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Physiological changes during first stage of labor

The first stage is chiefly concern with the preparation of the birth canal so as to facilitate expulsion of the fetus in the 2 nd stage. During first stage of labor, following physiological changes are occurs.

  • 1. Uterine action

I. Contraction and retraction of uterine muscles

Uterine contraction are involuntary, they are controlled by the nervous system and endocrine influence. Normally the uterus begins to contract effectively 280 days after the LMP. Contraction consists of regular, painful with hardening of uterus. The patient experiences pain, which is situated more on the hypogastric region, often radiating to the thighs. Probable causes of pain are myometrial hypoxia during contractions, stretching of the peritoneum over the fundus, stretching of the cervix during dilatation and compression of the nerve ganglion. At earlier the contractions are often week and may be imperceptible to the mother but it becomes more powerful at last.

The feature of uterine contraction:  Frequency: It is the interval of each contraction. In the
The feature of uterine contraction:
 Frequency: It is the interval of each contraction. In the early
stage of labor, the contractions come at intervals of ten to
fifteen minutes. The intervals gradually shorten with
advancement of labor until in the second stage, when it comes
every two or three minutes.
 Duration: It is length of each contraction. In the first stage, the
contractions last for about 30 seconds initially but gradually
increase in duration with the progress of labor. Thus in second
stage, the contractions last longer then in the first stage.
 Intensity: The intensity of uterine contraction describes the degree of uterine systole. Or degree of
 Intensity: The intensity of uterine contraction describes the
degree of uterine systole. Or degree of pain e.g. mild moderate
and strong. The intensity gradually increases with advancement
of labor until it becomes maximum in the second stage during
delivery of the baby.
 Tonus: It is intrauterine pressure in between contractions. It is
also increases with progress of labor. During pregnancy, as the
uterus is relatively inactive, the tonus is of 2-3 mmHg. During
the first stage of labor, it varies from 8-10 mmHg. The factors,
which govern the tonus, are contractility of uterine muscles,
intra abdominal pressure.

Retraction is a phenomenon of the uterus in labor in which the muscle fibers are permanently shorted. Contraction is a temporary reduction in length of the fibers, which attain their full length during relaxation. In contrast, retraction results in permanent shortening and the fibers are shorted once and for all. Retraction is a specially a property of upper uterine segment. It makes upper segment of uterus gradually shorter and thicker in progressive nature after each contraction and cavity diminishes which keeps place with the gradual descent of the presenting part.

The effects of retraction which is essential in normal labor are:

Formation of upper and lower uterine segment. Dilatation and effacement of up of the cervix. Reduce the surface area of the uterus favoring separation of placenta. Maintain the advancement of presenting part and help in expulsion of fetus.

II. Fundal dominance:

Uterine contraction that is strongest at the top of the uterus and weakest in the lower uterine segment. Each uterine contraction starts in the fundus near one of the cornua and spreads across and downwards. The contraction lasts longest in the fundus where it is also most intense, but the peak is reached simultaneously over the whole uterus and the contraction fades from all parts together. This pattern permits the cervix to dilate and the strongly contracting fundus to expel the fetus.

III. Polarity:

Polarity is the term used to describe the neuromuscular harmony that prevails between the two poles or segments of the uterus through out the labor. During each uterine contraction these two pole act harmoniously. The upper pole contracts strongly and retracts to expel the fetus; the lower pole contracts slightly and dilates to allow expulsion to take place. Thus coordination between fundal contraction and cervical dilatation called “Polarity of uterus” If the polarity of uterus disorganized then the progress of labor is inhibited.

IV. Formation of upper and lower segment:

Before onset of labor, there is no complete anatomical and functional division of the uterus. During labor, the body of uterus is divided in to two segments. Upper 2/3 rd of the uterus is known as upper segment, which is formed from the body of the fundus, is mainly concerned with contraction and retraction: it is thick and muscular. The lower uterine segment is formed of the isthmus and the cervix, and is about 8-10 cm in length, that portion of the non-pregnant uterus lying between the anatomical and the histological internal os. In early pregnancy, the lower segment is poorly formed. When labor begins, the retracted longitudinal fibers in the upper segment pull on the lower segment causing it to stretch; this is aided by the force applied by the descending part.

V. Formation of retraction rings

The ridge forms between the upper and lower uterine segment; this is known as ‘retraction’ or ‘Bandl’s ring’. The contraction and retraction of the upper segment cause the uterine thicker, shorter or smaller, so it attempts to push the fetus out into the birth canal and according to distend, stretch and thinner. During this processes, a distinct ridge is produced at the junction of the two segments, which is called retraction or physiological ring and moves up to the level of symphysis pubis as the lower segment is distended and it is perfectly normal if it does not move beyond the symphysis pubis.

In normal labor, retraction ring gradually rises as the upper segment contracts and retracts and lower uterine segment thins out to accommodate the descending fetus. Once the cervix is fully dilated and delivery takes place, so the retraction ring rises no further and ceases spontaneously.

VI. Taking up of the cervix (Cervical effacement):

Cervical effacement is the process by which the muscular fibers of the cervix are pulled upward and merges with the fibers of the lower uterine segment. Or it is process of thinning and shorting out of the cervix.

Effacement may occur late in pregnancy or it may not take place until labor begins. In the primigravida, the cervix will not dilate until effacement is complete, whereas in the multigravida effacement and dilatation may occur simultaneously.

VII. Cervical dilatation:

Dilatation of cervix is the process of enlargement of the os uteri from a tightly closed aperture to an opening large enough to permit passage of the fetal head. Dilatation is measured in centimeters and full dilatation at equates to about 10cm.

Dilatation occurs as a result of uterine action and the counter pressure applied by the bag of membranes and the presenting part. A well -flexed fetal head closely applied to the cervix favors efficient dilatation. Pressure applied evenly to the cervix causes the uterine fundus to respond by contraction.

VIII. Presentation of Show:

It is the bloodstain mucoid discharged seen a few hours before, or with in a few hours after labor has started. During pregnancy a woman's cervix produces thick mucus, filling the opening to act as a plug to seal the uterus. Towards the end of pregnancy, the cervix may start to thin and soften, sometimes releasing this mucus plug, known as a show. The blood comes from ruptured capillaries in the parietal deciduas where the chorion has become detached and from the dilating cervix.

2. Mechanical Factor I. Formation of the fore waters

As the lower uterine segment forms and stretches, the chorion becomes detached from it and the increased intrauterine pressure causes this loosened part of the sac of fluid to bulge downwards in to the dilating internal os, to the depth of 6-12 mm and forms bag of membranes. The well-flexed head fits snugly in to the cervix and cuts off the fluid in front of the head from that which surrounds the body. The part above the girdle of contact contain the fetus with bulk of the liquor called hind water and the part of water in front of the presenting part is called fore water.

II. General fluid pressure

While the membranes remain intact, the pressure of uterine contractions is exerted on the fluid and as fluid is not compressible, the pressure is equalized through out the uterus and over the fetal body and is known as general fluid pressure. When the membrane ruptures and quantity of fluid emerges, the placenta is compressed between the uterine wall and the fetus during contractions and the oxygen supply to the fetus is thereby diminished and there is risk of fetal hypoxia during uterine contraction.

III.

Rupture

of

membranes

ROM is a term used during pregnancy to describe a rupture of the amniotic sac at the onset of, or during, labor. This is colloquially known as "breaking water". A premature rupture of membranes (PROM) is a rupture that occurs

prior to the onset labor. The physiological moment for the membranes to rupture is at the end of the first stage of labor when the cervix becomes fully dilated and no longer supports the bag of fore waters. The uterine contractions are also applying increasing force at this time.

IV. Fetal axis pressure

During each contraction the uterus rears forward and the force of the fundal contraction is transmitted to the upper pole of the uterus, down the long axis of the fetus and is applied by the presenting part to the cervix. This is known as fetal axis pressure and becomes much more significant after rupture of the membranes and during the second stage of labor.