PENAPISAN IBU BERSALIN

DETEKSI KEMUNGKINAN KOMPLIKASI

GAWAT DARURAT

Nama Ibu : ...........................................................................................

GP : ...........................................................................................
Alamat : ...........................................................................................
Tanggal : ...........................................................................................

NO. KETERANGAN YA TIDAK

1 Riwayat bedah sesar
2 Perdarahan pervaginam
3 Kehamilan kurang bulan
4 Ketuban pecah dalam mekonium kental
5 Ketuban pecah lama (>24 jam)
6 Ketuban pecah pada kehamilan kurang bulan
7 Ikterus
8 Anemia berat
9 Tanda / gejala infeksi
10 Preeklampsi / hipertensi dalam kehamilan
11 Tinggi fundus uteri 40/ cm atau lebih
12 Gawat janin
13 Primipara dalam fase aktif persalinan dengan palpasi
kepala janin masih 5 / 5
14 Presentasi bukan belakang kepala
15 Presentasi majemuk
16 Kehamilan gemelli
17 Tali pusat menumbung
18 Syok

** Apabila ditemukan 1 saja yang “YA” maka pasien harus dirujuk ke RS

LEMBAR OBSERVASI

A. MASUK KAMAR BERSALIN

Tanggal : .......................................................................
His mulai tgl : ........................................ Jam .......................
Darah : .......................................................................
Lendir : .......................................................................
 Ketuban pecah /belum .................................. Jam ............................
Keluhan lain : ......................................................................
B. KEADAAN UMUM
Tensi : .......................................................................
Suhu / Nadi : .......................................................................
Oedema : .......................................................................
Lain – lain : .......................................................................
C. PEMERIKSAAN OBSTETRI
1. Palpasi : ........................................................................
2. DJJ : ........................................................................
3. His 10’ : .......................................................................
4. VT tgl : .......................................................................
5. Hasil : ........................................................................
........................................................................
6. Pemeriksaan lain : .......................................................................
His dalam 10 menit
Tgl Jam DJJ Tensi Suhu Nadi VT Ket
Frekw Durasi