Mechanisms of Labor

• Pelvic Floor Changes

• Fetal Lie
• Fetal Presentation
• Cephalic Presentation
• Fetal Attitude
• Fetal Position
Cephalic Presentation

• Berbicara mengenai presentasi pada jalan lahir, direlasikan dengan

posisi antara kepala dan badan fetus.
Fetal Attitude
• Fetus membentuk masa ovoid untuk mengikuti bentuk kavitas uterus
 melipat dirinya untuk membentuk punggung konveks:
• Kepala fleksi
• Dagu hampir berkontak dengan dada.
Fetal Lie
Fetal Position
• Posisi disini berkenaan dengan bagian presentasi fetal memiliki arah
ke kanan atau kiri dari jalan lahir.
• Di setiap presentasi, ada kemungkinan 2 posisi – LEFT atau RIGHT.
• Presentasi dapat berupa: OCCIPUT (vertex), MENTUM (dagu), dan
SACRUM (bokong).
• Arahnya dapat berupa: Anterior, Posterior, atau Transverse
Leopold Maneuvers
• Leopold 1: menilai fundus uteri.
• Identifikasi FETAL LIE – longitudinal or transversal – & FETAL POLE –
cephalic or podalic pole.
• Leopold 2: menilai sisi abdomen.
• Identifikasi sisi kiri-kanan – punggung atau ekstremitas.
• Gentle but deep pressure.
• Leopold 3: konfirmasi fetal presentation
• Jempol dan jari-jari 1 tangan meraba bagian bawah abdomen diatas
simfisis pubis.
• Leopold 4: menentukan derajat penurunan bayi
• Pemeriksa menghadap kaki pasien, ujung jari-jari kedua
tangan diposisikan pada masing-masing sisi presentasi.
Berikan tekanan kedalam dan digeser ke arah kaudal
sepanjang aksis
• Kalau sudah masuk ke pelvis, bahu atau celah leher dapat
dibedakan dengan kepala yang keras.
Vaginal Examination
• Ada 4 gerakan/tujuan dalam VT:
1. Masukkan 2 jari ke vagina dan temukan bagian
presentasi.
2. Jika sudah temukan, jari diarahkan ke posterior dan
disapu ke depan menuju simfisis pubis. (kalo
presentasi kepala, bisa dapat sagittal suture).
3. Posisi fontanel yang ditemukan pada kedua ujung
dipastikan dan diidentifikasi, dari anterior ke
posterior.
4. Fetal station = seberapa jauh bagian presentasi
sudah turun.
Cardinal Movement of Labor
Distinct Lower and Upper Uterine
Segments
OOGENE
SIS
OOGENESIS (process whereby
oogonia differentiate into mature
oocytes)
• Remember! Maturation of oocytes begins before birth
• Once PGC (primordial germ cells) have arrived in the gonad of genetic female,
they differentiate into oogonia.
• These cells undergo MITOTIC DIVISIONS!
OOGENESIS (process whereby
oogonia differentiate into mature
oocytes) cont..
• All of oogonia in one cluster are
probably derived from a single cell!
• The flat epithelial cells
(FOLLICULAR CELLS) originate from
surface epithelium covering the
ovary!
• Majority of oogonia continue to
divide by MITOSIS, but some of
them arrest their cell division in
prophase of MEIOSIS I and form
PRIMARY OOCYTES
 OOGENESIS – 5th & 7th month of
PRENATAL
• 5th month – total number of germ
cells in the ovary reaches its
maximum (± 7 millions)  then, cell
death begins (many oogonia and
primary oocytes degenerate and
become atretic).
• 7th month – majority of oogonia have
degenerated except for a few near
the surface & ALL surviving primary
oocytes have entered prophase of
MEIOSIS I & most of them are
individually surrounded by a layer of
flat follicular epithelial cells 
PRIMORDIAL FOLLICLE CELLS
OOGENESIS – NEWBORN
• near the time of birth – all primary oocytes have started prophase of meiosis I,
but instead of proceeding into metaphase, they enter the diplotene stage: a
resting stage during prophase that is characterized by a lacy network of
chromatin!
• Primary oocytes remain arrested in prophase and do not finish their first
meiotic division before puberty is reached.
• HOW CAN? Follicular cells secrete OMI (oocyte maturation inhibitor)
• Total number of primary oocytes at birth is estimated to vary from 600,000 to
800,000!
• During childhood, most oocytes become atretic; only ±40,000 are present by
the beginning of puberty and fewer than 500 will be ovulated!!!
MENSTRUAL
CYCLE!!!
OVARIAN-ENDOMETRIAL CYCLE
• The ovulatory menstrual cycles are regulated by complex interactions
of HPA axis!
Ovarian
Cycle
• Consist of:
• Follicular phase: the follicle operates in the first half of the cycle to produce a
mature egg ready for ovulation.
• 15 to 20 primordial follicles begin to grow (recruitment), passing through 3 stages:
• Primary (preantral) follicle  Vesicular (antral) follicle  Mature vesicular (graafian) follicle
Oocyte-dependent FSH-dependent

• Luteal phase: the corpus luteum takes over during the last half of the cycle to
prepare the female reproductive tract for pregnancy in case fertilization
occurs.
Follicular Phase
 Antral & Graafian Follicle
• There will be spaces filled with fluid
(antrum) between granulosa cells  antral
follicle. Antrum will enlarge until mature!
• At maturity, mature vesicular/ graafian
follicle may be 25mm or more in diameter!!!
• It is surrounded by:
• theca interna: secretes steroid
• theca externa: gradually merges with ovarian
connective tissue!
• With each ovarian cycle, only 1 reaches full
maturity, the others degenerate and become
atretic.
• A surge in LH induces the preovulatory growth phase: meiosis I is
completed, resulting in formation of 2 daughter cells of unequal size,
each with 23 double-structured chromosomes.
• One cell, the secondary oocyte, receiving most of the cytoplasm; the
other (first polar body), receives none.
• The cell then enters meiosis II but arrests in metaphase approximately
3 hours before ovulation. REMEMBER!! Meiosis II is completed only if
the oocyte is fertilized; otherwise, the cell degenerates approximately
24 hours after ovulation!
• During FSH rise in late luteal phase in previous
cycle,, there will be a selection window of a
group of antral follicles to develop further. Only
this follicles develop the capacity to produce
estrogen.
 Preantral Follicular Development
Selected Primordial Follicle  Primary (Preantral)
Follicle
• FLAT follicular cells  cuboidal epithelium (granulosa
cells)  proliferate to produce a STRATIFIED
EPITHELIUM of granulosa cells  PRIMARY FOLLICLE!!
• Granulosa cells and oocytes secrete a layer of
glycoproteins on the surface of oocytes  ZONA
PELLUCIDA
• There is BASEMENT MEMBRANE separating granulosa
cells from surrounding connective tissue (stromal cells)
 theca layer
• Theca and granulosa cells  called follicular cells:
LATER have the ability to function as a unit to secrete
estrogen.
• These processes take several months to complete and
occurs without gonadotropin influence!!!!!!!!!!
Formation of AN Antral
Follicle – Estrogen
Secretion
Primary (Preantral) Follicle  Antral Follicle
• This process is GONADOTROPIN-DEPENDENT. But, remember!! The EARLY antral follicles
are not influenced by fluctuating levels of those hormones (that occur during the
monthly reproductive cycle)!
• The early antral development takes ANOTHER 45 days and, like PREANTRAL
development, IT IS NOT PART OF FOLLICULAR PHASE OF OVARIAN CYCLE.
• A fluid-filled cavity (antrum) forms in the middle of granulosa cells: partially
from transudation of plasma and partially from follicular cell secrections.
• Follicular cells start producing estrogen: some of this hormone is secreted
into bloodstream, some is collected in antral fluid!!!
Formation of A Mature Follicle
• Dari beberapa antral follicles, hanya beberapa saja yang telah
berkembang menjadi folikel yang EXTREMELY SENSITIVE terhadap FSH
yang “direkrut” untuk perkembangan selanjutnya pada awal fase
folikuler!
• Of the follicles recruited, one, the “dominant” follicle, usually grows
more rapidly than the others, developing into a mature (preovulatory,
tertiary, or Graafian) follicle within about 14 days after being
recruited! Usually because it has the most FSH receptors!
• Jadi, yang terjadi selama Follicular Phase adalah  Rapid growth of
recruited follicles and development of a mature follicle
Ovulation
•  THECA FOLLICULI: theca interna (secretory cells) & theca externa
(fibrous capsule)
Implantation and Early Trophoblast
Formation
• Fetus bergantung pada plasenta untuk fungsi sementara pulmonal,
hepar dan renal.
• Overview: darah ibu tersembur dari pembuluh darah uteroplasenta ke
ruang intervili plasenta dan membanjiri syncytiotrophoblast. Hal ini
memperbolehkan pertukaran gas, nutrisi, dan zat-zat lainnya. Jadi,
darah ibu dan fetus TIDAK bercampur. Selain itu, ada sistem parakrin
yang menghubungkan sang ibu dengan bayi.
Fertilization
• Setelah ovulasi, oosit akan melewati tuba fallopi dimana merupakan
tempat terjadinya fertilisasi. Fertilisasi hanya bisa terjadi dalam
beberapa jam dan tidak lebih dari 1 hari setelah ovulasi.
• Oosit bertemu spermatozoa dan mengalami fusi pada nukleusnya 
fertilisasi  nama selnya menjadi ZIGOT.
• Zigot – sel diploid dengan 46 kromosom – mengalami pembelahan 
blastomer (2 sel, 4 sel, dan 8 sel).
• 16 sel  disebut morula, morula memasuki kavitas uterus +/- 3 hari
setelah fertilisasi.
• Adanya penumpukan cairan diantara sel morula  blastocyst.
Blastocyst
• 4-5 hari post ovulasi, 58 sel blastula berdiferensiasi menjadi 5 sel
produksi embrio – inner cell mass dan 53 sel di sekelilingnya – outer
cell mass yang didestinasikan menjadi trophoblasts.
• Sel terus membelah menjadi 107 sel blastocyst: 8 sel produksi embrio
dikelilingi oleh 99 sel trophoblastic. Sel blastocyst kemudian lepas dari
zona pellucida karena dicerna oleh enzim protease yang dikeluarkan
oleh kelenjar endometrium.
• Sitokin dan hormon yang diproduksi blastosit saat ini dapat langsung
mempengaruhi endometrium.
Implantasi
• 6-7 hari post fertilisasi, blastocyst BARU MULAI implan ke dinding
uterus:
1. Apposition – kontak awal blastocyst ke dinding uterus.
2. Adhesion – peningkatan kontak fisik antara blastokista dan desidua.
3. Invasion – penetrasi dan invasi syncytiotrophoblast dan cytotrophoblast ke
desidua, inner third of myometrium dan vaskuler uterus.
Trophoblastic Development - 8th day
• Trophectoderm  trophoblast cell layer  human placental formation
• 8th day postfertilization, trophoblast have differentiated into:
• an outer multinucleated syncytium – syncytiotrophoblast
• An inner layer of primitive mononuclear cells – cytotrophoblasts
• Cytotrophoblasts can proliferate (mitosis) and fuse to add to outer layer
of syncytiotrophoblast.
• Syncytiotrophoblast provides transport functions of the placenta.
• The trophoblast secretes enzyme to help blastocyst embedded in the
endometrium.
Trophoblastic Development - 9th day
• The blastocyst is more deeply
embedded in the endometrium.
• In embryonic pole, the syncytium
develop vacuoles  LACUNAE
(lacunar stage)
Trophoblastic Development – 11th –
12th day
• Syncytiotrophoblast penetrate
deeper and erode the maternal
capillaries which are known as
SINUSOIDS  the maternal blood
enters the LACUNAE SYSTEM!!
• We called it UTEROPLACENTAL
CIRCULATION
Trophoblastic Development - 13th
day
• The cytotrophoblast forms cellular
columns penetrating into and surrounded
by syncytium  PRIMARY VILLI
• Perhatikan sudah mulai ada connecting
stalk!
Trophoblastic Development –
beginning of 3rd weeks
• Liat potongan melintang dari primary villus. Di tengahnya sepenuhnya terisi oleh cytotrophoblast. Seiring
perkembangan, sel mesoderm akan mempenetrasi bagian tengah primary villus  secondary villus.
• Sel mesoderm akan berdiferensiasi menjadi sel-sel darah dan pembuluh darah kapiler  tertiary villus.
• Pembuluh darah ini akan menyambung dengan pembuluh darah kapiler yang terbentuk dari asal sel yang sama (sel
mesoderm) di Chorionic plate and connecting stalk.
• Inilah asal mula sistem sirkulasi yang menghubungkan plasenta dan embrio!!!
Trophoblastic Development –
beginning of 3rd weeks
• Cytotrophoblast berpenetrasi hingga mencapai maternal endometrium dan kedudukan berbalik  cyto di luar dan
syncytio di dalem  Outer Cytotrophoblast Shell
• Fungsinya apa? Sebagai tempat jangkar villi dari mesoderm (chorionic plate).
• Villi yang menjangkar dari mesoderm ke shell stem/anchoring villi.
• Villi yang bercabang dari sisi stem villi  free/terminal villi --> berfungsi sebagai tempat pertukaran nutrisi dan
faktor-faktor lain.
 Trophoblastic Development –
beginning of 3rd month
• Placenta:
• Fetal component is derived from trophoblast and extraembryonic mesoderm (chorionic plate)
• Maternal component is derived from uterine endometrium.
• Fetal: akan ada semakin banyak secondary and tertiary villi dan mereka mekar dari lapisan mesoderm ke cytotrophoblast shell.
Pembuluh kapiler dari villi akan menyambung dengan pembuluh kapiler di chorionic plate dan connecting stalk  extraembryonic
vascular system.
• Maternal: darah ibu dioper ke plasenta melalui arteri spiralis di uterus yang diinvasi oleh cytotrophoblast! Disebut endovascular
invasion. Darah ibu akan dilepas ke INTERVILLOUS SPACE!!!

• Sel cytotrophoblast menyerang dan menggantikan

sel endotel pembuluh darah maternal dengan cara
mengubah sifat selnya (epithelial-to-endotelial
transition).
• Small diameter  larger diameter
• High-resistance  low resistance
• Perubahan ini meningkatkan kuantitas darah
maternal ke ruang intervili.
Trophoblastic Development –
beginning of 3rd month and so
on
• Seiring perkembangan, akan banyak free villi yang
tumbuh memenuhi intervillous space. Tapi free
villinya masih primitive.
• In the beginning of 4th month, cytotrophoblast dan
connective tissue cells will disappear. Menyisakan
syncytium dan endothelial wall of blood vessel
yang menjadi lapisan yang memisahkan sirkulasi
fetal dan maternal.
Chorion Frondosum and Decidua
Basalis

End of 2nd month

End of 3rd month
Placenta in 2nd half of pregnancy
Bentuk Plasenta Full-Term
Circulation of Placenta
• Cotyledons receive their blood through 80-100 spiral arteries that
pierce the decidual plate and enter the intervillous spaces.
• When pressure decrease (mungkin karena mengikuti denyut jantung),
blood flows back from the chorionic plate towards decidua via
endometrial veins.
• Intervillous spaces volume = 150 ml, replenished 3x-4x/minute.
• The syncytium has a brush border consisting numerous microvilli 
greatly increase the surface area and exchange rate.
Placenta Membrane / Barrier
• Awalnya ada 4 layer of placenta membran. Pada usia kehamilan 4
bulan, cytotrophoblast dan connective tissue akan menghilang
perlahan sehingga akan semakin meningkatkan kecepatan pertukaran
nutrisi dan gas. Layer ini disebut PLACENTA BARRIER.
• Dari penjelasan ini, maka jelas bahwa darah maternal dan darah fetus
tidak bercampur.
Fungsi Plasenta
1. Exchange of Gases
• At term, fetus extracts 20-30 mL of oxygen per minutes.
2. Exchange of Nutrients and Electrolytes
• Amino acids, free fatty acids, carbohydrates, and vitamins.
3. Transmission of Maternal Antibodies
• Di akhir trimester pertama, fetus membuat komponen dari komplemen.
• Minggu ke-14, fetus mendapatkan imunoglobulin sebagian besar dari maternal immunoglobulin G (IgG).
4. Hormone Production by syncytial trophoblast
• Plasenta memproduksi hormon progesterone untuk menyokong dinding endometrium, estrogen untuk
stimulasi dinding uterus dan perkembangan kelenjar mammae.
• Pada 2 bulan pertama kehamilan, syncytiotrophoblast memproduksi hormon hCG (fungsinya untuk
mempertahankan korpus luteum) dan hormon somatomammotropin.