Abnormal Uterine Action

Normal uterine action

Uterus divided into UUS&LUS
Ccc of uterine contractions:
1-contraction &retraction
2-effective
3-coordinated
4-involuntary
5- rhytmic&progressive
 Classification :
(I) Over - active uterine action:
1. Precipitate labor: in absence of obstruction.
2. Excessive contraction and retraction: in
presence of obstruction(obstructed labor).
(II) Inefficient uterine action:
1. Hypotonic inertia.
2- Cervical dystocia
(III) in coordinate uterine action
a- Colicky uterus. b- Hyperactive lower uterine
segment.
C- Constriction (contraction) ring.
D- tonically contracted uterus
 1-PRECIPITATE LABOUR
Definition:
A labor lasting less than 3 hours
Aetiology:
It is more common in multiparas when
there are;
1- strong uterine contractions,
2- small sized baby,
3- roomy pelvis,
4- minimal soft tissue resistance
 Complications:

(A) Maternal:
(1) Lacerations of the cervix, vagina
and perineum.
(2) Shock.
(3) Inversion of the uterus.
(4) Postpartum haemorrhage :
a- no time for retraction,
b- lacerations.
 (B) Fetal:
1- Intracranial hemorrhage due to
sudden compression and decompression
of the head.
2- Fetal asphyxia due to :
- strong frequent uterine contractions
reducing placental perfusion,
3- Avulsion of the umbilical cord.
4- Fetal injury due to falling down
 Management:

(I) Before delivery :

Patient who had previous precipitate labor should be
hospitalized before expected date of delivery as she is
more prone to repeated precipitate labor.
(II) During delivery:
- Inhalation anesthesia: as nitrous oxide and oxygen is
given to slow the course of labor.
-- Episiotomy: to avoid perineal lacerations and
intracranial hemorrhage
(III) After delivery:
Examine the mother and fetus for injuries
 2-obstructed labor
Pathological Retraction Ring
(Bandls ring):
- It is the rising up retraction ring
during obstructed labor 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.
 - The Bandls ring is seen and felt
abdominally as a transverse groove
that may rise to or above the umbilicus.
Etiology:
1-fetal: malpresentation, malposition,
macrosomia,
2-maternal:cephalo pelvic
disproportionate , bony or soft tissue
obstruction.
 Clinical picture: is that of obstructed
labor with impending rupture uterus .
General examination :
shows signs of maternal distress as:
- exhaustion,
- high temperature (38oC),
- tachycardia
- signs of dehydration
 The uterus :
- is hard and tender,
- frequent strong uterine contractions with no relaxation in
between (tetanic contractions).
- rising retraction ring is seen and felt as an oblique groove
across the abdomen.
The fetus :
- fetal parts cannot be felt easily.
- FHS are absent or show fetal distress due to interference
with the utero-placental blood flow.
Vaginal examination:
1- Vulva: is oedematous.
2- Vagina : is dry and hot.
3- Cervix: is fully or partially dilated, edematous
4- The membranes : are ruptured.
5- The presenting part: is high and not engaged or impacted in
the pelvis. If it is the head it shows excessive moulding and
large caput.
 Complications:
(I) Maternal :
1- Maternal distress .
2- Rupture uterus.
3- Necrotic vesico -vaginal fistula.
4- Infections as chorioamnionitis and puerperal
sepsis.
5- Postpartum haemorrhage due to injuries or uterine
atony.
(II) Foetal:
1- Asphyxia.
2- Intracranial hemorrhage from excessive moulding.
3- Birth injuries.
4- Infections.
 Management:
(A) Preventive measures:
Careful observation , proper assessment,
early detection and management of the
causes of obstruction.
(B) Curative measures:
Caesarean section is the safest method even
if the baby is dead as labor must be
immediately terminated and any
manipulations may lead to rupture uterus..
 CONSTRICTION (CONTRACTION)
RING
Definition:
It is a persistent localized 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 labor
 Aetiology: unknown but the
predisposing factors are:
1. Malpresentations and malpositions.
2. Clumsy intrauterine manipulations
under light anaesthesia.
3. Improper use of oxytocins e.g.
- use of oxytocin in hypertonic inertia.
- IM injection of oxytocin
 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
 Complications:
1. Prolonged 1st stage: if the ring
occurs at the level of the internal os.
2. 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).
 Management:
1. Exclude malpresentations,
malposition and disproportion.
2. In the 1st stage: Pethidine may be
of benefit.
In the 2nd stage: Deep general
anesthesia and amyl nitrite inhalation
are given to relax the constriction ring:
 a- If the ring is relaxed, the fetus is
delivered immediately by forceps.
b- If the ring does not relax, caesarean
section is carried out with lower segment
vertical
incision to divide the ring.
4. In the 3rd stage: Deep general
anesthesia and amyl nitrite inhalation are
given followed by manual removal of the
placenta
 3-HYPOTONIC UTERINE
INERTIA
Definition:
Prolonged labor due to uterine contractions are
infrequent, weak and of short duration
Aetiology:
(A) General factors:
1. Primigravida particularly elderly.
2. Anaemia and athenia.
3. Nervous and emotional as anxiety and fear.
4. Improper use of analgesics.
.
 (B) Local factors:
1. Over distension of the uterus.
2. Developmental anomalies of the uterus e.g.
hypoplasia.
3. Myomas of the uterus interfering mechanically with
contractions.
4.Malpresentations, malpositions and cephalopelvic
disproportion.
The presenting part is not fitting in the lower uterine
segment leading to absence of reflex uterine
contractions.
5. Full bladder and rectum
 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
 Clinical Picture:

1. Labour is prolonged.
2. Uterine contractions are infrequent,
weak and of short duration.
3. Slow cervical dilatation.
4. Membranes are usually intact.
5. More susceptibility for retained
placenta and postpartum hemorrhage
due to persistent inertia.
6. Tocography: shows infrequent waves
of contractions with low amplitude.
 Management:
Amniotomy: Providing that;
a. vaginal delivery is amenable,
b. the cervix is more than 3 cm dilatation and
c. the presenting part occupying well the
lower uterine segment.
Artificial rupture of membranes augments the
uterine contractions by:
1. release of prostaglandins.
2-reflex stimulation of uterine contractions
when the presenting part is brought closer to
the lower uterine segment.
 Oxytocin:
Operative delivery:
1- Vaginal delivery: by forceps, vacuum
Caesarean section is indicated in :
i- failure of the previous methods.
ii- contraindications to oxytocin infusion
including disproportion.
iii- fetal distress before full cervical
dilatation
 ( Incoordinate Uterine Action )
Types:
a. Colicky uterus: incoordination of
the different parts of the uterus in
contractions.
b. Hyperactive lower uterine
segment: so the dominance of the
upper segment is lost.
 Clinical Picture:

The condition is more common in primigravidae

and characterized by:
1. Labour is prolonged.
2.Uterine contractions are irregular and more
painful. The pain is felt before and throughout
the contractions.
3.High resting intrauterine pressure in between
uterine contractions detected by tocography
normal value is 5-10 mmHg).
4. Slow cervical dilatation .
5. Premature rupture of membranes.
 Management:
Analgesic and antispasmodic as
pethidine.
- Epidural analgesia may be of good
benefit.
Caesarean section is indicated in :
i- Failure of the previous methods.
ii- Disproportion.
iii- Fetal distress before full cervical
dilatation
 CERVICAL DYSTOCIA
Definition:
Presence of cervical cause leading to
inadequate cervical dilatation within
a reasonable time in spite of
adequate regular uterine
contractions.
 (I) Organic (secondary) sequel to previous
amputation, cone biopsy ,extensive cauterization or
obstetric trauma.
2. Organic lesions as cervical myoma or carcinoma.
(II) 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
Rupture uterus.
Postpartum haemorrhage :
particularly if cervical laceration
extends upwards tearing the main
uterine vessels.
 Management:
(I) Organic dystocia:
Caesarean section is the management of
choice.
(II) Functional dystocia:
1. Pethidine and antispasmodics: may be
effective.
2. Caesarean section : if
- medical treatment fails or
- foetal distress developed.