SEKOLAH TINGGI ILMU KESEHATAN (STIKES)

DARUL AZHAR BATULICIN

PROGRAM STUDI PROFESI NERS
Kampus : Komplek YPI Darul Azhar Jl. Batu Benawa, Simpang Empat, Tanah Bumbu, Kal-Sel.
Telp & Fax.(0518)75217 Kode Pos 72171

LAPORAN PERSALINAN

I. Pengkajian Awal
1. Tanggal : ....................................Jam : ...............................................................
2. Tanda-Tanda Vital
TD : ............mmHg Nadi : .........x/menit
Suhu : ............°C RR : .........x/menit
3. Hasil pemeriksaan leopold
Leopold I : ..........................................................................................................................................
Leopold II : ..........................................................................................................................................
Leopold III : ..........................................................................................................................................
Leopold IV : ..........................................................................................................................................
4. Hasil pemeriksaan dalam :
.....................................................................................................................................................................
.....................................................................................................................................................................
5. Dilakukan klisma : ya / tidak
6. Dilakukan kateterisasi urine : ya / tidak
7. Pengeluaran pervaginam :
8. Kontraksi uterus
Frekuensi : ....../menit
Lamanya : ......detik
Kekuatan :
9. DJJ
Frekuensi : ......x/menit
Kekuatan : .................. Teratur / tidak
10. Status janin
Kembar : ..........................................................................................................................................
Presentasi : ..........................................................................................................................................
II. Persalinan
Kala I
1. Mulai persalinan : Tanggal : ................................. Jam ......................
2. Tanda dan gejala :
3. Tanda-Tanda Vital
TD : ............mmHg Nadi : .........x/menit
Suhu : ............°C RR : .........x/menit
4. Lama kala I : .........jam ........menit .......detik
5. Tindakan khusus : ..................................................................................................................
6. Keadaan psikologis ibu : ..................................................................................................................
7. Kebutuhan klien : ..................................................................................................................
8. Obat-obatan yang didapat : ..................................................................................................................
..................................................................................................................
9. Tindakan keperawatan
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
10. Observasi kemajuan persalinan :
Tanggal/ Jam Kontraksi Uterus DJJ (x/menit) Keterangan

11. Keluhan :
.....................................................................................................................................................................
.....................................................................................................................................................................

Kala II
1. Mulai kala II : Tanggal : ................................. Jam ......................
2. Tanda dan gejala :
3. Tanda-Tanda Vital
TD : ............mmHg Nadi : .........x/menit
Suhu : ............°C RR : .........x/menit
4. Lama kala II : .........jam ........menit .......detik
5. Penolong : ..................................................................................................................
6. Tindakan khusus : ..................................................................................................................
7. Perineum : ..................................................................................................................:
8. Keadaan psikologis ibu : ..................................................................................................................
9. Kebutuhan klien : ..................................................................................................................
10. Obat-obatan yang didapat : ..................................................................................................................
..................................................................................................................
11. Tindakan keperawatan
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
12. Keluhan
.....................................................................................................................................................................
.....................................................................................................................................................................

Kala III
1. Tanda dan gejala : ..................................................................................................................
2. Plasenta lahir : ..................................................................................................................
3. Cara lahir plasenta : ..................................................................................................................
4. Karakteristik plasenta : ..................................................................................................................
5. Ukuran dan berat plasenta : ..................................................................................................................
6. Panjang tali pusat : ............cm
7. Jumlah pembuluh darah : ............arteri ..........vena
8. Kelainan : ..................................................................................................................
9. Perdarahan : ..................................................................................................................
10. Keadaan psikososial : ..................................................................................................................
11. Kebutuhan khusus : ..................................................................................................................
12. Pengobatan : ..................................................................................................................
..................................................................................................................
13. Tindakan keperawatan
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
14. Keluhan
.....................................................................................................................................................................
.....................................................................................................................................................................
 Kala IV
1. Mulai jam : ....................................................................................................................................
2. Tanda-Tanda Vital
TD : ............mmHg Nadi : .........x/ menit
Suhu : ............°C RR : .........x/ menit
3. Perdarahan pervaginam :.........cc
4. TFU :........................
5. Keadan uterus :........................
6. After pain :........................
7. Robekan perineum :........................
8. Luka episiotomi dan jahitan : Ada / Tidak Ada
9. Data istirahat
Posisi berbaring :........................
10. Bonding Attachment :........................
11. Penggunaan obat-obatan :.....................................................................................................................
......................................................................................................................
12. Tindakan keperawatan
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
13. Keluhan
.....................................................................................................................................................................

Bayi :
1. Lahir tanggal/ jam : ....................................................................................................................................
2. Jenis Kelamin : ...............
3. Nilai APGAR : Menit I : ............ Menit V : ....................
4. Berat Badan : ........gram
5. Panjang Badan : ........cm
6. Lingkar Kepala : ........
7. Suhu : ........
8. Anus : Berlubang / Tertutup
9. Kharakteristik Khusus bayi
Perawatan Tali Pusat : Ada / Tidak
Perawatan Mata : Ada / Tidak
10. Tindakan khusus
...........................................................................................................................................................................
...........................................................................................................................................................................