MANAJEMEN KEBIDANAN IBU BERSALIN

AKADEMI KEBIDANAN SENTRA BINA YUDHISTIRA

Jl.Hos Cokroaminoto Blok A no.10 Komplek ciledug center , Tangerang
Telp/Fax : 730 6977

I. PENGKAJIAN
A. Identitas
Nama Klien : ______________________ Nama Suami : _______________________
Umur : ______________________ Umur : _______________________
Agama : ______________________ Agama : _______________________
Pendidikan : ______________________ Pendidikan : _______________________
Kebangsaan : ______________________ Kebangsaan : _______________________
Pekerjaan : ______________________ Pekerjaan : _______________________
Alamat Kantor: ______________________ Alamat Kantor: _______________________
Alamat Rumah: ___________________________________________________________

Manajemen kala I :
B. Anamnesa pada tanggal __________________________ pukul :
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Oleh: Mahasiswi _______________________________
1. Keluhan utama pada waktu masuk (tanyakan sejak kapan, ciri khas)
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2. Riwayat kehamilan ini :
2.1. Riwayat menstruasi
Haid pertama haid terakhir tanggal ______________ pasti / tidak, lamanya ___hari,
banyaknya ______________________
Haid sebelumnya tanggal : __________________________ lamanya ________ hari,
banyaknya : _____________________
Konsistensi _________________________________________________________
TP
2.2. Pergerakan fetus dirasakan pertama kali usia kehamilan ______________________
Pergerakan fetus dalam 24 jam terakhir ________________________________ kali
2.3. Keluhan yang dirasakan pada kehamilan ini (bila ada jelaskan), tidak ada
2.4. Tanda-tanda persalinan :
His ________________ Sejak _______________ Frekuensi ___________________
Lamanya ________________________ Kekuatannya ________________________
2.5. Pengeluaran pervaginam
Darah / air ketuban / darah lender, jumlah _________________ warna ___________
2.6. Riwayat imunisasi TT1: ____________________
TT2: ____________________
2.7. Buang air besar dan buang air kecil (kapan terakhir, ciri khas)
BAB terakhir pukul ___________________________________________________
BAK terakhir pukul ___________________________________________________

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 3. Riwayat kehamilan
Penyakit Bayi Nifas
Tgl./Tahun Tempat Usia Jenis
No. Penolong Kehamilan
Persalinan pertolongan Persalinan Persalinan JK BB Keadaan Keadaan laktasi
dan Persalinan TB

C. Pemeriksaan
1. Kesadaran : _______________________________________________________
2. Keadaan umum : _______________________________________________________
3. Tanda vital
Tekanan darah : _________________mmHg, Denyut nadi : ____________x/menit
Suhu tubuh : _________________° C, Pernafasan : ____________x/menit
4. Tinggi badan : _______________________________________________________
5. Pemeriksaan fisik : _______________________________________________________
5.1. Muka : Kelopak mata : _____________________________________
Konjungtiva : _____________________________________
Sklera : _____________________________________
5.2. Mulut dan gigi: Lidah dan geraham : _____________________________________
Gigi : _____________________________________
5.3 Kelenjar Thyroid
Pembesaran :  Ada  Tidak ada
Nyeri tekan :  Ada  Tidak ada
5.4 Kelenjar getah bening
Pembesaran :  Ada  Tidak ada
Nyeri tekan :  Ada  Tidak ada
5.5 Dada :
Jantung :  Mur-mur  Gallops  Tidak ada
Paru :  Ronchi  Weezing  Tidak ada
Payudara/mammae : Pembesaran :  Ada  Tidak ada
Bentuk :  Simetris  Tidak simetris
Puting susu : Kebersihan :___________________________
 Menonjol keluar  Datar  Tenggelam
Benjolan/tumor : _______________________________
Pengeluaran Colostrum :  Ada  Tidak ada
Rasa nyeri :  Ada  Tidak ada
Striae :  Ada  Tidak ada
Hyperpigmentasi areola mammae :  Ada  Tidak

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5.6 Abdomen
a. Bekas luka operasi : _____________ Pembesaran : __________________
b. Konsistensi : _____________ Benjolan : ___________________
c. Pembesaran lien/liver : ___________________________________________
d. Palpasi :
TFU : _________cm
Leopold I : _______________________________________________________
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Leopold II : _______________________________________________________
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Leopold III : _______________________________________________________
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Leopold IV : _______________________________________________________
TBJ :_______________________________________________________
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e. Auskultasi
Functum maksimum : ___________________________________________
Denyut jantung fetus : ____________________________ teratur / tidak
f. HIS : ___________________________________________
g. Kandung Kemih : ___________________________________________
5.7 Ekstermitas
Bentuk bagian atas / lengan :  Simetris  Tidak simetris
Bentuk bagian bawah / kaki :  Simetris  Tidak simetris
Oedema tangan dan kaki :  Ada  Tidak
Oedema tibia, kaki :  Ada  Tidak
Varises tungkai :  Ada  Tidak
Reflex patella Kanan :  Positif  negatif
Kiri :  Positif  Negatif
5.8 Punggung : _______________________________________________________
5.9 Pinggang (periksa ketuk : Costro Vertebra Angle Tenderness / CVAT)
Nyeri :  Ada  Tidak ada
5.10 Ano-genital (inspeksi)
Inspeksi
Perineum luka parut : __________________
Vulva vagina warna : ______________________ Luka : ___________________
Fistula : ________________ Varises :
___________________
Pengeluaran pervaginam : __________ Warna : ___________________
Konsistensi : ________________ Jumlah : ___________________
Kelenjar Bhartolini : ___________________________________________
5.11 Pemeriksaan dalam, atas indikasi ________________________________________

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 Oleh mahasiswa : ___________________
1. Dinding vagina : __________________________________________
2. Portio : __________________________________________
a. Pembukaan : __________________________________________
b. Konsistensi : __________________________________________
3. Ketuban : __________________________________________
4. Presentansi : __________________________________________
5. Penurunan bagian terendah : _________________________________________
- Imbang feto pelvic
6. Posisi : _________________________________________
D. Pemeriksaan Penunjang : _____________________
1. LABORATORIUM (*Jika ada indikasi albumin)
Darah : Hb : ____________ Haematokrit : __________
* Keton : ____________ Rhesus : __________
Golongan darah : _________
Urin : Protein : ____________
Reduksi : ____________
2. DIAGNOSTIK LAIN (Seperti USG, dsb)

II. ANALISA MASALAH / INTERPRETASI DATA

Diagnosa : ___________________________________________________________________
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Dasar
Subyektif :____________________________________________________________________
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Obyektif :____________________________________________________________________
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III.IDENTIFIKASI DIAGNOSA / MASALAH POTENSIAL

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IV. IDENTIFIKASI TINDAKAN SEGERA

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V. PERENCANAAN TINDAKAN
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VI. PELAKSANAAN TINDAKAN

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VII. EVALUASI
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 SOAP KALA I

Tanggal :_________________________ Pukul : _________________ WIB

Oleh :______________________________

Subyektif :_______________________________________________________________________
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Obyektif : _______________________________________________________________________
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Assesment : _____________________________________________________________________
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Planning : : _____________________________________________________________________
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SOAP KALA II

Tanggal :_________________________ Pukul : _________________ WIB

Oleh :______________________________

Subyektif :_______________________________________________________________________
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Obyektif : _______________________________________________________________________
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Assesment : _____________________________________________________________________
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Planning : : _____________________________________________________________________
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SOAP KALA III

Tanggal :_________________________ Pukul : _________________ WIB

Oleh :______________________________

Subyektif :_______________________________________________________________________
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Obyektif : _______________________________________________________________________
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Assesment : _____________________________________________________________________
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Planning : : _____________________________________________________________________
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SOAP KALA IV

Tanggal :_________________________ Pukul : _________________ WIB

Oleh :______________________________

Subyektif :_______________________________________________________________________
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Obyektif : _______________________________________________________________________
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Assesment : _____________________________________________________________________
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Planning : : _____________________________________________________________________
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 Mengetahui.
Mahasiswa, Pembimbing Lahan

( ) ( )

Diketahui,
Pembimbing Akademik,

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