Session 17: Care of a Woman with

Abnormal Uterine Action

Mwl. Mathew
2 Learning Tasks

At the end of this session, a learner is expected to be able

to:

∙ Define abnormal uterine action

∙ Describe types of abnormal uterine action
∙ Describe causes of abnormal uterine action
∙ Care of a pregnant woman with abnormal uterine action

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3 Definition of Uterine Action

∙ Abnormal uterine action is any deviation from normal

pattern of uterine contractions affecting the normal
course of labour.
∙ Its one of the factors causing dystocia (difficult labor) in
which uterine forces are insufficiently strong or
inappropriately coordinated to efface and dilate the cervix
(uterine dysfunction).

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4 Classifications or Types of Abnormal
Uterine Action
∙ Over-efficient uterine action
o Precipitate labour in absence of obstruction.
o Excessive contraction and retraction in presence of
obstruction.

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5 Classifications or Types of Abnormal
Uterine Action …
∙ Inefficient uterine action
o Hypotonic inertia
o Hypertonic inertia
▪ Colicky uterus

▪ Hyperactive lower segment

o Constriction ring
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6 Classifications or Types of Abnormal
Uterine Action …
Cervical Dystocia

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7 Care of Woman with Abnormal Uterine
Action
Over-efficient uterine action
∙ Precipitate labour Is the type of labour due to strong
coordinate uterine contractions from the onset of labour,
which results in abnormally rapid progress and delivery within
three hours of its commencement (excessive with or without
obstruction)

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8 Causes of precipitate labour

o It is more common in multiparas when there are;

▪ Strong uterine contractions
▪ Small sized baby
▪ Roomy pelvis
▪ Minimal soft tissue resistance

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9 Diagnosis

o It is a retrospective diagnosis as the patient is usually seen in

the second or third stages of labor.

o If seen during the 1st stage of the labor, the partograph will
show rapid progress of cervical dilation and effacement.

o If seen after delivery, examination of the mother and infant

should be performed.

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10 Care of a woman with precipitate labour

o The woman with past history of precipitate labour, should be

admitted to the hospital at the first perception of labour pain.
o Inhalation anaesthesia as nitrous oxide and oxygen is given
to slow the course of labour.
o Tocolytic agents as ritodrine may be effective.
o Episiotomy may be preformed to avoid perineal lacerations
and intracranial haemorrhage

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11 Care of a woman with precipitate labour…

o After delivery exploration of the birth canal for any injury

should be done and manage accordingly.

o Give the mother prophylactic antibiotics if delivery occurred in

unsuitable conditions.

o Proper examination of the fetus for detection of injury and any

complications.

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12 Complication of precipitate labour

o Maternal
▪ Lacerations of the cervix, vagina and perineum
▪ Shock
▪ Inversion of the uterus
▪ Postpartum haemorrhage
▪ Sepsis due to lacerations and inappropriate surroundings
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13 Complication of precipitate labour …

o Foetal
▪ Foetal Intracranial haemorrhage due to sudden compression
and decompression of the head
▪ Foetal asphyxia due to strong frequent uterine contractions
reducing placental perfusion and lack of immediate
resuscitation
▪ Avulsion of the umbilical cord
▪ Foetal injury 11/13/2023
14 Overstimulation of the uterus

Excessive use of syntocinon or prostaglandin may result

in titanic contractions with inadequate periods of
relaxation between them.

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15 Management

o Inform the doctor for immediate management.

o The administration of syntocinon or prostaglandins must
be stopped at once.
o Nurse the mother on her left side and monitor fetal heart
rate frequently.
o Puffs of a ventolin inhaler to reduce severe contraction.
o Administer oxygen in case fetal bradycardia.

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16 Complications

o Fetal hypoxia due to uterine spasm which reduces the

placento-fetal oxygen.
o Precipitate labour due to overstimulation of the uterus.
o Progress of labour may be slow due to lots of retraction.
o Uterine rupture in cases of some degrees of disproportion.

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17 Inefficient uterine contraction

Definition

∙ Uterine action is said to be inefficient when the

contractions do not effectively dilate the cervix.

∙ Progress in labour is slow and length of labour is

prolonged.

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18 Classification of inefficient uterine
contractions
∙ Hypotonic uterine inertia
o The contractions are weak, short and infrequent.

o The result is slow dilatation of the cervix or non.

o Hypotonic uterine action may be primary; occurring from the

onset of labour or secondary; developing during the course
of the previously normal labour.
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19

∙ Hypotonic uterine inertia …

o The cause of primary hypotonic is unknown but it is most
found in primgravida.

o Secondary hypotonic uterine action may be due to

cephalopelvic disproportion, malpresentation or malposition of
the fetal occiput.

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20 Management of hypotonic uterine action

• Encouragement and support from the midwife is

necessary
• Perform vaginal examination to exclude disproportion
or malpresentation or malposition and manage
according to the case
• Proper management of the first stage
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21 Management of hypotonic uterine action …

• Prophylactic antibiotics in prolonged labour

particularly if the membranes are ruptured.
• Artificial rupture of membrane can be done if still
intact providing that;
o Vaginal delivery is amenable.
o The cervix is more than 3 cm dilatation.
o The presenting part occupying well the lower uterine
segment.
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22 Management of hypotonic uterine action …

• Set intravenous infusion of cyntocinon, providing that

there is no contraindication for it.
• Maintain fluid and electrolyte balance and give
analgesia as required.
• Perform vaginal examination 2-4hourly interval to
assess cervical dilatation and use the partograph to
monitor labour progress.
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23 Management of hypotonic uterine action …

• You can perform operative delivery, vaginally either by

forceps, vacuum or breech extraction according to the
presenting part and its level providing that:
o Cervix is fully dilated and vaginal delivery is amenable.

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24 Complication of Hypertonic Inertia

• Nervousness and anxiety

• Exhaustion and starvation ketoacidosis
• Prolonged second stage
• Increased liability for instrumental delivery and C/S
• Retention of placenta and postpartum haemorrhage
▪ Subinvolution of the uterus
▪ Risks of abuse of uterine stimulants
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25 Hypertonic uterine inertia (Incoordinate
Uterine action)
• There are of two types

o Colicky uterus: Incoordination of the different parts of the

uterus in contractions.

o Hyperactive lower uterine segment: So the dominance

of the upper segment is lost.
▪ The condition is more common in primigravidae and
characterized by:
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26
Hypertonic uterine inertia (Incoordinate
Uterine action) …
• The condition is more common in primigravidae and
characterized by:
o Prolonged labour.
o 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.
o Slow cervical dilatation.
o Premature rupture of membranes.
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o Foetal and maternal distress.
27 Care of a woman with hypertonic inertia

▪ Inform the doctor.

▪ Reassurance to the women is important to promote
comfort as possible.
▪ Perform vaginal examination to exclude disproportion or
malpresentation or malposition.
▪ Proper management of the first stage.
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28 Care of a woman with hypertonic inertia …

▪ Prophylactic antibiotics in prolonged labour particularly if the

membranes are ruptured.
▪ Give intravenous infusion such as Hartmann’s solution to
correct Ketoacidoci’s.
▪ Fluid balance chart is kept and all specimens of urine are
tested for presence of ketones.
▪ Frequent mouth wash is given so that woman’s mouth remains
moist and fresh. 11/13/2023
29 Care of a woman with hypertonic inertia …

▪ Pain relief is essential to rest the woman from pain.

▪ Monitor fetal heart and uterine contractions continuously to
exclude fetal distress.
▪ Membranes may be ruptured artificially, and a low-dose of
syntocinon infusion may be commenced to stimulate normal
uterine contractions if the patient is eligible.
▪ Virginal examinations are performed at 2-4 hourly intervals to
assess the progress. 11/13/2023
30 Care of a woman with hypertonic inertia …

▪ Plot the findings on the partograph.

▪ Caesarean section may be performed in case of poor
progress with syntocinon, disproportion or foetal distress
before full cervical dilatation.

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31 Cervical dystocia

Cervical dystocia is the failure of the cervix to dilate

within a reasonable time despite of good uterine
contractions.

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32 Types of cervical dystocia

o Organic (secondary) which is due to: -

▪ Cervical stances as a sequel to previous amputation,

scarring, cone biopsy, extensive cauterization or obstetric
trauma.

▪ Organic lesions as cervical myoma or carcinoma

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33 Types of cervical dystocia …

o 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.

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34 Types of cervical dystocia …

o Functional (primary) …
▪ Also may be due to previous history of failure of external os to
dilate in previous birth, rigid cervix, insufficient uterine
contractions, malpresentations and malposition.

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35 Care of a woman with cervical dystocia

o All cases of dystocia are an obstetric emergency.

o The woman should be admitted in the labour unit and the
obstetrician should be present.
o Anesthetist and pediatrician should be informed.
o Oxytocin can be used if abnormal uterine contraction are
the cause of dystocia.

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36 Care of a woman with cervical dystocia …

o Assisted delivery may be required.

o The mother may need urgent cesarean section

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37 Complication of cervical dystocia

o Perinatal morbidity and mortality from hypoxia and

acidosis
o Brachial plexus injury
o Postpartum haemorrhage
o Perineal tear

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38 Key points

• Uterine action is said to be inefficient when the

contractions do not effectively dilate the cervix.

• Progress in labour is slow and length of labour is

prolonged.

• In hypertonic uterine action the fundal dominance is lost

and the contractions start and last longer in the lower
segment.
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39 Key points …

• Progress in labour is slow and length of labour is

prolonged
• Cervical dystocia means failure of the cervix to dilate
despite good uterine contraction
• Excessive use of syntocinon or prostaglandin may result
in titanic contractions with inadequate periods of
relaxation between them
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40 Thank you

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