LESSON PLAN
Subject : Obstetrics and Gynecological nursing.
Name of the topic : Constriction and pathological ring
Time :
Date :
Duration :
Method of teaching : Class room teaching
AV AIDS :
Group : B.SC. Nursing IV year.
Name of the student : Varna mohan
M.SC. Nursing II year.
CON, JIPMER.
Name of the evaluator : Mrs. Vanitha
Tutor,
CON, JIPMER.
GENERAL OBJECTIVE:
At the end of lecture, students will be able to get adequate knowledge regarding ‘pathological ring and constriction ring’and develop
positive attitude towards it and apply this knowledge in practice.
SPECIFIC OBJECTIVE:
At the end of this lecture the students will be able to:
SPECIFIC TEACHING
OBJECTIVE TIME CONTENT LEARNING AV EVALUATION
ACTIVITY AID
S
INTRODUCTION:
Introduce the 2 Normal labor is characterized by coordinated uterine contractions associated with Student
topic mins teacher
progressive dilatation of the cervix and descent of the fetal head. Normal labor is explaining
associated with cervical dilatation more than or equal to 1 cm/hr in a nulliparous woman and the
students are
and 1.5 cm/hr for a multiparous woman. This results in successful vaginal delivery. listening.
Overall labor abnormalities occur in about 25% of the nulliparous women and 10% of
multiparous women. Abnormal active phase of labor may be protraction or arrest
disorder. The most common cause of protraction disorder is inadequate or abnormal
What is
uterine contractions. Student
Define 2 abnormal
teacher
abnormal mins uterine action?
define
uterine action. ABNORMAL UTERINE ACTION abnormal
Any deviation of the normal pattern of uterine contractions affecting the course of labor is uterine
contraction
designated as disordered or abnormal uterine action. and students
List down the 2min are listening. What are the
etiological etiological
ETIOLOGY: factors of
factors of
abnormal As the physiology of normal uterine contraction is not fully understood, the cause of its abnormal
uterine uterine
disordered action remains obscure. However, the following clinical conditions are often contracrion?
contraction.
associated:
(1) Prevalent in first birth, especially with elderly women; (2) Prolonged pregnancy;
(3) Overdistension of the uterus (twins and fibroids);
(4) Emotional factor (anxiety, stress);
(5) Constitutional factor (obesity);
(6) Contracted pelvis and malpresentation;
Explain 5min (7) Injudicious administration of sedatives, analgesics and oxytocics; Student What are the
normal teacher mechanism of
uterine (8) Premature attempt at vaginal delivery (induction of labor or ARM) or attempted explain uterine
contraction. instrumental vaginal delivery under light anesthesia. normal contraction?
uterine
NORMAL UTERINE CONTRACTIONS: Polarity of the uterus means when the contraction
upper segment contracts, the lower segment relaxes. Normally, there are two and students
are listening.
pacemakers, one is situated at each cornua of the uterus. The uterine pacemakers
generate uterine contractions in a coordinated fashion. The properties of a normal uterine
contraction wave are:
The intensity of contraction diminishes from top to bottom of the uterus;
The contraction wave starts from the pacemaker and propagates towards the lower
uterine segment;
(iii) The duration of contraction diminishes progressively as the wave moves away
from the pacemaker. In dysfunctional labor, new pacemakers may come up
anywhere in the uterus.
The uterine pacemaker is situated at the cornua of the uterus and this generates uterine
contractions. Effective uterine contraction starts at the cornua and gradually sweeps
downwards over the uterus.
PRIMARY DYSFUNCTIONAL LABOR
Primary dysfunctional labor is defined when the cervix dilates less than 1 cm/hr
following a normal latent phase of labor. It is the most common abnormality and mostly
corrected by amniotomy and/ or oxytocin augmentation.
SECONDARY ARREST
Secondary arrest is defined when the cervical dilatation stops after the active phase of
labor has started normally. Secondary arrest of dilatation may be due to
(a) Poor uterine contractions (myometrial fatigue),
(b) Cessation of cervical dilatation despite strong uterine contractions (mechanical factors
like disproportion and malpresentation).
Uterine activity (contraction) is measured by noting;
basal tone;
active (peak) pressure; and
frequency.
Assessment is usually done by—
Clinical palpation—(inaccurate);
Tocodynamometer with external transducer;
Intrauterine pressure catheter (IUPC) is used to measure intrauterine pressure
during uterine contractions.
Normal baseline tonus is between 5 mm Hg and 20 mm Hg. Minimum uterine
pressure required to dilate the cervix is 15 mm Hg over the baseline. Normal
Define 2min uterine contractions in labor create an intrauterine pressure up to 60 mm Hg.
constriction What is
ring. Oxytocin is to be used when uterine contractions are inadequate. Oxytocin dose Student constriction
is to be escalated till the optimum uterine contractions (3–4 per 10 minutes) with teacher ring?
explain
a peak intrauterine pressure of 50–60 mm Hg and a resting tone of 10–15 mm Hg constriction
is obtained. ring and
students are
listening.
CONSTRICTION RING
(Syn: Contraction ring, Schroeder’s ring):
What are the
Enlist the It is one form of incoordinate uterine action where there is localized myometrial causes of
Student
causative contraction forming a ring of circular muscle fibers of the uterus. It is teacher constriction
factor? explain the ring?
usually situated at the junction of the upper and lower segment around a constricted
cause
part of the fetus usually around the neck in cephalic presentation. It may appear in all the constriction
Explain ring and
stages of labor. It is usually reversible and complete. How to diagnose
various students are
constriction
diagnostic listening.
ring?
method . The common causes are:
(1) Injudicious administration of oxytocics;
(2) premature rupture of the membranes; and
Discuss the (3) Premature attempt at instrumental delivery. What are the
treatment of DIAGNOSIS: Student treatment of
constriction teacher constriction ring
ring. Diagnosis is difficult. It is revealed during cesarean section in the first stage, during discussed ?
forceps application in the second stage and during manual removal in the third stage treatment
(hour-glass contraction). The ring is not felt per abdomen. Maternal condition is not
much affected but the fetus is in jeopardy because of the hypertonic state. Uterus never
ruptures.
TREATMENT:
Delivery is usually done by cesarean section. The ring usually passes off by deepening the
plane of anesthesia otherwise the ring may have to be cut vertically to deliver the baby.
The difficulties faced during forceps delivery (second stage) or during normal removal of
placenta (third stage) can be overcome by using deep anesthesia that relaxes the
constriction ring.
Introduce the
topic
TONIC UTERINE CONTRACTION AND
RETRACTION (Syn: Bandl’s ring,Pathological
retraction ring)
2min INTRODUCTION:
Define What is
pathological Student pathological
ring? This type of uterine contraction is predominantly due to obstructed labor. teacher ring?
defined
Pathological anatomy of the uterus: There is gradual increase in intensity, duration and pathological
frequency of uterine contraction. The relaxation phase becomes less and less; ultimately, ring.
a state of tonic contraction develops. Retraction, however, continues. The lower segment
elongates and becomes progressively thinner to accommodate the fetus driven from the
upper segment.
DEFINITION
A circular groove encircling the uterus is formed between the active upper segment and
the distended lower segment, called pathological retraction ring (Bandl’s ring). Due to
5min
pronounced retraction, there is fetal jeopardy or even death.
Discuss the
clinica What are the
feature. clinical feature
In primigravidae, further retraction ceases in response to obstruction and labor comes to Student
teacher of pathological
a standstill—a state of uterine exhaustion. Contractions may recommence after a brief discussed the ring?
period of rest with renewed vigor. clinical
feature
But in multiparae, retraction continues with progressive circumferential dilatation and
thinning of the lower segment. There is progressive rise of the Bandl’s ring, moving
nearer and nearer to the umbilicus and, ultimately, the lower segment ruptures.
Explain the
treatment of CLINICAL FEATURES: What are the
pathological Student treatment
ring. (1) Patient is in agony from continuous pain and discomfort and becomes restless; teacher options for
explained the pathological
(2) Features of exhaustion and ketoacidosis are evident;
treatment. ring?
(3) Abdominal palpation reveals—
(a) Upper segment is hard and tender,
(b) Lower segment is distended and tender. MANAGEMENT:
Prevention—Partographic management of labor, early diagnosis of malpresentation,
disproportion and delivery by cesarean section can prevent this condition completely.
TREATMENT
Rupture of uterus is to be excluded
Internal version is contraindicated
Correction of dehydration and ketoacidosis by infusion of Ringer’s solution.
Adequate pain relief
Parenteral antibiotic is given (Ceftriaxone 1 g IV)
Cesarean delivery is done in majority of the cases. Rupture of uterus must be excluded
before attempting destructive operation.
Preventive Measures of Dystocia due to Abnormal Uterine Action:
1. Quality antenatal care, emotional support to be parturient and close monitoring of labor
can reduce abnormal uterine action.
2. Induction of labor should be judicious, especially when the cervix is unfavorable.
3. Amniotomy in the latent phase or as a routine procedure is to be avoided.
5min
Discuss the
difference What are the
between Student difference
pathological teacher between
and explained the constriction and
constriction differences. pathological
ring. ring?
Summarize
the topic
2min
Conclude the
topic
SUMMARY
Today I have explained about abnormal uterine contraction and discussed specifically
pathological and constriction ring a, its etiological factor, clinical feature,treatment and
preventive measures and complication.
CONCLUSION
Abnormal uterine action is due to development of abnormal polarity on the uterus. It
may manifest as uterine inertia (common) or hypertonic dysfunction due to any
mechanical factor (obstruction). Hypertonic dysfunction may end in either formation of
Bandl’s ring or precipitate labor. Incoordinate uterine action (asymmetric uterine
contractions, constriction ring
and cervical dystocia) can affect the health of both the mother and the fetus adversely. It
is important to detect AUA early and to institute management appropriately to reduce
maternal and neonatal morbidity and mortality
BIBILIOGRAPHY
Myles. Textbook of midwives.17th edition:elseveir;Pg 536-548.
Dc Dutta’s Textbook Of Gynecology Including Contraception:6th Edition, Jaypee
Brothers Medical Publishers (P) Ltd;Pg 334-340.
Majhi AK , Bedside Clinics in Obstetics ,5th Edition.Kolkata: Academic Publishers ;2021
;370-385
Pillitteri A.Maternal and Child health Nursing.6" Ed. Wolters kluwer. Lippincott
Williams & Wilkins. Page no: 282-88.
