KEPERAWATAN MATERNITAS

PROGRAM STUDI ILMU KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN INDONESIA MAJU

PENGKAJIAN INTRANATAL

Nama Mahasiswa : Yulia Widasanti, S.Kep

Tempat Praktek : Ruang VK RSDH CIANJUR
NIM : 18200100058
Tanggal : 15 Februari 2021

A. DATA UMUM
Inisial klien : Nama Suami :
Umur : Umur :
Alamat : Pekerjaan :
Pekerjaan : Pendidikan Terakhir :
Agama :
Suku Bangsa :
Status Perkawinan :
Pendidikan terakhir :

B. DATA UMUM KESEHATAN

1. Tinggi Badan/Berat Badan : ................................................................................
2. Berat badan sebelum hamil : ................................................................................
3. Masalah kesehatan khusus : ...............................................................................
................................................................................
4. Obat-obatan : ................................................................................
................................................................................
5. Alergi : ...............................................................
...............................................................................
6. Diet khusus : ...............................................................................
7. Menggunakan : gigi tiruan/kacamata/lensa kontak/alat dengar
8. Lain-lain, sebutkan : ................................................................................
9. Frekuensi BAK : ................................................................... kali/hari
Masalah : .................................................................................
10. Frekuensi BAB : ................................................................... kali/hari
Masalah : .................................................................................
11. Kebiasaan waktu tidur : .................................................................................

C. DATA UMUM KEBIDANAN

1. Kehamilan sekarang direncanakan : ..................................................
2. Status obstetrikus : G ........... P........... A ............
3. Usia kehamilan : ................................................... minggu
4. HPHT : ............................
Taksiran partus : .......................

YuliaWs_18200100058
 5. Jumlah anak di rumah : ......................................................................................
No Jenis Cara lahir BB Lahir Keadaan Umur
1.
2.
3.
4.
5.

6. Mengikuti kelas prenatal : (ya/tidak)

7. Jumlah kunjungan pada kehamilan ini : ......................................................
8. Masalah kehamilan yang lain : ......................................................
9. Masalah kehamilan sekarang : ......................................................
10. Rencana KB : ......................................................
11. Makanan bayi sebelumnya : ......................................................
12. Pelajaran apa yang diinginkan saat ini (lingkari) : relaksasi, teknik pernafasan, manfaat
ASI, cara menyusui, memberi minum botol, senam nifas, metode KB, perawatan
perineum, perawatan payudara.
13. Setelah bayi lahir, siapa yang diharapkan membantu : suami/orangtua/teman *
Masalah dalam persalinan yang lalu..............................................................
......................................................................................................................................................
..........................................................................................
D. RIWAYAT PERSALINAN SEKARANG
1. Mulai persalinan (kontraksi/pengeluaran pervaginam)
Tgl/jam..........................................................................................................
2. Keadaan kontraksi (frekuensi dalam 10 menit, lamanya,
kekuatan) : ............................................................................................................................
....................................................................................................................
3. Frekuensi denyut janin : ................ x/menit
Kualitas denyut janin : .....................................................................
4. Pemeriksaan fisik :
Kenaikan BB selama kehamilan : .............................. kg
Tanda Vital : TD ........mmHg, Nadi ...... x/menit, Suhu ....... °c, P.......x/mnt
5. Pemeriksaan dalam (PD) pertama : jam ...................... oleh : .......................
Hasil : ............................................................................................................
........................................................................................................................
6. Ketuban (utuh/pecah*), jika sudah pecah. Tgl/jam.......................................
Warna............................................................................................................
7. Laboratorium : ..............................................................................................

E. DATA PSIKOSOSIAL
1. Penghasilan keluarga setiap bulan : Rp. .......................................................
2. Bagaimana perasaan Anda terhadap kehamilan sekarang : ..........................
........................................................................................................................
3. Bagaimana perasaan suami terhadap kehamilan sekarang : .........................
.......................................................................................................................
4. Jelaskan respon sibling terhadap kehamilan sekarang : ................................
........................................................................................................................
F. KELUARGA BERENCANA
1. Jenis kontrasepsi apa yang pernah digunakan: .............................................

YuliaWs_18200100058
 2. Apakah ada masalah dengan cara tersebut, jelaskan : ..................................
.......................................................................................................................
3. Jenis kontrasepsi yang direncanakan setelah persalinan sekarang : .............
........................................................................................................................
4. Berapa jumlah anak yang direncanakan oleh keluarga : ..............................
.......................................................................................................................
G. HASIL PEMERIKSAAN
BB sebelum hamil : ......................... kg, BB sekarang : ......................................
Tekanan darah : ...........mmHg, nadi : .......x/mnt, S : ......°c, P : .........x/mnt
Edema : .............................................................................................
Lab. Urin : .............................................................................................
.............................................................................................
Pemeriksaan abdomen : ............................................................................................
Tinggi Fundus : ............................................................................................
Taksiran kehamilan : ............................................................................................
Auskultasi : ............................................................................................
Ikhtisar pemeriksaan : ............................................................................................
H. Kesimpulan yang didapat sebagai dasar dalam asuhan keperawatan :
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

Bogor, ..............................................

(.........................................................)

YuliaWs_18200100058
 LAPORAN PERSALINAN

I. PENGKAJIAN AWAL
1. Tanggal : .................... Jam : .........................
2. Tanda-tanda vital : TD : ........mmHg, Nadi : ........x/mnt,
Suhu : ........°c, Pernafasan : ..........x/mnt
3. Pemeriksaan palpasi abdomen : ............................................................................
4. Hasil pemeriksaan dalam : ............................................................................
5. Persiapan perineum : ...........................................................................
6. Dilakukan klisma : Ya / Tidak,
Jika tidak, Alasan : ............................................................................
7. Pengeluaran pervaginam : ............................................................................
8. Perdarahan pervaginam : ............................................................................
9. Kontraksi uterus
- Frekuensi : ............................................................................
- Lamanya : ............................................................................
- Kekuatan : ............................................................................
10. Denyut jantung janin
- Frekuensi : ...........................................................................
- Kualitas : ...........................................................................
11. Status janin
- Hidup/tidak : ............................................................................
- Jumlah : ............................................................................
- Presentasi : ............................................................................

II. KALA PERSALINAN

KALA I
1. Mulai persalinan : tgl ........................................jam ....................................
2. Tanda dan gejala : ........................................................................................
..........................................................................................................................................
...........................................................................................................................................
3. Tanda-tanda vital : .......................................................................................
4. Lama Kala I : ....................... jam ........................ menit...............detik
5. Keadaan psikososial : .......................................................................................
..........................................................................................................................................
...........................................................................................................................................
6. Kebutuhan khusus klien : ........................................................................................
..........................................................................................................................................
7. Tindakan : .......................................................................................
..........................................................................................................................................
..........................................................................................................................................
8.Pengobatan : ........................................................................................

YuliaWs_18200100058
 OBSERVASI KEMAJUAN PERSALINAN
Tanggal/Jam Kontraksi Uterus DJJ Ket.

KALA II
1. Kala II mulai : tgl ............................................. jam .................................................
2. Lamanya kala II : ............................................. jam .................................................
3. Tanda dan gejala : .....................................................................................................
...................................................................................................................................
4. Jelaskan upaya meneran : .........................................................................................
...................................................................................................................................
....................................................................................................................................
5. Keadaan psikososial : ...............................................................................................
....................................................................................................................................
....................................................................................................................................
6. Tindakan : .................................................................................................................
......................................................................................................................................................
..................................................................................................................
*CATATAN KELAHIRAN
1. Bayi lahir jam : ...........................................................................................................
2. Nilai APGAR menit I ......................................... menit V .........................................
3. Perineum : Utuh ( ), Episiotomi ( ), Ruptur ( ), Tingkat .......................
4.Bonding ibu dan bayi :......................................................................................................
5. Tanda-Tanda Vital : TD : ...........mmHg, N : ........x/mnt, S : .......... C, RR : ....x/mnt
6. Pengobatan : ...............................................................................................................
KALA III
1. Tanda dan Gejala : .....................................................................................................
2. Plasenta Lahir Jam : ...................................................................................................
3. Cara lahir plasenta : ....................................................................................................
4. Karakteristik Plasenta :
Ukuran .............................cm x ..................................cm x ..................................cm
Panjang tali pusat : ........................................................... cm
Pembuluh darah .................................. arteri ............................................. vena
Kelainan : ...........................................................................................................
5. Perdarahan: ........................ ml , karakteristik : .........................................................
6. Keadaan psikososial : ................................................................................................
7. Kebutuhan Khusus Klien : .........................................................................................
8. Tindakan : ..................................................................................................................
.....................................................................................................................................
9. Pengobatan : ..............................................................................................................

YuliaWs_18200100058
KALA IV
1. Mulai jam : ...............................................................................................................
2. Tanda-tanda vital : .....................................................................................................
3. Keadaan Uteri : ..........................................................................................................
4. Perdarahan : ............................ ml. Karakteristik : ............................................
5. Bonding Ibu dan Bayi : ..............................................................................................
6. Tindakan : .................................................................................................................
..........................................................................................................................................

BAYI
1. Bayi lahir tanggal / jam : ...........................................................................................
2. Jenis Kelamin : ..........................................................................................................
3. Nilai APGAR : ..........................................................................................................
4. BB / PB bayi : ................................................ gram , ...........................................cm
5. Karakteristik bayi : ....................................................................................................
6. Lingkar kepala : .........................................................................................................
7. Kaput Suksadenum : ( ) , cepalhematom ( )
8. Suhu : .........................................................................................................................
9. Anus : berlubang / tertutu
10. Perawatan tali Pusat : .................................................................................................
11. Perawatan Mata : .......................................................................................................

CATATAN KELAHIRAN
1. Bayi lahir jam : ..........................................................................................................
2. Nilai APGAR menit I .............................................. menit V...................................
3. Perineum : ( ) utuh, ( ) episiotomi., ( ) ruptur, tingkat .................................
4. Bonding ibu dan bayi : ..............................................................................................
5. Tanda-tanda vital : TD : ....... mmHg, Nadi ......... x/mnt, Suhu ..... ºc, P : ......x/mnt
6. Pengobatan : .............................................................................................................
...................................................................................................................................

YuliaWs_18200100058
 LAPORAN PARTUS NORMAL
Inisial Klien :
Status Obstetrikus :

Tanggal/Jam Keterangan
Jam 11.00 S : - Mules-mules bertambah sering
- Klien ingin meneran
O : Status generalis : dalam batas normal
Status obstetrikus :
TFU ................jbpx, pu ka/ki, presentasi kepala,
djj............x/menit, kuat teratur, TBJ........................g
- His 2-3’/50’’/kuat/relaksasi baik
- PD : pembukuan lengkap, porsio tidak teraba ketuban (+) (-), kepala
HIII/HIV, uuk kidep/kadep, tidak ada hambatan jalan lahir, blood
sylm (+)
A: - Ibu, partus kala II, G ........... P........... A............
- janin hidup, presentasi kepala, tunggal/gemeli
P : - Pecahkan ketuban
- Pimpin meneran
Jam Ketuban dipecahkan, warna........................... jumlah...................cc,
bau...............................
Jam Pimpin meneran
Ibu dipimpin meneran sesuai dengan datangnya his kepala turun
menurut jalan lahir, sehingga tampak di vulva tampak suboksiput di
bawah simfisis, dengan suboksiput sebagai hipomoklion, kepala
mengadakn defleksi maksimal.
Berturut-turut lahir : UUB, dahi, mulut, dagu, dan seluruh kepala.
Kepala mengadakan putaran paksi luar.
Dengan pegangan biparietal dan tarikan ke bawah dan ke atas lahir
bahu depan dan belakang.
Kemudian dilahirkan trochanter depan, belakang, bokong, dan
seluruh kaki.

Jam Lahir bayi laki-laki/perempuan

Berat.................. gram, PB..................cm, A/S.............................

Jam Lahir plasenta :

- Spontan, lengkap
- Berat............. gram, ukuran......x.......x........ cm
- Panjang tali pusat........................ cm
- Insersio.............................................
- Robekan............................................

Klien mendapat methergin 0,2 mg IM (sesuai indikasi)

YuliaWs_18200100058
(kemudian dilakukan perineorafi dengan beberapa simpul cat-gut)

YuliaWs_18200100058
YuliaWs_18200100058
YuliaWs_18200100058