Continuity Of Care For Postpartum Mothers With Breastfeeding Problems At Puskesmas Batealit Jepara

Continuity of care (COC) midwifery care is one way to be able to provide care and carry out continuous documentation to reduce complications that occur, besides that this care is reviewed from the postpartum period which is carried out continuously and continuously. The purpose of the study is to apply midwifery care management to mothers in continuity of care (COC). Method; Type of descriptive research case study method conducted on 6 respondents who are different from puerperal cases. The results of pregnancy care are carried out according to the standards of care for the last postpartum visit, intervention is carried out according to existing complaints, namely with cabbage leaf compresses. The results that have been obtained by the patient feel that the milk comes out smoothly and does not look tense and full. The results of COC midwifery care are able to overcome the problem of breast milk that is not smooth with the use of materials at home


INTRODUCTION
Based on the Indonesian Demographic and Health Survey from 2012 to 2017, it is 390 per 100,000 live births.However, in 2021, the maternal mortality rate was still high at 359 per 100,000 live births, a slight decrease although not significant.MMR declined again in 2022 to 305 per 100,000 live births.With MMR still high, the government is carrying out the SDGs (Sustaainable Development Goals) program, which is a continuation program of the MDGs (Millennium Development Goals) starting from 2017 to 2030.One of the targets is to reduce maternal mortality to below 70 per 100,000 live births by 2030 (Kementrian Kesehatan RI, 2021).
The maternal mortality rate in Central Java Province has also decreased from 111.16 per 100,000 live births to 109.65 per 100,000 live birth in 2022.While in Central Java the causes of maternal death are bleeding (21.14%), hypertension (26.34%), and others (40.49%).Other causes of MMR include late recognition of danger signs and making decisions, late reaching health facilities, late getting health services (Dinkes Jawa Tengah, 2023).
Maternal mortality in Indonesia is still dominated by three main causes, namely bleeding (30.3%), hypertension in pregnancy (27.1%), and infection (7.3%).Therefore, to assess the welfare of the population including mothers and children, the Ministry of Health, in 2017 launched the Expanding Maternal and Neonatal Survival (EMAS) program in order to decrease in MMR and AKB by 25%.This program is implemented in provinces and districts with a large number of maternal and neonatal deaths, namely North Sumatra, Banten, West Java, Central Java, East Java, and South Sulawei (Kemenkes RI, 2021).
According to the Jepara District Health Office, the number of maternal deaths in Jepara Regency was 19 cases from 30 health centers, the most cases were found in the Annual Puskesmas as many as 3 cases, then Batealit 1 case and the most cases in hospitals as many as 12 cases.AKB until July as many as 42 cases, the most cases at Bangsri 1 Health Center with 9 cases then Mayong and Nalumsari as many as 6 cases.Meanwhile, at the Puskesmas Kembang there are no cases of maternal and infant deaths Midwifery care is a decision-making process and actions carried out by midwives in accordance with the authority and scope of their practice based on midwifery knowledge and tips.Midwifery care also applies functions and activities in providing services to clients who have needs/problems in the fields of maternal health during pregnancy, childbirth, postpartum, babies after birth, and family planning, (Sutanto & Fitriana, 2019).
In addition, students also carry out continuous care or COC (continuity of care) which is a patient-based learning concept and students can learn directly from patients.In addition, students also actively participate in the COC (continuity of care) experience so as to be able to develop and provide women-centered care.In order to achieve the correct COC (continuity of care) students are asked to provide a number of treatments in the field of obstetrics, involving different patients during the antenatal care, intranatal care, and postnatal periods (Ulfina et al, 2021).
One of the things that can cause obstacles in exclusive breastfeeding is the presence of breast problems.One of the problems in the breast that often occurs is breast milk dam or breast swelling.Breast milk dams are dams of milk due to narrowing of the active ducts or glands that are not emptied completely.Breast swelling often occurs on the second to tenth day postpartum.Most patients feel swollen, red, hard, painful and hot breasts.The causes of breast milk are not smooth including the ineffective frequency of milk discharge, this can be caused by several things, including the absence of breast care so that breast milk is not smooth, and the existence of improper and effective breastfeeding techniques (Subekti, 2017).
Cabbage or cabbage (Brassica oleracea var.Capitata) is an economical vegetable that is very easy to find.Cabbage.Contains the amino acid glutamine which is believed to treat all types of inflammation, one of which is inflammation that occurs in the breast.Cabbage is also rich in sulfur content which is believed to reduce breast swelling and inflammation.Based on the description above (Dalimartha, S dan Adrian, F. 2015), researchers are interested in conducting a case study study on the use of cold cabbage leaf compresses as a companion therapy for breast milk problems that are not smooth and tense in the breast.

METHODS
The method used in this study is descriptive by applying the principle of midwifery care continuity of care and documented in the form of SOAP. the implementation time is carried out at the Batealit Jepara Health Center from Mei 22, 2022 to June 3, 2023 Continuity of care implementation conducted on 6 patients studied in postpartum care to provide the success rate of COC care can be seen from the problems experienced by pregnant women and the provision of interventions on these problems.The analysis was carried out using an in-depth interview method related to the history of perceived complaints.

RESULT
Respondent 1, the assessment will be conducted on May 26, 2023, at 05.00 WIB.Subjective data, Mother said her belly still looks big, breast milk is not smooth.Objective data, normal vital sign.Fundus Uteri Height 2 fingers below center, contractions are good, hard, bladder is not full, lochea rubra.Analysis, Mrs. Sdr, 27 years old P1 A0 Post Partum 9 hours physiological puerperium.Planing, teach mothers to do cabbage leaf compresses, teach mothers proper breastfeeding techniques and keep breastfeeding to their babies, keep the baby warm, Provide explanations and teach about abdominal exercises, tell mothers can go home now and encourage mothers to revisit for another 3 days or anytime if there are complaints Respondent 2, the study was conducted on May 28, 2023, at 15.45 WIB Subjective data, mothers complain that their milk is not smooth and feel that their babies drink like just tasting.Objective data, normal vital sign, mid-center-symphytic Fundus Uteri Height, good contractions, hard, incomplete bladder, lochea sanguinolenta, there are sutures in the 2nd degree perineum, breasts appear tense.Analysis, Mrs. S 26 years P1A0 3 days post partum.Management, teaches mothers about cabbage leaf compresses, explains about puerperal danger signs, ensures mothers can meet their nutritional and rest needs, ensures mothers breastfeed well and tells mothers that mothers must maintain genital hygiene.
Respondent 3, the assessment will be conducted on May 30, 2023, at 15.00 WIB.Subjective data, the mother wants to check her health and her breast milk is not smooth.Objective data, normal vital sign, Fundus Uteri Height mid-center-symphytic, bladder not full, lochea alba, breasts appear tense.Analysis, Mrs. M 27 years P1A0 3 days post partum.Planing, teach mothers about cabbage leaf compresses, provide health education about the importance of breastfeeding babies.
Respondent 4, the assessment will be conducted on June 3, 2023, at 15.30 WIB.Subjective data, the mother said the milk was not smooth, the mother wanted to check her health.Objective data, normal vital sign, Fundus Uteri Height mid-center-symphytic, bladder not full, lochea alba.Analysis, Mrs. D 27 years P1A0 3 days post partum.Planing, tell the results of the examination, do inform consent, teach mothers about cabbage leaf compresses, teach proper breastfeeding techniques.
Respondent 5, the assessment was conducted on June 5, 2023, at 05.30 WIB.Subjective data, Mother has given birth 9 hours ago, breast milk has not been smooth.Objective data, normal vital sign.Fundus Uteri Height 2 fingers below center, contractions are good, hard, bladder is not full, breasts look tense, lochea rubra.Analysis, Mrs. R, 27 years old P1A0 Post Partum 9 hours physiological puerperium.Planing, Teach cabbage leaf compresses, encourage mothers to join and keep breastfeeding their babies, keep the baby warm.
Respondent 6 June 6, 2023, at 15.35 WIB Subjective data, the mother does not feel her milk comes out smoothly.Objective data, normal vital sign, mid-center-symphytic Fundus Uteri Height, good contractions, hard, not full bladder, lochea sanguinolenta, breasts appear tense and full, no perineal tear.Analysis, Mrs. W 27 years old P1A0 3 days post partum.Planing, explaining and teaching about cabbage leaf compresses, and health education on how to breastfeed properly.

DISCUSSION
Based on the above study, Obstetric Care for postpartum mothers in the first and fifth patients there were complaints at 9 hours post partum day 3, said breast milk had not been smoothly managed by giving oxytocin massage, while in patients 2nd and 3rd, 4th and 6th said that on day 3 breast milk came out less smoothly, there were no obstacles in the implementation of the study.In conducting studies to collect data, the author did not experience difficulties because in conducting interviews and observations patients were very cooperative.
At the data interpretation step, the diagnosis can be established because the assessment through subjective data and complete objective data is very supportive to establish the diagnosis, namely postpartum mothers with the need for cabbage or cabbage leaf compresses.Because postpartum mothers with breast milk needs less smoothly, breasts feel full and tense.The diagnosis in this case obtained data on the assessment of the mother feeling the complaint.Potential diagnoses in this care do not occur and anticipation of immediate action is not taken.
However, there is a gap between theory and practice, namely in the field only focused on the provision of non-pharmacological therapy with puerperal administration with the need for oxytocin massage.Intervention carried out in handling after the mother is given puerperium with cabbage leaf compresses.Implementation is easy to do with simple equipment in the patient's home.cabbage leaf compresses to facilitate breast milk are supported by several studies that have been done, Supported by the results of research from Siti Rofi'ah (2020) in Pitriani (2021), the results showed that the scale of breast swelling in postpartum mothers after being given cabbage leaf compresses was mostly on a scale of 2 which could mean there was a slight change in the breast.In this study, the result of p value <0.001 which means that cabbage leaf compresses are effective in reducing breast swelling.The results of the analysis were proven by descriptive analysis which showed that all respondents experienced a decrease in pain scale (Yefi Marliandiani, 2015).The results of this research by Yopi Suryatim, et al (2018) in Aprini, et all (2021) show that cabbage leaf compresses containing amino acids methionine, sinigrin (Allylisothiocyanate), mustard oil, magnesium, Oxylate sulfur heterosides are effective in reducing breast swelling, thereby extending the duration of breastfeeding and increasing breastfeeding success (Aprini, et all, 2021).
Supported by the results of research by Aniyeh, et al, (2021) said that the results of the study were obtained before the cabbage leaf compress, almost all respondents experienced breast swelling with a score of 4 totaling 9 (82%) respondents and a small number of respondents experiencing breast swelling with a score of 5 totaling 2 (18%) respondents.Meanwhile, after compressing cabbage leaves, most respondents did not experience breast swelling with a score of 2 totaling 7 (64%) respondents, almost half experiencing breast swelling with a score of 3 totaling 3 (27%) respondents and a small number experiencing breast swelling with a score of 4 amounting to 1 (9%).Based on the results of the Wilcoxon Signed Rank Test, a p.value of 0.002 was obtained.Because (0.002) < (0.05), it can be concluded that H1 is received which means there is an influence of cabbage leaf compresses on breast swelling in postpartum mothers days 3-6.It is expected that cabbage leaf compresses can be applied to help reduce breast swelling in postpartum mothers day 3-6 (Aniyeh, 2021).
In line with the results of research by Sarma, et al (2018), the results showed that breast milk dams after cold compresses were carried out in the majority control group reduced by 80%.Breast milk dam after cabbage leaf compress in the majority intervention group was reduced by 90%.Management of cabbage leaf compresses is the same effective with the management of cold water compresses against breast milk dams for postpartum mothers with a value of p = 0.542 (sarma, 2018).
According to the assumption of researchers that the decrease in breast enlargement after being given cabbage leaf compresses is due to high sulfur content so it is believed to reduce breast swelling and inflammation.Cabbage leaves contain inigrin (allylisothiocyanate) rapine, mustardoil, magnesium, oxylate, and sulfur and have antibiotic, anti-irritant, and antiinflammatory properties.The cabbage leaf content helps in increasing blood perfusion to the swelling area, dilates the capillaries and acts as a counter deterrent thereby reducing breast swelling and inflammation so that milk flows.
In line with the existing theory that cold compresses are a physiological effect that can provide a relaxing method in the use of low temperatures on tense muscles and joint stiffness.
Furthermore, it can be concluded that another name for cold compresses is the procedure for placing a cold item on the outer limbs.The influence of physiology is the narrowing of heart blood vessels, to reduce pain and to reduce the action of muscle nerve endings (Zulhana, 2018).

CONCLUSION
Based on obstetric care that has been carried out using COC care, it can be concluded: Postpartum care carried out on 6 different respondents, it was found that the problem of breast milk was not smooth management by giving cabbage leaf compresses, the results of the intervention were resolved maternal problems with breast milk coming out smoothly and pain reduced, management was very effective by utilizing existing materials and tools to overcome breast milk that was not smooth and breasts were visible tense.The limitations of this study were only conducted on 6 respondents with different age characteristics so that the results were still heterogeneous.