ASUHAN KEBIDANAN PADA IBU BERSALIN

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TANGGAL PENGKAJIAN :

JAM PENGAKJIAN :

Biodata Ibu Suami

Nama :................................ .......................................

Umur :................................ .......................................

Agama :................................ .......................................

Suku/Bangsa :................................ .......................................

Pendidikan :................................ .......................................

Pekerjaan :................................ .......................................

Alamat :................................ .......................................

DATA SUBJEKTIF

1. Alasan masuk kamar bersalin

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2. Keluhan utama
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3. Tanda-tanda persalinan
a. Kontraksi uterus sejak tanggal ................................................ jam...................................
Frekuensi : .............................. kali dalam 10 menit
Durasi : .............................. detik
Kekuatan : kuat/sedang/lemah
Lokasi ketidaknyamanan di ...............................................................................................
b. Pengeluaran pervaginam
Lendir darah : ya/tidak
Air ketuban : ya/tidak, banyaknya........................cc, warna ...................................
Darah : ya/tidak, banyaknya........................cc, warna ...................................
4. Riwayat sebelum masuk ruang bersalin
5. Riwayat kehamilan sekarang
HPHT : ...................................................... HPL : ..............................................................
Menarche umur ................ tahun, siklus ............... hari, teratur/tidak, lama ................ hari,
konsistensi: encer/beku, Bau :.................., fluor albus :ya/tidak, banyaknya .................cc,
ANC teratur/tidak, frekuensi ...................kali, di ...............................................................,
Keluhan/komplikasi selama kehamilan
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Riwayat merukok/minum minuman keras/minum jamu ....................................................
Imunisasi TT 1 : ya/tidak, tanggal ......................................................................................
Imunisasi TT 2 : ya/tidak, tanggal ......................................................................................
6. Pergerakan janin dalam 24 jam terakhir .............................................kali
7. Riwayat kehamilan, persalinan dan nifas yang lalu ( G...........P..........A.........H......... )

Persalinan Nifas

Ham Komplikasi
il ke Tahun Umur Jenis Lakt
Penolong JK BB Komplikasi
Lahir Kehamilan persalinan asi
Ibu Bayi

8. Riwayat kontrasepsi yang digunakan

Jenis Mulai Memakai Berhenti/Ganti Cara

No Kontraseps
Tahun Oleh Tempat Keluhan Tahun Oleh Tempat Alasan
i

9. Riwayat Kesehatan
a. Penyakit sistemik yang pernah/sedang diderita
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b. Penyakit sistemik yang pernah/sedang diderita keluarga
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c. Riwayat keturunan kembar
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10. Makan terakhir tanggal ................................, jam........................, jenis ............................
Minum terakhir tanggal ................................, jam........................, jenis ............................
11. Buan air besar terakhir tanggal ................................................., jam .................................
12. Buan air besar terakhir tanggal ................................................., jam .................................
13. Istirahat/tidur dalam 1 hari terakhir ........................................... jam
14. Keadaan psiko sosio spritual / kesiapan mengahadapi proses persalinan
a. Pengetahuan tentang tanda-tanda persalinan dan proses persalinan
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b. Persiapan persalinan yang telah dilakukan ( pendamping ibu, biaya, dll )
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c. Tanggapan ibu dan keluarga terhadap proses