29 - Abnormal Uterine Action
29 - Abnormal Uterine Action
Introduction
Abnormal uterine action is one of the factors causing dystocia (difficult labor) in
which uterine forces are insufficiently strong or inappropriately coordinated to
.(efface and dilate the cervix (uterine dysfunction
:Precipitate labor .1
:Definition
:Fetal
Intracranial hemorrhage: due to rapid compression and *
decompression of the fetal head during delivery
Fetal injuries *
Avulsion of the cord *
Neonatal sepsis *
:Management
:Prophylaxis
A patient with past history of precipitate labor should be admitted to the
.hospital at the first perception of labor pains
If the patient is seen after delivery: exploration of the birth canal for any
.injury and manage accordingly
:General factors .1
.Primigravida especially elderly
Anemia, chronic illness. (Antepartum hemorrhage leads to anemia
.that predisposes to inertia
.Hypertensive states with pregnancy
.Nervous, anxious patients
.Improper use of analgesics
:Local factors .2
:Primary inertia
.Poor uterine contractions from the start of labor
:Secondary inertia
Uterine contractions become weaker after a period of
good uterine contractions due to uterine exhaustion in cases of
cephalopelvic disproportion (act as a protective mechanism
.(against rupture uterus
:Clinical picture
The mother & the fetus are usually not seriously affected especially
.when the membranes remain intact, apart from prolonged labor
If the inertia persists after delivery of the fetus, there is liability for
retention of the placenta (prolonged 3rd stage of labor) and atonic
.postpartum hemorrhage
:Complications
Mostly that of prolonged labor
:A. Maternal
:In the 1st stage
.Nervousness, anxiety, exhaustion and starvation ketoacidosis
:In the 2nd stage
prolonged 2nd stage, increase liability for instrumental delivery and
.cesarean section
:In the 3rd stage
retention of the placenta and postpartum hemorrhage
Subinvolution of the uterus
.Risks of abuse of uterine stimulants
:B. Fetal
Usually no effect apart from fetal infection from prolonged
.premature rupture of the membranes
:Treatment of Hypotonic inertia
:General measures
Proper diagnosis that this patient is in active labor (and not in the prodroma of
labor) by proper identification of true labor pains (rhythmic, increase in
strength, frequency and duration and accompanied by bulge of the bag of
.forewater and cervical dilatation
It occurs at any part of the uterus but usually at the junction of the upper
.and lower segments
:Etiology
:Not known but the following may be associated
.Malpresentations and malposition
Rough or repeated intrauterine manipulations (especially under light
(anaesthesia
Improper use of uterine stimulants e.g. the use of oxytocin infusion in
.hypertonic inertia
:Diagnosis
Contraction ring is frequently preceded by colicky uterus and the
.patient is usually a primigravida
Contraction ring is only diagnosed by per vaginal examination
.i.e by feeling it with a hand introduced inside the uterus
Contraction ring causes prolonged 2nd stage (as it usually lies
.(opposite the neck of the fetus
It is suspected if there is prolonged 2nd stage without any
.obvious cause
In the 3rd stage it may cause hour glass contraction of the
.uterus with retained placenta and postpartum hemorrhage
:Treatment
.Exclude disproportion, malpresentations and malposition
In the 2nd stage, give deep general anesthesia and amyl nitrite inhalation
.then deliver the fetus immediately by forceps
If the forceps fails or if the ring is below the presenting part, cesarean
,section is needed
if the ring persists in spite of general aneasthesia, a vertical incision of the
.lower segment is needed to cut the ring
In the 3rd stage, give deep general anesthesia and amyl nitrite inhalation
then remove the placenta manually in cases of hour glass contraction
.of the uterus
CERVICAL DYSTOCIA
:Definition
This is a difficulty in labor due to failure of cervical
dilatation within a reasonable time in spite of the presence of
strong, regular uterine contractions, i.e. no abnormalities in
.the uterine expulsive power
:Types
:)Organic rigidity )2ry .1
Stenosis of the cervix by fibrosis following previous trauma or
iatrogenic surgical trauma e.g.: cervical amputation,
.overcauterization, conization, repeated cerclage
Organic obstruction of the cervix by cervical fibroid or
.carcinoma
:)Functional rigidity )1ry .2
It is non-dilatation of the external os of the cervix in absence of
.any organic lesion
The process affects the external os only, so the cervix may be
.well effaced and the head is well applied to it
:Clinically
.The external os is felt as a hard rim
:Complications
Besides the complications of prolonged labor and obstructed labor
(if labor is neglected), very rarely annular detachment of the cervix
.may result
:Treatment
In cases of stenosis of the cervix by fibrosis, cesarean section is
the safest method of delivery if the cervix fails to dilate after a
.reasonable time
In cases of organic obstruction of the cervix, cesarean section is
.the method of delivery
:In cases of functional rigidity
.Giving time this cervix may dilate with good uterine contractions
Analgesics as pethidine, and antispasmodics as hyoscine may be
.given
If fetal distress occurs with the cervix less than half dilated or
.the head is not engaged cesarean section is done
If fetal distress occurs with the cervix taken up and more than
half dilated with the head deeply engaged: Cesarean section is
.the safe preferable solution