Research Article

THE EFFECT OF PROGRESSIVE Indonesian Nursing Journal of Education and

Clinic (INJEC)
MUSCLE RELAXATION (PMR) ON IN PRESS
Volume 7 Issue 1, Juni 2022

THE MOTHER'S ANXIETY LEVEL DOI: 10.24990/injec.v7i1.506

injec.aipni-ainec.org/index.php/INJEC/index
Received : 2022-10-11
BEFORE SECTIO CAESAREA AT Accepted : 2022-11-11
The Association of Indonesian Nurse
DINDA’S HOSPITAL AT Education Center (AINEC)

TANGERANG CITY

Siti Nurjanah1, Lastri Mei Winarni2*, Yati Afiyanti3, Denny

Maulana4

Abstract
Introduction: The process of delivery through sectio caesarea is a complex event and causes anxiety.
Anxiety that occurs can have a negative impact on mothers and babies born. This study aims to
determine the effect of progressive muscle relaxation (PMR) on the level of anxiety of mother’s before
sectio caesarea at Dinda’s Hospital, Tangerang City.
Methods: The research method uses a quantitative approach with a quasi-experimental non-
equivalent control group conducted on 36 respondents with a simple random sampling technique.
Intrument of this study used Zung Self-Report Anxiety Scale (ZSAS) to measure mother’s anxiety levels.
Intervention delivered to the respondent by researcher a day before enter the operating room. Data
processing using editing, coding, cleaning and analysis, to test the effect of PMR to mother,s anxiety
level, data analysis used independent paired T-test.
Results: Result of the analysis show that the provision of PMR techniques can reduce score anxiety
levels by 8.2, from 58.3 before intervention to 50.1. The results show that independent paired t-test
obtained p-value of 0.001 which means that there is a significant effect between the level of anxiety of
the mothers before SC surgery compare with control group.
Conclusions: Nurses need to implement and educated mothers about PMR intervention to help
reduce the level of anxiety before sectio Caesarea.

Keywords: anxiety, pregnant mothers, section Caesarea, progressive muscle relaxation (PMR)

1
Nursing Program at Universitas Yatsi Madani, Tangerang, Indonesia
2
Midwifery Program at Universitas Yatsi Madani, Tangerang, Indonesia
3
Nursing Faculty at Universitas Indonesia, Depok, Indonesia
4
Clinical Instructor at Dinda’s Hospital, Tangerang, Indonesia

Corresponding Author
Lastri Mei Winarni
Nursing Program at Universitas Yatsi Madani, Tangerang, Indonesia
Email: lastri@uym.ac.id

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 Indonesian Nursing Journal of Education and Clinic (INJEC)

INTRODUCTION using non-pharmacological techniques such

as meditation, yoga, hypnotherapy, and
Sectio Caesarea (SC) operation as
relaxation to reduce anxiety (Weingarten
one of the triggers for anxiety has
et al., 2021). Another alternative action is
increased. In the last two decades the
the use of progressive muscle relaxation
proportion of caesarean sections has
(PMR) as an alternative to manage anxiety.
increased to around 30% in many
PMR action is an alternative intervention
countries. The trend of global use of SC
that can be considered to reduce anxiety.
has increased by 3.7% annually with an
PMR interventions can be used to help
increase of 12% in 2000 to 21% in 2015.
manage stress, improve individual coping
The rate of change varies widely between
and reduce anxiety levels (Ozgundondu &
regions. The largest increase occurred in
Gok, 2019).
North America with SC usage from 24.3%
to 32% in 2000 to 2015. In Western Progressive muscle relaxation
Europe from 19.6% to 26.9%, and from (PMR) is a relatively simple non-
32.3% to 44.3% in America Latin and pharmacological intervention. PMR
Caribbean (Schaal et al., 2020). intervention is easy, convenient, can be
done anytime, anywhere, and by anyone.
Mothers who face the birth would
Execution of PMR does not require special
have been anxiety and fear to spontaneous
equipment and can be done in just 5-15
or SC labor (Winarni et al., 2021). Anxiety is
minutes to achieve the desired effect. The
the most common disorder in pregnant
PMR intervention was developed by
women who will undergo caesarean
Jacobsen in 1938, where a relaxed body
section. Research result (Berhe et al.,
and mind can release tension and anxiety
2017) showed that of 178 surgery patients,
(Harorani et al., 2019). The PMR method is
59.6% experienced pre-operative anxiety.
based on muscle relaxation due to reduced
Other research conducted (Trisetyaningsih
sympathetic nerve activity and
et al., 2018) at the General Health Service
neuroendocrine function which can reduce
General Hospital of Muhammadiyah Bantul
physical and psychological stress
which involved 20 respondents found 4
(Ozgundondu & Gok, 2019).
respondents (20%) mild anxiety, 10
respondents (50%) moderate anxiety, 5 Research results have proven the
respondents or 25% were in a state of effect of PMR to reduce stress and anxiety.
severe anxiety. While the results of PMR has been shown to reduce stress and
research conducted (Sutira, 2017) feelings of anxiety in breast cancer patients
Maternity Clinic in Medan area showed 2 receiving chemotherapy (Vuttanon et al.,
mothers experienced mild anxiety (10%), 6 2019). A study states that PMR can reduce
mothers experienced moderate anxiety pain intensity in postoperative cesarean
(30%), and 12 mothers experienced severe clients (Pragholapati et al., 2020). Similar
anxiety 12 (60%) faced childbirth. studies have concluded that PMR
intervention can relieve anxiety conditions
Pregnant women who face SC
that occur in mothers when facing labor in
procedures are at risk of experiencing
the latent phase (Pratama et al., 2017). The
excessive anxiety conditions. Managing
PMR technique can reduce the level of
anxiety levels will help not only for the
anxiety in dealing with premenstrual
well-being of the mother but also for the
syndrome in adolescents at the junior high
fetus. The results show the benefits of
school level (Widyaningrum & Sari, 2018).

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Nurjanah, Winarni, Afiyanti, & Maulana
In Dinda’s Hospital, there was no non-
pharmacological action that is related to
the decrease in anxiety that mothers
experience before SC. Midwife only explain
about the informed consent, standard
operational procedure (SOP) and
therapeutic communications. So this
research aimed to determine the effect of
PMR intervention on the mothers level of
anxiety before SC at Dinda’s Hospital,
Tangerang City.
METHODS
Study Design
This study used a quasi-
experimental non-equivalent control group
design. This design is almost the same as
the pretest-posttest control group design,
only in this design the experimental group
and the control group are not chosen
randomly. In the quasi-experimental non-
equivalent control group design, both the
experimental and control groups were
compared, even though the groups were
selected and placed without going through
random.
Population, Samples, and Sampling
The study population was patients
who underwent caesarean section at Dinda
Hospital. The sampling method in this
study used random sampling, the
instrument to measure anxiety levels was
used the Zung Self-Report Anxiety Scale
(ZSAS). Analysis the ZSAS, researcher
calculate the score of anxiety
measurements before and after PMR in
intervention group, and collected the score
of anxiety before and after breathing
intervention in control group. The total
sample as respondents in this study were
36 respondents, this number is obtained
from the replication formula for quasi-
experimental research. Researchers divide
18 mothers as the intervention group and
http:// injec.aipni-ainec.org/index.php/INJEC/ index | 125
18 mothers as the control group with
random assignment, for the odd number
come to intervention group and for the
even number come to control group. Data
analysis used univariate analysis and
symmetric test. The research place was at
Rs Dinda Tangerang.
Instruments
The instrument in the study used a
questionnaire. The questionnaire used
consists of parts A and B. Part A is the
respondent's characteristic data which
consists of 4 questions. Part B is an anxiety
questionnaire from the ZSAS which has
been adapted into Indonesian. Part B
consists of 20 statements consisting of 15
positive statements and 5 negative
statements. The Anxiety Index score of the
ZSAS instrument was used to determine
the clinical interpretation of a person's
level of anxiety.
Procedure
The implementation procedure is
described as follows. Researchers examine
prospective respondents who are suitable
and meet the specified criteria. The
researcher divided the respondents into
two groups, namely the intervention group
which would be given PMR action as many
as 18 respondents and the control group
which would be given deep breathing
relaxation measures as many as 18
respondents. The researcher explained
about how to fill out the questionnaire and
the intervention procedures to be given,
namely the provision of PMR intervention
in the intervention group and the provision
of deep breathing relaxation in the control
group. The researcher explained the
mechanism and procedures for the
research procedure to the respondents.
Respondents who are willing, then fill out a
demographic data questionnaire and an
anxiety questionnaire.
 Indonesian Nursing Journal of Education and Clinic (INJEC)

The researcher accompanied the performing the exercise, participants

respondent when filling out the
questionnaire. After filling out the
questionnaire, it was followed by a PMR
session for the intervention group and
deep breathing relaxation in the control
group. The PMR intervention session was
carried out the day before the sectio
caesarea operation so that participants had
time to do the PMR exercise before the
day of the operation. Likewise, giving deep
breath relaxation in the control group was
taught the day before the operation.
In the intervention group, the
researcher explained that the time needed
to perform PMR was about 20 minutes.
The researcher explained that PMR
activities were carried out by tensioning
and relaxing the body. Participants were
instructed to perform PMR for each body
part in the order starting from the facial
and head muscles, followed by the neck,
shoulders, chest, abdomen, legs, and feet.
Participants were instructed to tense a
muscle group for five seconds while
inhaling, and then relax the same muscle
for 10 seconds while exhaling. While
visualize waves of relaxation flowing
throughout the body.
In the control group, the
researcher explained that giving the deep
breathing technique was done by inhaling
air through the nose deeply and exhaling
slowly through the mouth. This action can
be done for 20 minutes before surgery.
During the intervention process,
researchers did not forget to apply the
health protocol during the Covid-19
pandemic. Data processing using editing,
coding, cleaning and analysis, to test the
effect of PMR to mother’s anxiety level,
data analysis used independent paired T-
test.
RESULTS
Based on table 1.1 it was found
that the majority of respondents' ages
ranged from 20-35 years as many as 29
respondents (80.6%). The education level
of respondents is more highly educated as
many as 21 respondents (58.3%). Most of
the respondents work as private
employees as many as 16 respondents

Table 1.1 Univariate analysis (n=36)

Variable Frequency (n) Percentage (%)
Age
Risk (<20 or >35 years old) 7 19,4
No Risk (20-35 years old) 29 80,6
Education
Low 15 41,7
High 21 58,3
Occupation
Government employee 2 5,6
Private employee 16 44,4
Entrepreneur 8 22,2
Housewives 10 27,8
Parity
Primipara 14 38,9
Multipara 22 61,1

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Nurjanah, Winarni, Afiyanti, & Maulana

(44.4%). While the parity variable obtained Based on table 1.4 shows that the
more multipara as many as 22 respondents provision of PMR can reduce anxiety levels
(61.1%) of 36 respondents. by 8.2, namely from 58.3 anxiety levels
before giving PMR to 50.1 after
Table 1.2 Mean score of anxiety before intervention. The results of the
Intervention in group independent paired T-test obtained a p-
Minimum-
Group Mean SD value of 0.001 which means that there is a
Maximum
47-72 significant difference between the level of
Intervention 58,3 7,2
anxiety before and after giving ROP.
Control 54,8 7,8 45-69
Table 1.5 Effect of breathing intervention
Based on table 1.2, it was found in control group
that the average level of anxiety before Control
Mean SD p-value
being given PMR in the intervention group group
was 58.3. While the average level of Pre-test 54,8 7,8
0,659
anxiety in the control group was 54.8 Post-test 53,6 7,6
before being given a deep breath. The
Based on table 1.5 shows that the
level of anxiety in the intervention group,
provision of breathing can reduce score
the lowest was 47 and the highest was 72.
anxiety by18.2, namely from 54.8 to 53.6
Meanwhile, the level of anxiety in the
control group (inhale) the lowest was 45
DISCUSSION
and the highest was 69.
Anxiety is the most common
Table 1.3 Mean score of Anxiety After disorder in pregnant women who will
Intervention in group undergo caesarean section. The results of
Minimum- the study (Berhe et al., 2017), showed that
Group Mean SD
Maximum
of 178 surgery patients, 59.6%
Intervention 50,1 6,9 45-58
experienced pre-operative anxiety.
Control 53,6 7,6 44-65 Another study conducted (Trisetyaningsih
Based on table 1.3, it was found et al., 2018) at the General Health Service
that the average level of anxiety after General Hospital Muhammadiyah Bantul
being given PMR in the intervention group involving 20 respondents found 4
was 50.1. While the average level of respondents (20%) mildly anxious, 10
anxiety in the control group was 53.6 after respondents (50%) moderately anxious, 5
being given a deep breath. The level of respondents or 25% are in a state of
anxiety in the intervention group , the severe anxiety. While the results of
lowest is 45 and the highest is 58. research conducted (Sutira, 2017)
Meanwhile, the level of anxiety in the Maternity Clinic in Medan area showed 2
control group (inhale) is the lowest 44 and mothers experienced mild anxiety (10%),
the highest is 65. 6 mothers experienced moderate anxiety
(30%), and 12 mothers experienced severe
Table 1.4 Effect of PMR on intervention anxiety 12 (60%) faced labor.
group
Intervention Researchers consider that the use
Mean SD p-value
group of PMR can be an effective technique in
Pre-test 58,3 7,2 reducing anxiety experienced by mothers
0,001
Post-test 50,1 6,9 who face SC surgery. The PMR technique

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 Indonesian Nursing Journal of Education and Clinic (INJEC)
has been shown to be beneficial in various
anxiety conditions such as chronic pain in
cancer patients, phobic disorders,
situational stress, sleep disturbances, and
lowering of blood pressure. (Liu et al.,
2020b). n this study, respondents
reported the benefits of PMR techniques
in reducing tension and anxiety that
occurred before undergoing SC surgery
procedures. This is reflected in the results of
the comparison of answers in the pre and
post-test questionnaires.
The results of other studies are
corroborating, revealing that muscle
relaxation techniques are very effective in
reducing anxiety and tension
(Ozgundondu & Gok, 2019; Bostani et al.,
2020). The mechanism of progressive
muscle relaxation in reducing the level of
anxiety and tension is explained when the
muscles contract (tense) then the stimulus
will be conveyed to the muscles through
afferent nerve pathways. Tension is the
contraction of skeletal muscle fibers that
produces a sensation of tension.
Relaxation is the lengthening of muscle
fibers that can relieve the sensation of
tension after the muscle contracts.
Progressive muscle relaxation is a
technique that involves stretching and
relaxing all muscle groups in the body,
from head to toe (Pragholapati et al.,
2020).
The PMR technique is a general
procedure for identifying the location of
tension, relaxation and feeling the
difference between tension and relaxation
that will be applied to all major muscle
groups. Thus, in progressive muscle
relaxation it is taught to control the
skeletal muscles so as to allow each part
to feel the sensation of tension and
relaxation systematically. Progressive
muscle relaxation uses a series of relaxed
body muscle movements that aim to relax
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and provide a comfortable effect on the
entire body (Liu et al., 2020a). Thus, the
tension and anxiety levels will decrease.
Another research reported that
muscle relaxation techniques were
reported to be the most effective therapy
for reducing depression. Mothers who
face SC surgery have a tendency to change
their coping patterns in facing threatening
situations. Mothers will experience feelings
of fear, worry, and anxiety because of the
negative impacts that may occur. This
condition can increase anxiety and feelings
of helplessness. Muscle relaxation
techniques can be a medium that allows
patients to control tension and make them
more comfortable (Gallego-Gómez et al.,
2020; Vuttanon et al., 2019).
CONCLUSIONS
The results of the analysis show
that the provision of PMR techniques can
reduce anxiety levels by 8.2, namely from
58.3 before giving PMR techniques to 50.1
after giving PMR and the results of the
independent paired T-test obtained p-value
of 0.001 which means that there is a
significant effect between Mother's anxiety
level facing SC surgery before and after
PMR intervention. Hospitals need to
implement the non-pharmacological
policies to reduce mothers anxiety level
through PMR techniques to mothers
before SC surgery.
CONFLICT OF INTEREST
There is no conflict of interest in
this study.
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