Abnormal

uterine
action
 Normal uterine action
Normal labour is characterized by
 coordinated uterine contractions(interval gradually
shortens and intensity gradually increases)
 associated with progressive dilatation of the cervix
(Normal labour is associated with cervical dilatation
≥1cm \ hour in a nulliparous woman )
 descent of the fetal head.
Parameter of uterine
action
 Basal tone : 5- 20 mm Hg
 Peak pressure : 60 -80 mm Hg
 Frequency of contraction :adequate
uterine contractions are 1 in every 3
mints lasting for about 45 sec with good
relaxation in between
Assessment of
contraction
 Abdominal palpation

 Tocodynamometer :with the help of

external trasducers

 Intrauterine pressure catheter

 ETIOLOGY
1. Prevalent in primi with advancing age of the
mother
2. Prolonged pregnancy
3. Over distension of the uterus due to
twins and or ployhydramnios
4. Psychologic factor
 . 5 . Contracted pelvis,
ETIOLOGY



Contracted malpresentation and
pelvis, deflexed head. All
these lead to ill fitting of the presenting part
into the lower uterine segment. This probably
results in inhibition of the local reflex which
is needed to produce effective contraction of
the upper segment.
 Full bladder and loaded rectum reflexly
inhibit uterine contraction
 Injudicious administration of sedatives,
analgesics and oxytocics
 Premature attempt at vaginal delivery or
attempted instrumental vaginal delivery under
light anaesthesia.
 uterine contraction are weak and dilation of
cervix is slow.
 This is common type of abnormal uterine
contraction, which may present from the
beginning of labour or may develop
subsequently after a variable period of effective
contraction.
Complication
Effect on
mother:
Prolonged
labor
Maternal distress,
dehydration and psychological
depression
Increased risk for infection
Increased risk of PPH
Fetal
complication
 Fetal distress if membra
ruptures early ne
 Managemen
t
 Careful evaluation of the case is to bedone:
 To be sure that the patient is in true
labour
 To exclude cephalopelvic disproportion or
malpresentation
 To plan out the management protocol
In normal condition prepare for vaginal delivery
 General management
Reassure the mother to keep up the morale and
prevent psychological depression.
Change posture of women (avoid supine
position)
Empty the bowel by enema and encourage
mother to frequently empty bladder. If fails to
empty by herself, catheterization should be done.
Maintain hydration by infusion of ringer’s
solution.
Adequate pain relief by intramuscular pethidine
100mg
 Active management
Accelerate of uterine contraction can be brought
about by low rupture of membranes followed by
oxytocin drip.
If labour doesn't progress and there is sign of
maternal and fetal distress , caesarean section
should be done.
Keep keen and constant observation on maternal
and fetal condition.
If the head is low forceps or vacuum delivery is
indicated.
Continue the oxytocin drip till one hour after the
delivery of baby to prevent PPH.
Amniotomy:
Providing that;
• vaginal delivery is amenable,
• the cervix is more than 3 cm dilatation
and
• the presenting part occupying well the
lower uterine segment.

Artificial rupture of membranes augments the
uterine contractions by:
• release of prostaglandins.
• reflex stimulation of uterine contractions
when the presenting part is brought closer to
the lower uterine segment.
• If labour is not progress even though ARM
and first regime oxytocin drip, and there is
sign of maternal and fetal distress, she should
be prepared for caesarean section.
 HYPERTONIC UTERINE ACTION
In hypertonic uterine action ,the tone of the
uterus is high during and between contraction
with severe backache.
 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 contraction.
In the absence of obstruction , the
hypertonic uterine action result in
Precipitate labour
 whereas it result in Bandl’s ring
formation in presence of obstruction.
 PRECIPITATE LABOUR
A labour is called precipitate when the first
and second stage of is less then 2 hours.
This is an over active labour in which the
baby is expelled soon after the start of labour.
Rapid expulsion is due to the combined effort
of hyper active uterine contraction associated
with diminished soft tissue resistance.
Labour is short as the rate of cervical dilation
ie 5 cm/hr or more
It is common in multipara and may be
repetitive.
 Complications
1. Maternal Risk
Extensive laceration of the cervix, vagina and
perineum
Postpartum hemorrhage due to uterine
hypotonia that develops subsequently,
Inversion of uterus
Infection
Uterine rupture
Amniotic fluid embolism
2. Fetal
risk
Intracranial stress and hemorrhage because
of rapid expulsion without time for moulding
of head.
Fetal hypoxia because of strong, frequent
uterine action
Skull facture
Rupture of cord
 Management
The patient having previous history of precipitate
labour should be hospitalized prior to labour.
During labour, the uterine contraction may be
suppressed by administering either magnesium
sulphate during contraction.
Delivery of head should be controlled but not
prevented.
Episiotomy should be done liberally
Elective induction of labour by low rupture of
membrane and careful conduction of controlled
delivery may be advantageous
Oxytocin augmentation should be avoided.
2. Tonic uterine contractions and retraction
(BANDL’S RING)
This type of uterine contraction is predominantly
due to obstructed labour.
The pattern of uterine action is normal, the upper
uterine segment actively while the lower segment
remain passive.
There is gradual increase in intensity, duration, and
frequency of uterine contraction.
The relaxation phase become less and less;
ultimately a state of tonic contraction develops.
Retraction, however, continues.
The lower segment , elongates and becomes
progressively thinner to accommodate the fetus
driven from the upper segment.
A circular groove encircling the uterus is formed
between the active upper segment and the distended
lower segment called pathological retraction ring.
(Bandl’s ring)
In primigravidae, further retraction ceases in
response to obstruction and labour comes to a stand
still (remain fixed)- a state of uterine exhaustion.
Contraction may recommence (begin) after a brief
period of rest with renewed vigour.
But in multiparae , retraction continues with
progressive circumferential dilation and thinning of
the lower segment.
There is progressive rise of the bandl’s ring;
moving nearer and nearer to the umbilicus and
ultimately lower segment rupture.
Clinical features
Patient is agony from continuous pain and
discomfort and become restless
Features of exhaustion and ketoacidosis
Abdominal palpation reveals:
Upper segment is hard and tender, lower segment is
distended and tender.
The pathological retraction ring is placed obliquely
between umbilicus and symphysis pubis and rises
upwards in course of time
Fetal part may not be well defined
FHS is usually absent.
Internal examination reveals:
Dry ,hot vagina with offensive discharge
Cervix fully dilated
Causes of obstruction labour ir revealed.

Prevention
 The abnormalities either to passage or
passenger should be ruled out in antenatal
period and plan for appropriate treatment.
TREATMENT
 Rupture of membrane is excluded
Correction of dehydration and ketoacidosis by
infusion of ringer’s solution.
Adequate pain relief measures must be used
Parenteral antibiotic is given (ceftriaxone 1 gm iv)
Rupture of uterus must be excluded before
attempting destructive operation
Inco-ordinate uterine action
Strong and painful uterine
contraction
 High frequency
 Slow cervical dilatation
 Two pole of uterus doesn’t functions
rhythmically
Clinical feature
 Labour 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.
 High resting intrauterine pressure in between
uterine contractions detected by tocography (normal
value is 5-10 mmHg).
 Slow cervical dilatation .
 Premature rupture of membranes.
 Foetal and maternal distress.
Management
 CPD- C/S
 Vital monitoring
 I/V therapy
 I/O charting
 FSH every 15
min
 Partograph
 Fetal distress-C/S
Colicky uterus
 Various parts of uterus contracts
independently

Hyperactive lower uterine segment

 Fundal gradient is lost , reverse gradient of
the uterine activity starts from the lower
uterine segment goes toward fundus and
cervix
CONSTRICTION
(CONTRACTION) RING
 It is a persistent localised annular spasm of
the circular uterine muscles.
 It occurs at any part of the uterus but usually
atjunction of the upper and lower uterine
segments.
 It can occur at the 1st, 2nd or 3 rd stage
of labour.
 Aetiology
Unknown but the predisposing factors are:
 Malpresentations and malpositions.
 Premature rupture of membrane
 Premature attempt of instrumental
delivery
 Intrauterine manipulations under ligh
anaesthesia. t
 Improper use of oxytocin e.g.
 use of oxytocin in hypertonic inertia.
 IM injection of oxytocin.
Diagnosis
 The condition is more common in primigravidae and
frequently preceded by colicky uterus.
 The exact diagnosis is achieved only by feeling
the
ring with a hand introduced into the uterine cavity.

Complications
 Prolonged 1st stage: if the ring occurs at the level of
the internal os.
 Prolonged 2nd stage: if the ring occurs around the
foetal neck.
 Retained placenta and postpartum haemorrhage: fi
the ring occurs in the 3rd stage (hour- glass
contraction).
Management
 Exclude malpositio an
malpresentations,
disproportion. n d
 In the 1st stage: Pethidine morphine may be
of
beneficial .
 In the 2nd stage: Deep general anaesthesia and amyl
nitrite inhalation are given to relax the constriction ring:
 If the ring is relaxed, the foetus 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 anaesthesia and amyl
nitrite inhalation are given followed by manual removal
Pathological Retraction Ring
(Bandl’s ring)
Physiological Retraction Ring
 It is a line of demarcation between the upper and
lower uterine segment present during normal labour
and cannot usually be felt abdominally.
Pathological Retraction Ring (Bandl’s ring)
 It is the rising up retraction ring during obstructed
labour due to marked retraction and thickening of the
upper uterine segment while the relatively passive
lower segment is markedly stretched and thinned to
accommodate the foetus.
The Bandl’s ring is seen and felt abdominally as a
transverse groove that may rise to or above the
umbilicus.
Clinical picture: is that of obstructed labour with
impending rupture uterus (see later).
Obstructed should be treate
labour otherwise thinnedproperly
lower uterine segment d
rupture. the will
 DIFFERENCE BETWEEN
CONSTRICTION RING
ANDRETRACTION RING
CONSTRICTION RING RETRACTION
RING
Natur It is a manifestation of It is an end result of tonic
e localised inco-ordinated uterine contraction and
uterine contraction. retraction
Cause Undue irritability of the uterus. Following obstructed
labour

Situation Usually at the junction of upper At the junction of upper

and and lower segment but may occur lower segment. The
position in other places. The position doesprogressively
Uteru moves upwards contracts
Upper segment not alter.and Upper segment is tonically
s retracts with relaxation in contracted with no relaxation
between lower segment The wall becomes thicker,
remains
thick and lower
segment becomes distended
loose. and
Matern Almost unaffected unless Maternal exhaustion,
al
conditio the sepsis
appear
n
Abdomina labour isfeels
oUterus prolonged
normal and early
o Uterus is tense and
lExaminatio not tender tender
n oFetal parts are easily felt o Not easily felt
oFHS is usually felt o Ring is felt as a groove
placed
obliquely
Vagina oThe lower segment is not o Lower segment is very
lexaminatio pressed by the presenting much
pressed by the forcibly
n part driven
presenting
oRing is felt usually above the part
o Ring cannot be felt
head vaginally
o Features are
o Features of obstructed present
labour
End oMaternal exhaustion is a late o Maternal exhaustion
result are absent
and feature sepsis appear early
o Fetal anoxia usually appear late o Fetal anoxia and
even death
o Chance of uterine rupture is are usually early
absent o Rupture uterus in
multi
Clinical feature
 Mother becomes tired and restless due to continue
pain and discomfort
 Features of maternal distress and keto-acidosis
 Abdominal palpation
 Upper segment hard ,uniformly convex and tender
 Retraction ring obliquely placed between umblicus
and symphysis pubis
 Fetal part may not be well defined
 FHS usually absent
 Vaginal examination
 Dry hot vagina with offensive discharge
 Cervix fully dilated
 Causes of obstruction is revealed
Management
 Provide supportive therapy
 Analgesic and sedation
 Hydration
 Prophylactic antibiotic

 Definitive treatment
 Destructive surgery if fetus is
dead
 Fetus alive-C/S
 CERVICAL DYSTOCIA
Definition

Failure of the cervix to dilate within a reasonable time

in spite of good regular uterine contractions.
Types
 Organic (secondary) due to:
 Cervical stances as a sequel to previous
amputation, cone biopsy, extensive cauterisation or
obstetric trauma.
 Organic lesions as cervical myoma or carcinoma.
 Functional (primary):
 In spite of the absence of any organic lesion and
the well effacement of the cervix, the external os
fails to dilate.
 This may be due to lack of softening of the cervix
during pregnancy or cervical spasm resulted from
overactive sympathetic tone or excessive fibrous
tissue .
Etiology
 Ineffective uterine contractions
 Malpresentation, Malposition
(abnormal relationship between the
cervix and the presenting part)
 Spasm (contractions) of the cervix
Managemen
t
 Organic dystocia:
 Caesarean section is the management of
choice.
 Functional dystocia:
 Pethidine and antispasmodics: may be
effective.
 Caesarean section: if
 medical treatment fails or
 foetal distress developed.
 GENERALIZED TONIC
CONTRACTION (UTERINE

TETANY)
In this condition pronounces retraction occurs
involving whole of the uterus upto the level of
internal os. Thus there is no physiological
differentiation of the active upper segment and the
passive lower segment of the uterus. As there is no
thinning of the lower segment, there is no chance of
rupture of the uterus. The uterine contraction
ceases and the whole uterus undergoes a sort of
tonic muscular spasm holding the fetus inside
(active retention of the fetus)
Causes

 Failure to overcome the obstruction by

powerful contractions of the uterus
 Injudicious administration of oxytocics
 Irritation caused by repeated unsuccessful
attempt
of instrumental delivery
Clinical Features

 The patient is in prolonged labor having

severe and continuous pain.
Abdominal
examination revels the uterus to
be somewhat smaller in size,
tender. Fetal parts are tense and
define nor is neither heart well
d, Vaginalthe examination
fetal sound
audible. head
jammed reveals
with big caput; dry
and oedematous vagina.
Management

 Correction of dehydration and keto acidosis: by

rapid infusion of Ringer’s solution
 Antibiotics : To control infection
 Adequate pain relief