Presented by : Asmaa Beltagy. 194 Supervised by: Prof.dr.Hossam Ibrahim Azab.

Objectives
What are forces of normal labour?
Uterine contraction: Anatomical and physiologic considerations Uterine contractions throughout pregnancy and labour Methods of assesment of uterine contractions Effects of uterine contractions

Bearing down efforts Abnormalities of uterine contractions

I-Involuntary

II-Voluntary

Others

Uterine Contractions

Bearing down efforts

elastic recoil of birth canal.

gravity.

I-Uterine contractions
The uterine musculature during pregnancy is arranged in three strata:

An outer longtudinal layer.

An oblique middle layer. An internal layer.

The uterus in pregnancy is functionally divided into:

Upper uterine segment.

Lower uterine segment.

Constitutes the upper 3/4 of the uterus. Active contractile part of the uterus. It's muscle fibres contract and retract.

Constitutes the lower 1/4 of the uterus. It is Stretched and thinned out part.

The cervix.

thinned and taken up .

 Physiological retraction ring: a ridge around the inside of the uterus that forms at the junction of the thinned lower uterine segment and thickened upper segment.

Pathological Retraction Ring (Bandls ring) It is a retraction ring during obstructed labour due to marked retraction and thickening of the upper uterine segment while the lower segment is markedly stretched and thinned.

Physiological properties of uterine contractions:

1. Contraction:
It is temporary shortening of muscle fibres.

2. Retraction:
It is permanent shortening of muscle fibres contractions and retractions contribute to: a. Taking up (effacement) of the cervix. b. Reduction of uterine volume and Expulsion of the fetus. 3. Progressive: increase in intensity and frequency with time. 4. Effective.

5. co-ordination
The pace-maker:
The uterine pace-maker lies just anterior to the uterotubal-junction i.e. at the uterine cornu

Polarity Triple descending gradient Fundal-dominance

Important definitions:
1. Rest tone:
in between uterine contractions (6-12 mmHg).

2. Amplitude:
The amount of rise of the intra-uterine pressure caused by the contractions: 1st stage 40-60 mm Hg 2nd stage 80 mm Hg

3. Frequency of contractions:
The number of contractions/unit of time (10 minutes).

4. Uterine activity:
measured by Montevideo units. = Intensity X frequency over 10 minutes period. Inadequate uterine contractions, defined as less than 180 Montevideo units Or Alexandria units= montivideo units mean duration of each contraction.

Uterine activity throughout pregnancy and labour

1. In early pregnancy:
felt by P/V Palmer's sign.

2. Braxton Hicks Contractions:

also known as practice contractions, are sporadic Painless uterine contractions that are Felt abdominally from 16 weeks up to 36 weeks:

 False labour pains

infrequent, occur after 36 weeks, irregular Of short duration. Highest amplitude 10-15 mmHg. Respond to analgesics. No effect on the cervix. No bulging of the membranes. increasing in intensity and frequency and becoming more rhythmic

 true labour pains :

Painful contractions: Abdominal-Pain : Backache: Regular Don`t respond to analgesics Increased amplitude up to 60 mmHg. Frequency: 2-4/10 minutes. Progressive dilatation and effacement of the cervix. Membranes are bulging during contractions.

False labour pains

Less painful infrequent

True labour pains

More Painful More Frequent.

increases after 36 weeks

irregular Regular

.
Amplitude less than 10-15 mmHg Respond to analgesics No effect on the cervix. Increased amplitude up to 60 mmHg. Don`t respond to analgesics Progressive dilatation and effacement of the cervix. Membranes are bulging during contractions.

No bulging of the membranes.

Methods of assessment of uterine contractions: 1. Manual palpation. 2. External tocodynometry. 3. Internal manometry (intrauterine catheter).

Effects of uterine contractions

A) Descent of the fetus: 1- Before ROM: Generalised intraamniotic pressure:

 2- After ROM :Direct fetal axis pressure:

 B) Cervical effacement: contractions and retraction of the uterinelongtudinal fibers and dilatation The dilatation of the cervix is the result of two factors: active: retraction of the longitudinal fibers of the uterus. Passive: the downward push of the bag of water

 C) Expulsion of the placenta

 D) Control of bleeding from placental site :

II-Bearing down efforts

When to start ? At the end of first stage (onset of second stage) after full cervical-dilatation. Must be simultaneous with uterine contractions.

When to stop? With crowning of fetal head

 Contraindicated in:

Abnormalities of uterine powers:

Over-efficient uterine action

Inefficient uterine action

Precipitate labour:

Bandl`s ring

Hypotonic inertia

Hypertonic inertia

Constriction (contraction) ring

PRECIPITATE LABOUR
Definition
A labour lasting less than 3 hours.

Aetiology
It is more common in multiparas with: strong uterine contractions, small sized baby, roomy pelvis, minimal soft tissue resistance.

HYPOTONIC UTERINE INERTIA

Definition
The uterine contractions are infrequent, weak and of short duration.

Types
Primary inertia Secondary inertia

 Aetiology
the following factors may be incriminated: Primigravida particularly elderly. Anaemia and asthenia. Nervous and emotional as anxiety and fear. Overdistension of the uterus. Myomas of the uterus interfering mechanically with contractions. Malpresentations, malpositions and cephalopelvic disproportion. Full bladder and rectum.

HYPERTONIC UTERINE INERTIA (Uncoordinated Uterine Action)

The condition is more common in primigravidae and characterised by: Prolonged labour. Uterine contractions are irregular and more painful. High resting intrauterine pressure in between uterine contractions Slow cervical dilatation. Foetal and maternal distress.

CONSTRICTION (CONTRACTION) RING

It is a persistent localised annular spasm of the circular uterine muscles. at any part of the uterus but usually at junction of the upper and lower uterine segments. occur at the 1st, 2nd or 3 rd stage of labour.

Thank you:)