TUTORIAL 2.1.

1
BY:
1.
GROUP
Della Sri Resky 1610319001
8
2. Ulfa Inten Waluyani 1610312018
3. Ghina Muthmainnah 1610311077
4. Nadiah Mardhatillah D1610313050
5. Karina Shafira 1610313003
6. Hanifah Syilfana 1610313030
7. Rahla Azura 1610313043
8. Multazam Fahreza C 1610311001
9. Firmandika Buana 1610313041
10. Raissa Nabilla P 1610313002
 MODUL 1
PERUBAHAN TUBUHKU:
Ny. Rina 27 tahun datang ke Puskesmas untuk memeriksakan kehamilan
per tam anya yang sekarang berusia 16-1 8 mi nggu . Kepada Dokter, Ny. Ri na
menanyakan mengapa ia tidak langsung hamil setelah pernikahan dan
mengapa orang lain bisa langsung hamil sedangkan i a baru hamil setelah 8
bulan perni kahan . Ia juga menanyakan mengenai perubahan yang dirasakan
seper ti payudara dirasakan tegang dan areola menghitam ser ta buang air
besar kurang lancar.
Pada pemeriksaan fi sik didapatkan K U b aik , tanda vital dalam batas normal ,
fundus uteri 3 jari bawah pusat, ball otement positif, hasi l laboratorium Hb 1 2,2
gr/dL, leukosit 8.000/mm3, trombosit 234.000/mm3.Hasil pemeriksaan USG
sesuai usia kehamilan 17-1 8 minggu. Dokter menjelaskan b ahwa menurut skor
Poedji Rochj ati, kehamilan Ny. Rina termasuk kategori kehamilan ri siko rendah .
Selanj utnya dokter menjelaskan mengenai perawatan ANC yang harus diikuti
dan pengaturan diet ser ta obat-obatan .
Dari hasil pemeriksaan, dokter menyatakan perki raan per salinan dan
kemungkinan per salinan normal ser ta nifas yang akan dijalani Ny. Ri na, juga
tentang pengaturan kehamilan berikutnya.
Bagaimana anda menjelaskan apa yang terjadi pada Ny. Rina?
 STEP 1: TERMINOLOGY
 Ballotement: a sharp upward pushing against the
uterine wall with a finger inserted into the vagina for
diagnosing pregnancy by feeling the return impact of
the displaced fetus; also : a similar procedure for
detecting a floating kidney.
 USG: (also known as diagnostic sonography or
ultrasonography) is a diagnostic imaging technique
based on the application of ultrasound. It is used to
see internal body structures such as tendons,
muscles, joints, vessels and internal organs.
 Puerperal Blood: Blood that coming out from the
uterus after child birth.
 STEP 1: TERMINOLOGY
 Poedji Rochjati Score (KSPR): Card used by the
hospital to determine the level of risk of maternal
pregnancy.
 Fundus Uteri: The top part of the uteri. The fundus of
the uterus grows in a predictable pattern during the
weeks of pregnancy.
 ANC (Ante Natal Care): is the routine health control
of presumed healthy pregnant women without
symptoms (screeening), in order to diagnose
diseases or complicating obstetric conditions without
symptoms, and to provide information about
lifestyle, pregnancy and delivery.
 STEP 2: PROBLEMS
1. Why Mrs. Rina doesn’t get pregnant after marriage?
2. Why Mrs. Rina feels strained in her breast, areola
blackened and constipation?
3. Why Mrs. Rina checked her pregnancy 16-18 weeks
old?
4. Why Mrs. Rina's pregnancy categorized as a low-risk
pregnancy, is there anything to do with Poedji Rochjati
Score?
5. What is the diet arrangement that will be done by Mrs.
Rina?
6. How to determine the estimated labor?
7. Why doctor says it is necessary to set about the next
pregnancy?
 STEP 3: HYPOTHESIS
1. Why Mrs. Rina doesn’t get pregnant af ter marriage ?
 Readiness of ovum and sperm (in terms of nutrition &
metabolism) so that the sperm does not get to the ovum and
fertilization can’t be happen.
 The condition of the feminine area. For example the presence
of vaginal discharge that can inhibit sperm pathway.
 Fimbrae is rigid so it can’t catch a mature ovum that causes
the ovum can’t enter the fallopian tube.
 Family illness history, fat.
 The form of sperm is abnormal
 The fertile period of women. The pregnancy program is
incompatible with the fertile period
 Irregular menstrual cycles, psychic condition
 Doing heavy activity, unhealthy lifestyle, often wear tight
clothes
 STEP 3: HYPOTHESIS
2. Why Mrs. Rina feels strained in her breast, areola blackened
and constipation?
 Strained in breast: estrogen hormone stimulates the
lactiferous duct
 Areola blackened: excess pigment deposits and corticosteroid
hormone
 Constipation: increased levels of progesterone causes
relaxation of the small intestine muscles that slow the
process of digestion of food.

3. Why Mrs. Rina checked her pregnancy 16 -18 weeks old?

 Anticipation of pregnancy risk
 ANC process (<14 weeks, 14-28 weeks,>28 weeks)
 STEP 3: HYPOTHESIS
4. Why Mrs. Rina's pregnancy categorized as a low -risk
pregnancy, is there anything to do with Poedji Rochjati Score?
 Mother’s age is not <16 years and >35 years.
 Length of marriage is not >4 years.
 The result of physical check up is normal .

5. What is the diet arrangement that will be done by Mrs. Rina?

 Calories: 2500kcal / day.
 Protein: 85 gr / day. Must be increased: be aware of risks such
as abortion, premature birth
 Calcium: 1 .5 gr / day
 Iron: 15 grams / day
 Folic acid: 400 micrograms/day or equivalent with 2 glasses of
milk.
 STEP 3: HYPOTHESIS
6. How to determine the estimated labor ?
 By using The Naegele's formula is simple arithmetic method for
calculating the EDD (estimated date of delivery) based on the
LMP (last menstrual period). Example: To the date of the first day
of the LMP (e.g. 22nd June 2008):
 add seven days (i.e 29th)
 subtract 3 months (i.e March)
 add one year (i.e 2009)
 Measurement of fundal height of uteri
7. Why doctor says it is necessar y to set about the next
pregnancy?
 Maintain mother's health after giving birth
 Closer relationship between parents and children (KSPR >2
years)
 Preparing for Financial Affairs
 STEP 4: SCHEMA
FERTILISASI

PAYUDARA
BAB KURANG
TEGANG,AREOLA HAMIL LANCAR
MENGHITAM

NUTRISI PEMERIKSAAN PERSALINAN

DAN OBAT
ANC LABORATORIUM NORMAL

KSPR
USG
PEMERIKSAAN
FISIK PENGATURAN NIFAS
KEHAMILAN

UKURAN PANGGUL
 STEP 5: LEARNING
OBJECTIVE
1. Students are able to explain the process of fertilization,
implantation and fetal development.
2. Students are able to explain the normal delivery and
influencing factors.
3. Students are able to explain physical and physiological
changes in pregnant women.
4. Students are able to explain the regulation of medicines in
pregnant women.
5. Students are able to explain the dietary arrangements in
pregnant women.
6. Students are able to explain about USG.
7. Students are able to explain the anatomy of the pelvis and the
size of the baby's head.
8. Students are able to explain about ANC.
9. Students are able to explain the physiology of the puerperium.
 FERTILIZATION,
IMPLANTATION AND
FETAL DEVELOPMENT
 LEARNING OBJECTIVE
Discuss the process of pregnancy
Fertilization
Nidation
 Parts of the nidation
FERTILIZATION

FERTILISASI
 FERTILIZATION

 Is the process of joining  Most common in

spermatozoa and ovum ampula tube pars.
cells.
 SPERM AND OVUM
Sperma
 Meiosis 1 and 2 in the
seminiferous tubules.
 "Mature" in the epididymis
but has not been able to
fertilize the ovum as it is
inhibited by the substance
of the inhibitor released
by the genital duct
epithelium.
Ovum
 The first maturation
(meiosis 1) in the ovaries
in the form of secondary
oocytes  ovulation.
 The second maturation
(meiosis 2) occurs when
the sperm fertilizes the
ovum.
OOGENESIS
 SPERMATOZOA CAPACIT Y
 Is a series of spermatozoa
processes in the female
reproductive tract that
activate spermatozoa so that
it can perform fertilization.
 Occurs when spermatozoa
contact with female
reproductive tract fluid.
 Process sequence:
 Cleaning of the substance of
the inhibitor by the uterine
fluid and fallopian tubes.
 The reduction of cholesterol
that covers the acrosome
while traveling from the
vagina to the uterus.
 Sperm membrane becomes
more permeable to Ca ion
 Increased movement of
flagellum.
 Changing the cell
membrane that covers the
acrosome  More easily
removing enzymes and
penetrating ova
 FERTILIZATION
 Acrosome contains:
 Enzyme hyaluronidase
 Enzyme proteolitik
 Sperm secretes a
hyaluronidase enzyme 
Granulosa cells (corona
radiata) open.
 The anterior sperm membrane
is bound to the zona pellucida
protein receptor  All parts of
the dissolved acrosome and all
enzymes are released 
Sperm penetration into the
pellusid zone toward vitellus.
 Penetration of sperm causes:
 Secondary oocyte has
second maturation 
Pronucleus (haploid) &
polar body
 Oocytes release cortical
granules into the
perivitelina space  Closes
the pellucida zone and
prevents subsequent sperm
penetration.
 Spermatozoa lose the nuclear
membrane, leaving only
pronucleus (haploid).
 Pronucleus ovum unites with
pronucleus spermatozoa 
zygot (diploid)
FERTILIZATION PROCESS
FERTILIZATION PROCESS
 DEVELOPMENTS AND TRAVEL ZYGOTES

 Within hours, the

zygote splits.
 In 3 days, a group of
cells of the same size
is called a morula.
 Up to the uterine
cavity, in the form of
blastula (blastocyst).
 Blastula (Blastocyst) :
 Trofoblast (Outer layer)
 Inner cell mass (Spots of
embryonic seeds /
nodes)
 Exoselect cavity
 DEVELOPMENTS AND TRAVEL ZYGOTES

 The zygote is driven from

ampulla to pars ismika and
tubal interstitial pars to the
uterine cavity by ciliary
vibrations and tubal
contractions.
 In the first 3 days of
fertilization, tubal tube pars
are spastic.
 The ef fect of progesterone
 Pars ismika becomes
relaxed and easy to pass
morula.
 Morula turns into a blastula
and is embedded in the
endometrium  Nidation
NIDATION
 NIDATION

 Is the blastocyst  The blastula with the

embedded in the inner cell mass passes
endometrium. into the decidual layer,
 Location of nidation: and the wound in the
front or back of the decidua then closes
uterus near the uterine again  Hartman’s sign.
fundus.
 The smaller cells that
make up the blastula wall
will become trophoblasts.
 The trophoblast destroys
and dilutes the
endometrial tissue during
secretion with decidual
cells.
 NIDATION
 After the nidation, the
blastula begins to
dif ferentiate.
 Smaller cells, near the
exoselect form :
 Entoderm  intestine,
respiratory tract, bladder, liver.
 Yolk sac  intestinal tract
 The larger cell becomes :
 Ektoderm  Skin, hair, nails,
teeth, nervous system.
 Amnion Room  Where the
embryo grows
 Another layer of cells
entering between the
ectoderm layer and the
entoderm is called the
mesoderm  M us c l e, bo n e ,
c o n n e c t ive t i s su e , h e a r t & b l o o d
v e sse ls, l y m p h.
 The area between the
amnion chamber and the
yolk sac is called the
embryonal plate.
 Mesodermal fibroblasts
cells grow around the
embryo and coat the inner
side of the trophoblast 
chorionic membrane 
Chorion
 ENDOMETRIAL CHANGES

 Endometrium that changes due to the influence of pregnancy

is called the decidua.
 Decidua is divided into three layers :
 Stratum compactum  Where the egg is embedded
 Stratum spongiosum  Rich glands and blood vessels
 Stratum basale  do not change
 ENDOMETRIAL CHANGES

 With the enlargement

of eggs, the decidua
is divided into two:
 Desidua basalis  is
between the egg and the
uterine wall
 Desidua kapsularis 
There is between the egg
and the uterine cavity
 Decidua that is not
divided by egg cells :
desidua vera.
 KORION

 Korion consists of 2
layers :
 Sitotrofoblas  Inner
layers associated with
mesoderm and clear
boundaries. Consists of
mononucleous cells.
 Sinsisiotrofoblas  The
outer layer associated
with the decidua. It
consists of uncompleted
nuclei without cells.
 KORION

 Korion secretes
enzymes that dilute
decidual cells and
destroy blood vessels.
 Korion issued a branch
(villi) to the decidua :
 Korion laeve  Grow into
the decidua capsularis.
 Korion frondosum 
Grow into the decidua
basalis.
 EMBRYONIC GROWTH

 Embryonic growth occurs from the embryonal plate :

 Ektoderm
 Mesoderm
 Endoderm
 Amnionic space grows rapidly urging the exoseloma  Space
amnion approaching chorion.
 Mesoblast between amnion space and embryo becomes solid
called body stalk  The relationship between the embryo and
the trophoblast wall  Umbilical cord.
NORMAL DELIVERY
AND INFLUENCING
FACTORS
 LABOR
• Childbirth
• Uterine contractions
• Expulsion of the placenta.
• The process normally called labor
• Women with singleton cephalic presentations
at term had a spontaneous labor and deliver
• Characterized by brevity and considerable
biological variation.
 TRUE
CONTRACTION
Contractions occur at regular intervals.
Intervals gradually shorten.
Intensity gradually increases.
Discomfort is in the back and abdomen.
Cervix dilates.
Discomfort is not stopped by sedation.
 STAGE OF LABOR
Dilatation
Delivery
Placental
 FIRST STAGE OF LABOR :
DILATATION
Latent Phase.
 The onset of latent labor, as defined by Friedman
(1972), is the point at which the mother perceives
regular contractions.
 The latent phase for most women ends at between 3
and 5 cm of dilatation.
 Latent phase as being greater than
 20 hours in the nullipara and
14 hours in the multipara
Active Labor.
• Active labor can be reliably diagnosed when
Cervical dilatation is 3 cm or more in the presence of uterine
contractions.
 Once this cervical dilatation threshold is reached, normal
progress to delivery can be expected,
depending on parity, in the ensuing 4 to 6 hours.

• Anticipated progress during a 1- to 2-hour second stage is monitored to

ensure fetal safety.
Spontaneous labor

Most women in spontaneous labor, regardless

of parity and if left unaided, will deliver within
approximately 10 hours after admission for
spontaneous labor.
 Labor course divided functionally on the basis
of dilatation and descent curves into
(1)a preparatory division,
(2)a dilatational division,
(3)a pelvic division.
 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 .
 The second stage may become abnormally long  in
a woman with a contracted pelvis or a large fetus or
with impaired expulsive efforts from conduction
analgesia or sedation
 MECHANISM OF
LABOR
At the onset of labor, the position of the fetus
with respect to the birth canal is critical to the
route of delivery. It is thus of paramount
importance to know the fetal position within the
uterine cavity at the onset of labor.
 LIE, PRESENTATION, ATTITUDE, AND
POSITION
• Fetal Lie.
Longitudinal or transverse.
• Fetal Position.
• Fetal Presentation.
Position refers to the relationship of
Longitudinal lies an arbitrarily chosen portion of the
 cephalic and breech fetal presenting part to the right or
presentations left side of the maternal birth canal.
Long axis transversely, Accordingly, with each presentation
there may be two positions, right or
the shoulder left.
• Fetal Attitude or Posture.
In the later months
Described as attitude or habitus
 Longitudinal lie. Cephalic presentation. Dif ferences in
attitude of thefetal body in
 (A) vertex,
 (B) sinciput,
 (C) brow, and
 (D) face presentations.
 Longitudinal lie. Vertex presentation.
 A. Left occiput anterior (LOA)
 B. Left occiput posterior (LOP)
Longitudinal lie. Vertex presentation.
A. Right occiput posterior (ROP).
B. Right occiput transverse (ROT).
Longitudinal lie. Vertex
presentation.
 Right occiput anterior (ROA)
 CARDINAL MOVEMENTS
Engagement,
Descent,
Flexion,
Internal Rotation,
Extension,
External Rotation, and
Expulsion.
ENGAGEMENT.
The mechanism by which the biparietal diameter, the
greatest transverse diameter of the fetal head in
occiput presentations, passes through the pelvic inlet is
designated engagement.
ASYNCLITISM.
The sagittal suture frequently is deflected either
posteriorly toward the promontory or anteriorly toward
the symphysis . Such lateral deflection of the head to a
more anterior or posterior position in the pelvis is
called asynclitism.
DESCENT.
• This movement is the first requisite for birth of the newborn.
• In nulliparas, engagement may take place before the onset of
labor, and further descent may not follow until the onset of
the second stage.
• In multiparous women, descent usually begins with
engagement.
• Descent is brought about by one or more of four forces:
1) pressure of the amnionic fluid,
2) direct pressure of the fundus upon the breech with contractions,
3) bearing down efforts of maternal abdominal muscles, and
4) extension and straightening of the fetal body.
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.
• In this movement, the chin is brought into more
intimate contact with the fetal thorax, and the
appreciably shorter suboccipitobregmatic diameter is
substituted for the longer occipitofrontal diameter
INTERNAL ROTATION.
Internal rotation is essential for the completion of labor, except
when the fetus is unusually small.
EXTENSION.
After internal rotation, the sharply flexed head reaches the vulva
and undergoes extension.
EXTERNAL ROTATION.
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.
 PHYSICAL AND
PHYSIOLOGICAL
CHANGES IN
PREGNANT WOMEN
 ANATOMY CHANGES
 Cer vix and Perineum
- The cer vix begins to sof tening and cyanosis in result from increased
vascularity and edema of the entire cer vix, together with hyper trophy
and hyperplasia of the cer vical.
- Endocer vical mucosal cells produce copious tenacious mucus that
obstruct the cer vical canal soon af ter conception. This mucus is rich in
immunoglobulins and cytokines and may act as an immunological
barrier to protect the uterine contents against infection
glands
 Vagina
- Increased vascularity and hyperemia develop in the skin and muscles of
the perineum and vulva, with sof tening of the underlying abundant
connective tissue
- Increased vascularity prominently af fects the vagina and results in the
violet color
- Volume of cer vical secretions within the vagina increase, consists of a
somewhat thick , white discharge. The pH is acidic, var ying from 3.5 to
6. This results from increased production of lactic acid from glycogen
in the vaginal epithelium by the action of Lactobacillus acidophilus
 ANATOMY CHANGES
 S k i n a n d A b d o m i n al Wa l l
- S t r i a e gr av i d a r u m o r s t r et c h m a r ks d ev el o p i n t h e a b d o m i n al s ki n a nd s o m et i me s i n
the skin over the breasts and thighs.
- I n m ul t i p aro u s wo m e n , i n ad d i t i o n to t h e r ed d is h s t r i a e o f t h e p r e s e nt p r eg n an c y,
c i c a t r i ce s o f p r ev i o us s t r i a e f r e q u e n t l y a r e s e e n .
- L i n e a a l b a t a ke s o n d a r k b row n - b l ac k p i g me n t at i o n to fo r m t h e l i n e a n i g r a .
Oc c as i o n al l y, i r r e g ul ar b row ni s h p at c h e s o f v a r y i ng s i z e ap p e ar o n t h e f ac e an d
n ec k , g i v i ng r i se to c h l oa s m a o r a m e l a s m a g r av i d a r u m — t h e s o - c al l ed m a sk o f
p r e g n a n c y.
- A ng i o m a s ( va s c u l a r s p i d e r s ) P ar t i c ul ar l y c o m mo n o n t h e f ac e, n ec k , up p er c he s t ,
a n d ar m s , t h e s e a r e m i nute, r ed s ki n el ev at i o ns , w i t h r ad i c l es b r a nc hi ng o ut f ro m a
c e nt r al l e s i o n . T h i s c o nd i t i o n a r e o f no c l i ni c al s i g ni fi c a nc e a nd d i s ap p e ar i n m o s t
wo m e n s ho r t l y a f ter p r eg n an c y. T h ey ar e m o s t l i kel y t h e c o n s e qu e nc e o f
hy p e r e s t r o ge n e m i a .
 Breast
- I n t h e e a r l y w e e k s o f p r e g n a n c y, B r e a s t te n d e r n e s s a n d p a r e s t h e s i a s . A f te r t h e
second month, the breasts increase in size, The nipples become considerably
l a r g er, m o r e d e e p l y p i g m e n te d , a n d m o r e e r e c t i l e . A f te r t h e f i r s t f ew m o n t h s ,
c o l o s t r um c a n b e ex p r e s s e d f r o m t h e n i p p l e s b y g e n t l e m a s s a g e . D u r i n g t h e s a m e
m o n t h s , t h e a r e o l a e b e c o m e b r o a d e r a n d m o r e d e e p l y p i g m e n te d . S c a t te r e d
t h r o ug h t h e a r e o l a e a r e a n u m b e r o f s m a l l e l ev a t i o n s , t h e g l a n d s o f M o n t g o m e r y
 PHYSIOLOGY CHANGES
 METABOLIC CHANGES
a) Weigh gain  The average weight gain during
pregnancy is approximately 12.5 kg
b) Water metabolism  The minimum amount of
extra water accrues approximately 6.5 L (the water
content of the fetus, placenta, and amnionic fluid
approximates 3.5 L. Another 3.0 L accumulates
from increases in maternal blood volume and in the
size of the uterus and breasts)
 PHYSIOLOGY CHANGES

Metabolism - Total concentration of serum protein

Changes
Protein -
decreases by about 0,1g/dl during pregnancy
It is related to increased excretion and
utilization

- Average 3 – 4 kg of fat is stored during

Fat pregnancy mostly in abdominal wall,

breasts, hips, and thighs

- Insulin secretion increased

Carbohydrate -
-
Sensitivity of insulin receptor reduced
To ensure continuous supply of glucose
to fetus

- Nearly 1000 mEq of sodium and

Electrolyte & Mineral 300 mEq of potassium f are retained
(Lindheimer, 1987).
- Iodine requirements increase during
normal pregnancy for e several reasons
 PHYSIOLOGY CHANGES

Increase number of blood

cells
Blood Chemistry
Increased fibrinolytic activity
Iron deficiency and anemia

Increased CO and HR
Cardiovascular System
Increased SV

Displacement of diapraghm
supieriorly
Changes in Pregnancy Respiratory System Increased the risk of apnea
and dyspnea
Hyperventilation

Nausea and Vomiting

Gastrointestinal System
Heart burn and acidity

Mode and behavioural

changes
General Changes
Increased nutritional
demands
THE REGULATION OF
MEDICINES IN
PREGNANT WOMAN
A. THE CONCEPT OF DRUG DELIVERY
IN PREGNANCY
 Drastic changes:
Intestinal motility and increased blood plasma
volume  Decreased drug concentration, Increased
excretion of the kidneys
 This affects the effectiveness of drug doses
 Drugs given to pregnant women will be channeled
into the fetal blood circulation through the placenta
 Some drugs have negative / teratogenic effects on
the fetus
 Some birth defects in infants caused one of them
due to the use of drugs
FOOD DRUG ADMINISTRATION (FDA) 1979,
COMPILED A LIST OF DRUG USE
GUIDELINES FOR PREGNANT WOMEN
• Category A:
 Controlled studies do not show a risk to the
fetus in the first trimester of pregnancy. There is
no evidence of risk in the second and third
trimester. The likelihood of harm to the fetus is
very low.
• Category B:
 Study of animal experiments did not show any
risk to the fetus but no controlled study in
pregnant women showed any adverse effects .
There is no evidence of risk in the next trimester.
FOOD DRUG ADMINISTRATION (FDA) 1979,
COMPILED A LIST OF DRUG USE
GUIDELINES FOR PREGNANT WOMEN
• Category C:
 In animal experiments there are side effects on
the fetus (teratogenic). Drugs in this category
should only be given to pregnant women if the
benefits obtained are greater than the risk that
may occur in the fetus.
• Category D:
 The existence of evidence of risk to the human
fetus. This drug is only given when the benefits of
giving much greater than the risk that will happen.
(Life-threatening situation of pregnant women, in
which case other drugs can not be used /
ineffective).
FOOD DRUG ADMINISTRATION (FDA) 1979,
COMPILED A LIST OF DRUG USE
GUIDELINES FOR PREGNANT WOMEN

• Category X:
 Studies in experimental on human and
animals have demonstrated fetal
abnormalities or are shown to be at risk
for the fetus. The risk of drug use in
pregnant women is clearly greater than
the benefits gained. Drug category X is
contra indication for pregnant women
 CONCLUSION
The drug that can be used by pregnant
women is category A-C
Category D drugs should be vigilant and
need special attention
Drug category X is contraindicated
 DRUGS AFFECT THE FETUS IN
SEVERAL WAYS:
Directly causes damage to the fetus
The placenta becomes narrower, limiting the
exchange of oxygen and nutrients between the
fetus and the mother
The uterine muscle contracts thus reducing
blood flow to the fetus resulting in the
occurrence of preterm labor
THE PRINCIPLE OF USING DRUGS WHEN
PREGNANT
1. Consider treating the disease without taking
medication, especially in the first 3 months
of pregnancy.
2. Drugs are used when the benefits receives
are greater than the possible risks to the
fetus.
3. If you have to take medication, choose a
drug that has been widely used during
pregnancy.
THE PRINCIPLE OF USING DRUGS WHEN
PREGNANT
4. Avoid using polifarmasi drugs - swallowing
different types of drugs (4 or 5 types).
5. Find out whether the drug to be used safely
according to the category of treatment world.
 THE DIETARY
ARRENGEMENTS IN
PREGNANT WOMAN
 Changes that occur during pregnancy:
 1 . Physical changes
 2. Anatomical changes
 3. Biochemical changes

S O M E O F T H E E S S E N T I A L N U T R I E N T S N E E D E D BY
P R E G N A N T WO M E N I N C L U D E T H E S O U R C E S O F
C A LO R I E S ( C A R B O H Y D R AT E S A N D FAT S ) , P R OT E I N ,
FO L I C AC I D , V I TA M I N B 1 2 , I R O N , Z I N C , C A LC I U M ,
V I TA M I N C , V I TA M I N A , V I TA M I N D , V I TA M I N B 6 ,
V I TA M I N E . W H I L E N U T R I T I O N W H I C H I S N E E D E D FO R
T H E P E R S O N I N T H E WO M B I N C L U D I N G D H A ,
G A N G L I O S I DA ( G A ) , FO L I C AC I D , I RO N , E FA , F E A N D
CHOLINE.
 CARBOHYDRATE SOURCE
Energy requirements in the first trimester increase
minimally, then throughout the second and third
trimester energy needs continue to increase until
the end of pregnancy. Additional energy for the
second trimester is necessary for the expansion of
maternal tissue such as, the addition of blood
volume, uterine and breast growth, and fat
accumulation. During the third trimester additional
energy is used for growth of the fetus and placenta

265gr/day
Protein
Similar to energy, during pregnancy protein requirements also
increase, even up to 68% from before pregnancy
(+) 910-950 gr

Iron
Iron is needed for hemoglobin formation, whereas during
pregnancy blood volume will increase due to changes in the
mother's body and infant blood supply. Iron deficiency can cause
interference and resistance to fetal growth in both body cells and
brain cells, fetal death in the uterus, abortion, congenital defects,
low birth weight and anemia in infants.
(+) 20-26 mg / day
Vitamin C
Vitamin C is an antioxidant that protects tissue from
damage and is needed to form collagen and deliver
chemical signals in the brain. Daily pregnant women are
advised to consume 85 mg of vitamin C per day. Can
easily get vitamin C from foods such as tomatoes,
oranges, strawberries, guava and broccoli. Foods rich in
vitamin C also helps the absorption of iron in the body.
Vitamin A
Vitamin A plays an important role in body function,
including vision function, immunity, and embryo
development and growth. Vitamin A deficiency can lead to
premature birth and low birth weight babies.
USG
 A. DEFINITION
USG is an application of medical with
ultrasound-based imaging diagnostic
technique used to visualize internal
organs, the size, structure, and
pathological lessions.
 B. STRENGTHS AND
WEAKNESS
Strengths of ultrasound imaging :
-It images muscle and soft tissue very well.
-It shows the structure as well as some
aspects of the function of organ
-Equipment is widely available and
comparatively flexible; examinations can be
performed at the bedside
 Weakness of ultrasound imaging :
- Ultrasound can penetrate bone and
performs poorly when there is air between
the scanner and the organ of interest.
- Even in the absence of bone or air
- The method is operator-dependent
 C. MODE OF USG

A-mode : This display mode is the simplest;

signals are recorded as spikes on a graph.
B-mode (gray scale): this mode is most often
used in diagnostic imaging; signals are
displayed as a 2- dimensional anatomic
image.
M-mode : This mode is used to image moving
structures.
Doppler : this type of USG is used to assess
blood flow .
 D. USG EXAMINATION
TECHNIQUE
Transabdominal USG
Have two transducers, convex and linear
type. But the convex mostly used in the usg
examination. Because this type has a wide
field view. Worked on second and third
trimester of pregnance.
Transvaginal USG
Worked in the first trimester of pregnance.
the bladder is empty so that the pelvic
organs are close to the transducer surface
and inside the transducer penetration area
 E. STANDARD OF USG
EXAMINATION
 Trimester I
Ensure intrauterine pregnancy, gestational age,
mudigah heartbeat, evaluation of pregnance
complication, determination of multiple
pregnancies, ectopic pregnancy, detection of
pelvic tumor, CRL, GS, yolk sac.
- Trimester II – III
Life signs, numbers, presentations, and
activities of fetal movement, weight of fetus,
examination of amniotic fluid volume,
placenta, anatomy of fetus, evaluation of
congenital anomalies, mother anatomy
(servic, adneksa).
 F. INTERPRETATION OF USG
EXAMINATION
Intrauterine pregnancy, activity of fetus
Detection of congenital anomalies (exist,
normal, or no)
Sex of fetus; male or female
Fetal biometry; normal at the appropriate
gestational age or not
The condition of placenta and adequacy of
amnion fluid.
Etc
ANATOMY OF PELVIC
AND SIZE OF BABY’S
HEAD
ANATOMY OF PELVIC
TYPE OF PELVIC
FETAL SKULL
FONTANEL
DIAMETERS OF SKULL
 PELVIC INLET
Symphysis pubis -> Pubic crest -> Pubic tubercle -> Upper
border of pubie ramus -> Ilio-peetineal eminence -> Ilio-
pectineal line -> Sacroiliac joint -> Ala of sacrum -> Sacral
promontory
ANTEROPOSTERIOR
PELVIC AXIS
 PELVIC FASCIA
 between the vagina
and rectum -->
rectovaginal fascia
 it composed of (2
levator ani and 2
coccygeal muscles)
and the supporting
fascia (superior
andinferior pelvic
fascia)
 PELVIC DIAPHRAGM
 laterally -> the two peritoneal folds form the broad ligament
 it is divided into 2 part:
1 . parietal fascia : covers the muscles of pelvis
2. visceral fascia : endopelvic fascia, pelvic cellular CT
M. LEVATOR ANI
ANC
 WHAT IS ANTENATAL CARE?
 Antenatal care is the care you receive from
healthcare professionals during your pregnancy.
You'll be offered a series of appointments with a
midwife, or sometimes with a doctor who specialises
in pregnancy and birth (an obstetrician).
 They will check that you and your baby are well, give
you useful information to help you have a healthy
pregnancy (including healthy eating and exercise
advice) and answer any questions you may have.
 ANTENATAL APPOINTMENTS

 If you're expecting your first child, you'll have up to 10

antenatal appointments. If you've had a baby before,
you'll have around seven antenatal appointments. Under
certain circumstances, for example if you develop a
medical condition, you may have more.
 Early in your pregnancy, your midwife or doctor will give
you written information about how many appointments
you're likely to have and when they'll happen. You should
have a chance to discuss the schedule with them. If you
can't keep an antenatal appointment, let the clinic or
midwife know and make another appointment.
 FIRST VISIT
 Your first visit with your midwife or GP is the appointment when
you tell them that you're pregnant. At this first visit, you will be
given information about:
 folic acid and vitamin D supplements
 nutrition, diet and food hygiene
 lifestyle factors that may affect your health or the health of your
baby, such as smoking, recreational drug use and drinking
alcohol
 antenatal screening tests, including screening for sickle cell
disease and thalassaemia, infectious diseases and screening for
Down's syndrome. You should be offered screening for sickle cell
disease and thalassaemia before 10 weeks. This is so you and
your partner can find out about all your options and make an
informed decision if your baby is at risk of inheriting one of
these conditions.
 ANAMNESIS
 The midwife or doctor might ask about:
1. The date of the first day of your last period
2. Your health
3. Any previous illnesses and operations
4. Any previous pregnancies and miscarriages
5. Ethnic origins of you and your partner, to find out whether
your baby is at risk of certain inherited conditions, or other
relevant factors, such as whether your family has a history
of twins
6. Your job or your partner's job, and what kind of
accommodation you live in to see whether your
circumstances might af fect your pregnancy
7. How you're feeling and whether you've been feeling
depressed
 SECOND VISIT
 Your next appointment should happen when you are 8 -1 2 weeks
pregnant.It will last for up to two hour s.
 You'll see a midwife and sometimes a doctor. You may also be
of fered an ultrasound scan. You will be given information about:
 how the baby develops during pregnancy (see the pregnancy
development slideshow)
 nutrition and diet
 general exercise and pelvic floor exercises
 antenatal screening tests
 breastfeeding workshops
 planning your labour and where to have your baby
 The midwife or doctor will ask questions to build up a picture of you
and your pregnancy. This is to make sure you're given the suppor t
you need, and so that any risks are spotted early.
 Several antenatal screening tests are per formed on a sample of
your blood which is usually taken at your second visit.
 LATER ANTENATAL VISITS
 From around 24 weeks, your antenatal appointments will
usually become more frequent. However, if your pregnancy is
uncomplicated and you are in good health, you may not be
seen as often as someone who needs to be more closely
monitored.
 Later visits are usually quite short. Your midwife or doctor
will:
1. check your urine and blood pressure
2. feel your abdomen (tummy) to check the baby's position
3. measure your uterus (womb) to check your baby's growth
4. listen to your baby's heartbeat if you want them to
THE PHYSIOLOGY OF
THE PUERPERIUM
 WHAT IS PUERPERIUM?
Puerperium (Puerperium) is a period of
recovery, from complete copiness to
reproductive devices such as pre-pregnant.
This postpartum is 6-8 weeks
 CHILD BIRTH PERIOD
 Babies are divided into 3 periods, namely:
 1 . Early puerperium is a recovery where the mother has been
allowed to stand and walk. In Islamic religion, it is considered
clean and may work after 40 days.
 2. Puerperium is a thorough recovery of genetalia tools that
last 6-8 weeks.
 3. Remote puerperium is the time needed to recover and is
perfectly healthy especially if during pregnancy or labor time
has complications. Time to perfect can be weeks, monthly, or
yearly.
 PHYSIOLOGICAL CHANGES
 1 . Reproductive System
 A . Uterus
The uterus gradually (involution) returns just like before
pregnancy.
• Infants born fundus as high as the center with a weight of
1000 gr uterus.
• End of the third stage of high uterine fundus uteri 2 fingers
bottom center with a uterine weight of 750 gr.
• One week high uterine post uterine fundus uteri mid central
symphysis with a uterine weight of 500 gr.
• Two weeks post high uterine fundus uteri part is not palpable
above simpisis with a uterine weight of 350 gr.
• Six weeks post partum fundus uteri grows small with a 50 gr
uterus weight.
B. Lochia
Lochia is a secretory fluid from the uterine and vaginal cavities
during the puerperium.
Various Lochia:
 Lochia Rubra (Cruenta): Contains fresh blood and remnants of
amniotic membranes, decidual cells, vernix casease, lanugo, and
meconium, for 2 days post partum.
 Lochia Sanguinolenta: The yellow red color contains blood and
mucus, 3-7 days post partum.
 Lochia Serosa: Colored yellow, no more fluid, on 7 -14 post
partum days.
 Lochia Alba: White liquid, after 2 weeks.
 Lochia Purulenta: There was an infection, the discharge of a foul -
smelling pus.
 Lochiastasis: Lochia does not go well.
C. Cervix
 The cervix undergoes involution with the uterus. After delivery,
the external os is accessible by 2 to 3 fingers, after 6 weeks
of cervical labor closes.
D. Vulva and Vagina
 Vulva and vagina, the first day after delivery these two organs
remain in a sagging state. After 3 weeks back to the non -
pregnant state and rugae in the vagina will gradually reappear
while the labia becomes more prominent.
E. Perineum
 The perineum becomes sagging, on the post natal day 5,
Perineum has regained most of its tone even if it remains
slack from the state before delivery.
F. Breasts
Breast changes may include:
 Decrease in progesterone levels appropriately with an
increase in prolactin hormone after delivery.
 Colostrum is present at delivery. Breast milk production
occurs on day 2 or day 3 after delivery.
 Breasts become big and hard as a sign of the onset of the
lactation process.
2. Urinal System
Urination is often dif ficult during the first 24 hours. Large
amounts of urine will be produced within 12 -36 hours after
delivery. After the placenta is born, estrogen levels that are
resistant to water will experience a noticeable decrease. This
condition causes diuresis. The dilated Ureter will return to
normal within 6 weeks
3. Cardiovascular System
After striking diuresis due to decreased estrogen levels, blood
volume returns to a non-pregnant state. The number of red
blood cells and haemoglobin returned to normal on the 5th day.
The blood plasma is not so fluid and thus the coagulation power
increases. Blood clots should be prevented with careful
handling and an emphasis on early ambulance.
4. Gastrointestinal / Digestive System

Some women experience constipation during the puerperium,

due to the lack of fibrous food during the process of
persalinana and the fear of the mother because of the
perineum pain, especially if there is a perineal injury. Most
cases recover spontaneously, with early ambulation and by
eating fibrous foods. If not, a rectal suppositoria may be given
per rectal to soften the stool. Defakasi must occur within 3 days
post partum.