Physiology of Labor

Asheber Gaym M.D.

January 2009
 Outline

• Define labor and its stages

• Define determinants of labor
• Describe characteristics of uterine
contractions in labor
• Describe patterns of cervical dilatation in labor
• Describe normal patterns and durations of
labor

Asheber Gaym,2009 2
 Definition of labor and stages of labor

• Labor is the process by which the products of conception

are delivered through the birth canal
• Labor is a continuous process but for understanding and
management purposes classified into several stages:
– First stage – onset to full cervical dilatation
– Second stage- full cervical dilatation to fetal delivery
– Third stage- fetal delivery to delivery of the placenta
– Fourth stage- the first hour following delivery
• Based on gestational age:
– Preterm labor- labor onset before 37 completed weeks
– Term/post term labor- labor after 37 and 42 weeks

Asheber Gaym,2009 3
 Initiation of Labor – Exact cause unknown

• Theories of labor initiation:

– Fetal cortisol theory- mature fetus secretes cortisol which
initiates labor
– Oxytocin theory- secretion of oxytocin from posterior hypophysis
initiates labor
– Prostaglandin theory- release of prostaglandins from fetal
membranes initiates labor
– Other theories
– No concrete evidence found as yet as to the exact cause of
initiation of labor
– Diagnosis of the exact time of initiation of labor is also often
difficult due to the commonality of false labor pains

Asheber Gaym,2009 4
 Determinants of Labor

• The powers
– Primary powers- uterine contractions
– Secondary powers- maternal valsalva maneuver
• The passage
– The bony pelvis
– The pelvic soft tissues
• The passenger
– The fetus of fetuses
• The psychological state of the mother
Asheber Gaym,2009 5
 Labor determinants- Specific Characteristics
Labor determinant Specific characteristics of determinant that impact labor
outcome
The primary Coordination of contractions; presence of myomas; congenital
powers – uterine uterine anomalies (bicornuate, septate, double, …); primary
contraction uterine dysfunction; dehydration and electrolyte imbalance etc

The secondary Maternal glycemic status; maternal hydration status; maternal

powers exhaustion; maternal consciousness( e.g. eclampsia); maternal
instruction during labor; labor education during antenatal care

The passenger Fetal presentation; fetal size; fetal position ( occipitoposterior

versus occipitoanterior); number of fetuses; fetal congenital
anomalies ( e.g. hydrocephalus, hydrops fetalis etc); fetal tumors

The passage Shape of the bony pelvis; dimensions of pelvis; congenital

anomalies of bony pelvis; previous fractures of bony pelvis;
sublaxation of L4 ; Soft tissue dystocia- presence of a tumor
previa; cervical dystocia; vaginal septa… etc

Asheber Gaym,2009 6
 Characteristics of uterine contractions
• Uterine anatomy of relevance to labor:
– Myometrial content is highest in the fundus and decreases
downward to the cervix
– Cervix is predominantly (90%) connective tissue
– Hence during uterine contraction, the upper segment and body is
dominant, while the lower segment and cervix remain passive
– Gradient of uterine contractions is highest at the fundus and
decreases towards the cervix
– The cervix and lower segment are progressively pulled upwards
by the active upper segment leading to gradual thinning, cervical
effacement and dilatation
– Arrangement of uterine muscle fibers in three concentric
interwoven layers allows the contracting uterus to apply a
coordinated multidirectional downward pressure over the fetus

Asheber Gaym,2009 7
 Characteristics of uterine contractions – unique features
Characteristic Description and relevance
Contraction and Following each contraction, the length of the myometrial cells is
“retraction” shorter than its original length thus gradually decreasing uterine
volume and pushing the fetus downwards through the birth canal

Painful The only physiologic contraction that is painful. Cause of pain –

myometrial hypoxia; stretching of the cervix; stretching of
parametrial tissues; stretching of overlying serosa

Gradient of Three zones of activity with a highly active fundal segment;

activity moderately strong mid segment and an inactive lower segment
and cervix passively pulled upwards progressively getting thinned
out with cervical effacement followed by dilatation

Ferguson’s reflex Cervical dilatation and pressure on the cervix by the presenting
part leads to more stronger contractions through a local uterine
reflex that leads to a more stronger contraction

Cervical Follows a sigmoid curve pattern

dilatation
Descent of Follows a hyperbolic curve pattern
presenting part
Asheber Gaym,2009 8
 Characteristics of uterine contractions – unique features

Characteristic Latent phase of labor Active phase of labor

Frequency

Duration/ 10 minutes

Intensity in mmHg

Asheber Gaym,2009 9
 Cervical changes during labor

• Pre-labor cervical ripening

– A few days to weeks before the onset of labor the cervix ripens( becomes
softer; changes position from posterior to middle and anterior; begins
dilatation and effacement)
– Ripening is due to the hormonal effects of estrogen, progesterone and relaxin
leading to water absorption and separation of dense connective tissue fibers
• Changes during labor
– Cervical effacement- the initial and longest cervical change of labor. Occurs
during the latent phase of labor. It is a gradual shortening of the length of the
cervix from above downwards from its normal 3 cms length to paper thin
thickness
– Cervical dilatation- gradual process during effacement but once effacement is
complete becomes a rapid process until full cervical dilatation

Asheber Gaym,2009 10
 Rate of cervical changes during labor

Characteristic Primigravida Multigravida

Active phase – rate/hour

Total duration latent phase-

hours

Total duration active phase

– hours

Asheber Gaym,2009 11
Pattern of Cervical dilatation

Asheber Gaym,2009 12
Pattern of descent of presenting part

Asheber Gaym,2009 13