Unit II

Abnormal labour, pre-term labour &

obstetrical emergencies

Normal labour

Power
Passage

passenger

Power
Normal - Uterine contraction Abnormal uterine action
o Uncoordinated uterine actions, Antony of uterus, precipitate labour, prolonged labour
Rx - Augmentation of labour Medical and surgical induction

Passage Contracted pelvis CPD; dystocia

Rx- Obstetrical operation: Forceps delivery, Ventouse, Caesarian section, Destructive operations

Passenger
Abnormal lie, presentation, position compound presentation
Rx Version
Rx Obstetrical operation: Forceps delivery, Ventouse, Caesarian section, Destructive operations

Complications & Emergencies

Obstetrical emergencies: Obstetrical shock, vasa praevia, inversion of uterus, amniotic fluid embolism, rupture uterus, presentations and prolapse cord Genital tract injuries Third degree perinea tear, VVF,RVF Complications of third stage of labour: o Post partum Hemorrhage o Retained Placenta Manual removal of placenta

Etiology, pathopyhsiology and nursing management of

o Uncoordinated uterine actions, Antony of uterus, precipitate labour, prolonged labour o Abnormal lie, presentation, position compound presentation o Contracted pelvis CPD; dystocia o Obstetrical emergencies: Obstetrical shock, vasa praevia, inversion of uterus, amniotic fluid embolism, rupture uterus, presentations and prolapse cord o Augmentation of labour Medical and surgical induction o Version o Manual removal of placenta o Obstetrical operation: Forceps delivery, Ventouse, Caesarian section, Destructive operations o Genital tract injuries Third degree perinea tear, VVF,RVF Complications of third stage of labour: o Post partum Hemorrhage o Retained Placenta

Abnormal Uterine Action

Normal labour
Coordinated uterine contractions progressive dilation of Cx (>/1 cm/hr) & descent of fetal head

Abnormal/disordered/uncoordinated Uterine Action

Any deviation from normal pattern of uterine
contractions affecting the course of labour

abnormal uterine action

Incidence:

25% in nulliparous
10% in multiparous

Abnormal Uterine Action Normal polarity Abnormal polarity (Incoordinate Uterine Action)
Hypertonic dyfunction Hypotonic dyfunction (excessive contraction) (uterine inertia common) Obstruction(--) obstruction(+)

Precipitate labour

tonic uterine contraction & retraction (bandles ring) Hypertonic uterus

Abnormal Uterine Action Normal polarity Abnormal polarity

Hypotonic Hypertonic dyfunction dyfunction (excessive (uterine inertia) contraction) Spastic Colicky lower uterus uterine segment

(Incoordinate Uterine Action)

Asym Constri -metrical -ction Uterine ring contraction

Gener Cervical -alised dystocia Tonic Contr -action

Ineffective uterine contraction

Etiology
Physiology of normal labour not fully understood so this etiology is also obscure Risk factors Prevalent in primi esp. in elderly primi Prolonged pregnancy Over distension of Ux (twins & fibroid) Emotional factor (anxiety & stress) Obesity Contracted pelvis & malpresentation Injudicious administration of sedatives, analgesics & oxytocics Premature attempt to at vginal / instrumental delivery

Normal uterine contractions

Polarity of the uterus Normally 2 pacemakers, one is situated at each cornua of Ux Uterine pacemakers produce coordinated uterine contractions Properties of normal uterine contractions Diminishes from to bottom of Ux Starts from pace maker & propagates towards the lower uterine segment Duration of it diminishes progressively

Dysfunctional labour
New pacemakers may come up from anywhere in the uterus in Dysfunctional labour Primary Dysfunctional labour Cx dilates <1cm / hr following a normal latent phase of laboural dilation stops Secondary arrest cervical dilatation stops or slows after the active phase of labour has started normally

Normal uterine activity (contraction)

Measured by noting
Basal tone Active (peak) pressure Frequency

Measurement done by
Clinical palpation (inaccurate) Tocodynamometer With external transducer Intra uterine pressure catheter (accurate)

Normal baseline tonus is between 5 to 20 mm of Hg & peak pressure is around 60 mm of Hg (8Kpa)

HYPOTONIC UTERINE INERTIA (HYPOTONIC UTERINE DYSFUNCTION)

HYPOTONIC UTERINE INERTIA

Definition The uterine contractions are infrequent, weak and of short duration; good relaxation in between contractions & intervals are increased

Aetiology
Unknown but the following factors may be incriminated: General factors: > Primigravida particularly elderly. >Anaemia and asthenia. > Nervous and emotional as anxiety and fear. > Hormonal due to deficient prostaglandins or oxytocin as in induced labour. > Improper use of analgesics.

Aetiology
Local factors > Overdistension of the uterus. > Developmental anomalies of the uterus e.g. hypoplasia. >Myomas of the uterus interfering mechanically with contractions. >Malpresentations, malpositions and cephalopelvic disproportion. The presenting part is not fitting in the lower uterine segment leading to absence of reflex uterine contractions. >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
* Labour is prolonged. * Uterine contractions are infrequent, weak and of short duration. * Slow cervical dilatation. * Membranes are usually intact. * The foetus and mother are usually not affected apart from maternal anxiety due to prolonged labour. * More susceptibility for retained placenta and postpartum haemorrhage due to persistent inertia. * Tocography: shows infrequent waves of contractions with low amplitude.

Management
General measures > Examination to detect disproportion, malpresentation or malposition and manage according to the case. > Proper management of the first stage. > Prophylactic antibiotics in prolonged labour particularly if the membranes are ruptured.

Management
Amniotomy: a.Providing that; > vaginal delivery is amenable, >the cervix is more than 3 cm dilatation and > the presenting part occupying well the lower uterine segment

Management
Amniotomy: b. Artificial rupture of membranes augments the uterine contractions by: >release of prostaglandins. > reflex stimulation of uterine contractions when the presenting part is brought closer to the lower uterine segment.

Management
Oxytocin: Providing that there is no contraindication for it, 5 units of oxytocin (syntocinon) in 500 c.c glucose 5% is given by IV infusion starting with 10 drops per minute and increasing gradually to get a uterine contraction rate of 3 per 10 minutes.

Management
Operative delivery a.Vaginal delivery: by forceps, vacuum or breech extraction according to the presenting part and its level providing that, > cervix is fully dilated. > vaginal delivery is amenable. b.Caesarean section is indicated in: > failure of the previous methods. > contraindications to oxytocin infusion including disproportion. >foetal distress before full cervical dilatation.

HYPERTONIC UTERINE INERTIA (Uncoordinated Uterine Action)

HYPERTONIC UTERINE INERTIA (Uncoordinated Uterine Action)

Appears in active stage of labour New pace makers appear all over the uterus ^ frequency & duration of uterine tone , Cause rise in baseline tone diminish placental circulation The myometrium contracts spasmodically & irregularly This contraction force neither dilates the cervix nor pushes the fetus down

Etiology
Hypertonic dyfunction (uterine inertia) can arise from any of the conditions such as

Spastic Colicky lower uterus uterine segment

Asym Constri -metrical -ction Uterine ring contraction

Gener Cervical -alised dystocia Tonic Contr -action

Ineffective uterine contraction

Clinical features
Uterine tonus is elevated Pain is present before & after contractions results in fetal hypoxia in labour Placental abruption in case of high baseline tone (> 25 mm Hg) On CTG reduced variability & late decelaration Uterine hyper stimulation d/t oxytocics often associated with fetal tachycardia

Management
General measures Examination to detect disproportion, malpresentation or malposition and manage according to the case. Proper management of the first stage. Prophylactic antibiotics in prolonged labour particularly if the membranes are ruptured.

Management
Medical measures: Analgesic and antispasmodic as pethidine. Epidural analgesia may be of good benefit. Caesarean section is indicated in: Failure of the previous methods. Disproportion. Foetal distress before full cervical dilatation. Specific Mgt in each condition

Spastic lower segment

Lack of fundal dominace The pacemakers do not work in rhythm Reversed polarity The lower segment contractions are stronger Inadequate relaxation in between contractions Basal tone is > 20 mm Hg

Diagnosis
Patient is in agony with unbearable pain referred to the back Evidence of dehydration & ketoacidosis Distension of bladder & retension of urine, Distension of the stomach & bowel Premature attempt to bear down Fetal distress appears early Abd. Palpation uterus is tender & hardening of the uterus, palpation of the fetal parts is difficult

Internal examination
Cx is thik, oedematous, hangs loosely like a curtain Cx not well applied to the presenting part Inappropriate dilation of the Cx Absence of membranes Meconium stained liquor may be there

Management
No place for oxytocin augmentation C.S done majority Correct dehydration & ketoacidosis before C.S

CONSTRICTION (CONTRACTION) RING

CONSTRICTION (CONTRACTION) RING (schroeders ring)

Definition * 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 around a constricted part of the fetus usually around the neck in cephalic presentation. * It can occur at the 1st, 2nd or 3 rd stage of labour.

Aetiology
Unknown but the predisposing factors are: * Malpresentations and malpositions. PROM Premature attempt at instrumental delivery * Improper use of oxytocin 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. * diagnosis is difficult * The exact diagnosis is achieved only by feeling the ring with a hand introduced into the uterine cavity.

Diagnosis
Ring is not felt by abdomen Revealed during C.S in 1st stage of labour, During forceps application in 2nd stage of labour, during manual removal in 3rd stage of labour Uterus never rupture

Management
Exclude malpresentations, malposition and disproportion. In the 1st stage: Pethidine may be of benefit. In the 2nd stage: Deep general anaesthesia and amyl nitrite inhalation are given to relax the constriction ring: In the 3rd stage: Deep general anaesthesia and amyl nitrite inhalation are given followed by manual removal of the placenta.

Complications
Prolonged 1st stage: if the ring occurs at the level of the internal os. Prolonged 2nd stage: if the ring occurs around the fetal neck. Retained placenta and postpartum haemorrhage: if the ring occurs in the 3rd stage (hour- glass contraction).

CERVICAL DYSTOCIA

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

Varieties
a.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.

Varieties
b.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.

Management
a. Organic dystocia: > Caesarean section is the management of choice. b.Functional dystocia: Pethidine and antispasmodics: may be effective If head is sufficiently low down with thin rim of Cx push rim up manually during contraction & go for ventouse

Management
If Cx is very much thinned out but only half is dilated Duhrssens incision Duhrssens incision at 2 & 10 clock positions followed by forceps or ventouse If medical Mgt fails C.S

Generalised tonic contraction (syn: uterine tetany)

In this condition, pronounced retraction occurs involving a whole of the ulterus up to the level of internal os. Thus there is no physiological differentiation of the active upper segment and the passive lower segment of the uterus.

Generalised tonic contraction (syn: uterine tetany)

The whole uterus undergoes a sort of tonic muscular spasm holding the fetus inside ( active retention of the fetus) usuallly there is no risk of rupture. New pacemakers appear all over the uterus. Causes : (i) Cephalopelvic disproportion (ii) injudicious use of oxytocics.

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

Treatment
Correction of dehydration and ketoacidosis by rapid infusion of ringers solution Antibiotic- to control infection Adequate pain rellief Hypercontractility (tachysytole) induced by oxytocics can be managed by to tocolytics (terbutaline 0.25mg S.C) Oxytocin infusion should be stopped. Caesarean delivery is done in majority of the cases specially when obstruction is suspected.

Precipitate labour
A lobour is called precipitate when the combined duration of the first and second stage is less than two hours. It is common in multiparae and may be repetitive Rapid expulsion is due to the combined effect of hyperactive uterine contractions associated with diminished soft tissue resistance. Labour is short as the rate of cervical dilatation is 5cm/hours or more for the nulliparous women.

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

Maternal risks include :

(1) extensive laceration of the cervix, vagina and perineum ( to the extent of complete perineal tear) (2) PPH due to uterine hypotonia that develops subsequent to unusual vigorous contractions (3) Inversion (4)uterine rupture 5) infection (6) Amniotic fluid embolism.

fetal risks
intracranial stress and haemorrhage because of rapid expulsion without time for 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.

Treatment
The patient having previous history of precipitate labour should be hospitalised prior to labour During labour, the uterine contraction may be suppressed by administering ether or magnesium sulphate during contractions. Delivery of the head should be controlled. Episiotomy should be done liberally. Elective induction of labour by low rupture of membranes and conduction of controlled delivery is helpful. Oxytocin augmentation should be avoided

EXCESSIVE UTERINE CONTRACTION AND RETRACTION

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.

Tonic uterine contraction &retraction (Pathological Retraction Ring /Bandls 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 Bandls 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.

Pathological Retraction Ring

Constriction Ring

Occurs in prolonged 2nd stage.

Always between upper and lower uterine segments. Rises up. Felt and seen abdominally. The uterus is tonically retracted, tender and the foetal parts cannot be felt. Maternal distress and foetal distress or death. Relieved only by delivery of the foetus.

Occurs in the 1st, 2nd or 3rd stage.

At any level of the uterus.

Does not change its position. Felt only vaginally. The uterus is not tonically retracted and the foetal parts can be felt. Maternal and foetal distress may not be present. May be relieved by anaesthetics or antispasmodics.