PHYSIOLOGY OF LABOR

BARCELONA, LAICA
BHALAIYA, KARAN
GALABIT, NICA
VYAS, ANURADHA
 PHASES OF PARTURITION
• THE PRELUDE
• THE PREPARATION
• THE PROCESS
• THE RECOVERY
PHASE 1: UTERINE QUISCENCE AND CERVICAL
SOFTENING
• In this phase, the uterus must initiate extensive changes in its size and
vascularity to accommodate the pregnancy and prepare for uterine
contractions.
• Some low intensity contractions are felt during the quiescent phase,
but they do not normally cause cervical dilatation. These contractions
are called Braxton-Hicks contractions or false labor. They are more
common in multiparous women.
 CERVICAL SOFTENING
• MULTIPLE FUNCTIONS:
• Maintenance of barrier function to protect the reproductive tract
from infection
• Maintenance of cervical competence despite increasing gravitational
forces
• Orchestration of extracellular matrix changes that allow progressive
increases in tissue compliance.
Non-pregnant: closed and firm
End of pregnancy: easily distensible
SOFTENING
• First stage of remodeling of the cervix
• Characterized by an increase in tissue compliance, yet the cervix
remains firm and unyielding.
• Hegar Sign: palpable softening of the lower uterine segment at 4-6
weeks.
 PHASE 2 PARTURITION
• To prepare for labor, the myometrial trnquility of phase 1 must be
suspended-called uterine awakening or activation.
• Lasts 6-8 weeks
• Critical change in phase 2 is the formation of the lower uterine
segment from the isthmus- fetal head often descends to the pelvic
inlet – called lightening.
 CERVICAL RIPENING DURING PHASE 2
• Cervical modifications during this 2nd phase principally involve
connective tissue changes – called cervical ripening.
• Transition from the softening to the ripening phase begins weeks or
way before onset of contraction.
• The uterine corpus is predominantly smooth muscle, whereas the
cervix is primarily connective tissue. Cellular components of the
cervix include fibroblasts, epithelia, and few smooth muscle cells.
• Endocervical epithelia: lined with mucus-secreting columnar and
stratified squamous epithelia.
 CERVICAL CONNECTIVE TISSUE
• Collagen is largely responsible for structural disposition of the cervix.
• During cervical ripening, collagen fibril diameter is increased, and
there is increased spacing between fibrils.
• Changes in proteoglycan composition are thought to accompany
cervical ripening, although not well defined.
• In addition to the cervix, proteoglycans are also expressed in the fetal
membranes and uterus. Changes in expression levels may regulate
fetal membrane tensile strength and uterine function.
 INFLAMMATORY CHANGES
• The marked changes within the extracellular matrix during cervical
ripening in phase 2 are accompanied by stromal invasion with
inflammatory cells, that is why one model considers ripening as an
inflammatory process.
• In phase 3 or 4 of parturition, there is increased cervical expression of
chemokines and collagenase/protease activity. It was assumed that
process regulating phase 3 and 4 of dilation and post partum recovery
of the cervix are similar to those in phase 2 of cervical ripening.
 INDUCTION AND PREVENTION OF CERVICAL
RIPENING
• There are no therapies to prevent premature cervical ripening.
• Cervical cerclage is used to circumvent cervical insufficiency.
• Treatment to promote ripening for labor induction includes direct
application of prostaglandins E2 and F2A.
• Prostaglandins likely modify extracellular matrix structure to aid
ripening.
• Administration of progesterone antagonists causes cervical ripening.
Phase 3: LABOR
Stage of Cervical Effacement and Stage of Fetal Expulsion Stage of Placental and Expulsion
Dilation
Begins when spaced uterine Begins when cervical dilatation is Begins immediately after delivery
contractions of sufficient complete. of the fetus.
frequency, intensity and duration
are attained to bring about cervical
thinning, or effacement.
Ends when the cervix is fully Ends with delivery. Ends with delivery of the placenta.
dilated-about 10 cm- to allow
passage of the term-sized fetus.
First Stage: Clinical Onset of Labor
UTERINE LABOR CONTRACTIONS
• Causes:
1. Hypoxia of contracted myometrium
2. Compression of nerve ganglia in cervix and lower uterus
3. Cervical stretching during dilation
4. Stretching of peritoneum overlying the fundus
• Ferguson’s reflex- mechanical stretching of the cervix enhances uterine
activity
• Cervix manipulation and stripping- associated with rise in blood levels of
PGF2⍺
• In active-phase labor: duration of each uterine contraction ranges from 30-
90 sec, averages 1min
• Amniotic fluid pressure: 20-60mmHg, average 40mmHg
DISTINCT LOWER AND UPPER UTERINE SEGMENTS
• Upper segment- firm; contracts, retracts, and
expels fetus
• Lower segment- softer, distended, more passive
• Segment of cervix dilate expanded, thinned-
out tube fetus pass
• Physiological retraction ring- ridge on inner
uterine surface between lower segment thinning
and upper segment thickening
• Bandl Ring- ring is prominent when the thinning
of the lower segment is extreme, as in
obstructed labor
CHANGES IN UTERINE SHAPES
• Elongates the ovoid uterine shapes (~5-10cm) and thereby narrows
the horizontal diameter
1. Greater fetal axis pressure
- Smaller horizontal diameter--> straighten the fetal vertebral columnupper
pole of fetus presses against fundus lower pole thrust farther downward
2. Longitudinal muscle fibers are drawn taut
- Cervix pulled upward and around the lower pole of the fetus
ANCILLARY FORCES
• Maternal intraabdominal pressure- most important force in fetal
expulsion after cervix is dilated fully
• Pushing- contraction of abdominal muscles simultaneously with
forced respiratory efforts with glottis closed
• CERVICAL CHANGES
• Effacement- obliteration of the
cervix. It is manifest by shortening
of the cervical canal
• Dilation- uterine contraction
pressure on membranes
hydrostatic action of the amnionic
sac dilates cervical canal
CERVICAL CHANGES
• Uterine contraction pressure on membranes hydrostatic action of
the amnionic sac dilates cervical canal forebag of amniotic fluid
SECOND STAGE: FETAL DESCENT
• Nullipara- head engagement is accomplished before labor begins
• In descent pattern of normal labor, a typical hyperbolic curve is
formed when the station of fetal head is plotted as a function of labor
duration
• Active descent- takes place after dilation has progressed
PELVIC FLOOR CHANGES
• Birth canal is supported and functionally closed by pelvic floor
• Levator ani muscle and fibromuscular CT- most important of the floor
• Levator ani muscle:
1. Closes the lower end of the pelvic cavity as a diaphragm
2. During pregnancy, it undergoes hypertrophy
3. On contraction, it draws both rectum and vagina forward and upward in the
direction of the symphysis pubis
4. Acts to close the vagina
THIRD STAGE: DELIVERY OF THE PLACENTA
AND MEMBRANES
• Begins immediately after fetal
delivery
• When newborn is completely
delivered uterine cavity
obliterated uterine fundus lies
below the level of umbilicus
decrease area of placental
implantation placenta thickens but
limited elasticity forced to buckle
tension pulls decidua spongiosa from
the site placental separation
• Fetal membranes (amniochorion and parietal decidua) throws into
innumerable folds as uterine cavity surface decline
• Schultze mechanism- blood from the placental site pours into the
membrane sac and does not escape externally until after extrusion of
the placenta
• Duncan mechanism- placenta separates first at the periphery and
blood collects between membranes and uterine walls and escapes
from the vagina
UTEROTONINS IN PARTURITION PHASE 3
• OXYTOCIN- quick birth—first uterotonins in parturition initiation. It
synthesized in magnocellular neurons of supraoptic and
paraventricular neurons. It induces labor at term
• PRASTAGLANDINS- production within the myometrium and decidua
during labor is an efficient mechanism of activating contractions
• ENDOTHELIN 1- powerfully induces myometrial contraction
• ANGIOTENSIN II- bind to plasma-membrane receptor evokes
contraction
PHASE 4: THE PUERPERIUM
• Immediately and for about an hour after delivery myometrium
remains contracted compresses large uterine vessels allows
thrombosis to prevent hemorrhage
• Uterine involution and cervical repair- prompt remodeling processes
that restore these organs to nonpregnant state to protect the
reproductive tract from invasion by microsomal microorganisms and
restore endometrial responsiveness to normal hormonal cyclicity
• Lactogenesis and milk let-down begin in mammary glands
• Ovulation- within 4-6wks after birth