Departemen Keperawatan Keperawatan Maternitas
TINJAUAN TEORITIS “ PERSALINAN FISIOLOGIS ”
I. KONSEP DASAR INTRA NATAL CARE (INC) A. Definisi Persalinan
Persalinan adalah proses membuka dan menipisnya serviks dan janin turun ke dalam jalan lahir. Persalinan dan kelahiran normal adalah proses pengeluaran janin yang terjadi pada kehamilan cukup bulan (37-42 minggu), lahir spontan dengan presentasi belakang kepala yang berlangsung dalam 18 jam, tanpa komplikasi baik pada ibu maupun pada janin. (Prawirohardjo, 2001). Beberapa istilah / jenis yang berhubungan dengan persalinan antara lain sebagai berikut :
Me M enurut Cara Pe Persa rsalina linan n a. Partus biasa/normal disebut juga partus spontan adalah proses lahirnya bayi pada LBK dengan tenaga ibu sendiri tanpa bantuan alat alat serta tidak melukai ibu dan bayi yang umumnya berlangsung kurang dari 24 jam. b. Partus luar biasa (abnormal) ialah persalinan pervaginam dengan bantuan alat alat atau melalui dinding perut dengan operasi sectio sesaria. c. Partus Anjuran adalah roses persalinan dengan kekuatan yang diperlukan dan ditimbulkan dari luar dengan jalan rangsangan seperti pemberian pitocin atau prostaglandin atau pemecahan ketuban. Persalinan dibagi dalam 4 kala, yaitu : 1. Kala I
: Dimulai dari saat persalinan mulai sampai pembukaan lengkap (10
cm). Proses ini terbagi dalam 2 fase : a. Fase Laten (8 jam) serviks membuka sampai 3 cm dan b. Fase aktif (7 jam) serviks membuka dari 3 cm sampai s ampai 10 cm. 2. Kala II
: Dimulai dari pembukaan lengkap (10 cm) sampai bayi lahir. Proses
ini biasanya berlangsung 2 jam pada primi dan 1 jam pada multi.
1 Mukarramah, S.Kep (70900116061) (70900116061) Program Studi Profesi Ners Angkatan XII Uin Alauddin Makassar 2017
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Departemen Keperawatan Keperawatan Maternitas
3. Kala III
: Dimulai segera setelah lahir sampai lahirnya plasenta, yang yang
berlangsung tidak lebih dari 30 menit. 4. Kala IV
: Dimulai saat lahirnya plasenta sampai 2 jam pertama postpartum.).
B. Etiologi Persalinan
Penyebab timbulnya persalinan sampai sekarang belum diketahui secara pasti/jelas. Terdapat beberapa teori antara lain : 1. Teori penurunan hormon progesterone. Progesterone menimbulkan relaksasi otot rahim, sebaliknya estrogen meninggikan kerentanan otot rahim. Selama kehamilan terdapat keseimbangan antara kadar progesterone dan estrogen didalam darah, tetapi pada akhir kehamilan kadar progesterone menurun sehingga menimbulkan his. 2. Teori oxytocin. Oksitosin merupakan suatu hormon yang disekresikan oleh neurohipofise yang secara khusus menyebabkan kontraksi uterus. 3 alasan peranan oksitosin: a.
Otot uterus meningkatkan jumlah reseptor-reseptor oksitoksin, oleh karena itu meningkatkan
responnya terhadap dosis oksitosin yang
diberikan
selama beberapa bulan terakhir kehamilan. b.
Kecepatan sekresi oksitosin oleh neurohipofise sangat meningkat pada saat persalinan.
c.
Iritasi oleh regangan pada serviks uteri, dapat menyebabkan kelenjar hipofise posterior meningkatkan sekresi oksitosinnya
Pada akhir kehamilan kadar oxytosin bertambah. Oleh karena itu timbul kontraksi otot – otot – otot otot rahim. 3. Teori placenta menjadi tua. Plasenta yang tua akan menyebabkan turunnya kadar estrogen dan progesterone yang akan menyebabkan kekejangan pembuluh darah. Hal ini akan menimbulkan his. 4. Keregangan otot-otot. Seperti halnya dengan kandung kencing dan lambung bila dindingnya teregang oleh karena isinya bertambah maka timbul kontraksi untuk
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Departemen Keperawatan Keperawatan Maternitas
mengeluarkan isinya. Demikian pula dengan rahim, maka dengan majunya kehamilan makin teregang otot-otot dan otot-otot rahim makin rentan. 5. Teori prostaglandin. Prostaglandin yang dihasilkan oleh decidua, disangka menjadi salah satu sebab permulaan persalinan. Hasil dari percobaan menunjukkan bahwa Prostaglandin F2 dan E2 yang diberikan secara intra vena, intra dan extraamnial menimbulkan kontraksi myometrium pada setiap umur kehamilan. Hal ini juga di sokong dengan adanya kadar Prostaglandin yang tinggi baik dalam ai r ketuban maupun darah perifer pada ibu-ibu hamilsebelum melahirkan atau selama persalinan 6. Pengaruh janin. Hipofise dan supra renal janin memegang peranan oleh karena pada anencephalus, kehamilan sering lama dari biasanya 7. Teori distensi rahim. Rahim yang menjadi besar dan teregang yang menyebabkan iskemia otot – otot rahim sehingga mengganggu sirkulasi uteroplasenta. 8. Teori iritasi mekanik Dibelakang serviks terletak ganglion servikalis, bila ganglion ini digeser dan ditekan misalnya oleh kepala janin maka akan menimbulkan his.
F ak tor tor Utama Utama D alam P er salinan sali nan 1.
Passage / Pelvis (jalan lahir) a. Pintu atas panggul (PAP), disebut juga inlet. Bidang ini terletak miring, membentuk sudut 55 derajat dengan bidang horisontal. b. Pintu tengah panggul (PTP), midpelvis merupakan bagian panggul yang paling sempit karena terdapat spina ischiadika. c. Pintu bawah panggul (PBP), disebut juga autlet.
2.
Power a. Kontraksi miometrium, terutama berperan dalam kala l persalinan. b. Hejan perut ibu, kekuatan mengedan, terutama berperan pada kala ll persalinan, dapat dilatih dengan melatih otot perut.
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Departemen Keperawatan Keperawatan Maternitas
c. His atau kontraksi uterus, yang perlu diobservasi adalah frekuensi, kekuatan dan durasinya. Tiap his dimulai sebagai gelombang dari salah satu sudut dimana tuba masuk kedalam dinding uterus. Gelombang ini bergerak kedalam dan kebawah dengan kecepatan 2cm/sekon untuk mengikutsertakan seluruh uterus. His yang sempurna punya kejang otot paling tinggi difundus uteri. Jika persalinan mulai yakni pada permulaan kala I maka frekuensi dan amplitudo his meningkat. d. Kontraksi pada persalinan normal bersifat ; interval teratur, interval secara bertahap memendek, intensitas secara bertahap meningkat, serviks membuka dan rasa sakit tidak hilang dengan sedasi 3. Passenger; Keadaan janin (letak, presentasi, ukuran/berat janin, ada/tidak kelainan anatomik mayor) 4. Psyche Keadaan
psikis
mempengaruhi
proses
persalinan,
jika
tidak
diatasi/dikendalikan dapat membentuk lingkaran setan : tense mind, tense serviks tense labour tense mind dan seterusnya. Cara mengatasi dengan memutus mata rantai lingkaran tersebut, misalnya dengan memberi nasehat atau sedativa pada ibu. 5. Posisi ibu dalam persalinan a.
Posisi litotomi adalah posisi yang umum dimana wanita berbaring terlentang dengan lutut ditekuk, kedua paha diangkat kesamping kanan dan kiri.
b.
Posisi duduk.
c.
Posisi berbaring (Menurut Walcher : di tepi tempat tidur), (Menurut Tjeenk ; memakai bantal), (Menurut Jonges : untukmemperlebar pintu bawah panggul), dan (Menurut posisi sims : posisi miring).
C. Tanda – Tanda Tanda Persalinan
1. K ala I Tanda dan gejala : a. His sudah Adekuat ; Penipisan dan pembukaan serviks sekurang – kurangnya kurangnya 3 cm. Keluar cairan dari vagina dalam bentuk lendir bercampur darah
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Departemen Keperawatan Keperawatan Maternitas
b. His dianggap Adekuat bila : 1) His bersifat teratur, minimal 2x tiap 10 menit dan berlangsung sedikitnya 40 detik. 2) Uterus mengeras pada waktu kontraksi, sehingga tidak didapatkan cekungan lagi bila dilakukan penekanan diujung jari. 3) Serviks membuka.
2. Ka Kala la I I Persalinan kala II dimulai ketika pembukaan lengkap dan berakhir dengan lahirnya seluruh janin. Tanda dan gejala : a.
Ibu ingin meneran
b.
Perineum menonjol
c.
Vulva dan anus membuka
d.
Meningkatnya pengeluaran darah dan lender
e.
Kepala telah turun didasar panggul Pada kala II his menjadi lebih kuat dan lebih cepat, kira-kira 2-3 menit
sekali, kepala janin biasanya sudah masuk diruang panggul, maka pada his dirasakan tekanan pada otot-otot dasar panggul, yang secara reflektoris menimbulkan rasa meneran. Pada primigravida primigravida kala II berlangsung rata-rata 45 – 45 – 60 menit, dan multipara 15-30 menit.
3. Ka Kalla I I I Persalinan kala III dimulai setelah lahirnya bayi dan berakhir dengan lahirnya plasenta. Tanda dan gejala : a)
Bentuk uterus dan TFU Setelah bayi dilahirkan dan sebelum meomitrium menyesuaikan dengan perubahan ukuran rongga uterus, uterus berada dalam bentuk diskoid dan TFU berada dibawah umbilikus. Setalah uterus berkontraksi dan plasenta didorong kebawah, bentuk uterus menjadi globular dan TFU menjadi diatas pusat ( sering kali
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Departemen Keperawatan Keperawatan Maternitas
mengarah kesisi kanan ). Biasanya plasenta lepas dalam 15 – 15 – 30 30 menit, dapat ditunggu sampai 1 jam. b)
Tali pusat memanjang Semburan darah yang tiba – tiba – tiba tiba yang diikuti dengan memanjangnya tali pusat keluar vagina menandakan kelepasan plasenta plasenta dari dinding uterus.
c)
Semburan darah tiba – tiba – tiba tiba Darah yang terkumpul dibelakang plasenta akan membantu mendorong plasenta keluar bersama bantuan dari gravitasi. Semburan darah yang tiba – tiba – tiba menandakan bahwa kantung yang terjadi retroplasenta telah robek ketika plasenta memisah.
4. K ala I V Kala IV adalah kala pemulihan masa yang kritis ibu dan anaknya, bukan hanya proses pemulihan secara fisisk setelah melahirkan tetapi juga mengawali hubungan yang baru selama satu sampai dua jam. Pada kala IV ibu masih membutuhkan pengawasan yang intensive karena perdarahan dapat terjadi, misalnya mi salnya karena atonia uteri, robekan pada serviks dan perineum. Rata-rata jumlah perdarahan normal adalah 100 – 300 cc, bila perdarahan diatas 500 cc maka dianggap patologi. Perlu diingat ibu tidak boleh ditinggalkan sendiri dan belum boleh dipindahkan ke kamarnya. kamarn ya.
Tanda – Ta T anda Secar car a Umum P er mulaan ulaan Pe P er sali salinan nan a. Kepala turun memasuki PAP terutama pada primigravida. Pada primigravida kepala anak pada bulan terakhir berangsur – angsur turun kedalam rongga panggul. Pada multigravida, dinding rahim dan perut sudah kendor kekenyalannya sudah berkurang sehingga kekuatan mendesak kebawah tidak seberapa, biasanya kepala bru turun pada permulaan persalinan. b. Perut kelihatan lebih melebar, fundus uteri turun. c. Perasaan sering atau susah BAB karena vesika urinaria tertekan oleh bagian terbawah janin. d. Perasaan sakit diperut dan pinggang oleh adanya his.
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Departemen Keperawatan Keperawatan Maternitas
e. Serviks menjadi lembek, mulai mendatar, sekresi bertambah, kadang – kadang bercampur darah
G ej ala P er sali salina nan n a. Rasa sakit oleh adanya his yang datang lebih kuat, sering dan teratur b. Keluarnya lendir bercampur darah lebih banyak. Hal ini terjadi karena robekan – robekan – robekan robekan kecil yang terjadi pada serviks c. Kadang – Kadang – kadang kadang ketuban pecah dengan sendirinya. d. Pada pemeriksaan dalam serviks mendatar, lunak dan terdapat pembukaan D. Patofisiologi Persalinan / Mekanisme Persalinan
Dalam persalinan terdapat beberapa proses / mekanisme yaitu sebagai berikut:
sali nan Ka K ala 1 ( F ase P ematang tanga an / P embuka uk aan Se S er vik vi ks) 1. P er salinan Dimulai pada waktu serviks membuka karena his : kontraksi uterus yang teratur, makin lama, makin kuat, makin sering, makin terasa nyeri, disertai pengeluaran darah-lendir yang tidak lebih banyak daripada darah haid, dan berakhir pada waktu pembukaan serviks telah lengkap (pada periksa dalam, bibir porsio serviks tidak dapat diraba lagi). Selaput ketuban biasanya pecah spontan pada saat akhir kala I. Proses membukanya serviks sebagai akibat his dibagi dalam 2 fase : a) Fase laten : berlangsung selama 8 jam. Pembukaan terjadi sangat lembut sampai mencapai ukuran diameter 3 cm. b) Fase aktif : dibagi dalam 3 fase lagi, yakni : (1) Fase akselerasi : dalam waktu w aktu 2 jam pembukaan 3 cm menjadi 4 cm (2) Fase dilaktasi maksimal : dalam waktu2 jam pembukaan brlangsung sangat cepat, dari 4 cm menjadi 9 cm.
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Departemen Keperawatan Keperawatan Maternitas
terbukanya vaskular kapiler serviks, dan akibat pergeseran antara selaput ketuban dengan dinding dalam uterus b) Ostium uteri internum dan eksternum terbuka sehingga serviks menipis dan mendatar. c) Selaput ketuban pecah spontan (beberapa kepustakaan menyebutkan ketuban pecah dini jika terjadi pengeluaran cairan ketuban sebelum pembukaan 5 cm). Pematangan dan pembukaan serviks (cervical effacement) pada primigravida berbeda dengan pada multipara : a) Pada primigravida terjadi penipisan serviks lebih dahulu sebelum terjadi pembukaan – pada multipara serviks telah lunak akibat persalinan sebelumnya, sehingga langsung terjadi proses penipisan dan pembukaan b) Pada primigravida, ostium internum membuka lebih dulu daripada ostium eksternum (inspekulo ostium tampak berbentuk seperti lingkaran kecil di tengah) – pada multipara, ostium internum dan eksternum membuka bersamaan (inspekulo ostium tampak berbentuk seperti garis lebar). c) Periode kala 1 pada primigravida lebih lama (+ 20 jam) dibandingkan multipara (+14 jam) karena pematangan dan pelunakan serviks pada fase laten pasien primigravida memerlukan waktu lebih lama.
2. P er sali salinan nan kala 2 (F ( F ase penge ng eluaran ba bayi) yi ) Dimulai pada saat pembukaan serviks telah lengkap. Berakhir pada saat bayi telah lahir lengkap.His menjadi lebih kuat, lebih sering, lebih lama, sangat kuat. Selaput ketuban mungkin juga baru pecah spontan pada awal kala 2. Peristiwa penting pada persalinan kala 2 a. Bagian terbawah janin (pada persalinan normal : kepala) turun sampai dasar
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e. Kemungkinan diperlukan pemotongan jaringan perineum untuk memperbesar jalan lahir (episiotomi). f. Lama kala 2 pada primigravida + 1.5 jam, multipara + 0.5 jam. Gerakan utama pengeluaran janin pada persalinan dengan letak belakang kepala a. Engagement (Kepala masuk pintu atas panggul) : sumbu kepala janin dapat tegak lurus dengan pintu atas panggul (sinklitismus) atau
miring /
membentuk sudut dengan pintu atas panggul (asinklitismus anterior / posterior) b. Descent (Kepala turun ke dalam rongga panggul) akibat : 1) tekanan langsung dari his dari daerah fundus ke arah daerah bokong, 2) tekanan dari cairan amnion, 3) kontraksi otot dinding perut dan diafragma (mengejan), dan 4) badan janin terjadi ekstensi dan menegang c. Flexion : kepala janin fleksi, dagu menempel ke toraks, posisi kepala berubah dari
diameter
oksipito-frontalis
(puncak
kepala)
menjadi
diameter
suboksipito-bregmatikus (belakang kepala). d. Internal Rotation (putaran paksi dalam) : selalu disertai turunnya kepala, putaran ubun-ubun kecil ke arah depan (ke bawah simfisis pubis), membawa m embawa kepala melewati distansia interspinarum dengan diameter biparietalis. e. Ekstension : setelah kepala mencapai vulva, terjadi ekstensi setelah oksiput melewati bawah simfisis pubis bagian posterior. Lahir berturut-turut : oksiput, bregma, dahi, hidung, hidung, mulut, dagu. f. Eksternal Rotation Rotation
(putaran paksi luar) : kepala berputar kembali sesuai
dengan sumbu rotasi tubuh, bahu masuk pintu atas panggul dengan posisi
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Departemen Keperawatan Keperawatan Maternitas
3. P er sali salinan nan kala 3 (F ( F ase P enge ng eluaran Plas P lase enta) nta) Dimulai pada saat bayi telah lahir lengkap. Berakhir dengan lahirnya plasenta. Kelahiran plasenta : lepasnya plasenta dari insersi pada dinding uterus, serta pengeluaran plasenta dari kavum uteri. Lepasnya plasenta dari insersinya : mungkin dari sentral (Schultze) ditandai dengan perdarahan baru, atau dari tepi / marginal (Matthews-Duncan) jika tidak disertai perdarahan, atau mungkin juga serempak sentral dan marginal.
Pelepasan plasenta terjadi karena perlekatan perlekatan
plasenta di dinding uterus adalah bersifat adhesi, sehingga pada saat kontraksi mudah lepas dan berdarah. a. Pada keadaan normal, kontraksi uterus bertambah keras, fundus setinggi sekitar / di atas pusat. b. Plasenta lepas spontan 5-15 menit setelah bayi lahir. (jika lepasnya plasenta terjadi sebelum bayi lahir, disebut solusio/abruptio placentae – placentae – keadaan keadaan gawat darurat obstetric)
4. K ala 4 (Obs (Obse er vasi vasi P asca P er sali salina nan) n) Sampai dengan 1 jam postpartum, dilakukan observasi. 7 pokok penting yang harus diperhatikan pada kala 4 : a. Kontraksi uterus harus baik, b. Tidak ada perdarahan pervaginam atau dari alat genital l ain, c. Plasenta dan selaput ketuban harus sudah lahir lengkap d. Kandung kencing harus kosong, e. Luka-luka di perineum harus dirawat dan tidak ada hematoma f. Resume keadaan umum bayi, dan
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Departemen Keperawatan Keperawatan Maternitas
5. Malpresentasi dan malposisi 6. Distosia bahu 7. Distensi uterus 8. Gawat janin 9. Prolapsus tali pusat 10. Demam dalam persalinandan pasca persalinan F. PEMERIKSAAN PEMERIKSAAN PENUNJANG
1. Pemerikaaan darah lengkap : a. Hb normal = 11,4 – 11,4 – 15,1 15,1 gr/dl b. Golangan darah = A, B, AB & O c. Faktor RH = +/d. Waktu pembekuan 2. Protein Urine 3. Urine reduksi G. PENANGANAN NYERI PADA IBU
Tehnik mengurangi nyeri adalah sebagai berikut ; 1. Kenyamanan. Kenyamanan ini meliputi posisi dan pengololaan selama sakit. Posisi yang dianjurkan miring kekiri untuk untuk mengurangi mengurangi penakanan pada pada vena cava., kepala ditinggikan 45 O agar kerja jantung dan paru ringan. Sedangkan pengololaah selama rasa sakit adalah pengosongan pengosongan kandung kemih, kebersihan, alat tenun bersih dan rapih.Mengingat ibu dianjurkan untuk ekspirasi lewat mulut sehingga perlu menganjurkan ibu untuk kumur-kumur. kumur-kumur. 2. Relaksasi.
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Departemen Keperawatan Keperawatan Maternitas
Cara yang mudah untuk mengingatkan kepada ibu untuk bernafas adalah dengan mengajarkan kepada ibu untuk bernafas dalam dan mengeluarkan lewat hidung. 3. Massage Selain itu dapat dilakukan tehnik massage , untuk itu perawat-bidan perlu mengetahui \memahami teori gate control. Ada dua macam serabut syaraf yang perlu diketahui yakni serabut saraf yang berdiameter kecil dan serabut syaraf berdiameter besar yang masing-masing mempunyai fungsi fungsi yang berbeda. Impuls rasa sakit yang yang berdiameter kecil yang menyebabkan menyebabkan gate control di spinal cord membuka dan menimbulkan rasa nyeri, tetapi inpuls ini dapat diblok dengan memberikan rangsangan rangsangan pada pada serabut syaraf berdimeter
besar yang
menyebabkan gate control akan tertutup dan rangsangan nyeri tidak diteruskan kekorteks serebral. Pada prinsipnya serabut syaraf berdiameter besar banyak dijumpai dikulit dikulit
sehingga harus dilakukan segera pada awal rasa sakit atau
sebelum impuls rasa sakit yang dibawah oleh syaraf berdiameter kecil mencapai korteks serebri.
Ada beberapa cara massage yang dapat dilakukan dalam merangsang saraf
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Departemen Keperawatan Keperawatan Maternitas
Ibu dalam posisi duduk kemudian perawat-bidan atau suami klien menekan sakrum secara bergantian dengan tangan yang dikepalkan secara menetap. d)
Abdominal lifting Baringkan ibu pada posisi terlentang dan kepala agak tinggi letakkan kedua telapak tangan perawat-bidan pada pinggang bagian belakang klien lalu secara bersamaan lakukan usapan yang belahan dan menetap pada arah puncak perut, kemudian ulangi ulangi seterusnya.
e)
Distraction atau mengalihkan perhatian. Dalam mengatasi nyeri dengan cara mengalihkan perhatian klien, perawat-bidan dapat menganjurkan untuk melakukan kegiatan sehari-hari seperti membaca, menyenangkan hal-hal yang membahagiakan atau melakukan usapan secara teratur pada perut dan pinggang. Mekanisme kerjanya sama dengan teori gate teori gate control . Cara mengalihkan perhatian yang lainnya cukup efektif adalah dengan nafas dalam sebagaimana yang dikemukakan oleh Lamaze yakni ; (1) Pembukaan 3 cm Nafas dalam 6-9 X/ mnt, inspirasi dari hidung dan ekspirasi lewat mulut
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Departemen Keperawatan Keperawatan Maternitas
4. Mengurangi kecemasan dan ketakutan. Sebagaimana yang dikemukakan oleh Dick and Read (1959)
dalam
maternity Nursing bahwa ketidaktahuan akan menyebabkan ketakutan , ketakutan akan meningkatkan ketengangan otot dan menimbulkan nyeri. Dalam mengatasi hal ini perawat-bidan dapat memberikan informasi yang sesuai pendidikan dan latar belakang kebudayaan klien, antar lain ; a.
Kemajuan persalianan
b.
Alat-alat atau prosedur yang akan dilakuakan.
c.
Obat-obatan
5. Memanfaatkan orang terdekat. Ada dua keuntungan tehnik ini ; a. Keuntungan emosional; 1)
Ibu akan mempunyai pengalaman positif terhadap melahirkan
2)
Perasaan berpartisipasi nyata dalam melahirkan anaknya.
3)
Membantu tumbuhnya hubungan ibu , bapak dan anak
b. Keuntungan fisiologis. 1)
Ibu dapat bekerjasama pada saat pemeriksaan.
2)
Ibu tidak terlalu lelah pada saat sesudah melahirkan
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Departemen Keperawatan Keperawatan Maternitas
II. KONSEP ASUHAN KEPERAWATAN A. Pengkajian
Pengkajian merupakan tahap awal dari proses keperawatan dan merupakan suatu proses yang sistematis dalam pengumpulan data dari berbagai sumber, untuk mengevaluasi dan mengidentifikasikan status kesehatan klien (Nursalam, 2001). Pada Pengkajian ada beberapa yang siperlukan dalam Pengumpulan data antara lain : a. Biodata b. Keluhan Utama. c. Riwayat penyakit sekarang . d. Riwayat penyakit dahulu. e. Riwayat penyakit keluarga. f.
Riwayat Obstetri.
d. Riwayat haid. e. Riwayat kebidanan. g. Riwayat psikososialspiritual dan budaya. h. Pola Kebutuhan sehari-hari. 1) Nutrisi.
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Departemen Keperawatan Keperawatan Maternitas
kepala janin sudah masuk rongga PAP klien dalam posisi miring ke kanan / kiri . 4) Eliminasi. Adanya perasaan sering / susah kencing selama kehamilan dan proses persalinan (Chritina”s Ibrahim, 1993:7). Pada akhir trimester III dapat terjadi konstipasi. Personal Hygiene. Kebersihan tubuh senantiasa dijaga kebersihannya. Baju hendaknya yang longgar dan mudah dipakai, sepatu / alas kaki dengan tumit tinggi agar tidak dipakai lagi. 5) Seksual. Terjadi disfungsi seksual yaitu perubahan dalam hubungan seksual / fungsi dari sek yang tidak adekuat karena adanya proses persalinan dan nifas. 6) Pemeriksaan umum meliputi Tinggi badan dan berat badan, Tekanan Darah, Suhu badan nadi dan pernafasan. i.
Pemeriksaan fisik. 1) Kepala dan leher. Terdapat adanya cloasma gravidarum, terkadang adanya pembengkakan
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Departemen Keperawatan Keperawatan Maternitas
kiri / punggung kanan , letak kepala, sudah masuk PAP atau belum. Adanya his yang makin lama makin sering dan kuat. Auskultasi : ada / tidaknya DJJ,frekwensi antara 140 – 140 – 160 160 x / menit 4) Genetalia. Pengeluaran darah campur lendir, pengeluaran air ketuban. Bila terdapat pengeluaran mekonium yaitu feses yang dibnetuk anak dalam kandungan, menandakan adannya kelainan letak anak. Pemeriksaan dalam untuk mengetahui jauhnya dan kemajuan persalinan, keadaan servic, panggul serta keadaan jalan lahir. 5) Ekstremitas Pemeriksaan udema untuk melihat kelainan-kelainan karena membesarnya uterus, karena pre eklamsia atau karena karena penyakit jantung / ginjal.
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Departemen Keperawatan Keperawatan Maternitas
a) Meningkatkan emosi dan fisik klien / pasangan terhadap persalinan. b) Meningkatkan kemajuan persalinan c) Mendukung kemampuan koping klien / pasangan d) Mencegah komplikasi maternal / bayi. Secara Khusus :
a) Memeriksa tanda t-tanda vital. b) Mengkaji kontraksi tekanan uterus dilatasi cerviks dan penurunan karakteristijk yang mengambarkan kontraksi uterus : -
Frekwensi
-
Internal
-
Intensitas
-
Durasi
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Departemen Keperawatan Keperawatan Maternitas
3) Risiko tinggi terhadap infeksi maternal b/d pemeriksaan vagina berulang dan kontaminasi fekal. 4) Risiko tinggi terhadap kekurangan cairan b/d masukan dan peningkatan kehilangan cairan melalui pernafasan mulut. 5) Risiko tinggi terhadap koping individu tidak efektif b/d ketidakadekuatan system pendukung.
N
DIAGNOSA
O
KEPERAWATAN
1.
Ansietas b/d krisis situasi
NOC
Setelah dilakukan asuhan
kebutuhan keperawatan
tidak terpenuhi.
NIC
selama
……..diharapkan ansietas
a. Orientasikan klien pada lingkungan, prosedur
staf
dan
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Departemen Keperawatan Keperawatan Maternitas
diberikan, kesalahan hasil:
normal
interpretasi
Pasien
dapat
informasi.
mendemonstrasikan teknik
pernapasan atau relaksasi
pernafasan
dan
dengan tepat untuk setiap
yang
untuk
tepat
posisi fase
c. Demonstrasikan
teknik
fase persalinan
persalinan 3.
Risiko terhadap maternal
tinggi Setelah dilakukan asuhan infeksi keperawatan
berulang
klien.
b/d selama….diharapkan
pemeriksaan vagina infeksi dan
kontaminasi fekal.
maternal
b. Kaji sekresi vagina, dapat
terkontrol dengan criteria hasil:
a. Kaji latar belakang budaya
pantau tanda-tanda vital. c. Tekankan pentingnya mencuci tangan yang baik.
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Departemen Keperawatan Keperawatan Maternitas
individu
tidak
efektif
selama…..,diharapkan
b/d koping
pasien
efektif
ketidakadekuatan
dengan criteria hasil:
system pendukung.
Pasien
persalinan b. Anjurkan mengungkapkan perasaan
dapat
c. Beri anjuran kuat thd
mengungkapkan
mekanisme koping positif
perasaannya
dan Bantu relaksasi
b. F ase A kti kti f 1) Nyeri akut berhubungan berhubungan dengan tekanan mekanik dari bagian presentasi. 2) Risiko tinggi terhadap koping individu tidak efektif b/d krisis situasi. 3) Risiko tinggi terhadap cedera maternal b/d efek obat-obatan pertambahan mobilitas gastrik. 4) Risiko kerusakan pertukaran gas janin b/d perubahan suplay oksigen dan
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Departemen Keperawatan Keperawatan Maternitas
menggunakan obatobatan/tidak j. Berikan lingkungan yang tenang 2.
Risiko terhadap
tinggi Setelah koping
asuhan
dilakukan keperawatan
a. Tentukan pemahaman dan harapan terhadap proses
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Departemen Keperawatan Keperawatan Maternitas
oksigen dan aliran baik dengan criteria darah
hasil:
bila pecah ketuban c. Instuksikan untuk tirah
DJJ dbn
baring bila presentasi tidak
Presentasi kepala (+)
masuk pelvis
Kontraksi teratur
uterus
d. Pantau turunnya janin pada jalan lahir
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Departemen Keperawatan Keperawatan Maternitas
NO
DIAGNOSA
NOC
NIC
KEPERAWATAN
1.
Nyeri
akut
tekanan pada presentasi
b/d
Setelah
dilakukan
mekanis asuhan keperawatan bagian selama….,diharapka n
nyeri
terkontrol
a. Identifikasi
derajat
ketidaknyamanan b. Berikan
tanda/
tindakan
kenyamanan seperti perawatan
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Departemen Keperawatan Keperawatan Maternitas
D. KALA III 1. PENGKAJIAN KALA III
a) Pelepasan plasenta ditandai oleh tanda-tanda berikut: 1) Adanya kontraksi yang kuat 2) Perubahan pada bentuk uterus dari bentuk lonjong ke bentuk bulat pipih sehingga plasenta bergerak bergerak kebagian bawah
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Departemen Keperawatan Keperawatan Maternitas
NO
DIAGNOSA
NOC
NIC
KEPERAWATAN
1.
Risiko
tinggi Setelah
dilakukan
terhadap kekurangan asuhan
keperawatan
volume
cairan
b/d
kurang masukan oral,
selama….,diharapkan cairan
seimbang
a. Instruksikan klien untuk mendorong pada kontraksi b. Kaji tanda vital setelah pemberian oksitosin
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Departemen Keperawatan Keperawatan Maternitas
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Departemen Keperawatan Keperawatan Maternitas
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Departemen Keperawatan Keperawatan Maternitas
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Departemen Keperawatan Keperawatan Maternitas