CHAPTER 21: PHYSIOLOGY OF LABOR
during contractions
MATERNAL AND FETAL COMPARTMENTS
UTERUS:
• Qualities that confer adequate uterine contractions and efficiency
of fetal delivery:
o Degree of smooth muscle cell shortening with
contractions
o Forces can be exerted in smooth muscle cells in
multiple directions
o Smooth muscle cell is not organized in the same
manner as skeletal muscle – the thick and thin
filaments are found in long, random bundles throughout
the cells (plexiform arrangement which aids in greater
shortening and force-generating capacity)
o Greater multidirectional force generation in the fundus
permits versatility in expulsive force directionality
• Endometrium is transformed by pregnancy hormones = decidua
o Composed of stromal cells and maternal immune cells
o Serves to maintain the pregnancy via unique
immunoregulatory functions that suppress inflammatory
signals during gestation
o End of pregnancy: decidual activation ensues à
transition into inflammatory signals à withdrawal of
active immunosuppression à parturition initiation
CERVIX
• Functions of the cervix during pregnancy:
o Maintenance of barrier function to protect the
reproductive tract from infection
o Maintenance of cervical competence despite greater
gravitational forces as the fetus grows
o Orchestration of extracellular matrix changes that allow
progressively greater tissue compliance
PLACENTA
• Key source of steroid hormones, growth factors and other
mediators that maintain pregnancy and potentially aid the
transition to parturition
• Amnion: provides all of the fetal membranes’ tensile strength to
resist membrane tearing and rupture
o Highly resistant to penetration by leukocytes,
microorganisms and neoplastic cells
o Constitutes a selective filter to prevent fetal particulate-
bound lung and skin secretions from reaching the
maternal compartment
SEX STEROID HORMONE ROLE
In many species, the role of sex steroid hormones is clear, estrogen
promotes and progesterone inhibits the events leading to parturition
• 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
FIRST STAGE
• Onset of regular, painful, uterine contractions (labor) up to full
cervical dilatation of 10cm.
• Can vary – from 5 to 20 hours
• Unique among physiological muscular contractions
• Could be due to:
o Hypoxia of the contracted myometrium
o Compression of nerve ganglia in the cervix and lower
uterus by contracted interlocking muscle bundles
o Cervical stretching during dilation
o Stretching of the peritoneum overlying the fundus
• Mechanical stretching of the cervix enhances uterine activity à
known as the Ferguson Reflex
• Manipulation of the cervix and “stripping” the fetal membranes I
sssociated with a rise in blood levels of prostaglandin metabolites
• The interval between contractions narrows gradually from
approximately 10 minutes at the onset of first-stage labor to as
little as 1 minute or less in the second stage.
• Periods of relaxation between contractions, however, are
essential for fetal welfare. Unremitting contractions compromise
uteroplacental blood flow sufficiently to cause fetal hypoxemia. In
active-phase labor, the duration of each contraction ranges from
30 to 90 seconds and averages 1 minute.
• Contraction intensity varies appreciably during normal labor.
Specifically, amnionic fluid pressures generated by contractions
during spontaneous labor average 40 mm Hg, but vary from 20 to
60 mm Hg
• Distinct Lower and Upper Uterine Segments:
o Upper segment: firm during contractions
o Lower segment: softer, distended and more passive
o This mechanism is imperative because if the entire
myometrium, including the lower uterine segment and
cervix, were to contract simultaneously and with equal
intensity, the net expulsive force would markedly
decline.
o The upper segment contracts, retracts, and expels the
fetus. In response to these contractions, the softened
lower uterine segment and cervix dilate and thereby
form a greatly expanded, thinned-out tube through
which the fetus can pass.
Changes in Uterine Shape:
• Each contraction gradually elongates the ovoid uterine
• shape and thereby narrows the horizontal diameter.
• This change in shape has important effects on the labor process.
o Greater fetal axis pressure, that is, the smaller
horizontal diameter serves to straighten the fetal
vertebral column. This presses the upper pole of the
fetus firmly against the fundus, whereas the lower pole
is thrust farther downward.
o The lengthening of the ovoid shape has been estimated
at 5 to 10 cm.
o With lengthening of the uterus, the longitudinal muscle
fibers are drawn taut. As a result, the lower segment
and cervix are the only parts of the uterus that are
flexible, and these are pulled upward and around the
lower pole of the fetus.
• Divided into:
o Latent phase: from onset of regular painful uterine
contractions to around 4cm dilatation (0-4cm). Markedly
vary in different gravidas. We usually don’t admit
patients in the latent phase. Admit only if they are
already 4cm dilated.
o Active phase: once patient is already 4cm dilated, she
enters the active phase. Cervical dilatation of 3 to 5 cm
or more, in the presence of uterine contractions, can be
taken to reliably represent the threshold for active labor
(Williams).This phase is further divided into three:
§ Acceleration phase- faster dilatation is seen
here compared to the latent phase (4cm -5 to
6 cm)
§ Phase of maximum slope – faster and
biggest increase in dilatation is seen (from
5-6cm to 8cm in an hour)
§ Deceleration phase- once it reaches 8cm,
dilation is slowed down up to full dilation
(from 8-10cm, may take up to 2-3 hours)
*Descent starts at the midpoint of the phase of maximum slope
*Maximum descent occurs during the deceleration phase.
Functional Divisions of Labor:
• Entire labor is divided into three functional divisions:
1. Preparatory Division=latent phase + acceleration phase
- cervix prepares for eventual dilatation. Collagen will
rearrange, cervix will efface etc.
2. Dilatational Division- same as phase of maximal slope
- where we expect maximal dilatation to occur
- unaffected by sedation and analgesia.
3. Pelvic Division=deceleration phase + second stage of
labor
- where the descent happens
- baby enters into the pelvis already.
 SECOND STAGE
• In a woman of higher parity with a previously dilated vagina and
perineum, two or three expulsive efforts after full cervical dilatation
may suffice to complete delivery. Conversely, in a woman with a
contracted pelvis or a large fetus or with impaired expulsive efforts
from conduction analgesia or sedation, the second stage may
become abnormally long.
• From full cervical dilatation until delivery of the fetus (average of 20
mins for multiparous women; nulliparous- 50 mins to an hour)

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.

PHASE 4: THE PUERPERIUM

• 1st hour following delivery
• The placenta, membranes, and umbilical cord should be
examined for completeness and for anomalies
• The hour immediately following delivery is critical, and it has been
designated by some as the "fourth stage of labor."
• Even though oxytocics are administered, postpartum hemorrhage
as the result of uterine atony is more likely at this time
• The uterus and perineum should be frequently evaluated. The
American Academy of Pediatrics and the American College of
Obstetricians and Gynecologists (2002) recommend that maternal
blood pressure and pulse be recorded immediately after delivery
and every 15 minutes for the first hour.