LEMBAR OBSERVASI

Masuk Kamar Bersalin, tanggal : .................

Anamnese

jam : ............. WIB

: his mulai tanggal ................... jam : .............. WIB dan mengeluarkan lendir
darah sejak jam ............. WIB. Ketuban belum/sudah pecah.

Keadaan umum : T : ................ mmHg

S : ..........C
N : ........ x/menit
RR : ....... x/menit
Pemeriksaan Obstetri : 1. Palpasi : .......................................................................................
.......................................................................................
2. DJJ

: .......... x/menit

3. His 10 : ..........................
4. VT

: tanggal : ................. jam : .............. WIB

5. Hasil

: .....................................................................................
.....................................................................................
.....................................................................................

6. Pemeriksa : ...................

OBSERVASI KALA I

Tgl

Jam

His dalam DJJ/

10 menit mnt T(mmHg)

Jml

Lama

SC

N/menit

VT

Ket.