PEMERINTAH KABUPATEN SITUBONDO

RUMAH SAKIT UMUM DAERAH BESUKI

Jl. Olah Raga no.55 Telp / Fax (0338) 891505,891118
E-Mail :rsud.besuki@gmail.com

KRONOLOGIS PERSALINAN
I. ANAMNESA
Nama Ibu :…………………………………………………………….. Nama Suami :……………………………………………………………..
Umur :…………………………………………………………….. Umur :……………………………………………………………..
Alamat :…………………………………………………………….. Alamat :……………………………………………………………..
Nomor Kartu : ……………………………………………

Penderita datang Tanggal :…………………………………………….Jam……………………………………………………..

Keluhan :………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………………..
II. HASIL PEMERIKSAAN
a.Umum
Keadaan Umum :Baik/Cukup/Lemah.
Tensi :……………/………….mmhg Suhu :………………………….®C
Nadi :…………………………x/mnt RR :………………………….x/mnt
b.Obtetri
Palpasi : TFU (.......cm), Pu........, .................Belum/masuk PAP ( U ), ....../.......
VT : V/V Blood Slym ( / ), Ø cm, eff %, Ket ( )..................., ................Hodge......
III. DIAGNOSA KEBIDANAN
……………………………………………………………………………………………………………………………………………………………………………………………………………………………
IV. PENATALAKSANAAN
a.KALA I
tanggal :
Vt : tgl……-…….-........jam………………….Hasil: VT……………………………………………………………………………………………………………………
tgl……-…….-........jam………………….Hasil: VT……………………………………………………………………………………………………………………
tgl……-…….-........jam………………….Hasil: VT……………………………………………………………………………………………………………………
tgl……-…….-........jam………………….Hasil: VT……………………………………………………………………………………………………………………
Advis Dokter :
.............................................................................................................................................................................................
.............................................................................................................................................................................................
.............................................................................................................................................................................................
.............................................................................................................................................................................................
b.Kala II
Dipimpin tanggal :………-………-…………jam………….…wib
Bayi Lahir tanggal :………-………-…………jam………….…wib
Keadaan Bayi : Lahir spontan (langsung menangis/tidakmenangis/menangis beberapa saat),
warna kulit (kemerahan/kebiruan/pucat),
Tonus otot (aktif,lemah,tidak ada). AS :
Penatalaksanaan : Resusitasi (HAIKAP/VTP/Pasang O2......Lpm),
Pemeriksaan Fisik ( BB.........grm/PB........cm/L kep:......cm/Lida:........cm/Lila:......cm/Cacat......)
Perawatan Rutin BBL (Salep mata....., inj vit K 0,1mg IM)
c.Kala III
Placenta lahir tanggal :……………………………………….jam :……………………………………………
Keadaan placenta : placenta lahir (spontan/ Dengan manual), kotiledon (lengkap/tidak), Selaput (Utuh/Ada sisa)
Penyulit kala III : Ada/Tidak (Retplac/Perdahan)
Penatalaksanaan : - MAK III (inj oxytocyn 1 amp, PTT, Massase)
- Oksitocyn ke 2 (1Amp) jam ........wib
- Placenta Manual
d.Kala IV
Tensi :………..../........... mmhg
Suhu : ………………………. ⁰C
Kontraksi : Keras/Lembek
Tinggi Fundus Uteri(tfu) : .......................jari di bawah pusat/Setinggi Pusat/diatas Pusat
Jumlah Perdarahan : ……………………….CC
Kandung kemih : ……………………….CC/Kosong
Penyulit Kala IV : Tidak Ada/HPP (Atonia, Sisa jaringan Placenta)
Penatalaksanaan : - Rehidrasi Cairan .................Fls, drip oxitocyn/Syntocynon ..... Amp
- Masase, pasang catheter,Eksplorasi jaringan Placenta,KBI,Pasang Kondom kateter
-
-

Besuki,………………………………………………….
Penolong Persalinan

( Indah Purwaningsih, S.ST)

NIP.19720715 199301 2 002
 PEMERINTAH KABUPATEN SITUBONDO
RUMAH SAKIT UMUM DAERAH BESUKI
Jl. Olah Raga no.55 Telp / Fax (0338) 891505,891118
E-Mail :rsud.besuki@gmail.com

KRONOLOGIS TINDAKAN
I. ANAMNESA
Nama Ibu :…………………………………………………………….. Nama Suami :……………………………………………………………..
Umur :…………………………………………………………….. Umur :……………………………………………………………..
Alamat :…………………………………………………………….. Alamat :……………………………………………………………..
Nomor Kartu : ……………………………………………

Penderita datang Tanggal :…………………………………………….Jam……………………………………………………..

Keluhan :………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………
HPHT:…………………………………………………………………………HPL :……………………………………………UK:……………………………………………………………………..
II. HASIL PEMERIKSAAN
a.Umum
Keadaan Umum :………………………….
Tensi :………………………….mmhg .
Suhu :………………………….®C
Nadi :…………………………x/m
RR :………………………….x/m
b.Obtetri
Palpasi : ………………………………………………………………………………………………………………………………………………………………………………………..

VT :…………………………………………………………………………………………………………………………………………………………………………………………

III. DIAGNOSA KEBIDANAN

……………………………………………………………………………………………………………………………………………………………………………………………………………………………
IV. PENATALAKSANAAN

Besuki,………………………………………………….
Penolong Persalinan
 ( Indah Purwaningsih, S.ST)
NIP.19720715 199301 2 002

PEMERINTAH KABUPATEN SITUBONDO

RUMAH SAKIT UMUM DAERAH BESUKI
Jl. Olah Raga no.55 Telp / Fax (0338) 891505,891118
E-Mail :rsud.besuki@gmail.com

KRONOLOGIS PERSALINAN
I. ANAMNESA
Nama Ibu :…………………………………………………………….. Nama Suami :……………………………………………………………..
Umur :…………………………………………………………….. Umur :……………………………………………………………..
Alamat :…………………………………………………………….. Alamat :……………………………………………………………..
Nomor Kartu : ……………………………………………

Penderita datang Tanggal :…………………………………………….Jam……………………………………………………..

Keluhan :………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………………..
II. HASIL PEMERIKSAAN
a.Umum
Keadaan Umum :………………………….
Tensi :………………………….mmhg .
Suhu :………………………….®C
Nadi :…………………………x/m
RR :………………………….x/m
b.Obtetri
Palpasi : ………………………………………………………………………………………………………………………………………………………………………………………..

VT :…………………………………………………………………………………………………………………………………………………………………………………………

III. DIAGNOSA KEBIDANAN

……………………………………………………………………………………………………………………………………………………………………………………………………………………………
IV. PENATALAKSANAAN
a.KALA I
tanggal :
Vt : tgl………….jam………………….Hasil VT :……………………………………………………………………………………………………………………………….
tgl………….jam………………….Hasil VT :……………………………………………………………………………………………………………………………….
tgl………….jam………………….Hasil VT :……………………………………………………………………………………………………………………………….
tgl………….jam………………….Hasil VT :……………………………………………………………………………………………………………………………….
Advis Dokter :
.............................................................................................................................................................................................
b.Kala II
Dipimpin tanggal :………………………………………..jam………………………………………………..
Bayi Lahir tanggal :……………………………………….jam………………………………………………..
Keadaan Bayi :……………………………………………………………………………………………………………………………………………………………
Penatalaksanaan :………………………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………….................…
.............................................................................................................................................................................
c.Kala III
Placenta lahir tanggal :……………………………………….jam :……………………………………………
Keadaan placenta :……………………………………………………………………………………………………………………………………………………………………….
Penyulit kala III :………………………………………………………………………………………………………………………………………………………………………..
Penatalaksanaan :………………………………………………………………………………………………………………………………………………………………………..
.............................................................................................................................................................................
.............................................................................................................................................................................
d.Kala IV
Tensi :……………………………………………………………………………………………………………………………………………………………
Suhu : ……………………………………………………………………………………………………………………………………………………………
Kontraksi : ……………………………………………………………………………………………………………………………………………………………
Tinggi Fundus Uteri(tfu) : ……………………………………………………………………………………………………………………………………………………………
Jumlah Perdarahan : ……………………………………………………………………………………………………………………………………………………………
Kandung kemih : ……………………………………………………………………………………………………………………………………………………………
Penatalaksanaan :……………………………………………………………………………………………………………………………………........................…
...................................................................................................................................................................
...................................................................................................................................................................

Besuki,………………………………………………….
Penolong Persalinan
( Indah Purwaningsih, S.ST)
NIP.19720715 199301 2 002