MANAJEMEN KEBIDANAN
PADA IBU HAMIL (INC)
Tgl masuk : Pukul :
Ruangan : No. MR :
I. PENGUMPULAN DATA
A. DATA SUBJEKTIF
1. Identitas / Biodata pasien
Nama Ibu : ..Ny............................. Nama Suami : ..Tn..........................
Umur : .................................... Umur : ................................
Kebangsaan : .................................... Kebangsaan : ................................
Agama : .................................... Agama : ................................
Pendidikan : .................................... Pendidikan : ................................
Pekerjaan : .................................... Pekerjaan : ................................
Alamat kantor : .................................... alamat kantor : ................................
Alamat rumah : .................................... Alamat rumah : ................................
Telepon : .................................... Telepon : ................................
2. Alasan masuk : ..........................................................................
3. Keluhan Utama
Nyeri pinggang menjalar keari-ari : ..........................................................................
Keluar lendir bercampur darah : ..........................................................................
Keluar air-air yang banyak : ..........................................................................
4. Riwayat Menstrasi
Menarche : umur ....... tahun
Siklus : ..........hari
Lama : ..........hari
Dismenorhoe : ................
HPHT : ...................
TP : ...................
5. Riwayat kehamilan ini
Ø Riwayat hamil muda : .............................................
Ø Riwayat hamil tua : .............................................
Ø ANC ke : .............................................
6. Riwayat Penyakit Dahulu : ..........................................................................................
7. Riwayat Penyakit Keluarga : ..........................................................................................
8. Riwayat Perkawinan : ..........................................................................................
Ø Kawin umur : ..........tahun
Ø Lama kawin baru hamil : ...................
9. Riwayat Kehamilan, persalinan dan nifas yang lalu :
G P A H
| No. | Tahun | Tempat | Umur | Jenis | Penolong | BB/PB | Penyulit | Keadaan |
| | Partus | partus | hamil | persalinan | | | | Anak skarang |
| | | | | | | | | |
10. Riwayat Keluarga Berencana : .......................................
11. Makan Terakhir : .......................................
12. BAB terakhir : .......................................
13. BAK terakhir : .......................................
B. DATA OBJEKTIF
Pemeriksaan fisik ( umum dan kebidanan )
1. Data Umum
ü BB : .......................................
ü TB : .......................................
ü LiLA : .......................................
ü KU : .......................................
TTV : - TD : ..............mmHg - N : ........x/menit
- S : ..............⁰C - R : ........x/menit
ü Muka
- Kelopak mata : ......................................
- Konjungtiva : ......................................
- Sclera : ......................................
ü Leher : ......................................
ü Dada
- Simetris : .......................................
- Puting susu : .......................................
- Benjolan/tumor : .......................................
2. Data Kebidanan ( Obstetrik )
1) Inspeksi
a. Tanda-tanda kehamilan
- Cloasma gravidarum : .............................................
- Areola Mammae : .............................................
- Colostrum : .............................................
b. Pembesaran perut : .............................................
c. Bekas luka operasi : .............................................
2) Palpasi
· Leopold I : ...............................................................................
...............................................................................
· Leopold II : ...............................................................................
...............................................................................
...............................................................................
· Leopodd III : ...............................................................................
...............................................................................
...............................................................................
· Leopold IV : ...............................................................................
d. TFU : .........cm
e. TBBJ : .........gram
f. His
- Frekuensi : ....................
- Durasi : ....................
- Interval : ....................
g. Perlimaan : ....................
h. Auskultasi
- Frekuensi : ....................
- Irama : ....................
- Kekuatan : ....................
- Puntum maximum : ....................
3. Anogetalia
Inspeksi : .............................................................................
Pemeriksaan dalam
Indikasi :
- Pembukaan : .............................................................................
- Porsio : .............................................................................
- Ketuban : .............................................................................
- Presentasi : .............................................................................
- Posisi : .............................................................................
- Penurunan : .............................................................................
- Moulase : .............................................................................
- Bagian terkemuka : .............................................................................
ü Ukuran Panggul Dalam
- Promontorium : .............................................................................
- Linea Innominata : .............................................................................
- Os Sakrum : .............................................................................
- Dinding sampig panggul : .............................................................................
- Spina Ischiadica : .............................................................................
- Os cocygeus : .............................................................................
- Arcus Pubis : .............................................................................
ü Ukuran Panggul Luar : Distansia Inter Tuberum
Kesan : .................................................................................................
4. Ekstremitas
- Oedema : .................
- Varices : .................
- Reflek patella : .................
PEMERIKSAAN PENUNJANG
- Hb : .............. gram %
- Protein urine : ..............
- Gukosa urine : .............
..........................,20......
Klien Mahasiswa
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