ASUHAN PERSALINAN

Hari / Tanggal :

I. Identitas
Nama Istri : Nama Suami :
Umur : Umur :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat : Alamat :

II. Diagnosa
G....P....A....Hamil......Minggu, anak..........hidup intra uteri letak.......................
Puka / puki

III. Kala I
Pasien datang pada tanggal...............................jam.................dengan ............................
 Tekanan darah....................Suhu.................Respirasi...............Nadi...................
 TB / Penambahan BB :
 Palpasi..................................................................................................................
 DJJ :
 Kontraksi Uterus :
 Px Dalam ( VT ) :

IV. Kala II
Bayi Lahir Spontan tanggal :..........................................Jam :....................................
Jenis Kelamin :.......................................................................................
PB / BB :.......................................................................................

V. Kala III
Manajemen aktif kala III : Injeksi oksitosin...........ampul
Plasenta lahir..........................Kotiledon...........................TFU........................................
Kontraksi Uterus.....................................Jumlah perdarahan...........................................
Laserasi Jalan lahir................................................Heating..............................................

VI. Kala IV
Pemantauan pada :
 Kontraksi Uterus.............................................TFU..............................................
 Jumlah perdarahan................................................................................................
 Tekanan darah.........................Suhu................Nadi..............Respirasi................

VII. Tanggal / Jam

Pasien pulang dengan keadaan :.............................................................................
 KU Ibu :..................................................TFU :..................................................
Kontraksi uterus :.......................................Tekanan darah :................................
Jumlah perdarahan :.............................................................................................
 KU Bayi :.........................Menangis..........................Netek :...............................
 Reflek :.............................................................................................................
OBAT DAN PESAN :

Demak..........................................
Pelaksana pelayanan

Sri Chayatun S.SiT

PENGAMATAN KEADAAN BAYI BARU LAHIR

Nama ibu / Ayah :..........................................................................

Tanggal / jam melahirkan :..........................................................................

STATUS PRESENT Berat badan :................................................

Panjang badan :................................................

Lingkar dada :................................................

Lingkar lengan:...............................................

Nadi :...............................................

Suhu badan :...............................................

KEADAAN UMUM Kesan :..............................................

Warna / kulit :..............................................

Pernafasan :..............................................

Tonus :..............................................

Reflek Moro : Memegang...........................

Mengenyut..........................

KEPALA Bentuk :..............................................

Sutura :..............................................

Fontanel :..............................................

Capput succedanium:....................................

Cephal Hemathom:.......................................

Lingkaran :.............................................

Rambut :.............................................

Mata :.............................................

Telinga :.............................................

Hidung :.............................................

Mulut / bibir :............................................

Lidah :...........................................
 Palatum :..............................................

LEHER Bentuk :..............................................

Kelenjar :..............................................

DADA Paru – paru :..............................................

Jantung :.............................................

Pusar :.............................................

Persendian :....................................................................

Tulang Punggung :...................................................................

Reflek tonus leher :...................................................................

Alat kelamin :...................................................................

Anus / rektum :...................................................................

Kelainan lain – lain :...................................................................

Demak..........................................

Pemberi Pelayanan

Sri Chayatun S.SiT

 STEMPEL TELAPAK KAKI BAYI
KANAN KIRI

Tanggal / jam ...............................................................

( Sri Chayatun S.SiT )