Expert Review
org
Assessment of uterine contractions in labor
and delivery
Hadar Rosen, MD; Yariv Yogev, MD
Introduction
Monitoring uterine activity is a common
obstetrical practice. During labor, it
allows for the supervision of labor pro-
gression and can aid clinical decision-
making regarding intervention. Uterine
activity may be assumed adequate when
progressive cervical dilatation and fetal
descent occur. Dysfunctional labor has
been estimated to affect up to 21% of
primigravid labors,1 and it is the most
common cause of intrapartum cesarean
delivery2. Uterine contraction moni-
toring may guide the need for uterotonic
medication or operative delivery when
labor fails to adequately progress.
Furthermore, it allows for the accurate
classification of fetal heart rate de-
celerations (which requires accurate
timing against contractions, both ante-
partum and intrapartum) and ongoing
surveillance of uterine activity in the
setting of a trial of labor after cesarean
delivery (TOLAC).
The purpose of this review is to describe
the physiology of labor contractions, as
well as current widespread uterine
contraction monitoring methods of
assessment such as external tocodyna-
mometry and intrauterine pressure
From the Department of Obstetrics and
Gynecology, Mayanei Hayeshua Medical
Center, Bnei Brak, Israel (Dr Rosen); Lis
Maternity and Women’s Hospital, Tel-Aviv
Sourasky Medical Center, Tel Aviv, Israel (Dr
Yogev); and Sackler Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel (Drs Rosen and
Yogev).
Received May 28, 2022; revised Sept. 1, 2022;
accepted Sept. 1, 2022.
The authors report no conflict of interest.
Corresponding author: Hadar Rosen, MD.
rosenhadar@gmail.com
0002-9378/$36.00
ª 2022 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2022.09.003
ajog.
Normal labor and delivery are dependent on the presence of regular and effective
contractions of the uterine myometrium. The mechanisms responsible for the initiation
and maintenance of adequate and synchronized uterine activity that are necessary for
labor and delivery result from a complex interplay of hormonal, mechanical, and electrical
factors that have not yet been fully elucidated.
Monitoring uterine activity during term labor and in suspected preterm labor is an
important component of obstetrical care because cases of inadequate and excessive
uterine activity can be associated with substantial maternal and neonatal morbidity and
mortality. Inadequate labor progress is a common challenge encountered in intrapartum
care, with labor dystocia being the most common indication for cesarean deliveries
performed during labor. Hereafter, an accurate assessment of uterine activity during
labor can assist in the management of protracted labor by diagnosing inadequate uterine
activity and facilitating the titration of uterotonic medications before a trial of labor is
prematurely terminated. Conversely, the ability to diagnose unwanted or excessive
uterine activity is also critical in cases of threatened preterm labor, tachysystole, or
patients undergoing a trial of labor after cesarean delivery. Knowledge of uterine activity
in these cases may guide the use of tocolytic medications or raise suspicion of uterine
rupture. Current diagnostic capabilities are less than optimal, hindering the medical
management of term and preterm labor.
Currently, different methods exist for evaluating uterine activity during labor, including
manual palpation, external tocodynamometry, intrauterine pressure monitoring, and
electrical uterine myometrial activity tracing. Legacy uterine monitoring techniques have
advantages and limitations. External tocodynamometry is the most widespread tool in
clinical use owing to its noninvasive nature and its ability to time contractions against the
fetal heart rate monitor. However, it does not provide information regarding the strength
of uterine contractions and is limited by signal loss with maternal movements.
Conversely, the intrauterine pressure catheter quantifies the strength of uterine con-
tractions; however, its use is limited by its invasiveness, risk for complications, and
limited additive value in all but few clinical scenarios. New monitoring methods are being
used, such as electrical uterine monitoring, which is noninvasive and does not require
ruptured membranes. Electrical uterine monitoring has yet to be incorporated into
common clinical practice because of lack of access to this technology, its high cost, and
the need for appropriate training of clinical staff. Further work needs to be done to in-
crease the accessibility and implementation of this technique by experts, and further
research is needed to implement new practical and useful methods. This review de-
scribes current clinical tools for uterine activity assessment during labor and discusses
their advantages and shortcomings.
The review also summarizes current knowledge regarding novel technologies for
monitoring uterine contractions that are not yet in widespread use, but are promising and
could help improve our understanding of the physiology of labor, delivery, and preterm
labor, and ultimately enhance patient care.
Key words: action potentials, contraction frequency, contraction intensity, contractions,
dysfunctional labor, electrical activity, electrical uterine monitoring, electro hysterogram,
external tocodynamometry, gap junctions, hysterography, intrauterine pressure catheter,
labor augmentation, labor induction, labor progression, manual palpation, Montevideo
units, myometrium, preterm labor, tachysystole, uterine activity
MONTH 2022 American Journal of Obstetrics & Gynecology 1
Expert Review
catheter (IUPC), to introduce a newer
method using electrical uterine moni-
toring (EUM), and to describe the clinical
implementation of these methods.
Physiology
As is the case with any muscle in the body,
contractility of the uterine muscle is a
direct consequence of the underlying
electrical activity in the myometrial cells.3,4
For most of the duration of a normal
pregnancy, the uterus maintains a quies-
cent state and the cervix remains firm and
closed. This state is hormonally mediated
mainly by progesterone and human cho-
rionic gonadotropin (hCG), whereas later
on in gestation it is dependent on placental
production.5 Progesterone suppresses the
production of gap junctions between
myocytes and consequently prevents the
transmission of electrical activity between
these cells.6 Additional mechanisms that
contribute to uterine quiescence have
been proposed, including the anti-
inflammatory effects of placental proges-
terone on suppressing prostaglandin
production, which is known to promote
myocyte depolarization,7,8 and other
placental hormones such as hCG and
corticotropin-releasing hormone pro-
moting myometrial relaxation via
cyclic adenosine 3’-5’-monophosphate
(cAMP)edependent pathways.9,10 cAMP
plays important roles in cellular responses
to many hormones and neurotransmitters.
There are 3 main effectors of cAMP, one of
which is protein kinase (PKA), the well-
known target—a symmetrical complex of
2 regulatory (R) and 2 catalytic (C) sub-
units. It is activated by the binding of
cAMP to 2 sites on each of the R subunits,
which causes their dissociation from C
subunits.11 Beta-adrenoreceptor agonists
(ß-agonists) bind to ß-adrenoreceptors,
which are couples to G-proteins that acti-
vate adenylyl cyclase to form cAMP from
adenosine triphosphate. Increased cAMP
activates PKA that phosphorylates L-type
calcium channels, which causes increased
calcium entry into the cells. ß-agonists can
serve as potential drugs to influence the
cAMP-dependent pathway.11
In preparation for labor, the cervix
softens, and the myometrium undergoes
changes to allow efficient generation
and propagation of electrical activity
2 American Journal of Obstetrics & Gynecology MONTH 2022
throughout the myometrium. Myo-
metrial activity leading to uterine con-
tractions is the result of molecular
changes that cause increased coupling
and excitability of uterine muscle
cells.3e6 Electrical discharges of the
myometrium consisting of intermittent
bursts or spikes depolarize the myo-
metrial membrane, causing influx of
calcium ions.12,13
Transmembrane calcium flux is an
important modulator of intracellular
calcium and it initiates a cascade of
events including interaction of contrac-
tile proteins (myosin and actin) regu-
lated by myosin light-chain kinase,
ultimately resulting in muscle contrac-
tion (Figure 1). Thus, uterine contrac-
tility is a consequence of the electrical
activity underlying myometrial cells.3
Therefore, the frequency, amplitude,
and duration of uterine contractions can
be determined by the frequency of the
action potentials within a burst, the
duration of a burst, and the total number
of cells that are activated simultaneously.
The propagation of this electrical activity
is facilitated by gap junctions, which
increase in number before the onset of
labor.14
Gap junctions are composed of con-
nexin proteins that provide channels of
low electrical resistance between the
myometrial cells, creating a pathway for
efficient conduction of action potentials.
Throughout pregnancy these cell-to-cell
channels are low in number, resulting in
poor coupling and decreased electrical
conductance. At term, however, gap
junctions increase in number and form
an electrical syncytium required for
effective contractions.3 The hormonal
balance between estrogen and proges-
terone regulates the formation and
expression of gap junctions, whereby
estrogen is responsible for up-regulation
and progesterone is associated with
down-regulation of gap junctions.3,15,16
Estrogen also increases expression of
cyclooxygenase-2, which promotes
uterine myocyte depolarization and
contraction.17 In addition, oxytocin and
mechanical stretch cause increased
excitability of smooth muscle cells.18
Myometrial smooth muscle generates
phasic contractions in the absence of
ajog.org
FIGURE 1
Scheme showing how Ca2D
entry leads to smooth muscle
contraction
The contribution of the SR to augmenting Ca2þ
for contraction is not established for the uterus,
but is indicated for completeness, and the red
bar indicates its negative effect on contractility.
Some Ca2þ entry predominates in the uterus.
Adapted from: Wray S. Insights into the uterus.
Exp Physiol. 2007 Jul;92(4):621e31.
MLCK, myosin light-chain kinase; MLCP, myosin light-chain
phosphatase; SR, sarcoplasmic reticulum.
Rosen. Assessment of uterine contractions in labor and de-
livery. Am J Obstet Gynecol 2022.
stimuli from the central nervous system
or circulating hormones.3 The location
of the electrical activity initiation and the
propagation pattern of the electrical wave
during labor remain obscure.19 Some
studies suggest that myometrial cells
exhibit “pacemaker” capabilities.20 Early
work by Caldeyro-Barcia assumed a
catastalsis-like downward mechanism
with fundal fixed pacemakers.21 To date,
no pacemaker regions with specific
anatomic features have been described in
the mammalian uterus.22 Studies con-
ducted in animal and human models
failed to demonstrate a clear origin and a
specific pattern of propagation, which
was observed to be variable, shifting
from one site to the other and from one
direction to the other.19 High-resolution
recordings showed complex wave prop-
agation patterns, such as
3 wavefronts
emerging at different uterine positions
and time instants and propagating in
different directions.23 These recordings
refute theories that argue fundal domi-
nance and downward progression.
Nevertheless, the rhythmic pattern of
uterine contraction during labor is clear,
and it is dictated by the rhythm of the
ajog.org
electrical bursts. It has been suggested
that in contrast to longer tubular-shaped
organs such as the intestines where spe-
cific propagation pattern is necessary, the
uterus during pregnancy is more spher-
ically shaped. In that situation, the
intense rhythmic pressure that surges in
accordance with the electrical bursts
might be more important than a tightly
controlled propulsive contraction
wave.24,25 The myometrium has 2 layers.
The circular layer, called the sub-
endometrial or junctional endometrium,
is thinner and present at the innermost
aspect of muscle fibers. The outer lon-
gitudinal layer is made of intertwined
muscle bundles embedded in an extra-
cellular matrix made of collagen fibers,
which is highly vascular.20 Propagation
occurs more rapidly in the longitudinal
direction and more slowly in the trans-
versal and circumferential directions.
This structure further promotes building
the intense pressure needed for contrac-
tions.20 Thus, electrical activity is effi-
ciently transferred to the whole uterus,
resulting in rhythmic synchronous con-
tractions across the uterus that act to
raise the intrauterine pressure. Uterine
activity studies reveal the complexity of
its electrical propagation properties,
underscoring the need for further
investigation and clarification.
Methods for uterine contraction
assessment
Current methods in clinical practice for
assessing uterine activity are manual
palpation, external tocodynamometry,
IUPC measurement, and EUM. Char-
acteristics of uterine activity that are
traditionally analyzed include the fre-
quency (beginning of contraction to
beginning of the next contraction),
duration (length of contraction from its
beginning to end, measured in seconds),
intensity (strength of contraction
assessed via palpation or mm Hg), and
resting tone (intrauterine pressure when
uterus is not contracting, assessed via
palpation or mm Hg).
External palpation for assessment of
uterine activity
External palpation has the advantage of
being readily available and inexpensive.
It does not require any equipment and
can be easily taught. Nevertheless, it is a
subjective form of assessment, and
uterine contractions can only be
perceived by manual palpation when
their intensity exceeds a threshold of
approximately 20 mm Hg.21 Further-
more, sensitivity and accuracy of evalu-
ation are also dependent on the
myometrial and abdominal wall thick-
ness and the experience of the obstetrical
caregiver.26 Indeed, when the efficacy of
manual palpation was assessed by asking
observers to define contractions as mild,
moderate, or severe, without knowing
the recorded IUPC values,27 the ob-
servers’ assessment was accurate in only
49% of the 236 observations obtained in
46 laboring women during the first stage
of labor. Manual palpation consistently
underestimated the onset and length of
uterine contractions, and therefore the
primary use of manual palpation is for
determining the presence and frequency
of uterine contractions.26 It can also
detect uterine hyperstimulation or
tetany, which is important in diagnosing
uterine abruption. However, it is still an
effective method of evaluating uterine
contractions, particularly in low-
resource settings.
External tocodynamometry
External tocodynamometry is the most
common method for assessing uterine
contractility during pregnancy and la-
bor. Mechanical devices for monitoring
contractions externally were introduced
as early as 1861.28 Such monitoring is
based on mechanical measurement of
abdominal shape by placing a transducer
on the abdominal wall. The transducer
(Figure 2) detects the change in shape of
the uterus by detecting the changes in the
abdominal contour as a result of the
contraction. The main advantages of the
method are ease of application and
noninvasiveness. In optimal circum-
stances (ie, nonobese, relaxed patients),
it can accurately measure contraction
frequency with adequate positioning of
the transducer and sufficient tightness of
the belt.29 Furthermore, in contrast to
manual palpation, tocodynamometry
allows the classification of fetal heart rate
changes in relation to the timing of
MONTH 2022 American Journal of Obstetrics & Gynecology
Expert Review
FIGURE 2
External tocodynamometry
Image credit: Philips Healthcare.
Rosen. Assessment of uterine contractions in labor and de-
livery. Am J Obstet Gynecol 2022.
uterine contractions and providing
documentation of contractions inde-
pendently of staff presence.
There are, however, some limitations
of external tocodynamometry. Although
this method of uterine activity assess-
ment facilitates the evaluation of the
presence and frequency of uterine con-
tractions, it cannot accurately determine
the intensity or strength of contrac-
tions.30 In addition, external tocography
is also influenced by changes in maternal
position and abdominal wall muscle
contractions, such as coughing and
vomiting.31 Moreover, it is less reliable in
detecting contractions in obese women
because the accuracy of tocodynamom-
etry is limited by the abdominal wall
thickness and its position relative to the
uterus. These limitations lead to less
accurate results,32e34 and therefore
cautious interpretation is required.
Intrauterine pressure catheter for
uterine activity monitoring
Some of the above-mentioned limita-
tions of external tocodynamometry may
be overcome using internal monitoring
of uterine contractions during labor
with an IUPC. The first measurement of
intrauterine pressure to record uterine
contractions was performed in 1872 by
Friedrich Schatz. His method for
assessing uterine contractions used a
small bag of fluid introduced between
the membranes and the lower segment
of the uterus, connected to a mercury
manometer.
3
Expert Review
Currently, use of the IUPC requires its
placement within the intraamniotic
cavity following either spontaneous or
artificial rupture of the membranes, and
is therefore limited to only when delivery
is desired. There are 3 types of IUPCs:
fluid-filled, transducer-tipped, and
sensor-tipped. The fluid-filled catheter
has a column that connects a balloon in
the amniotic cavity to an external pres-
sure monitor, and the water column in
the catheter transmits the intrauterine
pressure to a transducer on the monitor
that converts the resulting electrical
signal to contraction waveforms. The 2
more modern systems are one in which
both the pressure sensor and the trans-
ducer are at the intrauterine tip, and one
in which the transducer is extrauterine.
Both transducer- and sensor-tipped
systems are connected to the fetal heart
rate monitor, obviating the need for a
fluid-filled catheter. Because no signifi-
cant difference has been demonstrated
between the different types of IUPCs in
relation to maternal and fetal complica-
tions, the choice of catheter used is
determined by availability, cost, or
preference.35e37 One randomized trial
that included 249 patients showed a
higher rate of extramembranous place-
ment with transducer-tipped than with
sensor-tipped catheter (12.5% vs 2.4%),
with no difference in the rate of com-
plications.37 One retrospective cohort
study showed that among 6445 women,
3944 (61.2%) had internal monitors.
Women with internal monitors were
more likely to have a fever than women
without internal monitors (11.7% vs
4.5%). The risk of cesarean delivery was
higher in women with internal monitors
(18.6% vs 9.7%). The routine use of
IUPC in laboring patients should be
avoided because of an increased risk of
maternal fever.38
Role of internal uterine monitoring in
labor management
The main advantage of IUPC over
external tocodynamometry is that it al-
lows quantification of contraction
strength, usually measured by Mon-
tevideo units. IUPC use may also be
considered when external tocodyna-
mometry fails to provide a clear tracing
4 American Journal of Obstetrics & Gynecology MONTH 2022
of uterine contraction pattern because of
technical limitations such as obesity or
patient movements. In 1952, Caldeyro-
Barcia et al39 introduced Montevideo
units to quantify uterine contraction
power. Montevideo units represent the
sum of the amplitude of each contrac-
tion over a 10-minute period.40 The
amplitude of each contraction is
measured as the peak contraction pres-
sure minus the baseline tone to give the
“active pressure” (Figure 3).
A major criticism of Montevideo units
is that contraction duration and the
resting period between contractions are
only indirectly accounted for in this
calculation. Other calculations incorpo-
rating duration of uterine contractions
have been suggested, such as Alexandria
units, which are equivalent to a Mon-
tevideo unit multiplied by the mean
duration of contractions over a 10-
minute period,41 or uterine activity
units, which calculate the area under the
pressure curve42 (Figure 4). However,
these have not been adopted in clinical
practice. Planimeter units are used
to determine the area of an arbitrary
2-dimensional shape, defined by the area
under the curve10.
The rise in cesarean delivery rates over
the years,43 in large part owing to intra-
partum cesarean deliveries for failure to
progress (Table 1), has highlighted the
importance of making an accurate
diagnosis of arrested labor, which de-
pends on the precise assessment of
uterine contractions. Table 1 is adapted
from a consortium study by Zhang et al2
that evaluated deliveries from 2002 to
2008. Since then, definitions and prac-
tices have changed, with new World
Health Organization recommendations
for nonclinical interventions to reduce
unnecessary cesarean deliveries.40 Un-
derstanding that nonprogressive labor is
often the result of insufficient uterine
contractions rather than a premature
diagnosis of arrest of dilatation allows for
the use of uterotonic medications and
thus may in theory reduce the rate of
cesarean deliveries performed for labor
dystocia. It also supports clinicians in
titrating uterotonic treatment during
inductions or augmentation of labor. It
has been suggested that an average of 150
ajog.org
FIGURE 3
Terminology of uterine
contractions
Adapted from Michele J. Grimm, Forces
involved with labor and delivery- a biochemical
perspective, annals of biochemical engineering,
49,1819-1835 (2021)
Rosen. Assessment of uterine contractions in labor and de-
livery. Am J Obstet Gynecol 2022.
to 250 Montevideo units are necessary to
cause cervical dilation and fetal
descent.40,44 Uterine activity is currently
defined by the American College of
Obstetricians and Gynecologists
(ACOG) as “adequate” when Mon-
tevideo units exceed 200 mm Hg.45 Early
descriptions by Caldeyro-Barcia et al46
suggested that the average uterine
contraction pressures achieved during
the final stages of the first and second
stage of labor can reach up to 250
Montevideo units, yet later studies found
that average Montevideo units during
the active phase of normal spontaneous
labors were even lower than those ob-
tained during induced labors.47 In a
study of 109 women undergoing induc-
tion or augmentation of labor, all of
whom ultimately delivered vaginally, it
was reported that 91% of induced
women and 77% of women receiving
oxytocin for augmentation achieved
>200 Montevideo units.48 It was subse-
quently reported that 92% of women
who underwent cesarean delivery for
arrest of labor in the active phase were
able to achieve greater Montevideo
units.49 Authors concluded that a
diagnosis of arrest of dilatation can
only be made in the presence of
uterine contractions with a minimum
of 200 Montevideo units >4 hours.
Some studies, however, dispute this
ajog.org
FIGURE 4
Contraction intensity measuring units
Adapted from Miller et al.42
Rosen. Assessment of uterine contractions in labor and delivery. Am J Obstet Gynecol 2022.
conclusion. Another study followed 501
women undergoing oxytocin augmen-
tation for active phase arrest or dystocia.
No difference in average Montevideo
units was found between women who
delivered vaginally and those who had a
cesarean delivery. Some women who
delivered vaginally never achieved a
contraction pattern of
200 Montevideo
units (43.9% nulliparous and 46.6%
multiparous women), and similar labor
patterns were observed in women
who ultimately underwent cesarean
delivery.50
When obese nulliparous women were
evaluated, only 47% of 2287 women who
had a successful vaginal delivery reached

200 Montevideo units.51 A prospec-
tive, randomized trial compared 2
groups of patients undergoing labor
induction assessed with IUPC with
respect to contractile power measure-
ment vs contraction frequency. The
study documented oxytocin titration
required to achieve either preset uterine
activity values (measured in kilopascals
in 15 minutes) or 6 to 7 contractions
every 15 minutes. There were no differ-
ences between the groups in terms of the
length of labor, mode of delivery, or
Apgar scores.52 A later study investigated
augmented labors and found no differ-
ence between the amount of oxytocin
required to achieve preset uterine activ-
ity levels and the amount necessary to
achieve a preset uterine contraction
frequency.52
The results of these findings suggest
that there are many causes behind the
arrest of dilatation and labor dystocia,
MONTH 2022 American Journal of Obstetrics & Gynecology
Expert Review
with inadequate uterine activity being
only one of these causes. Accordingly, in
the above-mentioned ACOG guideline,
it was cautioned that there is no
convincing proof that use of intrauterine
tocodynamometry results in a reduction
in cesarean delivery rates or improved
neonatal outcomes. IUPC may be useful
in cases where objective calculation of
contraction strength is desirable to help
determine the cause of protracted or
arrested labor, especially when contrac-
tion frequency is adequate. IUPC can
shorten the duration of obstructed labor
before decision for cesarean delivery is
made, with potential reductions in fetal
compromise and maternal risks of
infection or postpartum hemorrhage.
Excessive uterine activity is another
problem encountered in labor. The
Eunice Kennedy Shriver National Insti-
tute of Child Health and Human
Development (NICHD), ACOG, and
Society for Maternal-Fetal Medicine
adopted a standardized definition for
tachysystole as >5 contractions in a 10-
minute period, averaged over a 30-
minute window.53 There is a lack of a
sufficiently clear definition of hyper-
stimulation, which may be over-
simplified as any increase in uterine
activity associated with a fetal heart rate
change. Some definitions have also
involved increased baseline pressure,
insufficient relaxation between contrac-
tions, and prolonged isolated contrac-
tions. Tachysystole occurs in 10% to 50%
of all labors,54e58 and is more common
when labor is induced or augmented,
particularly with prostaglandins.54,58
The main concern associated with hy-
perstimulation is fetal compromise and
acidemia as a result of reduced blood
flow through the spiral arteries to the
placenta and fetus during uterine con-
tractions.59 Indeed, the duration of the
spiral artery compression depends on
the strength and the duration of the
contraction.60
Increased uterine activity, including
higher Montevideo units and increased
contraction frequency, has been associ-
ated with fetal acidemia, defined as
umbilical cord arterial pH <7.11.32
These findings have been supported by
another study observing an association
5
Expert Review ajog.org

in baseline. Five of the 13 studies docu-

TABLE 1 mented no changes in uterine activity or
Main recorded indications for cesarean delivery Montevideo units in uterine rupture
Prelabor cesarean Intrapartum cesarean cases. Thus, it was concluded that current
Indication delivery (%) delivery (%) data cannot provide evidence to support
Individual indicationsa the standard use of an IUPC in TOLAC.67
Previous uterine scar 45.1 8.2
Limitations and complications of
Failure to progress/cephalopelvic 2.0 47.1
disproportion intrauterine pressure catheter use
IUPCs are invasive and can only be used
Electiveb 26.4 11.7
after the amniotic sac has been ruptured,
Nonreassuring fetal testing/fetal 6.5 27.3 restricting its use to stages of labor after
distress membrane rupture and limiting its use in
Fetal malpresentation 17.1 7.5 any other scenario (eg, labor before
Hypertensive disorders 3.1 1.6 rupture or ripening of the cervix with
Fetal macrosomia 3.3 1.2
intact membranes). The invasive nature
of the procedure carries additional risks of
Multiple gestation 2.8 0.8 complications that occur at low rates such
Grouped indications (hierarchical, as infections, uterine perforation, fetal
mutually exclusive) injuries, and placental disruption.68e70
Clinically indicatedc 9.7 74.9 Known or suspected placenta previa or
Mixed d
80.7 23.0 vasa previa are contraindications to IUPC
e placement.
Truly elective 9.6 2.1
Extramembranous placement of
Total 100 100 IUPCs between the uterine wall and the
Adapted from Zhang et al.2 fetal membranes has been reported to
a
Women may have >1 indication. The total percentage may exceed 100%; b Indications for elective cesarean delivery include occur in approximately 14% to 38% of
“elective,” declining trial of labor, elderly gravida, multiparity, remote from term, postterm/postdate, diabetes mellitus,
chorioamnionitis, chronic or gestational hypertension without preeclampsia/eclampsia, premature rupture of the membranes, IUPC placements.70 Although extra-
human papillomavirus infection, group B streptococcusepositive, polyhydramnios, fetal demise, tubal ligation, and social/ membranous placement is rarely asso-
religious concerns; c Clinically indicated includes emergency, nonreassuring fetal heart rate tracing/fetal distress, failure to
progress, cephalopelvic disproportion, failed induction, failed forceps, failed vaginal birth after cesarean delivery, placental ciated with complications,68 some of
abruption, placenta previa, shoulder dystocia, and history of shoulder dystocia; d Mixed includes: previous uterine scar, them may be significant and require
breech/malpresentation, fetal anomalies, fetal macrosomia, HIV infection, multiple gestation, preeclampsia/eclampsia, and
other; e Truly elective: without any indication in the “clinically indicated” or “mixed” categories. emergency intervention. Uterine perfo-
Rosen. Assessment of uterine contractions in labor and delivery. Am J Obstet Gynecol 2022. ration is a rare complication occurring in
between 1 in 300 and 1 in 1400 cases.
Placental abruption, placental vessel
between uterine tachysystole and arterial intrauterine pressure or cessation of labor perforation, cord entanglement, endo-
cord pH <7.05.61 The NICHD noted the was not observed in any of the patients.62 metritis, and anaphylactoid syndrome
importance of qualifying tachysystole However, 2 case reports noted a stepwise are other adverse outcomes.70
with its associated fetal heart rate tracing. gradual decrease in uterine contraction Other rare reported complications
Therefore, IUPC may be useful in case amplitude preceding uterine rupture.65 A include placental abruption71 and am-
the accurate measurement of the onset caseecontrol study of women who un- niotic fluid embolism syndrome (also
and offset of a contraction provides a derwent TOLAC compared 9 cases of referred to as anaphylactoid syndrome of
superior means for determining the uterine rupture with 48 successful and 35 pregnancy) occurring immediately after
timing of fetal heart rate decelerations failed cases of vaginal birth after cesarean IUPC placement.69,72 IUPC insertion
when confronted with a potentially delivery followed with IUPCs with respect has been associated with colonization of
nonreassuring heart rate pattern. to the pattern of change of Montevideo the amniotic cavity with bacteria. In a
Because of its more accurate assess- units over time. No association between study of 30 consecutive labors, amniotic
ment of uterine activity, the IUPC may Montevideo units and uterine rupture fluid was collected from the IUPC
also be considered in the setting of a was noted.66 A systematic review exam- immediately after insertion and 1 hour
TOLAC when there is an increased risk of ining tocogram characteristics of uterine after insertion.73 Whereas the amniotic
uterine rupture. However, there is no ev- rupture included 13 studies with either fluid obtained at the time of insertion
idence suggesting that IUPC has a role in external or internal tocodynamometry,67 was sterile, 50% of patients had bacterial
diagnosing or reducing the risk of this and found that 3 tocogram characteris- colonization of the amniotic fluid 1 hour
significant complication.62e64 In a review tics were associated to varying extent later, and 36% developed postpartum
of 76 cases of uterine rupture, 39 of which with uterine rupture: hyperstimulation, fever, although there was no correlation
were monitored with an IUPC, loss of decrease of uterine activity, and increase between bacterial count and maternal

6 American Journal of Obstetrics & Gynecology MONTH 2022

ajog.org
fever. Data were not available on the
timing of rupture of membranes; there-
fore, it is unclear whether bacterial
colonization was caused by the insertion
of the IUPC or by membrane rupture. In
addition, IUPC use was associated with
an approximately 2-fold increase in the
risk of maternal fever before and after
delivery.38 However, in women under-
going cesarean delivery, internal IUPC
use did not place women at increased
risk of endometritis.74
Maternal fever and chorioamnionitis
have been examined as secondary out-
comes in studies that randomized
women to IUPC placement. One study
that randomized women diagnosed with
labor dystocia to either IUPC or external
tocography demonstrated no difference
in the use of antibiotics or clinical signs
of maternal or neonatal infection be-
tween groups.75
Another limitation of the IUPC con-
cerns its sensitivity and accuracy of
measuring uterine activity. During
quiescence, intrauterine tone is referred
to as the “resting uterine pressure” or
“baseline tone,” which comprises pressure
owing to the elastic recoil of the tissues,
and a hydrostatic component, which
varies with the depth below the upper
fluid level of the uterus. The contribution
of the hydrostatic component to the
overall intrauterine pressure varies from
0 when measured with the upper fluid
level of the uterus, to approximately 35
cm H2O (25.7 mm Hg, 3.43 kPa) if
measured at the lowest fluid level. Hence,
the baseline tone is not a single value but
rather varies according to the position of
the maternal posture referred to as “the
baseline problem.” Baseline is measured
supine, and is referred to the top of the
uterus if zeroed. For calibration purposes
the external transducer is initially placed
at the level of the symphysis pubis, and at
this fixed point the “baseline tone” is
registered. This uterine tone measure-
ment varies with maternal posture.
Comparison between external and
internal contraction monitoring
during labor
Comparison between external tocody-
namometry and the IUPC has been the
subject of a few investigations. One large,
randomized control trial evaluating in-
ternal vs external tocography during in-
duction and augmentation of labor
aimed to determine the effect of internal
tocodynamometry vs external moni-
toring on the rate of operative vaginal
and cesarean deliveries (the rates of
which are higher in the United States
than in the Netherlands, where the study
was conducted).75 Overall, 1456 women
with singleton cephalic term pregnan-
cies (the rates of which are higher in the
United States than in the Netherlands,
where the study was conducted) under-
went induction or augmentation of labor
with intravenous oxytocin and were
randomized to receive either IUPC or
external tocodynamometry. The authors
failed to demonstrate a decrease in
operative delivery with internal tocog-
raphy. There were also no differences
between the groups in the rate of anti-
biotic use, the time from randomization
to delivery, or rate of adverse neonatal
outcomes. There were no reported
complications with use of the IUPC, and
there were no neonatal or maternal
deaths. It is important to note, however,
that 12% of women randomized to
external monitoring received internal
monitoring because of either inability to
adequately monitor uterine activity us-
ing external tocodynamometry or sus-
pected arrest of dilation.
To better understand the effectiveness
of IUPC vs that of external tocography
when intravenous oxytocin is used to
induce or augment labor, a systematic
Cochrane review of 3 randomized trials
comparing internal with external toco-
dynamometry was conducted, including
1945 women undergoing induction or
augmentation of labor.76 There were no
reports of maternal or neonatal deaths in
any of the studies. Neonatal outcomes
(Apgar score <7 at 5 minutes, umbilical
artery pH <7.15, admission to the
neonatal intensive care unit, and >48
hours of hospitalization) did not differ
significantly between study groups.
There were no demonstrated increased
maternal or fetal complications with
IUPC vs external tocography. Risks of
invasive monitoring exist but should not
be overstated. In addition, there were no
significant differences between study
MONTH 2022 American Journal of Obstetrics & Gynecology
Expert Review
groups in the number of instrumental or
cesarean deliveries, the use of analgesia,
and time to delivery. Furthermore,
women in whom an intrauterine cath-
eter was placed had no increased risk of
infection. It was concluded that internal
tocodynamometry did not improve any
maternal or neonatal outcomes.74
Because external tocography correlates
well with internal tocography with
respect to frequency, and IUPC use may
be associated with complications, as
detailed above, ACOG does not recom-
mend routine use of IUPCs,77 but rather
suggests that they should be considered
only in select clinical situations.
Electrical uterine monitoring
Electromyography (EMG) of uterine
muscle activity is a monitoring tech-
nique that relies on the detection and
recording of bioelectrical signals pro-
duced by the contracting uterus in a
similar manner to other better-
recognized techniques such as
electrocardiography and electroence
phalography.
Electrical activity of the uterine mus-
cle was first recorded over half a century
ago.78 Early animal studies showed that
propagation of myometrial electrical
activity is facilitated by gap junctions,
which increase in number before the
onset of labor. These studies were then
followed by noninvasive recordings of
uterine EMG signals from the abdom-
inal surface in human participants. The
recordings provided convincing evi-
dence that uterine EMG activity tracing
or EUM can be elucidated from nonin-
vasive transabdominal surface measure-
ments evaluating uterine contractions
during pregnancy, labor, and delivery.
Some technical challenges were met
initially, such as the need to filter other
bioelectrical signals, for instance from
maternal electrocardiogram (ECG),
respiration, movement artifacts, and
skin impedance.79,80 In more recent
years, technological advancements have
overcome these limitations.
Different studies have used various
devices to measure EUM, or as it is
frequently termed, “hysterography.”
Nevertheless, no standardized form of
electrode placement for recording EUM
7
Expert Review ajog.org

has been established. Although some within 48 hours. EUM measurements of IUPC in 47 women during active
studies show that this placement is correlated strongly with the strength of labor.86 All women were monitored
possible either in a monopolar or bipolar contractions, suggesting they may be a simultaneously with IUPC and EUM.
configuration,81e83 the latter was shown valuable alternative to invasive mea- The correlation of the frequency, in-
to be more stable and less prone to noise surement of intrauterine pressure tensity, and tone of contractions be-
or interference.84 Other studies used a 9- and preferable to tocodynamometry. tween uterine EUM and IUPC was
or 16-electrode configuration to estab- Another study compared frequency and significant, suggesting that EUM yields
lish the spatial distribution of the largest timing of uterine contractions through information about uterine contractility
surface of the maternal abdomen.85,86 simultaneous monitoring of 53 laboring close to that obtained with IUPC
The bioengineering details of EUM women with external tocodynamometry, (Figure 5).
signal processing and analysis are EUM, and IUPC during labor.30 A A prospective observational study
beyond the scope of this review and are Contractions Consistency Index (CCI) attempted to validate EUM as a method
described elsewhere.87 was defined to allow comparison of for uterine activity monitoring during
Throughout most of pregnancy, the EUM and tocodynamometry with IUPC labor by comparing EUM with IUP re-
uterus is in a quiescent state, and there is measurements. CCI represents the cordings in 32 laboring women.89 EUM
only low uterine electrical activity con- number of consistent contractions detected uterine contractions accurately,
sisting of infrequent and low-amplitude divided by the average of those detected although the correlation of contraction
EMG bursts.3 When bursts occur before by either IUPC or EMG as the gold duration and amplitude between the 2
the onset of labor, they often correspond to standard, where the method is more methods was weak.
periods of perceived contractility by the accurate when CCI is closer to 1. The The results of these studies suggest
patient. During term and preterm labor, mean CCI for EUM was 0.880.17 vs that EUM is a sensitive method for
bursts of EMG activity are frequent, of 0.690.27 for tocodynamometry improving external uterine monitoring
large amplitude, and correlated with the (P<.0001) (Table 2). In contrast to throughout term labor for both non-
large changes in intrauterine pressure and tocodynamometry, EUM was not obese and obese women. EUM allows
pain sensation.3 significantly affected by obesity, leading the assessment of intensity of uterine
to the conclusion that EUM provides a contractions in clinical settings where
Electrical uterine activity monitoring reliable noninvasive alternative, regard- IUPC is contraindicated or when mem-
compared with intrauterine pressure less of body habitus. branes are intact. However, unlike IUPC,
catheter and external monitoring Another study was designed to EUM may provide some readings of false
Similar to IUPC, EUM enables evalua- determine the accuracy of EUM vs that positive contractions.
tion of the initiation, time to peak,
duration frequency, and intensity of
uterine contractions.86 Because it is
noninvasive and does not require TABLE 2
ruptured membranes, in contrast to the Comparison of operating characteristics for contraction detection
IUPC, it can be used as a diagnostic tool between electrohysterography and intrauterine pressure catheter and
both antepartum and intrapartum in tocography and intrauterine pressure catheter (n[59)
term and preterm pregnancies. Impor- Tocography
tant to note that it carries a warning of EHG vs IUPC vs IUPC Difference
false-positive contraction readings. Variable Mean SD Mean SD Mean SD P value
To validate that EUM is a reliable Consistent contractions 33.8 19.4 23.5 16.2 10.4 16.3 <.0001
method for evaluating uterine contrac-
CCI 0.88 0.17 0.69 0.27 0.19 0.33 <.0001
tile activity, studies have compared EUM
with IUPC by translating EUM data into CCI <0.75% 16.7 26.7 46.1 34.0 29.4 44.2 .0001
an “intrauterine pressureeestimated” Correlation 0.62 0.24 0.38 0.28 0.25 0.35 <.0001
waveform.88 Maul et al33 investigated
Positive predictive value 0.89 0.14 0.86 0.19 0.03 0.24 .37
whether the strength of uterine con-
tractions monitored by IUPC could be Sensitivity 0.89 0.20 0.62 0.29 0.27 0.37 <.0001
determined from transabdominal EMG. CCI calculated as:
Nc
They found that EUM correlated CCI ¼
1
ðNT þ NE Þ
strongly with intrauterine pressure and 2
NT is the number of contractions detected by IUPC, NE is the number detected in the EHG or tocographic signal, and NC is the
that EUM burst energy levels were number of consistent contractions.
significantly higher in patients who Adapted from Euliano et al.30
delivered within 48 hours than in those CCI, Contractions Consistency Index; EHG, electrohysterography; IUPC, intrauterine pressure catheter; SD, standard deviation.
who did not. Moreover, burst energy Rosen. Assessment of uterine contractions in labor and delivery. Am J Obstet Gynecol 2022.
levels were highly predictive of delivery

8 American Journal of Obstetrics & Gynecology MONTH 2022

ajog.org Expert Review

FIGURE 5
Simultaneous recordings of uterine contractions using 2 separate methods

Bottom: standard IUPC recording; top: simultaneous EUM measurement. (Orange dot) on bottom tracing represents the point in time reflected on the top
EUM graph. A, Uterine quiescence; although baseline uterine pressure is measured by IUPC, no electrical uterine activity is recorded simultaneously. B,
Uterine contraction; in parallel with peak intrauterine pressure, peak electrical myometrial electrical activity is recorded. IUPC records pressure of a
solitary point inside the uterus, whereas EUM measures numerous points on the uterine surface, allowing evaluation of progression of the contraction
wave.
EUM, electrical uterine monitoring; IUPC, intrauterine pressure catheter.
Rosen. Assessment of uterine contractions in labor and delivery. Am J Obstet Gynecol 2022.

MONTH 2022 American Journal of Obstetrics & Gynecology 9

Expert Review
Assessment of labor progression by
electrical uterine activity monitoring
A prospective double-blind study eval-
uated EUM in 63 active laboring women.
The control group consisted of 26 pa-
tients with normal labor progression,
and the study group included 37 patients
with abnormal labors.90 Analysis of pa-
tients with labor abnormalities in the
active phase revealed that the electrical
uterine activity increased after the
administration of oxytocin and during
the active phase in spontaneous labor.
Analysis of the electrical uterine activity
of patients in spontaneous labor vs those
receiving oxytocin augmentation was
similar, suggesting that comparable
electrical uterine activity occurs in
spontaneous and augmented labor.
In an attempt to assess the effect of
amniotomy on uterine electrical activity,
EUM was prospectively measured in 23
women with singleton pregnancies at
term in the active phase of labor.91 EUM
was continuously measured at least 30
minutes before and at least 30 minutes
following performance of amniotomy.
There was a significant increase in mean
EUM measurement after artificial
rupture of the membranes compared
with when the membranes were intact
(3.590.39 vs 3.420.47 mWs; P<.001),
confirming that amniotomy augments
uterine activity.
In a prospective study,92 electrical
uterine activity was measured in women
with singleton term gestations undergo-
ing labor augmentation by oxytocin
administration. Measurements begun 30
minutes before oxytocin infusion initia-
tion and continued until 4 contractions
per 10 minutes were achieved. The delta
EUM index was defined as the difference
between the mean EUM index (mean
electrical activity in 10-minute intervals
in microjoule) before and after the initi-
ation of oxytocin. It was found that uter-
ine electrical activity as evaluated by EUM
is significantly intensified following
oxytocin administration, regardless of
obstetrical characteristics, although no
correlation was observed between the
delta EUM index and time to delivery or
the mean EUM index during oxytocin
administration and time to delivery.
10 American Journal of Obstetrics & Gynecology MONTH 2022
Electrical uterine activity monitoring
during the third stage of labor
The third stage of labor is defined as the
time interval from delivery of the fetus
to the expulsion of the placenta and
membranes. EUM was prospectively
measured during the third stage of la-
bor and compared with that observed
in the second stage of labor.93 Signifi-
cant uterine activity was identified
during the third stage, and contraction
peaks were similar to those observed
during the second stage of labor
(3.430.64 vs 3.420.57 mWs; P¼.8).
No correlation was found between the
duration of the third-stage length and
EUM measurements during the third
or second stage of labor.
Electrical uterine activity monitoring
and labor induction
Assessment of uterine activity during
induction of labor allows the determi-
nation of uterine response to cervical
ripening and uterotonic agents and the
detection of uterine tachysystole. The
effect of prostaglandin E2 (PGE2) on
electrical uterine activity was studied in
patients undergoing induction of la-
bor94; 31 women were monitored before
and up to 12 hours after vaginal PGE2
application. The EUM index was not
increased significantly during the first 2
hours following PGE2 application. Peak
EUM activity was observed 2 to 8 hours
after PGE2 application.
Electrical uterine activity monitoring
in obese patients
Traditional noninvasive methods of
measuring uterine activity are limited in
obese women. One study compared
EUM with traditional tocodynamometry
and the IUPC in 25 obese (median body
mass index, 39.6) laboring women.95
Tocodynamometry identified 248 con-
tractions vs the 336 identified by EMG,
whereas IUPC monitoring identified 319
contractions vs the 342 identified by
EMG. These results suggest that in obese
women, EUM is as effective as invasive
IUPC measurement of uterine activity,
and that both are superior to tocodyna-
mometry. Therefore, consideration
should be given to EUM in these patients
ajog.org
because in addition to its accuracy, it
does not carry the previously mentioned
risks associated with IUPC placement.
Another study evaluated the influence
of maternal obesity on the performance
of external tocodynamometry vs EUM
during labor at term.96 Uterine con-
tractions were simultaneously measured
by EUM, external tocodynamometry,
and IUPC in 14 morbidly obese, 18
obese, and 20 nonobese women. Data
were compared among these groups. In
contrast to external tocodynamometry,
the sensitivity of EUM was not affected
by the degree of obesity, further sup-
porting a role for EUM in obese patients.
Limitations of electrical uterine
monitoring
Despite the mentioned advantages, there
are some limitations to the use of EUM.
The accuracy of EUM signal transmission
can be affected by the relative conductiv-
ity of tissue layers through which the
signal must be transmitted. Furthermore,
the quality of the signal can be affected by
interference from other signals, such as
the skeletal muscle electromyogram,
maternal ECG, and movement arti-
facts.40,97 The signal can even be lost,
which is a major problem of using EUM.
Cost is also a significant limitation. The
introduction of new technology into
already equipped and trained birthing
units demands capital investment in ma-
terial and training resources. In addition,
the use of EUM results in a substantial rate
of false-positives, and efforts need to be
undertaken to decrease this rate. Current
US Food and Drug Administration
clearances for ECG/EMG fetal monitors
are only for term pregnancies. In the past
years, there were no EUM devices that are
commercially available for clinical use.
Recently, the Monica device has been
made available for clinical use in the
United States, and the device of OBMed-
ical, which was acquired by Philips, may
be brought soon.
Summary
The monitoring of uterine activity is a
routine component of modern ante-
partum and intrapartum obstetrical care.
In the United States, fetal monitoring is
ajog.org
not thought to improve outcomes beyond
intermittent manual monitoring, but
nonetheless remains a mainstay of
obstetrical care. There are a few methods
for monitoring uterine activity that are
currently in clinical use, and each method
is associated with inherent advantages
and disadvantages, and limitations in
select clinical settings. External tocog-
raphy, although lacking the ability to
assess contraction intensity, remains the
mainstay of routine obstetrical care
because it is easy to use, relatively inex-
pensive, noninvasive, and provides
important information regarding the
presence, regularity, and duration of
contractions, all while maintaining a low
risk of complications. Although the IUPC
provides more accurate information
regarding contraction intensity and basal
uterine tone, there is insufficient evidence
for the routine use of IUPC in terms of
improving outcomes, including neonatal
outcomes, rates of instrumental de-
liveries, use of analgesia, cesarean delivery
rates, or time to delivery. The use of IUPC
is associated with certain risks and limi-
tations, namely the risk of infection and
uterine perforation, and the need for
ruptured membranes. In addition, there
is lack of evidence for IUPC superiority
relative to other methods, which limits its
use to specific clinical settings such as
oxytocin titration in cases of labor
dystocia with ruptured membranes. EUM
may be a promising technology that can
overcome the aforementioned challenges.
In addition to being noninvasive, EUM
provides an accurate assessment of
contraction intensity, and is not associ-
ated with the risks, limitations, and con-
traindications that accompany the use of
the IUPC. EUM has yet to be incorpo-
rated into clinical practice because of lack
of access to this technology, its high cost,
and the need for appropriate training of
clinical staff. Further research is needed to
elucidate the precise physiological process
of normal and abnormal term and pre-
term labor progression and their corre-
lation with uterine activity. - Young RC. Why the heart is like an orchestra and
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