KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN KEMENKES MALANG

JURUSAN KEBIDANAN
PROGRAM STUDI SARJANA TERAPAN KEBIDANAN KEDIRI
Jl. KH. Wakhid Hasyim No. 64 B Telp. (0354) 773095 – 772833
Website : http://www.poltekkes-malang.ac.id Fax. (0354) 778340
Email : direktorat@poltekkes-malang.ac.id Kediri 64114

Format Asuhan Kebidanan Pada Ibu bersalin (INC)

I. Pengkajian
Tanggal : 18 April 2022 Jam : 08.00 WIB
No. RM : 216829
Nama : Ny. Roichatul Jannah Nama Suami: Tn. Ibnu Sodiq
Umur : 21 tahun Umur : 28 tahun
Agama : Islam Agama : Islam
Pendidikan : SMA Pendidikan : SMA
Pekerjaan : IRT Pekerjaan : Swasta
Alamat : Ds Tanjung Kalang 03/05 Alamat : Ds Tanjung Kalang 03/05 Ngronggot, Nganjuk,
Ngronggot, Nganjuk,Jatim Jawa Timur
Cara Masuk :
Datang sendiri V Rujukan dari : Bidan Miyarsih
Diagnosa MRS : G1P0A0 Uk 41-42 minggu
dengan Postdate
A. DATA SUBJEKTIF T/H/I
1. Keluhan utama :
Ibu mengatakan hamil anak pertama merasakan perut kenceng-kenceng, mules
seperti ingin BAB, keluar lendir darah dari 3 hari yang lalu
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2. Kronologi MRS : (Sebelum dirujuk/datang ke RS (IGD) hingga sampai ke ruangan
(Bersalin/Nifas/ Bayi)
Ny. R.J mengandung anak pertama memeriksakan kehamilan ke Bidan Miyarsih
mengeluh perut kencang-kencang, mules seperti ingin BAB, mengeluarkan lendir
bercampur darah dari 3 hari yang lalu, ketuban (+), dengan riwayat pemeriksaan
ANC Bidan dan PKM 9 kali, 1 kali USG di RS Bhayangkara pada tanggal 30 Maret
2022 dengan hasil pemeriksaan Uk 34 Minggu, Plasenta anterior grade 2, ketuban
cukup, TBJ 2391, jenis kelamin laki-laki. Selanjutnya datang ke bidan Miyarsih pada
tanggal 18 April 2022 pukul 06.15 WIB selanjutnya bidan melakukan pemeriksaan
dengan hasil TFU 28 cm, Letkep UUK, Djj 142x/menit, His jarang 2x10x20 belum
ada pembukaan. Kemudian Ibu dirujuk ke RS Aura Syifa pada tanggal 18 April 2022
pukul 07.15 WIB diterima di PONEK pada tanggal 18 April 2022 pukul 07.30 WIB
dengan bidan dan dokter jaga selanjutnya di lakukan pemeriksaan dan pemasangan
infus RL dan dipindahkan ke ruang bersalin untuk dilakukan observasi lebih lanjut
pukul 08.00 WIB.
 3. Riwayat menstruasi
 Usia manarche : 13 tahun
 Jumlah darah haid : 3-4x ganti pembalut/hari
 HPHT : 04-07-2021
 Keluhan saat haid : tidak ada keluhan
 Lama haid : 5-7 hari
 Flour albus : tidak ada
 TP : 11-04-2022

3. Riwayat hamil ini

 Hamil muda : mual setiap pagi pada trimester 1
 Hamil tua : tidak ada keluhan
 Riwayat imunisasi
TT : TT5 (Lengkap)
 Gerakan janin pertama : 4 bulan
 Gerakan janin
terakhir : pada saat dilakukan pemeriksaan Djj pukul 08.00 WIB
 Tanda bahaya dan penyulit
kehamilan : tidak ada
 Obat/jamu yang pernah dan sedang di
konsumsi : tidak mengonsumsi jamu/obat diluar resep dokter/bidan
 Kekhawatiran
khusus : ibu khawatir karena belum ada pembukaan dan khawatir dengan janin yang
dikandung

4. Riwayat kehamilan, persalinan, dan nifas yang lalu.

G 1 P 0 A 0 Hidup 0

Keadaan
No Tgl,th Tempat Umur Jenis Penolong Penyulit Anak
anak
partus partus kehamilan persalinan persalinan JK/BB
sekarang
1. H A M I L I N I
5. Riwayat kesehatan penyakit yang pernah diderita :
Ibu memiliki riwayat penyakit asma

6. Riwayat penyakit keluarga (Ayah, Ibu, Mertua) yang pernah menderita sakit :
Tidak memiliki riwayat hipertensi, diabetes, jantung, kehamilan kembar

7. Status pernikahan : ya/tidak

Nikah 1 kali, nikah usia 20 tahun, lama menikah 1 tahun

8. Riwayat psiko sosial ekonomi

- Respon ibu dan keluarga terhadap kehamilan
Ibu dan keluarga merasa senang dan bahagia atas kehamilan pertama
- Dukungan keluarga
Suami, orang tua, mertua dan keluarga lain mendukung kehamilan
- Pengambilan keputusan dalam keluarga
Suami dan didiskusikan dengan istri
- Kebiasaan hidup sehat
Melakukan olahraga pagi seperti jalan-jalan pagi 10-15 menit setiap 2-3 kali seminggu,
mandi 2 kali sehari, ganti pakaian setelah mandi dan apabila pakaian kotor, gosok gigi
setiap pagi dan sebelum tidur malam, keramas 2-3 kali seminggu
- Beban kerja sehari
Melakukan pekerjaan rumah (memasak, menyapu rumah, mencuci baju,menyiapkan
pakaian untuk suami)
- Tempat dan penolong persalinan yang diinginkan
Bidan
- Penghasilan keluarga
± Rp. 2.500.000,00/ bulan
9. Riwayat KB dan rencana KB
Metode yang pernah dipakai : Belum pernah memakai alat kontrasepsi ,
Lama - bulan/tahun
Komplikasi dari KB - , Rencana KB selanjutnya: -

10. Riwayat Ginekologi :

Tidak ada penyakit ginekologi yang diderita ibu seperti HIV/AIDS, Sifilis, Gonorhea, dsb.
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11. Pola nutrisi/ eliminasi/ istirahat
- Pola makan: makan 3-4x sehari porsi sedang habis dengan nasi, lauk, sayur, sesekali
ditambah buah dan minum susu
- Pola minum : 7-9 gelas/hari dengan air putih, kadang dengan kacang hijau, degan, dan susu
- Pola eliminasi :
BAK 4-6 x/hari, keterangan
:kuning jernih
BAB 1-2 kali/hari, keterangan
:lembek
- Keluhan BAK : tidak ada keluhan
- Keluhan BAB : tidak ada keluhan
- Pola istirahat : .........7-8...................jam/hari, tidur terakhir jam : 03.00 WIB

B. DATA OBYEKTIF
1. Pemeriksaan umum
Keadaan umum : baik Kesadaran : compos mentis
BB/TB : 55 kg/154 cm Tekanan Darah: 150/100 mmHg
Nadi : 90x/menit Suhu :370C
Pernafasan :18x/menit Lila : 27 cm

2. Pemeriksaan Fisik
- Mata : tidak anemis, sklera tidak ikhterik,tidak ada pandangan kabur serta tidak ada
pandangan dua.
- Rahang, gigi,gusi : normal, gusi tidak berdarah dan gigi tidak ada caries/berlubang
- Leher : normal, tidak ada pembengkakan vena jugularis, tidak ada pembengkakan kelenjar
tiroid
- Dada : √ aerola hiperpigmentasi (+/+) Tumor Kolostrum
√ Puting susu menonjol/masuk ke dalam(+/+)
- Axilla : normal, tidak ada benjolan dan tidak ada nyeri tekan.
- Sistem respiratori : tidak wheezing, tachipneu,dispneu dan ada bunyi ronchi
- Sistem kardio : normal, tidak ada nyeri dada, murmur, dan palpitasi
- Postur tubuh : normal, simetris tidak ada cacat seperti skoliosis, lordosis, dan kifosis
- Keadaan ekstremitas (atas dan bawah) : Normal, ekstermitas atas dan bawah simetris tidak
ada oedema, reflek patella (+/+), dan tidak terdapat varises (-/-).
- Pemeriksaan khusus
a. Abdomen
Inspeksi : Perut membesar dengan arah melebar terdapat linea nigra dan strie livide.
Palpasi :
Leopold I : Teraba bulat, lunak, tidak melenting (bokong) TFU (mc donald) = 28 cm
Leopold II : Bagian kiri teraba keras, memanjang seperti papan (puki), bagian kanan
teraba bagian kecil janin (ekstremitas)
Leopold III : Teraba bulat, keras, dan melenting (kepala)
Leopold IV : Sudah masuk PAP (Divergen)
TBJ : (TFU-12) x 155 = (28-12) x 155 = 2.480 gram
Auskultasi : BJJ 147 x/mnt, reguler / irregular
His/kontraksi : 2x10’x10”
 b. Ano genital
Inspeksi :
Pengeluaran pervaginam lendir bercampur darah, tidak terdapat kondiloma dan ketuban
masih utuh.
Inspekulo :
Tidak dilakukan
Vaginal toucher : 1 cm eff 25 %, ketuban(+)
Presentasi Kepala, denominator UUK, hodge I, kesan panggul : Normal

3. Pemeriksaan laboratorium :
- Laboratorium lengkap.
(Pada tgl 18-4-2022 di RS Aura Syifa )
Hasil pemeriksaan lab :
HB : 9,2 gr/dL Leukosit : 9.400 sel/cmm
Hematokrit : 28,9% Trombosit : 273.000 sel/cmm
GDA : 74 mg/dl HbsAg : NR
Albumin : +2 Reduksi : NR
Anti HIV : NR Antigen : NR
Antibody : NR
- CTG : janin...............reaktif/tidak (tidak dilakukan)
- USG : (Pada tgl 18-4-2022 di RS Aura Syifa )
Hasil pemeriksaan USG (dr. Jonathan, SpOG) :
Janin : tunggal intrauterin Posisi janin : letak kepala
Jenis kelamin : Laki-laki TBJ : 2839 gram
AFI : < 15 Plasenta : corpus
DJJ : 153 x/menit TP : 03-05-2022
- Foto thorak : (Pada tgl 18-4-2022 di RS Aura Syifa )
Hasil pemeriksaan : Thorax AP
Cor : ukuran tidak membesar
Pulmo : corakan bronchovasculer pattern meningkat ringan di kedua lapang paru
Sinus phrenicocostalis kanan kiri tajam
Kesan : Bronchitis ringan
- EKG : Tidak dilakukan
 Ya Tidak
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4. Penapisan ibu bersalin

1. Riwayat bedah sesar

2. Perdarahan pervaginam
3. Persalinan kurang bulan (< 37 mgg)
4. Ketuban pecah dengan meconium kental
5. Ketuban pecah lama ( > 24 jam)
6. Ketuban pecah saat persalinan kurang bulan
( < 27 minggu )
7. Ikhterus
8. Anemia berat
9. Tanda / gejala infeksi
10. Pre eklamsi / hypertensi dalam kehamilan
11. TFU 40 cm atau lebih
12. Gawat janin
13. Primi para fase aktif dengan palpasi kepala
janin masih 5/5
14. Presentasi bukan belakang kepala
15. Presentasi Ganda
16. Kehamilan Gemeli
17. Talin pusat menumbung
18. Syok

C. ANALISIS/INTERPRETASI DATA
G1P0000 UK 37-38 minggu inpartu kala 1 fase laten janin tunggal hidup intrauterine
 dengan Preeklampsia + Oligohidramnion (USG dr Jonathan Sp.OG) + asma stabil (dr
Hamidah Sp.P)

D. PENATALAKSANAAN
Tanggal : 18 April 2022
Jam : 08.10 WIB

08.10 WIB Memberitahukan ibu hasil pemeriksaan TTV, pemeriksaan dalam dan
pemeriksaan DJJ, dimana hasil pemeriksaan TTV : TD : 150/100
mmHg, Nadi 90x/menit, Suhu : 37°C, rr : 18x/menit. Selanjutnya
hasil pemeriksaan dalam pembukaan 1 cm, eff 25%, H : I,
Dorminator UUK, Let Kepala, ketuban belum pecah, dan HIS (+),
selanjutnya hasil pemeriksaan DJJ = 147x/menit dengan irama DJJ
reguler/normal. Kemudian memberitahukan bahwa tekanan darah ibu
cukup tinggi atau ibu mengalami hipertensi dalam kehamilan, serta
menganjurkan ibu untuk miring ke kiri serta jika ingin buang air
kecil/besar bisa menggunakan pispot hal ini berguna untuk
mengurangi pergerakan pada ibu (Respons : ibu memahami dan
bersedia mengikuti anjuran yang telah diberikan)

08.12 WIB Melakukan kolaborasi dengan dr. Jonathan Sp.OG untuk memberikan
tindakan selanjutnya dan memberikan motivasi untuk melakukan
tindakan operasi SC ( sudah dilakukan)

08.15 WIB Memotivasi ibu untuk tmelahirkan dengan tindakan operasi SC,
seperti menjelaskan operasi SC, prosedur operasi SC, manfaat untuk
ibu dan janin jika melakukan operasi SC, dan hal lain yang berkaitan
dengan tindakan operasi SC (sudah dilakukan, Respons ibu : ibu,
suami serta keluarga setuju untuk dilakukan operasi SC)

08.20 WIB Memberikan inform consent kepada ibu sebagai tanda ketersediaan
ibu untuk dilakukan tindakan operasi SC (Sudah diberikan dan sudah
ditanda tangani oleh ibu)

08.22 WIB Melaporkan ACC tindakan operasi SC Ny R.J kepada dr. Jonathan
Sp.OG, dan dilakukan tindakan operasi SC pada tanggal 19 April
2022 pukul 07.30 WIB

08.25 WIB Memberikan dukungan emosional kepada ibu serta menganjurkan ibu
untuk berpuasa sebelum tindakan operasi SC (Respons : Ibu
memahami dan bersedia)
08.30 WIB Melakukan persiapan fisik ibu sebelum dilakukan tindakan operasi
SC yaitu mencukur daerah kemaluan ibu serta menganjurkan
istirahat untuk persiapan besuk operasi SC (sudah dilakukan, respond
: ibu bersedia)

Tanggal : 19 April 2022

Pukul : 06.30 WIB
06.30 WIB Persiapan pasien dengan mengenakan ibu baju OK, melepas
 perhiasan (Sudah dilakukan)

06.35 WIB Memberikan dukungan emosional kepada ibu serta menganjurkan

untuk meminta doa dan berpamitan kepada suami dan keluarga
(Sudah dilakukan)
06.40 WIB Mengantar ibu ke tempat operasi untuk dilakukan tindakan
selanjutnya.

KALA I
Fase Laten Tanggal /Jam : 18 April 2022 /
08.30 WIB
S : Ibu mengatakan perut kenceng- kenceng dan mulas seperti ingin BAB

O : S : 37°C, N : 90x/menit, TD : 150/100 mmHg, rr : 18x/menit

VT : 1 cm eff : 25 %, let kepala, dorminator uuk, ketuban (+), His : 2x10’x10”

A : G1P0000 UK 37-38 minggu inpartu kala 1 fase laten janin tunggal hidup intrauterine
dengan Hipertensi dalam Kehamilan + Oligohidramnion + asma stabil

P :
08.30 WIB : Memantau infus Rl 20tpm (Sudah terpasang dengan baik)
08.32 WIB : Melakukan observasi kondisi ibu dengan melakukan pemeriksaan TTV, DJJ
(Sudah dilakukan)
08.34 WIB : Memberikan terapi obat nifedipine 3x10 mg, inj dexa 1x24 jam dan
pemberian nebul ventolin 2x1 (sudah dilakukan)
08.35 WIB : Memberikan motivasi,dukungan emosional kepada ibu serta menganjurkan
untuk miring ke kiri dan istirahat serta menginformasikan bahwa akan dilakukan observasi
(Respons : ibu bersedia)
08. 36 WIB : Melakukan dokumentasi pada lembar observasi (Sudah dilakukan)
Lembar Observasi Persalinan

Tanggal/Jam His DJJ S/N/T Keterangan

18 April 2022 2x10’x10” 147x/menit S : 37°C VT : 1 cm
08.00 WIB N : 90x/menit Eff : 25 %
TD : 150/100 Ketuban (+)
mmHg Let : Kepala
rr : 18x/menit Dorminator : uuk
Fase Aktif Tanggal /Jam :
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Lampiran : Partograf

KALA II Tanggal /Jam :

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KALA III Tanggal /Jam :

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KALA IV Tanggal /Jam :

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SOAP PEMERIKSAAN SEGERA BAYI BARU LAHIR Tanggal /Jam :

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SOAP NIFAS HARI KE 1 Tanggal /Jam :

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SOAP NIFAS HARI KE 2 Tanggal /Jam :

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SOAP PEMERIKSAAN LANJUTAN BAYI

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Kediri,............................
Pembimbing Praktik Mahasiswa

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NIP. NIM.

Dosen Pembimbing

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NIP.