Fisiologi kehamilan,persalinan, dan nifas

8/10/2019 Fisiologi kehamilan,persalinan, dan nifas

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1st LOFertilization Implantation and

Placentation


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Fertilization

Fertilization occur when sperma meet ovum.

It happen in ampulla Tuba fallopii.

Sperma will come into the ovum by releasing

akrosom enzyme thet can


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Trofoblastik cell

will cover inner

cell mass

Dinding2 sel trofoblas yg masuk ke

endometrium luruh, mmbntuk

synsitium multinukleus

yg akan mnjadi plasenta janin

Blastokista akan

ditanam di desidua

Blastokista akan

ditanam di desidua


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embentukan Ruang mnion


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2nd LO

Anatomy and Physiology changes

in Pregnancy


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1. Cardiovaskular System

1) CARDIAC OUTPUT

The total blood volume increases by about40% above nonpregnant levels, with wide

individual variations. The disproportionate increase in plasma

volume compared to the red cell volumeresults in hemodilution with a decreased

hematocrit reading, sometimes referred to asphysiologic anemia of pregnancy


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Cardiac output rises by the 10th week of

gestation; it reaches about 40% above

nonpregnant levels by 20 to 24 weeks, after

which there is little change

For any given level of exercise, oxygen

consumption is higher in pregnant than in

nonpregnant women

2) INTRAVASCULAR PRESSURES

Systolic pressure falls only slightly during

pregnancy, whereas diastolic pressure

decreases more markedly; this decrease

begins in the first trimester, reaches its nadirin midpregnancy, and returns toward

nonpregnant levels by term


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3) MECHANICAL CIRCULATORY EFFECTS OF THE

GRAVID UTERUS

supine hypotensive syndrome

The venous compression by the gravid

uterus elevates pressure in veins that drain

the legs and pelvic organs, thereby

exacerbating varicose veins in the legs and

vulva and causing hemorrhoids

Because of venous compression, the rate of

blood flow in the lower veins is also

markedly reduced, causing a predisposition

to thrombosis


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4)REGIONAL BLOOD FLOW

Two of the major increases (those to

the kidney and to the skin) serve

purposes of elimination: the kidney of

waste material and the skin of heat

When maternal cardiac output falls,

blood flow to the brain, kidneys, and

heart is supported by a redistribution of

cardiac output, which shunts bloodaway from the uteroplacental

circulation


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5) CONTROL OF

CARDIOVASCULAR CHANGES

A unifying hypothesissuggests that the changes in

circulating steroid hormones

in combination with changesin production of vasodilatory

prostaglandins, atrial

natriuretic peptide, nitric

oxide, and aldosterone affect

venous distensibility and

arterial tone


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6) OXYGEN-CARRYING CAPACITY OF

BLOOD

Plasma volume expands

proportionately more than red

blood cell volume, leading to a fallin hematocrit

Despite the relatively low

"optimal" hematocrit, thearteriovenous oxygen difference in

pregnancy is below nonpregnant

levels.


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B. RESPIRATORY SYSTEM

The major respiratory changes in

pregnancy involve three factors:

the mechanical effects of the

enlarging uterus, the increasedtotal body oxygen consumption,

and the respiratory stimulant

effects of progesterone


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1) RESPIRATORY MECHANICS IN PREGNANCY

As pregnancy progresses, the enlarging uterus

elevates the resting position of the

diaphragm. This results in less negative

intrathoracic pressure and a decreased

resting lung volume, that is, a decrease in

functional residual capacity (FRC)

These characteristics-reduced FRC with

unimpaired VC-are analogous to those seen

in a pneumoperitoneum and contrast with

those seen in severe obesity or abdominalbinding, where the elevation of the

diaphragm is accompanied by decreased

excursion of the respiratory muscles


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2) OXYGEN CONSUMPTION AND

VENTILATION

Total body oxygen consumption

increases about 15% to 20% inpregnancy

pregnancy, the elevations in

both cardiac output and alveolar

ventilation are greater than

those required to meet the

increased oxygen consumption


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The rise in minute ventilation

reflects an approximate 40%

increase in tidal volume at term;

Such increased respiratory

sensitivity to CO2 is characteristic of

pregnancy and probably accounts

for the hyperventilation of

pregnancy


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In summary

both at rest and with exercise, minute

ventilation and, to a lesser extent, oxygen

consumption are increased during

pregnancy over the nonpregnant control

values.

The respiratory stimulating effect of

progesterone is probably responsible for

the disproportionate increase in minuteventilation over oxygen consumption


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3)ALVEOLAR-ARTERIAL GRADIENT

AND ARTERIAL BLOOD GASMEASUREMENTS

Pregnancy is characterized byhyperventilation (the arterial

PCO2 falls to a level of 27 to 32

mm Hg) and associatedrespiratory alkalosis


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C. RENAL PHYSIOLOGY

The urinary collecting system, including the

calyces, renal pelves, and ureters, undergoes

marked dilation in pregnancy, as is readily

seen on intravenous urograms. It begins in the

1st trimester, is present in 90% of women at

term, and may persist until the 12th to 16th

postpartum week.


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2) FLUID VOLUMES

The maternal extracellular volume,

which consists of intravascular and

interstitial components, increases

throughout pregnancy, leading, ineffect, to a state of physiologic

extracellular hypervolemia. The

intravascular volume, which consistsof plasma and red cell components,

increases approximately 50% during

pregnancy


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3) RENIN-ANGIOTENSIN SYSTEM IN PREGNANCY

Plasma concentrations of renin, renin substrate,

and angiotensin I and II are increased. Reninlevels remain elevated throughout pregnancy.

4) HOMEOSTASIS OF MATERNAL ENERGY

SUBSTRATES

The metabolic regulation of energy substrates,

including glucose, amino acids, fatty acids, and

ketone bodies, is complex and interrelated


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5)INSULIN EFFECTS AND GLUCOSE METABOLISM

In pregnancy, the insulin response to glucose

stimulation is augmented

Glycogen synthesis and storage by the liver

increases, and gluconeogenesis is inhibited

After early pregnancy, insulin resistance

emerges, so glucose tolerance is impaired. Thefall in serum glucose for a given dose of insulin is

reduced compared with the response in earlier

pregnancy


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A variety of humoral factors have been suggested

to account for the anti-insulin environment of the

latter part of pregnancy. Perhaps the mostimportant is human placental lactogen (hPL)

6)LIPID METABOLISM

During the second half of pregnancy, however,

probably as a result of rising hPL levels, lipolysis is

augmented, and the plasma concentration of free

fatty acids after an overnight fast is elevated. In the context of maternal lipid metabolism, the

most dramatic lipid change in pregnancy is the rise

in fasting triglyceride concentration


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D. Tractus Digestivus

Intestine move to lateral and top

Motility of intestine and secret of gastes ( as

hidrochlorid and peptine) go down causing

vomite and constipation


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F. Glandula mammae

Enlargement of sinus and ductus cause of

esterogen

Accumulating of lipid cause of progesteron


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G. Reproductive system

1) Uterus

Increasing volume and enlargement of uterus and hypertrofi of

miometrium

Accumulation of sheaf tissue and elastine increase its stregh

Placenta make a rough sign at uterus Itsmus hypertropy and longer formed hergar sign

Dextrorotation of uterus

Formed a sign upper and lower segmen caused by Contraction of uterus

called phycology retraction ring

Sporadic contraction at trisemster 2 called Braxton Hix contraction


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G. Reproductive system

2) Serviks

More soft and bluish after one month

Collagen are syntesized and formed by collagenase to prevent weakness of

its

3) Vagina

Formed chadwick sign

ovarium


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3rd LO

ANC and PNC


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b ckground

Maternal Mortality Rate (MMR)

because (60-80%) is bleeding, obstructedlabor, sepsis, high blood pressure It canactually be anticipated

One way to MMR with ANC(Antenatal Care)


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Antenatal Care a program planned by health workers

1. Observation Kehamilanaman

2. Education Ibu Hamil Persalinanaman

3. Medical treatment Deteksidini

(kelainan obstetri)


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Determine the health status of themother and fetus.

Determine the gestational age of the

fetus.

Initiated plans to continue obstetriccare.

Ensuring the safety and health of thepregnancy, both the mother and baby

Formulate a list of risk factors

Main purpose of

the ANC


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Antenatal care early or first visit

complete history

routine inspection

Assessment of risk factors

Next antenatal care.

On the first visit if found to be a risk factor of routinehistory taking and examination then be evaluated

during the next visit

Components of Antenatal Care


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Examination schedule (gestational age of HPHT):

- Up to 28 weeks (7 Months): 4 weeks. Once- 28-36 weeks (7-9 months): 2 weeks.Once- > 36 weeks: 1 week..Twice

except...

If found abnormalities / risk facto

need medical treatment needmore frequent inspection and int


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Obstetric examination

General inspectionFront chloasma gravidarum, edema +/-Eyes conjungtiva anemic +/-, sclera

jaundice +/-Mouth gums and teethNeck JVP, enlargement of the thyroid glandand lymph +/Mammary shapes, symmetrical,enlargement, nipple widened, areolahyperpigmentation, vascular, glandulartissue hyperplasia

Abdomen enlarged , pigmentation of linea alba andstriae,+/- scarring, motion +/- childrenVulva perineum, varices +/-, flour albus +/- anus hemorrhoids +/-,Limbs varices +/-, +/- edema (pretibial, ankle,

instep), scarring +/-

f h


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examination of theAbdomen(LEOPOLD)

Leopold I :Examiner stands facing the patient, and then with both

hands touching with fingers to determine the height ofthe fundus and what part of the child contained in the

fundus

Leopold II :The position is still the same, move the h

side. Determine where there is a child's b

gives the biggest hurdle then look for smare located in conflict


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Leopold III :

Wearing one hand only, Handle bottoming section and

determine whether they can be shaken to determinewhat is at the bottom and whether it has / has not been

held in check by the pelvic

Leopold IV :Examiner position facing the patient's legs, wit

hands specify what the bottom and whether thi

has been entered into the PAP and how the ent


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Fetal Heart Sounds

(auscultation)

Fetal heart sounds

can already be

heard at week 20 in

80 percent of

women

At week 21, the

sound of the fetal

heart was heard at95 percen

at week

all pregwome

S i l


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SpecialExamination

Imaging

Resonance

Magnetic

Amniocentesis

Cordosintesis Fetoscopy


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rovide exclusive

breastfeeding

Not give cow's milk

Breastfeeding

counseling ..


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4Th LO

Labor and Delivery


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Labor

Childbirth is the period from the onset of

regular uterine contractions until expulsion of

the placenta.

Uterus contraction -> effacement and dilatation

of servic -> push the baby out.

Needs huge energy, so its called labor (hard

work)

b


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Labor

Signs of labour , theres painful uterine contractions accompaniedby any one of the following:

1) ruptured membranes,

2) bloody "show,"

3) complete cervical effacement.

True labor?

Stages of labor:

First stage: Dilatation

Second stage: Delivery

Third stage: Placental


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First Stage of Labor (cont)

Active Labor.

These phase ischaracterized bydilatation of cervixuntil its complete.

Nulipara = 1,2 cm/hr,Multipara 1,5 cm/hour


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The curve

The first stage is divided into a relativelyflat

latent phase and a rapidlyprogressive active

phase.

In the active phase, there are three identifiable

component parts that include an acceleration

phase, a linear phase of maximum slope, and a

deceleration phase.


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The second Stage of Labor

This stage begins when cervical dilatation is completeand ends with fetal delivery.

The median duration is about 50 minutes for nulliparasand about 20 minutes for multiparas, but it can be highly

variable .

In a woman of higher parity with a previously dilatedvagina and perineum, two or three expulsive efforts afterfull cervical dilatation may suffice to complete delivery.

Conversely, in a woman with a contracted pelvis or alarge fetus or with impaired expulsive efforts fromconduction analgesia or sedation, the second stage maybecome abnormally long


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Mechanism of Labor

It is thus of paramount importance to know the

fetal position within the uterine cavity at the

onset of labor. The position of the fetus with

respect to the birth canal is critical to the routeof delivery.

Fetal orientation relative to the maternal pelvis

is described in terms of fetal lie, presentation,attitude, and position.

Mechanism of Labor


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Mechanism of Labor

LIE, PRESENTATION, ATTITUDE,

AND POSITION. Fetal Lie. The lie is the relation

of the long axis of the fetus tothat of the mother, and is

either longitudinal or transverse.

Fetal Presentation. Thepresenting part is that portion

of the fetal body that is eitherforemost within the birth canalor in closest proximity to it. Itcan be felt through the cervixon vaginal examination (VT).


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Mechanism of Labor

Position = Fetal Attitude or Posture. Inthe later months of pregnancy the fetusassumes a characteristic posturedescribed as attitude or habitus (flexion,extension)

Fetal Position. Position refers to therelationship of an arbitrarily chosenportion of the fetal presenting part to theright or left side of the maternal birthcanal.

The fetal occiput, chin (mentum), andsacrum are the determining points invertex, face, and breech presentations,respectively


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Mechanism of Labor

Longitudinal lie.Cephalic presentation.Differences in attitude

of the fetal body in

A) vertex, B) sinciput,

C) brow, and D) face

presentations.

L b


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Labor

Longitudinal lie. Vertexpresentation.

A. Left occiput anterior(LOA).

B. Left occiput posterior(LOP)

C. Right occiputposterior (ROP).

D. Right occiputtransverse (ROT)

E. Right occiput

anterior (ROA)

A

DC

BB


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CARDINAL MOVEMENT

The cardinal movements oflabor are engagement,

descent, flexion, internal

rotation, extension, externalrotation, and expulsion

During labor, these

movements are sequentialbut also show great

temporal overlap.


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1. Engagement

The fetal head may engage during the

last few weeks of pregnancy or not

until after the commencement of

labor. In many multiparous and some

nulliparous women, the fetal head is

freely movable above the pelvic inlet

at the onset of labor. In thiscircumstance, the head is sometimes

referred to as "floating."


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Labor


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Labor


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2. Descent

Descent is brought about by one or more of four forces:

1) pressure of the amnionic fluid,

2) direct pressure of the fundus upon the breech with contractions,

3) bearing down efforts of maternal abdominal muscles, and

4) extension and straightening of the fetal body.


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3. Flexion

As soon as the descending head meets

resistance, whether from the cervix, walls of

the pelvis, or pelvic floor, flexion of the head

normally results.


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4. Internal Rotation

This movement consists of a turning of thehead in such a manner that the occiput

gradually moves toward the symphysispubis anteriorly from its original positionor, less commonly, posteriorly toward the

hollow of the sacrum. Internal rotation is essential for the

completion of labor, except when the fetusis unusually small.

When the head fails to turn until reaching

the pelvic floor, it typically rotates duringthe next one or two contractions inmultiparas. In nulliparas, rotation usuallyoccurs during the next three to fivecontractions.


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5. Extension

. When the head presses upon the

pelvic floor, however, two forcescome into play. The first, exerted bythe uterus, acts more posteriorly, and

the second, supplied by the resistantpelvic floor and the symphysis, actsmore anteriorly.

The resultant vector is in thedirection of the vulvar opening,

thereby causing head extension. Thisbrings the base of the occiput intodirect contact with the inferiormargin of the symphysis pubis


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6. External Rotation

The delivered head next undergoes restitution. If theocciput was originally directed toward the left, it

rotates toward the left ischial tuberosity; if it was

originally directed toward the right, the occiput

rotates to the right.

Restitution of the head to the oblique position isfollowed by completion of external rotation to the

transverse position, movement that corresponds to

rotation of the fetal body, serving to bring its

bisacromial diameter into relation with the

anteroposterior diameter of the pelvic outlet.


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7. Expulsion

Almost immediately after external rotation, theanterior shoulder appears under the symphysis

pubis, and the perineum soon becomes

distended by the posterior shoulder.

After delivery of the shoulders, the rest of the

body quickly passes.


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5Th LO

PUERPERIUM

CHANGES THAT OCCUR DURING THE


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CHANGES THAT OCCUR DURING THE

PUERPERIUM

Is recovery period after childbirth whichlasted for 6 weeks.

1. Uterine

Soon after postpartum, the rest of deciduadifferentiate into:

Stratum superficial

Basale stratum Involution autolysis and necrosis of

decidua superficial


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Involution will produce lokhia (duh) which is

contain eritrocyt, leukocyt, epitel cells,

decidua cells, and bactery.

Type of lokhia:

Lokhia rubra

Lokhia serosa

Lokhia alba


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2. Cervix

Ostium cervix smaller but could not return asusual.

Ostium cervix externum widen as lip.

3. Urinary tract

Diuresis for 2-5 days

Decreased sensitivity of VU

4 Peritoneum and abdominal wall


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4. Peritoneum and abdominal wall

Broad and round ligament become loose, and

need long time to be recovered.Striae gravidarum ( during pregnancy)

become striae alba

5. Blood and Circulation

Leukocytosis, granulocytosis, trombocytosis.

CO increased in the first 48 hours, and will be

as usual in 2 weeks.

6 Weight loss


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6. Weight loss

Become as usual in 6 month post partum.

Due to: Diuresis

Uterine changes

7. Mamae

The first two days will produce colostrum, and

the next day produce ASI.

Due to: estrogen & progesteron prolactin

& oxytocin ASI produced


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6Th LO

Drugs in Pregnant


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7Th LOPrevention, Promote, and

Management of complicationwhi le pregnant, in labor , and

during postpartum per iod

Preventive promotive and


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Preventive, promotive, and

management complication1. Pregnant

- ANC

2. In Labor

- Partograf

3. Postpartum

- Active management in stage 3 of labour

- post partum Observation at least until one week

after labor


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1. Preeclampsia

1. Dietry and Lifestyle Modification

2. Antihypertensive Drugs

3. Antioxidants

f f


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Dietary and life style modification

1. Low-Salt Diet.

One of the earliest research efforts to prevent

preeclampsia was salt restriction

a sodium-restricted diet was ineffective in

preventing preeclampsia

2. Calcium Supplementation

women with low dietary calcium intake were at

significantly increased risk for gestational

hypertension


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3. Fish Oil Supplementation

supplementation with these fatty acids would

prevent inflammatory-mediate atherogenesis, it

was not a quantum leap to posit that they

might also prevent preeclampsia

4. Exercise

the protective effects of physical activity on

preeclampsia

Dietary and life style modification co

h d


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Anti hypertension drugs

women given diuretics had a decreasedincidence of edema and hypertension but not

of preeclampsia.

chronic hypertension are at high risk for

preeclampsia

i id


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Antioxidants

imbalance between oxidant and antioxidantactivity may play an important role in the

pathogenesis of preeclampsia

vitamins C, D, and Emight decrease such

oxidation

7 E l i


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7. Expulsion

Almost immediately after external rotation, theanterior shoulder appears under the symphysis

pubis, and the perineum soon becomes

distended by the posterior shoulder.

After delivery of the shoulders, the rest of the

body quickly passes.

Fisiologi kehamilan,persalinan, dan nifas

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