Pintu Atas Panggul

Pintu Bawah Panggul

Damage to pelvic floor muscle
Female internal genital organs
 Vagina
•  musculomembranous tube (7-9 cm); extends from the
cervix of the uterus to the vestibule
• Functions
– Serves as a canal for menstrual fluid
– Forms the inferior part of the pelvic (birth) canal
– Receives the penis and ejaculate during sexual intercourse
– Communicates superiorly with the cervical canal & inferiorly
with the vestibule
• Relations
– Anterior  fundus of the urinary bladder and urethra
– Lateral  levator ani, visceral pelvic fascia, and ureters
– Posterior  the anal canal, rectum, and rectouterine pouch
• 4 muscles compress
the vagina; act as
sphincters
–  pubovaginalis,
external urethral
sphincter,
urethrovaginal
sphincter, and
bulbospongiosus
• Arterial supply
– Superior  uterine arteries
– Middle & inferior  vaginal and internal pudendal arteries
• Venous drainage
– vaginal venous plexuses
 Uterus
•  thick-walled, pear-shaped, hollow muscular
organ; usually anteverted
(7,5 cm x 5 cm x 2 cm); 90g
• Parts  body, fundus, isthmus, cervix
• The wall of uterus’ body:
– Perimetrium  serous layer consists peritoneum +
thin layer of connective tissue
– Myometrium  smooth muscle coat + blood vessel
>>
– Endometrium  inner mucous coat
• Ligaments of uterus
– ligament of the ovary
– ligament of the uterus
– broad ligament of the uterus
– suspensory ligament of the ovary

• Ligaments of servix (mobile)

– Transverse cervical (cardinal) ligaments  cervix & lateral parts of
fornix to wall of pelvis
– Uterosacral ligaments  posterior side of cervix to middle sacrum
(palpable during examination)
• Relations
– Anterior  vesicouterine pouch and superior
surface of the bladder
– Posterior  rectouterine pouch containing loops
of small intestine and the anterior surface of
rectum
– Lateral  peritoneal broad ligament flanking the
uterine body; ureters run anteriorly slightly
superior to the lateral part of the vaginal fornix
and inferior to the uterine arteries
• Arterial supply
– uterine arteries
– collateral supply from the ovarian arteries
• Venous drainage
– uterine venous plexus  internal iliac veins
• Innervation of vagina & uterus
-. Sympathetic 
lumbar splanchnic
nerves +
intermesenteric-
hypogastric-pelvic

-. Parasympathetic 
pelvic splanchnic nerves
(S2-S4) to inferior
hypogastric-
uterovaginal plexus
 Uterine tubes
•  conduct the oocyte (ovum); 10 cm; lie in mesosalpinx
• Parts
– Infundibulum
• funnel-shaped distal end of the tube that opens into the peritoneal
cavity; fimbriae
– Ampulla
• widest and longest part of the tube; medial end of the infundibulum
– Isthmus
• thick-walled part of the tube, which enters the uterine horn
– Uterine part
• short intramural segment of the tube that passes through the wall of
the uterus
 Ovaries
• almond-shaped and -sized female gonads in
which the ova develop
• endocrine glands that produce reproductive
hormones

• Ligaments
– suspensory ligament of the ovary
– ligament of the ovary
• Arterial supply
– ovarian arteries
• Venous drainage
– Ovaries: pampiniform plexus of veins  ovarian vein
– Uterine tubes: tubal veins  ovarian veins and uterine (uterovaginal)
venous plexus
Female external genitalia
• Arterial supply (vulva)
– internal pudendal artery supplies most of the skin,
external genitalia, and perineal muscles. The labial
arteries are branches of the internal pudendal
artery, as are those of the clitoris
• Venous & lymphatic drainage (vulva)
– labial veins are tributaries of the internal
pudendal veins
– superficial inguinal lymph nodes
• Innervation (vulva)
– Anterior  lumbar plexus: the anterior labial nerves,
derived from the ilioinguinal nerve, and the genital
branch of the genitofemoral nerve
– Posterior  derivatives of the sacral plexus: the
perineal branch of the posterior cutaneous nerve of
the thigh laterally and the pudendal nerve centrally
– posterior labial nerves  labia
– deep and muscular branches of the perineal nerve
supply the orifice of the vagina and superficial
perineal muscles
– dorsal nerve of the clitoris supplies deep perineal
muscles and sensation to the clitoris
– The bulb of the vestibule and erectile bodies of the
clitoris receive parasympathetic fibers via cavernous
nerves from the uterovaginal nerve plexus
 Anatomic Changes
During Pregnancy
• Uterine:
• Hypertrophy of muscle fibers
• > weight (70g  1100g)
• > volume (5L)
• Early pregnant: corpus  thick • Cervix
• Later : thin, soft, readily
indentable walls  can be
palpated • Early  softening, cyanosis (
vascularity & edema)
• Estrogen and may be
• Smooth muscle (connective tissue) +
progesterone
collagen rich connective tissue
• Fundus  more grobular (12 • Extension / eversion, of the
weeks gestation) proliferating columnar endocervical
 ovoid (end of 12 glands  copius tenacious mucus (Ig
weeks) + cytokines)
• Contraction of Braxton Hicks
• Ovaries • Fallopian Tubes
Hormone relaxine ( corpus luteum) • Little hypertrophy
remodeling of reproductive tract • Epithelium of the mucosa  flattend
connective tissue
 augmented renal hemodynamics,
decreased serum osmolarity,
increased uterine artery

• Vagina & Perineum

• > vascularity  violet color characteristic (Chadwick sign)
• Mucosal thickness >, loosening of the connective tissue,
hypertrophy of smooth muscle cells
• Hypertrophy of papillae of vaginal epithelium
• Secret  thick, white discharge
The pH is acidic, varying from 3.5 to 6, the result of increased
production of lactic acid from glycogen in the
vaginal epithelium by the action of Lactobacillus acidophilus
 • Breats
• Early  tenderness, parastehsias
• After 2nd month  size
• Nipple  deeply pigmented, more erectile
• After 1st few month  thick, yellow fluid (colostrum) (gentle massage) ,
areola  broader, more pigmented

• Skin
1. Abdominal Wall  striae gradivarum or stretch marks (reddish, glistening, silvery lines)
2. Hyperpigmentation  linea alba – linea nigra (brown black pigmented)
 irreguler brownish (face and neck)  chloasma or melasma
gradivarum
 pigmented of the areola and genital skin
3. Vascular changes  angiomas or vascular spiders (face, neck, upper chest, and arms
 palmar erythema
 http://contemporaryobgyn.modernmedicine.com/contemporary-
obgyn/content/tags/aesthetic-lasers/skin-and-pregnancy-physiological-changes-and-
dermat?page=full

http://contemporaryobgyn.modernmedicine.com/contemporary-
obgyn/content/tags/aesthetic-lasers/skin-and-pregnancy-physiological-changes-and-
dermat?page=full

http://healthh.com/spider-angioma/
Metabolic Changes During
Pregnancy
http://www.dailymail.co.uk/health/article-3081873/From-head-toe-dozens-different-ways-pregnancy-changes-body-
Breathlessness-red-palms-unsightly-veins-s-gaining-2-5st.html
Pregnant women actually take more breaths
per minute than non-pregnant women to
supply oxygen to the womb, placenta and
foetus. This means some pregnant women may
feel constantly out of breath
• Although the respiratory rate in pregnancy is
not appreciably increased, the pregnant
woman experiences a relative
hyperventilation during the course of
pregnancy. The tidal volume, normally
450 ml/minute, is increased to
650 ml/minute, producing a greater gaseous
exchange despite the same frequency of
inspiration and expiration.
• Factors related to hyperventilation, such as
increased arterial pH and decreased PCO2,
• Progesterone
During pregnancy, a higher volume of blood is
being pumped by the heart per minute - so
women have a higher heart rate. More blood
vessels grow to accommodate this, but the
pressure of the expanding uterus on large
veins means blood is more slow at returning to
the heart. The hormone progesterone relaxes
the walls of the blood vessels, so the blood
pressure drops in the second trimester and a
woman may feel faint
ECG findings are suggestive of left axis
deviation of approximately 15 degrees. There
may be decreased voltage in the QRS
complexes, as well as alterations in T and P
waves. In a number of normal pregnant
women, there may be flattening or inversion of
T waves in lead III, as well as depression of the
S-T segment in limb and chest leads.

Fig. 5. Morphologic changes in the heart and

lungs. The figure shows the alterations
produced by pregnancy. Left axis deviation,
changes in the electrocardiogram, and
alterations in physical findings are common
concomitants of normal pregnancy. (Bonica J:
Principles and Practice of Obstetric Analgesia
and Anesthesia. Philadelphia, FA Davis, 1967)
The hormone progesterone causes the lower
esophageal sphincter - a bundle of muscles at
the low end of the esophagus, where it meets
the stomach - to relax, causing an increase in
acid reflex and heartburn. As there is
decreased emptying of the stomach, pregnant
women experience more constipation
Hormonal changes affect a pregnant woman's
entire body. The placenta produces large
amounts of oestrogen and progesterone to
help the uterus grow, so women may feel
warmer and experience hot flushes
Pregnant women may have temporary bladder control problems and may urinate
frequently, or find urine leaks when they sneeze, cough or laugh. This is because the uterus
expands, putting pressure on the bladder, urethra - the tube that allows urine to pass out
of the body

Pregnant women have an exaggerated arch in their back (called lumbar lordosis) as the spine realignes to maintain balance. The
ligaments become more lax due to hormones, causing back pain and pelvic pain (called symphysis pubis dysfunction)
Urinary Tract Changes
• Increased cardiac output results in an
increased volume of blood flow to the
kidneys. Because of this increase in blood
flow, the kidneys are perfused with larger
amounts of blood, and therefore with
larger amounts of solute and water
volume, than usual; thus the kidneys do
more filtering of the blood. This extra
kidney filtering action reduces the values
of some common laboratory blood tests;
blood urea nitrogen levels are decreased
markedly, as are creatinine levels.
• These changes are thought to be due to the
effects of progesterone or the mechanical
obstruction of the ureters and renal pelves
by the gravid uterus or markedly distended
ovarian veins. The right-sided ureteral and
renal dilatation may be produced by
pressure on the right ureter at the level of
the pelvic rim. On the left side, the ureter is
protected and padded by the presence of
the sigmoid colon. The increased volume of
the collecting system and ureters is thought
to predispose to upper urinary tract
infection by increasing the urinary dead
space and possibly the amount of reflux
from the bladder to the ureters.
Nutrition
Carbohydrate Metabolism

https://www.glowm.com/section_view/heading/Phy
siology%20of%20Pregnancy/item/103
 Diagnosis For Pregnancy
Clinical symptoms of pregnancy
• Amenorrhea
• Abdominal enlargement Clinical signs of pregnancy
• Fetal movement • Identification of fetal cardiac
• Breast tenderness action
• Nausea • Perception of fetal movements
• Ultrasonographic recognition
• Vomiting
of pregnancy
• Urinary complaints

http://www.glowm.com/section_view/heading
/The%20Diagnosis%20of%20Pregnancy/item/9
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 Biochemical Diagnosis Of Pregnancy
• hCG:
• Levels can first be detected by a blood test
about 11 days after conception and about 12-
14 days after conception by a urine test.
• Typically, the hCG levels will double every 72
hours. The level will reach its peak in the first
8-11 weeks of pregnancy and then will decline
and level off for the remainder of the
pregnancy.
• Total urinary and serum FSH
• Progesterone
• Early pregnancy factor (EPF):
It is detectable in the serum 36-48 hours after
fertilization, peaks in the early first trimester, and is
almost undetectable at term. EPF also appears within 48
hours of successful in vitro fertilization embryo transfers.
EPF cannot be detected 24 hours after delivery or at the
termination of an ectopic or intrauterine pregnancy. EPF
also is undetectable in many ectopic pregnancies and
spontaneous abortions, indicating that an inability to
identify EPF during pregnancy heralds a poor prognosis.

http://www.glowm.com/section_view/heading
/The%20Diagnosis%20of%20Pregnancy/item/9
3
 ULTRASONOGRAPHIC DIAGNOSIS OF
PREGNANCY
• Sonographic methodology
Transvaginal ultrasound allows early detection
of pregnancy

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Persalinan Normal
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http://cdn.babyresource.com/wp-content/uploads/2014/06/Lightening-is-
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Penanganan Bayi Baru Lahir Normal &
Kriteria Bayi Sehat
• Buku Saku Pelayanan Neonatal
Essensial
Rawat Gabung
• Panduan Pelayanan Bayi
Baru Lahir berbasis
Perlindungan Direltorat
Kesehatan Anak Khuss
 Masa Nifas
• Masa Nifas (Puerperium) adalah masa pulih kembali
mulai dari partus selesai
sampai alat – alat kandungan kembali seperti pra
hamil, lamanya 6-8 minggu.
( Rustam Muchtar, 1998 : 115 )

• Masa Nifas dimulai setelah plasenta lahir dan berakhir

ketika alat – alat kandungan kembali seperti keadaan
sebelum hamil, masa nifas berlangsung kira – kira 6
minggu.
( Panduan Praktis Pelayanan Kesehatan Maternal dan
Neonatal, 2002 : 23 )
 Anjurkan ibu untuk melakukan kontrol/kunjungan masa nifas setidaknya4 kali yaitu:
6-8 jam setelah persalinan (sebelum pulang)
6 hari setelah persalinan
2 minggu setelah persalinan
6 minggu setelah persalinan
Periksa  tekanan darah, perdarahan pervaginam, kondisi perineum,
tanda infeksi, kontraksi uterus, tinggi fundus, dan temperatur secara rutin
Nilai fungsi berkemih, fungsi cerna, penyembuhan luka, sakit kepala, rasa
lelah, dan nyeri punggung.
Tanyakan ibu mengenai suasana emosinya, bagaimana dukungan yang
didapatkannya dari keluarga, pasangan, dan masyarakat untuk perawatan bayinya
Tatalaksana atau rujuk ibu bila ditemukan masalah
Lengkapi vaksinasi tetanus toksoid bila diperlukan

Minta ibu segera menghubungi tenaga kesehatan bila ibu menemukan

salah satu tanda berikut:
Perdarahan berlebihan
Sekret vagina berbau
Demam
Nyeri perut berat
Kelelahan atau sesak
Bengkak di tangan, wajah, tungkai, atau sakit kepala atau pandangan
http://www.edukia.org/web/kbibu/3-2-3-
kabur
Nyeri payudara, pembengkakan payudara, luka atau perdarahan puting
asuhan-ibu-dan-bayi-selama-masa-nifas/#a
Gizi
• Tambah 500 kalori/hari
• Diet seimbang (cukup Senggama
protein, mineral dan • Senggama aman dilakukan
vitamin) setelah darah tidak keluar
• Minum minimal 3 liter/hari dan ibu tidak merasa nyeri
• Suplemen besi diminum ketika memasukan jari ke
setidaknya selama 3 bulan dalam vagina
pascasalin, terutama di • Keputusan bergantung
daerah dengan prevalensi pada pasangan yang
anemia tinggi. bersangkutan
• Suplemen vitamin A: 1
kapsul 200.000 IU diminum
segera setelah persalinan
dan 1 kapsul 200.000 IU
diminum 24 jam kemudian
http://www.edukia.org/web/kbibu/3-2-3-
asuhan-ibu-dan-bayi-selama-masa-nifas/#a