ISGH 3 | Vol 3. No. 1 | Oktober 2019 | ISSN: 2715-1948
Endorphin Massage and Effleurage Massage as a Management of Labour Pain on The Active First Stage of Primigravida
at Independent Midwife Practice in Cimahi
Flora Honey Darmawan*, Dede Waslia [email protected]
Department of Midwifery, School of Health Sciences Jenderal Achmad Yani Cimahi, Indonesia ABSTRACT
Labour pain is a manifestation of uterine muscle contractions. This contraction causes pain in the waist, abdomen and radiates towards the thigh. One of the treatments for labour pain is non-pharmacological techniques, namely endorphin massage and effleurage massage. Both of these techniques have differences in the way and place of massage causing different effects and sensations. The purpose of this study was to determine the ratio of endorphin massage with effleurage massage to the intensity of pain on the active first stage of primigravida. The design of the study used quasi experiments with pre and posttest designs. The study sample was the active first stage of primigravida at Independent Midwife Practice in Cimahi who was given massage intervention with endorphin massage and effleurage massage methods. The number of samples was 30 people divided into 2 groups, 15 respondents were done endorphine massage, 15 respondents used effleurage massage, data analysis using t test. The results showed that the average pain intensity before endorphin massage was 7.93 and after endorphin massage was 7.00. The average value of pain intensity before effluerage massage was 7.53 and after effluerage massage was 5.40. Data analysis using independent samples t-test is known to be a probability of 0,000 (<0.05) so that it can be concluded that there is a difference in pain intensity between endorphin massage and effluerage massage methods.
Keywords: Endorphin massage, effleurage massage, labour pain
INTRODUCTION
Labour is a series of processes that end with the release of the conception by the mother.1 In the first stage of labour, uterine contractions occur that cause cervical dilation and push the fetus through the birth canal. Uterine contractions in labour cause pain.2 In this condition, visceral pain occurs and feels like a heartburn that comes from the uterus and cervix.
Pain can be felt in the abdominal wall, lumbosacral region, iliac crest, buttocks and thighs.3
Some mothers experience low back pain related to continuous contractions so that they become tired and discouraged, often having difficulty facing contractions.4 This will cause the mother to have a bad labour experience, experience labour trauma that can lead to postpartum blues.5 Therefore it is very important for birth attendants to meet the mother's need to feel safe and comfort, especially in reducing pain due to contractions.
Labour pain management can be applied pharmacologically and non pharmacologically.
There are a variety of non-pharmacological physiological methods to relieve the pain that mothers can use during childbirth, such as setting
positions, relaxation and breathing exercises, reins in the abdominal, and the discharge of the bladder.6 Non-pharmacological maesures are always simpler and safer, relatively inexpensive and can be used on all childbirth with minimal side effects.7 One of the methods/massage in the abdominal that can be used is endorphin massage and effleurage massage.
Endorphin massage is a touch therapy or mild massage that is important enough to be given to pregnant women until the end of childbirth. This is due to the body stimulating massage to release endorphin compounds which are pain relief and can create a feeling of comfort.8 Effleurage massage is a mild massage using fingers, usually on the stomach, as a rhythm with breathing during contraction. Effleurage can be performed by self- maternity mothers or delivery companions during the contraction. It is used to distract the mother from pain during contraction.9
Research on non-pharmacological methods to reduce labour pain using endorphin massage techniques and effleurage massage has begun to be done but researchers have not found research comparing the both techniques of massage. Some
studies have mentioned that there is an influence of endorphin massage performed on maternity mothers to reduce labour pains. Research shows the results that a masase on the back that begins at the cervical 7 to the outside toward the rib side for 30 minutes can activate a large-diameter nerve fibers to close a pain delivery gate to the cerebral cortex and resulting in reduced pain.10 While other research results have shown that by doing effleurage massage on primigravida mother in the active phase to influence the reduction of labour pain level that is seen from the results posttest maternity pain rate is decreased compared to pre test results.11
The findings in the study of Shrestha et al (2013) show that of a total nulipara parturien, most of which describe childbirth pains as severe pain.
Another study found that during early delivery (before the opening of 5 cm), the experience of sensory pain in the average nulipara was greater than that of multipara women, but when the childbirth developed this distinction was less pronounced, except for increased pain intensity during the decelaration phase and during stage II.12 This explains that the handling of maternity pains in primigravida mothers is the main thing that a care giver shoud considered.
Seeing the benefits of these two massage techniques in labour, researchers are interested in researching about how endorphin massage and effleurage massage as a treatment for labour pain in primigravida in the active first stage. The purpose of this study was to determine the comparison of endorphin massage with effleurage massage on pain intensity in primigravida active first stage mothers at Midwife Independent Practice in Cimahi.
METHODS
The research design used is quasi experimental, namely by providing treatment/
intervention in one group with pre and post test designs. The variables in this study are endorphin massage and effleurage massage as independent variables and labour pain intensity as the dependent variable.
The population in this study were all maternity women in Midwife Independent Practice in Cimahi from March to October 2018. Sampling used a purposive sampling technique, which is a sampling technique in accordance with the consideration of researchers.
The samples studied were primigravida first stage active starting from a minimum opening of 4 cm. The sample size of 30 people was divided into 2 groups, 15 respondents who were given endorphin massage and 15 respondents who were given effleurage massage. The inclusion criteria in this study were primigravida first stage active mothers starting from opening 4 cm with physiological pregnancy (term pregnancy) and willing to be respondents, while the exclusion criteria in this study were first stage active mothers who were uncooperative active phase, have complications or accelerate labour with oxytocin or amniotomy.
This study uses primary data obtained from first stage active mothers starting from opening at least 4 cm. Endorphin massage and effleurage massage are performed during uterine contractions.
Data on pain intensity was obtained by asking respondents directly about the range of pain felt between numbers 1-10. This variable is measured before and after endorphin massage and effeurage massage.
After all data has been collected, the researcher performed the data processing through several stages, namely checking the accuracy and completeness of the data. The data that has been collected is corrected for accuracy and completeness, then entered into a computer program. Data is presented in the form of frequency distribution. Analysis of the data used in this study is bivariate. Bivariate analysis in this study was conducted to see the comparison of endorphin massage and effleurage massage variables on labuor pain intensity using t-test statistical test.
RESULT
1. Characteristics of Primigravida First Stage of Maternity Mother at the active phase at Midwife Independent Practice in Cimahi
Table 1. Characteristics of Primigravida First Stage of Maternity Mother at the Active Phase in Midwife Independent Practice in Cimahi
Characteristics
Management of Labour Pain Endorphin Massage Effleurage Massage n=15 % n=15 % Age
< 20 year or ≥ 35 year 20-34 year
5 10
33,3 66,7
3 12
20,0 80,0
Education
Elementary & Junior high school
Senor High School & College
3 12
20,0 80,0
2 13
13,3 86,7
Occupation Unemployment Employment
11 4
73,3 26,7
12 3
80,0 20,0
Viewed from the characteristics on the table 1, can be seen majority of the respondents are healthy reproductive (20-34 years), educated Senior High School and College, and an unemployment.
2. Difference of pain intensity in primigravida first stage of maternal active phase before and after endorphin massage at Independent Practice Midwife in Cimahi
Table 2. Difference of pain intensity in primigravida first stage of maternal active phase before and after endorphin massage at Independent Practice Midwife in Cimahi
Pain intensity Std.
Max
P value
n Mean Deviation Min
Before Endorphin Massage After Endorphin Massage
15 15
7,93 7,00
0,704 0,655
7 6
9 8
0,000
Based on table 4.2 it is found that the average value of pain intensity before endorphin massage is 7.93 and after endorphin massage is 7.00 with a p value of 0.000 (<0.05) which means there is a difference in pain intensity in the first stage of maternity mothers active before and after endorphin massage. There is a tendency for a decrease in pain
intensity, the average decrease is 0.993.
3. Difference of pain intensity in primigravida first stage of maternal active phase before and after effleurage massage at Independent Practice Midwife in Cimahi
Table 3. Difference of pain intensity in primigravida first stage of maternal active phase before and after effleurage massage at Independent Practice Midwife in Cimahi
Pain intensity Std.
Max
p value
n Mean Deviation Min
Before Effluerage Massage After Effluerage Massage
15 15
7,53 5,40
1,727 0,986
5 4
10 7
0,001
Based on table 3 it is found that the average value of pain intensity before effluerage massage is 7.53 and after effluerage massage is 5.40 with p value 0.001 (<0.05) which means that there is a difference in pain intensity in the first stage of labor during the delivery phase. active before and after effluerage massage. There was a tendency to decrease in pain intensity, the average
decrease was 2.133.
4. Comparison of endorphin massage with effleurage massage on pain intensity in primigravida first stage mothers in active phase at Midwife Independent Practice in Cimahi
Table 4. Comparison of endorphin massage with effleurage massage on pain intensity in primigravida first stage mothers in active phase at Midwife Independent
Practice in Cimahi
Pain intensity Sig
(2-tailed)
Mean Diff
Std.
Error Lower Upper
f Sig t df
Before Endorphin and Effluerage Massage
After Endorphin and Effluerage Massage
0,232 0,632 4,803
4,803
58
57,110
0,000
0,000
1,533
1,533
0,319
0,319
0,894
0,894
2,172
2,173
Data collected in this study has been tested for normality with normal results, homogeneity test with homogeneous results. Then the data analysis uses independent samples t-test with the known result F-count in the table 0.232 with a probability of 0.000 (<0.05) so that it can be concluded that there is a difference in pain intensity between the endorphin massage and effluerage massage methods.
DISCUSSION
1. Difference of pain intensity in primigravida first stage of maternal active phase before and after endorphin massage at Independent Practice Midwife in Cimahi
The results of this study are in line with research by Ratih and Aprilliya (2016) which states that there is an effect of endorphin massage on reducing the intensity of back pain in third trimester pregnant women with p value
= 0,000. Endorphin massage is one of the non- pharmacological therapies to reduce or relief pain in the mother who will give birth. Mongan (2009) states that endorphins can increase the release of oxytocin, a hormone that facilitates labor so as to reduce pain. Endorphin massage can regulate the production of sex growth hormones, control persistent aches and pains, control feelings of stress, and enhance immunity.13
Several other studies mention that there is an effect of endorphin massage performed on maternal to reduce labour pain. Research shows the results that massage on the back that starts on the cervical 7 outward toward the side of the rib cage for 30 minutes can activate large diameter nerve fibers to close the gate to deliver pain to the cerebral cortex and cause pain to decrease.3
The emergence of endorphins in the body can be triggered through various activities, such as deep breathing and relaxation, and meditation.
Endorphin is produced by the body itself, and is therefore considered the best painkiller.
Endorphin massage should be performed since the pregnant woman reaches 36 weeks' gestation because at this age endorphin massage can stimulate the release of the hormone oxytocin which can trigger the arrival of labor.8
Endorphin massage in this study was mostly conducted by researchers and all respondents had never known about this method before. This can be the cause of a tendency to decrease pain intensity by only 0.993. A study states that endorphin massage done by husband is more active in reducing pain intensity when compared to endorphin massage conducted by researchers. This is because there is a bond between husband and pregnant women when doing endorphin massage so the fine hairs on the surface of the skin stand. This technique increases the release of endorphin hormones.14 It can be concluded that controlling pain and persistent pain is one of the benefits of endorphin massage which can be used as a light touch technique to increase relaxation by triggering a feeling of comfort through the surface of the skin.
2. Difference of pain intensity in primigravida first stage of maternal active phase before and after effleurage massage at Independent Practice Midwife in Cimahi
Based on table 3 it is found that the average value of pain intensity before effluerage massage is 7.53 and after effluerage massage is 5.40 with p value 0.001 (<0.05) which means that there is a difference in pain intensity in the first stage of labor during the delivery phase. active before and after effluerage massage. There was a tendency to decrease in pain intensity, the average decrease was 2.133.
The results of this study are in line with Sri and Endang's research at PKU Muhammadiyah Delanggu Klaten Hospital in 2015 which states that effluerage massage has an effect on reducing labor pain in the first phase of active phase in
maternity mothers. Effleurage is a massage technique using the palms of the fingers with circular movements in various parts of the body or a sweep along the back and extremities. The mechanism of labor pain inhibition with effleurage techniques is based on the concept of gate control theory, namely tactile stimulation of skin fibers that can inhibit pain signals from the same body area or other areas. Stimulation of skin tactile fibers can be done with several techniques of massage, rubbing, rubbing, fibrous and analgesic smearing.15
This technique also facilitates distraction and decreases sensory transmission of stimulation from the abdominal wall thereby reducing discomfort in the affected area. As a relaxation technique effleurage reduces muscle tension, increases circulation to the area of pain and prevents hypoxia.1
Effleurage in the abdomen is usually used in the Lamaze method to reduce pain in normal labour. Effleurage is one of the non- pharmacological methods to reduce pain during labor which is listed in the Summary of pain relief measures during labor, where in the first stage the latent phase (opening 0-3 cm) and the active phase (opening 4-7 cm) activities that can carried out by labor mothers is effleurage.4
The results showed a tendency to decrease in pain intensity by an average of 2,133. This is in line with Yuliatun (2008) which states that effleurage massage in labor is done using soft and light fingertips. Smears are done lightly and without strong pressure, but try to keep the fingertips off the surface of the skin. Skin stimulation with effleurage technique produces impulses that are sent through large nerve fibers that are on the surface of the skin, these large nerve fibers will close the gate so that the brain does not receive pain messages because it has been blocked by skin stimulation with this technique, as a result the perception of pain will change in addition to relieve pain, massage will stimulate the muscles of the uterus to contract.9
According to the researchers' analysis, effleurage massage has an effect on reducing the intensity of labor in the first phase of active labour in primigravida mothers, despite the different factors of perception or tolerance to pain. Mothers in pain who do not believe that they have control of pain, will be able to increase anxiety and fear which then causes the mother to stress, and tense during contractions, this can cause the failure of effleurage massage.
Although this method is very efficient and does
not cause side effects and can reduce labor pain in primigravida mother stage 1 active phase during contractions.
3. Comparison of endorphin massage with effleurage massage on pain intensity in primigravida first stage mothers in active phase at Midwife Independent Practice in Cimahi
Researchers have not found any research comparing these two massage methods simultaneously. In other studies, the endorphin massage and effluerage massage methods were compared with the counterpressure method and were proven to be both ineffective in reducing the intensity of labour pain.
The Association for the Study of Pain defines that pain is an unpleasant emotional and sensory experience that arises from actual or potential tissue damage or indicates damage.
Pain is caused by a stimulus that can cause or almost cause tissue damage. Therefore, the sensation of pain can be distinguished from other sensations, although emotions such as fear and anxiety are also experienced simultaneously so that it affects one's perception of pain. It must also be remembered that with the presence of the sympathetic nervous system, pain stimulus can also cause various changes, such as increased heart frequency, increased blood pressure, release of adrenaline (epinephrine) into the bloodstream and increased blood glucose levels.
There is also a decrease in gastric motility and a decrease in the blood supply of the skin which causes sweating. Thus, the stimulus that causes pain will result in an incident or sensory event.16
In pregnancy and childbirth, pain is interpreted as a "signal" to inform the mother that she has entered the stage of labour.
According to Cunningham (2012), labor pain as myometrial contraction, is a physiological process with different intensities in each individual. The pain experienced during labor is unique to each mother and can be influenced by several factors including culture, fear, anxiety, previous labor experience, preparation for labor and support.2
Separately in several studies, both endorphin massage and effluerage massage have been shown to play a role in reducing the intensity of labour pain. In this study, the tendency to decrease pain intensity was more pronounced in effluerage massage with an average decrease of 2,133. Relieving pain is
important. It is not how pain experienced by women that needs to be considered but efforts on how to deal with the pain. This is in line with the program launched by the Ministry of Health (Kemenkes) namely the Making Pregnancy Saver (MPS) program with one of the aspects of management in labor which is the aspect of caring for the mother.
Midwives in providing childbirth care are expected to provide comfort during labor. for that it is necessary to manage pain during labour with non-pharmacological techniques, one of which is massage. Massage can increase body relaxation and reduce stress. In addition, massage is an effective, safe care that is simple and does not cause adverse effects on both the mother and fetus. There are various massage methods that can be used in labor by considering the comfort and characteristics of the maternity mothers that are unique and different from each other. The location and method of massage can affect the client's reaction when done massage.
In this study, researchers assumed that the effluerage massage method was more effective in reducing pain intensity because this method was carried out on the area or part that felt pain, namely the stomach. In addition, a soft, light and consistent fingertip touch can make the client more relaxed and his attention turned to the massage done. The conditions are different in endorphin massage which is carried out on more sensitive areas such as the arms, neck, waist and back which can make the client feel awkward especially if done by researchers /not by her husband.
CONCLUSION
There is a tendency to decrease pain intensity by an average of 0.993 in primigravida first stage mothers in the active phase before and after endorphin massage. There is a tendency to decrease pain intensity by an average of 2,133 in primigravida first stage mothers in the active phase before and after effleurage massage. There is a difference between endorphin massage and effleurage massage on pain intensity in primigravida first stage mothers in active phase at Midwife Independent Practice in Cimahi.
ACKNOWLEDGMENT
Praise to ALLAH SWT for all the abundance of grace and love Him so that Authors can complete this study. Thanks to the Ministry of Research and Technology of Higher Education for providing
opportunities and support in the form of budding lecturer research grants.Thanks and deepest appreciation to the midwife at Independent Practise in Cimahi, beloved family prayer, encouragement and support during this time. Thank you to all those who cannot be mentioned one by one which has given supports, moral support, and helpful suggestions for the author. May Allah SWT give all the goodness in the world and the hereafter.
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