Exploration Postpartum Sectio Caesarea with Ineffective Breastfeeding: A Case Report

Introduction: Problems often arise after section Caesarea such as pain in the incision area. Pain will cause the patient to delay breastfeeding from start. In addition, the psychological impact of post-section Caesarea patients is anxiety when giving breast milk, causing milk to not come out. This study reports the exploration of postpartum mothers with ineffective breastfeeding. Method: This method uses descriptive quantitative research through case reports. Participants were 2 post-section Caesarea patients on day 0 (Mrs. S and Mrs. M) who were treated at Lumajang Hospital, with lumbar anesthesia, had no history of infectious diseases, nipples did not protrude or flat, and were willing to be respondents with signed informed consent. Result: The results of the study on the third day, the patient Mrs. S said the milk came out smoothly, the nipples stood out, and the baby was able to suckle. Patient Mrs. M breastfeeds smoothly and the nipples are slightly protruding and the baby can suckle. Breast care using the Hoffman technique is an effective intervention to treat mothers with ineffective nursing problems due to flat nipples. Conclusion: Nursing problems are ineffective breastfeeding for patients seen from the condition of the patient's nipples and patient complaints, coupled with the Hoffman technique and other innovations so that nursing care provided can be resolved.


Introduction
Sectio Caesarea often causes problem pain in the area incision and result in difficulty Mother nursing baby (Wahyuningsih et al., 2021) so the pain will cause mother postpartum since early breastfeeding. Limitations activity move and arrange post section position Caesarea also made inability Mother in breastfeeding (Hastuti & Wijayanti, 2017). Besides that, a mother who experienced operation section Caesarea impossible could breast-feed the baby quickly because Mother is not yet aware consequences affect anesthesia. Effect anesthesia that affects the baby can too result in the baby being weak and lazy to breastfeed that.
Study behavior mothers breast-feed during the Covid-19 pandemic in Indonesia by the team Health Collaborative Center (HCC) researchers show that the prevalence success exclusive breastfeeding in Indonesia in 2020 reaches 89.4% (Kusumaningrum & Sari, 2021). At the hospital, numbers of breastfeeding reached 91% and 98%.
However, after going out of the hospital observed occur drop number breastfeeding that stands out in some months next. The decreasing number of breastfeeding at 3 months of birth reached 54.7-55%, and 34.1-36% at 6 months of birth.
Mother post section caesarea often experience difficulty in giving breast milk to the baby causing swelling of the breast, swelling breast occurs because of the increase in milk volume, lymphatics and congestion vessels blood, and edema during breastfeeding. The impact that can occur if Mother no breast-feeds the baby is cutting off the connection inner between the mother and the child, the pain in the swollen breast moment milked or moment used to pump or machine breast pump, let down reflex, breast milk doesn't visit arrived, imbalance Among milk production per day. Breast-feed not effective is a condition where the mother and baby experience dissatisfaction or difficulties in the breastfeeding process (PPNI, 2020).
Patients undergoing labor through the surgical process or operation Caesar with various indications. Condition psychic mother is very influential in milk production.
Condition psychic like fatigue, discomfort, and pain is a psychic condition frequently found after labor specifically with operation Caesar. A psychological mother's anxiety could end with restless feelings so alone will occur something obstacle from the letdown reflex that doesn't perfect. That thing occurs because existence releases epimerize causing vasoconstriction of vessels alveolar blood so that oxytocin no could Sri Wahyuningsih, Nurul Hayati, Rizeki Dwi Fibriansari, Nindi Bilih: Exploration Postpartum Sectio Caesarea with Ineffective Breastfeeding..... reach the target organ i.e. myoepithelium. Some studies conclude that the process of giving birth with the operation will hinder the formation production and production of breast milk.
To reduce the impact that can arise in babies as well as to overcome the problem of flat nipples or enter to in nurse could do counseling about maintenance breast (breast care), other than that during pregnancy nor after give birth to Mother need clean nipples with warm water while being pulled with the purpose of the mother's nipple clean and nipple could stand out go out.
Nipples no stand out could overcome with technique Hoffman that is with interesting nipple with use spud or could draw with hand before breastfeeding so you can stand out a little (ARDIANTI, 2020) and get breast-feed with corrector with permanent breastfeeding the baby, do counseling for mothers about importance nutrition for mother breastfeeding to achieve smooth breastfeeding, can also be done massage oxytocin to stimulate expenditure breastfeeding, help position Mother in breastfeeding ( PPNI, 2019), in addition to it, 's also a condition and psychology Mother breast-feed must relax and not in state stress, because stress could hinder smooth breastfeeding.
This thing causes linkages researchers to report technique Hoffman to improve milk production in post-partum mothers with problems nursing breast-feed no effective.

Method
Research design is quantitative with descriptive, the method used is report case. Patients undergoing labor through the surgical process or operation section Caesarea with various indications. Condition psychic mother is very influential in milk production. Condition psychic like fatigue, discomfort, and pain is a psychic condition frequently found after labor specifically labor with operation Caesar Patients post Section Caesarea. Ineffective breastfeeding is unpreparedness Mother gives breast milk to the baby so that baby no gets enough breast milk from her mother because there is breast problems Mother, especially flat nipple problem or enter to in.
Patient-given care nursing by comprehensive through a nursing process approach that consists of assessment, data analysis, diagnosis nursing, plan action nursing, intervention, implementation, and evaluation. This thing expected there is development about breastfeeding until effective.

Result
Patient Mrs. S with post-sectional diagnosis Caesarea on indication pelvis narrow, 24 years old now have a child first to experience obstacle in uncooked milk go out accompanied existence problems with the mammary papillae (nipples) coming in to in.
Mrs. M also with post-sectional diagnosis Caesarea on indication pelvis narrow, 28 years old and is a birth child the second to experience flat nipple problem.
In the reported case, the second patient Muslim, indication did the same SC that is Disproportion Head Pelvic (DKP), using the same anesthetic that is lumbal anesthesia.
Both patients conducted the same intervention start day 0. The patient said the milk had not come out because the right nipple went in and the left nipple wound Because the family felt that for two days the patient had no complaints, the family took the village midwife back on 27 February 2019. When examined by the midwife, the results were still opening 5, finally, the village midwife referred the patient to the Lumajang Hospital, and when examined at the obstetrics clinic the patient with narrow pelvis indication (CPD), and the doctor decided to have a cesarean section because of the pelvic indication narrow. The mother did labor with lumbar epidural anesthesia.
The patient says the milk has not come out because the right nipple is flat Because the patient already understands that it has entered the interpretation of labor. When the village midwife did not conduct an examination, the village midwife immediately took the patient to the puskesmas. When they were checked at the puskesmas, they found an opening. 2. After leaving the puskesmas, the patient was referred to Lumajang Hospital for further examination. When at the obstetrics clinic the patient was examined and the doctor decided to have a cesarean section because the patient indicated a narrow pelvis, besides that the pregnancy was already over enter interpretation of childbirth. The mother did labor with lumbar epidural anesthesia.

Breast care
The patient said he did not understand how to treat breasts and was new to breast care after giving birth The patient says he doesn't understand how to treat breasts Breast-feed Patients say this is an experience first time breastfeeding a baby and the patient is a little confused about how to breastfeed correctly The patient says already understand breastfeeding but experience obstacles because the nipples are flat and the mother does not know the current position breast-feed causing trauma to the mother, the mother is afraid that her nipples will hurt again. The patient says he doesn't understand either how to bring up the nipple the flat one Baby's condition 1. The baby is in good health with no physical defects 2. Baby boy with BB 3150 gr 3. The baby has not been able to breastfeed well (latch on) 4. The baby cries when the baby wants to suckle but the milk has not come out and the mother's nipple is in 5. The baby has been treated and joins the mother in the T-room 1. The baby is in good health with no physical defects 2. Baby girl with weight 3000 gr 3. The baby can suckle well, but when feeding the baby looks for the mother's nipple because the mother's nipple is flat 4. Babies are often fussy when placed in the crib and often cry asking to be carried 5. The baby has been treated, joined together mother in room T of the lotus General condition Consciousness compliments, hair disheveled, the patient appears to be grinning when tilted right and left, the patient looks weak, a little smelly The second patient has breast problems that are patient 1 nipple on the other side right enter to inside and patient with 2 nipples on the other side right flat. The reason for the problem is anomaly breast because sunken nipple with factors ignorance Mother does maintain breasts.

Discussion
Patient 1 was taught to position proper breastfeeding so that the baby can latch with good so that no occur sore on the nipple mother. on the day third after conducting intervention maintenance breast found the mother's nipple stand out. A good nipple shape for breastfeeding is a prominent nipple shape. Cause of reflex suck, the nipple will enter to mouth baby with the help tongue, where the tongue extended to the gum bottom. The writer thinks that the day third problem was resolved with the existence of protruding nipples so that the could baby can latch on with good, and the mom could give breastmilk effective to a baby. Intervention nursing who has done for breastfeeding is no effect with standard outside breast-feed is ability give breast milk live from breast to infants and children to meet need nutrition. Interventions provided are education breast-feed with action identification readiness and ability to accept information, provide educational materials and media health, give counseling breast-feed with teach 4 (four) positions breastfeeding and latch on with true and teach maintenance postpartum breast (massage breast) (PPNI, 2018).
Maintenance of postpartum breasts (massage breasts) was taught to both patients is with using the Hoffman technique. A good nipple shape for breastfeeding is a prominent nipple shape. Cause of reflex suck, the nipple will enter to mouth baby with the help tongue, where the tongue extended to the gum bottom (discussion from aspect theory). Research results previously so that the putting is fixed stand out the method what. Factor second postpartum physiology, even if breast milk comes out baby permanent breastfed, will influence condition psychologically. Besides it's to speed up second milk production patients also need to be taught mobilization. according to results of research (Putri, 2018) Mobilization is something movement and position to be do something activity or activity. Mobilization postpartum mother is something movement, position or existence activities carried out Mother after few hours of delivery with Caesar's birth. In the postoperative patients' section Caesarea first 6 hours it is recommended to immediately move member her body. motion body that can conduct is moved arms, hands, feet, and fingers to work digestive organs quickly back to normal.
Mobilization exercises early could increase the circulation of blood that will trigger drop pain and heal wounds faster. So the writer thinks that the second patient to get expedite milk production is not only to maintain breasts but also done mobilization so that the patient easier to give exclusive breastfeeding without there is pain The writer thinks that on the day third problem was resolved with the existence of protruding nipples so that baby can latch on with good, and the mom could give breastmilk effective to the baby. Maintenance of breast has been done on both patients with massage breast technique Hoffman. Importance maintenance breast this done to expedite milk production other than it's to overcome nipple problems breast with recommending the patient to do maintenance breast before breast-feeding baby or for 2 times a day to clean area breasts.
Maintenance of the breast aims to launch circulation and prevent clogged milk flow so that expedite milk production and avoid happening swelling and difficulty breastfeeding, other than it also takes care of cleanliness breasts so as not easy caught infection (Rukmini, 2015). Nursing actions taken on the problem of ineffectiveness Breastfeeding is one of them is studying knowledge and experience patients in breastfeeding. Knowledge and experience in Breastfeeding are needed by both patients.
Experience from 2 more patients many because the difference from total gives birth to the child. To add knowledge from the second patient conducted give counseling or health education about method maintenance breast, position proper breastfeeding and monitoring Skills baby in stuck to the breast mother to make sure baby could breastfeed with good.
Besides it's to speed up second milk production patients also need teaching mobilization. according to results of research (Putri, 2018) Mobilization is something movement and position to be do something activity or activity. Mobilization postpartum mother is something movement, position or existence activities carried out Mother after few hours of delivery with Caesar's birth. In the postoperative patients' section Caesarea's first 6 hours it is recommended to immediately move a member of her body. motion body that can be conducted is moved arms, hands, feet, and fingers so that the digestive organs work quickly back to normal. Mobilization exercises early could increase the circulation of blood will trigger drop pain and heal wounds faster. So the writer thinks that the second patient to get expedite milk production is not only to maintain breasts but also done mobilization so that the patient easier in give exclusive breastfeeding without there is pain On the evaluation on the day second, found colostrum go out baby not yet could breastfeeding with good (latch on). According to (Astatki, 2014) colostrum is the first milk that comes out. Colostrum is fluid with viscosity thick, sticky and colorful yellowish yellowness that is first secreted by the mammary glands which contain tissue debris and residual material present in the alveoli and ducts from mammary glands, before and soon after giving birth. Colostrum this secreted by glands breasts on the day first until a day to four post-childbirth.
The maximum attachment could facilitate reflex babies during the breastfeeding process. For a baby could suck effectively, then the baby must take enough many breasts in his mouth, isn't it only sucking nipples, so that the tongue baby could squeeze the lactiferous sinuses appropriate under the areola. When the baby is not attached with fine, just suck nipples, a baby will interesting nipples, biting and rubbing skin breast so that cause a lot of pain and when the baby keeps going breastfeeding will damage skin nipples and raise wound or cracks in the nipples (Mulder, 2006;Fitial, 2011) in (Bintang & Darti, nd).

Conclusion
Maintenance breast with technique Hoffman is an effective intervention to address mothers with problems nursing breast-feed no effective consequence nipple flat. Counseling about technique Hoffman as early as may be, that is since pregnancy if of course has detected existence nipples sink to get prevent happening breast milk dam.