Puerperal Period

Period Definition Ruling

1. Puerperal period is the period beginning a few hours after the birth of the placenta to 6 weeks after delivery (Pusdiknakes, 2003:003).
2. Puerperal period begins after the birth of the placenta and ends when the means of returning the content of such a state before pregnancy that lasted about 6 weeks. (Abdul Bari, 2000:122).
3. Puerperal period is a period during labor and immediately after birth, including the following weeks at the time of the reproductive tract return to normal non-pregnant state. (F. Gary Cunningham, Mac Donald, 1995:281).
4. Puerperal period is the period after a mother gave birth to a baby who is used to recuperate back that generally takes 6-12 weeks. (Abraham C, 1998).

Ruling Period Objectives
The purpose of the provision of care during childbirth to:

1. Maintaining the health of mother and baby, both physically and psychologically.
2. Skrinning implement a comprehensive, early detection, treat or refer the case of complications in the mother and baby.
3. Provide health education regarding self care, nutrition, family planning, means and benefits of breastfeeding, immunization and infant care everyday.
4. Providing family planning services.
5. Getting emotional health.

Roles and Responsibilities of the Midwife In Ruling Period
Midwives have a vital role in providing postpartum care. The roles and responsibilities during childbirth include:

1. Provide continuous support during childbirth in accordance with the needs of mothers to reduce the physical and psychological strain during childbirth.
2. As a promoter of the relationship between mother and baby and family.
3. Encouraging mothers to breastfeed their babies by increasing the sense of comfort.
4. Making policy, health program planners regarding the mother and child and is able to perform administrative activities.
5. Detecting complications and the need for referral.
6. Provide counseling to mothers and families about how to prevent bleeding, recognize the signs of danger, maintaining good nutrition, and practice safe hygiene.
7. Doing care management by collecting data, establishing a diagnosis and plan of action and implement it to speed up the recovery process, preventing complications by meeting the needs of mothers and babies during childbirth period.
8. Provide care in a professional manner.

Ruling Period Stages
Puerperal period is divided into three stages, namely:
   1. Early Puerperium
      A recovery period where the mother is allowed to stand and walk.
   2. Puerperium intermedial
      A time when recovery from the reproductive organs for approximately six weeks.
   3. Remote puerperium

The time required to recover and return in the development of state of perfect health, especially the mother if the mother during pregnancy or during labor and delivery complications.

Involution Content Tools

1. The uterus gradually becomes small (involution) and eventually returned as before pregnancy.

Involution	Uterine Fundus Height	Uterus Weight
Babies born	High center	1000 grams
Uri was born	2  finger down the center	750 grams
1 week	Center mid symphysis	500 grams
2  week	No palpable above the symphysis	350 grams
6  week	Burn down	50 grams
8  week	Normal registration	30 grams

2. Former implantation uri: placental bed decreases due to contraction and protruding into the uterine cavity with a diameter of 7.5 cm, after 2 weeks to 3.5 cm, 2.4 cm in the sixth week, and eventually recovered.
3. The wounds in the birth canal if not accompanied by infection will heal in 6-7hari.
4. The pain, called after pain, (Merian or mules-mules) caused contractions of the uterus, usually lasts 2-4hari postpartum. Understanding needs to be given to the mother about this and if too disturbing to be given anti-sickness drugs and anti mules.
5. lochia is fluid secretions originating from uterine cavity and vagina during childbirth.
• Lochia rubra (cruenta): contains fresh blood and the remnants of the amniotic membranes, decidual cells, verniks kaseosa, lanugo, and meconium, during 2hari postpartum.
• Lochia sanguinolenta: yellow red of blood and mucus, 3-7 days postpartum.
• Lochia serosa: yellow, the liquid does not bleed anymore, at days 7-14 postpartum.
• Lochia alba: white liquid, after 2 weeks.
• Lochia purulenta: an infection, like pus discharge foul smelly
• Lochiostasis: lochia discharge is not smooth.  
6. Cervical: After childbirth, the cervix forms a funnel rather gaping like a red-black. Soft consistency, sometimes there are injury-minor injury. After the baby is born, his hand still bias into the uterine cavity; after 2hours to be passed by 2-3 fingers, and after 7 days can be passed only 1 finger.
7. ligament-ligament: ligament, fascia, and the pelvic diaphragm are stretched at the time of birth, after birth, gradually become shriveled and recover so that not infrequently the uterus falls back and becomes lax. After delivery, the habit of Indonesian women do "berkusuk" or "sequential", in which when dikusuk intra-abdominal pressure is getting higher. Because after childbirth ligaments, fascia, and supporting tissues become lax, if done kusu / candidacy, many women will "implies down" or "upside down". To revert back preferably with gymnastic exercises and post-delivery.

National Program Policy On Ruling Period
Policies and programs on post partum period is at least four times a visit during childbirth, with the aim to:

1. Assess the health condition of mother and baby.
2. Prevention of the possibilities of interference puerperal women and their babies.
3. Detect any complications or problems that occur during childbirth.
4. Dealing with complications or problems that arise and disrupt the puerperal women and their babies.

   Visit	Time	Upbringing
   I	6-8 hours post partum	Prevent bleeding during childbirth due to uterine atony.
   		Detection and treatment of other causes of bleeding and do a referral if bleeding continues.
   		Provide counseling to mothers and families about how to prevent bleeding due to uterine atony.
   		Breastfeeding early.
   		Teaches how to strengthen the relationship between mother and newborn.
   		Keeping your baby stay healthy through prevention hipotermi.
   		After the midwife doing childbirth aid, then the midwife must take care of mom and baby for the first 2 hours after birth or until the state of the mother and the newborn in good condition.
   II	6 days post partum	Ensuring barjalan with normal uterine involution, the uterus to contract properly, high fundus uteri under the umbilicus, there was no abnormal bleeding.
   		Assess any signs of fever, infection and bleeding.
   		Ensure mothers get adequate rest.
   		Ensuring the mother gets enough nutritious food and fluids.
   		Ensuring nursing mothers with a good and right and there are no signs of trouble breastfeeding.
   		Provide counseling about newborn care.
   III	2 weeks post partum	Care at 2 weeks post partum with the care given at 6 days post partum visit.
   IV	6 weeks post partum	Asking complications-complications experienced by the mother during childbirth.
   		Providing family planning counseling at an early stage.

Masa Nifas

Pengertian Masa Nifas

1. Masa nifas adalah masa dimulai beberapa jam sesudah lahirnya plasenta sampai 6 minggu setelah melahirkan (Pusdiknakes, 2003:003).
2. Masa nifas dimulai setelah kelahiran plasenta dan berakhir ketika alat-alat kandungan kembali seperti keadaan sebelum hamil yang berlangsung kira-kira 6 minggu. (Abdul Bari,2000:122).
3. Masa nifas merupakan masa selama persalinan dan segera setelah kelahiran yang meliputi minggu-minggu berikutnya pada waktu saluran reproduksi kembali ke keadaan tidak hamil yang normal. (F.Gary cunningham,Mac Donald,1995:281).
4. Masa nifas adalah masa setelah seorang ibu melahirkan bayi yang dipergunakan untuk memulihkan kesehatannya kembali yang umumnya memerlukan waktu 6- 12 minggu. ( Ibrahim C, 1998).

Tujuan Masa Nifas

Tujuan dari pemberian asuhan pada masa nifas untuk :

1. Menjaga kesehatan ibu dan bayinya, baik fisik maupun psikologis.
2. Melaksanakan skrinning secara komprehensif, deteksi dini, mengobati atau merujuk bila terjadi komplikasi pada ibu maupun bayi.
3. Memberikan pendidikan kesehatan tentang perawatan kesehatan diri, nutrisi, KB, cara dan manfaat menyusui, pemberian imunisasi serta perawatan bayi sehari-hari.
4. Memberikan pelayanan keluarga berencana.
5. Mendapatkan kesehatan emosi.

Peran dan Tanggung Jawab Bidan Pada Masa Nifas

Bidan memiliki peranan yang sangat penting dalam pemberian asuhan post partum. Adapun peran dan tanggung jawab dalam masa nifas antara lain :

1. Memberikan dukungan secara berkesinambungan selama masa nifas sesuai dengan kebutuhan ibu untuk mengurangi ketegangan fisik dan psikologis selama masa nifas.
2. Sebagai promotor hubungan antara ibu dan bayi serta keluarga.
3. Mendorong ibu untuk menyusui bayinya dengan meningkatkan rasa nyaman.
4. Membuat kebijakan, perencana program kesehatan yang berkaitan ibu dan anak dan mampu melakukan kegiatan administrasi.
5. Mendeteksi komplikasi dan perlunya rujukan.
6. Memberikan konseling untuk ibu dan keluarganya mengenai cara mencegah perdarahan, mengenali tanda-tanda bahaya, menjaga gizi yang baik, serta mempraktekkan kebersihan yang aman.
7. Melakukan manajemen asuhan dengan cara mengumpulkan data, menetapkan diagnosa dan rencana tindakan serta melaksanakannya untuk mempercepat proses pemulihan, mencegah komplikasi dengan memenuhi kebutuhan ibu dan bayi selama priode nifas.
8. Memberikan asuhan secara professional.

Tahapan Masa Nifas

Masa nifas terbagi menjadi tiga tahapan, yaitu :

1. Puerperium dini
   Suatu masa kepulihan dimana ibu diperbolehkan untuk berdiri dan berjalan-jalan.
2. Puerperium intermedial
   Suatu masa dimana kepulihan dari organ-organ reproduksi selama kurang lebih enam minggu.
3. Remote puerperium
   Waktu yang diperlukan untuk pulih dan sehat kembali dlam keadaan sempurna terutama ibu bila ibu selama hamil atau waktu persalinan mengalami komplikasi.

Involusi Alat-alat Kandungan

1. Uterus secara berangsur-angsur menjadi kecil (involusi) sehingga akhirnya kembali seperti sebelum hamil.  

Involusi	Tinggi Fundus Uterus	Berat Uterus
Bayi lahir	Setinggi pusat	1000 gram
Uri lahir	2 jari bawah pusat	750 gram
1 minggu	Pertengahan pusat simfisis	500 gram
2 minggu	Tidak teraba di atas simfisis	350 gram
6 minggu	Bertambah kecil	50 gram
8 minggu	Sebesar normal	30 gram

2. Bekas implantasi uri : placental bed mengecil karena kontraksi dan menonjol ke kavum uteri dengan diameter 7,5 cm, sesudah 2 minggu menjadi 3,5cm, pada minggu keenam 2,4cm, dan akhirnya pulih.
3. Luka-luka pada jalan lahir bila tidak disertai infeksi akan sembuh dalam 6-7hari.
4. Rasa sakit, yang disebut after pain, (merian atau mules-mules) disebabkan kontraksi rahim, biasanya berlangsung 2-4hari pasca persalinan. Perlu diberikan pengertian pada ibu mengenai hal ini dan bila terlalu mengganggu dapat diberikan obat-obat anti sakit dan anti mules.
5. lochia adalah cairan secret yang berasal dari kavum uteri dan vagina dalam masa nifas.

·        Lochia rubra (cruenta): berisi darah segar dan sisa-sisa selaput ketuban, sel-sel desidua, verniks kaseosa, lanugo, dan mekonium, selama 2hari pasca persalinan.

·        Lochia sanguinolenta: berwarna merah kuning berisi darah dan lender, hari ke 3-7 pasca persalinan.

·        Lochia serosa: berwarna kuning, cairan tidak berdarah lagi, pada hari ke 7-14 pasca persalinan.

·        Lochia alba: cairan putih, setelah 2 minggu.

·        Lochia purulenta: terjadi infeksi, keluar cairan seperti nanah bebau busuk

·        Lochiostasis: lochia tidak lancer keluarnya.

6. Serviks : Setelah persalinan, bentuk serviks agak menganga seperti corong berwarna merah kehitaman. Konsistensinya lunak, kadang-kadang terdapat perlukaan-perlukaan kecil. Setelah bayi lahir, tangan masih bias masuk rongga rahim; setelah 2jam dapat dilalui oleh 2-3 jari dan setelah 7 hari hanya dapat dilalui 1 jari.
7. ligament-ligamen: Ligamen, fasia, dan diafragma pelvis yang meregang pada waktu persalinan, setelah bayi lahir, secara berangsur-angsur menjadi ciut dan pulih kembali sehingga tidak jarang uterus jatuh ke belakang dan menjadi kendor. Setelah melahirkan, kebiasaan wanita Indonesia melakukan “berkusuk” atau “berurut”, di mana sewaktu dikusuk tekanan intra-abdomen bertambah tinggi. Karena setelah melahirkan ligamenta, fasia, dan jaringan penunjang menjadi kendor, jika dilakukan kusu/urut, banyak wanita akan “kandungannya turun” atau “ terbalik”. Untuk memulihkan kembali sebaiknya dengan latihan-latihan dan gimnastik pasca persalinan.

Kebijakan Program Nasional Pada Masa Nifas
Kebijakan program nasional pada masa nifas yaitu paling sedikit empat kali melakukan kunjungan pada masa nifas, dengan tujuan untuk :

1. Menilai kondisi kesehatan ibu dan bayi.
2. Melakukan pencegahan terhadap kemungkinan-kemungkinan adanya gangguan kesehatan ibu nifas dan bayinya.
3. Mendeteksi adanya komplikasi atau masalah yang terjadi pada masa nifas.
4. Menangani komplikasi atau masalah yang timbul dan mengganggu kesehatan ibu nifas maupun bayinya.

Asuhan yang diberikan sewaktu melakukan kunjungan masa nifas:

Kunjungan	Waktu	Asuhan
I	6-8 jam post partum	Mencegah perdarahan masa nifas oleh karena atonia uteri.
		Mendeteksi dan perawatan penyebab lain perdarahan serta melakukan rujukan bila perdarahan berlanjut.
		Memberikan konseling pada ibu dan keluarga tentang cara mencegah perdarahan yang disebabkan atonia uteri.
		Pemberian ASI awal.
		Mengajarkan cara mempererat hubungan antara ibu dan bayi baru lahir.
		Menjaga bayi tetap sehat melalui pencegahan hipotermi.
		Setelah bidan melakukan pertolongan persalinan, maka bidan harus menjaga ibu dan bayi untuk 2 jam pertama setelah kelahiran atau sampai keadaan ibu dan bayi baru lahir dalam keadaan baik.
II	6 hari post partum	Memastikan involusi uterus barjalan dengan normal, uterus berkontraksi dengan baik, tinggi fundus uteri di bawah umbilikus, tidak ada perdarahan abnormal.
		Menilai adanya tanda-tanda demam, infeksi dan perdarahan.
		Memastikan ibu mendapat istirahat yang cukup.
		Memastikan ibu mendapat makanan yang bergizi dan cukup cairan.
		Memastikan ibu menyusui dengan baik dan benar serta tidak ada tanda-tanda kesulitan menyusui.
		Memberikan konseling tentang perawatan bayi baru lahir.
III	2 minggu post partum	Asuhan pada 2 minggu post partum sama dengan asuhan yang diberikan pada kunjungan 6 hari post partum.
IV	6 minggu post partum	Menanyakan penyulit-penyulit yang dialami ibu selama masa nifas.
		Memberikan konseling KB secara dini.

Referensi
Saifudin, Abdul Bari Dkk, 2000, Buku Acuan Nasional Pelayanan Kesehatan Maternal dan Neonatal, Yayasan Bidan Pustaka Sarwono Prawirohardjo, Jakarta
Ambarwati, 2008. Asuhan Kebidanan Nifas. Yogyakarta: Mitra Cendikia.
borneo-ufi.blog.friendster.com/2008/07/konsep-nifas-eklamsi-forceps/ diunduh 1 September 2009: 20.00 WIB.
Ibrahim, Christin S, 1993, Perawatan Keebidanan (Perawatan Nifas), Bharata Niaga Media Jakarta
masanifas.blogspot.com/ diunduh 1 September 2009: 20.10 WIB.
Pusdiknakes, 2003. Asuhan Kebidanan Post Partum. Jakarta: Pusdiknakes.
Saleha, 2009. Asuhan Kebidanan Pada Masa Nifas. Jakarta: Salemba Medika.
Suherni, 2008. Perawatan Masa Nifas. Yogyakarta: Fitramaya.

Rustam Mochtar,1998. Sinopsis Obstetri. Jakarta: EGC

Menstruation

Menstruation (Greek Word, men - month) is monthly uterine bleeding outflowing through vagina onto vulva for 4-5 days every 28 days during reproductive life of a women from menarche to menopause. Menses are normal uterine function whereby endometrium prepares to receive pregnancy.

Bleeding comes from oestrogen progesterone primed endometrium. Woman gets 13 menses in a year and around 400 menses in her reproductive life.

The menstrual cycle of 28 days starts on day of onset of menstruation (day 1) and ends at day 28 on start of next mens.

Menstruation signals that fertilization and embedding of fertilised ovum have not occurred on the preceding menstual cycle. Anovular menstruation is cyclical monthly bleeding from only oestrogen primed endometrium. This occurs for a few years after onset of menstruation (menarche) and before final cessation of menstruation (menopause).

Normal menstruation

Clinical features

Menstruation is normal body function. Most women get only vaginal bleeding for 3 5 days with no discomfort. However around one quarter women get menstrual discomforts menstrual molimina. These discomforts do not interfere with usual day's activity. Only 5 10 percent develops during some part in their about 30 years menstrual life painful mens interfering day's activities (dysmenorrhoea). The menstrual molimina are as :
Symptoms

 

1.      Feeling of heaviness and discomfort in the pelvis, lower abdomen and in the small of the back.

2.      Feeling of pricking and fullness in the breasts.

3.      Frequency of urination and constipation.

4.      Feeling of lassitude, irritability, and headache. Above symptoms vary in severity from individual to individual.

Rarely, bleeding from nose may occur as vicarious menstruation' since blood viscosity falls at mens.

Signs

1.      Sudden drop in temperature of about 1 degree F but with individual variations. Pulse rate and blood pressure tend to drop.

2.      Gain in weight occurs during premenstrual fortnight upto about 1 Kg. due to retention of water and salt; it occurs in about half of women. There is loss of weight with the onset of flow.

3.      Menstrual loss (mens). The vaginal menstrual bleeding mainly arterial, partly venous is a dark reddish liquid (not clotted) blood with shed endometrial tissue bits. The discharge has disagreeable smell due to the secretion of vulvar sebaceous glands and decomposition of blood elements. Menstrual blood is deficient in prothrombin, and fibrinogen but rich in calcium. Microscopically, it contains red cells, large number of leucocytes, vaginal epithelium, cervical mucus, fragments of endometrium with macrophages, histiocytes, mast cells and bacteria, Menstrual discharge also contains cholesterol, oestrogen, lipids and prostaglandins. Menstrual blood from the endometrium clots in the uterine cavity by its thromboplastic property. The clots are dissolved by the fibrinolysins released from the endometrium. Fibrin degradation products therefore circulate in increased amount during menstruation. Clots are passed when mens¬trual bleeding becomes excessive.

Interval and Duration

The menstrual cycle lasts on an average twenty eight days. A deviation of 2 to 3 days can be frequently encountered. The extremes of 21 and 35 days interval may also be found. In any woman's menstrual life, the interval can vary. The usual duration is three to five days with essentially normal extremes of two and seven days. Every woman needs sex education in this normal range of menstrual pattern so that she does not suffer from miseducation on normal menstrual pattern taken as menstrual irregularity.

Blood Loss

The average total blood loss during menstruation has been estimated as 35 ml (range 5 60 ml); average loss of iron was found as 12 mg. A rough clinical estimate is that normally not more than three fresh pads are necessary in the twenty four hours two during the day and one at night, thus requiring total 12 15 pads during a rnens. This loss widely varies and becomes greater in women living in warm climate than those living in cold climate.

Management

Proper education on mens is important. She should be educated that menstruation is not the drainage of noxious substance from the body but a normal manifestation of womanhood. During menses, she should carry on her usual activities including daily bathing, playing games. Personal hygiene is maintained by changing regularly sanitary pads. Intravaginal tampons can be used by the married provided she does not forget to leave it behind. Healthy couple can have sexual intercourse during menses. Postponement or advancement of menstruation. This becomes at times necessary for important social reason like marriage. This is not to be advocated on flimsy ground. The hormone therapy employed is the following:

1.      Progesterone norethisterone one tab. thrice daily starting from 20th day of menstrual cycle till beyond the date of postponement.

2.      Oestrogen progestogen contraceptive pills, two a day is started from the 20th day. Menstrual flow is expected 2 to 3 days after the treatment is suspended. Menstruation can be pre¬maturely brought by starting hormone therapy from 5th day of mens for 14 days, The therapy is (a) Oestrogen ethinyl oestradiol 0.05 mg. t.d.s. or (b) Oestrogen progestogen oral pill once daily. Anovulax menstrual flow is likely to begin within 2 3 days of the cessation of therapy.

Endocrine mechanism of menstruation

Play of sex hormones from hypothalamus in brain, anterior pituitary gland, ovary causes menstrual bleeding from uterine endometrium.

This is called hypothalamus- pituitary-ovarian-uterine axis

Steps are-

1.      In the brain, hypothalamus acts as switch to endocrine mechanism of menstruation and starts the process by secreting gonadotrophin releasing hormone (GnRH) or (LHRH) by peptidergic neuron. The latter is controlled by aminergic neuron. Environment influences menstruation via cerebral cortex and hypothalamus.

            GnRH flows down from hypothalamus via pituitary portal vessels to

2.     Anterior pituitary gland (gonadotroph cells) liberating follicle stimulating Hormone (FSH) and Luteinising hormone (LH) in blood circulation to initiate growth of ovarian follicles in both ovaries.

Ovarian Cycle. Ovarian follicles (20 in number) are grown in a menstrual cycle in three steps.

1.      ovarian Follicles are grown from primordial follicles. A single graarian follicle matures and becomes dominant by effect of FSH while other follicles undergo atresia.

2.      Oestradiol is secreted by maturing ovarian follicle in the circulation ' stimulates hypothalamus and anterior pituitary to cause surge of LH and FSH hormones in blood (Positive feed back) on day 12 of menstrual cycle.

3.      Ovulation (discharge of ovum from ovary) occurs on day 14 of menstrual cycle. Corpus luteum (yellow body) is formed in the shell of mature graafian follicle ovulation due to LH effect.

Corpus luteum remains mature From day 19-26, degenerates on day 27 and 28 if no pregnancy occurs in menstrual cycle'. Plasma prolactin (from anterior pituitary) rises (luring luteal phase and appears to maintain corpus luteum. Copious progesterone hormone., some oestradiol and inhibin (peptide hormone) are secreted by corpus luteum. Oestradiol causes luteolysis while inhibin depresses FSH.

Uterine cycle

1.      Proliferative phase

Oestradiol from ovarian follicles causes proliferative changes in uterine endometrium (day 7-14). All the endometrial tissue elements of I mm thick proliferate. Prior to start of proliferative phase, repair phase. runs with mens bleeding and ends by 48 hours after mens.

2.      Secretory phase. Progesterone (from corpus luteum) causes secretary changes in endometrium (day 15 - 26 to receive fertilised ovum for embedding. Glycogen appears as subnuclear vacuoles in endometrial gland followed by secretion of glycogen and mucus on the lumen of gland. Glands become Corkscrew . Endometrial vessels become coiled, stroma becomes vascular and oedernatous. Endometrium thickens to 5 mm into three layer (a) superficial compact layer with neck ot'glands (b) spongy layer with dilated glands (c) basal layer in contact with myometrial layer.

Stage of regression occurs in secretory endometriurn on day 27 to 28.

3.      Menstrual bleeding phase occurs for 4 - 5 days after day 28 of the cycle due to shedding away of endometrial bits and bleeding from endometria I bed. Necrosis and shedding of endometrial bits extend from region to region during first 2 days of menses. Bleeding occurs as (a) capillary bleeding with or without the formation of subepithelial haematoma (b) venous haemorrhage and (c) diapedisis.

Menstrual phase is caused by withdrawal of oestradiol and progesterone support to endometrium.. FSH rises again to start another, cycle.

Cause of menstrual bleeding. 

Exact cause is still obscure. The sequence of events are :

Withdrawal of oestrogen and progesterone due to degeneration of corpus luteum 'rapid shrinkage and regression of secretory endometrium overcoiling of endometrial spiral arterioles ' stasis of circulation in the functional layer of endometrium ' necrobiosis of vessels. Prostaglandins elaborated by endometrium also cause vasospasm of spiral vessels ' ischaemic necrosis of bit of endometrium suppfied by spiral artery relaxation of spiral vessel bleeding from spiral vessel end. These vascular changes are described by Markee (1940)

In the shedding process clotting and fibrinolysis at bleeding site occur so that unclotted dark red blood with endometrial tissue bits are discharged for 4-5 days. Dating of endometrium. Endometrium is dated from its histological appearance particularly during secretory phase e.g. prenuclear vacuoles - 16th day, basal nuclei, secretion in gland lume - 20th day.

MENSTRUAL SILKUS CONSIST OF 4 PHASE:

1. Menstrual phase of the event entirely mature ovum is not fertilized simultaneously with endometrial wall is torn. Can diakbiatkan also because the cessation of secretion of hormones estrogen and progesterone hormones in the blood so that content becomes tidaka there.
2. Proliferation phase / follicular phase is characterized by declining hormone progesterone which stimulate the pituitary gland to secrete FSH and stimulate the follicles in the ovaries, and can make the hormone estrogen is produced again. Tues follicle de Graaf follicle developed into a mature and produce hormones that stimulate the release estrogern LH from the pituitary. Estrogen can inhibit FSH sekersei but can repair the torn walls of the endometrium.
3. Phase Ovulation / luteal phase characterized by secretion of LH which stimulate maturation of the ovum on the 14th day after menstruation 1. The mature ovum will leave the follicle and follicle aka shrank and turned into a corpus luteum. Corpus luteum function to produce the hormone progesterone which serves to strengthen the walls of the endometrium is rich in blood vessels.
4. Post-ovulatory phase / phase corpus luteum secretion is characterized by a shrink and disappear and turned into a corpus albicans which serves to inhibit the secretion of hormones estrogen and progesterone that active pituitary to secrete FSH and LH. With the cessation of the secretion of progesterone stops endometrial thickening of the wall causing endometrial dried and torn. Phase ensued bleeding / menstruation.