Background

The success of maternal health programs can be assessed through the leading indicators of the Maternal Mortality Rate (MMR). In the Sustainable Development Goals (SDGs), the target for reducing the MMR globally in 2030 is 70 per 100,000 live births. The number of maternal deaths compiled from the recording of family health programs at the Ministry of Health in 2020 shows 4,627 deaths in Indonesia. This number shows an increase compared to 2019 of 4,221 deaths. Based on the causes, the majority of maternal deaths in 2020 were caused by bleeding 28.7% (1,330 cases), hypertension in pregnancy 23.98% (1,110 cases), circulatory system disorders 4.97% (230 cases), and other causes 42.3% (1,957 cases) [1]. The maternal mortality rate exposed to Covid 19 for the April 2020-April 2021 period was 3% of 536 pregnant women.

Efforts to accelerate the decline in Maternal Mortality Ratio (MMR) are carried out by ensuring that every mother can access quality maternal health services, such as health services for pregnant women. Other services are delivery assistance by trained health workers in health care facilities, postnatal care for mothers and babies, special care, and referrals in case of complications. Moreover, the services are family planning services, including postnatal family planning. Continuity of care in midwifery is a series of continuous service activities ranging from pregnancy, childbirth, postpartum, newborns, and family planning. Continuity of care carried out by midwives is generally oriented to improve the continuity of service within a period. Continuity of care has 3 services: management, information, and relationships. Continuity management involves communication between women and midwives. Continuity of information concerns the availability of relevant time. Both are important for regulating and providing midwifery services [2].

The World Health Organization recommends that regular pregnancy check-ups be carried out at least eight times after adaptation to related professions and programs. It is agreed that in Indonesia, antenatal care is carried out at least six times with a minimum of two doctor contacts to screen for risk factors and pregnancy complications in the first trimester and screening for risk factors for delivery once in the third Trimester (Ministry of Health, 2020). Pregnancy check-ups are carried out six times, namely twice in the first trimester (early pregnancy up to 12 weeks), once in the second trimester (pregnancy above 12 weeks to 24 weeks), and three times in the third trimester (pregnancy above 24 weeks to 40 weeks). Integrated antenatal care is provided to all pregnant women by providing positive experience opportunities for every pregnant woman to get integrated antenatal care [1]. The minimum integrated antenatal care standards are as follows: weigh and measure height, measure blood pressure, assess nutritional status (measure upper arm circumference), measure the height of the top of the uterus (fundus uteri), determine the fetal presentation and fetal heart rate, screening for tetanus immunization status and giving tetanus-diphtheria (Td) immunization if needed, giving blood supplements of at least 90 tablets during pregnancy, triple elimination tests (HIV, syphilis and hepatitis B), case management, and talk meeting.

Pregnancy is a condition in a woman’s uterus; there are products of conception (the meeting of the ovum and spermatozoa). Birth and pregnancy are physiological, but if not managed properly, they will become pathological [3]. Approximately 40% of pregnant women experience health problems, and 15% of all pregnant women suffer from life-threatening long-term complications that can even lead to death. The quality of antenatal care is needed during pregnancy, regularly following predetermined antenatal care guidelines to maintain and improve maternal health according to needs so that they can complete pregnancy well and give birth to healthy babies.

Pregnancy and childbirth are natural and regular events, but for some mothers, it can be a period of crisis in their lives. This is because in every pregnancy until delivery, the mother experiences physical and psychological changes, so there is a need for adaptation or adjustment. During the third trimester of pregnancy, maternal discomfort often occurs, one of which is back pain. This discomfort is expected due to changes in the center of gravity of the pregnant woman’s body as the fetus grows in the uterus, and increased levels of the hormone’s estrogen and progesterone, which can relax the joint area of ​​bone and muscle bonds in the hip area [4]. The cause of low back pain from a biomedical angle is due to the forward displacement of the center of gravity. The gravitational pressure of the uterus on the blood vessels reduces blood flow to the spine and causes back pain. 

Back pain is the most common cause of long-term disability worldwide, with as many as 6 out of 10 pregnant people during pregnancy. In Indonesia, 60% to 80% of pregnant women have back pain [5], which is one of the causes of the incidence of Sectio Caesarea delivery. Back pain in pregnant women usually occurs in the lower back area, sometimes spreading to the buttocks and thighs, sometimes down to the legs. The intensity of pain can usually occur because the mother is standing or sitting for too long, bending over, and lifting heavy weights. The effect of back pain is sleeping disturbances that can cause fatigue and discomfort in carrying out daily activities. This situation can cause the fetus to become fetal distressed, where the mother’s condition can affect the condition of the fetus, and insomnia can also inhibit mobility.

Management of low back pain is necessary to reduce discomfort. A preliminary study was conducted at the Serangan Sub-district Health Center from January to March 2022; 60% of 10 pregnant women had back pain. The bad impact if back pain does not get treatment is difficulty walking if the pain has spread to the pelvic and lumbar area, with various impacts that can occur, then the back pain must get treatment. Non-pharmacological therapy needs to be done to reduce complaints of low back pain experienced by pregnant women in the third trimester. This therapy includes continuous stimulation (massage, hot and cold applications, acupressure, contralateral stimulation), Transcutaneous Electrical Nerve Stimulation (TENS), acupuncture, relaxation, imagination, meditation, hypnosis, aromatherapy, yoga, and reflexology [6].

Based on this background, the author has the opportunity to provide midwifery care to pregnant women "WN" from the second trimester to the postpartum period and baby care with the consideration that the mother can meet the requirements as pregnant women who will be given comprehensive midwifery care and complementary care.

Theoretical Review

Continuity of Care Midwifery Care is midwifery care provided to women from pregnancy to using contraceptives. Pregnancy is the fertilization or union of spermatozoa and ovum and continues with nidation or implantation. Pregnancy is divided into 3 trimesters, namely, the first trimester lasts for 12 weeks, the second Trimester (13^th to 24^th week), and third Trimester (24^th to 40^th week) [7]. normal pregnancy will take place within 40 weeks. Spiegelberg used distance measurement from the symphysis to the fundus as the basis for calculating gestational age in weeks (Table 1,2,3). The average increase per week was 0.8 cm. The recommended regular fundal height measurement was done at the 10th to 90th percentile. A fundus smaller than the 10th percentile indicates IUGR, Small Gestational Age. More funds more significant than the 90th percentile reflect Large Gestational Age, polyhydramnios, or multiple pregnancies.

Table 1: Estimates of Fundal Height on Gestational Age according to Spiegelberg

Table 2: Estimated Fundal Heights of Various Gestational Ages

Source: [8]

Table 3: Fundal Height at 10th, 50th, and 90th Percentiles in Centimeters Between 20 and 40 Weeks of Gestation [9]

Case Determination Method

Case Pick-Up Location: This midwifery care is carried out at the auxiliary health center in The Regional Technical Implementation Unit of Public Health Center III Department of Health, South Denpasar District.

Case Determination Method

The method used in data collection was the method of interview, observation, and documentation. The first data review was carried out on September 30, 2021.

In the study, it was found that Mrs.’ WN” was pregnant with her second child at the age of 26 years with a distance of 3 years. The first day of the last menstruation was May 25, 2021, and the interpretation of labor was March 1, 2022.

Results of the Implementation of Midwifery Care for Mrs. “WN” and Her Fetus from Second Trimester Pregnancy until Before Delivery

The mother routinely checks her pregnancy to health facilities 8 times during pregnancy. Mother had made antenatal visits in the first Trimester 2 times, in the second Trimester 2 times, and in the third Trimester 4 times. During pregnancy, the mother carried out visitations under standards set by the Ministry of Health of the Republic of Indonesia. Visitation at least 6 times with details 2 times in the 1st trimester, 1 time in the 2nd trimester, and 3 times in the 3rd trimester. At least 2 times were examined by a doctor during the 1st trimester visit and the 5th visit in the 3rd trimester [1].

The measurement of the height of the uterine fundus at 33 weeks of gestasional ages did not match the gestational age, which was 30 cm. According to Yuliani [10], a regular uterine fundal height measurement must be the same as the gestational age in weeks determined based on the first day of the last menstruation. If the measurement results were 1-2 cm different, it could still be tolerated, but if the deviation was less than 2 cm from the gestational age. There may be fetal growth disturbances. The mother had been given biscuits for pregnant women and nutritional counseling, and the mother had an ultrasound with expected weight results. When the gestational age was 37 weeks 3 days, the fundal height was 31 cm and the fetal weight was interpreted using the Johnson Tausack formula by means that if the lowest part had entered the pelvic inlet, then the fundal height was reduced by 11 times 155 to get an interpretation of 3100 grams. According to [11] at 37 weeks of gestation, the fundal height measurement was 35.7 cm, with a standard deviation of 31.8. According to Yuliani [10], at 38 weeks of gestation, the estimated height of the uterine fundus was 33 cm. In the case of Mrs.’ WN’, the increase in gestational age did not match the ideal figure even though the mother’s weight had increased. Accordingly, this was due to the placenta functioning less than optimally in the absorption of maternal nutrients; hence, the correlation between maternal weight and uterine fundus increase was inappropriate and unbalanced.

Weight gain by 8 kg (from 64 kg to 72 kg during pregnancy). The body mass index before pregnancy was 27.7. BMI of 27.7 was included in the overweight category (BMI 26 – 29), and the recommended increase was 7–11.5 [12]. Supplementary feeding was an effort to prevent stunting, and it was hoped that mothers would not give birth to low birth weight babies. Supplementary food for pregnant women was nutritional supplementation in layered biscuits made with unique formulations and fortified with vitamins and minerals. The nutritional content of supplementary feeding per serving 3 pieces (60 grams) contains 100 kcal of energy, 4 g of fat, 2 g of protein, 14 g of carbohydrates, 70 mg of sodium, vitamins A, D, E, B1, B2, B3, B12, Folate, B6, B5, Vitamin C, Iron, Calcium, Zinc, Iodine, Phosphorus, Selenium. Indonesian women were given PMT starting at 30 weeks and 33 weeks for the prevention of low birth weight, where the height of the uterine fundus at 33 weeks of gestation was 30 cm, and at 37 weeks of gestation, the height of the uterine fundus became 31 cm, the interpretation of the fetal weight was 3100 grams.

Mrs. “WN” had a routine pregnancy control at 30 weeks to postpartum with complaints of back pain. The author provides counseling that back pain was a physiological change experienced by pregnant women and recommends ways to deal with lower back pain. Some solutions were standing with good posture (standing straight and shoulders pulled back), avoiding excessive bending, avoid wearing high heels, using warm compresses on the back and while sleeping, and using a mattress that supports and guides the mother to do some prenatal yoga movements. The author gives examples of pregnancy exercises carried out in pregnant women’s classes, which mothers could do at home through examples of pregnant exercise videos that mothers could easily access on the Youtube channel of midwife Jaba. (The videos were made in collaboration with Dr. Ni Wayan Ariyani, S.ST., M.Keb.) and then applied in the expected house to overcome the back pain that mothers complain about. Back pain is a discomfort disorder that occurs in pregnant women and is normal due to the changing center of gravity of the pregnant woman’s body as the fetus grows in the uterus. The increased levels of estrogen and progesterone can relax the joint area of ​​bone and muscle bonds in the hip area [4]. The cause of low back pain from a biomedical angle was due to the forward displacement of the center of gravity. The gravitational pressure of the uterus on the blood vessels reduces blood flow to the spine and causes back pain . The pain intensity can usually occur because the mother was standing or sitting too long, bending over and lifting heavy weights. The effect of back pain was sleep disturbances that can cause fatigue and discomfort in carrying out daily activities [13].

Prenatal yoga is a modification of basic yoga exercises adapted to pregnant women’s conditions. Yoga is a body, mind and mental exercise that helps pregnant women flex their joints and calm their minds, especially in their second and third trimesters. Movements in prenatal yoga are made at a slower tempo and adjust to the space capacity of the pregnant woman. Prenatal yoga has five ways: physical yoga practice, breathing (pranayama), position (mudra), meditation, and deep relaxation. It can be used to get benefits during pregnancy to help smooth pregnancy and birth naturally and help ensure a healthy baby. Based on Wulandari et al., [14]  prenatal yoga can reduce back pain complaints in third-trimester pregnant women. Prenatal yoga can reduce back pain in pregnant women [15].

The author provides counseling to mothers regarding physiological changes in the third trimester of pregnancy and how to overcome complaints of frequent urination. Mrs. “WN” complained of frequent urination at 38 weeks of pregnancy. This complaint was physiological in TM III, resulting from the pressure of the uterus forward, causing the bladder to feel full quickly and urinate frequently. Ziya [16] stated that frequent urination that often occurs in the third trimester was due to the pressure of the uterus on the bladder. Frequent physiologic urination, which usually occurs in pregnant women, was caused by increased urination due to a decrease in the head to the upper pelvic and frequent bowel obstruction (constipation) due to the increase in the hormone progesterone. Kegel exercise therapy is a non-pharmacological therapy that strengthens pelvis muscles to control urine output during intercourse. Moreover, it increases satisfaction during intercourse it is because this therapy increases vaginal grip and sensitivity to sexual stimulation, prevents “small bedwetting” that occurs when coughing or laughing, facilitates the birth process without having to tear the birth canal and accelerates healing after childbirth [16].

Results of the Implementation of Midwifery Care for Mrs. “WN” and Newborns During the Delivery Process

The labor process for Mrs. “WN” lasted 7 hours, and she entered labor at 38 weeks 4 days of gestation based on the calculation of first day of last menstruation. Labor is normal if it occurs between 37-42 weeks of gestation. Based on this, the mother’s gestational age was in the labor period. The first stage of labor is physiological. It begins until the cervix reaches complete dilatation (10 cm). It is divided into two phases: the latent phase marked by cervical dilatation to 3 cm. It is in ranges from eight hours, and the active phase starts from 4 cm dilatation to complete dilatation of 10 cm, which lasts for 7 hours. Contractions will be stronger and more frequent during the active phase [7].

In the first stage of labor, Mrs. “WN” experienced pain. The author recommends the mother’s relaxation techniques with lavender aromatherapy. Lavender aromatherapy is a therapeutic action that improves mothers’ physical and psychological conditions in labor. Physically it is good to use to reduce pain, while psychologically, it can relax the mind, reduce tension and anxiety and provide peace. Pleasant odors stimulate the thalamus to secrete enkephalins, which act as natural pain relievers and produce a feeling of well-being. Enkephalins are the same as endorphins, which are endogenous chemicals (produced by the body) with a structure similar to opioids [17]. One of the techniques to reduce pain during labor is non-pharmacologic techniques. During labor therapy, the mother sits as comfortably as possible, and the ball shape that can adjust to the mother’s body shape makes it easier for the mother to relax. Besides that, the ligaments and muscles, especially those in the pelvic area, become loose and reduce pressure on the sacroiliac joints, blood vessels around the uterus and pressure on the uterus, bladder, back, waist, tailbone and can reduce pressure on the perineum [18]. One form of birth ball used in labor is a peanut ball or known as a peanut ball. A peanut ball is used in physical therapy or simple exercises shaped like a pea and right between the woman’s legs so that both legs can open the pelvic muscles to increase labor progress and facilitate the descent of the fetal head [19]. Birth ball exercises can increase self-efficacy during labor. This effect may be due to the mechanisms responsible for coping skills that help with the pain. In addition, the birth ball can facilitate sacroiliac and lumbosacral joint mobilization and oblique and transverse muscle tightening to help pregnant women regulate their birth with good posture. Similarly, McCrea and Wright suggested that birth ball exercises can relieve labor pain by increasing positive emotional feelings in laboring women [20].

Based on the research of Pujiastutik et al. [21], giving massage can produce pain-relieving compounds, namely endorphins which can block pain messages so that they are not transmitted to the brain so that pain does not occur. In general, the results of the research above show that endorphin massage and effleurage massage are effective in reducing pain to reduce pain. However, in this study, the average respondent experienced much reduction in endorphin massage treatment compared to effleurage massage because in this study, most of the respondents experienced back pain and the duration of endorphin massage was 30 minutes every hour at the time of delivery. Endorphin massage was done by pressing the back area continuously so that the sensation of pain experienced by respondents during childbirth tends to decrease when compared to effleurage massage. Effleurage massage was done by gently massaging the lower part of the umbilicus above the pubic symphysis slowly in that area. Endorphin massage could reduce pain faster than effleurage massage. Thus, there was a comparison between endorphin and effleurage massage to reduce primigravida latent pain.

A warm compress will increase blood flow and relieve pain by removing inflammatory products, such as bradykinin, histamine, and prostaglandins, that cause local pain. The heat will stimulate the nerve fibers that close the gate so that the transmission of pain impulses to the spinal cord and the brain is inhibited and provides calmness [22]. Another technique to overcome labor pain is relaxation music therapy. Music that has entered the pituitary gland can provide emotional responses through negative feedback to the adrenal glands to suppress the release of the hormone epinephrine, norepinephrine and dopa, called the stress hormone. Mental problems such as reduced stress, calmness and relaxation [23].

The second stage of labor lasts 15 minutes from complete dilation until the baby’s birth. The second stage of labor begins when the cervix is ​​dilated to 10 cm and ends with the baby’s birth. This process usually lasts two hours in primigravida and one hour in multigravida. Based on the documentation results, the care provided during the second stage followed the standards. According to JNPK-KR , the standard of delivery care was before giving birth assistance by first observing the signs and symptoms of the second stage of labor, then preparing delivery assistance, preparing an environment suitable for newborns by ensuring a clean and warm room, providing maternal care, adjusting the delivery position and guiding effective pushing during peak contractions and resting between contractions, then assisting delivery following normal delivery care and applying the principles of infection prevention. The third stage of labor lasted for 5 minutes; the placenta was complete at 08:50 pm. This condition follows the standards according to [7]. third stage begins immediately after the baby’s birth and ends with the birth of the placenta, which lasts no more than 30 minutes. After the baby’s birth, active management of the third stage is carried out to produce more effective uterine contractions to reduce time, prevent bleeding, and reduce blood loss in the third stage of labor. The care that Mrs. “WN” received was following the standards. Active management of the third stage has been carried out within one minute after the baby was born, given an injection of oxytocin 10 IU intramuscularly in the distal lateral of the upper thigh. Giving oxytocin within one minute after the baby is born aims to increase uterine contractions. It will narrow the placental area because the uterus is smaller, and its walls thicken a few centimeters. Then change the base cloth and cover the baby’s body with a clean cloth, clamp and cut the umbilical cord, and hand the baby over to the mother for an early initiation of breastfeeding. Followed by controlled umbilical cord tension when there is a contraction. Controlled tension of the umbilical cord during contractions aims to release and deliver the placenta. This treatment has the effect of detachment and descent of the placenta. Potential complications are uterine inversion and partial retention of the placenta. The placenta was born at 1 am with a complete impression and no calcifications. Then proceed with uterine fundal massage for 15 seconds so that the results of maternal uterine contractions are good [24]. Uterine massage is done to stimulate the uterus to contract well and strongly. The uterus closes the open blood vessels in the placental area by continuing to contract. This closure prevents heavy bleeding and accelerates the shedding of the extra uterine lining that forms during pregnancy.

The fourth stage of care is following the standards. There was a grade II perineal laceration in the birth canal.

Results of the Implementation of Midwifery Care for Mrs. “WN” during the Postpartum Period Up to 42 Days

During the puerperium, the author visited and assisted the examination four times to determine the condition and development of the mother after giving birth. The care provided follows standards regarding guidelines for antenatal care, postpartum, postnatal, and newborns in the new normal era. The first postpartum care (KF 1) was carried out 6 to 2 days after delivery, and the second postpartum visit (KF2) was given three to 7 days after delivery. The third postpartum visit (KF 3) is given on days 8 to 28 after delivery, and the fourth postpartum visit (KF 4), services are carried out on days 29 to 42 days postpartum. Uterine involution usually proceeds with no complications up to 42 days. Lochia discharge was normal without any complications. The lactation process went well; there were no sore nipples, breast swelling, or other complications, and the mother was committed to exclusively breastfeeding her baby.

During the puerperium, the author gives IEC counseling to perform perineal wound care while maintaining good personal hygiene and consuming foods that contain lots of protein. Mother’s hygiene helps reduce the source of infection and will make the mother feel comfortable. Caring for and keeping the mother’s perineum clean and dry and cleaning the genitals from front to back will heal the wound healing process quickly. Performing care or personal hygiene aims to prevent the risk of infection [25]. This is in line with the theory put forward by Smeltzer et al. [26], which states that nutritional factors, especially protein, will significantly affect the wound healing process in the perineum because tissue turnover needs protein. With the realization of all the foods recommended for postpartum mothers, the wound healing process will heal faster and dry.

Expenditure of mother’s milk occurs on the first day postpartum. When the baby was born, there was a small amount of colostrum, but it was still stimulated by sucking the baby. On the first day, there was already a loss of colostrum but in small amounts. Milk production is influenced by stimulation from the baby’s sucking. The day after delivery, the mother was given complementary therapy with SPEOS massage (Stimulation of Endorphin Oxytocin Massage Suggestion) to facilitate breastfeeding. The husband also teaches this method to be done daily at home. The SPEOS method is a combination of endorphin, oxytocin, and suggestive massage stimulation carried out sequentially. The role of the pituitary is to release endorphins from the body; their effects resemble heroin and morphine. The next role is to secrete prolactin which will trigger and maintain the milk secretion from the mammary glands. In line with the above statement, the research of Widayanti et al. [27]  reported that after the SPEOS intervention, the majority of mothers produced breast milk 24 hours after giving birth, while the control group produced breast milk 72 hours after giving birth.

A study by Lestari et al. [28] showed that there are postpartum mothers, and the SPEOS method can be used as an intervention to increase breast milk production. In addition to increasing production, SPEOS has the advantage that it can be done early on to have a good impact on the acceleration of breast milk release and provide confidence and comfort.

Results of the Implementation of Midwifery Care for Mrs. “WN” Infants Up to 42 Days

Normal newborns are babies born from 37-42 weeks of gestation with a birth weight of 2,500-4,000 grams, crying immediately, active muscle tone, and without congenital disabilities [29]. Based on this, the Mrs. “WN” baby belongs to the category of normal newborns, namely those born at term gestational age of 38 weeks 4 days, crying immediately, active movement, firm muscle tone, reddish skin and weight of 2900 grams.

Mother’s baby “WN” was born spontaneously at 20.45 WITA, immediately cried, active muscle tone, and female gender. At the time of birth, the baby has been treated for newborns including prevention of heat loss, umbilical cord care, giving an injection of vitamin K1 1 mg intramuscularly (IM) on the baby’s left thigh, applying antibiotic eye ointment in both eyes of the baby, and giving Hepatitis B immunization (HB0) 0.5 ml 1 hour after giving the vitamin K injection. HB0 immunization for infants is given one hour until they are 7 days old.

• Midwifery care during pregnancy takes place physiologically. The mother has received the standard of care, and the examination was 2 times in the first trimester, once in the second trimester, and 3 times in the third trimester

• Midwifery care during labor takes place physiologically and without complications. The mother gave birth at 38 weeks 4 days of gestation. Babies born spontaneously immediately cry and in normal conditions

• Midwifery care during the puerperium takes place physiologically and without complications. Mother was already using intrauterine device contraception

• Midwifery care from neonates to 42 days takes place physiologically. During the provision of care, the baby does not experience problems, and the baby's growth and development proceeds normally

Recommendations

For Health Institutions: Health institutions are expected to be able to provide health services following standards related to care during pregnancy, childbirth, postpartum and infant.

Midwives

Midwives are expected to provide midwifery care according to standards and authority and improve early detection of complications to prevent problems and complications during pregnancy, childbirth, postpartum and infancy.

For Students

Students are expected to develop knowledge and improve skills in providing care

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