NURSING CARE FOR MOTHERS WITH INCOMPLETE ABORTIONS: CASE STUDY

Introduction: some of the products of conception of through the cervical canal left in from to in the jasmine of in 2019. Participant care at the hospital for three days—data collection techniques using interviews, observation, and documentation. Data analysis uses narrative analysis based on the analysis of relevant facts and theories. Results: The assessment of the two participants was the first and second pregnancies, with gestational ages of 12 and 16 weeks, experiencing vaginal bleeding and abdominal pain. There is abdominal tenderness, a pain scale of 5, and uterine contractions on examination. The nursing diagnosis was acute pain associated with uterine contractions and fluid volume deficit related to bleeding (abortion). The evaluation was carried out for 72 hours of reduced pain. The discussion is expected that nurses provide health education about pain and incomplete abortion. Conclusions: The pain and anxiety were reduced after implementing nursing for 72 hours. The reference from this study is for nurses to provide health education related to pain in incomplete abortion.


INTRODUCTION
Abortion is a threat or expulsion of the products of conception before the fetus can live outside the womb, as a limitation is a pregnancy of less than 20 weeks or a fetus weighing less than 500 grams (Prawiroharjo, 2016). An incomplete abortion is a subtype of spontaneous abortion, along with inevitable and missed abortion. Incomplete abortion which is described as partial loss of products of conception within the first 20 weeks of pregnancy. Patients will present with vaginal bleeding with lower abdominal and/or pain and cramping (Redinger & Nguyen, 2021).
According to the East Java Provincial Health Office (2021), in 2016 the National Maternal Mortality Rate was 305 per 100,000 live births. Meanwhile, the Maternal Mortality Rate in East Java Province in 2020 reached 98.39 per 100,000 live births (Dinas Kesehatan Provinsi Jawa Timur, 2020). Lamongan Regency in 2020 the number of maternal deaths was 14 people, namely 5 mothers giving birth and 9 postpartum mothers with a Maternal Mortality Rate (MMR) of 84 per 100,000 births (Mayssara A. Abo Hassanin Supervised, 2021).
Based on data obtained in the Melati room of Dr. Soegiri Lamongan Hospital in 2014, Incomplete Abortion was in fourth place with a total of 475 patients (35.9%). In 2019 ranks fourth with the number of patients as many as 381 (33.9%). In 2020 from January to March the number of patients with incomplete abortion was 364 (29.1%). From the data above, it is known that the number of patients with incomplete abortion has decreased by 4.8% but still ranks fourth after reproductive diseases.
The etiology that causes abortion is a growth abnormality resulting from conception; chromosomal abnormalities, environmental factors, endometrium and external influences; acute infections, pneumonia, pyelitis, typhoid fever, toxoplasmosis, and HIV; genital tract abnormalities, incompetent cervix, excessive cervical dilatation, cervical tearing, and uterine retroversion; placental abnormalities. Several factors predispose to abortion, such as parity and maternal age. The risk of abortion increases with increasing parity and increasing maternal age. Gestational age at the time of the abortion can give an idea of the cause of the abortion. At least 50% of abortions in the first trimester are cytogenetic abnormalities (Ahmad, 2016).
An incomplete abortion usually presents with moderate to severe vaginal bleeding and is frequently accompanied by lower abdominal and/or pelvic pain that is suprapubic, which may radiate to the lower back, buttocks, genitalia, and perineum. In almost all cases, the pelvic exam will reveal an open cervical os with products of conception readily visible. There may have already been the expulsion of some fetal tissue (Kosanke, 2019). Bleeding is profuse. The cervix often remains open because there is still an object in the uterus that is considered a foreign body (corpus alienum). Therefore, the uterus will try to expel it by contracting so that the mother feels pain. Based on the description above, nursing diagnoses that can be formulated are acute pain related to uterine contractions, and fluid volume deficit related to bleeding (abortion).

MATERIALS AND METHODS
Case study is a series of scientific activities carried out intensively, in detail and in depth about a program, event, and activity, either at the individual level, a group of people, institutions, or organizations to gain in-depth knowledge about the event (Julioe, 2017). Participants used in this study were two patients who had incomplete abortion. The data assessment includes subjective data and objective data, then analyzed, determines nursing diagnoses, interventions, implementations, and evaluations. In discussing the data obtained, they are compared with each other by complying with holistic and contextual principles. The five stages of the nursing process starting from the participant's assessment to the evaluation carried out in the jasmine room of Dr. RSUD Dr. Soegiri Lamongan for three days of treatment. Furthermore, it is presented in a narrative from the facts in the field and relevant theories, so that research is carried out for nursing care for mothers with incomplete abortions.

RESULTS
Based on the assessment of the two participants, the following results were obtained The results of data analysis found that acute pain nursing problems were related to uterine contractions and fluid volume deficits related to bleeding (abortion). Nursing interventions and implementations are carried out by providing health education to participants namely by explaining that the pain experienced by participants is normal due to uterine contractions that are being experienced by participants; besides distraction and relaxation techniques are also needed to reduce participants' pain, namely by breathing in through the nose and throw it out through the mouth and by distracting participants, for example by inviting participants to chat or see entertainment on social media; observing the degree of pain and TTV, collaboration with a team of doctors to provide information. RL 1500 cc / 24 hours / 21 tpm, cefrtriaxone 2 x 1000 mg / IV /12 hours, anthrax 3 x 2 mg / IV / 8 hours, kalnex 3 x 500 mg / IV / 8 hours, ranitidine 3 x 50 mg / IV / 8 hours, vitamin B 3 x 50 mg / IV / 8 hours and performed curettage.
Evaluation after the implementation of nursing for 3x24 hours the pain of both participants reduced with a pain scale of participant I pain scale 2, participant II pain scale 1, physical examination showed no signs of fluid volume deficit, pink conjunctiva, moist lip mucosa, warm accral, vital signs within normal limits (Participant I blood pressure 110/70 mmHg, temperature 36.6º C, pulse 84 x/min, Respiratory 20 x/min. Participant II blood pressure 140/90 MmHg, temperature 36.5º C, pulse 82 x/ min, Respiratory 20 x/min).

DISCUSSION
Abort is the end of a pregnancy (by certain consequences) at or before the age of 20 weeks of pregnancy or pregnancy has not been able to live outside the womb. Abortion case is a public health problem because it gives an impact on pain and the death of the mother. Abortion can cause complications that lead to the death of the mother (Agung, 2018). Incomplete abortion is a condition where some of the products of conception have come out of the uterine cavity and some of the products of conception are still left behind, so that the mother experiences abdominal pain and bleeding. On examination of the vaginal tourche there is an opening, and palpable tissue in the uterine cavity or prominence on the external uterine os. The size of the uterus does not match the gestational age because the products of conception have partially come out. Incomplete abortion can be caused by abnormal growth of the products of conception, placental abnormalities, maternal disease, and genital fracture abnormalities, factors of age, education, distance between pregnancies, parity and occupation. A large number of studies have shown that a woman's age is critical for embryo quality and endometrial receptivity. With age, the number and quality of oocytes significantly decreases, the number of mitochondria decreases, there is a significant decrease in the content of ATP in the cytoplasm, and the proportion of abnormal embryonic chromosomal structures increases. Spontaneous abortion is closely related to chromosomal abnormalities of the embryo18,19, several studies have shown that chromosomal abnormalities are the most common cause of spontaneous abortion so it can be concluded that the older a woman is, the higher the chances of having a spontaneous abortion (Li, Niu, Feng, Yan, & Chen, 2021). At the beginning of the abortion, bleeding occurs in the decidua basalis followed by necrosis of the surrounding tissue, this causes the products of conception to be partially detached, so that the uterus considers the products of conception to be foreign bodies that must be removed so that the uterus contracts. The movement of uterine contractions causes the muscles of the uterine wall to contract, clamping blood vessels, causing pain (Rukiyah, 2013).
Diagnosis acute pain is related to uterine contractions experienced by both participants because the participants feels contractions in the lower abdomen. Based on the diagnosis, the intervention and implementation provided by the nurse is providing health education to the participant and teaching the participant distraction and relaxation techniques to reduce the intensity of pain experienced, the relaxation technique used by the participants was to inhale through the nose and exhale through the mouth, while the distraction technique used by the participants was to watch entertainment on social media via mobile phones, as well as the active role of the family to invite participants to chat, intervention and subsequent implementation are collaboration with doctors regarding drug administration and curettage. If the products of conception that are still left in the uterus are not expelled immediately, it will be dangerous for the pregnant woman's condition, for example anemia or hemorrhagic shock caused by bleeding. After intervention on the participant and evaluation for 72 hours, the pain experienced by the participant is reduced.
The second diagnosis is fluid volume deficit related to bleeding (abortion). In this abortion both participants experienced bleeding and issued blood clots. Incomplete abortion is usually accompanied by moderate to severe vaginal bleeding associated with lower abdominal and/or pelvic pain (Redinger & Nguyen, 2021).
Fluid volume deficit occurs when the body loses extracellular fluids and electrolytes in proportionate (isotonic) amounts, this condition is also known as hypovolemia. In general, this disorder begins with intravascular fluid loss and is followed by intercellular fluid shifts to intravascular fluid, causing a decrease in extracellular fluid. To compensate for this condition, the body performs intracellular fluid transfer. In general, fluid volume deficits are caused by several things, namely abnormal fluid loss through the skin, decreased fluid intake, bleeding and fluid movement. Both participants were given intervention in the form of intravenous fluids which were expected to overcome the condition of the fluid volume deficit. After evaluation for 72 hours, the fluid volume deficit can be resolved, marked by no signs of dehydration.

CONCLUSIONS
Based on the results of research and discussion as well as the purpose of case study research on nursing care for mothers with incomplete abortion, there is a match between theory and facts in the field, namely independent intervention management by using distraction and relaxation techniques, collaborative analgesic administration, intravenous fluid administration, education and a curettage action plan so that nursing problems have been resolved according to the specified plan.