Lampiran 2

FORMAT PENDOKUMENTASIAN MANAJEMEN KEBIDANAN

PADA IBU BERSALIN

NO. REGISTER : .............................................................................................

MASUK RS TANGGAL/JAM : .............................................................................................
DIRAWAT DIRUANG : .............................................................................................

Biodata Ibu Ayah

Nama : .................................................
Umur : .................................................
Agama : .................................................
Suku/Bangsa : .................................................
Pendidikan : .................................................
Pekerjaan : .................................................
Alamat : .................................................
No. Telepon/HP : .................................................
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I. DATA SUBJEKTIF
1. Alasan masuk kamar bersalin
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2. Keluhan utama
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3. Tanda-tanda persalinan
a. Kontraksi uterus sejak tanggal ……………. Jam.....................wib
Frekuensi :............Kali dalam 10 menit
Durasi :............Detik
Kekuatan : kuat/sedang/lemah
Lokasi ketidaknyamanan di ...................................................................................
b. Pengeluaran per vagina
Lendir darah : ya/tidak
 Air ketuban : ya/tidak, banyaknya ……… cc, warna ………
Darah : ya/tidak, banyaknya ……… cc, warna ………
4. Riwayat sebelum masuk ruang bersalin
5. Riwayat kehamilan sekarang
HPM …………………………………. HPL ...............................................................
Menarche umur …… tahun. Siklus ……… hari. Lama..........Hari.
Banyaknya...................................cc.
ANC teratur/tidak, frekuensi ………… kali, di………………………
Keluhan/komplikasi selama kehamilan
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Riwayat merokok/minum-minuman keras/minum jamu ………….
Imunisasi TT 1 : ya/tidak, tanggal ...............................................................................
Imunisasi TT 2 : ya/tidak, tanggal ...............................................................................
6. Pergerakan janin dalam 24 jam terakhir.............................kali.
7. Riwayat Kehamilan, persalinan dan nifas yang lalu
Penulisan Nifas
Hamil
Tgl Umur Jenis Komplikasi Jenis BB
ke Laktasi Komplikasi
Lahir Kehamilan Persalinan Ibu Bayi Kelamin Lahir
8. Riwayat kontrasepsi yang digunakan
Jenis Mulai Memakai Berhenti/Ganti Cara
No
kontrasepsi Tanggal Oleh Tempat Keluhan Tanggal Oleh Tempat Keluhan

9. Riwayat kesehatan
a. Penyakit yang pernah/sedang diderita
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b. Penyakit yang pernah/sedang diderita keluarga
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c. Riwayat keturunan kembar

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10. Makan terakhir tanggal ............................ jam .............. jenis .................................
Minum terakhir tanggal ............................ jam .............. jenis .................................
11. Buang air besar terakhir tanggal ............... ...................... jam ...................................
12. Buang air kecil terakhir tanggal ............... ...................... jam ...................................
13. Istirahat/tidur dalam satu hari terakhir.................................jam
14. Keadaan Psiko Sosial Spiritual
a. Pengetahuan tentang tanda-tanda persalinan dan proses persalinan
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b. Persiapan persalinan yang telah dilakukan (pendamping, ibu, biaya, dll)
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c. Tanggapan ibu dan keluarga terhadap proses persalinan yang dihadapi
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II. DATA OBJEKTIF

1. Pemeriksaan Fisik
a. Keadaan umum.................................Kesadaran
b. Status emosional :
c. Tanda vital :
Tekanan darah :....................................................mmHg
Nadi :....................................................kali per menit
Pernafasan :....................................................kali per menit
Suhu :.................................................... oC
d. TB : cm
BB : sebelum hamil ……… kg, BB sekarang..............Kg
LILA :.....................................................cm
e. Kepala dan leher :
Edema wajah : ............................................................................................
Cloasma gravidarum +/ -
Mata : ............................................................................................
Mulut : ............................................................................................
Leher : ............................................................................................
f. Payudara
Bentuk : ............................................................................................
Putting susu : ............................................................................................
Colostrum : ............................................................................................
g. Abdomen
Pembesaran : ............................................................................................
Benjolan : ............................................................................................
Bekas luka : ............................................................................................
Strie gravidarum : ............................................................................................
 Palpasi Leopold
Leopold I : ............................................................................................
Leopold II : ............................................................................................
Leopold III : ............................................................................................
Leopold IV : ............................................................................................
Osborn test : ............................................................................................
TBJ : ............................................................................................
Auskultasi DJJ : Punctum maksimum ...........................................................
Frekuensi : ……. Kali per menit (……./……./…....)
His : Frekuensi :...........Kali dalam 10 menit
Durasi :...........Detik
Kekuatan : kuat/sedang/lemah
Palpasi supra publik : ...................................................................................
h. Punggung :
i. Pinggang : nyeri/tidak
j. Ekstremitas :
Kekuatan otot dan sendi : ...................................................................................
Edema : ...................................................................................
Varices : ...................................................................................
Refleks patella : ...................................................................................
Kuku : ...................................................................................
k. Genetalia luar
Tanda Chadwich : ...................................................................................
Varices : ...................................................................................
Bekas luka : ...................................................................................
Kelenjar bartholini : ...................................................................................
Pengeluaran : ...................................................................................
l. Anus :
Haemoroid/tidak : ...................................................................................
2. Pemeriksaan dalam, tanggal........................................, oleh
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 3. Pemeriksaan Penunjang
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III. ASSESSMENT
1. Diagnosis Kebidanan
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2. Masalah
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3. Kebutuhan
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4. Diagnosis Potensial
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5. Masalah Potensial
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 6. Kebutuhan Tindakan Segera Berdasarkan Kondisi Klien
a. Mandiri
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b. Kolaborasi
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c. Merujuk
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IV. PLANNING (Termasuk Pendokumentasian Implentasi dan Evaluasi)

Tanggal......................................Jam

Tanda Tangan

(……………..….………)
CATATAN PERKEMBANGAN
Tanggal ……………………………….…. Jam
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DATA SUBJEKTIF
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DATA OBJEKTIF
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ASSESSMENT
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PLANNING
Tanggal ………………………………………. Jam
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TT. CI Klinik/RB/RS Tanda Tangan

(…………….………….) (…………………………)