Intensity Duration Propagation of the uterine contractions Normally: Triple descending gradient of...
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Transcript of 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