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RUMAH SAKIT GRAHA HUSADA

Jl. Gajah Mada No. 6 GH Bandar Lampung

Telp. 0721 – 240000 Fax. 0721 - 242787


CEKLIST INISIASI MENYUSU DINI
Nama ibu : ....................................................................................................
Umur : ....................................................................................................
No.RM : ....................................................................................................
Tanggal dan Jam bayi lahir : ....................................................................................................
Jenis persalinan :
a. Persalinan normal
b. Persalinan dengan vakum ekstraksi
c. Persalinan dengan forceps
d. SC dengan spinal atau epidural
e. SC dengan anastesi umum
Episiotomi : ....................................................................................................
Penggunaan obat-obatan lain : ....................................................................................................
Kontak kulit dengan kulit : ....................................................................................................
Waktu mulai :.....................................................................................................
Waktu mengakhiri : ....................................................................................................
Lama kontak : ....................................................................................................
Alasan mengakhiri kontak kulit ke kulit : ............................................................................
............................................................................
Saat bayi menyusu pertama kali : ............................................................................
Tanggal dan jam menolong menyusui kedua : ............................................................................
Catatan : ............................................................................

Petugas Ruang Kebidanan/Neonatus

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