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A study of uterine inertia on the spontaneous of labor using uterine

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DOI: 10.1016/j.tjog.2021.03.010

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 Taiwanese Journal of Obstetrics & Gynecology 60 (2021) 449e453

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Original Article

A study of uterine inertia on the spontaneous of labor using uterine

electromyography
Pin Li, Lele Wang, Xueya Qian, Abraham Morse, Robert E. Garfield, Huishu Liu*
Department of Obstetrics, Preterm Birth Prevention and Treatment Research Unit, Guangzhou Women & Children's Medical Center, Guangzhou Medical
University, Guangzhou, China

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The purpose of this study is to analyze uterine electromyography burst patterns in patients
Accepted 30 September 2020 with spontaneous labor and patients with uterine inertia.
Materials and methods: Uterine electromyography was recorded using 4 silver/silver chloride electrodes
Keywords: placed periumbilical. Thirty women in the spontaneous labor were enrolled. Uterine electromyography
Uterine inertia was also recorded from patients with uterine inertia before and after oxytocin treatment. EMG bursts
Uterine electromyography
were characterized by analysis of multiple variables including burst frequency, duration, root mean
Oxytocin
squared, amplitude, and total power.
Cervical dilation
Uterine contractions
Results: There were significant reductions (P < .01) in all EMG burst characteristics. In addition, uterine
electromyography parameters were all increased after oxytocin treatment and were comparable (P > .05)
to patients in spontaneous labor.
Conclusions: Uterine electromyography can be used effectively to distinguish patients progressing with
spontaneous labor from patients that develop uterine inertia. Uterine inertia is characterized by reduced
EMG activity and failure of cervical dilation. Uterine electromyography is a quantitative, non-invasive
assessment tool that contributes to the diagnosis, evaluation and management of patients with spon-
taneous labor and uterine inertia.
© 2021 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction conditions have recently changed based on the definitions of latent

Normal labor is recognized as a transition to effective uterine
contractions and progressive effacement and dilation of the cervix
with fetal descent. Slow or inadequate progress in labor is among
the most common challenges in intrapartum care, especially for
nulliparous women [1e4]. This phenomenon, failure to progress or
arrest of labor, applies to women who first appear to be in active
labor with regular uterine contractions and significant cervical
dilation and then experience a prolonged period with weak and
inconsistent uterine contractions, failure of the cervix to dilate and
absence of fetal descent [5]. In this study, we address the issues of
assessment of uterine electromyography (EMG) and contractions in
the first stage of labor. We initially used the term uterine inertia
(UTIN) [1,6,7] to define a delay or arrest of labor because these
* Corresponding author. Department of Obstetrics, Guangzhou Women and
Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Guangz-
hou, 510623, China.
E-mail address: huishuliu@hotmail.com (H. Liu).
and active stages of labor [2,8e10]. This condition is often confused
with initial false labor and confounded by other factors producing
abnormal labor such as infant size, fetal presentation, and pelvic
dimensions. Additionally, Other factors also influence the labor
process, including anesthetics, stress, maternal age, diabetes and
obesity [11,12]. UTIN or failure to progress is of major concern
because this is one of the leading causes of cesarean deliveries,
accounting for about 30% [13,14]. Complications to cesarean de-
livery for the mother and child are well known and therefore UTIN
can lead to serious problems and increase fetal and maternal
mortality and morbidity. Thus, the timely identification and diag-
nosis of normal labor and UTIN are of utmost importance and these
are usually accomplished by labor progress charts of cervical dila-
tion and measuring uterine contraction patterns either with a
tocodynamometer (TOCO) or with an intrauterine pressure cath-
eter (IUPC) [2,10,15]. The most common intervention for UTIN is the
administration of oxytocin [8,15].
UTIN in labor is thought to be primarily a problem with
abnormal uterine contractility following a normal start of labor.

https://doi.org/10.1016/j.tjog.2021.03.010
1028-4559/© 2021 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
P. Li, L. Wang, X. Qian et al.
Thus, the physiological control of uterine contractile events is
important in understanding this condition. Uterine contractility is
recognized as being regulated by excitability of the muscle of the
uterus (myometrium) and movement of charged ions between the
interior and exterior muscle cells to produce voltage changes
(bursts) that propagate throughout the uterus to produce syn-
chronization of contractility. [16e18] Contractions of the myome-
trium are directly related to electrical bursts within the muscle cells
[16]. The contraction frequency, duration of contractions and force
of contractions are all directly proportional respectively to the
frequency, duration and propagation of electrical bursts [16,17,19].
However, clinically uterine contractility is estimated with either an
IUPC or with a TOCO which do not measure electrical activity. The
TOCO is routinely used to evaluate uterine contractions during la-
bor and fetal well-being in relationship to contractions. The TOCO
identifies the frequency of contractions, but not their intensity, and
can be limited by misalignment following maternal movement and
technical limitations in obese patients [20]. The alternative IUPC is
more reliable and adds contraction pressure information but carries
inherent risks, most prominently infection, bleeding and injury to
the fetus [23]. However, the TOCO and the IUPC provide only
qualitative or semi-quantitative assessments of uterine contrac-
tility and labor progress [21,22].
We have learned much about the physiology of excitation and
contraction of uterine contractility (see above) since Friedman in
1955 clinically quantified labor using cervical dialation [2]. As
noted, activation of the uterus for labor is characterized by an in-
crease in coupling and excitability of the muscle cells, and increased
responsiveness to oxytocics [17,23,24]. These events lead to pro-
gressive preparation of the myometrium, accompanied by dilata-
tion of the cervix, and eventual successful labor and delivery
[25,26]. Electrical activity of the myometrium can be monitored
noninvasively by measuring the uterine electromyography (EMG,
also termed electrohysterography or EHG) from the abdominal
surface [17]. Bursts of electrical signals responsible for contractions
are more frequent and their duration more constant during labor
[27]. Temporal and spectral characteristics of EMG activity also
change from pregnancy to parturition [28,29]. Many studies
demonstrate that uterine EMG burst characteristics are represen-
tative of myometrial activity during different periods of labor,
including normal, preterm and protracted labor [30e32].
Analysis of uterine EMG can also distinguish the transition of the
myometrium from the inactive to the active phase of labor [33].
Therefore, uterine EMG allows a timelier and accurate identifica-
tion of the development of spontaneous or drug-induced labor
compared with existing methods and EMG can document problems
with UTIN or effects of agents used to simulate or inhibit labor. The
objectives of this study were to: 1) Characterize uterine EMG ac-
tivity in women who spontaneously enter labor and compare this to
patients that develop UTIN; 2) Investigate whether analysis of
uterine EMG parameters can identify the effects of oxytocin; and 3)
Estimate if uterine EMG can aid in the diagnose of normal or
abnormal labor.
Materials and methods
Patients and groups
This IRB-approved study was conducted on nulliparous women
recruited from patients admitted to labor and delivery at Guangz-
hou Women and Children's Medical Center. China. Informed con-
sent was obtained from all subjects after the details of the study
were explained to them. Inclusion criteria were: singleton preg-
nancy, occiput anterior position between 37 and 42 weeks with
maternal age <35, spontaneous rupture of membranes and with
450
Taiwanese Journal of Obstetrics & Gynecology 60 (2021) 449e453
regular uterine contractions and strong EMG activity. Women were
excluded if there was a contraindication to either oxytocin
administration or the use of patient controlled epidural anesthesia
(PCEA). Furthermore, women with multiple gestation, poly-
hydramnios, malpresentations, hyperstimulation, or non-
reassuring fetal heart tracing during oxytocin administration
were also excluded. A total of 56 patients were recruited for the
study: 6 patients were excluded because they were delivered by
cesarean section. There were no patients from whom data was
collected that were not included in the analysis. Demographic and
obstetric data on patients used in this study, included maternal age,
BMI, gestational age, birth weight and duration of the first stage,
cervical dilation and the maximum oxytocin infusion rate and total
duration of oxytocin administration. Fetal heart rate and external
tocodynamometry (Philips, Avalon FM20, Best, Netherlands) were
recorded simultaneously with EMG.
Spontaneous labor and UTIN groups
Pregnant women (n ¼ 50) were divided into 2 groups based on
spontaneous labor and oxytocin use. They were: Group 1(Control
group), patients with normal spontaneous labor with progression
to delivery. Group 2, UTIN patients measured before and after
oxytocin treatment.
Patients in spontaneous labor were recognized by regular EMG
patterns and contractions as monitored with a tocodynamometer
in patients showing fetal descent and with progressive cervical
dilation. Uterine contractions had to last for 30e45 s and the in-
terval between contractions was 3e4 min (frequency). Contractions
measured with a tocodynamometer has been described previously
[34e37]. UTIN was determined by the initial presence of strong
EMG activity and uterine contractions and progressive cervical
dilation followed by a period of weak and/or infrequent EMG and
contractions, that were inadequate to produce further cervical
dilation and fetal descent for more than 2 h. Cervical exams were
performed at least every 2 h during labor and were assessed by the
same examiner. Intrauterine pressure catheters are not used for
labor management at our hospital or in any hospital in China.
Oxytocin treatment
The decision to administer oxytocin was at the discretion of the
patient's attending obstetrician for UTIN. Oxytocin administration
was begun at 4 mU oxytocin per minute and increased by 4 mU/min
every 15 min until strong, regular uterine contractions and pro-
gressive cervical dilation resulted or a maximum of 40 mU/min was
reached.
Recording and analysis of EMG
Uterine EMG activity was recorded noninvasively from the
abdominal surface using PowerLab electromyography (AD In-
struments, Castle Hill, Australia) and 4 AgeAgCl differential bipolar
electrodes (Shanghai Jun Kang Medical Supplies Co., Ltd, Shanghai)
placed around the navel. Each electrode was separated from the
others by approximately 3 cm. A reference electrode was placed
laterally on the patient's hip. EMG signals were amplified defer-
entially with respect to the reference electrode. Uterine EMG sig-
nals were digitally filtered to yield a final band-pass of 0.34e1.00 Hz
to exclude most components of motion, respiration, and cardiac
signals while preserving the main contraction signals where 98% of
uterine electrical activity is found [27]. All data were sampled at
1000 samples/second.
Uterine EMG was acquired continuously from the start of labor
until the end of the first stage. For patients with spontaneous labor
P. Li, L. Wang, X. Qian et al.
(Group 1) who entered labor and did not require oxytocin
augmentation, a 30-min EMG segment was identified for analysis
as soon as the patient was noted to have regular uterine contrac-
tions with strong EMG parameters accompanied by cervical dila-
tion and fetal descent. An additional 30-min EMG segment (Group
1, S2) was obtained when the cervical dilation of Group 1 approx-
imated that of Group 2 after oxytocin treatment. Patients with UTIN
were first noted to have good EMG activity followed by low EMG
activity for more than 2 h (before oxytocin). Sometime after the
start of oxytocin administration, 30 min segments were chosen for
EMG analysis as soon as the patients were noted to have regular
EMG, uterine contractions and changes in cervical dilation.
The following criteria were used to identify EMG bursts (Chart
8.0 software, AD Instruments, Castle Hill, Australia): (1) A contin-
uous group of positive and negative signals with twice the baseline
amplitude; (2) A group of signals not returning to baseline for
longer than 10 s and also; (3) A burst is usually accompanied by
contractions shown on the TOCO. Parameters analyzed for EMG
burst characteristics included burst frequency (number bursts/
30 min), duration of bursts (seconds), root mean square (RMS, mV),
mean peak PDS amplitude (uV), total EMG power (pV2). EMG power
and RMS are used respectively to assess energy and amplitude of
the EMG burst activity.
Statistics
Inter-group differences were assessed using the Student's t-test,
one way ANOVA, ManneWhitney U or KruskaleWallis tests as
appropriate. Student's t-test was 2-tailed and statistical significance
for all tests was set at p < .05. Statistical analyses were performed
using SPSS 13.0. Power analysis was performed using a power of
0.80 and an alpha of 0.05, to give a desired minimum sample size of
7 per group based on uterine EMG data from our previous studies.
Results
There were no statistically significant differences in the de-
mographic and obstetric characteristics between the 2 groups of
patients (Table 1) (see Table 2).
Fig. 1 shows representative uterine EMG tracings with TOCO
recorded from women in normal spontaneous labor (Fig. 1A, Group
1) and women with UTIN before (Fig. 1B, Group 2) and after the
administration of oxytocin (Fig. 1C, Group 2). During spontaneous
labor, regular, successive bursts of EMG activity with high ampli-
tude and long duration are seen corresponding to TOCO recordings
(Fig. 1A). Women diagnosed with UTIN prior to oxytocin demon-
strate infrequent isolated spikes of EMG with weak amplitude of
short duration accompanied by feeble and occasional TOCRO trac-
ings (Fig. 1B). After the administration of oxytocin to women with
UTIN the EMG shows a very similar pattern (Fig. 1C) to spontaneous
Table 1
Demographic and obstetric variables.
Characteristics Spontaneous Labor Uterine Inertia
Age (years) 28.00 ± 0.66 28.70 ± 0.53
Body height (cm) 158 ± 0.96 159 ± 1.11
BMI (kg/M2) 25.45 ± 0.67 25.80 ± 0.93
GA (weeks) 40 (38e41) 40 (38e41)
Baby weight(g) 3152 ± 67 3302 ± 97
1st stage of labor (min) 650 ± 65 695 ± 50
2nd stage of labor (min) 57.17 ± 4.87 73.25 ± 8.53
Shown are demographics and duration of labor from patients used in this study. All
values are means ± SEM. There were no significant differences (P > .05) between the
groups. Abbreviations: BMI, body mass index, GA, gestational age.
Labor and with UTIN.
Taiwanese Journal of Obstetrics & Gynecology 60 (2021) 449e453
effective contractions and compares to the EMG activity during
spontaneous labor (compare Fig. 1CeA).
There were significantly higher (P < .05) EMG values of all the
EMG parameters in the patients with spontaneous labor (Group 1,
S1) vs. the patients with UTIN before oxytocin treatment. There
were also significantly higher values for EMG burst characteristics
(P < .05) for all variables, in patients with UTIN after oxytocin
treatment vs. patients before oxytocin treatment. However, there
were no significant differences (P > .05) in EMG parameters in
patients after oxytocin treatment vs. spontaneous labor patients
(Group 1, S2) with cervical dilation at approximately equal to those
seen in the UTIN group plus oxytocin.
Discussion
It has long been recognized that the force generated by uterine
contractions is an important factor in the successful progress of
labor [36]. Inadequate contractions prolong labor and can thus
adversely affect the chances of spontaneous vaginal delivery and
outcome of delivery [15]. Uterine EMG, as used in this study,
provides a more objective, quantitative, and non-invasive
assessment of uterine activity during delivery because uterine
EMG provides detailed information relating to the cause of con-
tractions rather than the result of contractions. In a previous
study, we documented the evolution of uterine EMG parameters
such as the frequency, duration and RMS of EMG bursts in the
active phase of the first stage of labor and the second stage [35].
This is the first report documenting the details of uterine EMG
activity in pregnant women with spontaneous labor and with
UTIN before and after oxytocin administration with and without
PCEA. In this study, we also demonstrated that uterine EMG differs
qualitatively and quantitatively in women with clinically effective
spontaneous contractions from those with clinically diagnosed
UTIN, where infrequent uterine EMG and lower amplitude and
shorter duration EMG bursts are seen. Oxytocin augmentation
was used in women with UTIN and this treatment normalized
EMG activity to that seen in patients in normal spontaneous labor.
Thus, EMG measurements are an effective tool for the diagnosis
and for the guidance of therapy during labor. The use of uterine
EMG in women with UTIN could prevent unnecessary admissions
for false labor, may provide a more object diagnosis of this con-
dition, guide appropriate treatments, decrease cesarean sections
and prevent adverse reactions.
Measurement of inadequate uterine contractions with uterine
EMG may be better termed UTIN. UTIN is an old term that was
discussed many years ago [1,6,7],at a time when very little was
known about control of uterine contractility and extracts of the
posterior pituitary were used as treatment. The term UTIN as
diagnosed with EMG indicates slow and sluggish movement of
the uterus caused by lower EMG activity and this represents a
more precise and superior definition and terminology. The pre-
sent investigation does not examine the underlying causes of
UTIN. This could be due to a decrease in excitability, by a
decrease in ionic movement within muscle cells, a change in
P propagation of the signals, a decrease in levels of endogenous
0.14
contractile stimulants or an increase in regional uterine in-
0.56 hibitors. Use of uterine EMG may help to identify the mecha-
0.88 nisms involved in UTIN.
0.75 The ability of oxytocin to increase the effectiveness of uterine
0.51
contractions is well documented [37,38]. Previous animal and hu-
0.31
0.11 man studies using power density spectrum analysis of uterine EMG
have not included data obtained during oxytocin administration for
first stage labor arrest [39,40]. The present study documents at least
a 2-fold increase in the value of number of bursts, duration, RMS,
and amplitude in patients with UTIN following the implementation
451
P. Li, L. Wang, X. Qian et al. Taiwanese Journal of Obstetrics & Gynecology 60 (2021) 449e453

Table 2
EMG burst characteristics and cervical dilation in patients with spontaneous labor and uterine inertia.

Characteristics Spontaneous Labor Uterine Inertia

Group1 Group 2

S1 S2 before OT treated after OT treated

n ¼ 30 n ¼ 30 n ¼ 20 n ¼ 20

Number of bursts/30 mins 14.20 ± 0.61* 13.47 ± 0.47* 6.75 ± 0.61# 13.50 ± 0.63*
Mean duration (s) 55.79 ± 2.33* 61.44 ± 2.00* 26.56 ± 1.37# 61.15 ± 3.03*
RMS (mV) 0.09 ± 0.01* 0.10 ± 0.01* 0.04 ± 0.01# 0.10 ± 0.01*
Amplitude (uV) 59.13 ± 2.98* 59.41 ± 3.36* 22.60 ± 2.25# 52.78 ± 3.76*
Total power (pV2) 12.83 ± 1.79* 12.71 ± 1.16* 1.42 ± 0.32# 18.16 ± 3.78*
Cervical dilation (cm) 4.76 ± 0.28* 7.37 ± 0.23# 4.89 ± 0.37* 7.41 ± 0.43#

Group 1, S1 (first column) represents data from 30 patients with spontaneous labor and Group 1, S2 (second column) is the data from the same patients measured when the
cervical dilation approximated Group 2 after oxytocin treatment. Group 2 are the same patients with UTIN before and after oxytocin (third and fourth columns). Abbreviations:
EMG, electromyography; RMS, root mean square; SEM, standard error of the mean; OT, oxytocin. Different superscript letters (*, #) after mean values þSEM indicate significant
differences (P < .05) between each particular EMG characteristic and cervical dilation of various groups.

Declaration of competing interest

The authors report no conflicts of interests.

Acknowledgments

We thank Long Cui MD, PhD, Dean Coonrod, MD and Shao-Qing

Shi, MD for their valuable contributions in reviewing the manu-
script. Robert E. Garfield thanks Miha Lucovnik, MD, PhD at the
University of Ljubljana, Department of Obstetrics, Ljubljana,
Slovenia for his valuable discussions on application of EMG in
obstetrics.

References

[1] Friedman EA. Primigravid labor; a graphicostatistical analysis. Obstet Gynecol

Fig. 1. Representative uterine EMG tracings from women with or without UTIN in
labor. Fig. 1A shows an example of EMG activity during labor with successive bursts of
high-amplitude, long duration bursts (blue tracing) accompanied by the TOCO tracings
(green tracing). Fig. 1B illustrates the EMG of a woman with clinical UTIN before
oxytocin treatment showing infrequent, low amplitude, short duration EMG activity
(blue) and irregular TOCO (green). Fig. 1C demonstrates a typical EMG (blue) and
corresponding TOCO (green) after administration of oxytocin. Note that Fig. 1C is
similar to Fig. 1A. (For interpretation of the references to color in this figure legend, the
reader is referred to the Web version of this article.)
of oxytocin administration and this correlates with resumption of
labor progression as seen by the increased cervical dilation. No
prior study has systematically examined changes in EMG in rela-
tionship to UTIN with the use of oxytocin. In this study we were
able to analyze the uterine EMG of women in spontaneous labor
and those who experienced UTIN.
Taken together, our present findings suggest that uterine EMG
has significant applications as a non-invasive, integrated, and
quantitative technology for monitoring the effectiveness of uterine
contractions and thus aiding the clinical diagnosis and manage-
ment of labor. The same advantages of uterine EMG make it an
effective non-invasive tool to manage the induction and augmen-
tation of labor with uterine stimulants.
Funding
This study was supported by the Science and Technology Pro-
gram of Guangzhou, China (2021-02-01-04–0113) and the National
Natural Science Foundation of China (81871181).
1955;6(6):567e89.
[2] Zhang J, Troendle JF, Yancey MK. Reassessing the labor curve in nulliparous
women. Am J Obstet Gynecol 2002;187(4):824e8.
[3] El-Hamamy E, Arulkumaran S. Poor progress of labour. Current Obstet
Gynecol 2005;15(1):1e8.
[4] Bugg GJ, Siddiqui F, Thornton JG. Oxytocin versus no treatment or delayed
treatment for slow progress in the first stage of spontaneous labour. Cochrane
Database Syst Rev 2013;6(6):CD007123.
[5] Higgins M, Dan F. Assessment of labor progress. Expet Rev Obstet Gynecol
2014;8(1):83e95.
[6] Stern DM, Smythe HJ. Discussion on the management of uterine inertia in the
first stage of labor. Proc Roy Soc Med 1948;41(5):311e6.
[7] Friedman EA, Sachtleben MR. Dysfunctional labor: prolonged latent phase in
phase the nullipara. Obstet Gynecol 1961;17(2):135e48.
[8] ACOG practice bulletin number 49, december 2003: dystocia and augmenta-
tion of labor. Obstet Gynecol 2003;102(6):1445e54.
[9] ACOG. Practice bulletin number 107: induction of labor. Obstet Gynecol
2009;114(2):386e97. , part 1.
[10] Spong CY, Berghella V, Wenstrom K, Mercer BM, Saade GR. Preventing the first
cesarean delivery: summary of a joint eunice kennedy shriver national
institute of child health and human development, society for maternal-fetal
medicine, and American college of obstetricians and gynecologists work-
shop. Obstet Gynecol 2012;120:1181e93.
[11] Walsh J, Foley M, O'Herlihy C. Dystocia correlates with body mass index in
both spontaneous and induced nulliparous labors. J Matern Fetal Neonatal
Med 2011;24(6):817e21.
[12] Anim-Somuah M, Smyth RM, Howell CJ. Epidural versus non-epidural or no
analgesia in labour. Cochrane Db Syst Rev 2011;8(4):428e32.
[13] Zhang J, Troendle J, Reddy UM, Pettker CM, Funai EF, Illuzzi JL. Contemporary
cesarean delivery practice in the United States. Am J Obstet Gynecol
2010;203(4):326. e1-e10.
[14] Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL.
Contributing indications to the rising cesarean delivery rate. Obstet Gynecol
2011;118(1).
[15] O'Driscoll K, Foley M. Correlation of decrease in perinatal mortality and in-
crease in cesarean section rates. Obstet Gynecol 1983;61(1):1e5.
[16] Marshall JM. Regulation of activity in uterine smooth muscle. Physiol Rev
1962;5(5):213e27.

452
P. Li, L. Wang, X. Qian et al.
[17] Garfield RE, Blennerhassett MG, Miller SM. Control of myometrial contrac-
tility: role and regulation of gap junctions. Oxf Rev Reprod Biol 1988;10(1):
436e90.
[18] Euliano TY, Marossero D, Nguyen MT, Euliano NR, Principe J, Edwards RK.
Spatiotemporal electrohysterography patterns in normal and arrested labor.
Am J Obstet Gynecol 2009;200(1):1e7.
[19] Marque CK, Terrien J, Rihana S, Germain G. Preterm labour detection by use of
a biophysical marker: the uterine electrical activity. BMC Pregnancy Child-
birth 2007;7(1):1e6.
[20] Hadar E, Biron-Shental T, Gavish O, Raban O, Yogev Y. A comparison between
electrical uterine monitor, tocodynamometer and intra uterine pressure
catheter for uterine activity in labor. J Materna-Fetal Neo M 2015;28(12):
1367e74.
[21] Matsuo K, Lynch MA, Kopelman JN, Atlas RO. Anaphylactoid syndrome of
pregnancy immediately after intrauterine pressure catheter placement. Am J
Obstet Gynecol 2008;198(2):8e9.
[22] Euliano TY, Nguyen MT, Darmanjian S, McGorray, Susan P, Euliano N, et al.
Monitoring uterine activity during labor: a comparison of 3 methods. Am J
Obstet Gynecol 2013;208(1):1e6.
[23] Kawarabayashi T, Kishikawa T, Sugimori H. Effect of oxytocin on spontaneous
electrical and mechanical activities in pregnant human myometrium. Am J
Obstet Gynecol 1986;155(3):671e6.
[24] Sheldon RE, Mashayamombe C, Shi S-Q, Garfield RE, Shmygol A, M Blanks A,
et al. Alterations in gap junction connexin43/connexin45 ratio mediate a
transition from quiescence to excitation in a mathematical model of the
myometrium. J R Soc Interface 2014;11:1e10.
[25] Ekman-Ordeberg G, Stjernholm Y, Wang H, Stygar D, Sahlin L. Endocrine
regulation of cervical ripening in humansdpotential roles for gonadal
steroids and insulin-like growth factor-I. Steroids 2003;68(10e13):
837e47.
[26] Word RA, Li XH, Hnat M, Carrick K. Dynamics of cervical remodelling during
pregnancy and parturition: mechanisms and current concepts. Semin Reprod
Med 2007;25(25):69e79.
[27] Garfield RE, Maner WL, Maul H, Saade GR. Use of uterine EMG and cervical LIF
in monitoring pregnant patients. BJOG An Int J Obstet Gynaecol 2005;112(l 1):
103e8.
[28] Eswaran H, Preissl H, Wilson JD, Murphy P, Robinson SE, Lowery CL. First
magnetomyographic recordings of uterine activity with spatial-temporal
453
View publication stats
Taiwanese Journal of Obstetrics & Gynecology 60 (2021) 449e453
information using 151 channel sensor array (SARA). Am J Obstet Gynecol
2003;100(3):90e1.
[29] Maner WL, Mackay LB. Comparing uterine electromyography activity of
antepartum patients versus term labor patients. Am J Obstet Gynecol
2005;193(1):23e9.
[30] Garfield RE, Chwalisz K, Shi L, Olson G, Saade GR. Instrumentation for the
diagnosis of term and preterm labour. J Perinat Med 2004;26(6):413e36.
[31] Vasak B, Graatsma EM, Hekman-Drost E, Eijkemans MJ, vLJH Schagen,
Visser GH. Uterine electromyography for identification of first-stage labor
arrest in term nulliparous women with spontaneous onset of labor. Am J
Obstet Gynecol 2013;209(3):1e8.
[32] Kandil M, Emarh M, Ellakwa H. Abdominal electromyography in laboring and
non-laboring pregnant women at term and its clinical implications. Arch
Gynecol Obstet 2013;288(2):293e7.
[33] Bregar AT, Lucovnik M, Verdenik I, Jager F, Gersak K, Garfield RE. Uterine
electromyography during active phase compared with latent phase of labor at
term. Acta Obstet Gynecol Scand 2016;95(2):197e202.
[34] Ye Y, Song X, Lei L, Shi SQ, Liu H. Effects of patient-controlled epidural anal-
gesia on uterine electromyography during spontaneous onset of labor in term
nulliparous women. Reprod Sci 2015;22(11):1350e7.
[35] Qian X, Li P, Shi SQ, Garfield RE, Liu H. Simultaneous recording and analysis of
uterine and abdominal muscle electromyographic activity in nulliparous
women during labor. Reprod Sci 2016;24(3):471e7.
[36] Csapo AI. Force of labor. In: Principles and practice of obstetrics and perina-
tology, iffy I and kamientsky HA. New York: Wiley; 1981. p. 761e99.
[37] Caldeyro-Barcia R, Poseiro JJ. Oxytocin and contractility of the pregnant hu-
man uterus. Ann NY Acad Sci 1959;75(2 The Uterus):813e30.
[38] Costley PL, East CE. Oxytocin augmentation of labour in women with epidural
analgesia for reducing operative deliveries. Cochrane Db Syst Rev 2013;5(7):
1181e98.
[39] Buhimschi C, Boyle MB, Garfield RE. Electrical activity of the human uterus
during pregnancy as recorded from the abdominal surface. Obstet Gynecol
1997;90(1):102e11.
[40] Buhimschi C, Boyle MB, Saade GR, Garfield RE. Uterine activity during
pregnancy and labor assessed by simultaneous recordings from the myome-
trium and abdominal surface in the rat. Am J Obstet Gynecol 1998;178(4):
811e22.