TABLE OF CONTENTS
Figures .........................................................................................................
Chapter I.
Introduction .....................................................................
FIGURES
Figure 1.
Figure 2.
Figure 3.
Ligaments..................................................................................
CHAPTER I
INTRODUCTION
Pregnancy is generally characterized by smooth muscle myometrium
activity relative calm that enables the growth and development of fetal intrauterine
pregnancy until term. Before delivery, the uterine smooth muscle contraction is
starting to show activity in a coordinated manner, interspersed with a period of
relaxation, and reached its peak before the birth, and gradually disappeared in the
postpartum period. Regulatory mechanisms that regulate contraction activity of
myometrium during pregnancy, labor and birth, until now stay unclear.
Physiological processes of pregnancy in humans, leading to the initiation
of parturition and the onset of labor is not certain. Until now, generally accepted
opinion that the success of pregnancy in all mammalian species depend on the
activity of progesterone to maintain the tranquility of the uterus until near the end
of pregnancy.
This assumption is supported by the findings that the majority of
mammalian
pregnancy
nonprimata
studied,
disarmament
progesterone
CHAPTER II
ANATOMY OF THE UTERUS
The uterus varies considerably in size, shape and weight depending on the
status of parturition and estrogenic stimulation. The uterus is a fibromuscular
organ that can be divided into the upper muscular uterine corpus and the lower
fibrous cervix, which extends into the vagina.The uterus is a thick-walled
muscular organ capable of expansion to accommodate a growing fetus. It is
connected distally to the vagina, and laterally to the uterine tubes (Sokol, 2011).
The uterus has 3 parts (Sokol, 2011; Behera, 2012) :
Fundus
tubes.
Body
Cervix
Broad Ligament:
This is a double layer of peritoneum attaching the sides of the uterus to the
pelvis. It acts as a mesentery for the uterus and contributes to maintaining it in
position.
Round Ligament:
A remnant of the gubernaculum extending from the uterine horns to the labia
majora via the inguinal canal. It functions to maintain the anteverted position
of the uterus.
Ovarian Ligament:
Joins the ovaries to the uterus.
Cardinal Ligament:
Located at the base of the broad ligament, the cardinal ligament extends from
the cervix to the lateral pelvic walls. It contains the uterine artery and vein in
addition to providing support to the uterus.
Uterosacral Ligament:
Extends from the cervix to the sacrum. It provides support to the uterus.
Figure 2. Overview of the uterus and fallopian tubes, and associated ligaments
Blood is provided to the uterus by the ovarian and uterine arteries, the
latter of which arise from the anterior divisions of the internal iliac artery. The
uterine artery occasionally gives off the vaginal artery (although this is usually a
separate branch of the internal iliac around), which supplies the upper vagina, and
the arcuate arteries, which surround the uterus. It then further branches into the
radial arteries, which penetrate the myometrium to provide blood to all layers,
including the endometrium (Bahera, 2012).
CHAPTER III
NORMAL LABOR
NORMAL PHASES OF LABOR
The last few hours of pregnancy characterized by thinning causing
contractions, cervical dilation, and push out the fetus through the birth canal.
Many the energy released at this time. Therefore, the use of the term "in labor"
(hard work) is intended to illustrate this process. Contraction of the myometrium
during labor pain labor pain so the terms used to describe this process.
THIRD STAGE OF LABOR
Active labor when labor is divided into three distinct. The first stage of
labor begins when it has reached a uterine contraction frequency, intensity, and
duration sufficient to produce cervical effacement and dilation are sufficient.
Completed first stage of labor when the cervix is opened completely (about 10cm)
so as to allow the fetal head through. Therefore, when one persalina called staging
effacement and dilation of the cervix. Second stage of labor begins when cervical
dilation is complete and ends when the fetus is born. Second stage of labor is also
called the expulsion of the fetus stage. The third stage of labor begins immediately
after fetus is born, and ends with the birth of the placenta and fetal membranes.
The third stage is also referred to as stage separation and expulsion of the
placenta.
DIFFERENTIATION ACTIVITY UTERUS
During labor, the uterus transformed into two distinct parts. Segments on
the berkontaksi actively becomes thicker as direct labor. The bottom of the
relatively passive compared with the upper segment, and it evolved into a part of
the birth canal is much thinner-walled. Lower uterine segment analaog with
uterine isthmus is widened and thinned to women who are not pregnant; the lower
segment is gradually formed when gestational age and later became lime once at
the time of delivery. By abdominal palpation, both segments can be distinguished
when the contractions, though not ruptured membranes. Upper segment uterine
fast enough or loud, while the consistency of the lower uterine segment is much
less tight. Upper segment of the uterus is contracted uterus active part, the bottom
part is stretched, normally much more passive,
If all the muscle wall of the uterus, including the cervix and lower uterine
segment to contract simultaneously and with the same intensity, then a thrust labor
will clearly decline. Herein lies the importance of the division of the uterus into
contracting segmena atsa active and passive segments more under different not
only anatomical but also physiologically. Segments on contract retracted and push
the fetus out in response to the contraction of the upper segment dodrong power;
while the lower uterine segment and cervix will be soft dilated; and thereby
forming a muscular line and fibromuscular thinned so that the fetus can stand out.
Myometrium in the upper segment uterine relaxation to return to its
original length after contraction; but being relatively settled on a shorter length.
However, the voltage remains the same as before kontaksi. The top of the uterus,
or active segment berkontaksi down even when it is reduced, so that the pressure
remains konatan myometrium. The end effect is to tighten the slack, by
maintaining favorable conditions obtained from the expulsion of the fetus and
maintain uterine muscles still clung to the contents of the uterus. As a
consequence retraction, each kontaksi next start in the space left by the previous
contraction, so that the top of the uterine cavity be slightly smaller on each
subsequent contraction. Due to the shortening of the muscle fibers are continuous
at each contraction, the upper segment of the uterus becomes progressively more
active along the first and second stage of labor and becomes very thick right after
delivery of the fetus.
The phenomenon of retraction of the upper segment of the uterus depends
on the reduced volume of the contents of the uterus, especially in early labor when
the entire uterus is really a sealed bag with only a small hole in the cervical os.
This allows more isis intrauterine fill the lower segment, and the segment above
only in so far as the expansion beretraksi lower segment and cervical dilation.
Relaxation of the lower uterine segment is not a perfect relaxation, but
rather a retraction opponent. Fibers become stretched in the lower segment of each
segment kontaksi above, and thereafter did not return to the previous long but
relatively retaining a longer length; but the voltage remains essentially the same as
before. The muscles are still showing tone, still hold the stretch, and still
contracting slightly during the last stimulus. When the delivery of advanced,
pemanjangn successively lower uterine segment followed by shortening, normally
only a few millimeters at the thinnest part.
As a result of the depletion of the lower uterine segment and together with
thickening the upper segment of the boundary between the two is marked by a
circle on the surface of the uterus, called the physiologic retraction ring. If the
shortening of the lower uterine segment is too thin, as in obstructed, this ring is
very prominent so forming pathological retraction ring. This is an abnormal
condition is also referred to as ring Bandl. The existence of a gradient of the
physiological activity of the shrinking of the fundus to the cervix can be seen from
the measurement of the top and bottom of the uterus in normal labor.
AMENDMENT FORM UTERUS
10
on labor. First, the reduction of the horizontal diameter cause fetal vetebralis
rectification column, emphasizing the pole it tightly against the fundus, while the
lower pole is pushed further down and toward the pelvis.
Ovoid-shaped elongation of the resulting fetus is estimated to have
reached between 5 to 10 cm: the pressure exerted in this way is known as fetal
stress axis. Second, with prolonged uterus, longitudinal fibers pulled taut and
because of the lower segment and cervix is the only portion of the uterus flexible,
this section is pulled up in the lower pole of the fetus. This effect is an important
factor for cervical dilatation in the muscles of the lower segment and cervix.
ADDITIONAL FORCES IN LABOR
Once fully dilated cervix, the most important force in the process of
expulsion of the fetus is the force generated by the intra-abdominal pressure rises
mother. This style is formed by the contraction of the muscles of the abdomen
simultaneously through efforts pernapasa forced to closed glottis. This force is
called push.
The nature of the force created in the same style that happens to defikasi,
but the intensity is usually larger. The importance of intra-abdominal pressure on
the expulsion of the fetus is most clearly seen in patients with paraplegia labor.
Women like this do not suffer pain, although it may contract the uterus strong.
Cervical dilatation which largely is the result of uterine contractions acting on the
cervix to soften proceeds normally, but ekpulsi baby can be accomplished more
easily if she was asked to push, and can perform the command during a uterine
contraction.
Despite the high intra-abdominal pressure required to complete
spontaneous labor, this labor would be in vain until the full opening of the cervix.
Specifically, this power is the additional assistance needed by contractions of the
uterus in the second stage of labor, but pushing it only helped slightly in the first
stage besides causing sheer exhaustion. Intaabdominal pressure may also be
important in the third stage of labor, especially when the mother who gave birth
unsupervised. After the placenta separated, spontaneous expulsion of the placenta
may be assisted by the mother increased intra-abdominal pressure.
11
CHANGES IN CERVICAL
Power effective in the first stage of labor are uterine contractions, which in
turn will generate a hydrostatic pressure to the rest of the membranes of the cervix
and lower uterine segment. When the membranes have ruptured, the presenting
part is forced directly urged the cervix and lower uterine segment. As a result of
the thrust of this activity, there are two fundamental changes-effacement and
dilation of the cervix-which already softened. For the passage of an average head
aterem fetus through the cervix, cervical canal to be widened to about 10 cm in
diameter; at this time the cervix is said to have a complete open. Perhaps there is
no impairment of the fetus during cervical effacement, but most often the
presenting part tururn sediki start when it comes to the second stage of labor.
Decrease the presenting part be typically a little slow on the nulliparous. But in
multiparas, especially those of high parity, a decline usually takes place very
rapidly.
Cervical effacement
Obliteration or effacement of the cervix is shortening of the cervical canal
along approximately 2 cm into the estuary just a nearly circular with a paper-thin
edge. This process is referred to as a flattening (effacement) and going from top to
bottom. Muscle fibers as high as cervical os internum is pulled up, or shortened,
to the lower uterine segment, while the condition os eksternum temporarily
remain unchanged. The edge of the os internum ditaraik to the top few centimeters
to be a part (both anatomic and functional) of bawaj uterine segment. Shortening
can be compared with a bunch of a tunneling process that changes the whole
length of a narrow tube into a funnel that is very blunt and expands with small
circular exit holes. As a result of the myometrium activity increased throughout
the preparation of the uterus for childbirth, perfect effacement of the cervix that
sometimes software has been completed before the start of active labor. Leveling
cause expulsion of mucus plugs when the cervical canal shortened.
12
Cervical dilatation
When compared with the uterine corpus, cervix and lower uterine segment
is an area of resistance is smaller. Therefore, during the contraction of these
structures in the process to stretch the cervix undergoes a centrifugal pull. When
the contractions of the uterus puts pressure on the amniotic membrane, amniotic
bag hydrostatic pressure will dilate the cervix. When the membranes have
ruptured, the pressure at the bottom of the fetus against the cervix and lower
uterine segment as well as effective. Premature rupture of the membranes that do
not reduce cervical dilation during the presenting part is in a position to continue
the pressure on the cervix and lower uterine segment. The process effacement and
13
dilation of the cervix this causes the formation of pockets of amniotic fluid in the
front of the head.
PATTERNS OF CHANGES IN LABOR
Pattern cervical dilatation
Friedman, in his treatise on labor states that; clinical characteristics of
uterine contractions ie frequency, intensity, and duration can not be relied upon as
a measure of the progress of labor and childbirth as an index of normality. In
addition to cervical dilatation and fetal descent, there are no clinical
characteristics at birth mother seems to be beneficial to assess the progress of
labor. Cervical dilatation patterns that occur during normal labor to have a
sigmoid curve. Two phases of cervical dilatation is the latent phase and an active
phase. The active phase is further divided into acceleration phase, the phase of
maximum slope and deceleration phase. The duration of the latent phase is more
variable and susceptible to change by external factors, and by sedation
(prolongation of the latent phase). The duration of the latent phase little to do with
the trip next delivery process, while the characteristics of accelerated phase
typically have greater predictive value of the results of the late labor. Friedman
considers the maximum ramp phase as a good gauge of the efficiency of this
machine as a whole, while the deceleration phase properties better reflect the
relationships fetopelvik. The full cervical dilation in the active phase of labor
produced by retraction of the cervix around the presenting part. After cervical
dilation is complete, the second stage of labor begins; after that only the
progression of the decline in the presenting part is the only measure available to
assess the progress of labor,
14
16
17
Due to the separation of the placenta through the spongy layer of the
decidua, part of the decidua disposed of with the placenta, while the rest remain
attached to the myometrium. Number of decidua tissue left in the placenta varies.
Placental separation usually occurs within a few minutes after delivery. Because
the peripheral part of the placenta is the most attached, separation usually begin
anywhere. Sometimes a few degrees of separation initiated before the third stage
of labor, which may explain the occurrence of cases of fetal heart rate
decelerations just before the expulsion of the fetus.
EXTRUSION PLACENTA
After the placenta separates from the implantation, the pressure exerted on
it by the wall of the uterus causing this organ was sliding down the slope to the
lower uterine segment or the top of the vagina. In some cases, the placenta can be
pushed out as a result of heightened abdominal pressure. Artificial methods are
used to complete the delivery plasneta is alternately pressing and raising the
fundus, while doing a light traction on the center.
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Signs of labour
Sign
Feeling as if the baby has
dropped
lower.
Discharging a continuous
trickle or a gush of watery
fluid from your vagina.
What is is
Lightening: This is
commonly referred to as the
"baby dropping". The baby's
head has settled deep into
your pelvis.
Show: A thick mucus plug
has accumulated at the
cervix during pregnancy.
When the cervix begins to
open wider, the plug is
pushed into the vagina.
Rupture of Membranes:
The fluid-filled sac that
surrounded the baby during
pregnancy breaks (your
"water breaks").
What it Happens
From a few weeks to a few
hours before labour begins.
False Labor
Often are irregular and do
not consistently get closer
together (called BraxtonHicks contractions).
Often felt in the abdomen.
Contractions usually stop
when you walk or may even
stop with a change of
position.
Labor
Come at regular intervals
and, as time goes on, get
closer and closer together.
Usually felt in the back
coming around to the front.
Contractions continue,
despite movement.
pelvic structure. Neither care providers nor the laboring woman is directly
responsible for these position changes. The baby is the one responsible for these
position changes ~ the cardinal movements.
Engagement. the entering of
the
biparietal
diameter
markedly
these
molded
distances
are
spines,
it
can
be
This
movement
about
by
the
resistance felt by the baby's head against the soft tissues of the pelvis. The
resistance brings about a flexion in the baby's head so that the chin meets the
chest. The smallest diameter of the baby's head (or
suboccipitobregmatic plane) presents into the pelvis.
Internal rotation. As the head reaches the pelvic floor, it typically rotates to
accommodate for the change in diameters of the pelvis. At the pelvic inlet, the
diameter of the pelvis is widest from right to left. At the pelvic outlet, the diameter
is widest from front to back. So the baby must move from a sideways position to
one where the sagittal suture is in the anteroposterior diameter of the outlet (where
20
the face of the baby is against the back of the laboring woman and the back of the
baby's head is against the front of the pelvis). If anterior rotation does not occur,
the occiput (or head) rotates to the occipitoposterior position. The ocipitoposterior
position is also called persistent occipitoposterior and is the common cause for
true back labor.
Extension. After internal rotation is complete and the head passes through the
pelvis at the nape of the neck, a rest occurs as the neck is under the pubic arch.
Extension occurs as the head, face and chin are born.
External rotation. After the head of the baby is born, there is a slight pause in the
action of labor. During this pause, the baby must rotate so that his/her face moves
from face-down to facing either of the laboring woman's inner thighs. This
movement, also called restitution, is necessary as the shoulders must fit around
and under the pubic arch.
It is at this point that shoulder dystocia may be identified. Shoulder dystocia
occurs when the
baby's shoulders are halted at the pelvic outlet due to inadequate space through
which to pass.
Mother's birthing babies who are identified as macrosomatic (in excess of 9.9 lbs.)
are more
likely to experience sho ulder dystocia. Additionally, 15-30% of macrosomatic
babies
experiencing shoulder dystocia sustain some injury to the brachial plexus. Most of
these injuries (80%) resolve by the baby's first birthday.
Commonly, the McRobert's technique is used to resolve shoulder dystocia. This
technique
involves a sharp flexing of the maternal thighs against the maternal abdomen to
reduce the angle between the sacrum and the spine.
Expulsion. Almost immediately after external rotation, the anterior shoulder
moves out from under the pubic bone (or symphisis pubis). The perineum
becomes distended by the posterior shoulder, which is then also born. The rest of
the baby's body is then born, with an upward motion of the baby's body by the
care provider.
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MECHANISM OF LABOR
Ongoing Normal Delivery
Parturition is divided into 4 time
1. Stage I, called opening stage.
2. Stage II, called expenditure stage.
3. Stage III, or when the expultion of placenta.
4. Stage IV, called supervision.
The First Stage
Parturition begins when raised his and the woman blushed blood mucus
(bloody show). Bloody show is derived from the cervical canal because cervical
mucus began to open or flat. While the blood comes from capillaries that are
around canal srvikalis was broke because of the shifts due to cervical opening.
The first stage is divided into two phases:
1. latent phase, lasts for 8 hours with the opening of 3 cm.
2. The active phase: divided into three phases, namely:
a. Accelerated phase, opening to 4 cm within 2 hours.
b. Phase of maximum dilation, opening takes place very rapidly from 4 cm to 9
cm within 2 hours.
c. Deceleration phase, opening from 9 cm to complete within 2 hours.
These phases were found in primigravida. In multigravida, latent phase, active
phase and the deceleration phase becomes shorter.
The mechanism is different between the cervical opening and multigravida
primigravidae. In primigravida, os internum will open first, so that the cervix
opens and thins. Then os eksternum open. In multigravida os internum already
slightly open. Os internum and eksternum well as thinning and flattening of the
cervix occur in the same time.
Membranes will be broken by itself if the opening is almost or already
complete. Not infrequently the membranes have to be solved when the opening is
almost or already complete. When the membranes have ruptured before reaching
the opening of 5 cm is called premature rupture of membranes. When I have
22
finished, if the opening of the cervix is complete. On pda primigravidas first stage
lasts approximately 14 hours, whereas in multiparas approximately 7 hours.
The Second of stage
In his second stage to be stronger and faster, about 2-3 minutes. In this
case the head of the fetus is already entered in the pelvic area and on his perceived
pressure on the pelvic floor muscles that reflektoris cause a sense of straining,
increased pressure on the rectum and about to defecate. Then perineum start to
stand out and be the width of the anal opening. Labia begin to open and soon the
head of the fetus appears in the vulva in his time. At the time of holding the head
of deflection, hold the left hand behind your head (so that deflection is not too
fast), the right hand hold the perineum. By slowly starting born head of Uub,
forehead, nose, mouth, chin until the entire head passes through the perineum.
After a brief rest, his began again to pull out bodies and members of the baby. In
primigravidas second stage lasts an average of 1 hour and in multiparas lasts an
average of half an hour.
The third of stage
After the baby is born, the uterus palpable hard with fundus somewhat
above the center. A few minutes later the uterus to contract again to release the
placenta from the wall. Usually the placenta separated in 6 to 15 minutes after the
baby is born and come out spontaneously or with pressure on the uterine fundus.
Expulsion of the placenta is accompanied by vaginal bleeding. When more than
30 minutes palsenta unborn, called a retained placenta.
The fourth of stage
Fourth stage lasted until 1 hour after delivery of the placenta. At this time
conducted surveillance of postpartum hemorrhage. Even given oxytocin,
postpartum hemorrhage due to uterine atony most likely to occur at this time.
Similarly, the perineal area should be inspected to detect bleeding that much.
23
24
rectum anus opening. With his strength along with strength straining, successively
appear bregma, forehead, face and finally the chin. After the head is born, the
head immediately entered rotation, called the pivot round the outside.
Pivot round the outside this is a movement back before the rotation axis in the
case, to adjust the position of the head with the back of the child.
Shoulder across the inlet in an oblique. In the pelvic cavity shoulder will
conform to the shape of the pelvis in its path, resulting in pelvic floor, when the
head has been born, the shoulder will be in a position behind the front. Similarly,
the front trochanter was born first, then trochanter behind. Then the baby is born
entirely.
When the baby was born, soon airway cleared. The umbilical cord is
clamped between the two pliers at a distance of 5 and 10 cm. then cut between the
two pliers, and then tied up. Umbilical cord stump given antiseptic. Generally,
when it has a complete birthday, baby soon draw breath and cry. Resuscitation
25
with street cleaning and sucking lenders in the airway should be promptly
undertaken. Similarly liquid in the bubble about to inhaled to prevent aspiration
into the lungs when the baby vomits.
If the baby is born, the uterus shrink. Parturition are in the third stage.
Although the baby was born, when uri is no less important than the first stage and
second stage. Maternal death due to bleeding when the placenta is not uncommon
because the leadership of the third stage less carefully done. As has been stated,
immediately after the baby is born, his having amplitude that is approximately the
same height reduced frequency only. As a result of this his, the uterus will shrink
so that the attachment of the placenta to the uterus wall of separation. Remove the
placenta from the uterine wall can be started from 1). Central (central according to
Schultze); 2). The edge (marginal according to Mathews-Duncan); 3). A
combination of 1 and 2. The most is according to Schultze. Uri kala generally
lasts for 6-15 minutes. High fundus after the third stage of approximately two
fingers below the center.
Indications for episiotomy
The recent trend in Australia has been away a routine use of episiotomy in
favour of restrictive use. This transition came from evidence showing restrictive
policy to be associated with less posterior perineal trauma, less suturing and
fewer healing complications as compared to routine episiotomy. Importantly, no
difference was found between restrictive and routine episiotomy in rates of severe
lacerations,
dyspareunuria,
urinary incontinence
or
pain
measurements.
26
27
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Behera, M. (2012). Uterine Anatomy. In Medscape Reference. Last updated
04/10/2016.
Retrieved
from
http://emedicine.medscape.com/article/1949215-overview
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Obstetrics 21st Edition. Book Medical Publishers EGC. It 272-318,
Keman K. (2010). Physiology and mechanisms of normal deliveries in the book of
Obstetrics. Bina Library Sarwono Prawiwohardjo, Jakarta. The third
mold fourth edition, p 296-314
Sokol E. (2011). Clinical Anatomy of the Uterus, Fallopian Tubes,
and Ovaries. The Global library of womens medicine.
Strauss JF III, Lessey BA. (2010). The structure, function and evaluation of the
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Jaffe's Reproductive Endocrinology. 5th ed. Philadelphia, Pa: SaundersElsevier.
W. Power Hanifa (2010). Labor and delivery mechanisms, in the book of
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