Lppersalinan 2019

LAPORAN PERSALINAN

I.

PENGKAJIAN AWAL 1.

Tanggal :...............................jam................

2.

Tanda-tanda vital:TD.........mmHg, Nadi.........x/menit, suhu ......C,P..............x/menit

3.

Pemeriksaan palpasi Abdomen..............................................................................................................

II.

4.

Hasil periksa dalam:.....................................................................................

5.

Persiapan perineum:....................................................................................

6.

Dilakukan klisma, (ya/tidak), jelaskan...............................................

KALA PERSALINAN a. Kala I Mulai persalinan: tanggal.......................jam.......................... Tanda dan gejala:..................................................................................

Tanda-tanda vital:TD............mmHg, Nadi ...........x/menit, suhu ....C,P........x/menit Lama kala I.....................jam..................menit...............detik Keadaan

Psikososial............................................................................................ Kebutuhan khusus klien.............................................................. Tindakan:...............................................................................................

............................................................................................................................. Pengobatan :........................................................................................ ......................................................................................................................... ........................................................................................................................ Observasi kemajuan persalinan:..........................................................

b. Kala II 1. Kala II dimulai : Tanggal : .................., jam : .................... 2. Tanda-tanda Vital : TD: ..................... Nadi : ......................... P : ................................ Suhu : 3. Lama kala II ....................... jam................... menit.................detik 4. Tanda dan gejala : ............................................... 5. Upaya meneran ................................................................... 6. Keadaan psikososial ............................................... 7. Kebutuuhan Khusus .................................................... 8. Tindakan ............................................................ 9. Catatan Kelahiran Bayi lahir jam : ...............

Nilai APGAR menit 1 : ........................, menit 5 : ..................... Perineum : (utuh/episiotomy/ruptur), jika ruptur, tingkat ......... Bonding ibu dan bayi : ........................................ Tanda-tanda vital, TD : ................, nadi : .............., P : ............., Suhu : ...... Obat-obatan : ............................................................................................. c. Kala III Tanda dan gejala................................................................................................. Plasenta lahir jam................................................................................................ Cara lahir plasenta.............................................................................................. Karakteristrik plasenta: ukuran ............cm x........cm x...............cm Panjang tali pusat .........................................cm

Jumlah prmbulu darah:.........................arteri.................vena Kelainan:................................................................................................ Pendrahan:..........ml, karakteristrik................................................................... Keadaan Psikososial........................................................................................................................ Kebutuhan Khusus ..............................................................................................................................

Tindakan ............................................................................................................................ Pengobatan .......................................................................................................................

d. Kala IV Mulai jam ............................................................................................................ Tanda-tanda

vital:

TD

.................mmHg,

Nadi

...........x/menit,

suhu

.....C,P...........x/menit Kontraksi uterus ......................................................................................... Pendarahan ..................ml, karakteristrik..................................................... Bonding ibu dan bayi .............................................................................. Tindakan .............................................................................................................................. e. Bayi 1. Bayi lahir tanggal/jam ........................................................................................ 2. Jenis kelamin ............................................................................................................ 3. Nilai APGAR ................................................................................................................ 4. BB/PB/lingkaran kepala bayi .............gram............cm...........cm....

5. Karakteristrik khusus

Bayi ................................................................................................................. 6. Kaput : suksedaneum/ cephalhematom 7. Suhu .........................................C 8. Anus: berlubang/ tertutup 9. Perawatan tali pusat .............................................................................

10. Perawatan tali pusat .............................................................................

11. Perawatan mata ........................................................................................

III.

SYAIR OBSTETRI Tanggal/ Jam Jam ..................

Keterangan S:  

Mules-mules, bertambah sering Klien ingin meneran

 

Status generalis : ............. Status obstetrik : TFU:................ presentasi : ....................., djj :.................. TBJ: ................... gram His :...................................... PD : pembukaan .................... porsio teraba......................, ketuban ......................, kepala :.................... H-III, uuk kidep/kadep, hambatan jalan lahir ada/tidak, bloodslym +/-

O:

 

A:  

Ibu partus kala II, G..............P....................A.............. Janin hidup/ meninggal, presentasi : kepala/bokong, tunggal/gemelli

 

Pecahkan ketuban Pimpin meneran

P:

Jam ......................... Jam ......................

Jam ...................... Jam .........................

Ketuban dipecahkan, warna .................. jumlah ............................ bau .................. Pimpinan meneran Ibu dipimpin meneran sesuai dengan datangnya his Kepala turun sesuai jalan lahir, sehingga tampak di vulva Tampak perinium meregang, tipis, kebiruan jarak perineum-kepala minimal( dilakukan episiotomy mediolateral sesuai indikasi) Kepala mengadakan defleksi maksimal Berturut-turut lahir : uub, dahi, mulut, dagu dan seluruh kepala, kepala mengadakan paksi luar Dengan pegangan biparietal dan tarikan ke bawah dan keatas, lahir bahu depan dan belakang Kemudian lahir trochanter depan, belakang, bokong dan seluruh kaki Lahir bayi : laki-laki/perempuan Berat : ...............gram, PB : ............... cm, APGAR SCORE : ............. Lahir placenta  Spontaan, lengkap  Berat .......... gram, ukuran : ...... x ....... x ........ cm  Panjang tali pusat ......... cm  Insersio ........ cm  Robekan ................. Klien mendapat methergine 0,2 mg IM (sesuai indikasi) Kemudian dilakukan perineorafi dengan .............. simpul catgut