ASUHAN KEBIDANAN PADA IBU BERSALIN (INTRANATAL)

Tanggal :......... ............... Jam :................................ No.Rekam Medik :

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IDENTITAS
Nama Pasien :........................... Nama Suami :...........................
Umur :........................... Umur :...........................
Agama :........................... Agama :...........................
Suku / bangsa : ........................... Suku / bangsa : ...........................
Pendidikan : ........................... Pendidikan : ...........................
Pekerjaan : ........................... Pekerjaan : ...........................
Alamat : ........................... Alamat : ...........................
KELUHAN UTAMA
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(kaji keluhan utama yang membuat ibu datang periksa secara fisik maupun psikologis)
RIWAYAT KEBIDANAN
a. Riwayat Perkawinan
Status Pernikahan : Ya Tidak
Jika Kawin :
b. Riwayat kehamilan, persalinan, nifas, dan anak yang lalu
biasa/partus
Perkawinan

puerperium
perempuan
Kehamilan

buatan dan
kehamilan

penolong
Prematur

kematian
Laki-laki
Abortus

Imature
Ikhtisar

Partus

Sebab
Umur
No.

KB
No

c.Riwayat kehamilan sekarang

Diagnosis :..................................................................................................................
Umur Kehamilan :..................................................................................................................
HPHT :..................................................................................................................
Mulai merasakan gerakan janin :..............................................................................................
ANC : ......................................................... kali, di : ..............................................................
Imunisasi TT : .............................................kali, tanggal : ...................................................
Pemberian : Fe : ......................................... yodium : .............................................................
Keluhan selama hamil : ..........................................................................................................
Perawatan payudara : tidak pernah pernah
Alasan : ...............................................
Senam hamil : ........................................................
Rencana KB yang akan datang :
Pantang berkala IUD Suntik
C
V
C
C
 Steril Tidak KB lain-lain, jelaskan : ................
Alasan KB : ........................................

d. riwayat persalinan sekarang

Tanggal persalinan : ........................
Jenis persalinan : spontan secsio caesaria vakumekstrasi
Forceps ekstraksi : ...........................................
Lain-lain, jelaskan: ..........................................
Lama persalinan :
Kala I : ....................... kelainan ....................
Kala II : ....................... kelainan ....................
Kala III : ....................... kelainan ....................
Kala IV : ....................... kelainan ....................
Keadaan Ketuban :
Pecah jam : .......................................
Warna : ...........................................
Banyaknya/jumlah : ..............................
Bau : ...........................................
Keadaan plasenta
Lahir jam : ................. berat : ...................
spontan manual kurretage
utuh rusak lengkap
tidak lengkap
panjang : .................cm
lebar : ........................cm
tebal : ........................cm
insersi : marginalis lateralis medialis
jumlah pendarahan : ........................................cc
Tali pusat :
Panjang : ...................................cm, Kelaianan : ...................................
Keadaan perineum :
Episiotomi Medial

Lateral Medial Lateral

Intack ruptur : tingkat .........

Hecting : ya, berapa jumlah jahitan ................. tidak
Kontraksi uterus : baik lembek
TFU : ................................................ jari
Keadaan bayi :
Keadaan umum : .............................
Berat badan : ............................. Panjang Badan : ....................................
Jenis kelamin : ............................. A-S : ....................................
Kelainan : .............................
( untuk pengkajian bayi dilanjutkan dengan format asuhan bayi baru lahir )