AKADEMI KEBIDANAN RSPAD GATOT SOEBROTO Kode : FM/STD.

A/03/11
Jl. Abdul Rahman Saleh No.24Jakarta 10410 Tanggal : 01 Maret 2018
Telepon: (021) 3441008 Psw 2241 Fax (021) 3454373 Revisi :00
Laman : http://www.akbidrspad.ac.id Hal :
FORMULIR MANAJEMEN ASUHAN KEBIDANAN
PADA IBU HAMIL

MANAJEMEN ASUHAN KEBIDANAN PADA IBU HAMIL

No. Registrasi : ......................................................................................................................

Nama Pengkaji : ......................................................................................................................
Hari / Tanggal : ......................................................................................................................
Waktu Pengkajian : ......................................................................................................................
Tempat Pengkajian : .....................................................................................................................

Quick Check : ......................................................................................................................

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

I. PENGKAJIAN

1. DATA SUBJEKTIF
A. IDENTITAS ( Biodata ) :
Nama Pasien : ……………………………. Nama Suami : ………………………..
Umur : ……………………………. Umur : ………………………..
Suku / Bangsa : ……………………………. Suku / Bangsa : ………………………..
Agama : ……………………………. Agama : ………………………..
Pendidikan : ……………………………. Pendidikan : ………………………..
Pekerjaan : ……………………………. Pekerjaan : ………………………..
Penghasilan : ……………………………. Penghasilan/bln : ………………………..
Alamat Rumah : ……………………………. Alamat Rumah : ………………………..
Alamat Kantor : …………………………….. Alamat Kantor : ………………………..
Telp. …………………………

B. Keluhan Utama
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................

C. Riwayat Menstruasi
Umur menarche : tahun
Lamanya haid : hari
Jumlah darah haid : x ganti pembalut
Haid terakhir :
( ) Dismenorhea
( ) Menorragia
( ) Pre Menstruasi Sindrom
( ) Spooting
( ) Metrorhagia

D. Riwayat Kehamilan Sekarang

Hari Pertama Haid Terakhir : ..........................................................................................................
Taksiran Partus : ..........................................................................................................
Siklus Haid : ..........................................................................................................
Pergerakan janin yang pertama kali : ...................................................................................
Pergerakan janin yang dirasakan dalam 24 jam terakhir : ...........................................................

1
 Tanda-tanda bahaya / penyulit :
Hamil Muda : ( ) Mual ( ) Muntah
( ) Perdarahan ( ) Lain-lain

Hamil Tua : ( ) Pusing ( ) Sakit Kepala

( ) Perdarahan ( ) Lain-lain

Obat yang dikonsumsi (termasuk jamu) : ...................................................................................

Imunisasi TT 1 : Tanggal .................................................................................
Imunisasi TT 2 : Tanggal .................................................................................
Kekhawatiran-kekhawatiran khusus : ...................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

E. Riwayat Kehamilan, Persalinan, Nifas Yang Lalu

No TGL/TH TEMPAT UMUR JENIS PENOLONG PENY ANAK NIFAS KEADAAN
PARTUS PARTUS HAMIL PERSALINAN ULIT JENIS BB PB ANAK
SEKARANG

F. Riwayat Ginekologi
a. Infertilitas Ada Tidak ada
b. Cervisitis Cronis Ada Tidak ada
c. Polip Serviks Ada Tidak ada
d. Operasi Kandungan Ada Tidak ada
e. Infeksi Virus Ada Tidak ada
f. Endometriosis Ada Tidak ada
g. Kanker Kandungan Ada Tidak ada
h. PMS Ada Tidak ada
i. Myoma Ada Tidak ada
j. Perkosaan Ada Tidak ada

G. Riwayat Kesehatan / Penyakit yang diderita sekarang dan dulu

Riwayat Penyakit Keturunan

a. Masalah kardiovaskuler Ada Tidak ada
b. Hipertensi Ada Tidak ada
c. Diabetes Ada Tidak ada
d. Asma Ada Tidak ada
e. Kelainan darah Ada Tidak ada

Riwayat Gemelli Ada Tidak ada

Riwayat Penyakit Keluarga

a. Penyakit Menular Seksual Ada Tidak ada
b. HIV/AIDS Ada Tidak ada
c. Malaria Ada Tidak ada
d. TBC Ada Tidak ada
e. Hepatitis Ada Tidak ada

H. Riwayat Psikososial
Status pernikahan : Suami yang ke : .....................................................................
Istri yang ke : .....................................................................
Lamanya pernikahan : .....................................................................
Respon ibu / keluarga terhadap kehamilan : …………………………………………….....
Jenis kelamin yang diharapkan : …………………………………………….....
Bentuk dukungan keluarga : ........................................................................................................

2
 ........................................................................................................................................................
Adat istiadat yang berhubungan dengan kehamilan: ....................................................................
........................................................................................................................................................
Pengambil keputusan dalam keluarga : .................................................................................
Rencana persalinan Tempat : .................................................................................
Penolong persalinan : .................................................................................
Pendamping persalinan : .............................................................................
Persiapan persalinan : ........................................................................................................
........................................................................................................................................................
Riwayat KB terakhir
Metode KB yang pernah dipakai : ............................................................................................
Lama penggunaan : ............................................................................................
Komplikasi dari KB : ............................................................................................

I. Nutrisi
Pola makan (frekuensi) : .............................................................................................
Jenis makanan yang dikonsumsi : ............................................................................................
Jenis makanan yang tidak disukai : ...........................................................................................
Perubahan porsi makan : ............................................................................................
Alergi terhadap makanan (jenis) : .............................................................................................

J. Eliminasi
BAB
Frekuensi : ......................................................................................................................................
Konsistensi : ......................................................................................................................................
BAK
Frekuensi : .......................................................................................................................................
Warna : .......................................................................................................................................
K. Pola istirahat dan tidur
Tidur malam : ........................................................................................................................................
Tidur siang : ........................................................................................................................................
Masalah : ........................................................................................................................................

L. Kebiasaan hidup sehari-hari

Alergi terhadap obat : ...............................................................................................................
Merokok : ...............................................................................................................
Minuman beralkohol : ................................................................................................................
NAPZA : ................................................................................................................

M. Aktivitas sehari-hari
: .................................................................................................................
................................................................................................................................................................
................................................................................................................................................................

N. Hubungan Seksual
Hubungan seks dalam kehamilan : .....................................................................................................
Keluhan : .....................................................................................................

O. Personal Hygiene
Mandi : .....................................................................................................
Ganti pakaian dalam dan luar : .....................................................................................................
Irigasi vagina : ........................................................ Frekuensi ...........................

2. DATA OBJEKTIF

A. Keadaan Umum
: .................................................................................................................
Kesadaran : ................................................................................................................
Keadaan emosional : ................................................................................................................
Tanda Vital
Tekanan Darah : ...............................................................................................................
Nadi : ...............................................................................................................

3
 Pernapasan : ...............................................................................................................
Suhu : ................................................................................................................

B. Antropometri
TB : ................................................................................................................
BB sebelum hamil : .................................................................................................................
BB sekarang : ................................................................................................................
IMT : ................................................................................................................

C. Pemeriksaan Fisik
1. Kepala
Rambut : ................................................................................................................
Muka : Cloasma ..................................... Udem ...............................................
Mata : Conjungtiva : ........................................................................................
Sklera : .........................................................................................
Hidung : Pengeluaran: .........................................................................................
Polip : .........................................................................................
Telinga : Kebersihan : .........................................................................................
Mulut / gigi : Stomatitis : ........................................................................................
Gusi : ........................................................................................
Caries : .......................................................................................

2. Leher
Pembesaran Kelenjar Thyroid : ........................................................................................
Kelenjar Getah Bening : .......................................................................................
Vena Jugularis : .......................................................................................

3. Dada
Retraksi dinding dada : ..............................................................................................................
Bunyi pernapasan : ..............................................................................................................
Bunyi jantung : ...................................................................................................
Irama : ...................................................................................................
Payudara Bentuk : .......................................................................................
Puting susu : ......................................................................................
Areola : ......................................................................................
Pengeluaran : ......................................................................................
Benjolan : ......................................................................................
Tanda-tanda retraksi : ..........................................................................
Kebersihan : ......................................................................................
Lain-lain : ......................................................................................

4. Abdomen
Bekas luka operasi : ..................................................................................................
Bentuk perut : ..................................................................................................
Kontraksi : ..................................................................................................
TFU : ..................................................................................................
Palpasi Leopold I : ......................................................................................
Leopold II : ......................................................................................
......................................................................................
Leopold III : ......................................................................................
Leopold IV : ......................................................................................
TBJ : ..................................................................................................
Auskultasi : DJJ ...........................................................................................

5. Ektremitas Telapak tangan : ...................................................................................

Varices : .....................................................................................
Refleks patella: .....................................................................................
Udem : .....................................................................................
6. Pinggang (costo vertebra angel tenderness) : .............................................................

C. Pemeriksaan Genetalia
1. Pemeriksaan Genetalia Eksternal

4
 Labia mayora : ................................................................................................
Labia minora : ................................................................................................
Urificium uretra : ................................................................................................
Vulva : ................................................................................................
Varices : ................................................................................................
Pengeluaran : ................................................................................................
Bau : ................................................................................................
Kelenjar Skene : ................................................................................................
Kelenjar Bartolini : ................................................................................................
Lain-lain : ................................................................................................

2. Pemeriksaan Genetalia Internal

Inspekulo : ................................................................................................
Pemeriksaan Dalam
Dinding vagina : ................................................................................................
Serviks : ................................................................................................
Pelvimetri Klinis
Promontorium : .....................................................................................
Conjugata Diagonalis : .....................................................................................
Linea Innominata : .....................................................................................
Spina Ischiadica : .....................................................................................
Distansia Interspinarum : ....................................................................................
Sakrum : ....................................................................................
Os Coccygeus : .....................................................................................
Arcus Pubis : .....................................................................................
Kesan Panggul : ......................................................................................

3. Anus (Haemoroid) : .......................................................................................

D. Pemeriksaan Penunjang tanggal .....................................

Laboratorium Darah : Hb ..................... gr%
Golongan darah ........................ Rh .............................
Urine : Protein ..........................................................................
Glukosa ........................................................................
USG .....................................................................................................................................
II. ANALISA
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
III. PENATALAKSANAAN (RENCANA, TINDAKAN, EVALUASI)
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................

5
 ...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................

Jakarta, ……………………….

Mengetahui : PENOLONG
PEMBIMBING LAHAN

(………………………………) (…………………………………)

Mengetahui :

PEMBIMBING AKADEMIK

(………………………………..)