Labor

Definition
1. Inpartu
- Is a woman who was in a state of labor
(Sarwono, 2002)
- Labor that begins when the uterus to contract and cause changes in the cervix (opening and thinning)
(APN, October 2004)

   1. Labor
- It is a series of events that ended with infants spending enough or nearly enough month month, in accordance with the expenditure placenta and fetal membranes of the mother's body
(Sastrawinata, 1983)
- Is the process of spending the products of conception (fetus and uri), which had just months or can live outside of the relationship through the birth canal with the assistance or without assistance (Individual Strength).
(Manuaba, 1998)
Conclusion
Inpartu is a woman who was in a state of the uterus to contract during labor which will lead to changes in the cervix (thinning mendatardan)
Labor is a series of events spending the products of conception (fetus and uri), which had just months or can live outside the womb of tubuhibu through the birth canal or by other means with or without assistance


2.1.2 How delivery
a. Normal parturition (normal) is also called spontaneous parturition is the birth of a baby in the back where the mother's head with his own power, without the aid of tools, and not injure the mother and baby which generally lasts less dari24 hours
b. Extraordinary parturition (normal Ab) is a vaginal delivery with the aid of tools or through the abdominal wall with operasicaesar
(Mochtar Rustam, 1998)


2.1.3 Another term that has to do with parturition
a. According to the old (age) pregnancy
* Abortion (miscarriage) is the cessation of pregnancy before the fetus can live (viable), fetal weight below 1000 grams, pregnancy under 28 weeks old
* Partu prematurus is pesalinan of the conceptus at 28-36 weeks gestation, the fetus can be alive but premature, fetal weight between 1000-2500 grams
* Maturus or parturition at term, (quite a month) is parturition at 37-40 weeks of pregnancy / fetus is mature, weight above 2500 grams
* Maturus post parturition (serotinus) is labor that occurs two weeks or more of the estimated parturition time, called post mature fetus
* Parturition presipitatus is rapid parturition
* Parturition experiment is an assessment of the progress of labor to obtain evidence about the presence or absence of disroporsi sefatoedvik
b. According to the mode of delivery
* Normal parturition (normal) is also called spontaneous parturition, is the birth of a baby in breech position head with his own mother without the aid of power tools and do not injure the mother and baby are generally lasts less than 24 hours
* Parturition unusual (abnormal) is a vaginal delivery with the aid of tools or through the abdominal wall with the operation of Caesarea (Synopsis I, p. 91)
* Maternity recommendation is labor does not start by itself, but the new administration took place after the breakdown of membranes pitocin or prostaglandin


2.1.4 The causes that give rise to labor
How the birth is not known with certainty, giving rise to several theories related to the onset of his strengths, namely:

   1. Strain theory
- The muscles of the uterus has the ability to stretch to a certain extent
- After passing the contraction limit so that labor can begin

   1. Theory of progesterone decrease
- The process of aging placenta terjadimulai pregnant 28 weeks of age, where there is accumulation of connective tissue, blood vessels are narrowed and clogged
- The production of progesterone declines, so the muscles of the uterus is more sensitive to oxytocin
- As a result, the muscles begin to contract the uterus after a decline in progesterone levels reached a certain

   1. The theory of internal oxytocin
- Oxytocin is secreted in glands
- Changes in the balance of estrogen and progesterone can alter the sensitivity of the uterine muscle, so frequent Braxton Hicks contractions
- The decline in progesterone concentrations due to parents pregnancy, oxytocin can increase the activity, so that labor can begin

   1. Prostaglandins Theory
- The concentration of prostaglandins increases since the age of 15 weeks of pregnancy issued by the decidua
- Provision of prostaglandins during pregnancy can cause muscle contractions of the uterus so that the products of conception removed
- Prostaglandins considered to be a trigger of labor

   1. The theory of the hypothalamus - pluiriai and glands suprarenalis
- This theory suggests the pregnancy with frequent delays anenchepalus labor because it does not formed hypothalamus (Lingin, 1973)
- Malpar in 1933 raised the brain guinea pigs, rabbits pregnancy outcome lasts longer
- From the experiments it is concluded there is a relationship between the hypothalamus with the onset of labor pituarang
- Suprarenal glands is a trigger of labor


2.1.5 The signs of labor onset
Before the delivery is actually a few weeks before she entered the "month" or "wait" or "day" is called when the preliminary (preparatory stage of labor). The signs are as follows:

   1. Lightening or settling or dropping of the head down into the door or the pelvis, especially in primigravidae
   2. Appear dilated stomach, fundus down
   3. Feelings frequent or difficult urination (kisuma pattern) because the bladder is located by the lowest part of the fetus
   4. stomach pain to the waist by the presence of weak contractions of the uterus, sometimes called "phase labors paints"
   5. Cervix becomes soft, start flat and secretion can increase blood bercampura (bloody show)
(Synopsisi I, Page 93)


2.1.6 Tand-tand Inpartu
1. By the presence of his pain is coming more frequently and regularly
2. Out mucus mixed with blood (show) more as a small tear in the cervix
3. Sometimes the membranes rupture on its own
4. On examination of the cervix and the opening of the existing landscape


2.2 Mechanism of Labor
2.2.1 When Childbirth
The delivery process consists of 4 times, namely:

   1. First stage
Starting from the onset of uterine contractions and the opening servixs until it reaches the full opening (10 cm)

   1. Kala II
Starting from the full opening (10 cm) and ends with the birth of baby

   1. The third stage
Started after the birth of the baby and ends with the birth of the placenta and amniotic membranes

   1. Kala IV
Starting from the placenta after birth until the first 1-2 hours post partum


2.2.2 Physiology of Childbirth
1. Opening Kala (Kala I)
When the opening is divided into two phases, namely:
a. The active phase
In this phase of the opening takes place slowly, starting 0-3 cm lasts 7-8 hours
b. Active Phase
In this phase of rapid opening, began opening 40-10 cm, which lasted 6 hours, divided into 3 sub-phases:
- The period of acceleration: lasted 2 hours, opening 3-4 cm
- The period of maximal dilatation: lasted 2 hours, the opening takes place rapidly into 9 cm
- Period decelarasi lasted 2 hours, slow opening to 10 cm / complete
Phases mentioned above are found in primigravidae.
The difference with multigravida is:
- Cervix Landscape (effocement) first, dilatation
- Lasts 13-14 hours
Multi:
- Horizontal and could open the bersamaa
- Lasts 6-7 hours


Changes In Kala I
a. Changes in state of the upper segment and lower uterine segment:
In labor differences between upper uterine segment and lower uterine segment more clearly visible:

   1. Segment on hold due to contract actively and walls grew thicker with the progress of labor
   2. Conversely lower uterine segment and the more passive role with the progress of labor due to thin stretchable (Physiological Obstetrics, p. 227)
b. Changes in shape of the uterus
At each contraction of the long axis of the uterus, while increasing the length of the transverse size and the size of the rear face is reduced
c. Changes in physiology round ligament
Round ligament contain smooth muscle-ototo ototo and if the uterus to contract the muscles to contract up to go round ligament round ligament into short
d. Changes in the leveling of the cervix
Leveling especially apparent at the lower portion shorter and eventually razed to the progress of labor and a short cervix (more than half have been evenly distributed) is a sign of a mature cervix.
e. The opening of the cervix
is the opening of the cervix is ​​the enlargement of the ostium externum which had the form of a hole with a diameter a few millimeters into the hole that can be passed by the child is approximately 10 cm diamternya.
f. Changes in vaginal and pelvic floor
In the first stage, amniotic participate stretching of the vagina becomes stretched change increases, so the child can be passed
After the rupture of all the changes, especially in the pelvic floor caused by the front of the child
By the front of the advance, the pelvic floor is stretched into a channel with a thin wall
g. Changes in the anus
From the outside, stretching the perineum visible on the front of the stand out and become thinner while the anus into the open
2. When Expenditure Fetus (Kala II)
a. Decline in head
The fall in the head can be divided into

   1. The entry of the head in the pelvic
In primigravidae had occurred in the last month of pregnancy but in multigravid usually occurs at the beginning of labor
a. The entry of the head in the pelvic usually with transverse and sagittal suture with a mild flexion
b. If satura sagittal there in the middle of the birth canal, is right between symfisis and promontory, then said to the head in synclitismus
c. If the sagittal suture slightly ahead or slightly backward approach symfisis promontory close, then we face asynolitismus
- Asynclitismus Oisterior
If the sagittal suture close symfisis and parietal os os rear lower than front perietal
- Anterior Asynclistismus
If the sagittal suture so that the os parietale promontory near the front lower than rear os parietal

   1. Progress of Head
In primigravidae advanced head after head into the pelvic cavity and are usually just starting on the second stage. On the contrary multigravida masuknbya advanced head and head in the pelvic cavity occur simultaneously.
b. Flexion
With the rapid advancement of flexion of the head are usually also increased up to occiput, markedly lower than the crown of large, flexion is caused because the child gets pushed forward and reverse resistance of the upper edge of the door and got custody of the opposite side of the pelvic, cervical, wall pelvic or pelvic floor. As a result of this strength is due to the flexion moment causing flexion moment is greater than the deflection caused

   1. Round Paksi In
Playback from the front is such that the lowest part of the front of the next play down symfisis. Axis of rotation does not occur independently, but always in conjunction with advanced head and did not occur before the head to Hodge III, sometimes only after the head to the pelvis grounded.

   1. Extension / Fefleksi
Axis of the birth canal caused due to the lower door leading fore and upper pelvis. Extension so that the head should be held to get through. After the sub-occiput stuck on the edge of the perineum large crown, forehead, nose, mouth and chin with a movement finally extension.

   1. Round Out Paksi
Once the head is born, the child's head turned back towards the back of the child to eliminate the torque on the neck that occurs because putara axis in

   1. Expulsion
Once outside the front shoulder rotation axis to below symfisis and become hipomoclion for birth shoulders back. Then the front shoulder and then the whole body after child birth the direction of the axis of the birth canal.



   1. Expenditure Uri Kala (Kala III)
After the baby is born, contractions of the uterus a short break with a hard palpable uterine fundus as high as the center, and contains a thick placenta that previous 2x. A few moments later his release and expenditure arising uri. Within 5-10 minutes throughout the placenta detached, pushed into the vagina and will be born spontaneously or with a little encouragement from the top symfisis or fundus uteri.
The entire process usually lasts 50-30 minutes after birth. Removal of placenta is accompanied by extravasation of about 100-200 cc.
(Symfisis I, 1998, 97)



   1. Kala IV
Is when supervision for one hour after the baby is born and uri to observe the mother particularly to the danger of post partum hemorrhage.
(Symfisis I, 1998)
duration of labor in primigravidae and multi garavida


Primi mullite
When I 13 hours 7 minutes
Kala II 1 hour ½ hour
The third stage ¼ ½ hours hours
14 ½ hours of 7 ¾ hours


2.3 The course of Maternity In Clinical
2.3.1 When I
Labor on the first stage have long lead times that require patience parturien and helper. Mental patients need to be prepared quickly in order not to despair in waiting situations accompanied by abdominal pain because of his growing increasingly more robust.
Action needs to be done is:
1. Noting patience perturien
2. Perform blood pressure, pulse and respiration periodic temperature about 2-3 hours
3. Examination of the heart rate needle every ½ - 1 hour
4. Taking into account the circumstances of the bladder that is always empty
5. Noting the state of pathological
- Increase the circle bandl
- Membranes rupture before the time or with the fetus that menumbung
- Tactile fetal heart rate every half an hour
or
6. Expenditure on the location of the head of meconium
7. Pathological condition that his
8. Changes or decrease in the lowest position of the fetus
9. Parturien introduced straining


At the end of the first stage rupture can occur which may be accompanied by a desire to push marked anus began to open.
(Manuaba, 1998: 175)


2.3.2 Kala II
There are several signs and symptoms of second stage labor:
- Mom feel like meneran coincided with a contraction
- She felt the increasing pressure on the rectum and or vaginannya
- Perineum seen protruding
- The vulva and vagina and anus spingter visible open
- Increased spending lendiri and blood
- The opening of the cervix has been complete
- Seen the baby's head at the vaginal introitus
(APN, 2002)


for mengkooridnasikan all the resultant optimal activity at his and pushing can be done:

   1. Parturient asked to embrace her thighs, so as to increase the opening of the door under the pelvis
   2. Maternal body is curved, chin off chest so that the direction of force toward the birth canal
   3. And straining his bersamaa done, so the optimum strength
   4. When pushing the breath drawn, as far as possible be maintained thus helping boost the abdominal diaphragm toward the birth canal
   5. When the neck and his still ongoing, the breath can be issued and subsequently withdrawn for use push
   6. Observation
- DJJ each of his
- Circumference bandl
- Decrease in the lowest parts of the fetus
- The possibility of prolapse of the fetal
(Manuaba, 176)


Dipuncak his, a small part of the head appears in the vulva, but disappeared again when his stalled. In the next part of his head that look bigger, but difficult to return if his stop.
This event is called the head opens the door
Reflux head forward and continue, until the largest circle of the head terpegang vulva, so it can not back out of it, at the time bony crown had been born and exist under sub ocaput symfisis, these events are called head out the door.
After birth he fell down and then going round the outside axis, so that the head transverse vulva is now pressing on the neck and chest so depressed by the birth of the child's nose, out the mucus and fluid.
On his shoulder the next birth, shoulders back first then front shoulder, followed by the whole body of children with lateral flexion, according to the axis of the birth canal.
(Obs. Physiology, p. 261-262)


2.3.3 Kala III
After the birth of the baby, uterine muscle (myometrium) to contract following the reduction in the size of the cavity of a sudden. Depreciation is the size of the uterine cavity suddenly cause a reduction in the size of the implantation of the placenta, while the size of the placenta has not changed, then it will suppress plaseenta thicken, then removed from the uterine wall.


Signs of the release of the placenta:

   1. Changes in shape and height of fundus
Uterus full round (discoid) and fundal height generally decreased to below the center. When the uterus to contract and the placenta is pushed down, the moon and the fundus of the uterus above the center (often leading to the right side).

   1. Umbilical cord looks out lengthwise
   2. Sudden bursts of blood
Indicates that the blood is collected between the surface attachment of the placenta and maternal placenta (blood retroplasenter), out through the edge of the placenta is detached.


Active management of Kala III
Advantages of active management third stage:

   1. The third stage of labor is shorter
   2. Reducing the amount of blood loss
   3. Reduce the incidence of retained placenta
Three main rare active management third stage:

   1. Giving an injection of oxytocin
* Put a clean cloth over the mother's abdomen and uterus check to ensure no other babies
* Inform the mother that he would be injected
No later than within 2 minutes after the baby is born, immediately injecting oxytocin 10 unti 1M in 1 / 3 the outer right thigh

   1. Perform controlled cord tension
* One hand is placed just above the corpus uteri symfisis pubis
* Other hand holds the cord near the vagina and do the pull cord is continuous in the same voltage as the contraction
* Once the placenta is detached, remove it from the birth canal by moving the hand / clamp on the umbilical cord straight and upwards towards the bottom
* After the placenta is visible divagina, we catch the placenta and slowly rotate it clockwise to remove membranes
3. Massage fundus
* Gently but firmly, move the hand is turned on so that the fundus of the uterus to contract
* Check the uterus after one to two minutes to ensure that the uterus to contract properly, if the uterus is still contracting, repeat massage fundus
* Check for uterine contractions every 15 minutes during the first 1 hour and every 30 minutes for 1 hour the second postpartum
Various kinds of release of placental
1. In schultzel
The release starts from the central part of the placenta, the placenta is visible in the vulva is the fetal. No bleeding before the placenta is born.
2. In Duncan
The release starts from the central part of the placenta, the placenta is born with the edges first, which seems divulva is part of maternal hemorrhage has been there since a portion of the placenta detached.


Maneuver to determine the release of placental

   1. Kustner
By putting pressure on the hand with / above symfisis, umbilical cord tightened, then when the umbilical cord is not yet to get off, silent or forward / increased length means it's off
(Symfisis, 107-108)


2.3.4 Kala IV
Especially close observation, because of the danger of primary post partum hemorrhage occurred in the first 2 hours. Do not be left alone if parturien farthest place, so that bleeding can be known immediately.
Observations made

   1. Awareness of the patient
   2. Exam is performed:
- Blood pressure, pulse, respiration and temperature
- The contraction of the uterus is hard
- Bleeding that may occur in placental rest, episiotimi wounds, injury to the cervix
- The bladder is emptied because it may interfere with uterine contractions
(Manuaba, 184-185)


2.4 The factors that play a role in labor
a. Power
1. His (muscle contractions of the uterus)
* When pregnant
Its overall irregular, painless contractions called baraktonhiks
* When I
Contractions are symmetrical
Dominant fundus
Involuntary (not adjustable by the patient)
Increasingly shorter interval
Its power is a big time followed by retraction
Cause pain in the waist, stomach area and spread towards the thighs
* Kala II
His very strong, regular, symmetrical, coordinated and long reflection occurs because the head of a boy pushing pressing cervix where there fleksus Franken Hauser
* Kala III
After a break of about 8-10 minutes uterine contractions to release the placenta from incersinya dilapisan hitabusch
* Kala IV
Contractions are strong and thrombus formation occurs post partum cessation of extravasation
Can be strengthened by giving uterotonic drugs while breastfeeding, the baby can increase spending contraction since oxytocin by the posterior pituitary gland
(Manuaba, 162-163)
2. Pushing power
Straining power can only succeed if the opening of the lower portion is complete and effective Palling during uterine contractions
b. Passager (fetal factors)
In the delivery of the factors that inhibit a fetus is a measure of head shape abnormalities, abnormalities of the location and status of child disorders
c. Passage (factor of the birth canal)
What matters is the framework of the pelvis, hip room, the door of the pelvis, axis, size and type of pelvic
d. Psychic Woman
Mother's emotional state, his inner atmosphere, there was conflict or do not want kids
e. Helper
Your doctor or midwife who helped persalinann with the knowledge and skills and arts that is owned


2.5 Physical and psychological need for the mother at childbirth
Dear mother's care during labor include:
1) Emotional Support
Support and encourage husbands and other family to accompany selamapersalinan and birth mothers. Encourage them to play an active role in supporting and recognizing the steps that would have greatly helped comfort the mother. Appreciating the mother to be accompanied by a special friend or relative. In cooperation with family members to:
- Saying the words of encouragement and praise to the mother
- Helping the mother at the time of contraction bernafasn
- Massaging the back, legs or head of the mother and other beneficial actions
- Wiping the mother's face gently, using a cloth moistened with warm water or cold
- Creating a family atmosphere and sense of security
2) Set Position
Encourage the mother to try to comfortable positions during labor and birth. Mother may walk or stand, sit or squat and crawl onto his side. Upright position such as walking, standing or squatting can help decrease your baby's head and often shorten delivery time, do not make the mother in the supine position, because the weight of the uterus and its contents will suppress the inferior vena cava. This causes hypoxia in the fetus and the slow progress of labor
3) Giving fluids and nutrients
Advise the mother to receive fluid and nutrition intake during labor and childbirth. Encourage family members to offer mothers drink and snacks as often as possible during labor
- Prevent dehydration
- Provide power
If dehydration can slow down the contractions and make his or her njadi less tertur
4) Cleanliness
The birth canal (vulva) which allows moisture to breed microorganisms, which can cause infection and can result in death / morbidity in the mother and baby mother should shower / bath and using clean clothes at the time of delivery
Helper delivery should wash hands frequently and use a tool that has been disinfected or sterile
5) Dispose of clean water
Before the birth mother as much as possible SECTION first. Ractum who never gave any discomfort during labor, for mothers who have difficulty with the BAB can dibatnu with klisma. Avoid klisma in women who are in advanced stages of labor (membranes have ruptured, bleeding, suffering from hypertension)
6) Urinate
Birth mother should urinate at least every 2 hours or instead maybe more often. A full bladder will prevent the baby falling bottom of the pelvis and provide a sense of discomfort for the mother.