AKADEMI KEBIDANAN NYAI AHMAD DAHLAN YOGYAKARTA

SK MENKES RI No : HK.03.2.4.1.04569, SK MENDIKNAS RI No : 003/D/O/2008

ALAMAT : Jl. Wates Km.9,5 Plawonan Argomulyo Sedayu Bantul Yogyakarta 55753 TELP (0274) 6498250
e-mail : akbid_nad@yahoo.com

ASUHAN KEBIDANAN IBU BERSALIN FISIOLOGIS

PADA Ny ...... G ...... P ...... A ...... Ah ...... HAMIL ....... mgg ....... hr
DI RSIA SAKINA IDAMAN

Nama Mahasiswa : Sri Mulyani

NIM : 0613137
Ketrampilan ke : .................

S Tanggal : ................................. Jam : ............. WIB No RM : ................................

1. Identitas pasien dan penanggung jawab

Ibu
Nama : ........................................................
Umur : ........................................................
Agama : ........................................................
Pendidikan : ........................................................
Pekerjaan : ........................................................
Suku Bangsa : ........................................................
Alamat : ........................................................
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Suami
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2. Keluhan : ............................................................................................................................
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3. Riwayat Pernikahan
4. Pernikahan ke ......., lama ....... th

5. Haid
Menarche ........ th, siklus .......... hr, teratur/tidak, sakit/tidak, lama .......... hr, encer/beku
Flour albus .....................................................................................................................................
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HPHT ............................................................. HPL ...........................................................

6. Riwayat Obstetri
a. Riwayat kehamilan, persalinan, nifas yang lalu
No Tahun UK Jenis Penolong Tempat H/M JK BBL Komplikasi Ket.
persalinan
 b. Riwayat kehamilan sekarang
G ...... P ...... A ...... Ah ...... Hamil ....... mgg ....... hr, TM ......
TM Masalah/keluhan KIE Frek. Terapi
I
II
III

c. Status Imunisasi TT, TT I : .............................................................................

TT II : .............................................................................

d. Kapan merasakan janin pertama kali : ........................................................................

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e. Riwayat KB
 Kontrasepsi : .............................................................................
.............................................................................
 Alasan berhenti : .............................................................................
 Rencana yg akan digunakan : .............................................................................

7. Riwayat kesehatan
a. Riwayat kesehatan keluarga : ...............................................................................................
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b. Riwayat kesehatan yang lalu : ...............................................................................................
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c. Riwayat kesehatan sekarang : ...............................................................................................
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`
8. Pola kebutuhan sehari-hari
a. Pola nutrisi
makan minum
Porsi : ........................................................ ........................................................
Jenis : ........................................................ ........................................................
Frekuensi : ..................... x sehari ..................... x sehari
Masalah : ........................................................ ........................................................
Terakhir : pukul ......................................WIB pukul : ....................................WIB

b. Pola eliminasi
BAB BAK
Frekuensi : ..................... x sehari ..................... x sehari
Warna : ........................................................ ........................................................
Keluhan : ........................................................ ........................................................
Terakhir : pukul ......................................WIB pukul : ....................................WIB
c. Pola istirahat
Tidur siang ........... jam Tidur malam ........... jam
Keluhan : .................................................................................................................
 d. Pola aktivitas
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e. Pola hubungan seksual
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Keluhan : .................................................................................................................
f. Pola personal hygiene
Mandi ....... x/hr, ganti pakaian dalam ....... x/hr
Keramas ............ x/mgg, gosok gigi .......... x/hr

9. Riwayat persalinan sekarang

a. Kenceng-kenceng teratur, mulai tanggal ................................... jam ........................
b. Keluar lendir darah, mulai tanggal ................................... jam ........................
c. Keluar air ketuban, mulai tanggal ................................... jam ........................
d. Masuk kamar bersalin, mulai tanggal ................................... jam ........................

10. Psikososial spiritual

Tanggapan ibu dan keluarga tentang kehamilan
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Pengetahuan ibu dan keluarga tentang kehamilan
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Ketaatan beribadah ...........................................................................................................
Pengambilan keputusan ....................................................................................................
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Ibu tinggal bersama ..........................................................................................................
Hewan peliharaan .............................................................................................................
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Rencana persalinan ...........................................................................................................
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O Tanggal : ................................. Jam : ............... WIB

1. Pemeriksaan umum
KU : ............................
Kesadaran : ............................
TD : ............................ mm/Hg
N : ............................ x/menit
S : ............................ ͦ C
RR : ............................ x/menit
BB sebelum hamil : ............................ Kg
BB sekarang : ............................. Kg
TB : ............................. cm
LILA : ............................. cm
2. Pemeriksaan Fisik
a. Kepala : ..............................................................................................................
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b. Mata : ..............................................................................................................
c. Telinga : ..............................................................................................................
d. Hidung : ..............................................................................................................
e. Mulut dan gigi : ..............................................................................................................
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f. Leher : ..............................................................................................................
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g. Aksila : ..............................................................................................................
h. Dada : ..............................................................................................................
i. Abdomen : ..............................................................................................................
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j. Pinggang : ..............................................................................................................
k. Punggung : ..............................................................................................................
l. Genetalia : ..............................................................................................................
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m. Ekstremitas atas : ..............................................................................................................
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n. Ekstremitas bawah : ..............................................................................................................
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Perkusi : Reflek patella kanan/kiri : ...... / ......

3. Status Obstetri
a. Inspeksi : ..............................................................................................................
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b. Palpasi
Leopold I : ..............................................................................................................
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Leopold II : ..............................................................................................................
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Leopold III : ..............................................................................................................
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Leopold IV : ..............................................................................................................
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Mc Donald : TFU ............. cm
TBJ : .......................................... gram
HIS : ...................... x dalam 10 menit,durasi ............ detik
lemah/sedang/kuat
c. Auskultasi DJJ
Punctum maksimum : .....................................................................................................
Irama : teratur/tidak teratur
Frekuensi : .................. x/menit
d. Pemeriksaan dalam
Hasil : ..............................................................................................................
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 4. Data Penunjang
a. Hb : .........................................................
b. Urine rutin
Protein : .........................................................
Reduksi : .........................................................
c. USG : ..............................................................................................................
d. Pemeriksaan pelvimeter/panggul

A Tanggal : ................................. Jam : ............... WIB

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P Tanggal : ................................. Jam : ............... WIB

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Ketrampilan ke ......
CATATAN PERKEMBANGAN
ASUHAN KEBIDANAN IBU BERSALIN NORMAL
KALA I
PADA Ny ...... G ...... P ...... A ...... Ah ...... HAMIL ....... mgg ....... hr
No. RM : ........................................

Tanggal : ................................. Jam : ............... WIB

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Tanggal : ................................. Jam : ............... WIB

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Ketrampilan ke ......

ASUHAN KEBIDANAN IBU BERSALIN NORMAL

KALA II
PADA Ny ...... G ...... P ...... A ...... Ah ...... HAMIL ....... mgg ....... hr
No. RM : ........................................

Tanggal : ................................. Jam : ............... WIB

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Tanggal : ................................. Jam : ............... WIB

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Yogyakarta, .....................................................

Pembimbing Akademik Pembimbing Lahan Mahasiswa

( Diah Hapsari Putri S.Si.T ) ( Rodiah S.ST ) ( Sri Muslimatun )

Ketrampilan ke ......

ASUHAN KEBIDANAN IBU BERSALIN NORMAL

KALA III
PADA Ny ...... G ...... P ...... A ...... Ah ...... HAMIL ....... mgg ....... hr
No. RM : ........................................

Tanggal : ................................. Jam : ............... WIB

S
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Tanggal : ................................. Jam : ............... WIB

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Yogyakarta, .....................................................

Pembimbing Akademik Pembimbing Lahan Mahasiswa

( Diah Hapsari Putri S.Si.T ) ( Rodiah S.ST ) ( Sri Muslimatun )

Ketrampilan ke ......

ASUHAN KEBIDANAN IBU BERSALIN NORMAL

KALA IV
PADA Ny ...... G ...... P ...... A ...... Ah ...... HAMIL ....... mgg ....... hr
No. RM : ........................................

Tanggal : ................................. Jam : ............... WIB

S
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Tanggal : ................................. Jam : ............... WIB

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JAM TD NADI TEMP TFU KONTRAKSI KANDUNG PER

KE WAKTU (mm/Hg) ( x/mnt) KEMIH DARAHAN

Yogyakarta, .....................................................

Pembimbing Akademik Pembimbing Lahan Mahasiswa

( Diah Hapsari Putri S.Si.T ) ( Rodiah S.ST ) ( Sri Muslimatun )