Nama Mahasiswa : ......................................

NIM : ......................................
Tingkat : ......................................
Tempat Praktek : ......................................

FORMAT PENGKAJIAN
ASUHAN KEBIDANAN PADA IBU BERSALIN

I. Data Subyektif

Tanggal.............................. Pukul..........................
Tempat......................................

A. Biodata

Nama Klien :................................... Nama Suami :..........................

Umur :................................... Umur :..................................
Agama :................................... Agama :..................................
Suku/Bangsa :................................... Suku/Bangsa :..................................
Pendidikan :................................... Pendidikan :..................................
Pekerjaan :................................... Pekerjaan :..................................
Alamat/Tlp:........................................................................................................................................
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B. Anamnesa
Pada Tanggal :.......................................................... Pukul :............................. WIB
KeluhanUtama:..................................................................................................................................
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1. Riwayat Menstruasi
Menarche, Umur :.....................Tahun Haid sebelumnya : Teratur / Tidak Teratur
Siklus :.......................Hari Lamanya :..........................Hari
Banyaknya :................................ Sifat Darah :...................................
 HPHT :................................ Gangguan Menstruasi :............................
Tafsiran Persalinan :...............................

2.Riwayat Perkawinan
Status Perkawinan :............................. Berapa Kali:...................................
Lama Perkawinan :....... Tahun Kawin yang 1 umur :...... Tahun
Umur Suami :...... Tahun

3. Riwayat Kehamilan yang Lalu

Anak Tanggal Tempat Usia Jenis Penolong Penyulit ANAK ASI Komp.
Ke Persalinan Persalinan Kehamilan Persalinan Nifas
JK BB PB

Masalah/Keluhan :
Trimester I.............................................................................................................................
Trimester II..............................................................................................................................
Trimester III.............................................................................................................................
4. Riwayat Nifas yang Lalu
ASI : Colostrum keluar / tidak
ASI Eksklusif : ya / tidak
Berapa lama disusui : Anak ke-1....................................
Anak ke-2....................................
Anak ke-3....................................
dst
Komplikasi:..........................................................................................................................
Luka perineum:....................................................................................................................
5. Riwayat Kehamilan Ini
G.........P........A.......
ANC dimana :...................................................... Oleh:......................................
Frekuensi ANC :...............................Kali, Teratur/Tidak Terarur
Konsumsi FE : Ada / Tidak
Jumlah konsumsi Fe :........................
Imunisasi TT :........................
USG : Pernah/ tidak
Hasil USG :..............................................................................................................
Masalah/Keluhan :
Trimester I..........................................................................................................................
Trimester II.........................................................................................................................
Trimester III.........................................................................................................................
6. Riwayat KB
a. Kontrasepsi yang pernahdigunakan :..........................................................................
b. Lama penggunaan :.........................................................................
c. Kontrasepsi tearakhir :...........................................................................
d. Alasan berhenti :............................................................................
7. Riwayat Kebiasaan
Makan/Minum :...........................................................................
Eliminasi :...........................................................................
8. Riwayat Kesehatan
a. Riwayat penyakit yang pernah/sedang diderita........................................................
b. Obat rutin yang dikonsumsi....................................................................................
c. Riwayat kecelakaan/pendarahan/trauma..................................................................
d. Riwayat penyakit jiwa...............................................................................................
e. Riwayat transfusi......................................................................................................
f. Riwayat alergi obat/makanan...................................................................................
9. Riwayat Sosial
1. Emosi :........................................................
 2. Respons Terhadap Persalinan :.................................................................................
3. Hubungan dengan orang tua/mertua :........................................................................
4. Jenis kelamin yang diinginkan :................................................................................
5. Pengambilan keputusan dalam keluarga :.................................................................
6. Adat istiadat yang berkaitan dengan persalinan :......................................................

II. Data Obyektif

A. Pemeriksaan Fisik
1. Keadaan Umum..................................... Kesadaran :.....................................
2. Tanda – Tanda Vital
Tekanan darah :.................. mmHg Denyut nadi :.............. x/menit
Suhu tubuh :...................OC Pernafasan :...............x/menit
3. Tinggi Badan :...................cm BB :................Kg
Sebelum hamil :................Kg
Kenaikan BB selama hamil :....... kg
4. LILA :.........................cm
5. Kepala :Rambut :…………………………….....................................
Muka :................................................................................
Mata :...............................................................................
Mulut/gigi :...............................................................................
THT
Telinga :...............................................................................
Hidung :...............................................................................
Tenggorokan :...............................................................................
Leher : Kel.Tyroid :...............................................................................
Vena Jugolaris :...............................................................................
Kel. Getah bening :..........................................................................
6. Dada dan axila
Dada :
Mammae : Membesar :.............................
Simetris:..........................................
 Benjolan/tumor:...........................................................................
Areola :...................................................................................................................
Papilla mammae :............................................Pengeluaran :...................................
Striae :..............................................................................................
Axilla :.................................................................................
7. Abdomen
 Inspeksi
Pembesaran :................................................................................
Memanjang/melintang :........................................................................................
Linea alba/nigra :....................................
Striae albicans /livide :..........................
Bekas luka operasi / SC :.....................................................................................
Gerakan Janin : ....................................................................................
 Palpasi
Leopold I :TFU................................................................................................
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TFU : ...........................cm (Mc. Donald)
Leopold II : (kanan)...........................................................................................
(kiri)........................................................................................................................
Leopold III :.........................................................................................................
Leopold IV :.........................................................................................................
His : frekuensi...............x / 10 menit Lamanya....................
Kekuatan................................. Relaksasi...................
Pergerakan Janin :..................................................................................................
TBJ :.........................................................................................................
 Auskultasi
Frekuensi :.........................../menit, teratur/ tidak,intensitas.............................
Punctum maksimum................... tempat...............................................................
8. Punggung dan pinggang
Posisi tulang belakang :.................................................................................
Nyeri pinggang :............................................................................................
 9. Ekstremitas atas dan bawah
Atas : ..................................................................................
Bawah :...................................................................................
Refleks patela :...................................................................................
Varises :...................................................................................
10. Pemeriksaan anogenital
a. Inspeksi Vulva
 Warna vulva vagina : ………………
 Luka parut : ………………
 Varises : ………………
 Pengeluaran pervaginam : ………………
 Kebersihan : ………………
 Haemoroid pada anus : ………………
b. Palpasi Vulva
Pemeriksaan kel. Bartholin : ………………
Kelainan : ………………
c.Vaginal Toucher
Portio : - Arah : ……………… konsistensi : ………………
- Effishment ( penipisan ) : ………………
- Pembukaan : ………………
- Ketuban : ………………
Bagian bawah janin teraba : ……………… Penurunan Hodge : ………………
Dengan penunjuk : ……………… Arah : ………………
Molase / penyusupan : ………………
Bagian lain yang teraba : ………………

B. Pemeriksaan Penunjang
Darah : Hb........................gram% Golongan Darah :.........................................
Urine : Protein :......................... Reduksi :..........................................
Pemeriksaan penunjang lain :....................................................................................
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III. Analisa
Diagnosa Ibu:................................................................................................................
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Diagnosa Janin:.............................................................................................................
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IV. Penatalaksanaan
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Tanggal : .............................. Pukul :............

KEMAJUAN PERSALINAN KALA I
I. DATA SUBJEKTIF
Keluhan : ..........................................................................................................................
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II. DATA OBJEKTIF
1. Pemeriksaan Umum
Keadaan Umum ........................... Kesadaran ...............
Tekanan Darah ............................. Pernafasan ........................
Suhu......˚C Nadi.....x/menit
2. Abdomen
a. Inspeksi
Gerakan Janin : ..............................................................................................
b. Palpasi
Leopold I :TFU.....................................................................................
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TFU : ...........................cm (Mc. Donald)
Leopold II :
(kanan).............................................................................................................
(kiri).................................................................................................................
Leopold III :.............................................................................................
Leopold IV :.............................................................................................
His : frekuensi...............x / 10 menit Lamanya....................
Kekuatan................................. Relaksasi...................
Pergerakan Janin.......................................................................................
TBJ :.............................................................................................
c. Auskultasi
DJJ : - frekwensi.................. x/ mnt Teratur/ tidak.................
- Punctum Maximun.......................................................
3. Anogenital
Inspeksi : Vulva ..........................................................................
Pengeluaran pervaginam...........................................
 Vaginal Toucher : ..........................................................................
Portio :- Arah............................. konsistensi.............................
- Effishment ( penipisan ) .............................................
- Pembukaan..................................................................
- Ketuban..........................................................................
Bagian bawah janin teraba................... Penurunan Hodge...............................
Dengan penunjuk................................. Arah...................................................
Molase / penyusupan..........................
Bagian lain yang teraba.....................................................................................
III. ANALISA
Ibu .........................................................................................................................................
Bayi .......................................................................................................................................
IV. PENATALAKSANAAN
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Tanggal : ..................................... Pukul :........................................... WIB
KALA II
III. DATA SUBJEKTIF
Keluhan : ..........................................................................................................................
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IV. DATA OBJEKTIF
2. Pemeriksaan Umum
Keadaan Umum ........................... Kesadaran ...............
Tekanan Darah ............................. Pernafasan ........................
Suhu......˚C Nadi.....x/menit
2. Abdomen
a. Inspeksi
Gerakan Janin : ..............................................................................................
b. Palpasi
Leopold I :TFU.....................................................................................
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TFU : ...........................cm (Mc. Donald)
Leopold II :
(kanan).............................................................................................................
(kiri).................................................................................................................
Leopold III :.............................................................................................
Leopold IV :.............................................................................................
His : frekuensi...............x / 10 menit Lamanya....................
Kekuatan................................. Relaksasi...................
c. Auskultasi
DJJ : - frekwensi.................. x/ mnt Teratur/ tidak.................
- Punctum Maximun.......................................................
3. Anogenital
Inspeksi : Vulva ..........................................................................
Pengeluaran pervaginam...........................................
 Vaginal Toucher :
Portio :- Arah............................. konsistensi.............................
- Effishment ( penipisan ) .............................................
- Pembukaan..................................................................
- Ketuban..........................................................................
Bagian bawah janin teraba................... Penurunan Hodge...............................
Dengan penunjuk................................. Arah...................................................
Molase / penyusupan..........................
Bagian lain yang teraba.....................................................................................
III. ANALISA
Ibu .........................................................................................................................................
Bayi .......................................................................................................................................
IV. PENATALAKSANAAN
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Tanggal : ..............................Pukul :............

KALA III
I. DATA SUBJEKTIF
Tanggal : ..............................Pukul :............
Keluhan : ..........................................................................................................................
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II. DATA OBJEKTIF
1. Pemeriksaan Umum
Keadaan Umum ........................... Kesadaran ...............
2. Abdomen
Palpasi: TFU.......................................................................................................
Kontraksi Uterus :................................................................................................
Kandung Kemih : Penuh/Tidak
- Anogenital
Pengeluaran pervaginam : ..................................
Perineum : Ruptur/Tidak
Ruptur Grade..................................

III. ANALISA
Ibu ....................................................................................................................................

IV. PENATALAKSANAAN
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Tanggal : ………………………………………… Pukul : ……………… WIB

KALA IV
I. DATA SUBJEKTIF
Keluhan :…………………………………………………………………………
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II. DATA OBJEKTIF
1. Pemeriksaan Umum
Keadaan Umum : ………………… Kesadaran ……………………………
2. Abdomen
Palpasi : TFU………………………………………………………
Kontraksi Uterus :…………………………………………………………….
Kandung Kemih : Penuh / Tidak
3. Anogenital
Pengeluaran Pervaginam : …………… banyaknya: …………………
Perineum : Ruptur / Tidak
Ruptur Grade ……………

III. ANALISA
Ibu:…………………………………………………………………………………...
IV. PENATALAKSANAAN
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Mengetahui,

Pembimbing Pendidikan, Pembimbing Lahan/CI,

(……………………………………) (…………………………………)