Makalah Komplikasi dan Penyakit dalam Masa Nifas serta Penanganannya.docx

BAB I PENDAHULUAN 1.1 Latar Belakang

Angka Kematian Ibu (AKI) merupakan indikator utama derajat kesehatan masyarakat dan ditetapkan sebagai salah satu tujuan Millenium Development Goals (MDGs). AKI Indonesia diperkirakan tidak akan dapat mencapai target MDG yang ditetapkan yaitu 102 per 100 000 kelahiran hidup  pada tahun 2015. Kematian ibu akibat kehamilan, persalinan dan nifas sebenarnya

sudah

banyak

dikupas

dan

dibahas

penyebab

serta

langkah‐langkah untuk mengatasinya. Meski demikian tampaknya berbagai upaya yang sudah dilakukan pemerintah masih belum mampu mempercepat  penurunan AKI seperti diharapkan. Pada Oktober yang lalu kita dikejutkan dengan hasil perhitungan AKI menurut SDKI 2012 yang menunjukkan  peningkatan (dari 228 per 100 000 kelahiran hidup menjadi 359 per 100 000 kelahiran hidup). Diskusi sudah banyak dilakukan dalam rangka membahas mengenai sulitnya menghitung AKI dan sulitnya menginterpretasi data AKI yang berbeda ‐ beda  beda dan fluktuasinya kadang drastis. drastis. (Depkes, 2013) Masa nifas (puerpurium) adalah dimulai setelah plasenta lahir dan  berakhir ketika alat-alat kandungan kembali seperti keadaan sebelum hamil. Masa nifas berlangsung kira-kira 6 minggu. (Prawirohardjo, 2002). Masa nifas adalah masa segera setelah kelahiran sampai 6 minggu. Selama masa ini, saluran reproduktif anatomi kembali ke keadaan tidak hamil yang normal. (Obstetri William). Masa nifas (puerpurium) adalah masa pulih kembali, mulai dari  persalinan selesai sampai alat-alat kandungan kembali seperti pra hamil. Lama masa nifas 6-8 minggu. (Sinopsis Obstetri). Masa nifas merupakan masa yang rawan bagi ibu, sekitar 60% kematian ibu terjadi setelah melahirkan dan hampir 50% dari kematian pada masa nifas terjadi pada 24 jam pertama setelah melahirkan, diantaranya disebabkan oleh adanya komplikasi masa nifas. Selama ini perdarahan pasca  persalinan merupakan penyebab kematian ibu, namun dengan meningkatnya

1

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 persediaan darah dan system rujukan, maka infeksi menjadi lebih menonjol sebagai penyebab kematian dan morbiditas ibu. Infeksi nifas adalah infeksi pada dan melalui traktus genetalis setelah  persalinan. Suhu 38 °C atau lebih yang terjadi ter jadi antara hari ke 2-10 postpartum dan diukur peroral sedikitnya empat kali sehari. Istilah infeksi nifas mencakup semua peradangan yangdisebabkan oleh mesuknya kuman-kuman kedalam alat genetalia pada waktu persalinan dan nifas. Infeksi nifas pada awalnya adalah penyebab kematian maternal yang paling banyak,namun dengan kemajuan ilmu kebidanan terutama pengetahuan tentang sebab-sebab infeksi nifas, pencegahan dan penemuan obat-obat baru dari itulah dapat diminimalisir terjdinya infeksi nifas. Dari itulah seorang bidan perlu mengetahui tentang infeksi nifas, mulai dari apa itu infeksi nifas, bagaimana penyebab terjadinya infeksinya,  pencegahanya dan pengobatan dari infeksi nifas tersebut. Hal ini ditujukan untuk terwujudnya persalinan yang aman asuhan nifas yang higienis sehingga komplikasi pada masa nifas tidak lagi terjadi. 1.2 Tujuan Penulisan

Mengetahui berbagai komplikasi dan penyulit dalam masa nifas serta  penanganan yang dapat dilakukan untuk mengurangi angka kematian ibu dan  bayi dalam masa nifas. 1.3 Manfaat Penulisan

a. Bagi Pendidikan 1. Pendidikan mampu mengembangkan ilmu pengetahuan terutama pada asuhan kebidanan kegawatdaruratan maternal dan neonatal mengenai komplikasi dan penyakit dalam masa nifas serta penanganannya dengan teori yang terbaru dan penatalaksanaan sesuai teori. 2. Pendidikan mampu menjadi bahan acuan untuk penulisan selanjutnya yang berkaitan dengan asuhan kebidanan kegawatdaruratan maternal dan neonatal mengenai komplikasi dan penyakit dalam masa nifas

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 b. Bagi Klien/Masyarakat 1. Memberikan asuhan kebidanan kegawatdaruratan maternal dan neonatal mengenai komplikasi dan penyakit dalam masa nifas sesuai kebutuhan ibu dan bayi. 2. Menghindari pencegahan yang memicu terjadinya komplikasi dan  penyakit yang berkaitan dengan masa nifas pada ibu dan bayi.

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BAB II PEMBAHASAN

2.1 Infeksi

Infeksi nifas adalah keadaan yang mencakup semua peradangan alatalat genitalia dalam masa nifas. Masuknya kuman-kuman dapat terjadi dalam kehamilan, waktu persalinan, dan nifas. Demam nifas adalah demam dalam masa nifas oleh sebab apapun. (Rustam Mochtar, 1998) Morbiditas puerpuralis adalah kenaikan suhu badan sampai 38 oC atau lebih selama 2 hari dalam 10 hari pertama postpartum, kecuali pada hari  pertama. Suhu diukur 4 kali secara oral. (Rustam Mochtar, 1998) 2.2 Etiologi

Bermacam-macam jalan kuman masuk ke dalam alat kandungan, seperti eksogen (kuman datang dari luar), autogen ( kuman masuk dari tempat lain dalam tubuh), dan endogen ( dari jalan lahir sendiri). Penyebab yang terbanyak dari 50% adalah  streptococcus   streptococcus  anaerob yang sebenarnya tidak  patogen sebagai penghuni normal normal jalan lahir. Kuman-kuman yang sering menyebabkan infeksi antaralain adalah: 1)

Streptococcus Haemoliticus Aerobik Masuk secara eksogen dan menyebabkan infeksi berat yang ditularkan dari penderita lain, alat-alat yang tidak suci hama, tangan  penolong, dan sebagainya. sebagainya.

2)

Staphylococcus Aureus Masuk secara eksogen, infeksi sedang, banyak ditemukan sebagai penyebab infeksi di Rumah Sakit.

3)

Escherichia Coli Sering berasal dari kandung kemih dan rectum, menyebabkan infeksi terbatas.

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4)

Clostridium Welchii Kuman anaerobik yang sangat berbahaya , sering ditemukan  pada abortus kriminalis dan partus yang ditolong dukun dari luar Rumah Sakit. Cara terjadinya infeksi: a) Manipulasi penolong yang tidak suci hama, atau pemeriksaan dalam yang berulang-ulang dapat membawa bakteri yang sudah ada ke dalam rongga rahim.  b) Alat-alat yang tidak suci hama. c) Infeksi droplet, sarung tangan dan alat-alata terkena infeksi kontaminasi yang berasal dari hidung, tenggorokan, dari penolong dan pembantunya atau orang lain.

2.3 Predisposisi

a.

Partus lama, partus terlantar, dan ketuban pecah lama.

 b.

Tindakan obstetri operatif baik pervaginam maupun perabdominal.

c.

Tertinggalnya sisa-sisa uri, selaput ketuban, dan bekuan darah dalam rongga rahim.

d.

Keadaan-keadaan yang menurunkan daya tahan seperti perdarahan, kelelahan, malnutrisi, pre-eklamsi, eklamsi, dan penyakit ibu lainnya (penyakit jantung, TBC paru, pneumonia, dll).

2.4 Klasifikasi

1) Infeksi terbatas lokalisasinya pada perineum, vulva, serviks, dan endometrium. 2) Infeksi yang menyebar ke tempat lain melalui: pembuluh darah vena,  pembuluh limfe dan endometrium.

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2.5 Macam-Macam Infeksi Nifas 2.5.1

Endometritis

a. Pengertian 1. Endometritis adalah suatu peradangan endometrium yang  biasanya disebabkan oleh infeksi bakteri pada jaringan (Benzion Tuber, 1994). 2. Endometritis adalah infeksi pada endometrium atau yang disebut lapisan dalam dari rahim. ( Prof.dr.Ida Bagus,). 3. Endometritis adalah infeksi pada endometrium (lapisan dalam dari rahim). (Manuaba, I.B. G., 1998).- Endometritis adalah suatu

infeksi

yag

terjadi

di

endometrium,

merupakan

komplikasi pascapartum, biasanya terjadi 48 sampai 72 jam setelah melahirkan. 4. Endometritis secara umum adalah infeksi atau desidua endometrium, dengan ekstensi ke miometrium dan jaringan  parametrial. Endometritis dibagi menjadi kebidanan dan nonobstetric endometritis. Penyakit radang panggul (PID) adalah sebuah Common nonobstetric pendahulunya dalam  populasi. 5. Endometritis dapat juga terjadi karena kelanjutan dari kelahiran

yang

sekundinarum,

tidak

normal,

kelahiran

seperti

premature,

abortus,

kelahiran

retensi kembar,

keahiran yang sukar (distokia), perlukaan yang disebabkan oleh alat-alat yang dipergunakan untuk pertolongan pada kelahiran yang sukar.  b. Tipe Endometritis 1. Endometritis post partum (radang dinding rahim sesudah melahirkan) 2. Endometritis sinsitial (peradangan dinding rahim akibat tumor  jinak disertai sel disertai sel sintitial dan trofoblas yang banyak)

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3. Endometritis tuberkulosa (peradangan pada dinding rahim endometrium dan tuba dan tuba fallopi, biasanya fallopi, biasanya akibat Mycobacterium akibat  Mycobacterium tuberculosis. tuberculosis.) c. Etiologi Macam jalan kuman masuk ke dalam alat kandungan seperti eksogen (kuman datang dari luar), autogen (kuman masuk dari tempat lain dalam tubuh) dan endogen (dari jalan lahir sendiri). Penyebab yang terbanyak dan lebih dari 50% adalah streptococcus anaerob yang sebenarnya tidak patogen sebagai  penghuni

normal

jalan

lahir.

Kuman-kuman

yang

sering

menyebabkan infeksi antara lain adalah : 1) Streptococcus haemoliticus anaerobic Masuknya secara eksogen dan menyebabkan infeksi  berat. Infeksi ini biasanya eksogen (ditularkan dari penderita lain, alat-alat yang tidak suci hama, tangan penolong, infeksi tenggorokan orang lain). 2) Staphylococcus aureus Masuknya secara eksogen, infeksinya sedang, banyak ditemukan sebagai penyebab infeksi di rumah sakit dan dalam tenggorokan orang-orang yang nampaknya sehat. Kuman ini  biasanya menyebabkan infeksi terbatas, walaupun kadangkadang menjadi sebab infeksi umum. 3) Escherichia Coli Sering berasal dari kandung kemih dan rektum,

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Endometritis sering ditemukan pada wanita setelah seksio sesarea terutama bila sebelumnya ada riwayat koriomnionitis,  partus lama, pecah ketuban yang lama. Penyebab lainnya dari endometritis adalah adanya tanda jaringan plasenta yang tertahan setelah abortus dan melahirkan. Menurut

Varney,

H.

(2001),

hal-hal

yang

dapat

menyebabkan infeksi pada wanita adalah: 1. Waktu persalinan lama, terutama disertai pecahnya ketuban. 2. Pecahnya ketuban berlangsung lama. 3. Adanya pemeriksaan vagina selama persalinan dan disertai  pecahnya ketuban. 4. Teknik aseptik tidak dipatuhi. 5. Manipulasi

intrauterus

(pengangkatan

plasenta

secara

manual). 6. Trauma jaringan yang luas/luka terbuka. 7. Kelahiran secara bedah. 8. Retensi fragmen plasenta/membran amnion. Miroorganisme

yang

menyebabkan

endometritis

diantaranya Campylobacter foetus, Brucella sp., Vibrio sp., dan trikomoniasis foetus. Endometritis juga dapat diakibatkan oleh  bakteri oportunistik spesifik seperti Corynebacterium pyogenes, Eschericia coli

dan Fusobacterium necrophorum .Endometritis

 biasa terjadi setelah kejadian aborsi , kelahiran kembar , serta kerusakan jalan kelahiran sesudah melahirkan.

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Jika

dibandingkan

 perabdominan/sc, tersalinan

maka

pervaginam

dengan

timbulnya relatif

persalinan

endometritis

jarang.Bila

pada

persalinan

 pervaginam disertai penyulit yaitu pada ketuban pecah  prematur yang lama, partus yang lama dan pemeriksaan dalam  berulang, maka kejadian endometritis akan meningkat sampai mendekati 6%. Bila terjadi korioamniotis intrapartum, maka kejadian endometritis akan lebih tinggi yaitu mencapai 13%. 7. Persalinan SC SC merupakan faktor predisposisi utama timbulnya endometritis dan erat kaitannya dengan status sosial ekonomi  penderita. Faktor resiko penting untuk timbulnya infeksi adalah lamanya proses persalinan dan ketuban pecah,  pemeriksaan dalam berulang dan pemakaian alat monitoring  janin internal. Karena adanya faktor resiko tersebut america college

of

obsetricians

andgynekologists  menganjurkan andgynekologists 

 pemberian antibiotika profilaksis

pada tindakan secsio

caesarea. e. Tanda dan Gejala Endometritis Tanda dan gejala endometritis antara lain : 1. Peningkatan demam secara persisten hingga 40 derajat celcius. Tergantung pada keparahan infeksi. 2. Takikardia 3. Menggigil dengan infeksi berat

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10. Shock sepsis maupun hemoragik 11. Abdomen distensi atau pembengkakan. 12. Abnormal pendarahan vagina 13. Discomfort dengan buang air besar (sembelit mungkin terjadi) 14. Terjadi ketidaknyamanan, kegelisahan, atau perasaan sakit (malaise) f. Klasifikasi Endometritis Menurut Wiknjosastro (2002), 1. Endometritis akut Terutama terjadi pada masa post partum / post abortum.

Pada

endometritis

post

partum

regenerasi

endometrium selesai pada hari ke-9, sehingga endometritis  post partum pada umumnya terjadi sebelum hari ke-9. Endometritis post abortum terutama terjadi pada abortus  provokatus. Pada endometritis akuta, endometrium mengalami edema dan hiperemi, dan pada pemeriksaan mikroskopik terdapat hiperemi, edema dan infiltrasi leukosit berinti  polimorf

yang

banyak,

serta

perdarahan-perdarahan

interstisial. Sebab yang paling penting ialah infeksi gonorea dan infeksi pada abortus dan partus. Infeksi gonorea mulai sebagai servisitis akut, dan radang menjalar ke atas dan menyebabkan endometritis akut. Infeksi gonorea akan dibahas secara khusus.

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Sebab lain endometritis akut ialah tindakan yang dilakukan dalam uterus di luar partus atau abortus, seperti kerokan, memasukan radium ke dalam uterus, memasukan IUD (intra uterine device) ke dalam uterus, dan sebagainya. Tergantung dari virulensi kuman yang dimasukkan dalam uterus, apakah endometritis akut tetap berbatas pada endometrium, atau menjalar ke jaringan di sekitarnya. Endometritis akut yang disebabkan oleh kumankuman yang tidak seberapa patogen pada umumnya dapat diatasi atas kekuatan jaringan sendiri, dibantu dengan  pelepasan lapisan fungsional dari endometrium pada waktu haid. Dalam pengobatan endometritis akuta yang paling  penting adalah berusaha mencegah, agar infeksi tidak menjalar. Gejalanya : a.

Demam

 b.

Lochea berbau : pada endometritis post abortum kadang-kadang keluar lochea yang purulent.

c.

Lochea lama berdarah malahan terjadi metrorrhagi.

d.

Kalau radang tidak menjalar ke parametrium atau  parametrium tidak nyeri. Penatalaksanaan :

a. Dalam pengobatan endometritis akut yang paling  penting adalah berusaha mencegah agar infeksi tidak

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d.

Endometritis menyampingkan

senilis corpus

perlu

dikuret

carsinoma.

Dapat

untuk diberi

estrogen.

2. Endometritis kronik Radang ini jarang dijumpai , namun biasanya terjadi  pada wanita yang masih menstruasi. Dimana radang dapat terjadi pada lapisan basalis yang tidak terbuang pada waktu menstruasi. Endometritis kronik primaria dapat terjadi sesudah menopauase, dimana radang tetap tinggal dan meluas sampai ke bagian endometrium lain. Endometritis kronik ditandai oleh adanya sel-sel plasma pada stroma. Penyebab yang paling umum adalah Penyakit Radang Panggul (PID), TBC, dan klamidia. Pasien yang menderita endometritis kronis sebelumnya mereka telah memiliki riwayat kanker leher rahim atau kanker endrometrium. Gejala endometritis kronis berupa noda darah yang kotor dan keluhan sakit perut  bagian

bawah,

leukorea

serta

kelainan

haid

seperti

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Endometritis setengah

tuberkulosa

kasus-kasus

mikroskopik

TB

ditemukan

terdapat

genital.

tuberkel

Pada pada

pada

hampir

pemeriksaan tengah-tengah

endometrium yang meradang menahun. Pada abortus inkomplitus dengan sisa-sisa tertinggal dalam uterus terdapat desidua dan vili korealis di tengahtengah radang menahun endometrium. Pada partus dengan sisa plasenta masih tertinggal dalam uterus, terdapat peradangan dan organisasi dari jaringan tersebut disertai gumpalan darah, dan terbentuklah apa yang dinamakan polip plasenta. Endometritis kronika yang lain umumnya akibat ineksi terus-menerus karena adanya benda asing atau polip/tumor dengan infeksi di dalam kavum uteri. Gejalanya : a.

Flour albus yang keluar dari ostium.

 b.

Kelainan haid seperti metrorrhagi dan menorrhagi. Terapi :

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Infeksi uterus pada persalinan pervaginam terutama terjadi  pada tempat implantasi plesenta, desidua, dan miometrium yang  berdekatan.bakteri yang berkoloni diserviks akan dan vagina akan menginvasi

tempat

implantasi

plasenta

saat

itu

biasanya

merupakan sebuah luka dengan dengan diameter kurang kurang lebih 4

cm

dengan permukaan luka berbenjol –   –   benjol karena banyaknya vena yang ditutupi trombus. Daerah ini merupakan tempat yang baik untuk tumbuhnya kuman-kuman patogen Infeksi uterus pasca operasi sesar umumnya akibat infeksi  pada luka operasi selain infeksi yang terjadi pada tempat implantasi plasenta. h. Gambaran Klinis Gambaran klinis dari endometritis tergantung pada jenis dan virulensi kuman, daya tahan penderita dan derajat trauma pada  jalan lahir. Kadang-kadang lokhea tertahan oleh darah, sisa-sisa  plasenta dan selaput ketuban. Keadaan ini dinamakan lokiometra dan dapat menyebabkan kenaikan suhu yang segera hilang setelah rintangan dibatasi. Uterus pada endometrium agak membesar,

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4. Dapat terjadi penyebaran : a.

Miometritis

 b.

Parametritis

c.

Salpingitis

d.

Ooforitis

e.

Pembentukan

penahanan

sehingga

terjadi

abses.

(Manuaba, I. B. G., 1998)

Menurut Varney, H (2001), tanda dan gejala endometritis meliputi: 1. Takikardi 100-140 bpm. 2. Suhu 30 –  30  – 40ᵒ 40ᵒ celcius. 3. Menggigil. 4.  Nyeri tekan uterus yang meluas secara lateral. 5. Peningkatan nyeri setelah melahirkan. 6. Sub involusi. 7. Distensi abdomen. 8. Lokea sedikit dan tidak berbau/banyak, berbau busuk,

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dinding rahim agak kaku dan di dalam rahim ada cairan tetapi tidak dirasakan sebagai fluktuasi (tergantung derajat infeksi). Secara klinis karakteristik endometritis dengan adanya  pengeluaran mucopurulen pada vagina, dihubungkan dengan ditundanya

involusi

uterus.

Diagnosa

endometritis

tidak

didasarkan pada pemeriksaan histologis dari biopsy endometrial. Tetapi pada kondisi lapangan pemeriksaan vagina dan palpasi traktus genital per rectum adalah teknik yang sangat bermanfaat untuk diagnosa endometritis. Pemeriksaan visual atau manual pada vagina untuk abnormalitas pengeluaran uterus adalah penting untuk diagnosa endometritis, meski isi vagina tidak selalu mencerminkan isi dari uterus. Flek dari pus pada vagina dapat  berasal dari uterus, cervik atau vagina dan mukus tipis berawan sering

dianggap

normal.

Sejumlah

sistem

penilaian

telah

digunakan untuk menilai tingkat involusi uterus dan cervik,  pengeluaran dari vagina alami. Sistem utama yang digunakan adalah kombinasi dari diameter uterus dan cervik, penilaian isi dari vagina.

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uterus. Sejumlah kecil pus pus yang terdapat pada pipet inseminasi dan berwarna keputihan bukanlah suatu gejala yang mangarah  pada endometritis. Keradangan pada cervix (cervisitis) dan vagina (vaginitis)  juga mempunyai abnormalitas seperti itu. Bila terdapat sedikit cairan pada saat palpasi uterus, penting untuk melakukan  pemeriksaan selanjutnya yaitu dengan menggunakan spekulum. Untuk beberapa kasus endometritis klinis atau subklinis, diagnosa diperkuat dengan biopsy uterin. Pemeriksaan mikroskopis dari  jaringan biopsy akan tampak adanya peradangan peradan gan akut atau kronik  pada dinding uterus. Pemeriksaan biopsi uterin dapat untuk memastikan terjadinya endometritis dan adanya organisme di

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resistensi menggunakan vaginoscop karena dirasa tidak mudah,  potensial untuk transmisi penyakit dan harganya. Alat baru untuk  pemeriksaan mukus vagina terdiri dari batang stainless steel dengan hemisphere karet yang digunakan untuk mengeluarkan isi vagina.  j.

Komplikasi Komplikasi yang potensial dari endometritis adalah sebagai berikut: 1. Luka infeksi Infeksi luka biasanya terjadi pada hari kelima pasca operasi sebagai demam menetap meskipun pasien mendapat terapi antimikroba yang adekuat. Biasanya dijumpai eritema,

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 jam

meskipun

pasien

sudah

mendapat

terapi

untuk

endomiometritis pasca sesar. 4. Panggul abses Flegmon parametrium dapat mengalami supurasi, membentuk abses ligamentum latum yang fluktuatif. Jika abses ini pecah, dapat timbul peritonitis yang mengancam nyawa. Dapat dilakukan drainase abses dengan menggunakan tuntunan computed tomography, kolpotami, atau

melalui

abdomen, bergantung pada lokasi abses. 5. Abses subfasia dan Terbukanya jaringan parut uterus Kompilkasi serius endometritis pada wanita yang melahirkan sesar adalah terbukanya insisi akibat infeksi

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3. Pengganti darah dapat diindikasikan untuk anemia berat dengan post abortus atau post partum. 4. Tirah baring dan analgesia merupakan terapi pendukung yang  banyak manfaatnya. 5. Tindakan bedah: endometritis post partum sering disertai dengan jaringan plasenta yang tertahan atau obstruksi serviks. Drainase lokia yang memadai sangat penting. Jaringan  plasenta

yang

tertinggal

dikeluarkan

dengan

kuretase

 perlahan-lahan dan hati-hati. Histerektomi dan salpingo  –  oofaringektomi bilateral mungkin ditemukan bila klostridia telah meluas melampaui endometrium dan ditemukan bukti adanya sepsis sistemik klostridia (syok, hemolisis, gagal

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3. Tanda gejala selalu ada a.

Buah dada nyeri dan bengkak.

 b. 3-5 hari nifas. 4. Tanda gejala kadang-kadang ada : a. Buah dada bengkak  b. Kedua buah dada terkena 5. Pencegahan a.

Menyusui  bayi segera setelah lahir dengan posisi dan  perlekatan yang benar.

 b.

Menyusui bayi Menyusui bayi tanpa jadwal (nir jadwal dan on dan on demand). demand).

c.

Keluarkan ASI dengan tangan/pompa bila produksi melebihi kebutuhan bayi. kebutuhan bayi.

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i.

Lakukan pemijatan pada daerah  payudara yang  bengkak,  bermanfaat untuk membantu memperlancar  pengeluaran ASI.

 j.

Pada saat menyusui, saat menyusui, sebaiknya  sebaiknya ibu tetap rileks.

k. Makan makanan bergizi untuk meningkatkan daya tahan tubuh dan perbanyak minum.

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2. Faktor Risiko Beberapa faktor yang diduga dapat meningkatkan risiko mastitis, yaitu : a.

Umur Wanita berumur 21-35 tahun lebih sering menderita mastitis dari pada wanita di bawah usia 21 tahun atau di atas 35 tahun.

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menyusui, sumbatan pada saluran ASI, suplai ASI yang sangat  berlebihan dan menyusui untuk kembar dua/lebih.  b. Infeksi Organismen yang paling sering ditemukan pada mastitis dan abses payudara adalah organisme koagulase positif Staphylococcus

dan Staphylococcus albus.

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g. Peningkatan kadar natrium sehingga bayi tidak mau menyusu karena ASI yang terasa asin 2) Gejala mastitis non infeksiosa a. Adanya bercak panas/nyeri tekan yang akut  b. Bercak kecil keras yang nyeri tekan c. Tidak ada demam dan ibu masih merasa naik-baik saja.

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 b. Pemberian minuman lain pada bayi pada bulan-bulan  pertama c. Tindakan melepaskan mulut bayi dari payudara pertama sebelum ia siap untuk menghisap payudara yang lain. d. Beban kerja yang berat atau penuh tekanan e. Kealpaan menyusui bila bayi mulai tidur sepanjang malam

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