ABNORMAL

UTERINE
CONTRACTION
PREPARED BY:
NISHA DWA

DEFINITION:
Any deviation of the normal pattern of
uterine contractions affecting the course
of labour is designated as disordered or
abnormal uterine contraction.

The criterion of effective uterine

contraction is progressive dilatation of the
cervix with descent of the presenting part
withing the specified time limit.

ETIOLOGY:
As the physiology of normal uterine contraction is
not fully understood, the cause of its disordered
action remains obscure. The following are the
associated causes:
I. Primigravida with advancing age of mother.
II. Prolonged pregnancy (Post term pregnancy)
III. Over distension of the uterus due to twins and/or
hydramnious

IV. Contracted pelvis

V. Malpresentation and deflexed head
VI. Full bladder
VII.Injudicious
administration
analgesics and oxytocics.

of

sedatives,

VIII.Premature attempt at vaginal delivery or

attempted instrumental vaginal delivery under
light anaesthesia.

NORMAL UTERINE CONTRACTION:

There exists polarity in uterus i.e. when the upper
segment contracts the lower segment relaxes
There are two pacemakers situated at each cornua
of uterus
The intensity of contraction diminishes from top
to bottom of the uterus.

 The contraction wave starts at the pacemaker and

propagates to the lower segment.
The duration of contraction diminishes
progressively as the wave moves away from the
pacemaker

TYPES OF ABNORMAL UTERINE

ACTION:
1) Hypotonic dysfunction(Uterine inertia)
2) Hypertonic dysfunction(Excessive contraction)
Precipitate labour
Tonic
uterine
contraction
and
retraction(Bandls Ring)

3) Inco-ordinate uterine action

Spastic lower segment
Colicky uterus
Asymmetry uterine contraction
Constriction ring
Generalized tonic contraction
Cervical dystocia

NOTE:
The uterine space maker is situated at the cornua of
the uterus and this generates uterine contractions.
Effective uterine contraction, starts at he cornua and
gradually sweep downwards over the uterus.

Primary dysfunctional labour is defined when the

cervix dilates less than 1cm/hr following a normal
latent phase of labour. In a primary dysfunctional
labour, uterine activity instead of being governed by
a single dominant space maker, is shifted to less
efficient contractions due to emergence of other
pacemaker foci.

HYPOTONIC UTERINE
DYSFUNCTION(UTERINE INERTIA):
This is a common type of abnormal uterine
contraction, which may present from the
beginning of labour or may develop subsequently
after a variable period of effective contractions.
In uterine inertia, the pattern of the uterine
contraction is normal but the cervical dilatation is
slow.
The intervals between contractions are long, the
duration of contraction is short and the intensity is
weak.

SIGNS AND SYMPTOMS:

Patient feels less pain during uterine contraction.
Palpation reveals less hardening of the uterus.
Uterine wall is easily indentable at the acme of
pain.
Uterus becomes relaxed after the contraction;
fetal parts are well palpable and fetal heart rate
remains good.

 Internal examination reveals:

Poor dilatation of the cervix (<1cm/hour
beyond 3cm dilatation)
Membranes usually remain intact.
Associated presence of contracted pelvis,
malposition, deflexed head or malpresentation
may be evident.

COMPLICATIONS:
Maternal exhaustion and/or fetal distress are
unusual and appear late.
Prolonged labour
Infection
Possibility of Postpartum Haemorrhage due to
atonic uterus.

MANAGEMENT:
Careful evaluation of the case is to be done:
To be sure that the patient is in true labour.
To exclude CPD and malpresentation.
To plan out the management protocol.
In normal condition prepare for vaginal delivery.
Plan for caesarean section if mother have
contracted pelvis, malpresentation or evidence of
fetal and maternal distress.

GENERAL MANAGEMENT:
Reassure the mother to keep up the morale and
prevent psychological depression.
Change posture of woman(avoid supine position)
Empty the bowel by enema and encourage mother
to frequently empty the bladder. If fails to empty
by herself, catheterization should be done.

 Maintain hydration by infusion of Ringers

solution.
Adequate pain relief by intramuscular pethidine
100mg or combination of pethidine 75mg and
Sparine 50mg.

ACTIVE MANAGEMENT:
Acceleration of uterine contractions can be
brought about by low rupture of membranes
followed by oxytocin drip.
If labour does not progress and there is sign of
maternal and/or fetal distress, caesarean section
should be done.
Keep keen and constant observation on maternal
and fetal condition.

 If head is low forceps or vacuum delivery is

indicated.
Continue the oxytocin drip till one hour
after the delivery of baby to prevent PPH.

HYPERTONIC UTERINE DYSFUNCTION

(EXCESSIVE CONTRACTION):
It is the condition in which the tone of the uterus
is high during and between contractions with
severe backache.
The higher tonic state of the uterine segments,
colicky uterus, asymmetrical uterine contraction,
constriction ring or generalized tonic contractions
of the uterus and all these states are collectively
called incoordinate uterine action.

 In the absence of obstruction, the hypertonic

uterine action results in precipitate labour
whereas it results in Bandls ring formation
in the presence of any obstruction.

PRECIPITATE LABOUR:
A labour is called precipitate when the
combined duration of the first and second
stage is less than 2 hours.
This is an overactive labour in which the
baby is expelled soon after the start of
labour.

 Rapid expulsion is due to the combined effect of

hyper active uterine contractions associated with
diminished soft tissue resistance.
Labour is short as the rate of cervical dilatation is
5cm/hr or more.
It is common in multiparae and may be repetitive.

COMPLICATIONS:
a) Maternal Risk:
Extensive laceration of the cervix, vagina and
perineum
Postpartum haemorrhage due to uterine
hypotonia that develops subsequently
Inversion of uterus
Infection
Uterine rupture
Amniotic fluid embolism

b) Fetal Risk:
Intracranial stress and haemorrhage because of
rapid expulsion without time for moulding of
the head
Fetal hypoxia because of strong, frequent
uterine action
Skull fracture
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 ether or magnesium
sulphate during contractions.
Delivery of the head should be controlled but not
prevented.

Episiotomy should be done liberally.

Elective induction of labour by low rupture of
membranes and careful conduction of controlled
delivery may be advantageous.
Oxytocin augmentation should be avoided.

TONIC UTERINE CONTRACTION AND

RETRACTION (BANDLS 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
remains passive.
There is gradual increase in intensity, duration
and frequency of uterine contraction.

 The relaxation phase becomes 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(Bandls ring).

In primigravidae, further retraction ceases in

response to obstruction and labour comes to a
stand still a state of uterine exhaustion.
Contractions may recommence after a brief
period of rest with renewed vigour.

But in multiparae, retraction continues with

progressive circumferential dilatation and thinning
of the lower segment.
There is progressive rise of the Bandls ring;
moving nearer and nearer to the umbilicus and
ultimately, the lower segment ruptures.

CLINICAL FEATURES:
Patient is in agony from continuous pain and
discomfort and becomes restless.
Features of exhaustion and keto acidosis

 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 parts may not be well defined.
FHS is usually absent.

Internal examination reveals:

Dry, hot vagina with offensive discharge.

Cervix fully dilated
Membranes are absent
Cause of obstructed labour is revealed.

PREVENTION:
The abnormality either due 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 Ringers solution.
Adequate pain relief measures must be used.

 Parenteral antibiotic is given (Ceftriaxone 1gm

IV).
Caesarean delivery is done in majority of the
cases.
Rupture of uterus must be excluded before
attempting destructive operation.

THANK YOU!!!

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 inco-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.

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 is in agony 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.

 Internal 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.

MANAGEMENT:
Caesarean section is done in majority of cases.
Prior correction of dehydration and ketoacidosis
must be achieved by rapid infusion of Ringers
solution.
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:
It is one form of inco-ordinate uterine action where
there is localized spastic constriction of 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 stages of labour.

 It is usually irreversible and complete.

The constriction ring usually results from
abnormal uterine activity, which usually are
not effective to dialte cervix, or cause
rupture of uterus.

CAUSES:
Hypertonic lower uterine segment.
Injudicious use of oxytocics.
Premature application of instrumental delivery.
Premature rupture of membrane.

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 forcep 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 forcep
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. Alternatively,
adrenaline may be administered.

GENERALIZED TONIC
CONTRACTION(UTERINE TETANY):
It is the condition in which there is pronounced retraction
involving whole of the uterus upto 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 Ringers solution.
Antibiotic administration as per need.

 Oxytocin infusion is stopped and hyper

contractility induced by oxytocics can be
managed by tocolytics 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 despite of normal uterine
contraction.
Progressive cervical dilatation needs an effective
stretching force by presenting part.

CAUSES:
Inefficient uterine contraction
Malpresentation, Malposition
Spasm of the cervix

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 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. The
characteristic feature of this condition is the state of
the cervix. The cervix is effaced and well applied to
the engaged head but it has firm ring and does not
dilate normally.

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
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 It is an end result of tonic uterine
inco-ordinate
contraction.

uterine contraction and retraction.

CAUSE Undue irritability of the uterus. Following obstructed labour.

SITUATI Usually at the junction of upper Always situated at the junction
and lower segment but may of upper and lower segment. The
ON
occur in other places. The position progressively
position does not alter.
upwards.

moves

UTERUS Upper segment contracts and Upper segment is tonically

retracts with relaxation in contracted with no relaxation.
between;
lower
segment The wall becomes thicker; lower
remains thick and loose.
segment becomes distended and
thinned out.

CONSTRICTION
RING
MATERNAL
CONDITION

RETRACTION RING

Almost unaffected unless Features of maternal exhaustion,

the labour is prolonged.
sepsis appear early.

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

not tender.
b. Not easily felt.
EXAMINATIO
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
d. Round ligament is not
ligaments are felt.
felt
e. Usually absent.
e. FHS is usually present.

round

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

VAGINAL
not pressed by the
pressed by the forcibly driven
EXAMINATIO
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
RING
END RESULT

RETRACTION RING

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

followed by delivery by safe procedure after
TREATMENT
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

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THANK
YOU!!!