Ainalia lutfika rizki

CASE STUDY OF MIDWIFERY CARE WITH SECOND-DEGREE PERINEAL RUPTURE DURING LABOR

Abstract

Background: Perineal rupture is a common complication of vaginal delivery and may lead to postpartum hemorrhage if not managed properly. Appropriate obstetric and midwifery care is essential to prevent complications and support postpartum recovery. Objectives: This case study aimed to describe the implementation of obstetric care for Mrs. Y, a 33-year-old woman, G2P1A0, at 38 weeks of gestation with a second-degree perineal rupture at the Tutun Sehati Primary Inpatient Clinic in 2026. Methods: A descriptive case study design was used, applying Varney’s seven-step obstetric management approach, including assessment, diagnosis and problem identification, anticipation of potential complications, immediate intervention, planning, implementation, and evaluation. Data were collected through interviews, observations, physical examinations, and medical record reviews. Results: The assessment showed that the patient was in the active phase of the first stage of labor with 5 cm cervical dilatation and stable maternal and fetal conditions. A healthy male infant was delivered spontaneously at 19:15 WIB, weighing 3,875 grams and measuring 51 cm in length, with an APGAR score of 10/10. During the fourth stage of labor, a second-degree perineal rupture with an estimated blood loss of 200 cc was identified. Management included perineal suturing, monitoring of vital signs, uterine contractions, postpartum bleeding, and ensuring adequate nutrition and rest. Evaluation indicated that the mother's condition remained stable, bleeding was within normal limits, the perineal wound was successfully managed, and no complications occurred. Conclusions: Varney’s obstetric management approach was effective in managing second-degree perineal rupture, preventing postpartum complications, and promoting optimal maternal recovery.