
50ml of 40% glucose and 10ml of 10% Calcium
Chloride. Solution of vitamin B (160mg) should
be given simultaneously (i.m)

11. SCHEME 3 (V.N KHEMLEVSKY)
A mixture of 50g of glucose, 2g of Calcium
Chloride, 0.5g of ascorbic acid, 0.3g of vitamin
B1, 10 drops of dilute hydrochloric acid, and
150ml of water are given per os in a single dose.
The mixture can be given in 3hrs again.

12. CONT.
Oxytocin and Prostoglandin have been recently
used as uterine stimulants. Oxytocin is given as
i.v with glucose solution (5-10units of Oxytocin in
5% of 500ml glucose by infusion)…speed of
drops : 10drops per minute, increase drops after
some hours depending on the condition of the
patient.
Proserine plus Atropine hydrochloride can be
given as 0.003g and 0.002g respectively in
powder from an hour interval( 4-5times a day)
Prostaglandin is contraindicated in traumas and
hypertensive patients.

13. SECONDARY UTERINE INERTIA
A condition that develops during the second
(expulsive) stage of labor or at the end of dilation
stage following normal or satisfactory uterine
contractions.

14. ETIOLOGY
Often develops in prolonged labor due to general
fatigue of the Parturient and extraction of the
contractile power of the uterus.
Occurs in:
Contracted pelvis
large sized fetus
 Malpresentation,
rigid Os,
 Cicatrical narrowing of the vagina
 delayed rupture of membranes

15. PATHPHYSIOLOGY
It often occurs after discharge of the amniotic
fluid and its therefore often attended with
intrauterine infection and fetal asphyxia.

16. MANAGEMENT
Depends on the cause , if its due to delayed
rupture of the membranes, AMNIOTOMY is
indicated .
When the cervix is fully dilated and the fetal
head is engaged, 1ml of pitutrin or 0.25ml of
Oxytocin may be given simultaneously which will
rapidly stimulate uterine contractions.

17. GENERAL MANAGEMNET OF
HYPOTONIC INERTIA
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.

18. CONTD.
Amniotomy:Providing that;
vaginal delivery is amenable,
the cervix is more than 3 cm dilatation and
the presenting part occupying well the lower uterine
segment.
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.

19. CONTD.
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.
Operative delivery:
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.
Caesarean section is indicated in:
failure of the previous methods.
contraindications to oxytocin infusion including disproportion.
foetal distress before full cervical dilatation.

20. HYPERTONIC UTERINE INERTIA
(UNCOORDINATED UTERINE
ACTION)
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.

21. 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.

22. 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.

23. THE END…