ABNORMAL

UTERINE
CONTRACTION
IN LABOUR
PRESENTED BY-
Dr. Ruchi and
Dr. Shweta
NORMAL UTERINE CONTRACTION

 Regular Interval.
 Interval gradually shortens.
 Intensity gradually increases
 Duration gradually
 Associated with cervical dilatation, effacem

ent and descent of head.

NORMAL UTERINE CONTRACTION

 PATTERN OF CONTRACTION:

Uterine contraction start at one cornua few millise

conds later in other cornua. Excitation waves then
join and propagate towards lower uterine segmen
t at the rate 2cm/sec with its decrease duration a
nd intensity as it moves away from cornua.
Hence, whole organ depolarises at the same time
with it’s peak intensity.

(Ref-Williams 25th Edition)

NORMAL UTERINE CONTRACTION

Basal tone:-
 Uterine muscles are never relaxed completely durin

g pregnancy (3-5mmHg) during labour.(8-12 mm H

g)
Peak Pressure:-
 First stage-25-50 mm Hg

 Second stage-80-100 mm Hg

Frequency & Duration of contraction:-

 First stage:3-5 in every 10 minutes lasting for 45-6

0 sec.
 Second stage:5 in 10 minutes lasting for 60-90 sec.

(Ref-Williams 25th Edition)

NORMAL UTERINE CONTRACTION

Palpable uterine contraction-

 Uterine contraction when exceed >10mmHg

(can be depressed) >40mmHg(can not be depre

ssed).

Painful uterine contraction-

 Uterine contraction when exceed >25-30mmHg

Cervical dilatation-
 When exceed >15 mmHg pressure

(Ref-Williams 25th Edition)

 NORMAL UTERINE CONTRACTION

 POLARITY: When upper segment contracts

lower segment relaxes.

 PACEMAKERS: Two pacemaker situated at e

ach cornua of uterus.Right pacemaker usual
ly predominates.

(Ref-Williams 25th Edition)

ABNORMAL
UTERINE
CONTRACTION
 DEFINITION

 Any deviation in the normal pattern of uterine

contraction affecting the course of labour is d
efined as abnormal uterine contraction.

Overall labour abnormalities occur in

 25% nulliparous
 15% multiparous

(Ref-Williams 25th Edition)

 AETIOLOGY
General factors Local factors
 Elderly Primigravida  Overdistension of the u
 Anaemia and asthenia. terus.
 Developmental anomal
 Nervousness , anxiety
ies of the uterus
and fear.  Malpresentations, malp
 Injudicious use of
ositions and cephalope
analgesics and oxytocics lvic disproportion.
 Abnormal shape of pel

vis.
 Full bladder.
CLASSIFICATION
 r

ABNORMAL UTERINE
CONTRACTION

NORMAL ABNORMAL
POLARITY POLARITY
 NORMAL POLARITY
( CO-ORDINATE UTERINE CONTRACTIO
N)
 NORMAL
POLARITY

HYPERTONIC HYPOTONIC

UTERINE
PRECIPITATE TONIC UTERINE INERTIA
LABOUR CONTRACTION
AND RETRACTION
HYPERTONIC
(EXCESSIVE
UTERINE CONTRA
CTION)
TONIC UTERINE CONTRACTION AND
RETRACTION

 Contraction increases in intensity, duration

and frequency with decrease in relaxation i
n response to any obstruction in birth canal
.

 Pattern of uterine contraction is normal.

 Basal tone->15mmHg
 FEW TERMS

 TACHYSYSTOLE: Contraction more than 5 i

n every 10 minutes.

 TETANIC UTERINE CONTRACTION: Single

contraction lasting for more than 3 mins.

 HYPERTONIC UTERINE CONTRACTION: El

evated baseline pressure above 15mmHg.
(Ref-Williams 25th Edition)
1
 PATHOPHYSIOLOGY
The upper uterine segment overactively contract (in response to ob
struction) and retraction continues

Progressive thinning and elongation of lower uterine segment.

Development of the circular groove in between upper and lower ute

rine segment called Bandl’s ring or pathological retraction ring

(Note: Physiological Retraction Ring- It is a line of demarcation bet

ween the upper and lower uterine segment present during normal la
bour and cannot usually be seen & felt abdominally) (Ref-Williams
25th Edition)
Pathological Retraction Ring
(Bandl’s ring)
Pathological Retraction Ring
(Bandl’s ring)
 PATHOPHYSIOLOGY (CONT....)

Primigravida :-Often respon Multipara:-Retraction further c

d to obstruction by inefficie ontinues with more dilatation
nt uterine contraction and la and thinning of lower uterine
bour comes to a state of ex segment)
haustion(secondary inertia)

Bandl’s ring moves toward the umbilicus

Rupture of lower uterine segment

 CLINICAL FEATURE
 Patient is anxious and exhausted.

 There is rise in maternal temperature , pulse and respiration.

 Bladder become abdominal , in neglected cases pressure necr

osis and fistula formation can occur.

 Urine is diminished in amount and high coloured and along w

ith RBCs.

 Ketone bodies are present in urine and also smell in the patie
nts breath.(ACIDOTIC SMELL)

 There is metabolic acidosis and ketosis.

 DIAGNOSIS
ABDOMINAL EXAMINATION-

 Uterus is tense and tender.

 Fetal parts not easily felt.
 Ring is felt as a groove placed obliquely.
 Round ligaments are taut and tender (Fromm

el sign).- Ref-Holland & Brews

 FHS may show evidence of fetal distress or m

ay be absent.
 DIAGNOSIS

LOCAL EXAMINATION OF EXT GENITALIA-

 Vulva is usually swollen and oedematous.

VAGINAL EXAMINATION-

 Vagina is dry, hot, ocassionally there is offensive and pur

ulent vaginal discharge.
 Presenting part is extremely moulded and jammed in pelv

is.
 There is usually large CAPUT formation.

(Ref-Holland & Brews)

MANAGEMENT
 TONIC UTERINE CONTRACTION AND
RETRACTION

Correct maternal dehydration or

metabolic acidosis
Cover with broad spectrum antibiotic
Prepare her for surgical intervention
Blood for group and cross match

Fetus alive Fetus dead

Caeserean
section
Suspected uterine Uterus intact
rupture

Caesarean
Laparotomy
section
 PRECIPITATE LABOUR
 Precipitate labour refers to an overactive uterine
contraction in absence of obstruction in which
baby is expelled soon after regular uterine contr
action.(combined 1st stage and second stage
duration is <3 hours).
(Ref-Wlliams 25 th Edition)

 The pattern of contraction is essentially normal.

 The only abnormalities is strong intensity and fr

equency which is very rapid.

 AETIOLOGY

 An abnormally low resistance of soft part of

birth canal.
 Abnormally strong uterine and abdominal mu

scle contraction.
 Rarely from lack of painful sensation-lack of

awareness of vigorous labour.

(Ref-Williams 25 th Edition)
 COMPLICATION

Maternal

 Amniotic fluid embolism.

 Laceration of the cervix and the perineum.
 Postpartum haemorrhage due to atony (uteru

s that contract with unusual vigour before del

ivery likely to be hypotonic after delivery.)
(Ref-Williams 25th Edition)
 COMPLICATION

Foetal :
 Intracranial haemorrhage due to sudden com
pression and decompression of the head.
 Foetal Hypoxia due to strong and frequent ut

erine contractions reducing placental perfusio

n
 Foetal injury due to falling down.
 MANAGEMENT

Before delivery

Patient who had previous precipitate labour s

hould be hospitalized before expected date o
f delivery as she is more prone to repeated pr
ecipitate labour.
 During delivery
 Strict vigilance

 Inhalation anaesthesia: Nitrous oxide,Amyl

nitrite and oxygen is given to slow the course
of labour.

 Episiotomy: to avoid perineal lacerations an

d intracranial haemorrhage.

 Prophylactic antibiotic.
 After delivery
Examine the mother and foetus for injuries.
(HYPOTONIC)
INEFFICIENT
UTERINE CONTRACTION
Also called UTERINE INERTIA.
.
The pattern of uterine contraction is normal. (synch
ronus)

The interval between contraction is long ,the

duration of contraction is short and intensity is wea
k
<25mmHg,basal tone is <10mmHg
(Ref-Williams 25th Edition)
 TYPES

Protraction disorder:
 weak uterine contractions from the start of active phase of
labour therefore slow than normal progress.
 Cervical dilation of <1cm/hr in primi and<1.5cm/hr in mu
lti for minimum of 4hrs.

Arrest disorder:
 Complete cessation of progress after normal start.
 No dilation for 2hrs or more.

(Ref-Williams 25th Edition)

 CLINICAL PICTURE
 Patient feels less pain.

 Per abdomen-Contraction is ≤ 2 in 10 min and last

ing for ≤ 30 seconds. (Ref-Williams 25th Edition)

 Tocography: Shows infrequent (≤ 2 )contractions w

aves with low amplitude.

 Internal examination-
i. Membranes are usually intact.
ii. Slow dilatation of cervix.
 EFFECT ON MOTHER AND FETUS

 There is good relaxation in between contracti

on-hardly any adverse effect on fetus.If labou
r prolonged may affect.

 More susceptibility for retained placenta and

postpartum haemorrhage due to persistent in
ertia.
(Ref-Williams 25th Edition)
 MANAGEMENT

General measures:

 Examination to detect disproportion, malpresentati

on or malposition.
 Prophylactic antibiotics.
 Maintain hydration.
 Empty the bladder.
Active Measures
 If there is no contraindication like

CPD.
Malpresentation.
scarred uterus.
fetal distress.
 Amniotomy
 Artificial rupture of membranes after latent phase augmen
ts the uterine contractions by:

1. Release of prostaglandins.
2. Reflex stimulation of uterine contractions when the prese
nting part is brought closer to the lower uterine segment
.

Oxytocin Stimulation

 2 IU of oxytocin in 500mL Ringer lactate is given by IV inf

usion starting with 8 drops per minute (2mIU/min) and i
ncreasing gradually in multiples of 8 dropes in every 15
mins to get efficient uterine contraction.
(Ref-Williams 25th Edition)
Caesarean section -

 If labour is not progressed even after 8 hrs

of amniotomy or oxytocin stimulation.
 Fetal distress at any time
 contraindications to oxytocin infusion.

(Ref-Williams 25th Edition)

 ABNORMAL POLARITY
(INCOORDINATE UTERINE CONTRACTI
ON)
 ABNORMAL
POLARITY

GENERALISED SPASTIC ASSYMETRIC COLICKY

CONSTRICTION CERVICAL
TONIC LOWER UTERINE UTERUS
RING DYSTOCIA
CONTRACTION SEGMENT CONTRACTION
 CLINICAL FEATURE IN GENERAL
Per abdomen

 Uterus tense and tender.

 Palpation of fetal parts are difficul or sometimes not pal
pable.
 Fetal distress or sometimes heart sound are not audible.

Per vaginum

 Dry and oedematous vagina.

 Cervix is thick, loose, edematous,not well applied to the
presenting part.
 Jammed head with big caput.
 COMPLICATION IN GENERAL
MATERNAL FETAL
 Uterine Rupture.  Fetal hypoxia
 Infection-  Fetal infection.
Intrapartum chorioamnionitis.  Caput succedanum and
Postpartum pelvic infection. moulding.
 Pelvic floor injury – causes uri
 Nerve injury.
nary and rectal incontinence
 Fistula formation- Vesicovagi

nal fistula
Vesicocervical fistula
Rectovaginal fistula.
 Lower extremity nerve injury
 CONSTRICTION RING
(schroeder’s ring)

 These are localised area of myometrial hypert

onus.
 Can occur at any stage of labour.
 It occurs at any part of the uterus but usually

 At junction of the upper and lower uterine

segments
 In the region of natural groove of fetus like n

eck.
(Ref-Holland & Brews)
 CONSTRICTION RING CONSTRICTION RING
IN CEPHALIC PRESETATION IN BREECH PRESETATION
 CONSTRICTION RING
(schroeder’s ring)

 Maternal condition not affected.

 Ring is not palpable per abdominally.

Felt in-
 1 st stage of labour -during caesarean sectio

n.
 2 ndstage of labour -during forcep applicatio

n.
 3 rd stage of labour-during manual removal o

f placenta.
 ETIOLOGY

Unknown but the predisposing factors are:

 Intrauterine manipulations under light anaest

hesia.
 Injudicious use of oxytocin.
 Premature application of forcep.

(Ref-Holland & Brews)

 COMPLICATION

Prolonged 1st stage:

 If the ring occurs just above the level of the inte

rnal os.
Prolonged 2nd stage(more common):
 If the ring occurs around the foetal neck.

Retained placenta and postpartum haemorrha

ge:
 If the ring occurs in the 3rd stage.

(Ref-Holland & Brews)

 MANAGEMENT

In the 1 st & 2nd stage:

 Deep general anaesthesia ( Nitrous oxide,Amyl ni

trite )are given to relax the constriction ring:

 If the ring is relaxed-

Fetus is delivered immediately by forceps.

 If the ring does not relax-

Caesarean section is carried out and incision is gi

ven to divide the ring.
In the 3rd stage:
 Deep general anaesthesia are given followed by

manual removal of the placenta.

 DIFFRENCES

Constriction ring Retraction ring

 It is manifestation of localis  It is end result of tonic uterine con
ed incoordinate uterine con traction and retraction
traction

 Situated at the junction of upper a

 Usually situated at the junct
nd lower segment.
ion of upper and lower seg
ment but may occur at natu
ral groove of fetus.  Position progressively moves
 Position does not alter upwards.
 Upper segment contracts an  Upper segment is tonically contrac
d retracts with relaxation in
ted with no relaxation the wall bec
between ,lower segment re ome thicker,lower segment becom
main thick and loose. e distended and thinned out
 Can not feel on PA
 Can feel on PA
 CERVICAL DYSTOCIA

Failure of the cervix to dilate within a reasona

ble time in spite of good regular uterine contr
actions.

It is of two type
 PRIMARY
 SECONDARY
 TYPES

Functional (primary):
 In spite of the absence of any organic lesion an

d well effacement of the cervix, the external os

fails to dilate.

Organic (secondary) :
 Cervix fails to dilate as a sequel to previous am

putation,cone biopsy,extensive cauterisation, o

bstetric trauma and cervical myoma or carcino
ma
 COMPLICATION
MATERNAL
 Rupture uterus.
 Postpartum haemorrhage: Particularly if cervi

cal laceration extends upwards tearing the mai

n uterine vessels.
 Annular detachment of the cervix.(Rare)

FOETAL
 Foetal distress
 MANAGEMENT
 Caesarean section is the management of choice.

 Cervicotomy (duhrssen incision)-

 Incision given at 2,6 and 10 o’clock position.

 Not done in modern obstetrics.

Before doing this following points should be kept in mind.

1.Head should be engaged in the pelvis.

2.No suspicion of outlet disproportion.
3.Cervix tightly and thinly stretched over head.

(Ref-Holland & Brews)

GENERALISED TONIC CONTRACTIO
N

 The whole uterus both upper and lower segm

ent in the state of sustained contraction.
 Pronounced retraction occur in the whole uter

us upto internal os.

 No physiological difference in upper and lowe

r segment.
 AETIOLOGY

Cephalopelvic disproportion.

Forcep application before full dilatation.

Injudicious use of oxytocics.

MANAGEMENT - Caesarean section.

 SPASTIC LOWER SEGMENT

 Fundal dominance is lacking.

 Polarity reversed.

 Increased tone in Lower uterine segment and wea

kly acting upper uterine segment.

MANAGEMENT-
 Need to be terminated by caesarean section.

(Ref-Holland & Brews)

 ASSYMETRICAL UTERINE ACTION

 Conditions such as imperfect mullerian fusion

in which two halves act out Independent with
each other may result in production of severe
pain and contraction mainly on one side.

 Management-Caesarean section.
(Ref-Holland & Brews)
 COLICKY UTERUS
 Uterine muscle lack coordination completely.
 Upper uterine segment contract strongly and

spasmodically.
 The contractions are very painful,cramp like a

nd felt in hypogastrium.
 Management-Caesarean section.

(Ref-Holland & Brews)