The last few hours of human pregnancy are characterized by forceful and painful uterine contractions that effect cervical dilatation and cause the fetus to descend through the birth canal. There are extensive preparations in both the uterus and cervix long before this. During the first 36 to 38 weeks of normal gestation, the myometrium is in a preparatory yet unresponsive state. Concurrently, the cervix begins an early stage of remodeling—termed softening—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 loss of structural integrity.
The physiological processes that regulate parturition and the onset of labor continue to be defined. It is clear, however, that labor onset represents the culmination of a 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 between species, and it is these differences that complicate elucidation of the exact factors that regulate human parturition. When parturition is abnormal, then preterm labor, dystocia, or postterm pregnancy may result. Of these, preterm labor remains the major contributor to neonatal mortality and morbidity in developed countries.
The bringing forth of young—parturition—requires well-orchestrated transformations in both uterine and cervical function. As shown in Figure 21-1, parturition can be arbitrarily divided into four overlapping phases that correspond to the major physiological transitions of the myometrium and cervix during pregnancy (Casey, 1993, 1997; Challis, 2000; Word, 2007). These phases of parturition include: (1) a prelude to it, (2) the preparation for it, (3) the process itself, and (4) recovery. Importantly, the phases of parturition should not be confused with the clinical stages of labor, that is, the first, second, and third stages—which comprise the third phase of parturition (Fig. 21-2).
The phases of parturition.
Composite of the average dilatation curve for labor in nulliparous women. The curve is based on analysis of data derived from a large, nearly consecutive series of women. The first stage is divided into a relatively flat latent phase and a rapidly progressive active phase. In the active phase, there are three identifiable component parts: an acceleration phase, a linear phase of maximum slope, and a deceleration phase. (Redrawn from Friedman, 1978.)
Phase 1 of Parturition: Uterine Quiescence and Cervical Softening
Beginning even before implantation, a remarkably effective period of myometrial quiescence is imposed. This phase normally comprises 95 percent of pregnancy and is characterized by uterine smooth muscle tranquility with maintenance of cervical ...