Asuhan Kebidanan Continuity of Care Ny. E Usia 27 Tahun G1P0A0 di RSIA Asih Balikpapan

Abstract

Pregnancy, childbirth, postpartum, and neonates are physiological conditions that can potentially threaten the lives of mothers, babies and even cause death. One effort that can be made is to implement a comprehensive midwifery care model that can optimize the detection of high maternal neonatal risk. The purpose of the study was to analyze the implementation of midwifery care for pregnant women, giving birth, postpartum, BBL and KB. The research method was observational descriptive analytic. The case study approach to the implementation of midwifery care includes pregnancy, childbirth, newborns, postpartum, and family planning (KB) care. The sample was a pregnant woman G2 P1 A0 with a gestational age of 38 weeks. The research period was August 23-September 7, 2024 at RSIA Asih Balikpapan. The research instrument used the SOAP documentation method with a Varney management mindset. The collection technique used primary data through interviews, observations, physical examinations, and KIA books. The results of the care obtained were Mrs. E, a pregnant woman G2P1A0 with a gestational age of 38 weeks. The mother is pregnant with her second child with a gestational age of 9 months, the mother wants to check her pregnancy. The mother complained of tight stomach, frequent urination accompanied by blood and mucus, pain scale 8 (severe). On August 23 at 10.05 WITA to the Emergency Room at RSIA Asih Balikpapan because the stomach felt tight since 08.00 WITA and there was blood and mucus. To reduce the pain, endorphin massage was performed from 6 to 8 dilation. The baby was born spontaneously, immediately cried at 10.18 WITA, the placenta was born completely at 10.25 WITA and there was no bleeding. During the Postpartum Period Midwifery care during the postpartum period was carried out 3 times, namely, 6 hours postpartum, 7 days postpartum and 14 days postpartum. The results of subjective and objective data confirmed Mrs. "E" P20002 with normal postpartum. In newborns there were 3 visits, namely at 6 hours, 7 days and 14 days. The results of subjective data assessment, the newborn baby is normal, breastfed well and actively, there are no complications, the baby is in good health. Furthermore, Mrs. "E" decided to install an Implant KB 24 days after delivery.

Abstrak

Masa kehamilan, persalinan, nifas, neonatus merupakan suatu keadaan fisiologis yang kemungkinan mengancam jiwa ibu, bayi bahkan menyebabkan kematian. Salah satu upaya yang dapat dilakukan menerapkan model asuhan kebidanan komperehensif yang dapat mengoptimalkan deteksi risiko tinggi maternal neonatal. Tujuan penelitian melakukan analisis pelaksanaan asuhan kebidanan ibu hamil, bersalin, nifas, BBL dan KB. Metode penelitian observasional desktiptif analitik. Pendekatan studi kasus pada pelaksanaan asuhan kebidanan meliputi asuhan kehamilan, persalinan, bayi baru lahir, nifas, dan keluarga berecana (KB). Sampel adalah seorang ibu hamil G2 P1 A0 dengan usia kehamilan 38 minggu. Waktu penelitian 23 Agustus-7 September 2024 di RSIA Asih Balikpapan. Instrumen penelitian menggunakan metode dokumentasi SOAP dengan pola pikir manajemen varney. Teknik pengumpulan menggunakan data primer melalui wawancara, observasi, pemeriksaan fisik, buku KIA. Hasil asuhan didapatkan Ny.E ibu hamil G2P1A0 dengan usia kehamilan 38 minggu. Ibu hamil anak kedua dengan usia kehamilan 9 bulan, ibu ingin memeriksakan kehamilannya. Ibu mengeluh perut kencang, sering kencing disertai keluar darah dan lender, skala nyeri 8 (berat). Pada tanggal 23 Agustus jam 10.05 Wita ke UGD di RSIA Asih Balikpapan karna perut terasa kencang- kencang sejak 08.00 WITA  dan ada keluar darah dan lender. Untuk menguirangi nyeri dilakukan pijat endorphin dari pembukaan 6 sampai 8. Bayi lahir spontan, langsung menangis pada pukul 10.18 WITA, plasenta lahir lengkap pada pukul 10.25 WITA dan tidak ada pedarahan. Pada Masa Nifas Asuhan kebidanan pada masa nifas dilakukan sebanyak 3 kali kunjungan yaitu, 6 jam post partum, 7 hari post partum dan 14 hari post partum. Hasil dari data subyektif dan obyektif ditegakkan Ny “E” P20002 dengan nifas normal. Pada bayi baru lahir terdapat 3 kali kunjungan, yaitu pada 6 jam, 7 hari dan 14 hari. Hasil pengkajian data subjektif, bayi baru lahir normal menyusu dengan baik dan aktif tidak ada komplikasi apapun, bayi dalam keadaan sehat. Selanjutnya Ny “E” memutuskan untuk memasang KB Implant 30 hari setelah persalinan.