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

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Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
Jurusan Kebidanan
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
BAK :.............................................
BAB :.............................................
4. Aktivitas :................................................................. Dibantu/ Tidak
5. Pola istirahat dan tidur
Tidur siang :..........................jam
Tidur malam :..........................jam

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Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
Jurusan Kebidanan

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

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Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
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K. Riwayat persalinan yang lalu

No Tgl/Thn Tempat Usia Jenis Penolong Penyulit JK BB PB Ket-
Partus Partus Kehamilan Partus (gram (cm)
)

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

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Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
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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 ddengan tetangga....................................................................
6. Hubungan dengan mertua........................................................................
7. Susunan keluarga yang tinggal serumah
No Umur Jenis Hub. Pendidikan Pekerjaan Ket-
(tahun) Kelamin Keluarga

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Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
Jurusan Kebidanan
8. Kepercayaan yang mempengaruhi ibu hamil :
.......................................................................................................................................
.......................................................................................................................................
........................

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
IMT :……………
Kenaikan BB selama hamil :....... kg
4. LILA :.........................cm
5. Kepala : Rambut :.....................................................................................
Muka :.....................................................................................
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 :...................................................................................

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Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
Jurusan Kebidanan
Axilla :................................................................................

8. Abdomen
 Inspeksi
Pembesaran:.....................................................................................
Memanjang/
melintang.....................................................................Linea
alba/nigra....................striae albicans / livide.......................
Bekas luka operasi / SC............................
Gerakan Janin................................................................

 Palpasi
Leopold I : TFU
……………………………………………………….
………………………………………………………………..
TFU : …………………………… cm (Mc.Donald)
Leopold II:
(Kanan)…………………………………………………….
(Kiri)
…………………………………………………………………
…..
Leopold III :
……………………………………………………………..
Leopold IV :
……………………………………………………………..
His : frekuensi...............x / 10 menit
Lamanya :................................
Kekuatan :.................................
Relaksasi :...............................

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Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
Jurusan Kebidanan
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

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Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
Jurusan Kebidanan

III. Analisa

IV. Penatalaksanaan

Mengetahui :

Pembimbing Akademik CI / Pembimbing Lahan

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Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
Jurusan Kebidanan
(...........................................) (........................................)

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