ABNORMAL UTERINE CONTRACTION

INTRODUCTION

 Normal labor characterized by coordinated uterine contractions associated with

progressive dilatation of the cervix and descent of the fetal head.
 Normal labor is associated with cervical dilatation more than or equal to 1 cm/hr in a
nulliparous woman and 1.5 cm/hr for a multiparous woman. This results in successful
vaginal delivery.
 Overall labor abnormalities occur in about 25% of the nulliparous women and 10% of
multiparous women.
 Abnormal active phase of labor may be protraction or arrest disorder.
 The most common cause of protraction disorder is inadequate or abnormal uterine
contractions. Any deviation of the normal pattern of uterine contractions affecting the
course of labor is designated as disordered or abnormal uterine action.

1
ETIOLOGY:

As the physiology of normal uterine contraction is not fully understood, the cause of its
disordered action remains obscure. However, the following clinical conditions are often
associated:

(1) Prevalent in first birth, especially with elderly women

(2) Prolonged pregnancy

(3) Over distension of the uterus (twins and fibroids)

(4) Emotional factor (anxiety, stress)

(5) Constitutional factor (obesity)

(6) Contracted pelvis and malpresentation

(7) Injudicious administration of sedatives, analgesics and oxytocic

(8) Premature attempt at vaginal delivery (induction of labor or ARM) or attempted

instrumental vaginal delivery under light anaesthesia.

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 coordinated
fashion.

The properties of a normal uterine contraction wave are:

(i) The intensity of contraction diminishes from top to bottom of the uterus
(ii) The contraction wave starts from the pacemaker and propagates towards the lower
uterine segment
(iii) The duration of contraction diminishes progressively as the wave moves away from the
pacemaker. In dysfunctional labor, new pacemakers may come up anywhere in the
uterus.
The uterine pacemaker is situated at the cornua of the uterus and this generates uterine
contractions. Effective uterine contraction, starts at the cornua and gradually sweeps
downwards over the uterus.

2
In a primary dysfunctional labor, 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 effective
uterine contractions. Primary dysfunctional labor is defined when the cervix dilates less than
1 cm/hr following a normal latent phase of labor. It is the most common abnormality and
mostly corrected by amnioromy and/or oxytocin augmentation.
Secondary arrest is defined when the cervical dilatation stops after the active phase of labor
has started normally. Secondary arrest of dilatation may be due to
(a) Poor uterine contractions (myometrium fatigue),
(b) Cessation of cervical dilatation despite strong uterine contractions (mechanical factors
like disproportion and malpresentation). Uterine activity (contraction) is measured by noting
(i) Basal tone
(ii) Active (peak) pressure and
(iv) Frequency.

Assessment is usually done by—

(i) Clinical palpation—(inaccurate),

(ii) Tocodynamometer with external transducer,
(iii) Intrauterine pressure catheter (IUPC) is used to measure intrauterine pressure during
uterine contractions. Normal baseline tonus is between 5 mm Hg and 20 mm Hg.
(iv) Minimum uterine pressure required to dilate the cervix is 15 mm Hg over the baseline.
Normal uterine contractions in labor create an intrauterine pressure up to 60 mm Hg.
(v) Oxytocin is to be used when uterine contractions are inadequate. Oxytocin dose is to be
escalated till the optimum uterine contractions (3–4 per 10 minutes) with a peak
intrauterine pressure of 50–60 mm Hg and a resting tone of 10–15 mm Hg is obtained

UTERINE INERTIA (HYPOTONIC UTERINE DYSFUNCTION)

Uterine inertia is the common type of abnormal uterine contraction but is comparatively less
serious. It may complicate any stage of labor. It may be present from the beginning of labor
or may develop subsequently after a variable period of effective contractions.

3
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 labor is maintained but intrauterine pressure during contraction is less than 25
mm Hg.

Normal and abnormal patterns of uterine contract ones (dark shade indicate ng strong
contract on)— (A) Normal uterine contract ones with single dominant pacemaker focus; (B)
Uterus with three separate pacemakers fi ring sequent ally; (C) Normal uterine contract on;
(D) Uterine inert a; (E) Colicky uterus; (F) Spast c lower segment; (G) Asymmetrical contract
on; (H) Cervical dystocia

DIAGNOSIS:

(1) Patient feels less pain during uterine contraction

(2) Hand placed over the uterus during uterine contraction reveals less hardening of the uterus
(3) uterine wall is easily indentable at the acme of a pain
(4) Uterus becomes relaxed after the contraction, fetal parts are well palpable and fetal heart
rate remains normal
(5) Internal examination reveals
(a) Poor dilatation of the cervix (normal rate of dilatation in Primigravida should be at the
rate of 1 cm/hr beyond 4 cm dilatation)
(b) Presence of cephalopelvic disproportion, malposition, deflexed head or
malpresentation may be evident
(c) Membranes usually remain intact.

4
EFFECTS ON THE MOTHER AND FETUS: Maternal exhaustion and/or fetal distress
are unusual and appear late.

MANAGEMENT:
Case is reassessed to exclude cephalopelvic disproportion or malpresentation. Place of
caesarean section:
(1) Presence of contracted pelvis
(2) Malpresentation
(3) Evidences of fetal or maternal distress. Vaginal delivery
(A) General measures:

(1) To keep up the morale of the patient. Maternal stress, pain and anxiety appear to inhibit
uterine contractions through release of endogenous catecholamines.

(2) Posture of the woman is changed. Supine position is avoided.

(3) To empty the bladder, catheterization is made.

(4) To maintain hydration by infusion of Ringer’s solution.

(5) Adequate pain relief.

(B) Active measures:

Acceleration of uterine contraction can be brought about by low rupture of the membranes
followed by oxytocin drip. The drip rate is gradually increased until effective contractions are
set up (see Chapter 35). The drip is to be continued till 1 hour after delivery

INCOORDINATE UTERINE ACTION

It usually appears in active stage of labor. The hypertonic state of the uterus arises from any
of the conditions such as spastic lower uterine segment, colicky uterus, asymmetrical uterine
contraction, constriction ring or generalized tonic contraction of the uterus and all these states
are collectively called in coordinate uterine action. Increased frequency and/or duration of
uterine contractions cause rise in baseline tone and thereby diminish circulation in the
placental intervillous space. These contractions fail to make progressive cervical effacement
and dilatation. Frequent contraction of low amplitude causes elevation of basal intrauterine
pressure. There is often maternal discomfort. Aminotomy with or without oxytocin
augmentation is usually done when the women in the active phase of labor. Conservative

5
management is done if it occurs in the latent phase. Uterine tonus is elevated. Pain is present
before, during and after contractions. This result in fetal hypoxia in labor.Placental abruption
is often associated with high baseline tone (> 25 mm Hg). On CTG the FHR shows reduced
variability and late decelerations (Figs 25.2B and C). Uterine hyperstimulation due to
oxytocics (oxytocin, prostaglandins) are often associated with fetal tachycardia (fetal
adrenergic activity) due to fetal stress. Constriction ring, generalized tonic uterine contraction
and cervical dystocia have got their own separate clinical entity and as such will be discussed
separately.

SPASTIC LOWER SEGMENT — UTERINE CONTRACTION:

(1) Fundal dominance is lacking and often there is reversed polarity

(2) The pacemakers do not work in rhythm

(3) The lower segment contractions are stronger

(4) Inadequate relaxation in between contractions

(5) Basal tone is raised above the critical level of 20 mm Hg.

Diagnosis:

(1) The patient is in agony with unbearable pain referred to the back. There are evidences of
dehydration and ketoacidosis

(2) Bladder is frequently distended and often there is retention of urine; distension of the
stomach and bowels are visible

(3) There are premature attempts to bear down

(4) Abdominal palpation reveals

(a) Uterus is tender and gentle manipulation excites hardening of the uterus with pain,

(b) Palpation of the fetal parts is difficult,

(5) Fetal distress appears early

(6) Internal examination may reveal

6
(a) Cervix which is thick, oedematous hangs loosely like a curtain; not well applied to the
presenting part,

(b) Inappropriate dilatation of the cervix,

(c) Absence of the membranes,

(d) Meconium stained liquor amnii may be there. Effect on the fetus: Fetal distress appears
early due to placental insufficiency caused by inadequate relaxation of the uterus.
Management:

There is no place of oxytocin augmentation with this abnormality. Cesarean section is done in
majority of cases. Prior correction of dehydration and ketoacidosis must be achieved by rapid
infusion of Ringer’s solution.

CONSTRICTION RING (Syn: Contraction ring, Schroeder’s ring): It is one form of in

coordinate uterine action where there is localized myometrium 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 a constricted part of the fetus usually around the neck in cephalic
presentation.

It may appear in all the stages of labor. It is usually reversible and complete. The common
causes are:

(1) Injudicious administration of oxytocine.

(2) Premature rupture of the membranes, and

(3) Premature attempt at instrumental delivery.

7
Diagnosis:

Diagnosis is difficult. It is revealed during caesarean section in the first stage, during forceps
application in the second stage and 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 the hypertonic state. Uterus never ruptures. Treatment:
Delivery is usually done by caesarean section. The ring usually passes off by deepening the
plane of anaesthesia otherwise the ring may have to be cut vertically to deliver the baby. The
difficulties faced during forceps delivery (second stage) or during normal removal of placenta
(third stage) can be overcome by using deep anaesthesia that relaxes the constriction ring.
CERVICAL DYSTOCIA:

Progressive cervical dilatation needs an effective stretching force by the presenting part.
Failure of cervical dilatation may be due to—

(a) Inefficient uterine contractions

(b) Malpresentation, malposition (abnormal relationship between the cervix and the
presenting part)

(c) Spasm (contractions) of the cervix. Cervical dystocia may be primary or secondary.
Primary: Commonly observed during the

(i) First birth where the external os fails to dilate,

(ii) Rigid cervix,

(iii) Inefficient uterine contractions and the others (as mentioned earlier). Treatment: In
presence of associated complications (malpresentation, 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 contraction or traction is given by Ventouse.

In others, where the cervix is very much thinned out but only half dilated. Dührssen’s
incision at 2 and 10’O clock positions followed by forceps or Ventouse extraction is quite
safe and effective.

8
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: (i) Post-delivery (ii) Postoperative scarring (iii) Cervical cancer. GENERALIZED
TONIC CONTRACTION (Syn: Uterine tetany):

In this condition, pronounced retraction occurs involving whole of the uterus up to the level
of internal os. Thus, there is no physiological differentiation of the active upper segment and
the passive lower segment of the uterus. The whole uterus undergoes a sort of tonic muscular
spasm holding the fetus inside (active retention of the fetus). Usually there is no risk of
rupture uterus. New pacemakers appear all over the uterus.

Causes:

(i) Cephalopelvic disproportion

(ii) Obstruction
(iii) Injudicious use of oxytocic.

Clinical features:

o The patient is in prolonged labor having severe and continuous pain. Abdominal
examination reveals 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 

Antibiotic—to control infection  adequate pain relief. Hyper contractility
(tachysystole) may be induced by oxytocics (>5 contractions in 10 min).
 It may occur in spontaneous or with stimulated labor. Persistent tachysystole with
FHR abnormality can cause fetal hypoxia. It can be managed by tocolytics
(Terbutaline 0.25 mg SC). Oxytocin infusion should be stopped. Caesarean delivery is
done in majority of the cases, especially when obstruction is suspected.

9
REFERENCES

1. M.Modi, study book “Midwifery Nursing”, first edition: 2020, published by Amrutam
publisher, Ahmadabad, pp- 514-516.
2. M. Fraser, A.Cooper “MYLES text book for Midwives” 15th edition, publisher
ELSEVIER,pp-681-685
3. Mudaliar and Menon’s “Clinical Obstetrics” 11th edition, published by Universities
Press private,limited.pp-672-674.
4. D.C.Dutta, “obstetrics textbook”,4 the edition, jaypee published by Univesity
Press,pp-578-581
5. W.Lippincott & Wilkins “Maternal Neonate Nusing” 2nd edition, published by
Univesity Press,pp- 448-450
6. J.Annamma, A Comprehensive textbook of midwifery and Gynecological
Nursing,Jaypee brothers 3rd edition.534-536
7. Dawn C.S., Textbook obstretician and neonatology,Dawn books, 16th edition.563-564.

10