Abnormal Uterine Action

Defnition

Any deviation of the normal pattern

of uterine contractions afecting the
course of labour is designated as
disordered or abnormal uterine
action.
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Classifcation
a. Over-efcient uterine action
!recipitate labour" in absence of obstruction
#$cessive contraction and retraction" in
presence of obstruction
b.%nefcient uterine action
&ypotonic inertia
&ypertonic inertia
' Colic(y uterus
' &yperactive lower uterine segment
Constriction )contraction* ring
c.Cervical dystocia
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1efnition

.he uterine contractions are

infre2uent3 wea( and of short
duration.
Aetiology

Un(nown but the following factors may be

incriminated"

4eneral factors"
!rimigravida particularly elderly.
Anaemia and asthenia.
,ervous and emotional as an$iety and
fear.
&ormonal due to defcient prostaglandins
or o$ytocin as in induced labour.
%mproper use of analgesics.
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Aetiology
5ocal factors
Overdistension of the uterus.
1evelopmental anomalies of the uterus e.g.
hypoplasia.
6yomas of the uterus interfering mechanically
with contractions.
6alpresentations3 malpositions and
cephalopelvic disproportion. .he presenting part
is not ftting in the lower uterine segment
leading to absence of re7e$ uterine
contractions.
-ull bladder and rectum.
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.ypes

!rimary inertia" wea( uterine

contractions from the start.

8econdary inertia" inertia developed

after a period of good uterine
contractions when it failed to
overcome an obstruction so the
uterus is e$hausted.
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Clinical !icture
' 5abour is prolonged.
' Uterine contractions are infre2uent3
wea( and of short duration.
' 8low cervical dilatation.
' 6embranes are usually intact.
'.
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Cont999..
.he foetus and mother are usually not
afected apart from maternal an$iety
due to prolonged labour.
' 6ore susceptibility for retained
placenta and postpartum
haemorrhage due to persistent
inertia.
' .ocography" shows infre2uent waves
of contractionswith low amplitude
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6anagement

4eneral measures
#$amination to detect
disproportion3malpresentation or
malposition and manage according to
the case.
!roper management of the frst stage
!rophylactic antibiotics in prolonged
labourparticularly if the membranes
are ruptured.
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6anagement

Amniotomy"
a.!roviding that:
vaginal delivery is amenable3
the cervi$ is more than ; cm
dilatation and
the presenting part occupying well
the lower uterine segment
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6anagement

Amniotomy"
b. Artifcial rupture of membranes
augments the uterine contractions
by"
release of prostaglandins.
re7e$ stimulation of uterine
contractions when the presenting
part is brought closer to the lower
uterine segment.
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6anagement

O$ytocin" !roviding that there is no

contraindication for it3 < units of
o$ytocin )syntocinon* in <== c.c
glucose <> is given by %? infusion
starting with += drops per minute
and increasing gradually to get a
uterine contraction rate of ; per +=
minutes.
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6anagement

Operative delivery
a.?aginal delivery" by forceps3 vacuum
or breech e$traction according to the
presenting part and its level
providing that3
cervi$ is fully dilated.
vaginal delivery is amenable.
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Contttt999
b.Caesarean section is indicated in"
failure of the previous methods.
contraindications to o$ytocin
infusion including disproportion.
foetal distress before full cervical
dilatation.
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)Uncoordinated Uterine Action*
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.ypes
' Colic(y uterus" incoordination of the
diferent parts of the uterus in
contractions.
' &yperactive lower uterine segment"
so the dominance of the upper
segment is lost.
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Clinical !icture
.he condition is more common
in primigravidae and
characterised by"
' 5abour is prolonged.
' Uterine contractions are irregular
and more painful. .he pain is felt
before and throughout the
contractions with mar(ed low
bac(ache often in occipito-
posterior position.
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Cont99.
' &igh resting intrauterine pressure in
between uterine contractions
detected by tocography )normal
value is <-+= mm&g*.
' 8low cervical dilatation .
'!remature rupture of membranes.
' -oetal and maternal distress.
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.reatment of &ypertonic Uterine
Contractions

!rovide with CO6-O/. 6#A8U/#8

@arm shower
6outh Care
%magery
6usic
Aac( rub3 therapeutic touch

6ild sedation

Aed rest or position changes

&ydration

.ocolytics to reduce high uterine tone

6anagement
4eneral measures" as hypotonic inertia.
6edical measures"

Analgesic and antispasmodic as pethidine.

#pidural analgesia may be of good beneft.

Caesarean section is indicated in"

-ailure of the previous methods.

1isproportion.

-oetal distress before full cervical dilatation.

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1efnition
' %t is a persistent localised annular
spasm of the circular uterine muscles.
' %t occurs at any part of the uterus but
usually at Bunction of the upper and
lower uterine segments.
' %t can occur at the +st3 Cnd or ; rd
stage of labour.
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Aetiology
Un(nown but the predisposing factors are"
' 6alpresentations and malpositions.
' Clumsy intrauterine manipulations
under light anaesthesia.
' %mproper use of o$ytocin e.g.
use of o$ytocin in hypertonic
inertia.
%6 inBection of o$ytocin.
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1iagnosis
' .he condition is more common in
primigravidae and fre2uently
preceded by colic(y uterus.
' .he e$act diagnosis is achieved only
by feeling the ring with a hand
introduced into the uterine cavity.
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Complications

!rolonged +st stage" if the ring

occurs at the level of the internal os.

!rolonged Cnd stage" if the ring

occurs around the foetal nec(.

/etained placenta and postpartum

haemorrhage" if the ring occurs in
the ;rd stage )hour- glass
contraction*.
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1efnition
A labour lasting less than ; hours.
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%t is more common in multiparas

when there are"
' strong uterine contractions3
' small siDed baby3
' roomy pelvis3
' minimal soft tissue resistance.
Aetiology
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Complications

6aternal"
' 5acerations of the cervi$3 vagina and perineum.
'8hoc(.
'%nversion of the uterus.
'!ostpartum haemorrhage"
no time for retraction3
lacerations.
' 8epsis due to"
lacerations3
inappropriate surroundings.
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Complications
-oetal"
%ntracranial haemorrhage due to sudden
compression and decompression of the
head.
-oetal asphy$ia due to"
'strong fre2uent uterine contractions
reducing placental perfusion3
'lac( of immediate resuscitation.
Avulsion of the umbilical cord.
-oetal inBury due to falling down.
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6anagement

Aefore delivery"
!atient who had previous precipitate
labour should be hospitaliDed before
e$pected date of delivery as she is
more prone to repeated precipitate
labour.
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6anagement

1uring delivery"
' %nhalation anaesthesia" as nitrous
o$ide and o$ygen is given to slow the
course of labour.
' .ocolytic agents" as ritodrine )0utopar*
may be efective.
' #pisiotomy" to avoid perineal
lacerations and intracranial
haemorrhage.
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!hysiological /etraction /ing

%t is a line of demarcation between

the upper and lower uterine segment
present during normal labour and
cannot usually be felt abdominally.
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!athological /etraction /ing )AandlFs ring*

' %t is the rising up retraction ring during
obstructed labour due to mar(ed retraction
and thic(ening of the upper uterine
segment while the relatively passive lower
segment is mar(edly stretched and thinned
to accommodate the foetus.
' .he AandlFs ring is seen and felt
abdominally as a transverse groove that
may rise to or above the umbilicus.
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Pathological Retraction Ring Constriction Ring
Occurs in prolonged Cnd stage. Occurs in the +st3 Cnd or ;rd
stage.
Always between upper and lower
uterine segments.
At any level of the uterus.
/ises up. 1oes not change its position.
-elt and seen abdominally. -elt only vaginally.
.he uterus is tonically retracted3
tender and the foetal parts
cannot be felt.
.he uterus is not tonically
retracted and the foetal parts can
be felt.
6aternal distress and foetal
distress or death.
6aternal and foetal distress may
not be present.
/elieved only by delivery of the
foetus.
6ay be relieved by anaesthetics
or antispasmodics.
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6anagement
#$clude malpresentations3 malposition and
disproportion.

%n the +st stage" !ethidine may be of

beneft.

%n the Cnd stage" 1eep general anaesthesia

and amyl nitrite inhalation are given to rela$
the constriction ring"

%n the ;rd stage" 1eep general anaesthesia

and amyl nitrite inhalation are given
followed by manual removal of the placenta.
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1efnition

-ailure of the cervi$ to dilate within a

reasonable time in spite of good
regular uterine contractions.
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?arieties

a.Organic )secondary* due to"

Cervical stances as a se2uel to
previous amputation3 cone biopsy3
e$tensive cauterisation or obstetric
trauma.
Organic lesions as cervical myoma
or carcinoma.
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?arieties
b.-unctional )primary*"
%n spite of the absence of any
organic lesion and the well
efacement of the cervi$3 the
e$ternal os fails to dilate.
.his may be due to lac( of softening
of the cervi$ during pregnancy or
cervical spasm resulted from
overactive sympathetic tone.
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Complications
' Annular detachment of the cervi$"
surprisingly the bleeding from the cervi$ is
minimal because of fbrosis and avascular
pressure necrosis leading to thrombosis of
the vessels before detachment.
' /upture uterus.
' !ostpartum haemorrhage" particularly if
cervical laceration e$tends upwards
tearing the main uterine vessels.
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6anagement
a. Organic dystocia"
Caesarean section is the management
of choice.
b.-unctional dystocia"

!ethidine and antispasmodics" may be

efective

Caesarean section" if medical treatment

fails orfoetal distress developed.
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