UNIT 13.

1
INCOORDINATED (HYPO AND
AUGMENTATION OF LABOUR

HYPERTONIC)

UTERINE

ACTIONS

AND

Incoordinated Uterine Actions

Incoordinated uterine action is a state of uterine dysfunction. The contraction are usually strong,
painful and/or may be frequent but cervix dilates slowly. The two poles of uterus do not function
rhythmically (incordination between two poles). It may be any cause of prolonged labour.
Management

Exclude CPD and if moderate to severe degree of CPD present managed by caesarean
section.

Monitor vital sign, fluid intake and urine output to detect abnormal condition and prevent
from ketoacidosis.

Monitor and record FHS every 15 minute intervals.

Adequate fluid should be given to prevent dehydration.

Keep trial in labour by giving injection oxytocin.

Hypertonic uterine contraction is extremely dangerous for fetus so fetal condition should be
assessed frequently and if fetal distress present immediate delivery by C/S.

Hypotonic Uterine Actions (Uterine inertia)

Uterine inertia is the common ty.pe of disordered uterine contraction in which uterine
contractions are weak and dilatation of cervix is slow. It may be present from the beginning of
labour or may develop subsequently after a variable period of effective contractions. It is
comparatively less serious. It may complicate any stage of labour.
Characteristics of uterine contractions
The intensity is diminished, duration is shortened, good relaxations in between contractions and
the intervals are increased. General pattern of uterine contractions of labour is maintained but
intrauterine pressure during contraction is below 25 mmofHg.
Diagnosis

Patient feels less pain during uterine

Less hardening of the uterus during contraction.

Uterine wall is easily indentable at the acme of a pain.

Uterus becomes relaxed after the contraction

Fetal parts are well palpable and FHR remains normal.

Internal examinations:
poor dilatation of cervix

Associated presence of contracted pelvis

Malposition
Deflexed head or malpresentation
Membranes usually reamain intact
Cervix well applied the presenting part
Complication
Effects on mother:
-

Maternal distress

Prolonged labour (may go on several days)

Infection (if membrane ruptured early)

Risk of PPH during third stage of labour due to atony of uterus.

Effects on fetus:
-

Fetal distress

Management
1. Careful evaluation of the case is to be done.
- To be sure that patient is in true labour
- To exclude CPD and malpresentation and plan the management protocal
2. Plan caesarean section in case of contracted pelvis, malpresentation, evidence of fetal or
maternal distress.
3. Vaginal Delivery:
General Measures:
-

Reassure the patient to keep up the morale and psychological depression, maternal stress
and emotion appear to inhibit uterine contraction through endogenous adrenaline.

The posture of the patient is changed, supine position is avoided.

Encourage to empty the bladder frequently, if fails to empty herself catheterization

should be done.

Empty the bowel by enema

Maintain hydration and nourishment by infusion of Ringers Lactate or 5% dextrose and

frequent oral fluid intake.

Give adequate sedation to relief pain.

Provide calm and quite environment to induce good sleep.

Active Measures
Acceleration of uterine contraction can be brought by low rupture of membranes followed by
oxytocin drip if not contraindicated. The drip rate is gradually increased until effective
contractions are set up. The drip is to be continue till one hour after delivery.
Hypertonic Uterine Actions
The hypertonic uterine actions abnormal uterine actions in which tone of the uterus is high during
and between contractions with severe backache. The higher tonic state of the uterus arises from
any of the condition such as spastic lower uterine segments, colicky uterus, asymmetrical uterine
contraction, contriction ring or generalized tonic contraction of the uterus and all these states are
collectively called incoordinate uterine action.
Types

Colicky uterus: incoordination of the different parts of the uterus in contractions.

Hyperactive lower uterine segment: so the dominance of the upper segment is lost.

Clinical Picture
The condition is more common in primigravidae and characterised by:

Labour is prolonged.

Uterine contractions are irregular and more painful. The pain is felt before and
throughout the contractions with marked low backache often in occipito-posterior
position.

High resting intrauterine pressure in between uterine contractions detected by

tocography (normal value is 5-10 mmHg).

Slow cervical dilatation .

Premature rupture of membranes.

Foetal and maternal distress.

Management

General measures: as hypotonic inertia.

Medical measures:

Analgesic and antispasmodic as pethidine.

Epidural analgesia may be of good benefit.

Caesarean section is indicated in:

Failure of the previous methods.

Disproportion.

Foetal distress before full cervical dilatation.

CONSTRICTION (CONTRACTION) RING

Definition

It is a persistent localised spastic contraction of a ring of the circular muscles fibers of the
uterus.
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 1st, 2nd or 3 rd stage of labour. It is usually reversible and complete

Aetiology
Unknown but the predisposing factors are:

Malpresentations and malpositions.

Clumsy intrauterine manipulations under light anaesthesia.

Premature rupture of the membranes

Premature attemp at instrumental delivery

Improper use of oxytocin e.g.

use of oxytocin in hypertonic inertia.

IM injection of oxytocin.

Diagnosis

Diagnosis is difficult. Presenting part is failure to descent even during effective

contraction.

The condition is more common in primigravidae and frequently preceded by

colicky uterus.

The exact diagnosis is achieved only by feeling the ring with a hand introduced
into the uterine cavity.

It is revealed durign caesarean section in first stage, during forceps application in

2nd stage and during manual removal in 3rd stage.

Complications

Prolonged 1st stage: if the ring occurs at the level of the internal os.

Prolonged 2nd stage: if the ring occurs around the fetal neck.

Retained placenta and postpartum haemorrhage: if the ring occurs in the 3rd
stage (hour- glass contraction).

Management

Exclude malpresentations, malposition and disproportion.

In the 1st stage: Pethidine may be benefit.

In the 2nd stage: Deep general anaesthesia and amyl nitrite inhalation are given
to relax the constriction ring:

If the ring is relaxed, the fetus is delivered immediately by forceps.

If the ring does not relax, caesarean section is carried out with lower segment
vertical incision to divide the ring.

In the 3rd stage: Deep general anaesthesia and amyl nitrite inhalation are given
followed by manual removal of the placenta.

CERVICAL DYSTOCIA
Definition
Failure of the cervix to dilate within a reasonable time in spite of good regular uterine
contractions is called cervical dystocia.

TYPES

Primary (Functional) dystocia

In spite of the absence of any organic lesion and the well effacement of
the cervix, the external os fails to dilate despite normal pattern of
uterine contraction.

This may be due to lack of softening of the cervix during pregnancy or

cervical spasm resulted from overactive sympathetic tone.

Secondary (Organic) dystocia :

Failure to dilate cervix due to previous amputation, cone biopsy,

extensive cauterisation or obstetric trauma.

Organic lesions as cervical myoma or carcinoma

Complications

Annular detachment of the cervix: surprisingly the bleeding from the cervix is
minimal because of fibrosis and avascular pressure necrosis leading to
thrombosis of the vessels before detachment.

Rupture uterus.

Postpartum haemorrhage: particularly if cervical laceration extends upwards

tearing the main uterine vessels.

Management
(I) Primary dystocia:

Pethidine and antispasmodics: may be effective.

If head is sufficiently low down with only thick rim of cervix left behind, the rim
may be pushed up manually during contraction and vaginal delivery can be made.

Caesarean section: if

medical treatment fails or

fetal distress developed.

(II) Secondary dystocia:

Caesarean section is the management of choice.

Tonic uterine contraction and retraction (Bandls Ring)

Physiological Rings:
It is a line of demarcation between the upper and lower segment present during normal labour
and cannot usually be felt abdominally.
Pathological Rings (Bandls Ring):
It is the rising up retraction ring during obstructed labour due to marked retraction and
thickening of the upper uterine segment where the relatively passive lower segment is
markedly stretched and thinned to accommodate fetus.
The bandls ring is seen and felt abdominally as a transverse groove that may rise to or above the
umbilicus.
Sign and symptoms

Mother becomes tired and restless due to continuos pain and discomfort.

Feature of exhaustion and keto-acidosis seen.

Abdominal palpation revels:

- upper segment is hard, unformly convex and tender.
- retraction ring is placed obliquely between the umbilicus and symphsis pubis.
- fetal part may not be well defined.
- FHS is usually absent.

Vaginal examination revealed:

- dry, hot vagina with offensive discharge.
- cervix fully dilated

- cause of obstructed labour is revealed.

Prevention
Abnormality either in passage or in passenger can be detected during antenatal or early intranatal period
and delivery by caesarean section.
Management
a.
b.
c.
d.
e.
f.
g.

Rupture of uterus is excluded.

Analgesic and sedation should be given to keep patient calm.
Correction of dehydration and ketoacidosis by infusion of Ringers solution must be done.
Adequate pain relief measures must be used.
Prophylaxis antibiotics to be given to prevent secondary infection.
Prepare for delivery by Caesarean Section.
Destructive operation may be safe in advanced obstructed labour as it may rupture the uterus.