Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11917 The effect of deep breath relaxation and counterpressure massage on pain reduction during labor Rahmawati Wahyuni,1 Supriadi Supriadi,2 Dewi Susanti,3 Nursari Abdul Syukur,1 Rosalin Ariefah Putri1 1Department of Midwifery, Politeknik Kesehatan Kemenkes Kalimantan Timur, Samarinda; 2Department of Nursing, Politeknik Kesehatan Kemenkes Kalimantan Timur, Samarinda; 3Applied Midwifery Study Program, Politeknik Kesehatan Kemenkes Kalimantan Timur, Samarinda, Indonesia Abstract Labor pain is a manifestation of the contraction (shortening) of the uterine muscles. Non-pharmacological treatment in pain management, namely deep breathing relaxation and counterpres- sure massage is an alternative method and a new trend that can be developed. This study investigated the effectiveness of deep breathing relaxation and Counterpressure massage in alleviating labor pain during active phase I. Employing a quasi-experimental design with a two-group pre-test post-test approach, 30 postpar- tum mothers from June to July 2021 were consecutively sampled. Deep breathing relaxation (5 times for 3-5 minutes) and counter- pressure massage (3 times for 30-90 seconds) served as the inde- pendent variables, while pain intensity during the first active phase was the dependent variable. Utilizing the Wilcoxon and Mann Whitney tests at a 5% significance level, significant reduc- tions in pain intensity were observed after both interventions (p- values: 0.002 for deep breathing, 0.046 for counterpressure mas- sage). These non-pharmacological methods, enhancing endorphin release, contribute to relaxation and pain intensity reduction dur- ing labor. The findings underscore the potential of integrating deep breathing relaxation and counterpressure massage as effec- tive approaches in non-pharmacological labor pain management. Introduction Childbirth is a tense and emotional period for the mother and her family, and it can be a painful and frightening experience for the mother. Generally, pain during labor is intense, with only 2-4% of mothers experiencing mild pain.1,2 The combination of pain and fear contributes to stress. According to the Indonesian Hospital Association Data Center, 15% of mothers in Indonesia faced com- plications during childbirth, with 21% describing their labor as painful due to extreme pain. Surprisingly, 63% of mothers did not receive information about the necessary preparations to alleviate pain during labor.3 During this process, stretching and dilation of the cervix occur due to contractions of the uterine muscles, aiming to push the baby out. Consequently, the mother experiences pain that can disrupt her comfort.4 Labor pain is a physiological condition generally encountered by almost all birthing mothers, with the severity of the pain depending on individual sensations.5 Pain in labor is a manifestation of uterine contractions and results from both psy- chological responses and physical reflexes.6 This pain has reper- cussions, including an increase in sympathetic nervous system activity, leading to changes in blood pressure, respiratory rate, skin color, nausea, vomiting, and excessive sweating.7 Behavioral changes due to pain are also commonly observed, such as height- ened anxiety, narrowed thoughts, moaning, crying, hand move- ments, and intense muscle tension throughout the body.8 Various methods can assist in reducing pain during labor, encompassing both pharmacological (involving drugs) and non- pharmacological approaches. Whenever possible, non-pharmaco- logical therapeutic options for pain management during labor Correspondence: Rahmawati Wahyuni, Lecturer in the Department of Midwifery, Politeknik Kesehatan Kemenkes Kalimantan Timur, Samarinda, Indonesia. E-mail: rahmawati_wahyuni@poltekkes-kaltim.ac.id Key words: active phase, counterpressure massage, deep breathing relaxation, maternal health, pain intensity. Contributions: RW, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; SS, conceptualization, investigation, methodology, valida- tion, and writing – original draft, review and editing; DS, conceptualiza- tion, methodology, formal analysis, validation, and writing – original draft, review and editing; NAS, formal analysis, validation, writing – review and editing. rap original draft, writing – review and editing. All the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. Funding: none. Conflict of interest: the authors declare no potential conflict of interest. Ethics approval and consent to participate: the research has received eth- ical approval from the Health Research Ethics Commission, Health Polytechnic of The Ministry of Health of East Kalimantan, based on ethical certificate No. LB.02.01/4.3/13566/2021. During the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgement: this paper and the research behind it would not have been possible without the exceptional support of Health Polytechnique of East Kalimantan. Received: 4 October 2023. Accepted: 20 December 2023. Early access: 30 January 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11917 doi:10.4081/hls.2024.11917 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:11917] [page 203] Non -co mmerc ial us e o nly should be explored before resorting to analgesic drugs.9 The uti- lization of non-pharmacological measures in pain management is a burgeoning trend and presents an alternative method for mothers to mitigate labor pain. These methods can induce relaxation, alleviat- ing both muscle and emotional tension, ultimately reducing the intensity of labor pain.10 Moreover, non-pharmacological approaches contribute to heightened patient satisfaction during labor, empowering the mother to exert control over her emotions and strength.11 Non-pharmacological techniques such as relax- ation, breathing exercises, movement and position changes, mas- sage, hydrotherapy, hot/cold therapy, music, guided imagery, acu- pressure, and aromatherapy have proven effective in enhancing maternal comfort during childbirth and fostering a positive birthing experience.12 Given the aforementioned problem description, it is evident that unresolved labor pain can significantly impact the psycholog- ical well-being of the mother during labor. Therefore, this study aimed to investigate the effectiveness of deep breathing relaxation and Counterpressure massage in alleviating labor pain during the active phase I. These non-pharmacological therapies can serve as valuable interventions. Materials and Methods Research design This research was conducted from June 8 to July 10, 2021, in the Maternity Room of a hospital in East Kalimantan, Indonesia. The study employed a quasi-experimental research design with a 2-group research method, consisting of a deep breathing relaxation group and a Counterpressure massage group, utilizing a pre and post-test without control design. Study participants The population for this study included all active phase I birth patients in June-July 2021 in Maternity Room 108, with 30 partic- ipants each month. Non-Probability Sampling, specifically Consecutive Sampling, was used to select 30 participants, evenly divided into two groups (15 per group). Inclusion criteria com- prised mothers in labor in active phase I, cervical dilatation between 4 to 9 cm, and no prior exposure to nonpharmacological therapy. Variable, instrument and data collection The independent variables were deep breathing relaxation and counterpressure massage, while the dependent variable was pain intensity during the first active phase. The research instrument employed was an observation sheet. Pain scale during active phase I was measured using a Numeric Rating Scale (NRS). In the inter- vention group, counterpressure massage was administered three times for 30-90 seconds, and deep breath relaxation techniques were performed three times for 3-5 minutes. Data analysis The analysis involved the Wilcoxon test and Mann-Whitney test with a significance level (α) of 5%. The Wilcoxon test meas- ured the average pain before and after deep breath relaxation and massage counterpressure for 30 respondents. The Mann-Whitney Test determined the difference in the effectiveness of the average value, indicating a significant decrease in pain intensity between the deep breath relaxation group and the massage counterpressure group. Ethical clearance The research received ethical approval from the Health Research Ethics Commission, Politeknik Kesehatan Kementrian Kesehatan Kalimantan Timur, based on ethical certificate No. LB.02.01/4.3/13566/2021. Throughout the research, the researcher adhered to ethical principles, including informed consent, respect for human rights, beneficence, and non-maleficence. Results Respondent characteristics in this research provide basic infor- mation about respondents, including age, level of education, parity and gestational age. Based on Table 1, it is evident that almost all respondents were aged between 20-35 years (73.3%). The majority of respondents were not employed (73.3%). A significant portion of respondents had an educational background ranging from ele- mentary to junior high school (40%). The highest parity status among respondents was primipara (40%), and among those with multipara status, there were 12 mothers who gave birth (40%). Almost all respondents had gestational ages exceeding 37 weeks, with 29 mothers giving birth (96.7%). Based on Table 2, it is evi- dent that before the implementation of the breathing relaxation technique, the majority of mothers experienced severe pain during the first active phase, with 9 respondents (60%), and after the inter- vention, 1 birth mother (6.7%) still experienced severe pain. The Wilcoxon test results for the deep breathing relaxation group, both before and after treatment, yielded a p-value of 0.002, which is ≤0.05. This indicates a significant difference in the effectiveness of reducing the intensity of labor pain before and after the application of deep relaxation techniques. Similarly, Table 2 illustrates that before the massage counterpressure treatment, the majority of mothers experienced severe pain during the first active phase, with 8 respondents (53.3%), and after the intervention, 4 respondents (26.7%) still experienced severe pain. The Wilcoxon test results for the counterpressure massage group yielded a p-value of 0.046, which is also ≤0.05. This suggests a significant difference in the effectiveness of reducing the intensity of labor pain before and after the application of counterpressure massage. Discussion Based on the research results from the 30 respondents studied, the majority fell within the age range of 20-35 years (73.3%). It’s noteworthy that maternal age below 16 years or above 35 years can make pregnant women more susceptible to complications. This indicates that most respondents are within the healthy reproductive age, physiologically capable of enduring labor pain. The age range of 20-35 years is considered ideal for pregnancy, childbirth, and breastfeeding, allowing mothers to provide optimal care for their children.13 Employment is a vital activity, primarily undertaken to sustain one’s own life and family. Work can significantly impact a person’s economic status. A lower socioeconomic level may lead individu- als to pay less attention to health messages, prioritizing more immediate needs.14,15 The education level of some research respon- dents was primary school and junior high school (40%), aligning with previous research suggesting no relationship between educa- tion and labor pain.16 Education is a fundamental need for personal development and intellectual maturity. It also influences one’s insight into decision-making and actions.17-19 Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [page 204] [Healthcare in Low-resource Settings 2024;12:11917] Non -co mmerc ial us e o nly The intensity of labor pain is affected by the history of past deliveries. Mothers with childbirth experience understand the pain during labor, while primiparas may experience greater intensity due to the cervix requiring more energy to stretch during the first stage of labor.20,21 Based on the study, most gestational ages were >37 weeks (97.7%), falling within the term gestation period of 38 to 42 weeks. Deep breathing relaxation techniques have a significant impact on the intensity of labor pain when implemented during the active phase of the first stage of labor. This is because labor pain serves as a signal indicating that the mother has entered the stage of the labor process, where the intensity of pain varies.22 Since pain dur- ing labor is subjective, each mother will experience and describe her own pain.23 This research is supported by studies indicating that deep breathing relaxation effectively reduces labor pain in the first active phase.24 Of the 15 respondents, the average pain inten- sity before receiving a counterpressure massage was reported by 8 respondents, constituting 53.3% experiencing severe pain. Following the counterpressure massage, 11 respondents had a moderate pain intensity (73.3%), while 4 respondents still experi- enced severe pain, accounting for 26.7%. This indicates that the counterpressure massage technique is relatively effective in reduc- ing labor pain. These findings align with previous research25 that demonstrated a reduction in pain severity after implementing back massage techniques. The results suggest that massage techniques are effective in alleviating labor pain, as seen in the study where respondents expe- rienced a decrease in pain after the counterpressure massage. The effects of labor pain, including inflammation in the uterus and labor dystocia, can be mitigated through complementary treat- ments such as effleurage and counterpressure massage.26 This study aimed to analyze the effectiveness of effleurage and counter- pressure massages in reducing labor pain during the first stage of active labor phase.27 The research is supported by previous studies conducted by Yulianingsih et al. (2019)8 affirming the effective- ness of counterpressure massage during the active phase of labor. While indicating the potential integration of non-pharmacolog- ical approaches, such as deep breathing relaxation and counter- pressure massage, for alleviating labor pain during the initial active phase, the study acknowledges significant limitations. With a sam- ple size of only 30 postpartum mothers, concerns arise regarding the generalizability of results to a broader population, emphasizing caution in extrapolating findings across diverse demographic groups. Furthermore, the study’s temporal scope is limited, as post- intervention assessments occurred immediately after interventions, neglecting an exploration of the long-term effects on labor pain sustainability. Future research should extend assessment periods into the postpartum phase to elucidate the enduring impact of these non-pharmacological interventions. Recognizing these constraints highlights the imperative for ongoing research and refinement in the application of these methods within the broader context of labor pain management. Conclusions Deep breathing relaxation techniques and counterpressure massage can alleviate tension in mothers, relieving stress during labor pain. These techniques promote relaxation of the body and inhibit the production of adrenaline hormones, replacing them with endorphins—pain-relieving hormones that increase endorphin lev- els. This physiological response induces a state of relaxation, con- sequently reducing the intensity of labor pain. Subsequent research endeavors may involve observing the reduction in pain intensity within the counterpressure massage treatment group by consider- ing the involvement of both family members and healthcare pro- fessionals. Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Characteristics of respondents (N=30). Indicator F % Age <20 Years 3 10 20-35 Years 22 73.3 >35 Years 5 16.7 Employment Work 8 26.7 Doesn't work 22 73.3 Education Elementary and junior 12 40 High school Senior high school 9 30 College University 9 30 Parity Primipara 12 40 Multipara 12 40 Grande multipara 6 20 Gestational Age ≤37 weeks 1 3.3 >37 weeks 29 96.7 Total 30 100 Table 2. Deep breathing relaxation and massage counter pressure treatments on pain intensity in active phase I labor mothers. Pre-test Post-test p f % f % Pain intensity with deep breathing relaxation 0.002 Light 0 0 2 13.3 Normal 6 40 12 80 Heavy 9 60 1 6.7 Pain intensity with massage counterpressure 0.046 Light 0 0 0 0 Normal 7 46.7 11 73.3 Heavy 8 53.3 4 26.7 Total 15 100 15 100 [Healthcare in Low-resource Settings 2024;12:11917] [page 205] Non -co mmerc ial us e o nly References 1. Ria G, Maya A, Jamalluddin SB. Murotal Al-Quran therapy on decreasing labor pain and anxiety in maternity mothers first phase. Enferm Clin 2020;30:110-4. 2. 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Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [page 206] [Healthcare in Low-resource Settings 2024;12:11917] Non -co mmerc ial us e o nly