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42 Cards in this Set
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Contracted Pelvis ? Definition |
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. |
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Aetiology of Contracted Pelvis ? |
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." |
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Causes of Asymmetrical Pelvis ? |
1- Naegle's Pelvis 2- Scoliosis 3- Unilateral lower limb fracture / tumor 4- Unilateral lower limb disease "Polio." |
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Diagnosis of Contracted Pelvis ? |
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. |
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Clinical Pelvimetry ? |
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 |
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Cephalopelvic Disproportion tests ? Definition Value Tests Interpretition |
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 |
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Complications of Contracted Pelvis ? |
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 |
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Management of labour in CPD ? |
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 |
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Trial of Labour ? Definition Selection Conduct |
- 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" |
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Indications of CS in CPD ? |
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 |
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Contracted Outlet / Funnel Pelvis ? Definition Features Mechanism of labour Managment |
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 |
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Obstructed Labour = Dystocia = Pathological retraction ring = Impending rupture uterus ? - Definition - Causes |
- 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 |
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Clinical picture of Obstructed labour "Impending rupture of uterus" ? |
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 |
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Differential Diagnosis of Pathological retracterd ring ? |
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 |
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Complications of obstructed labour ? |
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 |
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Managment of obstructed labour ? |
- 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 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 |
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Soft Tissue Dystocia ? Definition Causes Dx Mx |
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 |
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Rupture of the Uterus ? Incidence Risk factors |
* 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 |
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Pathogenesis & Mechanism of rupture uterus ? |
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. 2- Traumatic : due to forceps application before full cervical dilatation. |
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Sites for rupture of uterus and cause of each ? |
- Fundal : Perforation - UUS : Scar - LUS : Scar / Forceps + May involve bladder - Lateral tear : Extension from cervical tear due to forcepsapplication before full cervical dilatation. |
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Pathology of uterine rupture ? |
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 |
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Clinical picture of rupture uterus ? |
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". |
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Management of rupture uterus ? |
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 Dehiscence : Refreshment of scar Cervical tear : Repair vaginally Broad ligament hematoma : Evacuation + bilateral ligation of anterior division of uterine artery |
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Complications of ruptured uterus ? |
A) Maternal : 1- Mortality Bleeding > Anaethesia > DIC 2- Morbidity Injury to bladder / ureters / uterine artery = BLH B) Fetal : Mortality in 100% Placental seperation |
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Uterine dysfunction ? Definition Classification |
- 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 |
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Physiology of uterine contractions ? |
- 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 - 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. |
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Precipitate labour ? Definition Causes Diagnosis |
- 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 |
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Complications of Precipitate labour ? |
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 |
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Managment of Precipitate labour ? |
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. |
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Excessive uterine contractions and retractions = Obstructed labour ? |
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 |
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Hypotonic uterine inertia ? Definition Classification Causes |
- 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 |
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Clinical picture of Hypotonic inertia ? |
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 |
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Complications of Hypotonic inertia ? |
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 |
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Managment of hypotonic inertia ? |
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 |
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Secondary Hypotonic Inertia ? |
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 |
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Hypertonic inertia ? Defintion Causes |
- 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 |
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Clinical picture of Hypertonic inertia ? |
* 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 |
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Complications of Hypertonic Inertia ? |
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 |
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Managment of Hypertonic inertia ? |
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 |
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Contraction "Constriction" ring ? Definition Time Site Aetiology |
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 |
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Diagnosis & Differential Dx of Contraction ring ? |
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 |
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Managment of Constriction Ring ? |
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 |