YAYASAN RUSTIDA

AKADEMI KESEHATAN “RUSTIDA”

PROGRAM STUDI DIII KEBIDANAN
Jl. Bhakti Husada Krikilan – Glenmore – Banyuwangi
Telp 0333-821495 Fax-0333 821193

No. Target :

ASUHAN PADA IBU BERSALIN NORMAL

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I. LANGKAH I (PENGKAJIAN)
Tanggal pengkajian : ……… Jam : …………
Oleh :
BIODATA
Nama Ibu : ………………… -Nama Suami :……………….
Umur : ………………… - Umur : ……………....
Pendidikan : ………………… - Pendidikan : ………………
Agama : ………………… - Agama : ………………
Suku/ Bangsa : ………………… - Suku / Bangsa : …………….
Pekerjaan : ………………… - Pekerjaan : ………………
Alamat : ………………… - Alamat : ………………
No. Telp. : …………………
No. Register : …………………

A. DATA SUBYEKTIF
KALA I (tanggal:......................................... Jam:....................)
1. Alasan kunjungan:
…………………………………………………………………………………………
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2. Keluhan utama : (keluhan yang dirasakan ibu saat ini)
 …………………………………………………………………………………………
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3. Kronologis
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4. Riwayat Perkawinan
Kawin : kali
Perkawinan ke- :
Umur kawin : tahun
Lama kawin : tahun
5. Riwayat Mentruasi
a. Haid
Menarche : th
Siklus : teratur/tidak
Banyaknya : cc/kotek/hari
Lamanya : hari
Warnanya :
Baunya :
Sifat darah : encer / beku
Dysmenorhoe : ya/tidak
Fluor albus : ya (gatal, panas, berbau)/tidak, konsistensi, warna
HPHT :
HPL :
b. Riwayat kehamilan sekarang dan masalahnya
ANC di : oleh:
Sejak UK :
Quickening (gerakan pertama janin pada UK):
Gerakan janin dalam 24 jam terakhir : kali
Frekuensi periksa selama hamil : TM I : TM II : TM III:
Senam hamil :
Riwayat imunisasi TT Caten :
Imunisasi TT : pernah /tidak
 Imunisasi TT I tgl ………………………. TT II tgl ……………………….
Obat - obatan / jamu yang dikonsumsi selama hamil:

c. Riwayat obstetrik
Kehamil
Persalinan Anak Nifas
an
No
usi Penln Temp Penyl BB/P AS
Ke Jenis Seks H/M Penylt
a g t t B I

d. Permasalahan dan keluhan dalam kehamilan

Trimester Masalah/keluhan Tindakan / terapi Oleh Tempat
I
II
III

6. Riwayat kontrasepsi yang digunakan

Jenis Mulai memakai Berhenti / ganti cara
No kontraseps Tempa Keluha Ole Temp
Tgl Oleh Tgl Alasan
i t n h at

7. Pola kebutuhan sehari – hari

a. Nutrisi
- Makan terakhir : jam………………………………
- Porsi makan :
…………………………………………………………………………………
- Jenis makanan :

…………………………………………………………………………………
- Makanan pantang :
…………………………………………………………………………………
- Minum terakhir : jam………………………………………
- Keluhan :
…………………………………………………………………………………
 b. Eliminasi
- BAK : frekuensi ……………………. Jumlah …………………… warna
……………… keluhan ………………………
- BAB : frekuensi ……………………. Jumlah …………………… warna
……………… keluhan ………………………
c. Istirahat /tidur (dalam satu hari terakhir)
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d. Aktivitas terakhir
:................................................................................................................................
e. Personal higine terakhir (mandi / keramas)
: …………………………………………………………………………………...
f. Pola seksual terakhir :
:................................................................................................................................

8. Riwayat persalinan dan kemajuan persalinan sekarang

a. Kenceng – kenceng mulai : tgl ……………………… Jam ………………………
Lamanya ........................ Intensitas ............................ Lokasi ketidaknyamanan
di..........................................
b. Pengeluaran pervaginan
- Lendir darah : tgl ……………………………. Jam …………………………..
- Air ketuban : tgl ……………………………. Jam …………………………..

9. Riwayat Kesehatan :
a. Riwayat penyakit yang pernah di derita / sedang diderita klien dan pengobatan yang
di lakukan seperti Hipertensi, Diabetes, Jantung, Paru – paru, Hepatitis) :
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b. Riwayat penyakit yang pernah di derita / sedang diderita keluarga dan pengobatan
yang di lakukan seperti Hipertensi, Diabetes, Jantung, Paru – paru, Hepatitis) :
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c. Riwayat alergi (makanan, minuman, obat-obatan dan bahan lain)
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d. Riwayat operasi : .....................................................................................................
 e. Riwayat kembar, cacat :
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10. Riwayat Psikososial:
Kesiapan ibu dan keluarga menghadapi persalinan ini
a. Pengambilan keputusan
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b. Pendamping persalinan
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c. Tanggapan ibu dan keluarga terhadap kehamilan ini
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d. Persiapan persalinan yang telah dilakukan
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e. Pengetahuan ibu tentang proses persalinan

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B. DATA OBJEKTIF
1. Pemeriksaan umum
a. Keadaan Umum : …………….
b. Kesadaran : …………….
c. Tanda – tanda vital
Tekanan Darah : …………. mmHg
Denyut Nadi : ………… X/menit
Pernafasan : ………… X/menit
Suhu : ………… 0C
d. BB sebelum hamil : ………... Kg
e. BB kunjungan lalu : ………… Kg
f. BB kunjungan ini : ........... Kg
g. TB : ………... cm
h. LILA : ………... Cm
i. IMT : ............
2. Pemeriksaan fisik
a. Kepala : ...........................................................................................................
b. Muka : ...........................................................................................................
c. Mulut : ...........................................................................................................
d. Gigi : ...........................................................................................................
e. Mata : ...........................................................................................................
f. Telinga : ...........................................................................................................
g. Hidung : ...........................................................................................................
h. Leher : ...........................................................................................................
 i. Aksila : ...........................................................................................................
j. Dada : ...........................................................................................................
k. Payudara : ...........................................................................................................
3. Pemeriksaan Obstetri
Abdomen :
Inspeksi : ...........................................................................................................
- TFU : ...........................................................................................................
- LI : ...........................................................................................................
- LII : ...........................................................................................................
- LIII : ...........................................................................................................
- LIV : ...........................................................................................................
- TBJ : ...........................................................................................................
- DJJ : frekuensi :......................kali/menit
Punktum maksimum di: ...................................................................................
HIS : frekuensi ........................kali/10menit,
durasi .........................detik , Intensitas (kuat , sedang, lemah )
Genetalia : ........................................................................................
Ekstrimitas : .........................................................................................
4. Pemeriksaan Dalam (VT)
Tanggal ............. Jam ............ WIB oleh : .............

atas Indikasi ........,

Tujuan :

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Hasil :

Pembukaan ...... cm, Efficement ..... %, Konsistensi ........., Ketuban .........., Presentasi
.........., Denominator.........., Hodge………., Bagian di samping bagian terendah janin
......., molase…………..

5. Pemeriksaan Penunjang (atas indikasi)

Tanggal : jam:
a. Hb : ………………………
b. Urine:
- Protein /albumin : ………………………
- Reduksi /glucosuria : ………………………
j. USG : ....................................
II. LANGKAH II (INTERPRETASI DATA DASAR)
a. Diagnosa :
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DS : ................................
DO : ................................
b. Masalah : ................................
DS : ................................
DO : ................................
c. Kebutuhan :

III. LANGKAH III (ANTISIPASI DIAGNOSA ATAU MASALAH POTENSIAL)

IV. LANGKAH IV (IDENTIFIKASI KEBUTUHAN TINDAKAN SEGERA)

V. LANGKAH V (PLANNING/ INTERVENSI)

Diagnosa :

Masalah :
Tujuan :
Kriteria :
No Planning Rasional
VI. LANGKAH VI (IMPLEMENTASI)
Tgl/jam Tindakan
VII.LANGKAH VII (EVALUASI)
Tanggal : Jam :

SUBYEKTIF : ...............................................................................................
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OBYEKTIF : ...............................................................................................
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ASSESMENT .............................................................................................. :
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PENATALAKSANAAN :
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 CATATAN PERKEMBANGAN
Tanggal/Pukul :

Data Subyektif (S)

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Data Obyektif (O)
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Asessment (A)
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Penatalaksanaan (P)
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 LEMBAR PENGESAHAN

Asuhan kebidanan ini telah disetujui/disahkan pada

Hari :
Tanggal :

Pemberi Asuhan

( )

Mengetahui

Pembimbing Akademik Pembimbing Lapangan

( ) ( )

Menyetujui

Bidan Koordinator

( )
 CEK LIST PENAPISAN IBU BERSALIN
Nama Ibu :
Usia :
No Keterangan Ya Tidak
1 Riwayat bedah sesar
2 Perdarahan pervagianam
3 Persalinan kurang bulan (UK < 37 minggu)
4 Ketuban pecah dengan meconium kental
5 Ketuban pecah lama (>12 jam)
6 Ketuban pecah pada persalinan kurang bulan (< 37
minggu)
7 Icterus
8 Anemia berat
9 Tanda/gejala infeksi
10 Pre eklamsi/hipertensi dalam kehamilan
11 Tinggi fundus uteri > 40 cm dan < 25 cm
12 Gawat janin
13 Primipara dalam fase aktif kala satu persalinan dengan
hasil palpasi kepala masih 5/5
14 Presentasi bukan belakang kepala
15 Presentasi majemuk
16 Kehamilan GEMELI
17 Tali pusat menumbung
18 Syok
19 Hipertensi
20 Kehamilan dengan penyulit sistemik (asma, DM.
jantung, kelainan darah)
21 Tinggi badan < 140 cm
22 Kehamilan di luar kandungan
23 Posterm pregnancy
24 Partus tak maju (kala I lama, kala II lama, kala II tak
maju)
25 Kehamilan dengan mioma uteri
26 Kehamilan dengan Riwayat penyakit tertentu (HIV,
Hepatitis)
 SATUAN ACARA PENYULUHAN

Topik : ........................................................................
Sub Topik : ........................................................................
Sasaran : ........................................................................
Target : ........................................................................
Hari/ tanggal : ........................................................................
Waktu : ........................................................................
Tempat : ........................................................................
Penyuluh : ........................................................................

A. Latar Belakang

B. Tujuan intruksional umum (TIU)

C. Tujuan intruksional khusus (TIK)

D. Materi penyuluhan

E. Metode

F. Media

G. Evaluasi

H. Pengorganisasian dan urutan tugas

1. Pembawa acara
2. Notulen
3. Penyuluh
4. Fasilitator
5. Observer

I. Proses pelaksanaan
No Waktu Kegiatan penyuluhan Kegiatan peserta
1 Pembukaan

2 Pelaksanaan
 3 Evaluasi

4 Terminasi

J. Evaluasi
1. Evaluasi struktur
2. Evaluasi proses
3. Evaluasi hasil

K. Referensi

L. Materi penyuluhan
Lampirkan materi peyuluhan yang diberikan

M. Lembar soal
Beri soal setelah kegiatan penyuluhan

N. Dokumentasi
Beri dokumentasi berupa foto kegiatan

...................,.............................20....
Penyuluh

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Mengetahui,

CI BPM/ PKM ....................... Pembimbing Akademik

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