1st LO

Fertilization, Implantation and

Placentation

Fertilization
Fertilization occur when sperma meet ovum.
It happen in ampulla Tuba fallopii.
Sperma will come into the ovum by releasing
akrosom enzyme thet can

Sperma + ovum
(at Ampulla Tuba falopii)

sperma come into the ovum

(akrosom enzyme)

diffusion sperm to
ovum

Sperm release nitrat

oxyde and memicu
mytotic differentiation
= morula (at ampula)
Trofoblastik cell
will cover inner
cell mass

Trofoblastik cell
will cover inner
cell mass

Attach to
uterin

Tuba uterina do peristaltic

+ cillia movement morula
terdorong to uterina

Releasing enzyme
pencerna protein

Outer layer of
blastokist
become sticky

Morula mengapung in
the uterin

Inner cell mass

in blastokista
embryo

Proliferation of morula
blastokista

Trofoblastik cell
will cover inner
cell mass

Dinding2 sel trofoblas yg masuk ke

endometrium luruh, mmbntuk
synsitium multinukleus
yg akan mnjadi plasenta janin

Blastokista akan
ditanam di desidua

Blastokista akan
ditanam di desidua

Pembentukan Ruang Amnion

2nd LO
Anatomy and Physiology changes
in Pregnancy

1. Cardiovaskular System
1) CARDIAC OUTPUT
The total blood volume increases by about
40% above nonpregnant levels, with wide
individual variations.
The disproportionate increase in plasma
volume compared to the red cell volume
results in hemodilution with a decreased
hematocrit reading, sometimes referred to as
physiologic anemia of pregnancy

 Cardiac output rises by the 10th week of

gestation; it reaches about 40% above
nonpregnant levels by 20 to 24 weeks, after
which there is little change
For any given level of exercise, oxygen
consumption is higher in pregnant than in
nonpregnant women
2) INTRAVASCULAR PRESSURES
Systolic pressure falls only slightly during
pregnancy, whereas diastolic pressure
decreases more markedly; this decrease
begins in the first trimester, reaches its nadir
in midpregnancy, and returns toward
nonpregnant levels by term

3) MECHANICAL CIRCULATORY EFFECTS OF THE

GRAVID UTERUS
supine hypotensive syndrome
The venous compression by the gravid
uterus elevates pressure in veins that drain
the legs and pelvic organs, thereby
exacerbating varicose veins in the legs and
vulva and causing hemorrhoids
Because of venous compression, the rate of
blood flow in the lower veins is also
markedly reduced, causing a predisposition
to thrombosis

4)REGIONAL BLOOD FLOW

Two of the major increases (those to
the kidney and to the skin) serve
purposes of elimination: the kidney of
waste material and the skin of heat
When maternal cardiac output falls,
blood flow to the brain, kidneys, and
heart is supported by a redistribution of
cardiac output, which shunts blood
away from the uteroplacental
circulation

5) CONTROL OF
CARDIOVASCULAR CHANGES
A unifying hypothesis
suggests that the changes in
circulating steroid hormones
in combination with changes
in production of vasodilatory
prostaglandins, atrial
natriuretic peptide, nitric
oxide, and aldosterone affect
venous distensibility and
arterial tone

6) OXYGEN-CARRYING CAPACITY OF
BLOOD
Plasma volume expands
proportionately more than red
blood cell volume, leading to a fall
in hematocrit
Despite the relatively low
"optimal" hematocrit, the
arteriovenous oxygen difference in
pregnancy is below nonpregnant
levels.

B. RESPIRATORY SYSTEM
The major respiratory changes in
pregnancy involve three factors:
the mechanical effects of the
enlarging uterus, the increased
total body oxygen consumption,
and the respiratory stimulant
effects of progesterone

1) RESPIRATORY MECHANICS IN PREGNANCY

As pregnancy progresses, the enlarging uterus
elevates the resting position of the
diaphragm. This results in less negative
intrathoracic pressure and a decreased
resting lung volume, that is, a decrease in
functional residual capacity (FRC)
These characteristics-reduced FRC with
unimpaired VC-are analogous to those seen
in a pneumoperitoneum and contrast with
those seen in severe obesity or abdominal
binding, where the elevation of the
diaphragm is accompanied by decreased
excursion of the respiratory muscles

2) OXYGEN CONSUMPTION AND

VENTILATION
Total body oxygen consumption
increases about 15% to 20% in
pregnancy
pregnancy, the elevations in
both cardiac output and alveolar
ventilation are greater than
those required to meet the
increased oxygen consumption

 The rise in minute ventilation

reflects an approximate 40%
increase in tidal volume at term;
Such increased respiratory
sensitivity to CO2 is characteristic of
pregnancy and probably accounts
for the hyperventilation of
pregnancy

In summary
both at rest and with exercise, minute
ventilation and, to a lesser extent, oxygen
consumption are increased during
pregnancy over the nonpregnant control
values.
The respiratory stimulating effect of
progesterone is probably responsible for
the disproportionate increase in minute
ventilation over oxygen consumption

3)ALVEOLAR-ARTERIAL GRADIENT
AND ARTERIAL BLOOD GAS
MEASUREMENTS
Pregnancy is characterized by
hyperventilation (the arterial
PCO2 falls to a level of 27 to 32
mm Hg) and associated
respiratory alkalosis

C. RENAL PHYSIOLOGY
The urinary collecting system, including the
calyces, renal pelves, and ureters, undergoes
marked dilation in pregnancy, as is readily
seen on intravenous urograms. It begins in the
1st trimester, is present in 90% of women at
term, and may persist until the 12th to 16th
postpartum week.

1) RENAL BLOOD FLOW AND

GLOMERULAR FILTRATION RATE
Renal plasma flow and the
glomerular filtration rate (GFR)
increase early in pregnancy,
achieve a plateau at about 40%
above nonpregnant levels by
midgestation, and then remain
unchanged to term
The elevated GFR is reflected in
lower serum levels of creatinine
and urea nitrogen

2) FLUID VOLUMES
The maternal extracellular volume,
which consists of intravascular and
interstitial components, increases
throughout pregnancy, leading, in
effect, to a state of physiologic
extracellular hypervolemia. The
intravascular volume, which consists
of plasma and red cell components,
increases approximately 50% during
pregnancy

3) RENIN-ANGIOTENSIN SYSTEM IN PREGNANCY

Plasma concentrations of renin, renin substrate,
and angiotensin I and II are increased. Renin
levels remain elevated throughout pregnancy.
4) HOMEOSTASIS OF MATERNAL ENERGY
SUBSTRATES
The metabolic regulation of energy substrates,
including glucose, amino acids, fatty acids, and
ketone bodies, is complex and interrelated

5)INSULIN EFFECTS AND GLUCOSE METABOLISM

In pregnancy, the insulin response to glucose
stimulation is augmented
Glycogen synthesis and storage by the liver
increases, and gluconeogenesis is inhibited
After early pregnancy, insulin resistance
emerges, so glucose tolerance is impaired. The
fall in serum glucose for a given dose of insulin is
reduced compared with the response in earlier
pregnancy

 A variety of humoral factors have been suggested

to account for the anti-insulin environment of the
latter part of pregnancy. Perhaps the most
important is human placental lactogen (hPL)
6)LIPID METABOLISM
During the second half of pregnancy, however,
probably as a result of rising hPL levels, lipolysis is
augmented, and the plasma concentration of free
fatty acids after an overnight fast is elevated.
In the context of maternal lipid metabolism, the
most dramatic lipid change in pregnancy is the rise
in fasting triglyceride concentration

D. Tractus Digestivus
Intestine move to lateral and top
Motility of intestine and secret of gastes ( as
hidrochlorid and peptine) go down causing
vomite and constipation

E.SKIN
Look like redness, dim, and etc called striae
gravidarum
in multipara, there are striae gravidarum and
black line and redness.
Linea alba look like as black, brown called
sLinea Nigra
In face called chloasma

F. Glandula mammae
Enlargement of sinus and ductus cause of
esterogen
Accumulating of lipid cause of progesteron

G. Reproductive system
1) Uterus
Increasing volume and enlargement of uterus and hypertrofi of
miometrium
Accumulation of sheaf tissue and elastine increase its stregh
Placenta make a rough sign at uterus
Itsmus hypertropy and longer formed hergar sign
Dextrorotation of uterus
Formed a sign upper and lower segmen caused by Contraction of uterus
called phycology retraction ring
Sporadic contraction at trisemster 2 called Braxton Hix contraction

G. Reproductive system
2) Serviks
More soft and bluish after one month
Collagen are syntesized and formed by collagenase to prevent weakness of
its
3) Vagina
Formed chadwick sign
ovarium

3rd LO
ANC and PNC

background......
Maternal Mortality Rate (MMR)
because (60-80%) is bleeding, obstructed
labor, sepsis, high blood pressure
It can
actually be anticipated

One way to MMR with ANC

(Antenatal Care)

Antenatal Care

a program planned by health workers

1. Observation
2. Education

3. Medical treatment

Kehamilan aman
Ibu Hamil

Persalinan aman

Deteksi dini
(kelainan obstetri)

Main purpose of
the ANC
Determine the health status of the
mother and fetus.
Determine the gestational age of the
fetus.
Initiated plans to continue obstetric
care.
Ensuring the safety and health of the
pregnancy, both the mother and baby
Formulate a list of risk factors

Components of Antenatal Care

Antenatal care early or first visit
complete history
routine inspection
Assessment of risk factors

Next antenatal care.

On the first visit if found to be a risk factor of routine
history taking and examination then be evaluated
during the next visit

Examination schedule (gestational age of HPHT):

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

except...

If found abnormalities / risk factor

need medical treatment need
more frequent inspection and inte

Obstetric examination
General inspection
Front chloasma gravidarum, edema +/Eyes conjungtiva anemic +/-, sclera
jaundice +/Mouth gums and teeth
Neck JVP, enlargement of the thyroid gland
and lymph +/
Mammary shapes, symmetrical,
enlargement, nipple widened, areola
hyperpigmentation, vascular, glandular
tissue hyperplasia
Abdomen enlarged , pigmentation of linea alba and
striae,+/- scarring, motion +/- children
Vulva perineum, varices +/-, flour albus +/ anus hemorrhoids +/-,
Limbs varices +/-, +/- edema (pretibial, ankle,
instep), scarring +/-

examination of the
Abdomen
(LEOPOLD)

Leopold I :
Examiner stands facing the patient, and then with both
hands touching with fingers to determine the height of
the fundus and what part of the child contained in the
fundus

Leopold II :
The position is still the same, move the ha
side. Determine where there is a child's ba
gives the biggest hurdle then look for sma
are located in conflict

Leopold III :
Wearing one hand only, Handle bottoming section and
determine whether they can be shaken to determine
what is at the bottom and whether it has / has not been
held in check by the pelvic

Leopold IV :
Examiner position facing the patient's legs, with
hands specify what the bottom and whether this
has been entered into the PAP and how the entr

Fetal Heart Sounds

(auscultation)

Fetal heart sounds

can already be
heard at week 20 in
80 percent of
women

At week 21, the

sound of the fetal
heart was heard at
95 percen

at week 2
all pregn
wome

42

Special
Examination
Imaging
Resonance
Magnetic

Amniocentesis

Cordosintesis

Fetoscopy

Breastfeeding
counseling ..

Provide exclusive
breastfeeding
Not give cow's milk

4Th LO
Labor and Delivery

Labor
Childbirth is the period from the onset of
regular uterine contractions until expulsion of
the placenta.
Uterus contraction -> effacement and dilatation
of servic -> push the baby out.

Needs huge energy, so its called labor (hard

work)

Labor
Signs of labour , theres painful uterine contractions accompanied
by any one of the following:
1) ruptured membranes,
2) bloody "show,"
3) complete cervical effacement.
True labor?
Stages of labor:
First stage: Dilatation
Second stage: Delivery
Third stage: Placental

First Stage of Labor

Latent Phase.

The latent phase for most women ends at

between 3 and 5 cm of dilatation.
This threshold may be clinically useful, for it
defines cervical dilatation limits beyond which
active labor can be expected.
latent phase as being greater than 20 hours in
the nullipara and 14 hours in the multipara

First Stage of Labor (cont)

Active Labor.

These phase is
characterized by
dilatation of cervix
until its complete.
Nulipara = 1,2 cm/hr,
Multipara 1,5 cm/hour

The curve
The first stage is divided into a relatively flat
latent phase and a rapidly progressive active
phase.
In the active phase, there are three identifiable
component parts that include an acceleration
phase, a linear phase of maximum slope, and a
deceleration phase.

The curve
(1)a preparatory division, including latent
and acceleration phases;
(2)a dilatational division, occupying the
phase of maximum slope of dilatation;
and
(3)a pelvic division, encompassing both
deceleration phase and second stage
concurrent with the phase of maximum
slope of descent.

The second Stage of Labor

This stage begins when cervical dilatation is complete
and ends with fetal delivery.
The median duration is about 50 minutes for nulliparas
and about 20 minutes for multiparas, but it can be highly
variable .
In a woman of higher parity with a previously dilated
vagina and perineum, two or three expulsive efforts after
full cervical dilatation may suffice to complete delivery.
Conversely, in a woman with a contracted pelvis or a
large fetus or with impaired expulsive efforts from
conduction analgesia or sedation, the second stage may
become abnormally long

Mechanism of Labor
It is thus of paramount importance to know the
fetal position within the uterine cavity at the
onset of labor. The position of the fetus with
respect to the birth canal is critical to the route
of delivery.
Fetal orientation relative to the maternal pelvis
is described in terms of fetal lie, presentation,
attitude, and position.

Mechanism of Labor
LIE, PRESENTATION, ATTITUDE,
AND POSITION.
Fetal Lie. The lie is the relation
of the long axis of the fetus to
that of the mother, and is
either
longitudinal
or
transverse.
Fetal
Presentation.
The
presenting part is that portion
of the fetal body that is either
foremost within the birth canal
or in closest proximity to it. It
can be felt through the cervix
on vaginal examination (VT).

Mechanism of Labor
Position = Fetal Attitude or Posture. In
the later months of pregnancy the fetus
assumes
a
characteristic
posture
described as attitude or habitus (flexion,
extension)
Fetal Position. Position refers to the
relationship of an arbitrarily chosen
portion of the fetal presenting part to the
right or left side of the maternal birth
canal.
The fetal occiput, chin (mentum), and
sacrum are the determining points in
vertex, face, and breech presentations,
respectively

Mechanism of Labor
Longitudinal lie.
Cephalic presentation.
Differences in attitude
of the fetal body in
(A) vertex, (B) sinciput,
(C) brow, and (D) face
presentations.

Labor

Longitudinal lie. Vertex

presentation.
A. Left occiput anterior
(LOA).
B. Left occiput posterior
(LOP)
C. Right occiput
posterior (ROP).
D. Right occiput
transverse (ROT)

E. Right occiput
anterior (ROA)

CARDINAL MOVEMENT
The cardinal movements of
labor are engagement,
descent, flexion, internal
rotation, extension, external
rotation, and expulsion
During labor, these
movements are sequential
but also show great
temporal overlap.

1. Engagement
The fetal head may engage during the
last few weeks of pregnancy or not
until after the commencement of
labor. In many multiparous and some
nulliparous women, the fetal head is
freely movable above the pelvic inlet
at the onset of labor. In this
circumstance, the head is sometimes
referred to as "floating."

Labor

Labor

2. Descent
Descent is brought about by one or more of four forces:
1)
2)
3)
4)

pressure of the amnionic fluid,

direct pressure of the fundus upon the breech with contractions,
bearing down efforts of maternal abdominal muscles, and
extension and straightening of the fetal body.

3. Flexion
As soon as the descending head meets
resistance, whether from the cervix, walls of
the pelvis, or pelvic floor, flexion of the head
normally results.

4. Internal Rotation
This movement consists of a turning of the
head in such a manner that the occiput
gradually moves toward the symphysis
pubis anteriorly from its original position
or, less commonly, posteriorly toward the
hollow of the sacrum.
Internal rotation is essential for the
completion of labor, except when the fetus
is unusually small.
When the head fails to turn until reaching
the pelvic floor, it typically rotates during
the next one or two contractions in
multiparas. In nulliparas, rotation usually
occurs during the next three to five
contractions.

5. Extension
.
When the head presses upon the
pelvic floor, however, two forces
come into play. The first, exerted by
the uterus, acts more posteriorly, and
the second, supplied by the resistant
pelvic floor and the symphysis, acts
more anteriorly.
The resultant vector is in the
direction of the vulvar opening,
thereby causing head extension. This
brings the base of the occiput into
direct contact with the inferior
margin of the symphysis pubis

6. External Rotation
The delivered head next undergoes restitution. If the
occiput was originally directed toward the left, it
rotates toward the left ischial tuberosity; if it was
originally directed toward the right, the occiput
rotates to the right.
Restitution of the head to the oblique position is
followed by completion of external rotation to the
transverse position, movement that corresponds to
rotation of the fetal body, serving to bring its
bisacromial diameter into relation with the
anteroposterior diameter of the pelvic outlet.

7. Expulsion
Almost immediately after external rotation, the
anterior shoulder appears under the symphysis
pubis, and the perineum soon becomes
distended by the posterior shoulder.
After delivery of the shoulders, the rest of the
body quickly passes.

5Th LO
PUERPERIUM

CHANGES THAT OCCUR DURING THE

PUERPERIUM
Is recovery period after childbirth which
lasted for 6 weeks.
1. Uterine
Soon after postpartum, the rest of decidua
differentiate into:
Stratum superficial
Basale stratum
Involution autolysis and necrosis of
decidua superficial

Involution will produce lokhia (duh) which is

contain eritrocyt, leukocyt, epitel cells,
decidua cells, and bactery.
Type of lokhia:
Lokhia rubra
Lokhia serosa
Lokhia alba

2. Cervix
Ostium cervix smaller but could not return as
usual.
Ostium cervix externum widen as lip.
3. Urinary tract
Diuresis for 2-5 days
Decreased sensitivity of VU

4. Peritoneum and abdominal wall

Broad and round ligament become loose, and
need long time to be recovered.
Striae gravidarum ( during pregnancy)
become striae alba
5. Blood and Circulation
Leukocytosis, granulocytosis, trombocytosis.
CO increased in the first 48 hours, and will be
as usual in 2 weeks.

6. Weight loss
Become as usual in 6 month post partum.
Due to:
Diuresis
Uterine changes
7. Mamae
The first two days will produce colostrum, and
the next day produce ASI.
Due to: estrogen & progesteron prolactin
& oxytocin ASI produced

6Th LO
Drugs in Pregnant

7Th LO
Prevention, Promote, and
Management of complication
while pregnant, in labor , and
during postpartum period

Preventive, promotive, and

management complication
1.

Pregnant
- ANC

2.

In Labor
- Partograf

3.

Postpartum
-

Active management in stage 3 of labour

post partum Observation at least until one week
after labor

1. Preeclampsia
1.
2.
3.

Dietry and Lifestyle Modification

Antihypertensive Drugs
Antioxidants

Dietary and life style modification

1. Low-Salt Diet.
One of the earliest research efforts to prevent
preeclampsia was salt restriction
a sodium-restricted diet was ineffective in
preventing preeclampsia
2. Calcium Supplementation
women with low dietary calcium intake were at
significantly increased risk for gestational
hypertension

Dietary and life style modification con

3. Fish Oil Supplementation
supplementation with these fatty acids would
prevent inflammatory-mediate atherogenesis, it
was not a quantum leap to posit that they
might also prevent preeclampsia
4. Exercise
the protective effects of physical activity on
preeclampsia

Anti hypertension drugs

women given diuretics had a decreased
incidence of edema and hypertension but not
of preeclampsia.
chronic hypertension are at high risk for
preeclampsia

Antioxidants
imbalance between oxidant and antioxidant
activity may play an important role in the
pathogenesis of preeclampsia
vitamins C, D, and Emight decrease such
oxidation

7. Expulsion
Almost immediately after external rotation, the
anterior shoulder appears under the symphysis
pubis, and the perineum soon becomes
distended by the posterior shoulder.
After delivery of the shoulders, the rest of the
body quickly passes.