https://doi.org/10.5812/aapm.22236v2

Benson Relaxation Technique in Reducing Pain Intensity in Women After Cesarean Section

authors:

avatar Tetti Solehati 1 , * , avatar Yeni Rustina 2

Faculty of Nursing, Padjadjaran University, Bandung, Indonesia
Faculty of Nursing, University of Indonesia, Jakarta, Indonesia
Anesthesiology and Pain Medicine: Vol.5, issue 3; e22236
published online: June 22, 2015
article type: Research Article
received: July 22, 2014
revised: October 1, 2014
accepted: October 14, 2014

how to cite: Solehati T, Rustina Y. Benson Relaxation Technique in Reducing Pain Intensity in Women After Cesarean Section. Anesth Pain Med. 2015;5(3):e22236. https://doi.org/10.5812/aapm.22236v2.

Abstract

Background:

Post-cesarean section women experience pain due to operative trauma. Pain sensation can be reduced by pain management. Pharmacological and non-pharmacological treatments can be used. The Benson Relaxation Technique is a non-pharmacological way suitable to reduce pain, but there are limited studies on its post-cesarean section use.

Objectives:

This study aimed to determine the effect of Benson Relaxation Technique in reducing pain intensity in women after cesarean section.

Patients and Methods:

This was a quasi-experiment study with pre and post-test design. A prospective, not blind, randomized assign, two groups parallel study was conducted in Cibabat hospital Cimahi as intervention group (IG) and Sartika Asih hospital as control group (CG). Post cesarean section women with quota sampling who met the inclusion criteria were consecutively assigned to either experimental (n = 30) or control group (n = 30). Women in the experimental group received the Benson relaxation technique and those in the control group received regular care from the health workers. The outcome pain severity was measured by visual analogue scale. Those instruments were applied before and after intervention.

Results:

The mean of pain score before intervention at CG was 4.43 cm. It was decreased to 4.40 cm (1 min), 4.27 cm (12 h), 4.10 cm (24 h), 4.00 cm (36 h), 3.93 cm (48 h), 3.83 cm (60 h), 3.67 cm (72 h) and 3.51 cm (84 h). Meanwhile, the IG was 4.97 cm. It was decreased to 4.90 cm (1 min), 4.23 cm (12 h), 3.57 cm (24 h), 3.03 cm (36 h), 2.77 cm (48 h), 2.73 cm (60 h), 2.67 cm (72 h) and 2.63 cm (84 h). The study found a significant difference comparing pain intensity before and after the intervention in CG and IG (P = 0.001), but pain reduced in IG more than CG.

Conclusions:

The Benson relaxation could reduce pain intensity in women after cesarean section.

1. Background

Surgery threatens the integrity of body, such as bio-psycho-social-spiritual aspects and may cause discomfort such as pain response. Experience of pain is associated with many immediate and long-term negative outcomes (1). Experience of pain is a combination of physiological and psychological features and is a non-persistent tissue damage (2, 3). Pain is the main reason for someone to seek medical assistance. Pain sensitivity is more in females than males (4). Cesarean section is among surgery procedures that induces pain. There are several reasons to perform C-section. A study found that reasons for performing caesarean section were baby’s weight more than normal, fetal distress, dystocia, placenta previa, placenta abruption, decreased fetal percentage and malposition (5-7). Besides, there is willingness to perform caesarean section by mothers’ request in the absence of an obstetric indication (8-10). A research found that 75% of patients undergone surgery experienced moderate to severe pain after surgery. The duration of pain can last for 24 to 48 hours, but can last longer depending on how the client can withstand and respond to pain. A study showed that women experience higher levels of pain intensity during the first 24 hours post-caesarean section. There were no differences in pain intensity between elective caesarean section and emergency caesarean section (11). Recently, many methods being developed to address the problem of pain in women with severe post caesarean section pain, either by pharmacological and non-pharmacological approaches. One non-pharmacological way suitable to reduce pain intensity is relaxation (12). Relaxation aims to reduce anxiety, decrease muscle tension and bone and indirectly relieve pain and reduce tension related to the body’s physiological status (12-14). Several studies showed that relaxation is effective in reducing pain (12, 14-22). Benson relaxation technique is simple, easy to learn and implementation and does not require high cost (23). This relaxation is a combination of relaxation response techniques with individual belief system/faith factor (focused on a particular form of expression of the names of God or a word that has a calming sense to the client) repeatedly spoken with a regular rhythm with resignation. From the preliminary study conducted by researchers in the postpartum hospital Cibabat Cimahi, many patients had a continuing pain. Data of interviews in five women post caesarean section revealed that women felt pain on the first day after surgery. The pain intensity was 6-7 and women asked for pain-killer; 3 of 5 people said to be tortured by pain. Three women said that they were told by nurses to take a deep breath in case of pain, but were not given training.

2. Objectives

Considering the problems mentioned above and lack of any research on the effect of Benson relaxation therapy to decrease pain intensity in women after Caesarean section, the researchers interested to assess women’s level of pain after Caesarean section using Benson relaxation techniques.

3. Patients and Methods

The principle of the study protocol was approved by the Ethic Committee of both hospitals and a written informed consent was obtained from each patient. The study design used a quasi-experiment with pretest and posttest with control group design. In the intervention group, Benson relaxation technique was performed (respondents in the Cibabat hospital); whereas, those who were not given the intervention Benson relaxation considered as control group (respondents in the Sartika Asih hospital). The experimental group was given the intervention Benson relaxation two hours after the operation, after the effects of anesthesia were lost and women were conscious. Prior to the intervention, participants were trained how to use a visual analogue scale (VAS ranged 0-10); patients’ pain scores were measured before the intervention. Then, the Benson relaxation was performed for participants. They were suggested to take a particular form of expression in the names of God or a word that has a calming sense to the participants, repeatedly spoken with a regular rhythm with resignation, they were suggested to take deep breath through nose and exhale with the lips while saying the names of God or the word that has a calming sense. After the intervention, patients’ pain scores were measured. The Benson relaxation method was presented to IG and continued after the operation for 10 minutes to 4 days (84 hours): then the second day, third, and fourth every 12 hours at 6 am and 6 pm. In the control group, Benson relaxation was not performed and regular care as room procedure was performed. Measurement of pain in the control group was performed as the intervention group for four days every 12 hours.

Based on standard deviation of previous study about relaxation, SD = 1.30, at a significant 1% (Z1 - α/2 = 2.58), power 95% (Z1-β or Z 95% = 1.64), µ1 (mean before intervention) = 4.50, µ2 (mean after intervention) = 3.41, the sample size calculated as 24 subjects. The sample size increased to 30 patients to consider attrition rate. Therefore, the total sample size of 30 (30 samples in each group) was selected for the study. Patients were randomly assigned into two groups of 30 by a table of random numbers. The sample was recruited who met the inclusion criteria (first birth by cesarean section, using ketoprofen therapy, using spinal anesthesia, awareness compos mentis and never experienced the Benson relaxation yet). The exclusion criteria were repeated cesarean section and sub-consciousness. Data collection tool had two parts: first a questionnaire concerning demographic characteristics of respondents and the second instrument was using scale VAS pain questionnaires. Data was collected in April - June 2008. The Statistical Package for Social Sciences version 10.0 (SPSS Inc. Chicago, IL, USA) was used to analyze data. Kolmogorov-smirnov z test was performed to assess distribution normality. The analyses were performed using chi square, independent t tests, dependent t tests, repeated measure ANOVA and multiple linear regression.

5. Discussion

5.1. Association Between Characteristics of Respondents With Women Pain Intensity After Caesarean Section

Age was not associated with pain intensity. It is consistent to the opinion (24) indicating that age was not a significant factor regarding pain. In this study, an association was found between education and pain intensity. Lack of knowledge about something, causes people to have a positive attitude towards it. Education level is related with knowledge, one about how to cope with post-caesarean section pain. This is consistent with the opinion (25) on the theory of transcultural environmental. In this case, education is one of the factors able to affect a person’s behavior. In this study, there was no association between employment (24) and pain intensity, but there was an association between parity and pain intensity. Parity effect is probably due to parity-related coping strategies in dealing with pain experience. In primiparity, the possibility is no experience of labor pain and how to cope with compared to those multiparous mothers. This is in accordance with the statement (26) that previous pain experience would affect client’s pain response. In this study, there was no significant correlation between the nature of caesarean section and pain intensity. This is consistent with a research (11), which found no differences between elective caesarean section and emergencies regarding pain level. In this study, characteristics of age, nature and work did not affect the intensity of pain, meaning that pain has a different meaning for each person. Pain has an important protective function by giving a warning that a damage is happening (12). In addition, it is likely that the intensity of pain experienced by clients affected by other factors such as environment and culture. At both hospitals under research, data showed a calm and comfortable environment. Environment would affect the intensity of pain. Besides, the pain intensity is influenced by cultural factors. Culture has a role in tolerating pain (26). This aspect has a high impact on the psychological perception of pain. A research (27) found that cultural factors influence the perception of pain.

5.2. The Difference in Average Pain Intensity of the Respondents

The result showed that the average pain intensity immediately after caesarean section before the intervention was moderate in the CG (4.43 cm) and severe in IG (4.97 cm). During this period, no significant difference was obtained regarding the average pain intensity in the both groups (P value = 0.10). This is in accordance with the statement (28) that post-caesarean section pain is moderate or severe. Likewise, a study (27) found that 75% of surgical patients experienced moderate to severe pain after surgery. In both hospitals, the intervention given to mothers after caesarean section reduced pain, but there was a significant difference in decreasing mean pain intensity after the intervention between CG and IG. Average pain intensity immediately after the caesarean section after the intervention was moderate (3.51 cm) in CG and mild (2.63 cm) in IG. The average pain of mothers in the CG was significantly different between before and after the intervention. This might be due to maternal post-caesarean section adaptation to pain as the wound healing process. When the wound is still wet, the tissue has not fused so that severe pain is felt. Once the wound is dry and tissue connection happens, pain is reduced. While in IG, pain reduction was due to Benson relaxation intervention. There was a decrease in pain intensity as 2.34 cm in the group given Benson intervention compared to the control group as 0.93 cm. Some other studies (14, 18) found that this relaxation technique is effective in reducing pain. The results are reinforced by research (15, 20, 21, 23, 29-32).

In multivariate analysis using multiple linear regression, it was found that the Benson relaxation had the greatest effect on reduction of pain intensity in women after caesarean section (P = 0.01). According to some studies (23, 33-37), Benson relaxation has a healing effect to decrease anxiety level, cognitive and somatic anxiety, mood disturbance, body discomfort and to a level capable of relieving pain. The results found that Benson relaxation techniques had the greatest influence to decrease pain intensity. Benson relaxation technique is a simple and inexpensive technique (23, 37) and nurses can use to manage pain. Thus, the researchers suggest, especially the maternity nursing services, to use the technique of Benson relaxation as one of the standard operating procedures as non-pharmacological pain management in maternal post caesarean section. Besides, Benson relaxation training can be used as training material for nurses/midwives in the maternity room. This study had some limitations. One was its small sample size. By increasing the sample size, the possibility of a markedly deviant sample diminishes. The large samples lead to removing atypical values (31).

Acknowledgements

References

  • 1.

    Alhani F. The effect of programmed distraction on the pain caused by venipuncture among adolescents on hemodialysis. Pain Manag Nurs. 2010;11(2):85-91. [PubMed ID: 20510838]. https://doi.org/10.1016/j.pmn.2009.03.005.

  • 2.

    Herr K, Coyne PJ, Key T, Manworren R, McCaffery M, Merkel S, et al. Pain assessment in the nonverbal patient: position statement with clinical practice recommendations. Pain Manag Nurs. 2006;7(2):44-52. [PubMed ID: 16730317]. https://doi.org/10.1016/j.pmn.2006.02.003.

  • 3.

    Keogh E, Ellery D, Hunt C, Hannent I. Selective attentional bias for pain-related stimuli amongst pain fearful individuals. Pain. 2001;91(1-2):91-100. [PubMed ID: 11240081].

  • 4.

    Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley J3. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain. 2009;10(5):447-85. [PubMed ID: 19411059]. https://doi.org/10.1016/j.jpain.2008.12.001.

  • 5.

    Hankins GD, Clark SM, Munn MB. Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise. Semin Perinatol. 2006;30(5):276-87. [PubMed ID: 17011400]. https://doi.org/10.1053/j.semperi.2006.07.009.

  • 6.

    Bergholt T, Stenderup JK, Vedsted-Jakobsen A, Helm P, Lenstrup C. Intraoperative surgical complication during cesarean section: an observational study of the incidence and risk factors. Acta Obstet Gynecol Scand. 2003;82(3):251-6. [PubMed ID: 12694122].

  • 7.

    Al Rowaily MA, Alsalem FA, Abolfotouh MA. Cesarean section in a high-parity community in Saudi Arabia: clinical indications and obstetric outcomes. BMC Pregnancy and Childbirth. 2014;14(1):92. https://doi.org/10.1186/1471-2393-14-92.

  • 8.

    Gonen R, Tamir A, Degani S. Obstetricians' opinions regarding patient choice in cesarean delivery. Obstet Gynecol. 2002;99(4):577-80.

  • 9.

    MacDonald C, Pinion SB, MacLeod UM. Scottish female obstetricians' views on elective caesarean section and personal choice for delivery. J Obstet Gynaecol. 2002;22(6):586-9. [PubMed ID: 12554241]. https://doi.org/10.1080/0144361021000020312.

  • 10.

    Turner CE, Young JM, Solomon MJ, Ludlow J, Benness C, Phipps H. Vaginal delivery compared with elective caesarean section: the views of pregnant women and clinicians. BJOG. 2008;115(12):1494-502. [PubMed ID: 18752584].

  • 11.

    Karlstrom A, Engstrom-Olofsson R, Norbergh KG, Sjoling M, Hildingsson I. Postoperative pain after cesarean birth affects breastfeeding and infant care. J Obstet Gynecol Neonatal Nurs. 2007;36(5):430-40. [PubMed ID: 17880313].

  • 12.

    Kwekkeboom KL, Cherwin CH, Lee JW, Wanta B. Mind-body treatments for the pain-fatigue-sleep disturbance symptom cluster in persons with cancer. J Pain Symptom Manage. 2010;39(1):126-38. [PubMed ID: 19900778]. https://doi.org/10.1016/j.jpainsymman.2009.05.022.

  • 13.

    Kwekkeboom KL, Gretarsdottir E. Systematic Review of Relaxation Interventions for Pain. Journal of Nursing Scholarship. 2006;38(3):269-77.

  • 14.

    Good M, Stanton-Hicks M, Grass JA, Anderson GC, Lai HL, Roykulcharoen V, et al. Relaxation and music to reduce postsurgical pain. J Adv Nurs. 2001;33(2):208-15. [PubMed ID: 11168704].

  • 15.

    Carroll D, Seers K. Relaxation for the relief of chronic pain: a systematic review. J Adv Nurs. 1998;27(3):476-87. [PubMed ID: 9543032].

  • 16.

    Fenlon D. Relaxation therapy as an intervention for hot flushes in women with breast cancer. Eur J Oncol Nurs. 1999;3(4):223-31. https://doi.org/10.1016/S1462-3889(99)81335-0.

  • 17.

    Dehghani M, Sharpe L, Nicholas MK. Selective attention to pain-related information in chronic musculoskeletal pain patients. Pain. 2003;105(1-2):37-46. [PubMed ID: 14499418].

  • 18.

    Bagheri-Nesami M, Mohseni-Bandpei MA, Shayesteh-Azar M. The effect of Benson Relaxation Technique on rheumatoid arthritis patients: extended report. Int J Nurs Pract. 2006;12(4):214-9. [PubMed ID: 16834582].

  • 19.

    Khanna A, Paul M, Sandhu JS. Efficacy of two relaxation techniques in reducing pulse rate among highly stressed females. Calicut Med J. 2007;5(2):23-5.

  • 20.

    Levin RF, Malloy GB, Hyman RB. Nursing management of postoperative pain: use of relaxation techniques with female cholecystectomy patients. J Adv Nurs. 1987;12(4):463-72. [PubMed ID: 3308992].

  • 21.

    Topcu SY, Findik UY. Effect of relaxation exercises on controlling postoperative pain. Pain Manag Nurs. 2012;13(1):11-7. [PubMed ID: 22341136]. https://doi.org/10.1016/j.pmn.2010.07.006.

  • 22.

    Mohammadi Fakhar F, Rafii F, Jamshidi Orak R. The effect of jaw relaxation on pain anxiety during burn dressings: randomised clinical trial. Burns. 2013;39(1):61-7. [PubMed ID: 22698840]. https://doi.org/10.1016/j.burns.2012.03.005.

  • 23.

    Rambod M, Sharif F, Pourali-Mohammadi N, Pasyar N, Rafii F. Evaluation of the effect of Benson's relaxation technique on pain and quality of life of haemodialysis patients: a randomized controlled trial. Int J Nurs Stud. 2014;51(7):964-73. [PubMed ID: 24332569]. https://doi.org/10.1016/j.ijnurstu.2013.11.004.

  • 24.

    Lawlis GF, Selby D, Hinnant D, McCoy CE. Reduction of postoperative pain parameters by presurgical relaxation instructions for spinal pain patients. Spine (Phila Pa 1976). 1985;10(7):649-51. [PubMed ID: 3906935].

  • 25.

    Dionne CE, Von Korff M, Koepsell TD, Deyo RA, Barlow WE, Checkoway H. Formal education and back pain: a review. J Epidemiol Community Health. 2001;55(7):455-68. [PubMed ID: 11413174].

  • 26.

    Lowdermilk DL, Perry SE, Bobak IM. Maternity womens health care. 7th ed. Philadelphia: Mosby Inc; 2000.

  • 27.

    Sloman R, Rosen G, Rom M, Shir Y. Nurses' assessment of pain in surgical patients. J Adv Nurs. 2005;52(2):125-32. [PubMed ID: 16164473].

  • 28.

    Good M, Stanton-Hicks M, Grass JA, Anderson GC, Makii M, Geras J. Pain after gynecologic surgery. Pain Manag Nurs. 2000;1(3):96-104. [PubMed ID: 11706465]. https://doi.org/10.1053/jpmn.2000.9857.

  • 29.

    Van Kooten ME. Non-pharmacologic pain management for postoperative coronary artery bypass graft surgery patients. J Nurs Scholarsh. 1999;31(2):157.

  • 30.

    Roykulcharoen V, Good M. Systematic relaxation to relieve postoperative pain. J Adv Nurs. 2004;48(2):140-8. [PubMed ID: 15369494].

  • 31.

    Seers K, Crichton N, Tutton L, Smith L, Saunders T. Effectiveness of relaxation for postoperative pain and anxiety: randomized controlled trial. J Adv Nurs. 2008;62(6):681-8. [PubMed ID: 18503652].

  • 32.

    Demiralp M, Oflaz F, Komurcu S. Effects of relaxation training on sleep quality and fatigue in patients with breast cancer undergoing adjuvant chemotherapy. J Clin Nurs. 2010;19(7-8):1073-83. [PubMed ID: 20492052].

  • 33.

    Galvin JA, Benson H, Deckro GR, Fricchione GL, Dusek JA. The relaxation response: reducing stress and improving cognition in healthy aging adults. Complement Ther Clin Pract. 2006;12(3):186-91. [PubMed ID: 16835029]. https://doi.org/10.1016/j.ctcp.2006.02.004.

  • 34.

    Kolt GS, Gill S, Keating J. An examination of the multi-process theory: the effects of two relaxation techniques on state anxiety. Aust J Psychol. 2002;54:39.

  • 35.

    Leon-Pizarro C, Gich I, Barthe E, Rovirosa A, Farrus B, Casas F, et al. A randomized trial of the effect of training in relaxation and guided imagery techniques in improving psychological and quality-of-life indices for gynecologic and breast brachytherapy patients. Psycho-Oncology. 2007;16(11):971-9.

  • 36.

    Park E, Oh H, Kim T. The effects of relaxation breathing on procedural pain and anxiety during burn care. Burns. 2013;39(6):1101-6.

  • 37.

    Solehati T, Rustina Y. The Effect of Benson Relaxation on Reduction of Pain Level Among Post Caesarean Section Mother at Cibabat Hospital, Indonesia. J Nurs Health Care. 2013;1:171-175. https://doi.org/10.5176/2345-718X_1.1.23.