YAYASAN HAJI SOEHEILY QARI

SEKOLAH TINGGI ILMU KESEHATAN (STIKES) MERANGIN

PRODI D III KEBIDANAN
Jln.Bangko–Kerinci Km.6 Kungkai, Kecamatan Bangko Kabupaten Merangin
email.stikes.merangin@yahoo.com
FORMAT ASUHAN KEBIDANAN PADA IBU BERSALIN
NAMA MAHASISWA :............................... RS/PUSKESMAS/RB/BPS
NIM :............................... NO.RM :..................................
TEMPAT PRAKTEK :............................... TANGGAL MASUK :..................................
PEMBIMBING :............................... PUKUL :..................................
TANGGAL :............................... RUANGAN :..................................

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

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

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 :......................................... TP :............................
Haid bulan sebelumnya :......................................... Lamanya :............................
Siklus :.........................................
ANC : Teratur / tidak, frekuensi................x di...............................
Keluhan lain :..............................................................................................

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 Tempat Usia Jenis Penolong Penyakit Anak

persalinan Pertolongan kehamilan Persalinan kehamilan &
persalinan 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 :.....................................Berat Badan.................................................
4. Muka : Kelopak Mata :..........................................................
Konjungtiva :..........................................................
Sklera :..........................................................
Mulut dan gigi : Lidah dan geraham :..........................................................
Gigi :..........................................................
Kelenjar Thiroid : pembesaran :..........................................................
Kelenjar Limfe : pembesaran :..........................................................
Dada :..............................................................................................
Jantung :..............................................................................................
Paru :..............................................................................................
Payudara : Pembesaran :..........................................................
Papila Mammae :..........................................................
Benjolan :..........................................................
Pengeluaran :..........................................................
Rasa Nyeri :..........................................................
Posisi tulang belakang
:..............................................................................................
Pinggang/ nyeri ketuk :..............................................................................................
Ekstremitas atas dan bawah : Oedema :..............................................
Kekakuan otot & sendi :..............................................
Kemerahan :..............................................
Varises :..............................................
Reflek :..............................................
Abdomen : Pembesaran :..........................................................
Benjolan :..........................................................
Bekas luka operasi :..........................................................
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 :..........................Teratur/Tidak..................................
Punctum maksimum :..................................................................................

3) Ano – Genital (inspeksi)

Perineum :..................................................................................
Vulva vagina :..................................................................................
Pengeluaran pervaginam :..................................................................................
Kelenjar Bartolini :..................................................................................
Anus :..................................................................................

4) Pemeriksaan Dalam
Atas indikasi :..................................................................................
Dinding vagina :..................................................................................
Porsio :....................Konsistensi...............,posisi..................
Pembukaan serviks :..................................................................................
 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 ) :..............................................................................................