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NYERI PADA PERSALINAN DAN NYERI PADA PERSALINAN DAN PENATALAKSANAANNYA SECARA PENATALAKSANAANNYA SECARA

NON FARMAKOLOGIKNON FARMAKOLOGIK

Imami Nur Rachmawati, SKp, MSc.KEPERAWATAN MATERNITAS

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Sasaran Pembelajaran

• Membandingkan nyeri persalinan dengan jenis nyeriyang lain

• Menggambarkan bagaimana nyeri memberikandampak bagi ibu dan janinnya

• Memeriksa bagaimana aspek fisik dan psikismemperkuat pengaruh pada pengalaman nyeri klien

• Menerangkan penggunaan manajemen nyeri secaranonfarmakologis dalam persalinan

• Menjelaskan implikasi keperawatan dalampenanganan nyeri secara nonfarmakologis

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Pendahuluan• Persalinan tanpa nyeri hanya dialami sedikit wanita• Sebanyak 78% primipara :

– 28 % nyeri sedang– 37% nyeri hebat– 35% nyeri sangat hebat (intolerable)

• Setiap perempuan: harapan tentang persalinan yang unik, tmsk tentang nyeri dan pengelolaannya, jika berhasilpengalaman yang positif

• Pengelolaan nyeri secara nonfarmakologis dan farmakologismemberikan pilihan bagi ibu dan klien

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NYERINYERIPain (Keele, 1983)• An unpleasant sensory experience distinct from other sensory modalities

such as touch, warmth or cold• Nyeri pengalaman universal tetapi sulit didefinisikan, sensasi yang

tidak menyenangkan akibat rangsangan saraf sensory• Nyeri 2 komponen

– Fisiologis: stimuli yang diterima oleh saraf sensori & ditansmisi olehSSP

– Psikologis: pengenalan sensasi, interpretasi, reaksi thd intepretasi• Nyeri personal, unik• Melzack & Wall (1991) indeks nyeri (0 – 50) MPI (McGill Pan Index)

– Primipara 38– Multipara 30– Amputasi 25– Kanker 28

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KEUNIKAN NYERI PERSALINANKEUNIKAN NYERI PERSALINAN

Nyeri persalinan berbeda karakteristik dgn jenis nyeri yang lain• Bagian dari proses normal• Ada waktu untuk mempersiapkan• Berhenti dengan sendirinya (self limiting) berlangsung

singkat, bersifat intermitten, dengan perbedaan karakteristik danpenyebab– Kala I penipisan dan pembukaan serviks– Pada Ǿ 0 – 3 cm: sakit, tidak nyaman

4 – 7 cm : terasa agak menusuk7 – 10 cm: terasa berat, parah, menusuk, kaku

• Berhubungan dengan kelahiran bayi, dan kondisi janin yang berkaitan dengan emosional

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Pain locations & intensity during labor

The nurse can use this illustrations to anticipate and monitor the client’s pain during labor. In each picture, darker color indicates more intense pain. During most stage 1, pain centers around the pelvic girdle. During stage late 1 and early stage 2, pain spread to the upper leg and perineum. During the late stage 2 and childbirth, intense pain develops at the perineum

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TEORI NYERI PERSALINAN

• The Gate Control Theory (Melzack & Wall, 1965)

• Endogenous Opiate Theory

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The Gate Control Theory (Melzack & Wall, 1965)

• Pain signals arrive from the pain fibers (A-delta and C) at the spinal cord, along with signals from other peripheral fibers (A-beta) and the brain. The solid arrows depict stimulation conditions that tend to open the gate and send pain signals through. The dotted arrows indicate inhibition conditions. Pain signals enter the spinal cord and pass through a gating mechanism before activating transmission cells, which send impulses to the brain (from text by Sarafino EP. Health Psychology, Biopsychosocical Interactions, Third Edition. John Wiley & Sons, Inc. New York: 1998.)

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• Transmisi nyeri dapat dimodifikasi/diblok olehcounterstimulation. Selama persalinan, impuls nyeri berjalandari uterus sepanjang serat saraf halus (C-fibers) ke arah atasmenuju substansi gelatinosa di dalam spinal column. Kemudiansel transmisi memproyeksikan pesan nyeri ke otak.

• Stimulasi taktil seperti pijatan, kompres panas/dinginmengakibatkan pesan yang berlawanan yang lebih kuat, cepatdan berjalan sepanjang serat saraf besar (A-delta fibers). Pesan yang ini menutup gate di substansi gelatinosa kemudianmemblok pesan nyeri. Otak tidak akan mencatat pesan nyeriyang dihalangi tersebut/ persepsi nyeri tidak dimodifikasi.

• Kegiatan yang melibatkan cortex cerebral, seperti kontrolpernapasan, distraksi dan imagery juga mengaktifkanmekanisme gate oleh pengiriman impuls ke arah bawah melaluispinal column untuk menutup gate pada substansi gelatinosa

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Gate-Control Theory

Brain

Spinal Cord

GatingMechanism

TransmissionCells

Frompainfibers

FromotherPeripheralfibers

Tobrain

Brain

Spinal Cord

GatingMechanism

TransmissionCells

Frompainfibers

FromotherPeripheralfibers

Tobrain

Gate is open Gate is closed

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Gate Control Theory

1. The projection neuron (P) carries both nociceptivestimulation from small fibers (S) and non-nociceptivesimulation from large fibers (L) on the way to the brain.

2. With no stimulation, the inhibitory neuron (I) keeps the gate "closed," and there is no painful sensation.

3. With painful stimulation, the small fiber (S) blocks the inhibitory neuron (I), "opening" the gate for the projection neuron (P) to send on the painful stimulus.

4. With the addition of non-painful stimulation, the large fiber (L) activates the inhibitory neuron (I), partially or completelyclosing the gate depending on the strength of the stimulation, and competes with the painful stimulation for access to the projection neuron (P).

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Endogenous Opiate Theory

• Pada saat nyeri dirasakan terdapat reseptor opiate padaotak dan tulang belakang yang menentukan SSP untukmelepaskan zat seperti morfin (endorphin & enkephalins). Endogenous opiates menjepit reseptor dan mengganggupersepsi nyeri

• Teori ini sangat berhubungan dengan pengurangan nyeridengan menggunakan accupressure dan accupunctureyang merangsang pengeluaran endogenous opiates

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ENDORPHINS

Reinforcesbehaviour

Endorphinproduction

Prolactin

Appetite for repetition of positive feelings

Blocks

dopamine ActionDepressive feelings

Pleasurable feelings (reduced sensitifity to pain; feelings of warmth, satisfaction,

nurturant behaviour)

Stress

Individual differences in endorphin levels – higher production of endorphins less pain, smaller production more pain.

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EFEK MERUGIKAN DARI NYERIEfek fisiologis• Takut & cemas ↑aktifitas sistem saraf simpatik ↑ sekresi katekolamin

(epinefrin & norepinefrin)• Katekolamin epinefrin menstimulasi reseptor α dan β, norepihefrin:

reseptor α• Stimulasi reseptor α vasokonstriksi dan ↑tonus uterus ↓aliran darah

uterus sambil me ↑ aliran darah & tekanan darah maternal• Stimulasi reseptor β relaksasi otot uterus & vasodilatasi pembuluh

darah, namun pembuluh darah uterus sudah dilatasi, dilatasi pd pembuluhdarah lain darah mengumpul perfusi plasenta ↓

KOMBINASI EFEK SEKRESI KATEKOLAMIN YG BERLEBIHAN• ↓ aliran darah ke & dari plasenta oksigen janin & sirkulasi zat sampah

terbatas• keefektifan kontraksi uterus ↓, memperlambat persalinan

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• Persalinan = aktifitas ↑ metabolisme rate ↑kebutuhan O2• Nyeri & kecemasan = metabolisme rate tinggi ↑RR pengeluaran

CO2 ↑↑• Perub PaO2, PaCO2 dan pH arteri maternal gangguan sirkulasi

plasenta ↓ O2 janin, krg dpt melepas CO2 metabolismeanaerobik janin ↑ risiko asidosis, jika tdk segera ditangani bayilahir dgn asidosis respiratory

EFEK PSIKOLOGIS• Kurangnya pengurangan nyeri kurangnya kebahagiaan pada event

penting kehidupan pasangan• Kesulitan partus menyebabkan gangguan interaksi ibu & bayi• Kenangan persalinan yang buruk akan mengakibatkan gangguan

terhadap respon aktifitas seksual atau persalinan yang lain• Pasangan merasa tidak cukup mampu memberikan dukungan pd saat

persalinan

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PERUBAHAN FISIOLOGIS SEKUNDER

TERHADAP NYERI PERSALINAN

(May & Mahlmeister, 1994)

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VARIABEL NYERI PERSALINANFAKTOR FISIK PADA NYERI PERSALINAN:• VISCERAL : Lambat, dalam lokasi tidak jelas Kala I

(kontraksi uterus & pembukaan serviks• SOMATIK : Cepat, tajam, lokasi jelas Akhir kala I, kala II• SUMBER NYERI:

– Iskemi jaringan– Pembukaan serviks dilatasi & peregangan serviks dan segmen

bawah uterus, nyeri melalui plexus hypogastric, masuk ke tlbelakang (T10, T11, T12 dan L1)

– Penekanan dan penarikan struktur pada panggul (ligamentum, tuba falopii, ovarium, vesica urinaria, peritoneum nyeri visceral

terasa menjalar di punggung dan kaki– Distensi pada vagina & perineum karena penurunan janin

sensasi terbakar, robek, terpisah (nyeri somatik) masuk ke tlbelakang pd S2, S3 dan S4

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• FAKTOR YANG M’PENGARUHI PERSEPSI/TOLERANSI TERHADAP NYERI– Intensitas persalinan– Kesiapan serviks– Posisi janin– Karakteristik panggul– Kelelahan– Tindakan tenaga kesehatan

• FAKTOR PSIKOSOSIAL– Budaya– Kecemasan & ketakutan– Pengalaman nyeri sebelumnya– Persiapan persalinan– Sistem pendukung

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RESPON NYERIRESPON NYERI•Latar belakang budaya stereotype•Kelelahan menakutkan•Konsep diri menyenangkan• hukuman•Pengalaman yang lalu•Kecemasan tension nyeri

•Perhatian belaian

serabut saraf besar

•menutup gate

↓ NYERI

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EFEK PSIKOLOGISIBU

PERSALINAN

Rasa sakit, lelah & ketergantungan

FOKUS PADA PERSALINAN

komunikasi langsungInteraksi pasangan & staf singkat

sentuhanKehilangan perhatian lingkunganRespon dramatik info sedikitIritabel istirahat & menghindar dari aktifitas

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RESPON SUAMI

Ketakutan tercurah pada istri & anakTidak tenang & tidak aman

Perlu persiapan dalam kelas prenatal partisipasi pada persalinan

RESPON ANGGOTA KELUARGA

Sibling dipersiapkan utk mencegah kecemburuan, namuntidak menghadiri persalinan trauma

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MANAJEMEN NYERI SECARA NON FARMAKOLOGIK

• Keuntungan– Tidak memperlambat persalinan– Tidak ada efek samping dan alergi ibu & janin/bayi– Alternatif dan dukungan untuk obat-obatan– Dapat menjadi pilihan untuk ibu yg masuk dgn persalinan yg cepat

tidak cukup waktu untuk mendapatkan reaksi obat-obatan• Keterbatasan

Memerlukan sikap kooperatif dan motivasi klien efek yang optimal• Persiapan

– Waktu yang ideal sebelum inpartu: ibu dan support person– Waktu kala I laten– Gunakan variasi cara

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Aplikasi Tehnik Nonfarmakologik

• RELAKSASIRelaksasi menyebabkan:

• Aliran darah uterus ↑ oksigenasi janin ↑• me↑ efisiensi kontraksi uterus• me↓ ketegangan yang me ↑ persepsi nyeri, menghambat

penurunan presentasi– Lingkungan yang nyaman: penerangan, suara, suhu,

pemandangan– Kenyamanan umum tergantung individu– me ↓ kecemasan & ketakutan ↑ kontrol diri– Tehnik relaksasi yang lain, mis posisi dan gerakan

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• CUTANEUS STIMULATION– Self massage menggosok abdomen, kaki, punggung

(effleurage), telapak tangan– Massase dibantu (pasangan, ners), mis counterpressure,

abdomen lifting, effleurage, knee press, bilateral hip pressure/ double hip squeeze

– Stimulasi thermal: kompres dingin/panas, mandi shower, waterbirth, hydrotherapy

– Acupressure– Acupuncture– Mesin TENS (transcutaneus electrical nerve stimulation)

menghalangi transmisi– Intradermal Injection sterile water

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• SENSORY/ MENTAL STIMULATION– Imagery– Focal point– Yoga– Pernapasan

• Lamaze• Dick-Read• Bradley

– Aromatherapy– Music

• COGNITIVE APPROACH– Edukasi persalinan– hypnotherapy

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Aromatherapy• Manfaat didapatkan melalui beberapa cara:

– Menawarkan lebih banyak pilihan me↓ nyeri, relaksasi tingkat kecemasan & stress ↓

– Kebut obat ↓ terpengaruh persepsi nyeri– Meredakan nausea & vomiting – me ↓ kebutuhan induksi persalinan.

• Aromatherapy dapat digunakan dgn berbagai cara, terutama melalui inhalasi & absorpsi melalui kulit. Contoh: – Massage – Inhalation from an aroma stone – Drop on taper / tissue – Footbath – Bath / Birthing pool – Hot / cold compress – Inhalation from a bowl of hot water – Perineal wash

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Waterbirth• Warm water immersion during labor &

birth to help alleviate pain & discomfort. It offers warmth, weightlessness & relaxation especially when the laboring mother is able to submerge her belly & lower body. This is accomplished easily with the use of a birthing tub.

• Water immersion during early labor can slow down progress sometimes wait until active labor to get into the tub. During active labor water immersion has been known to speed up progress, perhaps due to the profound relaxation experienced.

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• Waterbirth a gentle transition from mother’s womb to the outside world. Waterborn babies are birthed into an environment much the same as the amniotic sac- warm and watery. It is an intermediate step that allows the baby to adjust slowly to this new life. Babies do not begin the breathing process until they sense a change from a watery environment into the air. It is for this reason along with others that there is no risk of drowning for healthy waterborn babies. It is also for this reason that waterborn babies take a little longer than dry land birthed babies to initiate the breathing process. They may be a bit bluer in color at first, but are fine when they “catch up”.

bring the baby to the surface of the water as soon as the body is born.

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• Benefits of waterbirth include:– Pain relief and relaxation for mom- ↓ need for pain

medications– Less perineal tearing.– High satisfaction rating from moms.– Gentle transition for babies.

• Waterbirth does not:– Increase maternal infections or illness.– Increase infections or illness in babies.

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Waterbirth

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Massage

Two types of effleurage

Firm counterpressure of the fist on the lower back, while the mother is in the tailor sitting position, effectively relieves back labor Counter pressure

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Knee press

Double hip squeeze

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Deep back massage, while the mother lies on her side, relieves back pain between contraction

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Abdominal lifting

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RELAXATIONText used by nurses to encourage relaxation1. Close your eyes and take a slow, deep breath2. As you breath out, yourself relax and the tension draining

out of your body3. Breathe slowly comfortably from your abdomen4. Think about your breathing. Feel the air enter your nose

and your lungs and feel the air go out your lungs. Feel yourself relaxing as you breathe out

5. To help you breathe slowly and rhythmically, as you inhale I will say, ‘In, one two’ and as you exhale, ‘Out, one two’. (say these phrases in co-ordination with the patient’s breathing. Repeat this two or three times to help the patient to slow the rate of breathing and keep it regular).

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6. Feel yourself relax each time you breath out. Just let the air flow from the lungs and let the tension flow from your body.

7. As you breathe in you may say silently to yourself, ‘In, one, two’. As you breathe out you may say silently to yourself, ‘Relax’. (say these two or three times in co-ordination with the patient’s breathing. A word other than ‘relax’ may have been chosen by the patient before using the technique).

8. I am going to pause now let you concentrate on your breathing (Watch the patient and, if tension or difficulty arises, begin counting out loud and repeat the instructions in the step7).

9. When you are ready to end this relaxation you may do so yourself. When you are ready, count silently from one to three. At the count of three, inhale deeply, silently say to yourself, ‘I feel alert and relaxed’, and open your eyes.

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Intradermal Injection Sterile Water

Intradermal injections of 0.1 mL of sterile water in the treatment of women with back pain during labor. Sterile water is injected into four locations on the lower back, two over each posterior superior iliac spine (PSIS) & two 3 cm below & 1 cm medial to the PSIS. The injections should raise a bleb below the skin. Simultaneous injections administered by two clinicians will decrease the pain of the injections.

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Acupressure

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Yoga• Yoga designed specifically for pregnant women way to keep

the body in peak shape as the mother get closer to labor while also serving as a foundation to begin yoga soon after the mothergive birth.

• Here are some of the rewards: – The stretching & strengthening of the muscles will help to lessen the

aches & pains due to added weight & the mother shifting center of gravity.

– The strength building & added flexibility, obtained by holding various yoga postures, tones muscles, improves posture, and helps to maintain a sense of control as the body changes.

– Yoga helps to relieve stress and tension by training the body to relax, which can be very helpful during labor.

– The focus on breathing, an integral part of yoga, is both energizing and relaxing and can be applied in many different contexts, fromsimple stress management to breathing during child birth.

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Yoga

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TENS (Transcutaneous Electrical Nerve Stimulation)

• TENS works by stimulating the body's own natural defences against pain transmits gentle, electrical impulses through the skin via four self-adhesive electrode pads positioned on the mother’s back.

• These gentle impulses attack pain in two ways:– By stimulating the release of

endorphins, the body’s own pain-relieving hormones.

– By stimulating the nerves to block pain signals before they reach the brain

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MANAJEMEN NYERI PADA PERSALINANMANAJEMEN NYERI PADA PERSALINAN• Persiapan persalinan pada masa prenatal• Observasi• Pengkajian

– Pengkajian intranatal secara umum (ibu & bayi)– Manajemen nyeri yang dipilih– Status kehamilan (direncanakan/tidak)– Respon terhadap kehamilan– Hub dengan suami– Sistem pendukung– Nyeri (lokasi, tingkat, bentuk nyeri): ungkapan– verbal, permintaan pain relief, ungkapan non verbal, – posture tubuh, ekspresi wajah, Mis:

• sakit pinggang bawah occiput posterior tahap II• Perut tegang infeksi intrauterine, abruptio plasenta

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• Pertanyaan:– Dimana yang paling nyeri? Menjalar? Terus menerus?– Kapan nyeri mulai– Apakah ikut kelas prenatal?– Membutuhkan obat?

• Komponen:– Rangsangan– Ambang takut, capai, tegang & dehidrasi– Reaksi

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DIAGNOSIS KEPERAWATAN

PERENCANAANTUJUAN• Ibu mampu menjelaskan rasa nyerinya• Ibu mampu menggunakan tehnik relaksasi & pernapasan

mengurangi sakit tetapi tetap sadar tanpa menggangguproses persalinannya

• Ibu dan bayi bebas dari depresi

Nyeri b.d. efek kontraksi uterus, penipisan dan pembukaanserviks, penurunan janin

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TINDAKAN Mengurangi rasa sakit, dengan cara:

• FARMAKOLOGIK– Parental (naloxon, demerol) conduction anesthesia (pudendal

paracervikal, perineal block, epidural block), – inhalation anesthesia (entonox)

• NON FARMAKOLOGIK– Relaksasi

• Lingkungan• Personal• ↓ kecemasan dan ketakutan• Tehnik spesifik, mis posisi

– Stimulasi cutaneus• Massase sendiri• Massase dibantu, mis counter pressure, abdomen lifting, effleurage• Stimulasi thermal: kompres dingin/panas, mandi shower, water birth,

hydrotherapy

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• Stimulasi mental– Imagery– Focal point

• Pernapasan– Lamaze– Yoga

• Cognitive approach

• Lain-lain– Mesin TENS (transcutaneus electrical nerve stimulation) menghalangi

transmisi– Hypnotherapy– Acupuncture– Acupressure– Aromatherapy

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PERAN PERAWAT DALAM MEPERAN PERAWAT DALAM ME↓↓ NYERI NYERI PERSALINANPERSALINAN

• Memahami faktor fisiologis nyeri• Memahami perjalanan nyeri

• Memahami efek nyeri thd ibu, janin & persalinan

Intervensi ↓ nyeri

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FAKTOR FISIOLOGIS NYERI

•Pembukaan dan penipisan serviks•Segmen bawah uterus tegang

•Ligament uterus meregang•Peritoneum tertarik

•Kandung kemih, uretra tertekan•Hipoksia uterus

•Ganglion di uterus & vagina tertekan•Multi/ primipara

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PAIN PATHWAYSTAHAP ISaraf simpatis sumsum tulang belakang tulang belakang• Abdomen bagian bawah• Kulit lumbal bagian bawah• Sacrum bagian atas

TAHAP IIBagian post. Med. Spinalis sumsum tulang belakang Med.Oblongata, pons Mid

Brain• Distensi vagina dan perineum• n.Pudendal n.sacral II, III, I

TAHAP IIImid brain corteks

Akut : serabut A delta perihKronik : serabut C terbakar

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NYERI

IBU : ↑Cardiac Output↑ Tekanan Darah

Hiperrventilasi↓ darah ke otak & uterus

ACIDOCIS

Janin: Epinefrin vasokonstriksi

Hipoksia

Menghambat persalinan (fetal descent melambat )

Efek Nyeri

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EFEK PSIKOLOGIS

• Ketakutan• Panik• ↓harga diri• Kurang percaya diri• Marah pada bayi• Takut hamil• Gangguan aktifitas seksual

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Pathways of pain transmission during labor

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TERIMA KASIH