Politeknik Kesehatan Kementerian Kesehatan Jakarta 1 Nama Mahasiswa : ......................................

Jurusan Kebidanan NIM : ......................................

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

FORMAT KEBIDANAN IBU HAMIL

I. Data Subyektif
Tanggal...................................... Pukul...............................
A. Biodata
Nama Klien :................................... Nama Suami :..................................
Umur :................................... Umur :..................................
Agama :................................... Agama :..................................
Suku/Bangsa :................................... Suku/Bangsa :..................................
Pendidikan :................................... Pendidikan :..................................
Pekerjaan :................................... Pekerjaan :..................................
Alamat/Tlp :.................................................................................................................
B. Alasan Kunjungan
Pertama/Ulang/dengan keluhan
Gravida :
Usia Kehamilan :
Keluhan Utama : .......................................................................................................................
C. Riwayat Menstruasi
- Menarche : Umur...................................................................
- Menstruasi : Siklus...................................................................
Lama...................................................................
Banyak................................................................
Teratur/Tidak.......................................................
Disminore............................................................
Konsistensi..........................................................
- HPHT : Tanggal :..................................................................
Lama :..................................................................
Banyak :..................................................................
Konsistensi :..................................................................
- Taksiran Persalinan :..................................................................
D. Hasil Tes Kehamilan :..................................................................
Tanggal Tes :..................................................................
E. Pergerakan Fetus
Dirasakan pertama kali usia :...................................................
Pergerakan Fetus dalam 24 jam terakhir :...................................................
F. Kebiasaan Sehari-hari
1. Pola Makan....................................... Porsi:..........................................
2. Menu makanan sehari hari :
................................................................................................................................................
Perubahan makan yang dialami (termasuk ngidam, nafsu makan, dll)
................................................................................................................................................
3. Pola Eliminasi

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Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
Jurusan Kebidanan
BAK :.............................................
BAB :.............................................
4. Aktivitas :................................................................. Dibantu/ Tidak
5. Pola istirahat dan tidur
Tidur siang :..........................jam
Tidur malam :..........................jam
G. Riwayat Imunisasi
Imunisasi TT1 Tanggal..................................... Imunisasi TT2 Tanggal...............................
H. Riwayat KB
1. Kontrasepsi yang pernah digunakan......................................................................................
2. Efek samping.........................................................................................................................
3. Lama penggunaan..................................................................................................................
4. Kontrasepsi terakhir...............................................................................................................
5. Alasan berhenti......................................................................................................................
I. Riwayat Kehamilan sekarang
ANC dimana :..............................................................................................................
ANC oleh :..............................................................................................................
Frekuensi ANC :............................... Teratur/tidak
Konsumsi FE : Ada / tidak Jumlah konsumsi Fe :........................
USG : Pernah/ tidak
Hasil USG :..............................................................................................................
Masalah/Keluhan : Trimester I......................................................................................................
Trimester II.....................................................................................................
Trimester III....................................................................................................
J. Riwayat Kehamilan yang lalu
Masalah/Keluhan : Trimester I.....................................................................................................
Trimester II....................................................................................................
Trimester III...................................................................................................
K. Riwayat persalinan yang lalu
No Tgl/Thn Tempat Usia Jenis Penolong Penyulit JK BB PB Ket-
Partus Partus Kehamilan Partus (gram) (cm)

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Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
Jurusan Kebidanan
L. Riwayat nifas yang lalu
ASI : Colostrum Keluar / Tidak
ASI Eksklusif ya / tidak
Berapa lama disusui : Anak 1....................................
Anak 2....................................
Anak 3....................................
Komplikasi :...........................................................................................................................
Luka perineum:.............................................................................................................................
M. Riwayat Ginekologi
o Infeksi pada vagina.........................................................................................................
o Paps smear......................................................................................................................
o Pembedahan di daerah kemaluan....................................................................................
o Pembedahan di daerah payudara.....................................................................................
o Infertilitas........................................................................................................................
N. Riwayat Kesehatan
o Riwayat kecelakaan/ perdarahan.....................................................................................
o Riwayat transfusi.............................................................................................................
o Riwayat alergi..................................................................................................................
o Riwayat penyakit yang pernah / sedang
diderita .......................................................................................................................................
....
o Riwayat keluarga
 Riwayat keturunan kembar .................................................................................
 Riwayat penyakit keturunan ...............................................................................
o Perilaku yang merugikan kesehatan
 Penggunaan alkohol : .............................................
 Obat-obatan : .............................................
 Merokok, makan sirih : .............................................
 Iritasi vagina/ ganti pakaian dalam : ........................ / .......................................
O. Riwayat Sosial
1. Apakah kehamilan ini direncanakan/ diinginkan?..................................................................
2. Jenis kelamin yang diharapkan...............................................................................................
3. Status perkawinan...................................................................................................................
Jumlah............................... kali lama perkawinan :.................... tahun
4. Hubungan dengan suami........................................................................................................
5. Hubungan dengan tetangga....................................................................................................
6. Hubungan dengan keluarga/ibu dan mertua...........................................................................
7. Susunan keluarga yang tinggal serumah

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Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
Jurusan Kebidanan

No Umur Jenis Hub. Pendidikan Pekerjaan Ket-

(tahun) Kelamin Keluarga

8. Kepercayaan yang mempengaruhi ibu hamil :

..........................................................................................................................................................
I. 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 :.......................................................................................
6. Leher : Kel.Tyroid :........................................................................................
Vena Jugolaris :.......................................................................................
Kel. Getah bening :........................................................................................
7. Dada dan axila
Dada : Mammae : Membesar :...................... simetris:.................
Benjolan/tumor :.......................................................................................................
Areola :.....................................................................................................
Papilla mammae ............................................ Pengeluaran :.....................................
Striae :.......................................................................................................
Axilla :...................................................................................................................................
8. Abdomen
 Insfeksi
Pembesaran : ................................................................................................
Memanjang/melintang : .................................................................................................
Linea alba/nigra ....................................... striae albicans / livide.....................................
Bekas luka operasi / SC : .................................................................................................
Gerakan Janin : ................................................................................................

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Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
Jurusan Kebidanan
 Palpasi
TFU : ...........................cm (Mc. Donald)
Leopold I : TFU...................................................................................................
...........................................................................................................
Leopold II : (kanan)................................................................................................
(kiri)...................................................................................................
Leopold III : ..........................................................................................................
...........................................................................................................
Leopold IV :...........................................................................................................
Kontraksi :...........................................................................................................
Pergerakan Janin :...........................................................................................................
TBJ :...........................................................................................................
 Auskultasi
Frekuensi :............................./menit. teratur/ tidak,
Punctum maksimum................... tempat .........................................................................
9. Punggung dan pinggang
Posisi tulang belakang : .............................................................................................
Nyeri pinggang : .............................................................................................
10. Ekstremitas atas dan bawah
Atas : .............................................................................................
Bawah : .............................................................................................
Refleks patela : .............................................................................................
11. Pemeriksaan anogenital
 Warna vulva vagina : ............................................
 Luka parut : ............................................
 Varises : ............................................
 Pemeriksaan kel. Bartholin : ............................................
 Pengeluaran pervaginam : ............................................
 Kelainan : ............................................
 Kebersihan : ............................................
 Haemoroid pada anus : ............................................
B. Pemeriksaan Penunjang
Darah : Hb........................gram% Golongan Darah :............................
Urine : Protein :......................... Reduksi :............................
Pemeriksaan penunjang lain :.............................................................................................
.....................................................................................................................................................
....................................................................................................................................

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Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
Jurusan Kebidanan
II. Analisa

III. Perencanaan

Mengetahui :

Pembimbing Akademik CI / Pembimbing Lahan

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