Third International Seminar on Global Health (3rd ISGH)

Technology Transformation in Healthcare for a Better Life

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

florahoney.d@gmail.com

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 positions, relaxation and breathing exercises, reins

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
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

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Breast Milk, Anxiety, and Quality of Life Postpartum Mother
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.
Third International Seminar on Global Health (3rd ISGH)
Vol 3 | No. 1 | October 2019 |
Postpartum Exercise on Production of
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
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Table 1. Characteristics of Primigravida First Stage of Maternity Mother at the Active

Phase in Midwife Independent Practice in Cimahi
Management of Labour Pain
Characteristics Endorphin Massage Effleurage Massage
n=15 % n=15 %
Age
< 20 year or ≥ 35 year 5 33,3 3 20,0
20-34 year 10 66,7 12 80,0

Education
Elementary & Junior high 3 20,0 2 13,3
school
Senor High School & College 12 80,0 13 86,7

Occupation
Unemployment 11 73,3 12 80,0
Employment 4 26,7 3 20,0

Viewed from the characteristics on the table 1, 2. Difference of pain intensity in primigravida first
can be seen majority of the respondents are healthy stage of maternal active phase before and after
reproductive (20-34 years), educated Senior High endorphin massage at Independent Practice
School and College, and an unemployment. 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
Std.
Pain intensity Max
n Mean Deviation Min P value
Before Endorphin Massage 15 7,93 0,704 7 9 0,000
After Endorphin Massage 15 7,00 0,655 6 8

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

Std.
Pain intensity Max
n Mean Deviation Min p value
Before Effluerage Massage 15 7,53 1,727 5 10 0,001
After Effluerage Massage 15 5,40 0,986 4 7

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

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Breast Milk, Anxiety, and Quality of Life Postpartum Mother
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
f Sig t df
Before Endorphin and 0,232 0,632 4,803
Effluerage Massage
After Endorphin and 4,803
Effluerage Massage
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.
Third International Seminar on Global Health (3rd ISGH)
Vol 3 | No. 1 | October 2019 |
Postpartum Exercise on Production of
Sig Mean Std.
Lower Upper
(2-tailed) Diff Error
58 0,000 1,533 0,319 0,894 2,172
57,110 0,000 1,533 0,319 0,894 2,173
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
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maternity mothers. Effleurage is a massage not cause side effects and can reduce labor pain
technique using the palms of the fingers with in primigravida mother stage 1 active phase
circular movements in various parts of the body during contractions.
or a sweep along the back and extremities. The
mechanism of labor pain inhibition with 3. Comparison of endorphin massage with
effleurage techniques is based on the concept of effleurage massage on pain intensity in
gate control theory, namely tactile stimulation of primigravida first stage mothers in active
skin fibers that can inhibit pain signals from the phase at Midwife Independent Practice in
same body area or other areas. Stimulation of Cimahi
skin tactile fibers can be done with several
Researchers have not found any research
techniques of massage, rubbing, rubbing, fibrous
comparing these two massage methods
and analgesic smearing.15
simultaneously. In other studies, the endorphin
This technique also facilitates distraction
massage and effluerage massage methods were
and decreases sensory transmission of
compared with the counterpressure method and
stimulation from the abdominal wall thereby
were proven to be both ineffective in reducing
reducing discomfort in the affected area. As a
the intensity of labour pain.
relaxation technique effleurage reduces muscle
The Association for the Study of Pain
tension, increases circulation to the area of pain
defines that pain is an unpleasant emotional and
and prevents hypoxia.1
sensory experience that arises from actual or
Effleurage in the abdomen is usually used
potential tissue damage or indicates damage.
in the Lamaze method to reduce pain in normal
Pain is caused by a stimulus that can cause or
labour. Effleurage is one of the non-
almost cause tissue damage. Therefore, the
pharmacological methods to reduce pain during
sensation of pain can be distinguished from other
labor which is listed in the Summary of pain
sensations, although emotions such as fear and
relief measures during labor, where in the first
anxiety are also experienced simultaneously so
stage the latent phase (opening 0-3 cm) and the
that it affects one's perception of pain. It must
active phase (opening 4-7 cm) activities that can
also be remembered that with the presence of the
carried out by labor mothers is effleurage.4
sympathetic nervous system, pain stimulus can
The results showed a tendency to decrease
also cause various changes, such as increased
in pain intensity by an average of 2,133. This is
heart frequency, increased blood pressure,
in line with Yuliatun (2008) which states that
release of adrenaline (epinephrine) into the
effleurage massage in labor is done using soft
bloodstream and increased blood glucose levels.
and light fingertips. Smears are done lightly and
There is also a decrease in gastric motility and a
without strong pressure, but try to keep the
decrease in the blood supply of the skin which
fingertips off the surface of the skin. Skin
causes sweating. Thus, the stimulus that causes
stimulation with effleurage technique produces
pain will result in an incident or sensory event.16
impulses that are sent through large nerve fibers
In pregnancy and childbirth, pain is
that are on the surface of the skin, these large
interpreted as a "signal" to inform the mother
nerve fibers will close the gate so that the brain
that she has entered the stage of labour.
does not receive pain messages because it has
According to Cunningham (2012), labor pain as
been blocked by skin stimulation with this
myometrial contraction, is a physiological
technique, as a result the perception of pain will
process with different intensities in each
change in addition to relieve pain, massage will
individual. The pain experienced during labor is
stimulate the muscles of the uterus to contract.9
unique to each mother and can be influenced by
According to the researchers' analysis,
several factors including culture, fear, anxiety,
effleurage massage has an effect on reducing the
previous labor experience, preparation for labor
intensity of labor in the first phase of active
and support.2
labour in primigravida mothers, despite the
Separately in several studies, both
different factors of perception or tolerance to
endorphin massage and effluerage massage have
pain. Mothers in pain who do not believe that
been shown to play a role in reducing the
they have control of pain, will be able to increase
intensity of labour pain. In this study, the
anxiety and fear which then causes the mother to
tendency to decrease pain intensity was more
stress, and tense during contractions, this can
pronounced in effluerage massage with an
cause the failure of effleurage massage.
average decrease of 2,133. Relieving pain is
Although this method is very efficient and does

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Breast Milk, Anxiety, and Quality of Life Postpartum Mother
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
Third International Seminar on Global Health (3rd ISGH)
Vol 3 | No. 1 | October 2019 |
Postpartum Exercise on Production of
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.
REFERENCES
1. Varney, H. Buku Ajar Asuhan Kebidanan
“Varney’s Midwifery”. Edisi ke-3. Jilid I & II.
London: Jones and bartlett Publisher. 2009.
2. Cunningham, FG. Obstetri Williams. Cetakan
23. EGC: Jakarta. 2012.
3. Aprilia, Yessie. Terj. Ritchmond, Brenda.
Gentle Birth, Melahirkan Nyaman Tanpa Rasa
Sakit. Jakarta: Grasindo. 2011.
4. Creehan, P. Pain Relief and Comfort Measures
in Labor. In Rice Simpson K, Creehan P.
Editors: AWHONN’s Perinatal Nursing. Ed.3.
Philadephia: Lippincott & Wilkins. 2008.
5. Ma’rifah, A.R. Surtiningsih. Efektifitas Tehnik
Counter Pressure dan Endorphin Massage
Terhadap Nyeri Persalinan Kala 1 Pada Ibu
Bersalin di RSUD Ajibarang. Prosiding Seminar
Nasional dan Internasional. Universitas
Muhammadiyah Semarang. 2014.
6. NICE. 2014. Intrapartum Care: Care of Healthy
Women and Their Babies During Childbirth.
Clinical Guideline 190 Methods, Evidence and
Recommendations. London: National
Collaborating Centre for Women’s and
Children’s Health.
7. Indrayani & Djami, E.U.M. Update Asuhan
Persalinan dan Bayi Baru Lahir. Jakarta: TIM.
2016.
8. Kuswandi, L. Keajaiban Hypno-Birthing.
Jakarta: Pustaka Bunda. 2011.
9. Yuliatun, L. Penangangan Nyeri Persalinan
Dengan Metode Nonfarmakologi. Malang:
Bayumedia Publishing. 2008.
10. Rohani, dkk. Asuhan Pada Masa Persalinan.
Jakarta: Salemba Medika. 2011.
11. Wahyuni, S & Wahyuningsih, E. 2015.
Pengaruh Massage Effleurage Terhadap Tingkat
Nyeri Persalinan Kala I Fase Aktif Pada Ibu
Bersalin di RS PKU Muhammadiyah Delanggu
Klaten 2015. Jurnal Involusi Kebidanan. Vol. 5,
No. 10, Juni 2015.
12. Shrestha I, Pradhan n, Sharma J. Factors
Influencing Perception of Labor Pain among
Parturient Women at Tribhuvan University
Page 50

Breast Milk, Anxiety, and Quality of Life Postpartum Mother
Teaching Hospital. NJOG. JanJun;8(1):26-30.
2013.
13. Kartikasari, R.I. Nuryanti, A. Pengaruh
Endorphin Massage Terhadap Intensitas Nyeri
Punggung Ibu Hamil. Prosiding Rakernas
AIPKEMA 2016: 297-304. LPPM Universitas
Muhammadiyah Semarang.
14. Azizah, I.N. Widyawati, M.N. Anggraini, N.N.
Pengaruh Endorphin Massage Terhadap
Intensitas Nyeri Kala I Persalinan Normal Ibu
Primipara di BPS S dan B Demak Tahun 2011.
Third International Seminar on Global Health (3rd ISGH)
Vol 3 | No. 1 | October 2019 |
Postpartum Exercise on Production of
Jurnal Kebidanan Universitas Muhammadiyah
Semarang. Vol. 2 No. 1 Tahun 2013.
15. Wahyuni, S. Wahyuningsih, E. Pengaruh
Massage Effleurage Terhadap Tingkat Nyeri
Persalinan Kala I Fase Aktif Pada Ibu Bersalin
di RS PKU Muhammadiyah Delanggu Klaten
2015. Jurnal Involusi Kebidanan, Vol. 5, No. 10,
Juni 2015.
16. Bobak, L.J. Keperawatan Maternitas. Edisi 4.
Jakarta: EGC. 2005
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