Definition

Any deviation of the normal pattern of uterine

contractions affecting the course of labour is
designated as disordered or abnormal uterine
action.
 Incidence
Overall labour abnormalities occur in about
25% of the nulliparous women and 10% of
multiparous women.
 Abnormal
uterine action

Abnormal
polarity
Normal polarity
(incordinate
uterine action)
 Normal
polarity

Hypertonic dysfunction Hypotonic dysfunction (uterine

(excessive contraction) inertia)

Ineffective uterine
Obstruction absent Obstruction present
action

Precipitate Tonic uterine contraction and retarction

labour (bandles ring)

Hypertonic Hypertonic
uterus uterus
 Spastic lower segment

Colicky uterus

Incordinate uterine Asymmetrical uterine

action contraction
Abnormal polarity
Constriction ring

Generalized tonic
contraction

Cervical dystocia
 Normal uterine contractions
• Polarity of the uterus means when the upper
segment contracts, the lower segment relaxes.
• Normally there are two pacemakers, one is situated
at each cornua of the uterus.
• The uterine pacemakers generate uterine
contractions in a co-ordinated fashion.
• Effective uterine contraction, starts at the cornua
and gradually sweeps downwards over the uterus.
The properties of a normal uterine contraction
waves are,
• The intensity of the contraction diminishes
from the top to bottom of the uterus
• The contraction wave starts of the pacemaker
and propagates towards the lower uterine
segment
• The duration of contraction diminishes
progressively as the wave moves away from the
pacemaker
 Pathophysiology
• In dysfunctional labour, new pacemakers
may come up anywhere in the uterus
• In a primary dysfunctional labour, uterine
activity instead of being governed by a single
dominant pacemaker, is shifted to less
efficient contractions due to emergence of
other pacemaker foci.
• Oxytocin therapy may be effective in
restoring the global and uterine contractions.
 Primary & secondary dysfunctional labour
• Primary dysfunctional labour is defined when
the cervix dilates <1cm/hr following a normal
latent phase of labour.
• It is the commonest abnormality and mostly
corrected by amniotomy and or oxytocin
augmentation.
• Secondary arrest is defined when the cervical
dilatation stops or slows after the active phase of
labour has started normally.
Uterine activity is measured by noting
• Basal tone
• Active (peak) pressure
• Frequency

Assessment is usually done by

• Clinical palpation-inaccurate
• Tocodynamometer with external transducer
• Using intrauterine pressure catheter – accurate

Normal baseline tonus is between 5 and 20mm of hg and

peak pressure is around 60mm of hg
 Etiology
• Prevalent in first birth especially in elder women
• Prolonged pregnancy
• Over distension of the uterus
• Emotional factor like stress and anxiety
• Constitutional factors like obesity
• Contracted pelvis and malpresentation
• Injudicious administration of sedatives, analgesics and
oxytocics
• Premature attempt of vaginal delivery
• Instrumental delivery attempt under light anaesthesia
Abnormal Labor Patterns (according to
labor stages) by A. Friedman
 Phase of labor Labor Limits for abnormality
pattern Nulliparo Multiparo
us labor us
labor
Latent phase of Prolonged labor phase (no > 21 hour > 14
cervical stage progress from latent to active hours
phase of labor)
Active phase of Prolonged active phase of < 1.2 cm / < 1.5 cm /
cervical stage labor hour hour
Secondary arrest ( no change > 2 hours > 2 hours
in cervical dilatation )
Prolonged deceleration phase > 3 hours > 1 hour

Pelvic stage Impossibility to descend < 1 cm / < 2 cm

hour / hour
Protracted descend < 1 cm < 2 cm /
/hour hour
Arrest of descend > 1 hour > 1/2
hour
All stages Precipitous labor < 4 hours < 2 hours
Hypotonic contractions

Hypertonic contractions

Incordinate uterine
contraction
 Uterine inertia
Uterine inertia 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 beginning of labour or
may develop subsequently after available period
of effective contractions.
 Uterine contraction
• The intensity is diminished, duration is
shortened, good relaxation in between
contractions and the intervals are increased.

• General pattern of uterine contractions of

labour is maintained but intrauterine pressure
during contraction is below 25 mmhg
 Types

Primary • Weak uterine contractions

inertia from the start

• Inertia developed after a

Secondary period of good uterine
contractions when it fails to
inertia overcome an obstruction so
the uterus is exhausted
 Primary inertia
• Inadequate uterine activity
• Lack of the progressive cervical effacement and
dilation
• Station of presenting part in the pelvic inlet (- 3
station) for a long period of time and slowly
descent of the fetus in the case of “cephalopelvic
disproportion” absence
• Increased duration of labor
• Maternal exhaustion and impairment of fetal well-
being
 Diagnosis
• Diagnosis of primary uterine inertia is made during
dynamic monitoring for woman during 2-3 hours.

• Important clinical evaluation of labor duration is

the rate of cervical dilation.
• If the cervical dilation to 6 cm is absent from the
onset of labor in nulliparous women have been
passed 12 hours and in multiparous women have
been passed 6 hours, the diagnosis of primary
uterine inertia has been made.
 Secondary uterine inertia
• occurs after adequate uterine contractions and
manifests by decreasing of uterine contractions
strength, duration and frequency later.
• Secondary uterine inertia as a rule is presented
in the end of the cervical stage of labor and in
the pelvic stage.
• Its frequency is 2 - 4 % to all number of labor.
• The causes of secondary uterine inertia are the
same as primary uterine inertia
 Causes
• cephalopelvic disproportion in clinically contracted
pelvis, hydrocephalus, fetal malpresentations,
transverse and oblique fetal lies, tumors in true pelvis;
• unripe uterine cervix, its scar’s changes
• vaginal stenosis
• breech presentation
• expressed pain in uterine contractions
• inadequate usage of amniotomy
• endometritis
• administration of excess and inadequate anesthesia,
uterotonic and spasmolytics drugs.
 Diagnosis
• Patient feels less pain during uterine contraction
• Hand placed over the uterus during uterine
contractions reveals less hardening of the uterus
• Uterine wall is easily indentable at the acme of
the pain
• Uterus becomes relaxed after contraction, fetal
parts are well palpable and the fetal heart rate
remains normal.
Internal examination reveals
• Poor dilatation of the cervix
• Associated presence of contracted pelvis,
malposition, deflexed head or
malpresentation
• Membranes usually remain intact
 Effects on the mother and fetus
• Maternal exhaustion or fetal distress are
unusual and appear late
 Management
Case is reassessed to exclude cephalopelvic
disproportion or malpresentation

caesarean section-
• Presence of contracted pelvis
• Malpresentation
• Evidences of fetal or maternal distress
Vaginal delivery
• To keep up the morale of the patient. Maternal
stress and emotion appear to inhibit uterine
contractions through endogenous adrenaline
• Posture of the woman is changed, supine
position is avoided
• To empty the bladder catheterization is made
• To maintain hydration by infusion of RL
• Adequate pain relief
Active measures
• Acceleration of uterine contraction can be
bought about by low rupture of membranes
followed by oxytocin drip. The drip rate is
usually increased until effective contractions are
set up. The drip is to continued till one hour
after delivery
Hypotonic contractions

Hypertonic contractions

Incordinate uterine
contraction
Hypertonic contractions
 Meaning
Abnormally strong action with normal spread of
communication, little relaxation between
contraction occurs because the muscle fibres of
the myometrium do not repolarize or relax after a
contraction
 Types
Colicky uterus
Incordination of different parts of
the uterus in contractions

Hyperactive lower uterine segment

The dominance of the upper
uterine segment is lost
 Clinical features
• Its more common in primigravida
• Hypertonic contractions are marked by an increase in
resting tone to more than 15mmofhg (normal is 5 to 10).
• Prolonged labour
• Uterine contractions are irregular and more painful. The
pain is felt before and throughout the contractions with
marked low backache
• Premature rupture of membranes
• Slow cervical dilatation
• Fetal and maternal distress
• They tend to be more painful
 Medical measures

• Analgesia and antispasmodic- pethidine

• Epidural analgesics may be of good
benefit
• Caesarean section is indicated in failure of
previous methods, disproportion, fetal
distress
Hypotonic contractions

Hypertonic contractions

Incordinate uterine
contraction
Incordinate uterine action
• This variety usually occurs in the active stage of
labour.
• The hypertonic state of the uterus arises from
any of the conditions such as spastic lower
segment, colicky uterus, asymmetrical uterine
contraction, constriction ring or generalized
tonic contraction of the uterus and all these
states are collectively called incordinate uterine
action.
• Increased frequency and duration of uterine
contractions cause rise in baseline tone and
thereby diminish circulation in the placental
intervillous space.
• New pacemakers appear all over the uterus.
• The myometrium contracts spasmodically and
irregularly.
• This contraction force neither dilates the cervix
nor pushes the fetus down.
• Uterine tonus is elevated.
• Pain is present before, during and after
contractions.
• This results in fetal hypoxia in labour.
• Placental abruption is often associated with high
baseline tone (>25mmhg).
• On the CTG the FHR shows reduced variability
and late decelerations.
• Uterine hyperstimulation due to oxytocics are
often associated with fetal tachycardia (fetal
adrenergic activity) due to fetal stress
Spastic lower segment
Uterine contraction
• Fundal dominance is lacking and often there is
reversed polarity
• The pacemakers do not work in rhythm
• The lower segment contractions are stronger
• Inadequate relaxation in between contractions
• Basal tone is raised above the critical level of 20
mmhg
 Diagnosis
• The patient is in agony with unbearable pain
referred to the back. There is evidence of
dehydration and keto acidosis
• Bladder is frequently distended and often there
is retention of urine, distension of the stomach
and bowels are visible
• There is premature attempts to bear down
• Fetal distress appears early
Abdominal palpation reveals
• Uterus is tender and gentle manipulation
excites hardening of the uterus with pain
• Palpation of fetal parts is difficult
Internal examination may reveal
• Cervix thick and edematous hangs loosely like a
curtain, not well applied to the presenting part
• Inappropriate dilatation of the cervix
• Absence of the membranes
• Meconium stained amniotic fluid might be
there
 Effect on fetus

• Fetal distress appears early due to placental

insufficiency caused by inadequate relaxation of
the uterus
 Management
• There is no place for oxytocin augmentation
with this abnormality.
• Caesarean section is done in majority of the
cases.
• Prior correction of dehydration and
ketoacidosis must be achieved by rapid infusion
of ringers lactate.
 Constriction ring

Contraction ring, Schroeder’s ring

• It is one of form of incordinate uterine action
where there is localized myometrial contraction
forming a ring of circular muscle fibres of the
uterus.
• It is usually situated at the junction of the upper
and lower segment around the constricted part of
the fetus usually around the neck in cephalic
presentation.
• It may appear in all stages of labour. It is usually
reversible and complete
 Causes
• Injudicious administration of
oxytocics
• Premature rupture of membranes
• Premature attempt at instrumental
delivery
 Diagnosis
• Diagnosis is difficult.
• It is revealed in the first stage of labour during
caesarean section
• during forceps application in second stage of labour
• during manual removal in the third stage (hour glass
contraction).
• The ring is not felt per abdomen.
• Maternal condition is not much affected but the fetus
is in jeopardy because of hypertonic state and uterus
never ruptures.
 Treatment
• Delivery is usually done by caesarean section.
• The ring usually passes of by deepening the
plane of anaesthesia otherwise the ring might
have to be cut vertically to deliver the baby.
• The difficulties can be overcomed by using
deep anaesthesia.
 Cervical dystocia
• Progressive cervical dilatation needs an effective
stretching force by the presenting part.
 Causes
Progressive cervical dilatation needs an effective
stretching force by the presenting part. Failure of
cervical dilatation may be due to
• Ineffective uterine contractions
• Malpresentation, Malposition (abnormal
relationship between the cervix and the
presenting part)
• Spasm (contractions) of the cervix
 Types

Primary cervical Secondary

dystocia cervical dystocia
 Primary cervical dystocia
• Commonly observed during the first birth where
the external os fails to dilate.
• Uterine contractions are often ineffective.
• On occasion, edema of the anterior lip may occur
• delivery may be accomplished with avulsion of the
anterior lip or by annular detachment of the cervix.
 Treatment
• In presence of associated complications
(malpresentations and malposition) caesarean
section is preferred.
• If the head is sufficiently low down with only thin
rim of cervix left behind, the rim may be pushed
up manually during contractions or tractions is
given by ventouse.
• In others where the cervix is very much thinned
out but only half dilated. Duhrssen’s incision at 2
and 10’o clock positions followed by forceps or
ventouse extraction is quite safe and effective.
 Secondary cervical dystocia
• This type of cervical dystocia results usually due
to excess scarring or rigidity of the cervix from
the effect of previous operation or disease.

• Others are postoperative scarring, post delivery,

cervical cancer.
Generalized tonic contraction
(uterine tetany)
• In this condition pronounces retraction occurs
involving whole of the uterus upto the level of internal
os.
• Thus there is no physiological differentiation of the
active upper segment and the passive lower segment of
the uterus.
• As there is no thinning of the lower segment, there is
no chance of rupture of the uterus.
• The uterine contraction ceases and the whole uterus
undergoes a sort of tonic muscular spasm holding the
fetus inside (active retention of the fetus)
 Causes
• Failure to overcome the obstruction by
powerful contractions of the uterus

• Injudicious administration of oxytocics

 Clinical Features
• The patient is in prolonged labor having severe and
continuous pain.

Abdominal examination revels

• The uterus to be somewhat smaller in size, tense and tender.
• Fetal parts are neither well defined, nor is the fetal heart
sound audible.

Vaginal examination reveals

• Jammed head with big caput; dry and oedematous vagina.
 Treatment
• Correction of dehydration and ketoacidosis by
rapid infusion of Ringer’s solution
• Antibiotics : To control infection
• Adequate pain relief
 Hyper contractility (Tachysystole)

• Induced by oxytocics can be managed by tocolytics

(terbutalin 0.25mg S.C) Oxytocin infusion should
be stopped.

Caesarean Delivery
• Is done in majority of the cases specially when
obstruction is suspected. Destructive operation is
an option when the fetus is dead.
Precipitate labour
• A labour is called precipitate when the combined
duration of the first and second stage is less than
two hours.
• It is common in multipara and may be repetitive.
• Rapid expulsion is due to the combined effect of
hyper active uterine contractions associated with
diminished soft tissue resistance.
• Labour is short as the rate of cervical dilation is 5
cm/hour or more for the nulliparous women.
 Maternal risk
• Extensive laceration of the cervix, vagina and
perineum (to the extent of complete perineal
tear)
• PPH due to uterine hypotonia that develops
subsequently
• Inversion
• Uterine rupture
• Infection
• Amniotic fluid embolism
 Fetal risk
• Intracranial stress and haemorrhage because of
rapid expulsion without time for moulding of the
head.
• The baby may sustain serious injuries if delivery
occurs in standing position.
• Bleeding from the torn cord and direct hit on the
skull are real hazards
 Treatment
• The patient having previous history of
precipitate labour should be hospitalized
before labour.
• During labour, the uterine contractions may
be suppressed by administering ether or
magnesium sulphate during contractions.
• Delivery of the head should be controlled.
• Episiotomy should be done liberally.
• Elective induction of labour by low
rupture of membranes and careful
conduction of controlled delivery may be
advantageous.
• Oxytocin augmentation should be
avoided.
 Tonic uterine contraction and retraction
( bandl’s ring)
• This type of uterine contraction is
predominantly due to obstructed labour
Pathologic anatomy of the uterus
There is a gradual increase in
intensity, duration and frequency
of uterine contraction.

The relaxation phase becomes less

and less; ultimately a state of tonic
contraction develops

Retraction however continues

The lower segment already thinned by
circumferential dilatation in the first stage,
elongates and becomes progressively thinner to
accommodate the fetus driven from the upper
segment.

A circular groove encircling the uterus is

formed between the active upper segment
and the distended lower segment, called
pathological retraction ring ( Bandl’s ring)

Due to pronounced retraction, the

placental site is also affected and there is
marked reduction of blood flow to the
intervillous space leading to fetal
jeoparady or even death.
In primigravida,
• further retraction ceases in response to obstruction
and labour comes to a stand still- a state of uterine
exhaustion. Contractions may recommence after a
brief period of rest with renewed vigour.

In multipara
• retraction continues with progressive circumferential
dilatation and thinning of the lower segment. There is
progressive rise of the Bandl’s ring, moving nearer and
nearer to the umbilicus and ultimately the lower
segment ruptures.
 Clinical features
• Patient is in agony from continuous pain and
discomfort and becomes restless.
• Features of exhaustion and keto – acidosis are evident

Internal examination reveals:

• Vagina- dry and hot and the discharge is offensive
• Cervix fully dilated
• Membranes are absent
• Cause of obstructed labour is revealed
Abdominal palpation reveals;
• Upper segment is hard, uniformly convex and tender.
Lower segment is distended and tender.
• The pathological retraction ring is placed obliquely
between the umbilicus and symphysis pubis and rises
upwards in course of time.
• Taut tender round ligaments may be felt on either
side. This is because, the uterine attachments of the
round ligaments have been raised by the shortening of
the upper segment and distension of the lower
segment.
• Fetal parts may not be well defined
• FHS is usually absent
 Prevention
• It is a preventable condition.

• The abnormality, either in the passage ( bony or

soft tissue) or in the passenger ( malpresentation
or malformation of the fetus) can be detected
during antenatal or early intranatal period and
appropriate treatment solves the problem
 Treatment

Supportive therapy
• Morphine 15 mg is given intramuscularly
• 5% dextrose drip is started
• Ampicillin 500 mg intramuscularly is given
• Keto – acidosis is to be promptly and effectively
corrected prior to definite treatment by infusion of
5% dextrose and Ringer’s solution
 Definitive treatment
• To rule out the presence of rupture uterus
• To relieve the obstruction with minimal hazard to
the mother. Fetus is either dead or in moribund
state. Frantic attempts at delivering a moribund
baby by any method ignoring the risk involved to
the mother, should not be contemplated.
• There is no place of internal version
• Routine uterine exploration after vaginal delivery is
to be done to exclude rupture uterus
• Caesarean section is rarely indicated
Difference between constriction ring and
retraction ring
 CONSTRICTION RING RETRACTION RING
Nature It is a manifestation of localised inco- It is an end result of tonic uterine
ordinated uterine contraction. contraction and retraction
Cause Undue irritability of the uterus. Following obstructed labour
Situation Usually at the junction of upper and lower At the junction of upper and lower
segment but may occur in other places. segment. The position progressively
The position does not alter. moves upwards
Uterus Upper segment contracts and retracts with Upper segment is tonically contracted
relaxation in between lower segment with no relaxation
remains thick and loose. The wall becomes thicker, lower segment
becomes distended and thinned out
Principle of To relax the ring followed by delivery of To relieve the obstruction by safe
treatment the baby or to cut the ring during C.S procedure after excluding rupture uterus.
Maternal Almost unaffected unless the labour is Maternal exhaustion, sepsis appear early
condition prolonged

Abdominal oUterus feels normal and not tender o Uterus is tense and tender
Examination oFetal parts are easily felt o Not easily felt
oIon Ring is not felt o Ring is felt as a groove placed obliquely
oRound ligament is not felt o Usually absent
oFHS is usually felt

Vaginal o The lower segment is not pressed by the o Lower segment is very much pressed by the
examination presenting part forcibly driven presenting part
o Ring is felt usually above the head o Ring cannot be felt vaginally
o Features of obstructed labour are absent o Features are present

End result o Maternal exhaustion is a late feature o Maternal exhaustion and sepsis appear early
o Fetal anoxia usually appear late o Fetal anoxia and even death are usually early
o Chance of uterine rupture is absent o Rupture uterus in multi gravida is common
Nursing management
Conclusion
References