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pathologic retraction ring n.

A constriction of the junction between the thinned lower uterine segment and the thick
retracted upper uterine segment caused by obstructed labor; a sign of impending
rupture of the uterus. Also called Bandl's ring.

pathologic retraction ring medical dictionary

A constriction located at the junction of the thinned lower uterine segment with the
thick retracted upper uterine segment, resulting from obstructed labour; this is one of
the classic signs of threatened rupture of the uterus.

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 labour should be properly treated otherwise the thinned lower
uterine segment will rupture.

pathologic retraction ring,


a ridge that may form around the uterus at the junction of the upper and lower uterine
segments during the prolonged second stage of an obstructed labor. The lower
segment is abnormally distended and thin, and the upper segment is abnormally thick.
The ring, which may be seen and felt abdominally, is a warning of impending uterine
rupture. Also called Bandl's ring. Compare constriction ring, physiologic retraction ring.

Bandl’s Ring
Posted on November 3, 2009 by Kathy

I recently received the following comment:


This is a really great post. I had never heard of women having a VBAMC before…but
now that I know about this I am curious. I have had 1 CS, after a 24 hr homebirth
turned emergency. Our daughter was born still after Csec to save her life was
performed…

Our miracle baby was born c-sec after more than 24hrs of VBAC-ing labor. His heart
rate de-celled enough times that we decided to get him out, after I was stuck at 9/5
cm’s for many, many hrs with no progress!

As it turned out, i had an obstructed labor…and a Bandel’s Ring, so baby was never
coming out vaginally. So, now I am concerned for the next baby (prob a yr from now).
Should I attempt another VBAC? How do I find out if I have a true Bandels Ring? What
are things I can do to prevent this from happening?

I’ve done some research into this topic, but it is frustrating.

What is “Bandl’s Ring”? There are two types of uterine muscles, one to help the cervix
dilate and the other to help push the baby out. At their juncture, rarely (usually during
a prolonged and/or obstructed labor) a ring develops around a “depression” in the
fetus, usually over the neck. [Click here to see a picture of a woman's abdomen,
showing the stark outlines of the baby's body, due to a Bandl's Ring. Sometimes when
this happens, even a birth by C-section is difficult, because the ring prevents the birth
of the shoulders and the rest of the body. Usually, the uterus will greatly constrict,
which disrupts placental blood flow, and therefore oxygen flow, to the fetus. Bandl's
Ring was named after the doctor who first identified it.

One source said that a T incision was indicated for Bandl's Ring. Since a T incision is
usually (if not always) a contraindication to a VBAC, it seems pretty certain that it is
not always necessary. One mother said that she had a Bandl's Ring but still had a
vaginal birth, and someone else responding to the comment questioned whether she
really had a "true" Bandl's Ring, since she actually had a vaginal birth. In the old days,
and currently in areas of the world without access to medical care, Bandl's Ring
frequently results in high perinatal mortality (many times the baby is stillborn, or dies
of birth injuries soon after birth) and also maternal mortality and morbidity. Uterine
rupture will likely occur after a Bandl's Ring develops, because the lower uterine
segment is just stretched so thin, and subsequent contractions stress it even more. In
the old days, it was sometimes necessary to dismember the fetus (who was usually
dead, due to lack of oxygen); and even then, sometimes the woman died or suffered
debilitating injuries to her internal organs.

One of the frustrating elements in doing the search was a paucity of materials on
Bandl's Ring, especially recent materials -- many of the Google Scholar results were
case studies from the 1960s and before; including at least one from 1891 (yes, not
1981, but 1891, right before an article debating chloroform and ether). This article
from 1961 (click on the pdf to read the article) included many alternate names: ring of
Bandl, contraction of the ring of Bandl, contraction ring dystocia of White, retraction
ring dystocia of Pride, simple contraction or retraction ring, uterine contraction ring, or
constriction ring of Rudolph. Then it launches into a discussion of what different
doctors have differentiated between the various names (and perhaps various types) of
ring.

Johnson also commented that the terminology and assumptions used in reference to
pathologic rings are bewildering, and he, too, emphasized the difference between the
rings of obstructed and nonbstructed labor, although he referred to both as
contraction rings.

"Bewildering" is correct. I tried to find information on Bandl's Ring, Bandel's Ring, and
"uterine constriction ring," and got precious little information. On one message board,
someone identifying herself as a midwife said that once a woman develops a Bandl's
Ring, it will always happen again, and the woman will always need C-sections. But on
another board, a doctor said that since the woman asking the question was being
offered a VBAC, then that was proof that a vaginal birth was still a possibility.

The blogger at Abundant B'earth wrote the following for a "complications project,"
which is a nice summary (and is more informative than Google Scholar turned out to
be!):

Pathological Retraction Ring of Bandl

Definition and Etiology:

-Occurs in second stage labor (after dilation complete).


-Cause is 2nd stage obstructed labor due to CPD, malposition, uterine neoplasm/
abnormality, or fetal abnormality such as hydrocephalus.
-Uterus tries to compensate by increasing in tone and intensity & frequency of
contractions.
-As a result, the lower uterine segment lengthens and thins, and becomes tender.
-Upper segment becomes hard and thick, and progressively retracts.
-The physiologic ring at the junction of upper and lower segments becomes
extremely pronounced. Ring rises in abdomen.

Si/sx: ["symptoms"]
-Hypertonic contractions
-presenting part driven/jammed
-mother experiences severe pain and excited or restless emotions
-maternal pulse, temperature rise
-palpable, taut round ligaments; may also be visible
-Baby entirely or almost entirely in lower uterine segment.
-ring felt as transverse ridge, as high up as umbilicus or potentially even higher

Differential Diagnosis: May appear to be constriction ring. (see chart Frye p. 1043)
Complications/Sequelae:
-rupture of the lower segment, maternal hemorrhage
-placental abruption
-maternal exhaustion, inertia, and arrest of contractions
-uteroplacental insufficiency with resultant fetal hypoxia and distress.
-maternal fistula, lacerations more likely

So, I don’t know how common it is. I don’t know what the rate of recurrence is. It
seems that uterine fatigue is the chief cause of it (although there are other factors —
for instance, fetal malposition may cause obstructed labor which may lead to uterine
fatigue due to a lengthy labor), which makes me think that perhaps red raspberry leaf
tea may help to prevent it. I don’t think there are any contraindications to this tea in
the third trimester, although some people think it might increase the risk of
miscarriage in the first trimester. This website says, “Red Raspberry leaf does not start
labor or promote contractions. It is NOT an emmenagogue or oxytocic herb. What it
does is help strengthen the pelvic and uterine muscles so that once labor does start
the muscles will be more efficient.” So, this may help in general to prevent uterine
fatigue. Chiropractic adjustments and optimal fetal positioning may help to prevent
fetal malposition (along with the mother being upright and mobile during labor, if she
desires). Cephalopelvic Disproportion (CPD) is over-diagnosed, but it may occasionally
happen even in well-nourished mothers. [In developing countries, many women have
malformed pelvises due to poor nutrition in childhood and adolescence, and many
cultures have child-brides which leads to many still-developing adolescents giving
birth to children, so the incidence of true CPD is higher there.]

Bandl's Ring - Pathological Retraction Ring

From pg 855 of "Principles and Practice of Obstetrics: Joseph DeLee, Saunders


Publishing"
Threatened Rupture -- It is vitally important that the diagnosis of dangerous
thinning of the uterus be made before the rupture occurs, because if anything can be
done to save the woman, it must be done at once. The findings on examination are:
1. A restless excited, anxious patient, high pulse (90-110), irregular
respiration, temperature 99.6 to 100.4 and if infection is beginning, 101 to
103F.
2. Strong uterine contractions without proportionate advance of the
presenting part
3. The uterus hard and drawn up over the child, which lies in the dilated
lower uterine segment. The fundus is thick, hypertonic and hyperergic, but
not in pure tetanus, and the lower uterine segment is soft; it balloons out
during the pains, allowing the fetal body to be outlined with startling
distinctness. The latter seems to lie under the skin. This finding is possible
under anesthesia -- the exquisite tenderness prevents it otherwise
4. A groove is visible and palpable, running obliquely across the belly,
higher on the side of the greatest stretching -- the pathologic retraction
ring or ring of Bandl. It may rise as high as the navel or higher
5. The round ligaments are inserted high on the uterus, are tender, hard, and
wiry, and particularly the one on the side which is going to burst may be
tense and taut.
6. The bladder is drawn up high, but the distended lower uterine segment
may imitate a full bladder
7. A general abdominal tenderness is present, but he lower uterine segment
is so sensitive that the woman will hardly allow it to be touched
8. Internal examination will reveal the cervix, either imprisoned in the pelvis
and swollen, black and blue, or drawn up out of he pelvis with e vagina on
the stretched, taut around the presenting part, and hot, reddened, and
dry. A caput succedaneum may reach the perineum with the head at the
inlet
All my texts are in agreement with the statement that the uterus seems to be working
exceptionally hard -- contractions are frequent, intense and painful. This diagnostic
point is important I think since modern thinking is that CPD is often shown by weak,
erratic and ineffectual contractions. If a mom has a good labor pattern many of us
were taught that all will be well. In fact, if she does NOT have a good labor pattern we
might even use medications (pitocin) to bring on harder contractions. Yet this is the
scene which can lead to rupture.
The prolonged labor pattern we usually deal with is a result of weak and irregular
contractions. These moms usually do very well if they get enough food and rest during
labor, even if it continues for many hours longer than average. But a mom with
frequent, hard, STRONG contractions should have a rapid labor -- not a prolonged
labor! This is the mom which the older authors thought most at risk of uterine
rupture.
To sum up the signs/symptoms of impending rupture:
Rising pulse and perhaps temperature (possibly due to dehydration, exhaustion,
ketosis??)

STRONG UTERINE CONTRACTIONS WITHOUT PROPORTIONATE ADVANCE OF THE


PRESENTING PART
Bandl's Ring becomes visible and rises. Fundus is thickened and tense
Round ligaments become visible and tense
Uterus is extremely painful and sore to the touch. The mother complains of severe
abdominal pain.
During normal birth, what is known as a 'retraction ring' forms in the uterus. This is a
ridge that forms between the upper and lower part of the uterus as a result of
contractions. Usually, when a muscle contracts, what happens is that the muscle fibres
get shorter while it's contracting, and then go back to their normal length afterwards.
When the uterus contracts in labour, though, the muscle fibres retract, which means
that they hold part of the contraction and don't go back to their normal length
afterwards, so that they become progressively shorter with each contraction. In
labour, it's mainly the upper part (segment) of the uterus that contracts and retracts.
This pulls on the bottom part (the lower segment), especially on the area of the cervix,
causing it to thin out. (Incidentally, if you have a caesarean, it's the lower segment
that is opened to perform the operation, hence the initials LSCS - for lower segment
caesarean section.) The retraction ring is the ridge that gradually forms between the
shortened, thickened muscles of the upper segment of the uterus, and the thin,
stretched lower segment. A Bandl's ring is an exaggerated pathological form of this
retraction ring. It forms when, for some reason or another, labour becomes obstructed.
This may happen when there is cephalopelvic disproportion (the baby won't fit through
the pelvis), or it may be associated with the baby being in an unfavourable position.
The ring actually becomes visible through the abdomen above the symphysis pubis
(the pubic joint), and, as you rightly, say means the baby can't be pushed out
vaginally. If left untreated, the uterus would eventually rupture. This is why a
caesarean is performed.

Pathological Retraction Ring Constriction Ring


Occurs in prolonged 2nd stage. Occurs in the 1st, 2nd or 3rd stage.
Always between upper and lower uterine At any level of the uterus. Rises up. Does
segments. not change its position.
Felt and seen abdominally. Felt only vaginally.
The uterus is tonically retracted, tender The uterus is not tonically retracted and
and the fetal parts cannot be felt. the foetal parts can be felt.
Maternal distress and foetal distress or Maternal and foetal distress may not be
death present.
Relieved only by delivery of the foetus. May be relieved by anaesthetics or
antisp
asmod
ics.