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Postgraduate Courses, continued

SEXUAL COUNSELLING: A PRACTICAL APPROACH TO OFFICE PROBLEMS. Westbury Hotel, Toronto. April 17-19, 1974. Seminar sponsored by OMA, conducted by Drs. Beryl and Avinoam Chernick. Directed primarily toward family physicians. Information: Dr. J. A. Saunders, Director of Health Services, Ontario Medical Association, 240 St. George St., Toronto, Ont. M5R 2P4 CLINICAL PHARMACOLOGY - CARDIOVASCULAR DRUGS. Toronto Western Hospital. April 20, 1974. Information: The Director, Division of Postgraduate Medical Education, Medical Sciences Building, University of Toronto, Toronto, Ont. M5S 1A8 GERIATRIC MEDICINE - A YOUNG SPECIALTY. NEW TECHNIQUES AND APPROACHES. 2-115, Clinical Sciences Bldg., University of Alberta, Edmonton. April 22-23, 1974. Information: Department of Continuing Medical Education, Faculty of Medicine, The University of Alberta, Edmonton, Alta. REFRESHER COURSE FOR FAMILY PHYSICIANS. Royal Victoria Hospital, Montreal. April 22-26, 1974. Information: The Secretary, Centre for Continuing Medical Education, McGill University, 1110 Pine Ave. W., Montreal, Que. H3A 1A3 PEDIATRIC EMERGENCIES FOR PRACTISING PHYSICIANS. Hospital for Sick Children, Toronto, April 24-25, 1974. Information: The Director, Division of Postgraduate Medical Education, Medical Sciences Building, University of Toronto, Toronto, Ont. M5S 1A8 23rd ANNUAL REFRESHER COURSE FOR FAMILY PRACTITIONERS. Ottawa Civic Hospital. April 24-26, 1974 Information: Department of Medical Education, Ottawa Civic Hospital, 1053 Carling Ave., Ottawa, Ont. K1Y 4E9 DIAGNOSIS AND MANAGEMENT OF CARCINOMA OF THE BREAST. The Montreal General Hospital. April 25-26, 1974. Information: The Secretary, Postgraduate Board, The Montreal General Hospital, 1650 Cedar Ave., Montreal, Que. H3G 1A4 MEDICAL ASPECTS OF SCUBA DIVING. Edmonton. April 25-26, 1974. Information: Dr. W. Yakimets, Chairman, Continuing Medical Education, 13-106 Clinical Sciences Building, University of Alberta, Edmonton, Alta. T6G 2B7 PHYSICIAN AS TEACHER. Teaching methods in medicine. Health Sciences Building, University of Saskatchewan, Saskatoon. April 25-26, 1974. Information: Mrs. M. P. Sarich, Continuing Medical Education, 408 Ellis Hall, Saskatoon, Sask. S7N OW8

Constriction ring dystocia

Christopher H. Kaye, B.M., B.CH. (Oxon.), Vancouver, B.C.
Summary: A case of constriction ring dystocia in a 40-year-old multiparous white woman is described. She was postmature; the fetus occupied an unstable lie for which no cause could be demonstrated clinically or radiologically; during the course of an inert labour every third fetal heart sound was abnormal. At cesarean section it appeared that no lower uterine segment had formed and extreme thickness of the myometrium was encountered.
was November 7, 1971. When she was first seen at eight weeks' gestation the uterus was the size of a 12-week pregnancy and no pelvic abnormalities were noted. She weighed 77.1 kg and her blood pressure was 125/75. Throughout her pregnancy she was seen at regular intervals, and her blood pressure showed no significant elevation. At 34 weeks' gestation a breech presentation was diagnosed. Two weeks later an external version was performed without complications or disturbance of the fetal heart rate. At 37 weeks the fetus had assumed a transverse lie and, when seen by the consultant one week later, was lying obliquely. The consultant was unable to offer any explanation for the abnormal presentation and soft tissue masses were not identified. A radiograph of the abdomen confirmed the oblique lie and demonstrated no fetal abnormalities. On November 18, 11 days past her expected date of confinement, the mother was admitted to Grace Hospital for induction of labour. She was not in labour on admission. The fetal heart rate was 130 per minute and, because every third heart sound was muffled, the fetal heart was monitored. At 6:00 p.m. on November 18 she was having mild irregular contractions and was given an enema of soap and water. At 7:00 p.m. mild irregular contractions were occurring every three or four minutes. The cervical os was 2 cm dilated but not effaced, and the fetus was presenting as a vertex with the head not engaged. Between 8:00 p.m. November 18 and 9:30 a.m. November 19 mild irregular contractions continued. The fetal heart rate and sounds were unchanged. An x-ray showed the fetus to be occupying the left occipitotransverse position with the head floating above the pelvic brim. A diagnosis of uterine inertia was made, and an intravenous infusion of 5% glucose in water with 2 units of oxytocin per 1000 ml added was given at 125 ml/ hr from 10:00 a.m. to 6:00 p.m. on November 19. When the patient was reexamined at 6:00 p.m. the fetus was found in a transverse lie with the head to the left. It was decided to perform a cesarean section in view of the coexistence of postmaturity, uterine inertia, an unstable lie and possible fetal distress. At operation no gross adnexal abnormality was discovered. After reflecting the bladder the uterus was incised transversely and it was noted that its wall was extremely thick, as if the lower uterine segment had not formed. Repeated attempts to deliver the fetal head were unsuccessful and therefore a vertical incision was made, extending upward from the midpoint of the transverse incision. The myometrium of this zone of the uterus showed marked thickening - to at least 1/2 inches - wich was judged to be due to a constriction ring. The infant

R6sume: Cas de dystocie par formation d'un anneau musculaire uterin

Nous decrivons ici un cas de dystocie par formation d'un anneau musculaire ut6rin chez une multipare de 40 ans. Le foetus etait postmatur6 et occupait une position instable dont la cause n'a pu 6tre decouverte ni par la clinique ni par la radiologie. Au cours d'un travail non productif, chaque troisieme bruit du coeur foetal 6tait anormal. La cesarienne a rhvel6 que le segment ut6rin inferieur n'avait pas pris forme et que le myombtre 6tait d'une

6paisseur extrAme.
In 1743 William Smellie' first described the arrest of the shoulders in the constriction ring of labour: ". . . or when (the waters having been long evacuated) the under part of the uterus contracts round the neck and before the shoulders, keeping up the body of the child". The importance of intrauterine rings as a cause of dystocia in the presence of normal cephalopelvic relations was emphasized by White.',' Subsequently, Mills4 reported that constriction ring: ". .. of the parturient uterus has provoked as much controversy as any subject in obstetrics,; opinion is divided over its nomenclature, its pathology, its incidence, its treatment, and indeed over the very existence of such a condition". Until these problems are more clearly defined, and in view of its rarity, additional cases of this disorder are worth reporting. We describe below a case of constriction ring dystocia and comment on the frequency and theories of causation.

JOURNEES CHIRURGICALES DE L'HOTELDIEU. H6tel-Dieu de Montr6al. Les 26-27 avril 1974. Renseignements: Directeur du Service d'education medicale continue, Universit6 de Montr6al, C.P. 6128, Montr6al 101, Qu6. TECHNIQUES AND PRINCIPLES OF ACUPUNCTURE. Saskatoon City Hospital. April 2627, 1974. Information: Mrs. M. P. Sarich, Continuing Medical Education, 408 Ellis Hall, Saskatoon, Sask. S7N OW8
PROGRAMME REGIONAL. 16 avril au 31 mai, 1974. Renseignements: Dr Pierre Jobin, Education m6dicale permanente, Facult6 de m6decine, Universite Laval, Quebec, Qu6. GlK 7P4
SYMPOSIUM ON NEURO-OPHTHALMOLOG Y. University Hospital. May 1, 1974. Information: Assistant Dean, Continuing Education, Faculty of Medicine, The University of Western Ontario, London, Ont. N6A 3K7

CARDIOLOGIE EN PRATIQUE GENERALE. Institut de Cardiologie de Montr6al. Les 2-4 mai 1974. Renseignements: Directeur du Service d'6ducation medicale continue, Universit6 de Montr6al, C.P. 6128, Montr6al 101, Que.

COURS DE CHIRURGIE CONSACRE AUX MALADIES INTESTINALES ET ANO-RECTALES. Centre hospitalier universitaire, Sherbrooke, Que. Du 2 au 4 mai 1974. II s'adresse plus particulierement aux chirurgiens gen6raux et gastro-ent6rologiques. Renseignements: Dr Roger R. Dufresne, Directeur, Departement d'Education M6dicale Permanente, Centre hospitalier universitaire, Sherbrooke, Que.
CLINICAL DAY - RECOGNITION AND MANAGEMENT OF THE DEPRESSED PATIENT FROM CHILDHOOD TO OLD AGE. Royal Victoria Hospital, Montreal. May 7, 1974. Information: The Secretary, Centre for Continuing Medical Education, McGill University, 1110 Pine Ave. W., Montreal, Que. H3A 1A3

Case report
The expected date of confinement of Mrs. L., aged 40, para 3, gravida 5,
Reprint requests to: Dr. C. H. Kaye, 2005 East 44th Ave., Vancouver 16, B.C.

CMA JOURNAL/MARCH 2, 1974/VOL. 110 535

could eventually be extracted; it breathed and cried within one minute. The two incisions in the uterus were closed and peritonealized in the conventional manner. The postoperative course was uneventful. The baby weighed 2438 g. His appearance was abnormal, for he had a birdlike face, microphthalmia and low-set malformed ears, and there was a generalized pansystolic cardiac murmur. He vomited the first feeding, appeared to aspirate, and a tracheoesophageal fistula was diagnosed. He was transferred to The Vancouver General Hospital where a type 3 tracheoesophageal fistula was repaired. The infant survived for six weeks and chromosomal studies subsequently confirmed a diagnosis of trisomy E syndrome.

Discussion

One of the curious things about constriction rings is the wide discrepancy in their reported frequency. In 1935 Rudolph could collect only '371 cases from the entire world's literature.5 The frequency was only one in several thousand cases in the Johns Hopkins series.' Kennedy7 states that the frequency of constriction ring dystocia is 0.26%, or 1 in 400 labours, and this corresponds with the reports of McKenzie8 of 0.25%, Adams9 of 0.28% and Fields10 of 0.23%. Johnson"1 reports an incidence of 1.26% and Rucker"2 1.67%; these latter figures seem high. Two pathologic uterine rings have been described.13 Because lack of a standard terminology has contributed to misunderstanding of the problem, only two terms are used here, namely, constriction ring and the retraction ring of Bandl and Barbour. The constriction ring (sometimes referred to as contraction ring) forms most commonly at the junction of the upper and lower uterine segments, often forming a projection between the fetal head and neck, thus preventing the expulsion or easy extraction of the fetus from the uterus. This may occur in nonobstructed labour as in the case reported by Smellie' and in the case reported here. The retraction ring of Bandl and Barbour, the commoner development, forms when there is prolonged obstruction to the descent of the fetus with resultant thinning of the lower uterine segment. Its level can therefore be extremely variable and is by no means restricted to the groove between the shoulders and head of the fetus. Review of the literature does not make clear whether there are, in fact, two such types of pathologic rings.13'14 Some authorities maintain that they represent varying degrees of the same abnormality, whereas others declare that there are two separate entities. The latter regard constriction ring dystocia as an incoordination of uterine

activity which, by forming a circular band applied to an indentation in the contour of the fetus, may contribute to the failure to progress in labour. Fields"0 concluded that constriction ring dystocia is due chiefly to a functional disturbance of the uterine muscle, and as long as this persists the uterus cannot empty itself. In this condition there is no marked thinning of the lower uterine segment - indeed, the thickness of the uterine wall above and below the ring is approximately equal. Bandl's ring or retraction ring, on the other hand, is regarded as an exaggeration of the physiological retraction ring and is associated with excessive thinning of the lower uterine segment. The presence of a well marked retraction ring indicates that rupture is imminent.
I wish to express my sincere gratitude to Dr. G. C. Robinson and his staff, Department of Paediatrics, and to Dr. F. E. Bryans, Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, for their cooperation and help in the preparation of this paper.

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References
1. SMELLIE W: Treatise on the Theory and Practice of Midwifery, edited with annotations by MCCLINTOCK AH, London, New Sydenham Society, 1876, p 223 2. WHrm C: The contraction ring as a cause of dystocia, with a description of a specimen removed by hysterectomy during labour. Proc R Soc Med VI (Obstet Gynaecol): 70, 1912-13 3. WHITE C: The contraction ring as a cause of dystocia, with a desciption of a specimen removed by hysterectomy during labour. Lancet I: 604, 1913 4. MiLLs WG: Treatment of contraction ring dystocia. J Obstet Gynaecol Br Commonw 56: 838, 1949 5. RUDOLPH L: Constriction ring dystocia. I Obstet Gynaecol Br Commonw 42: 992, 1935 6. EASTMAN NJ, HELLMAN LM: Williams Obstetrics, 12th ed. New York, Appleton, 1961, p 872 7. KENNEDY C: Inco-ordinate uterine action. Edinb Med 1 56: 445, 1949 8. McKENZIE CH: Contraction ring dystocia: an analysis of thirty-six cases, with observations on the use of adrenalin in twenty cases. Am J Obstet Gynecol 33: 835, 1937 9. ADAMS GS: Uterine inertia and contraction ring dystocia. Med J Aust II: 383, 1939 10. FmLDs C: Constriction ring dystocia. Am J Obstet Gynecol 65: 960, 1953 11. JOHNSON HW: The clinical diagnosis of varying degrees of uterine contraction rings. Am J Obstet Gynecol 52: 74, 1946 12. RUCKER MP: Constriction ring dystocia. Ibid, p 984 13. Mont JC, MYERSCOUGH PR: Munro Kerr's Operative Obstetrics, eighth ed. London, Bailliere, Tindall and Cassell 1971, p 358 14. HELLMAN LM, PRrrCHARD JA: Williams Obstetrics, 14th ed. New York, Appleton, 1971, p 849

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