Incoordinate Uterine Action

Incoordinate uterine action is irregular, asymmetrical uterine contractions with loss of fundal dominance, so that the lower segment contracts together with the fundus and the cervix does not dilate. It is often called the colicky uterus and is related to malposition (occiput posterior), an unripe cervix, anxiety and cervical dystocia. It matters because contractions are painful, labour is prolonged and oxytocin is not helpful until the pattern is regular.

• Risk factors: first labour, occiput posterior position, unfavourable cervix, anxiety, previous cervical surgery, early sedation.
• Pain is often felt in the back and out of proportion.
• The cervix may feel rigid or thick (cervical dystocia).

Women have irregular, painful contractions of varying strength, with severe backache, little cervical change and distress. Palpation shows uneven tension in the uterus, and the head is high.

• Contractions vary in length and strength.
• Thick, rigid cervix with slow dilatation.
• Differential diagnosis: hypotonic dysfunction, hypertonic dysfunction, false labour, cephalopelvic disproportion, abruption, uterine rupture, urinary infection.
• Complications: prolonged labour, maternal exhaustion, ketosis, fetal distress, chorioamnionitis, caesarean section, cervical lacerations.

The diagnosis is by palpation and tocography showing the loss of a regular pattern.

• Contractions palpated for 10 minutes: irregular, uneven strength, without fundal dominance; tocography where available.
• Cervical consistency, dilatation, station and position; bony pelvis; membrane status.
• Cardiotocography; maternal pulse, temperature, ketones.
• Ultrasound for occiput position and estimated weight; exclusion of abruption.

The principle is analgesia and rest to regularise contractions, with oxytocin only after the pattern improves, and caesarean section for obstruction or fetal compromise.

• Supportive: Ringer's lactate 1 litre IV over 1 to 2 hours; empty the bladder; position change (hands and knees for occiput posterior); warm bath; one to one support; continuous cardiotocography.
• Pharmacological: epidural analgesia (most effective), or morphine 10 mg IM plus promethazine 25 mg IM for therapeutic rest; hyoscine butylbromide 20 mg IV or IM repeated once after 30 minutes if needed (maximum 100 mg in 24 hours) for cervical rigidity; oxytocin 10 IU in 1 litre Ringer's lactate (10 mU/mL) started at 12 mL per hour (2 mU/minute) and doubled every 30 minutes to a maximum of 192 mL per hour (32 mU/minute) after the pattern becomes regular; benzylpenicillin 5 million units IV then 2.5 million units 4-hourly for group B streptococcus or rupture for 18 hours or more; ampicillin 2 g IV 6-hourly plus gentamicin 5 mg/kg IV once daily for chorioamnionitis; cefazolin 2 g IV before caesarean section.
• Procedures: amniotomy when the head is engaged; manual rotation of an occiput posterior head when fully dilated; caesarean section for no progress after 4 hours of adequate contractions, cephalopelvic disproportion, cervical dystocia with failure to dilate, or fetal compromise.
• Special groups: women with previous cervical surgery (cone biopsy, loop excision) may have cervical dystocia and need earlier caesarean section when the cervix fails to dilate after rest and oxytocin.
• Red flags: abnormal fetal heart rate, bleeding, fever above 38 degrees Celsius, scar pain, maternal exhaustion.
• Follow-up: cervical examination every 2 to 4 hours; maternal temperature 4-hourly; postnatal review of bladder and perineum; counselling about the next birth.