ABNORMAL UTERINE ACTION

MODERATOR - Dr. Monika Ramola

 BRIEF REVIEW OF NORMAL UTERINE
CONTRACTIONS
• Polarity of uterus is that upper segment of
uterus contracts and lower segment relaxes.
• 2 pacemakers one in each cornua of uterus
generating contraction in coordinated manner.
• For coordinated uterine contractions
intensity of contractions decreases from top
to bottom, starts from pacemakers towards
lower segment
 PARAMETERS OF UTERINE
CONTRACTION
• Basal tone = 5-20 mm Hg
• Peak pressure = around 60 mm Hg
• Frequency of contraction = adequate uterine
contractions are 1 in 3 minutes lasting for 45
seconds.
• DEFINITION
Any deviation of normal pattern of uterine
contractions affecting course of labour is
designated as abnormal or disordered uterine
action.
EXCESSIVE UTERINE CONTRACTION
• POLYSYSTOLE/ Tachysystole = contractions
more than once in every 2 minutes.
• TETANIC UTERINE CONTRACTION = single
contraction lasting for more than 3 minutes.
• HYPERTONIC UTERINE CONTRACTION =
elevated baseline pressure above 20 mm Hg.
 ETIOLOGY
• Prolonged pregnancy
• overdistension of uterus eg twin, fibroid
• constitutional factors eg obesity
• contracted pelvis
• malpresentation
• emotional factor ( anxiety, stress)
• injudicious use of sedatives, analgesics, oxytocics
• Premature attempt at vaginal delivery via ARM or
induction of labour
• Attempted instrumental vaginal delivery under light
anesthesia
 TYPES OF ABNORMAL UTERINE
ACTION
1. WITH NORMAL POLARITY
A- Hypertonic dysfunction
• with obstruction: tonic uterine contraction
and retraction (bandl ring)
• Without obstruction : precipitate labor
B- Hypotonic dysfunction
• Uterine inertia
• 2- WITH ABNORMAL POLARITY
A- spastic lower segment
B- colicky uterus
C- asymmetric uterine contraction
D- constriction ring
E- generalized tonic contraction
F- cervical dystocia
 Primary dysfunctional labor
• When after normal latent phase of labor,
cervic dilates less than 1cm/hour
• most common abnormality
• most commonly corrected by amniotomy or
oxytocin augmentation
 Secondary arrest
• When after start of normal active phase of
labor, cervical dilatation stops
• causes -
poor uterine contraction
myometrial fatigue
disproportion
malpresentation
• Uterine contractions are assessed by
clinical palpation
tocodynamometer with external transducer
intrauterine pressure catheter
• normal baseline tone = 5-20 mmhg
• Min pressure required to dilate the cervix= 15
mm hg over baseline
• uterine contractions in labour create 60 mm hg
intrauterine pressure
 Hypotonic uterine dysfunction/
uterine Inertia
FEATURES-
• Intensity of uterine contractions decreased
• Duration shortened
• Good relaxation in between contractions
• Interval increased
DIAGNOSIS –

• Patient feels less pain during contraction.

• Per abdomen= uterus less hard on feel
uterine wall easily indentable
fetal parts well palpable
fetal heart rate normal
• Per vaginal examination = Poor cervical dilatation
membranes usually
intact
• can lead to = maternal exhaustion
fetal distress
• MANAGEMENT-
• Rule out CPD or malpresentation
• General measures : Empty the bladder
Maintain hydration
pain relief
• Active measures : C section if contracted pelvis,
malpresentation, fetal or maternaldistress.
Low rupture of membranes
followed by oxytocin drip until effective uterine
contractions set up.
 Incordinated uterine action
• occurs in active stage of labor usually
• includes hypertonic uterus due to
spastic lower uterine segment
colicky uterus
asymmetrical uterine contractions
constriction ring
generalized tonic contraction of uterus
• there is increased frequency, increased duration of contraction,
decreased circulation in placental intervillous space, no effective
cervical effacement and dilatation, increased basal intrauterine
pressure, maternal discomfort, pain present before/ during and
after contractions
• can lead to fetal distress
placental abruption
 Spastic lower segment
• No fundal predominance
• Reversed polarity
• Pacemaker not working in rhythm
• Lower segment contractions are stronger
• Inadequare relaxation in between
contractions
• Increased basal tone
• Premature bearing down
DIAGNOSIS –
• Patient has unbearable pain, dehydration, ketoacidosis
uterus hard and tender to palpate
fetal distress appear early
cervix thick, edematous with inappropriate dilatation
meconium stained liqor may be there
MANAGEMENT –
• No oxytocin augmentation
Mostly c section
Prior correction of dehydration and ketoacidosis with ringer lactate
infusion
 Constriction ring
• Also known as contraction ring or schroeder
ring
• Type of incordinated uterine action where
there is localised myometrial contraction
forming ring of circular muscle fibres of uterus
• Usually at junction of upper and lower
uterine segment
• Reversible
• May appear in all stages of labour.
CAUSES –
• Injudicious use of oxytocics
• PROM
• Premature attempt at instrumental delivery
FEATURES –
• Maternal condition not affected
• Fetal distress may occur
• Ring is not palpable during per abdomen
DIAGNOSIS –
• Difficult to made
• Revealed during c section in first stage, during forceps
application in second stage, during manual removal in third
stage.
• Ring is not felt on per abdomen exam
TREATMENT –
• Usually c section
• Ring passes off by deepening plane of anesthesia or cut the
ring vertically to deliver the baby
• If normal delivery, overcome the ring by deep anesthesia,
as it relaxes constriction ring
 Cervical Dystocia
• Progressive cervical dilatation needs effective
stretching force by presenting part.
• Here there is failure of progressive cervical dilatation.

• Causes –
inefficient uterine contractions
malpresentation/ malposition
cervical spasm
• Types –
primary and secondary
• Causes of primary dystocia –
external os fails to dilate
rigid cervix
inefficient uterine contractions
malpresentation, malposition
• Treatment of primary dystocia –
c section if malpresentation/ malposition,
If only thin rim of cervix left behind – it is pushed up
amnually during contraction.
Duhressen incision at 2 and 10 o clock position in
cervix followed by forceps or ventouse extraction, if cervix
is thinned out but only half dilated.
 Secondary dystocia
• due to scarring/ rigidity of cervix from
previous disease or operation or cancer
 Generalized tonic contractions/
uterine tetany
• Retractions involve whole uterus upto
internal os
• No physiological difference of upper and
lower segment of uterus
• Whole uterus has tonic muscular spasm
leading to active retention of the fetus
• New pacemakers appear all over the uterus
CAUSES –
• Cephalopelvic disproportion
• Obstruction
• Injudicious use of oxytocics
CLINICAL FEATURES –
• Severe and continuous pain
• Uterus is tense , hard and tender
• On P/V jammed head with big caput, dry and
edematous vagina
TREATMENT –
• Correction of dehydration and ketoacidosis with RL
infusion
• Antibiotic
• Pain relief
• Tocolytics
• C section
• Oxytocics can lead to hypercontractility or tachysystole
when there are more than 5 contractions per 10 min,
this can lead to fetal distress and hypoxia. Treatment
tocolytics eg terbutaline 0.25mg sc
 Precipitate labor
• When combined duration of first and second
stage of labor is less than 3 hrs .
• 2 per cent prevalence.
• commoner in multi para.
• Due to hyeractive uterine contractions and
diminished soft tissue resistance
• Maternal side effects= laceration/ tear
PPH due to subsequent uterine
hypotonia
uterine inversion
uterine rupture
infection
amniotic fluid embolism
• fetal side effects = intracranial haemorrhage as no
time for moulding
torn cord and bleeding
brachial plexus injury
 Treatment
• Patient with prior history should be hospitalised
prior to labour.
• During labour, uterine contractions suppressed
by ether, mgso4
• controlled delivery of head
• episiotomy done liberally
• elective induction of labour by low rupture of
membranes
• conduction of controlled delivery
• avoid oxytocin augmentation
 Tonic uterine contractions and
retraction= bandl ring/ pathological
retraction ring
• Mostly occurs in obstructed labor
• Relaxation phase decreases, tonic contraction
develops, lower segment elongates and thins out
to accomodate fetus driven from upper segment
• Circular groove forms between active upper
segment and distended lower segment known as
pathological retraction ring/ bandl ring
• Can lead to lower segment rupture , fetal
jeopardy and death
CLINICAL FEATURES –
• Patient has pain, discomfort, restlesness
exhaustion, ketoacidosis
• On palpation= upper segment: hard and tender
lower segment distended and tender
MANAGEMENT –
Prevention
Early diagnosis of malposition/ malpresentation
Treatment
Rule out uterine rupture
Correction of dehydration and ketoacidosis with ringer lactate infusion
Adequate pain relief
Parenteral antibiotic
C section in majority of cases
THANKYOU