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    31 views22 pages

    The Parturient

    Uploaded by

    Marco Paulo Reyes Naoe
    lectures on the parturient

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    © All Rights Reserved
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    408 aaa Physiology of Labor PHASES OF PARTURITION. 408 PHASE 1 OF PARTURITION: UTERINE (QUIESCENCE AND CERVICAL SOFTENING 408 PHASE 2 OF PARTURITION: PREPARATION FOR LABOR. 410, PHASE 3 OF PARTURITION: LABOR am PHASE 4 OF PARTURITION: THE PUERPERIUM ay PHYSIOLOGICAL AND BIOCHEMICAL PROCESSES REGULATING PARTURITION a7 PHASE 1: UTERINE QUIESCENCE AND CERVICAL COMPETENCE a9 PHASE 2: UTERINE ACTIVATION AND CERVICAL RIPENING ‘23 PHASE 3: UTERINE STIMULATION 426 “The last few hours of human pregnancy are characterized by forceful and painful uterine contractions that effect cervical dle atation and cause the fetus to descend through the birth canal “There ate extensive preparations in both the uterus and cervix long before this. During the fist 36 0 38 weeks of normal gesta- tion, the myometsium isin a preparatory yet unresponsive state Concurrency, the cervix begins an early sage of remodeling — termed sofening—yet maintains structural integrity. Following, this prolonged uterine quiescence, there is a transitional phase during which myometrial unresponsiveness is suspended, and the cervix undergoes ripening, effacement, and los of structural integrity. “The physiologieal processes that regulate parturition and the onset of labor continue to be defined. It is cleat, however, that labor onset represents the culmination of series of biochemical changes in the uterus and cervix, These result from endocrine and paracrine signals emanating from both mother and fetus. “Their relative contributions vary berween species, nd it ie shese differences that complicate elucidation of the exact factors that regulate human parturition. When parturition ie abnor- ‘mal, chen preterm labor, dystocia, of postterm pregnancy may result, OF these, preterm labor remains the major contributor to neonatal morcliy and morbidity in developed countries. PHASES OF PARTURITION “The bringing forth of young—parturition—requires well- ‘orchestrated transformations in both uterine and cervical fune- tion. As shown in Figure 21-1, parcurtion can be arbitrarily divided into four overlapping phases that correspond to the :ajor physiological wansitions of the myometsium and cervix luring pregnancy (Casey, 1993, 1997; Challis, 2000; Word, 2007). These phases of parturition include: (1) a prelude to i, (2) the preparation fo it (3) she process itself, and (4) recovery Importantly, the phair of parturition should not be confused with the clinical sages of labor, that is, the fist, second, and third stages—which comprise the third phase of parturition (ig. 21-2) Phase 1 of Parturition: Uterine Quiescence and Cervical Softening Uterine Quiescence Beginning even before implantation, a remarkably effective petiod of myometrial quiescence is imposed. This phase nor- rally comprises 95 percent of pregnancy and is characte ied by werine smooth muscle tanguility with maintenance ‘of cervical structural integrity. The inherent propensity of the myometrium to conteact is eld in abeyance, and ater ine muscle is rendered unresponsive to natural stimuli Concurrently, the uterus must initiate extensive changes in ite size and vascularity to accommodate the pregnancy and. Physiology of Labo’ Cervical Softening = Fraa Frais —] press] Frame 5 auestsece | _Acivaton_|stmusion | _ alan ‘Tae crv has multiple Functions during :| Pee Preparation rene Parrot ‘pregnancy that include: (1) maintenance 5 Of barrier Function to pote the repro 5 Contacts} Uterine trie Uterine rvespasveness | preparedness | contacton, | _ivotute, dlecve tact fom infection, (2) mai Corea sonenng | “"ertabor | cerca atte, | convalrpa tenance of cevieal competence despite corvcal | anaptacona| breastfeeding | increasing gravitational forees and’ (3) cone reorng | expulsn treo crchetraion of extrclllar matic Initiation of a0 changes that allow progressive increases Parton Ose in sue compliance Daler ot ety Tn nonpregnant women, the cervix (estes is closed and fm, and is consistency FIGURE 21-1 The phases of patuilion propare for uterine contractions ‘The myometrial uncespon- siveness of phase I continues until aca the end of pregnancy. Some low-intensity myometrial contractions are fle daring the quiesent phase, but they da not normally cause cervi- cal dilatation. Contraction of this type become more com son toward the end of pregnancy, expecially in multiparous women, and ate referred to as Braxton Hicks contractions or fale labor (Chap. 4, p. 47) Stages of Labor FIGURE 21-2 Composite ofthe average dilatation curve for labor in sully The curve is based on analysis of data derived ftom 2 large, neatly women, the fist stage is civided into a relatively lat latent phase sive active phase Inthe acive phase, there are three identifiable acceleration phase, a linear ghase af maximum slope, and a dace from Fiedman, 1978) is similar to nasal cartilage. By che end of pregnancy, the cervix is easly disten- sible, and ite consistency i similar to the lip of the oral cavity “Thus, che first stage of this remodeling —termed soffening—is characterized by an increase in tissue compliance, yet the cervix remains firm and unyielding, Hegar (1895) frst described pal ppable soltening of the lower uterine segment at 4 co 6 weeks? sgestation, and this sign was once used co diagnose pregnancy. Clinically, ehe maintenance of cervical snatomsieal and struc: cal integrity is essensial for continuation of pregnancy to term. latation, structural incompetence, of both may forecast delivery Jams, 1996) Structural Changes with Softening. Cervical softening increased vascularity, stromal. hyper results from ant ged Foal doscont Placonta twophy, glandular hypertrophy and ‘and deivery. delvery phy, ypertrophy hyperplasia, and progressive ‘compositional of structural changes of the extracellular matsix (House, 2009; Leppert, 1995: Mahendeoo, 2012: ‘Word, 2007). During matrix changes, collagen, the main structural prosein in slow, the cervix, undergoes conformational changes that alter tissue strength and flexibility. Specifically. collagen pro- cessing and the number or type of cova lent cross-links between collagen tiple helices are altered, These cross-links are normally requited for stable col: lagen fibril formation (Caney, 2005). A teduetion in. cros newly synthesized collagen from reduced expression and activity of the crose-link forming ‘enzymes, lysyl hydroxylase and lysyl Jinks berween oxidase, beginning in eatly pregnancy (Akins, 2011; Drewes, 2007; Ozasa, 1981). Concurrently there is reduced expression of the matricelular proceins thtombospondin 2 and tenascin C. These proteins also influence collagen fibril structure and strength. Together, these early pregnancy changes concrib- parous women, consecutive series of and a rapidly progres mponent paris: an ration phase. ( ‘ute to the gradual increase in tissue ‘compliance during pregnancy. 409 each Tb) 410 PAN TBES Labor “The clinical importance ofthese macrix changes is supported by the greater prevalence of cervical insufficiency in those with inherited defects in collagen and elastin synthesis or assem= bly (Anum, 2009; Hermanns-Lé, 2005: Paternoster, 1998 Rahman, 2003; Wang. 2006). Examples are Ehlers-Danl and Marfan syndromes, discussed in Chapter 59 (p. 1181). Additionally, human cervical stromal cells express a transcrip. tion factor, microphthalmia-astocited transcription factor (MITF-Cx). During pregnancy, this factor maintains cervical competency by repressing the expression of genes involved in cervical dilation and pareurtion (Hari Kishore, 2012). Phase 2 of Parturition: Preparation for Labor ‘To prepare for labor, the myometrial tranquility of phase 1 of parturition must be suspended—so-called uterine awakening ot activation. This phase 2 is a progression of uterine changes dduting the last 6 to 8 weeks of pregnancy. Importantly, shift ing events associated with phase 2 can cause either preterm of delayed labor Myometrial Changes Phase 2 myometrial changes prepare it for labor contractions. ‘This shift probably results from alterations in the expression of key proteins that control conteactiliy, These contraction ‘asociated proteins (CAP) include the oxytocin receptor, pros taglandin F receptor, and connexin 43 (Smith, 2007). Thus, myometrial oxytocin receptors markedly increase along with increased numbers and surface areas of gap junction proteins such as connexin 43, Together, these lead to increased wer- ine iriability and responsivences to uterotoninz—agente that stimulate contractions ‘Another critical change in phase 2 is formation of the lower uterine segment from the isthmus. With this development, the fetal head often descend to ot even chtough the pelvic inlet so-called lightening. The abdomen commonly undergoes 4 shape change, sometimes deseribed by women as “the baby dropped.” Ics also likely tha che lower segment myomecriurs is unique from that in the upper uterine segment, resulting ring labor. This is supported by differential expression of pros- receptors within myomettial regions. There are also ‘human studies that report an expression gradient of oxytocin receptors, with greater expression in fundal myometsial cells (Fuchs, 1984; Havelock, 2005: Smith, 200 Cervical Before contractions begin, the cervix must undergo more exten sive remodeling. ‘This eventually results in cervical yielding and dilatation upon initiation of forceful uterine contractions Cervical modifications daring thie second phase principally involve connective tissue changes—to-called cereal ripening. “The transition ftom the softening to the ripening phase begins weeks or days before onset of contractions. During this tans- formation, the total amount and composition of proteoglycans and glycosaminoglycans within the matrix are altered. Many of the processes that aid cervical remodeling are controlled by the same hormones regulating uterine function. ‘That said, che molecular events of each are varied because of differences in cel- lular composition and physiological requirements, 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 Dring pregnancy, endocervical epithelial cell proliferate such that endocerveal glands occupy a signitieane pereencage of cervical mast. The endocervical canal i lined with mucus- secreting cohumnar and arated squamous epithelia, which protect against microbial invasion. Mucosal epithelia function a sentinel fr antigens by expressing Toll-like receptors that recognize pathogens. In addition, epithelia respond in ways that lead to bacttial and viral king, For ths, the epithelia apres antimicrobial peptides and protease inhibitors and sg nal co underlying immune cells when a pathogenic challenge cenceede thee protective capacity (Wira, 2005). Tn mice, studies suggest that cervical epithelia may also aid cervical remodeling by regulating tissue hydration and main- tenance of barrier function. Hydration may be regulated by capresion of aquaporin-—watet channel proteins. Maintenance of barrie function and paracellular transport of fon and solutes is regulated by tight junction proteins, such a audins 1 and 2 (Anderson, 2006; Timmons, 2007). Inthe human cevieal and ‘vaginal mucosal epithelia, juneional proteins ae also reported co be expressed (Blatkewics, 2011) Cervical Connective Tissue Collagen. ‘The cervix is an extracellular matrixrich tissue Constituents of the matrix include type I, I, and IV colla- gen, elycosaminoglycans, mattieellula proteins, proteoglycans, and elastin. OF these, collagen is largely responsible for struc tural disposition of the cervix, Collagen is the most abundant mammalian protein and has a complex biosynthesis pathway that includes at lease six enzymes and chaperones to accom plish macuration. Each collagen alpha chains, which wind around each other to form procolla- 40. Multiple collagen triple-helial molecules are eross-linked to one another by the actions of lysyl oxidase to form Abril Collagen ibis interact with small proscoglyeans such as deco- rin or biglycan, as well as maticllular proteins such as throm bospondin 2, These interactions determine fibril size, packing, and organization (Pig, 21-3). This ensues that collagen fibsis ate of uniform diameter and are packed together in a regular and highly organized pattern (Canty, 2005) Dring cervical ripening, collagen bri diameter is increased, and there is increased spacing between fibrils. ‘These changes ‘may result in part from accumulation of poorly crosslinked collagen and reduced expression of matrcellular proteins. Dispersion of collagen fibrils leads to a loss of tissue ince, rigy and increased issue compliance, Matrix metalloproteases (MMPS) ate proteases capable of degrading extracellular mattix proteins, OF these, collagenase members of the MMP farily degrade collagen. Some studies support a role of MMPs in cervical ripening. But, others suggest that the biomechanical changes are not consistent solely with collagenase aexvation and cle ie composed of three Collagen for / é \ Fibrl Before During cervical cervical feonagen ripening ripening 708s tins * Collagen fiber Tightly packed Cyaan tee ‘ib Colagen fibar FIGURE 21-3 Fibila: collagen synthesis and organization. Collagen fis by small pro! pening, bail size is uniform, and fibrils are nized. During cervical ipening, fib size isles uniform, and spacing into collagen fibers. Fibil size and packing are regulated in p as decorin that bind collagen. Belote ce Il packed and o feen collagen ibis and fib is increased and disaiganized loss of collagen. For example, Buhmschi and colleagues (2004) performed tissue biomechanical studies in the rat and suggest that ripening coreelases with changes in the three-dimensional seructure of collagen rather than its degradation by collagenaee. Moreover, mouse and human studies document no changes in, collagen content between nonpregnancy and term pregnancy (Akins, 2011; Myers, 2008: Read, 2007). ‘Thus, ic is likely chat dynamic changes in collagen steue cure rather than collagen content may regulate cemodeling, ‘This point is well illustrated in specialized microscopy images of mouse and human cervical collagen (Zhang, 2012). In fur- ther support, polymoxphisms of mutations in genes required for collagen assembly are ascciated with an increased incidence of cervical insufficiency (} 1998; Rahman, 2003; Warren, 2007 sam, 2009; Paternosce, Glycosaminoglycans (GAGS). ‘These are high-molecular- ‘weight polysaccharides that complex with proteins to form proteoglycans, One glycosaminoglyean is hyaluronan (FIA), a carbohydrate polymer whose synthesis is carried out by hyah tuonan synthase isoenzymes, Expression of these enzymes is increased in the cervix during ripening (Akgul, 2012; Osmers, 1993; Stach, 2005). "The functions of hyaluronans are depen dent on size, and the breakdown of large- to small-molectlar- weight molecules is carried out by a family of hyaluronidase enzymes. Hyaluronidase genes are expressed in both the mouse sed hyaluronidase activity is reported in the mouse cervix at term (Akgul, 2012). Large- molecular-weight HA predominates in the mouse cervix during. ripening and has a dynamic role co increase viscoelasticity and matrix disorganization, Low-moleculat-weight HA has proin fammacory properties, and studies in mice and women teveal increased concentrations during labor and in the puerperium and human cervix, and incr Physiology of Labo’ (Akgul, 2012; Ruscheinsky, 2008) The importance of regulated changes in HA size during cervical ripening and distation is supported by a suudy seporting hyaluronidase administration to the cervix for ripening in ttm pregnant women Gpallicci, 2007). Activaion of, inacelluar signaling cascades and other biological functions requites HA-binding proteins such a versican ‘uscheinsky, 2008) swith cell-associated Proteoglycans. ‘These _glycopro: teins are composed of a protein core and GAG chains. Changes in the amount of core protein ot in the umber, length, oF degree of sul- fation of GAG chains can influence proteoglycan function, Although not well-defined, changesin proteoglycan composition are thought to accom: pany cervical ripening. Atleast three small leucine-rich proteoglycans are expressed in the cervix—decorin, biglyean, and fibromodulia, (Westergren-Thorsson, 1998). In other connective tissues, deco rin and other family members interact with collagen and influ ence the packing and order of collagen fbrils (Ameye, 2002) Collagen fibrils are rearranged in the skin of decorin-d mice and result in collagen fibers that are weakened, shortened, and disorganized (see Fig. 21-3). In addition to the cervix, these proteoglycans aze expressed in the fetal membranes and wets. Changes in expression levels may regulate feral membrane cen- sile scrength and uterine Function (Meiner, 2007; Wa, 2012). An Loosely packed fois ssemblee glycans such Inflammatory Changes. The marked changes within the estracelhlar matrix during cervical ripening in phase 2 are accom- panied by stromal invasion wich inflammatory cells."Thishasled to 4 model in which cervical ripening is considered an inflammatory process. As such, cervical chemoattractants attract inflammatory: cell, which in tutn release proteases that may aid degradation of collagen and other matsix components In phase 3 of 4 of part tion, there is increased cervical expression of chemokines and co: lagenase/ protease activity. Teas assumed that processes regulating phases 3 and 4 of dilation and postpartum recovery ofthe cervix ‘were similar to those in phase 2 of cervical ripening (Bokstrom, 1997; Osman, 2003; Sennstrém, 2000; Young, 2002). This has been challenged by observations from both human and animal studies. Skamoto and associates (2004, 2005) found no correla- tion between the degree of clinical cervical ripening and the tesue concentrations of cervical newtrophilchemoateactant interleukin 8 (ILS), Microarray studies compating gene expression pat a cerm before and afer cervieal ripening report lite increase in expression of proinflammatory genes. In contrast, thete isa robust, increase in proinaramatory and immunosuppressive genes in the cervix alter delivery compared with during cervical ripening (GBollapragads, 2009; Hassan, 2006, 2009). a each Tb) an PAN TBES Labor In mouse models, monocyte migration, but not activa- tion, takes place before labor (Timmons, 2006, 2007, 2009). Mice deficient in the chemokine receptor CCR2, import in monocyte homing to tissues, have normally timed lab “This further supports the suggestion that labs by an inflammatory response (Menzies, 2012). Furthermore, issue depletion of neutrophils before birth has no effect on, the timing oF stecess of parturition, Finally, activation of neu: wophils, proinflammatory MI macrophages, and alternatively of activated M2 macrophages is increased within 2 houss after birth. This suggests a role for inflammatory cells in postpartum, cervical remodeling and repair. not initiated Induction and Prevention of Cervical Ripening “There ate no therapies to prevent premature cervical ripening, Cenvieal cerdage is sed to cteumvent cervical insucency, although success appeats limited (Owen, 2012). In contast, tteatment to promote cervical ripening for labor induction includes direct application of prostaglandins E, (PGE,) and F,, (PGF). Prostaglandins likely modify extracellular matix structure toa ripening. Although the role of prostaglandins in the normal physiology of cervical ripening remains uncles, thie property is wsefl clinically to awa labor induction (Chap. 26, . 526). In some nonhuman species, che cascades of events that allow cervical ripening ate induced by deceasng serum proges tctone concentrations. And in humans, administration of pro sgesterone ancagonists causes cervial ripening, As discussed late, humans may have developed unique mechaniame to localize decreases in progesterone action inthe cervc and rayon Phase 3 of Parturition: Labor “This phase is synonymous with active labor, which is custom- arily divided into three stages. Taese compose the commonly used labor graph shown in Figute 21-2, The clinical sages of labor may be summatized as follows, The frst stage begins when spaced uterine contractions of sufficient frequency, inter sity, and duration are attained to bring about cervieal thin- ning, or effacement. This labor stage ends when the cervix is fally dlaced—about 10 em—to allow passage ofthe term-sized feeus, The frst stage of labor, cherefoe, isthe stage of cervical effacement and dilatation “The cond stage begins when cervical dilatation is complete and ends with delivery, Thas, the second stage of labor is the stage of fetal expulsion. Las, the thied stage begins immediately afier delivery of the fetus and ends with the delivery of the placenta. Thus, the chi stage of labor is the stage of placental separation and expubion First Stage of Labor: Clinical onset of Labor In some women, forceful uteine contractions that effect deliv- ery begin suddenly. In othets, labor initiation is heralded by spontaneous tl amount of blood-tinged mucus fiom the vagina. This exeuson of the mucus plug that had previously filled the cervical canal duting pregnancy is referred to at “show” of “bloody show.” There i very lie blood wich the macous plug, and its passage indicates that labor i already in progres or likely wil ensue in hours to day. Uterine Labor Contractions ‘Unique among physiological muscular contractions, those ‘of uterine smooth muscle during labor ate painful. The ‘cause of this is not known definitely, but several possibilities have been suggested: (1) hypoxia of the contracted myome- ‘trium—such a5 that with angina pectoris: (2) compression ‘of nerve ganglia in the cervix and lower uterus by contracted interlocking muscle bundles: (3) cervical stretching during dilatation; and (4) stretching of the peritoneum overlying the fundus, Of these, compression of nerve ganglia in the cervix and lower uterine segment by the contracting myometrium is an ‘specially attractive hypothesis. Paracervical infiltration wish local anesthetic usually produces appreciable pain relief with contractions (Chap. 25, p. 509). Uterine contractions are involuntary and, for the most part, independent of extra ine control. Neural blockade from epidural analgesia doce not diminish their frequency oF intensity. In other examples, mettial contsactions in paraplegic women and in women aft bilateral Lumbar sympathectomy are normal but painless, Mechanical stretching of the cervix enhances uterine aetiv- ity in several species, ineluding humans. This phenomenon, hhae been referred to at the Ferguow refex (Ferguson, 1941), ‘exact mechanism i not clear, and release of oxytocin has been suggested but not proven. Manipulation of the cervix and “stripping” the fetal membranes is associated with an increase in blood levels of prostaglandin F,, metabolite (PGEM). ‘The interval between contractions diminishes gradually from approximately 10 minutes at the onset of first-stage labor to as little as 1 minute of less in the second stage. Periods of relaxation berween contractions, however, ae essential for fetal, welfare. Unremitting contractions compromise uteroplacental ‘blood flow sufficiently to cause fetal hypoxemia. In active- pphase labor, the duration of each contraction ranges from 30 0 90 seconde, averaging about 1 minute. There is apprecia- Dle vatiability in contraction intensity during normal labor. Specifically, amnionie fluid pressures generated by contractions during spontaneous labor average 40 mm Hg, but vary from 20 eo 60 mm Hg (Chap. 24, p. 498) Distinct Lower and Upper Uterine Segments. During active labor, the anatomical uterine divisions that wete ini tiated in phase 2 of parturition become inereasingly evident (figs. 21-4 and 21-5). By abdominal palpation, even before membrane rupture, the swo segments can sometimes be dif- ferentiated. ‘The upper segment is firm during contractions, ‘whereas the lower segment is softer, distended, and more pas- sive. This mechanism is imperative because if the entte myo: metsium, including the lower uterine segment and cervix, were to contract simultaneously and with equal intensity, the nec cexpubsive force would be markedly decreased, Thus. the upper segment contracts, retracts, and expels the fers, In response tw these contractions, the softened lower uterine segment and cervix dilate and thereby form a greatly expanded, thinned-out tube through which the fecus can pass. The myometrium of the upper segment docs not relax to its original length after contractions. Instead, it becomes relatively fixed at a shorter length. ‘The upper active uterine segment Physiology of Labor Pathological retraction ring (as) segment Body. Physiologica, Paleve themus. Anat o- ‘retraction ring” segment Con =, Oblterated 1.0 £o EO. EO: NONPREGNANT PREGNANT UTERUS INLABOR UTERUS INLABOR UTERUS IN LABOR, UTERUS UTERUS ATTERM NORMAL. NORMAL “ABNORMAL EARLY FIRST STAGE, SECOND STAGE SECOND STAGE - DYSTOCIA FIGURE 21-4 Sequence of development of the segments and rings inthe uterus at term and in labor. Nate comparison between the uterus of a nonpregnant woman, the uterus at term, and the uterus during labor. the passive lower uterine segment is derived ftom the isthmus, ané the physiological retraction ring develops atthe junction ofthe upper anc lower uterine segments, the pathological etac- tian ring develops fram the physiclagical ring. nat, 10, = anatomical internal 95, £.. = extemal a5; Hist 10, = histological internal os, Ph, R= physiological retraction ring. contracts down on its diminishing contents, but myomettal Cension remains constant, The not effect i to cake up slack, thus maintaining the advantage gained in expulsion of the fetus. Concurrently, the uterine musculature is kept in firm contact with the uterine contents. As the consequence of retraction, cach successive contraction commences where its predecessor left off ‘Thus, the upper part of the uterine cavity becomes slightly smaller with each successive contraction. Because of the suecesive shortening of the muscular fibers, the upper active segment becomes progressively thickened throughout frst- and second-stage labor (see Fig. 21-4). This process continues and results in a tremendously thickened upper uterine segment immediatly after delivery Clinically, ic is importane to understand that the phenom- enon of upper segment retraction is contingent on a decrease in Passive sogment “Level of internal cervical os Cena — Levelt external earvieal os Vagina FIGURE 21-5 The uterus atthe time of vaginal delivery. The active upper segment retracts around the presenting part as the fetus descends through the bith canal. Inthe passive lower segment, there is considerably less myometial one the volume ofits contents. For this t happen, particularly eatly in labor when the entire uterus is virtually & closed sac with only minimal cervical dilatation, che musculacue of che lower segment must strech. This permits an increasing portion af che uterine contents co occupy the lower segment. The upper seg- ment retracts only to the extent that che lower segment distends and the cervix dilate. Relaxation of the lower uterine segment mirrors the same gradual progression of reuaction. Recall chat after each con- traction of the upper segmens, the muscles do nos return to thet previous length, but tension remains essentially the same. By comparison, in the lower segment, successive lengthening. of the fibers with labor i accompanied by thinning, normally to only a few millimeters in che chinnest part. As a resule of the lower segment thinning and concomitant upper segment thickening, a boundary between the «wo is marked by a ridge fon the inner uterine surfuce—the phyiolaical retraction ring ‘When the thinning of the lower uterine segment is extreme, as in obstructed labor, the sing is prominent and forms a patho- logical reraction ring. This abnortal condition is also known as the Band! ring, which is discussed further and illustrated in ‘Chapter 23 (p. 470) ‘changes in Uterine Shape During Labor. Each contrac- tion produces an elongation ofthe ovoid uterine shape with a concomitant dectease in horizontal diameter. This change in shape has importanc effects on the labor process. Fist, there is increased fetal axis presur, that is, the decreased horizontal diameter serves to sisighten the fea vertebral column. This prestes the upper pole of che ferus firmly against the fundus, ‘whereas the lower pole is thrust farther downward. The lengsh- ‘ening of the ovoid shape has been estimated at 5 and 10 em. Second, with lengthening ofthe 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 polled upward and around the lower pole ofthe fetus Ancillary Forces in Labor ‘Ace the cervix is dilated fully, the most imporcant foree in fetal expulsion is that produced by maternal intrsabdominal a3 each Tb) a4 PAN TBES Labor Pressure, Contraction of the abdominal muscles simultane- ‘ously with forced respiratory efforts with the glotis closed is referred to as pushing. ‘The force is similar wo that with def cation, but the intensity usually is much greater. The impor- tance of intsaabdominal pressure is shown by the prolonged descent during labor in paraplegic women and in those with a dense epidusal block. And, although increased intraabdominal pressure is necessary to complete second-stage labor, pushing accomplishes lite in the frst stage. Itexhauss the mother, and its associated inereased intrauterine pressures may be harmfil co the fees. Cervical Changes ‘As the result of contraction forces, two fundamental changes— ‘effacement and dilatation —oeeur in the alteady-ripened cervix. For an average-sied fetal head co pass through the cervix, its ‘anal must dilace to a diameter of approximately 10 cm. Ac this time, the cervix is said to be completely or fly dilated. Although there may be no fetal descent during cervical efface- ment, most commonly the presenting fetal part descends somewhat as the cervix dilates. During second-stage labor in nullipaas, the presenting part «ypically descends slowly and steadily. In multiparas, however, particularly those of high parity, descent may be rapid. Cervical elacement is “obliteration” ot “taking up” of the cervix, It is manifest clinically by shortening of the cervical Muttpara Primigravia FIGURE 21-6 Schematic showing effacement and dilatation ‘A. Before labo, the primigravid cervix is lang and undated in «contrast to that of the mutipaa, which has dilatation of the inter= nal and external os, B. AS effacement begins, the mutiparous

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