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NORMAL LABOR
RIRIN FARDIANTI ATMAYASARI NIM : 011.06.0050
Clinical Work of Obstetrics and Gynecology RSUD Tanjung-KLU Medical Faculty Islamic University Al-Azhar Mataram 2016
TABLE OF CONTENTS
Table of contents .........................................................................................
1
Figures .........................................................................................................
2
Chapter I.
Introduction .....................................................................
3
Chapter II. Anatomy of the uterus ...................................................
4
Chapter III. Normal labor ...................................................................
8
Normal Phases Of Labor.................................................
8
Third Stage Of Labor.......................................................
8
Differentiation Activity Uterus........................................
8
Amendment Form Uterus................................................ 10 Changes In Cervical......................................................... 12 Normal Labor Criteria..................................................... 16 Mechanism of Labor ....................................................... 19 References.................................................................................................... 24
1
FIGURES Figure 1.
The three anatomical divisions of the uterus.............................
Figure 2.
Overview of the uterus and fallopian tubes, and associated
Figure 3.
4
Ligaments..................................................................................
6
Blood supply of the uterine.......................................................
7
Figures 4. Uterine vaginal deliveries ........................................................ 10
2
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 ed by the findings that the majority of mammalian
pregnancy
nonprimata
studied,
disarmament
progesterone
(progesterone breakthrough) either naturally occurring, induced by surgical or pharmacological turns may precede the initiation of parturition. In many species, the decline in progesterone levels in maternal plasma which sometimes occurs suddenly usually begins after approaching 95 percent of pregnancies. In addition, experiments with progesterone istration on the species-spesie this late in pregnancy can slow the onset of labor. However in pregnancy primates (including humans), disarmament progesterone did not precede the onset of parturition. Progestron levels in the plasma of pregnant women throughout pregnancy increases precisely, and only declined after the birth pasenta, which is the network location of progesterone synthesis in human pregnancy.
3
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
: Top of the uterus, above the entry point of the uterine
tubes.
Body
: Usual site for implantation of the blastocyst.
Cervix
:Lower part of uterus linking it with the vagina. This part is
structurally and functionally different to the rest of the uterus.
Figure 1. The three anatomical divisions of the uterus. The exact anatomical location of the uterus varies with the degree of distension of the bladder. In the normal adult uterus, it can be described as anteverted with respect to the vagina, and anteflexed with respect to the cervix. 1) 4
Anteverted: Rotated forward, towards the anterior surface of the body; 2) Anteflexed: Flexed, towards the anterior surface of the body. Thus, the uterus normally lies immediately posterosuperior to the bladder, and anterior to the rectum (Sokol, 2011). The fundus and body of the uterus are composed of three tissue layers (Sokol, 2011; Behera, 2012): 1. Peritoneum: A double layered membrane, continuous with the abdominal peritoneum. Also known as the perimetrium. 2. Myometrium: The thick smooth muscle layer. Cells of this layer undergo hypertrophy and hyperplasia during pregnancy in preparation to expel the fetus at birth. 3. Endometrium: An inner mucous membrane lining the uterus. It can be further subdivided into 2 parts – the stratum basalis and the stratum functionalis: a. Deep stratum basalis: Changes little throughout the menstrual cycle and is not shed at menstruation. b. Superficial stratum functionalis: Proliferates in response to oestrogens, and becomes secretory in response to progesterone. It is shed during menstruation and regenerates from cells in the stratum basalis layer. The tone of the pelvic floor provides the primary for the uterus. Some ligaments provide further , securing the uterus in place.They are (Behera, 2012; Stauss, 2010):
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: s the ovaries to the uterus.
5
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 to the uterus.
Uterosacral Ligament: Extends from the cervix to the sacrum. It provides 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).
6
Figure 3. Blood supply of the uterine Once these vessels reach the endometrial level, they branch into the basal arteries and spiral arteries, which the specialized functions of each layer. The basal arteries are not responsive to hormones; they the basal endometrial layer, which provides the proliferative cells for endometrial growth. The spiral arteries supply the functionalis layer and are uniquely sensitive to steroid hormones. In ovulatory cycles in which pregnancy does not occur, menses results following constriction of these terminal arteries, causing endometrial breakdown with desquamation of the glands and stroma (Bahera, 2012).
7
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 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 ive 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
8
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 ive, 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 ive 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
9
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
Figure 4. uterine vaginal deliveries. Segments on the active retracted uterus around the fetus because the fetus down through the birth canal. In the lower segment of the ive tone of myometrium much smaller Each contraction produces ovoid shaped uterus elongation accompanied by a reduction in horizontal diameter. With this shape change, no important effects
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 age 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
DECREASE IN FETAL PATTERNS In many nulliparous, the entry of the head of the fetus into the pelvic has been reached before the start, and further descent will not occur until the onset of labor. Meanwhile, in multiparas entry of the fetal head to the pelvic initially not so perfect, further decline will occur in the first stage of labor. In a declining pattern in normal labor, the formation of a typical hyperbolic curve when the fetal head station plotted on a function of the duration of labor. In the current declining pattern typically occurs after cervical dilatation has been developed for some time. In nulliparous, speed down usually increases rapidly during the phase of maximum lerang cervical dilation. At this time, the speed drops increases to a maximum, and the maximum decline rate is maintained until the presenting part reaches the bottom of the perineum. NORMAL LABOR CRITERIA Friedman also tried to choose the criteria that will give the limits of normal delivery, so that abnormalities significant labor can be immediately identified. This group of women studied were nulliparous and multiparous not 15
have dispoporsi fetopelvik, no multiple pregnancy, and no treated with heavy sedation, analgesia conduction, oxytocin, or operative intervention. All had normal pelvis, term pregnancies with vertex presentation, and average-sized babies. From this research, friedman develop the concept of three functional parts, namely childbirth preparation, dilatation, and pelvik- to find that part of the preparation for labor might be sensitive to sedation and analgesia conduction. Despite the little cervical dilation at this time, a big change in the extracellular matrix (collagen and components of other connective tissue) in the cervix. Part dilatation childbirth, when dilatation with the most rapid pace, in principle, not affected by sedation or analgesia conduction. Part of the pelvic labor begins simultaneously with cervical deselarasi phase. Classic delivery mechanisms, involving the major movements of the fetus, especially so during the pelvic part of this labor. The early part of this quaint clinically rarely be separated from the dilatation of labor. In addition, the speed of cervical dilation is not always reduced when it has reached full dilatation; perhaps even sooner.
16
Spontaneous rupture of membranes most often occur at any time in active labor. Rupture of membranes typical secra apparent as the liquid jet that is normally clear or slightly cloudy, virtually colorless varying amounts. The membranes intact until after the baby is born is more rare. If by chance the membranes intact until delivery is completed, the fetus is born is wrapped by membranes, and the part that wraps a newborn baby's head is sometimes referred to as caul. Rupture of membranes before labor begins at any stage of pregnancy is referred to as membrane rupture. DISPOSAL PLACENTA Third stage labor begins after the birth of the fetus and involve the release of and expulsion of the placenta. After delivery of the placenta and fetal membranes, active labor was completed. Because the baby is born, spontaneously contracting uterine hard to fill the empty. Normally, when the baby has been born almost obliterated the uterine cavity and Reviews These organs form an almost solid mass of muscle, with some thick lower segment above sentimerer thinner. Fundus now under the height limit of the umbilicus. The sudden depreciation uterine size is always accompanied by a reduction in the field of placental implantation site. So that the placenta can accommodate themselves to the surface of this shrinking, this organ enlarges its thickness, but the limited elasticity of the placenta, the placenta was forced to bend. The resulting voltage causes the decidua weakest layer of spongy layer, or decidua spongiosa relented, and separation occurred at this place. Therefore, the release of the placenta and shrinking beneath the implantation site. In cesarean section this phenomenon may be observed directly when the placenta implants in the posterior. The separation of the placenta is very easy by the structural properties of the decidua spongiosa loose. When the separation took place, formed a hematoma between separate placenta and decidua were tersisisa. Hematoma formation is usually a consequence and not the cause of the separation. However hematoma can accelerate the process of separation.
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.
18
Signs of labour Sign Feeling as if the baby has dropped lower.
Discharging a thick plug of mucus or an increase in vaginal discharge (clear, pink or slight bloody).
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.
Several days before labour begins or at the onset of labour.
From several hours before labour begins at anytime during labour.
Differences between false labour and labour Contractions
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.
The Seven Cardinal Movements Labor is a physical and emotional event for the laboring woman. For the infant, however, there are many positional changes that assist the baby in the age through the birth canal. Because of the resistance met by the baby, positional changes are specific, deliberate and precise as they allow the smallest diameter of the baby to through a corresponding diameter of the woman's 19
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
(measuring ear tip to ear tip across the top of the baby's head) into the pelvic inlet. Descent. The baby's head moves deep into the pelvic cavity and is commonly called lightening. The baby's head becomes when
markedly
these
molded
distances
are
closely the same. When the occiput is at the level of the ischial
spines,
it
can
be
assumed that the biparietal diameter is engaged and then descends into the pelvic inlet. Flexion.
This
movement
occurs during descent and is brought
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 es 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 . 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.
21
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 es through the perineum. After a brief rest, his began again to pull out bodies and 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
NORMAL DELIVERY MECHANISM Three factors that play a role in labor, namely: 1). The forces that exist in the mother as his strength and the strength of straining; 2). The birth canal; and 3). Fetus itself. His is the power of the mother that cause cervical opening and push the fetus down. At the presentation of his head when strong enough, will head down and started to get into the pelvic cavity. The entry of the head across the pelvic inlet can be in a state of sinklitismus is when the fetal head axis direction perpendicular to the plane of the pelvic. Can also head into the state asinklitismus, ie towards the axis of the fetal head tilted to the field of the pelvic inlet. Asinklitismus anterior according to Naegele is when the head axis direction to make acute angle to the front with the door on pnggul. Can also asinklitismus posterior according to Litzman; the situation is the opposite of the anterior asinklitismus. Asinklitismus anterior circumstances more favorable than the decline in the head with a mechanism for asinklitismus posterior pelvic space in the posterior region wider than the space pelvs in daerh anterior. It is important asinklitismus pelvis when the power of accommodation is rather limited. As a result of the eccentric axis of the fetal head or not symmetrical with the axis closer subocciput, then the detainee in the underlying tissue of the head that will decrease mengakibatkn head held flexion in the pelvic cavity. With flexion of the fetal head into the pelvic cavity with the smallest size, the diameter suboccipito-bregmatica (9.5 cm) and with sirkumferensia suboccipito-bregmatica (32 cm). reached the pelvic floor fetal head in a state of maximum flexion. Head from the fall meet pelvic diaphragm that runs from top to bottom rear forward. As a result of the elasticity combination pelvic diaphragm and intrauterine pressure caused by his repeated, holding the head of the rotation, called the rotation axis inside. In the case of holding round occiput axis will rotate towards the front so that the pelvic floor occiput under the symphysis. After the fetal head to the bottom of the pelvis and occiput under the symphysis, then by subocciput as hipomoklion, head deflection maneuver to be born. In each of his vulva is more open and more visible fetal head. Perineum becomes increasingly wide, thin wall
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.
Restrictive episiotomy is, however, associated with more anterior perineal traumas. As per the RANZCOG College Statement, episiotomy should be considered where there is: • a high likelihood of severe laceration; • soft tissue dystocia; • a requirement to accelerate the birth delivery of a compromised fetus; • a need to facilitate operative vaginal delivery; or • a history of female genital mutilation.
26
Operative vaginal delivery is one instance in which the decision of whether to employ episiotomy or not must be made on a case-by-case basis, using well-considered clinical judgement. The literature is unclear as to whether a routine episiotomy in this setting is advisable.
27
REFERENCES Behera, M. (2012). Uterine Anatomy. In Medscape Reference. Last updated 04/10/2016.
Retrieved
from
http://emedicine.medscape.com/article/1949215-overview Garry Cunningham F, Leveno, K J. (2006). Normal labor and delivery;. Williams 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 women’s medicine. Strauss JF III, Lessey BA. (2010). The structure, function and evaluation of the female reproductive tract. Strauss JF III, Barbieri RL, eds. Yen and Jaffe's Reproductive Endocrinology. 5th ed. Philadelphia, Pa: SaundersElsevier. W. Power Hanifa (2010). Labor and delivery mechanisms, in the book of obstetrics surgery. Bina Library Sarwono Prawiwohardjo, Jakarta. The eighth edition of the mold first, p 19-29,
28
RIRIN FARDIANTI ATMAYASARI NIM : 011.06.0050
Clinical Work of Obstetrics and Gynecology RSUD Tanjung-KLU Medical Faculty Islamic University Al-Azhar Mataram 2016
TABLE OF CONTENTS
Table of contents .........................................................................................
1
Figures .........................................................................................................
2
Chapter I.
Introduction .....................................................................
3
Chapter II. Anatomy of the uterus ...................................................
4
Chapter III. Normal labor ...................................................................
8
Normal Phases Of Labor.................................................
8
Third Stage Of Labor.......................................................
8
Differentiation Activity Uterus........................................
8
Amendment Form Uterus................................................ 10 Changes In Cervical......................................................... 12 Normal Labor Criteria..................................................... 16 Mechanism of Labor ....................................................... 19 References.................................................................................................... 24
1
FIGURES Figure 1.
The three anatomical divisions of the uterus.............................
Figure 2.
Overview of the uterus and fallopian tubes, and associated
Figure 3.
4
Ligaments..................................................................................
6
Blood supply of the uterine.......................................................
7
Figures 4. Uterine vaginal deliveries ........................................................ 10
2
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 ed by the findings that the majority of mammalian
pregnancy
nonprimata
studied,
disarmament
progesterone
(progesterone breakthrough) either naturally occurring, induced by surgical or pharmacological turns may precede the initiation of parturition. In many species, the decline in progesterone levels in maternal plasma which sometimes occurs suddenly usually begins after approaching 95 percent of pregnancies. In addition, experiments with progesterone istration on the species-spesie this late in pregnancy can slow the onset of labor. However in pregnancy primates (including humans), disarmament progesterone did not precede the onset of parturition. Progestron levels in the plasma of pregnant women throughout pregnancy increases precisely, and only declined after the birth pasenta, which is the network location of progesterone synthesis in human pregnancy.
3
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
: Top of the uterus, above the entry point of the uterine
tubes.
Body
: Usual site for implantation of the blastocyst.
Cervix
:Lower part of uterus linking it with the vagina. This part is
structurally and functionally different to the rest of the uterus.
Figure 1. The three anatomical divisions of the uterus. The exact anatomical location of the uterus varies with the degree of distension of the bladder. In the normal adult uterus, it can be described as anteverted with respect to the vagina, and anteflexed with respect to the cervix. 1) 4
Anteverted: Rotated forward, towards the anterior surface of the body; 2) Anteflexed: Flexed, towards the anterior surface of the body. Thus, the uterus normally lies immediately posterosuperior to the bladder, and anterior to the rectum (Sokol, 2011). The fundus and body of the uterus are composed of three tissue layers (Sokol, 2011; Behera, 2012): 1. Peritoneum: A double layered membrane, continuous with the abdominal peritoneum. Also known as the perimetrium. 2. Myometrium: The thick smooth muscle layer. Cells of this layer undergo hypertrophy and hyperplasia during pregnancy in preparation to expel the fetus at birth. 3. Endometrium: An inner mucous membrane lining the uterus. It can be further subdivided into 2 parts – the stratum basalis and the stratum functionalis: a. Deep stratum basalis: Changes little throughout the menstrual cycle and is not shed at menstruation. b. Superficial stratum functionalis: Proliferates in response to oestrogens, and becomes secretory in response to progesterone. It is shed during menstruation and regenerates from cells in the stratum basalis layer. The tone of the pelvic floor provides the primary for the uterus. Some ligaments provide further , securing the uterus in place.They are (Behera, 2012; Stauss, 2010):
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: s the ovaries to the uterus.
5
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 to the uterus.
Uterosacral Ligament: Extends from the cervix to the sacrum. It provides 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).
6
Figure 3. Blood supply of the uterine Once these vessels reach the endometrial level, they branch into the basal arteries and spiral arteries, which the specialized functions of each layer. The basal arteries are not responsive to hormones; they the basal endometrial layer, which provides the proliferative cells for endometrial growth. The spiral arteries supply the functionalis layer and are uniquely sensitive to steroid hormones. In ovulatory cycles in which pregnancy does not occur, menses results following constriction of these terminal arteries, causing endometrial breakdown with desquamation of the glands and stroma (Bahera, 2012).
7
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 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 ive 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
8
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 ive, 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 ive 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
9
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
Figure 4. uterine vaginal deliveries. Segments on the active retracted uterus around the fetus because the fetus down through the birth canal. In the lower segment of the ive tone of myometrium much smaller Each contraction produces ovoid shaped uterus elongation accompanied by a reduction in horizontal diameter. With this shape change, no important effects
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 age 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
DECREASE IN FETAL PATTERNS In many nulliparous, the entry of the head of the fetus into the pelvic has been reached before the start, and further descent will not occur until the onset of labor. Meanwhile, in multiparas entry of the fetal head to the pelvic initially not so perfect, further decline will occur in the first stage of labor. In a declining pattern in normal labor, the formation of a typical hyperbolic curve when the fetal head station plotted on a function of the duration of labor. In the current declining pattern typically occurs after cervical dilatation has been developed for some time. In nulliparous, speed down usually increases rapidly during the phase of maximum lerang cervical dilation. At this time, the speed drops increases to a maximum, and the maximum decline rate is maintained until the presenting part reaches the bottom of the perineum. NORMAL LABOR CRITERIA Friedman also tried to choose the criteria that will give the limits of normal delivery, so that abnormalities significant labor can be immediately identified. This group of women studied were nulliparous and multiparous not 15
have dispoporsi fetopelvik, no multiple pregnancy, and no treated with heavy sedation, analgesia conduction, oxytocin, or operative intervention. All had normal pelvis, term pregnancies with vertex presentation, and average-sized babies. From this research, friedman develop the concept of three functional parts, namely childbirth preparation, dilatation, and pelvik- to find that part of the preparation for labor might be sensitive to sedation and analgesia conduction. Despite the little cervical dilation at this time, a big change in the extracellular matrix (collagen and components of other connective tissue) in the cervix. Part dilatation childbirth, when dilatation with the most rapid pace, in principle, not affected by sedation or analgesia conduction. Part of the pelvic labor begins simultaneously with cervical deselarasi phase. Classic delivery mechanisms, involving the major movements of the fetus, especially so during the pelvic part of this labor. The early part of this quaint clinically rarely be separated from the dilatation of labor. In addition, the speed of cervical dilation is not always reduced when it has reached full dilatation; perhaps even sooner.
16
Spontaneous rupture of membranes most often occur at any time in active labor. Rupture of membranes typical secra apparent as the liquid jet that is normally clear or slightly cloudy, virtually colorless varying amounts. The membranes intact until after the baby is born is more rare. If by chance the membranes intact until delivery is completed, the fetus is born is wrapped by membranes, and the part that wraps a newborn baby's head is sometimes referred to as caul. Rupture of membranes before labor begins at any stage of pregnancy is referred to as membrane rupture. DISPOSAL PLACENTA Third stage labor begins after the birth of the fetus and involve the release of and expulsion of the placenta. After delivery of the placenta and fetal membranes, active labor was completed. Because the baby is born, spontaneously contracting uterine hard to fill the empty. Normally, when the baby has been born almost obliterated the uterine cavity and Reviews These organs form an almost solid mass of muscle, with some thick lower segment above sentimerer thinner. Fundus now under the height limit of the umbilicus. The sudden depreciation uterine size is always accompanied by a reduction in the field of placental implantation site. So that the placenta can accommodate themselves to the surface of this shrinking, this organ enlarges its thickness, but the limited elasticity of the placenta, the placenta was forced to bend. The resulting voltage causes the decidua weakest layer of spongy layer, or decidua spongiosa relented, and separation occurred at this place. Therefore, the release of the placenta and shrinking beneath the implantation site. In cesarean section this phenomenon may be observed directly when the placenta implants in the posterior. The separation of the placenta is very easy by the structural properties of the decidua spongiosa loose. When the separation took place, formed a hematoma between separate placenta and decidua were tersisisa. Hematoma formation is usually a consequence and not the cause of the separation. However hematoma can accelerate the process of separation.
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.
18
Signs of labour Sign Feeling as if the baby has dropped lower.
Discharging a thick plug of mucus or an increase in vaginal discharge (clear, pink or slight bloody).
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.
Several days before labour begins or at the onset of labour.
From several hours before labour begins at anytime during labour.
Differences between false labour and labour Contractions
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.
The Seven Cardinal Movements Labor is a physical and emotional event for the laboring woman. For the infant, however, there are many positional changes that assist the baby in the age through the birth canal. Because of the resistance met by the baby, positional changes are specific, deliberate and precise as they allow the smallest diameter of the baby to through a corresponding diameter of the woman's 19
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
(measuring ear tip to ear tip across the top of the baby's head) into the pelvic inlet. Descent. The baby's head moves deep into the pelvic cavity and is commonly called lightening. The baby's head becomes when
markedly
these
molded
distances
are
closely the same. When the occiput is at the level of the ischial
spines,
it
can
be
assumed that the biparietal diameter is engaged and then descends into the pelvic inlet. Flexion.
This
movement
occurs during descent and is brought
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 es 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 . 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.
21
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 es through the perineum. After a brief rest, his began again to pull out bodies and 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
NORMAL DELIVERY MECHANISM Three factors that play a role in labor, namely: 1). The forces that exist in the mother as his strength and the strength of straining; 2). The birth canal; and 3). Fetus itself. His is the power of the mother that cause cervical opening and push the fetus down. At the presentation of his head when strong enough, will head down and started to get into the pelvic cavity. The entry of the head across the pelvic inlet can be in a state of sinklitismus is when the fetal head axis direction perpendicular to the plane of the pelvic. Can also head into the state asinklitismus, ie towards the axis of the fetal head tilted to the field of the pelvic inlet. Asinklitismus anterior according to Naegele is when the head axis direction to make acute angle to the front with the door on pnggul. Can also asinklitismus posterior according to Litzman; the situation is the opposite of the anterior asinklitismus. Asinklitismus anterior circumstances more favorable than the decline in the head with a mechanism for asinklitismus posterior pelvic space in the posterior region wider than the space pelvs in daerh anterior. It is important asinklitismus pelvis when the power of accommodation is rather limited. As a result of the eccentric axis of the fetal head or not symmetrical with the axis closer subocciput, then the detainee in the underlying tissue of the head that will decrease mengakibatkn head held flexion in the pelvic cavity. With flexion of the fetal head into the pelvic cavity with the smallest size, the diameter suboccipito-bregmatica (9.5 cm) and with sirkumferensia suboccipito-bregmatica (32 cm). reached the pelvic floor fetal head in a state of maximum flexion. Head from the fall meet pelvic diaphragm that runs from top to bottom rear forward. As a result of the elasticity combination pelvic diaphragm and intrauterine pressure caused by his repeated, holding the head of the rotation, called the rotation axis inside. In the case of holding round occiput axis will rotate towards the front so that the pelvic floor occiput under the symphysis. After the fetal head to the bottom of the pelvis and occiput under the symphysis, then by subocciput as hipomoklion, head deflection maneuver to be born. In each of his vulva is more open and more visible fetal head. Perineum becomes increasingly wide, thin wall
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.
Restrictive episiotomy is, however, associated with more anterior perineal traumas. As per the RANZCOG College Statement, episiotomy should be considered where there is: • a high likelihood of severe laceration; • soft tissue dystocia; • a requirement to accelerate the birth delivery of a compromised fetus; • a need to facilitate operative vaginal delivery; or • a history of female genital mutilation.
26
Operative vaginal delivery is one instance in which the decision of whether to employ episiotomy or not must be made on a case-by-case basis, using well-considered clinical judgement. The literature is unclear as to whether a routine episiotomy in this setting is advisable.
27
REFERENCES Behera, M. (2012). Uterine Anatomy. In Medscape Reference. Last updated 04/10/2016.
Retrieved
from
http://emedicine.medscape.com/article/1949215-overview Garry Cunningham F, Leveno, K J. (2006). Normal labor and delivery;. Williams 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 women’s medicine. Strauss JF III, Lessey BA. (2010). The structure, function and evaluation of the female reproductive tract. Strauss JF III, Barbieri RL, eds. Yen and Jaffe's Reproductive Endocrinology. 5th ed. Philadelphia, Pa: SaundersElsevier. W. Power Hanifa (2010). Labor and delivery mechanisms, in the book of obstetrics surgery. Bina Library Sarwono Prawiwohardjo, Jakarta. The eighth edition of the mold first, p 19-29,
28
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