ASUHAN KEBIDANAN PERSALINAN DAN BAYI BARU LAHIR

TERHADAP NY. DI PMB Bd. SITI KHUZAIMAH, S.Tr.Keb

LAMPUNG TIMUR TAHUN 2021

Tanggal MKB : Tanggal Pengkajian :

Jam MKB :
Jam Pengkajian :

SUBJEKTIF
1. Biodata

IBU SUAMI/WALI

Nama : ............... Nama : .. : ............

Umur : ............... Umur : ............
Agama : ............... Agama : ............
Suku/bangsa : ............... Suku : ............
Pendidikan : ............... Pendidikan : ............
Pekerjaan : ............... Pekerjaan : ............
Alamat : ............... Alamat/Hp. : ............

2. Alasan masuk kamar bersalin (MKB)

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

3. Riwayat menstruasi
Siklus : ................ hari
HPHT : .........................

TP: ………………….
4. Riwayat obstetrik yang lalu
 Kompl ikasi
Hami l Penyulit Jeni s Tem Penolo ng Anak
Persal inan
ke U Kehamian persali pat Bayi Nifas Hidup/
- K nan persalin Mati/
an U sia
b a ib u P B/ Keadaan IM D Penyulit La kta
yi BB si

5. Riwayat kehamilan sekarang

Kunjungan ANC : Ya/Tidak
Tempat ANC : .............................................................
Tanda-tanda bahaya kehamilan : ........................................

6. Riwayat persalinan sekarang

Tanda-tanda persalinan:
Kontraksi/His
a) Kontraksi sejak tanggal : .........................................
Pukul : ..........................................
b) Frekuensi & durasi his : ..........................................
c) Keluhan : ..........................................
Pengeluaran pervaginam
a) Darah lendir : ada/tidak
b) darah segar/darah campur lendir
c) Air ketuban : ada/tidak warna :.....
Tgl/jam pecah: ………..…..
d) Lain-lain : ada/tidak,
e) sebutkan: ………………………
7. Riwayat kesehatan ibu sekarang dan lalu yamg dapat
mempengaruhi kehamilan dan persalinan (termasuk status HIV
dan HBsAg):
...............................................................................................
9. Riwayat sosial ekonomi dan psikologi
Status perkawinan : ............... Ya/Tidak,
Kawin : ........... kali
 Perasaan ibu dan keluarga terhadap kehamilan
: ...............................................................................................
Pengambil keputusan dalam keluarga
: ...............................................................................................
Tempat yang diinginkan untuk membantu persalinan
: ...............................................................................................
Petugas yang diinginkan untuk membantu persalinan
: ...............................................................................................
Tempat rujukan jika terjadi komplikasi
: ...............................................................................................
Pendanaan persalinan
: ...............................................................................................
Orang yang diinginkan untuk mendampingi persalinan
: ...............................................................................................
Budaya yang akan dilakukan saat persalinan
: ...............................................................................................
10. Pemenuhan kebutuhan sehari-hari
A. Makan dan minum terakhir
Tgl/Jam : ............................................................
Jenis &porsi : ............................................................
B. Istirahat terakhir
Tgl/Jam : .............................................................
Lama : .............................................................
C. Eliminasi terakhir
BAK Tgl/Jam : ......................
BAB Tgl/Jam : ......................

OBJEKTIF
1. Keadaan umum : ......................
2. Cardinal Sign
Tekanan darah : .............. mmHg
Nadi : .............. kali/menit
Suhu : ..............0C
Respirasi : ..............kali/menit
3. Pemeriksaan fisik
Inspeksi
a) Muka
Oedema : ............
 Mata
Konjungtiva : .......... Sklera: ....................
b) Leher
Pembesaran kelenjar tiroid : ...............................................
c) Payudara
Keadaan papilla mammae : ...............................................
d) Abdomen
Bekas luka operasi : ................ Jenis operasi: ....................
e) Genetalia eksterna
Pengeluaran pervaginam : ...............................
Jenis:…..........................
Varises : ..................................................
Oedema : .................................................
Pembesaran kelenjar bartolini/skene : ..............................
Haemoroid : ....................................................
f) Tangan dan kaki
Oedema : .................................................
Varises : ..................................................
Palpasi
a) Payudara (kolostrum): .................................
b) Abdomen
TFU...........................................cm
Leopold I : ......................................................
Leopold II : ................................................
Leopold III : .............................................
Leopold IV : ....................................................
c) His : ....... kali/10 menit, lama ....... detik
d) Perlimaan WHO : ................................
Auskultasi
DJJ : .............................................
4. Pemeriksaan Dalam/Vaginal Toucher (VT)
Indikasi : ......................... Pukul : ............
Vulva/Vagina : .............................................................
Porsio : .................................................................
Serviks : .................................................................
Selaput amnion dan ketuban:.................................
Denominator : ...........................
Penurunan bagian terendah : Hodge ..........
5. Data Penunjang (bila diperlukan)
Tanggal : ..................... Jenis pemeriksaan : ...............
Hasil : .......................................

ASSESSMENT:
Diagnosa Kebidanan : ...........................................................................................
Masalah Kebidanan : .......................... ................................................................

PENATALAKSANAAN:
Hari/Tanggal ……………………………………….

Jam Penatalaksanaan Nama dan

Paraf
 CATATAN PERKEMBANGAN KALA ……………….

Tanggal : Pukul :

SUBJEKTIF : ..........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................

OBJEKTIF : ..........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................

ASSESMENT :
Diagnosa Kebidanan : ...............................................................................
................................................................................
Masalah Kebidanan : ...............................................................................
PENATALAKSANAAN
Hari/Tanggal ……………………………………….

Jam Penatalaksanaan Nama dan

Paraf

Pembimbing Institusi Pembimbing Lahan

Martini, SKM., MKM. Bd. Siti Khuzaimah, S.Tr. Keb

NIP.197503102005012002 NIP. 197010101990122003
ASUHAN KEBIDANAN PADA BAYI BARU LAHIR
 ASUHAN KEBIDANAN PADA BAYI BARU LAHIR
Pemeriksa (nama dan tanda tangan) : ……………………………………….....................
Nama bayi :…… Jenis kelamin :………… Nama orang tua :…… alamat : ………………
Tanggal dan jam lahir:……………… lahir pada umur kehamilan :…………………

Pemeriksaan Tanggal……jam……. Tanggal……..jam……

(saat lahir)
Hasil Hasil
1. Postur, tonus dan ekstremitas
2. Kulit bayi
3. Pernafasan ketika bayi sedang menangis
4. Detak jantung
5. Suhu ketiak
6. Kepala
7. mata
8. mulut (lidah, selaput lemndir)
9. perut dan tali pusat
10. punggung tulang belkang
11. lubang anus
12. alat kelamin
13. berat badan
14. panjang badan
15. lingkar kepala

ASUHAN/KONSELING Waktu (waktu, jam) Keterangan

dilakukan asuhan
1. inisiasi menyusui dini
2. salep mata antibiotika proflaksis
3. Sintikan vit k
4. Imunisasi hepatitis B1
5. Rawat gabung
6. Memandikan bayi
7. Konseling menyusui
8. Tanda-tanda bahaya pada bayi
9. Menjelaskan pada ibu tentang perawatan bayi dirumah
10. Melengkapi catatan medis
Waktu pemeriksaan kembali/kunjungan ulang Tanggal………….. Tanggal……….

Pembimbing Institusi Pembimbing Lahan

Martini, SKM., MKM. Bd. Siti Khuzaimah, S.Tr. Keb

NIP.197503102005012002 NIP. 197010101990122003