Академический Документы
Профессиональный Документы
Культура Документы
LABOUR
Labour is a physiologic process during which the products of conception (i.e., the fetus, membranes, umbilical cord and placenta) are expelled outside the uterus. Labour is achieved with changes in the biochemical connective tissue and with gradual effacement and dilatation of the uterine cervix as a result of rhythmic uterine contractions of sufficient frequency, intensity, and duration.
Onset of labour
Show (bloody show) - sign of the impending onset of active labor - extrusion of mucus plug of the cervical canal discharge of small amount of bloodtinged mucus from vagina
4/34
Uterine contractions
Uterine Contractions Characteristic of Labor ; muscular contractions, those of uterine smooth muscle of labor are painful cause of pain (not known definitely) hypoxia of contracted myometrium compression of nerve ganglia in cervix & lower uterus by the tightly interlocking muscle bundles stretching of cervix during dilatation stretching of peritoneum overlying the fundus
Ferguson reflex : mechanical stretching of cervix enhances uterine activity : manipulation of the cervix and stripping the fetal membranes is associated with an increase in PGF2 metabolite in blood : exact mechanism : not clear Interval between contractions : 10 minutes at the onset of the first stage diminishes gradually 1 minute or less in the second stage
Periods of relaxation between contractions - essential to welfare of the fetus - unremitting contraction of uterus compromises uteroplacental blood flow, cause fetal hypoxia Duration of contraction : in active phase Duration 30-90 seconds (average 60 sec) Pressure 20-60 mmHg (average 40 mmHg)
Cervical Effacement
obliteration or taking up of the cervix shortening of the cervical canal (2cm mere circular orifice with almost paper thin edge) muscular fibers at about the level of the internal os are pulled upward or taken up into the lower uterine segment external os remains temporarily unchanged
Smooth muscle cell shortening with contraction>striated muscle Forces can be exerted in multiple directions Plexiform arrangement aids greater shortening and force generating capacity Greater multidirectional force generation in fundus permits versatality in expulsive forces
CRH ;synthesized in placenta and hypothalamus ,found to have dual role during pregnancy and labour, During pregnancy it binds the receptor CRHR1 production of cAMP and subseqent inhibition of myometrial activity At term CRH can activate the Gq prtein pathway which favours myometrial contraction
Prostaglandins ;most commonly considered as uterotonins however they have diverse effects and some acts as smooth muscle relaxants Both PGE2 and PGI2 could potentially act to maintain uterine quiscence by increasing cAMP signaling yet PGE2 can promote uterine contractility through binding to EP1 and EP2 receptors Thus either the generation of specific prostaglandins or relative expression of the various prostaglandins receptors may determine myometrial response to prostaglandins
Atrial and brain natriuretic peptide and cGMP Accelarated uterotonin degradation e.g.by oxyticinase and PGDH
Posttranslational modifications of progesterone receptor Alterations in progesterone receptor activity through changes in in the expression of coactivators or co-repressors that directly influence receptor function Local inactivation of progesterone by steroidmetabolizing enzymes or synthesis of a natural antagonist.
Oxytocin receptors
There is an increase in myometrial oxytocin receptors and there activation results in increased phospholipase C activity and subsequent increase in cytosolic calcium and uterine contractility
Relaxin
Causes remodeling of extracellular matrix of uterus,cervix,vagina, breast and pubic symphysis as well as promoting cell proliferation and inhibiting apoptosis.
This ability makes it possible to create a feed forward endocrine cascade that does not end untill separation of fetus from placenta at delivery. Resulting high levels of CRH may modulate myometrial cotractility via interaction with the CRH receptor isoform CRH-R1d this isoform is known to enhance myometrial contractile response
It has also been proposed that cortisol affects the myometrium indirectly by stimulating the fetal membranes to increase PG synthesis Finally CRH has been shown to stimulate fetal adrenal C19- steroid synthesis thereby increasing substrate for placental aromatization and increased levels of oestrogen
Onset of labour
Uterotonins that are candidates for labour induction include,oxytocin,PGs,serotonin;histamine,PAF,ang iotensin II and many others All have been shown to stimulate smooth muscle contraction through G-protein coupling
Oxytocin
It was first uterotonin to be implicated in parturition initiation following observations provide support for this theory The number of oxytocin receptors strikingly increases in myometrial and decidual tissues near end of gestation Oxytocin acts on decidual tissue to promote prostaglandin release Oxytocin is synthesized directly in decidual and extraembryonic fetal tissues and in the placenta.
Prostaglandins
Evidence supportive of trhis theory includes; Levels of prostaglandins or their metabolites in amniotic fluid ,maternal plasma and maternal urine are increased during labour Treatment of pregnant women with PGs by any of several routes of administration,causes abortion or labour at all stages of gestation. Administration of PGHS type 2 inhibitors to pregnant women will delay spontaneous onset of labour and sometimes arrest preterm labour.
Endothelin-1
The endothelins are a family of 21-amino acid peptides that powerfully induce myometrial contraction. It is produced in myometrium and its potential contribution to phase 3 of parturition is not defined.
Angiotensin-II
There are two G-protein-linked angioteneism II receptors in the uterus - AT1 and AT2. In non pregnant women the AT2 receptors is predominant, but the AT1 receptor is preferentially expressed in pregnant. Angiotenism II is binding to the plasmmembrane receptor evokes contraction.
Crticotropin-Releasing Hormone(CRH)
Late in pregnancy phase 2 or 3 of parturition modification in the CRH receptor favours a switch cAMP formation to increased myometrial cell calcium levels via protein kinase C activation. Oxytocin acts attentuate CRH-stimulated accumulation of cAMP myometrial tissue and CRH augments the contraction-inducing potency of a given dose of oxytocin n human myometrial strips. Finally CRH acts to increase myometrial contractile force in response to PGF2.