FORMAT ASUHAN KEBIDANAN PADA IBU BERSALIN

Ny.A..... umur ...24.. tahun G.2..P.0..A.1.. hamil ..... minggu dengan partus normal di ........

Tanggal Pengkajian : ........................, pukul ............... WIB

Ruang Pengkajian : ..............

I. PENGKAJIAN
Identitas/ Biodata
Nomor RM : ...........................
Nama Ibu :............................ Nama Suami : .............................
Umur : ........................... : .............................
Pendidikan : ........................... : .............................
Pekerjaan/Penghasilan : .......................... : .............................
Suku/Bangsa : ........................... : .............................
Agama : ........................... : .............................
Alamat :............................. : .............................

Anamnesa pada tanggal ................................ pukul .................................

Jenis Anamnesa : ..........
1. Keluhan Utama / Alasan datang :
............................................................................................................................
............................................................................................................................
2. Tanda – tanda persalinan :
a. Kontraksi : ....................sejak
tanggal : ...................pukul : .......................................
b. Frekuensi : .........kali setiap 10 menit

3. Pengeluaran pervaginam :
a. Darah
: ........................................................................................................................
b. Air ketuban
: ........................................................................................................................
c. Lendir darah
: ........................................................................................................................
4. Riwayat menstruasi :
a. Menarche : .....................tahun Siklus : ...........................hari
b. Lama : ............................... Jumlah : ..................................
c. Warna : ............................... Keluhan : ..................................

5. Riwayat Perkawinan :
a. Umur waktu nikah : ............................................................................................
b. Lama : ..........................................................................................
c. Perkawinan ke : ............................................................................................
d. Jumlah anak : ............................................................................................
e. Genogram :

6. Riwayat Kesehatan :
a. Riwayat kesehatan sekarang (DM,Jantung,Hipertensi,Asma,TBC,
IMS,Hepatitis,Anemia,Covid-19)
........................................................................................................................
........................................................................................................................
b. Riwayat Kesehtan yang lalu
........................................................................................................................
........................................................................................................................
c. Riwayat Kesehatan Keluarga
........................................................................................................................
........................................................................................................................
7. Riwayat Kehamilan Sekarang :
a. HPHT : ............................................................................................
b. HPL : ............................................................................................
c. Haid bulan sebelumnya : ................. lamanya .........................................................
d. Siklus : ........................................................hari
e. ANC : teratur/tidak, frekuensi......kali, TM I: ....Kali, TM II: .....kali, TM
III: .....Kali di.........................................................................................
f. Riwayat USG:
- Trimester I : kali di ...
- Trimester II : kali, di ............
- Trimester III : kali di ....
 g. Imunisasi TT : ..................kali, di..............................................
h. Keluhan TM I
: ........................................................................................................................
TM II
: ........................................................................................................................
TM III
: ........................................................................................................................
i.
Pergerakan janin
pertama : ........................................................................................................................
j. Pergerakan janin
terakhir : ........................................................................................................................
8. Riwayat Kehamilan, Persalinan dan Nifas yang lalu :
Ham Penyulit/ Umu Jenis Jenis Penyu Penol BB Keadaa Nifa
il Ke r Kelami Persalin lit / ong lahir n Anak s
komplika
n Anak an kompl
si
ikasi

9. Riwayat
ginekologi : ........................................................................................................................
10. Riwayat KB :
Jenis Waktu Lama Keluhan Alasan
penggunaan penggunaan berhenti

11. Pola Pemenuhan Kebutuhan Sehari-hari :

Kebutuhan Selama bersalin Keluhan
Nutrisi :
 Makan
 Minum

Eliminasi :
  BAK
 BAB
Istirahat

Aktifitas

12. Data
Psikologis : ........................................................................................................................
13. pengeambilan keputusan dalam
keluarga : ........................................................................................................................
14. Data Sosial – Budaya :
a. Hewan
peliharaan : ....................................................................................................................
....
b. Lingkungan : ...........................................................................................................
.............
c. Hubungan dengan suami
dan/keluarga : .........................................................................
d. Adat
istiadat : ..................................................................................................................
15. Data
Spiritual : ......................................................................................................................
16. Pengetahuan Ibu tentang persalinan :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

II. PEMERIKSAAN
1. Pemeriksaan umum
a. Keadaan
Umum : ......................................................................................................
b. Kesadaran
: .......................................................................................................
c. Status
emosional : .....................................................................................................
d. Tanda vital
 1) Tensi : ....................mmHg
2) Nadi : ..................../ menit
3) RR : ..................../ menit
4) Suhu : ..................ºC
e. Lila : ................. cm
f. TB : ................. cm
g. BB saat hamil : ........ kg
h. BB sebelum hamil : ........ kg
i. Status present
1) Kepala
a) Rambut : ............................................................................................
....
b) Muka
: ..........................................................................................................
c) Mata :
conjungtiva......................................................................................
sklera..............................................................................................
d) Hidung : .................................................................................................
.......
e) Telinga: ..................................................................................................
.......
f) Mulut
: .........................................................................................................
2) Leher : ........................................................................................................
3) Dada : ........................................................................................................
4) Mammae : .....................................................................................................
5) Abdomen: .....................................................................................................
6) Genetalia : .....................................................................................................
7) Ekstremitas
- Atas : ...........................................................................................................
- Bawah: ............................................................................................................
2. Pemeriksaan Obstetri
a. Wajah/muka
: ....................................................................................................................
...
b. Mammae : ...........................................................................................
...........................
c. Abdomen : ............................................................................................
...........................
d. TBJ : ...........................................................................................
...........................
e. Auskultasi
DJJ : frekuensi ......................................x/menit
: irama.........................teratur/tidak
 f. Kontraksi uterus (His)
1) Lama : ............................................................................................
...............
2) Frekuensi : ............................................................................................
...............
3) Interval
: ...........................................................................................................
4) Sifat
: ...........................................................................................................
g. Reflek patella
: .....................................................................................................................
...
h. Periksa Dalam :
1) V/U/V
: ...........................................................................................................
2) Pembukaan : ............................................................................................
...............
3) Effecement
: ...........................................................................................................
4) KK
: ...........................................................................................................
 Penurunan
: ...........................................................................................................
 Presentasi
: ...........................................................................................................
 POD
: ............................................................................................................
3. Pemeriksaan Penunjang/ laboratorium
a. Pemeriksaan Laboratorium
1) Protein Urine : .................................................................................
2) Urine reduksi : .................................................................................
3) Hb : .................................................................................
4) USG : .................................................................................

b. Therapi
1) Selama hamil : .................................................................................
2) Selama bersalin : .................................................................................
 Asuhan Kebidanan Persalinan
Pada Ny. Y, Umur 35 Tahun, G3P2A0 Umur Kehamilan 40 Minggu dengan Partus Normal
Interprestasi data Diagnosa
Antisipasi/
Tanggal/Jam Pengkajian (diagnosis, masalah, Potensial/masalah Intervensi Implementasi Evaluasi
tindakan segera
kebutuhan) potensial
1 20 -12- 2018 DS: Diagnosis: Tidak Ada Tidak ada Jam: Jam:
Jam 09.30 -Ibu mengatakan Ny. Y umur 35 tahun 1. Lakukan 1. Melakukan 1. Ds: -
WIB mulas sejak 4 jam G3P2A0 hamil 40 pemeriksaan pemeriksaan fisik Do:
yang lalu, disertai mingggu janin 1 fisik meliputi KU dan KU: baik
keluarnya lendir hidup intra uterin, status present Kesadaran:CM
bercampur darah PuKa, Presentasi Status present dalam
-Ibu merasa nyeri di Kepala, inpartu kala I batas normal
punggung bawah Fase aktif normal.
-Ibu mengatakan
berumur 35 tahun, Masalah:
saat ini hamil Nyeri somatik daerah
ketiga, belum punggung
pernah keguguran Jam: Jam:
dan melahirkan 2 Kebutuhan: 2. Lakukan 2. Melakukan 2. Ds: -
anak hidup Informasi tentang pengawasan pengawasan 10: Do:
- Ibu mengatakan manajemen nyeri 10 KU, TD, N, P, S , His: 4x10’30”
HPHT 13 Maret PPV, his, DJJ, PPV: lendir darah
2018 Bandl ring, dan -Tidak ada bandlring
tanda gejala kala TD:120/80mmHg
DO: II N: 84x/menit: 36,50C
KU: baik RR: 20x/menit
Kesadaran: PPV: lendir darah
composmentis DJJ: 146x/menit
Status emosional: Tidak ada bandl ring
stabil Belum ada tanda gejala
HPL: 20-12-2018 kala II
TTV:
TD:120/80 mmHg
Nadi: 84×/menit
RR: 22 ×/menit
Suhu: 36,5◦C
BB sebelum hamil 56
kg
BB sekarang 65 kg