ABNORMAL UTERINE ACTION

MASTER PLAN ON ABNORMAL

UTERINE ACTION
CONTENTS

1. Normal uterine action

2. Measurement of uterine activity
3. Uterine activity in normal labour
4. Abnormal uterine action
A. Definition
B. Aetiology
CONTENTS
4. Abnormal uterine action (conti….)
C. Types
1. Hypotonic or inadequate uterine action
2. Excessive uterine activity
a. Uterine tetany
b. Hypertonic uterine action
c. Polysystole and uterine hyper stimulation
d. Incoordinate uterine activity
3. Constriction ring
(Sheila Balakrishnan. Text book of Obstetrics. 2nd edition. New Delhi: Para
Medical Publisher; 2013 page no 356-358)
CONTENTS
4. Abnormal uterine action (conti….)
C. Types (DC Dutta’s Textbook of Obstetrics.9th edition)
1. Normal polarity
• Hypertonic dysfunction (excessive contraction)
• Hypotonic dysfunction (uterine inertia common)
2. Abnormal polarity (incoordinate uterine action)
• Spastic lower segment
• Colicky uterus
• Asymmetric uterine contraction
• Constriction ring
• Generalized tonic contraction
• Cervical dystocia
CONTENTS
5.Management of abnormal uterine action
6.Nursing management of abnormal uterine action
7. Research articles
8. Bibliography
GENERAL OBJECTIVE
• At the end of the class students get adequate knowledge regarding
abnormal uterine action and apply this knowledge in their clinical
setting.
SPECIFIC OBJECTIVES
At the end of the class, students will be able to,
1. Define abnormal uterine action
2. Identify etiology of abnormal uterine action
3. Enlist the types of abnormal uterine action
4. Explain management of abnormal uterine action
5. Apply nursing management of abnormal uterine action
 NORMAL UTERINE ACTION
• BASELINE TONE
Uterine pressure or tone between contractions.
• AMPLITUDE
Maximum uterine pressure above the baseline tone
• FREQUENCY
No. of contractions occurring over a 10 min period
 NORMAL UTERINE ACTION
• DURATION
Time in seconds where the uterine tone is above its baseline
• RELAXATION TIME
Time in second, between the end of one contraction and beginning of
the next.
 Measurement of uterine activity
• Manual palpation
• External tocography
• Internal tocography
 Uterine Activity in Normal Labour
At the end of the first stage
 Contractions have a Frequency of 3-5 in 10 min
 Amplitude of more than 50 mmHg
 Duration 60 sec
 Abnormal uterine activity
Any deviation of the normal pattern of uterine contractions affecting the
course of labour is designated as disordered or abnormal uterine action.

DC Dutta’s Textbook of Obstetrics.9th edition.

 AETIOLOGY
• Nulliparity and advanced maternal age
• Contracted pelvis and cephalo-pelvic disproportion
• Malpresentation
• Malposition
• Injudicious use of oxytocin and prostaglandins
• Over distension as in multiple pregnancy and hydramnios
• Psychological factors
• Constitutional factor
 Types
1. Hypotonic or inadequate uterine action
2. Excessive uterine activity
a. Uterine tetany
b. Hypertonic uterine action
c. Polysystole and uterine hyperstimulation
d. Incoordinate uterine activity
3. Constriction ring

(Sheila Balakrishnan. Text book of Obstetrics. 2 nd edition. New Delhi: Para Medical Publisher; 2013
page no 356-358)
 Types

Normal polarity Abnormal polarity

(incoordinate uterine action)

Hypertonic dysfunction Hypotonic dysfunction

(excessive contraction) (uterine inertia common)

Obstruction Obstruction
(-) (+)
spastic colicky asymmetric constri- genera- cervical
lower uterus uterine ction ring lized dystocia
segment contraction tonic
contra-
precipitate tonic uterine ction
contraction and
retraction
(Bandl’s ring)

Hypertonic uterus Ineffective uterine contraction

DC Dutta’s Textbook of Obstetrics.9th edition
 1. HYPOTONIC UTERINE ACTION OR
UTERINE INERTIA
• Most common type of abnormal uterine action and can complicate any
stage of labour.
• Intervals between contractions are long, the duration of contractions
are short and intensity is weak.
• There is no basal activity and the slight rise in pressure during a
contraction is insufficient to dilate cervix.
• Contractions are considered inadequate if < 3 in 10 min and each
contraction lasts less than 40 seconds
 1. HYPOTONIC UTERINE ACTION OR
UTERINE INERTIA
Diagnosis
1. patient feels less pain during contraction
2. Hand placed over the uterus during contraction reveals less
hardening of the uterus
3. Uterine wall is easily indentable at the acme of a pain
4. Uterus become relaxed after contraction, fetal parts are well palpable
and fetal heart rate remains normal
 1. HYPOTONIC UTERINE ACTION OR
UTERINE INERTIA
Diagnosis
5. Internal examination
a. Poor dilatation of the cervix
b. Presence of cephalopelvic disproportion, malposition, deflexed
head or malpresentation may be evident
c. Membranes usually remain intact
 1. HYPOTONIC UTERINE ACTION OR
UTERINE INERTIA
Management
Cephalopelvic disproportion and malpresentations are to be excluded
Place of caesarean section:
1. Presence of contracted pelvis
2. Malpresentation
3. Evidences of fetal or maternal distress
 1.HYPOTONIC UTERINE ACTION OR
UTERINE INERTIA
Management
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 bladder, catheterization is made
4. To maintain hydration by infusion of Ringer’s solution
5. Adequate pain relief
 1.HYPOTONIC UTERINE ACTION OR
UTERINE INERTIA
Management
Vaginal delivery
B) Active measures
Acceleration of uterine contraction can be brought about by low rupture
of the membranes followed by oxytocin drip.it should be continued till
1 hour after delivery.
2. EXCESSIVE UTERINE ACTIVITY
Common cause is exogenous oxytocin administration
a. uterine tetany
• If a few contractions merge to form a contractions lasting for 3 min or
more , it is termed a tetanic contraction.
• Associated with dramatic reduction of perfusion to the fetus and may
cause severe fetal heart rate abnormalities.
2. EXCESSIVE UTERINE ACTIVITY
b. hypertonic uterine activity
• The contractions do not merge, but the baseline pressure is increased
above 20 mmHg for more than 3 min.
• Most common cause is oxytocin or prostaglandins
2. EXCESSIVE UTERINE ACTIVITY
c. Polysystole Or Tachysystole
• If contractions occur more than once every 2 min or more than 5 in 10
min, it is defined as polysystole or tachysystole.
• If this is in response to oxytocin or prostaglandins, it is said to be
uterine hyperstimulation.
• The most common cause is exogenous oxytocin.
2. EXCESSIVE UTERINE ACTIVITY
Management
If oxytocin infusion or prostaglandins are the cause, the infusion is
stopped immediately, left lateral position is employed and tocolytics are
given.
Terbutaline can be given subcutaneously. This is usually reverses the
condition, but if there is persistent fetal hypoxia as seen on
cardiotocography, Caesarean section may have to be done.
2. EXCESSIVE UTERINE ACTIVITY
Complications
• Fetal distress and fetal death
• Rupture uterus
• Postpartum haemorrhage
• Amniotic fluid embolism
3. INCOORDINATE UTERINE ACTION
• Contractions have irregular frequency or irregularity in shape of the
contractions on a cardiotocograph.
• Appears in active stage of labour.
a. Spastic lower segment
1. Fundal dominance is lacking and often there is reversed polarity
2. The pacemakers do not work in rhythm
3. Lower segment contractions are stronger
4. Inadequate relaxation in between contraction
5. Basal tone is raised
3. INCOORDINATE UTERINE ACTION
a. Spastic lower segment
Diagnosis
1. Patient is in agnoy with unbearable pain referred to the back
2. Bladder is frequently distended and retention of urine.
3. Distension of stomach and bowels
4. Premature attempt to bear down
3. INCOORDINATE UTERINE ACTION
a. Spastic lower segment
Diagnosis
5. Abdominal palpation
• Uterus is tender
• Palpation of fetal parts is difficult
• Fetal distress
6. Internal examination
• Cervix thick, edematous hangs loosely
• Inappropriate dilatation of the cervix
• Absence of membranes
• Meconium stained liquor amnii
 4. CONSTRICTION RING
(SCHOROEDER’S RING)
• This is a localised area of hypertonicity of the myometrium.
• The ring typically occurs at the junction of the head and neck, thus
preventing descent
• It is usually due to the injudicious use of oxytocics.
• In the third stage, it presents as hour glass contraction causing retained
placenta
 4. CONSTRICTION RING
(SCHOROEDER’S RING)
Common causes
• Injudicious administration of oxytocics
• Premature rupture of membranes
• Premature attempt at instrumental delivery
 TONIC UTERINE CONTRACTION AND
RETRACTION(BANDL’S RING,
PATHOLOGICAL RETRACTION RING)
Type of uterine contraction due to obstructed labour
• Clinical features
1. Patient is in agony from continuous pain and discomfort and
becomes restless
2. Features of exhaustion and ketoacidosis
3. Abdominal palpation
• Upper segment is hard and tender
• Lower segment is distended and tender
 TONIC UTERINE CONTRACTION AND
RETRACTION
Treatment
• Rupture of uterus is to be excluded
• Internal version is contraindicated
• Correction of dehydration and ketoacidosis
• Adequate pain relief
• Parenteral antibiotic
• Cesarean delivery
 Difference between Retraction and
Constriction Ring
Retraction ring Constriction ring
Cause Obstructed labour Not due to obstructed labour
Site Junction of upper and lower Any site
segments

Stage of First and second stage Any stage

labour

Migration Progressively moves up Position does not alter

 Difference between Retraction and
Constriction Ring
Retraction ring
Abdominal Uterus tense and tender
examination Fetal parts not easily felt
Ring seen and felt
FH usually absent
Maternal and Maternal distress early
fetal condition Fetal hypoxia and death early
Uterine Common in multipara
rupture
Constriction ring
Uterus normal
Fetal parts easily felt
Ring is not seen or felt
FH usually present
Maternal distress late
Fetal hypoxia late
unlikely
 CERVICAL DYSTOCIA
Progressive cervical dilatation needs an effective stretching force by the
presenting part.
Failure of cervical dilatation may be due to:
1. Inefficient uterine contractions
2. Malpresentations and malposition
3. Spasm of the cervix
 CERVICAL DYSTOCIA
Types
• Primary cervical dystocia
• Secondary cervical dystocia
 PRECIPITATE LABOUR
A labour is called precipitate when the combined duration of the first and
second stage is less than 3 hours
Maternal risks
• Extensive laceration of the cervix, vagina and perineum
• PPH is due to uterine hypotonia
• Inversion
• Uterine rupture
• Infection
• Amniotic fluid embolism
PRECIPITATE LABOUR
• Fetal risks
1. Intracranial haemorrhage due to sudden compression and
decompression of the head.
2. Fetal asphyxia due to:
1. strong frequent uterine contractions reducing placental
perfusion,
2. lack of immediate resuscitation.
3. Avulsion of the umbilical cord.
4. Fetal injury due to falling down.
 PRECIPITATE LABOUR
Management
• Before delivery
Patient who had previous precipitate labour should be hospitalized
before expected date of delivery as she is more prone to repeated
precipitate labour.
• During delivery
Inhalation anaesthesia: as nitrous oxide and oxygen is given to slow
the course of labour.
Tocolytic agents: as ritodrine (Yutopar) may be effective.
Episiotomy: to avoid perineal lacerations and intracranial
haemorrhage.
• After delivery
Examine the mother and foetus for injuries.
 NON PROGRESS OF LABOUR
. Arrest in cervical dilatation
. Arrest in descent of fetal head

Reassessment
Mother Fetus
. Uterine contractions . FHR pattern
. Pelvic adequacy by clinical pelvimetry . Estimated fetal weight
. Pain tolerance . Fetal presentation, position, station
Evidence of any infection, dehydration . Liquor colour

To correct dehydration, sepsis(start IV Ringer solution and antibiotics)

evidence of pelvis adequate, average weight fetus, with engaged

. CPD head but inadequate uterine contractions
. Fetal distress
. Big baby
. start oxytocin
. Amniotomy--- if not done before
Cesarean delivery . Pain relief ----epidural analgesis
when cervical dilation > 3 cm
. Fetal monitoriung (EFM preferred)

progress satisfactory No progress of labour

vaginal delivery first stage second stage

CS . CS
. Operative vaginal delivery by forceps or ventouse
PREVENTIVE MEASURES OF DYSTOCIA
DUE TO ABNORMAL UTERINE ACTION
1. Quality antenatal care, emotional support and close monitoring of
labour
2. Induction of labour should be judicious
3. Amniotomy in the latent phase is to be avoided
4. Adequate moral support, rest and analgesics
5. partograph
 NURSING MANAGEMENT
• Nursing diagnosis
1. Risk for maternal injury related to alteration of muscle tone
/contractile pattern or mechanical obstruction to fetal descent
2. Risk for fetal injury related to abnormalities of maternal
pelvis/prolonged labour
3. Risk for fluid volume deficit
4. Ineffective individual coping
5. Anxiety related to the outcome of delivery
6. Risk for complications rupture,PPH,infection
Journal articles
The two types of uterine contraction disorders such as hypotonic and
hypertonic contractions exist. In the hypotonic disorder regardless
hypertonic uterine dysfunction, in the active phase of labor (dilatation >
4 cm), the base tonicity of uterus is not increased. In addition in the
cases of hypertonic contractions, due to lack of harmony in the impulses
which root from one or both cornea and because the contractions of the
middle segment of the uterus are more powerful from fundal
contractions’ force, effective contractions during labor are absent (
Cunningham, 2009; Shields et al., 2007; Savitsky et al.,2013).
Journal articles
• Pattern of uterine contractions can be evaluated using external
monitoring as well as internal. With the start of contractions and
increase of intrauterine pressure, the height of the contraction curve
increases and decreases following reduced intrauterine pressure (
Gonçalves, Pinto, Ayres-de-Campos, & Bernardes, 2014). One
landmark for evaluating quality of a contraction is F/R ratio which
means the time that a contraction needs to return from its peak to
baseline (Fall) divided to the time for a contraction to rise to its peak
(Rise). In the case of a CPD, the interval between contractions
increases and the height of the contraction curve is reduced, a warning
sign for re-evaluating the patient.
Journal articles
Use of tocolytic drugs to reverse oxytocin induced uterine hyper stimulation.
The use of oxytocin in labor has the inherent danger of producing uterine
hyperstimulation with resultant fetal distress. When produced by gradual titration
of intravenous oxytocin, discontinuation of the medication is usually sufficient to
reverse the process. However, the rapid administration of a large intravenous
dose of oxytocin, as occurred in this patient, may result in hypertonic uterine
contractions and fetal distress unresponsive to traditional measures. The rationale
for using a tocolytic drug to reverse the uterine hypertonus, produce intrauterine
fetal resuscitation, and prevent cesarean section is discussed in this report.
The American College of Obstetricians and Gynecologists
 BIBLIOGRAPHY
1. Sheila Balakrishnan. Text book of Obstetrics. 2nd edition. New
Delhi: Para Medical Publisher; 2013 page no 356-358
2. Hiralal Konar.DC Dutta’s Textbook of Obstetrics.9th edition. New
Delhi: jay pee brothers publications Pvt. Ltd; 2018. page no 335-342
3. King L T, Brucker C M, Kriebs M J. Varney’s Midwifery.5th
edition.Greater Noida:Jones and Bartlett India Pvt. Ltd;2014.
4. Gilbert SE. Manual of High Risk Pregnancy and Delivery.5th edition.
Missouri:MOSBY,Inc;2011