MATERI OBGYN

Steven Irving, S. Ked

 KESEHATAN REPRODUKSI
Reproductive health is a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and
processes. Reproductive health implies that people are able to have a satisfying and safe sex life and that
they have the capability to reproduce and the freedom to decide if, when and how often to do so.
(WHO, 2020)

2
REPRODUCTIVE HEALTH
What are the essential elements of
reproductive health ?
1. The opportunity, particularly for
women, to regular and control
fertility. This includes not only family
planning, but for some couples, the
proper treatment of infertility
2. Should allow all women to have a
safe pregnancy and childbirth
3. Striving for neonatal excellence,
allowing every newborn to have the
benefits of a healthy infancy https://www.who.int/westernpacific/health-
topics/reproductive-health
4. The freedom from sexually-
transmitted disease
3
FAMILY PLANNING / CONTRACEPTION
Benefits of Family Planning / Contraception
(WHO, 2018) :
1. Preventing pregnancy-related health risks
in women
2. Reducing infant mortality
3. Helping to prevent HIV/AIDS
4. Empowering people and enhancing
education
5. Reducing adolescent pregnancies
6. Slowing population growth

https://www.who.int/news-room/fact-
sheets/detail/family-planning-contraception
4
 MODERN CONTRACEPTION
Method Description How it works Effectiveness to Comments
Prevent Pregnancy

COCs (Combined Contains two Prevents the release >99% with correct Reduce risk of
oral contraceptives) hormones (estrogen of eggs from the and consistent use endometrial and
or “The Pill” and progesterone) ovaries (ovulation) > 92% as commonly ovarian cancer
used

POPs (Progestogen- Contains only Thickens cervical 99% with correct Can be used while
only Pills) or “The progestogen mucous to block and consistent use breastfeeding, must
Minipill” hormone, not sperm and egg from 90-97% as be taken at the
estrogen meeting and commonly used same time each day
prevents ovulation

5
 MODERN CONTRACEPTION
Method Description How it works Effectiveness to Comments
Prevent Pregnancy
Implants Small, flexible rods Thickens cervical >99% Health care provides
or capsules placed mucous to block must insert and
under the skin of the sperm and egg from remove, can be
upper arm; contains meeting and used for 3-5 years
progestogen prevents ovulation depending on
hormone only implant; irregular
vaginal bleeding
common but not
harmful

Progestogen only Injected into the Thickens cervical  99% with correct Delayed return to
injectables muscle or under the mucous to block and consistent fertility (about 1-4
skin every 2 or 3 sperm and egg from use months after use);
months meeting and  97% as irregular vaginal
prevents ovulation commonly used bleeding common,
but not harmful 6
 MODERN CONTRACEPTION
Method Description How it works Effectiveness to Comments
Prevent Pregnancy

CIC (Monthly Injected monthly into Prevents the release >99% with correct Irregular vaginal
Injectables or the muscle, contains of eggs from the and consistent use bleeding common,
combined injectable estrogen and ovaries 97% as commonly but not harmful
contraceptives) progestogen used

CVR (Combined Continuosly Prevents the release The patch and the The patch and the
contraceptive patch releases 2 of eggs from the CVR are new and CVR provide a
and combined hormones – a ovaries research on comparable safety +
contraceptive progestin and an effectiveness is pharmacokinetic
vaginal ring) estrogen – directly limited. May be more profile to COCs with
through the skin effective that the similar hormone
(patch) or from the COCs formulations
ring
7
 MODERN CONTRACEPTION
Method Description How it works Effectiveness Comments
to Prevent
Pregnancy
IUD (Intrauterine Small flexible plastic Copper component >99% Longer and heavier
Device): Copper device containing damages sperm and periodes during first
containing copper sleeves or prevents it from months of use are
wire that is inserted meeting the egg common but not
into the uterus harmful; can also be
used as emergency
contraception
IUD : Levonorgestrel A T-Shaped plastic Thickens cervical >99% Decreases amount of
device inserted into mucous to block blood lost with
the uterus that sperm and egg from menstruation over time;
steadily releases meting Reduces menstrual
small amounts of cramps and symptoms
levonorgestrel each of endometriosis;
day amenorrhea (no
8
menstrual bleeding)
 MODERN CONTRACEPTION
Method Description How it works Effectiveness to Comments
Prevent Pregnancy

Male Condoms Sheaths or Forms barrier to 98 % with correct Also protects

coverings that fit prevent sperm and use against sexually
over a man’s erect egg from meeting 85 % as commonly transmitted
penis used infections, including
HIV

Female condoms Sheaths, or linings, Forms barrier to 90% with correct Also protects
that fit loosely inside prevent sperm and use against sexually
a woman’s vagina, egg from meeting 79% as commonly transmitted
made of thin, used infections, including
transparent, soft HIV
plastic film
9
 MODERN CONTRACEPTION
Method Description How it works Effectiveness to Comments
Prevent Pregnancy
Male Sterilization Permanent Keeps sperm out of >99% after 3 months 3 months delay in
(VASECTOMY) contraception to ejaculated semen semen evaluation taking effect while
block or cut the vas 97-8% with no stored sperm is still
deferens tubes that semen evaluation present; does not
carry sperm from the affect male sexual
testicles performance;
voluntary and
informed choice is
essential

Female Sterilization Permanent Eggs are blocked >99% Voluntary and

(TUBAL LIGATION) contraception to from meeting sperm informed choice is
block or cut the essential
fallopian tubes 10
 MODERN CONTRACEPTION
Method Description How it works Effectiveness to Comments
Prevent Pregnancy

LAM (Lactational Temporary Prevents the 99% with correct A temporary family
Amenorrhea contraception for new release of egs use planning method
Methode) mothers whose from the ovaries 98% as commonly based on the natural
monthly bleeding has used effect of
not returned; requires breastfeeding on
exclusive fertility
breastfeeding of an
infant less than 6
months old

Emergency Pills taken to prevent Delays ovulation If all 100 women Does not disrupt an
Contraception Pills pregnancy up to 5 used progestin-only already existing
(Ulipristal acetate 30 days after unprotected emergency pregnancy
mg OR sex contraception, one
levonorgestrel 1.5 would likely become
mg) pregnant 11
 MODERN CONTRACEPTION
Method Description How it works Effectiveness Comments
to Prevent
Pregnancy
SDM Women track their Prevents 95% with Can be used to identify fertile
(Standard fertile periods (usually pregnancy by consistent and days by both women who want
Days Method) days 8 to 19 of each 26 avoiding correct use to become pregnant and women
to 32 day cycle) using unprotected 88% with who want to avoid pregnancy.
cycle beads or other vaginal sex during common use Correct, consistent use requires
aids most fertile days partner cooperation

BBT (Basal Women takes her body Prevents 99% with If the BBT has risen and stayed
body temperature at the pregnancy by correct use higher for 3 full days, ovulation
Temperature) same time each avoiding 75% with has occurred and the fertile
morning before getting unprotected typical use of period has passed. Sex can
out of bed observing an vaginal sex during FABM resume on the 4th day until her
increase of 0.2 to 0.5 fertile days next monthly bleeding
degrees C 12
 MODERN CONTRACEPTION
Method Description How it works Effectiveness Comments
to Prevent
Pregnancy
TwoDay Women track their Prevents 96% with Difficult to use if a woman has a
Method fertile periods by pregnancy by correct use vaginal infection or another
observing of cervical avoiding 86% with condition that changes cervical
mucus (if any type color unprotected common use mucus. Unprotected coitus may
or consistency) vaginal sex during be resumed after 2 consecutive
most fertile days dry days (or without secretions)
Sympto- Women track their Prevents 98 % with May have to be used with
thermal fertile periods by pregnancy by correct use caution after an abortion around
Method observing changes in avoiding 98 % with menarche or menopause, and
the cervical mucus unprotected typical use in conditions which may
(clear texture), body vaginal sex during increase body temperature
temperature (slight most fertile days
increase) and
consistency of the
cervix (softening) 13
TRADITIONAL CONTRACEPTION

14
 SAFE MOTHERHOOD
4 Pillars of Safe Motherhood (WHO, 1998)

“
https://apps.who.int/iris/bitstream/handle/10665/63268/WHO_FHE_MSM_94.11_Rev.1.pdf;jsessionid=9D9905DC95A2
F26F95E4836146EA4616?sequence=1
https://www.who.int/docstore/world-health-day/en/documents1998/whd98.pdf
15
SIX PILLARS OF SAFE MOTHERHOOD
1. FAMILY PLANNING – To ensure that
individuals and couples have the information
and services to plan the timing, number, and
spacing of pregnancies
2. ANTENATAL CARE – To provide vitamin
supplements, vaccinations, and screen for risk
factors in order to prevent complications
where possible, and to ensure that
complications of pregnancy are detected early
and treated appropriately
3. OBSTETRIC CARE – To ensure that all birth
attendants have the knowledge, skills, and
equipment to perform a clean and safe delivery,
http://www.policyproject.com/pubs/advoc
and to ensure that emergency care for high risk
pregnancies and complication is made available acy/MaternalHealth/AM_MH_16Sec3-
to all women who need it. 2.pdf

16
SIX PILLARS OF SAFE MOTHERHOOD
4. POSTNATAL CARE – To ensure that postpartum
care is provided to mother and baby, including
lactation assistance, provision of family planning
services, and managing danger signs
5. POSTABORTION CARE – To prevent
complications where possible and ensure that
complications of abortion are detected early and
treated appropriately; to refer other reproductive
health problems; and to provide family planning
methods as needed.
6. STD/HIV/AIDS Control – To screen, prevent, and
manage transmission to baby; to assess risk for http://www.policyproject.com/pubs/advoc
future infection; to provide voluntary counseling acy/MaternalHealth/AM_MH_16Sec3-
and testing; to encourage prevention; and where 2.pdf
appropriate to expand services to address mother
to child transmission 17
 FISIOLOGI KEHAMILAN,
PERSALINAN, KELAHIRAN,
DAN MASA NIFAS

18
HUMAN TIMELINE
▷ WEEKS  embryonic development from
fertilization.
▷ GESTATIONAL AGE  is from the first day of the
Last Menstrual Period (LMP).
▷ STAGES  Carnegie stages of development.
▷ TIMING  days from fertilization or post
conception age (PC), not the clinical or gestational
age (GA) calculated from LMP (add 2 weeks).

▷ CLASSIFICATION

 Week 1 to Week 8 (GA 10)are considered

 the embryonic period of development.
Week 9 to week 37 (GA 11-39) or birth are
considered the fetal period of
 development.
First month (4 weeks) after birth is
the neonatal period of development.
https://embryology.med.unsw.edu.au/embryol
ogy/index.php/Timeline_human_development
19
HUMAN TIMELINE

▷ Sampai sekitar usia 4 minggu, tampak kantong

gestasi dengan embrio yang belum tampak
▷ Minggu 6  Jantung telah terbentuk penuh
▷ Minggu 7  Mata tampak pada muka
▷ Minggu 8  Mulai pembentukan genitalia
eksterna. Sirkulasi melalui tali pusat dimulai
▷ Minggu 9  Kepala meliputi separuh besar janin,
terbentuk muka janin
20
HORMONES IN PREGNANCY

21
PELVIC TYPES
▷ Gynecoid  DAP = DT
(BULAT)
▷ Anthropoid  DAP > DT
▷ Android  DT dekat
sacrum
▷ Platypelloid  DT > DAP

22
STATION PERSALINAN
Mengetahui penurunan kepala
dengan metode perlimaan ini
dapat dilakukan dengan palpasi
abdominal atau leopold,
dengan menggunakan tekhnik
jari tangan seorang pemeriksa
untuk meraba kepala janin
berada pada station atau
hodge berapa.

▷ Station dalam persalinan adalah ketinggian

bagian bawah janin pada jalan lahir yang
digambarkan dalam hubungannya dengan spina
ischiadika (panggul tengah) yang terletak di
tengah-tengah antara PAP dan PBP.
▷ Pada pemeriksaan VT, derajat desensus
ditentukan berdasarkan Zero Station. Zero point
berada pada posisi setinggi dengan spina
ischiadica dan derajat desensus diperkirakan
berada pada berapa cm di atas atau di bawah zero
point. Bila bagian terendah janin sudah berada
pada titik zero, maka disebut sudah engange
23
 MEKANISME PERSALINAN NORMAL
(7 Cardinal Movements of Labor)
1. Engagement: Terjadi ketika diameter terbesar dari presentasi bagian janin (biasanya kepala)
telah memasuki rongga panggul. Engagement telah terjadi ketika bagian terendah janin telah
memasuki station nol atau lebih rendah. Pada nulipara, engagement sering terjadi sebelum
awal persalinan. Namun, pada multipara dan beberapa nulipara, engagement tidak terjadi
sampai setelah persalinan dimulai (Cunningham et. al, 2013; McKinney, 2013).
2. Descent: Descent terjadi ketika bagian terbawah janin telah melewati panggul. Descent/
penurunan terjadi akibat tiga kekuatan yaitu tekanan dari cairan amnion, tekanan langsung
kontraksi fundus pada janin dan kontraksi diafragma serta otot-otot abdomen ibu pada saat
persalinan, dengan sumbu jalan lahir

○ Sinklitismus yaitu ketika sutura sagitalis sejajar dengan sumbu jalan lahir
○ Asinklistismus anterior: Kepala janin mendekat ke arah promontorium sehingga os
parietalis lebih rendah.
○ Asinklistismus posterior: Kepala janin mendekat ke arah simfisis dan tertahan oleh
simfisis pubis (Cunningham dkk, 2013; McKinney, 2013).

24
 MEKANISME PERSALINAN NORMAL
(7 Cardinal Movements of Labor)
3. Fleksi (flexion): Segera setelah bagian terbawah janin yang turun tertahan oleh serviks, dinding
panggul, atau dasar panggul, dalam keadaan normal fleksi terjadi dan dagu didekatkan ke arah dada
janin. Fleksi ini disebabkan oleh:

○ Persendian leher, dapat berputar ke segala arah termasuk mengarah ke dada.

○ Letak leher bukan di garis tengah, tetapi ke arah tulang belakang sehingga kekuatan his
dapat menimbulkan fleksi kepala.
○ Terjadi perubahan posisi tulang belakang janin yang lurus sehingga dagu lebih menempel
pada tulang dada janin .
○ Kepala janin yang mencapai dasar panggul akan menerima tahanan sehingga memaksa
kepala janin mengubah kedudukannya menjadi fleksi untuk mencari lingkaran kecil yang
akan melalui jalan lahir (Cunningham dkk, 2013; McKinney, 2013).
4. Putaran paksi dalam (internal rotation): Putaran paksi dalam dimulai pada bidang setinggi spina
ischiadika. Setiap kali terjadi kontraksi, kepala janin diarahkan ke bawah lengkung pubis dan kepala
berputar saat mencapai otot panggul (Cunningham dkk, 2013; McKinney, 2013).
5. Ekstensi (extension): Saat kepala janin mencapai perineum, kepala akan defleksi ke arah anterior oleh
perineum. Mula-mula oksiput melewati permukaan bawah simfisis pubis, kemudian kepala keluar
mengikuti sumbu jalan lahir akibat ekstensi.
6. Putaran paksi luar (external rotation): Putaran paksi luar terjadi ketika kepala lahir dengan oksiput
anterior, bahu harus memutar secara internal sehingga sejajar dengan diameter anteroposterior
panggul. Rotasi eksternal kepala menyertai rotasi internal bahu bayi.
7. Ekspulsi: Setelah bahu keluar, kepala dan bahu diangkat ke atas tulang pubis ibu dan badan bayi
dikeluarkan dengan gerakan fleksi lateral ke arah simfisis pubis. 25
PROBABLE SIGN PREGNANCY

Mual dan Keluhan

Amenorrhea Mastodinia Quickening
Muntah kencing

Peningkatan
temperature Perubahan
Konstipasi Perubahan BB Warna kulit
basal > 3 Payudara
minggu

Pembesaran
Perubahan Kontraksi Ballotement (UK
Perut (> UK 16
Pelvis Uterus 16-20 minggu)
minggu)

26
 TANDA PASTI KEHAMILAN
DJJ Fetal ECG
• Laenec (17-18 minggu)
• 12 minggu dengan fetalkardiografi
• Doppler (12 minggu)

Palpasi  22 minggu Laboratorium (hCG)

Rontgenografi • Urine : 6-8 hari setelah ovulasi
• Blood
• Tulang tampak (minggu 12-14)
• Jika terdapat keragu-raguan mendesak • Qualitative  hCG present
• Quantitative  measures exact amount of
USG hCG
• Minggu 3-5 : Gestational sac • If you get NEGATIVE PREGNANCY RESULT,
• Minggu 6-7 : Polus embryonal try RETESTING WITHIN ABOUT A WEEK
• Minggu 8-9 : Gerak Janin TO DOUBLE CHECK
• Minggu 9-10 : Plasenta

27
PERUBAHAN UTERUS
•Perubahan warna kebiruan atau ungu pada cervix, vagina, dan labia karena
Tanda Chadwick peningkatan vaskularisasi. Muncul pada minggu ke 6-8 gestasi

Tanda Goodel •Perlunakan portio vaginalis cervix karena peningkatan vaskularisasi

•Perlunakan pada bagian midline uterus pada bagian depan junction antara
Tanda Ladin uterus dan serviks. Muncul pada minggu ke 6 gestasi

Tanda Hegar •Perlunakan pada segmen bawah Rahim (antara uterus dan cervix)

Tanda Mc Donald •Mudahnya corpus uteri untuk difleksikan terhadap cervix

•Pada awal kehamilan minggu 5-8 perlunakan pada fundus uteri terjadi
Tanda Van Fernwald implantasi

•Terjadi pembesaran asimetris di tempat implantasi (bagian tuba uterine

Tanda Piskacek bertemu dengan uterus: cornu uteri)

28
 ANTENATAL CARE
To achieve the Every Woman Every Child vision and the Global Strategy for Women's, Children's
and Adolescents' Health, we need innovative, evidence-based approaches to antenatal care. I
welcome these guidelines, which aim to put women at the centre of care, enhancing their
experience of pregnancy and ensuring that babies have the best possible start in life.
(Ban Ki-moon, United Nations Secretary-General, 2016)

WHO Recommendations on antenatal care for a positive pregnancy experience

https://apps.who.int/iris/bitstream/handle/10665/250796/9789241549912-
eng.pdf;jsessionid=D76A0531FCA8F99F389352AFB06399D0?sequence=1

https://kanalpengetahuan.fk.ugm.ac.id/rekomendasi-who-dalam-pelayanan-antenal-care-anc/
29
Summary of WHO recommendations on ANC

30
Summary of WHO recommendations on ANC

31
Summary of WHO recommendations on ANC

32
Summary of WHO recommendations on ANC

33
Summary of WHO recommendations on ANC

34
FREKUENSI ANC

The GDG stresses that the four-visit focused ANC (FANC) model does not offer women adequate
contact with health-care practitioners and is no longer recommended. With the FANC model, the
first ANC visit occurs before 12 weeks of pregnancy, the second around 26 weeks, the third
around 32 weeks, and the fourth between 36 and 38 weeks of gestation. Thereafter, women are
advised to return to ANC at 41 weeks of gestation or sooner if they experience danger signs.
Each ANC visit involves specific goals aimed at improving triage and timely referral of high-risk
women and includes educational components. However, up-to-date evidence shows that the FANC
model, which was developed in the 1990s, is probably associated with more perinatal deaths than
models that comprise at least eight ANC visits. Furthermore, evidence suggests that more ANC
visits, irrespective of the resource setting, is probably associated with greater maternal
satisfaction than less ANC visits. (WHO, 2016)

35
 Menentukan Usia Kehamilan
▷ RUMUS NAEGLE : (Siklus mens 28 hari) ▷ RUMUS BARTHOLOMEW
○ (Day+7), (Month-3), (Year+1)
▷ RUMUS PARIKH : (Sikus mens bukan 28 hari)
○ (Day+[Siklus-21]), (Month-3), (Year+1)
▷ RUMUS MCDONALD
○ 𝑇𝑖𝑛𝑔𝑔𝑖 𝐹𝑢𝑛𝑑𝑢𝑠 𝑥 8
7
= UK (Minggu)
○ 𝑇𝑖𝑛𝑔𝑔𝑖 𝐹𝑢𝑛𝑑𝑢𝑠 𝑥 2
7
= UK (Bulan)
○ TBJ (Taksiran Berat Janin) = (TFU-n)x155
■ n = 12 (Kepala belum masuk PAP)
■ N = 11 (Kepala sudah masuk PAP)
36
PEMERIKSAAN LEOPOLD
▷ Leopold I : menentukan tinggi fundus
uteri dan bagian janin yang terletak di
fundus uteri
▷ Leopold II : menentukan bagian janin
pada sisi kiri dan kanan ibu (dilakukan
mulai akhir trimester II)
▷ Leopold III : menentukan bagian janin
yang terletak di bagian bawah uterus
(dilakukan mulai akhir trimester II)
▷ Leopold IV : menentukan berapa jauh
masuknya janin ke pintu atas panggul
(dilakukan bila usia kehamilan >36
minggu)

37
 OBSTETRIC STETHOSCOPE
Can detect fetal heart beats from 20 weeks

“
Applying the stethoscope perpendicularly on the auscultation focus that corresponds to the fetus’s
anterior shoulder, which had been previously detected through palpation; the pregnant woman
must be asked to lie down in dorsal recumbent position.
The examiner’s head exerts a mild but uninterrupted pressure on stethoscope. His/her free hand
takes the mother’s pulse to tell her beats apart from those of the fetus. The hand that was holding
the stethoscope is released to prevent it from interfering with outside noises, and it is then placed
on the uterus to detect the presence of contractions
This is especially important during labor, since auscultation during and outside of the contraction
will allow the health professional to notice the existence of DIPS. BUT NOW, Doppler effect, the
sensitivity of the doppler-based devices currently available is significantly higher than that of the
obstetric stethoscope. Doppler detector also can be used to detect embryo-fetal heart beats since
12 weeks gestational age.
DIPs I: Drop of the FHR coinciding with the uterine contraction.
DIPs II: Late deacceleration of FHR related to uterine contractions.

https://www.paho.org/clap/index.php?option=com_docman&view=download&category_slug=salud-de-mujer-reproductiva-materna-
y-perinatal&alias=240-sexual-and-reproductive-health-guides-for-the-phc-continuum-women-and-newborns&Itemid=219&lang=en
 Page38 109-110
FETAL BIOMETRICS PARAMETER
https://www.jogc.com/article/S1701-2163(19)30464-
5/pdf

39
NUTRISI PADA KEHAMILAN

Kalori • Ibu hamil 2300 kkal

• Ibu menyusui 2800 kkal

Protein • Membutuhkan 30 gram/hari

Kalsium • Kebutuhan sekitar 1.5-2 gram/hari

• Untuk mengurangi risiko Pre-Eklampsia

Zat Besi • Kebutuhan akan besi sekitar 60 mg/hari atau setara 320 mg sulfas ferrous
• Untuk mencegah anemia

Asam Folat • Kebutuhan sekitar 0.4 mg /hari

• Untuk mencegah anemia

40
PERTAMBAHAN BB PADA KEHAMILAN

BMI sebelum hamil (kg/𝑚2 ) Pertambahan BB (kg)

BMI < 18.5 12.5 – 18

18.5 – 24.9 11.5 – 16

25 – 29.9 7 – 11.5

BMI > 30 5–9

41
 PHANTOM
(Persalinan Normal)

https://apps.who.int/iris/bitstream/handle/10665/260178
/9789241550215-eng.pdf?sequence=1
42
 Persalinan Normal
Persalinan dan Kelahiran dikatakan normal jika :
1. Usia kehamilan cukup bulan (37-42 minggu)
2. Persalinan terjadi spontan
3. Presentasi belakang kepala
4. Berlangsung tidak lebih dari 18 jam
5. Tidak ada komplikasi pada ibu maupun janin

Kala 1 Kala 2 Kala 3 Kala 4

• Fase laten : • Pembukaan • Segera setelah • Segera setelah

Pembukaan lengkap bayi lahir lahirnya
serviks 1 sampai bayi sampai plasenta
hingga 3 cm ; lahir plasenta lahir hingga 2 jam
sekitar 8 jam • 2 jam pada lengkap post partum
• Fase aktif : primigravida, 1 • 30 menit
Pembukaan jam pada
serviks 4 multigravida
hingga lengkap
(10 cm),
sekitar 6 jam

43
 Parameter Frekuensi pada fase Frekuensi pada fase
laten aktif

Kala I
Tekanan Darah, Suhu Setiap 4 jam Setiap 4 jam
Nadi Setiap 30 menit Setiap 30-60 menit
DJJ Setiap 30 menit Setiap 30 menit
1. Fase laten (0-3 cm) Produksi urin, protein, Tiap 2-4 jam
○ Berlangsung sekitar 8 jam asetopn
2. Fase aktif Kontraksi Setiap 30 menit Setiap 30 menit
○ Fase akselerasi (sekitar 2 jam)
Minimal 1-2x/60” / 20” 3-4x/10’/ 30-40”

■ Pembukaan 3-4 cm Pembukaan Serviks Setiap 4 jam Setiap 4 jam

○ Fase dilatasi maksimal (sekitar 2 jam) Penurunan Setiap 4 jam Setiap 4 jam
■ Pembukaan 5-9 cm
TRUE LABOR BRAXTON HICKS (FALSE LABOR)
○ Fase deselerasi (sekitar 2 jam)
■ Pembukaan 9-10 cm
Regular Intervals Irregular Intervals
Intervals gradually often Intervals remains long

Intensity gradually increase Intensity remains unchanged

Discomfort in abdomen and back Discomfort is chiefly in the lower
abdomen

Progressive effacement and Cervix does not dilate and effacement

dilatation of Cervix
Contractions continue despite Contractions may stop when rest or
movement changing position

With bloody show Without bloody show

44
 https://evidencebasedbirth.com/evidenc
e-birthing-positions/

KALA II
Pembukaan serviks lengkap atau
Kepala janin tampak di vulva dengan diameter 5-6 cm
Penanganan :
• Kosongkan VU
• Mengatur posisi partus (Posisi saat mengejan)
• Jaga kenyamanan ibu, asupan nutrisi, rehifrasi
• Ajarkan cara mengejan
• Cek DJJ saat dan setelah kontraksi

Tanda Kala II :
• Ibu mempunyai keinginan untuk meneran
• Ibu merasa tekanan yang semakin meningkat pada
rectum dan atau vaginanya
• Perineum menonjol dan menipis
• Vulva-vagina dan sfingter ani membuka

45
EPISIOTOMI pada KALA II
Medial Mediolateral
Episiotomi adalah insisi perineum untuk
memperlebar ruang pada jalan lahir yang Surgical Repair Easy Difficult
menyebabkan terpotongnya selaput lendiri Faulty healing Rare Common
vagina, cincin selaput dara, jaringan septum
Post op pain Minimal Common
rectovaginal, otot-otot dan fascia perineum
dan kulit sebelah depan perineum Anatomical Excellent Not Excellent
result
Indikasi :
Blood loss Less More
a. Indikasi Janin
• Distosia bahu
Dysparenia Rare Occasionally

• Gawat janin, tali pusat Extensions Common Uncommon

menumbung
b. Indikasi Ibu In general, two types of episiotomy have been described: the median (or midline or

• Primigravida umumnya
medial) episiotomy and the mediolateral episiotomy. The median episiotomy tends to

• Peregangan perineum
be a simpler incision to repair and is the more commonly used procedure in the United
States. However, median episiotomy is associated with a greater risk of extension to the
anal sphincter (third-degree extension) or rectum (fourth-degree extension).
berlebihan (persalinan dengan
Mediolateral episiotomy, an incision at least 45 degrees from the midline, maximizes
cunam, ekstraksi vakum, bayi perineal space for delivery while reducing the likelihood of third- or fourth-degree
besar) extension. Reported disadvantages of the mediolateral procedure include difficulty of
• Arkus pubis yang sempit repair, greater blood loss, and, possibly, more discomfort during the early postpartum

• Perineum kaku
period. Although the data are insufficient to determine the superiority of either
approach, the procedures seem to have similar outcomes, including pain from the
incision and time to resumption of intercourse. (ACOG, 2006)
46
RUPTUR PERINEUM
DERAJAT Keterangan

1 Laserasi epitel vagina atau laserasi

pada kulit perineum saja
2 Melibatkan kerusakan pada otot-otot
perineum, tetapi tidak melibatkan
kerusakan sfingter ani
3 Kerusakan pada otot sfingter ani

3a : Robekan < 50% sfingter ani

eksterna
3b : robekan > 50% sfingter ani
eksterna
3c : Robekan juga meliputi sfingter
ani interna
4 Robekan stadium 3 disertai robekan
epitel anus 47
KALA III
Tanda-tanda Plasenta Lepas :
1. Semburan darah banyak tiba-tiba • Tali pusat dikencangkan  Tekan simphisis pubis  bila tali
2. Uterus globular Kustner pusat masuk kembali, maka plasenta belum lepas

3. Tali pusat memanjang

• Pasien disuruh mengejan  Tali pusat memanjang  Jika
Tatalaksana yang diberikan di kala III : Klein setelah mengejan tali pusat kembali memendek, maka plasenta
belum lepas

▷ Pemberian suntikan oksitosin

Suntikan oksitosin 10 unit IM pada 1/3
bawah paha kanan bagian luar
• Tali pusat dikencangkan  Uterus diketuk  Jika getaran sampai
Strasman tali pusat, maka plasenta belum lepas
▷ Penegangan tali pusat terkendali
Jika plasenta belum lahir dalam waktu 15
menit  10 IU Oksitosin IM (Dosis kedua
• Tangan kiri memegang uterus pada segmen bawah Rahim,
dan siapkan rujukan)
30 menit plasenta belum lahir  Rujuk atau Manuaba sedangkan tangan kanan memegang dan mengencangkan tali
pusat, kedua tangan ditarik berlawanan  Tarikan terasa berat
bila tali pusat tidak memanjang, berarti plasenta belum lepas
manual plasenta

▷ Masase fundus uteri 48

KALA IV
Montior tanda vital (sampai 2 jam post partus)
•1 jam pertama : tiap 15 menit
•1 jam kedua : tiap 30 menit
Monitor kontraksi uterus

Perineorafi
•Penjahitan untuk perineum yang robek paska persalinan

PPV (Perdarahan per vaginam) Evaluasi dan estimasi jumlah perdarahan

•Biasanya 100-300 mL

IMD (Inisiasi menyusui dini)

49
 POST NATAL CARE

https://apps.who.int/iris/bitstream/handle/10665/97603/9789241506649_eng.pdf?sequence=1

50
POST NATAL CARE (WHO, 2013)

51
MASA NIFAS (PUERPERIUM)
Masa Nifas (Puerperium) adalah masa pulih kembali, mulai dari persalinan selesai sampai alat-alat
kandungan kembali seperti pra hamil. Lama masa nifas ini yaitu 6 – 8 minggu. Umumnya 40 hari
INVOLUSI ALAT-ALAT KANDUNGAN :
Uterus
• Secara berangsur-angsur menjadi kecil (involusi) sehingga akhirnya kembali seperti sebelum hamil

Bekas Implantasi
• Placental bed mengecil karena kontraksi ke cavum uteri dengan diameter 7.5 cm
• Minggu ke 2 d = 3.5 cm
• minggu ke 6 d= 2.4 cm
Jalan Lahir
• Bila tanpa infeksi sembuh dalam 6-7 hari

After pain
• Rasa sakit yang disebabkan kontraksi uterus menghilang dalam 2-4 hari pasca persalinan

Lochia : Cairan sekret berasal dari cavum uteri dan vagina dalam masa nifas
• Lochia rubra  2 hari postpartum berisi darah segar dan sisa-sisa selaput ketuban, sel desidua, verniks kaseosa, lanugo, dan meconium
• Lochia sanguinolenta  hari 3-7 postpartum berisi warna merah kuning berisi darah dan lendir
• Lochia serosa  hari ke 7-14 : berwarna kuning, cairan tidak berdarah lagi
Cerviks

Ligamen-ligamen
52
 SKDI 2019
Standar Nasional Pendidikan Profesi Dokter Indonesia

53

1 ASI tidak keluar / kurang
2 Benjolan di daerah payudara
3 Pembesaran payudara tanpa
benjolan
4 Puting terluka di luar masa
menyusui
5 Gangguan / Perubahan
warna / Permukaan payudara
(Puting tertarik ke dalam /
retraksi, Payudara seperti
kulit jeruk)
6 Payudara mengencang
bengkak dan/atau nyeri pada
payudara
7 Payudara mengeluarkan
cairan/discharge
MASALAH SISTEM REPRODUKSI
Nyeri perut waktu hamil
Perdarahan vagina saat
hamil
Persalinan kurang bulan dan
lewat waktu
Kehamilan pada anak dan
remaja yang tidak diinginkan
Keluhan waktu hamil (sakit
kepala, sulit tidur, demam,
sesak, pingsan, anyang-
anyangan, kaki bengkak,
sakit pinggang, perubahan
warna kulit, ambeien, mual
muntah selama hamil)
Ketuban pecah dini
Masalah terkait proses
persalinan dan kelahiran
Masalah nifas dan pasca
salin
Perdarahan jalan lahir saat
proses persalinan
Keputihan / Duh (discharge)
vagina
Gangguan daerah vulva &
vagina (gatal, nyeri, rasa
terbakar, benjolan, kutil, luka)
Gangguan menstruasi (tidak
menstruasi, menstruasi
sedikit, menstruasi banyak,
menstruasi lama, nyeri saat
menstruasi)
Gangguan masa menopause
dan perimenopause
Sulit punya anak
Masalah terkait penggunaan
kontrasepsi
Peranakan turun
Benjolan di lipat paha
Gangguan ejakulasi (dini,
sedikit, encer, berdarah)
Gangguan jiwa waktu hamil,
bersalin, nifas
Gangguan libido
Benda asing dalam vagina
54
DAFTAR PENYAKIT SISTEM REPRODUKSI (4)
INFEKSI GANGGUAN PADA KEHAMILAN

Sindrom discar genital (gonore dan non Aborsi spontan inkomplit

gonore)
Aborsi spontan komplit
Infeksi virus Herpes tipe 2
PERSALINAN DAN NIFAS
Infeksi saluran kemih bagian bawah non Ruptur perineum tingkat 1-2
komplikata
Vaginitis Infeksi nifas

PAYUDARA
Vaginosis bakterialis
Breast engorgement / galaktokel
Servisitis
Mastitis
KELAINAN ORGAN GENITAL
Cracked nipple
Abses folikel rambut atau kelenjar sebasea
Inverted nipple
55
 DAFTAR PENYAKIT SISTEM REPRODUKSI (3B)
GANGGUAN PADA KEHAMILAN PERSALINAN DAN NIFAS KELAINAN ORGAN GENITAL
Persalinan preterm
Infeksi intra-uterin : Korioamnionitis Vulnus pada vulva dan vagina
Ruptur uteri
Ketuban Pecah Dini (KPD)
Aborsi mengancam TUMOR DAN KEGANASAN PADA
Distosia ORGAN GENITAL
Partus lama
Hiperemesis Gravidarum Torsi dan rupture kista
Prolaps tali pusat
Kehamilan ektopik Hipoksia janin
Robekan serviks
Preeklampsia Ruptur perineum tingkat 3-4
Retensi plasenta
Eklampsia
Inversio uterus
Abrupsio plasenta Perdarahan Post Partum
Syok pada kehamilan / persalinan
Subinvolusio uterus
56
DAFTAR PENYAKIT SISTEM REPRODUKSI (3A)
INFEKSI KELAINAN ORGAN GENITAL
Toxoplasmosis Kista dan Abses Kelenjar Bartolini

Kondiloma akuminata (kutil kelamin) Corpus Alienum Vaginae

Kista Gartner
Penyakit radang panggul
Prolaps uterus, sistokel, rektokel
GANGGUAN PADA KEHAMILAN
Perdarahan uterus abnormal
Infeksi pada kehamilan : TORCH,
Hepatitis B, Malaria
Hipertensi pada kehamilan MASALAH REPRODUKSI PRIA
Infertilitas
Diabetes Gestasional
Gangguan Ereksi
Anemia pada kehamilan Gangguan Ejakulasi
57
 DAFTAR PENYAKIT SISTEM REPRODUKSI (2)
GANGGUAN PADA KEHAMILAN PERSALINAN DAN NIFAS INFEKSI
Inkompatibilitas Darah Kematian Janin Intra Uterin (Intra Uterine Fetal Lympho Granuloma Venereum
Death (IUFD)
Mola Hidatidosa KELAINAN ORGAN GENITAL
Malpresentasi
Kehamilan postterm Fistula (Vesiko-vaginal, uretero-vagina,
Inkontinensia urin pasca persalinan
rektovagina)
Insufisiensi Plasenta
Inkontinensia feses pasca persalinan
Kista Nabotian
Plasenta previa
Tromboflebitis pada kehamilan dan pasca Polip endoserviks
Vasa Previa
kehamilan Endometriosis
Inkompeten Serviks
TUMOR DAN KEGANASAN Menopause, Perimenopausal syndrome
Polihidramnion
ORGAN GENITAL Polikistik ovarium
Kelainan letk janin setelah 36 minggu
Karsinoma serviks PAYUDARA
Karsionam endometrium Inflamasi, Abses
Kehamilan ganda
Karsinoma ovarium Pubertas Terlambat
Kembar siam
Teratoma ovarium (Kista dermoid) Fibroadenoma Mammae (FAM)
Pertumbuhan janin terhambat
Kista ovarium Karsinoma payudara
Kelainan janin
Koriokarsinoma Ginekomastia
DKP 58
Adenomiosis, Mioma Hipomastia DAN Gigantomastia
DAFTAR PENYAKIT SISTEM REPRODUKSI (1)

KELAINAN ORGAN GENITAL

Malformasi Kongenital Organ Reproduksi

Sistokel

Rektokel

59
KETERAMPILAN KLINIS SISTEM REPRODUKSI
(Does, Shows, Knows How, Knows)

60
Thanks!
Any questions?
You can find me at:
Quora : Steven Irving
IG / Twitter : @sleep_devotee
Web : thesleepdevotee.wordpress.com
61