abnormal uterine actioN.pptx MSC. NURSING

abnormal uterine actioN.pptx MSC. NURSING

• 1.
  ABNORMAL UTERINE ACTION
• 2.
  • Normal labouris characterized by coordinated uterine contractions associated with progressive dilation of cervix and descent of fetal head. • Associated with cervical dilatation ≥ 1 cm /hr in Nulliparous woman • Likely to end in successful vaginal delievery.
• 3.
  Normal Uterine Contractions:- ❖Polarityof Uterus ➢ When the upper segment contracts, the lower segment relaxes ❖Pacemakers ➢ There are two pacemakers ➢ situated at each cornua of the uterus ➢ Generates uterine contractions in a coordinated fashion
• 4.
  Properties of NormalUterine Contractions:- ➢ The intensity of contraction diminishes from top to bottom of the uterus ➢ The contraction waves starts of the pacemaker and propogates towards the lower uterine segment ➢ The duration of contraction diminishes progressively as the wave moves away from the pacemaker ❖In dysfunctional labor, new pacemaker may come up anywhere in
• 5.
  DEFINITION:- of the normal “Anydeviation pattern contractions affecting of uterine the course of designated as disordered labour is or abnormal uterine action.”
• 6.
  ➢Effective Uterine Contractionsstrats at the cornua and gradually sweeps downwards over the uterus. ➢In Primary Dysfunctional Labor, Uterine Activity instead of being governed by a single dominant pacemaker, is shifted to less efficient contractions due to emergence of other pacemaker foci. ➢ Oxytocin therapy may be effective in restoring the global and effective uterine contractions.
• 7.
  < ➢Primary Dysfunctional Labor,is defined when the cervix dilates 1cm/hr following a normal latent phase of labor. ➢ Commonest abnormality ➢ Mostly corrected by, ✓Amniotomy or/and ✓Oxytocin Augmentation
• 8.
  ➢ Secondary Arrest,is defined when the cervical dilatation stops or slows after the active phase of labour has started normally.
• 9.
  ❑ Uterine activityis measures by noting... ▪ Basal tone ▪ Active (peak) pressure ▪ Frequency
• 10.
  ❑Assesment is usuallydone by... ▪ Clinical Palpation (inaccurate) ▪ Tocodynamometer with external transducer ▪ Using intrauterine pressure catheter (accurate) ❖Normal baseline tonus is between 5 and 20 mm of Hg and peak pressure is around 60 mm of Hg
• 11.
  INCEDENCE:- ▪ 25 %in Nulliparous Women ▪ 10 % in Multiparous Women
• 12.
  ETIOLOGY:- ▪ Unknown ▪ Prevalentin first birth specially with elderly women ▪ Prolonged Pregnancy ▪ Overdistension of uterus ( twins & fibroids ▪ Emotional factor ( anxiety, stress) ▪ Constitutional labor ( obesity) ▪ Contracted pelvis & malpresentation ▪ Injudicious administration of sedatives, analgesics & oxytocics ▪ Premature attempt of VD &
• 13.
  TYPES:-
• 15.
  Abnormal Polarity Ineffective UterineContraction
• 17.
  UTERINE INERTIA / HYPOTONICUTERINE CONTRACTION
• 18.
  • Common butcomparatively less serious • May complecate at any stage of labour • May be present from beginning of labour or develop subsequently after a variable period of effective contraction
• 19.
  Uterine Contractions... ❑The intensityis diminished ❑ Duration is shortened ❑ Good relaxation inbetween contractions ❑ Intervals are increased ❖General pattern of uterine contractions of labor is maintained but intrauterine pressure during contraction is below 25 mm of Hg.
• 20.
  Diagnosis... ❑ Patient feelsless pain during contraction ❑Hand placed over the uterus during uterine contraction reveals less hardening of the uterus ❑Uterine wall is easily indentable at the acme of a pain ❑ Uterus remains relaxed after contraction ❑ Fetal parts are well palpable ❑ Fetal heart rate remains normal
• 21.
  Internal Examination reveals... ❑Poor dilation of the cervix ❑Associated presence of contracted pelvis, malposition, deflexed head or malpresentation ❑ Membranes usually remains intact Effects on mother and fetus... ❑ Maternal Exhaustion ❑Fetal Distress , are unusual and appear late.
• 22.
  Management... ❑Case is reassessedto exclude CPD or Malpresentation Place of Cesarean Section... ❑ Presence of Contracted Pelvis ❑ Malpresentation ❑ Evidences of fetal or maternal distress
• 23.
  Vaginal Delivery... ❖Genral Measures:- ➢Keep up the morale of patient ➢ Manage maternal stress and emotion ➢ Avoid supine position ➢ Empty the bladder ( catheterization) ➢Maintain hydration by infusion of Ringer's solution ➢ Adequate pain relief
• 24.
  Vaginal Delivery... ❖ ActiveMeasures:- ➢Acceleration of uterine contraction by low rupture of the membrane followed by oxytocin drip ➢ The drip rate is gradually increased until effective contractions are set up ➢ The drip is to be continued till one hour after delivery
• 25.
  INCOORDINATE UTERINE CONTRACTION
• 26.
  • Usually appearsin active stage of labour. • The hypertonic state of the uterus arises from any of the conditions such as spastic lower uterine segment, colicky uterus, asymmentrical uterine contraction, contriction ring or generalized tonic contraction of the uterus and all thes states are collectively called incoordinate uterine contraction.
• 27.
  • Increased frequencyand or duration of uterine contractions cause rise in baseline tone and thereby diminish circulation in the placental intervillous space. • New pacemakers appear all over the uterus. • The myometrium contracts spasmodically and irregularly.
• 28.
  • These contractionsforce neither dilates the cervix nor pushes the fetus down. • Uterine tonus is elevated. • Pain is present before, during and after contraction. • This results in fetal hypoxia in labour. • Placental abruption is often associated with high baseline tone ( >25 mm Hg ).
• 29.
  • On cardiotocography(CTG) the FHR shows reduced variability and late decelerations. • Uterine hyperstimulation due to oxytocics are often associated with fetal tachycardia due to fetal stress. • Constriction ring, generalized tonic uterine contraction and cervical dystocia have got their own separate clinical entity and as such will be discussed separately.
• 30.
  SPASTIC LOWER SEGMENT UterineContractions... ❑Fundal dominance is lacking and often there is reversed polarity ❑ The pacemakers do not work in rhythm ❑The lower segment contractions are stronger ❑Inadequate relaxation in between contractions ❑Basal tone is raised above the critical level of 20 mm Hg
• 31.
  Diagnosis... ❑The patient isin agony with unbearable pain reffered to the back ❑There are evidences of dehydration and ketoacidosis ❑Bladder is frequently distended and often there is retention of urine, distension of stomach and bowels are visible ❑There are premature attemps of bear down
• 32.
  ❑ Abdominal palpationreveals: a) Uterus is tender and gentle manipulation excites hardening of the uterus with pain b)Palpation of the fetal parts is difficult ❑ Internal examination may reveal : a)Cervix with thick, edematous hangs loosely like a curtain, not well appliedto the presenting part b) Inappropriate dilation of the cervix c) Absence of mebranes d)Meconium stained liquor amnii may ne there
• 33.
  Effect on thefetus... ❑Fetal distress appears early due to placental insuffiency caused by inadequate relaxation of the uterus
• 34.
  Management... ❑There is noplace of oxytocin augmentation with this abnormality ❑Cesarean section is done in majority of cases ❑Prior correction of dehydration and ketoacidosis must be achieved by rapid infusion of Ringer's solution
• 35.
  CONSTRICTION RING (Syn. Contraction ring/Schroeder'sring)
• 36.
  ➢ It isone one form of incoordinate uterine action where there is localized myomatrial contraction forming a ring of circular muscle fibres of the uterus ➢ It is usually situated at the junction of the upper and lower segment around a constricted part of the fetus usually around the neck in cephalic presentation ➢ It may appear in all the stages of labour ➢ It is usually reversible and complete
• 37.
  Causes... ❑Injudicious administration ofoxytocics ❑Premature rupture of the membranes ❑Premature attempt at instrumental delivery
• 38.
  Diagnosis... ❑Difficult ❑Revealed during cesareansection in the first stage of labour, during forcep application in second stageand during manual removal in the third stage ❑The ring is not felt per abdomen ❑Maternal condition is not much affected but the fetus is in jeopardy because of the hypertonic state ❑Uterus never ruptures
• 39.
  Treatment... ❑Delivery is usuallydone by cesarean section ❑The ring usually passes off ny deepening the plane of anesthesia, otherwise the ring may to be cut vertically to deliver the baby ❑The difficlties faced during forceps delivery or during normal removal of placenta can be overcome by using deep anesthesia that relaxes the constriction ring
• 40.
  CERVICAL DYSTOCIA
• 41.
  ➢ Progressive cervicaldilatation needs an effective stretching force by the preseting force by presenting part ➢ Failure of cervical dilatation may be due to : a) Insufficient uterine contractions b)Malpresentation, Malposition (abnormal relationship between the cervix and the presenting part) ➢ Cervical dytocia may be primary or secondary
• 42.
  Primary cervical dystocia... ❑Commonlyobserved during the... i. First birth where the external os fails to dilate ii. Rigid cervix iii. Insufficient uterine contractions iv. others
• 43.
  Treatment... ❑In presence ofassociated complications (malpresentation, malposition) cesarean section is preferred ❑If the head is sufficiently low down with only thin rim of cervix left behind, the rim may be pushed up manually during contraction or retraction is given by ventouse ❑In others where the cervix is very much thinned out but only half dilated, Duhrssen's incision at 2 and 10 O'clock positions followed by forceps or ventouse extraction is quite safe and effective
• 44.
  Secondary cervical dystocia... ❑Thistype of cervical dystocia results usually due to excess scarring or rigidity of the cervix from the effect of previous operation or disease ❑Others are: i. Post delivery ii. Postoperative scarring iii. Cervical cancer
• 45.
  GENERALIZED TONIC CONTRACTION (Syn. UterinrTetany)
• 46.
  ➢ In thiscondition, pronounced retraction occurs involving whole of the uterus up to the level of internal os ➢ Thus, there is no physiological differentiation of the active upper segment and the passive lower segment of the uterus ➢ The whole uterus undergoes a sort of tonic muscular spasm holding the fetus inside (active retention of the fetus) ➢ Usually there is no risk of rupture uterus
• 47.
  Causes... ❑Cephalopelvic disproportion ❑Obstruction ❑Injudicious useof oxytocics
• 48.
  Clinical features... ❑The patientis in prolonged labour, having severe and continuous pain ❑Abdominal examination reveals the uterus to be somewhat smaller in size, tense and tender ❑Fetal parts are neither well defined, nor is the fetal heart sound audible ❑Vaginal examination reveals jammed head with big caput, dry and adematous vagina
• 49.
  Treatment... ❑Correction of dehydrationand ketoacidosis by rapid infusion of Ringer's solution ❑Antibiotic ❑Adequate pain relief ❑Hypercontractility (tachysystole) induced by oxytocics can be managed by tocolytics. Oxytocin infusion should be stopped ❑esarean delivery is done in majority of the cases specially when obstruction is suspected
• 50.
  PRECIPITATE LABOUR
• 51.
  “ A labouris called precipitate when the combined duration of the first and second stage is less than two hours” ➢ It is common in multiparae and be repetitive ➢ Rapid expulsion is due to the combined effect of hyperactive uterine contractions associated with diminished soft tissue resistance ➢ Labour is short as rate of cervical dilatatiion is 5 cm/hour or more in nulliparous women
• 52.
  Maternal risk... 1. Extensivelaceration of the cervix, vagina and perineum 2. PPH due to uterine hypotonia that develops subsequent to unusual vigorous contractions 3. Inversion 4. Uterine rupture 5. Infection 6. Amniotic fluid ambolism
• 53.
  Fetal risk... 1. Intracranialstress and hemorrhage because of rapid expulsion without time for moulding of the head 2. The baby may sustain serious injuries if delivery occurs in standing position, bleeding from the torn cord and direct hit on the skull are real hazards
• 54.
  Treatment... ▪ The patienthaving previous hystory of precipitate labour should be hospitalized prior to labour ▪ During labour, the uterine contraction may be suppressed by administering ether or magnesium sulfate during contractions ▪ Delivery of the head should be controlled ▪ Episiotomy should be done liberally ▪ Elective induction of labour by low rupture of membranes and conduction of controlled delivery is helpful
• 55.
  TONIC UTERINE CONTRACTION AND RETRACTION (Syn.Bandal's ring / pathological retraction ring)
• 56.
  This type ofuterine contraction is predominantly due to obstructed labour Pathological anatomy of uterus... ▪There is gradual increase in intensity, duration and frequency of uterine contraction ▪The relaxation phase becomes less and less, ultimately a state of tonic contraction develops ▪ Retraction, however, continues
• 57.
  ▪ The lowersegment elongates and becomes progressively thinner to accomodate the fetus driven from the upper segment “ A circular groove encicling the uterus is formed between the active upper segment and the distended lower segment, called pathological retraction ring (Bandal's ring)” ▪ Due to pronounced retraction, there is fetal jeopardy or even death
• 58.
  ▪ In primigravidae,further retraction ceases in response to obstruction and labor comes to a stand still a state of uterine exhaustion ▪ Contractions may recommence after a brief of rest with renewed vigour ▪ But in multipare, retraction continues with progressive circumferential dilatation and thinning of the lower segment
• 59.
  ▪ There isprogressive rise of the Bandal's ring, moving nearer and nearer to the umbilicus and ultimately, the lower segement ruptures
• 60.
  Clinical features... 1. Patientis in agony from continuous pain and discomfort and becomes restlessness 2. Features of exhaustion and ketoacidosis are evident 3. Abdominal palpation reveals: •Upper segment is harder and tender •Lower segment is distended and tender
• 61.
  Management... Prevention:- –Partographic management oflabour, early diagnosis of malpresentation, disproportion and delivery by cesarean section can prevent this condition completely
• 62.
  Treatment... ▪ Rupture ofthe uterus is to be excluded ▪ Internal version is contraindicated ▪ Correction of dehydration and ketoacidosis by infusion of Ringer's solution ▪ Adequate pain relief ▪ Parenteral antibiotic ( Cefriaxone 1 g IV ) ▪ Cesarean delivery is done in majority of the cases ▪ Rupture of the uterus must be excluded before attempting destructive operation