Premature birth accounts for the majority of fetal morbidity and mortality in the developed world and is disproportionately represented in some populations, such as African Americans in the United States. The costs associated with prematurity are staggering in both monetary and human terms. Present therapeutic approaches for the treatment of labor leading to preterm delivery are inadequate and our understanding of the regulation of myometrial smooth muscle contraction-relaxation is incomplete. The ability of nitric oxide to relax smooth muscle has led to an interest in employing nitric oxide-donors in the treatment of preterm labor. Fundamental differences exist, however, in the regulation of uterine smooth muscle relaxation and that of other smooth muscles and constitute a conundrum in our understanding. We review the evidence that nitric oxide-mediated relaxation of myometrial smooth muscle, unlike vascular or gastrointestinal smooth muscle, is independent of global elevation of cyclic guanosine 5'-monophosphate. Applying our current understanding of microdomain signaling and taking clues from genomic studies of pregnancy, we offer a framework in which to view the apparent conundrum and suggest testable hypotheses of uterine relaxation signaling that can explain the mechanistic distinctions. We propose that understanding these mechanistic distinctions in myometrium will reveal molecular targets that are unique and thus may be explored as therapeutic targets in the development of new uterine smooth muscle-specific tocolytics.