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  • SOAP Retensio Plasenta

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    PAOGI UNAND
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    This SOAP note summarizes the case of Ny U, a 22 year old woman experiencing retained placenta after two doses of oxytocin failed to deliver the placenta following a spontaneous home birth. On examination, the midwife found the uterus fundus was two fingers above the navel with weak contractions and slight bleeding from the vagina. The diagnosis was retained placenta after a spontaneous third stage of labor at home. The care plan was to explain the condition, start an IV with RL at 30 drops per minute, and inform the patient and family that a referral to the hospital was needed.

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    This SOAP note summarizes the case of Ny U, a 22 year old woman experiencing retained placenta after two doses of oxytocin failed to deliver the placenta following a spontaneous home birth. On examination, the midwife found the uterus fundus was two fingers above the navel with weak contractions and slight bleeding from the vagina. The diagnosis was retained placenta after a spontaneous third stage of labor at home. The care plan was to explain the condition, start an IV with RL at 30 drops per minute, and inform the patient and family that a referral to the hospital was needed.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    903 views2 pages

    SOAP Retensio Plasenta

    Uploaded by

    PAOGI UNAND
    This SOAP note summarizes the case of Ny U, a 22 year old woman experiencing retained placenta after two doses of oxytocin failed to deliver the placenta following a spontaneous home birth. On examination, the midwife found the uterus fundus was two fingers above the navel with weak contractions and slight bleeding from the vagina. The diagnosis was retained placenta after a spontaneous third stage of labor at home. The care plan was to explain the condition, start an IV with RL at 30 drops per minute, and inform the patient and family that a referral to the hospital was needed.

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    of 2

    TINJAUAN KASUS

    ASUHAN KEBIDANAN SOAP PADA NY U

    DENGAN RETENSIO PLASENTA

    DI PUSKESMAS PAUH

    Hari / tanggal :
    Kamis, 26 Juli 2018
    Pukul : 08.00 WIB

    Identitas / Biodata :
    Nama Ibu : Ny U
    Umur : 22 Tahun
    Suku : Minang
    Agama : Islam
    Pendidikan : SMA
    Pekerjaan : IRT
    Alamat : Binuang

    Keluhan Utama : plasenta tidak lahir setelah diberi suntikan 2x oksitosin selama 30 menit.

    Subjektif
    Perdarahan pervaginam (+) sedikit mengalir, warna merah kehitaman
    Pasien mengeluh sedikit pusing dan lemas

    O
    Ku ibu : baik
    TTV :
    TD : 100/70
    N : 92
    S : 36,8
    P : 22

    Pemeriksaan Fisik
    Abdomen :
    Inspeksi : perut tampak sedikit membuncit
    Palpasi : Fundus uteri teraba 2 jari diatas pusat, kontraksi (+) lemah
    Genitalia :
    Inspeksi : perdarahan pervaginam (+) sedikit mengalir, warna merah kehitaman,
    Tampak tali pusat menjulur dari introitus vagina dan terpasang klem, laserasi
    perineum (-)
    A
    Retensio plasenta pada P3A0H3 post partus spontan di luar
    P
    Pukul 08.00
    Planning : menjelaskan hasil pemeriksaan bahwa kondisi persalinan ibu sedang mengalami gangguan
    dalam proses persalinannya

    Evaluasi
    Ibu dan keluarga memahami kondisinya

    Pukul 08.05
    Planni ng : melakukan pemasangan infus dan RL  30 tts/menit

    Evaluasi :
    tanda vital ibu mengalami perbaikan
    TD 110/80 Nadi 80 P 18

    Pukul 08.10
    Planning : memberikan informasi terkait rencana untuk merujuk

    Evaluasi : ibu bersedia dirujuk ke rumah sakit

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