Expert Review ajog.

org

Assessment of uterine contractions in labor

and delivery
Hadar Rosen, MD; Yariv Yogev, MD

Normal labor and delivery are dependent on the presence of regular and effective contractions of the uterine myometrium. The
mechanisms responsible for the initiation and maintenance of adequate and synchronized uterine activity that are necessary for
labor and delivery result from a complex interplay of hormonal, mechanical, and electrical factors that have not yet been fully
elucidated.
Monitoring uterine activity during term labor and in suspected preterm labor is an important component of obstetrical care because
cases of inadequate and excessive uterine activity can be associated with substantial maternal and neonatal morbidity and
mortality. Inadequate labor progress is a common challenge encountered in intrapartum care, with labor dystocia being the most
common indication for cesarean deliveries performed during labor. Hereafter, an accurate assessment of uterine activity during
labor can assist in the management of protracted labor by diagnosing inadequate uterine activity and facilitating the titration of
uterotonic medications before a trial of labor is prematurely terminated. Conversely, the ability to diagnose unwanted or excessive
uterine activity is also critical in cases of threatened preterm labor, tachysystole, or patients undergoing a trial of labor after
cesarean delivery. Knowledge of uterine activity in these cases may guide the use of tocolytic medications or raise suspicion of
uterine rupture. Current diagnostic capabilities are less than optimal, hindering the medical management of term and preterm
labor.
Currently, different methods exist for evaluating uterine activity during labor, including manual palpation, external tocodynamometry,
intrauterine pressure monitoring, and electrical uterine myometrial activity tracing. Legacy uterine monitoring techniques have advantages
and limitations. External tocodynamometry is the most widespread tool in clinical use owing to its noninvasive nature and its ability to time
contractions against the fetal heart rate monitor. However, it does not provide information regarding the strength of uterine contractions
and is limited by signal loss with maternal movements. Conversely, the intrauterine pressure catheter quantifies the strength of uterine
contractions; however, its use is limited by its invasiveness, risk for complications, and limited additive value in all but few clinical
scenarios. New monitoring methods are being used, such as electrical uterine monitoring, which is noninvasive and does not require
ruptured membranes. Electrical uterine monitoring has yet to be incorporated into common clinical practice because of lack of access to
this technology, its high cost, and the need for appropriate training of clinical staff. Further work needs to be done to increase the
accessibility and implementation of this technique by experts, and further research is needed to implement new practical and useful
methods. This review describes current clinical tools for uterine activity assessment during labor and discusses their advantages and
shortcomings.
The review also summarizes current knowledge regarding novel technologies for monitoring uterine contractions that are not yet in
widespread use, but are promising and could help improve our understanding of the physiology of labor, delivery, and preterm labor, and
ultimately enhance patient care.
Key words: action potentials, contraction frequency, contraction intensity, contractions, dysfunctional labor, electrical activity, electrical
uterine monitoring, electro hysterogram, external tocodynamometry, gap junctions, hysterography, intrauterine pressure catheter, labor
augmentation, labor induction, labor progression, manual palpation, Montevideo units, myometrium, preterm labor, tachysystole, uterine
activity

Introduction
From the Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak, Monitoring uterine activity is a common
Israel (Dr Rosen); Lis Maternity and Women’s Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv,
Israel (Dr Yogev); and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Rosen and
obstetrical practice. During labor, it
Yogev). allows for the supervision of labor pro-
Received May 28, 2022; revised Sept. 1, 2022; accepted Sept. 1, 2022. gression and can aid clinical decision-
The authors report no conflict of interest.
making regarding intervention. Uterine
activity may be assumed adequate when
Corresponding author: Hadar Rosen, MD. rosenhadar@gmail.com
progressive cervical dilatation and
0002-9378/$36.00 ! ª 2022 Elsevier Inc. All rights reserved. ! https://doi.org/10.1016/j.ajog.2022.09.003
fetal descent occur. Dysfunctional
labor has been estimated to affect up to
Click Video under article title in Contents at
21% of primigravid labors,1 and it is the

MAY 2023 American Journal of Obstetrics & Gynecology S1209

Expert Review
FIGURE 1
Scheme showing how Ca2D
entry leads to smooth muscle
contraction
The contribution of the SR to augmenting Ca2þ
for contraction is not established for the uterus,
but is indicated for completeness, and the red
bar indicates its negative effect on contractility.
Some Ca2þ entry predominates in the uterus.
Adapted from: Wray S. Insights into the uterus.
Exp Physiol. 2007 Jul;92(4):621e31.
MLCK, myosin light-chain kinase; MLCP, myosin light-chain
phosphatase; SR, sarcoplasmic reticulum.
Rosen. Assessment of uterine contractions in labor and de-
livery. Am J Obstet Gynecol 2023.
most common cause of intrapartum
cesarean delivery2. Uterine contraction
monitoring may guide the need for ute-
rotonic medication or operative delivery
when labor fails to adequately progress.
Furthermore, it allows for the accurate
classification of fetal heart rate decelera-
tions (which requires accurate timing
against contractions, both antepartum
and intrapartum) and ongoing surveil-
lance of uterine activity in the setting of a
trial of labor after cesarean delivery
(TOLAC).
The purpose of this review is to describe
the physiology of labor contractions, as
well as current widespread uterine
contraction monitoring methods of
assessment such as external tocodyna-
mometry and intrauterine pressure
catheter (IUPC), to introduce a newer
method using electrical uterine moni-
toring (EUM), and to describe the clinical
implementation of these methods.
Physiology
As is the case with any muscle in the body,
contractility of the uterine muscle is a
direct consequence of the underlying
electrical activity in the myometrial cells.3,4
S1210 American Journal of Obstetrics & Gynecology MAY 2023
For most of the duration of a normal
pregnancy, the uterus maintains a quies-
cent state and the cervix remains firm and
closed. This state is hormonally mediated
mainly by progesterone and human cho-
rionic gonadotropin (hCG), whereas later
on in gestation it is dependent on placental
production.5 Progesterone suppresses the
production of gap junctions between
myocytes and consequently prevents the
transmission of electrical activity between
these cells.6 Additional mechanisms that
contribute to uterine quiescence have
been proposed, including the anti-
inflammatory effects of placental proges-
terone on suppressing prostaglandin
production, which is known to promote
myocyte depolarization,7,8 and other
placental hormones such as hCG and
corticotropin-releasing hormone pro-
moting myometrial relaxation via
cyclic adenosine 3’-5’-monophosphate
(cAMP)edependent pathways.9,10 cAMP
plays important roles in cellular responses
to many hormones and neurotransmitters.
There are 3 main effectors of cAMP, one of
which is protein kinase (PKA), the well-
known target—a symmetrical complex of
2 regulatory (R) and 2 catalytic (C) sub-
units. It is activated by the binding of
cAMP to 2 sites on each of the R subunits,
which causes their dissociation from C
subunits.11 Beta-adrenoreceptor agonists
(ß-agonists) bind to ß-adrenoreceptors,
which are couples to G-proteins that acti-
vate adenylyl cyclase to form cAMP from
adenosine triphosphate. Increased cAMP
activates PKA that phosphorylates L-type
calcium channels, which causes increased
calcium entry into the cells. ß-agonists can
serve as potential drugs to influence the
cAMP-dependent pathway.11
In preparation for labor, the cervix
softens, and the myometrium undergoes
changes to allow efficient generation
and propagation of electrical activity
throughout the myometrium. Myo-
metrial activity leading to uterine con-
tractions is the result of molecular
changes that cause increased coupling
and excitability of uterine muscle
cells.3e6 Electrical discharges of the
myometrium consisting of intermittent
bursts or spikes depolarize the myo-
metrial membrane, causing influx of
calcium ions.12,13
ajog.org
Transmembrane calcium flux is an
important modulator of intracellular
calcium and it initiates a cascade of events
including interaction of contractile pro-
teins (myosin and actin) regulated by
myosin light-chain kinase, ultimately
resulting in muscle contraction
(Figure 1). Thus, uterine contractility is a
consequence of the electrical activity
underlying myometrial cells.3 Therefore,
the frequency, amplitude, and duration
of uterine contractions can be deter-
mined by the frequency of the action
potentials within a burst, the duration of
a burst, and the total number of cells that
are activated simultaneously. The prop-
agation of this electrical activity is facili-
tated by gap junctions, which increase in
number before the onset of labor.14
Gap junctions are composed of con-
nexin proteins that provide channels of
low electrical resistance between the
myometrial cells, creating a pathway for
efficient conduction of action potentials.
Throughout pregnancy these cell-to-cell
channels are low in number, resulting in
poor coupling and decreased electrical
conductance. At term, however, gap
junctions increase in number and form
an electrical syncytium required for
effective contractions.3 The hormonal
balance between estrogen and proges-
terone regulates the formation and
expression of gap junctions, whereby
estrogen is responsible for up-regulation
and progesterone is associated with
down-regulation of gap junctions.3,15,16
Estrogen also increases expression of
cyclooxygenase-2, which promotes
uterine myocyte depolarization and
contraction.17 In addition, oxytocin and
mechanical stretch cause increased
excitability of smooth muscle cells.18
Myometrial smooth muscle generates
phasic contractions in the absence of
stimuli from the central nervous system
or circulating hormones.3 The location
of the electrical activity initiation and the
propagation pattern of the electrical wave
during labor remain obscure.19 Some
studies suggest that myometrial cells
exhibit “pacemaker” capabilities.20 Early
work by Caldeyro-Barcia assumed a
catastalsis-like downward mechanism
with fundal fixed pacemakers.21 To date,
no pacemaker regions with specific
ajog.org
anatomic features have been described in
the mammalian uterus.22 Studies con-
ducted in animal and human models
failed to demonstrate a clear origin and a
specific pattern of propagation, which
was observed to be variable, shifting
from one site to the other and from one
direction to the other.19 High-resolution
recordings showed complex wave prop-
agation patterns, such as #3 wavefronts
emerging at different uterine positions
and time instants and propagating in
different directions.23 These recordings
refute theories that argue fundal domi-
nance and downward progression.
Nevertheless, the rhythmic pattern of
uterine contraction during labor is clear,
and it is dictated by the rhythm of the
electrical bursts. It has been suggested
that in contrast to longer tubular-shaped
organs such as the intestines where spe-
cific propagation pattern is necessary, the
uterus during pregnancy is more spher-
ically shaped. In that situation, the
intense rhythmic pressure that surges in
accordance with the electrical bursts
might be more important than a tightly
controlled propulsive contraction
wave.24,25 The myometrium has 2 layers.
The circular layer, called the sub-
endometrial or junctional endometrium,
is thinner and present at the innermost
aspect of muscle fibers. The outer lon-
gitudinal layer is made of intertwined
muscle bundles embedded in an extra-
cellular matrix made of collagen fibers,
which is highly vascular.20 Propagation
occurs more rapidly in the longitudinal
direction and more slowly in the trans-
versal and circumferential directions.
This structure further promotes building
the intense pressure needed for contrac-
tions.20 Thus, electrical activity is effi-
ciently transferred to the whole uterus,
resulting in rhythmic synchronous con-
tractions across the uterus that act to
raise the intrauterine pressure. Uterine
activity studies reveal the complexity of
its electrical propagation properties,
underscoring the need for further
investigation and clarification.
Methods for uterine contraction
assessment
Current methods in clinical practice for
assessing uterine activity are manual
palpation, external tocodynamometry,
IUPC measurement, and EUM. Char-
acteristics of uterine activity that are
traditionally analyzed include the fre-
quency (beginning of contraction to
beginning of the next contraction),
duration (length of contraction from its
beginning to end, measured in seconds),
intensity (strength of contraction
assessed via palpation or mm Hg), and
resting tone (intrauterine pressure when
uterus is not contracting, assessed via
palpation or mm Hg).
External palpation for assessment of
uterine activity
External palpation has the advantage of
being readily available and inexpensive. It
does not require any equipment and can
be easily taught. Nevertheless, it is a
subjective form of assessment, and uter-
ine contractions can only be perceived by
manual palpation when their intensity
exceeds a threshold of approximately 20
mm Hg.21 Furthermore, sensitivity and
accuracy of evaluation are also dependent
on the myometrial and abdominal wall
thickness and the experience of the
obstetrical caregiver.26 Indeed, when the
efficacy of manual palpation was assessed
by asking observers to define contractions
as mild, moderate, or severe, without
knowing the recorded IUPC values,27 the
observers’ assessment was accurate in
only 49% of the 236 observations ob-
tained in 46 laboring women during the
first stage of labor. Manual palpation
consistently underestimated the onset
and length of uterine contractions, and
therefore the primary use of manual
palpation is for determining the presence
and frequency of uterine contractions.26
It can also detect uterine hyperstimula-
tion or tetany, which is important in
diagnosing uterine abruption. However,
it is still an effective method of evaluating
uterine contractions, particularly in low-
resource settings.
External tocodynamometry
External tocodynamometry is the most
common method for assessing uterine
contractility during pregnancy and la-
bor. Mechanical devices for monitoring
contractions externally were introduced
as early as 1861.28 Such monitoring is
MAY 2023 American Journal of Obstetrics & Gynecology
Expert Review
FIGURE 2
External tocodynamometry
Image credit: Philips Healthcare.
Rosen. Assessment of uterine contractions in labor and de-
livery. Am J Obstet Gynecol 2023.
based on mechanical measurement of
abdominal shape by placing a transducer
on the abdominal wall. The transducer
(Figure 2) detects the change in shape of
the uterus by detecting the changes in the
abdominal contour as a result of the
contraction. The main advantages of the
method are ease of application and
noninvasiveness. In optimal circum-
stances (ie, nonobese, relaxed patients),
it can accurately measure contraction
frequency with adequate positioning of
the transducer and sufficient tightness of
the belt.29 Furthermore, in contrast to
manual palpation, tocodynamometry
allows the classification of fetal heart rate
changes in relation to the timing of
uterine contractions and providing
documentation of contractions inde-
pendently of staff presence.
There are, however, some limitations
of external tocodynamometry. Although
this method of uterine activity assess-
ment facilitates the evaluation of the
presence and frequency of uterine con-
tractions, it cannot accurately determine
the intensity or strength of contrac-
tions.30 In addition, external tocography
is also influenced by changes in maternal
position and abdominal wall muscle
contractions, such as coughing and
vomiting.31 Moreover, it is less reliable in
detecting contractions in obese women
because the accuracy of tocodynamom-
etry is limited by the abdominal wall
thickness and its position relative to the
uterus. These limitations lead to less
accurate results,32e34 and therefore
cautious interpretation is required.
S1211
Expert Review
FIGURE 3
Terminology of uterine
contractions
Adapted from Michele J. Grimm, Forces
involved with labor and delivery- a biochemical
perspective, annals of biochemical engineering,
49,1819-1835 (2021)
Rosen. Assessment of uterine contractions in labor and de-
livery. Am J Obstet Gynecol 2023.
Intrauterine pressure catheter for
uterine activity monitoring
Some of the above-mentioned limita-
tions of external tocodynamometry may
be overcome using internal monitoring
of uterine contractions during labor
with an IUPC. The first measurement of
intrauterine pressure to record uterine
contractions was performed in 1872 by
Friedrich Schatz. His method for
assessing uterine contractions used a
small bag of fluid introduced between
the membranes and the lower segment
of the uterus, connected to a mercury
manometer.
Currently, use of the IUPC requires its
placement within the intraamniotic
cavity following either spontaneous or
artificial rupture of the membranes, and
is therefore limited to only when delivery
is desired. There are 3 types of IUPCs:
fluid-filled, transducer-tipped, and
sensor-tipped. The fluid-filled catheter
has a column that connects a balloon in
the amniotic cavity to an external pres-
sure monitor, and the water column in
the catheter transmits the intrauterine
pressure to a transducer on the monitor
that converts the resulting electrical
signal to contraction waveforms. The 2
more modern systems are one in which
both the pressure sensor and the trans-
ducer are at the intrauterine tip, and one
in which the transducer is extrauterine.
Both transducer- and sensor-tipped
S1212 American Journal of Obstetrics & Gynecology MAY 2023
systems are connected to the fetal heart
rate monitor, obviating the need for a
fluid-filled catheter. Because no signifi-
cant difference has been demonstrated
between the different types of IUPCs in
relation to maternal and fetal complica-
tions, the choice of catheter used is
determined by availability, cost, or
preference.35e37 One randomized trial
that included 249 patients showed a
higher rate of extramembranous place-
ment with transducer-tipped than with
sensor-tipped catheter (12.5% vs 2.4%),
with no difference in the rate of com-
plications.37 One retrospective cohort
study showed that among 6445 women,
3944 (61.2%) had internal monitors.
Women with internal monitors were
more likely to have a fever than women
without internal monitors (11.7% vs
4.5%). The risk of cesarean delivery was
higher in women with internal monitors
(18.6% vs 9.7%). The routine use of
IUPC in laboring patients should be
avoided because of an increased risk of
maternal fever.38
Role of internal uterine monitoring in
labor management
The main advantage of IUPC over
external tocodynamometry is that it al-
lows quantification of contraction
strength, usually measured by Mon-
tevideo units. IUPC use may also be
considered when external tocodyna-
mometry fails to provide a clear tracing
of uterine contraction pattern because of
technical limitations such as obesity or
patient movements. In 1952, Caldeyro-
Barcia et al39 introduced Montevideo
units to quantify uterine contraction
power. Montevideo units represent the
sum of the amplitude of each contrac-
tion over a 10-minute period.40 The
amplitude of each contraction is
measured as the peak contraction pres-
sure minus the baseline tone to give the
“active pressure” (Figure 3).
A major criticism of Montevideo units
is that contraction duration and the
resting period between contractions are
only indirectly accounted for in this
calculation. Other calculations incorpo-
rating duration of uterine contractions
have been suggested, such as Alexandria
units, which are equivalent to a
ajog.org
Montevideo unit multiplied by the mean
duration of contractions over a 10-
minute period,41 or uterine activity
units, which calculate the area under the
pressure curve42 (Figure 4). However,
these have not been adopted in clinical
practice. Planimeter units are used
to determine the area of an arbitrary
2-dimensional shape, defined by the area
under the curve$10.
The rise in cesarean delivery rates over
the years,43 in large part owing to intra-
partum cesarean deliveries for failure to
progress (Table 1), has highlighted the
importance of making an accurate
diagnosis of arrested labor, which de-
pends on the precise assessment of
uterine contractions. Table 1 is adapted
from a consortium study by Zhang et al2
that evaluated deliveries from 2002 to
2008. Since then, definitions and prac-
tices have changed, with new World
Health Organization recommendations
for nonclinical interventions to reduce
unnecessary cesarean deliveries.40 Un-
derstanding that nonprogressive labor is
often the result of insufficient uterine
contractions rather than a premature
diagnosis of arrest of dilatation allows for
the use of uterotonic medications and
thus may in theory reduce the rate of
cesarean deliveries performed for labor
dystocia. It also supports clinicians in
titrating uterotonic treatment during
inductions or augmentation of labor. It
has been suggested that an average of 150
to 250 Montevideo units are necessary to
cause cervical dilation and fetal
descent.40,44 Uterine activity is currently
defined by the American College of
Obstetricians and Gynecologists
(ACOG) as “adequate” when Mon-
tevideo units exceed 200 mm Hg.45 Early
descriptions by Caldeyro-Barcia et al46
suggested that the average uterine
contraction pressures achieved during
the final stages of the first and second
stage of labor can reach up to 250
Montevideo units, yet later studies found
that average Montevideo units during
the active phase of normal spontaneous
labors were even lower than those ob-
tained during induced labors.47 In a
study of 109 women undergoing induc-
tion or augmentation of labor, all of
whom ultimately delivered vaginally, it
ajog.org Expert Review

was reported that 91% of induced

FIGURE 4
women and 77% of women receiving
oxytocin for augmentation achieved
Contraction intensity measuring units
>200 Montevideo units.48 It was subse-
quently reported that 92% of women
who underwent cesarean delivery for
arrest of labor in the active phase were
able to achieve greater Montevideo
units.49 Authors concluded that a
diagnosis of arrest of dilatation can
only be made in the presence of
uterine contractions with a minimum
of 200 Montevideo units >4 hours.
Some studies, however, dispute this
conclusion. Another study followed 501
women undergoing oxytocin augmen-
tation for active phase arrest or dystocia.
No difference in average Montevideo
units was found between women who
delivered vaginally and those who had a
cesarean delivery. Some women who
delivered vaginally never achieved a
contraction pattern of #200 Montevideo
units (43.9% nulliparous and 46.6%
multiparous women), and similar labor
patterns were observed in women
who ultimately underwent cesarean
delivery.50
When obese nulliparous women were
evaluated, only 47% of 2287 women who
had a successful vaginal delivery reached
#200 Montevideo units.51 A prospec-
tive, randomized trial compared 2 Adapted from Miller et al.42
groups of patients undergoing labor in- Rosen. Assessment of uterine contractions in labor and delivery. Am J Obstet Gynecol 2023.
duction assessed with IUPC with respect
to contractile power measurement vs
contraction frequency. The study docu- the above-mentioned ACOG guideline, Development (NICHD), ACOG, and
mented oxytocin titration required to it was cautioned that there is no Society for Maternal-Fetal Medicine
achieve either preset uterine activity convincing proof that use of intrauterine adopted a standardized definition for
values (measured in kilopascals in 15 tocodynamometry results in a reduction tachysystole as >5 contractions in a 10-
minutes) or 6 to 7 contractions every 15 in cesarean delivery rates or improved minute period, averaged over a 30-
minutes. There were no differences be- neonatal outcomes. IUPC may be useful minute window.53 There is a lack of a
tween the groups in terms of the length in cases where objective calculation of sufficiently clear definition of hyper-
of labor, mode of delivery, or Apgar contraction strength is desirable to help stimulation, which may be over-
scores.52 A later study investigated determine the cause of protracted or simplified as any increase in uterine
augmented labors and found no differ- arrested labor, especially when contrac- activity associated with a fetal heart rate
ence between the amount of oxytocin tion frequency is adequate. IUPC can change. Some definitions have also
required to achieve preset uterine activ- shorten the duration of obstructed labor involved increased baseline pressure,
ity levels and the amount necessary to before decision for cesarean delivery is insufficient relaxation between contrac-
achieve a preset uterine contraction made, with potential reductions in fetal tions, and prolonged isolated contrac-
frequency.52 compromise and maternal risks of tions. Tachysystole occurs in 10% to 50%
The results of these findings suggest infection or postpartum hemorrhage. of all labors,54e58 and is more common
that there are many causes behind the Excessive uterine activity is another when labor is induced or augmented,
arrest of dilatation and labor dystocia, problem encountered in labor. The particularly with prostaglandins.54,58
with inadequate uterine activity being Eunice Kennedy Shriver National Insti- The main concern associated with hy-
only one of these causes. Accordingly, in tute of Child Health and Human perstimulation is fetal compromise and

MAY 2023 American Journal of Obstetrics & Gynecology S1213

Expert Review ajog.org

uterine rupture with 48 successful and 35

TABLE 1 failed cases of vaginal birth after cesarean
Main recorded indications for cesarean delivery delivery followed with IUPCs with respect
Prelabor cesarean Intrapartum cesarean to the pattern of change of Montevideo
Indication delivery (%) delivery (%) units over time. No association between
Individual indicationsa Montevideo units and uterine rupture
Previous uterine scar 45.1 8.2 was noted.66 A systematic review exam-
ining tocogram characteristics of uterine
Failure to progress/cephalopelvic 2.0 47.1
disproportion rupture included 13 studies with either
external or internal tocodynamometry,67
Electiveb 26.4 11.7
and found that 3 tocogram characteris-
Nonreassuring fetal testing/fetal 6.5 27.3 tics were associated to varying extent
distress with uterine rupture: hyperstimulation,
Fetal malpresentation 17.1 7.5 decrease of uterine activity, and increase
Hypertensive disorders 3.1 1.6 in baseline. Five of the 13 studies docu-
Fetal macrosomia 3.3 1.2
mented no changes in uterine activity or
Montevideo units in uterine rupture
Multiple gestation 2.8 0.8 cases. Thus, it was concluded that current
Grouped indications (hierarchical, data cannot provide evidence to support
mutually exclusive) the standard use of an IUPC in TOLAC.67
Clinically indicatedc 9.7 74.9
Mixed d
80.7 23.0 Limitations and complications of
intrauterine pressure catheter use
Truly electivee 9.6 2.1
IUPCs are invasive and can only be used
Total 100 100 after the amniotic sac has been ruptured,
Adapted from Zhang et al.2 restricting its use to stages of labor after
a
Women may have >1 indication. The total percentage may exceed 100%; b Indications for elective cesarean delivery include membrane rupture and limiting its use in
“elective,” declining trial of labor, elderly gravida, multiparity, remote from term, postterm/postdate, diabetes mellitus,
chorioamnionitis, chronic or gestational hypertension without preeclampsia/eclampsia, premature rupture of the membranes, any other scenario (eg, labor before
human papillomavirus infection, group B streptococcusepositive, polyhydramnios, fetal demise, tubal ligation, and social/ rupture or ripening of the cervix with
religious concerns; c Clinically indicated includes emergency, nonreassuring fetal heart rate tracing/fetal distress, failure to
progress, cephalopelvic disproportion, failed induction, failed forceps, failed vaginal birth after cesarean delivery, placental intact membranes). The invasive nature
abruption, placenta previa, shoulder dystocia, and history of shoulder dystocia; d Mixed includes: previous uterine scar, of the procedure carries additional risks of
breech/malpresentation, fetal anomalies, fetal macrosomia, HIV infection, multiple gestation, preeclampsia/eclampsia, and
other; e Truly elective: without any indication in the “clinically indicated” or “mixed” categories. complications that occur at low rates such
Rosen. Assessment of uterine contractions in labor and delivery. Am J Obstet Gynecol 2023. as infections, uterine perforation, fetal
injuries, and placental disruption.68e70
Known or suspected placenta previa or
acidemia as a result of reduced blood superior means for determining the vasa previa are contraindications to IUPC
flow through the spiral arteries to the timing of fetal heart rate decelerations placement.
placenta and fetus during uterine con- when confronted with a potentially Extramembranous placement of
tractions.59 Indeed, the duration of the nonreassuring heart rate pattern. IUPCs between the uterine wall and the
spiral artery compression depends on Because of its more accurate assess- fetal membranes has been reported to
the strength and the duration of the ment of uterine activity, the IUPC may occur in approximately 14% to 38% of
contraction.60 also be considered in the setting of a IUPC placements.70 Although extra-
Increased uterine activity, including TOLAC when there is an increased risk of membranous placement is rarely asso-
higher Montevideo units and increased uterine rupture. However, there is no ev- ciated with complications,68 some of
contraction frequency, has been associ- idence suggesting that IUPC has a role in them may be significant and require
ated with fetal acidemia, defined as diagnosing or reducing the risk of this emergency intervention. Uterine perfo-
umbilical cord arterial pH <7.11.32 significant complication.62e64 In a review ration is a rare complication occurring in
These findings have been supported by of 76 cases of uterine rupture, 39 of which between 1 in 300 and 1 in 1400 cases.
another study observing an association were monitored with an IUPC, loss of Placental abruption, placental vessel
between uterine tachysystole and arterial intrauterine pressure or cessation of labor perforation, cord entanglement, endo-
cord pH <7.05.61 The NICHD noted the was not observed in any of the patients.62 metritis, and anaphylactoid syndrome
importance of qualifying tachysystole However, 2 case reports noted a stepwise are other adverse outcomes.70
with its associated fetal heart rate tracing. gradual decrease in uterine contraction Other rare reported complications
Therefore, IUPC may be useful in case amplitude preceding uterine rupture.65 A include placental abruption71 and am-
the accurate measurement of the onset caseecontrol study of women who un- niotic fluid embolism syndrome (also
and offset of a contraction provides a derwent TOLAC compared 9 cases of referred to as anaphylactoid syndrome of

S1214 American Journal of Obstetrics & Gynecology MAY 2023

ajog.org
pregnancy) occurring immediately after
IUPC placement.69,72 IUPC insertion
has been associated with colonization of
the amniotic cavity with bacteria. In a
study of 30 consecutive labors, amniotic
fluid was collected from the IUPC
immediately after insertion and 1 hour
after insertion.73 Whereas the amniotic
fluid obtained at the time of insertion
was sterile, 50% of patients had bacterial
colonization of the amniotic fluid 1 hour
later, and 36% developed postpartum
fever, although there was no correlation
between bacterial count and maternal
fever. Data were not available on the
timing of rupture of membranes; there-
fore, it is unclear whether bacterial
colonization was caused by the insertion
of the IUPC or by membrane rupture. In
addition, IUPC use was associated with
an approximately 2-fold increase in the
risk of maternal fever before and after
delivery.38 However, in women under-
going cesarean delivery, internal IUPC
use did not place women at increased
risk of endometritis.74
Maternal fever and chorioamnionitis
have been examined as secondary out-
comes in studies that randomized
women to IUPC placement. One study
that randomized women diagnosed with
labor dystocia to either IUPC or external
tocography demonstrated no difference
in the use of antibiotics or clinical signs
of maternal or neonatal infection be-
tween groups.75
Another limitation of the IUPC con-
cerns its sensitivity and accuracy of
measuring uterine activity. During
quiescence, intrauterine tone is referred
to as the “resting uterine pressure” or
“baseline tone,” which comprises pressure
owing to the elastic recoil of the tissues,
and a hydrostatic component, which
varies with the depth below the upper
fluid level of the uterus. The contribution
of the hydrostatic component to the
overall intrauterine pressure varies from
0 when measured with the upper fluid
level of the uterus, to approximately 35
cm H2O (25.7 mm Hg, 3.43 kPa) if
measured at the lowest fluid level. Hence,
the baseline tone is not a single value but
rather varies according to the position of
the maternal posture referred to as “the
baseline problem.” Baseline is measured
supine, and is referred to the top of the
uterus if zeroed. For calibration purposes
the external transducer is initially placed
at the level of the symphysis pubis, and at
this fixed point the “baseline tone” is
registered. This uterine tone measure-
ment varies with maternal posture.
Comparison between external and
internal contraction monitoring
during labor
Comparison between external tocody-
namometry and the IUPC has been the
subject of a few investigations. One large,
randomized control trial evaluating in-
ternal vs external tocography during in-
duction and augmentation of labor
aimed to determine the effect of internal
tocodynamometry vs external moni-
toring on the rate of operative vaginal
and cesarean deliveries (the rates of
which are higher in the United States
than in the Netherlands, where the study
was conducted).75 Overall, 1456 women
with singleton cephalic term pregnancies
(the rates of which are higher in the
United States than in the Netherlands,
where the study was conducted) under-
went induction or augmentation of labor
with intravenous oxytocin and were
randomized to receive either IUPC or
external tocodynamometry. The authors
failed to demonstrate a decrease in
operative delivery with internal tocog-
raphy. There were also no differences
between the groups in the rate of anti-
biotic use, the time from randomization
to delivery, or rate of adverse neonatal
outcomes. There were no reported
complications with use of the IUPC, and
there were no neonatal or maternal
deaths. It is important to note, however,
that 12% of women randomized to
external monitoring received internal
monitoring because of either inability to
adequately monitor uterine activity us-
ing external tocodynamometry or sus-
pected arrest of dilation.
To better understand the effectiveness
of IUPC vs that of external tocography
when intravenous oxytocin is used to
induce or augment labor, a systematic
Cochrane review of 3 randomized trials
comparing internal with external toco-
dynamometry was conducted, including
1945 women undergoing induction or
MAY 2023 American Journal of Obstetrics & Gynecology
Expert Review
augmentation of labor.76 There were no
reports of maternal or neonatal deaths in
any of the studies. Neonatal outcomes
(Apgar score <7 at 5 minutes, umbilical
artery pH <7.15, admission to the
neonatal intensive care unit, and >48
hours of hospitalization) did not differ
significantly between study groups.
There were no demonstrated increased
maternal or fetal complications with
IUPC vs external tocography. Risks of
invasive monitoring exist but should not
be overstated. In addition, there were no
significant differences between study
groups in the number of instrumental or
cesarean deliveries, the use of analgesia,
and time to delivery. Furthermore,
women in whom an intrauterine cath-
eter was placed had no increased risk of
infection. It was concluded that internal
tocodynamometry did not improve any
maternal or neonatal outcomes.74
Because external tocography correlates
well with internal tocography with
respect to frequency, and IUPC use may
be associated with complications, as
detailed above, ACOG does not recom-
mend routine use of IUPCs,77 but rather
suggests that they should be considered
only in select clinical situations.
Electrical uterine monitoring
Electromyography (EMG) of uterine
muscle activity is a monitoring tech-
nique that relies on the detection and
recording of bioelectrical signals pro-
duced by the contracting uterus in a
similar manner to other better-
recognized techniques such as
electrocardiography and electroence
phalography.
Electrical activity of the uterine mus-
cle was first recorded over half a century
ago.78 Early animal studies showed that
propagation of myometrial electrical
activity is facilitated by gap junctions,
which increase in number before the
onset of labor. These studies were then
followed by noninvasive recordings of
uterine EMG signals from the abdom-
inal surface in human participants. The
recordings provided convincing evi-
dence that uterine EMG activity tracing
or EUM can be elucidated from nonin-
vasive transabdominal surface measure-
ments evaluating uterine contractions
S1215
Expert Review ajog.org

determined from transabdominal EMG.

TABLE 2
Comparison of operating characteristics for contraction detection
between electrohysterography and intrauterine pressure catheter and
tocography and intrauterine pressure catheter (n[59)
EHG vs IUPC
Variable Mean
Consistent contractions 33.8
CCI 0.88
CCI <0.75% 16.7
Correlation 0.62
Positive predictive value 0.89
Sensitivity 0.89
CCI calculated as:
Nc
CCI ¼
1
ðNT þ NE Þ
2
NT is the number of contractions detected by IUPC, NE is the number detected in the EHG or tocographic signal, and NC is the
number of consistent contractions.
Adapted from Euliano et al.30
CCI, Contractions Consistency Index; EHG, electrohysterography; IUPC, intrauterine pressure catheter; SD, standard deviation.
Rosen. Assessment of uterine contractions in labor and delivery. Am J Obstet Gynecol 2023.
during pregnancy, labor, and delivery.
Some technical challenges were met
initially, such as the need to filter other
bioelectrical signals, for instance from
maternal electrocardiogram (ECG),
respiration, movement artifacts, and
skin impedance.79,80 In more recent
years, technological advancements have
overcome these limitations.
Different studies have used various
devices to measure EUM, or as it is
frequently termed, “hysterography.”
Nevertheless, no standardized form of
electrode placement for recording EUM
has been established. Although some
studies show that this placement is
possible either in a monopolar or bipolar
configuration,81e83 the latter was shown
to be more stable and less prone to noise
or interference.84 Other studies used a 9-
or 16-electrode configuration to estab-
lish the spatial distribution of the largest
surface of the maternal abdomen.85,86
The bioengineering details of EUM
signal processing and analysis are
beyond the scope of this review and are
described elsewhere.87
Throughout most of pregnancy, the
uterus is in a quiescent state, and there is
only low uterine electrical activity con-
sisting of infrequent and low-amplitude
They found that EUM correlated
strongly with intrauterine pressure and
that EUM burst energy levels were
significantly higher in patients who
Tocography delivered within 48 hours than in those
vs IUPC Difference who did not. Moreover, burst energy
SD Mean SD Mean SD P value levels were highly predictive of delivery
19.4 23.5 16.2 10.4 16.3 <.0001 within 48 hours. EUM measurements
correlated strongly with the strength of
0.17 0.69 0.27 0.19 0.33 <.0001
contractions, suggesting they may be a
26.7 46.1 34.0 &29.4 44.2 .0001 valuable alternative to invasive mea-
0.24 0.38 0.28 0.25 0.35 <.0001 surement of intrauterine pressure
0.14 0.86 0.19 0.03 0.24 .37 and preferable to tocodynamometry.
Another study compared frequency and
0.20 0.62 0.29 0.27 0.37 <.0001
timing of uterine contractions through
simultaneous monitoring of 53 laboring
women with external tocodynamometry,
EUM, and IUPC during labor.30 A
Contractions Consistency Index (CCI)
was defined to allow comparison of
EUM and tocodynamometry with IUPC
measurements. CCI represents the
number of consistent contractions
divided by the average of those detected
EMG bursts.3 When bursts occur before by either IUPC or EMG as the gold
the onset of labor, they often correspond to standard, where the method is more
periods of perceived contractility by the accurate when CCI is closer to 1. The
patient. During term and preterm labor, mean CCI for EUM was 0.88%0.17 vs
bursts of EMG activity are frequent, of 0.69%0.27 for tocodynamometry
large amplitude, and correlated with the (P<.0001) (Table 2). In contrast to
large changes in intrauterine pressure and tocodynamometry, EUM was not
pain sensation.3 significantly affected by obesity, leading
to the conclusion that EUM provides a
Electrical uterine activity monitoring reliable noninvasive alternative, regard-
compared with intrauterine pressure less of body habitus.
catheter and external monitoring Another study was designed to deter-
Similar to IUPC, EUM enables evalua- mine the accuracy of EUM vs that of
tion of the initiation, time to peak, IUPC in 47 women during active labor.86
duration frequency, and intensity of All women were monitored simulta-
uterine contractions.86 Because it is neously with IUPC and EUM. The cor-
noninvasive and does not require relation of the frequency, intensity, and
ruptured membranes, in contrast to the tone of contractions between uterine
IUPC, it can be used as a diagnostic tool EUM and IUPC was significant, sug-
both antepartum and intrapartum in gesting that EUM yields information
term and preterm pregnancies. Impor- about uterine contractility close to that
tant to note that it carries a warning of obtained with IUPC (Figure 5).
false-positive contraction readings. A prospective observational study
To validate that EUM is a reliable attempted to validate EUM as a method
method for evaluating uterine contrac- for uterine activity monitoring during
tile activity, studies have compared EUM labor by comparing EUM with IUP re-
with IUPC by translating EUM data into cordings in 32 laboring women.89 EUM
an “intrauterine pressureeestimated” detected uterine contractions accurately,
waveform.88 Maul et al33 investigated although the correlation of contraction
whether the strength of uterine con- duration and amplitude between the 2
tractions monitored by IUPC could be methods was weak.

S1216 American Journal of Obstetrics & Gynecology MAY 2023

ajog.org Expert Review

FIGURE 5
Simultaneous recordings of uterine contractions using 2 separate methods

Bottom: standard IUPC recording; top: simultaneous EUM measurement. (Orange dot) on bottom tracing represents the point in time reflected on the top
EUM graph. A, Uterine quiescence; although baseline uterine pressure is measured by IUPC, no electrical uterine activity is recorded simultaneously. B,
Uterine contraction; in parallel with peak intrauterine pressure, peak electrical myometrial electrical activity is recorded. IUPC records pressure of a solitary
point inside the uterus, whereas EUM measures numerous points on the uterine surface, allowing evaluation of progression of the contraction wave.
EUM, electrical uterine monitoring; IUPC, intrauterine pressure catheter.
Rosen. Assessment of uterine contractions in labor and delivery. Am J Obstet Gynecol 2023.

The results of these studies suggest throughout term labor for both non- contractions in clinical settings where
that EUM is a sensitive method for obese and obese women. EUM allows IUPC is contraindicated or when mem-
improving external uterine monitoring the assessment of intensity of uterine branes are intact. However, unlike IUPC,

MAY 2023 American Journal of Obstetrics & Gynecology S1217

Expert Review
EUM may provide some readings of false
positive contractions.
Assessment of labor progression by
electrical uterine activity monitoring
A prospective double-blind study eval-
uated EUM in 63 active laboring women.
The control group consisted of 26 pa-
tients with normal labor progression,
and the study group included 37 patients
with abnormal labors.90 Analysis of pa-
tients with labor abnormalities in the
active phase revealed that the electrical
uterine activity increased after the
administration of oxytocin and during
the active phase in spontaneous labor.
Analysis of the electrical uterine activity
of patients in spontaneous labor vs those
receiving oxytocin augmentation was
similar, suggesting that comparable
electrical uterine activity occurs in
spontaneous and augmented labor.
In an attempt to assess the effect of
amniotomy on uterine electrical activity,
EUM was prospectively measured in 23
women with singleton pregnancies at
term in the active phase of labor.91 EUM
was continuously measured at least 30
minutes before and at least 30 minutes
following performance of amniotomy.
There was a significant increase in mean
EUM measurement after artificial
rupture of the membranes compared
with when the membranes were intact
(3.59%0.39 vs 3.42%0.47 mWs; P<.001),
confirming that amniotomy augments
uterine activity.
In a prospective study,92 electrical
uterine activity was measured in women
with singleton term gestations undergo-
ing labor augmentation by oxytocin
administration. Measurements begun 30
minutes before oxytocin infusion initia-
tion and continued until 4 contractions
per 10 minutes were achieved. The delta
EUM index was defined as the difference
between the mean EUM index (mean
electrical activity in 10-minute intervals
in microjoule) before and after the initi-
ation of oxytocin. It was found that uter-
ine electrical activity as evaluated by EUM
is significantly intensified following
oxytocin administration, regardless of
obstetrical characteristics, although no
correlation was observed between the
delta EUM index and time to delivery or
S1218 American Journal of Obstetrics & Gynecology MAY 2023
the mean EUM index during oxytocin
administration and time to delivery.
Electrical uterine activity monitoring
during the third stage of labor
The third stage of labor is defined as the
time interval from delivery of the fetus
to the expulsion of the placenta and
membranes. EUM was prospectively
measured during the third stage of la-
bor and compared with that observed
in the second stage of labor.93 Signifi-
cant uterine activity was identified
during the third stage, and contraction
peaks were similar to those observed
during the second stage of labor
(3.43%0.64 vs 3.42%0.57 mWs; P¼.8).
No correlation was found between the
duration of the third-stage length and
EUM measurements during the third
or second stage of labor.
Electrical uterine activity monitoring
and labor induction
Assessment of uterine activity during
induction of labor allows the determi-
nation of uterine response to cervical
ripening and uterotonic agents and the
detection of uterine tachysystole. The
effect of prostaglandin E2 (PGE2) on
electrical uterine activity was studied in
patients undergoing induction of la-
bor94; 31 women were monitored before
and up to 12 hours after vaginal PGE2
application. The EUM index was not
increased significantly during the first 2
hours following PGE2 application. Peak
EUM activity was observed 2 to 8 hours
after PGE2 application.
Electrical uterine activity monitoring
in obese patients
Traditional noninvasive methods of
measuring uterine activity are limited in
obese women. One study compared EUM
with traditional tocodynamometry and
the IUPC in 25 obese (median body mass
index, 39.6) laboring women.95 Tocody-
namometry identified 248 contractions vs
the 336 identified by EMG, whereas IUPC
monitoring identified 319 contractions vs
the 342 identified by EMG. These results
suggest that in obese women, EUM is as
effective as invasive IUPC measurement of
uterine activity, and that both are
superior to tocodynamometry. Therefore,
ajog.org
consideration should be given to EUM in
these patients because in addition to its
accuracy, it does not carry the previously
mentioned risks associated with IUPC
placement.
Another study evaluated the influence
of maternal obesity on the performance
of external tocodynamometry vs EUM
during labor at term.96 Uterine con-
tractions were simultaneously measured
by EUM, external tocodynamometry,
and IUPC in 14 morbidly obese, 18
obese, and 20 nonobese women. Data
were compared among these groups. In
contrast to external tocodynamometry,
the sensitivity of EUM was not affected
by the degree of obesity, further sup-
porting a role for EUM in obese patients.
Limitations of electrical uterine
monitoring
Despite the mentioned advantages, there
are some limitations to the use of EUM.
The accuracy of EUM signal transmission
can be affected by the relative conductivity
of tissue layers through which the signal
must be transmitted. Furthermore, the
quality of the signal can be affected by
interference from other signals, such as the
skeletal muscle electromyogram, maternal
ECG, and movement artifacts.40,97 The
signal can even be lost, which is a major
problem of using EUM. Cost is also a sig-
nificant limitation. The introduction of
new technology into already equipped and
trained birthing units demands capital
investment in material and training re-
sources. In addition, the use of EUM re-
sults in a substantial rate of false-positives,
and efforts need to be undertaken to
decrease this rate. Current US Food and
Drug Administration clearances for ECG/
EMG fetal monitors are only for term
pregnancies. In the past years, there were
no EUM devices that are commercially
available for clinical use. Recently, the
Monica device has been made available for
clinical use in the United States, and the
device of OBMedical, which was acquired
by Philips, may be brought soon.
Summary
The monitoring of uterine activity is a
routine component of modern ante-
partum and intrapartum obstetrical care.
In the United States, fetal monitoring is
ajog.org
not thought to improve outcomes beyond
intermittent manual monitoring, but
nonetheless remains a mainstay of
obstetrical care. There are a few methods
for monitoring uterine activity that are
currently in clinical use, and each method
is associated with inherent advantages
and disadvantages, and limitations in
select clinical settings. External tocog-
raphy, although lacking the ability to
assess contraction intensity, remains the
mainstay of routine obstetrical care
because it is easy to use, relatively inex-
pensive, noninvasive, and provides
important information regarding the
presence, regularity, and duration of
contractions, all while maintaining a low
risk of complications. Although the IUPC
provides more accurate information
regarding contraction intensity and basal
uterine tone, there is insufficient evidence
for the routine use of IUPC in terms of
improving outcomes, including neonatal
outcomes, rates of instrumental de-
liveries, use of analgesia, cesarean delivery
rates, or time to delivery. The use of IUPC
is associated with certain risks and limi-
tations, namely the risk of infection and
uterine perforation, and the need for
ruptured membranes. In addition, there
is lack of evidence for IUPC superiority
relative to other methods, which limits its
use to specific clinical settings such as
oxytocin titration in cases of labor
dystocia with ruptured membranes. EUM
may be a promising technology that can
overcome the aforementioned challenges.
In addition to being noninvasive, EUM
provides an accurate assessment of
contraction intensity, and is not associ-
ated with the risks, limitations, and con-
traindications that accompany the use of
the IUPC. EUM has yet to be incorpo-
rated into clinical practice because of lack
of access to this technology, its high cost,
and the need for appropriate training of
clinical staff. Further research is needed to
elucidate the precise physiological process
of normal and abnormal term and pre-
term labor progression and their corre-
lation with uterine activity. - Young RC. Why the heart is like an orchestra and
REFERENCES
1. Selin L, Wallin G, Berg M. Dystocia in labour -
risk factors, management and outcome: a
retrospective observational study in a Swedish
setting. Acta Obstet Gynecol Scand 2008;87:
216–21.
2. Zhang J, Troendle J, Reddy UM, et al.
Contemporary cesarean delivery practice in the
United States. Am J Obstet Gynecol 2010;203:
326. e1e10.
3. Garfield RE, Maner WL. Physiology and
electrical activity of uterine contractions. Semin
Cell Dev Biol 2007;18:289–95.
4. Kao CY. Electrical properties of uterine
smooth muscle. In: Biology of the uterus. New
York, NY: Plenum Press; 1977. p. 423–96.
5. Fanchin R, Ayoubi JM, Righini C, Olivennes F,
Schönauer LM, Frydman R. Uterine contractility
decreases at the time of blastocyst transfers.
Hum Reprod 2001;16:1115–9.
6. Renthal NE, Chen CC, Williams KC,
Gerard RD, Prange-Kiel J, Mendelson CR. miR-
200 family and targets, ZEB1 and ZEB2,
modulate uterine quiescence and contractility
during pregnancy and labor. Proc Natl Acad Sci
U S A 2010;107:20828–33.
7. Young RC, Smith LH, McLaren MD. T-type
and L-type calcium currents in freshly dispersed
human uterine smooth muscle cells. Am J
Obstet Gynecol 1993;169:785–92.
8. Young RC, Zhang P. Inhibition of in vitro
contractions of human myometrium by mibe-
fradil, a T-type calcium channel blocker: support
for a model using excitation-contraction
coupling, and autocrine and paracrine signaling
mechanisms. J Soc Gynecol Investig 2005;12.
e7e12.
9. Slattery MM, Brennan C, O’Leary MJ,
Morrison JJ. Human chorionic gonadotrophin
inhibition of pregnant human myometrial
contractility. BJOG 2001;108:704–8.
10. Tyson EK, Smith R, Read M. Evidence that
corticotropin-releasing hormone modulates
myometrial contractility during human preg-
nancy. Endocrinology 2009;150:5617–25.
11. Sassone-Corsi P. The cyclic AMP pathway.
Cold Spring Harb Perspect Biol 2012;4:
a011148.
12. Bursztyn L, Eytan O, Jaffa AJ, Elad D.
Mathematical model of excitation-contraction in
a uterine smooth muscle cell. Am J Physiol Cell
Physiol 2007;292:C1816–29.
13. Wray S, Jones K, Kupittayanant S, et al.
Calcium signaling and uterine contractility. J Soc
Gynecol Investig 2003;10:252–64.
14. Demianczuk N, Towell ME, Garfield RE.
Myometrial electrophysiologic activity and gap
junctions in the pregnant rabbit. Am J Obstet
Gynecol 1984;149:485–91.
15. Garfield RE, Saade G, Buhimschi C, et al.
Control and assessment of the uterus and cervix
during pregnancy and labour. Hum Reprod
Update 1998;4:673–95.
16. Smith R, Imtiaz M, Banney D, Paul JW,
the uterus is like a soccer crowd. Am J Obstet
Gynecol 2015;213:181–5.
17. Bisits AM, Smith R, Mesiano S, et al. In-
flammatory aetiology of human myometrial
activation tested using directed graphs. PLoS
Comput Biol 2005;1:132–6.
MAY 2023 American Journal of Obstetrics & Gynecology
Expert Review
18. Maul H, Maner WL, Saade GR, Garfield RE.
The physiology of uterine contractions. Clin
Perinatol 2003;30:665–76.
19. Lammers WJEP. The electrical activities of
the uterus during pregnancy. Reprod Sci
2013;20:182–9.
20. McEvoy A, Sabir S. Physiology, pregnancy
contractions. 2022. Available at: http://www.
ncbi.nlm.nih.gov/books/NBK532927/. June
17, 2022.
21. Caldeyro-Barcia R, Poseiro JJ. Physiology
of the uterine contraction. Clin Obstet Gynaecol
1960;3:386–410.
22. Lutton EJ, Lammers WJEP, James S, van
den Berg HA, Blanks AM. Identification of
uterine pacemaker regions at the myometrial-
placental interface in the rat. J Physiol
2018;596:2841–52.
23. Zhang M, La Rosa PS, Eswaran H,
Nehorai A. Estimating uterine source current
during contractions using magnetomyography
measurements. PLoS One 2018;13:
e0202184.
24. Csapo AI, Jaffin H, Kerenyi T, Lipman JI,
Wood C. Volume and activity of the pregnant
human uterus. Am J Obstet Gynecol 1963;85:
819–35.
25. Young RC, Goloman G. Mechano-
transduction in rat myometrium: coordination of
contractions of electrically and chemically iso-
lated tissues. Reprod Sci 2011;18:64–9.
26. Bakker PCAM, van Geijn HP. Uterine activ-
ity: implications for the condition of the fetus.
J Perinat Med 2008;36:30–7.
27. Arrabal PP, Nagey DA. Is manual palpation
of uterine contractions accurate? Am J Obstet
Gynecol 1996;174:217–9.
28. Freeman RK, Garite TJ, Nageotte MP,
Miller L. Fetal heart rate monitoring, 4th ed.
Baltimore, MD: Williams & Wilkins; 2012.
29. Bakker PC, Van Rijswijk S, van Geijn HP.
Uterine activity monitoring during labor. J Perinat
Med 2007;35:468–77.
30. Euliano TY, Nguyen MT, Darmanjian S, et al.
Monitoring uterine activity during labor: a com-
parison of 3 methods. Am J Obstet Gynecol
2013;208:66. e1e6.
31. Steer PJ. Standards in fetal monitoring–
practical requirements for uterine activity mea-
surement and recording. Br J Obstet Gynaecol
1993;100(Suppl 9):32–6.
32. Bakker PC, Kurver PH, Kuik DJ, Van
Geijn HP. Elevated uterine activity increases the
risk of fetal acidosis at birth. Am J Obstet
Gynecol 2007;196:313. e1e6.
33. Maul H, Maner WL, Olson G, Saade GR,
Garfield RE. Non-invasive transabdominal uter-
ine electromyography correlates with the
strength of intrauterine pressure and is predic-
tive of labor and delivery. J Matern Fetal
Neonatal Med 2004;15:297–301.
34. Newman RB. Uterine contraction assess-
ment. Obstet Gynecol Clin North Am 2005;32:
341–67.
35. Dowdle MA. Comparison of two intrauterine
pressure catheters during labor. J Reprod Med
2003;48:501–5.
S1219
Expert Review
36. Dowdle M. Evaluating a new intrauterine
pressure catheter. J Reprod Med 1997;42:
506–13.
37. Sciscione AC, Duhl A, Pollock MA,
Hoffman MK, Rhee A, Colmorgen GHC. Extra-
membranous placement of an air-coupled vs.
transducer-tipped intrauterine pressure cath-
eter. J Reprod Med 2005;50:578–84.
38. Harper LM, Shanks AL, Tuuli MG, Roehl KA,
Cahill AG. The risks and benefits of internal
monitors in laboring patients. Am J Obstet
Gynecol 2013;209:38. e1e6.
39. Caldeyro-Barcia R, Poseiro JJ. Oxytocin
and contractility of the pregnant human uterus.
Ann N Y Acad Sci 1959;75:813–30.
40. Alberola-Rubio J, Prats-Boluda G, Ye-Lin Y,
Valero J, Perales A, Garcia-Casado J. Com-
parison of non-invasive electrohysterographic
recording techniques for monitoring uterine dy-
namics. Med Eng Phys 2013;35:1736–43.
41. el-Sahwi S, Gaafar AA, Toppozada HK.
A new unit for evaluation of uterine activity. Am J
Obstet Gynecol 1967;98:900–3.
42. Miller FC, Yeh SY, Schifrin BS, Paul RH,
Hon EH. Quantitation of uterine activity in 100
primiparous patients. Am J Obstet Gynecol
1976;124:398–405.
43. Martin JA, Hamilton BE, Osterman MJK,
Driscoll AK, Drake P. Births: final data for 2017.
Natl Vital Stat Rep 2018;67:1–50.
44. ACOG Practice Bulletin No. 107: induction
of labor. Obstet Gynecol 2009;114:386–97.
45. Obstetric care consensus no. 1: safe pre-
vention of the primary cesarean delivery. Obstet
Gynecol 2014;123:693–711.
46. Caldeyro-Barcia R, Sica-Blanco Y,
Poseiro JJ, et al. A quantitative study of the ac-
tion of synthetic oxytocin on the pregnant human
uterus. J Pharmacol Exp Ther 1957;121:18–31.
47. Steer PJ, Carter MC, Beard RW. Normal
levels of active contraction area in spontaneous
labour. Br J Obstet Gynaecol 1984;91:211–9.
48. Hauth JC, Hankins GD, Gilstrap LC,
Strickland DM, Vance P. Uterine contraction
pressures with oxytocin induction/augmenta-
tion. Obstet Gynecol 1986;68:305–9.
49. Hauth JC, Hankins GD, Gilstrap LC. Uterine
contraction pressures achieved in parturients
with active phase arrest. Obstet Gynecol
1991;78:344–7.
50. Rouse DJ, Owen J, Savage KG, Hauth JC.
Active phase labor arrest: revisiting the 2-hour
minimum. Obstet Gynecol 2001;98:550–4.
51. Chin JR, Henry E, Holmgren CM,
Varner MW, Branch DW. Maternal obesity and
contraction strength in the first stage of labor.
Am J Obstet Gynecol 2012;207:129. e1e6.
52. Arulkumaran S, Yang M, Ingemarsson I,
Singh P, Ratnam SS. Augmentation of labour:
does oxytocin titration to achieve preset active
contraction area values produce better obstetric
outcome? Asia Oceania J Obstet Gynaecol
1989;15:333–7.
53. ACOG Practice Bulletin No. 106: intra-
partum fetal heart rate monitoring: nomencla-
ture, interpretation, and general management
principles. Obstet Gynecol 2009;114:192–202.
S1220 American Journal of Obstetrics & Gynecology MAY 2023
54. Heuser CC, Knight S, Esplin MS, et al.
Tachysystole in term labor: incidence, risk factors,
outcomes, and effect on fetal heart tracings. Am J
Obstet Gynecol 2013;209:32. e1e6.
55. Kunz MK, Loftus RJ, Nichols AA. Incidence
of uterine tachysystole in women induced with
oxytocin. J Obstet Gynecol Neonatal Nurs
2013;42:12–8.
56. Stewart RD, Bleich AT, Lo JY,
Alexander JM, McIntire DD, Leveno KJ.
Defining uterine tachysystole: how much is too
much? Am J Obstet Gynecol 2012;207:290.
e1e6.
57. Smith S, Zacharias J, Lucas V, Warrick PA,
Hamilton EF. Clinical associations with uterine
tachysystole. J Matern Fetal Neonatal Med
2014;27:709–13.
58. Crane JM, Young DC, Butt KD, Bennett KA,
Hutchens D. Excessive uterine activity accom-
panying induced labor. Obstet Gynecol 2001;97:
926–31.
59. Gee SE, Frey HA. Contractions: traditional
concepts and their role in modern obstetrics.
Semin Perinatol 2020;44:151218.
60. Sukumaran S, Jia YJ, Chandraharan E.
Uterine Tachysystole, hypertonus and hyper-
stimulation: an urgent need to get the definitions
right to avoid Intrapartum Hypoxic-ischaemic
Brain Injury. Published online April 1, 2021. doi:
10.19080/GJORM.2021.08.5556735
61. Jonsson M, Nordén-Lindeberg S, Ostlund I,
Hanson U. Acidemia at birth, related to obstetric
characteristics and to oxytocin use, during the
last two hours of labor. Acta Obstet Gynecol
Scand 2008;87:745–50.
62. Rodriguez MH, Masaki DI, Phelan JP,
Diaz FG. Uterine rupture: are intrauterine pres-
sure catheters useful in the diagnosis? Am J
Obstet Gynecol 1989;161:666–9.
63. Devoe LD, Croom CS, Youssef AA,
Murray C. The prediction of ”controlled” uterine
rupture by the use of intrauterine pressure
catheters. Obstet Gynecol 1992;80:626–9.
64. Menihan CA. Uterine rupture in women
attempting a vaginal birth following prior cesar-
ean birth. J Perinatol 1998;18:440–3.
65. Matsuo K, Scanlon JT, Atlas RO,
Kopelman JN. Staircase sign: a newly described
uterine contraction pattern seen in rupture of
unscarred gravid uterus. J Obstet Gynaecol Res
2008;34:100–4.
66. Maggio L, Forbes J, Carey LL, Sangi-
Haghpeykar H, Davidson C. Association of
Montevideo units with uterine rupture in women
undergoing a trial of labor. J Reprod Med
2014;59:464–70.
67. Vlemminx MWC, de Lau H, Oei SG. Toco-
gram characteristics of uterine rupture: a sys-
tematic review. Arch Gynecol Obstet 2017;295:
17–26.
68. Madanes AE, David D, Cetrulo C. Major com-
plications associated with intrauterine pressure
monitoring. Obstet Gynecol 1982;59:389–91.
69. Matsuo K, Lynch MA, Kopelman JN, Atlas RO.
Anaphylactoid syndrome of pregnancy immedi-
ately after intrauterine pressure catheter placement.
Am J Obstet Gynecol 2008;198:e8–9.
ajog.org
70. Wilmink FA, Wilms FF, Heydanus R,
Mol BWJ, Papatsonis DNM. Fetal complications
after placement of an intrauterine pressure cath-
eter: a report of two cases and review of the
literature. J Matern Fetal Neonatal Med 2008;21:
880–3.
71. Lind BK. Complications caused by extra-
membranous placement of intrauterine pressure
catheters. Am J Obstet Gynecol 1999;180:
1034–5.
72. Harbison L, Bell L. Anaphylactoid syndrome
after intrauterine pressure catheter placement.
Obstet Gynecol 2010;115:407–8.
73. Thadepalli H, Appleman MD, Chan WH,
Maidman JC, Davidson EC. Amniotic fluid
contamination during internal fetal monitoring.
J Reprod Med 1978;20:93–6.
74. Gibbs RS, Jones PM, Wilder CJ. Internal
fetal monitoring and maternal infection following
cesarean section. A prospective study. Obstet
Gynecol 1978;52:193–7.
75. Bakker JJ, Verhoeven CJM, Janssen PF,
et al. Outcomes after internal versus external
tocodynamometry for monitoring labor. N Engl J
Med 2010;362:306–13.
76. Bakker JJH, Janssen PF, van Halem K, et al.
Internal versus external tocodynamometry dur-
ing induced or augmented labour. Cochrane
Database Syst Rev 2013;8:CD006947.
77. American College of Obstetrics and Gyne-
cology Committee on Practice Bulletins-Ob-
stetrics. ACOG Practice Bulletin Number 49,
December 2003: dystocia and augmentation of
labor. Obstet Gynecol 2003;102:1445–54.
78. Steer CM, Hertsch GJ. Electrical activity of
the human uterus in labor; the electro-
hysterograph. Am J Obstet Gynecol 1950;59:
25–40.
79. de Lau H, Rabotti C, Haazen N, Oei SG,
Mischi M. Towards improving uterine electrical
activity modeling and electrohysterography: ul-
trasonic quantification of uterine movements
during labor. Acta Obstet Gynecol Scand
2013;92:1323–6.
80. Devedeux D, Marque C, Mansour S,
Germain G, Duchêne J. Uterine electromyog-
raphy: a critical review. Am J Obstet Gynecol
1993;169:1636–53.
81. de Lau H, Rabotti C, Oosterbaan HP,
Mischi M, Oei GS. Study protocol: PoPE-prediction
of preterm delivery by electrohysterography. BMC
Pregnancy Childbirth 2014;14:192.
82. Ye-Lin Y, Alberola-Rubio J, Prats-Boluda G,
et al. Non-invasive electrohysterogram
recording using flexible concentric ring elec-
trode. Annu Int Conf IEEE Eng Med Biol Soc
2014;2014:4050–3.
83. Ye-Lin Y, Alberola-Rubio J, Prats-Boluda G,
Perales A, Desantes D, Garcia-Casado J. Feasi-
bility and analysis of bipolar concentric recording
of electrohysterogram with flexible active elec-
trode. Ann Biomed Eng 2015;43:968–76.
84. Huang H, Zhou P, Li G, Kuiken TA. An
analysis of EMG electrode configuration for tar-
geted muscle reinnervation based neural ma-
chine interface. IEEE Trans Neural Syst Rehabil
Eng 2008;16:37–45.
ajog.org
85. Alexandersson A, Steingrimsdottir T,
Terrien J, Marque C, Karlsson B. The Icelandic
16-electrode electrohysterogram database. Sci
Data 2015;2:150017.
86. Haran G, Elbaz M, Fejgin MD, Biron-
Shental T. A comparison of surface acquired
uterine electromyography and intrauterine
pressure catheter to assess uterine activity. Am
J Obstet Gynecol 2012;206:412. e1e5.
87. Blanks AM, Eswaran H. Measurement of
uterine electrophysiological activity. Curr Opin
Physiol 2020;13:38–42.
88. Vlemminx MWC, Thijssen KMJ, Bajlekov GI,
Dieleman JP, Van Der Hout-Van Der Jagt MB,
Oei SG. Electrohysterography for uterine moni-
toring during term labour compared to external
tocodynamometry and intra-uterine pressure
catheter. Eur J Obstet Gynecol Reprod Biol.
2017;215:197-205.
89. Jacod BC, Graatsma EM, Van Hagen E,
Visser GHA. A validation of electrohysterography
for uterine activity monitoring during labour.
J Matern Fetal Neonatal Med 2010;23:
17–22.
90. Farinelli C, Langer O, Playforth K, David GB,
Calderon I. Uterine electromyography during
spontaneous and abnormal labor. Am J Obstet
Gynecol 2008;199:S65.
91. Hiersch L, Rosen H, Salzer L, Aviram A,
Ben-Haroush A, Yogev Y. Does artificial
rupturing of membranes in the active phase of
labor enhance myometrial electrical activity?
J Matern Fetal Neonatal Med 2015;28:
515–8.
92. Lavie A, Shinar S, Hiersch L, Ashwal E,
Yogev Y, Aviram A. Uterine electrical activity,
oxytocin and labor: translating electrical into
mechanical. Arch Gynecol Obstet 2018;297:
1405–13.
93. Rosen H, Salzer L, Hiersch L, Aviram A,
Ben-Haroush A, Yogev Y. Uterine electric activity
during the third stage of labor; a look into the
MAY 2023 American Journal of Obstetrics & Gynecology
Expert Review
physiology of a deserted stage. J Matern Fetal
Neonatal Med 2014;27:921–5.
94. Aviram A, Melamed N, Hadar E, Raban O,
Hiersch L, Yogev Y. Effect of prostaglandin E2
on myometrial electrical activity in women un-
dergoing induction of labor. Am J Perinatol
2014;31:413–8.
95. Euliano TY, Nguyen MT, Marossero D,
Edwards RK. Monitoring contractions in obese
parturients: electrohysterography compared
with traditional monitoring. Obstet Gynecol
2007;109:1136–40.
96. Vlemminx MWC, Thijssen KMJ, Bajlekov GI,
Dieleman JP, Van Der Hout-Van Der Jagt MB,
Oei SG. Could electrohysterography be the so-
lution for external uterine monitoring in obese
women? J Perinatol 2018;38:580–6.
97. Rabotti C, Mischi M. Propagation of elec-
trical activity in uterine muscle during preg-
nancy: a review. Acta Physiol (Oxf) 2015;213:
406–16.
S1221