UNIVERSITAS GUNADARMA

Program Studi Diploma III Kebidanan

SK Mendiknas No. 2102 / D / T / 2004

Rekomendasi Badan PPSDM Kesehatan No. HK.03.2.4.1.016

FORMAT
ASUHAN KEBIDANAN PADA IBU HAMIL

No.Reg : ....................................................................................................
Nama Pengkaji : ....................................................................................................
Hari / Tanggal : ....................................................................................................
Waktu Pengkajian : ....................................................................................................
Tempat Pengkajian : ....................................................................................................

I. PENGKAJIAN
1 . Data Subjektif
a. Identitas
Nama : Nama Suami :
Umur : Umur :
Pekerjaan : Pekerjaan :
Agama : Agama :
Pendidikan : Pendidikan :
Suku/Bangsa : Suku/Bangsa :
Alamat : Alamat :
Alamat Kantor : Alamat Kantor :
b. Keluhan Utama
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

c. Riwayat Kesehatan Sekarang

GPA : ......................................................................
HPHT : ......................................................................
TP : ......................................................................
iklus Haid : ......................................................................

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 Pergerakan janin pertama kali :.......................................................................
Pergerakan janin 1 jam terakhir : ................................................................kali
Tanda bahaya / penyulit : ......................................................................
Obat / jamu yang dikonsumsi : ......................................................................
Imunisasi TT 1 : tanggal .........................................................
Imunisasi TT 2 : tanggal .........................................................
Kekhawatiran – kekhawatiran khusus: ...........................................................................

d. Riwayat Kehamilan, Persalinan, Nifas yang Lalu

No. Tgl/Thn Usia Jenis Tempat Penyulit JK BB/ Keadaan IMD- Nifas
Kehamilan Persalinan anak
Lahir Persalinan PB ASI
Anak /Penolong esklusif

e. Riwayat Kesehatan / Penyakit

Riwayat Kesehatan yang diderita sekarang / dulu:

.........................................................................................................................................
Riwayat Keturunan :

.........................................................................................................................................
Riwayat Penyakit Keluarga :

.........................................................................................................................................

f. Riwayat Psikososial
Status Pernikahan - Suami yang ke : .........................................................
- Istri yang ke : .........................................................
- Lamanya pernikahan : .........................................................

Respon ibu / keluarga terhadap kehamilan : .........................................................

Jenis kelamin yang diharapkan : .........................................................

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 Bentuk dukungan keluarga : .........................................................
Adat istiadat yang berhubungan dengan kehamilan : .....................................................
Pengambilan keputusan dalam keluarga : ......................................................... Rencana
Persalinan - Tempat : .........................................................

- Penolong Persalinan : .........................................................

Persiapan Persalinan
- Pendamping Persalinan: ........................................................
: .........................................................
Riwayat KB terakhir - Jenis Kontrasepsi :
......................................................... - Lama Penggunaan :
.........................................................

g. Aktifitas Sehari – hari 1 . Nutrisi

Pola Makan ( frekuensi ) : ...................................................................... Jenis

makanan yang dikonsumsi : ...................................................................... Jenis
makanan yang tidak disukai : ......................................................................

Perubahan porsi makan : ......................................................................

2 . Eliminasi
BAB - Frekuensi : ...................................................................................
- Konsistensi : ...................................................................................
BAK - Frekuensi : ...................................................................................
- Warna : ...................................................................................
3. Pola Istirahat dan Tidur
Tidur malam : ..........................................................................................jam Tidur
siang : ..........................................................................................jam Masalah :
................................................................................................

4. Kebiasaan Hidup Sehari – hari

Obat-obatan / jamu : ................................................................................................
Alergi obat : ................................................................................................ Merokok :
................................................................................................

Minuman Beralkohol : .............................................................................................

NAPZA : ................................................................................................
5. Aktivitas Sehari – hari : ............................................................................................

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 6. Hubungan Seksual
Hubungan seks dalam kehamilan : ...................................................................... Keluhan :
......................................................................
7. Personal Hygiene
Mandi : ...................................................................................
Ganti Pakaian dalam dan luar : .................................................................................
Irigasi Vagina : .....................................Frekuensi : ...........................

2 . Data Objektif
a. Keadaan Umum : ................................................................................................ -
Kesadaran : ................................................................................................ -
Keadaan emosional : ................................................................................................

- Tanda Vital
Tekanan Darah : ..................................................mmHg
Nadi : ..................................................x/menit
Pernafasan : ..................................................x/menit
Suhu : ..................................................ºc

b. Antropometri
- TB : .....................................cm
- BB Sebelum hamil : ......................................kg
- BB Sekarang : ......................................kg IMT : ..............
c. Pemeriksaan Fisik
1 . Kepala
Rambut : .............................................................................................................
Muka Chloasma : ....................................Oedema : ...............................
Mata Konjungtiva : ...................................................................................
Sklera : ...................................................................................
Hidung Pengeluaran : ...................................................................................
Polip : ...................................................................................
Telinga Kebersihan : ...................................................................................

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 Mulut / gigi Stomatitis : ...................................................................................
Gusi : ...................................................................................
Caries : ...................................................................................

2 . Leher
Pembesaran Kelenjar Tiroid : ...................................................................................
Kelenjar Getah Bening : ......................................................................
Vena Jugularis : ...................................................................................
3. Dada
Retraksi Dinding Dada : ...................................................................................
Bunyi pernafasan : ...................................................................................
Bunyi Jantung : ...................................................................................
Irama : ...................................................................................
Payudara Bentuk : ...................................................................................
Puting susu : ...................................................................................
Areola : ...................................................................................
Pengeluaran : ...................................................................................
Benjolan : ...................................................................................

Tanda – tanda retraksi : ......................................................................

Kebersihan : ...................................................................................
Lain – lain : ...................................................................................
4. Perut
Bekas luka operasi : ................................................................................................
Bentuk perut : ................................................................................................ Kontraksi :
................................................................................................

TFU ( Mc Donald ) : ....................................cm

Palpasi Leopold I : ...................................................................................
Leopold II : ...................................................................................
...................................................................................
Leopold III : ...................................................................................
...................................................................................
Leopold IV : ...................................................................................
...................................................................................
Auskultasi DJJ : .....................................x/menit ( teratur/tidak )

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 5. Ekstremitas
Telapak tangan : ................................................................................................
Varices : ................................................................................................ Reflek
Patella : ................................................................................................ Oedema :
................................................................................................

6. Pinggang ( costo vertebra angel tenderness ) : ...........................................................

d. Pemeriksaan Genitalia
1. Pemeriksaan Genetalia Eksternal
Labia Mayora : ................................................................................................
Labio Minora : ................................................................................................
Urifisium Uretra : ................................................................................................
Vulva : ................................................................................................
Varices : ................................................................................................
Pengeluaran : ................................................................................................
Bau : ................................................................................................
Kelenjar Skene : ................................................................................................
Kelenjar Bartholin : ................................................................................................
Lain – lain : ................................................................................................
2. Genetalia Interna ( bila ada indikasi )
Pemeriksaan dalam

Dinding Vagina: ................................................................................................

Serviks dan Vagina : ...................................................................................
Pelvimetri Klinis
Promontorium : ................................................................................................
Conjugata Diagonalis : ...................................................................................
Linea Inominata : ................................................................................... Spina
Isciadika : ................................................................................................ Distansia
Interspinarum : ...................................................................................

Sacrum : ................................................................................................ Arcus

Pubis : ................................................................................................ Kesan Panggul :
................................................................................................ 3. Anus ( Haemoroid ) :
................................................................................................

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 e. Pemeriksaan Penunjang
1. Laboratorium
Darah Hb : .................................gr%
Gol. Darah : .......................
Urine Protein : .............................
Glukosa : ............................
2. USG : ..........................................................................................................................
..........................................................................................................................
II. ANALISA
....................................................................................................................................................................
...................................................................................................................................................................
III. PENATALAKSANAAN ( RENCANA, TINDAKAN, EVALUASI )
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