ASUHAN KEBIDANAN PADA PERSALINAN DAN BAYI BARU LAHIR

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

Jam MKB : .... Jam Pengkajian : ...

A. SUBJEKTIF
1. Biodata
IBU SUAMI/WALI
Nama : ..... Nama : .....
Umur : ..... Umur : .....
Agama : ..... Agama : .....
Suku/bangsa : ..... Suku : .....
Pendidikan : ..... Pendidikan : .....
Pekerjaan : ..... Pekerjaan : .....
Alamat : ..... Alamat/Hp. : .....
2. Alasan masuk kamar bersalin (MKB)
...............................................................................................................................................
3. Riwayat menstruasi
Siklus : .............................................
HPHT :.............................................
TP : .............................................
4. Riwayat obstetrik yang lalu
Komplikasi Anak
Bayi Nifas
Jenis Persalinan

Persalinan Hidup/
Kehamilan

UK
persalinan

Penolong
Penyulit

Tempat

Hamil PB/ Mati/

(mgg)
Keadaan

Penyulit

Laktasi
ke-
IMD
Bayi

Ibu

TB Usia

5. Riwayat kehamilan sekarang

Kunjungan ANC : Ya/Tidak
Tempat ANC : ............................................................................
Tanda-tanda bahaya
kehamilan : ..................................................................................................................................
 ...................
6. Riwayat persalinan sekarang Tanda-tanda persalinan:
Kontraksi/His
a) Kontraksi sejak tanggal : .........................................
Pukul : .........................................
b) Frekuensi & durasi his : .........................................
c) Keluhan : .........................................
Pengeluaran pervaginam
a) Darah lendir : ada/tidak darahsegar/darah campur lendir
b) Air ketuban : ada/tidak warna:.........
Tgl/jam pecah: ………..…..
c) Lain-lain : ada/tidak, sebutkan: ………………………....................
7. Riwayat kesehatan ibu sekarang dan lalu yamg dapat mempengaruhi
kehamilan dan persalinan (termasuk status HIV dan HBsAg):
.....................................................................................................................
8. Riwayat sosial ekonomi dan psikologi
- Status perkawinan : ............... Ya/Tidak, Kawin :........... kali
- Perasaan ibu dan keluarga terhadap kehamilan : ...........
- Pengambil keputusan dalam keluarga : ...........
- Tempat yang diinginkan untuk membantu persalinan : .............
- Petugas yang diinginkan untuk membantu persalinan : .............
- Tempat rujukan jika terjadi komplikasi: ...........................................
- Pendanaan persalinan : ..............
- Orang yang diinginkan untuk mendampingi persalinan : ..............
- Budaya yang akan dilakukan saat persalinan :…………
9. Pemenuhan kebutuhan sehari-hari
- Makan dan minum terakhir
Tgl/Jam : ......................................................
Jenis &porsi : .............................................................
- Istirahat terakhir
Tgl/Jam : ................................................................
Lama : .............................................................
- Eliminasi terakhir
BAK Tgl/Jam : ............
BAB Tgl/Jam : ............

B. OBJEKTIF
1. Keadaan umum : .........................................................................
- Cardinal Sign
- Tekanan darah :..............mmHg
- Nadi :..............kali/menit
- Suhu :.............0C
- Respirasi :.............kali/menit
- Pemeriksaan fisik Inspeksi
a) Muka
Konjungtiva :............ Sklera: ....................
Oedema : ............
b) Leher
Pembesaran kelenjar tiroid : ........................................
 c) Payudara
Keadaan papilla mammae: ...................................
d) Abdomen
Bekas luka operasi : ................ Jenis operasi: ………
e) Genetalia eksterna
Pengeluaran pervaginam :..................................................
Jenis :…..............................................
Varises : ..................................................
Oedema : ..................................................
Pembesaran kelenjar bartolini/skene : ......................................
Haemoroid : ..................................................
f) Tangan dan kaki
Oedema : ..........................................................................
Varises : .....................................................................................
- Palpasi
a) Payudara (kolostrum) : .................................
b) Abdomen
TFU :....................cm
Leopold I : .....................................................................................................
Leopold II : .....................................................................................................
Leopold III : .....................................................................................................
Leopold IV : .....................................................................................................
c) His : ..... kali/10 menit, lama................detik
d) Perlimaan WHO : ................................................................................................
e) Auskultasi : DJJ : ........................................................... x/mnt, reguler / irreguler
2. Pemeriksaan Dalam/Vaginal Toucher (VT)
Indikasi : ......................... Pukul : ............
Vulva/Vagina : ..........................................................................................
Porsio : ..........................................................................................
Serviks : ..........................................................................................
Selaput amnion dan ketuban :...........................................................................................
Denominator : ..........................................................................................
Penurunan bagian terendah : Hodge ..........

3. Data Penunjang (bila diperlukan)

Tanggal : ..................... Jenis pemeriksaan : ...............
Hasil :.......................................
- Laboratorium lengkap.
- CTG : janin................reaktif/tidak
- USG : ...........................................
- Foto thorak : ............................................
- EKG : ............................................

4. Penapisan ibu bersalin

Ya Tdk

1. Riwayat bedah sesar

2. Perdarahan pervaginam
 3. Riwayat bedah sesar
4. Perdarahan pervaginam
5. Persalinan kurang bulan ( < 37 minggu )
6. Ketuban pecah dengan mekonium kental
7. Ketuban pecah lama (>24 jam)
8. Ketuban pecah saat persalinan kurang bulan (<27 minggu)
9. Ikhterus
10. Anemia berat
11. Tanda/gejala infeksi
12. Pre eklamsi / hypertensi dalam kehamilan
13. TFU 40 cm atau lebih
14. Gawat janin
15. Primi para fase aktif dengan palpasi kepala janin masih 5/5
16. Presentasi bukan belakang kepala
17. Presentasi Ganda
18. Kehamilan Gemeli
19. Tali pusat menumbung
20. Syok

C. ASSESSMENT:
Diagnosa Kebidanan:
...........................................................................................................................................
...........................................................................................................................................

D. PENATALAKSANAAN:
KALA I Fase Laten
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 LEMBAR OBSERVASI

JAM/
S/N/T HIS DJJ KET
TANGGAL
KALA I Fase Aktif
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KALA II
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KALA III
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KALA IV
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PEMERIKSAAN BAYI BARU LAHIR
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Mahasiswa

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NIM.

Pembimbing Akademik Pembimbing Praktik

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NIP. NIP.