ABNORMAL UTERINE ACTION

Normal labour is characterized by

coordinated uterine contractions
associated with progressive dilatation
of the cervix & descent of the fetal
head.
Any deviation of the normal pattern of
uterine contractions affecting the
course of labour is designated as
disordered or abnormal uterine action.
TYPES:
1.NORMAL POLARITY:
a.Excessive contraction
b.Uterine inertia
a.Excessive uterine contraction or
Hypertonic uterus:
i.Precipitate labour(-ve obstruction)
ii.Tonic uterine contraction &
retraction(Bandal’s ring)(+ve
obstruction)
b.Uterine inertia(Hypotonic uterus)
2.ABNORMAL POLARITY:
i.Spastic lower segment
ii.Colicky uterus
iii.Asymmtrical contraction
iv.Constriction ring
v.Generalised tonic contraction
vi.Cervical dystocia
ETIOLOGY:
*Advancing age of the mother
*Prolonged pregnancy
*Ovrdistension of the uterus due to twins or
hydramnios
*Psychologic factor
*Contracted pelvis,malpresentation
*Injudicious administration of analgesics or
sedatives
*Premature attempt at vaginal delivery or
attempted instrumental vaginal delivery under
light anaesthesia.
TYPES OF ABNORMAL UTERINE
CONTRACTION
UTERINE INERTIA:
It is the common type of disordered
uterine contraction but is comparatively
less serious.It may complicate any stage of
labour.It may be present from the of the
beginning of labour or may develop
subsequently after a variable period of
effective contractions.
Features of uterine contraction:
*Intensity is diminished
*Duration is shorter
*Good relaxation in between
contractions
*Intervals are increased
*Intruterine pressure during
contraction hardly rises above25mm
Hg.
DIAGNOSIS:
*Patient feels less pain during uterine contraction
*Hand placed over the uterus during uterine
contraction reveals less hardening of the uterus
*Uterine wall is easily indentable at the acme of a
pain.
*Uterus becomes relaxed after the contraction ,fetal
parts are well palpable & fetal heart rate remains
good.
*Internal examination reveals:
*poor dilatation of cervix
*associated presence of contracted pelvis,malposition
,deflexed head or malpresentation
*membranes usually remains intact.
EFFECTS ON THE MOTHER AND
FETUS:
*Maternal exhaustion or fetal
distress
MANAGEMENT:
Case is reassessed to exclude CPD or
malpresentation
Place of caesarean section:
*Presence of contracted pelvis
*Malpresentation
*Evidences ors fetal or maternal
distress
VAGINAL DELIVERY:
*General measureses:
i.To keep up the morale of the patient
ii.Posture of the woman is changed .Supine
position is avoided
iii.To empty the bladder by catherization if needed
iv.To maintain hydration by infusion of Ringer’s
solution
v.Adequate pain relief by IM Pethidine 100mg
Active measures:
*Acceleration of uterine contraction by low rupture
of the membranes followed by oxytocin drip.
*If the cervical dilatation remains unsatisfactory or
fetal distress appears caesarean section is done.
ABNORMAL POLARITY:
SPASTIC LOWER SEGMENT:
UTERINE CONTRACTION:
1.Fundal dominance is lacking & often
there is reversed polarity
2.Inadequate relaxation in between
contractions
3.Basal tone is raised above the critical
level of 20mm Hg.
DIAGNOSIS:
1.The patient is in agony with
unbarable pain referred to the back.
2.Bladder is frequently distended &
often there is retention of urine
3.Premature attempt to bear down
4.Abdominal palpation reveals:
a.tender uterus,tense & tenderness remains
even after contraction passes off
b. Palpation of fetal parts is difficult
5.Fetal distress appears early.
6.Internal examination reveals:
a. Cervix which is thick,oedematous & hangs
loosely like a curtain
b.Inappropriate dilatation of the cervix
c.Absence of the membranes
d.Varying degree of caput
e.Meconium stained liquor amnii.
EFFECT ON THE FETUS:Fetal distress appears
early due to placental insufficiency caused by
inadequate relaxation of the uterus.
MANAGEMENT:
Casearean section is done.Prior correction of
dehydration & ketoacidosis must be achieved by
rapid infusion of Ringers solution.
Conservative approach:with adequate pain
relief & correction of dehydration in the hope of
spontaneous vaginal deliveryis an
alternative.There is no place oxytocin
augmentation in a such type of abnormality.
CONSTRICTION RING
/CONTRACTION RING/SCH
ROEDER’S RING
It is one form of inco-ordinate uterine
action where there is localized spastic
contraction of a ring of circular muscle
fibers of the uterus.It is usually situated
at the junction of the upper & lower
segment around a constricted part of the
fetus usually around the neck in
cephalic presentation.It may appear in
CAUSES:
1.Injudicious administration of oxytocis
2.Premature rupture of the membranes
3.Premature attempt at instrumental
delivery specially under light anasthesia.
DIAGNOSIS:
Diagnosis difficult .It is revealed during
Caesarean section in the first
stage,during forceps application in the
second stage & during manual removal
in the third stage.The ring is not felt per
abdomen.
TREATMENT:The outline of treatment protocol
is based on the stage at which the diagnosis is
made.
I STAGE:The diagnosis is made during caesarean
section after opening te uterine cavity.The ring
may have to be cut vertically to deliver the
baby.
II STAGE:If there is delay in delivery of
head ,forceps can be applied.
III STAGE:If there is delay in the delivery of the
placenta ,manual removal removal is done
under anasthesia .
 CERVICAL DYSTOCIA
Progressive cervical dilatation an effective
streching force by the presenting
part.Failure of cervical dilatation is due to:
1.Ineffective uterine contractions
2.Malpresentations,malposition
3.Spasam of the cervix.
Primary cervical Dystocia:Commonly
observed during the first birth where the
external os fails to dialate.Uterine
contractions are often ineffective.
TREATMENT:
In presence of associated complications
caesarean section is preferred.
If the head is sufficiently low down with
only a thick rim of cervix left behind,the
rim may be pushed up manually during
contraction or traction given by ventouse.
Secondary cervical dystocia:It results from
the excessive scarring or rigidity of the
cervix from the previous effect of previous
operation or disease.
GENERALIZED TONIC CONTRACTION/UTERINE
TETANY
In this condition ,pronounced retraction occurs
involving whole of the uterus upto the level of
internal os.
There is no physiological differentiation of the
active upper segment & the passive lower
segment of the uterus.
The uterine contraction ceases & the whole
uterus undergoes a sort of tonic muscular
spasm holding the fetus inside .
CAUSES:
1.Failure to overcome the
obstruction by powerful
contractions of the uterus
2.Injudiciousadministration of
oxytocis.
CLINICAL FEATURES:
*The patient is in prolonged labour
having severe & continuous pain
*Abdominal examination
reveals :smaller in size,tense &tender.
*Fetal parts are neither well defined
nor is the fetal heart sound audible
*Vaginal examination reveals:jammed
head with big caput dry & odematous
vagina.
TREATMENT:*Correction of dehydration &
keto-acidosis-by rapid infusion of Ringer’s
solution.
*Antibiotic -to control infections
*Adequate pain relief
Hypercontractility induced by oxytocics
can be managed by tocolytics .Oxytocin
infusion should be stopped.
Caesarean delivery:is done specially when
obstruction is suspeced.Destructive
operation is an option when fetus is dead.
PRECIPITATE LABOUR
A Labour is called precipitate when the
combined duration of the first &
second stage is less than two hours.It
is common in multiparae .Rapid
expulsion is due to the combined effect
of hyper-active uterine contractions
associated with diminished soft tissue
resistance.
COMPLICATIONS:Maternal
complications:
*Extensive laceration of the
cervix,vagina & perineum
*PPH
*Inversion
*Uterine rupture
*Infection
*Amniotic fluid embolism
Fetal complications:
*Intracranial stress
*Haemorrhage due to rapid
expulsion
*Bleeding from torn cord
*Direct hit on the skull
TREATMENT:
1.Patient having previous history of
precipitate labour should be hospitalized
prior to labour
2.During labour ,the uterine contraction
may be supressed by administering ether
or magnesium sulphate.
3.Episiotomy should be done liberally.
4.Oxytocin augmentation should be
avoided.
TONIC UTERINE CONTRACTION AND
RETRACTION
(BANDAL’S RING /PATHOLOGICAL RETRACTION
RING)
This type of uterine contraction is
predominanatly due to obstructed labour.
Pathologic anatomy of the uterus:
There is gradual increase in intensity ,durtion
& frequency of uterine contraction.The
relaxation phase becomes less &less,ultimately
a state of tonic contraction
develops .Retraction,continues.
A circular groove encircling the uterus is
formed between the active upper segment
& the distended lower segment,called
pathological retraction ring .Due to
pronounced retraction,there is fetal
jeopardy or even death.
CLINICAL FEATURES:
1.Patient is in agony from continuous pain &
discomfort &becomes restless.
2.Features of exhaustion & ketoacidosis
3.Abdominal palpation reveals:
*upper segment is hard & tender,lower
segment is distended & tender
*The pathological retraction ring is placed
obliquely between the umbilicus & symphysis
pubis
*Tender ligament felt on either side
*Fetal parts is diffcult to palpate.
4.Internal examination reveals:
*Vagina dry & hot & discharge offensive
*Cervix fully dilated
*Membranes are absent
PREVENTION:
It is a preventable condition.The
abnormality,either in the passage or in the
passenger can be detected during
antenatal or early intranatal period &
delivery by caesarean section is done.
TREATMENT:
*Rupture of uterus is to be excluded
*Internal version is contraindicated
*Correction of dehydration &
ketoacidos is by infusion of RL solution
*Adequate pain relief
*Parentral antibiotic is given
*Caesarean delivery is done .
Pathological Retraction Ring Constriction Ring

Occurs in prolonged 2nd stage. Occurs in the 1st, 2nd or 3rd stage.

Always between upper and lower At any level of the uterus.

uterine segments.

Rises up. Does not change its position.

Felt and seen abdominally. Felt only vaginally.

The uterus is tonically retracted, tender The uterus is not tonically retracted and
and the foetal parts cannot be felt. the foetal parts can be felt.

Maternal distress and foetal distress or Maternal and foetal distress may not be
death. present.

Relieved only by delivery of the foetus. May be relieved by anaesthetics or

antispasmodics.