Bandl’s Ring

I recently received the following comment:

This is a really great post. I had never heard of women having a VBAMC before…but now that I know about this I am curious. I have had 1 CS, after a 24 hr homebirth turned emergency. Our daughter was born still after Csec to save her life was performed…

Our miracle baby was born c-sec after more than 24hrs of VBAC-ing labor. His heart rate de-celled enough times that we decided to get him out, after I was stuck at 9/5 cm’s for many, many hrs with no progress!

As it turned out, i had an obstructed labor…and a Bandel’s Ring, so baby was never coming out vaginally. So, now I am concerned for the next baby (prob a yr from now). Should I attempt another VBAC? How do I find out if I have a true Bandels Ring? What are things I can do to prevent this from happening?

I’ve done some research into this topic, but it is frustrating.

What is “Bandl’s Ring”? There are two types of uterine muscles, one to help the cervix dilate and the other to help push the baby out. At their juncture, rarely (usually during a prolonged and/or obstructed labor) a ring develops around a “depression” in the fetus, usually over the neck. [Click here to see a picture of a woman's abdomen, showing the stark outlines of the baby's body, due to a Bandl's Ring. Sometimes when this happens, even a birth by C-section is difficult, because the ring prevents the birth of the shoulders and the rest of the body. Usually, the uterus will greatly constrict, which disrupts placental blood flow, and therefore oxygen flow, to the fetus. Bandl's Ring was named after the doctor who first identified it.

One source said that a T incision was indicated for Bandl's Ring. Since a T incision is usually (if not always) a contraindication to a VBAC, it seems pretty certain that it is not always necessary. One mother said that she had a Bandl's Ring but still had a vaginal birth, and someone else responding to the comment questioned whether she really had a "true" Bandl's Ring, since she actually had a vaginal birth. In the old days, and currently in areas of the world without access to medical care, Bandl's Ring frequently results in high perinatal mortality (many times the baby is stillborn, or dies of birth injuries soon after birth) and also maternal mortality and morbidity. Uterine rupture will likely occur after a Bandl's Ring develops, because the lower uterine segment is just stretched so thin, and subsequent contractions stress it even more. In the old days, it was sometimes necessary to dismember the fetus (who was usually dead, due to lack of oxygen); and even then, sometimes the woman died or suffered debilitating injuries to her internal organs.

One of the frustrating elements in doing the search was a paucity of materials on Bandl's Ring, especially recent materials -- many of the Google Scholar results were case studies from the 1960s and before; including at least one from 1891 (yes, not 1981, but 1891, right before an article debating chloroform and ether). This article from 1961 (click on the pdf to read the article) included many alternate names: ring of Bandl, contraction of the ring of Bandl, contraction ring dystocia of White, retraction ring dystocia of Pride, simple contraction or retraction ring, uterine contraction ring, or constriction ring of Rudolph. Then it launches into a discussion of what different doctors have differentiated between the various names (and perhaps various types) of ring.

Johnson also commented that the terminology and assumptions used in reference to pathologic rings are bewildering, and he, too, emphasized the difference between the rings of obstructed and nonbstructed labor, although he referred to both as contraction rings.

"Bewildering" is correct. I tried to find information on Bandl's Ring, Bandel's Ring, and "uterine constriction ring," and got precious little information. On one message board, someone identifying herself as a midwife said that once a woman develops a Bandl's Ring, it will always happen again, and the woman will always need C-sections. But on another board, a doctor said that since the woman asking the question was being offered a VBAC, then that was proof that a vaginal birth was still a possibility.

The blogger at Abundant B'earth wrote the following for a "complications project," which is a nice summary (and is more informative than Google Scholar turned out to be!):

Pathological Retraction Ring of Bandl

Definition and Etiology:

-Occurs in second stage labor (after dilation complete).

-Cause is 2^nd stage obstructed labor due to CPD, malposition, uterine neoplasm/ abnormality, or fetal abnormality such as hydrocephalus.

-Uterus tries to compensate by increasing in tone and intensity & frequency of contractions.

-As a result, the lower uterine segment lengthens and thins, and becomes tender.

-Upper segment becomes hard and thick, and progressively retracts.

-The physiologic ring at the junction of upper and lower segments becomes extremely pronounced.   Ring rises in abdomen.

Si/sx: ["symptoms"]

-Hypertonic contractions

-presenting part driven/jammed

-mother experiences severe pain and excited or restless emotions

-maternal pulse, temperature rise

-palpable, taut round ligaments; may also be visible

-Baby entirely or almost entirely in lower uterine segment.

-ring felt as transverse ridge, as high up as umbilicus or potentially even higher

Differential Diagnosis: May appear to be constriction ring.  (see chart Frye p. 1043)

Complications/Sequelae:

-rupture of the lower segment, maternal hemorrhage

-placental abruption

-maternal exhaustion, inertia, and arrest of contractions

-uteroplacental insufficiency with resultant fetal hypoxia and distress.

-maternal fistula, lacerations more likely

South Carolina Regulation 61-24

Midwives shall obtain consultation for, or refer for care, any woman who:

(39.) develops pathological retraction ring.

Midwifery Management/Care Plan

Transport at once.

Medical Management

Tocolytic medications.

Holistic Midwifery Volume II p.241, 251, 376-7, 1038-45

Human Labor & Birth p.655-7, 662-3, 664-5, 671

11/2/2009

So, I don’t know how common it is. I don’t know what the rate of recurrence is. It seems that uterine fatigue is the chief cause of it (although there are other factors — for instance, fetal malposition may cause obstructed labor which may lead to uterine fatigue due to a lengthy labor), which makes me think that perhaps red raspberry leaf tea may help to prevent it. I don’t think there are any contraindications to this tea in the third trimester, although some people think it might increase the risk of miscarriage in the first trimester. This website says, “Red Raspberry leaf does not start labor or promote contractions. It is NOT an emmenagogue or oxytocic herb. What it does is help strengthen the pelvic and uterine muscles so that once labor does start the muscles will be more efficient.” So, this may help in general to prevent uterine fatigue. Chiropractic adjustments and optimal fetal positioning may help to prevent fetal malposition (along with the mother being upright and mobile during labor, if she desires). Cephalopelvic Disproportion (CPD) is over-diagnosed, but it may occasionally happen even in well-nourished mothers. [In developing countries, many women have malformed pelvises due to poor nutrition in childhood and adolescence, and many cultures have child-brides which leads to many still-developing adolescents giving birth to children, so the incidence of true CPD is higher there.]