PARTURITION - Encompasses birthing PHASE PHASE PHASE PHASE 0: 1: 2: 3: all physiological processes involved in

o o

prelude to preparation for process of recovery from

Increase in hyaluronic acid which increased in the capacity of cervix to retain water and decrease in dermatan sulfate Increase production of cytokines and infiltration of leukocytes to degrade collagen

LEADS to cervical thinning, softening, and relaxation DILATATION Myometrial changes o Expression of contraction associated proteins o Increase myometrial oxytocin receptors o Increased number and surface areas of myometrial cell gap junctions and proteins (Connexin-43)

CHILD BIRTH PHASES OF PARTURITION

Increased uterine irritability and responsiveness to uterotonins o Formation of lower uterine segment Lightening baby dropped

PHASE 0: UTERINE QUIESCENCE Begins before implantation until the near end of pregnancy Uterine smooth muscle integrity Cervical structural integrity Braxton-Hicks contraction or false labor o Irregular, low intensity o Brief duration o Doesnt cause cervical dilatation PHASE 1: PREPARATION FOR LABOR Uterine awakening or activation Cervical changes o Collagen breakdown and fibers

PHASE 2: PROCESS OF LABOR (ACTIVE LABOR) CLINICAL STAGES: 1st Stage: Stage of Cervical Effacement and Dilatation o Regular contractions to full cervical dilatation (10 cm) 2nd Stage: Stage of Expulsion o Full cervical dilatation to delivery of fetus 3rd Stage: Stage of Separation and Expulsion of Placenta o From delivery of fetus Delivery of placenta

rearrangement

of

First Stage of Labor: Clinical Onset of Labor Show or bleeding slow extrusion of mucus plug Labor pain causes: o Hypoxia of contracted myometrium o Compression of nerve ganglia o Stretching of cervix o Stretching of the peritoneum overlying the fundus Ferguson reflex mechanical strectching of cervix enhances uterine contractions ; false labor Manipulation of cervix and stripping of membranes PGF2 contraction Formation of upper and lower uterine segments FORMATION OF UPPER AND LOWER UTERINE SEGMENTS Upper segment: Actively contracting o Thicker, firm, and hard o Contracts, retracts, and expel fetus Lower segment: Passive o Thinner, less firm, and distended o Dilate, expands fetus extruded Physiologic retraction ring - ridge between the upper and lower uterine segment Pathologic retraction ring (Bandls Ring) extreme thinning of the lower segment as in obstructed labor

CHANGES IN THE UTERINE SHAPE DURING LABOR 1. Decrease in horizontal diameter producing straightening of the fetal vertebral column. Pressure exerted Fetal Axis pressure 2. Lengthening of the uterus longitudinal fibers are drawn taut Pulling of lower segment and cervix Ancillary forces in labor Maternal Intra abdominal pressure Pushing

CERVICAL CHANGES INDUCED DURING 1st STAGE OF LABOR CERVIX 1. Collagen 2. Smooth muscles (25 to 6%) 3. Extracellular matrix Glycosaminoglycans Hyaluronic acid Dermatan Sulfate Softened Phases of uterine + preparedness Uterine contractionsAwakening Dilatation Cervical effacement obliteration or taking up of the cervix from length of 2 cm to a paper thin cervix CERVICAL EFFACEMENT AND DILATATION

2 PHASES OF CERVICAL DILATATION Latent Phase variable length and sensitive to sedation Active Phase o Acceleration Phase predictive of the outcome of labor o Phase of Maximum slope overall efficiency of machine o Deceleration Phase fetopelvic relationship

Second Stage of Labor: Fetal Descent Nulliparas engagement before labor begins and descent does not occur until late labor Changes in Pelvic Floor during labor o Stretching of levator ani muscles o Thinning of central portion of the perineum o Dilatation of anus o Increase in the size of the blood vessels Third Stage of Labor Delivery of Fetus Uterus contracts Decrease in uterine size and area of placental Implantation Placenta buckles up Cleavage of Decidua Spongiosa Separation of placenta

Types of Placental Separation 1. Schultze - Central type of separation (usual type) - Glistening amnion presents at the vulva - Blood pours into the inverted sac 2. Duncan - Peripheral type of separation - Blood escapes from the vagina - Maternal surface appears first at the vulva - Placenta is delivered sideways

PHASE 3: PUERPERIUM Uterus must be contracted: IF NOT postpartum hemorrhage Maternal infant bonding begins Involution of uterus to non pregnant state Reinstitution of ovulation for the next pregnancy

1. 2. 3. 4.

Remove agonist from receptor Decrease cytoplasmic Calcium Dephosphorylate MLC Activate Inhibitory Pathways (AMP or cAMP)

PHASE 0 SUBSTANCES RESPONSIBLE FOR UTERINE QUISCENCE

Physiological and Biochemical Processes Regulating Parturition I. Anatomical and physiological consideration of the myometrium

1. ESTROGEN and PROGESTERONE Progesterone decrease expresseion of contraction assoctiated proteins, prevent expression of connexin 43 and gap junction Estrogen promote progesterone responsiveness

Differences between Smooth muscle and Striated muscle SMOOTH STRIATED Greater degree of shortening Lesser degree of shortening Forces directed in any Aligned with the axis of direction muscle fibers Arranged in long random Uniformly arranged bundles Multidirectional force Unidirectional force generation

2. HEPTAHELICAL RECEPTOR 1. Beta adenoreceptors increase cAMP relaxation 2. Leutenizing hormone and Chorionic Gonadotropin (HCG) increase adenylcyclase relaxation 3. Relaxin insulin like growth factor which activates edenylcyclase 4. Corticotropin Releasing Hormone (CRH) can be a uterorelaxant by activation of CAMP or Uterotonin by activation of Calcium 5. Parathyroid Hormone Related Protein Expressed by myometrium , deciduas, amnion and trophoblast Vasorelaxant action

Regulation of Myometrial Contraction and Relaxation What 1. 2. 3. favors Contraction Agents that increase intracellular Calcium Contraction associated protein Activation of phospholipase C

What favors Relaxation

Facilitate maintenance of uterine tranquility

6. Prostaglandin PGE2, PGD2, PGI2 vasodilatation and smooth muscle relaxation 7. Atrial and Brain Natriuretic Peptide and cyclic GMP BNP secreted by amnion the uterus ANP secreted by placenta 8. Enzymatic degradation of Uterotonin PHASE I - UTERINE ACTIVATION Uterotonin Sensitivity Improved intracellular communicability via gap junction Increase capacity of myometrial cells to concentrate CALCIUM Will progesterone withdrawal Parturition? o ANIMALS Estrogen changes in cervix and myometrium o HUMAN Progesterone decreases only after delivery of placenta Roles of CRH 1. Placental CRH enhance fetal cortisol production to give protein back to placenta to produce more CRH myometrial contractility. 2. Cortisol stimulate membrane to increase PG synthesis. Relaxation of

3. Stimulate fetal adrenal C19 Steroid synthesis leading to increase substance for placental aromatization. Fetal Anomalies and Delayed Parturition Hypoestrogenism Delayed parturition Ex. Fetal Anencephaly Adrenal Hypoplasia Placental Sulfatase Deficiency small adrenal glands

C19 Steroid

Decrease estrogen Fetal adrenals important in timely onset of parturition.

PHASE 2 PARTURITION UTERINE CONTRACTIONS LEADING TO CERVICAL DILATATION Uterine Theory of Initiation of Labor Uterotonin Oxytocin, prostaglandin, serotonin, histamine, PAF, angiotensin II

Use of Progesterone Receptor Antagonist Important for activation of parturition but there is a sudden and unique form of functional progesterone that ends the uterine quiescence. 1. Change in the expression of progesterone receptor 2. Modification of progesterone receptor

3. Alteration in progesterone receptor activity 4. Inactivation of progesterone by steroid metabolizing enzyme Oxytocin Receptors Controversy: Early phase of uterine contraction or expulsive phase of labor Estradiol: increase in uterine oxytocin receptor Increase prostaglandin production Fetal Contribution to Initiation of Parturition 1. Fetal stretch increase gap junction protein Connexin 43, oxytocin receptors 2. Fetal Endocrine Cascades Involves hypothalamic-pituitary-adrenal-placental axis ~Corticotrophin releasing hormone (Adrenal Gland) stimulate DHEAS and Cortisol Cortisol stimulates CRH production in placenta increase ACTH Role of Oxytocin: Phase 2 Acts thru the activation of phospholipase 2 and and participates in ensuring effectiveness of uterine contractions

Increase in number of oxytocin receptors in myometrium and deciduas near the end of gestation Acts on decidualtissue to promote prostaglandin release Oxytocin is synthesized in the placenta, deciduas and extraembryonic fetal tissues

Increase oxytocin levels is observed during: Second stage of labor Early postpartum period Breast feeding

Prostaglandin and Phase 2 Parturition (PGF2 alpha and PGE2) Increase levels of PG in AF, maternal plasma and urine during labor If given in pregnant women may cause abortion and labor Administration of PG synthetase inhibitors will delay parturition Smooth muscle treatment with PG contraction

Uterine events Regulating PG production Trauma to deciduas in the formation of the forebag Devascularisation of the deciduas Actions of vaginal fluids inflammatory response in the decidual fragments of the forebag production of cytokines increase PG

Evidences to support role of oxytocin in initiation of labor

PAF (PG, Cytokines, Endothelin I) produced by the leukocytes as a result of inflammatory process contraction Endothelin I o Play a role in uterine contraction in Preterm Labor

Angiotensin II o Increase myometrial cell calcium near term part of uterotonin system of phase 2 parturition CRH, HCG and PTHrP CRH augments contraction inducing potency of oxytocin and PGF2
Transcribed by: Annapot/Aebi/Belle/Donna/Sid

CRH, HCG, PTHrP Favors switch of CaMP formation to increase myometrial cell calcium