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 : Jam :
No. RM :
Nama : Nama Suami :
Umur : Umur :
Agama : Agama :
Pendidikan : Pendidikan :
Alamat : Alamat :
Cara Masuk :
Datang sendiri Rujukan dari :
Diagnosa MRS :

A. DATA SUBJEKTIF
1. Keluhan utama :
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2. Kronologi MRS : (Sebelum dirujuk/datang ke RS (IGD) hingga sampai ke ruangan

(Bersalin/ Nifas/ Bayi))
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3. Riwayat menstruasi
 Usia manarche :
 Jumlah darah haid :
 HPHT :
 Keluhan saat haid :
 Lama haid :
 Flour albus :
 TP :

3. Riwayat hamil ini

 Hamil muda :
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 Hamil tua :
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 Riwayat imunisasi
TT : ......................................................................................................
 Gerakan janin pertama :..................bulan
 Gerakan janin
terakhir :..........................................................................................................
 Tanda bahaya dan penyulit
kehamilan :.................................................................................
 Obat/jamu yang pernah dan sedang di
konsumsi :................................................................
 Kekhawatiran
khusus : .........................................................................................................

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

G ................. P ................ A ............. Hidup ..................

Tgl,th Jenis Keadaan

Tempat Umur Penolong Anak
No partu persalina Penyulit anak
partus kehamilan persalinan JK/BB
s n sekarang
5. Riwayat kesehatan penyakit yang pernah diderita :
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6. Riwayat penyakit keluarga (Ayah, Ibu, Mertua) yang pernah menderita sakit :
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7. Status pernikahan : ya/tidak

Nikah .............kali, nikah usia..............tahun, lama menikah....................tahun

8. Riwayat psiko sosial ekonomi

- Respon ibu dan keluarga terhadap kehamilan
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- Dukungan keluarga
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- Pengambilan keputusan dalam keluarga
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- Kebiasaan hidup sehat
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- Beban kerja sehari
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- Tempat dan penolong persalinan yang diinginkan
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- Penghasilan keluarga
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9. Riwayat KB dan rencana KB

Metode yang pernah dipakai : ...................................., Lama : ...................bulan/tahun
Komplikasi dari KB : ......................., Rencana KB selanjutnya: .....................

10. Riwayat Ginekologi :

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 11. Pola nutrisi/ eliminasi/ istirahat
- Pola makan :
- Pola minum : .................gelas/hari
- Pola eliminasi :
BAK................. x/hari,
keterangan :.................................................................................
BAB.................. kali/hari,
keterangan :.............................................................................
- Keluhan BAK
: ..............................................................................................................
- Keluhan BAB
: ..............................................................................................................
- Pola istirahat : ............................jam/hari, tidur terakhir jam : ...................

B. DATA OBYEKTIF
1. Pemeriksaan umum
Keadaan umum : Kesadaran :
BB/TB : Tekanan Darah :
Nadi : Suhu :
Pernafasan :

2. Pemeriksaan Fisik
- Mata : ..........................................................................................................
- Rahang, gigi, gusi : ..................................................................................................
- Leher : ..........................................................................................................
- Dada : aerola hiperpigmentasi Tumor Kolostrum
Puting susu menonjol/masuk ke dalam
- Axilla : ..........................................................................................................
- Sistem respiratori : ...................................................................................................
- Sistem kardio : ..................................................................................................
- Postur tubuh : ...................................................................................................
- Keadaan ekstremitas (atas dan bawah) :
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- Pemeriksaan khusus
a. Abdomen
Inspeksi :
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 Palpasi :
Leopold I
: .....................................................................................................
Leopold II
: .....................................................................................................
Leopold III
: ....................................................................................................
Leopold IV
: ....................................................................................................
TBJ : ...........................gram
Auskultasi : BJJ................x/mnt, reguler / irregular
His/kontraksi : ......................

b. Ano genital
Inspeksi : ...............................................................................................
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Inspekulo :
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Vaginal toucher : ............cm eff.........% ketuban(+/-) presentasi.................
denominator ....................... hodge ...............kesan panggul : ....................

3. Pemeriksaan laboratorium :
- Laboratorium lengkap.
- CTG : janin................reaktif/tidak
- USG : ...........................................
- Foto thorak : ............................................
- EKG : ............................................

Ya Tdk
4. Penapisan ibu bersalin
1. Riwayat bedah sesar
2. Perdarahan pervaginam
3. Persalinan kurang bulan ( < 37 minggu )
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
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D. PENATALAKSANAAN
Tanggal : ........................
Jam : .................................

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KALA I
Fase Laten Tanggal /Jam :
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Lembar Observasi Persalinan
Tanggal/Jam His DJJ S/N/T Keterangan
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

.................................................... ......................................................
NIP. NIM.

Dosen Pembimbing

....................................................
NIP.