Abnormal Uterine Action

Any deviation of the normal pattern of uterine contractions

affecting the course of labor is designated as disordered or
abnormal uterine action.

TYPES:

Etiology:

(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;
(7) Injudicious administration of sedatives, analgesics and oxytocics;
(8) Premature attempt at vaginal delivery (induction of labor or ARM) or
attempted instrumental vaginal delivery under light anesthesia.
UTERINE INERTIA
(HYPOTONIC UTERINE DYSFUNCTION)

Uterine inertia is the common type of abnormal uterine contraction

but is comparatively less serious. It may complicate any stage of labor. It
may be present from the beginning of labor or may develop subsequently
after a variable period of effective contractions.

Uterine contraction: The intensity is diminished; duration is shortened;

good relaxation in between contractions and the intervals are
increased. General pattern of uterine contractions of labor is maintained
but intrauterine pressure during contraction is less than 25 mm Hg.

Diagnosis:
(1) Patient feels less pain during uterine contraction;
(2) Hand placed over the uterus during uterine contraction reveals less
hardening of the uterus;
(3) Uterine wall is easily indentable at the acme of a pain;
(4) Uterus becomes relaxed after the contraction, fetal parts are well
palpable and fetal heart rate remains normal;
(5) Internal examination reveals—
(a) Poor dilatation of the cervix
(b) Presence of cephalopelvic disproportion, malposition, deflexed
head or malpresentation may be evident;
(c) Membranes usually remain intact.

EFFECTS ON THE MOTHER AND FETUS:

Maternal exhaustion and/or fetal distress are unusual and appear late.

Management:

Place of cesarean section:

(1) Presence of contracted pelvis
(2) Malpresentation
(3) Evidences of fetal or maternal distress.
Vaginal delivery —
(A) General measures:
(1) To keep up the morale of the patient.
(2) Posture of the woman is changed. Supine position is avoided
(3) To empty the bladder,catheterization is made.
(4) To maintain hydration by infusion of Ringer’s solution.
(5) Adequate pain relief.
(B) Active measures:
Acceleration of uterine contraction can be brought about by low rupture of
the membranes followed by oxytocin drip. The drip rate is gradually
increased until effective contractions are set up. The drip is to be
continued till 1 hour after delivery.
INCOORDINATE UTERINE ACTION
It usually appears in active stage of labor.
The hypertonic state of the uterus arises from any of the conditions
such as spastic lower uterine segment, colicky uterus, asymmetrical
uterine contraction, constriction ring or generalized tonic contraction of
the uterus and all these states are collectively called incoordinate
uterine action. Increased frequency and/or duration of uterine
contractions cause rise in baseline tone and thereby diminish circulation
in the placental intervillous space. These
contractions fail to make progressive cervical effacement and dilatation.

SPASTIC LOWER SEGMENT _

UTERINE CONTRACTION:
(1) Fundal dominance is lacking and often there is reversed polarity
(2) The pacemakers do not work in rhythm;
(3) The lower segment contractions are stronger;
(4) Inadequate relaxation in between contractions;
(5) Basal tone is raised above the critical level of 20 mm Hg

Diagnosis:
(1) The patient is in agony with unbearable pain referred to the back.
There are evidences of dehydration and ketoacidosis;
(2) Bladder is frequently distended and often there is retention of
urine; distension of the stomach and bowels are visible;
(3) There are premature attempts to bear down;
(4) Abdominal palpation reveals:
(a) Uterus is tender and gentle manipulation excites hardening of the
uterus with pain,
(b) palpation of the fetal parts is difficult,
(5) Fetal distress appears early;
(6) Internal examination may reveal:
(a) Cervix which is thick, edematous hangs loosely like a curtain; not
well applied to the presenting part,
(b) Inappropriate dilatation of the cervix,
(c) Absence of the membranes,
(d) Meconium stained liquor amnii may be there.

Effect on the fetus: Fetal distress appears early due to placental

insufficiency caused by inadequate relaxation of the uterus.

Management:
There is no place of oxytocin augmentation with this abnormality.
Cesarean section is done in majority of cases. Prior correction of
dehydration and ketoacidosis must be achieved by rapid infusion of
Ringer’s solution.
CONSTRICTION RING
(Syn: Contraction ring, Schroeder’s ring):

It is one form of incoordinate uterine action where there is localized

myometrial contraction forming a ring of circular muscle fibers of the
uterus.
It is usually situated at the junction of the upper and lower
segment around a constricted part of the fetus usually around the neck
in cephalic presentation.
It may appear in all the stages of labor. It is usually reversible and
complete.

The common causes are:

(1) injudicious administration of oxytocics,

(2) premature rupture of the membranes, and
(3) premature attempt at instrumental delivery.

Diagnosis:

Diagnosis is difficult.
It is revealed during cesarean section in the first stage, during forceps
application in the second stage and during manual removal in the third
stage (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.
CERVICAL DYSTOCIA:

Progressive cervical dilatation needs an effective stretching force by the

presenting part.

Failure of cervical dilatation may be due to—

(a) Inefficient uterine contractions
(b) Malpresentation, malposition
(c) Spasm (contractions) of the cervix.

Cervical dystocia may be primary or secondary.

Primary: Commonly observed during the

(i) First birth where the external os fails to dilate,
(ii) Rigid cervix,
(iii) Inefficient uterine contractions and the others.

Treatment:
In presence of associated complications (malpresentation, malposition),
cesarean section is preferred.
If the head is sufficiently low down with only thin rim of cervix left
behind, the rim may be pushed up manually during contraction or traction
is given by ventouse.
In others, where the cervix is very much thinned out but only half dilated.
Dührssen’s incision at 2 and 10’O clock positions followed by forceps or
ventouse extraction is quite safe and effective.

Secondary:
This type of cervical dystocia results usually due to excess scarring or
rigidity of the cervix from the effect of previous operation or disease.
Others are:
(i) Post-delivery
(ii) Postoperative scarring
(iii) Cervical cancer.
GENERALIZED TONIC CONTRACTION
(Syn: Uterine tetany):
In this condition, pronounced retraction occurs involving whole of the
uterus up to the level of internal os. Thus, there is no physiological
differentiation of the active upper segment and the passive lower
segment of the uterus. The whole uterus undergoes a sort of tonic
muscular spasm holding the fetus inside (active retention of the fetus)
Usually there is no risk of rupture uterus. New pacemakers appear all
over the uterus.

Causes:
(i) Cephalopelvic disproportion
(ii) Obstruction
(iii) Injudicious use of oxytocics.

Clinical features:
The patient is in prolonged labor having severe and continuous pain.
Abdominal examination reveals the uterus to be somewhat smaller in
size, tense and tender.
Fetal parts are neither well defined, nor is the fetal heart sound audible.
Vaginal examination reveals jammed head with big caput, dry and
edematous vagina.

Treatment:

 Correction of dehydration and ketoacidosis—by rapid infusion of

Ringer’s solution
 Antibiotic—to control infection
 Adequate pain relief.

Hypercontractility (tachysystole) may be induced by oxytocics (>5

contractions in 10 min). It may occur in spontaneous or with stimulated
labor. Persistent tachysystole with FHR abnormality can cause fetal
hypoxia. It can be managed by tocolytics (Terbutaline 0.25 mg SC).
Oxytocin infusion should be stopped.

Cesarean delivery when obstruction is suspected.

PRECIPITATE LABOR

A labor is called precipitate when the combined duration of the

first and second stage is less than 3 hours.

Prevalence is about 2%.

Short labors may be associated with:

 placental abruption and uterine tachysystole.
 multiparae and may be repetitive.
 hyperactive uterine contractions associated with diminished soft
tissue resistance.

Labor is short as the rate of cervical dilatation is 5 cm/hr or more for the
nulliparous women.

Maternal risks include:

(1) Extensive laceration of the cervix, vagina and perineum
(2) PPH
(3) Inversion,
(4) Uterine rupture,
(5) Infection,
(6) Amniotic fluid embolism.

The fetal risks include—

 intracranial stress and hemorrhage
 The baby may sustain serious injuries if delivery occurs in standing
position;
 bleeding from the torn cord
 direct hit on the skull,
 brachial plexus injury.

Treatment:

 The patient having previous history of precipitate labor should be

hospitalized prior to labor.
 During labor, the uterine contraction may be suppressed by
administering ether or magnesium sulfate during contractions.
 Delivery of the head should be controlled.
 Episiotomy should be done liberally.
 Elective induction of labor by low rupture of membranes and
conduction of controlled delivery is helpful.
 Oxytocin augmentation should be avoided.
TONIC UTERINE CONTRACTION AND RETRACTION
(Syn: Bandl’s ring, Pathological retraction ring)
This type of uterine contraction is predominantly due to
obstructed labor.

Pathological anatomy of the uterus:

There is gradual increase in intensity, duration and frequency of uterine
contraction.
The relaxation phase becomes less and less; ultimately 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.
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 pronounced retraction, there is fetal jeopardy or even death.

In primigravidae, further retraction ceases in response to obstruction

and labor comes to a stand still—a state of uterine exhaustion.
Contractions may recommence after a brief period of rest with renewed
vigor.
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.

Clinical features:
(1) Patient is in agony from continuous pain and discomfort and
becomes restless
(2) Features of exhaustion and ketoacidosis are evident
(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
 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.