ASUHAN KEBIDANAN PADA IBU BERSALIN………………………………………

NY. “…” …. Tahun G…P…A… dengan UK …………….minggu

Di …………………………………………………………………..

No. Register :..................................... Waktu Pengkajian :..........................

Tanggal masuk :..................................... Tempat Pengkajian :..........................

A. DATA SUBJEKTIF
1. Identitas Pasien
Nama : Ny. “… “ Nama Suami : Tn. “ … “
Umur : ..... th Umur : ..... th
Pekerjaan : .................................... Pekerjaan : .........................................
Agama : .................................... Agama : .........................................
Pendidikan : .................................... Pendidikan : .........................................
Suku / bangsa: ................................... Suku / bangsa : .........................................
Alamat : .................................... Alamat : .........................................
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No. HP : .................................... No. HP : .........................................

2. Alasan Masuk Kamar Bersalin

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3. Keluhan Utama
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4. Tanda-tanda persalinan
a. Kontraksi uterus : ................................................. Pukul : .....................................
Frekuensi : ...................................................................................................
.
Durasi : ...............................................................................................
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Lokasi Ketidaknyamanan : .....................................................................................
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b. Pengeluaran Per vaginam
Lendir darah : ..........................................................................................................
Air Ketuban : .........................................................................................................
Darah : ..........................................................................................................

5. Riwayat Kesehatan
a. Riwayat Kesehatan Dahulu.....................................................................................
Menurun : ................................................................................................................
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Menular : .................................................................................................................
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Menahun : ...............................................................................................................
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 b. Riwayat Kesehatan Sekarang ..................................................................................
Menurun : ...............................................................................................................
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Menular : .................................................................................................................
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Menahun : ...............................................................................................................
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c. Riwayat Kesehatan Keluarga ..................................................................................
Menurun : ...............................................................................................................
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Menular : .................................................................................................................
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Menahun : ...............................................................................................................
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6. Riwayat Perkawinan
Perkawinan ke ............................. Menikah sejak umur P : …. th L : ….. th
Lama perkawinan......................... Status perkawinan sah / tidak

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

8. Riwayat Obstetric (Terlampir)

9. Riwayat KB (Terlampir)

10. Riwayat Kehamilan Sekarang

ANC .................................................... Sejak umur kehamilan .....................................
Gerakan pertama kali dirasakan pada umur
kehamilan ...................................................
Gerakan dalam satu
hari ..................................................................................................
Frekuensi periksa TM I ...................... TM II ...................... TM
III ................................
Imunisasi TT
……… ......................................................................................................

11. Pendidikan kesehatan yang diperoleh

Trimeste Meteri pendidikan kesehatan

r

I
 II

III

Permasalahan dan keluhan dalam kehamilan

Trimester Masalah/ Keluhan Tindakan/ Therapy

II

III

12. Pola Kebutuhan akan Persalinan

a. Nutrisi
Makan Teratur / Tidak teratur … kali/hari ………………………………………
Konsumsi air putih ± …… gelas/hari
b. Eliminasi
BAB … kali/hari, Teratur / Tidak teratur
BAK … kali/hari, Lancar / Tidak lancar
c. Istirahat
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d. Aktivitas
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e. Personal Hygiene
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f. Pola Seksual
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13. Data Psiko Sosial Spiritual/Kesiapan menghadapi proses persalinan

Tanggapan ibu dan keluarga terhadap proses persalinan: Ibu dan keluarga
menginginkan dan mendukung persalinan ini / tidak menginginkan dan mendukung
Pengetahuan Ibu dan keluarga tentang tanda- tanda dan poses persalinan: Baik /
kurang dalam pengetahuan persalinan
Persiapan ibu dan keluarga menghadapi persalinan : Siap / Belum
…………………….
Pengambilan keputusan oleh : Suami / Ibu / Keluarga
 Ketaatan ibu beribadah menganut agama :
……………………………………………..
Ibu tinggal bersama : Keluarga / sendiri
Hewan peliharaan : Tidak memiliki /
memiliki…………………………………………
Latar belakang sosial budaya : Ibu mempercayai adat………………………………...

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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TFU Mc Donald = ………………………………………………………………...
Leopold I : ………………………………………………………………………
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Leopold II : Pada perut bagian kanan :
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Pada perut bagian kiri :
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Leopold III :
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Leopold IV :
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Osborn Test :…………………………………………………………………….
TBJ : ………………………………………………………………………..
Auskultasi DJJ : …………………………………………………………………..
Frekuensi : ………………………………………………………………………..
His : ..............................................................................................................
...
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
Tgl : .........................................
Jam : .........................................
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4. Pemeriksaan Penunjang
Tgl : ................................... Tempat : .........................................................
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C. ANALISIS
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 : ……………………........
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CATATAN PERKEMBANGAN KALA I FASE AKTIF

Tanggal : ........................................... Jam : ………………………….

A. DATA SUBJEKTIF
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B. DATA OBJEKTIF
1. Keadaan umum : ……………………… Kesadaran : Compomentis/ Apatis
2. His : ..... X/ 10 menit, lamanya ...... detik DJJ : …… X /menit
3. VT :
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C. ANALISIS
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D. PENATALAKSANAAN
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CATATAN PERKEMBANGAN KALA II

Tanggal : ........................................... Jam : ………………………….

A. DATA SUBJEKTIF
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B. DATA OBJEKTIF
1. Keadaan umum : ……………………… Kesadaran : Compomentis/ Apatis
2. His : ..... X/ 10 menit, lamanya ...... detik DJJ : …… X /menit
3. VT :
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C. ANALISIS
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D. PENATALAKSANAAN
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CATATAN PERKEMBANGAN KALA III

Tanggal : ........................................... Jam : ………………………….

A. DATA SUBJEKTIF
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B. DATA OBJEKTIF
1. Keadaan umum : ……………………… Kesadaran : Composmentis/ Apatis
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C. ANALISIS
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D. PENATALAKSANAAN
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CATATAN PERKEMBANGAN KALA IV

Tanggal : ........................................... Jam : ………………………….

A. DATA SUBJEKTIF
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B. DATA OBJEKTIF
1. Keadaan umum : ……………………… Kesadaran : Composmentis/ Apatis
2. TFU :
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3. Kontraksi uterus : ………….. …………. TFU:
…………………………………...
4. Genetalia :
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5. Perdarahan :
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C. ANALISIS
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D. PENATALAKSANAAN
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