A. Biodata
Nama : ..............................................................................................
Jenis Kelamin : ..............................................................................................
Umur : ..............................................................................................
Pekerjaan : ..............................................................................................
Agama : ..............................................................................................
Pendidikan Terakhir : ..............................................................................................
Alamat : ..............................................................................................
No. registrasi : ..............................................................................................
Tgl. MRS : ..............................................................................................
Tgl. pengkajian : ..............................................................................................
Diagnosa medis : ..............................................................................................
C. Riwayat Kebidanan
1. Riwayat haid
E. Pemeriksaan Persalinan
Kala I
a. Mulai pembukaan : Tanggal/ pukul : ..................................................................
b. Keluhan klien : ..........................................................................................
c. Pervaginam : ..........................................................................................
d. Leopold I, II, III, IV : .........................................................................................
.............................................................................................................................
e. Observasi kemajuan persalinan
Kala II
a. Mulai pembukaan (Tanggal/ pukul) : ................................................................
b. Lamanya kala II : ..................................................................................
c. Keadaan psikososial : ..................................................................................
.....................................................................................
d. Jumlah perdarahan : ..................................................................................
e. Bayi lahir (Tanggal/ pukul) : ..............................................................................
f. Apgar Score : 1 menit .....................................................................
5 menit......................................................................
g. Perineum : ..................................................................................
h. Kontraksi uterus : ..................................................................................
i. TTV Ibu : ..................................................................................
.....................................................................................
Kala III
a. Kala III mulai pukul : ..................................................................................
b. Cara kelahiran plasenta : ..................................................................................
c. Lamanya kala III : ..................................................................................
d. Kondisi plasenta dan tali pusat : .........................................................................
.....................................................................................
e. Jumlah dan sifat perdarahan : .............................................................................
.....................................................................................
f. Jumlah kotiledon : ..................................................................................
g. Panjang tali pusat : ..................................................................................
h. Kontraksi uterus : ..................................................................................
i. TTV Ibu : ..................................................................................
.....................................................................................
Kala IV
a. TTV klien : ..................................................................................
.....................................................................................
b. Kontraksi uterus : ..................................................................................
c. Kondisi kandung kemih : ..................................................................................
d. Jumlah dan sifat perdarahan : .............................................................................
.....................................................................................
e. Tinggi fundus uteri : ..................................................................................
Perawat
NIM.