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“Approved”
on methodological meeting
of Department of Obstetrics and Gynecology
with course of Infant and Adolescent Gynecology
“___”______________________ 201_ year
protocol #
T.a. The Head of the department
Professor
________________ O. Andriyets
METHODOLOGICAL INSTRUCTION
for practical lesson
“Uterus activity anomalies”
Chernivtsi – 2010
Aim: to learn the causes, clinic, diagnostic, treatment and preventing measures of abnormalities of
uterine contractions.
Basic level:
1. Estimation of normal uterine contractions.
2. Medicines which are used for normalization of uterine contractions
STUDENTS' INDEPENDENT STUDY PROGRAM
I. Objectives for Students' Independent Studies
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. Obstetrics terminology.
2. External and internal obstetric examination.
3. Segments of fetal head
4. Lower segment of uterine and contraction ring.
5. Signs of normal uterine contractions
6. Conduct of normal labor & delivery and their clinic.
7. Classification of uterine contractions abnormalities.
8. Factors that provide normal uterine contractions.
9. Definition of primary and secondary uterine inertia.
10. Incoordinative uterine activity,
11. Excessive uterine activity.
12. Medicines for correction of uterine contractions.
13. Methods of treatment of uterine inertia in the first and second stages of labor.
14. Prevention of uterine contractions abnormalities.
Key words and phrases: uterine dysfunction, hypotonic and hypertonic, incoordinative,
excessive uterine activity.
The character of birth activity is detected on the basis of quantitative assessment of the
three main processes:
1) dynamics of uterine contractions;
2) dynamics of cervical dilation;
3) dynamics of the advancement of the presenting part of the fetus along the parturient canal.
Assessment methods:
1.Uterine activity assessment:
— subjective sensation of the parturient woman (inaccurate, different threshold of pain
sensitivity);
— palpation;
— external cardiotocography (single-channel and multichannel);
— internal tocography.
Treatment:
— terbutaline in the dose of 250 meg i.v. slowly during 5 min or salbutamol — 10 mg in 1
L of physiologocal liquids for i.v. infusions or Ringer's lactate — 10 drops a min.
The culmination of normal pregnancy involves three stages: prelabor, cervical ripening and
labor. These occur as a continuum rather than as isolated events. Endogenous prostaglandins
play a part in all these processes. Interventions to artificially ripen the cervix, induceute
rinecontractions and augment labor onceit is in progress also lack distinct boundaries. This
chapter will briefly discuss reasons for these interventions and methods which may be
used. Labour induction and augmentation may be a source of conflict and distress. For most
health workers they are seen as routine, technical procedures. For many women, they have
emotive connotations, evoking a sense of personal inadequacy and eroded self-esteem. It is
important for health workers to approach the question of labor induction with sensitivity, and
to involve women in the decision-making process. Labor induction is one of the most frequent
medical procedures in pregnant women. It is a major intervention in thenormal courseof
pregnancy, with thepote ntial to set in motion a cascade of interventions,
particularly Caesarean section. However, with modern methods of labour induction, this risk
appears to have diminished.
When should labour be induced? The decision to induce labour is a matter of rather
complex clinical judgement. It usually constitutes a choice between three options: allowing
the pregnancy to continue, inducing labour or performing elective Caesarean section.
The decision takes into account a number of factors.
• Anticipated benefits to the mother, such as improving a medical condition which is
caused or aggravated by pregnancy, including pre-eclampsia, placental abruption and certain
respiratory, hepatic and cardiac disorders; relieving discomfort, such as from multiplepr
egnancy, polyhydramnios or spontaneous symphysiotomy; allowing essential treatment to be
commenced, such as for cervical cancer; relieving emotional distress after intrauterine death;
or alleviating anxiety about the baby’s well-being.
• Estimated risks to the mother, such as increased pain and need for analgesia, uterine
hyperstimulation, Caesarean section, infection, complications of the procedures, post-partum
haemorrhage, uterine rupture (very rarely), anxiety if the induction is protracted or
unsuccessful, and loss of self-esteem because of perceived failure to givebirth normally. •
Anticipated benefits to the baby, such as improved growth and development when intrauterine
growth is suboptimal, and reduced risk of intrauterine death from complications such as
diabetes, prolonged pregnancy (beyond 41 weeks), amnionitis, prelabour ruptured
membranes, rhesus immunization, fetal compromise and cholestasis of pregnancy.
• Estimated risks to the baby, such as prematurity and compromisefr om uterinehype
rstimulation. Several factors influence the decision.
• The condition of the mother. • The condition of the baby.
• The gestational age of the baby, and level of certainty about the baby’s age. When fetal
lung maturity is uncertain, amniocentesis may be performed to assess markers for lung
maturity such as the alcohol ‘shake’ test, lecithin/sphingomyelin ratio and phosphatidyl
glycerol level.
• The likelihood that induction of labour will be efficient and vaginal delivery
successful. The last factor is in part dependent on the state of the uterine cervix, which is
related to the imminence of spontaneous labour.
The ‘ripeness’ of the uterine cervix The process of softening, shortening and partial
dilation of the cervix usually takes place in the days or weeks prior to the onset of labour, but
thetiming of this process is variable. An unfavourable or ‘unripe’ cervix is one which has
undergoneminimal changeand is morer esistant to attempts at induction of labour. In the first
trimester, 50% of the dry weight of the cervix is tightly aligned collagen, 20% smooth
muscleand the rest is ground substance composed of elastin and
glycosaminoglycans (Chondroitin, dermatan sulphate and hyaluronidase). During pregnancy,
hyaluronidase increases from 6 to 33%, whereas dermatan and chondroitin, which bind
collagen more tightly, decrease. Collagenase and elastase enzymes increase, as do the
vascularity and water content. A standardized method of semiquantitative clinical scoring of
the cervix was described by Bishop in 1964, and has since been modified (see Table 3).
4. All of the following are risks to the fetus from prolonged labor Except:
A - Sepsis;
B - subdural hematoma;
C - Cerebral damage;
D - Hemorrhage.
References:
1. Danforth's Obstetrics and gynaecology. - Seventh edition.- 1994. - P. 545- 550|
2. Obstetrics and gynaecology. Williams & Wilkins Waverly Company. - Thin Edition.-
1998. -P. 107-115.
3. Basic Gynecoiogy and Obstetrics. - Norman F. Gant, F. Gary Cunningham. 1993. - P.
356-361.
4. Obstetrics.Edited by Prof. I. Ventskivska. – Kyiv. – 2008. – P. 205- 208.