Nama Ibu: ............................................................. Umur : .................. Alamat : ................................................................
Datang Tanggal : .................................................... Jam : ..................... G:................ P:.................. A:.................
Kontraksi Keadaan Ibu Penurunan
Tgl Jam DJJ Serviks Molase Uterus Suhu TD Nadi Vol. Urin Kepala Catatan : ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ......