AKADEMI KEBIDANAN SULUH BANGSA

JalanOtista Raya 113 BC Jakarta Timur

Telepon (021) 8517104 Faksimile (021) 8517105
Website : www.suluhbangsa.ac.id,Email : suluhbangsa@yahoo.co.id

NamaMahasiswa :……………………
NIM :…………………...
Pembimbing :…………………...

MANAJEMEN ASUHAN KEBIDANAN PADA IBU BERSALIN

Tanggalmasuk : ………………............ Pukul :..............................

Nomorregister : …….………............. Ruangan : .............................

I. PENGKAJIAN

A. IDENTITAS (biodata)
Nam Pasien : ............................... NamaSuami : ..............................
Umur : ………………….. Umur : ..............................
Suku/Bangsa : ………………….. Suku/Bangsa : ……………...........
Agama : ………………….. Agama : ...............................
Pendidikan : ………………….. Pendidikan :..............................
Pekerjaan : ………………….. Pekerjaan : ..............................
Penghasilan/Bulan : …………………... Penghasilan/Bulan :..............................
AlamatRumah : …………………... AlamatRumah : ……………..........
Alamat Kantor : …………………… Alamat Kantor : ……………..........
Telp : ……………............ Telp :…………….....

B. ANAMNESIS (DATA SUBYEKTIF)padatanggal: ……………. Pukul: ….

1. Keluhanutamapadawaktumasuk :
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2. Riwayatpenyakitsekarang :
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 3. Riwayatmenstruasi :
a. Haidpertama/ menarche : Umur : ………………… Tahun : …………
b. Siklus : ………………………………Hari
c. Banyaknya : ………………………………
d. Teratur / tidakteratur : ………………………………
e. Lamanya : ………………………………
f. Sifatdarah : ………………………………
g. Dismenorhoe : ………………………………
4. RiwayatPerkawinan :
a. Status perkawinan :…………………… kawin : ………………..kali
b. Kawin 1 : umur : …………….tahun, dengansuamiumur : ………tahun,
Lamanya: ………….. tahun, Anak : ……………orang,
c. Kawin 2 : umur : ……………. tahun, dengansuamiumur : ……tahun,
Lamnya: ……………. tahun, Anak : ………………….... orang.

5. RiwayatKehamilan, Persalinan, danNifas yanglalu :

No Tgl/th Tempat Umur Jenis penolong penyulit anak nifas Keadaan

partus partus hamil persalinan jenis BB PB anak
sekarang

1
2
3
4
5
6

6. RiwayatLaktasi : …………………………………………………………
7. Riwayathamilini :
a. HPHT : …………………………………………………………
b. Ramalanpersalinan :…………………………………………………………
c. Hamilmuda : …………………………………………………………
 Keluhan : …………………………………………………………
 ANC : ………… kali ,teratur / tidakteratur…………………
Imunisasi (TT) : ………………………………………..
d. Hamiltua : …………………………………………………………
 Keluhan : …………………………………………………………
 ANC : …………kali, teratur / tidakteratur …………………
Imunisasi(TT) : ………………………………………
 8. RiwayatKeluargaBerencana :
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….................

9. RiwayatPenyakitSistemik :
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10. RiwayatPenyakityanglalu / riwayatOperasi :

……………………………………………………………………………………
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11. RiwayatPenyakitKeluarga/KeturunanKembar :
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12. Riwayatkebiasaansehari-hari :
a. ..............................…………………………………………………………..................
b. ...................................……………………………………………………………..........
c. ………………………………….....................................................................................

13. Riwayat Psikososial :

..............……………………………………………………………………………………
..............……………………………………………………………………………………

C. PEMERIKSAAN FISIK (data Obyektif)

1. Status Generalis :
a. Keadaanumum :…………………………………………………………
b. Kesadaran : …………………………………………………………
c. Tekanandarah: …………………………………………………………
d. Suhu : …………………………………………………………
e. Nadi : ………………………………………………………...
f. Respirasi : …………………………………………………………
g. Tinggibadan : …………………………………………………
h. BeratBadansekarang : …………………………………………………
i. BB sebelumHamil :…………………………………………………………
j. LingkarLenganAtas : …………………
2. PemeriksaanSistematis :
a. Kepala :
1) Rambut :………………………………………………………….......................
2) Muka : …………………………………………………………....................
3) Mata : …………………………………………………
 Conjunctiva : ……………………………………………..
 Sclera : ……………………………………………..
4) Hidung : ……………………………………………..
5) Telinga : ……………………………………………….
6) Mulut/Gigi/Gusi : …………………………………………………
b. Leher :
1) Kel. Gondok (Thyroid) :………………………………………………
2) Tumor : ………………………………………………
3) PembesarankelGetahBening :………………………………………
c. Dada danAxila (ketiak)
1) Mammae :
a. Membesar : …………………………………………...........
b. Tumor : …………………………………………………
c. Simetris : …………………………………………………
d. Aerola : ………………………………………………...
e. Puttingsusu : …………………………………………………
f. Kolostrum : …………………………………………………
2) Axial :
a. Tumor : …………………………………………………
b. Nyeri : …………………………………………………

d. Perut : status lokalis / status obstetricus

e. Ano-genital : status lokalis
f. Ekstremitas
1) Tungkai : …………………………………………...........
2) Varices : …………………………………………………
3) Oedema : …………………………………………………
4) Reflekspatella : …………………………………………………
5) Keluhan lain : …………………………………………………
3. PemeriksaaannKhususObstetri (statuslokalis)
a. Abdomen:
1. Inspeksi :
a) Membesar : ………………....... ...........................................
b) Pelebaran Vena : ………………………………...........................
c) linea alba / nigra:............................................................................
d) Strialalbican / livide:……………………………………………..
e) Kelainan : …………………………………………
2. Palpasi :
a) Kontraksi : …………………………………………
b) Leopold I : TFU …………………………………
FU terisi …………………………………
c) Leopold II : kanan …………………………………
Kiri ………………………………
d) Leopold III Bagianbawahterisi …………………………….
e) Leopold IV : …………………………………......................
f) Osborn Test : ……………………………...................
g) TaksiranBeratJanin : ……………………………...............
3. Auskultasi :
DJJ -punctum maximum (PM) : …………………………………
- Tempat : …………………………………………
- Frekuensi : ………………………………………….
b. Annogenital :
1. Kelainan :.....................................................................................
2. Pengeluaran :.....................................................................................
3. Inspekulo : - Vagina :.......................................................................
- Portio : ......................................................................
4. Vaginal Toucher (periksa dalam):
a) Vaginal :......................................................................................
b) Portio :..................................................................................................
c) Pembukaan :..................................................................................................
d) Ketuban :..................................................................................................
e) Presentasi :..................................................................................................
f) Posisi :..................................................................................................
g) Penurunan :................................................................................................
h) Kesan panggul :................................................................................................
D. Pemeriksaan laboratorium
Darah: - HB ;.....................% - golongan darah :............................
Urine: - protein :..................... – reduksi :.................................
 Pemeriksaanpenunjang lain :...............................................................

II. INTERPRETASI DATA DIAGNOSA DAN MASALAH

DIAGNOSA
a. Ibu : ........................................................................................................................
Dasar : ..................................................................................................................
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b. janin: ..................................................................................................................
dasar : .......................................................................................................................
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MASALAH:...........................................................................................................................
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KEBUTUHAN .....................................................................................................................
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III. DIAGNOSA DAN MASALAH POTENSIAL
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IV. ANTISIPASI AKAN KEBUTUHAN TINDAKAN SEGERA
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V. RENCANA
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VI. TINDAKAN ..........................................................................................................................

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VII. EVALUASI :. .............................................................................................................
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VIII. PENGAWASAN HIS
Tgl Jam Lamanya Kekuatan/konistensi/ Masuknya BJF Pengeluaran
His Kuat/ sedang/ lemah Bag. Pervaginam
Terendah

Jakarta,..........................................
Pemeriksa

(....................................)

Pembimbing Akademik CI/Pembimbing Lahan

(....................................) (.....................................)
KALA I.
S :...................................................................................................................................
O : - keadaan umum :........................................................................................................
- TTV :TD............. mmHg,N:.........x/menit,R...........x/menit, S:...... oC
- Palpasi uterus : - His ..............................................................................................
- Palpasi leopold
Leopold I :.............................................................................................
Leopold II :...........................................................................................
Leopold III :.............................................................................................
Leopold IV :..............................................................................................
- Auskultasi :DJJ..............................x/menit,teriatur/tidak
Punctum maximum...............................................................
- Vulva : Varises...............................Edema..........................................
- Pengeluaran :..........................................................................................
- Anus :..............................................................................................
Genetalia interna (Vaginal Toucher)
Dinding vagina :...............................................................................................
Portio :.................................................................................................
Pembukaan :.................................................................................................
Selaput ketubanm :...............................................................................................
Presentasi :.............................................................................................
Penunjuk :.............................................................................................
Posisi :.................................................................................................
Penurunan :..............................................................................................
Moulage :..........................................................................................

A :........................................................................................................................................
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P :.........................................................................................................................................
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KALA II.
S :...................................................................................................................................
O : - keadaan umum :........................................................................................................
- TTV :TD............. mmHg, N:.........x/menit, R...........x/menit, S:...... oC
- Palpasi uterus : - His ..............................................................................................
- Palpasi leopold
Leopold I :.............................................................................................
Leopold II :...........................................................................................
Leopold III :.............................................................................................
Leopold IV :..............................................................................................
- Auskultasi :DJJ..............................x/menit,teriatur/tidak
Punctum maximum...............................................................
- Vulva : Varises...............................Edema..........................................
- Pengeluaran :..........................................................................................
- Anus :..............................................................................................
Genetalia interna (Vaginal Toucher)
Dinding vagina :...............................................................................................
Portio :.................................................................................................
Pembukaan :.................................................................................................
Selaput ketubanm :...............................................................................................
Presentasi :.............................................................................................
Penunjuk :.............................................................................................
Posisi :.................................................................................................
Penurunan :..............................................................................................
Moulage :..........................................................................................

A :........................................................................................................................................
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P :............................................................................................................................................
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KALA III.
S :........................................................................................................................................
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O : keadaan umum :..............................................kesadaran................................

Palpasi :.............................................................................................
TFU :............................................kontraksi...................................
Kandung kemih :...........................................................................................
Perdarahan :..............................................................................................

A :........................................................................................................................................
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KALA IV.
S :........................................................................................................................................
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O : keadaan umum :..............................................kesadaran................................

Palpasi :.............................................................................................
TFU :............................................kontraksi...................................
Kandungkemih :...........................................................................................
Perdarahan :..............................................................................................

A :........................................................................................................................................
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Laporan Persalinan
Jenis persalinan:.......................................tanggal:.....................pukul:......................
Jenis kelamin anak yang dilahirkan:................BB......PB..........Keadaan anak............
Proses persalinan :...........
Ketuban : pecah...................jam..................menit (spontan/amniotomi)
Jumlah perdarahan :
Kala I :..........................................cc
Kala II :..........................................cc
Kala III :..........................................cc
Kala IV :..........................................cc
Total :..........................................cc

Penyulit dan komplikasi :.........................................................................................

Tekanan darah tinggi :..........................................................................................
Kejang :..........................................................................................
Infeksi :..........................................................................................
Lain-lain :..........................................................................................

Tindakan atau pengobatan pada masa persalinan

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