The document describes different types of abnormal uterine contractions that can occur during labor, including: - Precipitate labor and tonic uterine contraction caused by overly strong and frequent contractions. - Spastic lower segment, colicky uterus, asymmetric contractions and constriction ring which are localized abnormalities. - Uterine inertia where contractions are weak, infrequent and ineffective. It also discusses causes, diagnostic features and management approaches for each abnormality.

2. Problems with the Powers

3.  Regular interval
 Interval gradually shortens
 Intensity gradually increases
 Discomfort in the back and abdomen
 Associated with cervical dilatation
 Discomfort not relieved by sedation

4.  Any deviation from normal pattern of
uterine contractions affecting the normal
course of labour is designated as disordered
or abnormal uterine contraction.
 Over all labour abnormalities occur in 25%
nulliparous and 10% multiparous.

5. Abnormal
Uterine
Action
Normal
Polarity
Excessive
Contraction
1. Precipitate Labour
2. Tonic Uterine
Contraction & Retraction
Uterine
Inertia
Abnormal
Polarity
1. Spastic Lower
Segment
2. Colicky Uterus
3. Asymmetric Uterine
Contraction
4. Constriction Ring
5. Generalized Tonic
Contraction
6. Cervical Dystocia
Types of Abnormal
Uterine Contraction

6. First birth specially with advancing age of the mother
Prolonged pregnancy
Over distention of the uterus
Psychological factor
Contracted pelvis, mal-presentation and deflexed
head

7. Injudicious administration of
sedatives, analgesics and oxytocics
Premature attempt at vaginal
delivery or attempted
instrumental vaginal delivery
under light anesthesia
Cervical rigidity
Massively obese clients

8.  Weak, infrequent and ineffective uterine
contractions
 Intensity is diminished
 Duration is shortened
 Good relaxation in between contractions
and the intervals are increased.

9. 1. General factors:
 Primi-gravida especially elderly.
 Anemia, chronic illness, antepartum
hemorrhage
 Hypertensive states with pregnancy.
2. Local factors:
 Over distension of the uterus
 Anomalies in development of the uterus
 Mal-presentations and mal-position
 Full bladder or rectum.
 Uterine fibroids
 Induction of premature labour.

10. Classification
of Uterine
Inertia
Primary
Inertia
Secondary
Inertia

11.  Labor is prolonged
 On Examination:
 weak increase in the uterine tone
 uterine contractions in 10 minutes are less
than 3 contractions and each lasting less
than 30 seconds.

12.  In the 1st stage: Nervousness, anxiety, exhaustion and
starvation ketoacidosis
 In the 2nd stage: Prolonged 2nd stage, increase liability
for instrumental delivery and cesarean section.
 In the 3rd stage: Retention of the placenta and
postpartum hemorrhage.
 Sub-involution of the uterus.
 Risks of abuse of uterine stimulants.

13.  Proper diagnosis
 Exclusion of cephalo-pelvic
disproportion and mal-presentations
 Oxytocin stimulation:
• To increase the strength, frequency and
duration of the uterine contractions.
 Close observation of the mother & the
fetal well being.
 Assessment of efficiency of uterine
contractions

14.  Operative interference:
 Artificial rupture of the membranes
 Operative delivery indicated if labor is prolonged beyond
24hours or if there is fetal distress at any time.
 One of the following may be done:
o Vaginal delivery by forceps if the cervix is fully dilated
and the conditions are suitable for vaginal delivery.
o Caesarean section: if fetal distress occurs before full
dilatation of the cervix.

15. It is defined as either a series of single
contractions lasting 2 minutes or more or a
contraction frequency of five or more in 10
minutes.
 Strong and painful uterine contraction
 High frequency
 Slow cervical dilatation
 Two pole of uterus doesn’t functions

16.  Labour is prolonged
 Uterine contractions are
irregular and more painful
 High resting intrauterine
pressure in between uterine
contractions detected by
tocography
 Slow cervical dilatation
 Premature rupture of
membranes
 Fetal and maternal distress

17.  CPD, Fetal Distress- Caesarean
Section
 Vital monitoring
 I/V therapy: correction of
dehydration and ketoacidosis
 I/O charting
 FSH every 15 min
 Partograph

18. Uterine Contraction:
 Fundal dominance is lacking
 Reverse polarity
 Lower segment contractions are
stronger
 Inadequate relaxation in between
the contractions
 Premature bearing down
 Cervix loose, edematous, not well
applied to the presenting part

19.  Patient is agony with unbearable pain referred to the back.
 Bladder is frequently distended; distension of stomach and
bowels are visible.
 Premature attempts to bear down.
 Abdominal palpation reveals:
 Uterus is tender and gentle manipulation excites hardening of the
uterus with pain
 Uterus remains tense even after contraction passes off and as
such
 Palpation of the fetal parts is difficult

20.  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 membrane
 Varying degree of caput
 Meconium stained liquor amnii
 Effect on the Fetus: Fetal distress
appears early due to placental
insufficiency caused by inadequate
relaxation of the uterus.

21.  Caesarean section-most
common.
 Prior correction of
dehydration and ketoacidosis
 Conservation approach with
adequate pain relief.
* NO OXYTOCIN
AUGMENTATION

22.  It is a persistent localized annular spasm of the circular
uterine muscles .

23.  It occurs at any part of the uterus but usually at junction of the
upper and lower uterine segments around a constricted part of the
fetus usually around the neck in cephalic presentation.
 It can occur at the any stage of labour and is usually reversible and
complete.

24. Etiology is unknown but the predisposing
factors are:
 Malpresentations and malpositions
 Premature rupture of membrane
 Premature attempt of instrumental delivery
 Intrauterine manipulations under light
anesthesia.
 Improper use of oxytocin e.g. use of
oxytocin in hypertonic inertia or IM
injection of oxytocin.

25.  Maternal condition not affected.
 Fetal distress may occur
 Ring is not palpable during per abdomen
 Felt into first stage during – Caesarean
Section
 Second stage – Forceps application
 Third stage – Manual removal of
placenta.

26. Diagnosis is difficult.
More common in primi gravida and
frequently preceded by colicky uterus
The exact diagnosis is achieved only by
feeling the ring with a hand introduced into
the uterine cavity.

27. Prolonged 1st
stage
Prolonged 2nd
stage
Retained placenta
and postpartum
hemorrhage
• if the ring
occurs at the
level of the
internal Os.
• if the ring
occurs around
the fetal neck.
• if the ring
occurs in the
3rd stage

28. 3rd stage: Deep general anesthesia and amyl nitrite inhalation
followed by manual removal of the placenta.
2nd stage: Deep general anesthesia and amyl nitrite
ring is relaxed, delivery by
forceps
ring does not relax,
caesarean section
1st stage: Pethidine morphine
Exclude malpresentations, malposition and
disproportion

29.  This type of uterine contraction is predominately due to
obstructed labor.
 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.
 As a result of lower segment thinning and concomitant upper
segment thickening.

30. Pathological Retraction 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 fetus.
Contraction increases in intensity ,duration and frequency
with decreased relaxation in between.
Retraction continues
Progressive thinning & elongation of lower uterine segment
Development of circular groove between upper and lower
segment-called BANDL’S RING.

33. Continuous pain, discomfort, restlessness.
Features of exhaustion and ketoacidosis
Abdominal palpation reveals:
• Upper uterine segment is tender and hard. Lower uterine
segment distended and tender.
• Groove is seen between the umbilicus and symphysis pubis
and rises upwards in course of time.
• Fetal part may not be well defined.
• F.H.S. is usually absent.
Internal examination reveals:
• Vagina-dry and hot and the discharge - offensive.
• Cervix fully dilated.
• Membranes are absent.
• Cause of obstructed labour is revealed.

34.  Correction of dehydration and keto-acidosis by
infusion of Ringer's solution.
 Adequate pain relief.
 Parenteral antibiotic is given.
 Caesarean delivery is done in majority of the cases.
 Rupture of uterus must be excluded before attempting
destructive operation.

36. 1. Organic (secondary)
Due to:
 Cervical stances as a sequel to
previous amputation, cone biopsy,
extensive cauterization or
obstetric trauma.
 Excessive scarring or rigidity of
cervix from previous operation or
disease.
 Post delivery.
 Organic lesions as cervical myoma
or carcinoma.
2. Functional (primary):
In spite of the absence of any
organic lesion and the well
effacement of the cervix, the
external Os fails to dilate.
Due to:
 lack of softening of the cervix
during pregnancy or cervical
spasm resulted from overactive
sympathetic tone or excessive
fibrous tissue.
 Insufficient uterine contraction.
 Malpresentation and
malposition.
Failure of the cervix to dilate within a reasonable time in spite of
good regular uterine contractions

37. If only thin rim of cervix left behind- it is pushed up
manually during contraction.
If cervix is thinned out but only half dilated –
Duhrssens’s incision is given at 2’oclock and 10 o’clock
position followed by forceps or ventouse extraction.

38. Organic dystocia:
• Caesarean section is the management of choice.
 Functional dystocia:
• Pethidine and antispasmodics: may be effective.
Caesarean section: if medical treatment fails or
fetal distress developed.

39.  Pronounces retraction occurs involving whole of the uterus up
to the level of internal Os.
 No physiological differentiation of the active upper segment
and the passive lower segment of the uterus.
 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).

40. Failure to overcome the obstruction by
powerful contractions of the uterus.
Injudicious administration of oxytocics
Irritation caused by repeated unsuccessful
attempt of instrumental delivery.

41.  The patient is in prolonged labor having severe and
continuous pain.
 PER ABDOMINAL EXAMINATION
 Uterus is smaller in size, tense, tender
 Fetal parts are not palpable
 Fetal heart sounds not audible
 PER VAGINAL EXAMINATION
 Dry and edematous vagina
 Jammed head with a big caput

42.  Correction of dehydration and keto acidosis: by rapid
infusion of Ringer’s solution
 Antibiotics : To control infection
 Adequate pain relief
 Tocolytic agents for e.g terbutalin 0.25mg S.C : to
manage hypercontractility (tachysystole) induced by
oxytocics.
 Caesarean delivery is done in majority of cases.

44. Precipitate labour refers to a labour pattern that
progresses rapidly and ends with delivery occurring in less
than 3 hours is typically less than 5 hours after the onset
of uterine activity.
It is due to strong coordinate uterine contractions in
absence of obstruction in the birth canal, and resistance
of the soft tissues.
The patient does not feel contractions except the last
contractions during the expulsion of the fetus.

45. 1
• Maternal multi parous status.
2
• Small fetus
3
• Relaxed pelvic and vaginal musculature
4
• History of rapid labors with previous deliveries
5
• A particularly efficient uterus which contracts
with great strength

46. A sudden onset of intense, closely timed contractions
with little opportunity for recovery between
contractions.
The sensation of pressure including an urge to push
that comes on quickly and without warning.
Often times this symptom is not accompanied by
contractions as the cervix dilates very quickly.

47.  It is a retrospective diagnosis as the patient is usually
seen in the 2nd or 3rdstages of labor.
 If seen during the first stage of the labor, the
Partograph will show rapid progress of cervical
dilatation and effacement.

48. FOR MOTHER
 Increased risk of tearing and laceration of the cervix and
vagina
 Predisposing to postpartum hemorrhage and sepsis
 Atonic Uterus: due to uterine exhaustion
 Hemorrhaging from the uterus or vagina
 Shock following birth which increases recovery time
 Delivery in an unsterilized environment such as the car or
bathroom

49. FOR BABY
 Risk of infection from unsterilized delivery
 Potential aspiration of amniotic fluid
 Intracranial hemorrhage: due to rapid compression
and decompression of the fetal head during delivery.
 Fetal injuries
 Avulsion (forcible separation) of the cord
 Neonatal sepsis

50. BEFORE DELIVERY
A patient with past history of precipitate labor should be admitted to
the hospital at the first perception of labor pains.
DURING DELIVERY
Rarely if the patient is seen during delivery, general anesthesia
(inhalation by nitrous oxide and oxygen or sedation) may be given to
slow down the course of delivery to prevent forcible bearing down.
AFTER DELIVERY
 If the patient is seen after delivery: exploration of the birth canal for
any injury and manage accordingly.
 Prophylactic antibiotics if delivery occurred in unsuitable
conditions.
 Proper examination of the fetus for detection of any complications.
 Continuous assessment of maternal and fetal status.

52. Preterm labor is defined as the presence of
contractions of sufficient strength and
frequency to effect progressive effacement
and dilatation of the cervix between 20 and
37 weeks’ gestation.
(American College of Obstetricians and
Gynecologists, 2003)

53. Obstetric
complications
Demographic
factors
Psychosocial
factors
Past obstetric
history
Infection
Genetic
factors

55. The two most promising markers currently available are:
1. Fetal fibronectin levels
2. Ultrasound assessment of cervical length.
Fetal fibronectin (fFN) testing:
 It is an extracellular glycoprotein secreted by the chorionic
tissue at maternal-fetal interface.
 It acts as a biological glue which binds blastocyst to
endometrium.
 It can be normally present in cervico-vaginal secretions up
to 20-22 wks. Thus, presence of fFN between 27 to 34
weeks can provide important marker of preterm labour

56. SAMPLE : Sample is taken from the posterior fornix of
the vagina.
VALUES: A cut-off of 50 ng/ml is considered positive.
Length of cervix:
 Cervix can be assessed digitally or by ultrasound.
 A reduction in cervical length of >6mm between 2
ultrasounds have higher risk.

57. PRIMARY PREVENTION :
 Smoking cessation .
 Nutritional counseling .
 Lower workload for women with stressful jobs
SECONDARY PREVENTION :
 Self-measurement of the vaginal pH for B.V.
 Cervix length measurement by TVS .
 The accepted cutoff value for cervix length is ≤ 25 before GW
24 ).
 Cerclage and complete closure of the birth canal.
 Progesterone supplementation.

58.  Inhibition of uterine contractions with tocolysis.
 Corticosteroids to induce fetal lung maturation.
 Treatment of infection with antibiotics.
 Bed rest and hospitalization.
INTRAPARTUM MANAGEMENT
1. Monitoring: The preterm fetus should be monitored closely
for signs of hypoxia during labour, preferably by continuous
electronic fetal monitoring.
2. Antibiotic prophylaxis
3. Delivery: Delivery must be conducted in the presence of
expert neonatologist capable of dealing with complications
of prematurity.
* Ventouse is contraindicated in preterm deliveries.
1. Caesarean section: only for obstetric indications.

60. The labour is said to be prolonged when the combined
duration of the first and second stage is more than the
arbitrary time limit of 18 hrs.
Latent Phase: Latent phase is the preparatory phase of the
uterus and the cervix before the actual onset of labour.
Normal latent phase is about 8 hours in primi gravida & 4
hours in multi gravida.
Prolonged Latent Phase: A latent phase that exceeds 20
hrs in primi gravida or 14 hrs in multi gravida is abnormal.

61. Unripe cervix
Malposition and malpresentation
Cephalopelvic disproportion
Premature rupture of the membranes
Abnormal uterine contraction
Contracted pelvis
Congenital malformation of the baby

62. FIRST STAGE: First stage of labour is considered prolonged
when the duration is more than 12 hrs.
 The rate of cervical dilatation is < 1 cm/hr in primi and < 1.5
cm/hr in multi.
 The rate of descent if the presenting part is < 1 cm/hr in
primi and < 2 cm/hr in multi.
SECOND STAGE: The 2nd stage is considered prolonged if it
lasts for more than 2 hrs in primi, and 1 hr in multi. The
diagnostic features are:
 Sluggish or non descent of the presenting part even after full
dilatation of the cervix.
 Variable degrees of molding and caput formation in cephalic
presentation.
 Identification of the cause of prolongation.

63. FETAL
• Hypoxia
• Intrauterine
infection
• Intracranial stress
or hemorrhage
• Increased operative
delivery
MATERNAL
• Distress
• Postpartum
hemorrhage
• Trauma to the
genital tract
• Increased operative
delivery
• Puerperal sepsis
• Sub-involution

64.  Antenatal or early intranatal detection of the factors likely to
produce prolonged labour (big baby, malpresentation or position).
 Use of partograph helps early detection.
 Selective and judicious augmentation of labour by low rupture of
membranes followed by oxytocin drip.
 Change of posture in labour other than supine to increase the
uterine contractions.
 Avoidance of labour dehydration. Use of adequate analgesia for
pain relief.

65. First Stage Delay
 Vaginal examination is done to verify the fetal presentation,
position and station.
 Clinical pelvimetry is done, if only uterine activity is sub-
optimal.
 Amniotomy and/ or oxytocin infusion is adequate.
 Effective pain relief is given by IM Inj: Pethidine or by regional
analgesia.
 Caesarean section is done when vaginal delivery is unsafe.

66. Second Stage Delay
 Short period of expectant management is reasonable
provided the FHR is reassuring and vaginal delivery is
imminent.
 Otherwise appropriate assisted delivery vaginal
(forceps,ventouse) or abdominal (caesarean) should
be done.