5.

Riwayat Perkawinan
Perkawinan ke ............................. Menikah sejak umur P :…. Th L :…. Th
Lama perkawinan......................... Status perkawinan sah / tidak

6. Riwayat Haid
Manarche : .......... Tahun Banyaknya darah: ........ Ganti pembalut/ Hari
Siklus haid : .......... Hari Konsistensi : .................................................
Lama : .......... Hari Disminorhoe : ..................................................
Flour Albus : ..................................................

7. Riwayat Obstetric ( P…A… )

Ha Persalinan Nifas Ket.

mil Tg UK Jenis Penolong Komp. JK BB/ H/ Penyu Komp.
ke- l Tempant TB M lit

8. Riwayat KB

No Mulai Memakai Berhenti / Ganti Cara

Metode Tangga Petugas Tempat Tanggal Petugas Tempat Alasan
l

9. Pola Kebutuhan Sehari-hari

a. Nutrisi
Makan Teratur / Tidak teratur … kali/hari ………………………………………
Konsumsi air putih ± …… gelas/hari
Tidak ada/ ada masalah
b. Eliminasi
BAB … kali/hari, Teratur / Tidak teratur
BAK … kali/hari, Lancar / Tidak lancar
Tidak ada/ ada masalah
c. Istirahat
Tidur siang / Tidak tidur siang± … jam
Tidur malam ± ….. jam
Tidak ada/ ada masalah
 d. Aktivitas
Ibu dapat beraktivitas normal/ tidak
normal……………………………………….
…………………………………………………………………………………….
e. Personal Hygiene
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f. Pola Seksual
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10. Data Psiko Sosial Spiritual

Tanggapan ibu tentang alat kontrasepsi : Ibu mengerti dan dapat menjelaskannya
ulang/ ibu bingung/
Pengetahuan ibu tetntang alat kontrasepsi yang dipakai sekarang : Setelah mendapat
informasi, ibu paham / tidak paham
Riwayat ketergantungan obat dan narkotika : Tidak / Iya
Pengambilan keputusan/dukungan suami dan
keluarga………………………………..
………………………………………………………………………………………….
Ketaatan ibu beribadah, ibu menganut
agama………………………………………….
Ibu tinggal bersama : Keluarga/ sendiri
Latar belakang sosial budaya, ibu mempercayai adat………………………………….
Ibu memiliki kebiasaan pijat perut. Tidak/ Iya

B. DATA OBJEKTIF
1. Pemeriksaan Umum
Keadaan umum : Baik/ Cukup Baik/ Buruk
Kesadaran : Compomentis/ Apatis / Delirium / Somnolen / Soporou / Koma
Postur Tubuh : Tegak/ Bungkuk
Sikap tubuh : Lordosis/ Skoliosis / Kifosis
Cara berjalan : Normal/ Tidak
TTV : Tekanan Darah : ........... mmHg Suhu : .......... oC
Nadi : ........... x/menit Pernapasan : .......... x/menit
BB : ......Kg
TB : ........ cm
LILA : ........ cm
IMT : ........

2. Pemeriksaan Fisik
a. Kepala
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b. Muka
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c. Mata
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d. Hidung
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e. Telinga
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f. Mulut
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g. Leher
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h. Dada
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i. Axila
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j. Payudara
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k. Abdomen
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l. Genetalia
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m. Anus
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n. Ekstremitas
1) Atas : ………………………………………………………………………
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2) Bawah :
……………………………………………………………………….
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3. Pemeriksaan Dalam/Ginekologi
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4. Pemeriksaan Panggul
Lingkar panggul : ......... cm

C. ANALISA DATA
Tanggal : ............................................. Jam : …………………
 1. Diagnosa Kebidanan
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2. Masalah
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3. Kebutuhan
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D. PENATALAKSANAAN
Tanggal : ............................................. Jam : …………………
1). Memberitahukan hasil pemeriksaan kepada ibu, yaitu
BB:…… Kg TB: …… cm LILA: …… cm
TD:…… mmHg N: … x/menit RR: … x/menit S: … °C
Ibu mengerti akan hasil pemeriksaan
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