1. Apa yang menyebabkan pasien masih mengeluh keluar darah dari kemualuannya?

2. Apa yang menyebabkan payudara kanannya terasa bengkak?

3. Apakah aman payudara yang membengkak dipakai untuk menyusui?/berpengaruh
atau tidak?
4. Penyebab putting payudara masuk
5. Bagaimana edukasi dokter terhadap pasien tersebut?
6. Apa saja obat yang harus dikonsumsi pasien?
7. Apa aja makanan yang dibutuhkan pada ibu menyusui?
8. Mengapa terjadi anemis pada mata?

Masa nifas

 Pengertian periode nifas

a. Periode immediate postpartum
Masa segera setelah plasenta lahir sampai dengan 24 jam. Pada masa ini sering
terdapat banyak masalah, misalnya pendarahan karena atonia uteri, oleh karena itu,
bidan dengan teratur harus melakukan pemeriksaan kontraksi uterus, pengeluaran
lokhea, tekanan darah, dan suhu.
b. Periode early postpartum (24 jam-1 minggu)
Pada fase ini bidan memastikan involusi uteri dalam keadaan normal, tidak ada
perdarahan, lokhea tidak berbau busuk, tidak demam, ibu cukup mendapatkan
makanan dan cairan, serta ibu dapat menyusui dengan baik. Selain itu, pada fase ini
ibu sudah memiliki keinginan untuk merawat dirinya dan diperbolehkan berdiri dan
 berjalan untuk melakukan perawatan diri karena hal tersebut akan bermanfaat pada
semua sistem tubuh.
c. Periode late postpartum (1 minggu- 5 minggu)
Pada periode ini bidan tetap melakukan perawatan dan pemeriksaan sehari-hari serta
konseling KB.

 Perubahan fisiologi
 Macam atau jenis lochia

 Perawatan postpartum dan mammae

 Kebutuhan gizi
 Penggunaan ASI
 Inisiasi Menyusu Dini
 Let down reflex
 Manajemen laktasi

Mastitis

 Mastitis is inflammation of the breast tissue and can be broken down into :
o Lactational : the most common form of mastitis.
 Lactational mastitis, also known as puerperal mastitis, is typically due to
prolonged engorgement of milk ducts, with infectious components from the
entry of bacteria through skin breaks. Patients can develop a focal area of
erythema, pain, and swelling, and can have associated systemic
symptoms, including fever. This occurs most commonly in the first six weeks
of breastfeeding but can occur at any time during lactation, with most cases
falling off after 3 months
 Worldwide, lactational mastitis occurs in 2%-30% of breastfeeding women.
o non-lactational mastitis.
 periductal mastitis
 Periductal mastitis is a benign inflammatory condition affecting the
subareolar ducts and occurs most commonly in reproductive-aged
women
 idiopathic granulomatous mastitis (IGM).
 Idiopathic granulomatous mastitis is a rare and benign inflammatory
condition that can clinically mimic breast cancer

Lactation mastitis

 Etiologi :
o Lactational mastitis is most commonly caused by bacteria that colonize the skin:
 Staphylococcus aureus being the most common.
  Terdapat pada 40% wanita mastitis
 Bisa menyebabkan toxic shock syndrome
 Biasanya menyebabkan abses
 Methicillin-resistant S. aureus (MRSA) has become an increasingly common
cause of mastitis, and risk factors for MRSA should be considered.
 Other causative organisms include Streptococcus pyogenes, Escherichia
coli, Bacteroides species, and Coagulase-negative staphylococci.
 Viridans streptococci
 Bakteri masuk ke payudara melalui putting pada fisura atau lesi kecil.

 Faktor Risiko :
o prior history of mastitis
o nipple cracks and fissures
o inadequate milk drainage
o maternal stress
o lack of sleep
o tight-fitting bras
o use of antifungal nipple creams

 Patofisiologi :
o Lactational mastitis occurs due to a combination of inadequate drainage of milk, and the
introduction of bacteria. Common scenarios leading to poor milk drainage include
infrequent feeding, an oversupply of milk, rapid weaning, illness in mother or child, and
a clogged duct. The inadequately drained milk stagnates, and organisms grow, leading
to infection. It is thought that bacteria (usually from the infant’s mouth, or mother’s
skin) gain entry to the milk via cracks in the nipple.
o Terdapat beberapa cara masuknya kuman yaitu melalui duktus laktiferus ke lobus
sekresi, melalui puting yang retak ke kelenjar limfe sekitar duktus (periduktal) atau
melalui penyebaran hematogen (pembuluh darah).
 Gejala :
o panas dingin, kaku, diikuti demam dan takikardi. Nyeri, merah. 10% wanita mengalami
abscess.
o Gejala supuratif mastitis jarang terjadi di minggu perttama postpartum. Biasanya pada
minggu ke 3-4 postpartum
 Terapi :
o Terapi dimulai sebelum mulai suppurasi. biasanya Infeksi selesai dalam waktu 48 jam.
o Dicloxacillin 500 mg, oral, 4x sehari
o Eritromisin (bagi yang sensitive penisilin),
o Vancomycin atau anti MRSA anti microba (jika bakteri resisten atau jika disebabkan
staphylococcus yang menghasilkan penicillinase)
o Bayi biasanya tidak disusui dari payudara yang inflamasi, karena areola yang
membengkak bikin sulit. Dalam hal ini, pompa menjadi solusi
o

o Patients should be encouraged to continue to breastfeed, pump, or hand express. If the

patient stops draining the milk, further stasis occurs, and the infection will progress.
o Non-steroidal anti-inflammatory drugs (NSAIDs) can be used for pain control.
o Heat applied to the breast just before emptying can help increase milk letdown and
facilitate with emptying.[25]Cold packs applied to the breast after emptying can help
reduce edema and pain.
o If the symptoms of lactational mastitis persist beyond 12 to 24 hours, antibiotics should
be administered. Because S. aureus is the most common cause, antibiotic therapy
should be tailored accordingly.
o In the setting of mild infection without MRSA risk factors, outpatient treatment can be
initiated with dicloxacillin or cephalexin.
o If the patient has a penicillin allergy, erythromycin can be used.
 o If the patient has risk factors for MRSA infection, treatment options include
trimethoprim-sulfamethoxazole (TMP-SMX) or clindamycin.
 TMP-SMX should be avoided in women who are breastfeeding infants less
than 1-month-old, and in infants who are jaundiced or premature. If a patient
requires hospitalization, empiric treatment with vancomycin should be
initiated until cultures and sensitivities return. There are not sufficient studies
on the appropriate duration of outpatient treatment, but most sources
recommend a 10-14 day course.
Kelainan putting susu (cracked nipple dan Inverted nipple)

Inverted Nipple :

 Nipple inversion is a common pathologic condition affecting 2%–10% of women. Congenital

inversions are the most common forms
 This frequent pathologic condition can be
o congenital or acquired
 congenital paling sering. they depend on hypoplasia and the retraction of the
lactiferous ducts produced by the presence of surrounding fibrous bands at the
base of the nipple
 Acquired inversions can be secondary to mammary carcinoma, periductal
mastitis, breast surgery, or breastfeeding.
o unilateral or bilateral

 Klasifikasi :
The universally accepted classification of inverted nipple was proposed by Han and Hong, 6 and they
classified the inversion into 3 grades:

 - Grade I: the nipple can be easily pulled out by gentle palpation around the areola and
maintains its projection quite well without any traction. Lactiferous ducts are normal.

 - Grade II: the nipple is also pulled out by palpation but not as easily as in grade I and
tends to retract. The nipple has medium fibrosis, and the lactiferous ducts are mildly
retracted but do not need to be cut to release the fibrosis. Also, there are histologically
rich collagenous stromata with several bundles of smooth muscle.

 - Grade III: severe form in which inversion and retraction are important. Pulling the
nipple out manually is really difficult, and a traction suture is needed to keep it
protruded. Fibrosis beneath the nipple is severe and the soft tissue is insufficient.
Histologically, the terminal lactiferous ducts and lobular units are atrophic and replaced
with severe fibrosis.
Another classification proposed by Schwager et al7 divides inverted nipples into 2 forms depending on the
severity of the inversion:
o “umbilicated” form (intermittently inverted)
o “invaginated” form (permanently inverted).

Inverted nipple can induce psychological problems such as severe psychosexual discomfort.8,9 Moreover,
this condition can cause cosmetic and functional problems that prevent adequate breast feeding and can
create local irritation and infection.
Generally, the nipple and areola can present in different size, color, and shape. The average height and
diameter of the nipple are both about 1 cm, and the average diameter of the areola is about 3 cm. 10 Five
normal shapes of nipples were identified: rectangular, omega, round, cup, and slanting.11
Since 1879, when Kehrer described the first surgical correction of nipple inversion, many surgical and
nonsurgical corrective strategies have been proposed. Indeed, there is not a single technique adapted to all
types of inverted nipples because of the heterogeneity of the clinical presentation. Ideally, the aim of
every treatment should be to permanently recover normal projection and shape; to maintain a normal
sensitivity; and finally to preserve the lactiferous ducts causing minimal scars. Nonoperative strategies,
including manual traction, piercing, and vacuum therapy, can be used only in grade I inversion. The aim
of this article was to provide a comprehensive review of the literature about surgical treatment of inverted
nipples.
Infeksi pada vulva, vagina, serviks, endometrium, dan rongga pelvis