Midwife is a health worker that plays an important role in decreasing maternal and neonates’ mortality rate. Focusing on promotive, preventive, and community empowerment along with other health worker to serve patients in dire need [1].

One of the indicators of health development in a country is maternal and neonates’ mortality rate [2]. Indonesia Demographic and Health Surveillance (SDKI) stated that maternal mortality rate (MMR) is defined as the number of maternal deaths occurring during pregnancy, delivery, and postpartum, not due to other cause such as accident or fall, per 100,000 live births. In Indonesia, mortality rate has lowered from 390 in 1991 to 305 in 2015 [3]. Neonates mortality rate (NMR) is the number of neonates deaths occurring in their first 28 days of live per 100,000 live births. Based on SKDI, there was a reduction of NMR from 32 per 1,000 live births on 2012 to 24 per 1,000 live births on 2017 [4]. Indonesia was in the top ten ranking countries in MMR and NMR [1].

Basically mother, fetus, and neonates deaths in developing countries often happened without the help of skilled health workers, limited access to high quality health care, etc [5]. According to 2018 West Java Health Records, maternal mortality rate in Bandung was 29 cases, higher compared to 2017 which was 22 cases. Highest number of deaths was found in Sukajadi and Babakan Ciparay, which was 3 cases in 2018. This number was lower compared to 129 cases in 2017. The most neonate deaths were in Bojongloa Kidul which was 19 cases [4].

Efforts done to accelerate the decline of MMR and NMR was by ensuring that every mother had adequate access to high quality health care.⁴ Several government programs, such as Birth Planning and Complication Prevention Program (P4K) and Health Operational Assistance (BOK) in primary health care at cities; safe motherhood initiative, a program ensuring every women had proper care for safe pregnancy and delivery (1990), and Gerakan Sayang Ibu in 1996 [4].

West Java government has increase health care facilities (primary health care, midwife, private practice, and hospital) in caring for mother and baby emergency cases, availability of birth waiting houses, access to family planning services, utilization of mother and child health book, pregnant mother and mother of toddlers classes, integrated healthcare center, use of village funds, role of PKK, delivery planning and complication prevention (village ambulance and blood donor), specialist placement (obstetric, pediatric, internal medicine, anesthetist, surgeon), the availability of blood transfusion unit/hospital blood bank in cities, antenatal, pregnancy, and postpartum strengthening according to standard and training from the hospital. Midwife plays a role in comprehensive, thorough, and continuous care in simple follow-up and counselling such as pregnancy, delivery, postpartum, neonates, and family planning care [6].

Therefore, author reported on comprehensive description on midwifery care based on standard on pregnancy, delivery, postpartum, neonates, and family planning.

Mrs. M., 27-year-old, G5P4A0 (first day of last menstruation 01 September 2021, delivery date 08 June 2022, first fetal movement on gestation 16 weeks), did pregnancy care and Midwife J, on 5^th April 2022, complained pain in her back especially during lifting heavy loads for 1 week. Pregnancy, delivery, and postpartum history, was delivery on 1^st March 2013 (female, birth weight 2500-gram, height 49 cm), 24^th July 2022 (female, birth weight 2700-gram, height 50 cm), 13^th August 2017 (female, birth weight 2850-gram, height 51 cm), 12^th March 2020 (male, birth weight 3100-gram, height 51 cm), respectively; all delivery occurred during the 9^th month, spontaneous, helped by a midwife, and no complications.

Immunization TT was complete 4 times (4^th April 2012, 5^th Mei 2012, 6^th November 2012, and 10^th June 2013). She used pill for family planning from January – August 2021, although not routinely. Husband and family support is good. There was no problem in socioeconomic, rest, defecation or urination, personal hygiene, food/drink, and activity pattern. There was not history of other disease, smoking, alcohol consumption, or drug dependency.

From physical examination, general status, consciousness, vital sign, and general physical examination were normal. Nutrition status revealed birth weight before pregnancy 50 kg, birth weight during pregnancy 61 kg, height 155 cm, fundal height 29 cm, leopold I posterior presentation, leopold II fetal back on the right, leopold III cephalic presentation, leopold IV not inside pelvic door, fetal heart rate 145 x/min, fetal weight 2480 gram. The result of laboratory examination on primary health care was on 6^th November 2021 revealed Hb 11.5 gr%, negative infectious disease (HbsAg, HIV, Syphilis), proteinuria and glucosuria negative. She was analyzed with G5P4A1 gestation 30 weeks 6 day, JTH. She was given education on complaints, how to deal with them, suggestions of activity that may reduce complaints, danger signs, routine pregnancy control, exercise, consumption of food with high nutrition and supplements (Fe), and personal care.

Pregnancy care on the second visit (5^th May 2022) on midwife J, Mrs. M complained of often urinate. Physical examination was normal. Obstetric examination showed fundal height 30 cm, leopold I posterior presentation, leopold II fetal back on the left, leopold III cephalic presentation, leopold IV divergent 4/5, fetal heart rate 148 x/min, fetal weight 2790 gram. Patient was diagnosed with G5P4A0 gestation 35 weeks 1 day, JTH. She was given education on condition, delivery signs, danger signs of pregnancy, delivery preparation, and pregnancy control.

On 27^th Mei 2022, Mrs. M felt frequent and regular contractions from 12.00 WIB and mucus mixed with blood with no other fluid was present. From obstetric examination disclosed fundal height 31 cm, leopold I posterior presentation, leopold II fetal back on the right, leopold III cephalic presentation, leopold IV divergent 2/5, his 3 x/10 min, fetal heart rate 146 x/min, fetal weight 2945 gram. On internal examination, portio was thin, tender; opening 7 cm, fetal membrane (+), cephalic presentation, lowering station 0, molase 0, presentation small crown at right front, and no other parts were palpable. She was diagnosed as G5P4A0 gestation 28 weeks parturient term 1^st period active phase. Patient was educated on delivery process, was suggested to walk so baby’s head drop faster, breathing regulation during contraction, proper push technique, support from husband and family, not to withhold urination. The midwife needs to prepare for delivery and observed fetal heart rate, his, heart rate every 30 minutes and wrote them on partograph.

On 07.00 PM, Mrs. M said she wanted to push and contraction was stronger and more often. On obstetric examination, leopold IV was divergent 0/5, his 4 x/10’-45”, fetal heart rate 146 x/min. From internal examination showed opened vulva/vagina, portio not palpable, complete opening (10 cm), intact fetal membrane, cephalic presentation, lowering station +2, molase 0, presentation small crown at right front, and no other parts were palpable, and anus was opened. Our patient was diagnosed as G5P4A0 gestation 38 weeks parturient term 2^nd period. During contraction, she was guided to push. Midwife gave delivery, position alternative, and primary care for mother during 2^nd period such as hygiene, hydrate, emptying her bladder, and guide the mother to push. The midwife than guide her to push again when fetal head has shown 5 – 6 cm on vulva. The baby cried spontaneously after birth on 08.00 PM, female.

On 8 pm, Mrs. M was examined, and no second fetus was found, strong contraction, fundal height as high as navel, diagnosed as G5P4A0 parturient 3^rd period. Patient was injected by oxytocin 1 ampoule (10 unit) intramuscular on a third upper thigh lateral distal. Oxytocin was injected on 8.01 pm by the midwife. Umbilical cord was clamped on 3 cm from the umbilical, 2^nd clamp was administered on 2 cm from the 1^st clamp, umbilical cord was cut. The baby was placed on mother’s stomach . There was no placental detachment on 15 minutes after birth. On 8.16 pm, she was injected by oxytocin 1 ampoule (10 unit) intramuscular on a third distal lateral thigh. Controlled cord stretching was done. Placenta was born spontaneously on 8.25 pm. Uterine massage was done for 15 times in 15 minutes. Uterus felt hard. Midwife checked for placental completeness which contained fetus part (chorion frondosum and villi chorea) and maternal part (decidua compacta formed of lobi and cotyledon). Cotyledon was complete, 20.

On 8.30 pm, Mrs. M’s examination showed vital sign was normal. Obstetric examination revealed strong uterus contraction, fundal height 2 fingers below the navel, no perineal laceration, and the amount of bleeding ± 200 mL. Patient was diagnosed as P5A0 parturient 4^th period. She was not sutured, taught how to massage appropriately, postpartum hygiene, postpartum education for mother. 4^th period observation was done every 15 minutes on the 1^st hour and every 30 minutes on the 2^nd hour. The result was written on the back of the partograph.

On postpartum period, midwifery care was carried out on 6 hours, 6 days, and 6 weeks. On 6^th day postpartum care, Mrs. M was able to eat, good personal hygiene, no defecation, able to spontaneously urinate, and breast milk was given soon after birth. On physical examination, colostrum was positive on both breasts, uterus was hard, fundal height 2 fingers below the navel, normal external genitalia, lochea rubra and no smell, and no hemorrhoid. Patient was diagnosed as P5A0 postpartum 6 hours. The midwife educate patient on condition, motivation to mobilization, routine breast care, given Fe tablet (1 x 1 tablet) and vitamin A (2 x 1 tablet), exclusive breastmilk, resting time, balanced nutrition consumption, family planning, and next follow up.

On 6^th day midwifery care, Mrs. M. complained of constipation. Physical examination was normal. Ample breastmilk, fundal height in the middle of navel – symphysis, normal genitalia. On 2^nd weeks postpartum, Mrs. M presented with no complaint. Normal physical examination, fundus not palpable. The midwife educated the patient on exclusive breastmilk, resting time, balanced nutrition consumption, family planning, and next control. 6^th week postpartum she was informed on family planning.

Neonate care was performed on 6hours, 6 days, 2 weeks, and 28 days. On 6^th hour, the baby had strong suckling, no complications, was injected by vitamin K, hepatitis B0, defecation (+), urination (+). Neonate evaluation demonstrated strong crying, reddish skin, active muscle tone, birth weight 3200-gram, height 52 cm, heart rate 141 x/min, respiration 42 x/min, regular, head circumference 32 cm, positive neonates normal reflex, and all orifices were present. The result was term neonate 6-hour-old. Mother was educated on neonate care, appropriate breast-feeding techniques, burping baby after breast-feeding, umbilical cord care, sunbathing, danger sign of infections on umbilical cord (reek, fluid from the cord, reddish around the navel) or baby (high fever or low temperature, dyspnea, chest wall retraction, no breastfeeding, not active, yellowish or bluish, seizure, diarrhea, pale defecation), and control.

On 6^th day, the baby suckled strongly, no complaints. Baby’s weight was 3400-gram, height 52 cm, heart rate 128 x/min, respiration 44 x/min, positive neonates normal reflex, and other examination was normal. The midwife checked for umbilical cord, and it was unattached. Information on exclusive breastfeeding until 6^th month, baby care counselling (keeping the baby warm, bathing the baby, and sunbathing), danger signs, 5 basic immunizations (hepatitis B on baby 0 – 7 days, BCG and polio 1 on 1^st month, pentabio 1 and polio 2 on 2^nd month, pentabio 2 and polio 3 on 3^rd month, pentabio 3 and polio 4 on 4^th month, and measles on 9^th month), and follow up was given.

On the 2^nd week, the baby breastfed strongly, no fussing. Weight was 3750-gram, height 54 cm, heart rate 130 x/min, regular, respiration 48 x/min, positive neonates normal reflex, and other examination was normal. She was diagnosed as term neonates 14-day-old. The midwife gave education on 6 month exclusive breastfeeding, danger signs, reminder on BCG and polio immunizations, and sunbathe every morning from 7 – 8 am for 15 – 30 minutes while covering her eyes and genitalia. On 28^th day, her weight was 4350-gram, height 55 cm, BCG immunization was given on her right arm IC on 5 pm. The midwife instructed on BCG and polio adverse effects also follow up on 2^nd month for immunization.

On 11^th June 2022, Mrs. M stated wanted to used contraception. Last child’s age was 42 days and breastfed. She has not yet menstruated and not yet had sexual intercourse during postpartum. Mother did not have history on pelvic inflammatory disease, sexually transmitted infection, cervical cancer, and fluid from her vagina. The patient preferred IUD. Physical examination was normal. Our patient was analyzed as P5A0 new IUD acceptor. She was educated on IUD placement, evaluation post placement, and education on danger signs after IUD placement, and further control schedule.

Midwifery care was comprehensively done starting from the pregnancy, delivery, postpartum, neonates, and family planning. During pregnancy, Mrs. M G5P4A0 routinely checked her pregnancy, amounting 6 times: twice on the 1^st trimester, once on the 2^nd trimester, and thrice on the 3^rd trimester. USG was done twice: once on 1^st trimester and once on 3^rd trimester. This frequency fulfilled the requirement from health department that stated every pregnant mother was suggested for antenatal care and USG on 1^st and 3^rd trimester to analyze mother and baby health, minimum 6 times during pregnancy: 2x on 1^st trimester, 1x on 2^nd trimester, and 2x on 3^rd trimester [7].

The author gave minimum standard health care 10T, consist of measure weight and height, blood pressure test, upper arm circumference measuring, fundal height examination, fetus presentation and fetal heart rate examination, TT immunization, Fe tablet consumption, laboratory examination, therapy, and counseling. On Mrs. M case, nutritional status was good, appeared from weight before pregnancy 50 kg, weight during pregnancy 61 kg, height 155 cm, upper arm circumference 29 cm, and BMI 22 (normal: 19.8 – 26). The increase of normal pregnant mother from 1^st to 3^rd trimester was 9 – 13.5 kg. Mother’s height was normal due to her height not less than 145 cm [8]. In this case, the increase of the patient’s weight and her height was normal, therefore, there was no discrepancy between theory and practice.

Fetal heart rate was 145 x/min, where normal was 120 – 160 x/min, according to the normal range. In Mrs. M case, blood examination was done on 3^rd trimester, with the result of Hb 11.5 gr% showing normal hemoglobin and not anemic. Normal Hb for pregnant mother was 11 – 14 gr/dL.⁸ Further laboratory examination on HIV, Syphilis, and HbsAg was nonreactive which means mother did not suffer from sexually transmitted disease. HIV, Syphilis, and HbsAg tests were done to evaluate the presence of sexually transmitted disease early on which may interfere with maternal and neonate health [9].

Delivery was the process of opening and thinning of cervix and fetus go down through birth canal, ended in baby’s expulsion of term or preterm babies or able to live outside mother’s body through birth canal with or without help [10]. Delivery 1^st period was delivery period started from regular uterus contraction and kept increasing (by means of frequency and strength) until cervix completely dilated or 10 cm.⁶ On our case, at 10 am contraction was regular and adequate. The range between cervix opening from 7 to 10 cm was ± 2 hours. Theoretically, 1^st period in primigravida was around 8 hours, and in Mrs. M was in accordance with theory [6].

Delivery 2^nd period started from cervical opening 10 cm until baby’s expulsion [6]. In primigravida, 2^nd period was around 2 hours while in multigravida was around 1 hour. In our patient, 2^nd period was around 1 hour, which is normal, appropriate with theory and birth attendant followed the 60 steps of APN [11].

3^rd period started after birth until placenta and amniotic membrane’s birth with a maximum of 30 minutes (ranges 6 – 15 minutes after delivery) and born spontaneously or with a pressure from uteri fundus.⁶ 3^rd period active management was oxytocin injection on the 1^st minute after birth, controlled cord stretching (PTT), and uterus fundus massage [6]. Signs of placental detachment was the change on fundal shape and height, lengthened cord, and sudden and short blood burst. Placenta retention was diagnosed when placenta was born > 30 minutes, no placental detachment, and normal bleeding ± 250 cc [11]. 3^rd period care to Mrs. M was normal and according to the theory.

4^th period delivery, or observation, was phase after 3^rd period until 2 hours postpartum. Several actions were performed such as 2 – 3 times uterus muscle tone evaluation in 10 minutes, 15 minutes in the 1^st hour, and 30 minutes in the 2^nd hour, examinations of blood pressure, heart rate, uterine contraction, bladder, uterus fundus height, bleeding, joint care of mother-baby, and breastfeeding (IMD). There was no complication present on Mrs. M’s 4^th period and no discrepancies with theory.

Postpartum care (puerperium) started from the birth of placenta until uterine organs returned to their state before pregnancy, take place around 6 weeks [11]. Based on standard policy, postpartum visits were 4 times: 6 – 8 hours, 6 days, 2 weeks, and 6 weeks after birth [11]. In Mrs. M case, postpartum visits were done 4 times: 6 hours on the midwifery practice, 6 days on Mrs. M’s house, 2 weeks on Mrs. M’s house, and 6 weeks on the midwifery practice, respectively, after delivery. Postpartum care was done according to the theory.

Mrs. M’s baby cry spontaneously after birth, female with birth weight 3200 and height 51 cm, in accordance with theory on term babies 2500 – 4000 grams [11]. There were no gaps to the theory in neonate’s care. Neonates care was done 4 times: 6 hour, 6 days, 2 weeks, and 28 days in this case. On 2 weeks care, Mrs. M’s baby was educated on BCG immunization, to decrease the risk of severe TB, and polio 1, to prevent polio on extremities. On 28 days, Mrs. M’s baby was given BCG and polio 1 immunizations on 24^th June 2022, according to BCG immunization schedule which was done on 1-month-old babies.

The advantage of IUD was effective, long-term, no effect to sexual activities, no hormonal side effects, and no impact on breastmilk volume quality [12]. On 6 weeks postpartum care after family planning counselling, Mrs. M decided on IUD. This is after mother’s and her husband’s considerations because they wanted to give some time from her next pregnancy and decreasing the risk factor of multiparity complications (P5A0) and exclusive breastmilk for her baby.

Comprehensive Midwifery Care started from pregnancy, delivery, postpartum, neonates, and family planning was done great by the author, according to midwifery standard care.

1. Minister of Health. KEPMENKES 320 of 2020 Concerning the Professional Standards of Midwives. Jakarta: Minister of Health, 2020.

2. World Health Organization. Maternal Mortality. WHO, 2019, https://www.who.int/news-room/fact-sheets/detail/maternal-mortality.

3. USAID. Indonesia Demographic and Health Survey 2017. Jakarta: Statistics Indonesia, 2018.

4. The Ministry of Health of the Republic of Indonesia. Indonesia Health Profile 2017. Jakarta: Ministry of Health RI, 2018.

5. Legawati. Normal Childbirth Care. Yogyakarta: Nuha Medika, 2018.

6. Widia Shopa. Normal Childbirth Care. Yogyakarta: Nuha Medika, 2016.

7. Lyndon Saputra, and Anita Lockhart. Physiological and Pathological Postpartum Midwifery Care. Tangerang: South Tangerang Karisma Publishing Group, 2013.

8. Munthe, J. Textbook of Continuity of Care. Jakarta: Trans Info Media, 2019.

9. Darwiten, Yati Nurhayati. Midwifery Care in Pregnancy. Yogyakarta: CV, June 2019.

10. Mutmainah. Normal Childbirth and Newborn Care. Yogyakarta: CV Andi Offset, 2017.

11. Rukiyah, Aiyeyeh, et al. Childbirth and Newborn Midwifery Care. Jakarta: CV Trans Info Media, 2019.

12. Jitowinoto, Sugeng. Ministry Textbook: Family (KB) in Midwife Perspective. Yogyakarta: PT Pustaka JNPK-KR, 2019.