The midwifery care for pregnant mother tm lll with physiological vaginal discharge at Gondokusuman Health Center I Baciro Yogyakarta

The purpose of this research was to be able to provide midwifery care for pregnant women with third trimester physiological vaginal discharge at Gondokusuman Health Center I Yogyakarta. The research design used descriptive observational method and observational approach. The sampling technique in this study used accidental sampling method with a sample of third trimester pregnant women who experienced physiological vaginal discharge and used picot analysis. The results of this study after a visit for 3 times and given a counseling intervention about personal hygiene and maternal hygiene in caring for women, complaints of physiological vaginal discharge in third trimester pregnant women can be resolved. The suggestions for pregnant women should always be routine and regular in doing personal hygiene and taking care of their feminine area properly.


INTRODUCTION
Vaginal discharge (Leucorrhea/Fluor Albus) is a non-blood vaginal discharge. Leucorrhoea is a clinical manifestation of various infections, malignancies or benign reproductive tumors. This disorder does not cause mortality but morbidity because it always moistens the inside and causes irritation, itchiness so that it disrupts and reduces comfort in sex. Physiological leucorrhoea is found in the condition before menstruation, when sexual desire increases, during pregnancy, after menstruation, emotions and obesity.
Cases of leucorrhoea in Indonesia are caused by the humid weather in Indonesia that is easily infected with fungus candida albicans which is one of the causes of vaginal discharge. In addition to infection, vaginal discharge is also caused by hormonal problems, underwear that do not absorb sweat, excessive use of vaginal rinses, and one of them is an unhygienic examination factor. Based on the cause of vaginal discharge is divided into two, namely physiological and pathological vaginal discharge. Physiological leucorrhoea is usually clear, odorless, not excessive and does not cause complaints. This leucorrhoea comes close to ovulation, sexual stimulation, before and after menstruation, or the presence of hormonal influences. Whereas pathological leucorrhoea is usually yellow, green or grayish smells fishy or has a foul odor, the amount is numerous and causes complaints such as itching and burning around the outer vaginal lips in the intimate area. This leucorrhoea occurs due to vaginal infection, fungal candida albicans infection, trichomonas vaginalis infection, and also the presence of foreign objects. A survey conducted by Widayati of female visitors to several pharmacies in Yogyakarta for 1 month showed that 60% of female visitors were or had been using drugs to overcome health problems in reproductive organs to overcome the frequent problems of vaginal discharge. Abnormal leucorrhoea can be caused by infection / inflammation that occur due to washing the vagina with improper deep examination dirty water, excessive use of vaginal flushing, and the presence of foreign objects in the uterus.
Leucorrhoea increases the risk of low infant weight, premature birth and PROM (premature rupture of membranes) in pregnant women. Premature rupture of membranes occurs because it is caused by Chlamydia infection which often causes hormonal factors and the presence of blood flowing in the uterine and vaginal areas can improve the process of vaginal secretion, characterized by a yellowish / greenish yellow color, fishy odor, coming out very much and causing an itchy feeling called with bacterial vaginosis. This type of leucorrhoea can cause premature rupture of membranes if treatment is not immediately carried out because it can stimulate the release of inflammatory mediators, trigger contractions, and then spread to the amniotic membrane (Chorioamnionitis), so that the membranes thin and break easily when contractions occur. Stress can also trigger vaginal discharge because all organs of the body are affected and controlled by the brain, experiencing stressful conditions; this can lead to changes and hormonal hormone balance in the body.

RESEARCH METHODS
This research was observational descriptive method. The populations in this study were third trimester pregnant women who experienced physiological vaginal discharge. The sampling technique was accidental sampling. The samples in this study were 2 third trimester pregnant women who experienced physiological vaginal discharge at Gondokusuman health center I. This study used secondary data based on the MCH book and medical records of patients at Gondokusuman Health Center I Yogyakarta. Primary data was taken from observations and interviews directly with respondents, midwives and families of patients.

RESULTS AND DISCUSSION
The research subjects that the researchers used were patients of pregnant women with physiological vaginal discharge named Ny.M aged 22 years and Mrs. E 25 years old. Patients chose the Gondokusuman health center I as a place of examination because the distance between the patient's home and the health center was close. Other informants were midwives who directly provided care to the research subjects so that they knew the problems faced by patients related to their pregnancies and medical history, so that they could strengthen the authors' research with interviews about the case of pregnant women with physiological vaginal discharge.
After midwifery care was carried out in Mrs. M. and Ny.E with physiological leucorrhoea at gondokusuman Health Center I Yogyakarta, the author will discuss the comparison and the gaps contained in the theoretical review with the reality that the authors found. The gap can be described by the writer according to the form of SOAP documentation.
The case of 22-year-old Mrs. M G1P0A0Ah0, pregnant with physiological leucorrhea in the results of subjective data assessment found that the mother complained of vaginal discharge and felt uncomfortable. Physiological leucorrhoea is a physiological change in the third trimester of pregnant women. The case of 25-year-old Mrs. E G2P1A0Ah1 pregnant with physiological leucorrhoea in the results of subjective data assessment found that the mother complained of vaginal discharge, felt uncomfortable during vaginal discharge. Physiological leucorrhoea is a physiological change in the third trimester of pregnant women. Leucorrhoea experienced by the mothers because they did not maintain personal hygiene properly.
Mrs. E, 25 years old, has had childbirth and has active sexual intercourse which means having the risk of vaginal discharge because the vagina is a female reproductive organ that is very susceptible to infection. The second home visit of maternal complaints had been reduced from before, the examination also found that vaginal discharge had decreased, and the third visit to the mother's complaint was gone, the mother said there was no vaginal discharge anymore. So the care given for 9 days to Mrs. S brought good changes to subjective data.
First home visit of Mrs. E experienced vaginal discharge. The mother's second home visit said it was still vaginal discharge but had already been reduced. The third home visit was that the maternal complaints had diminished from before and had not been leucorrhoea, so that the care given for 9 days to Ny.S brought good changes to subjective data.
Based on these observations, researchers looked for causes of complaints the mothers felt, so the researchers examined from several aspects, the factors that cause mothers experiencing vaginal discharge was in Mrs. M results in maternal personal hygiene was less so that the mother did not understand the cause of vaginal discharge. In Mrs. E maternal hygiene patterns were still lacking, so that mothers did not understand the good and correct procedures for maintaining the female feminine area. And other causes of vaginal discharge were hormonal changes during pregnancy. This is in accordance with the theory according to Manuaba, the factors that influence vaginal discharge are the number of underwear that do not absorb sweat causing moisture, the use of tight underwear, hormonal changes during pregnancy. Based on the causes experienced by Mrs. M and Mrs. E showed there was no gap between theory and case. Objective data assessment was obtained from the examination of Mrs. M, namely the general condition of the mother was good; body weight before pregnancy (55 kg); body weight now (74), height (156.5 cm); LILA (30 cm); blood pressure (100/60 mmHg); Pulse (80x / minute); Respiration (21x/minute); Temperature (36.4 o C). Physical examination carried out found that Inspection of genitalia: there was vaginal discharge, odorless. Palpation: There was no swelling of the Bartholin's gland, no edema, no varices or condyloma acuminatum, no pus coming out. Laboratory examination on 4 May 2016 showed Hb results: 11.9 gr / dl, GD: A, Rh: positive, Syphilis: NR. From the study showed that the mother experienced physiological vaginal discharge.
At Ny.E's examination, the general condition of the mother was good; body weight before pregnancy (43 kg); body weight now (54.6), height (152 cm); LILA (27 cm), blood pressure (90/60 mmHg); Pulse (81 x / minute); Respiration (22 x / minute); Temperature (36 o C). Physical examination carried out found that inspection: there was vaginal expenditure in the form of mucus, clear vaginal discharge, odorless. Palpation: There was no swelling of the Bartholin gland, no edema, no varices or condyloma acuminatum. On laboratory examination on 18 May 2016 urine protein was negative. From the study showed that the mother experienced physiological vaginal discharge.
According to Usman, the mechanism of the occurrence of physiological leucorrhoea in pregnant women is caused by hormonal changes that occur during pregnancy, where there is an increase in estrogen and progesterone hormones that increase during pregnancy which can lead to increased viscosity of cervical mucus and an increase in estrogen levels causing water levels in mucus cervix increases, resulting in physiological vaginal discharge in pregnant women. Then marked by the presence of signs of physiological leucorrhoea, the discharge of clear liquid is colorless, odorless and not itchy. This liquid can amount to a little or a lot. Signs and symptoms of physiological vaginal discharge experienced by Mrs. M and Mrs. E according to the theory were appropriate.
The subjective and objective data collection obtained a diagnosis that 22-yearold Mrs. M G1P0A0Ah0 with physiological vaginal discharge and 25-year-old Mrs. E G3P1A0Ah1 with physiological leucorrhoea. The anticipation in this case is to provide health education about right hygiene and personal hygiene one of them in choosing underwear that absorbs sweat and cleanse the genitals from front to back.
According to the anticipation theory according to Varney is the midwife in carrying out the action must be according to the priority of the problem or need faced by the client. After the midwife formulates the actions taken to anticipate diagnoses / potential problems in the previous step, the midwife must also form an emergency / immediate action. Immediate action can be carried out independently, collaboratively, or referral. In this case the midwife carries out immediate action independently which provides health education about physiological vaginal discharge, and collaboration with doctors if vaginal discharge continues to pathological vaginal discharge.
Planning and management in the case of Mrs. M. and Mrs. E with the theory was appropriate with the theory and there were no gaps, even more by reminding patients to take medicine given by the PHC. Mrs. M. with as much as 30 1x1 Fe drugs, as many as 30 items taken by 1x1, but also provided health education about physiological vaginal discharge such as choosing underwear that is not made of nylon but choosing one made of cotton cloth. And plan for visits at Health Center another 2 weeks for both Mrs. M, and Mrs. E, and home visit every 4 days.
The evaluation on the case of Mrs. M and Mrs. E had been conducted midwifery care for 9 days from May 4, 2015 to May 14, 2015, with home visits 3 times. Mrs. M's first home visit complained of vaginal discharge. The second home visit of vaginal discharge had decreased, and the third visit had not experienced vaginal discharge. Mrs. E's first home visit experienced vaginal discharge. Mother's second home visit was still vaginal discharge and her third home visit said she had not had vaginal discharge.
During the 3 visits given hygiene counseling interventions, maternal female personal hygiene, routine antenatal care, therapy and preventive measures on the causative factors, on the third visit/last visit, the mother's condition was good, there were no complaints, the mother's general condition was good, and the results of physical examination on genitalia did not show any vaginal discharge. To Mrs. M and Ny.E found that the mother had not experienced vaginal discharge.
The evaluation of the expected results from the actions taken on physiological leucorrhoea according to mothers' KU is good, they understand about hygiene and