Dystocia of uterotonic and

spasmolytic medication dynamics

Dr. Daniela Dumitru Cărăuleanu

 I. THE PHYSIOLOGY OF BIRTH

 the work is represented by strong UC which have as an effect the dilatation of the cervix and the
flattening of the fetal presentation at the level of the upper strait.

 physiological process by which the fetus is expelled from the uterus

 the work can be divided into 3:

• first part: contraction to clear and dilate the cervix
• Part Two: Expulsion (Undertaking + Release)
• third part: delivery of the placenta

 disturbance of myometrium function during work:

 contractions anomaly
 inefficiency on expansion

Dystocia = difficult delivery

Dyskinesia = labour/childbirth too slow.

 II. ENDOCRINE CONTROL AT WORK- Work initiation 

• etiology is not well known

• Childbirth is the end of a series of hormonal changes that are mediated by the fetus, placenta, fetal
membranes and maternal endocrin e sistem

1. maturation of hipotalamo-hipofizo-suprarenalian ax, which will result in fetal cortisol secretion

2. stimulation of secretion of oxytocin and prostaglandins which are utero-stimulating factors (=work
initiation)
3. decreased placental hormonal secretions (progesterone, prostacyclin, relaxin, hPL) which will have
the effect of stopping the inhibition of the myorelaxing effect caused by these hormones.
4. activation of hormonal receptors in myometrium
5. intrinsecs in the myometrium that determine UC and pogressive dilation of the cervix
 II. ENDOCRINE CONTROL AT WORK- Work initiation:

Thus, the spontaneous beginning of the work, shows the availability of the fetus for birth and the fact
that the mother is phisiologically receptive to this process

The birth initiation is therefore linked to “3 compartments” or components:

 fetal compartment: production of cortisol by fetal adrenals

 placental compartment: secretion of hormones, but mainly CRH = key hormone in initiating the
release of oxytocin.

 maternal compartment: secretion of oxytocin by the pituitary gland.

 III. PHASES OF WORK: Effects of Uterine Contractions

1. Cervical dilation during work

-the cervix is an obstacle to childbirth which is why cervical dilation is essential.
-dilatation during work is not homogeneous.
-the first phase of the work is divided into two:
 a latency phase:
- corresponds to the obliteration of the cervix and the start of its dilatation, from 0 to 4 cm
-the beginning is often difficult to establish
 an active phase:
-acceleration of cervical expansion to full expansion
- is characterized by CU d+, rhythmic which will produce an expansion of > 1.2 cm/h G1 and > 1.5 cm/h Gm

latency phase active phase

primipare 8.6 +/- 0.27 hours 4.9 +/- 0.13 hours

multipare 5.3 +/- 0.19 hours 2.2 +/- 0.07 hours

 IV. PHASES OF LABOUR: Effects of Uterine Contractions

• during work, UC is the primary driver of cervical expansion

• the lower segment of the uterus collects the forces of the uterine body to direct them towards the
cervix.
• erasure and dilatation occur from the internal to the external orifice of the cervix
• Fetal presentation also plays an important role in cervical dilation, as UC, due to increased
intrauterine pressure, results in presentation support on the cervix.
• The disturbances of this dilatation can then be understood when presenting the seat, the face or the
forehead because the collar is not properly applied.
• vaginal touch remains one of the best methods to observe cervical changes (position, consistency,
length, dilatation and height of presentation
• vaginal touch occurs on average every hour
• During work, the measurement of UC is important to diagnose as quickly as possible an
abnormality of uterine dynamics.
 Evaluation of uterine contractions

• UC can then be accurately described: frequency, total intensity (maximum pressure recorded), true
intensity (total intensity minus base tone), duration and base tone (lowest pressure between CU).

• frequency goes from 1 every 15-20 minutes to 3-4 by 10 minutes before expulsion.
• intensity, duration and frequency also increase between the start and end of work
• Cervical dilation only started if the UC has an intensity > 30mmHg.

• the frequency and intensity of contractions are important for good uterine dynamics

• During work, the UC is intermittent, total and affects the entire uterine muscle.

• between the start of work and the end of work, the UC is very different.
 Evaluation of uterine contractions

Tocography is used to evaluate UC.

Two methods can be used to measure contractions:

- external tocography, the most used
a capsule, containing a spring, placed at the level of the uterine bottom, which allows to measure the frequency
and duration of contractions, but does not allow to know the intensity and the tone of base

- internal tocography.
a semi-invasive method requiring prior membrane rupture and 2 cm expansion.
used as a second intention, because of the infectious risk it presents, to measure the true intensity of
contractions, their basic tone and thus make a better diagnosis of dynamic abnormalities

- the unit of measurement of the CU is the Montevideo unit (UM)

- UC assessment and vaginal touch diagnose abnormalities

 Dynamic dystocia
1. Definition:
- Dynamic dystocia = all contractile abnormalities
- “all phenomena which disturb the functioning of the uterine muscle, during work contractions, which may result in
inefficiency in cervical dilatation”

In the presence of an abnormality of cervical dilatation, mechanical dystocia must first be eliminated. It results in fetal
pelvic disproportion (PFD) (narrowed pelvis and/or macrosomy) and abnormal or poorly flexed presentation.
Then we look for dynamic dystocia.

2. Circumstances of Discovery
- it is the analysis of the partogram which makes it possible to diagnose dynamic dystocia.
- it allows to see a defect, a slowness or a stagnation of the dilatation, an anomaly of the partogram, a defect of
progression of the presentation and an anomaly of the UC.

3. Methods of Analysis
- The UC corresponds to the painful subjective sensations felt by the patient, the periodicity and duration of the UC.
- the objective clinic, with the help of the operator’s hand, appreciates to palpate, these same parameters.
- the external tocographic record assesses the frequency of contractions and the internal tocography makes it
possible to know the actual intensity of contractions, their duration and the base tone
- analysis methods will make it possible to qualify dynamic dystocia in two groups: start-up dystocia and dystocia
during work
 Dynamic dystocia- Start-up dystocia

 in situations where there is an absence of cervical dilatation in women, often primiparous, with
painful and poorly tolerated contractions that do not spontaneously give way

 Start-up dystocia are often related to anxiety and agitation caused by UC

 Contractions are irregular, have poor cervix strain and are 5 minutes or more apart

 If the latency phase is greater than 20 h for a nullipare and 14 h for a multipare, then we are talking
about start dystocia

 For WHO the latency phase must be greater than 8 hours to talk about start dystocia

 The more mature the cervix at the beginning of work, the shorter the duration of the latency phase.

 The height of the presentation at the beginning of work seems to be a predictor of dystocia.
 Dynamic dystocia- Start-up dystocia

 Starting dystocia are most often diagnosed by partogram, showing an absence or slowness of cervical dilation.

 They are also diagnosed by tocography, which allows to observe frequency hypokinesia or irregularity of UC

 The treatment of these dystocias is different depending on whether the cervix is rigid with an dilatation < at 2cm,
or whether the cervix is practically erased, flexible with an dilatation at 2cm or almost

 When the cervix is long, rigid with dilatation 2 cm a calming therapy is recommended. This does not require
Syntocinon® infusion.

 If the cervix is virtually obliterated, supple and dilated to almost 2 cm, an infusion of Syntocinon® following
an epidural analgesia is required to regulate UC and make it more effective on the cervix.

 When contractions occur every 2-3 minutes, the membranes can be artificially ruptured if this has not been done
spontaneously
Dynamic dystocia- Start-up dystocia
 Dynamic dystocia- Dystocia in the course of work

• stagnation of dilatation while the patient is frankly in labor, when she has entered the active
phase.

• Hypokinesia is responsible for 30% of dilation abnormalities. This anomaly results in :

• regular but insufficient UC frequencies,
• CU are spaced, less than 2 CU/ 10 min
• CU duration < 25 mmHg (duration hypokinesia)
• Intensity CU < 30 mmHg ( intensity hypokinesia)
• Uterine activity 50-100 UM
• hypotonia (uterine tone < 10 mmHg) is often associated with hypokinesia

• it can be of primary origin (large multiparity, uterine malformation, uterine fibroid) or secondary
(dystocic presentation, DFP, precvia obstacle, uterine overdistension, poorly flexed presentation,
epidural analgesia (APD) too early, excessive use of sedatives or analgesia)

• hypokinesia results in long, tiring work, and often instrumental extractions as well as maternal-
fetal infections, amniotic fluid (LA) tinted, abnormalities of the cardio-fetal rhythm (FCR)
related to fetal suffering and fetal hypoxia
 Dynamic dystocia- Dystocia in the course of work

• The direction of the work is established by artificial rupture of the membranes (RAM) then by the
installation of an oxytocin infusion if there was no response 30 to 60 minutes after the RAM

• Oxytocin produces uterine contractions every 2 to 3 minutes.

• If the fetal presentation is very high, it is recommended that a Syntocinon® infusion be initiated
prior to AMR because of the risk of procidence of the cord.

• When the UC appears sufficient but the dilatation does not progress, it is recommended to install an
internal tocography to check the intensity of contractions

• The direction of the work (amniotomy and use of oxytocin) allows to obtain a reduction of the
working time in case of abnormality of the dilatation, a correct uterine dynamics and a resumption
of the dilatation.

• When dilatation remains the same for 2 hours, even if RCF is correct, C-section is recommended
Dynamic dystocia- Dystocia in the course of work
 Dynamic dystocia- Dystocia in the course of work

 However, there are rhythm anomalies.

 We can sometimes observe bi- or trigeminal contractions, that is to say that two or three
successive contractions are not separated by a return to the base tone between each
contraction.

 This situation is dangerous in case of use of oxytocin, because there is a risk of hypertonia.

 It would therefore be more advisable to use β-mimetics that are utero-relaxing

 Syntocinon® is a first-line treatment to increase the frequency and intensity of uterine

contractions during the initiation or activation of labor to reduce the duration of labor.
 Oxytocics

 Oxytocins - its trade name - Syntocinon®

 a natural hormone: oxytocin, which is identical to that produced by the POSTERIOR PITUITARY
GLAND;

 OXT is the most effective treatment when work is slow

 Oxytocics are powerful uterotonics that accentuate the contractile force of the uterus and regulate
UC

 Indications for use of oxytocin

 The direction of labour during childbirth is indicated in the presence of dynamic dystocia
either at the beginning or during labor.
 in case of dystocic fetal presentation and dystocia of the second phase of labor.
 Work that has been artificially triggered on a mature cervix can also be directed.
 Epidural placement is not an indication of a Syntocinon® infusion
 Oxytocin

The absolute contraindications:

- DFP
- the obstacles ahead
- dystocic presentation (forehead or transverse),
- previous or early fetal pain,
- uterine hypertonia when childbirth is not imminent and drug hypersensitivity

The contraindications relating to:

- the scarred uterus,
- the great multiparity,
- the presentation of the headquarters,
- multiple pregnancies,
- hydramnios,
- cardiovascular disorders,
- severe hypertension (HTA),
- Predisposition to amniotic embolism (in-utero fetal death and retroplacental hematoma).
 Oxytocin

General Effects
- When the dose of injected oxytocin is very high, low blood pressure and tachycardia can be observed followed
by high blood pressure (HTA), bradycardia and increased central venous pressure.

- For a massive dose of Syntocinon® there will be an antidiuretic effect with transient water poisoning. This is
rare but serious, and is related to a massive supply of oxytocin and oxytocin dilution solute.

- This intoxication results in nausea, vomiting, headache, then coma with convulsions and hyponatremia.

Uterine effects
- The Syntocinon® may cause uterine hyperstimulation and hyperkinesia of intensity and/or frequency.

- A high dose will increase the resting tone of the UC.

- We are talking about uterine hyperkinesia or hypertonia.

- We can also see a uterine rupture that remains exceptional, but this risk is increased in case of scarred uterus.
 Oxytocin

Fetal effects

- Acute fetal pain can be the result of hypertonia or uterine hyperkinesia.

- Early, systematic amniotomy and/or administration of high doses of oxytocin are associated with
SCR disturbances

- Such practices therefore require a great deal of caution and oversight.

- It also appears that Syntocinon® is indirectly responsible for neonatal hyperbilirubinemia.

- Oxytocin would weaken fetal red blood cells as a result of hypo-osmolarity induced by
Syntocinon®.

- But this anomaly is found in the presence of a long work, a sero-blood lump or even a
cephalhematoma.
 THE DIFFERENT POSSIBILITIES OF INTERVENTION DURING CHILDBIRTH

Oxytocic treatments: this is the maneuver or medication stimulating/inducing uterine contractions.

Indications:
- Induction of work required
- Simulation of slow work
- R/ uterine atony
- Testing for Fetal Vitality

Types:
- INSTRUMENTAL (releases GPs that lead to myocyte contractions) (RAPE)

- MEDICATED (Oxytocin or PG)

 THE DIFFERENT POSSIBILITIES OF INTERVENTION DURING CHILDBIRTH

Prostaglandins
- Dinoprostone (Prostin®, Prepidil® gel)
- Misoprostol (Cytotec®)

Beware they are VERY POWERFUL because they cause very important contractions

The indications are:

- Maturation of the cervix: We use PG rather than oxytocin when the cervix is unfavourable that it does not adapt
and that we want to provoke the birth
- PG is given in the form of vaginal or rectal supositories (to soften the cervix)
- Expulsion of a stopped pregnancy (miscarriage, IMG)
- R/ from delivery hemorrhage (risk of death for the mother) 
- Ne donne JAMAIS de PG pendant le travail car cela provoque une souffrance fœtale.

Remarque : sécrétion naturelle de prostaglandines lors :

- stripping : stimulation du col avec le doigt : Sécrétion de PG qui peut déclencher l’accouchement !
Particulièrement efficace chez les patientes qui ont déjà un col un petit peu dilaté
- rapport sexuel sans préservatif (le sperme contient des PG)
 Dystocie démarrage / faux travail

Contractions régulières Faux travail

• Espacées >5mn • Contractions irrégulières

• Tendant à se rapprocher • Espacées

• + en + intenses • Intensité irrégulière

• Augmentées par marche • Pas augmentée par marche

• Col : non modifié • Col: non modifié

* Dystocie démarrage

* •Col long , rigide Sédatif IM : –Pétidine ou Nalephine; Salbumol suppo  examen 2 h après si
idem= faux travail

* •Col effacé souple > 2cm ( Bishop >6)  Perfusion de Syntocinon  RAM dès CU toutes les 2
ou 3 min
 Dystocie dynamique en cours de travailm- Hypocinésie

• Définition: de l ’intensité de la durée de la fréquence des CU 6 •Fréquence = 50% des anomalies de la dilatation

• Terrain:
Conséquence de l ’hypocinésie
• multipares
• gemellaires Maternelles :
• hydramnios * fatigue
* augmentation - forceps et ventouses
Fœtales :
• Diagnostic clinique ou tocographique
* Prolongation durée du travail
Fréquence < 3 CU/10 min * Augmentation risque infectieux
Durée < 70 sec * Liquide amniotique teinté
intensité < 30 mmHg
* Anomalie RCF
* Baisse PH<7.25
dilatation < 1.2 cm/h Primipares * SFA Apgar <6
< 1.5 cm/h Multipares

Primitive : multiparité, malformations utérines, fibromes

Secondaire  Surdistention utérine : Grossesse multiple Hydramnios Macrosomie Dysproportion foeto –pelvienne,
obstacle praevia

Iatrogène : utilisation de sédatifs , anesthésiques Péridurale

 CAT devant une hypotonie
* Prévention : déambulation, station debout
* Rompre les membranes si intactes car favorise
la sollicitation du col et accélère la dilatation
* Syntocinon ® jusqu ’à CU 1/3min
* Toco interne interne surtout si utérus
cicatriciel
* Anesthésie peridurale: améliore dilatation si
femme anxieuse si travail hyperalgique, mais
allonge la phase de dilatation
* Attendre 2 H si RCF Normal
* Attendre passage 5U Syntocinon ®
* Attendre 4H si dilatation > 0,5 cm/h sourtout
si APD et variétés postérieures
* Si pas de progression=disproportion
foetopelvienne =césarienne
Si pas d ’engagement :
* Syntocinon®+ APD Position demi assise+
Cuisses sur bassin
* Attendre 1 à 2 H si pas de SFA
* Pas d ’engagement >2H + Césarienne
Si pas de descente :
* revoir Syntocinon®
* Attendre 2 heures si pas de SFA
* Forceps ou césarenne selon hauteur
 Dystocie dynamique en cours de travail- Les hypercinésies

Conséquence des Hypercinésies

Définition: ↑ intensité, durée et fréquence des •Maternelle:
CU * fatigue ++++
* acidose métabolique
Diagnostic clinique ou tocographique:
* Hypercinésie fréquence :>5 cu / 10mn •Fœtale :
* Hypercinésie intensité :>80 mmHg * hypoxie
* Hypercinésie globale = association des deux * acidose
* Hypertonie =Tonus base > 20mmHg * altération du RCF  SFA

Etiologie des hypertonies CAT devant hypercinésie

* Excès de Syntocinon ® * Arret perfusion Syntocinon
* Dysproportion foeto pelvienne * Administration de ß Mimétiques = 1/5 Amp
* Chorioamniotite Salbumol faible IV
* Retroplacental hematoma * Césarienne si hématome rétroplacentair ou
dysproportion foetopelvienne
 Médication spasmolytique

* Beta-mimmetics * Sedatives et tranquilisantes

- in perfusion, sont indiqués pours les episodes - Effet sour le psychique de la patiente
aigue d’hypocinésie
- Mais, peut influencer les CU
- Periodes courtes pendant le travail
- Effet secondaires
* Narcotiques
- Action prinicpallement sur la douleur
* Atosiban = antagonist de recepteurs pour l’
OXT
-effet immediat * Agents anesthésiques: on prefere APD
-sans avoir les effet secondaires de beta-
mimmeics * Les agents antispastique – ont pas un effet
demontré
* Inhibiteurs d’oxid nitrique –
NITRIGLYCERINE
- Relaxatio musculaire au niveau du col et du
myométre
- Utilise dans les situation aigue comme relaxant
uterin
- Souslingual ou intraveneux
MERCI !!!