YAYASAN HAJI SOEHEILY QARI

SEKOLAH TINGGI ILMU KESEHATAN (STIKES)

MERANGIN
PRODI D III KEBIDANAN
Jln.BangkoKerinci Km.6 Kungkai, Kecamatan Bangko Kabupaten Merangin
email.stikes.merangin@yahoo.com

MANAJEMEN KEBIDANAN PADA IBU HAMIL

Tempat praktek

:.............................

Nama Mahasiswa

:............................

Nomor MR

:.............................

No.Absen

:.............................

Keterampilan ke

:.............................

Masuk RS.H/Tgl/Jam :.............................

1. Pengkajian data
1. Identitas
Nama
Umur
Agama
Suku/Bangsa
Pendidikan
Pekerjaan

ISTRI
:.................................................
:..................................................
:..................................................
:..................................................
:..................................................
:..................................................

SUAMI
...................................................
...................................................
...................................................
...................................................
...................................................
...................................................

Alamat
:...................................................... .......................................................
2. Anamnesia (Data Subjektif)
a. Alasan Datang
:...........................................................................................
.................................................................................................................................
Keluhan Utama
:...........................................................................................
b.Riwayat Perkawinan
Kawin....kali,Kawin Pertama Kali Umur.....Tahun, Dengan suami sekarang
sudah .........tahun.
c. Riwayat Haid
Menarche Umur ....tahun, Cyclus..... hari, HPHT ....................... TP........................
Teratur/Tidak, Sakit/Tidak, Lamanya.... hari, Sifat Darah : Encer/Beku, Bau..........
Flour Albus...............
d.Riwayat Obstetri :
Proses
Usia
NO
Persalinan
Kehamilan
/Penolong

BAYI
BBL

JK

Hidup
/Mati

NIFAS
Penyulit
Pendarahan
Lain

Ket

e. Kontrasepsi Terakhir
Alat/Cara
:...........................................................................................
Mulai Pakai
:...........................................................................................
..........................................................................................................................
Berhenti
:...........................................................................................
..........................................................................................................................

 Alasan
:...........................................................................................
..........................................................................................................................
f. Riwayat Kesehatan Ibu
Penyakit yang diderita ibu
:..............................................................
Penyakit menular yang diderita ibu :..............................................................
.........................................................................................................................
Riwayat kesehatan keluarga
Penyakit yang menurun
:.............................................................................
Penyakit yang menular
:............................................................................
........................................................................................................................
Gangguan Mental
:............................................................................
Operasi
: ............................................................................
g. Riwayat Kehamilan Sekarang
1. Selama hamil ibu periksa di :...........................................................................
2. Mulai periksa UK
:...........................................................................
.........................................................................................................................
3. Frekuensi periksa
: TMT I
:.........Kali
TMT II
:.........Kali
TMT III
:.........Kali
Jumlah
:.........Kali
4.
5.
6.
7.

Kapan mulai merasakan pergerakan anak pertama kali :................................

Pergerakan fetus dalam 24 jam terakhir :.........................................................
Imunisasi T.T (tanggal)
:.l: .................................. ll: ..................................
Obat yang diminum
:.............................................................................
.........................................................................................................................
8. Jamu yang diminum
:..............................................................................
9. Keluhan/Masalah/Keadaan yang dirasakan IBU TMT Lalu :..........................
TMT
I
II
III

Keluhan/Keadaan

Tindakan

Oleh

Ket

h. Pola Kebutuhan Sehari-hari

1) Nutrisi
Porsi makan perhari
:.........................................................................
Frekuensi makan
:..........................................................................
...................................................................................................................
Jenis makanan
:..........................................................................
Makanan Pantangan
:..........................................................................
...................................................................................................................
Perubahan pola makan :..........................................................................
1. Nafsu makan
:..........................................................................

2. Ngidam
:...........................................................................
2) Eliminasi
a. BAK
Frekuensi
:...........................................................................
Warna
:...........................................................................
Keluhan
:...........................................................................
b. BAB
Frekuensi
:............................................................................
Sifat
:............................................................................
Warna
:............................................................................
Keluhan
:...........................................................................
3) Istirahat
a. Siang
:............................................................................
b. Malam
:............................................................................
c. Keluhan
:............................................................................
4) Aktifitas Sehari-hari
:.............................................................................
Keluhan
:............................................................................
5) Personal Hygiene
Kebiasaan membersihkan alat kelamin :................................................
Kebiasaan mengganti pakaian dalam
:................................................
Kebiasaan ibu mandi
:................................................
Jenis bahan pakaian yang dipakai
:.................................................
6) Aktifitas seksual
Frekuensi
:.................................................................................
Keluhan
:.................................................................................
.........................................................................................................................

i. Data Psikososial, Spiritual

Tanggapan ibu terhadap keadaan dirinya :....................................................
Tanggapan ibu terhadap kehamilan
:....................................................
Ketaatan ibu beribadah
:....................................................
Coping/pemecahan masalah dari ibu
:....................................................
j. Sumber informasi mengenai kehamilan
:...................................................
k. Lingkungan yang berpengaruh
1. Ibu tinggal dengan siapa
:...................................................
.........................................................................................................................
2. Hewan Piaraan : Dalam Rumah/Luar Rumah
Kucing
:.............................................................................
Kambing
:.............................................................................
Burung
:.............................................................................
Dan lain-lain, sebutkan :.............................................................................
...................................................................................................................
l. Hubungan sosial ibu dengan mertua, orang tua, anggota keluarga yang lain: ......
m. Penentu Pengambil Keputusan
:..................................................
...............................................................................................................................
Dalam Keluarga
:.................................................
.........................................................................................................................
Untuk Akses Transportasi
: ................................................
.........................................................................................................................
n. Jumlah Penghasilan Keluarga
:................................................

o. Yang menanggung biaya ANC dan Persalinan

: .................................................

3.Data Obyektif
a. Pemeriksaan Umum
Kesadaran
: .......................................................................................
TB
: .......................................................................................
.........................................................................................................................
BB sebelum hamil : .......................................................................................
BB sekarang
: ........................................................................................
LILA
: ........................................................................................
.........................................................................................................................
TD
: ........................................................................................
.........................................................................................................................
Suhu
: ........................................................................................
.........................................................................................................................
Nadi
:.........................................................................................
Pernafasan
: .........................................................................................
.........................................................................................................................

b. Pemeriksaan Khusus (Obstetri)

1. Insfeksi
Kepala
: ........................................................................................
.........................................................................................................................
Muka
: .........................................................................................
.........................................................................................................................
Mata
: .........................................................................................
.........................................................................................................................
Mulut/gigi
: .........................................................................................
.........................................................................................................................
Leher
: .........................................................................................
.........................................................................................................................
Mammae
:.........................................................................................
.........................................................................................................................
Perut
:..........................................................................................
.........................................................................................................................
Punggung/Pinggang : .........................................................................................
.........................................................................................................................
Vulva
: ..........................................................................................
.........................................................................................................................
Anus
:...........................................................................................
.........................................................................................................................
Kaki
: ..........................................................................................
.........................................................................................................................
2. Palpasi
Leopold I
:......................................................................................................
.........................................................................................................................
Leopold II
:.......................................................................................................
.........................................................................................................................
Leopold III :......................................................................................................
Leopold IV :......................................................................................................

Mc. Donald :.....................................................................................................

.........................................................................................................................
TBJ
:.....................................................................................................
.........................................................................................................................
3. Auskultasi : +/Frekuensi............Teratur/Tidak, Kekuatan : ..................................................
Punctum Maximum........................................................................................
4. Perkusi
Reflek Patella Ka/Ki
: ....................................................................................
.........................................................................................................................
5. Ukuran Panggul Luar
a. Distansia Spinarum
:.........................................................................
b. Distansia Cristarum
:........................................................................
c. Distansia Bondelague
:.........................................................................
d. Lingkar Panggul
:........................................................................
...................................................................................................................
Periksa dalam (kalau perlu)

:........................................................................

In Spekulo (kalau perlu)

: .......................................................................
...............................................................................................................................

4.Pemeriksaan Penunjang
Laboratorium
Urine
Protein
: ...............................................................................
...................................................................................................................
Gula
: ..............................................................................
...................................................................................................................
Gravidex Test
: ...............................................................................
...................................................................................................................
Darah
HB
: ...............................................................................
...................................................................................................................
Golongan Darah
: ...............................................................................