INTRODUCTION:

Cesarean section is the birth of fetus through a trans-abdominal incision in the uterus. It is one of most common surgical procedure worldwide (1).Cesarean section women had a particular condition after the operation when compared to the patients who went through other surgical procedures. As she needs to perform more activities in order to take care of the newborn and herself, therefore, she is subjected to more pains in the surgical section location (2).

Although patients tended to have the available multimodal analgesic management this was not always used to its maximum effectiveness.

It was evident that analgesic administration practices did not consistently reﬂect management that was responsive to pain intensity nor did it always reﬂect a multimodal approach to treatment(3). Sousa et al. (2009) found high pain scores among cesarean section women which rated from moderate 51.7% to sever 20% in spite of using analgesics (2). In addition, the persistent pain is more common one year after cesarean section and the women with persistent pain recalled significantly more pain on the day after cesarean section (4).

It is necessary that pain relief be safe and effective, that it is not interfere with the mother's ability to move around and care for her infant, and that it is resulted in no adverse neonatal effects in breast-feeding women (5).

Recently, many complementary therapies such as music, TENS, relaxation, reflexology were effective in managing post cesarean section pain (6-8). Also massage has been shown beneficial to reduce stress, enhance blood circulation, decrease pain, promote sleep, reduce swelling, enhance relaxation, and increase oxygen capacity of the blood. It has also been recognized as a non-pharmaceutical treatment for cancer and postoperative pain (9).

Foot and hand massage has the potential to aid in pain relief. The Massage stimulates cutaneous mechanoreceptors that activate large primary afferents. They release GABA and endorphins, which inhibit neurotransmitters discharged from the primary nociceptive neurons and evoke depressive reactions within the receptive field in the pain pathway. As a result, receptor activation of second transmission neurons is blocked preventing nociceptive information from reaching consciousness (10).

According to the gate control theory painful impulses are transmitted by large diameter and small diameter nerve fibers. Stimulation of large diameter fibers prevents the small diameter fibers from transmitting signals. Tactile stimulation produced by massage travels through the large diameter fibers. These fibers also carry a faster signal. In essence, massage sensations win the race to the brain, and the pain sensations are blocked because the gate is closed (11).

Significance of the study:

Effective postoperative pain control can be achieved through non-pharmacological therapies. Massage is one of the most widely used as complimentary therapies in nursing practice. Foot and hand massage have the potential to aid pain relief (10). So this study was conducted to investigate the utilization of foot and hand massage as Natural Measures on relieving post cesarean incision pain.

Aim of the study

The aim of this study was to investigate the utilization of natural measures on relieving post cesarean incision pain.

Research Hypotheses

Foot and hand massage has positive effect on relieving post cesarean section incision pain.

Study design

This study is an intervention study design.

Setting

It was conducted on postnatal cesarean section room at Ain Shams Maternity University Hospital from January 2011 to September 2011.

Sampling

The desired sample size was calculated to be 150 women using type I error =0.05 and power of 0.80 and assuming the standard deviation of the NRS =2 a sample size of 70-75 per group is satisfactory to detect a difference of 1 between control and exposed groups. Sample size calculation is done with PS program Version 3.0.43 (12). The sample was a systematic random sample. It is divided into two groups, 75 control and 75 intervention groups.

Sample Criteria:

Post cesarean section women were selected according to the following criteria:

· Conscious women.

· Women with intact hand and foot skin and free from arthritis, phlebitis, burn wound, injury, inflammation, eczema, cardiovascular and respiratory disease.

Ethical consideration:

Before conducting the study, the researcher obtained an approval from the ethical committee at Faculty of Nursing Ain Shams University. Also the researcher was obtained written consent from director of Ain Shams University Maternity Hospital to carry out the study.

Tools of the study

Three tools were used for data collection,

1. A structured interviewing questionnaire sheet containing general characteristics.

2. A numerical rating scale, it is an assessment scale with fixed scale steps, a linear line with marks spaced 1 cm apart ranging from 0 (no pain) to 10 (worst pain imaginable). It is widely preferred by national and international investigators for its applicability and clarity in determining the pain intensity of patient.

3. Modified McGill pain questionnaire short form: this scale was used by the researcher to assess pain characteristic.

Data collection

The control group received post cesarean section hospital routine care (analgesic) for pain relief measure and their pain measured at 6, 12 and 18 hours after the surgery. While the intervention group received foot and hand massage for 20 minutes, 5 minutes for each hand then 5 minutes for each foot. Foot and hand massage was applied at three times at 5:40, 11:40, 17:40 hour after delivery the researcher measure the level of pain before the massage session and immediately after massage and one hour after massage.

Technique:

The researcher applied the massage without using no special equipment, which includes petrissage, kneading, and friction applied to the patient's hands and feet using classical massage techniques. The researcher held the mother’s hand gently in one of her hands. The researcher used thumb and fingers to make circles over the mother’s entire palm, all fingers, and the outer surface of the hand. The palm was spread by the researcher’s fingers. Hand massage applied to each hand for 5 minutes avoiding an intravenous catheter inserted area if any. Following hand massage, the mother's foot was elevated by supporting it with a pillow. The sole was spread and rubbed by the researcher's fingers. The thumb was used to make circles over the entire sole of the foot. The knuckles of one hand stroked the sole with an up-and-down motion. The heel and ankle was kneaded between the researcher's thumb and forefinger. The pillow support was removed to finish the massage (10).

Table (1): Comparison between mean score of pain level among control and intervention groups at 6, 12 and 18 hours post Cesarean.

Variables	Groups		Significance
Variables	Control	Intervention	T	P- value
Pain level score 6 hours after delivery (Mean and S.D)	6.44±1.90	4.09±1.55	8.23	0.00**
Pain level score 12 hours after delivery (Mean and S.D)	5.37±1.84	3.05±1.17	9.22	0.00**
Pain level score 18 hours after delivery(Mean and S.D)	3.52±1.40	1.84±1.10	8.17	0.00**

* Statistically significant (p <0.05) ** Statistically highly significant (p <0.001 )

Table (2): Pair wise comparison of pain scores before and after foot and hand massage in intervention group

Variables	Mean	SD	95% Confidence Interval of the Difference		Significant
Variables	Mean	SD	Lower	Upper	T	P- value
Pain score before 1^st massage and immediately after 1^st massage	2.813	±0.485	2.702	2.925	50.26	0.00**
Pain score before 1^st massage and one hour after 1^st massage	2.107	±0.669	1.953	2.261	27.26	0.00**
Pain score before 1^st massage and one and half hour after 1^st massage	1.360	±0.799	1.176	1.544	14.74	0.00**
Pain score before 2^nd massage and immediately after 2^nd massage	2.880	±0.434	2.780	2.980	57.51	0.00**
Pain score before 2^nd massage and one hour after 2^nd massage	2.227	±0.628	2.082	2.371	30.73	0.00**
Pain score before 2^nd massage and one and half hour after 2^nd massage	1.560	±0.740	1.390	1.730	18.27	0.00**
Pain score± before 3^rd massage and immediately after 3^rd massage	2.493	±0.529	2.372	2.615	40.78	0.00**

* Statistically significant (p <0.05) ** Statistically highly significant (p <0.001)

Table (3): Comparison of Mother's pain description between study groups.

Variables	Groups				Significance
	Control		Intervention		X²	P- value
	No	%	No	%	X²	P- value
Stabbing	1	1.3	10	13.3	7.946	0.05*
Spasmodic (cramping)	39	52.0	27	36.0	3.896	0.048*
Hot burning	12	16.0	12	16.0	0	1.0
Aching	16	21.3	22	29.3	1.269	0.260
Heavy	1	1.3	7	9.3	4.754	0.029*
Tender	2	2.7	9	12.0	4.807	0.028*
Cutting	18	24.0	29	38.7	3.749	0.053
Fearful	0	0.0	9	12.0	9.574	0.002*
Punishing	0	0.0	1	1.3	1.007	0.316
Pulling	16	21.3	18	24.0	0.152	0.697
spreading	3	4.0	6	8.0	1.064	0.302
Throbbing	25	33.3	27	36	0.118	0.731

* Statistically significant (p <0.05)

Table (4): Frequency distribution of observed mother's behavior immediately post cesarean birth among control compared to intervention group.

Variables	Groups				Significant
	Control		Intervention		X²	P- value
	No	%	No	%	X²	P- value
Moaning	24	32.0	34	45.3	2.811	0.094
Crying	19	25.3	22	29.3	0.302	0.583
Grimace	27	36.0	34	45.3	1.354	0.245
Clenched teeth	17	22.7	25	33.3	2.116	0.146
Lip pitting	13	17.3	23	30.7	3.655	0.056
Wrinkled fore head	14	18.7	14	18.7	0.000	1.0
Restlessness	6	8.0	10	13.3	1.119	0.290
Immobilization	34	45.3	22	29.3	4.103	0.043*
Changing position in bed	4	5.3	6	8.0	0.429	0.513

* Statistically significant (p <0.05)

Table (5): Frequency distribution regarding mother's first mobility post cesarean section among intervention compared to control group.

Mobility after delivery	Groups		Significant
Mobility after delivery	Control	Intervention	T	P- value
Mean	9.37	9.08	0.366	0.72*
Median	9	8
Std. Deviation	3.039	3.467

* Not statistically significant (p >0.05)

Table (6): Frequency distribution of intervention and control groups regarding conditions aggravating pain.

Conditions aggravating pain	Groups				Significant
	Control		Intervention		X²	P- value
	No	%	No	%	X²	P- value
Sitting	35	46.7	33	44.0	0.108	0.743
Standing	24	32.0	26	34.7	0.120	0.729
Walking	21	28.0	31	41.3	2.943	0.086
Defecation	2	2.7	2	2.7	0	1.0
Carrying the newborn	40	53.3	21	28.0	9.974	0.002*
Breast feeding	40	53.3	24	32.0	6.977	0.008*
Cough/sneezing	15	20.0	16	21.3	0.041	0.840
Movement (turning in bed)	44	58.7	53	70.7	2.363	0.124
Urination	4	5.3	7	9.3	0.883	0.347

* Statistically significant (p <0.05)

Analysis of the Results

Table (1) highlights a value shows that a statistically significant difference in mean of pain level among study groups at 6, 12, 18 hours after delivery, (P-value˂0.000). As mean of pain level was (6.44±1.9, 5.37±1.84, 3.52±1.4) in control group versus (4.09±1.55, 3.05±1.17, 1.84±1.1) in intervention group after foot and hand massage.

Table (2) shows that, there is a statistical significant difference between mean of difference of pain score before and after massage immediately, one hour after massage, and one and half hour after massage in 1^st, 2^nd and 3^rd massages.

Table (3) shows no statistical significant difference between two groups regarding mothers own description of pain except for description of pain as stabbing , heavy, tender, and fearful were more common in intervention group than control group as represent (13.3%, 9.3%,12%, 12%) while 52% of control group described their pain as cramping.

Table (4) presents different observational behaviour (voices, face, and body expressions) experienced by women during their pain. It highlights different observation behaviour but there were no significance differences between the two groups.

Table (5) shows that, there is statistical significant difference between two groups only, regarding carrying the newborn and breastfeeding as 53.3% of control group reported that carrying the newborn and breastfeeding aggravating pain versus (28% and 32%) of intervention group.

Table (6) shows that the mean duration until mobility after delivery was 9.37 and 9.08 in control and intervention group respectively. No statistical significant difference was found between the two groups.

DISCUSSION:

The aim of this study was to investigate the utilization of natural measures on relieving post cesarean incision pain. The research hypotheses of this study was foot and hand massage as a natural measures has appositive effect on relieving post cesarean section incision pain. This hypotheses was achieved because there was statistically significant difference in mean of pain score between control and intervention group at different assessment times, (p value=0.00). This difference demonstrated that a highly significant improvement in pain management in intervention group than in control group. This finding was supported by the study carried out to investigate the effect of 20 minutes foot and hand massage, each extremity 5 minutes on post operative cardiac pain in the cardiac surgery wards, which found that there was statistically significant difference on the pain intensity between control and massage group after intervention (p value=0.000). Also Eghbali et al. (2010) results showed that, there was a significant difference between the mean score of pain severity of intervention group and control group after 20 minutes of applying foot and hand massage in orthopedic patient (13 and 14).

In relation to the mean of pain score before and after 20 minutes of foot and hand massage in the intervention group, the results showed that, there was statistical significant difference in mean of pain score before and after foot and hand massage. It was demonstrated that the mean of pain score in intervention group was 6.91±1.62 before 1^st massage and reduced to 4.09±1.55 immediately after 1^st massage, 5.93±1.35 before 2nd massage and reduced to 3.05±1.17 immediately after 2^nd massage, 4.33±1.22 before 3^rd massage and reduced to 1.84±1.1 immediately after 3^rd massage. These results reflected that difference between the mean of pain score before and immediately after 1^st, 2^nd and 3^rd massages were 2.82, 2.88 and 2.49 points respectively. These results are similar to the finding of the study conducted by Degirmen et al. (2010) on Turkish post cesarean section women, who reported that 20 minutes foot and hand massage reduced post operative cesarean section pain intensity significantly within the first 24 hours after cesarean section, as the mean of pain intensity score decrease of 2.76 points from 5.76±1.23 pre-massage score to 3±1.08 post massage score (15).

Also, Wang and Kick (2004) stated that, foot and hand massage appears to be effective, in expensive, low risk, flexible and easily applied strategy for post operative pain management. As 20 minute foot and hand massage were proved to significantly reduced post operative pain in 1st post operative day, suggesting that pain intensity score of 4.65±1.93 reduced to 2.35±1.87 (t=8.15, p<0.001). Moreover Dunning and James (2001) stated that, a significant reduction in pain was apparent after all three treatments (use of aromatherapy hand and foot massage) (p=0.05) (10and16). Also Eghbali et al. (2010) found that, the difference between mean score of pain severity is significant in the intervention group that received 20 minutes foot and hand massage and this agree with the study result (14).

In contrast, Hulme et al (1999) did not obtain significant results on pain intensity score from 5 minutes foot massage. The duration of massage may play an important role in its effect on post-operative pain. Probably the time duration of massaging in this study was enough to see parasympathetic respond and functioning of endocrine that increase the secretion of endorphins and could reduce pain severity (14and17).

In relation to the descriptions and characteristics of the post cesarean section pain presented by the mothers, it was verified that the most mentioned descriptors, in the control group were cramping for 52%, throbbing for 33.3%, cutting for 24%, aching and pulling for 21.3% of mothers. While in the intervention group, the descriptors were cutting for 38.7%, cramping and throbbing for 36%, aching for 29.3%, and pulling for 24% of mothers. The study results showed that there was a greater tendency to choose descriptors from the sensory category of McGill tool in both groups. In the same line Sousa (2009) and Pitangui et al. (2009) results found that the most cesarean section women choose descriptors from the sensorial category of McGill tool while in souse study the women's descriptors were annoying for 55%, tight for 55%, pulling for 50%, boring for 41% and cramping for 38.3% of women while in Pitangui study it was aching for 67.5% and squeezing for 60% of women (2and18). Also Niven et al. (2000) results reported that the cramping was frequently mentioned by the parous women (19).

According to the literature review the degree of behavioral response factors in to the degree of pain intensity of patient experience while absence of pain behaviors does not mean that the patient is not experiencing pain and pain behavior is affected by believes and culture (Stacy et al., 2010). So this study presents different observational behavior (verbal, facial, and body expression) experienced by women during their post cesarean section pain e.g. the most prominent verbal expression was moaning and grimace as facial expression and immobilization as body expression in both groups (20).

In the same line, Yildirim and Sahin (2004) results stated that women expressed pain in different behaviors such as crying, screaming, changing facial expression (wrinkled forehead, lip biting) and body movement (21). While the Jewish patients expressed their pain through crying, moaning and complaining (22). In addition, With regard to culture, Javanese and Batak patients responded to pain somewhat differently. Javanese patients showed stoic responses. In contrast, Batak patients demonstrated expressive responses (23).

Regarding conditions aggravating mothers' pain in both groups, it was reported that turning in bed, sitting, standing and walking aggravation pain and that is not a surprising with present of lower abdominal wound . In the same line the study conducted by Sousa et al. (2009) reported that sitting down and standing up followed by walking were the physical activities with the highest pain scores among cesarean section women (2). Also Kolawole and Fawole (2003) found that factors aggravating pain in cesarean section women included turning in bed, coughing and ambulation (24). In the other study, patient in post operative abdominal pain reported that worst pain occurs with various activities for example mobilizing, turning in bed and coughing (25).

Regarding mothers' first mobility after cesarean section, although there was no significance difference between both groups, the mean of the intervention group first mobility after cesarean section was less than the control group. This is in agreement with Gadsden et al. (2005) results who stated that good pain relief will improve mobility (5). While no statistical difference between two groups may be due to present of some reasons that encourage both groups for mobility: 1st early removal of catheter which make mothers must mobile to went to bathroom, 2nd according to hospital system, in the morning of postnatal unit the mother encouraged to move for hygienic care and change their clothes, 3rd mothers' need help for mobility and this make some mothers delayed their mobility until visiting time as their families will helping and supporting them in mobility.

Similarly, Ahmed and Najib (2010) results found that there was no statistical significance difference between intervention and control groups concerning mobility after cesarean section. Also, they stated that all women encouraged for early ambulation in the first day of operation according to hospital routine and most of the study sample in both groups required help for mobility (26).

So, our results stressed the importance of utilizing foot and hand massage as natural pain management post cesarean section which is inexpensive, no harm to women and highly minimize incision pain. Moreover, in Egypt, we are a developing country with limited facilities and limited hospital beds, this method can be utilized by all maternity nurses with prescription during postnatal period as a successful measure for pain relief rather than pharmacological methods which may be costly to health system.

CONCLUSION:

The present study concluded that foot and hand massage as natural pain relief measures highly minimizes post cesarean section incision pain.

RECOMMENDATION:

This study recommended that the intervention used in this study to be a booklet or brochure about pain management post cesarean section and distributed among maternity health services in Egyptian Ministry of Health for health team.

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Received on 02.04.2014 Modified on 15.05.2014

Asian J. Nur. Edu. and Research 4(4): Oct.- Dec., 2014; Page 388-393