Riwayat persalinan Riwayat persalinan

Nama ibu :............................................... Nama ibu :...............................................

No KIS :............................................... No KIS :...............................................
Umur :..................tahun Umur :..................tahun
GPO :G....P....O.... GPO :G....P....O....
Tanggal datang :.................................. PKL :.................. Tanggal datang :.................................. PKL :..................
Tanggal pulang :.................................. PKL :.................. Tanggal pulang :.................................. PKL :..................
Keluhan :................................................................................................... Keluhan :...................................................................................................
....................... .......................
.......................................................................................................................... ..........................................................................................................................
Bb :..................Kg TD :..................mmHg Bb :..................Kg TD :..................mmHg
TB :..................cm RR :..................x/mnt TB :..................cm RR :..................x/mnt
LP :..................cm Nadi :..................x/mnt LP :..................cm Nadi :..................x/mnt
TFU :.................. DJJ :..................x/mnt TFU :.................. DJJ :..................x/mnt
Riwayat alergi :............................................. Riwayat alergi :.............................................
Terapi obat :................................................................................................... Terapi obat :...................................................................................................
BMHP :................................................................................................... BMHP :...................................................................................................

Tanggal lahir bayi :.................................. PKL ..................wib Tanggal lahir bayi :.................................. PKL ..................wib
Jenis kelamin : laki- laki / perempuan Jenis kelamin : laki- laki / perempuan
BB bayi :..................gram BB bayi :..................gram
PB bayi :..................cm PB bayi :..................cm
LIKA :..................CM LIKA :..................CM
Presentasi :................................ Presentasi :................................
Tindakan untuk bayi Tindakan untuk bayi
:......................................................................................................... :.........................................................................................................