OBSTETRI GINEKOLOGI

Obstetric examination

No S T E P

I History taking in obstetrical assessment

A Chief complaint
1. Greet the patient and introduce yourself , develop a warm and helpful environment
2. Politely ask : Patient identity
Find out : is there anyone accompanying the patient, if so, ask one to accompany her in
the examining room
B Anamnesis
3. Ask the reason why the patient needs to come to the clinic
4. Ask the followings
Ø marital history
Ø Menstrual cycles, first day of last menstrual period (LMP)
Ø Previous history of disease of the patient and her family (which may be related to
the current pregnancy)
Ø Personal habits (smoking, taking medication or traditional remedies, pets)
Ø Previous obstetric history
5. Determine gestational age conclusive of LMP, and determine expected day of
confinement
Note :
For further explanation regarding history taking, please refer to History taking
learning guide in the other section of this book.
II INFORMED CONSENT
6. Explain the procedure to the patient
7. Explain the goals or the expected result of the examination
8. Explain that some women may experience certain discomfort during procedure and
sometime worry, but that it shall not harm or put her and the baby in danger
9. Make sure that the patient understand about the procedure and the aim of the examination
10. Ask for verbal consent, if the patient agrees, soon as she understands the procedure
III PREPARATION
11 A. Examination tools
• Examining table and a blanket
• Cotton and high disinfectant level solution
• Nelaton catheter
• Grave’s speculum and tray
• Instrument table
• Lamp
B. Examining physician
• High-level disinfected hand gloves
• Soap and water
• Apron
• Clean and dry towel
IV PHYSICAL EXAMINATION
12. General
 Ø General state
Ø Habitus ( asthenia, athletic, picnic)
Ø Height
Ø Weight
Ø Color of conjunctiva, notice any icterus, edema, chloasma
Ø Vital sign (blood pressure, pulse, respiratory, temperature)
Ø Cardiopulmonary state
Ø Inspection for hyperpigmentation on areola mammae and striae
Ø Palpation of liver and spleen
Ø Hyperpigmentation ( areola mammae, linea nigra) and striae
Ø Abdominal countour and symetry
IV GETTING READY
13. Ask the patient to void and to expose the area to be examined (limit to a certain area in
time)
14. Ask the patient to lay down on the examining table. Using apron and then turn on the
lamp and direct it to the examining area.
15. Wash the hands with soap, and dry with clean dry towel
Specific
16. Inspect suprapubic bulging and try to palpate uterine fundus.
Locate mass or abdominal tenderness.
Note :
Abdominal palpation of uterine fundus may not be possible if gestational age is 12 weeks
or less. At 12 weeks, it is 2 fingers width above the symphysis.
Step 22 – 59 explains how to find probable signs of pregnancy and assess uterine
enlargement in early pregnancy by performing speculum and bimanual
examination .
In later stage of pregnancy, examination is conducted differently. Some positive signs of
pregnancy can already be elicited.
V PUTTING ON HANDGLOVES
17. Take the gloves, unfold it and put it on the table.
18. Use your left thumb and index finger to hold the the right gloves on the tip of the folded
part
19. Insert your right hand by gentle traction of the tip of the folded part up way to your fore
arm
20. Take the left glove by slipping your four right fingers under the folded part of the left
glove, and use your thumb to hold the gloves upright.
21. Insert your left hand to the gloves and tighten it up by unfolding and pulling it upward to
your fore arm
Specific
22. Sitting on a chair the physician faces genital aspect of the patient
23. Take some cotton and high disinfectant level solution and wipe it on the examining area
24. Inspect the whole vulva and perineum
25. Separate the labium mayora to open the vulva with the left thumb and index fingers, then
inspect the urethral meatus and vaginal introitus
26. With your right thumb and index finger palpate and explore both sides of the labium
mayora, especially in the bartholin gland area. Inspect and pay attention to any
abnormalities found.
27. Take a Grave’s speculum with your right hand, apply speculum using gel lubricant, insert
 the left index finger into the introitus to make a slit, and then insert the tip of the specula
into the introitus parallel to the labia. Make sure that there is no tissue trapped between
the blades, and slowly push them in.
28. When the blades are far enough inside the vagina, turn it 90 ° clockwise so that the handle
is directed downward.
29. Arrange the blades by opening the blade lock, so each blade touches the anterior and
posterior vaginal wall.
30. Push the knob on the speculum to make it open wider and the vaginal lumen and portio is
visible.
• Notice the color change of the vaginal wall, which usually turn bluish (Chadwick’s
sign).
• Notice the shape and size of portio, fornices, the vaginal wall, also any secret from
the ostium.
• Pay attention to any abnormalities on portio like erosion, fragile mass on the portio
lips or any mass coming out from external uterine ostium
31. Release the knob and let the blades be in the original position, turn it 90 ° counter
clockwise until the blades are pararel to the labia and take it out.
32. Put the speculum in a basin filled with decontamination solution
33. The examining physician shall now stand, apply your right index and middle finger using
gel lubricant, and then separate the labium mayora to open the vulva with the left thumb
and index fingers.
34. Insert your right index and middle finger into the vagina to perform vaginal examination
(bimanual examination)
35. Put the tip of your left four fingers upon the suprasymphisis, try to feel the uterine fundus
(if the size may be palpable, usually begins on 12 weeks pregnancy, it is 2 finger width
above symphysis).
36. Define the uterine size
37. Move your fingers (inside and outside) to the isthmic level and let them meet. Try to find
Hegar sign
38. Try to palpate the adnexal area, find any mass or tenderness.
(If you find anything, describe it further. See learning guide for gynecologic examinations)
39. In the fornices try to find any cervical motion tenderness.
Note :
Cervical motion tenderness is aiming at eliciting visceral pain which usually result
from peritoneal irritation.
The visceral peritoneum covering the female genoital tract is ligamentum latum or broad
ligament. Refer further to your anatomy book, to precisely see the connenctions with
uterus, tubes, ovaries and Douglas pouch.
Performing cervical motion tenderness :
• With your 2 inner fingers surround the portio, move the portio gently to the left and
right
• Pay attention to patient’s reaction and expression.
Caution:
It may be very painfull if peritoneal irritation exists !!
40. While your left hand is still on the supra symphisis, take out your inner fingers from the
vagina.

41. Take your outer fingers off the abdominal wall.

42. Wipe clean the vulva and perineum from secret or liquids
43. Put the cotton/gauze into the disposal bin
44. Tell the patient that the examination is completed
45. Let her get dressed and be seated for consultation
46. Put the instrument soaked in the decontamination solutions.
47. Put your hands (still wearing the glove) in the decontamination solution and then slowly
take it off.
Pay attention that you do not spill any liquids or secret to your surroundings.
Note :
The gloves and the instruments should be processed further.
See equipment treatment in the other chapter of infection prevention of this learning guide.
VII DATA RECORDING
48. Record your result in the medical record
FINAL CONCLUSION
49. Draw a conclusion of the examination result and record it in the medical record
50. State the patient condition in the conclusion/working diagnosis/differential diagnosis
51. State the prognosis of the disease in regards to the result of examination
VIII MANAGEMENT PLAN
52. Suggest additional examination if necessary, such as routine laboratory, ultrasonography
scanning and others
Note:
Final diagnosis sometimes includes the findings from routine laboratory and other
additional examination.
53. Describe the condition to the patient
54. Arrange for follow up visit
55. Explain that if special examination or interdisciplinary consultation is needed . informed
consent would be requested.
Note :
The patient has the right to ask for expert assistant and referral to higher rank
medical facility
56. Tell important signs of symptoms the patient should be aware of and to immediately
come back for consultation
57. Tell the patient where the higher rank health facility is located and the referral system
58. Make sure that the patient understands about all the information, the result of examination
and diagnosis and the management plan
59. Give the medical record visiting card , show the patient the way out and greet her.

If gestational age is 12- 20 weeks the uterine fundus is normally palpable. Other signs of
pregnancy are more obvious. Speculum and vaginal examination are conducted only when
there is clinical indication.
Follow the steps below for specific physical examination after step 15.
Specific
60. Inspect suprapubic bulging and try to palpate uterine fundus.
Locate mass or abdominal tenderness.
61. Palpation of fundal height :
Use the palm of your dominant hand to locate the tip of uterine fundus, with the radial
side of its index finger.
Note :
Fundal height measurement for gestational age 12 – 18 is based on the rule of Forth.
(But the rule is sometimes applicable for later gestational age)
 • 12 week : 2 fingers above symphisis
• 16 week : middle way from symphisis to
navel
• 18-20 weeks : 2 fingers below the navel
Fundal height measurement by measuring tape is applicable only for gestational age 18
and more.
Result of FH measurement is in accordance with gestational age from 18 to 32 week
Refer to the instruction for fundal height measurement prior to Leopold maneuver in
other part of this book.
Beginning at 16 weeks ballottement in toto is possible with bimanual examination.
Ballotement aims to feel any floating objects within a fluid-filled cavity.
At 16 week the fetal size is large enough to cause this ballottement effect due to its small proportion
to uterine cavity which is filled with amniotic fluid in the amnion sack.

62. Performing Ballotement :

• Perform bimanual vaginal examination
• Hold the uterine fundus with your outer fingers on the abdomen
• Attempt a gentle push from the fornices tomards the uterus, this will cause the fetus
being pushed away from your fingers. There will be a ‘bumping’ sensation on your
outer fingers on the abdomen and the fetus will ‘bump’ back to your inner fingers.
AUSCULTATION OF FETAL HEART BEAT
It is aiming at detection one of the positive sign of pregnancy, other than ballottement. Furthermore
it is used to assess fetal well-being.
The following steps describe how to perform the task using ‘monoaural stethoscope’.
A more advanced tool for this task is called ‘doptone’ which is using the Doppler effect sound to
detect fetal heart beat.
Additional Equipments :
• Monoaural stethoscope
• Doppler fetal heart detector
63. Take a monoaural stethoscope with your left hands and place the conus base at the
proposed back area of fetus
64. Adhere your ears to the ‘phone’ and listen to the fetal heart sound.
65. Choose an area with the clearest pulse.
66. When abdominal thinckness interfered with this, put the conus base at the thinner area
,i.e. 3 cm below the umbilicus.
67. Listen and count the fetal heart sound every other 5 second, do it three times with 5
second interval each
68. Sum the result and multiply by four to have the approximate fetal heart rate per minute.
69. Note the differences in the 5-second counts, it can be used for monitoring irregularity
rhythm.
70. Put all the equipment back to its place
Tell the patient that the procedure is over.
Do the rest as described in step 46 – 60 as necessary

If gestational age is 20 weeks and more fundal height measurement and assessment of fetal
lie and presentation are possible.
Fetal heart rate should also be assessed routinely.
Speculum and vaginal examination are conducted only when there is clinical indication.
Follow the steps below for specific physical examination after step 15.
 PREPARATION
A. Patient
• Obstetric examining table
• Blanket
B. Examining physician
• Tap water
• Soap
• Clean and dry towel
• Measuring tape
• Monoaural stethoscope
PHYSICAL EXAMINATION
Fundal height measurement
72. Prior to examination, make sure that the uterine axis is in the midline.
Reposition the uterus and the baby until it is confirmed in the mid line.
There is a tendency for the uterus in late pregnancy to fall to one certain side, and a
measurement bias can occur.
73. Put the radial side of the (left) index finger at the uterine fundus.
Notice that this should not put downward compression to the uterus.
(When necessary, fixation of uterine fundus can be achieved with the help of the right
thumb and index finger, just above the symphisis)
74. Mark the fundus and place the tip of measuring tape on the mid line at the fundus level.
This will be the starting point.
75. Extend the measuring tape until it reaches the superior rami of the pubic bone, the so
called pubic symphisis.

76. Look at the figures on the measuring tape, the number you see is the the fundal height.
Note :
The starting point is interchangeable between the uterine fundus or the pubic symphisis,
but the principles are the same.
77. Put the equipment back to its place
78. Leopold 1 :
• Change position, so that examiner face the patient
• Put the tips of examiner fingers on the fundus and try to palpate any fetal part by
gently move both hands to explore this area with the fingers
• Indicate what fetal part is in the fundus
78. Leopold 2
• The hands are moved to lateral sides of the uterus parallely and approximately
about the same level
starting from the upper side alternatingly or with the fingers of both hands gently
press the uterine wall and try to palpate a long flat area (the back of baby) or some
small parts (extremities)
79. Leopold 3
• Palpate the area above the symphisis to feel the fetal presenting part (the head
feels round and hard, the buttock feels softer and non symmetrical)
80. Leopold 4
• Rearrange your position so you face the patients leg
• Put your palms on both the lower side part of the uterus so the tip of your fingers
 touch the upper border of symphisis
• Let your thumbs lie side by side and your fingers are abductally closer to one
another and palpate the uterine wall and check the angle created by your right and
left fingers(convergen or divergen)
• Afterwards move you left thumb and index finger to the presenting part of the fetus
(In a cephalic presentation, make sure you grab the baby at the neck area,or the
baby’s wrist in a breech presentation
• Direct this presenting part to the pelvic inlet and assess fetal descend (in cephalic
presentation this can be done by using your right fingers that is put between the
left hands and symphisis.
AUSCULTATION
For auscultation of fetal heart beat, refer to the previous section of learning guide, after
ballottement examination, step 64 - 71
When the examination is completed, do the rest of the steps as described in step 46 – 60
as necessary.
GYNECOLOGIC ASSESSMENT

No. S T E P

I History taking in gynecologic assessment

A Chief complaint
Greet the patient and introduce yourself , develop a warm and helpful environment
Politely ask : Patient identity
Find out : is there anyone accompanying the patient, if so, ask one to accompany
her in the examining room
B Anamnesis
1. Ask the reason why the patient needs to come to the clinic
2. Ask the followings
Ø marital history
Ø Menstrual cycles, first day of last menstrual period (LMP), duration
Ø Parity and number of living children, last delivery/abortion
Ø History of ectopic pregnancy
Ø History of menstruation-related pain
Ø Anemia, general fatigue
Ø History of urinary tract infection, sexually transmitted disease or pelvic
inflammatory disease
Ø Promiscuity (multiple sexual partner)
Ø Other complaints such as bleeding or vaginal discharge, enlargement of
abdomen, feeling abdominal mass that brings the patient to the clinic.
Note :
For further explanation regarding history taking, please refer to History taking
learning guide in the other section of this book
II INFORMED CONSENT
5. Explain the procedure to the patient
6. Explain the goals or the expected result of the examination
7. Explain that some women may experience certain discomfort during procedure and
sometime worry, but that it shall not harm or put her in danger
8. Make sure that the patient understand about the procedure and the aim of the
examination
9. Ask for verbal consent, if the patient agrees, soon as she understands the
procedure
III PREPARATION
10. A. Patient
• Examining table
• Cotton and high disinfectant level solution
• Nelaton catheter (voiding is best)
• Grave’s speculum and tray
• Instrument table
• Lamp
 B. Examining physician
• High-level disinfected hand gloves
• Soap and tap water
• Apron
• Clean and dry towel
IV PHYSICAL EXAMINATION
11. General
Ø General state
Ø Habitus ( asthenia, athletic, picnic)
Ø Height
Ø Weight
Ø Color of conjunctiva, icterus, edema,
Ø Vital sign (blood pressure, pulse, respiratory, temperature)
Ø Cardiopulmonary state
Ø Inspection for abdominal enlargement or mass
Ø Palpation of liver and spleen
V GETTING READY
12. Ask the patient to void and to take off her under wear
13. Ask the patient to lay down on the examining table, and put her in a lithotomy
position
14. Using apron and turn on the lamp and direct it to the examining area
15. Wash the hands with soap, and dry with clean dry towel
SPECIFIC
16. Inspect suprapubic bulging and try to palpate uterine fundus. Locate mass or
abdominal tenderness
VI PUTTING ON HANDGLOVES
17. Take the gloves, unfold it and put it on the table.
18. Use your left thumb and index finger to hold the the right gloves on the tip of the
folded part
19. Insert your right hand by gentle traction of the tip of the folded part up way to your
fore arm
20. Take the left glove by slipping your four right fingers under the folded part of the
left glove, and use your thumb to hold the gloves upright.
21. Insert your left hand to the gloves and tighten it up by unfolding and pulling it
upward to your fore arm
SPECIFIC
22. Sitting on a chair the physician faces genital aspect of the patient
23. Take some cotton and high disinfectant level solution and wipe it on the examining
area
24. Inspect the whole vulva and perineum
25. Separate the labium mayora to open the vulva with the left thumb and index
fingers, then inspect the urethral meatus and vaginal introitus
26. With your right thumb and index finger palpate and explore both sides of the
labium mayora, especially in the bartholin gland area. Inspect and record any
abnormalities found.
27. Take a Grave’s speculum with your right hand, apply speculum using gel
lubricant, insert the left index finger into the introitus to make a slit, and then insert
the tip of the specula into the introitus parallel to the labia. Make sure that there is
no tissue trapped between the blades, and slowly push them in.
28. When the blades are far enough inside the vagina, turn it 90 ° clockwise so that the
handle is directed downward.
29. Arrange the blades by opening the blade lock, so each blade touches the anterior
and posterior vaginal wall.
30. Push the knob on the speculum to make it open wider and the vaginal lumen and
portio is visible.
• Notice the shape and size of portio, fornices, the vaginal wall, also any
bleeding or discharge from the ostium.
• Pay attention to any abnormalities on portio like erosion, fragile mass on the
portio lips or any mass coming out from external uterine ostium
NOTE :
If pap smear collection is planned for current examination, it is done after the step
above
See learning guide for pap smear collection in other parts of the learning guide
31. Release the knob and let the blades be in the original position, turn it 90 ° counter
clockwise until the blades are pararel to the labia and take it out.
32. Put the speculum in a basin filled with decontamination solution
33. The examining physician shall now stand, apply your right index and middle
finger using gel lubricant, and then separate the labium mayora to open the vulva
with the left thumb and index fingers.
34. Insert your right index and middle finger into the vagina to perform vaginal
examination (bimanual examination)
35. Put the tip of your left four fingers upon the suprasymphisis, try to feel the uterine
fundus (if the size may be palpable).
36. Define the uterine size, consistency and mobility
Note :
If the uterus is retroflexed, try to do the step above by performing rectovaginal
toucher (see bottom of this learning guide)
37. Try to palpate the adnexal area, find any mass or tenderness, also the mobility of
the mass.
38. In the fornices try to find any cervical motion tenderness
Note :
Cervical motion tenderness is aiming at eliciting visceral pain which usually result
from peritoneal irritation. The visceral peritoneum covering the female genital tract
is ligamentum latum or broad ligament. Refer further to your anatomy book, to
precisely see the connections with uterus, tubes, ovaries and Douglas pouch.
Performing cervical motion tenderness :
• With your 2 inner fingers surround the portio, move the portio gently to the
left and right
• Pay attention to patient’s reaction and expression.
Caution: It may be very painful if peritoneal irritation exists !!
39. While your left hand is still on the suprasymphisis, take out your right fingers from
 the vagina.
40. Take your outer fingers off the abdominal wall.
41. Wipe clean the vulva and perineum from secret or liquids.
42. Put the cotton/gauze into the disposal bin
43. Tell the patient that the examination is completed
44. Let her get dressed and be seated for consultation
45. Put the instrument soaked in the decontamination solutions.
46. Put your hands (still wearing the glove) in the decontamination solution and then
slowly take it off.
Pay attention that you do not spill any liquids or secret to your surroundings.
Note : The gloves and the instruments should be processed further.
See equipment treatment in the other chapter of infection prevention of this
learning guide.
VII DATA RECORDING
47. Record your result in the medical record
FINAL CONCLUSION
48. Draw a conclusion of the examination result and record it in the medical record
49. State the patient condition in the conclusion/working diagnosis/differential
diagnosis
50. State the prognosis of the disease in regards to the result of examination
VIII MANAGEMENT PLAN
51. Suggest additional examination if necessary, such as routine laboratory,
ultrasonography scanning and others
Note:
Final diagnosis sometimes includes the findings from routine laboratory and other
additional examination.
52. Describe the condition to the patient
53. Arrange for follow up visit
54. Explain that if special examination or interdisciplinary consultation is needed .
informed consent would be requested.
Note :
The patient has the right to ask for expert assistant and referral to higher rank
medical facility
55. Tell important signs of symptoms the patient should be aware of and to
immediately come back for consultation
56. Tell the patient where the higher rank health facility is located and the referral
system
57. Make sure that the patient understands about all the information, the result of
examination and diagnosis and the management plan
58. Give the medical record visiting card , show the patient the way out and greet her.
PROSEDUR PERSALINAN NORMAL

No Kegiatan
I. MENGENALI GEJALA DAN TANDA KALA DUA
1. Mendengar dan melihat adanya tanda persalinan Kala Dua
• Ibu merasa adanya dorongan kuat dan meneran
• Ibu merasakan tekanan yang semakin meningkat pada rectum dan vagina
• Perineum tampak menonjol
• Vulva dan sfingter ani membuka
II. MENYIAPKAN PERTOLONGAN PERSALINAN
2. Pastikan kelengkapan peralatan, bahan dan obat-obatan esensial untuk
menolong persalinan dan menatalaksana komplikasi ibu dan bayi baru lahir.
• Untuk resusitasi : tempat datar, rata, bersih, kering dan hangat, 3 handuk/kain
bersih dan kering, alat penghisap lender, lampu sorot 60 watt dengan jarak 60
cm diatas tubuh bayi.
• Menggelar kain diatas di atas perut ibu dan tempat resusitasi serta ganjal bahu
bayi
• Menyiapkan oksitosin 10 unit dan alat suntik steril sekali pakai di dalam perut
sesuai.
3. Pakai celemek plastic
4. Melepaskan dan menyimpan semua perhiasan yang dipakai, cuci tangan dengan
sabun dan air bersih mengalir kemudian keringkan tangan dengan tissue atau
handuk pribadi yang bersih dan kering.
5. Pakai sarung tangan DTT pada tangan yang akan digunakan untuk periksa dalam.
6. Masukkan oksitosin ke dalam tabung suntik (gunakan tangan yang memakai
sarung tangan DTT dan steril, pastikan tidak terjadi kontaminasi pada alat suntik).
III. MEMASTIKAN PEMBUKAAN LENGKAP DAN KEADAAN JANIN
BAIK
7. Membersihkan vulva dan perineum, menyekanya dengan hati-hati dari depan ke
belakang dengan menggunakan kapas atau kasa yang dibasahi air DTT.
Jika introitus vagina, perineum dan anus terkontaminasi tinja, bersihkan dengan
seksama dari arah depan ke belakang.
Buang kapas atau kasa pembersih (terkontaminasi) dalam wadah yang tersedia.
Ganti sarung tangan jika terkontaminasi (dekontaminasi, lepaskan dan rendam
dalam larutan klorin 0,5%).
8. Lakukan periksa dalam untuk memastikan pembukaan lengkap.
Bila selaput ketuban belum pecah dan pembukaan sudah lengkap,maka lakukan
amniotomi.
9. Dekontaminasi sarung tangan dengan cara mencelupkan tangan yang masih
memakai sarung tangan ke dalam larutan klorin 0,5% kemudian lepaskan dan
rendam dalam keadaan terbalik dalam larutan 0,5% selama 10 menit. Cuci kedua
tangan setelah sarung tangan dilepaskan
10. Periksa denyut jantung janin (DJJ) setelah kontraksi/ saat relaksasi uterus
untuk memastikan bahwa DJJ dalam batas normal (120-160 x/menit)
• Mengambil tindakan yang sesuai jika DJJ tidak normal.
• Mendokumentasikan hasil-hasil pemeriksaan dalam, DJJ dan semua hasil-
hasil penilaian serta asuhan lainnya pada partograf.
IV. MENYIAPKAN IBU DAN KELUARGA UNTUK MEMBANTU PROSES
BIMBINGAN MENERAN
11. Beritahukan bahwa pembukaan sudah lengkap dan keadaan janin baik dan bantu
ibu dalam menemukan posisi yang nyaman dan sesuai dengan keinginannya.
Tunggu hingga timbul rasa ingin meneran, lanjutkan pemantauan kondisi dan
kenyamanan ibu dan janin (ikuti pedoman penatalaksanaan fase aktif dan
dokumentasikan semua semua temuan yang ada).
Jelaskan pada anggota keluarga tentang bagaimana peran mereka untuk
mendukung dan member semangat pada ibu untuk meneran secara benar.
12. Minta keluarga membantu menyiapkan posisi meneran. (Bila ada rasa ingin
meneran dan terjadi kontraksi yang kuat, bantu ibu ke posisi setengah duduk atau
posisi lain yang diinginkan dan pastikan ibu merasa nyaman).
13. Laksanakan bimbingan meneran pada saat ibu merasa ada dorongan kuat
untuk meneran :
• Bimbing ibu agar dapat meneran secara benar dan efektif.
• Dukung dan beri semangat pada saat meneran dan perbaiki cara meneran
apabila caranya tidak sesuai.
• Bantu ibu mengambil posisi yang nyaman dan sesuai pilihannya (kecuali posisi
berbaring terlentang dalam waktu yang lama).
• Anjurkan ibu untuk beristirahat di antara kontraksi.
• Anjurkan keluarga memberi dukungan dan semangat untuk ibu.
• Berikan cukup asupan cairan per-oral (minum).
• Menilai DJJ setiap kontraksi uterus selesai.
• Segera rujuk jika bayi belum atau tidak akan segera lahir setelah 120menit (2
jam) meneran (primigravida) atau 60 menit (1 jam) meneran (multigravida).
14. Anjurkan ibu untuk berjalan, berjongkok atau mengambil posisi yang nyaman, jika
ibu merasa ada dorongan untuk meneran dalam 60 menit.
V. PERSIAPAN PERTOLONGAN KELAHIRAN BAYI
15. Letakkan handuk bersih (untuk mengeringkan bayi) di perut ibu, jika kepala bayi
telah membuka vulva dengan berdiameter 5-6 cm.
16. Letakkan kain bersih yang dilipat 1/3 bagian di bawah bokong ibu.
17. Buka tutup partuset dan perhatikan kembali kelengkapan alat dan bahan.
18. Pakai sarung tangan DTT pada kedua tangan.
VI. PERSIAPAN PERTOLONGAN KELAHIRAN BAYI
LAHIRNYA KEPALA
19. 20. Setelah tampak kepala bayi dengan diameter 5-6 cm membuka vulva maka
lindungi perineum dengan satu tangan yang dilapisi dengan kain bersih dan
kering. Tangan yang lain menahan kepala bayi untuk menahan posisi defleksi
dan membantu lahirnya kepala. Anjurkan ibu untuk meneran perlahan atau
bernafas cepat dan dangkal.
21. 20. Periksa kemungkinan adanya lilitan tali pusat dan ambil tindakan yang sesuai jika
hal itu terjadi, dan segera lanjutkan proses kelahiran bayi.
• Jika tali pusat melilit leher secara longgar, lepaskan lewat bagian atas kepala
bayi.
• Jika tali pusat melilit leher secara kuat, klem tali pusat di dua tempat dan
potong diantara kedua klem tersebut.
22. 21. Tunggu kepala lahir melakukan putaran paksi luar secara spontan.
LAHIRNYA BAHU
23. Setelah kepala melakukan putaran paksi luar, pegang secara biparietal. Anjurkan
ibu untuk meneran pada saat kontraksi. Dengan lembut gerakkan kepala ke arah
bawah dan distal menuju bahu depan muncul di bawah arkus pubis dan kemudian
gerakkan arah atas dan distal untuk melahirkan bahu belakang
LAHIRNYA BADAN DAN TUNGKAI
24. Setelah kedua bahu lahir, geser tangan ke bawah untuk kepala dan bahu. Gunakan
tangan atas untuk menelusuri dan memegang lengan dan siku sebelah atas.
25. Setelah tubuh dan lengan lahir, penelusuran tangan atas berlanjut ke punggung,
bokong, tungkai dan kaki. Pegang kedua mata kaki (masukkan telunjuk diantara
kaki dan pegang masing-masing mata kaki dengan ibu jari dan jari-jari lainnya).
VII. PENANGANAN BAYI BARU LAHIR
26. Lakukan penilaian (selintas)
• Apakah bayi cukup bulan ?
• Apakah air ketuban jernih, tidak bercampur mekonium ?
• Apakah bayi menangis kuat dan/atau bernafas tanpa kesulitan ?
• Apakah bayi bergerak dengan aktif ?
Bila salah satu jawaban adalah “Tidak”, lanjutkan ke langkah resusitasi pada
asfiksia bayi baru lahir (melihat penuntun berikutnya). Bila semua jawaban adalah
“Ya”, lanjut langkah ke-26.
27. Keringkan tubuh bayi
Keringkan bayi mulai dari muka, kepala dan bagian tubuh lainnya kecuali bagian
tangan tanpa membersihkan verniks. Ganti handuk basah dengan handuk/kain
yang kering. Biarkan bayi diatas perut ibu.
28. Periksa kembali uterus untuk memastikan tidak ada lagi bayi dalam uterus (hamil
tunggal).
29. Beritahu ibu bahwa ia akan disuntik oksitosin agar uterus berkontraksi baik
30. Dalam waktu 1 menit setelah bayi lahir, suntikkan oksitosin 10 unit IM
(intramuskuler) di 1/3 paha atas bagian distal lateral (lakukan aspirasi sebelum
menyuntikkan oksitosin).
31. Setelah 2 menit pacsa persalinan, jepit tali pusat dengan klem kira-kira 3 cm dari
pusat bayi. Mendorong isi tali pusat kearah distal (ibu) dan jepit kembali tali pusat
pada 2cm distal dari klem pertama.
32. Pemotongan dan pengikatan tali pusat
Dengan satu tangan, pegang tali pusat yang telah dijepit (lindungi perut bayi), dan
lakukan pengguntingan tali pusat di antara 2 klem tersebut
33. Letakkan bayi agar ada kontak kulit ibu ke kulit bayi.
Letakkan bayi tertelungkup di dada ibu. Luruskan bahu bayi sehingga bayi
 menempel di dada/perut ibu. Usahakan kepala bayi berada di antara payudara ibu,
dengan posisi lebih rendah dari puting payudara ibu.
34. Selimuti ibu dan bayi dengan kain hangat dan pasang topi di kepala bayi.
VIII. PENATALAKSANAAN AKTIF PERSALINAN KALA III
35. Pindahkan klem pada tali pusat hingga berjarak 5-10 cm dari vulva.
36. 35. Letakkan satu tangan di atas kain pada perut ibu, di tepi atas simfisis, untuk
mendeteksi. Tangan lain menegangkan tali pusat.
37. 36. Setelah uterus berkontraksi, tegangkan tali pusat kearah bawah sambil tangan yang
lain mendorong uterus kearah belakang-atas (dorso-cranial) secara hati-hati (untuk
mencegah inversio uteri). Jika plasenta tidak lahir setelah 30-40 detik, hentikan
penegangan tali pusat dan tunggu hingga timbul kontraksi berikutnya dan ulangi
prosedur di atas.
Jika uterus tidak segera berkontraksi, minta ibu, suami atau anggota keluarga untuk
melakukan stimulasi puting susu.
MENGELUARKAN PLACENTA
38. Lakukan penegangan dan dorongan dorso-cranial hingga plasenta terlepas, minta
ibu meneran sambil penolong menarik tali pusat dengan arah sejajar lantai dan
kemudian kearah atas, mengikuti poros jalan lahir (tetap lakukan tekanan dorso-
cranial).
• Jika tali pusat bertambah panjang, pindahkan klem hingga berjarak sekitar 5-10
cm dari vulva dan lahirkan plasenta.
• Jika plasenta tidak lepas setelah 15 menit menegangkan tali pusat :
1. Beri dosis ulangan oksitosin 10 unit IM.
2. Lakukan kateterisasi (aseptik) jika kandung kemih penuh
3. Minta keluarga untuk menyiapkan rujukan
4. Ulangi penegangan tali pusat 15 menit berikutnya.
5. Jika plasenta tidak lahir dalam 30 menit setelah bayi lahir atau bila terjadi
perdarahan, segera lakukan manual plasenta.
39. Saat plasenta keluar dari introitus vagina, lahirkan plasenta dengan kedua tangan.
Pegang dan putar plasenta hingga selaput ketuban terpilin dan kemudian lahirkan
dan tempatkan plasenta pada wadah yang telah disediakan.
Jika selaput ketuban robek, pakai sarung tangan DTT atau steril untuk melakukan
eksplorasi sisa selaput kemudian gunakan jari-jari tangan atau klem DTT atau
steril untuk mengeluarkan bagian selaput yang tertinggal.
RANGSANGAN TAKTIL (MASASE) UTERUS
40. 39. Segera setelah plasenta dan selaput ketuban lahir, lakukan masase uterus, letakkan
telapak tangan di fundus dan lakukan masase dengan gerakan melingkar dengan
lembut hingga uterus berkontraksi (fundus teraba keras).
IX. MENILAI PERDARAHAN
41. 40. Periksa kedua sisi plasenta baik bagian ibu maupun bayi dan pastikan selaput
ketuban lengkap dan utuh. Masukkan plasenta ke dalam kantung plastic atau
tempat khusus.
42. Evaluasi kemungkinan laserasi pada vagina dan perineum. Lakukan penjahitan bila
laserasi menyebabkan perdarahan.
43. Bila ada robekan yang menimbulkan perdarahan aktif, segera lakukan penjahitan.
X.MELAKUKAN PROSEDUR PASCA PERSALINAN
44. Pastikan uterus berkontraksi dengan baik dan tidak terjadi perdarahan pervaginam.
45. 43. Biarkan bayi tetap melakukan kontak kulit ke kulit di dada ibu paling sedikit 1 jam.
Sebagian besar bayi akan berhasil melakukan inisiasi menyusui dini dalam waktu
30-60 menit. Menyusu pertama biasanya berlangsung sekitar 10-15 menit. Bayi
cukup menyusui dari satu payudara.
Biarkan bayi berada di dada ibu selama 1 jam walaupun bayi sudah berhasil
menyusu.
46. Setelah satu jam, lakukan pemeriksaan fisik bayi baru lahir, beri antibiotika salep
mata pencegahan, dan vitamin K1 1 mg intramuscular dipaha kiri anterolateral
47. Setelah 1 jam pemberian vit K1 1 mg berikan suntikan imunisasi Hepatitis B
dipaha kanan anterolateral.
Letakkan bayi di dalam jangkauan ibu agar sewaktu-waktu bisa disusukan.
Letakkan kembali bayi pada dada ibu bila bayi belum berhasil menyusu di dalam
satu jam pertama dan biarkan sampai bayi berhasil menyusu.
EVALUASI
48. Lanjutkan pemantauan kontraksi dan mencegah perdarahan per vaginam :
• 2-3 kali dalam 15 menit pertama pasca persalinan.
• Setiap 15 menit pada 1 jam pertama pascapersalinan.
• Setiap 20-30 menit pada jam kedua pascapersalinan.
• Jika uterus tidak berkontraksi dengan baik, melakukan asuhan yang sesuai
untuk menatalaksanakan atonia uteri.
Ajarkan ibu atau keluarga cara melakukan masase uterus dan nilai kontraksi
49. Evaluasi dan estimasi jumlah kehilangan darah.
50. Memeriksa nadi ibu dan keadaan kandung kemih setiap 15 menit selama 1 jam
pertama pascapersalinan
• Memeriksa temperatur tubuh ibu sekali setiap jam selama 2 jam pertama pasa
persalinan.
• Melakukan tindakan yang sesuai untuk temuan yang tidak normal
51. Periksa kembali bayi dan pantau setiap 15 menit untuk pastikan bahwa bayi
bernafas dengan baik (40-60 kali/menit) serta suhu tubuh normal (36,5 - 37,5 0C).
• Jika bayi sulit bernafas, merintih atau retraksi, diresusitasi dan segera merujuk
ke rumah sakit.
• Jika bayi bernafas terlalu cepat, segera dirujuk.
• Jika kaki teraba dingin, pastikan ruangan hangat. Kembalikan bayi kulit-ke-
kulit dengan ibunya dan selimuti ibu dan bayi dengan satu selimut
KEBERSIHAN DAN KEAMANAN
52. Tempatkan semua peralatan bekas pakai dalam larutan klorin 0,5% untuk
dekontaminasi (10 menit). Cuci dan bilas peralatan setelah didekontaminasi.
53. Buang bahan-bahan yang terkontaminasi ke tempat sampah yang sesuai.
54. Bersihkan ibu dengan menggunakan air DTT. Bersihkan sisa cairan ketuban, lendir
dan darah. Bantu ibu memakai pakaian yang bersih dan kering.
55. Pastikan ibu merasa nyaman. Bantu ibu memberikan ASI. Anjurkan keluarga
untuk memberi ibu minuman dan makanan yang diinginkannya.
56. Dekontaminasi tempat bersalin dengan larutan klorin 0,5%.
57. Celupkan sarung tangan kotor ke dalam larutan klorin 0,5%, balikkan bagian
 dalam ke luar dan rendam dalam larutan klorin 0,5% selama 10 menit.
58. Cuci kedua tangan dengan sabun dan air mengalir.
DOKUMENTASI
59. Lengkapi partograf (halaman depan dan belakang), periksa tanda vital dan asuhan
kala IV.