Family Nursing with

Childbearing Families (p.288)

Nur Lailatul M., MNS
 Historical Perspective of Childbearing
Family Nursing
Late 1800s: Industrialization
■ Setting keluarga beralih ke daerah perkotaan, sehingga
fungsi dan ukuran rumah tangga terjadi perubahan
■ Traditional networks perempuan tdk selalu tersedia
(nenek/ ibu mertua), dan peran ibu dibutuhkan untuk
menggantikan perawatan yg sebelumnya dilakukan di
rumah
■ Childbearing still occurred at home for many middle-
class families (Leavitt, 1986; Wertz & Wertz, 1989).
 Sebelum abad 20

■ RS menjadi tempat untuk persalinan dan early postpartum

recovery untuk middle-class families.
■ Many immigrant and working-class urban families continued to
have newborns at home with their traditional care providers.
■ Mendorong perkembangan public health nursing untuk lebih
memperhatikan kesehatan ibu dan bayi/anak di area urban
■ Menyadari bhw kebutuhan kesehatan dari seluruh anggota klg
saling berkaitan, early public health nurses considered families,
not individuals, as their clients.
 1930s Through the “Baby Boom” of the
1950s
■ Adanya perubahan pola persalinan di RS yang meningkat
tajam, keterlibatan klg dlm perawatan anak mengalami
penurunan (Leavitt, 1986).
■ Dengan adanya upaya untuk menurunkan/ mengontrol
infeksi, menyebabkan perpisahan dengan anggota klg
Bayi dipisahkan dengan ibunya ( dirawat di ruang khusus
bayi ) dan hanya didekatkan ke ibunya pada saat waktunya
menyusui.
 1960-an sampai dengan 1970-an
■ Kaum perempuan dan beberapa dokter mulai mempertanyakan
penggunaan obat penenang dan anti nyeri untuk proses persalinan,
dan lebih mengutamakan proses persalinan normal/ alami
■ Gambaran persalinan alami adalah adanya hubungan yang erat
antara perempuan yg melahirkan dg seseorang yg dinilai supportive
dlm proses persalinan, and in North America, husbands assumed this
supportive role (Wertz & Wertz, 1989).
■ Klg berusaha untuk mendptkan layanan dari dokter dan RS yang
sesuai dg harapan mereka ( yg memungkinkan keterlibatan suami dlm
proses persalinan dan rawat gabung ). Childbearing berubah dr
konteks RS ke keluarga
 Next....
■ Beberapa RS bersalin mulai mempertimbangkan
memberikan pelayanan dlm bentuk perawat ibu dan anak dari
pada nursery atau perawat postpartum, dan perawat
penolong persalinan kerap berkolaborasi dengan anggota
keluarga untuk menolong ibu dalam mengatasi nyeri
persalinan
 1980s to the Present
■ Klaus and Kennel’s research (1976) mendorong pertumbuhan
family-centered care
Family-centered care (FCC) is a partnership approach to health
care decision-making between the family and health care
provider. FCC is considered the standard of pediatric health care
by many clinical practices, hospitals, and health care groups.
■ Childbearing care ditandai dengan keterlibatan seluruh anggota
keluarga dalam perawatan anak
■ Beberapa RS merubah nama layanan obstetrinya menjadi Family
Birth Center untuk mempromosikan betapa pentingnya peranan
anggota klg dalam perawatan kesehatan Childbearing
 Definisi childbearing family nursing
Perubahan fokus dari perawatan individual kepada pentingnya peran
keluarga dlm perawatan mulai dari preconception sampai dg periode
postpartum period dikenal sebagai childbearing family nursing
(Kaakinen, J.R et al, 2010)
• Childbearing family nursing, considers the family as client, the family as
context for the care of its members, or both primarily.
• It is a health and wellness, rather than an illness model of care.
• Family nursing with childbearing families covers : the period before
conception, pregnancy, labor, birth, and the postpartum period
Childbearing Family :
• Keluarga baru / tahap perkembangan keluarga =
tahap II (Friedman, 2002)
• Adalah keluarga yang dimulai dengan kelahiran anak
pertama dan berlanjut sampai dengan bayi berusia
30 bln
• Tahap yang penuh dengan stressor karena tahap
transisi menjadi orang tua dan berpotensi
menimbulkan krisis
 THEORY-GUIDED, EVIDENCEBASED
CHILDBEARING NURSING
Family Systems Theory
• Sebuah keluarga yang sedang dalam proses perubahan karena dinamika yang
ada didalamnya, cenderung akan memiliki batasan yang permeabel atau lbh
terbuka terhadap lingkungan diluar klg, hal tsb disebabkan klg membutuhkan
sumber2/ dukungan yang lebih besar.
• Sehingga keluarga akan meningkatkan interaksi dengan sistem diluar klg dan
mungkin menjadi lebih receptive thd intervensi, contohnya : health education
(Martell, 2005).
• Batas yang terbuka memungkinkan perawat untuk memberikan health
promotion
Family Developmental Theory
Tahap Perkembangan Keluarga
Berdasar Konsep Duvall Dan Miller ( Friedman,1998 )

• Tahap I : Pasangan Baru (Keluarga Baru )

• Tahap II : Keluarga Kelahiran Anak Pertama
• Tahap III : Keluarga dengan Anak Pra-Sekolah
• Tahap IV : Keluarga dengan Anak Sekolah
• Tahap V : Keluarga dengan Anak Remaja
• Tahap VI : Keluarga dengan Anak Dewasa ( Pelepasan )
• Tahap VII : Keluarga Usia Pertengahan
• Tahap VIII : Keluarga Usia Lanjut
 Family Developmental and Life Cycle Theory
• Teori ini menjelaskan suatu proses perkembangan individu dlm keluarga
yang terjadi secara terus menerus dan dapat diprediksi.
• Meskipun siklus hidup dari sebagian besar keluarga diseluruh dunia
mengikuti tahapan yang universal dari perkembangan keluarga, penting bagi
perawat keluarga untuk mengenali macam2 variasi yang terjadi dalam hal
waktu dan tahapan dari siklus hidup klg
• Saat ini beberapa siklus hidup klg tdk mengikuti tahapan perkembangan
keluarga (menurut Duvall & Miller, 1985)
• For example, families might be blended with one or both partners having
children from previous relationships; parents also may be cohabitating,
unmarried, single, of the same sex, or have children born later in life (Berk,
2007; Pillitteri, 2003).
• Family Developmental and Life Cycle
Theory menjadi acuan praktek kep keluarga
karena memberikan gambaran ttg pola
adaptasi bagi oarang tua dg bermacam-
macam latar belakang klg
• Teori ini relevan untuk perawat keluarga
berkenaan dg bagaimana keluarga
terbentuk dan bagaimana masing-masing
anggota keluarga mampu menjalankan
tugas pentingnya shg sebagai healthy unit
mampu mempertahankan kesehatan scr
keseluruhan
(Pillitteri, 2003).
9 Tugas untuk childbearing families dan
Intervensi Keperawatan
1. TASK ONE: Penyediaan/ Pengaturan tempat/ ruang untuk anak

2. TASK TWO: Pembiayaan Childbearing dan Pengasuhan anak

3. TASK THREE: Bertanggung jawab dalam perawatan dan pemeliharaan anak

4. TASK FOUR: Memfasilitasi Peran belajar bagi seluruh anggota keluarga

5. TASK FIVE: Penyesuaian terhadap perubahan pola komunikasi

6. TASK SIX: Perencanaan kehadiran anak berikutnya

7. TASK SEVEN: Pengaturan ulang pola antar generasi

8. TASK EIGHT: MAINTAINING FAMILY MEMBERS’ MOTIVATION AND MORALE

9. TASK NINE: ESTABLISHING FAMILY RITUALS AND ROUTINES

1. ARRANGING SPACE (TERRITORY) FOR A CHILD
Family Nursing Interventions
■ Mengkaji kecukupan area tempat tinggal, persiapan fisik dan material yang dimiliki oleh seluruh
klg

■ Menggali pemikiran, nilai, kepercayaan dan rasa takut yang kemungkinan muncul akan
persiapan akan kehadiran bayi

■ Bantu keluarga untuk mengeksplorasi dan memanage ketakutan mereka akan kemampuannya
untuk mempertahankan kesehatan bayi sehingga kemudian mampu menggunakan sumber2
untuk membantu mereka dalam mengatasinya, sehingga tugas perkembangan keluarga dapat
berlanjut
Next......
■ Bantu remaja untuk mencari
cara u dapat
mengkomunikasikan kepada
orang tua mereka dan membuat
rencana untuk masa depan bayi
dan bagaimana menjadi orang
tua dimasa remaja

■ Rujuk keluarga yang tidak

memiliki tempat tinggal
(homeless or live in inadequate
or unsafe housing) ke tempat
yang lebih layak
2. FINANCING CHILDBEARING AND CHILDREARING
Family Nursing Interventions
■ Bantu klg untuk mengeksplore sumber2 yang dibutuhkan , spt :
program nutrisi, prenatal klinik, yg sesuai dg kemampuan finansial
klg
• Provide families with information and resources that will help
them choose safe and appropriate child care.
■ Identifikasi hambatan perawatan prenatal, contoh : tidak
memiliki alat transportasi, jam layanan kesehatan yang tidak
matching dg jam kerja
3. ASSUMING MUTUAL RESPONSIBILITY FOR
CHILD CARE AND NURTURING
Family Nursing Interventions
■ Educate parents about the realities of parenting, such as
interrupted sleep and a change in how time is spent.
■ Teach a family to alternate who responds to the baby’s needs,
including feeding, changing, and comforting.
■ Assist parents to develop new skills in care giving and ways of
interacting with their babies.
■ Observasi tanda-tanda kedekatan (antara org tua dg baby) dengan
cara mendengarkan apa yang orang tua ceritakan tentang bayinya
dan perhatikan perilakunya
■ Rujuk keluarga yang menunjukkan perilaku tidak mampu
melakukan perawatan terhadap anak mereka, kepada tenaga
professional untuk mendapatkan intervensi yg intensif
4. FACILITATING ROLE LEARNING OF FAMILY MEMBERS
Family Nursing Interventions

■ Bantu dan dorong pasangan suami-istri untuk mengeksplore sikap dan harapan
mereka akan peran pasangannya

■ Dorong orang tua untuk mengikuti kelas parenting, khususnya bagi orang tua yang
menjalani isolasi, masih berusia remaja, atau scr kultur berbeda dan hidup terpisah
dengan traditional networks mereka

■ Dorong para ibu untuk mengajak suaminya ikut merasakan/ sharing their physical
sensations and emotions of being pregnant.

■ Provide opportunities for fathers and other partners to become skilled infant
caregivers.
 5. ADJUSTING TO CHANGED COMMUNICATION
PATTERNS
Family Nursing Interventions
■ Berikan orang tua pendidikan kesehatan tentang berbagai karakter/ sifat bayi
shg mereka mampu menginterpretasikan their baby’s unique style of
communication.
■ Encourage parents to talk to and engage in eye contact with the baby.
■ Incorporate couple communication into care and education of expectant
parents.
■ Promote effective couple communication by encouraging the partners to listen
to each other actively
■ Encourage couples to set aside a regular time to talk and enjoy each other as
loving partners.
6. PLANNING FOR SUBSEQUENT CHILDREN
Family Nursing Interventions
■ Pertimbangkan kultur keluarga dan latar belakang
religiusnya, dan identifikasi struktur kekuatan serta
bagaimana proses membuat keputusan dalam keluarga
terutama berkaitan dg fungsi reproduksi
■ Berikan informasi lengkap disertai data yang akurat
tentang berbagai pilihan metode kontrasepsi
■ Refer to a nurse genetic specialist for assessment and
counseling when appropriate.
7. REALIGNING INTERGENERATIONAL
PATTERNS
Family Nursing Interventions
■ Childbearing changes relationships within extended families. The
parents’ siblings become aunts and uncles, children from previous
relationships become stepsiblings, and their own parents become
grandparents.
Assist new parents to seek support from friends, family members,
organized parent groups, and work colleagues as a way to cope with
the demands of parenting.
■ Facilitate partner discussions about perceptions of extended family
involvement in care of the new child.
8. MAINTAINING FAMILY MEMBERS’ MOTIVATION AND
MORALE
Family Nursing Interventions
■ Berikan informasi kepada anggota keluarga ttg
strategi mempertahankan rasa nyaman, istirahat –
tidur adekuat, sehingga akan mengurangi rasa lelah
( yg berpotensi menurunkan motivasi )
• Diskusikan bersama keluarga ttg pembagian
peran/ tanggungjawab, sehingga khususnya
menghadapi situasi bayi menangis malam hari
karena lapar/ eliminasi
■ Teach parents ways to cope with a crying infant,
which will boost family morale, increase confidence,
and allow family members to get additional sleep.
 Next......
■ Berikan informasi kpd orang tua tentang strategi untuk meurunkan
stress karena perasaan terisolasi (menyendiri) dengan mencari
dukungan dari support system ( teman, orang tua, organized parents
group)
■ Dorong orang tua untuk dapat menyampaikan kebutuhan mereka
dan mencari pertolongan yang dpt menunjang harga diri mereka
sebagai orang tua baru
■ Diskusikan tentang perubahan sexuality setelah proses persalinan
and help them develop mutually satisfying sexual expression.
■ Help families to develop strategies that maintain their couple
activities, adult interests, and friendships.
9. ESTABLISHING FAMILY RITUALS AND ROUTINES

Family Nursing Interventions

■ Determine the special cultural meaning each ritual has for the family
and respect those meanings.
■ Encourage families to carry out their usual routines and established
rituals related to their babies and other children.
■ Facilitate couple discussion of bedtime and bathing routines, a
baby’s special possessions such as a treasured blanket, nicknames,
language for body functions, and welcoming rituals such as
announcements, baptisms, circumcision, or other celebrations.
CHILDBEARING FAMILY STRESSORS
1. Infertility
Common Symptoms and Stressors Infertile Couples May Experience
■ Irritability
■ Insomnia
■ Tension
■ Depression
■ Increased anxiety
■ Anger toward each other, God, friends and other fertile women
■ Feel rejected, alienated, stigmatized, isolated and estranged
Nursing Interventions that are Helpful to
Couples Dealing with Infertility
■ Sarankan untuk menghindari saling menyalahkan baik pasangan
maupun orang lain
■ Fasilitasi komunikasi antara pasangan untuk mengekspresikan
perasaan mereka dan respon terhadap pengalaman infertil
■ Berikan informasi yang lengkap terkait biaya dan asuransi untuk
treatment infertil
■ Sarankan untuk melakukan aktivitas yang dapat membantu
menurunkan stress
■ Refer to support groups and/or other professionals for counseling.
2. Adoption
International and Transracial Adoption:
Issues and Challenges to Families Before International and Transracial
Adoption
■ Kemampuan untuk perjalanan menjemput anak adopsi
■ Merubah status kewarganegaraan yang mungkin rumit dan butuh waktu
■ Berbagai cara keluarga akan berusaha mempertahankan status pewaris asli
bagi anak yang diadopsi
■ Berbagai cara keluarga untuk mengatasi masalah terkait berbedaan ras dan
prasangka2 yang lain
Issues and Challenges to Families After International Adoption
■ Terbatasnya sumber2 post-adoption contoh : pediatricians trained in
international adoption or international adoption clinics for families seeking
help for a child’s developmental and behavioral problems
■ Child’s emotional and developmental issues can be exhausting and financially
tax the family
Issues and Challenges to Families After Transracial
Adoption
■ Need to redefine the family as multiracial and multiethnic when
white families adopt non-white children
■ Extra attention and comments about the child’s looks from
strangers in public places
■ Neighbors, family members, and others may express prejudice
toward the child
 Nurse Interventions for Adoptive Families
■ Encourage families to seek help from adoption experts and agencies
■ Refer families to adoption specialists such as social workers and counselors
■ Recommend families speak with and secure pediatric providers during the pre-
adoptive process
■ Recommend adoptive parents attend parenting classes and include them in prenatal
and infant care classes
■ Incorporate adoptive sensitive material into classes and other educational resources
■ Keep lines of communication open between nurses and adoptive families as a way to
alleviate fears about being judged or undermined
■ Address other siblings’ response to the adopted child because a biological child’s
feelings of inferiority or superiority to an adopted child can interfere with relationships
within the family
4. Perinatal Loss
Loss of a child during pregnancy, after birth, or
in the early postpartum period is one of the
hardest losses for a family.
Types of Perinatal Loss Families May
Experience
■ Miscarriage
■ Elective abortion
■ Ectopic pregnancy
■ Selective reduction after in vitro implantation
of multiple fertilized eggs
■ Stillbirth ( lahir mati)
■ Death of a child after a live birth
■ Recurrent pregnancy loss
■ Loss of a perfect child because of anomalies
or malformations
■ Death of a twin during pregnancy, labor,
birth, or after birth
■ Termination of pregnancy for identified fetal
anomalies, which is increasing because of
technologic advances in prenatal diagnosis of
such anomalies
Perinatal Loss Cultural Practices and Rituals
■ Jewish families may request to remain with the body at all times out of respect.
Newborns are named and circumcised at burial so they can be included in family
records.
■ Muslim babies born after more than 4 months’ gestation are to be named, bathed,
wrapped in a seamless white sheet, and buried within 24 hours. Bodies are buried intact,
so taking locks of hair is not permitted.
■ Puerto Rican families may call on faith healers and spiritualists to assist the baby on
their journey into the next life.
■ Roma (gypsy) families want to avoid any association between death and bad
luck/impurity (mahrime), so they may leave the hospital suddenly and shift
responsibility for burial to the hospital.
■ American Indians/Alaskan Natives may request to remain with the baby until death to
pray and perform a ritual.
 Family Nursing Interventions for Childbearing
Families who are Experiencing Chronic Threats
to Health
Assuming Household Tasks

■ Help families find ways to streamline and prioritize household tasks to reduce stress
and increase adherence to medical regimens.

■ Assist adults to list household management tasks and determine who does what when
so that the family can be more efficient and effective in managing these tasks.

■ Educate families about the impact of parents’ health difficulties on children.

■ Provide practical, age-appropriate suggestions for managing children such as hiring a

teenager after school for active play with young children.

■ Encourage parents to provide ways for young children to have some quiet one-on-one
time with their mothers as a way to reduce stress for both mothers and children.
 Next...
Managing Changes in Income and Resources
■ Refer to an appropriate counselor who can assist the family explore ways to manage
financial problems.
■ Assist families to identify others outside of the nuclear family who can assume various
household tasks such as meal preparation, laundry, and cleaning.
■ Help families identify and use resources, such as home-health agencies and parents’
groups in the community, that will assist with household management.
■ Encourage families with necessary resources to use a computer to connect with each
other, friends, coworkers, and other at-risk families to prevent or decrease feelings of
isolation.
■ Direct families to appropriate Internet sites such as the ones listed in the Selected
Resources section at the end of this chapter.
 Next.....
Facing Uncertainty and Separation and Loss: Nursing Interventions

■ Acknowledge the difficulties of uncertainties associated with difficult perinatal situations.

■ Be honest and informative about the condition and prognosis of both the mother and fetus.

■ Use terms understood by all family members to provide accurate and thorough explanations
tailored to families’ anxiety levels.

■ Assist families to cope with basic tasks of living in high-tech settings such as the neonatal intensive
care unit.

■ Investigate and reduce the barriers families encounter at the distant perinatal center, such as lack
of transportation, other responsibilities, employment, and the threatening environment of the
setting.

■ Provide families with information on where to stay, how to find reasonably priced meals, how to
obtain transportation, or where to park a car.
 Next...
Encourage use of electronic communication, such as e-mail,
which facilitates contact between family members and health
care professionals.
■ Encourage calling families about their members’ progress
and sending photographs as a way to help families cope with
uncertainty and enhance relationships of physically
separated family members.
■ Encourage family members to participate in care of their
infants to promote development of parenting skills.
 FAMILY NURSING OF POSTPARTUM FAMILIES
1. Feeding Management
A family’s comfort with its infant feeding method is as crucial for physical, emotional, and social
well-being of the infant as the food itself.
2. Attachment
Positive parent-infant attachment must take place to foster optimal growth and development of
infants, as well as to encourage the parent-infant love relationship.
3. Sibling
No matter what age siblings are, the addition of a new baby affects the position, role, and power of
older children, thereby creating stress for both parents and children.
4. Postpartum Depression
The period after childbirth can be a stressful time for women because of their need to face the new
tasks of the maternal role. Changes in relationships, economic demands, and social support also
take place during this time and can result in postpartum stress (Hung, 2005).
Signs of Postpartum Depression
• Sadness • Lack of concern about personal
appearance
• Frequent crying
• Feelings of worthlessness
• Insomnia or excessive sleeping
• Fatigue or loss of energy
• Lack of interest or pleasure in usual
activities, including sexual relations • Depressed mood

• Difficulties thinking, concentrating, • Thoughts of death: suicidal ideation

or making decisions without a plan; suicide plan or
attempt
Nursing Interventions for Postpartum
Depression
Help women differentiate between myths of the mother role, which imply at 6
weeks after birth women are ready to resume all their previous activities, versus
the reality of motherhood where pre-pregnancy clothes do not fit, infants
periodically become demanding malcontents, and houses are messy because
family members are too exhausted to clean.

■ Encourage women with postpartum depression to share feelings as they grieve

the loss of who they were and begin to build on who they are becoming.

Encourage women to seek help with symptoms of anxiety, anger, obsessive

thinking, fear, guilt, and/or suicidal thoughts.

■ Assist women to recreate, restructure, and integrate changes that new

motherhood brings into their daily lives.

■ Develop standard protocols for screening of men whose partners are depressed
after childbirth.
IMPLICATIONS FOR FAMILY NURSING
PRACTICE
The concerns of childbearing family nursing go beyond care of the individual
family. Nurses are participants in guiding nursing practice, developing and using
research, and setting and implementing policy.

• PRACTICE

• RESEARCH

• POLICY
WASSALAM
Q&A