FORMAT PENGKAJIAN INTRANATAL

A. Biodata
Nama : ..............................................................................................
Jenis Kelamin : ..............................................................................................
Umur : ..............................................................................................
Pekerjaan : ..............................................................................................
Agama : ..............................................................................................
Pendidikan Terakhir : ..............................................................................................
Alamat : ..............................................................................................
No. registrasi : ..............................................................................................
Tgl. MRS : ..............................................................................................
Tgl. pengkajian : ..............................................................................................
Diagnosa medis : ..............................................................................................

B. Riwayat Kesehatan Klien

1. Keluhan utama
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2. Riwayat penyakit dahulu
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3. Riwayat penyakit sekarang
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4. Riwayat penyakit keluarga
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C. Riwayat Kebidanan
1. Riwayat haid

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2. Riwayat perkawinan
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3. Riwayat penggunaan KB
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D. Riwayat Kehamilan / Persalinan dan Nifas yang lalu

a. Riwayat kehamilan yang lalu
Dengan Jenis keluhan pada
Anak Kehamilan berakhir
suami tribulan ke-
ke-
ke- I II III Aterm Premature Mati Hidup

b. Riwayat persalinan yang lalu

Nifas
Anak Cara Tanggal Jenis (Lamanya
Penolong BBL AS
ke- melahirkan lahir kelamin dan
masalah)

E. Pemeriksaan Persalinan
Kala I
a. Mulai pembukaan : Tanggal/ pukul : ..................................................................
b. Keluhan klien : ..........................................................................................
c. Pervaginam : ..........................................................................................
d. Leopold I, II, III, IV : .........................................................................................
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e. Observasi kemajuan persalinan

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 Denyut
Kontraksi Selaput
Tgl/pukul Pembukaan jantung Pervaginam
uterus ketuban
janin

Kala II
a. Mulai pembukaan (Tanggal/ pukul) : ................................................................
b. Lamanya kala II : ..................................................................................
c. Keadaan psikososial : ..................................................................................
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d. Jumlah perdarahan : ..................................................................................
e. Bayi lahir (Tanggal/ pukul) : ..............................................................................
f. Apgar Score : 1 menit .....................................................................
5 menit......................................................................
g. Perineum : ..................................................................................
h. Kontraksi uterus : ..................................................................................
i. TTV Ibu : ..................................................................................
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Kala III
a. Kala III mulai pukul : ..................................................................................
b. Cara kelahiran plasenta : ..................................................................................
c. Lamanya kala III : ..................................................................................
d. Kondisi plasenta dan tali pusat : .........................................................................
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e. Jumlah dan sifat perdarahan : .............................................................................
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f. Jumlah kotiledon : ..................................................................................
g. Panjang tali pusat : ..................................................................................
h. Kontraksi uterus : ..................................................................................
i. TTV Ibu : ..................................................................................
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Kala IV
a. TTV klien : ..................................................................................
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b. Kontraksi uterus : ..................................................................................
c. Kondisi kandung kemih : ..................................................................................
d. Jumlah dan sifat perdarahan : .............................................................................
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e. Tinggi fundus uteri : ..................................................................................

Data Bayi Baru Lahir

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 a. Berat badan : ..................................................................................

Perawat

NIM.

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