obg seminar uncoordinated uterine action

2. UNCOORDINATED UTERINE ACTION
 INTRODUCTION:=
The hypertonic state of the uterus arises from any of the
condition such as spastic lower uterine segment, colickly uterus, asymmetrical
uterine contraction, constriction ring or generalized tonic contraction of the uterus
and all these states are collectively called uncoordinate uterine action.

3. DEFINITION
 Any deviation from normal pattern of uterine contraction associated with
cervical dilation and descent of the head is known as abnormal uterine
contraction.
 Any deviation of the normal pattern of uterine contraction affecting the course
of labour is designated as disordered or abnormal uterine action.

4. ETIOLOGY
 Unknown
 Prevalent in first birth specially with elderly women
 Prolonged pregnancy
 Over distension of uterus
 Emotional factor
 Contracted pelvis and malpresentation
 Premature attempt of VD and instrumental VD
 Injudicious administration of sedatives, analgesics and oxytocin

5. INCIDENCE
 25% in nulliparous women
 10% in multiparous women

6. TYPES
ABNORMAL UTERINE ACTION
Normal polarity Abnormal polarity

7. UTERINE INERTIA
 INTRODUCTION:= Uterine inertia is the common type of abnormal uterine contraction
but is comparatively less serious. It may complicate any stage of
labour. It may present from the beginning of labour or may develop
subsequently after a variable period of effective contraction.
 UTERINE CONTRACTION:=
 The intensity is diminished
 Duration is shortened
 Good relaxation in between contraction
 Interval are increased
 General pattern of uterine contraction of labour is maintained but intrauterine pressure during
contraction is below 25mmHg

8. DIAGNOSIS
 Patient feels less pain during contraction
 Hand placed over the uterus during uterine contraction reveals less handing of the uterus
 Uterus remain relaxed after contraction
 Uterus remain releaxed after contraction
 Fetal parts are well palpable
 Fetal heart rate remains normal
 INTERNAL EXAMINATION REVEALS:=
 Poor dilation of the cervix
 Associated presence of contracted pelvis, malposition, deflexed head or malpresentation.
 Membranes usually remain intacts

9. EFFECTS ON MATERNAL AND FETUS
 Maternal exhaustion
 Fetal distress are unusual and appear late

10. MANAGEMENT
Case is reassessed to exclude cephalopelvic disproportion or malpresentation.
 PLACE OF CESEAREAN SECTION:=
 Presence of contracted pelvis
 Malpresentation
 Evidence of fetal or maternal distress

11.  VAGINAL DELIVERY:=
 GENERAL MEASURES :-
o To keep up the morale of the patient
o Posture of the women is changed[ supine position is avoided]
o To empty the bladder, catherization is made
o To maintain hydration by infusion of ringer solution
o Adequate pain relief
 ACTIVE MEASURES :-
o Acceleration of uterine contraction can be brought by low rupture of membrane followed by
oxytocin drip
o The drip is to be continued till 1hr after delivery

12. INCOORDINATED UTERINE ACTION
 INTRODUCTION :=
It is usually appears in active stage of labour. The hypertonic state of the
uterus arises from any of the condition such as spastic lower uterine segment, colicky uterus,
asymmetrical uterine contraction, contraction ring or generalized tonic contraction of the uterus
and all these states are collectively called incoordinate uterine contraction.
 Increased frequency and or duration of uterine contraction cause rise in baseline tone and
thereby diminish circulation in the placental intervillous space
 These contraction fails make progressive cervical effacement and dilation.

13. TYPES

14. SIGN AND SYMPTOMS

15. MANAGEMENT
 GENERAL MEASURES := As hypotonic inertia
 MEDICAL MEASURES :=
 Analgesics and antispasmodic as pethidine
 Epidural analgesia may be of good benefit.
 CAESAREAN SECTION IS INDICATED IN :=
 Failure of the previous method
 Disproportion
 Foetal distress before full cervical dilation

16. SPASTIC LOWER SEGMENT
 UTERINE CONTRACTION :=
 Fundal dominance is lacking and often there is reversed polarity
 The pacemaker do not work in rhythm
 The lower segment contraction are stronger
 Inadequate relaxation in between contraction
 Basal tone is raised above the critical level of 20 mmHg.

17. DIAGNOSIS
 The patient is in agony with unbearable pain reffered to the back
 There are evidence of dehydration and ketoacidosis
 Bladder is frequently distended and often there is retention of urine, distension of stomach and bowel
are visible.
 There are premature attempts of bear down.
 ABDOMINAL PALPATION REVEALS :=
o Uterus is tender and gentle manipulation excites handening of the uterus with pain.
o Palpation of the fetal parts is difficult.
 INTERNAL EXAMINATION MAY REVEALS :=
o Cervix with thick, edematous hangs lossely like a curtain, not well applied to the presenting part
o Inappropriate dilation of the cervix.
o Absence of membranes
o A meconium stained liquor amnii may be there.

18. EFFECTS OF THE FETUS
 Fetal distress appear early due to placental insuffiency caused by inadequate relaxation of
the uterus.
 MANAGEMENT :=
o There is no place of oxytocin augmentation with this abnormality
o Cesarean section is done in majority of cases.
o Prior correction of dehydration and ketoacidosis must be achieved by rapid of “ringer
solution.”

19. CONTRACTION RING
 It is one form of incoordinate uterine action where there is localized
myometrial contraction forming a ring of circular muscle fibers of the uterus.
 It is usually situated at 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 stage of labour.
 It is usually reversible and complete
 It is also called constriction ring or Schroeder’s

20. CAUSES
 Injudicious administration of oxytocic’s.
 Premature rupture of the membrane.
 Premature attempt at instrumental delivery.

21. DIAGNOSIS
 Difficult
 The ring is not felt per abdomen
 Revealed during cesarean section in the first stage of labour, during forcep
application in second stage and during manual removal in the third stage.
 Uterus never ruptures
 Maternal condition is not much affected but the fetus is in jeopandy because of
the hypertonic state.

22. TREATMENT
 Delivery is usually done by cesarean section
 The ring usually passeses off deepening the plane of anesthesia, other wise the
ring may be cut vertically to deliver the baby.
 The difficulties faced during forceps delivery or during normal removal of
placenta can be overcome by using deep anesthesia that relaxes the constriction
ring.

23. CERVICAL DYSTOCIA
 DEFINITION :=
Failure to the cervix to dilate within a reasonable time in spite of
good regular uterine contraction

24. VARITIES
FUNCTIONAL ORGANIC

25. COMPLICATION
ANNULAR
DETACHMENT
OF THE CERVIX
POSTPATRUM
HAEMORRHAGE

26. MANAGEMENT
 ORGANIC DYSTOCIA :=
o Caesarean section is the management of choice
 FUNCTIONAL DYSTOCIA :=
o Pethidine and antispasmodic :- may be effective.
o Caesarean section if medical treatment fails or fetal distress developed.

27. GENERALIZED TONIC CONTRACTION
 In this condition, pronounced retraction occurs involving whole of the
uterus up to the level of internal os.
 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.
 Usually there is no risk of rupture uterus.

28. CAUSES
Cephalopelvic
disproportion
Injudicious
use of
oxytocic's
Obstruction

29. CLINICAL FEATURES
 The patient is in prolonged labour, having severe and continuous pain.
 Abdominal examination reveals the uterus to be some what in size, tense and
tender
 Fetal parts are neither well defined, normally is the fetal heart sound audible.
 Vaginal examination reveals jammed head with big caput, dry and adematous
vagina

30. TREATMENT
 Correction of dehydration and ketoacidosis by rapid infusion of ringer solution.
 Antibiotics
 Adequate pain relief
 Hyper contractility [ tachysystole] include by oxytocic can be managed by
tocolytics.
 Caesarean delivery is done in majority of the cases specially when obstruction
is suspaected.

31. PRECIPITATE LABOUR
“ A labour is called precipitate when the combined duration of the first and
second stage is less than two hours”
 It is common in multiparous and be repetitive
 Labour is short as rate of cervical dilatation is 5cm/ hr. or more in nulliparous
women.
 Rapid expulsion is due to the combined effect of hyperactive uterine
contraction associated with diminished soft tissue resistance.

32. MATERNAL RISK
 Extensive laceration of cervix, vagina and perineum.
 PPH due to uterine hypotonia that develops subsequent to unusual vigorous
contractions
 Inversion
 Uterine rupture
 Infection
 Amniotic fluid embolism

33. FETAL RISK
 Intracranial stress and hemorrhage because of rapid expulsion without time of
moulding of the head.
 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.

34. TREATMENT
 The patient having previous history of precipitate labour should be hospitalized
prior of labour.
 During labour the uterine contraction may be suppressed by administering
either or magnesium sulfate during contraction.
 Delivery of the head should be controlled.
 Episiotomy should be done.
 Elective induction of labour by low rupture of membranes and conduction of
controlled delivery is helpful.
 Oxytocin augmentation should be avoided.

35. TONIC UTERINE CONTRACTION AND
RETRACTION
INTRODUCTION := It is a line of demarcation between the upper and lower uterine segment
present during normal labour and usually be felt abdominally.
 It’s also called “ bandal ring or pathological retraction ring.”
DEFINITION := It is rising up retraction ring during obstructed labour 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 foetus.

36. CLINICAL FEATURES
 Patient is in agony from continuous pain discomfort and becomes restlessness.
 Features of exhaustion and ketoacidosis are evident.
 Abdominal palpation reveals.
 Upper segment is harden and tender
 Lower segment is distended and tender.

37. MANAGEMENT
 PREVENTION := Partographic management of labour early diagnosis of malpresentation, disproportion and delivery by
caesarean section can prevent this condition completely.
 TREATMENT :=
o Rupture of the uterus is to be excluded.
o Internal version is contraindicated.
o Adequate pain relief.
o Parenteral antibiotic [ ceftriaxone 1gm/IV]
o Correction of dehydration and ketoacidosis by infusion of ringer solution.
o Caesarean delivery is done in majority of the cases.
o Rupture of the uterus must be excluded before attempting destructive operation.

38. NURSING
MANAGEMENT

39. NURSING MANAGEMENT
 Provide bed rest and monitor vital signs and FHR.
 Provide fluid to maintain hydration and electrolyte balance.
 Observe for normal contraction when women awakens.
 Check intake and output every 2hr.
 Continue observe the fetal movement.