Discoordinated labor activity is an abnormal contractile activity of the uterus during labor, characterized by a lack of consistency of contractions between individual segments of the uterus. Discoordinated labor activity is manifested by irregular, ineffective and extremely painful contractions, delaying the opening of the uterine pharynx. The anomaly of labor forces is diagnosed when assessing the condition of the woman in labor, external and internal obstetric examination, CTG. Correction of discoordinated labor activity includes infusion of calcium antagonists, b-adrenomimetics, spasmoanalgesics; application of epidural analgesia; as indicated, cesarean section.
General information
With discoordinated labor, various parts of the uterus (its right and left halves, bottom, body and lower parts) contract chaotically, inconsistently, haphazardly, which leads to a violation of the normal physiology of the labor act. The danger of discoordinated labor activity lies in the likelihood of a violation of placental-uterine circulation and the development of fetal hypoxia. Discoordination of labor activity is often noted when the pregnant woman’s body is not ready for childbirth, including immaturity of the cervix. The frequency of development of discoordinated labor activity is 1-3%.
Causes
Obstetrics and gynecology distinguish several groups of factors that determine the development of discoordinated labor activity. Obstetric risk factors may include early outpouring of amniotic fluid; overgrowth of the uterus caused by polyhydramnios or multiple births; mismatch in the size of the birth canal and fetal head; pelvic presentation of the fetus; abnormal placenta (placenta previa) and fetoplacental insufficiency; late gestosis, the age of a woman younger than 18 and older than 30 years. Discoordinated labor activity can occur with intrauterine infection of the fetus, anencephaly and other malformations in the child, hemolytic disease of the fetus (immunoconflict pregnancy).
Gynecological factors provoking discoordinated labor activity include various types of pathology of the reproductive system. Uterine malformations (bicornuate uterus, septate uterus, uterine hypoplasia, etc.), transferred endometritis and cervicitis, tumor processes (uterine fibroids), cervical rigidity caused by impaired innervation or scar changes (for example, after cauterization of cervical erosion) contribute to the violation and discoordination of the labor act. The presence of an operational scar on the uterus, menstrual cycle disorders, artificial termination of pregnancy in the anamnesis adversely affects the physiology of childbirth.
General somatic pathology, intoxication, infections, organic lesions of the central nervous system, obesity, anemia, neurocirculatory dystonia can contribute to the development of discoordinated labor activity. In some cases, abnormal labor activity is provoked by external influences – unjustified use of birth-stimulating agents, insufficient anesthesia of childbirth, untimely opening of the fetal bladder, rough manipulations and studies.
Symptoms
Clinically discoordinated labor activity can be expressed in its general discoordination, hypertonicity of the lower segment (reverse gradient), tetany of the uterus (convulsive contractions), circulatory dystocia.
General discoordination is characterized by very painful, irregular, contractions of varying strength and duration, lack of dynamics in smoothing and opening of the cervix, and a prolonged protracted course of labor. In this case, the outpouring of amniotic fluid often occurs ahead of time, the underlying part of the fetus is pressed against the entrance to the pelvis or is located above the entrance to it. The danger of general discoordinated labor activity lies in the violation of placental circulation and the risks of fetal asphyxia. The course of the postpartum period may be complicated by anomalies of placental abruption and delay of its parts; in the postpartum period, the probability of hypotonic bleeding is high.
With hypertonicity of the lower segment of the uterus, its contractions are more pronounced than contractions of the body and the bottom of the uterus. This type of discoordinated labor activity is typical for immaturity and rigidity of the cervix. Clinically, with hypertension, painful intense contractions are noted, but there is no opening of the neck and the advancement of the fetal head along the birth canal.
Uterine tetany is spoken of when there are prolonged, consecutive uterine contractions. Such an anomaly of the birth forces occurs with the incorrect appointment of contraception drugs, an attempt to impose obstetric forceps, rotation, fetal extraction. With tetany, the uterus becomes very dense and painful, and the condition of the fetus is rapidly deteriorating. Discoordinated labor activity according to the type of circulatory dystocia is due to the absence of contraction of circular muscle fibers in the cervical region. Childbirth in this case is delayed, which can lead to fetal asphyxia.
In all clinical variants of discoordinated labor, the woman in labor has anxiety, fear, severe pain in the sacrum, nausea, urination disorders. Despite the apparent activity of contractions, the dynamics of cervical dilation is almost completely absent. Such unproductive contractions tire the woman in labor, which further delays childbirth.
Diagnostics
The discoordinated nature of labor is diagnosed based on the condition and complaints of the woman, the results of obstetric examination, fetal cardiotocography. During the vaginal examination, the absence of dynamics in the readiness of the birth canal is determined – thickening and swelling of the edges of the uterine pharynx. Palpation of the uterus reveals its unequal tension in different departments as a result of discoordinated contractions.
Cardiotocography allows to objectively assess the contractile activity of the uterus. During hardware examination, irregular contractions in strength, duration and frequency are recorded; their arrhythmicity and asynchrony; the absence of a triple descending gradient against the background of increased uterine tone. The importance of CTG in childbirth lies not only in the ability to control labor activity, but also to monitor the increase in fetal hypoxia.
Obstetric tactics
Childbirth occurring in conditions of discoordinated labor activity can be completed independently or promptly. With discoordination and hypertonicity of the lower segment of the uterus, electroanalgesia (or electroacupuncture) is performed, antispasmodics are administered, obstetric anesthesia is used. In case of deterioration of the fetal vital activity, prompt delivery is required.
In the case of uterine tetany, obstetric anesthesia is administered, and α-adrenomimetics are prescribed. Taking into account the obstetric situation, childbirth can be completed by cesarean section or fetal extraction with obstetric forceps. With circulatory dystocia, an infusion of b-adrenomimetics is indicated, aimed at removing discoordinated labor activity, and operative delivery. At the same time, therapy is carried out aimed at preventing intrauterine fetal hypoxia.
Indications for operative delivery without attempts to correct discoordinated labor activity may be situations where past pregnancies ended in miscarriage or stillbirth. Also, the choice in favor of cesarean section is made with prolonged infertility in the mother’s anamnesis; cardiovascular, endocrine, bronchopulmonary diseases; gestosis, uterine fibroids, pelvic presentation of the fetus or its large size; in primiparous women over 30 years old. In case of stillbirth, a fruit-destroying operation is performed, manual separation of the afterbirth with examination of the uterine cavity.
Prevention
Measures to prevent discoordinated labor include pregnancy management in women at risk with increased attention, compliance with the required settings of an obstetrician-gynecologist, ensuring adequate anesthesia during childbirth.
Drug prevention of discoordinated labor is necessary for young women in labor and late-giving women, pregnant women with a burdened general somatic and obstetric-gynecological status, structural inferiority of the uterus, fetoplacental insufficiency, polyhydramnios, multiple births or large fetuses. Women at risk for the development of discoordinated labor activity require psychoprophylactic preparation for childbirth, training in muscle relaxation techniques.
Complications
The danger of discoordinated labor is caused by a violation of the physiological course of labor, which can lead to complications on the part of the fetus and mother. Delaying the delivery process increases the risks of intrauterine hypoxia and fetal asphyxia. Due to discoordinated labor activity, the mother increases the likelihood of atonic postpartum bleeding. The discoordinated course of labor activity in frequent cases requires the use of an operative aid in childbirth.
