PRELIMINARY REPORT MATERNITY NURSING

UTERINE PROLAPSE

Arranged by:

DEVI LAILIN NAJAH

P1337420617068

POLYTECHNIC OF HEALTH MINISTRY OF HEALTH SEMARANG

NURSING DEPARTMENT OF SEMARANG

2019
A. BASIC CONCEPTS

1. Definition
Uterine prolapse is the circumstances in which it occurs when the ligaments that
support the uterus cardinal and vagina does not return to normal after delivery (Bobak
LM; 2002)
Prolpas uteri is the decline in the uterus of a regular place because of muscle
weakness or fascia that normally support it, or fall in the uterus by pelvic or genital
(Winkjosastro, 2007).
Uterine prolapse is the descent of the uterus through the pelvic or genital hiatus
caused by the weakening of the pelvic floor muscles, especially the levator ani muscles,
ligaments and fascia that support the uterus, so that the uterus drops into the vagina and
possibly out of the vagina. This can affect the quality of life that is a result of the
suppression and the discomfort of uterine prolapse (Faraj R & Broome J, 2009).
Uterine prolapse is one of pelvic organ prolapse and become the number two
most common cases after cystourethrocele (bladder and urethral prolapse) (Barsoom RS
& Dyne PL 2011).

2.Classification
To classify pelvic organ prolapse developed several practical purposes
sistem.Untuk clinical, Baden-Walker system developed extensively, while the system
of Pelvic Organ Prolapse Quantification (POP-Q) have been widely used for clinical
practice and resesarch on Baden-Walker system, checks carried out in patients with
lithotomy position. Then the patient is asked meneran, after it was rated a decrease
prolapse and graded according to the degree of prolapse as follows:
stage 0 : Normal position for each location
stage 1 : Reduction of up to half the distance to the hymen
stage 2 : Prolapse tip down to the hymen
stage 3 : Half till end prolapse outside the vagina
stage 4 : End more than half of existing prolapse outside the vagina

(Standring S, Ellis H, Healy JC, 2008)

 3. Etiology
Parturition occurs repeatedly and too often, in labor with
complications, a cause of uterine prolapse, and exacerbating existing prolapse.
Other factors are pulling the fetus at the opening is not yet complete, Prasat
excessive Crede to remove the placenta, and so on. So it's not surprising that
genital prolapse occurs immediately after parturition or during childbirth.
Ascites and tumors in the pelvis predisposes to uterine prolapse. When
prolapse of the uterus is found in nulliparous, the causes are congenital
abnormalities such as weakness of the supporting tissues of the uterus.
(Wiknjosastro H, Saifuddin AB, Rachimhadhi T, 2009)

4.pathophysiology
Normally, uterine fixation in place by muscles and ligaments form the
pelvic floor. Uterine prolapse occurs when the pelvic floor muscles and
ligaments are stretching, damage to, and weaknesses so that they are not able
to support the pelvic organs, so that the uterus and other pelvic organs fall into
introitus vaginae. Prolapse can occur as incomplete, or in some severe cases,
complete prolapse occurs so that the uterus falls to exit vagina (Barsoom RS,
Dyne PL 2011).

Picture : Uterine Prolapse

Uterine prolapse occurs in various levels, from the lightest to the uterine
prolapse totalis.Terutama due to childbirth, especially pervagina hard labor
and the presence of flaws belonging to the fascia ligament endopelviks and
muscles and fascia-fascia base in a state panggul.Juga increased intra-
abdominal pressure and chronic will facilitate the reduction of the uterus,
especially if the tone of the muscles abate such as in patients in menopause
(Mitayani, 2013).
 The uterine cervix is located outside of the vagina, will be displaced by
the women's clothing tersebut.dan eventually lead to ulcers, called ulcers
dekubitus.Jika fascia on the front wall of the vagina loose typically obstetric
trauma, he will be pushed by the bladder, causing protrusion of the front wall
of the vagina back of so-called sistokel.Sistokel that initially only mild, can be
great for the next delivery substandard, or resolved in the decline and cause
urethrokel.Urethrokel must be distinguished from the circumstances
diverticulum diverticulum urethra.Pada urethra and bladder normally just
behind the urethra there is a hole create a pouch between the urethra and
vagina.looseness fascia on the back wall of the vagina by obstetric trauma or
other causes can cause a drop in the rectum forward and causing the back wall
protruding vagina vagina, called retrokel.Enterokel kelumen is
Douglasi.Dinding vaginal cavity hernia of the back down and protrude into the
hernia depan.Kantong this may include bowel or omentum (Mitayani, 2013).

5. Pathway

Heredity, pregnancy and

childbirth, age or menopause,
multiparity, etc.

prolapsed uteri

Superior posterior wall The corpus uteri are Lack of information

of the vagina down outside the vulva about the disease

Exposure to Guggup, Panic,

Stimulate pain nerve
microorganisms and Restless
fibers

Acute pain risk of Infection Ineffective

individual coping

anxiety
5. Clinical manifestations
Symptoms are very different and individual. Sometimes patients with
one severe enough prolapse do not have any complaint, otherwise other
patients with mild prolapse have many complaints. Complaints are almost
always met:
 Feeling the presence of a lump or protruding objects in genialia
eksterna.
 The pain in the pelvis and lumbar (backache). Usually, if people lie,
complaints disappear or become less. Uterine prolapse can cause the
following symptoms:
- Expenditure of the uterine cervix vulva disturb people running and working
time. Friction portio uteri by pants cause blisters to sores and pressure sores in
the lower portion of the uterus.
- Leukorrhea due to congestion of blood vessels in the cervical region and due
to infection and injury to the lower portion of the uterus (Barsoom RS, Dyne
PL 2011).

6. complication
Complications that can accompany uterine prolapse are:
 keratinization of the vaginal mucosa and uterine portio, Procidentia uteri
accompanied by the release of the vaginal wall (inversio); because the
vaginal and cervical mucous becomes thick and wrinkled, and whitish.
 decubitus, If the cervix uteri were kept out of the vagina, the tip shifted to the
thighs and underwear; it can cause injury and inflammation, and gradually
raised decubitus ulcers. In such circumstances, to think about the possibility
of carcinoma, especially in patients aged protracted.
 Hypertrophy of the cervix uteri and elangasio Kolli, If the cervix uteri down
into the vagina while retaining tissues and backers of the uterus is still strong,
because the pull down on the uterus down and the damming of blood vessels,
cervical hypertrophy and become long anyway. The latter is called elongasio
Kolli.
 sterility, Because cervical down to near the introitus vaginae or completely
out of the vagina, it is not easy to conceive (Wiknjosastro H, Saifuddin AB,
Rachimhadhi T, 2009).
7. Supporting investigation
a. Laboratory examination
Laboratory tests are not so much help. Papanicolaou test (Pap smear
cytology) or biopsy may be indicated in rare cases of suspected carcinoma,
although it should be deferred to the primary care physician or gynecologist.
b. ultrasound examination
Ultrasound may be used to make into prolapse of other abnormalities
(Barsoom RS, Dyne PL 2011)

8. Medical Management
a. Observation
The degree of prolapse extent not associated with symptoms. Maintaining
prolapse remains in Stage I is a more appropriate choice. Some women may prefer to
observe the continuation of the prolapse. They also should check regularly to seek the
development of new symptoms or disorders (such as urinating or defecating
hampered, vaginal erosion) (Doshani A, Teo R, Mayne CJ, Tincello DG, 2007).
Conservative b.Terapi
 Pelvic floor muscle exercises
This exercise is very useful in mild prolapse, especially those that occur in the
future postpartum 6 months. The aim is to strengthen the muscles of the pelvic floor
and the muscles that affect micturition. However, research conducted by the Cochrane
review of conservative management of uterine prolapse, published in 2006 concluded
that pelvic floor muscle latiahan no scientific evidence to support. The trick is, the
patient was told pursed anus and pelvic floor tissue as usual after completion hunger
or the patient was told to imagine as if I'm diuretic and suddenly menghentikkanya.
 installation pessary
Treatment with pessary actually only palliative, which hold the uterus in place
during the pessary use. Therefore if the pessary is removed, prolapse arise again.
Despite the evidence supporting the use pessarieum not strong, they are used by 86%
of gynecologists and 98% of urogynaecologists. Pessary user principle is that the tools
create a pressure on the walls of the vagina, so that part of the vagina besereta uterus
can not go down and pass the lower vagina. Pessary is best for genital prolapse
pessary is a ring, made of plastic. If too weak pelvic floor can be used pessary Napier.

c. Surgical therapy
Uterine prolapse is usually accompanied with vaginal prolapse. So, if the
surgery for uterine prolapse, vaginal prolapse need to be addressed as well. There may
exist a vaginal prolapse requiring surgery, when there is no uterine prolapse or uterine
prolapse that is not yet needed surgery. In England and Wales in 2005-2006, 22 274
operations performed for vaginal prolapse. Some literature reports that from uterine
prolapse surgery, accompanied by vaginal prolapse repair at the same time.
Indications for surgery on uterine prolapse depends on several factors, such as patient
age, the desire to still have a child or to preserve the uterus, the degree of prolapse,
and their complaints. Various kinds of surgery for uterine prolapse as follows: 8
 Ventrofiksasi:In women who are still relatively young and still want
children, surgery for uterine ventrofiksasi by way of shortening the round
ligaments or round ligament bind to the abdominal wall or surgically
Purandare.
 Operation Manchester: At this operation is usually performed amputation of
the uterine cervix, and suturing the cardinal ligaments that have been cut, in
front of the anterior cervical done anyway kolporafia and
kolpoperineoplastik. Amputation of the cervix is made to shorten the
elongated cervical (elo ngasio Kolli). This action can cause infertility,
abortion, obstructed labor prematurus and cervical dystocia during labor.
An important part of Manchester is the sewing operation cardinal ligaments
in front of the cervix due to this action cardinal ligaments are shortened, so
that the uterus will be located in a position anteversifleksi and downs of the
uterus can be prevented.
 Vaginal Hysterectomy:This operation is right to do for uterine prolapse in
advanced, and in women who have menopause. Once the uterus is removed,
suspended from the top of the vagina round ligament right and left, up to the
ligament infundibulo pelvikum, then the operation will proceed with
anterior and kolpoperineorafi kolporafi to prevent vaginal prolapse later in
life.
 Kolpokleisis (operation Neugebauer-Le Fort):At the time of medicine and
anesthesia delivery and care of pre / post-operation has not been kind to old
ladies who are no longer active sex can be a simple operation to sew the
front vaginal wall to the rear wall of the vagina, so that the uterine lumen
vagian enclosed and located on top of the vagina. However, this surgery
does not correct the cystocele and retrokel that can lead to incontinence
urinae. Obstipasi prolapse and other complaints also not lost.
A. CONCEPT OF NURSING CARE

1. assessment
1.1 Subjective Data
a. Biography
Prolpase uteri are more often found in women who have given birth, the
old lady and women who work hard (Wiknjosastro, 2007).
b. Main complaint
Symptoms and signs are very different and individual. Sometimes patients
with one severe enough uterine prolapse do not have any complaint, on the
contrary, other people with mild prolapse have many complaints. Complaints
complaint most often occur:
 Feelings of some objects that block or stand
 Pain in the hips and waist, usually when the patient was lying,
complaints disappear and be reduced.
(Wiknjosastro, 2007).
c. History of Nursing
 Menstruation
Early menstruation at age 11 or younger. Regular menstrual cycles,
irregular, exceptional menstrual pain, pelvic pain during menstruation or
intercourse (Wiknjosastro, 2010: 346)
 Pregnancy history
Risk factors that cause uterine prolapse spontaneous birth lot number,
overweight, history of operations in the area, coughing in the long term while
pregnant.
 labor history
Parturition which occurs terlamapu repeatedly and often obstructed
labor is the cause of the prolapse complicated by Genetalis and exacerbate
existing prolpas. Another factor is the pull factor of the fetus at the opening is
not yet complete. When prolpas uteri found in mulipara, the causes are
congenital abnormalities such as weakness of the supporting tissues of the
uterus (Wiknjosastro, 2007).
d. The pattern of daily habits
1) Elimination of cystocele can cause these symptoms:
a) Miksi frequently and in small increments. Early in the afternoon,
then more severe at night
b) feeling like the bladder can not be emptied completely
 c) Stress incontinence is unable to hold urine when coughing and
straining. Sometimes the urine retention can occur on a large cystocele
once rectocele can be a nuisance on defecation
2) Activity and Expenditure rest of the uterine cervix vulva interfere
patient when walking and activity. Friction portio uteri by pants can
causing blisters to sores on porsio.

1.2 Objective Data

a. The general state of the weak
b. Vital sign
c. Physical examination :
1) Face: pale Looks sign of anemia, cold sweat when going on in shock. If the
bleeding of the conjunctiva looks anemic. On the client with pain client looks
grimace. (Manuaba, 1998: 410).
2) Mouth: lips and oral mucosa pale, Kelon odor in the mouth in case of
severe hypovolemic shock.
3) The chest and breasts: rapid breathing movement for their efforts to meet
the needs of O2 due to the levels of O 2 in the blood is high, the state of the
heart is not abnormal.
4) Abdomen: A lump in the lower abdomen (Sastrawinata, 1981: 158).
Palpable mass in the lower abdomen consistent hard / chewy, irregular,
motion, no pain, but sometimes encountered pain (Sastrawinata, 1981: 160).
5) genitalia: In mild cases, part of the uterus down to the top of the vagina and
in very severe cases can occur protrude through the vaginal orifice and being
outside the vagina.
6) Anus: There will be haemoroid, injuries and varices rupture due to
circumstances myomas obstipasi due emphasis on the rectum.
7) Extremities: edema of the lower limbs due to the pressure on the inferior
vena cava (Sastrawinata, 1981: 159).

d. Supporting investigation
Investigations can be carried out, namely
a. Post-voiding residual urine
b. The ability of emptying the bladder needs to be assessed by measuring the
volume of urination when patients feel full bladder, followed by
measurement of residual urine volume after voiding by catheterization or
ultrasonography.
 c. Screening for urinary tract infections.
d. Ultrasound examination

2. Nursing diagnoses
1.1 Nursing diagnoses that may arise
Diagnosis 1: Acute Pain (00132)
a. Factors related:
Injury-causing agents; biological, chemical, physical and psychological
Objectives and expected outcomes Nursing interventions and rationale

NOC: NIC:
 Pain Level,  Perform a comprehensive pain
 pain control, assessment including location,
 comfort level characteristics, duration, frequency,
After the actions of any nursing during quality and precipitation factors
.... Patients do not experience pain,  Observation of nonverbal reactions
with expected outcomes: of discomfort
 Being able to control the pain (to  Help patients and families to seek
know the cause of pain, was able to and find support
use nonpharmacological techniques  Control environment that may
to reduce pain, seek help) influence pain such as room
 Reported that pain was reduced by temperature, lighting and noise
the use of pain management  Reduce pain precipitation factors
 Being able to recognize pain (scale,  Assess the type and source of pain
intensity, frequency and signs of to determine interventions
pain)  Teach about non-pharmacological
 Stating feeling comfortable after the techniques: dala breath, relaxation,
pain has subsided distraction, compress warm / cold
 Vital signs within normal range  Give analgesics to reduce pain: ......
 Not having trouble sleeping ...
 Increase break
 Provide information about the
causes of pain such as pain, how
long the pain will be eased and the
anticipation of discomfort from the
procedure
Monitor vital signs before and after
the first analgesic administration

Diagnosis 2: Anxiety (00146)

a. Factors related
1) Crisis situation and maturation
2) stress
3) Threats or changes in the status of the role, role function, environment,
health status, economic status, or patterns of interaction
 4) Threats of self-concept

Goals and Criteria Results a. Intervention and

Rationale

NOC: Anxiety is reduced, as a) assess and document the

evidenced by the level of patient's level of anxiety,
anxiety only mild to including physical reaction
moderate and obtaining show b) to examine cultural factors that
restraint against anxiety, self- cause anxiety
esteem, koping.Kriteria c) determining the patient's
results: decision-making ability
1) Planning a coping d) Teach family members how to
strategy to a distinguish between panic
stressful situation attacks and symptoms of
2) Maintaining the physical illness
performance of the e) Instruct the patient about the use
role of relaxation techniques
3) Monitor distortions f) give medication to reduce
of perception anxiety if necessary
4) Monitor the g) Use a calm and reassuring
behavioral approach
manifestations of h) Help the patient to identify
anxiety situations that trigger anxiety
5) Using relaxation
techniques to relieve
anxiety

Diagnosis 3: Risk of infection (00004)

These risk factors:

- invasive procedures
- Tissue damage and increased environmental exposure
- Imonusupresi
- Inadequate secondary defenses (decreased hemoglobin, Leukopenia,
suppression of inflammatory responses)
- chronic diseases
 Goals and outcomes Nursing interventions and rational:
NOC: NIC:
 immune Status  Keep technique aseptif
 Knowledge: Infection control  Limit visitors when necessary
 risk control  Wash hands before and after each
After nursing actions during ...... nursing action
patients do not have an infection with  Use clothes, gloves as a protective
outcomes: device
 Client is free of signs and symptoms  Change the location of a peripheral IV
of infection and dressing in accordance with the
 Demonstrated ability to prevent general instructions
infection  Use intermittent catheters to reduce
 The number of leukocytes in the bladder infection
normal range  Increase intake of nutrients
 Show healthy behavior  Give antibiotic therapy:
 Immune status, gastrointestinal, .................................
genitourinary within normal limits  Monitor for signs and symptoms of
systemic and local infections
 Maintain isolation techniques k / p
 Inspection of skin and mucous
membranes of the redness, heat,
drainage
 Monitor the wound
 Encourage fluid intake
 Push break
 Teach the patient and family signs
and symptoms of infection
 Assess the body temperature in
neutropenic patients every 4 hours
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