Post Partum

Complications

Postpartum Hemorrhage
Postpartum Infections
Postpartal psych disorders
POSTPARTUM HEMMORHAGE
 Adalah perdarahan lebih dari 500 cc yang terjadi
setelah anak lahir.
Primer : terjadi dlm waktu 24 jam pp.
Sekunder : after 24 jam pertama pp.

 Masalah di Indonesia
Sebagian besar persalinan terjadi tidak di rumah
sakit, sehingga sering pasien yang bersalin di luar
kemudian terjadi HPP terlambat datang di rumah
sakit, waktu tiba keadaan umum / hemodinamiknya
sudah memburuk. Akibatnya mortalitas tinggi.

KEMUNGKINAN PENYEBAB

1. Atonia uteri
2. Perlukaan jalan lahir
3. Pelepasan plasenta dari uterus
4. Tertinggalnya sebagian plasenta dalam uterus
(retensio, akreta, suksenturiata..)
5. Kelainan proses pembekuan darah akibat
hipofibrinogenemia
6. Iatrogenik - tindakan yang salah untuk
mempercepat kala III : penarikan tali pusat,
penekanan uterus ke arah bawah untuk
mengeluarkan plasenta dengan cepat, dll
Tanda dan Gejala Umum

 Perdarahan merah terang

 Kontraksi uterus lembek, tidak ada respon ketika
dilakukan massage
 Pengeluaran bekuan-bekuan darah abnormal
 Nyeri panggul dan punggung
 Perdarahan persistent dgn tidak kuat kontraksi uterus
 Fundal height lebih dari normal
 Hematoma di area perineal
 Perubahan karakteristik lokea lambat
 Penurunan tingkat kesadaran
 DIAGNOSIS
Prinsip :
 Bila seorang ibu bersalin mengalami perdarahan setelah anak
lahir, pertama-tama dipikirkan bahwa perdarahan tersebut
berasal dari retensio plasenta atau plasenta lahir tidak lengkap
 Bila plasenta telah lahir lengkap dan kontraksi uterus baik,
dapat dipastikan bahwa perdarahan tersebut berasal dari
perlukaan pada jalan lahir.

 HATI-HATI pada perdarahan lambat, sedikit-sedikit tapi terus-

menerus, dapat tidak terdeteksi / terdiagnosis.
Sehingga pada perawatan pascapersalinan perlu observasi
klinis dan laboratorium serial.
 Bedakan :
Perdarahan karena perlukaan jalan lahir, kontraksi uterus baik.
Perdarahan karena atonia uteri atau sisa plasenta, kontraksi
uterus kurang baik.
 SISTEMATIKA TINDAKAN PADA
Postpartum Hemorrhage
1. Segera sesudah bayi lahir, injeksi intramuskular ergometrin dan / atau
oksitosin untuk meningkatkan kontraksi uterus (dilakukan juga pada
persalinan normal biasa)
2. Jika terjadi perdarahan, sementara plasenta belum lahir (paling lama 30
menit sesudah bayi lahir), lakukan manuver aktif untuk mengeluarkan
plasenta (dianjurkan cara Brandt-Andrews atau manual)
Atonia Uterus

 The most causes 80% -90% (Cunningham, dkk. 2001)

 Faktor yang berkontribusi:
1. Overdistensi uterus (gemelli, makrosomia, polihidroamnion)
2. Dysfunctional/persalinan lama abnormalitas kontraksi
uterus
3. Pemberian pitosin pada induksi persalinan
4. High parity
5. Penggunaan anestesia dan obat-obatan utk relaksasi
uterus
6. Preeklamsia
7. Persalinan dgn pembedahan
8. Tertahannya sisa plasenta
9. Plasenta previa
Panatalaksaan Medis

 Massage uterus
 Pemberian cairan melalui infus
 Pemberian utero-tonika (im, iv, or infus)
 Observasi vital’s sign dan tanda syok
 Informasikan kondisi persalinan dan keadaan
saat itu
Nursing Assessment
 Prenatal history for putting client at high-risk for
postpartal hemorrhage
 Periodic assessment of fundal height and uterus
contraction
 Obs. Perdarahan pervaginam, visually by pad counts
with weighing the perineal pads

Nursing Diagnosis
 Fluid volume deficit : high risk for complications related
to postpartal hemorrhage
 Fatigue related to blood loss
 Fear related to acute hemorrhage
Nursing Implementation

 Kontrol kontraksi uterus tiap 10-15 menit dan

pengeluaran lokea
 Lakukan massage uterus, jika tetap tidak
berkontraksi, segera dilaporkan utk tindakan lebih
lanjut
 Monitor reaksi klien dgn pemberian utero-tonika
 Observasi tanda-tanda intoksikasi cairan
 Identifikasi faktor risiko
Postpartum Infections

Common Postpartum Infections

 Endometritis

 Wound site infection

 Urinary tract infection

 Thrombophlebitis

 Mastitis
Postpartal Infection:
 Reproductive system infection occurring
during the postpartal period.
 Bacterial invasion of birth canal; most
common = localized infection of the lining of
the uterus (endometritis).
 Etiology:
 Anaerobic nonhemolytic streptococci.
 E.coli.
 C.trachomatis (bacteroides).
 Staphylococci.
 Predisposing conditions.
 Assessment:
 Fever 38 C or more, after 1st 24 hrs pp.
 Other signs of infection: pain, malaise, dysuria,
subinvolution, flour lochial odor.
 Nursing Mgt:
 Prevent anemia (minimize bld loss; high protein, high
vitamin diet; vitamin suppliments).
 Prevent entrance / transport of microorganisms (strict
aseptic technique during labor, birth, and pp;
minimize vag exams in labor).
 Health teaching (hand washing, perineal care,
using clean pads – apply from front to back; avoid
use of tampons until normal menstrual cycle
resumes).
 Endometritis:
 Infection of the lining of the uterus.
 Etiology: most common = invasion by normal
body flora.
 Characteristics:
 Mild, localized: asymptomatic, or low-grade fever.
 Severe: resiko infeksi akan me parametritis,
pelvic abscess, pelvic thrombophlebitis.
 Jika infeksi terlokalisasi pd 1 tempat, akan
sembuh sendiri usually 10 days.
 Assessment:
 Signs of infection: fever, chills, malaise, anorexia, h/a,
backache.
 Uterus: large, extremely tender.
 Subinvolution
 Lochia: dark brown; foul odor.
 Nursing Mgt:
 Prevent cross-contamination (contact isolation).
 Facilitate drainage (position – semi-fowlers).
 Nutrition / hydration (high calorie, high protein, high
vitamin diet; push fluids; I&O).
 Increase uterine tone / facilitate involution (meds:
oxytocics, antibiotics).
 Minimize energy expenditure (bed rest).
 Emotional support.
 Urinary Tract Infections
 Normal physiological changes associated
with pregnancy & postpartal period, increase
susceptibility to bacterial invasion and
growth, and can lead to ascending infections
(cystitis, pylonephritis).
 Etiology: usually bacterial.
 Predisposing factors:
 Birth trauma to bladder, urethra, or meatus.
 Bladder hypotonia with retention (d/t intrapartal
anesthesia or trauma).
  Repeated or prolonged catheterization, or poor
technique.
 Weakening of immune response secondary to
anemia, hemorrhage.
 Assessment:
 Maternal VS (fever, tachycardia).
 Dysuria, frequency (flank pain – with
pyelonephritis).
 Feeling of “not emptying” bladder.
 Cloudy urine; frank pus.
 Nursing Mgt:
 Minimize perineal edema (ice pads).
 Prevent overdistention of bladder.
 Monitor level of fundus, lochia, bladder distention).
 Encourage fluids and voiding; I&O.
 Aseptic technique for catheterization.
 Slow emptying of bladder on catheterization – to
maintain tone.
 Identification of causative organism.
 Obtain clean-catch (or catheterized) specimen.
 Health teaching (fluids, general hygiene, diet,
and meds).
 Thrombophlebitis:
 Inflammation of a vein secondary to lodging of a
clot.
 Etiology:
 Extension of endometritis with involvement of pelvic and femoral
veins.
 Clot formation in pelvic veins
 Clot formation in femoral (or other) veins secondary to poor
circulation, compression, and venous stasis.
 Assessment:
 Pelvic – pain; abd or pelvic tenderness.
 Calf – pain; positive Homans’ sign.
 Femoral – pain; malaise, fever, chills, swelling “milk leg”.
 Nursing Mgt:
 Prevent clot formation.
 Encourage early ambulation

 Position – avoid prolonged compression of popliteal space, use

of knee gatch.
 Reduce threat of emboli.
 Bed rest, with cradle to support bedding.

 Discourage massaging “leg cramps”.

 Prevent infection.
 Administer antibiotics as ordered.
 Mastitis
 Inflammation of breast tissue.
 Local inflammatory response to bacterial invasion;
suppuration may occur; organism can be recovered
from breast milk.
 Etiology: most common
= staf aureus
 Assessment:
 Signs of infection (fever, chills, tachycardia,
malaise, abdominal pain).
 Breast:
 reddened area(s)
 localized / generalized swelling
 Heat, tenderness, palpable mass.
 Nursing Mgt:
 Prevent infection (health teaching: hand washing, breast care, clean
bra, alternate position of infant to change pressure areas).
 Comfort measures (bra or binder, local heat or ice packs to reduce
engorgement & pain, analgesics as needed).
 Emotional support.
 Promote healing (maintain lactation, antibiotics)
 PP Depression / Psychosis:
 General aspects:
 Usually occurs within 2 wks of birth.
 Increased incidence among single parents.
 Increased incidence among women with history of
clinical depression.
 Most common symptomatology: affective disorders.
 Psychiatric intervention required if prolonged or
severe; if underlying cause unresolved; increased
risk in subsequent pregnancies.

 Etiology: Theory – birth of a child may

emphasize unresolved role conflicts, unachieved
normal development tasks.
 Assessment:
 Withdrawal.
 Paranoid.
 Anorexia, sleep disturbance, mood swings.
 Depression – may alternate with manic behavior.
 Potential for self-injury or child abuse / neglect.
 Nursing Mgt: FCMC
 Emotional support.
 Safeguard status of mother and infant.
 Maintain nutrition / hydration.
 Minimize stress, facilitate effective coping.