The Effectiveness of Green Betel Leaf (Piper betle Linn) on Perineal Wound Healing: A Literature Review Study

The perineal injury during delivery can increase the risk of infection in postpartum mothers. This paper reviews the effectiveness of green betel leaf (Piper betle Linn) on perineal wound healing. It was a literature review study. The first literature review stage was to determine the problem using PICO questions. Then, search and collect data/literature with the following steps: write keywords in the journal database and choose articles according to the specified criteria. The databases were Google Scholar, Science Direct, and Technology Index (SINTA), and PMC. The population was national journals examing the effectiveness of betel leaf on perineal wound healing. In addition, inclusion criteria were national journals researching the effectiveness of betel leaf on perineal wound healing and published from 2015 to 2020. Meanwhile, the exclusion criteria were journals with no full text. The journal searching was carried out from 1 to 20 August 2020. Data analysis used the following methods: critical appraisal, skimming, scanning, separating irrelevant articles from relevant articles, reading relevant articles, and making notes or summaries. Then we arranged publications in the table and analyzed them. There were seven relevant journals from Google Scholar. The findings showed that betel leaf was effective for perineal wound healing. The betel leaf contains an antiseptic five times stronger than ordinary phenol. It also contains saponins that trigger collagen formation for wound healing. Future researchers should examine the degree of the perineal wound and explain the processing of betel leaf in detail.


INTRODUCTION
Childbirth is a physiological event. Many women experience a tear in the perineum during childbirth.
Half of the tears occur between the vaginal opening and the anus, outside the genitals, vagina, and cervix.
Further, it often causes symptoms such as pain accompanied by heat in the infected part. If the infection has spread to the bladder tract, it will feel sore when urinating and often accompanied by fever (Oxorn, 2010).
The incidence of infection in postpartum mothers is 20%, while perineal infection of 11%. Many actions have overcome this incidence, but the results have not been as expected (Manuaba, 2012). During delivery, wounds in the birth canal can be an entry point for infectious germs and commensal bacteria.
Several conditions can increase the risk of infection in postpartum mothers, including perineal injury due to episiotomy, spontaneous rupture, and trauma in the fetus. Perineal wounds are localized, but they can cause systemic infection and spread to other body parts if not treated properly (Manuaba, 2012).
If there is not excellent and correct wound care in postpartum mothers, the perineal wound affected by lochia will become moist. Further, it increases the risk for the proliferation of bacteria that trigger perineal infection. Then, the infection can spread to the urinary tract and the birth canal. As a result, it can inhibit the wound healing process and cause tissue damage (Prawirohardjo, 2011). There is pharmacological and non-pharmacological perineal wound care. Pharmacological perineal wound care uses antiseptic.
Piper betle Linn is the Latin name of betel leaf. It has essential oils consisting of hydroxychavicol, cavibetol, estragole, eugenol, methyl eugenol, carvacrol. In addition, One-third of these chemical content consists of phenol. Most of it is chavicol which gives the betel leaf a distinctive odor and has five times the bacteria-killing power of ordinary phenol (Moeljanto, 2003). Betel leaf also contains saponins that can trigger the formation of collagen, a structural protein that plays a role in the wound healing process (Suratman et al., 1996in Celly, 2010. Chavicol content in betel leaf can function as an antiseptic. In addition, chavicol and chavibetol act as antiseptics to inhibit bacterial growth in wounds (Arifin, 2008in Celly, 2010. In addition, eugenol and chavicol in green betel leaf have antibacterial properties (Ibrahim, 2015). Much research has analyzed the effect of betel leaf on perineal wounds. However, there has been no literature review study regarding the outcomes of betel leaf on perineal wounds. This paper reviews the effectiveness of green betel leaf (Piper betle Linn) on perineal wound healing.

RESULTS
There were 121 publications in Google Scholar with seven relevant articles, while there were 403 journals in Science Direct with no relevant articles. Thus, seven reports revealed the effectiveness of green betel leaf on perineal wound healing (Table 1).

Ringinan yar Village
The authors used betel leaf decoction. The tools and materials were betel leaf, boiling water, one measuring cup, and one basin. Data collection techniques were observing time in the wound healing process until the wound dries and using standard operating procedures of perineal care.
There was a difference in perineal wound healing time between intervention and control groups (p=0.000).

Location
All studies were carried out in Indonesia -71.4% in IMPs, 14.3% in a clinic, and 14.3% in the village.
The research location is where the researchers obtain information about the data and conducts the research. Place selection should consider attractiveness, uniqueness, and suitability for the chosen topic so https://doi.org/ 10.33086/jhs.v15.i1.2509 Devi Endah Sarasawati -The Effectiveness of Green Betel Leaf (Piper betle Linn) on Perineal Wound Healing: A Literature Review Study that researchers can find meaningful and new things (Muchtar, 2015). In addition, it can explain the characteristics of the community/respondents in the research. In this paper, there were no journals that used two research locations. Thus, the study results were not biased due to differences in the characteristics of respondents from two different places.

Research Design
The research design in this paper was two journals with quasi-experimental design (28.5%), two with preexperimental (28.5%), two with experimental (28.5%), and one with true experimental (14.3%). The research design is a method or strategy to obtain data and facts processed for research purposes (Sugiyono, 2010). It is an overview of the research that researchers will carry out to achieve specific goals (Indrawan and Yuniawati, 2014). All journals in this literature review used an experimental design, with or without the control group. This design was based on the research objectives because the experimental design can determine the effects of the therapy/treatment. The treatment is given by the same person and technique, so that effects could be measured properly and minimized bias.

Sample
The sampling techniques in this paper were one journal (14.3%) with cluster sampling, two journals (28.5%) with purposive sampling, one journal (14.3%) with total sampling, one journal (14.3 %) with accidental sampling, and no description in 2 journals (28.5%). The average sample used in this literature review was 16 -70 respondents. The population is a collection of subjects, variables, concepts, or phenomena. Each sample member determines the population's nature (Morissan, 2012). In addition, the sample is part of the population or part of the characteristics of the population (Hidayat, 2018). The population in the research journal follows the sampling procedure. The advantage of using samples in research are cost and time savings. In addition, the data is more accurate because the authors do not involve too many respondents.

Betel leaf
All journals in this literature review used green betel leaf (100%) -6 journals (85.7%) washed the perineal wound with betel leaf decoction, and one journal (14.3%) did vulva hygiene with betel leaf. The betel plant has been used for various kinds of treatment. Almost all parts of the betel plant can be used, such as roots, stems, stalks, leaves, and fruit (Chakraborty, A. K., Rhambade and Patil, 2011). Betel plant decoction is medicine for impetigo, eczema wounds, burns, lymphangitis, furunculosis, and stomach pain.
In addition, betel leaf can heal urticaria, pharyngitis, and swelling. The roots and fruit of the betel plant can be used to treat malaria and asthma (Dwivedi and Shalini, 2014) (Triyanti et al., 2017) Betel leaf contains various substances to neutralize the imbalance of acid-base metabolism in the body, such as Si, Cl, Zn, Mg, Ca, and K (Periyanayagam, Mubeen, and Basha, 2014 (Bangash et al., 2012).
Not all of the processing of the betel leaves in the seven journals are explained in detail. Overall, that processing by boiling directly, and some are extracted first and then boiled. The different ways of processing betel leaves will have other content produced. However, the content was still effective and had better perineal wound healing outcomes than the control group.

Perineal Wound
In this paper, most journals did not mention the degree of the perineal wound in their studies. In addition, the authors observed perineal wounds on the first, fifth, seventh, and ninth days. A perineal wound is an injury in the perineum caused by a tear in the birth canal due to an episiotomy or rupture during delivery (Purwoastuti and Walyani, 2015). It is an injury in the urogenital diaphragm and levator ani muscle during delivery. It is not visible because the injuries occur in the perineal skin or the vagina. Further, it can weaken the hip base so that it is easy for genital prolapse occurs (Rukiyah and Yulianti, 2014).
Wounds on the perineum are classified in several degrees, namely degrees 1 to 4. Each degree has a different area and depth of the injury. The observation of perineal wounds can be appropriately measured by examining the degree of the wound.

The Effectiveness of Green Betel Leaf Against Perineal Wound Healing
All journals (100%) showed the effects of betel leaf on perineal wound healing in postpartum mothers.
Betel leaf contains chemical content consisting of hydroxychavicol, chavibetol, estragole, eugenol, methyl eugenol, carvacrol. Those contents have five times the bacteria-killing power of ordinary phenol.
In addition, chavicol and chavibetol are substances that function as antiseptics that can inhibit the growth of bacteria in wounds (Arifin 2008 in Celly, 2010). Betel leaf also contains saponins that stimulate collagen formation, which plays a role in wound healing (Suratman et al., 1996in Celly, 2010. A study by Celly (2010) showed the effect of betel leaf on the acceleration of perineal wound healing among postpartum mothers in Sumbermulyo Village, Jogotoro District, Jombang.
Perineal wound care can prevent infection in birth canal injuries. Using betel leaf decoction is one of the non-pharmacological perineal wound cares. Betel leaf contains antifungal, antibacterial, and antibiotic therapeutic effects. In addition, there is an arecoline to help activate the central nervous system. So that peristaltic motion and blood circulation in the wound area increase. In addition, it can improve oxygenation, so that wound healing becomes faster. The betel leaf's chemical contents and properties can support perineal wound healing because containing an antiseptic five times stronger than ordinary phenol.
It also contains saponins that trigger collagen formation for wound healing. So, using betel leaf decoction can cause perineal wounds to heal faster than without using betel leaves.