
Asuhan Kebidanan Komprehensif Pada Ny. M Di RSU Carsa Tarakan
Pengarang : Mariama - Personal Name;
Perpustakaan UBT : Universitas Borneo Tarakan., 2024XML Detail Export Citation
Abstract
Asuhan komprehensif atau Continuity of care adalah pelayanan yang dicapai ketika terjalin hubungan yang terus menerus antara seorang wanita dan bidan. Tujuan dari pelayanan kebidanan ini adalah untuk mendeteksi apa yang terjadi pada seorang Wanita mulai dari masa kehamilan, persalinan, bayi lahir hingga masa nifas serta melakukan pengkajian, memberikan diagnosis, mengantisipasi masalah yang mungkin timbul, menentukan tindakan segera, merencanakan dan bertindak sesuai kebutuhan ibu serta mampu mengevaluasi tindakan yang dilakukan. Asuhan Kebidanan komprehensif yang dilakukan penulis dimulai pada kehamilan trimester III, persalinan, nifas, dan bayi baru lahir secara berkelanjutan dengan menggunakan standar asuhan kebidanan. Asuhan kebidanan dilakukan dari tanggal 02 Maret 2024 - 21 Maret 2024. Kunjungan Asuhan kebidanan dilakukan di RSU Carsa Tarakan. Kunjungan Kehamilan dilakukan sebanyak dua kali, kunjungan bersalin satu kali, kunjungan nifas dan bayi baru lahir dua kali. Sehingga penulis melakukan kunjungan komprehensif sebanyak lima kali. Pelayanan asuhan kebidanan pertama kali dilakukan pada saat kunjungan kehamilan di trimester III tanggal 02 Maret 2024 pada Ny. M G2P1A0 usia kehamilan 39 minggu, didapatkan ibu mengalami masalah Anemia ringan dan sudah teratasi dengan pemberian penkes tentang Tablet Fe dan nutrisi. Kunjungan kedua kehamilan pada tanggal 14 Maret 2024 dengan usia kehamilan 40 minggu 4 hari. Asuhan persalinan berlangsung pada tanggal 15 Maret 2024 sesuai standar 60 langkah Asuhan Persalinan Normal (APN) dengan usia kehamilan 40 minggu 4 hari, dengan lama kala I 5 jam 50 menit, kala II 15 menit dan malakukan penilaian sepintas bayi lahir cukup bulan, segera menangis kuat, tonus otot baik, warna kulit kemerahan, kala III 5 menit plasenta lahir lengkap dan tidak ada kelainan serta terdapat robekan perineum derajat II sehingga dilakukan penjahitan, kala IV berlangsung selama 2 jam dengan pemantauan tanda-tanda vital dalam batas normal, kontrakri uterus baik, TFU 2 jari dibawah pusat, kandung kemih kosong serta perdarahan kurang lebih 100 cc. Asuhan masa nifas dilakukan sebanyak 2 kali yaitu asuhan 6 jam Pospartum (KF-1) pada tanggal 15 Maret 2024 dengan hasil pemeriksaan fisik dan tanda-tanda vital dalam batas normal, TFU 2 jari dibawah pusat dan terdapat pengeluaran lochea rubra. Asuhan 7 hari Postpartum (KF-2) pada tanggal 21 Maret 2024, hasil pemeriksaan tanda-tanda vital dalam batas normal dan tidak ada komplikasi masa nifas, TFU pada pertengahan pusat sympisis dan terdapat pengeluaran lochea serosa. Asuhan bayi baru lahir dilakukan sebanyak 2 kali yaitu asuhan 6 jam (KN-1) pada tanggal 15 Maret 2024, hasil berat badan lahir 3.800 gram, panjang badan 50 cm, lingkar kepala 33 cm, lingkar dada 34 cm bayi berjenis kelamin perempuan serta telah diberikan salep mata, vitamin-k 1 mg dengan dosis 0,5 cc dan pemberian Hb-0 2 jam setelah bayi lahir. Asuhan 7 hari (KN-2) dilakukan pada tanggal 21 Maret 2024 dengan, kondisi bayi normal tidak ada komplikasi, tali pusat sudah lepas dan bayi menyusu dengan kuat. Telah dilakukan Asuhan Komprehensif pada Ny. M dari masa kehamilan, persalinan, nifas hingga bayi baru lahir dengan didapatkan terdapat kesenjangan antara teori dan data. Kualitas pelayanan kesehatan yang sesuai standar pelayanan dapat mencegah risiko dan komplikasi bagi klien.
Comprehensive care or Continuity of care is a service achieved when a continuous relationship is established between a woman and a midwife. The purpose of this midwifery service is to detect what happens to a woman from pregnancy, childbirth, birth to the postpartum period and to conduct assessments, provide diagnoses, anticipate problems that may arise, determine immediate actions, plan and act according to the mother's needs and be able to evaluate the actions taken. Comprehensive midwifery care carried out by the author began in the third trimester of pregnancy, childbirth, postpartum, and newborns continuously using midwifery care standards. Midwifery care was carried out from March 2, 2024 - March 21, 2024. Midwifery care visits were carried out at Carsa Tarakan Hospital. Pregnancy visits were carried out twice, one maternity visit, two postpartum and newborn visits. So the author made five comprehensive visits. The first midwifery care service was carried out during the third trimester pregnancy visit on March 2, 2024, on Mrs. M G2P1A0 at 39 weeks of gestation, it was found that the mother had mild anemia problems and had been resolved by providing health education on Fe tablets and nutrition. The second pregnancy visit was on March 14, 2024 with a gestational age of 40 weeks 4 days. Delivery care took place on March 15, 2024 according to the 60-step standard of Normal Delivery Care (APN) with a gestational age of 40 weeks 4 days, with a duration of stage I of 5 hours 50 minutes, stage II of 15 minutes and a cursory assessment of the baby born at term, immediately crying loudly, good muscle tone, reddish skin color, stage III 5 minutes the placenta was born completely and there were no abnormalities and there was a second degree perineal tear so that stitching was performed, stage IV lasted for 2 hours with monitoring of vital signs within normal limits, good uterine contractility, TFU 2 fingers below the navel, empty bladder and bleeding of approximately 100 cc. Postpartum care was carried out 2 times, namely 6-hour Postpartum care (KF-1) on March 15, 2024 with the results of physical examination and vital signs within normal limits, TFU 2 fingers below the navel and there was discharge of lochia rubra. 7-day Postpartum Care (KF-2) on March 21, 2024, the results of the examination of vital signs were within normal limits and there were no postpartum complications, TFU in the middle of the symphysis center and there was lochia serosa discharge. Newborn care was carried out 2 times, namely 6-hour care (KN-1) on March 15, 2024, the results of birth weight 3,800 grams, body length 50 cm, head circumference 33 cm, chest circumference 34 cm, the baby was female and had been given eye ointment, vitamin-k 1 mg with a dose of 0.5 cc and Hb-0 administration 2 hours after the baby was born. 7-day care (KN-2) was carried out on March 21, 2024 with, the baby's condition was normal, there were no complications, the umbilical cord had fallen off and the baby was breastfeeding strongly. Comprehensive Care has been carried out on Mrs. M from pregnancy, childbirth, postpartum to newborns with a gap between theory and data. Quality of health services that meet service standards can prevent risks and complications for clients.