Normal / Abnormal Uterine Action

Definitions

Contractions Shortening of muscle with return to its original length Retraction Muscle shortens but does not return to its original length. Muscles becomes fixed at shorter length but tension remains the same Retraction is responsible for descent and control of PPH Physiologic retraction ring As labor and retraction proceed, upper part of uterus becomes thicker and lower gets progressively longer and thinner. Boundary between the two segments is physiologic retraction ring

Definitions

Pathological Retraction Ring Bandls ring exaggeration of physiological ring -- seen in obstructed labor
Constriction ring localised segment of myometrial spasm gripping the fetus preventing descent Tonus lowest intrauterine pressure between contractions 8-12 mm of Hg (Normal resting tension)

Definitions

Intensity or Amplitude rise in intrauterine pressure brought about by each contraction. Measured from baseline resting tonus (30-50mm of Hg) Frequency number of contractions /10 minute Caldeyro-Bracia
Uterine activity

Montevideo unit i.e average intensity of uterine contraction x frequency Alexandria unit i.e. average intensity of uterine contraction in mm of Hg x frequency / 10 min x average duration contraction in minutes

Labour Pains

Normal pain in labour Intermittent, starts with uterine contraction, reaches peak and disappears with relaxation Degree varies in different patients, in same patient in subsequent and in same labor at different stages or may even be painless Causes

Distension of lower pole Stretching of ligaments adjacent to uterus Pressure on or stretching of nerve ganglia around uterus Angina of uterine muscle esp when uterine tonus is high or contractions too frequent or prolonged

Labour Pains
Pain lower abdomen activity of upper segment

Pain low back related to tension in lower uterus and cervix. Usually present in early stages of cervical dilatation. Severe with resistant cervix and in posterior presentations-less the backache more efficient the uterus

Normal Uterine Contractions

By placing hand over uterus or by electronic technique external or internal tocodynamometer frequency duration and strength of uterine contractions can be measured Curve of a uterine contraction is bell shaped. Steep crescentic slope leading to apex of the curve comprises 1/3rd and represents actual power of contraction. Period of relaxation makes up 2/3rd initially steep decrescentic slope that becomes more horizontal in last third

Triple Descending Gradient

Propagation of wave is from above downwards starting from the pacemaker Duration of contraction diminishes as wave moves away from pacemaker. Upper portion of uterus is in action for longer period Intensity of contraction diminishes from top to bottom of uterus. Upper segment contracts more strongly All parts of triple descending gradient must perform in a coordinated manner Caldeyro-Barcia

Triple Descending Gradient

Pacemakers two one at each cornu. Their activities must be coordinated Most efficient moderately low tonus and strong contractions Propagation of wave must also be coordinated

Triple Descending Gradient

Coordination wave begins earlier in some part than other but the contraction attains maximum in the different parts of uterus at the same time. At peak of contraction entire uterus acts as a single unit. Relaxation starts simultaneously in all parts of uterus. For normal uterine action coordination is required between both halves of uterus as well as between upper and lower segments

Triple Descending Gradient

Dilation of cervix

Regular and well fitting presenting part favours efficient uterine action Longitudinal traction on cervix by upper part of uterus as it contracts and retracts. After each contraction the upper segment becomes shorter and thicker while lower segment becomes longer, thinner and more distended and cervix becomes more dilated

Round ligament contraction contain muscles which contract with upper segment. Anchors the uterus and prevents it from ascending in the abdomen and so helps force the presenting part down

Contractions During Pregnancy

Less than 30 weeks frequency and strength of contraction low i.e.<20 Montevideo units After 35 weeks contractions are more frequent and may be noticeable by patient. When painful false labor pains Pre labor associated with cervical ripening and increase uterine activity readiness for true labor. Pre labour merges with true labor , the exact point is difficult to determine

Classification of uterine action

Normal Labor

Intensity or amplitude of contractions vary from 30-50mm of Hg Frequency 2-5 per 10 minutes
Intensity of contraction < 25 (<15 mm of Hg labor does not begin and if begun ceases) Frequency <2 per 10 minute Progress slow and labor prolonged No damage done to mother or fetus

True Inertia

Precipitate Labor

Less than three hours duration Increase in amplitude over 50 may be responsible Mostly lack of maternal tissue resistance Conditions that predispose Multiparity Large pelvis Lax and unresistant soft tissues Strong uterine contractions Small baby Previous precipitate labor Induction Risks maternal lacerations, cerebral haemorrhage, fetal brain damage, fetal asphyxia

Cervical Dystocia

Primary

Achalasia of cervix failure of cervix to relax and open Rigid cervix anatomical abnormality Conglutination of external os- the lips of cervix stay together

Secondary
Post delivery Postoperative scarring Cancer Cervix may rupture or annular detachment may occur

Obstructed Labor

Uterus tends to overcome obstruction Contraction stronger, more frequent and tonus rises Progressive retraction of upper segment - stretching and thinning of lower segment Bandls ring Round ligaments may be palpably tender and tense Severe pain Obstruction unrelieved rupture lower segment. Occassionally uterine inertia due to myometrial exhaustion Fetal demise because of cut off placental circulation due to strong frequent contraction

Contractile waves with inverted gradient

Propagation of wave from above downward Duration of contraction diminishes as wave moves away from pacemaker Intensity of contraction decreases from top of uterus to lower part Varieties of incoordinate action

All three gradients reversed no progress in dilatation or descent Partial one or two gradients reversed slow cervical dilatation Seen in pre labor or false labor. Fetus high, cervix thick, uneffaced and poorly applied presenting part

Inco-ordination of uterus: localised contraction wave

Asymmetric uterine action

Uterine fibrillation

Constriction ring

Pain in incoordinate uterine action

Excessive back pain Persistent high tonus or spasm in some parts of uterus pain even in the intervals between contractions Pain may start even before uterus hardens and persists even after uterus relaxes /softens

DD Constriction / Bandls rings

Constriction Ring

Pathologic Retraction

Localised ring of spastic myometrium May occur any part Muscle at ring thicker Uterus below neither distended nor thin Never ruptures Uterus above ring relaxed, nontender Round ligament not tense May occur in any stage Position of ring does not change Pres part not driven down Fetus wholly/mainly above ring GC good Uterine action inefficient Abnormal polarity Results in obstructed labor

Excessive retraction upper segment Always at junction of upper and lower segment Myometrium much thicker above than below ring Wall below thin and overdistended Uncorrected may rupture Uterus above ring is hard Round lig tense and stand out Usually occur in second stage Ring gradually rises in abdomen Pres part jammed into pelvis Part of child below the ring GC poor Uterine action efficient or overefficient Normal polarity Caused by obstruction

Incoordinate Uterine Action

Aetiology 1-7% - Mild CPD / Abnormal presentations Age/Parity 95% in primis, elderly Constitutional factors Thickset, obese, masculine, relatively infertile Nervous / emotional Uterine factors overdistended uterus, fibroids, scarred uterus, congenital uterine anomalies Rupture of membranes Not well applied presenting part posterior presentations, malpresentations, malpositions, mild CPD Improper uterine stimulation

Clinical Picture

Prolonged labor Uterine hypertonicity / localised spasm increased resting intrauterine pressure Frequent irregular contractions with slow progress Slow cervical dilatation, delay in advancement Labor may become incoordinate at any time PROM with closed uneffaced cervix Severe pain before uterine contractions / severe backache prolonged labor exhaustion dehydration Desire to bear down early urinary retention

Dangers

Maternal

Exhastion Haemorrhage / shock / Infection Birth injuries difficult deliveries Annular detachment
Asphyxia Injuries

Fetal mortality < 15%

Management

Moral boost I.V. infusion of crystalloids RL Empty bladder Sedation and analgesia Uterine stimulation syntocinon, ARM Operative measures

Manual cervical dilatation Forceps rotation and extraction CS

Management

Constriction ring relaxing drugs and forceps extraction / CS Bandls ring CS Cervical Dystocia manual dilation / incisions over cervix