Abnormal Labour & Obstetric Injuries

Front 1

Contracted Pelvis ?

Definition

Back 1

Definition

- Anatomical :

Pelvis in which one or more of the main diameters are reduced below average normal by one or more cm.

- Obstetric :

Pelvis in which one or more of the main diameters are reduced to the extent that interferes with normal mechanism of labour.

Front 2

Aetiology of Contracted Pelvis ?

Back 2

A) Causes in pelvic bone :

- Developmental = Abnormal Shape :

1- Small gynecoid "Generally contracted pelvis"

2- Small android / anthrapoid / platypelloid

3- Naegle's : absent 1 alae

4- Robert's : absent 2 alae

5- High assimilation pelvis : sacralization of the last lumbar vertebrae = C.INLET

- Diseases of pelvic bone & joints :

1- Metabolic :

- Rickets : flat rachitic pelvis =

generally contracted pelvis

- Osteomalacia : Triradiate pelvis =

C.INLET + CAVITY

2- Fractures of pelvic bones

3- Tumors of pelvic bones

4- Pelvic Joint diseases : TB

B) Causes in the spine :

1- Dorsolumbar scoliosis

2- Lumbar kyphosis = C.OUTLET

3- Spondylolisthesis :

Proplapse of vertebral column & last lumbra vertebrae in frront of sacral promontry =

C.INLET + C.OUTLET

C) Causes in lower limbs :

1- Dislocation of one or both femurs

2- Atrophy of one or both limbs

3- Unilateral fracture / tumor

4- Unilateral lower limb disease "Polio."

Front 3

Causes of Asymmetrical Pelvis ?

Back 3

1- Naegle's Pelvis

2- Scoliosis

3- Unilateral lower limb fracture / tumor

4- Unilateral lower limb disease "Polio."

Front 4

Diagnosis of Contracted Pelvis ?

Back 4

A) History : Bad Obstetric history :

1- Prolonged labour ending in CS, SB, birth injury

2- Difficult forceps ending in SB or birth injury

3- History of pelvic / Spinal / lower limb

- Trauma : Accident

- Disease : Rickets = Delayed teething / walking

B) Examination :

1- General

- Height : Short < 150 cm is associated with CP

- Gait : abnormal gait = LL / Spine disease

- Stigmata of old rickets : Box shaped head - pigeon chest - costal rosary - Harrison's sulcus spine deformities - bow legs.

- Dystrophia Dystocia Syndrome :

(( Short / Obese / Muscular / Male distribution of hair / Android pelvis ))

- Spines : Scoliosis / Kyphosis

- LL : abnormalities

2- Abdominal :

- Malpresentations : Face / brow / breech / TL

- Nonengaged head in PG in last 3-4 weeks

- Penulous abdomen in PG "Conclusive"

3- Pelvimetry :

A) Clinical :

- External : Inlet "little significant" + Outlet

- Internal

B) Radiological :

Seldom resorted to except in very selected cases "VBD is attempted" as it is expensive and unavailable in many centers, Include :

- Lateral View X-ray

- CT scan pelvimetry to assess pelvis diameters accurately.

4- Cephalometry = Ultrasound assessment of fetal head diameters :

Accurate method to assess fetal head size during pregnancy or 1st stage of labour by measuring the following diameters :

- BPD = 9.5 Cm

- OFD = 11.5 Cm

- HC

- AC : Estimation of fetal weight for Dx of LGA /

HA/AC ratio in prediction of shoulder dystocia in LGA fetus.

5- Cephalopelvic disproportion tests

Has replaced Pelvimetry as a better judgment on the capability of head to traverse pelvis.

Front 5

Clinical Pelvimetry ?

Back 5

A) External Pelvimetry :

1- At Inlet :

Little significance as it measures diameters of false pelvis "Interspinous & Intercrestal"

2- At Outlet :

- Subpubic angle :

Direct palpation of ischio-pubic rami

= Normally Obtuse in females.

- Bituberous diameter :

Roughly admits 4 knuckles of closed fist or measured by pelvimeter = 8-11 cm

- Anterior & Posterior Saggital diameter :

By Thom's pelvimeter

Ant.Saggital = 6-7 cm , Post.Saggital = 7-10 cm

Value : Thom's Dictum

average sized head pass pelvic outlet if

BT + PS > 15 provided that BT > 8

B) Internal Pelvimetry

1- Diagonal Conjugate

- Between lower border of SP and S.Promontry

- Measured by PV during ANC at 38 Weeks or during labour BUT head mustn't be engaged.

- Normally 12.5 cm ( DC - 1.5 = TC ) =

Sacral promontry is not easily felt / reached.

2- Palpation of Sacrum

From above downwards and from side to side

Normally = Concave with smooth concavity

3- Palpation of pelvis sidewalls

Normally not converging

4- Estimation of width of sacrosciatic notch

Normally accommodates 2 fingers

5- Palpation of ischial spines

Normally not felt when opening index and middle fingers at same time ( No Jutting )

6- Palpation of sub pubic angle

Normally accommodates 2 fingers

Front 6

Cephalopelvic Disproportion tests ?

Definition

Value

Tests

Interpretition

Back 6

A) Definition :

Tests to judge ability of fetal head to traverse pelvis.

B) Value :

Evaluation of a Primigravida especially those with non engagement of head near end of 3rd TM ( > 36 Weeks )

C) Tests :

1- Pinard's Method :

- Patient : Empty bladder / Semi setting position to bring fetus in axis of pelvic inlet.

- Examiner :

Rt Hand Placed over Symphesis Pubis = determine degree of disproportion.

Lt Hand Grasps fetal head and push it downward and backward in pelvis

2- Muller-Kerr Mehod :

- Patient : Empty bladder / Dorsal position

- Examiner :

Rt Hand

- Index & Middle finger : Put in vagina to perform steps of internal pelvimetry and detect station of head in pelvis.

- Thumb : Placed over Symphesis Pubis = determine presence of any disproportion.

Lt Hand Grasps fetal head and push it downward in pelvis

D) Interpretition :

1- No Disproportion

- Head can be pushed into pelvis "head is at level of posterior surface of SP"

- VD usually occurs

2- Moderate Disproportion = 1st degree

- Head doesn't enter the pelvis and stops at same level of Anterior surface of SP

- VD may occur depending on undeterminable factors or labour "TOL"

3- Marked Disproportion = 2nd degree

- Head overrides anterior surface of SP = marked degree of CP

- VD cannot occur

Front 7

Complications of Contracted Pelvis ?

Back 7

A) Maternal :

1- Prolonged labour & Slow Cervical dilatation

2- PROM & Cord prolapse

3- Obstructed Labour that may end with rupture uterus

4- Higher incidence of instrumental / operative delivery

5- Necrotic GUF

6- Injury of joints or nerves during instrumental delivery

7- Postpartum Hge ( Atonic + Traumatic )

8- Maternal Infection

9- Incarcerated RVF Uterus :

Sacrum presses on uterus inducing contractions = abortion / rupture uterus

10- HAP : kinking of ureters = Pyelonephritis

B) Fetal :

1- Asphyxia ( Intrapartum + Neonatal )

2- Birth injury : ICH + Fracture + nerve injury

3- IUFD : Cord Prolapse = high non-engaged

4- Intraamniotic infection : PROM

Front 8

Management of labour in CPD ?

Back 8

A) Moderate = 1st Degree

- Trial of labour in selected cases

- CS if TOL is failed / contraindicated

B) Marked = 2nd Degree

- CS if fetus is livinig

- Craniotomy if dead fetus but CS is safer

Front 9

Trial of Labour ?

Definition

Selection

Conduct

Back 9

- Definition :

Clinical test for undeterminable factors of labour in MODERATE degree of CPD including :

- Fetal head Moulding

- Maternal pelvis Yielding

- Efficiency of contractions in descent of head and cervical dilatateion

- Selection :

ONLY

Young healthy primigravida

+ 1st degree disproportion by Muller-Kerr test

+ Cephalic presentation with non engaged head at onset of labour

Exclude

- Bad obstetric history

- Outlet contraction

- Postmaturity : Macrosomia + Oligohydramnios + No moulding "Closed PF"

- Conduct :

- Only in a hospital with available facilities for CS.

- 1st stage : As normal labour for full 2 hours

- No frequent PV or ROM

- Proper assessment of labour progress by Partogram

- Proper & adequate analgesia "epidural" to avoid maternal exhaustion.

Successful : end by engagement and succesful vaginal delivery

Failed :

- Managed by CS when :

Failed progress / fetal distress / Marked maternal exhaustion

- Causes :

1- Improperly diagnosed 2nd degree CPD

2- Failed LAR in OP position

3- Incoordinate uterine action "Hypotonic/Hypertonic Inertia"

Front 10

Indications of CS in CPD ?

Back 10

1- Marked Disproportion "2nd Degree" with a living fetus

2- Moderate Disproportion if TOL is CI / Failed

3- Markedly Contracted outlet

4- CP in EPG / Malpresentations / PP

Front 11

Contracted Outlet / Funnel Pelvis ?

Definition

Features

Mechanism of labour

Managment

Back 11

Definition

A Variant of contracted pelvis in which

Bituberous diameter is 8 cm or less.

Features

Pelvic capacity is reduced from above downwards :

- Narrow deep pelvis

- Converging sidewalls

- Reduced transverse & AP diameter of outlet

Mechanism of labour

Extreme flexion and moulding at outlet with backward displacement of fetal head.

NB : Contracted outlet interferes with LAR in OP position.

Managment

According to Thom's Dictum :

- Adequate Outlet =

BT + PS > 15 cm & BT is > 8 cm & SP angle is not very narrow

Generous Episiotomy + Low Forcepes VD

- Inaddequate Outlet =BT + PS < 15 cm :

CS is performed if living fetus

Front 12

Obstructed Labour

= Dystocia

= Pathological retraction ring

= Impending rupture uterus ?

- Definition

- Causes

Back 12

- Definition :

Failure of delivery of fetus through maternal passages due to mechanical obstruction.

- Causes :

A) Maternal :

1- Contracted pelvis

2- Soft tissue obstruction :

Uterus : large fibroid / ovarian tumor impacted in douglas pouch Contraction ring

Cervix : Cervical dystocia

Vaginal : Stricture or septum

Vulva : edema / hematoma / neoplasm

Perineum : Rigid

B) Fetal :

1- Macrosomia : fetus > 4 kgm

Diabetic mother

Rh Isoimmunization = Hydrops fetalis

Obese mother = Constitutional

Multiparity

Post Term pregnancy

Local : hydrocephalus / abdominal tumors

2- Malpresentations :

OCP : POP / DTA

Face : PMP / DTA / DMP

Brow : Persistant

Breech : Impacted

Shoulder : neglected

3- Shoulder dystocia : Difficulty delivery of shoulders due to :

- Macrosomia & broad shoulders : DM

- Short neck : anencephaly

- Non-rotation of shoulder

4- Locked Twins : In MFP

Front 13

Clinical picture of Obstructed labour

"Impending rupture of uterus" ?

Back 13

A) History :

- Prolonged labour ( > 24H ) with prolonged ROM in spite of good uterine contractions.

B) General Ex. :

- Exhausion of patient due to prolonged labour

- Dehydration Signs : Evident as

Low BP - Rapid pulse - Low Temperature - Dry woody tongue and mucos membranes.

C) Abdominal Ex. :

Palpation

- Uterus : Hard, tender with rapid & strong contractions + BANDL'S RING "Pathological contraction ring" = Transverse or oblique groove across abdomen that rises with time.

- Fetal parts : Difficult to palpate

Auscultation FHS = Inaduible or shows severe distress

D) Vaginal Ex. :

- Vulva : edematous

- Vagina : Dry / hot / balloned to recieve fetus

- Cervix :

- Edematous so appear reformed

- Hanging : Not well applied on presenting part unless fully dilated

- ROM

- Presenting part :

- Not engaged

- Pelvic Caput Succidanum of fetal scalp in vertex presentation :

1- Hide sutures making determination of head position difficult

2- False impression of station of head in pelvis = False impression of descent =

Wait for further descent or apply forceps on non-engaged head = Rupture uterus / Cervical and perineal tears / fetal birth injury.

- Cause of obstruction :

CPD / POP / Neglected shoulder

Front 14

Differential Diagnosis of Pathological retracterd ring ?

Back 14

1- Full bladder Exclude by catheterization

2- Fundal fibroid Not rising with time + No Signs of obstruction

3- Patho. Retraction ring vs Contraction ring

- Prolonged 2nd stage vs occur at any stage

- Felt abdominally vs Only vaginally

- always between vs At any level

UUS & LUS But usually between

- Rises up with time vs Doesn't change pos.

- Maternal distress vs Not Necessarily

Fetal distress / death

- Picture of Impending vs Not present

Rupture :

- Uterus is tonically vs Not tonically retracted

retracted and tender

- Fetal parts can't be vs Can be felt

felt

- Relieved by :

- Only by delivery vs Antispasmodic or GA

Front 15

Complications of obstructed labour ?

Back 15

A) Maternal :

1- Prolonged labour = Maternal exhausiton distress & shock

2- Rupture uterus

3- Prolonged ROM

4- Cord Prolapse

5- Birth tract injury : Cervical / vaginal / perineal laceration

6- Peurperal infection

7- Necrotic obstetric GUF

B) Fetal :

1- Fetal distress & asphyxia

2- birth injuries

3- Intraamniotic infection

4- Prolapse of the cord

Front 16

Managment of obstructed labour ?

Back 16

- Immediate CS with the least possible manipulations is the safest choice.

- Difficulties encountered :

1- Extension of LUS incision with subsequent injury to uterine vessels / bladder,

Avoided by : adequate incision " high as possible in LUS" & C-shaped

2- Impaction of presenting part = difficult extraction of fetus, Avoided by : disimpaction of head vaginally & gentle extraction of fetus
- Precautions :

1- Exploration : of birth canal under anaethesia is essential after any vaginal manipulation to exclude traumatic lesions especially ruptured uterus.

2- No Forceps : High risk of complications especially rupture uterus

Front 17

Soft Tissue Dystocia ?

Definition

Causes

Dx

Mx

Back 17

Definition

Failure of delivery of fetus through maternal passages due to mechanical obstruction by soft tissue.

Causes

1- Large fibroids in douglas pouch

2- Ovarian tumors especially solid ones

Dx :

- Clinically = Abdominal & Vaginal

- US

Mx :

CS Best option

Front 18

Rupture of the Uterus ?

Incidence

Risk factors

Back 18

* Incidence :

- 1/2000 - 1/4000 deliveries

Depend on level of obstetric care so more prevalent in developing countries with inadequate medical servic

- Accounts for 20% of maternal mortality from hemorrhage in obstetric practice.

* Risk Factors :

1- Grand multipara " >90% of cases "

Week uterine wall / Pendulous abdomen / Higher incidence of Macrosomia & Malpresentations & CP due to osteomalacia

2- Uterine Scar CS > Myomectomy

3- Obstructed labour Malpresentations / CPD

4- Obstetric trauma improper forceps use

5- Misuse of uterine stimulants PGL & Oxy.

* Etiology :

A) During Pregnancy :

- Spontaneous rupture = Scar :

1- Prev. CS scar :

- Classic US : 1/3 of cases rupture in late preg.

- LUS scar : Stronger, rarely rupture in preg.

2- Gyn.Op. scar :

Myomectomy / Metroplasty / Perforation

- Traumatic rupture :

Rare = Car accident or fall from height

B) During Labour :

- Spontaneous rupture :

1- Pre-existing uterine scar

2- Obstructed labour :

- Malpresentations

- FPD ( CP / CPD / Hydrocephalus )

- Improper use of uterine stimulants as oxytocin & PGL E1 "Mesoprostol" for augmentation of labour.

- Traumatic rupture :

1- Forceps application before Full C.dilatation

2- Breech extraction before full C.dilataion

3- Internal podalic version

4- Difficult manual removal of placenta

5- Excessive fundal pressure

6- Destructive operations

NB :

Developing = Obstructed labour / Inappropriate instrumental delivery /

Improper use of uterine stimulants

Developed = Prev.CS scar / VBACS

Front 19

Pathogenesis & Mechanism of

rupture uterus ?

Back 19

A) Rupture Uterine Scar :

1- Type :

- CS Commonest to rupture = higher incidence

- Myomectomy Less liable to rupture except if multiple and reaching endometrial cavity

2- Site :

- USCS rupture in 4-9% of cases

- LSCS rupture in 0.2-1.5% = Stronger due to better coaptation

3- Timing :

- During pregnancy more in USCS

- During labour more in LSCS especially in prolonged obstructed labour as USCS is not allowed TOVD

4- PDF for rupture :

- Weak Scar : Improper hemostasis / coaptation

- Erosion : PO Infection / Implantation of placenta over the scar

- Increased pressure : Overdistension by twins or polyhydramnios / Uterine stimulants

B) Rupture of an unscarred uterus :

1- Spontaneous :

In obstructed labour : Progressive thinning and stretching of LUS.
Late in labour + Transverse / longitudinal + Left side of LUS due to dextrorotation

2- Traumatic :
Extension of Cervical tear upwards to LUS

due to forceps application before full cervical dilatation.

Front 20

Sites for rupture of uterus and cause of each ?

Back 20

- Fundal : Perforation

- UUS : Scar
- In between UUS & LUS : Obstructed labour

- LUS : Scar / Forceps + May involve bladder

- Lateral tear : Extension from cervical tear due to forcepsapplication before full cervical dilatation.
MOST dangerous : Injury of descending branch of uterine artery at 3 & 9 o'clock = Broad liagemnt hematoma / Injury of ureters

Front 21

Pathology of uterine rupture ?

Back 21

1- Complete rupture :

Complete disruption of entire mymoetrial thickness including peritoneum.

2- Incomplete rupture :

Rupture doesn't involve visceral peritoneum over the uterus which remain intact.

NB :Uterine Dehiscence :

Seperation of small part of uterine scar with intact peritoneam & fetal membranes = Asymptomatic

Front 22

Clinical picture of rupture uterus ?

Back 22

A) Spontaneous :

- Preceded by Clinical picture of Obstructed laboou

- Symptoms :

Abdominal Pain : Sudden Severe

Vaginal Bleeding : may be severe

Cessation of uterine contractions

- Signs :

1- General :

Hypovolemic shock = severe blood loss

2- Abdominal :

Abdomen Signs of Internal Hge = Tenderness & Rigidity

Fetus Parts easily felt beneath abdominal wall muscles = abnormal acrobatic attitude

FHS Severe bradycardia = Marked distress

Absent = dead = Placental seperation

3- Vaginal :

- Excessive bleeding

- Recession & loss of station of presenting part

- Site of rupture maybe felt vaginally

B) Traumatic :

Suspected after difficut / instrumental delivery with :

1- Excessive vaginal bleeding & Hypovolemic shock after delivery

2- Retained placenta after delivery of fetus & Manual removal reveals rupture

3- Manual exploration of uterus & cervix under GA to confirm diagnosis "Maybe done routinely after difficult instrumental delivery and in VBACS".

Front 23

Management of rupture uterus ?

Back 23

A) Correction of Hypovolemic Shock :

While preparing the patient for immediate laparotomy.

B) Surgery :

Type of surgery depend on :

- General condition, amount of bleeding, state of shock

- Rupture type / site / extent

- Patient age / parity / desire for future preg.

Either :

1- Surgical repair :

- Limited tear / fair general condition / young patient desiring future childbearing :

- Resuture torn muscles + arrest bleeding is

optimum choice

- Successful pregnancy may occur after repair but delivery by CS at 37 Weeks is mandatory to avoid spontaneous rupture.

2- Abdominal Hysterectomy :

Old age with no future desire of child bearing / Extensive teasr / Lifethreatening blood loss

NB :

Dehiscence : Refreshment of scar

Cervical tear : Repair vaginally

Broad ligament hematoma : Evacuation + bilateral ligation of anterior division of uterine artery

Front 24

Complications of ruptured uterus ?

Back 24

A) Maternal :

1- Mortality Bleeding > Anaethesia > DIC

2- Morbidity

Injury to bladder / ureters / uterine artery = BLH

B) Fetal : Mortality in 100% Placental seperation

Front 25

Uterine dysfunction ?

Definition

Classification

Back 25

- Definition :

Difficult labour "Dystocia" due to abnormal uterine action in which uterine forces are insufficiently strong or inappropriately coordinated to efface and dilate cervix & Expell fetus.

- Classification :

A) Uterine overactivity :

1- Percipitate labour : No obstruction

2- Obstructed labour : Obstruction is present

B) Uterine Inertia :

Underactive uterus with fetus inside

1- Hypotonic Inertia

2- Hypertonic Inertia

Front 26

Physiology of uterine contractions ?

Back 26

- Physiological control of myometrium :

Depend on Balance between :

E & PRG & PGs & Oxytocin & cAMP & Ca & B2 receptors.

- Initiation of labour :

Change in balance between these factors favouring increase in uterine activity & Onset of labour

- Waves of excitation :

Begin at fundus & travels downward to LUS.

- Normal Uterine Contractions :

Paralleled with cervical effacement & dilatation and descent of presenting part though birth canal

- Assessment of uterine activity :

- Frequency / Amplitude / Duration / Resting tone of Ms

- Normally : 3 contractions / 10 mins each is 50-60 seconds

- Done by :

1- Tocography : graphic recording of previous factors
2- CTG : same but coupled with FHR

- Assessment of uterine work :

Evaluated by Montevideo units through :

Substracting baseline uterine pressure from peak uterine contraction pressure for each contraction in a 10 mins window and adding pressure generated by each contraction.

Front 27

Precipitate labour ?

Definition

Causes

Diagnosis

Back 27

- Definition :

Rapid expulsion of fetus through birth canal in a duration less than 4 hours

- Causes : Common in MP

- Due to : Strong co-ordinated uterine contractions & Absence of obstruction of birth canal or resistance of cervix

- Leading to : Rapid cervocal dilataion & effacement + Rapid expulsion of fetus through birth canal

- Dx :

- Retrospective Dx as the patient is usually seen in 2nd or 3rd stage of labour

- The patient doesn't feel except the last contraction during fetal expulsion.

- If Discovered during 1st stage : Partogram shows rapid progress of cervical dilatation and effacement

Front 28

Complications of Precipitate labour ?

Back 28

A) Maternal :

1- Birth tract injury : Cervical / Vaginal / Perineal lacerations

2- Inversion of uterus

3- Shock : Hypovolemic + Neurogenic

3- Atony : uterine exhaustion

PP Hge / Retained Placenta

5- PP Hge : Atonic + Traumatic

6- Sepsis : Delivery in unsuitable surroundings

B) Fetal :

1- Asphyxia

- Excessive uterine contractions with short recovery period in between

- Late suction of secetions

2- ICH

- Rapid compression & decompression of head during felivery through bony pelvis

- Hitting the floor if long cord

3- Avulsion of cord especially if short

Front 29

Managment of Precipitate labour ?

Back 29

1- Prophylaxis :

Patient with Past Hx of Precipitate labour should be admitted to hospital at first perception of labour pains

2- During 1st Stage : If discovered

- Slow down course of delivery by :

Prevention of forcible bearing down using Sedation and epidural analgesia.

3- During 2 & 3 stage :

- Inhalation analgesia via NO + O2 inhalation

- Allow slow controlled delivery of presenting part and avoid forcible bearing down

- Enusre complete expulsion of placena

4- After Delivery :

- Mother :

-Exploration of birth canal for any injury and manage accordingly

- Prophylactic Antibiotics if delivery in unsuitable conditions.

- Fetus : Proper Examination of fetus to detect complications.

Front 30

Excessive uterine contractions and retractions = Obstructed labour ?

Back 30

Due to : Variable degrees of FPD or CP

UUS : Marked retraction and thickening

LUS : Marked stretching and thinning

Bandl's ring : transverse groove between UUS & LUS that is seen abdominally and rises with continuous retraction toward level of umblicus

Complications : Unless obstruction is dealt with = Rupture of thinned out LUS

Front 31

Hypotonic uterine inertia ?

Definition

Classification

Causes

Back 31

- Definition : Prolonged labour due to weak, infrequent & ineffective uterine contractions.

- Classification :

1- Primary : Poor contractions from the start of labour

2- Secondary : Contractions become weaker after prolonged labour due to Ms exhaustion.

- Etiology : Unknow but associated with the following factors :

A) General :

1- Primigravida especially elderly

2- Anemia / Chronic disease / HTN

3- Nervous anxious patient

4- Improper use if analgesics

B) Local :

1- Uterine overdistension : twins & Polyhyd.

2- Uterine anomalies:Uni/Bicornuate & Septate

3- Uterine Fibroids : interfere with proper cont.

4- Malpresentation & Malpositions

5- induction of preterm labour

6- Full bladder & Rectum

Front 32

Clinical picture of Hypotonic inertia ?

Back 32

A) Symptoms : Prolonged labour

B) Signs :

- Abdominal examination : A hand on fundus

Weak contractions , Infrequent < 3 in 10 Mins & Each lasting less than 30 Seconds

- Monitoring by :

1- Partogram : Prolonged labour in various stages : prolonged latent phase / protraction disorders / arrest of of cervical dilatation.

2- Tocodynamometer :

External monitoring by a sensor on abdomen

Infrequent contractions of a short duration with poor increase in uterine tone.

- Vaginal Ex. :

- Slow cervical dilatation & Effacement

- Intact membranes

- Mother & Fetus : Usually not seriously affected especially when membranes are intact

- If persistant after delivery :

- Retained placenta : prolonged 3rd stage

- Atonic PP Hge

Front 33

Complications of Hypotonic inertia ?

Back 33

A) Maternal :

Prolonged 1st stage :

- Nervousness & Anxiety

- Exhaustion

- Starvation ketoacidosis

Prolonged 2nd stage :

- Increased incidence of CS

- Increased incidence for instrumental delivery

= Birth tract injury

Prolonged 3rd stage :

- Retention of placenta

- Postpartum Hge : Atonic & Traumatic

Remote :

- Peurperal sepsis

B) Fetal : None if intact membrane

Front 34

Managment of hypotonic inertia ?

Back 34

A) General measurment :

1- Ensure that the patient is truly in 1st stage of labour not in prelabour stage by identification of true labour pains : rhythmic / increase in strength & frequency & duration / accompanied by bulge of bag of fore waters & Cervical dilatation.

2- Exclude CPD & Malpresentations that are managed accordingly

3- Managment of 1st stage of labour

"Mention only steps"

B) Uterine Stimulants : Oxytocin stimulation

Aim : Increase strength / frequency / duration of contractions

Administration :

1 ampuole = 10 units

- PG = 5 Units, MG = 1 Unit In 500 ml lactated ringer so every 1 ml = 10 m IU of oxytocin

- Continuous IV drip best using automated computer adjusted infusion pump

"10 drops/min, Maximum = 50 drops/mins"

Precautions :

- Close observation of FHR :

Continuous monitoring to detect fetal distress = Late Decceleration pattern "repeated FHR decceleration at end of contraction"

If detected : Stop infusion, reevaluate case and consider CS.

- Assessment of uterine contractions effeciency :

- Clinically by hand on patient's abdomen

- Better electronic via tocodynamometer :

Detect frequency / regularity / duration / strength = adjust dose accordingly

- Continue drip for at least 1 hour after delivery of fetus : Gaurds against retained placenta & Atonic PP Hge

Contraindications :

1- Grandmultipara

2- Uterine scar : Prev.CS / myomectomy

3- Incoordinate uterine action

4- CPD

4- MFP

5- Malpresentations

6- Fetal distress

C) Operative Interference :

1- Artificial ROM :

Effective in cases with polyhydramnios = relieve stretch on uterine ms & release PGLs

2- CS : If fetal distress befoe full cervical dilatation

3- Instrumental delivery by forceps / ventouse : if prolonged 2nd stage with early signs of maternal exhaustion or fetal distress

Front 35

Secondary Hypotonic Inertia ?

Back 35

Definition :

- Weak infrequent ineffective uterine contractions following a prolonged labour with previous good uterine contractions that has failed to overcome obstruction to delivery due to exhaustion of uterine ms.

Mostly in Primigravia

Mx :

- Careful examination to detect cause of obstruction

- CS is usually the solution

Front 36

Hypertonic inertia ?

Defintion

Causes

Back 36

- Definition :

Prolonged labour due to incoordinated uterine contractions.

- Causes : Unknown

Mostly in PG associated with :

1- Anxiety

2- Repeated rough manipulations

3- Maluse of oxytocin

4- CPD / Malpresentations / Malpositions

Front 37

Clinical picture of Hypertonic inertia ?

Back 37

* Clinical Picture :

A) Symptoms :

- Prolonged labour

- Painful uterine contractions in which pain precedes and outlasts contractions + Low back ache

B) Signs :

- Uterine contractions :

- By Abdominal Examination or better by External Tocodynamometer.

- Irregular with high basal tone in between contractions.

- Cervical Effacement & Dilatation :

- Detected on Partogram

- Slow & Ineffecient although strong uterine contractions.

- Vaginal examination :

- Early ROM

- Non engagement of presenting part

Front 38

Complications of Hypertonic Inertia ?

Back 38

A) Maternal :

Prolonged 1st stage :

- Nervousness & Anxiety

- Exhaustion

- Starvation ketoacidosis

Prolonged 2nd stage :

- Increased incidence of CS

- Increased incidence for instrumental delivery= Birth tract injury

Prolonged 3rd stage :

- Retention of placenta

- Postpartum Hge : Atonic & Traumatic

Remote :

- Peurperal sepsis

B) Fetal :

- Asphyxia

- Infection : Prolonged rupture of membranes

- Intracranial Hge

Front 39

Managment of Hypertonic inertia ?

Back 39

A) General :

1- Exclude CPD

2- Proper Mx of 1st Stage of labour

B) Specific :

1- Sedatives + Antispasmodics + Epidural analgesia :

Control hypertonic inertia and allow regaining normal uterine action with progressive cervical dilatation and progression of labour normally.

2- Cesarean Section :

1- CPD

2- Fetal distress before full cervical dilatation

3- Failure of analgesia to regain normal uterine action & Progressive cervical dilataion

Front 40

Contraction "Constriction" ring ?

Definition

Time

Site

Aetiology

Back 40

Definition :

Persistant localized annular spasm uterine muscles

Time : Any stage of labour

Site : Any part of the uterus but usually at the junction of upper & lower segments

Cause : Unknown mostly in PG associated with

1- Repeated rough intrauterine manipulations

especially under light anathesia

2- Maluse of uterine stimulants :

Oxytocin in hypertonic inertia

3- Malpresentations / Malpositions

Front 41

Diagnosis & Differential Dx

of Contraction ring ?

Back 41

A) Symptoms :

- Preceded by : Colicky uterus mostly in PG

- Suspected if :

1st Stage : Arrest of cervical dilatation

2nd Stage : Prolonged 2nd stage without any obvious cause / failed forceps & Ventouse

- 3rd Stage : Hour glass contraction of uterus / Retained placenta / Post partum Hge

B) Examination :

-Not felt abominally

- Only diagnosed by PV examination by feeling it with hand introduced inside uterus.

- Usually lies opposite to fetal neck mostly at junction between UUS & LUS

* Differential Dx : Bandl's Ring

Front 42

Managment of Constriction Ring ?

Back 42

1- Exclude CPD / Malpresentation & Malpositions

2- Analgesia + Antispasmodics or better epidural / spinal analgesia

3- 2nd stage

- Deep general anaethesia till ring disappears

- Deliver fetus immediately by Forceps

- If Failed Forceps or ring below presenting part = CS

- If persistant in spite of GA = Vertical incision of LUS to cut the ring

4- Retained Placenta Due to hour glass contraction of uterus in 3rd stage :

Deep general anathesia then manual removal of placenta