Abnormal uterine action

Complicates 2-3% of labours at term In normal labour cervical dilatation goes through 3 stages: Latent phase of several hours ,during which cervix dilates only slightly. Active phase of rapid progressive dilatation. deceleration phase of slow dilatation just prior to onset of second stage.

Types: Hypotonic; with well coordinated waves. Hypertonic; with uncoordinated waves.

Etiology: Pelvic disproportion. Excessive analgesia. malpresentations. primigravida. Dystocia dystrophia syndrome:hypertonic contractions more common in heavily built obese patients. postmaturity.

Etiology/cont.:
full bladder and rectum. intrauterine manipulations. bicornuate uterus. uterine exhaustion: with prolonged labour adherent membranes. premature rupture of membranes.

Classification: A.Coordinate: Clinical presentation 1. Hypoactivity Hypotonic inertia 2.Hyperactivity (a)exaggerated retraction with obstruction (b)Precipitate labour without obstruction

B.Incoordinate: 1.Hypoactivity: 2.Hyperactivity

false labour (a)secondary inertia (b)hypertonic lower uterine segment.

c) contraction ring (d)asymmetric uterus

(e)colicky uterus
C.Achalasia of the cervix

Primary uterine inertia:

Coordinated weak,short and infrequent contractions More frequent in primigravida. Clinical picture: Little or no pains dilatation and effacement are very slow. no maternal or foetal distress No moulding or caput formation . Persistance in 3rd stage leads to post partum haemorrhage. Management: A.Prohylactic: Assurance Education of physiology of labour. Regular antenatal excercises.

B. Active: False labour pains should be ruled out. Disproportion should be excluded. Emptying bladder and rectum. Dextrose drip infusion. Antibiotics if membranes are ruptured. Analgesics .eg. pethidine im Uterine stimulants:oxytocin infusion. Stripping the membranes around the internal os and amniotomy. If foetal distress occurs or delivery is prolonged above 48 hours: forceps or vacuum if fully dilated,caeserian section if incompletely dilated.

Pathological retraction (Bandles ring):

Caused by mechanical obstruction to delivery. More in multipara. General examination: Ketoacidemia:patient is irritable,flushed,exhausted. Tachycardia,fever,sweating,rapid respiration and vomiting Abdominal examination: Strong uterine contraction in rapid succession. Round ligaments are tense and easily seen(Frommels sign) Retraction ring is seen and felt at or above the umbilicus. Foetal heart sounds are irregular, slow or absent.

Vaginal examination: Vula and vagina are dry, hot and oedematous. cervix thick and oedematous not fitting on presenting part. Big caput succedaneum and excess moulding. Cause of obstruction maybe detected. Treatment: Early recognition and treatment of obstructed labour. Sedation:morhia or pethidine. delivery should be effected immediately with the safest method. Following delivery ,intrauterine exploration should be done to exclude rupture uterus.

Precipitate labour: Usually in multipara with strong uterine contractions, roomy pelvis and small foetus. Compilcations: A.Maternal: Lacerations. Haematoma of the vulva. Rupture of symphysis pubis. Inversion of the uterus. Post partum haemorrhage. Acute mania. B.Foetal: Rupture of umbilical cord Fracture of the skull. Intracrnial haemorrhage. Asphyxsia neonatorum. Management: Patients with history of ppt labour should be hospital;ized before term.Once labour starts they should be instructed not to bear down Induction of labour at appropriate time.

Secondary inertia:

Apparent uterine inactivity following a long period of strong contractions fighting against obstruction. More in primigravida. Clinical picture: Mother is exhausted,anxious. Foetus is distressed. Vaginal examination shows obstructed labour. Management: Early detection and management of obstructed labourt. Sedation. Termination of labour:forceps,vacuum or caeserian section.

Hypertonic lower uterine segment:

Weak action of upper segment,strong contractions in lower segment. Constant backache with contractions. Cervix doesnot dilate progressively.

Contraction ring:

Localized annular contraction and hypertonus in the myometrium. Etiology:Irritability and nervousness. Oxytocics . Premature rupture of membranes. Abnormal foetal presentations. Inappropriate intrauterine manipulations. Clinical pictuere: Unexplained arrested progress. Constant pain at the site of the ring. Nondescent of the presenting parts during contractions. Intrauterineexporation may reveal it. Management: A.Prophylactic: assurance Colicky ineffective contraction should be treated by sedation B.Active: Sedatives Caeserian delivery;lower segment incision.

Asymmetrical uterus: Disturbance in synchronization between rthe two pace makers of the uterus. Clinical picture: Sluggish unilateral pains. Slow dilatation of the cervbix. Obliquity of the uterus during contractions. Delay is usually temporary followed by normal coordination between both sides.

Colicky uterus:

Normal uterine polarity is absent. More in nervous primigravida. Strong purposeless colicky activity of the uterus. Etiology: Pychic derangement,fear. abuse of oxytocics. abnormal presentations. Clinical picture: Intense constant pains. Early maternal distress. Early foetal distress Rectal spasm and bowel distension. Thick undilated cervix. Minimal moulding or caput. Management: Assurance and sedation. iv fluids. Caeserian delivery if maternal of foetal distress.

Achalasia of the cervix:

The polarity of the cervix is normal but cervix fails to dilate due to inherent defect in mechanism of dilatation. Etiology Previous cervical obstetric injury. Cervical cauterization or amputation. Carcinoma of cervix, Clinical picture: margin of external os feels tense and firm Cervical dilatation very slow and progressive. Labour unduly prolonged,maternal exhaustion. foetal asphyxsia and intrauterine infection. In neglected cases; annular detachment of cervix,cervical tears that extend to lower uterine segment. Management: Asuurance,analgesia ,sedation Antibiotics if membranes are ruptured. operative delivery by caeserian section.

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