INCO-ORDINATE UTERINE

ACTION:

 It is a type of abnormal uterine action in which the

two poles of the uterus do not function rhythmically
i.e. there is in co-ordination between the two poles.

 It is a state of uterine dysfunction in which the

contractions are usually strong, painful and/or may
be frequent but cervix dilates slowly.

 It usually appears in active stage of labour.

3) Inco-ordinate uterine action
 Spastic lower segment
 Colicky uterus
 Asymmetry uterine contraction
 Constriction ring
 Generalized tonic contraction
 Cervical dystocia
 Clinical feature
Labor is prolonged.
Uterine contractions are irregular and more
painful.
The pain is felt before and throughout the
contractions with marked low backache often in
occipito-posterior position.
 Slow cervical dilatation .
Premature rupture of membranes.
 Fetal and maternal distress.
 Management
• CPD- C/S
•Vital monitoring
• I/V therapy
• I/O charting
• Analgesic and antispasmodic
• FSH every 15 min
• Partograph
• Fetal distress-C/S
 SPASTIC LOWER SEGMENT:

 This is a common type of abnormal uterine action

in the primigravida.

 The pain comprises mainly severe backache,

intensified during contractions

 The cervix is thick edematous and is poorly

applied to the presenting part.
 There is reversal of uterine action, increased tone
in lower uterine segment and weakly acting upper
uterine segment.

 Fundal dominance is lacking and often there is

reversed polarity.

 Inadequate relaxation in between contractions.

 CLINICAL FEATURES:

 The patient with unbearable pain referred to the

back.

 There are evidences of dehydration and keto

acidosis.

 Bladder is frequently distended and often there is

retention of urine; distension of the stomach and
bowels are visible.

 There are premature attempts to bear down.

 Abdominal palpation reveals:

 Uterus is tender and gentle manipulation

excites hardening of uterus with pain which
precedes and out lasts the uterine contraction.

 Uterus remains tense and tender even after the

contraction passes off.

 Palpation of the fetal parts is difficult.

 Fetal distress appears early.

 vaginal examination may reveal:

 Cervix which is thick, oedematous, hangs

loosely like a curtain, not well applied to the
presenting part.

 Inappropriate dilatation of the cervix.

 Absence of membranes.

 Varying degree of caput.

 Meconium stained liquor amnii.

 Effect on fetus
• Fetal distress appears early due to placental
insufficiency caused by inadequate relaxation
of the uterus.
 MANAGEMENT:

 Careful watch of fetal condition.

 Caesarean section is done in majority of cases.

 Prior correction of dehydration and ketoacidosis

must be achieved by rapid infusion of Ringer’s
solution with adequate pain relief.

 There is no place of oxytocin augmentation.

 COLICKY UTERUS:

 In colicky uterus various parts of uterus contract

independently with feeling of pain at fundus and
lower segment.

 There is lack of polarity and uterus contracts

strongly.

 The contractions are very painful and felt

predominantly in the hypogastrium region.
 The uterus has high resting tone, is irritable
and tender.

 The cervix is thick, unaffected and poorly

applied to the presenting part.
 CONSTRICTION RING, (contraction
ring/schroeder’s ring):

 It is one form of in co-ordinate uterine action

where there is localized spastic constriction of a
ring of circular muscle fibers 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 stages of labour.

 It is usually reversible and complete.

 The constriction ring usually results from

abnormal uterine activity, which usually are
not effective to dilate cervix, or cause
rupture of uterus.
 CAUSES:

 Injudicious use of oxytocics.

 Premature application of instrumental delivery.

 Premature rupture of membranes.

 DIAGNOSIS:

 Diagnosis is difficult.

 Constriction ring is suspected when descent of

fetus is arrested for no obvious reason.

 The ring is not palpable per abdomen.

 Maternal condition is not much affected but the

fetus is in jeopardy because of hypertonic state.
 It is revealed during:

 Caesarean section in first stage.

 During forceps application in second stage.

 Manual removal in third stage (hour glass

formation)
 MANAGEMENT:

Management is based on the stage of labour at

which diagnosis is made:

 First stage: The diagnosis is made during

caesarean section after opening the uterine cavity.
The ring may have to be cut vertically to deliver
the baby.
 Second stage: Failure to deliver head even after
correct and judicious application of forceps
suspicious of constriction ring. The confirmation
is made by palpating the ring after removing the
forceps blade.

 Third stage: The diagnosis is made during

attempted manual removal. Deepening the plane
anesthesia is usually effective.
Management

• Exclude malpresentations ,malposition and disproportion.

• In the 1st stage:Pethidine, morphine maybe of beneficial .
• In the 2nd stage: Deep general anesthesia and amyl nitrite
inhalation are given to relax the constriction ring:
If the ring is relaxed, the fetus is delivered
immediately by forceps.
 If the ring does not relax, caesarean section is carried out with
lower segment vertical incision to divide the ring.
• In the 3rd stage: Deep general anesthesia and amyl nitrite
inhalation are given followed by manual removal of the placenta
 GENERALIZED TONIC
CONTRACTION(UTERINE TETANY):

 It is the condition in which there is pronounced retraction

involving whole of the uterus up to the level of internal
os resulting in no physiological differentiation of active
upper segment and passive lower segment of the uterus.

 The uterine contraction ceases and the whole uterus

undergoes a sort of tonic muscular spasm holding the
fetus inside.

 New pacemakers appear all over the uterus.

 CAUSES:

 Failure to overcome the obstruction by powerful

contractions of the uterus.

 Irritation caused by repeated unsuccessful attempt

at assisted delivery.

 Injudicious administration of oxytocics.

 CLINICAL FEATURES:

 Prolonged labour with continuous and severe

pain.

 Evidences of dehydration and ketoacidosis.

 Abdominal palpation reveals somewhat small

sized uterus which is also tense and tender.
 Fetal parts are neither well defined nor is FHS
audible.

 Per vagina reveals jammed head with big caput

formation, dry and edematous vagina.
 MANAGEMENT:

 Adequate pain relief.

 Correction of dehydration and ketoacidosis by

rapid infusion of Ringer’s solution.

 Antibiotic administration as per need.

 Oxytocin infusion is stopped and hyper
contractility induced by oxytocics can be
managed by tocolytic administration.

 Caesarean delivery is done in majority of the

cases where the obstruction is suspected.
 CERVICAL DYSTOCIA:

 The rigid cervix is the condition in which the

cervix fails to dilate may be due to
 Inefficient uterine contraction
 Malpresentation, Malposition
 Spasm of the cervix

 Progressive cervical dilatation needs an effective

stretching force by presenting part.
Cervical dystocia may be:

 Primary cervical dystocia

 Secondary cervical dystocia
Primary cervical dystocia:
 It is commonly observed during the first birth
where the external os fails to dilate, rigid cervix
due to ineffective uterine contraction.

 The non dilatation may be due to the presence of

excessive fibrous tissue or spasm of circular
muscles firms surrounding the os.
b. Secondary cervical dystocia:

 This type of cervical dystocia results usually due

to excess scarring or rigidity of cervix from the
effect of previous operation or disease.

 The cervix does not dilate due to previous

obstetric injury or gynecological operation such
as amputation of the cervix.
 MANAGEMENT:

 In the presence of associated complications as

malpresentation and malposition, caesarean
delivery is performed
 Monitor mother’s pulse, blood pressure,
hydration and ketosis.
 Monitor FHS , meconium, continuous fetal
monitoring.
 If the head is sufficiently low down with only
thin rim of cervix left behind, the rim is
pushed up manually during contraction or
traction is given by ventouse.

 If the cervix is thinned with half dilatation

ventouse extraction is quite safe and effective.
 DIFFERENCE BETWEEN CONSTRICTION RING AND
RETRACTION RING:
CONSTRICTION RING RETRACTION RING
NATURE It is manifestation of localized in It is an end result of tonic uterine
co-ordinate uterine contraction. contraction and retraction.

CAUSE Undue irritability of the uterus. Following obstructed labour.

SITUATI Usually at the junction of upper Always situated at the junction of

ON and lower segment but may upper and lower segment. The
occur in other places. The position progressively moves
position does not alter. upwards.

UTERUS Upper segment contracts and Upper segment is tonically

retracts with relaxation in contracted with no relaxation.
between; lower segment remains The wall becomes thicker; lower
thick and loose. segment becomes distended and
thinned out.
 CONSTRICTION RETRACTION RING
RING
MATERNAL Almost unaffected unless Features of maternal exhaustion,
CONDITION the labour is prolonged. sepsis appear early.

ABDOMINAL a. Uterus feels normal and a. Uterus is tense and tender.

EXAMINATIO not tender. b. Not easily felt.
b. Fetal parts are easily c. Ring is felt as a groove felt
N felt. obliquely.
c. Ring is not felt. d. Taut and tender round
d. Round ligament is not ligaments are felt.
felt e. Usually absent.
e. FHS is usually present.

VAGINAL a. The lower segment is a. Lower segment is very much

EXAMINATIO not pressed by the pressed by the forcibly driven
presenting part. presenting part.
N b. Ring is felt usually b. Ring cannot be felt vaginally.
above the head. c. Features are present.
c. Features of obstructed
labour are absent.
 CONSTRICTION RETRACTION RING
RING
END RESULT a. Maternal a. Maternal exhaustion
exhaustion is a late and sepsis appear early.
feature. b. Fetal anoxia and even
b. Fetal anoxia death are usually early.
usually appear late. c. Rupture uterus in
c. Chance of uterine multigravidae is
rupture is absent. common.
PRINCIPLE OF To relax the ring To relieve the obstruction
TREATMENT followed by delivery by safe procedure after
of the baby or to cut excluding rupture uterus.
the ring during
caesarean section.
REFERENCES:

 D.C. Dutta, “Text Book of Obstetrics(2004)”, 6 th

edition, New Central Book Agency (P) LTD, Pg.
no. 357 – 364
 Durga Subedi, Saraswoti Gautam, “Midwifery
Nursing Part II (2010),” 1st edition, Medhavi
Publication, Kathmandu, Pg. no. 195 – 202
 Roshani Tuitui, “Manual of Midwifery
II(Intrapartum Care) (2012),” 8th edition,
Vidyarthi Pustak Bhandar, Kathmandu, Pg. no.
290 - 299
 Retrieved from: URL:
 www.gfmer.ch/Obstetrics_simplified/abnormal
_uterine_action.htm
 nursingcontentbank.blogspot.com/2013/03/abn
ormal-uterine-actions.html?m=1
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