PLENARY DISCUSSION

By: Group
22 D

1. ANATOMICAL AND PHYSIOLOGICAL CHANGES

DURING PREGNANCY

PHYSIOLOGICAL CHANGES IN PREGNANCY

Reproductive organs
I. Uterus:
The muscular organ holding the fetus during pregnancy,
nourishment of the fetus through the placenta. It is divided into
the body (Corpus, and fundus)and the cervix.
During pregnancy, the uterus increases in weight from 60 to

1000g. In size, it changes from 6.5 to 32 cm. In a non pregnant

state, the uterus is situated in the pelvic cavity. During
pregnancy, it expands into the abdominal cavity. In addition to the
growing foetus, uterine expansion is caused by an increase in
connective tissue and in the size and number of blood vessels
supplying the uterus

Uterine change during pregnancy

b) Ligamentous
supports:
:

1) Round ligaments are fibrous cords attaching to the

uterus and libia majora During pregnancy, they
become elongated and hypertrophied. They supportthe
uterus in its move from the pelvic cavity into the
abdominal cavity.

2) Broad ligaments are large folds of peritoneum

separating the pelvis into the anterior and posterior
divisions. The lower portion of the ligament is known
asthe cardinal ligaments, it attaches the lateral aspect
of the uterus to the supravaginal area of the cervix.

3) Utero sacral ligaments attach the sacrum to the

posterior aspect of the cervix to support the cervix.

c) Cervix:
The portion of the uterus connecting the body of
the uterus and the vagina.
1) The internal os joins the body of the uterus with
the cervix.
2) The external os opens into the vagina.
3) During pregnancy, the cervix is closed. A mucus
plug forms over the cervix ,providing a protective
barrier between the vagina and the uterine
contents.

4) During labour and delivery, the cervix shortens

(or effaces) and widens (or dilates), effectively
disappearing. A 10 cm opening is left between
the uterus and the vagina to allow for passage of
the foetus into the birth canal.
5) If the cervix begins dilating prematurely, it is
sometimes stitched together during the second
trimester, until the foetus in mature. This
procedure is known as a cerclage.

II. Ovaries:
The organs storing ova. Through hormonal
influence , one ovum is developed per month. It
then travels into the fallopian tube and has the
potential to be fertilized. One ovary is located on
either side of the uterus, encased in the posterior
aspect of the broad ligaments.

III. Fallopian tubes:

The ducts bringing mature ova from the ovaries
to the uterus via peristaltic action.
a) The fallopian tubes connect the uterine cavity to
the abdominal cavity, near to the ovary. The
opening at the abdominal site is lined with cilia to
promote the peristalsis necessary to convey the
ovum into the tube.
b) They are situated in the superior margin of the
broad ligaments

IV. Vagina:
The connecting passage between the uterus and
the perineum, serving as the birth canal
a) The anterior borders include the bladder and the
urethra.
b) Laterally, the ureters and broad and round
ligaments lie.
c) Posteriorly, the peritoneum and the rectovaginal
fascia.

Respiratory system
During pregnancy, the body is in a state of
hyperventilation due to high level of progesterone.
a. Breathing becomes more costal than abdominal.
Additionally, most women are mouth breathers
during pregnancy.
b. Anatomically. the diaphragm is progressively
elevated. Possibly because of expansion and
elevation of the rib cage. Uterine pressure during
the first and second trimesters does not appear to
be a factor in this phenomenon

Metabolic and endocrine changes

1. Relaxin is a hormone secreted by the corpus luteum. the
endocrine body located in the ovary at the site of the ruptured
ovarian follicle.
a. Relaxin softens connective tissue during pregnancy in

preparation for labour and delivery. when the pelvis must

open to allow for the birth of the foetus. Relaxin. However is
not specific to the pelvis. Other joints can also be affected.
b. Relaxin peaks in early and late pregnancy. Women with

chronic joint instability may notice an increase in symptoms

during these times.

c. Relaxin has also been speculated to increased in the non

pregnant women after ovulation and throughout the
menstrual period. This may cause softening of the joints and
pain in affected women.
2. Other major hormones effecting a woman during pregnancy
include estrogen, progesterone. human placental lactogen,
and
3. Edema is present in the hands. feet. face and eyelids. This is
due in part to sodium and water retention. Additionally.
hormones circulating by the placenta. ovaries, and adrenal
cortex cause increased capillary permeability, which
contributes to the edema many pregnant women experience.

Musculoskeletal System
Abdominal muscles are stretched to the point of their

elastic limit by the end of pregnancy. Hormonal

influence on the ligaments is profound producing
systemic decrease in ligamentous tensile strength
and an increase in mobility of structures supported
by ligaments and may predispose the patient to joint
injury especially in the weight-bearing joints of the
back, pelvis and lower extremities. The pelvic floor
muscles must withstand the weight of the uterus, the
floor drops as much as 2.5 cm.

Postural changes:
During pregnancy, postural changes occur to accommodate for
abdominal growth.
a. These changes include forward head, rounded shoulders,
increased lumbar lordosis, hyperextended knees, and
pronated feet.
b. The center of gravity changes, resulting in changes in
balance.
c. Muscular changes are also typical. often noted alterations
include shortened hip flexors, lower back musculature, and
pectorals. Abdominal muscles, neck, and upper back muscle
groups elongate. This may promote stretch weakness or
adaptive shortening.

Postural changes in pregnancy

Bones and joints:

There is tendency to decalcification of bones,
sublaxation of joints due to softening of
ligaments by relaxin hormone. It is more marked
in sacroiliac joint and symphysis pubis, leading to
waddling gait.

Cutaneous system
Cutaneous system
Due to overstretching of the skin, the elastic fiber
may rupture together with small blood vessels and so
red streaks appear; known as striae gravida rum.
They are usually more marked below the umbilicus,
on the breasts and may appear on the buttocks and
thighs. In some women they are not marked or even
don't appear during pregnancy. After labour, the red
striae become pale silvery white due to fibrosis and
are known as (striae albicantes).

Linea nigra

Pigmentation: It is due to suprarenal changes, it

usually begins to appear after the 4th month. The
pigmentation may appear anywhere but the
commonest sites are:

1. Linea nigra: which is a line of pigmentation

between the umbilicus and the symphysis pubis.
2. Increased pigmentation of the nipple as primary
areola and appearance of the secondary areola.

Stria gravidarum

3. Cloasma gravidarum or mask face of pregnancy

which is butterfly pigmentation of the forehead,
nose, upper lip and the adjoining parts of the
checks. This pigmentation may persist but the
cloasma gravidarum usually disappears. Falling
of hairs and brittleness of nails may occur during
pregnancy.

Butterfly pigmentation

Maternal weight gain

There are no reliable data available for weight gain in the first 12
weeks of pregnancy. But in normal pregnancy the average gain
is 0.3 Kg/week up to 18 weeks, 0.45 Kg/week from 18-28
weeks and a slight reduction with a rate of 0.36- 0.41 Kg/week
until term.
Failure to gain weight and sometimes slight weight loss may
occur in the last 2 weeks. The average weight gain for
primigravidae for the inhal pregnancy is 12.5 kg. and is
probably about 0.9 Kg. less for multigravidae. Acute excessive
weight gain is commonly associated with abnormal fluid
retention.

Weight gain is produced by:

Fetus 3.63-3.88 Kg
Placenta 0.48-0.72 Kg
Amniotic fluid 0.72-0.97 Kg
Uterus and breasts 2.42-2.66 Kg
Blood and fluid 1.94-3.99 Kg
9.70-14.55Kg total=
2.91 kg

Muscle and fat 0.48-

Nervous system
Functional changes may appear especially in
neurotic women as :
-sleepy, depressed
-while others become irritable, excited and suffer
from insomnia.
-The nausea and vomiting may have a neurotic
element.
-Change of appetite such as refusal of some types of
food.

2. Intrauterine fetal
development

A couple of
hours after
fertilization

The cleavage stage of the zigot.

3 days after

The zigot has been changing into the morulla stage.

Vitelus is the energy source for cleavadging. Then,
the vitelus is decreasing in number because of
recurly utilization.

4 days after

The morula has been changing into the blastula

stage. The outer side of the blastocyst, theres a
trofoblas, which will be function to implant on the
endometrium. Trofoblas also produce the hCG
hormones.

2 weeks after

The invasif trofoblas has penetrated into blood

vessels in endometrium. The intertrofoblastic sinus
has formed.

8 weeks after
gestation

the zigot has invated the spralis artery. The invated

artery is about 40-60 arteries.

14-15 weeks

The formation of the placenta has completely

Gestasion
weeks

organs

the formation of nose, chin, palatum, and lungs

bulge. The fingers has formed, but still in the hold
form. And the heart has been formed completely

The eyes have formed and the formation of eyebrow

and tongue

Its close to the human form, and the starting of

genitals formation. The sirculation through the
umbilical cords started. And the sceletals have
started to form.

The face of the fetus has been formed, and the eyelid
also. But, the eyes wont be open after the 28th weeks
of gestasion.

13-16

The length of the fetus is 15 cm. The early stage of

second trimester. The skin of the fetus is still
transparant, and the lanugo is starting to shape. The
heart rate is 120-150/minute

17-24

The eye components have been completely formed,

otherwise the fingerprints. The fetus also has a reflex.

25-28

The early stage of the third trimester. The fastest

development of the brain. The eyes have opened.

the gastrointestine system : the develompment of GI

could be checked through USG after the 12 weeks of
gestation. On the 26th weeks of gestation, the
enzymess starting to produce.
Renal system : On the 22nd weeks of gestation, the renal
corpuscles formed in the jukstaglomerulus zone which
function to filtrate the blood. The renals completely
formed on the 36th weeks of gestation.
The respiratory system : the respiratory movement could
be check after 12 weeks of gestation. On the 34th
weeks of gestation, the regular respiratory movement is
40-60/minute. The alveoli is divided into two kind of
types, type 1 and type 2. the second type is important
to secrate the surfactan. The main surfactans are
sfingomielin and lecitine, and also glicerol phospatidil.

3. Antenatal Care ( ANC )

ANC is a preventative measure of obstetric

care for maternal and neonatal state
through a series of monitoring during
pregnancy
ANC includes 3 things:
Observation
Education
Medical Treatment

Schedule visits, in high risk pregnancy,

attention and schedule a visit should be
more stringent. In normal pregnancy, just
4 visits (K1: before 28 weeks, K2: between
28-39 weeks, K3-K4: after 36 weeks)
Education is important for health workers to
provide information for pregnant women
(related birth plan, fund, where, helpers,
etc.) as well as how to care for baby

Medical Treatment, there are

some things you should watch

out for health care workers about
the problems that occur in
pregnant women.
example:
Bleeding (still the leading cause
of death tinggu)
preeclampsia
Severe pain in the
abdominopelvikum area.

4. Normal Delivery
Process

Delivery

3rd L.O.

Uterine contraction

cervical dilatation

fetal and placenta expulsion.

The clinical stages of labor may be

summarized as follows:
1. Stage of cervical effacement

and dilatation
2. Stage of fetal expulsion
3. Stage of placental separation
and expulsion

Definition
if a baby is born with the back of the head
without the aid of tools or help and not hurt
the mother and the baby
delivery mechanisms :
a. Stage I
b. Stage II
c. Stage III

Stage I
is the opening of the cervix .
divided into 2 phases :
1 . latent phase
dilatation of 1 to 3 cm , which is very slow for 8 hours .
2 . active phase
divided into 3 phases :
a. Acceleration phase
opening occurs 3 to 4 cm for 2 hours
b. Maximum dilation phase
opening occurs very quickly that opening 4 to 9 cm for 2 hours
c. Deceleration phases
opening becomes slow again from the opening 9 to 10 cm ( full opening ) for 2
hours
So, the active phase lasted for 6 hours , a total of all that for 14 hours .
Membranes : membranes will rupture on its own at the opening of the first stage is
complete ( 10 ) .
ruptured membranes is less than the opening 5 is called premature rupture of
membranes .

Stage II
a child spending process.
after rupture of the membranes before, HIS pressure will be felt
more strongly and more quickly during the time in 2 to 3 minutes
Usually the baby's head has entered the pelvic inlet, so that will
be felt pressure on the pelvic muscles, and reflexively raised
curiosity straining
And also felt the pressure in the rectum that makes the perineum and
rectum stand open, and the labia will open and will look a little part of
the baby's head

And then relaxation of the pelvic floor will

then,
with his pressure and straining pressure, exit
Forehead and right shoulder was then going
to
play and then exit out the left shoulder limbs

Stage III
Is the detachment of the placenta from the uterus
walls and expenditure .

after the baby was out, the uterus will be felt hard
in the top of the center, a few minutes later, the
uterus contracts to the placenta detaches from
the
uterine wall, the placenta will come out in 6 until
15
minutes with spontaneous and expenditure
accompanied with blood.

5. prepaturation

Puerperal period is the period starting few

hours after birth placenta until 6 weeks

afterchildbirth (Pusdiknakes,2003:003).
The purpose of the provision of care in the

futureparturition for:
1. Maintaining the health of the mother
andbaby, both physically andpsychological.

2. Implement screening of

bothcomprehensive, early detection,treat or

refer whencomplications in the mother
andbaby
.3. Provide health educationabout health care
themselves,nutrition, family planning, how
and benefitsbreastfeeding, immunizationas
well as the daily baby care.
4. Provide family servicesplans
5. Getting emotional health.

Puerperal period is divided into three

stages,namely:
1. Early puerperiumA recovery period in which
the motherallowed to stand anda walk.
2. Puerperal intermedialA period in which the
recovery ofreproductive organs
duringapproximately six weeks

.3. Remote puerperalThe time required to

recoverand healthy again dlam stateperfect,

especially the mother if the motherduring
pregnancy or during laborexperiencing
complications.

6. Fetal Imaging

SONOGRAPHY IN
OBSTETRICS
The real-time image on the ultrasound

screen is produced by sound waves

reflected back from organs, fluids, and
tissue interfaces of the fetus within the
uterus.
Sound waves pass through layers of tissue,
encounter an interface between tissues of
different densities, and are reflected back
to the transducer

Clinical Applications
Accurate assessment of gestational age,

fetal growth, and the detection of fetal and

placental abnormalities are major benefits
of sonography.
The sensitivity of sonography for detecting
fetal anomalies varies according to factors
such as gestational age, maternal habitus,
position of the fetus, features of the
equipment, skill of the sonographer, and
the specific abnormality in question

First-Trimester Evaluation

Early pregnancy can be evaluated using

transabdominal or transvaginal
sonography, or both.
With transvaginal scanning, the gestational
sac is reliably seen in the uterus by 5
weeks, and fetal echoes and cardiac
activity by 6 weeks
The crown-rump length is the most
accurate biometric predictor of gestational
age

With first-trimester sonography,

anembryonic gestation, embryonic demise,

and molar and ectopic pregnancies can all
be reliably diagnosed

Anembryonic gestation

Ectopic pregnancies

Parasagittal views shows an empty uterine cavity (white

arrows) and a mass lateral to the uterine fundus (red arrow)

Molar pregnancies

Multifetal gestation

Fetal Biometry
Various formulas and nomograms allow

accurate assessment of gestational age

and describe normal growth of fetal
structures.
Equipment software computes the
estimated gestational age from the crownrump length. It also estimates gestational
age and fetal weight using measurements
of the biparietal diameter, head and
abdominal circumference, and femur
length.

Gestational Age

Crown-rump length is most accurate in the

first trimester. Biparietal diameter (BPD) is

most accurate from 14 to 26 weeks
The BPD is measured from the outer edge of
the proximal skull to the inner edge of the
distal skull, at the level of the thalami and
cavum septum pellucidum
The head circumference (HC) also is
measured. If the head shape is flattened
dolichocephaly, or roundedbrachycephaly,
the HC is more reliable than the BPD.

The femur length (FL) correlates well with

both BPD and gestational age.

It is measured with the beam perpendicular
to the long axis of the shaft, excluding the
epiphysis, and has a variation of 7 to 11
days in the second trimester

Second- and Third-Trimester

Evaluations

7. Drugs in pregnancy

Category of the safetyness of drug in

pregnancy:
A : safe for pregnant woman. Eg: folic
acid, vit c, prasetamol, etc
B: safe but limited for usage. Eg:
amoxicilin, eretromisin
C: bad effect to fetus. Eg: aminofilin,
digoksin
D: caused malformation. Eg:
tetrasiklin, diazepam
X: contra indication. Eg: thalidomid -->

Drugs that needed to be careful for lactation:

1. Antikoagulan. Eg: warfarin. Only given to

abnormal blood case. Because the amount of
the drug in ASI is higher than in the plasma.
Danger --> index therapy is narrow.
2. Antimikroba. Eg: tetrasiklin. Contra indication:
to children under 11 and to pregnant woman.
Prohibit growth of bone and teeth. Tetrasiklin
teeth --> brown or gray.
3. Aminoglikosida. Eg: streptomisin, gentamisin,
karamisin. Nervus VIII and microflora in
intestinal disorders.
4. Kloramfenikol, caused anemia megaloblastik
and gray baby syndrom.

8. Efforts to prevent
complication in
pregnancy,labor and
parturition

pregnancy

same with ANC

Labor
- infection prevention practice
- providing routine care
- explaining the process of childbirth to the
mother and
family
- avoid excessive or dangerous action
- setting up referral

Parturition

- ensuring the uterus remains contracted

within one hour after delivery
- placenta manual, if placenta does not
come out after an hour of labor
- infection prevention
- social support