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Chapter 21
Chapter 21
during contractions
MATERNAL AND FETAL COMPARTMENTS o This mechanism is imperative because if the entire
myometrium, including the lower uterine segment and
UTERUS: cervix, were to contract simultaneously and with equal
• Qualities that confer adequate uterine contractions and efficiency intensity, the net expulsive force would markedly
of fetal delivery: decline.
o Degree of smooth muscle cell shortening with o The upper segment contracts, retracts, and expels the
contractions fetus. In response to these contractions, the softened
o Forces can be exerted in smooth muscle cells in lower uterine segment and cervix dilate and thereby
multiple directions form a greatly expanded, thinned-out tube through
o Smooth muscle cell is not organized in the same which the fetus can pass.
manner as skeletal muscle – the thick and thin Changes in Uterine Shape:
filaments are found in long, random bundles throughout • Each contraction gradually elongates the ovoid uterine
the cells (plexiform arrangement which aids in greater • shape and thereby narrows the horizontal diameter.
shortening and force-generating capacity) • This change in shape has important effects on the labor process.
o Greater multidirectional force generation in the fundus o Greater fetal axis pressure, that is, the smaller
permits versatility in expulsive force directionality horizontal diameter serves to straighten the fetal
• Endometrium is transformed by pregnancy hormones = decidua vertebral column. This presses the upper pole of the
o Composed of stromal cells and maternal immune cells fetus firmly against the fundus, whereas the lower pole
o Serves to maintain the pregnancy via unique is thrust farther downward.
immunoregulatory functions that suppress inflammatory o The lengthening of the ovoid shape has been estimated
signals during gestation at 5 to 10 cm.
o End of pregnancy: decidual activation ensues à o With lengthening of the uterus, the longitudinal muscle
transition into inflammatory signals à withdrawal of fibers are drawn taut. As a result, the lower segment
active immunosuppression à parturition initiation and cervix are the only parts of the uterus that are
CERVIX flexible, and these are pulled upward and around the
• Functions of the cervix during pregnancy: lower pole of the fetus.
o Maintenance of barrier function to protect the • Divided into:
reproductive tract from infection o Latent phase: from onset of regular painful uterine
o Maintenance of cervical competence despite greater contractions to around 4cm dilatation (0-4cm). Markedly
gravitational forces as the fetus grows vary in different gravidas. We usually don’t admit
o Orchestration of extracellular matrix changes that allow patients in the latent phase. Admit only if they are
progressively greater tissue compliance already 4cm dilated.
o Active phase: once patient is already 4cm dilated, she
PLACENTA enters the active phase. Cervical dilatation of 3 to 5 cm
• Key source of steroid hormones, growth factors and other or more, in the presence of uterine contractions, can be
mediators that maintain pregnancy and potentially aid the taken to reliably represent the threshold for active labor
transition to parturition (Williams).This phase is further divided into three:
• Amnion: provides all of the fetal membranes’ tensile strength to § Acceleration phase- faster dilatation is seen
resist membrane tearing and rupture here compared to the latent phase (4cm -5 to
o Highly resistant to penetration by leukocytes, 6 cm)
microorganisms and neoplastic cells § Phase of maximum slope – faster and
o Constitutes a selective filter to prevent fetal particulate- biggest increase in dilatation is seen (from
bound lung and skin secretions from reaching the 5-6cm to 8cm in an hour)
maternal compartment § Deceleration phase- once it reaches 8cm,
dilation is slowed down up to full dilation
SEX STEROID HORMONE ROLE (from 8-10cm, may take up to 2-3 hours)
In many species, the role of sex steroid hormones is clear, estrogen *Descent starts at the midpoint of the phase of maximum slope
promotes and progesterone inhibits the events leading to parturition *Maximum descent occurs during the deceleration phase.
• Progesterone withdrawal directly precedes progression of
parturition
• Giving progesterone during pregnancy will delay parturition via a
decline in myometrial activity and continued cervical
competency
ROLE OF PROSTAGLANDINS
• Lipid molecules with varied hormone like actions
• Play a prominent role in myometrial contractility, relaxation and
inflammation
• Produced using plasma membrane derived arachidonic acid and
is usually released by the action of phospholipase A2 or C
• Arachidonic acid can act as a substrate for both type 1 and 2
prostaglandin H synthase (PGHS-1, PGHS-2) aka COX-1 and
COX-2
STAGES OF LABOR
THIRD STAGE
• From delivery of fetus until delivery of placenta. (30 minutes
average)
• Immediately after delivery of the newborn, the size of the uterine
fundus and its consistency are examined. If the uterus remains firm
and there is no unusual bleeding, watchful waiting until the placenta
separates is the usual practice. Massage is not employed, but the
fundus is frequently palpated to make certain that the organ does
not become atonic and filled with blood from placental separation.