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YAYASAN HAJI SOEHEILY QARI

SEKOLAH TINGGI ILMU KESEHATAN


(STIKES) MERANGIN
PRODI D III KEBIDANAN
Jln.BangkoKerinci Km.6 Kungkai, Kecamatan Bangko Kabupaten Merangin
email.stikes.merangin@yahoo.com

FORMAT ASUHAN KEBIDANAN PADA IBU BERSALIN


NAMA MAHASISWA
NIM
TEMPAT PRAKTEK
PEMBIMBING
TANGGAL

:
:
:
:
:

RS/PUSKESMAS/RB/BPS
NO.RM
:
TANGGAL MASUK :
PUKUL
:
RUANGAN
:

PENGUMPULAN DATA
A. IDENTITAS
Nama Ibu
Umur
Suku/Bangsa
Agama
Pendidikan
Pekerjaan
Alamat Kantor
Alamat Rumah
Telp

:
:
:
:
:
:
:
:
:

Penanggung Jawab
Nama
Umur
Pekerjaan
Alamat
No. Telp/HP
Hubungan dengan klien

Nama Suami
Umur
Suku/Bangsa
Agama
Pendidikan
Pekerjaan
Alamat Kantor
Alamat Rumah
Telp

:
:
:
:
:
:
:
:
:

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:

B. ANAMNESA
Pada Tanggal
:
Pukul
:
Cara masuk
: datang sendiri / kiriman
1. Keluhan Utama

2. Tanda-tanda bersalin
Kontraksi.......................sejak tanggal..........................pukul....................................
Frekuensi .......................x setiap 10 menit
Lamanya ........................detik kekuatan...................................................................
Lokasi ketidaknyamanan...........................................................................................
3. Pengeluaran pervaginam
Darah lendir
ada tidak, tanggal...................pukul...........................
Air ketuban
ada
tidak, jam........................jumlah..........................
Warna...................................bau...................................
Darah
ada
tidak, jam.......................jumlah..........................
Warna................................
4. Masalah masalah khusus

( Tanyakan hal-hal yang berhubungan dengan faktor resiko/predisposisi maupun


resiko tinggi yang di alami) .....................................................................................
.................................................................................................................................
5. Riwayat kehamilan sekarang
HPHT
Haid bulan sebelumnya
Siklus
ANC
Keluhan lain

:.............................. TP
:.................................
:.............................. Lamanya :.................................
:..............................
: Teratur / tidak, frekuensi................x di..................
:.................................................................................

6. Riwayat penyakit yang sedang/ pernah di derita :


Hepatitis
:............................... Astma
Hipertensi
:............................... Ginjal
TBC
:............................... Malaria
Jantung
:............................... Penyakit Kelamin
DM
:............................... Dll

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

7. Riwayat imunisasi : TT1 :................................TT2 :.................................................


8. Riwayat kehamilan dan persalinan yang lalu

No

Tgl/Thn
persalinan

Tempat
Pertolongan

Usia
kehamilan

Jenis
Persalinan

Penolong

Penyakit
kehamilan &
persalinan

Anak
JK

BB

PB

keadaan

9. Pergerakan Janin dalam 24 jam terakhir :


Frekuensi :.............................../24 jam, Kekuatan :..................................................
10. Makan dan Minum
Terakhir makan jam............................Jumlah..................Jenis.................................
Terakhir minum jam...........................Jumlah...................Jenis.................................
11. Eliminasi
BAB Terakhir..........................................Konsistensi...............................................
BAK Terakhir..........................Jumlah........................Warna...................................
12. Tidur
Tidur terakhir jam.................................lamanya.......................................................
13. Psikologis
Reaksi ibu
:......................................................................
Interaksi ibu dengan pendamping
:......................................................................
Cara mengatasi stress
:......................................................................
Harapan akan kelahiran
:......................................................................
Pengambil keputusan
:......................................................................
Kecanduan obat obatan /minuman keras :..........................................................
C. PEMERIKSAAN FISIK
1. Keadaan Umum
:..............................................................................................
Keadaan emosional :..............................................................................................
2. Tanda-tanda vital :
- Tekanan Darah

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

Denyut nadi
Pernafasan
Suhu tubuh
3. Tinggi Badan
4. Muka

:..............................................................................................
:..............................................................................................
:..............................................................................................
:.....................................Berat Badan.....................................
: Kelopak Mata
:..............................................
Konjungtiva
:..............................................
Sklera
:..............................................
Mulut dan gigi
: Lidah dan geraham
:..............................................
Gigi
:..............................................
Kelenjar Thiroid
: pembesaran
:..............................................
Kelenjar Limfe
: pembesaran
:..............................................
Dada
:..................................................................................
Jantung
:..................................................................................
Paru
:..................................................................................
Payudara
: Pembesaran
:..............................................
Papila Mammae
:..............................................
Simetris
:..............................................
Benjolan
:..............................................
Pengeluaran
:..............................................
Rasa Nyeri
:..............................................
Punggung dan pinggang
:..................................................................................
Posisi tulang belakang
:..................................................................................
Pinggang/ nyeri ketuk
:..................................................................................
Ekstremitas atas dan bawah : Oedema
:..................................
Kekakuan otot & sendi
:..................................
Kemerahan
:..................................
Varises
:..................................
Reflek
:..................................
Abdomen
: Pembesaran
:..............................................
Benjolan
:..............................................
Bekas luka operasi :..............................................
Konsistensi
:..............................................
Pembesaran lien/limfe
:..................................
Kandung Kemih
:..................................................................................
-

5. Pemeriksaan kebidanan
1) Palpasi Uterus
Leopold I
:..................................................................................
( dengan pita cm )
:.....................................TBJ......................................
Leopold II
:..................................................................................
Leopold III
:..................................................................................
Leopold IV
:..................................................................................
Pergerakan
:..................................................................................
Kontraksi
: Frekuensi........./10, lama............kekuatan.............

2) Auskultasi
Denyut Jantung Janin
Frekuensi
Punctum maksimum

:......................................................................
:..........................Teratur/Tidak......................
:......................................................................

3) Ano Genital (inspeksi)


Perineum
Vulva vagina
Pengeluaran pervaginam
Kelenjar Bartolini
Anus

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

4) Pemeriksaan Dalam

Atas indikasi
Dinding vagina
Porsio
Pembukaan serviks

:......................................................................
:......................................................................
:....................Konsistensi...............,posisi......
:......................................................................

Ketuban
Presentasi Serviks
Penurunan bagian terendah
Penunjuk ( Point Of Direction )

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

Pemeriksaan panggul
Promontorium...............................................Linea inominata.............................
Konjungata vera..........................................Konjungata Diagonalis....................
Sacrum..........................................Dinding Samping...........................................
Spina ischiadica........................................................Distansia Interspinarum.....
...............................................,Koksigeus............................................................
Arcus Pubis.......................................Distansia Intertuberosum..........................
D. UJI DIAGNOSTIK
Pemeriksaan laboratorium
CT/CB
Hemoglobin
Golongan Darah
Haemotokrit
Rhesus
DII ( Sesuai Kebutuhan )

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