DOKUMENTASI KEBIDANAN

ASUHAN KEBIDANAN PERSALINAN & BAYI BARU LAHIR

Tanggal MKB : ..... Tanggal Pengkajian : ...

Jam MKB : ..... Jam Pengkajian : ...
Fasilit : ….. Nama Nakes & Profesi: ….

SUBYEKTIF (S)
1. Biodata
ISTERI SUAMI/WALI

Nama : ..... Nama : .....

Umur : ..... Umur : .....

Agama : ..... Agama : .....

Suku/Bangsa : ..... Suku/Bangsa : .....

Pendidikan : ..... Pendidikan : .....

Pekerjaan : ..... Pekerjaan : .....

Penghasilan : ..... Penghasilan : .....

Alamat : …... Alamat/Hp. : …..

2. Alasan masuk kamar bersalin (MKB)
.............................................. .............................................. ............................................

.............................................. .............................................. ............................................

Keluhan Utama
.............................................. .............................................. ............................................
3. Riwayat menstruasi
Siklus
: ................ hari TP: ………………….
HPHT
: ........................
4. Riwayat obstetri yang lalu

UK
Penyulit Persalinan Bayi Nifas Anak
Hamil Saat Penyulit Jenis Tempat Peno-
Hidup/
ke- Partus Kehamilan Partus Partus long Bayi Ibu PB/ Keadaan IMD Penyulit Laktasi
Mati/
BB
Usia
5. Riwayat kehamilan sekarang

Frekuensi ANC: ……………………………………………………………………………

Tempat ANC : ............................................................................................................

Tanda bahaya kehamilan yang pernah dialami, dan terjadi pada

UK berapa:

......................................................................................................................

6. Riwayat persalinan sekarang

Kontraksi uterus/His

a) His sejak tanggal : .......................................... Pukul : ...........................

b) Frekuensi & durasi his : .............................................................................

c) Skala nyeri his : .............................................................................

Pengeluaran pervaginam

a) Darah & lendir : ……………………………………………………………………..

b) Air ketuban : ……………………………………………………………………..

c) Lain-lain : ……………………………………………………………………..
7. Riwayat kesehatan ibu sekarang dan lalu yang dapat mempengaruhi proses persalinan dan
kelahiran bayi (termasuk riwayat alergi obat dan makanan):
...................................................................................................................
.....................................................................................................................................
9. Riwayat sosial dan psikologi
Status perkawinan : ..............., kawin :..........................kali

Perasaan ibu saat ini : ..............................................................

Pengambil keputusan dalam keluarga : ..............................................................

Penolong persalinan yang diinginkan : ..............................................................

Tempat rujukan jika terjadi komplikasi : ..............................................................

Sumber biaya persalinan : ..............................................................

Pendamping persalinan yang diinginkan : ..............................................................

Budaya yang akan diterapkan saat persalinan : …………………………………….….

Asuhan yang diinginkan pada kala I persalinan : ………………………………………..

 Asuhan yang diinginkan pada kala II persalinan : ….……………………………………

10. Pemenuhan kebutuhan sehari-hari

a. Makan dan minum terakhir

Tanggal/Jam : ...................................................................................................

Jenis & Porsi : ...................................................................................................

b. Istirahat/tidur terakhir

Tanggal/Jam : ...................................................................................................

Lama : ........................................................................................................

d. Eliminasi terakhir

BAK Tanggal/Jam : .........................................................................................

BAB Tanggal/Jam : .........................................................................................

OBYEKTIF (O)
1. Keadaan umum : .....................................................................................................

2. Cardinal Sign/tanda-tanda vital Tekanan

darah............................................mmHg

Nadi..............................................kali/menit

Suhu..............................................0C

Pernafasan.....................................kali/menit

3. Pemeriksaan fisik

Inspeksi

a) Muka

Konjungtiva : ................ …. Sklera: .................... Odema : ...................

b) Leher

Pembesaran kelenjar tiroid : .........................................................................

Pembesaran vena jugularis: …………………………………………………….

c) Payudara

Keadaan papilla mammae: ..............................................................................

d) Abdomen

Bekas luka operasi: ................................ Jenis operasi: ………………..………

e) Genetalia eksterna

Pengeluaran pervaginam : ada/tidak Jenis: …............................................

Varises : ..................................................................................................

Odema : ..................................................................................................
 Tanda-tanda IMS : ..........................................................................................

Hemoroid : ........................................ Grade: ……………………………………

f) Tangan dan kaki

Odema : .......................................................................................................

Varises : .......................................................................................................

g) Disabilitas : .......................................................................................................

Palpasi

a) Payudara (kolostrum): ............................................................................................

b) Abdomen

TFU : ................. cm TBJ..............................gram

Leopold I : .................................................................................................

Leopold II : .................................................................................................

Leopold III : .................................................................................................

Leopold IV : .................................................................................................

c) His : ....... x./10’/............”

d) Perlimaan WHO: ................................

Auskultasi

DJJ................................................x/menit
4. Pemeriksaan Dalam/Vaginal Toucher (VT)
Indikasi : .......................................... Pukul : ..................... Oleh : .....................

Vulva/Vagina : .......................................................................................................

Porsio : ...............................................................................................................

Serviks : ...............................................................................................................

Selaput amnion dan ketuban: ................................................................................

Denominator: ...........................................................................................................

Presentasi : .............................................................................................................

Penurunan : Hodge ..........

5. Data Penunjang (bila diperlukan)

Tanggal : ................................ Jenis pemeriksaan : ..........................................

Hasil : .....................................................................................................................
ASSESSMENT (A)

Diagnosis Kebidanan:

.............................................. .............................................. ............................................

Masalah Kebidanan:

.............................................. .............................................. ............................................

PLANNING (P)

Hari/Tanggal: ………………………………………………………………………………….
Jam (WIB) Penatalaksanaan Nama dan
Paraf Bidan
(Mahasiswa)
 CATATAN PERKEMBANGAN I
SUBJEKTIF

OBJEKTIF CATATAN
PERKEMBANGAN II
SUBJEKTIF

ASSESSMENT

PLANNING
OBJEKTIF

ASSESSMENT

PLANNING