Continuity Of Care In Ny. L 29 th G1P0A0 at Publik Health Care

One of the programs the Central Java Provincial Government to reduce MMR and AKB which is relatively high is the One Student One Client (OSOC) program. The implementation of the One Student One Client (OSOC) program that uses the Continuity Of Care approach which is a series of continuous and continuous and comprehensive service activities. The method used in the Care of this Final Project Report is in the form of a case study using Varney's 7-step midwifery management approach and the form of SOAP. The results obtained are a case study on Mrs. L with during the postpartum period, care is given according to the needs of the mother, The conclusion from the results of this case study is that there are several gaps between theory and practice in the field, according to the situation and conditions in the field, is adjusted to the SOP that has been set.


INTRODUCTION
One of the health indicators of a country is a decrease in Maternal Mortality Rate (MMR) and Infant Mortality Rate (AKB) (Mandriwati, 2019).The Maternal Mortality Rate in this indicator is defined as all maternal deaths in every 100,000 live births during pregnancy, childbirth, and postpartum periods caused by its management but not due to other causes such as accidents or incidentals.The Infant Mortality Rate (AKB) is the number of infant deaths per 1,000 live births within one year (Ministry of Health, 2022).High MMR and AKB indicate low socioeconomic status and inadequate health services, including low perinatal and obstetric services (Rustina, 2019).
In 2021, the number of maternal deaths in Indonesia reached 7,389 deaths.This number shows an increase compared to 2020 of 4,627 deaths.Based on causes, most cases of maternal deaths in 2021 were affected by COVID-19 as many as 2,982 cases, bleeding as many as 1,320 cases and hypertension in pregnancy as many as 1,077 cases.Meanwhile, infant mortality cases in Indonesia have decreased, based on data from the Directorate of Nutrition and Maternal and Child Health shows that the number of infant deaths in 2021 was 27,566 deaths, a decrease compared to 2020, which was 28,158 deaths.The biggest cause of infant death in Indonesia is due to Low Birth Weight (BBLR) and asphyxia, other causes of death include congenital abnormalities, infections, and others (Ministry of Health, 2022).
The number of maternal death cases in Central Java Province in 2021 increased to 867 cases from the previous number of 530 maternal death cases in 2020.Based on these data, the Maternal Mortality Rate (MMR) in Central Java in 2021 increased from 98.6 per 100,000 live births in 2020 to 199 per 100,000 live births in 2021.As many as 50.7% of maternal deaths in Central Java Province occur during puerperium.The Infant Mortality Rate (AKB) in Central Java in 2020 was 7.8 per 1,000 live births and increased to 7.9 per 1000 live births in 2021.The biggest causes of infant mortality in Central Java Province are low birth weight and asphyxia (Ministry of Health, 2022).
The number of maternal death cases in Jepara Regency in 2021 has increased, from 15 deaths in 2020 to 19 deaths in 2021.Meanwhile, the number of infant deaths in Jepara Regency in 2021 decreased by 89 cases of death in 2020 to 84 cases of death in 2021 (Central Java Health Office, 2019).
The persistence of MMR in Central Java is due to an increase in the number of highrisk pregnancies, low early detection in the community, and a lack of speed and accuracy in making high-risk pregnancy referral decisions.Likewise with AKB caused by asphyxia (shortness of breath at birth), low birth weight babies (BBLR), newborn infections, pneumonia, diarrhea, and malnutrition.Efforts that can be made to reduce Maternal Mortality Rate (MMR) and Infant Mortality Rate (AKB) include implementing the Maternal and Infant Mortality Meeting (M3) Program from the village level to the district level, increasing the network of safe baby mothers by improving the referral system, efforts to early detect pregnant women with the Childbirth Planning and Prevention of Complications (P4K) Program and Antenatal Care (ANC) integrated, as well as improving the skills and knowledge of officers with various trainings including Normal Childbirth Care (APN) and Obstetric and Neonatal Emergency First Aid (PPGDON) at PONED Health Centers and PONEK Hospitals (Central Java Health Office, 2019).
Efforts to accelerate MMR reduction are carried out by ensuring that every mother is able to access quality maternal health services, such as pregnant women's health services, childbirth assistance by trained health workers in health care facilities, postpartum care for mothers and babies, special care and referrals in case of complications, and family planning services including postpartum family planning.The reduction of MMR and AKB is important because it aims to assess the quality of health services in terms of accessibility and quality in Indonesia (Mandriwati, 2019).
Assessment of the implementation of pregnant women's health services can be done by looking at K1 and K4 coverage.K1 coverage is the number of pregnant women who have received antenatal services for the first time by health workers compared to the target number of pregnant women in one work area within one year.While K4 coverage is the number of pregnant women who have received antenatal services according to standards at least four times according to the recommended schedule in each trimester compared to the target number of pregnant women in one work area within one year.The indicator shows access to health services for pregnant women and the level of compliance of pregnant women in checking their pregnancies to health workers.The coverage of K4 pregnant women's health services from 2017 to 2021 in Central Java tends to increase.However, the decrease occurred in 2020 compared to 2019, from 94.7 to 94.1% (Jepara Regency Health Office, 2021).
Another effort made to reduce maternal mortality and infant mortality in Central Java is by encouraging that every delivery is assisted by trained health workers, namely obstetrics and gynecology specialists (SpOG), general practitioners, and midwives, carried out in health care facilities.The success of this program is measured through indicators of the percentage of deliveries in health care facilities.In 2021, there were 99.9% of deliveries assisted by health workers.While pregnant women who undergo childbirth with the help of health workers in health care facilities amounted to 99.7%.Thus, only about 1.2% of deliveries are assisted by health workers but are not carried out in health care facilities (Hamdani, 2015).
The coverage of the First Neonatal Visit or KN1 is an indicator that describes health efforts made to reduce the risk of infant mortality in the neonatal period, which is 6-48 hours after birth, which includes, among others, visits using the Young Toddler Integrated Management (MTBM) approach including newborn care counseling, exclusive breastfeeding, vitamin K1 and Hepatitis B0 injection if not already given.In addition to KN1, the indicator that describes neonatal health services is complete KN, which requires that every newborn receive services.
Neonatal visits at least 3 times, namely 1 time at 6-48 hours, 1 time at 3-7 days, 1 time at 8-28 days according to standards in one work area in one year.The trend of KN 1 and KN Complete achievements from 2017 to 2021 in Central Java tends to increase although it decreased slightly in 2020 (Sarwono, 2012).
The complete KF coverage of Central Java Province in 2021 was 98.1%, an increase compared to the coverage in 2020 which was 96.5%.The trend of complete KF coverage from 2017-2021 shows that there is an increase every year (Central Java Provincial Health Office, 2022).
Birth control is one strategy to reduce maternal mortality, especially mothers with 4T conditions, namely Too young to give birth (under the age of 20 years), Too often to give birth, Too close to the distance to give birth, and Too old to give birth (over the age of 35 years).Active birth control participants are acceptors who are currently taking contraception to delay pregnancy or terminate fertility.The coverage of active family planning participants is a comparison between the number of active family planning participants and EFA in one work area at a certain period of time.EFA is a married couple bound in a legal marriage, whose wives are between the ages of 15 and 49.Henceforth, it is expected that EFA will use these contraceptives correctly.The number of EFAs in Central Java Province in 2021 was 6,408,024 pairs.Of all EFAs, 70.4 percent are active family planning participants.The coverage of active birth control participants shows the rate of contraceptive utilization among EFAs.The coverage of active family planning participants in Central Java Province in 2021 decreased by 2.5% compared to the achievement in 2020 of 72.9% (Central Java Provincial Health Office, 2022).
The program initiated by the Central Java Provincial Government to reduce the relatively high value of MMR and AKB is the One Student One Client (OSOC) program.The OSOC program uses the Continuity Of Care approach, The application of the One Student One Client (OSOC) program is one student responsible for one pregnant woman which aims to prevent complications in pregnancy that can affect the condition of the fetus in the womb, if pregnant women are monitored early, then the decrease in MMR or AKB can be minimized (Musta'in, Nugraheni & Sujianto, 2017).
Continuity Of Care is a series of continuous service activities starting from pregnancy, childbirth, postpartum, newborns and family planning services that are continuous and comprehensive, which specifically integrate women's health needs and personal circumstances of each individual (Ningsih, 2017).Continuity Of Care is a service that is achieved when an ongoing relationship is established between a woman and a midwife.Midwives are the mother's first point of contact through continuous care starting from pregnancy, childbirth and postpartum (Ministry of Health RI, 2018).
Based on this background, the author is interested in conducting a case study on "Comprehensive Midwifery Care for Mrs. L Age 29 Years at the Batealit Health Center in Jepara Regency".Obstetric care that will be carried out starts from pregnancy, childbirth, postpartum and birth control, newborns and neonates.Care was carried out comprehensively using Varney's midwifery management approach with the SOAP documentation model.

METHODS
The method used in the Care of this Final Project Report is in the form of a case study using Varney's 7-step midwifery management approach and documented in the form of SOAP, carried out on one patient who is postpartum reviewed, the success rate of COC Care can be seen from the development of the mother's condition during the puerperal phase.

RESULT
Obstetric Care for Postpartum Mothers Date : March 8, 2023 Time : 11.35 WIB.Subjective data (S), the author did puerperal care on Mrs. L, Mother said her stomach still felt heartburn, heartburn in the stomach area and milk that came out was still a little.Objective data (O), normal TTV. 2 fingers below the center, good contractions, hard, empty bladder, lochea rubra, There is a grade I perineal injury and hecting has been done.Analysis (A), Mrs. L age 29 years P2A0 6 hours postpartum with a period of taking in.Management (P), Health related to physiological changes in postpartum mothers and health care related to nutrition of breastfeeding mothers so that breast milk runs smoothly; Tell the mother the results of the examination that her condition is in good condition; Tell you that heartburn is normal because your uterus is contracting; Teaching mothers and families how to prevent puerperal bleeding due to uterine atony, namely by circularly memasase uterus; Ask mothers to fulfill nutrition during the postpartum period such as increasing the diet of vegetables, fruits, and foods that contain protein such as meat, eggs, fish, and encouraging mothers not to have food restrictions; Telling mothers to keep breastfeeding their babies as often as possible because the baby's suction reflex can stimulate milk production and encourage mothers to consume green bean juice and papaya leaf vegetables so that milk production is smoother; Encourage mothers to increase egg consumption because eggs can have a good influence on the healing of perineal wounds.It is recommended that mothers consume boiled eggs 2 eggs per day in an effort to accelerate wound healing and avoid puerperal infections; Encourage mothers to always keep their babies warm by the way the baby is always near the mother, the baby must be dressed and covered at all times, wear dry clothes, change diapers and clothes every wet, keep the baby warm by using hats, socks, hand socks, and avoid the baby being put to sleep in a cold place; Give mothers amoxicilin 500 mg 10 tablets taken one day three times, paracetamol 500 mg 10 tablets taken one day three times, Fe tablets 60 mg 10 tablets taken once a day at night; Give a vitamin A capsule of 1x200,000 IU and tell the mother to take it 24 hours after taking the first capsule, and give a blood-added tablet taken once a day at night.
March 12, 2023 Time : 10.00 WIB Subjective data (S), Mom said no complaints.The milk produced is smoother than before.Mother eats 3 times a day with moderate portions, side dishes, and various vegetables and drinks 8 glasses of water per day.Mother BAK 4-5 times per day and have defecated on day 2. Mother sleeps 5-6 hours a night, but often wakes up to breastfeed her baby, and naps 2 hours.The mother's feelings are now very happy with the presence of her baby and do not feel burdened and the husband helps the mother to take care of the needs of the mother and baby.(O), normal TTV, mid-center-symphytic TFU, contractions are good, hard, bladder is not full, lochea sanguinolenta, Sutures have begun to tighten and dry, there are no signs of infection such as wet and purulent sutures.Analysis (A), Mrs. L age 29 years P2A0 4 days postpartum.Management (P), Encouraging mothers to breastfeed their babies every 2 hours or every baby asking to breastfeed, breastfeeding babies until the baby feels full and breasts feel empty, and encouraging mothers to get enough rest that is when the baby sleeps the mother also rests.Encourage mothers and husbands to routinely do oxytocin massage so that milk production increases.
Subjective data (S), mothers say they already know about how to care for newborns, namely how to keep the baby warm, breastfeeding, and personal hygiene.Mothers want to know what birth control is suitable and allowed for breastfeeding mothers.Objective data (O), normal TTV, non-palpable TFU, Brown Lochea (serous).Analysis (A), Mrs. L age 29 years P2A0 puerperium 14 days.Management (P), Encouraging mothers to provide exclusive breastfeeding for 6 months.Tell the mother to keep breastfeeding by continuing to do oxytocin massage.Explain to mothers about the types of birth control that can be used for breastfeeding mothers such as MAL, condoms, progestin injections, IUDs, implants and pills.
Date : April 12, 2023, Time : 11.00 WIB Subjective data (S), mothers say they already know about how to care for newborns, namely how to keep the baby warm, breastfeeding, and personal hygiene.Objective data (O), normal TTV, TFU not palpable, bladder not full, No redness, no swelling of the perineum, no bleeding spots, no pus or serum, no perineal wounds.Analysis (A), Mrs. L age 29 years P2A0 puerperium 35 days.Management (P), Explain back to the mother about the types of birth control that can be used for breastfeeding mothers such as MAL, condoms, progestin injections, IUDs, implants and pills, explain the disadvantages and advantages of each birth control allowed for breastfeeding mothers.Explain to mothers about immunization for their babies listed in the MCH book.Tell the mother how to store milk properly according to the MCH book.

DISCUSSION
According to Situmorang & Pujiyanto, (2021) postpartum visits are carried out at least 4 times during the postpartum period, namely Postpartum Visit 1 at 6 hours -8 hours after delivery, KF II at 6 days after delivery, KF III at 2 weeks after delivery, KF IV at 6 weeks after delivery.At Mrs. A's postpartum visit, KF I was carried out at 6 hours after delivery, KF II at 6 days after delivery, KF III at 14 days after delivery.
Assessment of puerperium at KF 1 (6 hours post partum), it was found that Mrs. L's stomach complaints still felt heartburn and the milk released was still small.The results of the examination on Mrs. L were TFU 2 fingers below the center, hard contractions, and fresh red vaginal blood discharge (lokhea rubra) approximately 5cc.There is a suture wound on the perineum.Mom has BAK but not defecated.
The care given to KF I is to teach mothers how to breastfeed and encourage mothers to breastfeed their babies, tell mothers how to care for the umbilical cord on babies, tell mothers about danger signs during the puerperium, according to the Ministry of Health of the Republic of Indonesia (2020, p. 28) danger signs in postpartum mothers, namely: Fever for more than 2 days, smelly discharge from the birth canal, bleeding through the birth canal, depression, oedem in the face and extremities, swollen breasts accompanied by pain, giving mothers health care to fulfill nutrition during the puerperium such as increasing eating vegetables, fruits, and foods that contain protein such as meat, eggs, fish, and encouraging mothers to have no dietary restrictions, telling mothers to keep breastfeeding their babies as often as possible because the baby's suction reflex can stimulate milk production and encourage mothers to consume green bean juice and papaya leaf vegetables so that milk production is smoother, encourage mothers to increase egg consumption because eggs can have a good influence on the healing of perineal wounds, health related to keeping the baby warm by the way the baby is always near the mother, the baby must be dressed and covered at all times, wear dry clothes, change diapers and clothes every wet, keep the baby warm by using a hat, socks, hand socks, and avoid putting the baby to sleep in a cold place.
KF II was carried out on 4 days post partum and in the results of the study, Mrs. L found a complaint that the mother said her stomach was still heartburn and the milk released by the mother was small.The results of the examination conducted on KF II Mrs. L were palpable TFU mid-center-sympisis, PPV yellowish-red (sanguinolenta), no redness in the calves and no oedem in the extremities, no nipples blisters but little milk produced.The care given to KF II is to provide KIE balanced nutrition for postpartum mothers, because breastfeeding mothers need 500 calories more per day than those who do not breastfeed, explain to mothers and families the benefits of oxytocin massage, which can facilitate and multiply milk production, make mothers more relaxed and comfortable, teach mothers and families how to do oxytocin massage, Encourage mothers to do regular massage every day.
Based on research conducted by Pilaria and Sopiatun (2017) in their journal on the Effect of Oxytocin Massage on Breast Milk Production in Postpartum Mothers in the Working Area of the Pejeruk Health Center in Mataram City in 2017 stated that there is an effect of oxytocin massage on milk production in postpartum mothers due to massage or stimulation of the spine, neurotransmitters will stimulate the medulla oblongata directly send a message to the hypothalamus in the posterior hypophyse to secrete oxytocin causes the breasts to release milk.
KF III was carried out on 14 days after Mrs. L's delivery, the mother said that milk production had increased and the milk released was smooth.The results of the examination obtained by the mother's breasts were felt tense and the milk had smoothly come out, there was no swelling and redness, TFU was not palpable, there was no oedem on the extremities or face.The care given to mothers is, asking mothers to breastfeed and evaluate how to breastfeed mothers, encouraging mothers to breastfeed babies as often as possible at least once every 2 hours, and exclusively for 6 months.The author also provides care about preliminary information about effective birth control for breastfeeding mothers.Birth control counseling is given with the aim of increasing knowledge and stability in choosing the right contraceptive, in accordance with research conducted by Basuki & Soesilowati (2015) in their research on the Effect of Knowledge About the Kb Program on the Stability of Contraceptive Selection at RSIA Aprillia Cilacap, state that counseling is effective to increase knowledge and stability in choosing contraceptives.
At the end of the counseling, the author helped the mother to determine the type of contraception that Mrs. L would use with the media using leaflets.Mother plans after 42 days to use injectable birth control for another 3 months.KF IV was carried out on the 35th day after giving birth Mrs. L, ibu said there were no complaints and already knew about how to care for newborns, namely how to keep the baby warm, breastfeeding, and personal hygiene.The author reminds mothers about the types of birth control, benefits, disadvantages, advantages and types of birth control that mothers will use.The visit of KF I to KF IV carried out by the author is in accordance with theory and needs, so there is no gap between theory and practice in the field.

CONCLUSION
In postpartum obstetric care at Mrs. L evidence based postpartum given in the form of oxytocin massage which is useful for increasing milk production, eating vegetables dun papaya to increase milk production and consuming broiler eggs to accelerate the healing of perineal wounds.Mothers follow every recommendation given and evidence-based given by the author successfully, characterized by increased milk production.Then in obstetric care, birth control in Mrs. L was given by providing evidence-based given by the author about the health care method used after childbirth that does not interfere with breast milk production using leaflet media.At the end of the counseling, the mother was helped to determine what type of contraception she wanted to use, and Mrs. L said she wanted to use a 3-month injectable contraceptive that would be done after her postpartum period was over.There is no gap between theory and practice in postpartum care and family planning. .