Uterine Contractions Preceding Labor

The latent phase of labor

The latent phase of labor extends from the initiation of labor to the onset of the active phase. Because neither margin is always precisely identifiable, the duration of the latent phase often can only be estimated. During this phase, the cervix undergoes a process of rapid remodeling, which may have begun gradually weeks before. As a consequence of extensive changes in its collagen and ground substance, the cervix softens, becomes thinner and dramatically more compliant, and may dilate modestly. All of these changes prepare the cervix for the more rapid dilatation that will occur during the active phase to follow. For the clinician, it is important to recognize that the latent phase may normally extend for many hours. The normal limit for the duration of the latent phase should be considered to be approximately 20 hours in a nullipara and 14 hours in a multipara. Factors that have been associated with a prolonged latent phase include deficient prelabor or intrapartum cervical remodeling, excessive maternal analgesia or anesthesia, maternal obesity, and chorioamnionitis. Approximately 10% of women with a prolonged latent phase are actually in false labor, and their contractions eventually abate spontaneously. The management of a prolonged latent phase involves either augmenting uterine activity with oxytocin or providing a sedative-induced period of maternal rest. Both are equally effective in advancing the labor to active phase dilatation. A very long latent phase may be a harbinger of other labor dysfunctions.

Monitoring uterine contractions during labor: current challenges and future directions

Organ-level models are used to describe how cellular and tissue-level contractions coalesce into clinically observable uterine contractions. More importantly, these models provide a framework for evaluating the many different contraction patterns observed in laboring patients, ideally offering insight into the pitfalls of currently available recording modalities and suggesting new directions for improving recording and interpretation of uterine contractions. Early models proposed wave-like propagation of bioelectrical activity as the sole mechanism for recruiting the myometrium to participate in the contraction and increase contraction strength. However, as these models were tested, the results consistently revealed that sequentially propagating waves do not travel long distances and do not encompass the gravid uterus. To resolve this discrepancy, a model using 2 mechanisms, or a "dual model," for organ-level signaling has been proposed. In the dual model, the myometrium is recruited by action potentials that propagate wave-like as far as 10 cm. At longer distances, the myometrium is recruited by a mechanotransduction mechanism that is triggered by rising intrauterine pressure. In this review, we present the influential models of uterine function, highlighting their main features and inconsistencies, and detail the role of intrauterine pressure in signaling and cervical dilation. Clinical correlations demonstrate the application of organ-level models. The potential to improve the recording and clinical interpretation of uterine contractions when evaluating labor is discussed, with emphasis on uterine electromyography. Finally, 7 questions are posed to help guide future investigations on organ-level signaling mechanisms.

Diagnosing onset of labor: a systematic review of definitions in the research literature

BACKGROUND

The diagnosis of labor onset has been described as one of the most important judgments in maternity care. There is compelling evidence that the duration of both latent and active phase labor are clinically important and require consistent approaches to measurement. In order to measure the duration of labor phases systematically, we need standard definitions of their onset. We reviewed the literature to examine definitions of labor onset and the evidentiary basis provided for these definitions.

METHODS

Five electronic databases were searched using predefined search terms. We included English, French and German language studies published between January 1978 and March 2014 defining the onset of latent labor and/or active labor in a population of healthy women with term births. Studies focusing exclusively on induced labor were excluded.

RESULTS

We included 62 studies. Four 'types' of labor onset were defined: latent phase, active phase, first stage and unspecified. Labor onset was most commonly defined through the presence of regular painful contractions (71% of studies) and/or some measure of cervical dilatation (68% of studies). However, there was considerable discrepancy about what constituted onset of labor even within 'type' of labor onset. The majority of studies did not provide evidentiary support for their choice of definition of labor onset.

CONCLUSIONS

There is little consensus regarding definitions of labor onset in the research literature. In order to avoid misdiagnosis of the onset of labor and identify departures from normal labor trajectories, a consistent and measurable definition of labor onset for each phase and stage is essential. In choosing standard definitions, the consequences of their use on rates of maternal and fetal morbidity must also be examined.

Study of correlation between maternal fatigue and uterine contraction pattern in the active phase of labour

AIMS AND OBJECTIVES

To evaluate the correlation between maternal fatigue and uterine contraction pattern at the beginning of the active phase of labour.

BACKGROUND

Fatigue is one of the most common complaints in pregnant women that often continues until delivery. Maternal fatigue prolongs the labour process and increases the rate of cesarian section. Studies on the pattern of uterine contractions have shown that the length of the fall time is longer in prolonged labours than in normal deliveries.

DESIGN

A cross-sectional study.

METHODS

This study was conducted on 100 primiparous women who were referred to Ommolbanin Hospital (Mashhad, Iran) in 2011. Maternal fatigue was assessed at the beginning of the active phase of labour. Then, the pattern of uterine contractions was monitored for 30 minutes by an external tocodynamometer. The F/R ratio was determined by measuring the time for a contraction to return to its baseline from its peak and the time for a contraction to rise to its peak. The data were analysed by chi-square and anova tests.

RESULTS

The results showed that there was a significant relationship between maternal fatigue and uterine contraction pattern. The F/R ratio was increased with increase in fatigue severity.

CONCLUSIONS

Fatigue causes changes in the pattern of uterine contractions. The return time of a contraction from its peak to its baseline (fall) is increased with increase in fatigue severity.

RELEVANCE TO CLINICAL PRACTICE

Offering strategies to prevent tiredness and reduce the related fatigue complications.

Labor analgesia for patients with preterm premature rupture of membranes

OBJECTIVE

Cervical examination is relatively contraindicated in women with preterm premature rupture of membranes (PPROM), limiting our ability to determine the onset of labor by traditional definition (contractions with cervical change). We sought to determine whether two maternal requests for analgesia within 3 h predicted delivery within 24 h to allow appropriate epidural placement.

STUDY DESIGN

We performed a retrospective chart review of all patients with PPROM for a period of 18 months. Our primary outcome was the percentage of women with PPROM (<34 weeks) who delivered within 24 h from the second analgesia request.

RESULT

Among women with PPROM, 63% delivered within 24 h from their second request for analgesia and 98% delivered within 48 h.

CONCLUSION

Two medication requests within 3 h for regular, painful contractions can be used as an indicator of onset of labor in women with PPROM to allow for labor analgesia.

Evaluation of newborn canine viability by means of umbilical vein lactate measurement, apgar score and uterine tocodynamometry

Newborn viability evaluation and early detection of fetal distress could contribute to reducing mortality at birth in canine species. High neonatal mortality rate in dogs is reported subsequent to complicated or uncomplicated whelping. Umbilical vein lactate and tocodynamometry could provide valuable clinical information to the obstetricians so that appropriate medical and surgical treatments or oxygen and warm administration can be properly and timely applied to mother and newborn pup. In humans, the fetal lactate level represents an objective indicator of fetal distress and a valid predictor of babies' survival. Fetal acidosis recognition by umbilical lactate (UL) measurement, APGAR score classification, and uterine activity monitoring during labour, can represent an advanced system in the evaluation of the canine newborn patient. The purpose of this study was to correlate UL levels with canine neonatal morbidity and mortality within 48 h of birth. We evaluated the relationship among neonatal parameters at birth (mucous membrane color, heart and respiratory rate, reflex irritability, mobility, suckling and vocalization, UL, weight, and temperature) with labour characteristics (uterine contractions recorded by the tocodynamometric system of Whelpwise ™ Veterinary Perinatal Specialties ®, delivery time, and pup presentation), in view to predict pup viability. We considered also vaginal parturition versus elective and emergency Caesarean section, and uterotonic drugs influence on delivery. Umbilical lactate concentration proved to be useful to predict canine neonatal mortality within 48 h of birth (P < 0.05). We identified 5 mmol/L of vein umbilical lactate concentration as the cut off value, allowing us to distinguish between healthy and distressed pups. Higher values of UL were related with distressed pups, whereas lower values characterized vigorous pups. Lactate concentrations lower than 5 mmol/L and APGAR scores higher than 9, related to mean delivery time of 105 min with effective uterine contractions (10 mm of Hg of strength or more, frequency from 4 to 12 contractions per hour, and 2-5 min in duration), should be considered good prognostic factors in canine labour and neonatology.