LAPORAN OBSERVASI PERSALINAN

A. Pengkajian Awal
1. Tanggal:
2. TTV: TD : N: RR: Suhu
3. Pemeriksaan Abdomen
a. Leopold I : _________________________________________________________
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b. Leopold II : _________________________________________________________
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c. Leopold III: _________________________________________________________
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d. Leopold IV:_________________________________________________________
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4. Hasil Periksa Dalam : _____________________________________________________
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5. Persiapan perineum : ____________________________________________________
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6. Dilakukan Klisma (ya/tidak), jelaskan ________________________________________
7. Pengeluaran pervaginam : ________________________________________________
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8. Perdarahan pervaginam ( ya/tidak ), jelaskan _________________________________
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9. Kontraksi Uterus ( frekuensi, lamanya, kekuatan): _____________________________
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10. Denyut jantung Janin (frekuensi, kualitas) : ___________________________________
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11. Status Janin ( hidup/tidak, jumlah, presentasi) : _______________________________
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B. Kala Persalinan
1. Kala I
a. Mulai kala I tanggal ....................................... Jam:
b. Tanda dan Gejala ____________________________________________________
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c. TTV : TD : N: RR: Suhu
d. Lama Kala I : .................. jam .....................menit......................detik
e. Keadaan psikososial _________________________________________________
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f. Kebutuhan khusus klien: ______________________________________________
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g. Tindakan keperawatan: _______________________________________________
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h. Pengobatan : ______________________________________________________
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2. Kala II
a. Mulai kala I tanggal ....................................... Jam:
b. Tanda dan Gejala _____________________________________________________
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c. TTV : TD : N: RR: Suhu

d. Lama Kala I : .................. jam .....................menit......................detik
e. Keadaan psikososial ___________________________________________________
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f. Kebutuhan khusus klien: _______________________________________________

g. Tindakan keperawatan: ________________________________________________

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h. Pengobatan : ________________________________________________________
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3. Kala III
a. Tanda dan gejala: ___________________________________________________
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b. Plasenta lahir jam : __________________________________________________
c. Cara lahir plasenta___________________________________________________
d. Karakteristik plasenta ________________________________________________
e. Ukuran .......................cm x ......................cm x .............................cm
f. Perdarahan: ml, karakteristik ___________________________________
g. Keadaan psikososial : ________________________________________________
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h. Kebutuhan Khusus klie : ______________________________________________
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i. Tindakan Keperawatan _______________________________________________
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j. Pengobatan : _______________________________________________________
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4. Kala IV
a. Mulai Kala IV tanggal................................jam:.....................
b. TTV: TD Nadi: Respirasi Suhu:
c. Kontraksi Uterus: ___________________________________________________
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d. Perdarahan: ml, karakteristik __________________________________
e. Bonding ibu dan bayi: ________________________________________________
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f. Tindakan : _________________________________________________________
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5. Bayi
a. Bayi lahir tanggal /jam : _____________________________________________
b. Jenis kelamin : ____________________________________________
c. Nilai APGAR : _____________________________________________
d. BB / PB / Lingkar Kepala : _____________________________________________
e. Karakteristik Khusus bayi : ____________________________________________
f. Kaput : ____________________________________________
g. Suhu : ____________________________________________
h. Anus (berlubang/tutup) : _____________________________________________
i. Perawatan tali pusat : _____________________________________________
j. Perawatan Mata : _____________________________________________