ABNORMAL UTERINE

ACTION
HNS 317
Review Normal uterine action
• Normal uterine action is strengthened in labour by effects of
prostaglandins and oxytocin.
• Myometrium contracts and retracts and its efficiency depends
on the fundal dominance and the polarity between the upper
and the lower uterine segments
• Coordination and harmony of the segment is facilitated by the
cell electrical impulses in the myometrium.
Review Normal uterine action
• NB if the process above is ineffective, then results abnormal
uterine action.
• NB effectiveness of contractions is further influenced by
cervical and soft tissue resistance, size and position of fetus
and maternal pelvis.
ABNORMAL UTERINE ACTION
• Def-Abnormal uterine action is a dysfunction of uterine
muscles due to neuromuscular disharmony.

Types of abnormal uterine action include:

1. Hypotonic uterine action
2. Incoordinate uterine action
3. Cervical dystocia
4. Precipitate labour
1.Hypotonic Uterine Action
• Def. This is poor tone in the uterine muscle fibres which
results from weak/short contractions.
• The contractions are infrequent and cause less pain.
• The uterus may be indented at the height of a contraction.
• Both mother and baby are not affected by the contractions.
• The effects of weak contractions bring about very slow or no
cervical dilatation.
• This results in prolonged labour.
• There are two types of hypotonia; primary and secondary
uterine inertia also respectively known as primary and
secondary hypotonia
• Primary hypotonia- starts at the onset of labour.
• The cause is unknown and it is common in primigravida.
• Secondary hypotonia occurs when labour has already been
established.
• The uterus is exhausted and contractions slow down, due to:
• Retained second twin
• Cephalopelvic disproportion
• Malpresentation or malposition
• Effect after epidural anaesthesia
• Complications
• Maternal exhaustion
• Poor coping abilities
• PPH due to insufficient uterine contraction after birth
• Intrauterine infection if labour is prolonged
• Foetal distress-prolonged labour
• Foetal/ neonatal sepsis
 Management of Hypotonic Uterine
Action
• Admit the mother in hospital or transfer to a hospital if she is in a
health centre.
• Reassure her and then sedate her to reduce anxiety and calm her
down to sleep.
• Perform an abdominal and pelvic exam to exclude cephalopelvic
disproportion.
• Determine the cause of OPP. If this is present she should be
prepared for a caesarean section.
• Evaluate nature of contractions , if need be augmentation is done
Active management of labour is instituted.(artificial rapture of
membranes, timed VE, augmentation,) to prevent prolonged
labour.
Check on the following factors:
• Frequency, strength and duration of the contractions
• Vital signs, that is, maternal pulse and BP and general condition
• Foetal heart rate
• Descent of the presenting part
• A vaginal examination is done every two to four hours to
determine cervical dilatation.
• The urine is tested every two hours for sugar, acetone and
albumin.
• If there is foetal or maternal distress in the first stage of labour,
the mother is prepared for caesarean section.
• However, if the mother is in the second stage or nearing second
stage and contracting and dilating well, the delivery can be
assisted by vacuum extraction.
• The possibility of post partum haemorrhage should be
anticipated.
• Oxytocic should be administered routinely and IV access secured
Incoordinate Uterine Action

Def-Incoordinate uterine action is alteration in the polarity of the

uterus with an increase in the resting tone.
• The uterus is very irritable.
• The contractions are strong, painful and erratic but in spite of
strong contractions, the cervix dilates slowly.
• Clinically, the patient experiences a lot of pain both before and
after contraction.
• She is exhausted and with every contraction bears down early
due to severe backache.
• This may lead to retention of urine.
• Foetal hypoxia occurs due to the hypertonic state of uterus,
which interferes with the placental circulation.
• On Vaginal Examination (VE) the cervix is noted to dilate
slowly despite frequent painful contractions.
• The cervix is tight, unyielding and oedematous since the
mother bears down with each contraction.
 • There are four variations of Incoordinate uterine action.
i. Hypertonic Lower Uterine Segment
• In this case, the lower uterine segment is hypertonic.
• There is loss of polarity and intermittent abdominal pains.
• The pains occur before and persist long after a uterine
contraction.
• The cervix fails to dilate.
• This pattern is associated with malposition of occiput and
minor degree of disproportion.
• Colicky Uterus
• The upper uterine segment contracts strongly and
spasmodically.
• Coordination of different parts is lacking.
• As a result of the different parts of the uterus contracting
differently the cervical dilatation is ineffective.
• There may be reduced placental blood flow leading to foetal
distress.
• There is severe generalized pain, contractions are not effective
and the uterus is tender.
• The mother may not experience severe backache.
iii. Constriction Ring Dystocia.
• It is a localized spasm of a ring of muscle fibres.
• This is a result of disorganized uterine action.
• It is commonly found near the junction of both the upper and
lower uterine segment.
• It usually embraces a narrow part of the neck of the foetus.
• It may happen at any stage of labour but if it occurs in the third
stage, it is known as an hourglass constriction.
• It is associated with use of oxytocin
• The spasm may be triggered by an early rupture of membranes.
• The hypertonic uterus is irritated by being moulded round the
foetus or by inter-uterine manipulation.
• The condition can be diagnosed vaginally when there is a delay
in labour.
• There is no advance of the presenting part and the upper
segment feels tender to the touch.
• 10ml of 2% IV magnesium sulphate solution may relieve
spasms.
• Spurious Labour
• Spurious labour is a condition where contractions occur before
the onset of labour, which are painful and are accompanied by
backache.
• Giving pethidine or morphine 1ml to relax the uterine
contractions can abolish them.
• This differentiates it with true labour.
Management of Incoordinate Uterine
Action
• Cephalopelvic Disproportion (CPD) is usually the underlying
cause of this condition.
• Malpresentation should be ruled out through an abdominal
and vaginal examination.
• If malpresentation is present, the patient should be prepared
for a caesarean section.
• If CPD is not present, she may be allowed to continue in labour.
Management of Incoordinate Uterine
Action
• Close observation is carried out and a record of observations
should be maintained.
• Reassure the mother/family to allay anxiety.
• Assess foetal heart rate, maternal pulse, and respiratory rate
half-hourly.
• Blood pressure should be taken every four hours and urine
testing should be done every two hours.
• Any signs of maternal/foetal distress; dehydration and ketosis,
should be reported promptly and may be corrected by giving
intravenously (IV) 5% dextrose alternating with normal saline.
• Input/output record.
• Analgesics to relieve pain/ sleep/ anxiety
• Epidural analgesia is very effective in prompting normal uterine
action (or pethidine if added to the drip).
• A low dose of 0.25 units oxytocin drip can be given.
• If, after four to six hours, there is still no progress, the mother
should be prepared for a caesarean section.
• A small proportion of mothers with Incoordinate uterine action
may end up in normal delivery or vacuum extraction.
• Effective assessment, management and judgement is
important to prevent complications
 Cervical Dystocia
• Uterine factors
• Normally contractions are regular and intermittent from the
fundus and move downwards towards the cervix (lower uterine
segment ).
• If the uterine activity and contractions are uncoordinated, short
or infrequent this labour will be difficult and prolonged.
• A primigravida is at a higher risk of dystocia as they have a
degree of uterine uncordination thus labour is abnormal.
Fetal factors
Position or lie e.g transverse or breech.
This results in as a combination of fetal factors and pelvic
passage factors.
Pelvic passage factors
A pelvic with a round brim is very favourable in labour.
However, there are some women with a long and oval brim
thus unfavorable.
They fail to dilate due to trauma to the cervix or previous
cone biopsy or catheterization for cervical dysplasia.
 Maternal factors
 A pelvis – a pelvis that is gynecoid – with an adequate brim. Favourable for
vaginal delivery. Although others have android pelvis which have an
adequate brim and sharp ischial spines.
 Other factors – prolonged labour demand to the cervix
 Contractions that are abnormal
 Induction of labour- if contractions are normal but the cervix fails to dilate.
 Gestational diabetes mellitus – increase in glucose levels. The baby is very
big and as a result may damage the cervix or engage before the cervix
dilates
 Maternal obesity:- overweight too much muscle and the contractions are
not in coordination with dilation.
 N/B –Too much oxytocin can lead to hyper stimulation of the uterus.
Diabetes mellitus and macrasomia are associated.
• Cervical dystocia can be divided into two classes; primary and
secondary.
• Primary Cervical Dystocia , the uterine contractions are normal.
• The presenting part is low down in the pelvis but the cervix fails to
dilate.
• The delay is due to the formation of a cartilaginous ring round the
cervix.
• This condition occurs mainly in primigravidae whereby the first
stage is prolonged and there is severe and persistent backache.
• On vaginal examination the cervix feels thin, tight and unyielding.
• Secondary Cervical Dystocia
• This type occurs due to previous trauma to the cervix, for
example, tears which were repaired, scarring, congenital or
from infection.
• The cervix fails to dilate in spite of good uterine contractions.
• The management of cervical dystocia is by encouraging the
mother to lie on her back, knee chest position, elevation of the
bed foot to ease pressure on the cervix and care must be taken
to avoid lacerations.
• Caesarean section should be done to hasten delivery of the
baby.
Cervical dystocia can be further divided into one of three types,
any of which can occur as primary or secondary cervical
dystocia.
1. Rigid cervix
Rigid cervix is a rare condition in which the cervix fails to dilate
despite normal uterine contractions.
It is characterized by severe persistent backache.
On vaginal examination the cervix feels thin, tight and unyielding.
• Annular detachment of the cervix
• Annular detachment of the cervix is characterized by persistent and
prolonged pressure on the rigid cervix, which causes ischemia.
• The necrosed ring of the cervix is detached and expelled and
contributes to a uterine rupture.
• Oedematous anterior lip of cervix
• Oedematous anterior lip of the cervix involves the anterior lip
being nipped between the foetal head and the pelvic brim.
• It becomes swollen due to pressure.
• On vaginal examination the oedematous cervix feels like a firm
ridge as thick as a finger.
• It may also be seen at the vulva as a bluish glistering cervix.
• It delays the first stage of labour, as the cervix does not dilate
effectively.
Complications
• Perinatal morbidity and mortality- from hypoxia and acidosis
• Brachial plexus injury due to the compression of the fetus/baby
during delivery
• Post partum hemorrhage due to damage of the uterine walls
and cervix
• Perineal tears
Management
Its an obstetric emergency. Require to go for immediate surgery
Oxytocin can be used if abnormal uterine contractions are the
cause of dystocia
Monitor the vitals and document in preparation for theatre.
Prepare for theatre call the theatre room for preparations or
transfer the woman to a hospital with such facilities.
Perform blood tests, blood count and urinalysis for preparations
of surgery immediately.
 Precipitate Labour / over efficient
uterine activity
• Def: Precipitate labour, labour that lasts less than 3-4hours,
characterized by strong and frequent contractions from the
onset of labour. This results in an abnormally rapid progress of
labour and delivery may occur within an hour from the onset of
labour.

Contributing factors: multiparity, large pelvis, previous precipitate

labour, a small foetus in a favourable position.
One or more of these factors plus strong contractions result in
rapid descent through birth canal.
Complications
• Maternal
–Cervical and pereneal lacerations.
–The uterus may fail to contract during the third stage of
labour,
–leading to a retained placenta.
–Post partum haemorrhage,
–Uterine inversion,
–Shock and collapse may occur due to sudden relief of
pressure.
• Foetal
–Hypoxia, which may occur as a result of frequent and
strong contractions.
–Rapid moulding may result in intracranial pressure and,
–during delivery, this may lead to intracranial haemorrhage.
– Asphyxia may occur due to rapid expulsion of the baby’s
unmoulded head.
–Birth of baby in an inappropriate place without adequate
care
Other contributing factors to abnormal
Uterine action
1. Over-Stimulation of the Uterus This may occur as a result of
excessive use of syntocinon or prostaglandin, which may cause
tetanic contractions with inadequate periods of relaxation.
• Complications of over-stimulation of the uterus include foetal
hypoxia.
• If uterine spasms that reduce the transfer from the placenta of
foetal oxygen are not treated, foetal death may occur.
• Other complications include precipitate labour and rupture of
uterus in cases of disproportion.
Methods of management should include the following:
• Stop the administration of syntocinon or prostaglandin at
once
• In case of tonic contractions, the patient should be given
tocolytics eg ventolin
• If there is foetal distress, give dextrose IV and oxygen by
mask
• Consider and institute the best course of management.
2. Tonic Contractions
• This is where the contractions are excessively longer, stronger
and more frequent.
• This results in almost continuous contractions with short periods
of relaxation.
• Tonic contractions are caused by cephalopelvic disproportion.
• The uterus attempts to overcome the obstruction and so it
increases its strength and frequency.
• The condition is common in primigravidae.
• Possible complications of tonic contractions include the rupture
of the uterus and foetal death due to prolonged labour.
 Management of Tonic Contractions
 If on syntocinon drip, it should be discontinued and the doctor
informed. Vital sign and labour assessment done.
predisposing factors
 Age, elderly primigravida is more likely to have abnormal uterine action
 Parity, the condition is more frequent in primigravida
 Cephalopelvic disproportion or malpresentation OPP, which may either
cause hypotonic uterine action or incoordinate uterine action
 Post maturity
 Other factors -over distension of the uterus in multiple pregnancy
 Early rupture of membranes
 Emotional tension of the patient
• THE END
• QUESTIONS