MIDWIFERY CARE MANAGEMENT FOR AN 18-YEAR-OLD Ms. A WITH A SECOND-DEGREE PERINEAL TEARAT  PMB MAIDAWATI

Azrina Fetta; Khairunnisa; Ratna Sekar Wati; Ariska Fauzianty; Maidawati

Authors

Azrina Fetta Sekolah Tinggi Ilmu Kesehatan Mitra Husada Medan
Khairunnisa Sekolah Tinggi Ilmu Kesehatan Mitra Husada Medan
Ratna Sekar Wati Sekolah Tinggi Ilmu Kesehatan Mitra Husada Medan
Ariska Fauzianty Sekolah Tinggi Ilmu Kesehatan Mitra Husada Medan
Maidawati PMB Maidawati

Keywords:

Second-Degree Perineal Tears, Midwifery Care, Antenatal Care; Breech Presentation; Midwifery Management; Primigravida, Placental retention, midwifery care, postpartum hemorrhage, placenta manual, Varney management., Postpartum Period

Abstract

Background: This critical medical emergency directly hinders the target of the United Nations' Sustainable Development Goals (SDGs), specifically Goal 3.1, which demands a drastic reduction in the global maternal mortality ratio to less than 70 per 100,000 live births. Second-degree perineal tear is one of the most common complications of vaginal delivery, especially in young primigravida. This condition is characterized by tears involving the vaginal mucosa, perineal skin, and perineal muscles without affecting the anal sphincter, thus risking postpartum hemorrhage, infection, and decreased quality of life of the mother. Objective: This case report aims to describe comprehensive midwifery care management using Varney's seven steps and SOAP documentation in Mrs. A, an 18-year-old primigravida who experienced a second-degree perineal tear at PMB Maidawati in 2025. Method: A descriptive case study was used with an obstetric management approach. The assessment was carried out through anamnesis, physical examination, and perineal examination. The results of the assessment showed that Mrs. A, an 18-year-old primigravida (G1P0A0), gave birth to a baby with a birth weight of 3,100 grams spontaneously pervaginally and was found to have a second-degree perineal tear. Management included aseptic wound suturing under local anesthesia, vital sign observation, bleeding monitoring, education on perineal wound care, vulvar hygiene, high-protein nutrition, early mobilization, and postpartum danger sign counseling. Results: The mother's condition improved, the perineal wound was healing well, and there were no signs of infection. Comprehensive, prompt, and targeted midwifery care has been shown to prevent further complications in cases of second-degree perineal tears.

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