Effectiveness of Preoperating Teaching with Anxiety Levels in Preoperating Sectio Caesarea Patients

Surgery is an experience that can cause anxiety. Anxiety is a feeling of fear that is unclear and not supported by the situation. In lowering anxiety, health education is needed. The purpose of the study was to analyze the effect of Pre Operating Teaching (Informed Consent) with anxiety levels in preoperative sectio caesarea patients in the Maternity Room of Arga Husada Hospital, Kediri,


INTRODUCTION
Labor is often interpreted as a series of events of expulsion of full-term babies, followed by removal of the placenta and fetal membranes from the mother's body through the birth canal or through other means, taking place with assistance or without assistance (the mother's own strength) (Kurniarum, 2016). Labor is divided into 3, namely spontaneous, artificial and recommended labor. Childbirth with Secsio Caesarea is an action aimed at saving the mother and fetus. Secsio Caesarea childbirth is one of the services carried out at the Hospital for maternal emergency measures (Jumilia &;Emilia, 2018).
Surgery is a surgical procedure on a part of the body that is carried out in the operating room of a hospital with a predetermined procedure. The preoperative phase begins when the decision for surgery is made and ends when the patient is moved to the operating shirt (Jumilia &;Emilia, 2018). Surgery is an experience that usually causes anxiety , anxiety related to all kinds of foreign procedures that patients undergo and also threats to life safety due to surgical procedures. 90% of preoperative patients have the potential to experience anxiety so that patients and families often show excessive attitudes with the anxiety they experience (Carpenito (2009) in Jumilia (2018)).
Anxiety is a feeling of fear that is vague and unsupported by the situation. Individuals who feel anxious will feel uncomfortable or afraid, but do not know the reason for the condition. Anxiety has no obvious identifiable stimulus. Anxiety is a normal state that occurs in various circumstances, such as growth, change and new experiences. (Mandagi, 2013). Anxiety is inevitable from everyday life (Saseno, 2013). Anxiety can be felt by everyone if they experience deep stress and feelings that cause psychiatric problems and can develop over a long period of time. (Shodiqoh, 2014). Anxious symptoms that arise vary in each individual. Anxiety can be in the form of anxiety, dizziness, palpitations, trembling, and so on. Anxiety can interfere with daily life (Mandagi, 2013).
A preliminary study that researchers conducted in September on 10 maternity mothers who were about to undergo Sectio Caesarea, 8 of whom experienced anxiety, showed an increase in vital signs. Based on the description above, researchers are interested in conducting a study entitled The Effect of Pre Operating Teaching (Informed Consent) with anxiety levels in preoperative section caesarea patients at RSU Arga Husada.

METHODS
The research to be carried out by researchers uses pre-experimental design with pretest and post-test design approaches. Pre-experimental design is a design that includes only one group or class given pre and post test. The design of one group pretest and posttest design was carried out on one group without a control or comparison group.
The population in this study was all maternity mothers who would have a cesarean section in the Maternity Room of Arga Husada Hospital Kediri. some maternity mothers who will have sectio caesarea surgery in the Maternity Room of Arga Husada Hospital Kediri in Januari-Maret 2023 who meet the inclusion and exclusion criteria.
The sampling technique uses accidental sampling with a sample of 93 respondents.
In this study the independent variable was Pre Operating Teaching (Informed Consent), while the dependent variable was the level of anxiety in preoperative section cesarean section patients. The data collection process in this study was by using HRS-A questionnaires. Data processing is carried out by several stages of data checking, coding, and data tabulation. Data analysis was carried out using the Statistical Package for Social Science (SPSS) program with Univariate and Bivariate analysis. Based on table 1 shows that most respondents aged 20-35 years as many as 51 people (54.8%). The education level of respondents was mostly Secondary (SMA Seequal) as many as 56 people (60.3%). The economic status of respondents is mostly in the middle class category as many as 45 people (48.4%). The employment status of respondents was mostly unemployed as many as 50 people (53.8%). Parity among respondents was mostly primiparous as many as 48 people (51.6%). Based on table 3, it can be seen that the difference in the anxiety level of preoperative sectio caesarea patients before and after pre-operating teaching is that most respondents before pre-operating teaching are 24 respondents (25.8%) experiencing severe anxiety, and 52 respondents (55.9%) experiencing moderate anxiety, and 17 respondents (18.3%) experiencing mild anxiety. After being given pre-operating teaching, 17 respondents (18.3%) experienced moderate anxiety, 61 respondents (65.6%) experienced mild anxiety, and 15 respondents (16.1%) did not experience anxiety. Based on table 4 it can be seen that of the 17 respondents (18.3%) who experienced mild anxiety before giving informed consent, after being given pre operating teaching they experienced a change to not being anxious as many as 15 respondents (16.1%) and mild anxiety as many as 2 respondents ( 2.2%). Of the 52 respondents (55.9%) who experienced moderate anxiety before being given pre operating teaching, after being given pre operating teaching they became mildly anxious as many as 52 respondents (55.9%). Meanwhile, of the 24 respondents (25.8%) who had not been given pre operating teaching experienced severe anxiety, after being given pre operating teaching they became mildly anxious as many as 7 respondents (7.5%) and moderately anxious as many as 17 respondents (18.3%). ). The results of the Mc Nemar test obtained a p-value = 0.000 (p <0.05), namely that there was an effect of preoperative teaching on the anxiety level of preoperative sectio caesaria patients in the delivery room of Arga Husada Hospital, Kediri.

Characteristics of Respondents by Age
In this study, the age of respondents <20 years as many as 18 respondents (19.4%), 20-35 years as many as 51 respondents (54.8%), and the age of > 35 years as many as 24 respondents (25.8%).
Pregnant women aged 20-35 years are the age that is considered safe to undergo the process of pregnancy until labor and puerperium. Conversely, at the age of <20 years, physical conditions, especially reproductive and psychological organs, are not 100% ready to undergo this period. While pregnant women aged >35 years are a high risk condition for congenital abnormalities and the presence of complications during pregnancy, childbirth and puerperium. This will increase anxiety in mothers if there is a complication of pregnancy (Guritnawati, Sutresna and Darmawan, 2021).
It can be assumed that the older the age of the mother in facing childbirth, the lower the level of anxiety, as well as mothers who have undergone childbirth the level of anxiety in facing the next childbirth will decrease and also when pregnant women have experienced in dealing with trauma, the smaller the level of anxiety.

Characteristics of Respondents by Education Level
The results showed that the education level of basic respondents (elementary / junior high) as many as 11 people (11.8%), secondary (equivalent high school) as many as 56 people (60.3%), and higher (academy / bachelor) as many as 26 people (27.9%).
The level of education will affect the understanding of information. The level of education will affect knowledge and understanding so that it has an impact on a person's psychological condition (Wahyuningsih and Agustin, 2020;Zuhana, Prafitri and Ersila, 2020;Fatmawati and Pawestri, 2021).
The higher a person's education, the better his level of knowledge. However, it should be emphasized that it does not mean that someone with low education is absolutely low knowledge, because knowledge is not only obtained from formal places but can also be obtained from experience from others around him (Mubarak, 2012).
According to Ahsan, Lestari and Sriati (2019) stated that a low level of education in a person will cause the person to experience anxiety easily compared to those who have higher education status (Guritnawati, Sutresna and Darmawan, 2021). Researchers assume that the mother's education level will affect the understanding of information, especially related to health

Characteristics of Respondents by Economic Status
The results showed the economic status of respondents with the lower class category as many as 23 people (24.7%), being in the middle class as many as 45 people (48.4%), and being in the upper class as many as 25 people (26.9%).
Income is the factor that most determines the quantity and quality of health so that there is a relationship between income and a person's state of health. The level of income will affect the pattern of habits in maintaining health For those with low incomes are only able to meet health needs as they are, if the income level is good, then their health utilization will be better (Wulandari, 2020).
According to Mubarak (2012), the socioeconomic status of the community indicates the level of welfare and opportunity to use and receive health services.
The family's financial ability is one of the considerations in making childbirth selection decisions

Characteristics of Respondents by Employment Status
The results showed the employment status of respondents who did not work as many as 50 people (53.8%), and those who worked as many as 45 people (46.2%).
Nekada, Amigo and Krisnanto (2020) argue that people who don't work tend to have more ideas than people who work. Puspitasari and Wahyuntari (2020) stated that work correlates with the problem solving mechanism in itself. Sihombing, Saptarini and Putri (2017) argue that someone who has a job will generate an income to meet daily needs.
In relation to work, a person will be more confident in utilizing health facilities when they have a job status. Because by working someone will have income so that they can determine what kind of health facilities they want.

Characteristics of Respondents by Parity
The results showed parity in respondents, namely primiparous as many as 48 people (51.6%) and multipara as many as 45 people (48.4%).
Primiparous is a woman who has been pregnant once with the fetus reaching the point of being able to survive. Primigravida is a woman who is pregnant for the first time. Multiparous is a woman who has experienced two or more pregnancies with the fetus reaching the point of being able to survive Boland and Verduin (2021).
Parity is the state of women who have ever given birth to a live baby. Where women gain knowledge from personal experience. Experience is a way to gain the truth of knowledge. Therefore, personal experience can also be used as an effort to gain knowledge. Whether obtained directly or indirectly, not all personal experiences can lead a person to draw conclusions correctly (Matthias and Samarasekera, 2012;Veneris and Pubis, 2021;Yuliani et al. , 2021) .
The parity of a person will determine the selection in labor. The use of childbirth facilities which include childbirth methods and helpers will be determined based on the experience that the mother has. The more children, the more experience in childbirth.

Pre-Operating Teaching (Informed Consent) to Preoperative Sectio Caesarea Patients
The results showed that all respondents received complete pre-operating teaching (informed consent), which was 93 respondents (100%).
Providing informed consent is a liaison between doctors and patients which is a communication in determining the best treatment and therapy to patients, and must be explained completely and clearly to patients. or the patient's family. In addition, the explanation and process of recording and requesting signatures is a necessary consent as a condition for implementing good informed consent according to legal aspects (Astuti and Kulsum, 2018).
Sectio caesarea at Arga Husada Kediri Hospital, performed on patients in accordance with the conditions determined by the doctor in charge and the patient's condition in an emergency. Before sectio caesarea, patients are given an explanation regarding the procedure for sectio caesarea. Explanations in informed consent are delivered to patients using clear language and easy to understand patients or families, the provision of informed consent at Arga Husada hospital is given in full, namely as many as 93 respondents (100%).
One aspect of procedural action services that is often carried out and felt the need to provide information to patients and families is operative action. The provision of informed consent is necessary not only based on moral obligations related to the human rights of individuals and individual responsibilities for their health, but serves to protect humans from being manipulated as objects of interest. When considered cases of malpractice lawsuits that have surfaced, most of the uncertainty is caused by lack of communication between health workers and patients plus low patient knowledge of the implementation of surgery (Wahyuni and Sugiarti, 2017;Prahesti and Putriningrum, 2021).
Anxietylevel n in preoperative sectio caesarea patients before pre-operating teaching (informed consent) The characteristics of respondents at Arga Husada Hospital, Kediri based on the anxiety level of preoperative sectio caesarea patients before being given pre-operating teaching (informed consent), namely as many as 52 respondents (55.9%) experienced moderate anxiety. This can happen possibly influenced by loss of control, panic so that you cannot do something and there is an increase in anxiety as a result of which there is a decrease in the ability to relate to others. In line with research conducted by Hepp et al. (2016) which measured the level of anxiety on the day of SC surgery and the results of his research stated that the highest level of anxiety was during pre-surgery compared to skin closure and 2 hours post SC with STAI scores close to 55 (STAI-State score 20-80), at VASA values close to 7 (VASA in cm 0-10), and at cortisol above 30 (observation of saliva).
This can be explained according to the opinion of Vogt et al. (2021) that surgery is a psychosocial stressor that can cause anxiety for preoperative patients, because surgery is considered a threat to life, health and body integrity. Smeltzer, S.C. & Bare (2016) explained the patient's fear that patients feel fear and anxiety, including fear due to ignorance of surgical procedures and anesthesia, pain, complications, and even death. In line with that, this opinion is also corroborated by Carpenito (2021) that 90% of preoperative patients experience anxiety.
Everyone always says that childbirth is very painful, therefore there are fears in mothers who are pregnant for the first time and have not had the experience of childbirth. When viewed from the experience of childbirth, there are two groups of mothers who are overwhelmed with fear and anxiety facing childbirth. The first group is women who have given birth, but have had unpleasant experiences in previous pregnancies and childbirths. The second group is first-time pregnant women and has never had childbirth experience before, but many hear about scary stories and experiences from others about the labor process (Dartiwen, 2019).
Anxiety triggers the activity of the HPA axis (hypothalamus, pituitary, and adrenal) which is the body's neuroendocrine system involving the hypothalamus, pituitary hormone glands, and adrenal glands as a complex communication system responsible for stress reactions by regulating the production of cortisol, a type of hormone and an excitatory nerve mediator. When individuals experience anxiety, it increases the secretion of cortisol and catecholamines and causes activation of sympathetic nerves. The sympathetic system is the system that dominates when individuals are in emergency situations or stressful conditions ("fight or flight") (Sherwood, 2015;McCloughan et al., 2016).
Activation of the sympathetic system causes physiological changes in the body. This happens because the cortex of the brain receives stimuli sent through sympathetic nerves to the adrenal glands which will release adrenaline and epinephrine so that the effects include changes in vital signs, disorders in diet, sleep pattern disorders and body muscles become tense (Stuart &;Laraia, 2005;Videbeck, 2011;Sahin et al., 2016).

Effectiveness of Preoperating Teaching with Anxiety Levels in Preoperating Sectio Caesarea Patients
Muscle tissue reaches 40-50% of body weight and is composed of contractile cells called muscle fibers. When a person is startled, scared, anxious or in a state of tension, the nervous system will spur blood flow to the skeletal muscles and tension causes muscle fibers to contract. During contraction, the lengths of actin myofilament (thin myofilamen) and myosin (thick myofilament) remain the same but their positions cross each other. The sarcoplasmic reticulum will release calcium ion reserves around the thick and thin filaments that overlap so that the length of the sarcomere will shorten which will shorten the muscle fibers. Conversely, if a person feels calm and relaxed after being given therapy, there will be muscle relaxation that will run simultaneously with the autonomic response of the parasympathetic nerves.
The nerve impulse stops and the depolarization of the membrane is completed, calcium ions are recaptured by the sarcoplasmic reticulum so that the contraction process stops. Each muscle fiber will receive one nerve cell end in the spinal cord that transmits impulses to the muscle, this is where there will be a connection between the nervous system and bibs (Sloane, 2004;Ramadani & Son, 2009). SC surgery with its various complications can cause anxiety in patients (Pawatte, Pali &;Opod, 2013).
The anxiety felt by patients is associated with feelings of fear of foreign procedures to be undertaken, injections, postoperative wound pain, becoming dependent on others, even threats of death due to surgical procedures and anesthesia, including the onset of disability or death (Potter & Perry, 2005). The anxiety felt by mothers who will undergo SC surgery if not given the right treatment to reduce their anxiety will have an impact such as increasing postoperative healing time and is related to depression after childbirth.
The lack of information provided by medical personnel during informed consent or when health education is carried out about why sectio caesarea surgery should be done will increase the patient's anxiety in undergoing surgical operations so that it can worsen the process of action and recovery after childbirth. Preoperative patients of sectio caesarea who experience anxiety will result in an increase in blood pressure so that anesthesia or surgery is postponed.
Researchers assume that the right treatment to reduce the patient's anxiety level before cesarean section is the role of the midwife towards the patient. Quality obstetric care, one of which is by providing informed consent, can provide a sense of calm to patients before cesarean section. With the low anxiety experienced, it will speed up postoperative healing time.
Anxiety levels in preoperative sectio caesarea patients after being given pre-operating teaching (informed consent) The results showed that most respondents at Arga Husada Hospital, Kediri, experienced mild anxiety after being given pre-operating teaching (informed consent), which was 61 respondents (65.6%).
In accordance with the Dick-Read method, to replace anxiety and fear about the unknown through understanding and belief, one of which is by providing information about labor and childbirth. In general, pregnant women have an idea of events that will be experienced at the end of their pregnancy and when labor occurs, so this causes maternal anxiety in facing labor (Pieter, 2010).
Age, education and parity factors affect the mother's level of knowledge and the way the mother examines the information obtained so that it tends to affect the anxiety she experiences. It is also stated by some people that to prepare yourself with various information about matters related to childbirth is one of the best ways to deal with childbirth (Rohmah, 2013).
In this study, it can be concluded that the decrease in anxiety that occurs due to providing information through pre-operating teaching with informed consent given can increase respondents' knowledge. The decrease in anxiety occurs because patients get a complete and adequate understanding carried out by health workers by prioritizing SOPs in the hospital. Communication techniques that are applied interpersonally, systematically, mastery and guidance techniques owned by midwives in the delivery room can help patients recognize their current condition, the problems they are facing, and determine solutions or efforts to overcome these problems (Susilowati, Pramana and Muis, 2019;Al Ahkam and Esti, 2020). This is in accordance with the results of research by Pragholapati, Megawati and Suryana (2021) after being given health education, maternal anxiety decreases. Of the 24 respondents (25.8%) experienced severe anxiety, and 52 respondents (55.9%) experienced moderate anxiety, and 17 respondents (18.3%) experienced mild anxiety. After being given pre-operating teaching , 17 respondents (18.3%) experienced moderate anxiety, 61 respondents (65.6%) experienced mild anxiety, and 15 respondents (16.1%) did not experience anxiety.
Effect of Pre Operating Teaching (Informed Consent) with Anxiety leveln in preoperative section caesarean patients The results showed that there was a difference before and after the administration of pre-operating teaching (informed consent) with the anxiety level of preoperative sectio caesaria patients in the delivery room of Arga Husada Hospital, Kediri with a p-value = 0.000 (< 0.05).
This change in anxiety levels occurred because respondents got information about how the sectio caesarea process occurred, which is something they do not yet know so that it can reduce anxiety. We know that one of the sources that causes anxiety in pregnant women is that they do not know what will happen during the labor process that will be carried out later (Fatmawati and Pawestri, 2021).
The provision of informed consent is carried out without coercion from health workers to patients so that an agreement is formed between health workers and patients for medical action. Patients and their families can request and utilize informed consent to obtain complete information about the patient's condition, therapy and risks from actions taken in the process of patient care. Providing adequate informed consent can occur because health workers have understood and complied with the SOPs set by the hospital, thus providing informed consent in accordance with applicable provisions (Al Ahkam and Esti, 2020).
Providing adequate informed consent, such as providing complete information about the disease suffered, therapy that must be done, feelings of pain, all possibilities if surgery is not performed, how to operate, risks, side effects, the patient's right to refuse and ask for a doctor's opinion on the action taken, the purpose of signing the form and alternative actions other than surgery. Things that need to be informed to the patient or the patient's family include information about the diagnosis of the disease, therapy and other possible alternative therapies, how the doctor works and experiences who take action on him, possible feelings of pain or other feelings, the risk of any action taken on the patient, the benefits of therapy, the prognosis of the disease or the action to be taken on the patient (Sitopu et al. , 2018;Sukarini, 2020).
Preoperative patient anxiety is caused by the patient feeling threatened by physiological abilities or interference with basic needs such as self-mobilization. The patient feels helpless and must depend on others to meet his basic needs. The patient feels that he has no ability and cannot be useful to himself and others. The threat can cause anxiety and if not overcome will cause anxiety with a heavier level and cause physical disturbances. This condition, of course, will interfere with the healing process of the patient's disease (Pragholapati, Megawati and Suryana, 2021).

Effectiveness of Preoperating Teaching with Anxiety Levels in Preoperating Sectio Caesarea Patients
Patients who experience mild anxiety may be because the patient has obtained complete information about the results of the examination and the reasons for surgery and the possibilities that occur if surgery is not performed, so that patients can consider the benefits obtained with the consequences if the patient does not perform surgery. Patients can prepare themselves physically and mentally to face the surgery that will be carried out so that they experience mild anxiety. Patients who experience moderate and severe anxiety may be caused by patients not obtaining detailed information about their health conditions and the surgery to be performed (Ndapaole, Tahu and Gerontini, 2020).
The patient feels the operation to be a threat to his integrity. This is in accordance with Stuart's theory which states that factors that influence anxiety can be external factors including (1) threats to self-integrity, namely physiological disabilities or interference with basic needs (illness, physical trauma, surgery to be performed; (2) Threats to the self-system include: threats to self-identity, self-esteem, and interrelated relationships, loss and changes in status/role; (3) Provision of informed consent. The provision of informed consent aims to provide an explanation to patients in carrying out medical actions, so that patients are not overwhelmed with uncertainty and excessive anxiety about the risks arising from medical actions taken by health workers (Gezer and Arslan, 2019;Bouka and Widani, 2020).
The results of this study are in accordance with the research of Aggresmawati et al. (2018) which states that there is an influence of providing informed consent with the anxiety level of preoperative patients. Health workers do not provide information about the risks and side effects of surgery that will be performed adequately because the more patients know the risks and side effects of the action to be carried out in fear will increase the patient's anxiety level. So sometimes the information provided can also be said to be incomplete.
The following is a line of thinking about the effect of pre-operating teaching with informed consent on the anxiety of preoperative patients sectio caesarea based on the results of the study. The characteristics of patients in this study consisted of age, education level, economic status, employment status, and parity. Furthermore, pre-operating teaching with informed consent is given with the material presented including diagnosis, proposed or planned actions, alternative procedures if any, the interests and benefits of medical actions, implementation procedures or how doctors work in medical actions, implementation procedures or how doctors work in medical actions, risks or side effects contained in these actions, Confirmation of the patient's understanding of the information submitted so as to be able to make decisions, the patient's voluntariness in giving permission, prognosis. By providing complete informed consent, it is hoped that the patient's understanding of his condition will be better. Understanding of the patient's health condition that is not good will affect the emergence of stress. When a person is under stress and physiologically tense, it activates the Limbic Hypothalamus Puitutary Adrenal Axis (LHPA), then stimulates the hypothalamus and causes the secretion of corticotrophin relesing hormone (CRH). This will cause an increase in the production of the Sympathetic Adrenal Medular axis (SAM), with this response causing stimulation in the limbic groove of the Hypothalamus Puitutary Adrenal Axis (LHPA), then stimulating the hypothalamus and causing the secretion of the hormone Corticotrophin Relesing Hormone (CRH). This causes the activation of Adeno Cortico Trophin Hormone (ACTH) which will stimulate the production of cortisol hormone from the adrenal cortex, besides that it will cause activation of andrenergic neurons from Locus Ceruleus (LC), where LC is the site of NE production which will then secrete epinephrine. The LC system is responsible for responding directly to stressors by "fight or flight".
Based on the results of the research that has been done, the researcher advises respondents that the provision of pre-operating teaching through complete informed consent can have a psychological effect on prospective cesarean section patients where a good understanding of the information provided can reduce anxiety before surgery. As for the place of research, health workers should emphasize more on mutual communication in providing informed consent to patients so that they can find out the patient's information needs so as to reduce the patient's anxiety level. It is necessary to increase the provision of informed cosent in accordance with applicable SOPs in hospitals by health workers in the delivery room. For preoperative patients, you should use the means of providing informed consent to obtain complete information about the surgery performed by the medical team. . Providing health education for patients visiting the hospital about factors that can trigger the growth of uterine myoma. The provision of this information can be through the installation of posters, leaflets, and counseling or counseling as well as appropriate and fast handling. In addition, the results of this study are expected to be an additional insight into science about midwifery. It is also hoped that other researchers can develop research on measuring anxiety levels before, during, and after sectio caesarea which needs further research so as to determine what management is appropriate for the patient's condition.

CONCLUSION
The level of anxietyn in preoperative sectio caesarea patients before being given preoperating teaching (informed consent) showed that almost all respondents, namely 52 respondents (55.9%) experienced moderate anxiety. The level of anxiety n in preoperative sectio caesarea patients whohave been given pre-operating teaching (informed consent) showed that almost all respondents, namely 61 respondents (65.6%) experienced mild anxiety. Based on the Mc Nemar statistical test, it was found that there was an influence of Pre Operating Teaching (Informed Consent) with the level of anxiety in preoperative section caesarea patients at Arga Husada Hospital, Kediri with a value of signifikansi = 0.000 (<0.05).