The uterine pacemaker of labor

The laboring uterus is generally thought to initiate contractions much similar to the heart, with a single, dedicated pacemaker. Research on human and animal models over decades has failed to identify such pacemaker. On the contrary, data indicate that instead of being fixed at a site similar to the sinoatrial node of the heart, the initiation site for each uterine contraction changes during time, often with each contraction. The enigmatic uterine "pacemaker" does not seem to fit the standard definition of what a pacemaker should be. The uterine pacemaker must also mesh with the primary physiological function of the uterus - to generate intrauterine pressure. This requires that most areas of the uterine wall contract in a coordinated, or synchronized, manner for each contraction of labor. It is not clear whether the primary mechanism of the uterine pacemaker is a slow-wave generator or an impulse generator. Slow waves in the gut initiate localized smooth muscle contractions. Because the uterus and the gut have somewhat similar cellular and tissue structure, it is reasonable to consider if uterine contractions are paced by a similar mechanism. Unfortunately, there is no convincing experimental verification of uterine slow waves. Similarly, there is no convincing evidence of a cellular mechanism for impulse generation. The uterus appears to have multiple widely dispersed mechanically sensitive functional pacemakers. It is possible that the coordination of organ-level function occurs through intrauterine pressure, thus creating wall stress followed by activation of many mechanosensitive electrogenic pacemakers.