
Asuhan Komprehensif Pada Ny. R Di Puskesmas Karang Rejo
Pengarang : Oken Jelianti
Perpustakaan UBT : Universitas Borneo Tarakan,2024Abstrak Indonesia
Pelayanan kebidanan komprehensif merupakan pelayanan asuhan kebidanan yang dilaksanakan secara menyeluruh mulai dari kehamilan, persalinan, nifas hingga bayi baru lahir. tujuan dari pelayanan kebidanan ini adalah untuk dapat mendeteksi apa yang terjadi pada seorang wanita mulai dari masa kehamilan, persalinan, lahirnya bayi hingga masa nifas serta melatih cara melakukan pengkajian, memberikan diagnosis yang akurat, mengantisipasi masalah yang mungkin timbul, menentukan tindakan segera, merencanakan dan bertindak sesuai kebutuhan ibu serta mampu mengevaluasi tindakan yang dilakukan. asuhan kebidanan komprehensif atau continuity of care yang dilakukan penulis dimulai pada kehamilan trimester iii, persalinan, nifas, dan bayi baru lahir secara berkelanjutan dengan menggunakan standar asuhan kebidanan. asuhan diberikan mulai dari tanggal 14 maret 2024 – 29 maret 2024. kunjungan asuhan kebidanan dilakukan di puskesmas karang rejo. kunjungan hamil dilakukan sebanyak satu kali, kunjungan bersalin satu kali, kunjungan nifas dan bayi baru lahir dua kali. sehingga penulis melakukan kunjungan komprehensif sebanyak enam kali. asuhan kebidanan komprehensif pertama kali dilakukan pada saat kunjungan kehamilan di trimester iii pada tanggal 14 maret 2024 dengan usia kehamilan ibu 39 minggu 4 hari, didapatkan hasil setelah pengkajian dilakukan dari kunjungan masa kehamilan dalam kondisi normal dan tidak ditemukan adanya komplikasi apapun. asuhan persalinan diberikan pada tanggal 29 maret 2024 pada usia kehamilan ibu 41 minggu 5 hari. asuhan yang diberikan sesuai dengan standar 60 langkah asuhan persalinan normal (apn), didapatkan kala i berlangsung selama 2 jam, dan kala ii berlangsung selama 30 menit, dilakukan penilaian sepintas, bayi lahir cukup bulan, segera menangis, warna kulit kemerahan, dan tonus otot baik. kala iii berlangsung salama 5 menit setelah oksitosin disuntikkan, palasenta lahir lengkap dan tidak ada kelainan dan robekan. asuhan kebidanan pada kala iv dilakukan selama 2 jam dengan memantau tanda-tanda vital ibu, dan didapatkan hasil keadaan umum dalam batas normal, perdarahan kurang lebih 50 cc, terdapat laserasi perineum derajat 2 dan telah dilakukan penjahitan dengan anastesi. asuhan masa nifas dilakukan sebanyak 2 kali yaitu asuhan 6 jam postpartum (kf-1) pada tanggal 29 maret 2024 dengan hasil pemeriksaan fisik dan tanda-tanda vital dalam batas normal dan tidak ada komplikasi masa nifas dan terdapat pengeluaran lochea rubra. asuhan 10 hari postpartum pada tanggal 8 april 2024, hasil pemeriksaan tanda-tanda vital dalam batas normal dan tidak ada komplikasi masa nifas, tfu 1 jari dibawah pusat, tfu tidak teraba dan terdapat pengeluaran lochea serosa, terdapat jahitan perineum. asuhan bayi baru lahir dilakukan 2 kali yaitu pada tanggal 29 maret 2024 sampai tanggal 8 april 2024, yang dilakukan pada bayi baru lahir berupa penilaian sepintas apakah bayi cukup bulan, segera menangis, bayi bergerak aktif. didapatkan hasil bayi berjenis kelamin perempuan, berat badan 3.500 gr, panjang badan 47 cm, lingkar kepala 30 cm, dan lingkar dada 31 cm lingkar perut 32 cm. asuhan 10 hari bayi baru lahir pada tanggal 8 april 2024, di dapat hasil pemeriksan keadaan dalam batas normal, bayi menyusui kuat, tali pusat terlepas, warna kulita sedikit kuning. maka dari hasil data di atas menunjukan tidak ada komplikasi. telah dilakukan asuhan komprehensif pada ny. r selama masa kehamilan, persalinan, nifas, dan bayi baru lahir dengan didapatkan bahwa tidak tedapat penyulit dan berlangsung fisiologis. asuhan kebidanan yang berkelanjutan jika diberikan secara aktif dapat meningkatkan kesehatan ibu dan anak. maka dapat di simpulkan tidak ada kenjangan antara teori dan praktik.
Abstrak Indonesia
Comprehensive midwifery services are midwifery care services that are carried out comprehensively starting from pregnancy, childbirth, postpartum to newborn babies. the aim of this midwifery service is to be able to detect what happens to a woman from pregnancy, childbirth, the birth of a baby to the postpartum period as well as training how to carry out assessments, provide an accurate diagnosis, anticipate problems that may arise, determine immediate action, plan and act according to the mother's needs and be able to evaluate the actions taken. comprehensive midwifery care or continuity of care carried out by the author begins in the third trimester of pregnancy, delivery, postpartum and newborn babies on an ongoing basis using standard midwifery care. care is provided from march 14 2024 – march 29 2024. midwifery care visits are carried out at the karang rejo community health center. pregnancy visits are carried out once, maternity visits once, postpartum and newborn visits twice. so the author made comprehensive visits six times. comprehensive midwifery care was first carried out during a pregnancy visit in the third trimester on march 14 2024 with the mother's gestational age being 39 weeks 4 days. the results were obtained after the assessment was carried out from the pregnancy visit in normal conditions and no complications were found. maternity care was provided on march 29 2024 at the mother's gestational age of 41 weeks 5 days. the care provided was in accordance with the standard 60 steps of normal childbirth care (apn), it was found that the first stage lasted 2 hours, and the second stage lasted 30 minutes, a cursory assessment was carried out, the baby was born full term, cried immediately, had reddish skin color and muscle tone. good. the third stage lasted 5 minutes after oxytocin was injected, the placenta was born complete and there were no abnormalities or tears. midwifery care in the fourth stage was carried out for 2 hours by monitoring the mother's vital signs, and the results showed that the general condition was within normal limits, the bleeding was approximately 50 cc, there was a grade 2 perineal laceration and suturing had been carried out under anesthesia. postpartum care was carried out twice, namely 6 hours postpartum care (kf-1) on march 29 2024 with the results of the physical examination and vital signs within normal limits and there were no postpartum complications and there was lochea rubra discharge. 10 days postpartum care on april 8 2024, vital signs examination results were within normal limits and there were no postpartum complications, tfu was 1 finger below the center, tfu was not palpable and there was lochea serous discharge, there were perineal sutures. newborn care is carried out twice, namely from march 29 2024 to april 8 2024, which is carried out on newborns in the form of a cursory assessment of whether the baby is full term, cries immediately, and the baby moves actively. the results showed that the baby was female, weighing 3,500 grams, body length 47 cm, head circumference 30 cm, and chest circumference 31 cm, abdominal circumference 32 cm. 10 days of care for newborn babies on april 8 2024, examination results are obtained the condition is within normal limits, the baby is breastfeeding strong, the umbilical cord is loose, the skin color is slightly yellow. so the results of the data above show that there are no complications. comprehensive care has been provided for mrs. r during pregnancy, childbirth, postpartum and newborns with the result that there are no complications, and the progress is physiological. sustainable midwifery care, if provided actively, can improve the health of mothers and children. so, it can be concluded that there is no gap between theory and practice.