intensity duration propagation of the uterine contractions normally: triple descending gradient of...

Intensity

Duration

Propagationof the uterine contractions

Normally:

Triple descending gradient of activity

Early labor contractions at 3-5 min, 20-30 mmHg

Active labor contractions at 2-4 min, 30-50 mmHg

+ pushing 100-150 mmHg

Resting pressure 5-10/12-14 mmHg

Duration 30-60/60-90 seconds

hypoactivestates

HYPERACTIVEstates

Incoordinatestates

hpokinetics

I: i.a. p < 25 mmHg

F: < 2/10 min

hypotoniauterine tonus< 10 mmHg ± Associated

UA 50-100 UM

inert

HYPERKINETICS

I: i.a. p > 70 mmHg

F: > 6 / 10 min

UA > 250 UM

HYPERTONIAbasal tonus > 35 mmHg ± Associated

Dyskinetics

I, F, durate, interval anarchic

+ H: miometrial

tetany

+ h tonia

Ectopic centers – fibrilation

Asincronism

Upword propagation of the contractile wave

Primitive (labor onset): organic causes, neuro-hormonal defects, Hyp/hyp disfunctions, diabetes, obesity,

Hypertiroidy,PIH

Secondary (during labor): overdistension of the uterus, intempestive RM, excessive sedation

Uterine malformations, H.excitability,

obstacles (praevia tumors, narrow pelvis,

fetal malpositions/ malformations, big

fetus), excess of oxytocin

Malformations of the uterus, deviation of the

cervix, adherent membranes,disproport

ions, malpositions of the fetal head,

hormonal/nervous dysfunctions

+ Epidural analgesia

Chorioamniotitis

Maternal position

Clinical diagnosis tocometry minimum 15 min

VDE: progress of the presentation,

dilatation of the cervix

clinical signs of fetal distressDilation does not progress, tensed membranes, lack of presentation progress, long

durate of labor, fetal distress

Intense pain, anxiety, frequent,strong, but

ineffective contractions, rigid oedematous cervix,

no progress of the presentation, Ht+Hk,

prerupture syndrome,fetal distress

Abnormal contractions, the

cervix fail to dilate, oedema of the

cervix

ParaclinicallyTocometry/tocography (external by tocodynamimeter, internal transducer)

Phonocardiogram

Fetal ECG

pH of the fetal scalp

Continous carefully follow-up

during labor

Prognosis

Maternal goodProlonged labor

Tiredness/exausted patient

Intraamniotic infection

Obstetrical manoeuvres

Sudden delivery

Lesions of the soft tissues

Fetal

good

fetal distress

reserved/bad

Prophylaxy

correct management

of labor

correct use of drugs

correct amniotomy

Promptly diagnose the abnormalities in labor, correction

AT THE RIGHT TIME

ManagementEnema, amniotomy,

Oxytocin 1 UI/100 ml Hartman sol/glucose

10 drops/min, increase every 30 min

Csection/forceps/vidextraction

Stop oxytocin if in place

Tocolitics,amniotomy, spasmolitics (ivp), analgesia, anaesthesia

Csection/Embriotomy

spasmolitics, oxytocin, amniotomy, Csection

Specific forms

“Hypertonia” in hydramnios

Hypertonia in Utero-Placental Apoplexy

Constriction ring dystocia (Demelin, Schickele)

Hyperactive lower uterine segment

Colicky uterus

Pathological bony pelvis

Dimensions

Shape

Pubic arch

morphological

ethiological

dimensional

Classification

Morphological classification

ring shaped pelvis (flat sacrum)

funnel pelvis

narrow pelvis (all dimensions smaller than normal)

flat pelvis - antero-posterior

flat pelvis - transversal

assimetric

1. Pathology of the hole bony system

dwarfism (endocrine, rachitic, achondroplazic)

narrow pelvis

rickets (atrophy, deformities)

narrow and a-p flat pelvis

osteomalacia (deformities)

triradiate pelvic brim

Ethiological classification

2. Diseases of the pelvic bones•congenital

•inflammatory

•tumors

•traumatic

Naegele pelvis, Robert, Litzman

Assimetric pelvis

Obstructed pelvis

Smaller pelvis due to fractures or calus

Causes in the pelvisDevelopmental (congenital):

Small gynaecoid pelvis (generally contracted pelvis).Small android pelvis.

Small anthropoid pelvis.Small platypelloid pelvis (simple flat pelvis).Naegele’s pelvis: absence of one sacral ala.Robert’s pelvis: absence of both sacral alae.

High assimilation pelvis: The sacrum is composed of 6 vertebrae.Low assimilation pelvis: The sacrum is composed of 4 vertebrae.

Split pelvis: splitted symphysis pubis.Metabolic:

Rickets.Osteomalacia (triradiate pelvic brim).

Traumatic: as fractures.Neoplastic: as osteoma.

Naegele’s pelvis: absence of one sacral ala.

Robert’s pelvis: absence of both sacral alae.

3. Spinal diseasesLordosis

Kyphosis

Scoliosis

Spondylolisthesis

Flat a-p pelvis

Funnel pelvis

Deformities

Causes in the spine• Lumbar kyphosis.• Lumbar scoliosis.• Spondylolisthesis: The 5th lumbar vertebra with the above vertebral column is pushed forward while the promontory is pushed backwards and the tip of the sacrum is pushed forwards leading to outlet contraction.

4. Diseases of the lower limbs

• coxo-femural arthrosis

• coxo-femural displasia

• amputation of one limb

• congenital

• post traumatic/surgery

Causes in the lower limbs

•Dislocation of one or both femurs.•Atrophy of one or both lower limbs. N.B. oblique or asymmetric pelvis: one oblique diameter is obviously shorter than the other. This can be found in:

•Naegele’s pelvis.•Scoliotic pelvis.•Diseases, fracture or tumours affecting one side.

Minor disproportion

(borderline contracted pelvis, on the limit of normal)

Obstetrical conjugate 10,5 - 9 cm

Mild disproportion

(first degree contracted pelvis

Obstetrical conjugate 9 - 7 cm

! Severe disproportion

(second degree contracted pelvis

Obstetrical conjugate < 7 cm

Diagnosis of contracted pelvis

History

Examination

General

Abdominal

Vaginal digital exam

HistoryRickets: is expected if there is a history of delayed walking and dentition.Trauma or diseases: of the pelvis, spines or lower limbs.Bad obstetric history: e.g. prolonged labour ended by:

difficult forceps,caesarean section or still birth.

ExaminationGeneral examination:

Gait: abnormal gait suggesting abnormalities in the pelvis, spines or lower limbs.

Stature: women with less than 150 cm height usually have a contracted pelvis.

Spines and lower limbs: may have a disease or lesion.

Manifestations of rickets as:square head,

rosary beads in the costal ridges.pigeon chest,Harrison’s sulcus and bow legs.

Dystocia dystrophia syndrome: the woman is short, stocky, subfertile, has android pelvis and masculine hair distribution, with history of delayed menarche.

Abdominal examination:

Nonengagement (up situated head) in the last 3-4 weeks in primigravida.Pendulous abdomen: in a primigravida.Malpresentations: are more common.

Pelvimetry

Externalpelvimetry

antero-post. diameter 20 cmbispinous 24 cmbicrestal 28 cm

bitrochanterian 32 cmbase of Trillat triangle 12 cm

diamant of Michaelis 11/10 cm(4 cm sup.+7 inf., 5+5)

biischiatic 11 cm

Internal pelvimetry

Diagonal conjugate 12 cm- 1,5 cm

True conjugate 10,5 cmInterspinous diameter 10 cmSacral promontory position

Subpubic angle

Imaging pelvimetry: US, X-ray CT, MRI

Prognosis

Fetal: RESERVED

Maternal: RESERVED

Abnormal presentation

Malposition of the presenting part (deflected head)

Large baby (4000 g)

Congenital malformations (hydrocefaly, tumors of the neck)

Contracted pelvis + abnormal presentation or large baby =

C section

In other casesaccording to the severity of contraction

Second degree contracted pelvis: Csection (alive or dead fetus)

First degree contracted pelvis: C section (alive fetus) or embriotomy (dead fetus)

Minor disproportion: TRIAL OF LABOR