ASKEP PERSALINAN NORMAL Juwitasari, S.Kep. Ns
ESSENTIALS OF NURSING CARE: REPRODUCTIVE HEALTH Needs of the Childbearing Family: Preconception
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).
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.
PENGERTIAN PERSALINAN BUATAN (PARTUS ABNORMAL) Proses kelahiran dengan bantuan alat, misalnya: Vakum ekstraksi Forcep ekstraksi Dekapitasi SC
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.
FAKTOR-FAKTOR YANG MEMPENGARUHI PERSALINAN Power Passage (jalan lahir) Passanger Psikologis Penolong
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.
HIS ADEKWAT 1.
2.
3.
Bersifat teratur minimal 2x tiap 10 menit lamanya 40 detik kuat Kuat, mengeras saat kontraksi sehingga tak ada cekungan lagi bila ditekan dengan ujung jari. Servik membuka.
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
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 910 cm/lengkap) Pada multigravida lebih 7 jam, primi gravida 14 jam.
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
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,
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
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
THE TRIPLE SCREEN (CONT’D) Group
Beta Strep Bacteria detection
Not an uncommon finding Requires Abx upon rupture of membrane or onset of active labor Recommended 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
FETAL ASSESSMENT DURING LABOR
ASSESSMENT FOR GENETIC DISORDERS
Maternal age Ethnic background Family history Reproductive history Maternal disease Environmental hazards
Chapter 22
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.
BIOPHYSICAL PROFILE VARIABLES
Fetal breathing movements Gross body movement Fetal tone Amniotic fluid volume index Non-stress test
Chapter 22
BPP: VARIABLES & SCORES FETAL 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)
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)
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)
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)
INTERPRETATION OF BPP SCORES: Normal = 8-10 (if Amniotic fluid index is adequate) Equivocal = 6 Abnormal = <4
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
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
INDICATIONS FOR THE NST
Suspected post-maturity Maternal diabetes Maternal hypertension: chronic and pregnancyrelated disorders Suspected or documented IUGR History of previous stillbirth Isoimmunization
Chapter 22
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
ELECTRONIC FETAL MONITORING External:
ultrasound transducer
Internal:
spiral
electrode
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.
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.
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.
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.
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.
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.
FHR CHANGES Accelerations Decelerations
Early Late Variable Prolonged
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.
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.
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.
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.
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.
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.
VARIABLE Interventions:
DECELERATIONS
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
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).
NURSING CARE DURING LABOR
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?
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?
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?
General emotional well-being: Are you relaxed? Are you using breathing techniques? (can also be observed). Transportation: Is transportation to the birth site available?
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.
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.
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.
HOW LABOR PROGRESS IS MEASURED: Contraction pattern. Cervical consistency & effacement. Cervical changes. Cervical dilatation. Station.
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.
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
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).
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.
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).
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.
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.
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.
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.
“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).
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.
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
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 ).
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 obatobatan , trauma mekanis/ jaringan, edema jaringan, kelemahan fisik dan psikologis, ansietas. 2. perubahan proses keluarga berhubungan dengan transisi/peningkatan perkembangan anggota keluarga.
