YAYASAN AMAL HUSADA KALIMANTAN TIMUR

AKADEMI KEBIDANAN
PERMATA HUSADA SAMARINDA
SK Mendiknas RI No.:2436/D/T/K-XI/2010 Rekomendasi Depkes RI No.: HK.03.2.4.1.01.832
Alamat : Jl. A. Yani (Cendrawasih) Gg. Masyarakat No. 2 Telp/ Fax. 0541 – 7770380 Samarinda
Website: http//www.akbidpermatahusada.ac.id Email: akbid_permata@yahoo.com

ASUHAN KEBIDANAN PADA PERSALINAN

Nama mahasiswa :
NIM :
Semester :

Tanggal masuk RS/PMB/Klinik/PKM :

Jam :
Tanggal pengkajian :
Jam :

I. PENGKAJIAN
A. Data Subyektif
1. Identitas
Nama Klien : Nama Suami :
Umur : Umur :
Bangsa/Suku : Bangsa/Suku :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Penghasilan : Penghasilan :
Alamat : Alamat :

2. Alasan kunjungan saat ini :

3. Keluhan utama :

4. Tanda-tanda persalinan :
a. Kontraksi :

b. Sejak tanggal :

c. Frekuensi :

d. Lamanya :

e. Kekuatan :

f. Lokasi ketidaknyamanan :

g. Pengeluaran pervaginam :

Lender /darah, cairan ketuban (jumlah, warna)

5. Riwayat obstetric :
a. Riwayat haid
HPHT :
Menarche :
Lama haid :
Dismenorhoe :
Siklus :
Flour Albus :
Jumlah :
b. Riwayat perkawinan
Umur waktu nikah :
Lama :
Perkawinan ke :
Jumlah anak :
c. Riwayat kehamilan sekarang
1) Ibu hamil ke :
2) Usia Kehamilan : minggu
3) Hasil test Kehamilan tanggal :
4) Imunisasi TT tanggal :
5) Pergerakan Fetus yang dirasakan pertama kali:
6) Pergerakan fetus pada 24 jam terakhir:
7) ANC
Uraian TM I TM II TM III

Teratur /tidak

Banyaknya

Keluhan

Terapi

Penyuluhan

d. Riwayat Kehamilan,Persalinan dan Nifas yang lalu

No Tgl/thn Tempat Jenis Penyulit Persalinan Bayi Nifas
Pers Persalinan/ Persali
Ibu Bayi BB/PB/ Keadaan KB/ Laktasi
penolong nan
Seks keadaan

6. Riwayat KB

No Jenis Alkon Lama Pakai Keluhan Tahun lepas Alasan

7. Riwayat kesehatan :
a. Riwayat kesehatan sekarang :
b. Riwayat Kesehatan Yang Lalu
Ibu pernah menderita sakit : Sakit apa :
Ibu pernah operasi : operasi apa :

c. Riwayat Kesehatan Keluarga

Adakah faktor penyakit keluarga :
Adakah faktor keturunan kembar :

d. Perilaku Kesehatan
Merokok :
Minum Alkohol :
Minum obat :
Minum jamu :
Hewan peliharaan :
 8. Pola Pemenuhan Kebutuhan sehari-hari
Kebutuhan Selama hamil Selama persalinan Keluhan
Nutrisi :
a. Makan
b. Minum
Eleminasi :
a. BAK
b. BAB
Istirahat /
tidur
Personal
hygiene

Aktifitas

9. Keadaan psikososial budaya

Apakah kehamilan ini diinginkan :
Apakah jenis kelamin yang diinginkan :
Pengantar klien :
Hewan peliharaan :
10. Data spiritual :
11. Pengetahuan ibu tentang persalinan :

B. Data Obyektif
1. Pemeriksaan umum
a. Keadaan umum :
b. Kesadaran :
c. Keadaan emosional :
d. Tanda vital
1) BB sebelum hamil : Kg
2) BB saat ini : Kg
3) TB : Cm
4) Tekanan Darah : mmHg
5) Nadi : x/mnt
6) Suhu : C
7) Resp : x/mnt
8) Lingkar lengan atas : cm

e. Status head to too

1) Kepala :
 2) Rambut :

3) Muka :

4) Mata :

5) Hidung :

6) Telinga :

7) Mulut :

8) Leher :

9) Dada :

10) Mammae :

11) Perut :

12) Anogenatal :

13) Ekstriminitas :

a) Atas :

b) Bawah :

2. Pemeriksaan obstetri
a. Palpasi
1) Leopold I :

2) Leopold II :

3) Leopold III :

4) Leopold IV :

Mc. Donald :

TBJ :

b. Auskultasi
 1) DJJ :
2) Frekuensi :
3) Irama :
4) Teratur /tidak :
5) Interval :
c. Kontraksi uterus (His)
1) Lama :
2) Frekuensi :
3) Interval :
4) Sifat :
d. Perkusi: reflek patella :
e. Periksa dalam :
Atas indikasi : pukul :
1) Pembukaan :
2) Effacement :
3) Ketuban :
4) Penurunan :
5) Presentasi :
3. Pemeriksaan penunjang
a. Produksi urine :
b. Urin reduksi :
c. Hb :
d. Golongan darah :
e. HbSAg :

II. INTERPRETASI DATA DASAR

Tanggal / jam Diagnosa/Masalah/Kebutuhan Data Dasar
Diagnosa: Data Subyektif :

Data objectif :

Masalah : Data Subyektif :

 Data objectif :

Kebutuhan :

III. IDENTIFIKASI MASALAH / DIAGNOSA POTENSIAL

Tanggal / Jam Masalah / Diagnosa Potensial

IV. IDENTIFIKASI KEBUTUHAN TINDAKAN SEGERA

Tanggal / Jam Kebutuhan / Tindakan Segera

V. PERENCANAAN TINDAKAN /INTERVENSI

Tanggal /Jam Intervensi diagnose Rasional

VI. IMPLEMENTASI
Tanggal /Jam Implementasi diagnose
VII. EVALUASI
EVALUASI
Tanggal/Jam :
Subyektif
Obyektif

Assesment

Perencanaan

Tanggal / KALA I
Jam
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LANGKAH PERTOLONGAN PERSALINAN

Tanggal / KALA II
Jam

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Tanggal / KALA III
Jam

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Tanggal / KALA IV
Jam

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