Abnormal uterine action

1. ABNORMAL UTERINE
ACTION
Mrs. U SREEVIDYA Msc.
NURSING,
Associate Professor,
Apollo college of nursing,
CHITTOOR

2. NORMAL UTERINE
ACTION
Normal labour is characterized by
 coordinated uterine contractions(interval gradually
shortens and intensity gradually increases)
 associated with progressive dilatation of the cervix
(Normal labour is associated with cervical dilatation
≥ 1cm hour in a nulliparous woman )
 descent of the fetal head.

3. upper polePolarity of uterus: When
contracts lower pole relax
Pacemakers : Two pace makers are
each cornua of the uterus
contraction in co-ordinated
situated at
generating
manner
 Pattern of contraction : uterine contraction
starts at cornua and propagate towards
lower uterine segment with decrease in
duration and intensity as it moves away
from the pacemaker

5. PARAMETER OF UTERINE ACTION
 Basal tone : 5- 20 mm Hg
 Peak pressure : 60 -80 mm Hg
 Frequency of contraction :adequate uterine
contractions are 1 in every 3 mints lasting for
about 45 sec with good relaxation in between

6. ASSESSMENT OF CONTRACTION
 Abdominal palpation
 Tocodynamometer :with the help of external
transducers
 Intrauterine pressure catheter

8. ABNORMAL UTERINE
ACTION
 Any deviation of the normal pattern of uterine
contractions affecting the course of labour is
designated as disordered or abnormal uterine
action.

9.  OVERALL LABOUR ABNORMALITIES
OCCUR IN ABOUT 25% OF THE
NULLIPAROUS WOMEN
 AND 10% OF MULTIPAROUS WOMEN.
Incidenc
e:

10. ETIOLOGY
 Prevalent in primi with advancing age of the mother
 Prolonged pregnancy
 Over distension of the uterus due to twins and or
polyhydramnios
 Psychologic factor
 Contracted pelvis, malpresentation and deflexed head. All
these lead to ill fitting of the presenting part into the lower
uterine segment.
This probably results in inhibition of the local reflex
which is needed to produce effective contraction of the upper
segment.

11.  Full bladder and loaded rectum reflexly inhibit
uterine contraction
 Injudicious administration of sedatives,
analgesics and oxytocics
 Premature attempt of vaginal delivery or
attempted instrumental vaginal delivery under
light anaesthesia.

12. a. Over-efficient uterine action
> Precipitate labour: in absence of obstruction
> Excessive contraction and retraction: in presence of
obstruction
b.Inefficient uterine action
> Hypotonic inertia
> Hypertonic inertia
* Colicky uterus
* Hyperactive lower uterine segment
>Constriction (contraction) ring
 Generalised tonic uterus
c.Cervical dystocia
CLASSIFICATION OF ABNORMAL
UTERINE ACTIVITY

13. PRECIPITATE
LABOUR

14. PRECIPITATE LABOUR
• Definition
A labour lasting less than 3 hours.
 Combined duration of 1st and 2ndstage of labour
is < 2 hours.
 Rate of cervical dilatation greater than 5cm/H in
primipara & 10 cm/H in multipara.
 Due to combined effect of hyperactive uterine
contractions and diminished soft tissue
resistance

15. • It is more common in multiparous when
there are:
* strong uterine contractions,
* small sized baby,
* roomy pelvis,
* minimal soft tissue resistance.
AETIOLOGY

16. COMPLICATION
S
Maternal:
* Lacerations of the cervix, vagina and perineum.
*Shock.
*Inversion of the uterus.
*Postpartum haemorrhage: due to,
>no time for retraction,
> lacerations.
* Sepsis due to:
> lacerations,
> inappropriate surroundings.

17. COMPLICATIO
NS
Foetal:
>Intracranial haemorrhage due to sudden
compression and decompression of the head.
>Foetal asphyxia due to:
*strong frequent uterine contractions reducing
placental perfusion,
*lack of immediate resuscitation.
>Avulsion of the umbilical cord.
>Foetal injury due to falling down.

18. MANAGEMEN
T
• Before delivery:
Patient who had previous precipitate labour
should be hospitalized before expected date
of delivery as she is more prone to repeated
precipitate labour.

19. MANAGEMENT CONT..
• During delivery:
* Inhalation anaesthesia: as nitrous oxide and
oxygen is given to slow the course of labour.
* Tocolytic agents: as ritodrine (Yutopar) may be
effective.
* Episiotomy: to avoid perineal lacerations and
intracranial haemorrhage.

20. EXCESSIVE UTERINE
CONTRACTION AND
RETRACTION
(TONIC UTERINE
CONTRACTION AND
RETRACTION)

21. Physiological Retraction Ring
• It is a line of demarcation between the upper
and lower uterine segment present during
normal labour and cannot usually be felt
abdominally.

22. • Pathological Retraction Ring (Bandl’s ring)
* It is the 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.
* The Bandl’s ring is seen and felt abdominally as a
transverse groove that may rise to or above the
umbilicus.
* Clinical picture: is that of obstructed labour with
impending rupture uterus.
* Obstructed labour should be properly treated otherwise
the thinned lower uterine segment will rupture.

24. TONIC UTERINE CONTRACTION AND
RETRACTION
PATHOLOGICAL ANATOMY OF UTERUS:
Contraction increases in intensity ,duration and
frequency with decreased relaxation in between
Retraction continues
Progressive thinning & elongation of lower uterine
segment
/
Development of circular groove b/n upper and lower
segment-called BANDL’S RING.

25. In primigravidae further retraction ceases in
response to obstruction and labour comes
to a stand still-a state of exhaustion.
In multiparae retraction continues with
progressive dilatation and thinning of lower
uterine segment
Bandl’s ring moves towards the
umblicus
Rupture of lower uterine segment
Fetal jeopardy and death

27. CLINICAL FEATURES
•
•
•
•
•
Patient is anxious looking
Features of exhaustion and ketoacidosis
Upper uterine segment is tender and hard
Lower uterine segment distended and
tender
Groove is seen between the two.

28. TREATMEN
T
•
•
•
Correction of dehydration & ketoacidosis
Adequate pain relief
Parenteral antibiotics
EXCLUDE RUPTURE OF UTERUS
Caesarean delivery in majority of cases

29. HYPOTONIC UTERINE INERTIA

30. UTERINE INERTIA
Dystocia: abnormal or difficult labour. It is characterized
by slow progress or arrest of labour.
Definition of uterine inertia:
• The uterine contractions are infrequent, weak, inefficient
and of short duration.
 Uterine contraction: the intensity is
diminished; duration is shortened; good
relaxation in between contractions and the
intervals are increased.
General pattern of uterine contractions of
labour is maintained but intrauterine
pressure during contraction hardly rises
above 25mm Hg

31. ETIOLOGY
 Elderly primi gravida
 Anemia or other chronic illness
 Hypertensive state in pregnancy
as in twin or Overdistension of uterus such
polyhydraminous
 Malpresentation and malposition
 Full bladder
 Uterine fibroid
 Premature induction of labour
o Nervous and emotional as anxiety and fear.
o Improper use of analgesics.
• Unknown but the following factors may be incriminated:

32. TYPES
 Primary inertia :weak uterine contrations from the
beginning
 Secondary inertia :interia developed after a
period of good contraction probably as the
result of contracted pelvis as protective
mechanism .

33. SIGNS AND
SYMPTOMS
 1.Patient feels less pain and discomfort
during uterine contraction
 2.Hand placed over the uterus during uterine
contraction reveals less hardening of the
uterus.
 3.Uterine wall is easily intenable at the
contractions.
 4.Uterus becomes relaxed after the
contraction; fetal parts are well palpable and
fetal heart rate remains good.

34. DIAGNOSIS
Internal examination reveals;
 Poor dilatation of thecervix
Membranes usually remain intact
Cervix well applied to the presenting part
 Associated presence of contracted
pelvis, malposition, deflexed head or
malpresentation may be evident.

35. COMPLICATIONS
Effects on mother:
Prolonged labor
Maternal distress, dehydration and
psychological depression
Increased risk for infection
Increased risk of PPH
Subinvolution

36. FETAL COMPLICATION
membraneFetal distress if
ruptures early

37. MANAGEMENT
 Careful evaluation of the case is to be
done:
 To be sure that the patient is in true
labour
 To exclude cephalopelvic disproportion
or malpresentation
 To plan out the management protocol

38. Detected in first stage:
Place of caesarean section:
 Presence of contracted pelvis
Malpresentation
Evidences of fetal or maternal distress
In these cases where vaginal delivery is
found unsafe and fetal condition
remains good, caesarean section may
be preferred.

39. VAGINAL DELIVERY
 General measures:
 To keep up the morale of the patient
 To empty the bowel by enema and bladder by
encouraging the patient to empty at intervals,
failing which catheterization is to be done
 To maintain nourishment by infusion of 5%
dextrose
 Adequate sedation is ensured by intramuscular
Pethidine 100 mg

40. ACTIVE
MEASURES Acceleration of uterine contraction can be brought about by low
rupture of the membranes followed by Oxytocin drip if not
contraindicated.
• An infusion of 2 unit of Oxytocin dissolved in 500ml 5% dextrose
is started.
• The drip rate should be slow at first and is to be gradually
increased until effective contractions are set up.
• Close watch of the maternal and fetal conditions and nature of
uterine contractions is mandatory.
• The drip is to be continued till 1 hour after delivery;
unsatisfactory and or fetal
If, however, cervical dilatation
distress
remains
appears,
Caesarean section is the best alternative.

41. DETECTED IN SECOND STAGE
If the case is first seen at this stage, careful
evaluation of the case is to be done to
exclude contracted pelvis, malpresentation
and to determine station of the head in
relation to ischial spines and fetal condition.

42. PLACE OF CAESAREAN SECTION
In presence of contracted pelvis or
malpresentation where vaginal
delivery is found unsafe and fetal
condition
caesarean
remains good,
section may be
preferred even at this stage.

43. VAGINAL DELIVERY
 Head low down – Forceps or ventouse
delivery
 Head not sufficiently low down
· Stimulation of uterine contraction by
oxytocin drip or
 Ventouse extraction. Difficult forceps
should be avoided
 Craniotomy – If the baby is dead

44. THIRD
STAGE
Active management of the
third stage is advocated

45. HYPERTONIC UTERINE
INERTIA
(UNCOORDINATED
UTERINE ACTION)

46. TYPES
* Colicky uterus: incoordination of the different
parts of the uterus in contractions.
* Hyperactive lower uterine segment: so the
dominance of the upper segment is lost.

47. HYPERTONIC UTERINE ACTION
 It is defined as either a series of single
contractions lasting 2 minutes or more or
a contraction frequency of five or more in
10 minutes.Uterine hyperstimulation may
result in
abnormalities,
fetal heart rate
uterine rupture,
or placental abruption

48. EXAMPLE
Spastic lower uterine segment
Colicky uterus
Asymmetrical uterine contraction
Constriction ring
Generalised tonic contraction
All these states are collectively
called as incordinate uterine action

49. IN CO-ORDINATE UTERINE
ACTION
Strong and painful uterine
contraction
High frequency
Slow cervical dilatation
Two pole of uterus doesn’t functions
rhythmically

50. CLINICAL
FEATURES
 Labour is prolonged.
 Uterine contractions are irregular and more painful.
The pain is felt before and throughout the
contractions with marked low backache often in
occipito-posterior position.
 High resting intrauterine pressure in between uterine
contractions detected by tocography (normal value
is 5-10 mmHg).
 Slow cervical dilatation .
 Premature rupture of membranes.
 Foetal and maternal distress.

51. MANAGEME
NT
CPD- C/S
 Vital monitoring
 I/V therapy
 I/O charting
 FHS every 15 min
Partograph
 Fetal distress-C/S

52. COLICKY UTERUS
 Various parts of uterus contracts independently
Hyperactive lower uterine segment
 Fundal gradient is lost , reverse gradient of the
uterine activity starts from the lower uterine
segment goes toward fundus and cervix

53. CONSTRICTION
RING
(CONTRACTION) RING
 It is a persistent localised 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
labour.

56. AETIOLOGY
Unknown but the predisposing factors are:
 Malpresentations and malpositions.
 Premature rupture of membrane
 Premature attempt of instrumental delivery
light Intrauterine manipulations under
anaesthesia.
 Improper use of oxytocin e.g.
 use of oxytocin in hypertonic inertia.
 IM injection of oxytocin.

57. 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
 Prolonged 1st stage: if the ring occurs at the level of
the internal os.
 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).

59. CLINICAL
FEATURES
 Mother becomes tired and restless due to continue pain
and discomfort
 Features of maternal distress and keto-acidosis
 Abdominal palpation
 Upper segment hard ,uniformly convex and tender
 Retraction ring obliquely placed between umblicus and
symphysis pubis
 Fetal part may not be well defined
 FHS usually absent
 Vaginal examination
 Dry hot vagina with offensive discharge
 Cervix fully dilated
 Causes of obstruction is revealed

60. DIFFERENCE BETWEEN
CONSTRICTION RING AND
RETRACTION RING
CONSTRICTION RING RETRACTION RING
Nature It is a manifestation of localised
inco-ordinated uterine
contraction.
It is an end result of tonic uterine
contraction and retraction
Cause Undue irritability of the uterus. Following obstructed labour
Situation Usually at the junction of upper At the junction of upper and
and lower segment but may occur lower segment. The position
in other places. The position does progressively moves upwards
not alter.
Uterus Upper segment contracts and
retracts with relaxation in
between lower segment remains
thick and loose.
Upper segment is tonically
contracted with no relaxation
The wall becomes thicker, lower
segment becomes distended and
thinned out

61. Maternal
condition
Almost unaffected unless the
labour is prolonged
Maternal exhaustion, sepsis
appear early
Abdominal
Examination
oUterus feels normal and not
tender
oFetal parts are easily felt
oFHS is usually felt
o Uterus is tense and tender
o Not easily felt
o Ring is felt as a groove
placed obliquely
Vaginal
examination
oThe lower segment is not
pressed by the presenting part
oRing is felt usually above the
head
o Features of obstructed labour
are absent
o Lower segment is very much
pressed by the forcibly driven
presenting part
o Ring cannot be felt vaginally
o Features are present
End result oMaternal exhaustion is a late o Maternal exhaustion and
feature sepsis appear early
o Fetal anoxia usually appear late o Fetal anoxia and even death
o Chance of uterinerupture is are usually early
absent o Rupture uterus in multi
gravidae is common

62. MANAGEME
NT
 Provide supportive therapy
 Analgesic and sedation
 Hydration
 Prophylactic antibiotic
 Definitive treatment
 Destructive surgery if fetus is dead
 Fetus alive-C/S

63. MANAGEME
NT
 Exclude malpresentations, malposition and
disproportion.
 In the 1st stage: Pethidine, morphine may be of
beneficial .
 In the 2nd stage: Deep general anaesthesia and amyl
nitrite inhalation are given to relax the constriction ring:
 If the ring is relaxed, the foetus is delivered
immediately by forceps.
 If the ring does not relax, caesarean section is carried out with
lower segment vertical incision to divide the ring.
 In the 3rd stage: Deep general anaesthesia and amyl nitrite
inhalation are given followed by manual removal of the placenta

64. GENERALIZED TONIC
CONTRACTION (UTERINE
TETANY)
 In this condition pronounces retraction occurs involving
whole of the uterus upto the level of internal os. Thus
there is no physiological differentiation of the active upper
segment and the passive lower segment of the uterus. As
there is no thinning of the lower segment, there is no
chance of rupture of the uterus. The uterine contraction
ceases and the whole uterus undergoes a sort of tonic
muscular spasm holding the fetus inside (active retention
of the fetus)

66. CAUSE
S
 Failure to overcome the obstruction by powerful
contractions of the uterus
 Injudicious administration of oxytocics
 Irritation caused by repeated unsuccessful attempt
of instrumental delivery

67. CLINICAL
FEATURES
The patient is in prolonged labor having
severe and continuous pain. Abdominal
examination revels the uterus to be
somewhat smaller in size, tense and
wellFetal
nor
parts
is the
are neither
fetal heart sound
tender.
defined,
audible. Vaginal examination reveals
jammed head with big caput; dry and
oedematous vagina.

68. MANAGEME
NT
 Correction of dehydration and keto acidosis: by
rapid infusion of Ringer’s solution
 Antibiotics : To control infection
 Adequate pain relief
• Tocolytic agents for e.g terbutalin 0.25mg S.C.
• Caesarean delivery is done in majority of cases.

69. CERVICAL
DYSTOCIA
Definition
Failure of the cervix to dilate within a reasonable time
in spite of good regular uterine contractions.

70. TYPES
 Organic (secondary) due to:
 Cervical stances as a sequel to previous amputation,
cone biopsy, extensive cauterisation or obstetric
trauma.
 Organic lesions as cervical myoma or carcinoma.
 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 or excessive fibrous tissue .

71. ETIOLOGY
 Ineffective uterine contractions
 Malpresentation, Malposition (abnormal
relationship between the cervix and the
presenting part)
 Spasm (contractions) of the cervix

72. MANAGEMENT
 Organic dystocia:
 Caesarean section is the management of choice.
 Functional dystocia:
 Pethidine and antispasmodics: may be effective.
 Caesarean section: if
 medical treatment fails or
 foetal distress developed.

73. ThankYou