Transcript
Page 1: ASKEP PERSALINAN NORMAL.ppt

ASKEP PERSALINAN NORMALJuwitasari, S.Kep. Ns

Page 2: ASKEP PERSALINAN NORMAL.ppt

ESSENTIALS OF NURSING CARE: REPRODUCTIVE HEALTHNeeds of the Childbearing Family: Preconception

Page 3: ASKEP PERSALINAN NORMAL.ppt

PENGERTIAN PERSALINAN NORMAL

Adalah proses alamiah dimana terjadi pembukaan cervik serta pengeluaran janin dan plasenta dari tubuh ibu.

Suatu proses pengeluaran hasil konsepsi yang dapat hidup dari dalam uterus melalui vagina ke dunia luar (Sarwono, 1999).

Persalinan yang dimulai secara spontan, beresiko rendah pada awal persalinan da tetap demikian selama proses persalinan (WHO, 1998).

Page 4: ASKEP PERSALINAN NORMAL.ppt

PENGERTIAN PERSALINAN ANJURAN(INDUCTION OF LABOR) Persalinan yang hisnya/kontraksi

uterusnya muncul setelah dibantu dengan cara:- Pemecahan ketuban, mengurangi ketegangan otot rahim sehingga uterus kontraksi.- Pemberian prostaglandine/mesoprostol- Pemberian oksitosin drip- Merangsang pleksus frankenhauser dengan pemasangan laminaria di kanalis servikalis.

Page 5: ASKEP PERSALINAN NORMAL.ppt

PENGERTIAN PERSALINAN BUATAN(PARTUS ABNORMAL)

Proses kelahiran dengan bantuan alat, misalnya:

Vakum ekstraksi Forcep ekstraksi Dekapitasi SC

Page 6: ASKEP PERSALINAN NORMAL.ppt

PERSALINAN BERDASARKAN USIA KEHAMILAN

Persalinan post term/post date/serotinus adalah persalinan pada

usia kehamilan lebih dari 42 minggu.

Persalinan aterm/matur adalah persalinan pada usia kehamilan

37-42 minggu dengan BBL > 2.500 gr.

Persalinan prematur adalah persalinan pada usia kehamilan 28-

37 minggu atau BBL>1.000 gr-2.499 gr.

Persalinan immatur adalah persalinan pada usia kehamilan 22-

28 minggu atau BBL>500gr-999 gr.

Abortus adalah pengeluaran buah kehamilan <22mg atau BBL

< 500 gr.

Persalinan presipitatus merupakan persalinan yang berlangsung

cepat kurang dari 3 jam.

Page 7: ASKEP PERSALINAN NORMAL.ppt

FAKTOR-FAKTOR YANG MEMPENGARUHI PERSALINAN Power Passage (jalan lahir) Passanger Psikologis Penolong

Page 8: ASKEP PERSALINAN NORMAL.ppt

TANDA TANDA PERSALINAN

His makin cepat makin sering

Penipisan dan pembukaan servik sekurang-

sekurangnya 3 cm

Keluar lendir darah dari vagina (bloody

show)/kelur air secara tiba-tiba.

Page 9: ASKEP PERSALINAN NORMAL.ppt

HIS ADEKWAT

1. Bersifat teratur minimal 2x tiap 10 menit lamanya 40 detik kuat

2. Kuat, mengeras saat kontraksi sehingga tak ada cekungan lagi bila ditekan dengan ujung jari.

3. Servik membuka.

Page 10: ASKEP PERSALINAN NORMAL.ppt

ADAPTASI IBU DAN JANIN SELAMA PERSALINAN

Proses Persalinan: Kala I: Pembukaan 0-10 cm Kala II: Pengeluaran janin Kala III: Pengeluaran Plasenta Kala IV: 2 jam post partum

Page 11: ASKEP PERSALINAN NORMAL.ppt

KALA I (PEMBUKAAN CERVIK)

Fase Latent Fase Aktif:

- fase akselerasi (2 jam pembukaan servik 3cm-4cm)- fase dilatasi maksimal (dlm 2 jam pembukaan jadi 9 cm)- fase deselerasi (dlm 2 jam pembukaan 9-10 cm/lengkap)

Pada multigravida lebih 7 jam, primi gravida 14 jam.

Page 12: ASKEP PERSALINAN NORMAL.ppt

COUNSELING AND PLANNING FOR PARENTHOOD

Preconception care focuses on risk assessment and promoting healthy behaviors

Healthy well-informed women who plan pregnancy have better outcomes

Contraception is important aspect in planning process

Page 13: ASKEP PERSALINAN NORMAL.ppt

PRENATAL CARE To promote positive outcomes for both

mother & child Should begin prior to conception First prenatal visit

Typically scheduled between weeks 8-12 of gestation

Obtain health hx (first menarche, sexual & family hx’s, Gravida/Para)

Physical exam (vaginal exam, pap smear Confirm pregnancy Prenatal labs (blood type, Rh factor, rubella status,

Hep B status, STD, pap smear,

Page 14: ASKEP PERSALINAN NORMAL.ppt

TESTING (THE TRIPLE SCREEN)

Alpha-fetoprotein test Performed between week 16 – 18 Indicates neural tube defects and chromosomal

disorders High incidence of false positives If complication indicated amniocentesis is

recommended

Page 15: ASKEP PERSALINAN NORMAL.ppt

THE TRIPLE SCREEN (CONT’D) Gestational Diabetes Screening

Performed at week 28 Fasting glucose test If failed, glucose tolerance test If positive, dietary consult and/or diabetes educator

consult Instruct on proper diet How to monitor blood glucose levels (glucometer) If diet control unsuccessful, insulin injections may be

required

Page 16: ASKEP PERSALINAN NORMAL.ppt

THE TRIPLE SCREEN (CONT’D)

Group Beta Strep Bacteria detectionNot an uncommon findingRequires Abx upon rupture of membrane

or onset of active laborRecommended that one dose of Abx be

administered at least 4 hours prior to delivery to reduce risk of infant contracting group beta strep Can cause serious illness in infant but harmless

to mother

Page 17: ASKEP PERSALINAN NORMAL.ppt

FETAL ASSESSMENT DURING LABOR

Page 18: ASKEP PERSALINAN NORMAL.ppt

ASSESSMENT FOR GENETIC DISORDERS

Maternal age Ethnic background Family history Reproductive history Maternal disease Environmental hazards

Chapter 22

Page 19: ASKEP PERSALINAN NORMAL.ppt

BIOPHYSICAL PROFILE (BPP)

A noninvasive assessment of the fetus and its environment by U/S, noting normal and abnormal biophysical responses to stimuli.

A normal BPP indicates that the CNS is functional and the fetus is not hypoxemic.

A scoring system, of 5 variables, with a total score up to 10.

Page 20: ASKEP PERSALINAN NORMAL.ppt

BIOPHYSICAL PROFILE VARIABLES

Fetal breathing movements Gross body movement Fetal tone Amniotic fluid volume index Non-stress test

Chapter 22

Page 21: ASKEP PERSALINAN NORMAL.ppt

BPP: VARIABLES & SCORESFETAL BREATHING MOVEMENTS: >1 episode in 30 min, each > 30 seconds.

(normal score = 2) Episodes absent or no episode > 30 sec in 30

min. (abnormal = 0)GROSS BODY MOVEMENTS: >3 discrete body or limb movements in 30 min.

(normal = 2) < 3 episodes of body or limb movement in 30

min. (abnormal =0)

Page 22: ASKEP PERSALINAN NORMAL.ppt

FETAL TONE:> episodes of active extgension with return to flexion of fetal limb(s) or trunk, opening & closing hand being considered normal tone. (normal =2)

Slow extension with return to flexion, movement of limb in full extension, or fetal movement absent. (abnormal = 0)

Page 23: ASKEP PERSALINAN NORMAL.ppt

REACTIVE FETAL HEART RATE:> 2 episodes of acceleration (>15 bpm) in 20 min, each lasting > 15 sec. & associated with fetal movement. (normal = 2)

< 2 episodes of acdceleration or acceleration of < 15 bpm in 20 min. (abnormal = 0)

Page 24: ASKEP PERSALINAN NORMAL.ppt

QUALITATIVE AMNIOTIC FLUID VOLUME:

> 1 pockets of fluid measuring >1 cm in 2 perpendicular planes. (normal =2)

Pockets absent or poscet < 1 cm in 2 perpendicular planes. (abnormal = 0)

Page 25: ASKEP PERSALINAN NORMAL.ppt

INTERPRETATION OF BPP SCORES:

Normal = 8-10 (if Amniotic fluid index is adequate)

Equivocal = 6 Abnormal = <4

Page 26: ASKEP PERSALINAN NORMAL.ppt

DOCUMENTATION OF A CONTRACTION STRESS TEST

Negative: No late decelerations with 3 adequate uterine contractions in a 10-minute window, normal baseline FHR and accelerations with fetal movement.

Positive: Late decelerations occur with more than half the uterine contractions.

Chapter 22

Page 27: ASKEP PERSALINAN NORMAL.ppt

DOCUMENTATION OF A CONTRACTION STRESS TEST (CONT.)

Suspicious: Late decelerations occur with less than half the uterine contractions.

Unsatisfactory: Inadequate fetal heart rate recording or less than 3 uterine contractions in 10 minutes.

Chapter 22

Page 28: ASKEP PERSALINAN NORMAL.ppt

INDICATIONS FOR THE NST

Suspected post-maturity Maternal diabetes Maternal hypertension: chronic and

pregnancy-related disorders Suspected or documented IUGR History of previous stillbirth Isoimmunization

Chapter 22

Page 29: ASKEP PERSALINAN NORMAL.ppt

INDICATIONS FOR THE NST (CONT.)

Older gravida Decreasing fetal movement Sever maternal anemia Multiple gestation High-risk antepartal conditions: PROM, PTL,

bleeding Chronic renal diseases

Chapter 22

Page 30: ASKEP PERSALINAN NORMAL.ppt

ELECTRONIC FETAL MONITORING

External: ultrasound transducer

Internal: spiral electrode

Page 31: ASKEP PERSALINAN NORMAL.ppt

ULTRASOUND TRANSDUCER High-frequency sound waves reflect

mechanical action (fetal heart tone & valves) of the fetal heart.

Noninvasive. (Does NOT require rupture of membranes or cervical dilation)

Used in both antepartum and intrapartum period.

Short-term variability and beat-to-beat changes in the FHR cannot be assessed accurately by this method.

Page 32: ASKEP PERSALINAN NORMAL.ppt

SPIRAL ELECTRODE Applied to the fetal presenting part to assess

the FHR. Converts the fetal ECG as obtained from the

presenting part to the FHR via a cardiotachometer.

Used ONLY when membranes are ruptured & cervix is sufficiently dilated.

Short-term variability CAN be assessed using this method.

Page 33: ASKEP PERSALINAN NORMAL.ppt

FHR VARIABILITY Increased Variability: marked variability from a

previous average variability. Causes: early mild hypoxia; fetal stimulation

(uterine palpation, contractions, fetal activity; maternal activity; illicit drugs).

Significance: unknown. Nsg.Intervention: observe for any nonreassuring

patterns; if using external fetal monitoring consider an internal mode for a more accurate tracing.

Page 34: ASKEP PERSALINAN NORMAL.ppt

FHR VARIABILITY

Decreased Variability: marked decrease in variability from a previous average variability. Causes: hypoxia / acidosis; CNS depressants;

analgesics / narcotics; barbiturates; tranquilizers, anaractics; parasympatholytics; general anesthetics; prematurity (<24 wks); fetal sleep cycles; congenital abnormalities; fetal cardiac dysrhythmias.

Page 35: ASKEP PERSALINAN NORMAL.ppt

FHR VARIABILITY Decreased Variability (continued):

Significance: benign when associated with fetal sleep cycles; if drugs, variability usually increases as drugs are excreted; when associated with uncorrectable late decelerations indicates presence of fetal acidosis and can result in low APGARs.

Nsg.Interventions: none, if fetal sleep cycle, or CNS depressants; consider fetal scalp stimulation or apply a spiral electrode; monitor fetal oxygen saturation; prepare for birth if indicated.

Page 36: ASKEP PERSALINAN NORMAL.ppt

OTHER DEFINITIONS

Tachycardia: a baseline FHR >160 bpm for a duration of 10 minutes or longer.

Bradycardia: a baseline FHR <110 bpm for a duration of 10 minutes or longer.

Page 37: ASKEP PERSALINAN NORMAL.ppt

FHR CHANGES

Accelerations Decelerations

Early Late Variable Prolonged

Page 38: ASKEP PERSALINAN NORMAL.ppt

BASELINE FHR

Definition: the average rate during a 10 minute period that excludes periodic or episodic changes, periods of marked variability, and segments of the baseline that differ by more than 25 bpm.

Range: 110-160 bpm.

Page 39: ASKEP PERSALINAN NORMAL.ppt

ACCELERATIONS

Definition: A visually apparent abrupt increase in FHR above the baseline rate.

An increase of 15 bpm and lasting 15 seconds or more, with the return to baseline less than 2 minutes from the beginning of the acceleration.

Can be periodic or episodic.

Page 40: ASKEP PERSALINAN NORMAL.ppt

EARLY DECELERATIONS Definition: a transitory gradual decrease and

return to baseline FHR in response to fetal head compression.

Generally starts before the peak of the uterine contractions.

Returns to the baseline at the same time as the contraction returns to its baseline.

Considered benign. No interventions.

Page 41: ASKEP PERSALINAN NORMAL.ppt

LATE DECELERATIONS Definition: a transitory gradual

decrease in and return to baseline of FHR associated with contractions.

Begins after the contraction has started, and the lowest part of the decel occurs after the peak of the contraction.

Usually does NOT return to baseline until after the contraction is over.

Indicates uteroplacental insufficiency. Interventions required!

Considered ominous sign when they’re uncorrectable, especially when associated with decreased variability and tachycardia.

Page 42: ASKEP PERSALINAN NORMAL.ppt

LATE DECELERATIONS Interventions:

Change maternal position (lateral) Correct maternal hypotension (elevate legs) Increase rate of maintenance IV D/C oxytocin if infusing Administer O2 at 8-10 L/min (face mask) Fetal scalp or acoustic stimulation Assist with fetal O2 saturation if ordered Assist with birth if pattern cannot be corrected.

Page 43: ASKEP PERSALINAN NORMAL.ppt

VARIABLE DECELERATIONS Definition: an abrupt decrease in FHR that is

variable in duration, intensity,and timing related to onset of contractions; caused by umbilical cord compression.

Onset to the beginning of the nadir is <30 seconds; decrease in > 15 bpm, lating >15 seconds; variable times in contracting phase; often preceded by transitory acceleration.

Return to baseline is rapid and <2 min from onset; sometimes with transitory acceleration immediately before and after decel.

Described as: mild, moderate, or severe.

Page 44: ASKEP PERSALINAN NORMAL.ppt

VARIABLE DECELERATIONS Interventions: Change maternal position (side to side).

If severe: D/C oxytocin if infusing Administer O2 at 8-10 L/min (face mask) Assist with vag or speculum exam If cord is prolapsed, examiner will elevate fetal

presenting part with cord between gloved fingers until c/s is accomplished

Assist with amnioinfusion if ordered Assist with fetal O2 saturation monitoring if ordered Assist with fetal O2 saturation if ordered

Page 45: ASKEP PERSALINAN NORMAL.ppt

PROLONGED DECELERATIONS Definition: a visually apparent decrease

in FHR below the baseline 15 bpm or more and lasting more than 2 minutes but less than 10 minutes.

Benign causes: pelvic exam, application of spiral electrode, rapid fetal descent & sustained maternal valsalva maneuver.

Other causes (severe): progressive severe variable decels, sudden umbilical cord prolapse, hypotension, paracervical anesthesia, tetanic contraction & maternal hypoxia (may occur with seizure).

Page 46: ASKEP PERSALINAN NORMAL.ppt

NURSING CARE DURING LABOR

Page 47: ASKEP PERSALINAN NORMAL.ppt

QUESTIONS TO ASK LABORING CLIENT:

UTERINE CONTRACTIONS Time of onset: What was the time of the 1st

ctx, & at what time did the ctx.become regular?

Frequency: How often do the ctx. occur? Duration: How long do the ctx.last?

Page 48: ASKEP PERSALINAN NORMAL.ppt

Intensity: What is the level of pain? Describe the nature & location of the pain?

Effect of Ambulation: do the ctx.become more or less frequent and intense with ambulation?

ADDITIONAL HISTORY: Bloody show: What was the frequency &

amt.of discharge? Vaginal bleeding: What was the amount, color,

and consistency?

Page 49: ASKEP PERSALINAN NORMAL.ppt

Membranes: Is there leaking or have you experienced spontaneous rupture of membranes? What was the amont, color, consistency, & time of occurrence?

Fetal Activity: Has the fetus moved or kicked since labor began?

Nutrition, hydration, and sleep: When was the last time you ate, drank, or slept?

Social support available: Is someone with you?

Page 50: ASKEP PERSALINAN NORMAL.ppt

General emotional well-being: Are you relaxed? Are you using breathing techniques? (can also be observed).

Transportation: Is transportation to the birth site available?

Page 51: ASKEP PERSALINAN NORMAL.ppt

MONITORING DURING LABOR:

Purpose = to determine that maternal-fetal status is within normal limits during labor and that maternal status is within normal limits in the immediate postpartum period; to intervene when deviations from normal are noted.

Page 52: ASKEP PERSALINAN NORMAL.ppt

Assess the following parameters during the 1st and 2nd stages of labor at regular intervals:

Vital signs: BP on admission & at least hourly during the active phase of labor (more frequently if elevated or epidural). T-P-R on admission & q4hr (more frequently if ROM or elevation).

Fetal well-being: auscultate & record FHR on admission or place on EFM for 20-30 min. Use continuous or intermittent monitoring depending on maternal-fetal risk.

Page 53: ASKEP PERSALINAN NORMAL.ppt

Uterine activity: Assess & record frequency, duration, and intensity of uterine ctx q30-60 minutes by direct palpation or through interpretation of electronic fetal monitoring strips.

Labor progress: perform a vag.exam to assess cervical effacement & dilatation, fetal position & station, & status of membranes. (use Friedman’s curve).

I & O: ensure adequate hydration. Initiate IV fluid as needed or before administration of epidural. Encourage to empty bladder frequently.

Page 54: ASKEP PERSALINAN NORMAL.ppt

HOW LABOR PROGRESS IS MEASURED:

Contraction pattern. Cervical consistency & effacement. Cervical

changes. Cervical dilatation. Station.

Page 55: ASKEP PERSALINAN NORMAL.ppt

WAYS TO FACILITATE LABOR PROGRESS:

Work with ctx.rather than against them. Encourage relaxation between ctx. Assist in paced breathing techniques, focus, visual imagery, ambulation, change position regularly, good communication with nurse & support person.

Page 56: ASKEP PERSALINAN NORMAL.ppt

PSYCHOSOCIAL ASSESSMENT IN LABOR:

Support system. Level of understanding of labor

process & procedures. Effectiveness of coping strategies to

deal with labor process & pain of level.

The psychosocial assessment provides the basis for education of the patient, anticipatory guidance, and provision of supportive care including both pharmacologic & nonpharmacologic measures

Page 57: ASKEP PERSALINAN NORMAL.ppt

LABORATORY DATA: URINE: test for protein, ketones, glucose,

WBCs, nitrates (should all be negative). HEMATOCRIT & HEMOGLOBIN: HCT <32%, and

HGB <11g/L may indicate iron deficiency anemia or hemorrhage.

WBC COUNT: values of 4500 – 11,000 are normal; up to 25,000 can be normal for labor, birth, and early pp (d/t stress).

Page 58: ASKEP PERSALINAN NORMAL.ppt

SEROLOGIC TESTS FOR SYPHILIS (VDRL): samples may be obtained on admission, depending on institutional policy. Results should be negative.

HEPATITIS B SURFACE ANTIGEN: repeat test if antepartum results are > 30 days old.

Rh FACTOR & ABO TYPING: necessary during the antepartum period, and pp when indicated.

Page 59: ASKEP PERSALINAN NORMAL.ppt

PROMOTING A NORMAL CHILDBIRTH:

Maintain an awareness and appreciation of the individuality of each woman’s labor.

Be aware of cultural differences related to labor and birth.

Update your knowledge on intrapartum research topics (stay current).

Page 60: ASKEP PERSALINAN NORMAL.ppt

Become reenergized by meeting and sharing with other professionals who work with the same challenges & issues. Join specialty organizations.

Know your professional standards of practice. These form your basis for safe practice.

Advocate for women’s needs on the basis of your knowledge of safe practice.

Be aware of your biases regarding labor and birth.

Page 61: ASKEP PERSALINAN NORMAL.ppt

POSSIBLE NURSING DX:FIRST-STAGE LABOR: Knowledge deficit: lack of information related

to expected physical changes, symptoms of labor, and options available to the childbearing woman.

Pain related to the process of labor or birth. Anxiety related to childbirth, pelvic

examinations, or obstetric interventions. Fear related to parenting.

Page 62: ASKEP PERSALINAN NORMAL.ppt

Fluid volume excess related to intake during labor.

Altered nutrition: less than body requirements related to decreased intake during labor.

SECOND-STAGE LABOR: Fear related to birth process, pain, and

unknown outcome. Fatigue related to physical exertion during

labor and lack of sleep. Pain related to fetal descent, crowning, and

perineal stretching.

Page 63: ASKEP PERSALINAN NORMAL.ppt

THIRD- AND FOURTH-STAGE LABOR: Risk for infection related to uterine placental

site, episiotomy incision, and fatigue. Urinary retention related to loss of sensation to

void and rapid bladder filling. Ineffective breastfeeding related to maternal

knowledge deficit, anxiety, or fatigue.

Page 64: ASKEP PERSALINAN NORMAL.ppt

“FRIEDMAN’S CURVE” Emanuel Friedman began work in 1950s, and

over 20 years defined the phases and length of the stages of labor for nulliparous and multiparous women.

His work showed that cervical dilatation & fetal descent follow a predictable pattern & appear as an S curve when plotted on a graph.

Analysis of labor progress is plotted on a graph (a partograph).

Page 65: ASKEP PERSALINAN NORMAL.ppt

Can be used to plot cervical dilatation and fetal descent on the graph, and if labor begins to slow in comparison to the average rate of progress defined by Friedman, and this data can provide a basis for decision making about the progress of a woman’s labor.

Friedman’s work is the most universally accepted scientific treatment of labor & is nationally used in normal labor, and to diagnose dystocia (abnormal labor) when deviations are apparent.

Page 66: ASKEP PERSALINAN NORMAL.ppt

DX KEP

Kala I :1.Nyeri akut berhubungan dengan

tekanan mekanik pada bagian presentasi,dilatasi/regangan, tegangan emosional

2.Risiko infeksi terhadap maternal berhubungan dengan prosedur invasif, pemeriksaan vagina berulang

Page 67: ASKEP PERSALINAN NORMAL.ppt

DX KEP

Kala II :1.     Nyeri akut berhubungan dengan tekanan

mekanik pada presentasi, dialatasi/peregangan  jaringan, kompresi syaraf, pola kontraksi semakin intensif

2.     Risiko kerusakan integritas kulit/jaringan berhubungan dengan pencetusan persalinan, pola kontraksi hipertonik,janin besar,pemakaian forcep.

3.     Risiko cedera terhadap janin berhubungan dengan malpresentasi/posisi,pencetusan kelahiran disproporsi, sefalopelvik ( CPD ).

Page 68: ASKEP PERSALINAN NORMAL.ppt

DX KEP   Kala III :1.      Risiko kekurangan volume cairan

berhubungan dengan peningkatan kehilangan cairan secara tidak disadari, atonia uteri, laserasi jalan lahir,tertahannya fragmen plasenta

2.      Nyeri ( akut ) berhubungan trauma jaringan , respons fisiologis setelah melahirkan

3.      Risiko perubahan proses keluarga berhubungan dengan terjadinya transisi, krisis situasi

  Kala IV :1.      Nyeri ( akut ) berhubungan dengan efek2

obat-obatan , trauma mekanis/ jaringan, edema jaringan, kelemahan fisik dan psikologis, ansietas.

2.      perubahan proses keluarga berhubungan dengan transisi/peningkatan perkembangan anggota keluarga.


Top Related