Identifying and Managing Bandl’s Ring: Insights for Anesthesia Providers
By Scarlett Hinson, DNP, MSN, CRNA
Regional Clinical Officer & Education Liaison, CCI Anesthesia
Bandl’s Ring is a rare but potentially life-threatening obstetric complication requiring prompt recognition and management by the entire care team, including anesthesia providers.
While rare, the incidence of this condition appears to be on the rise, making it critical for clinicians to be aware of surgical and pharmacologic interventions necessary to treat this occurrence.
In this summary, I share clinical insights into Bandl’s Ring, including a real-life case first encounter, in the hopes that other providers will understand and be better prepared to address this rare complication and prevent a potentially devastating outcome.
Understanding Bandl’s Ring
Bandl’s Ring, also known as the pathological retraction ring, is located at the junction between the thick, retracted upper uterine segment and the thin, stretched lower segment, typically at the level of the umbilicus. It should neither be visible nor palpable during labor.
Critical Facts About Bandl’s Ring:
- Incidence: Approximately 1 in every 5,000 births.
- Suspected Causes: Prolonged labor, dystocia, or changes in labor guidelines.
- Risks: If unrecognized or untreated, it can lead to uterine rupture and severe fetal trauma. Infant mortality in these cases exceeds 50%.
Recognizing Bandl’s Ring
Clinical Indicators:
- Physical Exam: A visible or palpable constriction ring dividing the uterus into thick and thin segments.
- Maternal Symptoms: Severe abdominal pain or signs of obstructed labor.
- Fetal Distress: Sudden decelerations or bradycardia on fetal monitoring.
Comparison of the normal abdominal contour during labor (A) with the abnormal presentation of Bandl’s Ring (B), highlighting the retracted upper uterine segment, distended lower uterine segment, and the constriction caused by the pathological Ring.
A Real-Life Case Study
I encountered Bandl’s Ring during the care of a 27-year-old primigravida attempting vaginal delivery with a functioning labor epidural. The fetus experienced decelerations and sustained bradycardia during late stage of vaginal delivery, prompting an emergency cesarean.
Key Events:
- Obstruction Encountered: After uterine incision, the obstetrician was unable to push the fetus’s head from the vaginal canal due to the constriction of Bandl’s Ring.
- Anesthetic Management:
- Nitrous oxide and sevoflurane were administered via mask to promote uterine relaxation.
- Despite this, the lower uterine segment remained resistant.
- A microdose (100 mcg) of intravenous nitroglycerin successfully relaxed the uterus, enabling safe delivery of the fetus.
- Outcome: The fetus suffered a right facial hematoma, which resolved within weeks, and the mother recovered without complications.
This experience underscored the importance of understanding Bandl’s Ring and the critical role of anesthesia providers in managing such emergencies.
Educational Gaps and the Role of Training
Despite its potential severity, Bandl’s Ring is typically not included in obstetric residents’ training curricula. However, the Accreditation Council for Graduate Medical Education (ACGME) requires a minimum of 145 cesarean deliveries during residency, so simulation-based training on rare complications, including Bandl’s Ring, is increasingly encouraged.
As anesthesia providers, we can advocate for:
- Interdisciplinary Training: Simulations involving obstetricians, anesthetists, and nurses.
- Awareness Initiatives: Educational sessions to familiarize teams with this rare phenomenon and its management strategies.
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Anesthesia Management for Bandl’s Ring
Anesthesia providers are instrumental in managing the complications associated with Bandl’s Ring. Key considerations include:
- Recognizing the Condition:
- Collaborate with obstetric teams to identify signs of obstructed labor.
- Be prepared for sudden emergencies involving fetal distress.
- Managing Uterine Relaxation:
- Use inhaled agents like nitrous oxide and sevoflurane to relax uterine muscles.
- Administer tocolytics, such as nitroglycerin and terbutaline, to facilitate uterine relaxation.
- Supporting Rapid Delivery:
- Ensure readiness for conversion to general anesthesia if needed.
- Monitor maternal hemodynamics closely, as prolonged labor can cause instability.
The Path Forward: Increased Awareness and Education
Bandl’s Ring is a rare condition that is becoming more frequently recognized due to changes in labor practices. Awareness, early detection, and effective management can significantly improve outcomes for mothers and babies.
At CCI Anesthesia, we are committed to advancing clinical education and fostering interdisciplinary collaboration to handle complex cases like Bandl’s Ring with expertise and confidence.
If you’ve encountered Bandl’s Ring or would like to learn more about its management, I encourage you to share your experiences and insights. Together, we can enhance patient safety and outcomes in obstetric anesthesia care.
Find More at CCI Anesthesia
Enhance your clinical expertise with CCI Anesthesia’s educational programs designed for anesthesia providers. Learn from seasoned professionals like Scarlett Hinson, DNP, MSN, CRNA, and stay prepared for rare but critical scenarios like Bandl’s Ring. Join us in advancing your knowledge and delivering exceptional care.
Scarlett Hinson, DNP, MSN, CRNA serves as Regional Clinical Officer and Education Liaison for CCI Anesthesia, bringing decades of experience and dedication to advancing clinical excellence.
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