IDENTITAS IBU BERSALIN

NAMA :.................................. NAMA SUAMI :..................................

UMUR :.................................. UMUR :..................................
PENDIDIKAN :.................................. PENDIDIKAN :..................................
PEKERJAAN :.................................. PEKERJAAN :..................................
AGAMA :.................................. AGAMA :..................................
ALAMAT :.................................. ALAMAT :..................................
RIWAYAT PENYAKIT :.............................................................................................
HAID TERAKHIR :.................................. HPL :..................................
KELUHAN UTAMA :.............................................................................................
:.............................................................................................
MICTIE/DEFAECATIE :.............................................................................................
KEHAMILAN KE :G P A
TEKANAN DARAH :...........mmHg Suhu :...................C Nadi :............../menit
MULAI ADA KONTRAKSI :.............................................................................................
PENDERITA DATANG : Tgl....................... Jam......................WIB

LEMBAR OBSERVASI FASE LATEN

JAM NADI KONTRAKSI UTERUS DJJ KETERANGAN