ASKEP HEMORROID POST PARTUM (HPP)

CHAPTER 2

STUDY LICTERATUR

2.1     Anatomy and Physiology of post partum hemorrhage

Anatomy physiology female reproductive system is divided into two parts: in the female reproductive organs located in the pelvis, and female reproductive organs located outside of the perineum.

Female reproductive system consists of:

1.    Know the Sex Organs of Foreign

External female genital organs have two functions, namely:

a. Serves as the entrance of sperm into the woman's body

b. Protective genital organs in a variety of organisms that cause infection.

Alien Sex organs in women include:

a.         Mons veneris / mons pubis

Also called venus mountain is an important part in front of the symphysis composed of fatty tissue and connective tissue slightly after the mature hair covered by a triangular shape. Mons pubis contains many sebaceous glands (oil) serves as a cushion at a time to have sex.

b.        Big lips (labia majora) is a continuation of veneris, mons elliptical labia majora 7-8 cm long, 2-3 cm wide and slightly pointed at the lower end. Both of these lips meet to form the bottom of the perineum, the surface consists of:

1) The outside: Closed by hair which is a continuation of the hair on the mons veneris.

2) Inner: No hair membranes that contain sebaceous glands (fat).

c.    Small lips (labia minora)

Folds of skin that long, narrow, situated in the large lips (labia majora) with no hair extending to the bottom of the clitoris and fused with the Fourchette, whereas the lateral and anterior labia usually contain pigment, similar to the medial surface of the labia minora with the vaginal mucosa pink and moist.

d.        The clitoris

Is an important part of the erection of external reproduction, and is located near the superior tip of the vulva. This organ contains many blood vessels and sensory nerve fibers are very sensitive so analogous to the male penis. The main function of the clitoris is to stimulate and enhance sexual tension.

e.         The front room is a means of reproduction exterior shaped like a boat or oval, situated between the labia minora, the clitoris and Fourchette. Vestibule mouth urethra, glans parauretra, vagina and glands paravagina. The surface of the front room are thin and somewhat slimy easily irritated by chemicals, heat, and friction.

f.         Perinium

Muscle is covered areas of skin between the vaginal introitus and anus. Perinium perinium form the basis of the body.

g.        Bartholin gland

Is important gland in the vulva and vagina are fragile and easily torn. At the time of having sex expenditures increased mucus.

h.        Hymen (the hymen)

Is a network that covers the vaginal opening fragile and easily torn, perforated hymen so that lenders who issued lines the uterus and blood during menstruation.

i.          Fourchette

Is the transverse folds of tissue flat and thin, situated at the lower end of the meeting of the labia majora and labia minora. In the midline below the vaginal opening. A small basin and navikularis fossa lies between Fourchette and hymen

2. Internal Sex Organs

Bobak, IM, (2000)

a.         Vagina

The vagina is a thin-walled tubes that can be folded and able to stretch the cervix widely because of the bulge to the top of the vagina. The length of the anterior vaginal wall is only about 9 cm, while the posterior wall length of 11 cm. The vagina is located in front of the rectum and behind the bladder. The vagina is the tube that connects the uterus to the vulva muskulomembraneus. Muscular network is a continuation of the anal sphincter and levator ani muscles so the muscles can be controlled. In the vaginal wall transverse folds called rugae and especially at the bottom. At the apex (tip) cervical vaginal prominent in the womb. Part of the cervix that protrudes into the vagina is called the bottom. Top of the lower vagina uteri were divided into four, namely: fornik anterior, posterior fornik, fornik artery, which fornik left. Vaginal wall cells contain much glycogen that produces lactic acid with a pH of 4.5. Acidity of the vagina provides protection against infection. The main function of the vagina as a conduit for cervical mucus and menstrual blood, sex tools and the birth canal during labor.

b.        Strong uterine muscle tissue, thick-walled, muscular, flat, concave and looks like a light bulb / fruit associates located in the small pelvis backwards between the bladder and rectum. Normal uterus has a symmetrical shape, soft, smooth and solid palpable. The uterus consists of three parts: the fundus of the corpus uteri is located on the foundation of the fallopian tubes, uterine corpus is the main part which surrounds the cavity of the uterus and triangles, and cylinders seviks uteri. Rear wall, front wall and the top covered with peritoneum, while the bottom is related to the bladder. To maintain the position of the uterus against multiple tissues, connective ligaments and the peritoneum. The size of the uterus depends on the woman's age, in children, the size of the uterus 2-3 cm, 6-8 cm in nullipara, multiparous and 8-9 cm. Uterine wall consists of three layers of lining, the peritoneum myometrium / muscle, and endometrium.

1) Peritoneum

a) Includes outside wall of the uterus

b) Includes outside the womb

c) is a thickening of connective tissue filled and

d) the lymph vessels and nerves

e) Includes tube and reach the abdominal wall

2) Muscle layer

a)  Outer layer such as a curved hood of fundus uteri to the ligament

b) The inner layer: from the uterus into the fallopian internum osteum uterine lining osteum

c) The middle section: located between the two layers to form a thick layer of woven fibers of the uterus muscle. The middle layer is penetrated by blood vessels arteries and veins. Arch muscle fibers are formed so that the incidence rate and contraction of blood vessels so tightly wedged bleeding can be stopped.

3) Increasingly toward reducing cervical uterine muscle and increase tissue binding. Uterus, which lies between osteum uteri internum anatomy that limits and channels the uterine cavity and cervix uteri osteum histologikum (where there are changes in the mucous membrane lining the uterine cavity to the cervical mucus) is called the isthmus. Isthmus uteri will lower uterine segment and stretching during childbirth.

4) The position of the uterus in the pelvic bone is determined by the uterine muscle it self, which supports ligament tone, the tone of the pelvic floor muscles, ligaments supporting the uterus broad ligament, round ligament (teres uteri) pelvikum infindibulo ligament (ovarian suspensory) machenrod kardinale ligament, ligament and Sacro uterinum uterinum ligaments.

a. The broad ligament

·      This is a fold of peritoneum right and left uterine wall extending to the pelvic

·      Contains a space between two folds of loose connective tissue containing blood and lymphatic vessels and ureter

·      Broad ligament as if it depends on the fallopian tubes

·      Round ligament (teres uteri)

·      Starting from the insertion tube slightly caudal to the inguinal canal and reached the labia

·      Mayus Composed of smooth muscle and connective tissue function

·      Hold the uterus in position antefleksi

b. Ligament infundibulo pelvikum

·      Extends from the infundibulum and ovary to the pelvic wall

·      Hanging wall of the uterus into the pelvic

·      Between the fallopian tubes and ovaries is the ovarian ligaments proprium

c.    Ligament kardinale machenrod

·      From the cervix uteri internum osteum as high on the pelvic

·      Impede the movement of the uterus to the right and left  

·      Place the entry of blood vessels to the uterus

d.   Sacro ligament uterinum

Is a thickening of the ligament kardinale machine rod toward the os sacrum

e.    Ligament vesika uterinum

·      From the uterus to the bladder

·      It is a rather loose connective tissue so that it can follow the development of the uterus during pregnancy and childbirth

5) Uterine blood vessels

a. Ascending uterine artery that leads along the lateral wall of the corpus uteri and gives branches to the uterus and on the base formed spinal artery uterine endometrium.

b. At the top there is the ovarian arteries to deliver blood to the fallopian tubes and ovaries through the ramus and the ramus of the ovarian tubarius.

6) Nervous system of the uterus

Muscle contractions of the uterus is autonomous and is controlled by the sympathetic and parasympathetic nerves through cervical ganglion is situated at the confluence fronkenhouser sacro uterinum ligament.

c.         Fallopian tubes

Fallopian tube is a channel that extends between the ovum to the uterine cornu some where near the ovaries and ova reach the uterine cavity road. located on the top edge of the broad ligament runs from the lateral direction osteum internum tubae to the uterine wall. The fallopian tubes are 12cm long 3-8cm in diameter. The walls of the tube consists of three layers, namely serous, muscular, and mucosal epithelium with ciliated.

The fallopian tubes are composed of:

-        Pars interstitial (intramularis) lies between the muscles of the uterus from the fallopian osteum internum.

-        Pars istmika tubae, the tube that is outside the uterus and is the most narrow part.

-        Pars ampuralis tubae, the most extensive part of the tube-shaped "s".

-        Pars infindibulo tubae, which has the final part tubae lumbai tubae called fimbriae.
The function of the fallopian tube:

-        As road transport ova from the ovary to the uterine cavity.

-        To capture the ovum that is released during ovulation.

-          As a channel of spermatozoa and ovum products of conception

-        Place of conception.

-          Place growth and product development from conception until it reaches a form that is ready to hold a blastula implantation.

f.         Ovary
Ovarian function in the formation and maturation of follicles into the ovum, ovulation, synthesis, and secretion of hormones - steroid hormones. The location: The ovaries toward the uterus depends on infundibulo pelvikum ligament and attached to the broad ligament through mesovarium.

Types: There are two parts of the ovary, namely:
1) The cortex ovary

·         Contains primordial follicles

·         The various phases of follicular growth to follicles de graff

·         There is a corpus luteum and albikantes

2) The medulla ovary

·         There is blood and lymph vessels

·         There is a nerve fiber

g.        Parametrial
Parametrial connective tissue is found in between the two sheets of the broad ligament.
Limitation of parametrial
1) The top of the fallopian tubes are mesosalping
2) The front contains the ligamentum teres uteri
3) The caudal-related mesometrium.
4) The back of the ligament of ovary conta

(Bobak, Jansen, dan Zalar, 2001)

2.2     Definition

Bleeding pervagina whose numbers exceed 500 cc and occurs within the first 24 hours after birth or fetal blood loss exceeding 1,000 cc in the caesarae. Postpartum hemorrhage is bleeding in stage IV, more than 500-600 cc in 24 hours after the birth of the child and the placenta (Rustam Mochtar, 1998).

Postpartum hemorrhage is bleeding 500 cc / more after the third stage of completion / placenta after birth (midwifery Surgery, 2000).

Post-delivery bleeding is bleeding that occurs in the postpartum period more than 500 cc immediately after birth (Williams & Wilkins, 1988).

Postpartum hemorrhage is bleeding that occurs in the postpartum period which led to changes in vital signs such as a client complains weak, shaky, cold sweats, in hiperpnea physical examination, systolic <90 mm Hg, pulse> 100 x / min and the level of HB <8 g% (POGI , 2000).

Bleeding after childbirth or HPP much bleeding from the genital tract shortly after birth until 6 weeks post partum (Linda K. Brown. 1994).

1.3         Pathophysiology

Basically bleeding occurs because blood vessels in the uterus was still open. The release of placental blood vessels in the stratum spongiosum so decided maternalis sinus clearing placental insertion. At the time of the uterus to contract, blood vessels that are open will close, then the blood vessels clogged by a blood clot so the bleeding will stop. A retracted muscle disorders and uterine contractions, will impede the closing of blood vessels and cause bleeding that much. Thus the state became a major factor in postpartum haemorrhage. Extensive injuries will increase as vaginal bleeding, cervical tear and perinium.

2.4     Etiology

1. The cause of hemorrhage after premature birth:

a. The birth canal injury: uterine rupture, laceration of the vagina, cervix and perineum, episiotomy wound (4-5%).

b. Bleeding at the site of attachment placenta as: atonic uterus (50-60%), retained placenta (16-17%), inversio uteri.

c. The mechanism of blood clotting disorders (0.5 to 0.8%).

2. Causes of postpartum hemorrhage is usually caused by placental end residue or blood clots, infection due to retention of waste products in the uterus resulting in sub-involution of the uterus (23-24%).

The frequency of postpartum hemorrhage include:

1. Atonic uterus 50% - 60%

2. Placental retention 16% - 17%

3. The placenta remaining 23% - 24%

4. Lacerations of the birth canal 4% - 5%

5. Blood disorders 0.5% - 0.8% (Mochtar, 1995).

Cause

1. Atonic uterus

2. Retained placenta

3. The remaining placenta and amniotic membrane

4. Abnormal attachment (placenta accreta and percreta)

5. There is no attachment disorders (placental seccenturia)

6. Trauma to the birth canal width

- Episiotomy

- Lacerasi perineum, vagina, cervix, fornix, and uterine

- Rupture  uteri

7.    Diseases of blood clotting disorders such as afibrinogenemia / hipofibrinogenemia. A common sign:

-          Bleeding that many Sulusio old fetal death in utero placental

-          Pre-eclampsia and eclampsia

-          infections, hepatitis and septic shock Hematoma

8.    Inversion of the uterus

9.    Subinvolution uterus

2.5         Classification
Post-delivery bleeding or bleeding after childbirth is divided into 2 types, namely:

1.        Bleeding after giving birth to preterm / early HPP / primary HPP is excessive bleeding (600 ml or more) of the genital tract that occurs within 12-24 hours after birth. Genesis 1: 200 births.

2.        Bleeding after delivery is slow / late HPP / secondary HPP is bleeding that occurs between two days to six weeks after delivery. Genesis 1: 1000 births and increased in women with a history of abortion or with a history of bleeding during pregnancy.

2.6         Several Factors Predisposing

Conditions during pregnancy and childbirth can be a factor predisposing bleeding after childbirth, that situation again with no maximum plus health and nutritional condition of mothers during pregnancy. Therefore, these factors must be known from the beginning and anticipated at the time of delivery:

1.        Birth trauma

Any action to be performed during the birth process to be followed by examination of the birth canal so that the discovery of a tear in the birth canal and immediately infibulation is performed correctly.

2.        Atonic uterus

In cases of suspected high risk of uterine atony should be anticipated with the installation of a drip. Likewise uterotonic drugs should be prepared as well as the third stage of labor with the right help.

3.        small amount of blood

This situation is a little amount of blood should be considered in case of a bad situation, hypertension during pregnancy, pre eclampsia and eclampsia.

4.        Blood clotting disorders

Although blood clotting disorder is rare but often fatal event, so it should be anticipated with careful and thorough.

2.7     Clinical Manifestations

Common clinical symptom is loss of blood occurs in significant amounts (> 500 ml), weak pulse, pale, red lochea, thirst, dizziness, anxiety, fatigue, and hypovolemic shock may occur, cold extremities, and nausea. Clinical symptoms according to the cause:

1.        Atonic uterus

-       Symptoms that are always there: the uterus does not contract and mushy and bleeding shortly after childbirth (postpartum hemorrhage primary)

-       Symptoms that sometimes arise: shock (pulse rapid and small, cold extremities, restlessness, nausea, etc.)

2.        Laceration of the birth canal

-          Symptoms that always exist: immediate bleeding, fresh blood immediately after birth, both uterine contractions and the placenta.

-          Symptoms that sometimes arise: pale, weak and shivering.

3.        Retained placenta

-       The symptoms are always there: the unborn placenta after 30 minutes, bleeding and uterine contractions soon either.

-       Symptoms that sometimes arise: the umbilical cord broke up due to excessive traction, uterine inversion due to the pull and bleeding continued.

4.        Retained placenta (placenta remaining)

-        The symptoms are always there: the placenta or part of the membranes (containing blood vessels) is incomplete and the bleeding immediately.

-        Symptoms that sometimes arise: either the uterus to contract but fundal height is not reduced.

5.        Inversio uterus

-        The symptoms are always there: no palpable uterus, vaginal lumen filled mass, it appears the umbilical cord (if the placenta is not yet born), bleeding immediately, and a little pain or weight.

-        Symptoms that sometimes arise: neurogenic shock and pale

2.8         Infection Types of Post Partum

Infection types of post partum infection, vulva, perineum, vagina cervix, and endometrium.

a.         Vulvitis, infection of the perineal wound / episiotomy, wound redness, swelling, loose stitching, a ulcer pus

b.        Vaginitis: Wounds through vaginal or perineal wound redness swollen mucosa, lymph flow ulcer.

c.         Cervicitis: causes various symptoms of wound infection extends into the broad ligament spread to the parametrial.

d.        Endometritris: Germs enter the endometrium is usually on the former insersio placenta, and in a short time had spread necrosis of decidua-smelling sap.

e.         A Piemia Septicemia: Infection with a common goal a Streptoccocus Haemoliticus.

f.         Â parametritis peritonitis: The infection spreads through the lymph vessels in the uterus

2.9         Risk factors

a.       use of general anesthesia drug magnesium sulfate

b.      Parturition presipitatus

c.       Solutio placenta

d.      traumatic childbirth

e.       the uterus is too stretched (Gemelli, hydramnios)

f.       presence of uterine anomalies tumor scar defects

g.      long parturition

h.      Grandemultipara

i.        Placenta previa

j.        Maternity by race

k.      A history of postpartum hemorrhage

2.10     Complication
Short term:

1. Anemia

2. Hypovolemic shock

3. Acute renal failure

4. Acute liver failure (hepato-renal syndrome)

5. Acute pulmonary edema, consumption coagulopathy, transfusion reactions

Long-term:

1. Infection: puerperal infection, HIV, hepatitis.

2. Sheehanas syndrome (anterior pituitary necrosis)

3. Chronic anemia

4. Chronic renal failure

2.11     Diagnosis

1.      Palpation: uterine contractions and the SFH.

2.      Inspection: Uri, amniotic (complete or not), whether there is a tear in the vagina or the presence of varicose veins.

3.      Exploration of the cavum uteri: uri and the remaining tissue, rupture of the uterus.

4.      Laboratory examination: DL (Hb), Physiology of hemostasis, observastion Clot test (COT).

5.      Ultrasound examination if necessary.

Criteria Diagnosis:

1.      Physical examination:

Pallor, accompanied by signs of shock, low blood pressure, rapid pulse, a small, cold extremities and the blood looked out through the vagina continuously

2.      Obstetric examination:

Maybe flaccid bowel contractions, the uterus is enlarged when there is uterine atony. When both uterine contractions, bleeding may be due to the birth canal injury

3.      Gynecological examination:

Done in good condition or has been repaired, it can be seen contraction of the uterus, injury of the birth canal and the rest of the placenta retention

2.12     Prognosis

Maternal mortality rate reached 7,9 % (Mochtar. R), and according Wignyosastro maternal mortality rate reached 1,8-4,5% of the cases.

2.13     Examination Support

1.         Laboratory tests

-       Complete blood examination should be performed since the antenatal period. Hemoglobin below 10 g / dL was associated with adverse pregnancy outcomes.

-       Examination of the blood group and antibody testing should be performed since the antenatal period.

-       A follow-coagulation factors such as bleeding time and clotting time.

2.         Radiology

-       Incidence of postpartum hemorrhage is usually very fast. With proper diagnosis and treatment, usually occurs before resolution of laboratory or radiological examinations can be done. Based on experience, ultrasound examination can help to see the retention of residual blood clots and the placenta.

-       Ultrasound in the antenatal period can be performed to detect high-risk patients with predisposing factors for post partum hemorrhage such as placenta previa. Ultrasound examination may also increase the sensitivity and specificity in the diagnosis of placenta accreta and its variants.

2.14     Assessment Clinic

Table 1. Assessment Clinic for Determining the Degree of Shock

Loss of Blood Volume	Blood pressure (systolic)	Symptoms and Signs	degree of shock
500-1.000 mL (10-15%)	Normal	Palpitations, tachycardia, dizziness	uncompensated
1000-1500 mL (15-25%)	mild decrease (80-100 mm Hg)	Weakness, tachycardia, sweating	mild
1500-2000 mL (25-35%)	The decline was (70-80 mm Hg)	Restless, pale, oliguria	was
2000-3000 mL (35-50%)	The sharp decline (50-70 mm Hg)	Fainting, hypoxia, anuria	weight

Table 2. Assessment Clinic for Determining the cause of post partum haemorrhage

Symptoms and Signs	Complications	diagnosis Work
The uterus does not contract and mushy. Bleeding immediately after child birth	shock Blood clots in the cervix or the supine position would impede the flow of blood out	uterine atony
Fresh blood immediately after birth The uterus contracted and hard complete placenta	pale limp shiver	Laceration of the birth canal
The placenta has not been born after 30 minutes bleeding immediately The uterus contracted and hard	Umbilical cord broke up due to excessive traction Inversio uteri due to the pull bleeding continued	retained placenta
The placenta or some incomplete membrane bleeding immediately	Fundus of the uterus to contract high but not reduced	Retention of residual placental
The uterus was not palpable Mass filled the lumen of the vagina Looks cord (when the placenta is not yet born)	neurogenic shock Pale and unsteady	Inversio uteri
subinvolution uterus Lower abdominal tenderness and uterine bleeding secondary	anemia fever	Endometritis or residual fragments of the placenta (infected or not)

2.15     Management

Correct diagnosis should be done by way of immediately identifying excessive bleeding after childbirth. An experienced team of rescuers available. Drugs, equipment, operating room and have a blood transfusion should be available. Determining the etiology for the possibility of uterine atonia, hypotonia, rupture or inversion. Value below the genital tract to the possibility of injury to the vagina, cervix and perineum. Assessing the possibility of coagulopathy. Assess whether there is retention of the placenta.

1.        General management

a.       Know with certainty the condition of early maternal

b.      Lead delivery with reference to the delivery of clean and safe

c.       Always clean and safe to prepare emergency action

d.      The purpose of immediately do the assessment clinic and rescue efforts when faced with problems and complications.

e.       Overcome shock in case of shock

f.       Make sure the contraction lasts well (to remove blood clots, perform uterine massage, uterotonic give 10 IV infusion of 20 ml up in 500 cc NS / RL with drip 40 drops / minute).

g.      Make sure the placenta had been born and exploration of the possibility of a complete tear birth canal

h.      If the bleeding does not last, do the test a blood clot.

i.        Attach the catheter remains and monitor fluid out of the

j.        Strictly observe the first 2 hours post-birth and continue to monitor the next scheduled up to 4 hours.

2.        Special management

a.       Uterine atony

-          Identify and work atonic uterus standing

-          While doing the installation and provision of intravenous uterotonic, do the sorting uterus

-          Make sure the placenta was born complete and there is no birth canal laceration

-          Conducting special measures are necessary:

1.      external bimanual compression is pressing the uterus through the abdominal wall by the road near one another, either palms uteus surroundings. If bleeding is reduced compression continued, keeping the uterus can be re-contracted or taken to a referral health facility.

2.      Internal bimanual compression of uterus is pressed between the palms of the hands in the abdominal wall and boxing hand in the vagina to clamp the blood vessels in the myometrium.

3.      Femoral artery compression of the abdominal aorta is touched with a finger left hand, hold that position and then holding his right hand to emphasize on the umbilicus, perpendicular to the axis of the body, until it reaches the column pressure, the corresponding spine will stop or reduce, the pulse of the femoral artery.

b.      Retained placenta with a partial separation

-          Determine the type maintained that occur relating to actions to be taken.

-          Cable Stretch and ask the patient to push, if the expulsion does not occur driven by controlled cord traction.

-          Connect the infusion of oxytocin 20 unit/500 cc NS or RL with droplets 40/mnt, if necessary in combination with rectal misoprostol 400 mg.

-          When traction control failed delivery of the placenta, the placenta do manual carefully and smooth.

-          Restoration of fluid to overcome hypovolaemia.

-          Conducting blood transfusions when necessary.

-          Give prophylactic antibiotics (ampicillin 2 g IV / oral metronidazole 1 g + supp / oral).

c.       Placenta inkarserata

-          specify the working diagnosis

-          Prepare equipment and materials to eliminate cervical kontriksi strong, but prepare infusion fluothane or ether to remove the cervix kontriksi strong, but preparing the infusion of oxytocin 20 To 500 NS or RL to anticipate disruption of uterine contractions that may arise.

-          When the anesthetic material is not available, perform the maneuver screws for the delivery of the placenta.

-          Replace the Sims speculum so that the ostium and part of the placenta was evident.

-          Pinch clamps porsio with ova at 12 o'clock, 4 and 8 and remove the speculum which

-          Clamps Pull ova to third ostium, the umbilical cord and placenta was evident.

-          Pull the cord to the lateral so that the opposite side of the placenta seems cut off as much as possible, ask your assistant to hold the clamp.

-          Do the same thing in the contra lateral placenta

-          Combine the two clamps, and then rotated clockwise, while the placenta out slowly.

d.      Ruptured uteri

-          Give isotonic fluids immediately (RL / NS) 500 cc in 15-20 minutes and prepare

-          Perform laparotomy laparotomy to give birth and placenta, primary health care facilities should refer the patient to a referral hospital.

-          When the conservation of the uterus is still needed and conditions allow the network, perform uterine surgery.

-          If the wound is extensive necrosis and the patient's condition deteriorates can do hysterectomy

-          Conduct peritonial rinses and drain plug from the abdominal cavity

-          Antibiotics and anti-tetanus serum, when there are signs of signs of infection.

e.       The rest of the placenta

-          Initial findings, by examining the completeness of the placenta after birth

-          Give antibiotics for possible endometriosis

-          Conduct a digital exploration / when the cervix is ​​open and remove blood clots or tissue, if the cervix can only be traversed by the instrument, to evacuate the rest of the placenta with dilated and curettage.

-          8 gr% Hb transfusion or give ferosus 600mg/day provide sulfate for 10 days.

f.       Peritoneum rupture and tearing of the vaginal wall

-          Conducting exploration to identify the location of the laceration and bleeding

-          Do irrigation on the site of injury and provide antiseptic solution

-          Pinch clamps the source of bleeding edge then tie with string that can be absorbed

-          Conduct stitch the wound of the most especially in the distal perineal suturing

-          Complete rupture is done layer by layer with the help of the spark plug in the rectum, as follows:

-          After aseptic-antiseptic procedure, the rectum until the end of the tear plugs

-          Starting from suturing lacerations with stitches and knot the end of the sub-mucosa, using threads polyglikolik No. 2 / 0 (deton / vierge) until sfinter ani, ani sfinter second clip with clamping and sewing with thread No. 2 / 0.

-          Continue to layer suturing perineal muscles and sub-mucosa with the same thread (or chromic 2 / 0) to baste.

-          Vaginal mucosa and perineal skin sewn on the sub and sub-mucosa kutikuler.

-          Give prophylactic antibiotics. If the wound is dirty give antibiotics for therapy.

g.      Cervical laceration

-          Often occurs on the lateral side, because the cervix is ​​pulled will have a tear in the spine position ishiadika depressed by the baby's head.

-          When both uterine contractions, the placenta was born complete, but there is bleeding a lot then immediately see the bottom left and right lateral porsio

-          Ovum clamp clamps on both sides of the torn porsio so that bleeding can be stopped, if the exploitation continues to tear the other is not found, do sewing, stitching starting from the upper end of the tears and then to the outside so that all the tears can be sutured.

-          After the action check vital signs, uterine contractions, height of fundus uteri and bleeding post-action.

-          Give prophylactic antibiotics, unless signs of infection are clearly met.

-          When the recovery of fluid deficit and if Hb below 8% g provides transfusion

1.        Phase I (bleeding that is not too much): Give a uterotonic, massage / massage of the uterus, attach the octopus.

2.        Phase II (more bleeding): Perform fluid replacement (transfusion or intravenous), maneuver (zangemeister, frits), bimanual compression, aortic compression, uterovaginal tamponade, uterine artery clamping. 

3.        If all the above steps do not help: hipogastrika artery ligation, histerekstomi.

Prevention

1.        Care during pregnancy

Prevent or at least alert in case of suspected bleeding will occur is important. Vigilance is not only done during the delivery but the pregnant woman has been started by doing good antenatal care. Treating anemia in pregnancy is important, mothers who have a tendency or a history of postpartum hemorrhage is highly recommended for the maternity hospital.

2.        Preparation for labor

At the hospital to check the physical condition, general condition, Hb, blood type, and if possible give blood donors and stored in blood banks. Installation cateter intravenously with a large hole in preparation for a transfusion if necessary. For patients with severe anemia transfusion should be done immediately.

3.        Labor

After the baby is born, the uterus massage do with the direction of circular motion or back and forth until the uterus becomes hard and contract properly. Massae excessive or too hard on the uterus before, during and after the birth of the placenta may interfere with normal contractions of myometrium and even accelerate the contraction will cause excessive blood loss and lead to postpartum hemorrhage.

4.        Stage three and stage four

a.       Uterotonica can be given immediately after birth the front shoulder.

b.      In general, the placenta will take on its own within 5 minutes after birth.

c.       Do a thorough inspection to find the birth canal injuries can cause bleeding with adequate lighting.

CHAPTER 3

NURSING CARE

3.1 Assessment

1.      Identity:

a.       The identity of the patient, name, age (common in women under 20 years old and above 35 years), ethnicity / nation, religion, education, occupation, address, marital status.

b.      Husband of identity: name, age, tribe / nation, religion, education, occupation, address, length of marriage.

2.      The main complaint: Bleeding pervagina, weakness, unsteady, cold sweat, shortness of breath, dizzy, dizzy vision.

3.      History of pregnancy and childbirth: History of hypertension in pregnancy, preeclampsia / eclampsia, big baby, gamelli, hidroamnion, grandmulti gravida, primimuda, anemia, bleeding during pregnancy. Maternity by action, ripping the birth canal, birth precipitatus, parturition long, chorioamnionitis, induction of labor, manipulation of stage II and III.

4.      Medical history: Blood disorders and hypertension

5.      Physical Assessment:

ü  Awareness: composmentis / decreased consciousness

ü  Weight loss: decreased

ü  Common situation: a weak, pale, bedrest

ü  Vital signs: Blood pressure: Normal / down (less than 90-100 mmHg), N: Normal / increased (100-120x/mnt), RR: Normal / increased (28-34x/mnt), Temperature: Normal / increased

ü  Eyes: conjunctiva pale, dizzy outlook

ü  Mouth: mucosa anemis

ü  Neck: normal

ü  Thoracic and lung cancer: shortness of breath, shortness of breath

ü  Breast: Hyperpigmentation aerola mammary, out colostrum.

ü  Cardiovascular: BP down, pulse rapid and small, akral cold and pale, elongated CRT.

ü  Abdomen: The uterus is soft, weak contractions, pain, striae, linea, nausea, bladder distention, constipation.

ü  Genitalia: Bleeding (lokea spending that much), less micturition, injury in the vagina, episiotomy wound.

ü  Musculoskeletal and Integumentary: Weakness of the body, pale skin, cold, sweating, dry.

ü  Laboratory
a. Blood: Hemoglobin and Hematocrit 12-24 hours post partum (if Hb <10 g / dl)

b. Red blood cell count: <4.2 to 5.4 million cells / microliter.
c. White blood cell count <4000 cells / microliter.
d. Platelet count <150,000 platelets / microliter.
e. Urine Culture: BJ urine, BUN.

3.2    Nursing Diagnosis

1.         Lack of fluid volume associated with vaginal bleeding

2.         Impaired tissue perfusion associated with vaginal bleeding

3.         Anxiety / fear related to changes in circumstances or threat of death

4.         The risk of infection associated with bleeding

5.         The risk of hypovolemic shock associated with hemorrhage.

3.3    Intervention

1.         Lack of fluid volume associated with vaginal bleeding

Objectives: purpose of preventing dysfunctional bleeding and repair the volume of fluid.

Plan of action:

1.      Tidurkan patients with higher foot position while her body remained supine.

Rationale: With a foot higher would increase venous return and allow the blood to the brain and other organs.

2.      Monitor vital signs

Rational: Changes in vital signs occurred when the bleeding is more severe

3.      Monitor intake and output every 5-10 minutes

Rationale: The change in output is a sign of impaired renal function

4.      Evaluation of the bladder

Rationale: urinary bladder is full to prevent contraction of the uterus

5.      Is uterine masage with one hand and the other hand placed on the simpisis.

Rational: Massage stimulates uterine contractions of the uterus and helps release the placenta, one hand on top simpisis prevent inversio uteri

6.      Limit the vaginal and rectal examination

Rational: Trauma that occurs in the vaginal area and rectum increases the incidence of bleeding is more severe, if there is cervical laceration hematoma / perineum or if there is decreased blood pressure, pulse weaker, smaller and faster, the patient

7.      Given infusion or intravenous fluids

Rational: intravenous fluids to prevent shock.

8.      Give a uterotonic (when bleeding due to uterine atony)

Rational: uterotonic stimulate contractions of the uterus and control bleeding

9.      Give antibiotics

Rational: Antibiotics to prevent infections that may occur due to bleeding in subinvolusio

10.  Give whole blood transfusions (if needed)

Rational: whole blood helps normalize the volume of body fluids.

2.         Impaired tissue perfusion associated with vaginal bleeding

Purpose: of vital signs and blood gases within normal limits

Plan of action:

1.      Monitor vital signs every 5-10 minutes

Reason: Changes in tissue perfusion caused by changes in vital signs

2.      Note the discoloration, lip mucosa, gums and tongue, skin temperature

Rational: With vasoconstriction and relationships with vital organs, the circulation in peripheral tissues is reduced, causing cyanosis and cold skin temperature.

3.      Assess the presence / absence of milk production

Rationale: Poor Perfusion inhibit the production of prolactin, which is required in the production of milk

4.      Collaborative action:

-          Monitoring of blood gas and pH levels (changes in blood gas and pH levels of tissue hypoxia marks)

-          Give oxygen therapy (oxygen is needed to maximize the transportation network circulation).

3.         Anxiety / fear related to changes in circumstances or threat of death

Objectives: The client can express verbally say a sense of anxiety and feelings of anxiety is reduced or lost.

Plan of action:

1.      Assess the client's psychological response to hemorrhage after childbirth

Rational: Perceptions of client affect the intensity of anxiety

2.      Assess the client's physiological responses (tachycardia, tachypnea, shivering)

Rational: Changes in vital signs, causes changes in physiological responses

3.      Treat the patient is calm, empathy, and attitudes to support

 Rational: Provides emotional support

4.      Provide information about the care and treatment

Rational: Accurate information can reduce anxiety and fear of the unknown

5.      Helping clients to identify feel worried

 Rational: expression can reduce feelings of anxiety

6.      Assess the client's coping mechanisms are used

Rational: Anxiety can be prevented with prolonged appropriate coping mechanisms.

4.      The risk of infection associated with bleeding

Purpose: No infection (lokea odorless and TV within normal limits)

Plan of action:

a.       Watch for changes in vital signs

Rationale: Changes in vital signs (temperature) is indicative of infection

b.      Watch for signs of fatigue, chills, anorexia, uterine contractions are weak, and pelvic pain

Rational: The signs are an indication of the occurrence of bacteremia, shock is not detected

c.       Monitor uterine involution and expenditure lochea

Rational: Infection of the uterus and inhibits involution occurs lokea spent rolonged.

d.      Consider the possibility of infection elsewhere, such as respiratory tract infections, mastitis and urinary tract

Rational: Infections in other places aggravate the situation

e.       Collaborative action

-       Provide iron (anemia worsen the situation)

-       Provide antibiotics (Provision of appropriate antibiotic treatment is necessary for the state of infection).

CHAPTER 4

CONCLUTION AND SUGGESTION

4.1     Conclution

Postpartum hemorrhage is the leading cause of maternal deaths ever. All women who are pregnant 20 weeks have a risk of haemorraghi postpartum. Although maternal mortality has fallen dramatically in developing countries, haemorraghi post partum remains the largest cause of maternal death is every where.

Bleeding pervagina whose numbers exceed 500 cc and occur within the first 24 hours after birth or fetal blood loss exceeding 1000 cc at caesarae section. Haemorraghi post partum is bleeding in stage IV are more than 500-600 cc in 24 hours after the child and placenta were born (Rustam Mochtar, 1998).

Bleeding after childbirth or HPP is a lot of bleeding from the genital tract shortly after birth until 6 weeks post partum.

Handling of post partum hemorrhage should be performed in two parts, namely: (1) resuscitation and management of obstetric hemorrhage and hypovolemic shock possibilities and (2) identification and handling of the causes of postpartum hemorrhage.

4.2     Suggestion

By understanding the basic theory of the hemorrhagic postpartum (HPP) nurses are expected to improve its ability to treat patients with hemorrhagic post partum (HPP). So it can minimize the occurrence of complications, and accelerate healing.

Referensi

Brunner & Suddart,s (1996), Textbook of  Medical Surgical Nursing –2, JB. Lippincot Company, Pholadelpia.

Lowdermilk. Perry. Bobak (1995),  Maternity Nuring ,  Fifth Edition, Mosby Year Book, Philadelpia.

Prawirohardjo Sarwono ; EdiWiknjosastro H (1997), Ilmu Kandungan, Gramedia, Jakarta.

RSUD Dr. Soetomo (2001), Perawatan Kegawat daruratan Pada Ibu Hamil, FK. UNAIR, Surabaya

Hidayat. (2009). Askep Perdarahan Post Partum. http://hidayat2.wordpress.com/2009/04/09/askep-post-partum-resikotinggi/. diakses pada tanggal 12 November 2011

Khaidirmuhaj. (2009). Askep Nifas dengan Perdarahan Post. http://khaidirmuhaj.blogspot.com/2009/03/askep-nifas-denganperdarahan- post.html. diakses pada tanggal 12 November 2011.

Qittun . (2008). Askep Haemoraghi Post Partum. http://qittun.blogspot.com/2008/06/asuhan-keperawatan-pada-klienpost. html. diakses pada tanggal 12 November 2011.

Yulianti, Devi .( 2005). Manajemen Komplikasi Kehamilan dan Persalinan.Jakarta : EGC