ASUHAN KEBIDANAN PADA IBU BERSALIN

PADA NY....... USIA ......TAHUN G.... P.... A......USIA HAMIL.....MGG

DI ...........................................................................

PENGKAJIAN:
Target :
Tanggal :............................................... Jam:....................................
IDENTITAS PASIEN:
Identitas Pasien Penanggung Jawab
Status :....................
1. Nama : 1.Nama :
2. Umur : 2.Umur :
3. Agama : 3.Agama :
4. Pendidikan : 4. Pendidikan :
5. Pekerjaan : 5.Pekerjaan :
6. Suku bangsa : 6. Suku Bangsa :
7. Alamat : 7.Alamat :

KALA I
(tanggal,jam)
I. DATASUBJEKTIF
1. Alasan masuk kamar bersalin :
2. Keluhan Utama :
3. Tanda-tanda persalinan
a. Konraksi sejak …................... lamanya...................intensitas…....................
lokasi ketidaknyamanan di..............................................................................
b. Pengeluaran pervaginam (pengeluaran lendir darah, air ketuban,darah) :
..................................................................................................................................
................................................................................................................................
4. Pergerakan janin dalam 24 jam terakhir ………kali
5. Riwayat sebelum masuk kamar bersalin………
6. Riwayat Perkawinan
7. Kawin ................. kali, penikahan ke-…. , umur saat menikah ...... tahun, lamanya
pernikahan……tahun.
8. Riwayat Menstruasi
9. Menarche usia………Tahun Siklus……hari Teratur/Tidak. Lama.........hari.
Sifat darah: encer/beku. Bau......... Flour albous : ya/ tidak.
Disminorhee: ya/tidak. Banyaknya........................
a. HPMT : C. UK :
b. HPL :

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 10. Riwayat Kehamilanini:
a. Riwayat ANC
ANC : teratur/tidak, frekuensi selama hamil......... kali, oleh...............
di.................................
b. Obat-obatan/jamu yang dikonsumsi selama hamil
c. Imunisasi TT
TT 1 : TT 4 :
TT 2 : TT 5 :
TT 3 :
d. Keluhan/masalah/keadaan yang dirasakan ibu selama hamil:
No. Keluhan Tindakan Oleh Ket. (Tempat)

11. Riwayat Kehamilan, Persalinan dan Nifas yang

Lalu G … P … Ab …… Ah……

Hamil Persalinan Nifas

Ke Tangga Umur Jenis Penolong Komplika J BB Perdarahan Laktasi KOMPLIKA
lLahir kehamila persalinan Si K Lahir SI

n Ibu Bayi

No. Jenis Mulai Memakai Berhenti / Ganti Cara

Kontrasepsi Tgl Oleh Tempat Keluhan Tgl Oleh Tempat Alasan

13 RiwayatKesehatan
a. Penyakit sistemik, menurun, menular yang pernah/sedang diderita… jantung asma
TBC,ginjal,DM,malaria , HIV/AIDS...........................................................................................
b. Penyakit yang pernah/ sedang diderita keluarga..........................................................................
c. Riwayat operasi............................................................................................................................
d. Riwayat kembar, ..........................................................cacat......................................................
14. KebutuhanFisik
a. Nutrisi : ibu makan terakhir tanggal........................................jam......................, minum terakhir
tanggal.............................................jam...........................porsi......................................................
Jenis makanan dan minuman..........................................................................................................
b. Eliminasi :
1) BAK terakhir tanggal..................................jam.........................................................................
Sifat......................jumlah.....................warna............bau............keluhan..................................
2) BAB terakhir tanggal....................................jam........................................................................
Sifat.................jumlah........................ warna ....................bau ...................Istirahat (tidur)
dalam satu hari terakhir..............................................................................................................
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c. Personal hygiene mandi dan keramas terakhir.................................................................................
15. Keadaan Psiko, Sosio dan Spiritual (kesiapan menghadapi proses persalinan)

a. Pendamping persalinan
.................................................................................................................................................
.................................................................................................................................................
.

b. Tanggapan ibu dan keluarga terhadap proses persalinan yang dihadapi :

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

c. Persiapan persalinan yang telah dilakukan :

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..

d. Pengetahuan tentang proses persalinan :

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II. DATAOBJEKTIF
1. PemeriksaanUmum
a. Keadaan umum:
Kesadaran:
b. Tanda – TandaVital
- Tekanan Darah : - Respirasi :
- Suhu : - Nadi :
c. Berat Badan:
Sebelum hamil : kg, kunjungan lalu: kg, kunjungan ini: kg.
2. PemeriksaanFisik
a. Kepala: (rambut, muka (odema, cloasma), mata (sklera, konjungtiva), hidung,
mulut, gigi, lidah, gusi, telinga)
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b. Leher : ( kelenjar thyroid, kelenjar getah bening, vena jugularis eksterna)
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c. Dada (payudara): (Bentuk, areola, putting susu, pengeluaran colostrum,
massa/ benjolan)
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d. Abdomen
1) Inspeksi
- Bentuk
- bekas luka
- striae gravidarum/ striae albican _______ linea nigra _____________
- gerakan janin :

2) Palpasi
a) Leopold1:.............................................................................................
b) Leopold2:.............................................................................................
..............................................................................................................
..............................................................................................................
..
c) Leopold3:.............................................................................................
.
d) Leopold4:.............................................................................................
.
e) Osborn Test (dilakukan / tidak dilakukan)
hasil……….......................
f) TFU Mc.Donald:
..................................................................................
Taksiran Berat Janin
................:.............................................................................................
3) Auskultasi:
Punctum maksimum di
:.............................................................................

DJJ: frekuensi.....................kali/menit, teratur/tidak, intensitas

:................
4) His: frekuensi …… kali/10 menit, durasi …… detik, intensitas
....................... (kuat, sedang,lemah)
5) Palpasi supra
pubik.....................................................................................
e. Ekstrimitas (odema, kelainan, varices, warna kuku, reflex Patella) :
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
.

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 f. Genetalia eksterna
- Vagina:.....................................................................................................
.........................................................................................................................
(kebersihan, tanda Chadwick, kelainan, fluor albus, oedem, varises, bekas
luka, infeksi, kelenjar Bartholini, kelenjar Skene)
- Anus : (hemoroid)
III. Pemeriksaan dalam (pukul) :
1. Indikasi :
2. Tujuan :
3. Hasil :
(vagina, uretra, cerviks (pendataran dan pembukaan), selaput ketuban, presentasi,
petunjuk presentasi, penurunan bagian terendah, pengeluaran (air ketuban, lendir
darah, darah

IV. Pemeriksaan laboraturium atas indikasi

a. Darah (Hb, golongan darah, HbSAg,WR/VDRL)
Hasil :
b. Urine (Protein urin, glukosa urin, lakmus test)
Hasil:
c. Pemeriksaan Laboratorium lain
Hasil:
d. Kesimpulan :

V. Pemeriksaan dalam (pukul) :

1. Indikasi :
2. Tujuan :
3. Hasil :
(vagina, uretra, cerviks (pendataran dan pembukaan), selaput ketuban, presentasi,
petunjuk presentasi, penurunan bagian terendah, pengeluaran (air ketuban, lendir
darah, darah)

VI. Pemeriksaan laboraturium atas indikasi

a. Darah (Hb, golongan darah, HbSAg,WR/VDRL)
Hasil :
b. Urine (Protein urin, glukosa urin, lakmus test)
Hasil:
c. Pemeriksaan Laboratorium lain
Hasil:
d. Kesimpulan :

VII. Pemeriksaan dalam (pukul) :

1. Indikasi :
2. Tujuan :
3. Hasil :
(vagina, uretra, cerviks (pendataran dan pembukaan), selaput ketuban, presentasi,
petunjuk presentasi, penurunan bagian terendah, pengeluaran (air ketuban, lendir
darah, darah)

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 VIII. Pemeriksaan laboraturium atas indikasi
a. Darah (Hb, golongan darah, HbSAg,WR/VDRL)
Hasil :
b. Urine (Protein urin, glukosa urin, lakmus test)
Hasil:
c. Pemeriksaan Laboratorium
lain
d. Hasil:Kesimpu
f. ANALISIS DATA

Diagnosa :

Dasar :

Masalah :

Kebutuhan :

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g. PENATALAKSANAAN Kala I (Asuhan yang telah dilakukan , Rasionalisasi setiap
tindakan dan evaluasinya)

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 Kala II (tanggal : pukul: )
Nama Pasien :
G P A
Jam: Catatan Perkembangan
(SOAP)
Subjektif

Objektif
Keadaan Umum:
TD :
Nadi :
RR :
Suhu :
Pemeriksaan Fisik terfokus

Analisis
Diagnosa :
Dasar :

Masalah :
Kebutuhan :

Planning kala II :
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 Planning kala II :
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Subjektif :

Objektif Keadaan
Umum:
TD :
Nadi :
RR :
Suhu :
Pemeriksaan Fisik terfokus :

Analisis
Diagnosa :
Dasar :

Masalah : Kebutuhan :

Planning Kala III :

1. ............................................................................................................................................
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Kala IV (tanggal: pukul : )
Nama Pasien :
G P A
Jam: Catatan Perkembangan
(SOAP)
Subjektif :

Objektif
Keadaan Umum:
TD :
Nadi :
RR :
Suhu :
Pemeriksaan Fisik terfokus :

Analisis
Diagnosa :
Dasar :

Masalah :
Kebutuhan:

Planning kala IV:

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.....................................2021

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