Physiology, Cervical Dilation

Article Author:
Osarieme Evbuomwan
Article Editor:
Yuvraj Chowdhury
Updated:
5/11/2020 12:21:02 PM
PubMed Link:
Physiology, Cervical Dilation

Introduction

The cervix is a narrow, tubular passage that comprises the inferior end of the uterus. The uterus is a pear-shaped organ with the narrower part, the cervix, facing downwards and protruding slightly into the vagina in pre-menopausal women. As such, the cervix serves as a passageway between the endometrial cavity and the vagina and is physiologically important in reproduction and childbirth.[1]

The cervix divides into the endocervix, the endocervical canal, and the ectocervix. The endocervix is the portion of the cervix that meets the corpus of the uterus. The ectocervix is the most inferior portion of the cervix that protrudes into the vagina. The internal os of the cervix is the opening of the cervix that joins the uterus, while the external os of the cervix is the junction between the cervix and the vagina. During labor, the internal os will undergo effacement, while the external os will undergo dilation. 

The cervix serves as a barrier between the endometrial cavity and the vagina, which is effectively the external world. Depending on the phase a female is in during her menstrual cycle, the cervix will produce mucus of different consistencies to either facilitate or hinder sperm entry into the endometrial cavity. Furthermore, during pregnancy, the cervix produces a thick mucus plug that keeps pathogens out of the endometrial cavity to protect the developing fetus and to maintain a sterile environment in the uterus.

Towards the end of pregnancy as the time of labor approaches, the cervix must thin and open wider to facilitate and accommodate the passage of the fetus during delivery. This process is known as cervical effacement and dilation.[2] The determining factor for the first stage of labor is cervical progression; when the cervix has become completely effaced and dilated, it marks the beginning of the second stage of labor. Should this process become impaired or proceed too slowly, the obstetrician can augment cervical effacement and dilation.

Issues of Concern

Dilation of the cervix is achieved when the cervix dilates to 10 cm. How rapidly a female will progress to full dilation is dependent on several factors, including her parity, medical history, her pelvic anatomy, the size of the fetus, and the position of the fetus at the time of labor.[3][4][5] Multigravidas progress to full dilation more quickly than primigravidas. A history of diabetes mellitus or gestational diabetes increases the likelihood of a large-for-gestational-age fetus and macrosomia, which can lead to labor complications such as the arrest of descent, a prolonged latent phase or active phase arrest.[6][7][8] If the pelvic anatomy of the mother is too narrow or has any other anatomic anomaly, cephalopelvic disproportion between the fetus and the mother may lead to prolonged or arrest of labor.[9] If the fetus is in the breech position, this may also lead to labor abnormalities and hinder the ability of the cervix to dilate fully.[10]

The stages of labor are as follows: Stage 1 is effacement and dilation of the cervix, Stage 2 is the delivery of the fetus, and Stage 3 is the delivery of the placenta. Stage 1 subdivides into latent and active where 0 to 6 cm is the latent phase of Stage 1, and 6 cm to complete dilation of the cervix is recognized as the active phase of Stage 1 labor.[11]

In a primigravida, the latent phase should not exceed 20 hours. In a multigravida, the latent phase should not exceed 14 hours. If a female is in labor and exceeds these average time frames, she is said to be having a prolonged latent phase. Newer data suggest that these parameters are longer.[12] The active phase of labor should occur much more rapidly, usually within 4 hours after the rupture of membranes when there are adequate uterine contractions. If the mother does not fully dilate by these average estimations, she is said to be having an arrest of the active phase of Stage 1 labor. 

Cellular

The cervix is composed of multiple cell types. The endocervix is composed of columnar epithelium interspersed with mucus-producing goblet cells. Towards the outer edge of the cervix, the epithelial cell type transitions to squamous cell epithelium.[13][14] The ectocervix and the upper third of the vagina are composed of squamous epithelium.[14] The area of transition between the two types of epithelium is called the "transition zone." The transition zone is clinically significant in the development of cervical cancer, which this article discusses elsewhere. 

On a more micromolecular level, the cervix is a collagenous structure composed of proteoglycans, fibrin, and glycosaminoglycans (GAGs). It is not a muscle like a uterus, but instead, it is more elastic and has fibers interwoven into the foundation that gives it the ability to dilate and efface during pregnancy and recoil after delivery, which makes it more similar to connective tissue.[15] The composition of collagen and GAGs enable the cervix to quickly metabolize these proteins and transform from a firm, tubular structure to a soft, flattened structure well suited for birth.[16][15] 

While the mechanism is not entirely understood, studies suggest that the cervix undergoes temporary hyperplasia with a multitude of collagenous cells to support the birthing process.[17] Once delivery is complete, these cells undergo apoptosis and return the cervix to its pre-pregnancy state.[13][18][2]

Development

The cervix and upper one-third of the vagina form from two paramesonephric (Mullerian) ducts that fuse and recanalize, which also gives rise to the body of the uterus and the fallopian tubes. This process occurs during the sixth week of embryological development. The paramesonephric ducts are present in all embryos from day 0. Without the Mullerian inhibiting factor (MIF), which is a hormone produced by male embryos, the paramesonephric ducts will develop into the fallopian tubes, uterus, upper one-third of the vagina and the cervix by default.[14] The normal length of the cervix in a premenopausal female who is not pregnant is 2 to 3 cm. Complications of a shorter cervix, otherwise known as cervical insufficiency, and its effect on the normal progression of pregnancy are discussed in another topic elsewhere.  

Function

The cervix is a barrier between the external realm of the vagina and the internal, sterile environment of the uterus. It secretes mucus containing mucins and other fluids that are thick and acidic in nature to protect the internal environment from pathogens, microbes, and also prevents the entry of sperm during certain times of the menstrual cycle. When the mucus is thin and more basic in its pH, it serves as a transporter for sperm during the middle of the menstrual cycle to promote fertilization. 

The cervix maintains its anatomy as a tubular structure throughout pregnancy. The normal length of 2 to 3 centimeters is detectable by ultrasound.[19] As a mother approaches the term segment of her pregnancy, which is recognized anywhere between 37 and 42 weeks, the cervix undergoes rapid changes to enable passage of the fetus from the uterus down through the vaginal canal.[20]   

Effacement is the flattening of the internal of the cervix, while dilation refers to the softening and widening of the external os of the cervix.[15]  

Related Testing

The most commonly used method of measuring cervical dilation during labor is with a digital cervical exam. The obstetrician places two fingers inside the vagina and measures the width of the opening of the external os of the cervix using fingers to approximate the distance. One meta-analysis suggested that ultrasound may play a new role in measuring cervical dilation to assess labor progression more accurately, but at the moment, the digital cervical exam remains the gold standard.[21]

Clinical Significance

Cervical dilation occurs at faster rates in multiparous women compared to nulliparous women.[22] Clinicians consider this factor when evaluating the arrest of labor. 

The obstetrician can facilitate cervical dilation during the induction of labor. Both mechanical and medical means are options. One of the most common mechanical methods of cervical dilation is the placement of a balloon catheter. A catheter is guided through the cervix and inflated just above the endocervical os. This process places pressure on the cervix, mimicking the pressure of the fetus' head against the cervix, which in turn signals the cervix to begin dilation and ripening. [23]

Another way an obstetrician may augment cervical dilation is by the placement of misoprostol, a PDE4 inhibitor that stimulates the cervix to widen and thin. Further, the obstetrician may administer an oxytocin derivative, which does not directly induce cervical dilation but instead causes the uterus to contract more forcefully, pushing the fetus against the cervix and further stimulating the cervix to open. 

Either method may only be used effectively until about 3 cm, after which point the obstetrician must allow time for the mother's body to facilitate further cervical dilation. 


References

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