Praktikum Anatomi Blok 2.

Clinical Oriented Anatomy of Pelvic,

Perineum, and Reproductive Organs
Relate It to Labor Process
 KLASIFIKASI PANGGUL CALDWELL-
MOLOY
 tipe gynaecoid : PAP seperti ellips melintang kiri-kanan, hampir mirip lingkaran.

Diameter transversal terbesar terletak di tengah. Dinding samping panggul lurus.

Merupakan jenis panggul tipikal wanita (female type)

 tipe anthropoid : PAP seperti ellips membujur anteroposterior. Diameter transversal

terbesar juga terletak di tengah. Dinding samping panggul juga lurus. Merupakan

jenis panggul tipikal golongan kera (ape type)

 tipe android : PAP seperti segitiga. Diameter transversal terbesar terletak di

posterior dekat sakrum. Dinding samping panggul membentuk sudut yang makin

sempit ke arah bawah. Merupakan jenis panggul tipikal pria (male type)

• tipe platypelloid : PAP seperti "kacang" atau "ginjal". Diameter transversal terbesar

juga terletak di tengah. Dinding samping panggul membentuk sudut yang makin lebar

ke arah bawah.
KLASIFIKASI PANGGUL CALDWELL-
MOLOY
 Pelvimetry
• Pintu Atas Panggul
• Pintu Tengah Panggul
• Pintu Bawah Panggul
 Pintu Atas Panggul
• Diameter AnteroPosterior
Conjugata Vera Anatomica (11,5 cm)
Conjugata Vera Obstetrica (>10cm / Conjugata Diagonalis –
1,5/2 cm)
Conjugata Diagonalis (12,5 – 13 cm)
• Diameter Transversa (13 cm)
• Diameter Oblique Dexta et Sinistra
 Pintu Tengah Panggul
• Distansia Interspinarum (10 / >10 cm)
• Diameter AnteroPosterior (12 cm)
 Pintu Bawah Panggul
• Distansia Intertuberosum ( 10,5- 11 cm)
• Diameter AnteroPosterior (9,5- 12 cm)
Pelvic or Bimanual examination
Clinical pelvimetry
 Bidang Hodge dan Station
• Bidang untuk menentukan posisi bagian
terendah janin turun dalam panggul dalam
persalinan
• Di amerika menggunakan Station (tiap Station
berjarak 1 cm)
• Patokan  Spina Ischiadica
• Hodge III = Station 0
Bidang Hodge
Station
 Fetal Factor
• Lies/ Letak
• Presentation/ Presentasi
• Attitude/ Sikap
• Position/ Posisi
 Lies/ Letak
• Letak/Lies : relation between fetal long axis against
maternal long axis
• Letak:
– Letak memanjang: Sumbu fetus searah / sejajar
sumbu jalan lahir
– Letak melintang: Sumbu fetus tegak lurus sumbu
jalan lahir
– Letak oblik: Sumbu fetus dalam sudut tertentu
dengan sumbu jalan lahir (transient)
Lies/ Letak
 1. Letak Memanjang
Presentasi kepala:
• belakang kepala (prebelkep, occiput presentation)
• puncak kepala (sinsiput presentation)
• dahi (Brow presentation)
• muka (face presentation)
Presentasi bokong:
• bokong-kaki sempurna/ complete breech
• bokong murni/ frank breech
• kaki (footlink breech / incomplete breech)
 Normal Labor
• 97% of pregnancies, at
the time of delivery, the
fetus is entering the
pelvis as a cephalic
presentation
 Face presentation
• The head is hyperextended
• The occiput is in contact with the
fetal back and the chin (mentum) is
presenting
• The mentum can present in any
position relative to the maternal
pelvis.
• If the mentum presents in the left
anterior quadrant of the maternal
pelvis, it is designated as left
mentum anterior (LMA).
 Etiology
• causes which may be :
– Anencephaly: due to absence of the bony vault of the skull
and the scalp while the facial portion is normal.
– Loops of the cord around the neck.
– Tumors of the fetal neck e.g. congenital goitre.
– Hypertonicity of the extensor muscles of the neck.
– Dolicocephaly: long antero-posterior diameter of the head,
so as the breadth is less than 4/5 of the length.
– Dead or premature fetus.
– Idiopathic
 Brow Presentation
• The rarest presentation
• the fetal head is midway
between full flexion (vertex)
and hyperextension (face)
along a longitudinal axis
• The causes of a persistent
brow presentation are
generally similar to those
causing a face presentation
 Transverse Lie
• Long axis of the fetus is approximately
perpendicular to that of the mother
• Oblique  when the long axis forms acute
angle
 Etiology
• Prematurity
• Placenta Previa
• Abnormal uterus
• Contracted pelvis or relaxed abdominal wall
• Polyhydramnios
• multiparity
 Types of Breech

Complete Footling Frank

 2. Letak lintang atau oblik
• presentasi bahu (shoulder presentation)
• punggung.

3. Presentasi majemuk
(compund presentation)
• Kepala dan tangan
• Kepala dan kaki
 Sikap/ Attitude
• Sikap/Attitude: relation between fetal longitudinal axis of the
head against fetal longitudinal axis of the body
• Biasanya fetus berada dalam sikap fleksi
• Dikenal:
– Fleksi: pres belakang kepala (Denominator: occiput)
– Defleksi:
• Ringan: presentasi puncak kepala (sinsiput)
• Sedang: presentasi dahi (brow)
• Maksimal: presentasi muka (chin)
Sikap/ Attitude
 Posisi/ Position
• Posisi/Position: relation of the arbitrarily point of the
presenting part (denominator) against plane of the
birth canal
 In vertex presentation (occiput): LOT, ROT or
LOA, RCA, and less common, LOP and ROP
 In breech presentation (sacrum): LST, RST, LSA
and LSP
 In face presentation, chin is the denominator
Hubungan sikap, presentasi, diameter
kepala janin dan titik penunjuk pada
persalinan
Sikap Presentasi Diameter Kepala Titik penunjuk

Fleksi maksimal Belakang kepala Suboksipito- UUK

bregmatika

Defleksi ringan Puncak kepala Fronto-oksipitalis Puncak kepala,

UUB, UUK

Defleksi sedang Dahi Vertikomental Glabella

Defleksi Muka Submento- dagu

maksimal bregmatika
 ANTROPOMETRI KEPALA JANIN
 Ukuran-ukuran diameter kepala bayi yang menentukan di
antaranya :
1. suboksipito-bregmatikus (+ 9.50 cm) : pada persalinan presentasi
belakang kepala
2. oksipito-frontalis (+ 11.75 cm) : pada persalinan presentasi
puncak kepala
3. oksipito-mentalis (+ 13.50 cm) : pada persalinan presentasi dahi
4. submento-bregmatikus (+ 9.50 cm) : pada persalinan presentasi
muka
5. bi-parietalis (-+ 9.50 cm) : ukuran terbesar melintang dari kepala
6. bi-temporalis (+ 8.00 cm) : ukuran antara os temporalis kiri dan
kanan
 ANTROPOMETRI KEPALA JANIN
 Ukuran-ukuran sirkumferensia / lingkar kepala bayi :
1. suboksipito-bregmatikus (+ 32 cm)
2. oksipito-frontalis (+ 34 cm)
3. oksipito-mentalis (+ 35 cm)
4. submento-bregmatikus (+ 32 cm)
ANTROPOMETRI KEPALA JANIN
 Supporting Structures of the Pelvic
and Pelvic’s Internal Organ
• Diaphragma Pelvis
1. m. Levator ani
 m. Puborectalis
 m. Pubococcygeus
 m. illiococcygeus
2. m. Ischiococcygeus/ m. coccygeus
Supporting Structures of the Pelvic
and Pelvic’s Internal Organ
Perineum
Canalis Alcock/ Canalis Pudendalis
• A. Pudenda interna
• V. Pudenda interna
• N. Pudendus
• N. obturatorius
 Fascia Pelvis
• Fascia Pelvis Parietalis
• Fascia Pelvis Visceralis

• Arcus tendineus fascia perinei

• Arcus tendineus m. Levator ani
 Spasium Perinei Profunda
• Terletak antara fascia diaphragma urogenital
superior et inferior

• M. Sphincter urethra
• M. Transversus perinei profunda
 Spasium Perinei Superficialis
• Terletak antara fascia diapragma urogenitalis
inferior dengan fascia perinea superficialis

• Radix clitoridis
• M. Ischiocavernosus
• M. Bulbospongiosus
• M. Transversus perinei superficialis
• Bulbus vestibuli
• Glandula vestibularis major
Reproductive Organ and Supporting
Structure
Vascularisation
Episiotomy
 Episiotomy Medial
• Yang terptong adala corpu perinei,secara
anatomy area paling ideal
• Keuntungan: tidak memtong serabut otot,
mudah dilakukan dan dijahit, hasil
penyembuhan baik, perdarahan minimal
• Kerugian: bisa mengenai rectum
 Episiotomy Mediolateral
• Paling sering digunakan
• Yang dipotong kulit & sbkutis, m.
Bulbocavernosus, m. Transversus perinei, m.
Levator ani
• Keuntungan: tidak meluas ke rectum
• Kerugian: menimbulkan disparenia
 Episiotomy Lateral
• Hampir tidak pernah digunakan
• Berisiko perdarahan
 Incontinence
• Kondisi keluarnya urin tak terkendali,
yang dapat didemonstrasikan secara
obyektif dan menimbulkan gangguan
kesehatan & sosial.

• Penyebab
1. AKUT
Biasanya dapat diatasi  sembuh

2. KRONIK
Tak dapat hilang 100%
• Inkontinensia Stress
• Urin keluar saat tekanan dalam perut
naik
(batuk, bersin, tertawa, olah raga)
• Karena Otot Dasar Panggul Lemah
• Wanita lansia >>
• Jumlah urin bervariasi.
• Inkontinensia Urgensi
• Urin keluar TANPA DISADARI/DIKEHENDAKI
• Karena Otot Detrusor Kandung kemih
Hiperaktif (over active bladder)
• Neurologis > (stroke, demensia, parkinson,
dll)
• Mengeluh tak cukup waktu utk menahan
kencing s/d kloset.
• Terbanyak pada lansia
• Inkontinensia Luber
• (overflow)
• Urin keluar TANPA DISADARI/DIKEHENDAKI
• Karena Overdistension (menggelembung) Kandung kemih,
• Pria > ok. Sumbatan: prostat, saraf (DM) & obat.
• Wanita ok. Lemahnya otot detrusor (neuropati DM, trauma medula
spinalis, obat)

• Mengeluh kencing sedikit-sedikit keluar tanpa ada sensasi kendung

kemih penuh.

• Terjadi jika pengisisan urin melebih kapasitas

kandung kemih

•
•
• Inkontinensia Fungsional
• Ngompol karena DILUAR/BUKAN faktor
saluran kemih.
• Karena demensia berat, gangguan
muskuloskeletal, imobilisasi, lingkungan tak
mendukung sehingga sulit mencapai toilet,
depresi.

• Ouslander ,2000; Dubeau,2000

•
•
 Uterine Prolapse
• Uterine Prolapse
The cervix, and occasionally a portion of the body of the uterus, may
protrude to a variable extent from the vulva during early pregnancy. With
further growth, the uterus usually rises above the pelvis and may draw the
cervix up with it. If the uterus persists in its prolapsed position, symptoms
of incarceration may develop from 10 to 14 weeks. To prevent this, the
uterus is replaced early in pregnancy and held in position with a suitable
pessary. Successful vaginal deliveries have been reported following
sacrospinous uterosacral fixation done before pregnancy to correct severe
uterine prolapse (Kovac and Cruikshank, 1993).

• 1st degree: To the upper vagina

• 2nd degree: To the introitus
• 3rd degree: Cervix is outside the introitus
• 4th degree: (sometimes referred to as procidentia): Uterus and cervix
entirely outside the introitus
Pessary Ring
 Cystocele, Rectocele, Enterocele
• Cystocele and Rectocele

Attenuation of fascial support between the vagina and the bladder

can lead to prolapse of the bladder into the vagina, or cystocele.
Attenuation of fascia between the vagina and the rectum results in
a rectocele. A large defect may fill with feces that, at times, can only
be manually evacuated. During labor, either a cystocele or a
rectocele can block normal fetal descent unless they are emptied
and pushed out of the way. Urinary stasis with a cystocele
predisposes to infection. Pregnancy may worsen associated urinary
stress incontinence, because urethral closing pressures do not
increase sufficiently to compensate for the progressive increase in
bladder pressure caused by increasing uterine weight (Iosif and
Ulmsten, 1981).
Cystocele, Rectocele, Enterocele
Anaesthesia
 Pudendal and Ilioinguinal Nerve
Blocks
• To relieve the pain experienced during childbirth,
pudendal nerve block anesthesia may be performed by
injecting a local anesthetic agent into the tissues
surrounding the pudendal nerve. The injection may be
made where the pudendal nerve crosses the lateral
aspect of the sacrospinous ligament, near its
attachment to the ischial spine. Although a pudendal
nerve block anesthetizes most of the perineum, it does
not abolish sensation from the anterior part of the
perineum that is innervated by the ilioinguinal nerve.
To abolish pain from the anterior part of the perineum,
an ilioinguinal nerve block is performed
 Spinal Block
• To obtain a sample of CSF from the lumbar cistern, a
lumbar puncture needle, fitted with a stylet, is inserted
into the subarachnoid space. Lumbar spinal puncture
(spinal tap) is performed with the patient leaning
forward or lying on the side with the back flexed.
Flexion of the vertebral column facilitates insertion of
the needle by stretching the ligamenta flava and
spreading the laminae and spinous processes apart
(Fig. B4.7). Under aseptic conditions, the needle is
inserted in the midline between the spinous processes
of the L3 and L4 (or the L4 and L5) vertebrae. At these
levels in adults, there is little danger of damaging the
spinal cord.
 Cauda Epidural Block
• An anesthetic agent can be injected into the extradural
(epidural) space using the position described in clinical
correlation “Lumbar Spinal Puncture”. •The anesthetic has a
direct effect on the spinal nerve roots of the cauda equina
after they exit from the dural sac (Fig. B4.8). The patient
loses sensation inferior to the level of the block. An
anesthetic agent can also be injected through the sacral
hiatus into the extradural space in the sacral canal a “caudal
epidural block”. The agent spreads superiorly and acts on
the spinal nerves (caudal analgesia). The distance the agent
ascends (and hence the number of nerves affected)
depends on the amount injected and on the position
assumed by the patient.