Abnormal uterine action is the one of the factors causing dystocia in which uterine forces are insuffiently strong or inappropriate coordinated to efface and dilate the cervix. Pelvic contraction is often accompanied by uterine dysfunction and the two together constitute the most common cause of dystocia.

1. ABNORMAL UTERINE
ACTION
Prepared By
Ms. Nivetha Manikandan
Tutor, KGNC

2. INTRODUCTION
Abnormal uterine action is the one of the factors
causing dystocia in which uterine forces are
insuffiently strong or inappropriate coordinated to
efface and dilate the cervix. Pelvic contraction is
often accompanied by uterine dysfunction and the
two together constitute the most common cause of
dystocia.

3. BRIEF REVIEW OF NORMAL UTERINE
CONTRACTIONS
POLARITY OF UTERUS: When upper segment contracts, lower
segment relaxes.
PACEMAKERS: Two pacemakers situated at each cornua of
uterus generating the contraction in co-ordinated manner.
PATTERN OF CONTRACTIONS: uterine
contraction starts at cornua, propagates towards lower uterine
segment with decrease in the duration and intensity of
contraction as it moves away from pacemaker.

4. DEFINITION OF ABNORMAL UTERINE
ACTION
Any deviation of the normal pattern of
uterine contractions affecting the
course of labor is designated as
disordered or abnormal uterine action.

5. CLASSIFICATION

6. ETIOLOGY
 Prevalent in first birth specially with elderly
women
 Prolonged pregnancy
 Overdistension of the uterus (twins and
fibroids)
 Emotional factor (anxiety, stress)
 Constitutional factor (obesity)
 Contracted pelvis and malpresentation

7.  Injudicious administration of
sedatives, analgesics and
oxytocics
 Premature attempt at vaginal
delivery or attempted instrumental
vaginal delivery under light
anesthesia.

9. UTERINE INERTIA (HYPOTONIC UTERINE
DYSFUNCTION)
Uterine inertia is the common type of disordered
uterine contraction but is comparatively less
serious. It may complicate any stage of labor. It
may be present from the beginning of labor or may
develop subsequently after a variable period of
effective contractions.

10. UTERINE CONTRACTION
The intensity is diminished; duration is shortened;
good relaxation in between contractions and the
intervals are increased. General pattern of uterine
contractions of labor is maintained but intrauterine
pressure during contraction is below 25 mm of Hg.

11. DIAGNOSIS
 Patient feels less pain during uterine contraction
 Hand placed over the uterus during uterine
contraction reveals less hardening of the uterus
 Uterine wall is easily indentable at the acme of a
pain
 Uterus becomes relaxed after the contraction;
fetal parts are well palpable and fetal heart rate
remains normal

12. Internal examination reveals
 Poor dilatation of the cervix
 Associated presence of contracted pelvis,
malposition, deflexed head or mal
presentation may be evident
 Membranes usually remain intact.

13. EFFECTS ON THE MOTHER AND FETUS
Maternal exhaustion and or fetal distress are unusual and
appear late.
MANAGEMENT:
Case is reassessed to exclude cephalopelvic disproportion or
malpresentation.

14. Place of cesarean section
Presence of contracted pelvis
Malpresentation
Evidences of fetal or maternal distress

15. VAGINAL DELIVERY
GENERAL MEASURES:
 To keep up the morale of the patient. Maternal stress and emotion
appear to inhibit uterine contractions through endogenous
adrenaline
 Posture of the woman is changed. Supine position is avoided
 To empty the bladder, catheterization is made
 To maintain hydration by infusion of Ringer’s solution
 Adequate pain relief

16. ACTIVE MEASURES:
Acceleration of uterine contraction can be brought
about by low rupture of the membranes followed by
oxytocin drip. The drip rate is gradually increased
until effective contractions are set up

17. TONIC UTERINE CONTRACTION AND
RETRACTION
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.
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).

18. In primigravidae further retraction ceases in response to
obstruction and labour comes to a stand still-a state of
exhaustion.
In multiparae retraction continues with progressive dilatation
and thinning of lower uterine segment
Bandl’s ring moves towards the umblicus
Rupture of lower uterine segment Fetal jeopardy
and death

20. Clinical features
 Patient is in agony from continuous pain and
discomfort and becomes rest-less
 Features of exhaustion and ketoacidosis are
evident
 Abdominal palpation reveals—
(a) Upper segment is hard and tender
(b) Lower seg-ment is distended and tender.

21. Management:
Partographic management of labor, early
diagnosis of malpresentation, disproportion and
delivery by cesarean section can prevent this
condition completely.

22. Treatment:
 Rupture of uterus is to be excluded
 Internal version is contraindicated
 Correction of dehydration and ketoacidosis by infusion
of Ringer’s solution
 Adequate pain relief
 Parenteral antibiotic is given (Ceftriaxone 1 g IV)
 Cesarean delivery is done in majority of the cases.
Rupture of uterus must be excluded before attempting
destructive operation.

23. PRECIPITATE LABOUR

25. INCOORDINATE UTERINE ACTION
This variety usually appears in active stage of labor.
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 action.

27. SPASTIC LOWER SEGMENT
UTERINE CONTRACTION
 Fundal dominance is lacking and often there is reversed
polarity
 The pacemakers do not work in rhythm
 The lower segment contractions are stronger
 Inadequate relaxation in between contractions
 Basal tone is raised above the critical level of 20 mm Hg

28. Diagnosis:
 The patient is in agony with unbearable pain referred to
the back. There are evidences of dehydration and
ketoacidosis
 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

29. Abdominal palpation reveals:
 Uterus is tender and gentle manipulation excites
hardening of the uterus with pain
 palpation of the fetal parts is difficult
 Fetal distress appears early

30. Internal examination may reveal:
 Cervix which is thick, edematous hangs
loosely like a curtain; not well applied to
the presenting part
 Inappropriate dilatation of the cervix
 Absence of the membranes
 Meconium stained liquor amnii may be
there

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

32. Management:
There is no place of oxytocin
augmentation with this abnormality.
Cesarean section is done in majority of
cases. Prior correction of dehydration and
ketoacidosis must be achieved by rapid
infusion of Ringer’s solution.

33. Constriction ring
It is one form of incoordinate uterine action where there is
localized myometrial contraction forming 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 the stages of labor. It is usually reversible and complete.

35. The common causes are:
 injudicious administration of oxytocics
 premature rupture of the membranes
 premature attempt at instrumental
delivery.

36. Treatment:
Delivery is usually done by cesarean section. The ring usually
passes off by deepening the plane of anesthesia, otherwise the
ring may have to be cut vertically to deliver the baby. The
difficulties faced during forceps delivery (second stage) or
during normal removal of placenta (third stage) can be
overcome by using deep anesthesia that relaxes the constriction
ring.

37. CERVICAL DYSTOCIA
 Progressive cervical dilatation needs an effective stretching force
by the presenting part. Failure of cervical dilatation may be due to
 Inefficient uterine contractions
 Malpresentation, malposition (abnormal relationship between the
cervix and the presenting part)
 Spasm (contractions) of the cervix. Cervical dystocia may be
primary or secondary.

38. PRIMARY CERVICAL DYSTOCIA:
Commonly observed during the
 First birth where the external os fails to dilate (
 Rigid cervix
 Inefficient uterine contractions and the others

39. Treatment
In presence of associated complications (malpresentation,
malposition), cesarean section is preferred. If the head is
sufficiently low down with only thin rim of cervix left behind, the
rim may be pushed up manually during contraction or traction is
given by ventouse. In others, where the cervix is very much thinned
out but only half dilated. Duhrssen’s incision at 2 and 10’O clock
positions followed by forceps or ventouse extraction is quite safe
and effective.

40. SECONDARY CERVICAL DYSTOCIA:
 This type of cervical dystocia results usually due to
excess scarring or rigidity of the cervix from the
effect of previous operation or disease
 Post delivery
 Postoperative scarring
 Cervical cancer.

41. GENERALIZED TONIC CONTRACTION
In this condition, pronounced retraction occurs involving
whole of the uterus up to the level of internal os. Thus,
there is no physiological differentiation of the active upper
segment and the passive lower segment of the uterus. The
whole uterus undergoes a sort of tonic muscular spasm
holding the fetus inside (active retention of the fetus).

42. Causes
Cephalopelvic disproportion
 Obstruction
 Injudicious use of oxytocics.

43. Clinical features
 The patient is in prolonged labor having severe and
continuous pain. Abdominal examination reveals the
uterus to be somewhat smaller in size, tense and tender.
Fetal parts are neither well defined, nor is the fetal
heart sound audible. Vaginal examination reveals
jammed head with big caput; dry and edematous vagina.

44. Treatment:
Correction of dehydration and
ketoacidosis — by rapid infusion of
Ringer’s solution
Antibiotic — to control infection
 Adequate pain relief.

45. NURSE’S ROLE IN ABNORMAL UTERINE CONTRACTION
 Review the history of labor, onset, and duration.
 Note timing/type of medication(s). Avoid administration of
narcotics or of epidural block anesthetics until the cervix is 4
cm dilated.
 Note the condition of cervix. Monitor for signs of amnionitis.
Note elevated temperature or WBC; odor and color of vaginal
discharge.

46.  Evaluate the current level of fatigue, as well as activity
and rest prior to onset of labor.
 Note effacement, fetal station, and fetal presentation.
 Evaluate degree of hydration. Note amount and type of
intake.
 Graph cervical dilation and fetal descent against time
(i.e., Friedman curve).
 Review bowel habits and regularity of evacuation

47.  Use nipple stimulation to produce endogenous oxytocin
or initiate infusion of exogenous oxytocin (Pitocin) or
prostaglandins.
 Prepare for forceps delivery, as necessary.
 Assist with preparation for cesarean delivery, as
indicated, e.g., malposition, CPD, or Bandl’s ring.

48. JOURNAL PRESENTATION
Uterine Contractions in Normal Labor Developed by
a Positive Feed-back and Oscillation by KAZUO
MAEDA
Regular stable labor contractions of uterus is formed in the
oscillation by the positive feed-back system composed of
hypothalamus-hypophysis-oxytocin secretion, uterine
contractions and uterus-brain innervations.