NYERI PADA PERSALINAN DAN PENATALAKSANAANNYA SECARA NON FARMAKOLOGIK

Imami Nur Rachmawati, SKp, MSc. KEPERAWATAN MATERNITAS

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Sasaran Pembelajaran
Membandingkan nyeri persalinan dengan jenis nyeri yang lain Menggambarkan bagaimana nyeri memberikan dampak bagi ibu dan janinnya Memeriksa bagaimana aspek fisik dan psikis memperkuat pengaruh pada pengalaman nyeri klien Menerangkan penggunaan manajemen nyeri secara nonfarmakologis dalam persalinan Menjelaskan implikasi keperawatan dalam penanganan 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 berhasil pengalaman yang positif Pengelolaan nyeri secara nonfarmakologis dan farmakologis memberikan pilihan bagi ibu dan klien
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NYERI
Pain (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 oleh SSP 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 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 dan penyebab
Kala I penipisan dan pembukaan serviks Pada 0 3 cm: sakit, tidak nyaman 4 7 cm : terasa agak menusuk 7 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 clients 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 (Abeta) 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 oleh counterstimulation. Selama persalinan, impuls nyeri berjalan dari uterus sepanjang serat saraf halus (C-fibers) ke arah atas menuju substansi gelatinosa di dalam spinal column. Kemudian sel transmisi memproyeksikan pesan nyeri ke otak. Stimulasi taktil seperti pijatan, kompres panas/dingin mengakibatkan pesan yang berlawanan yang lebih kuat, cepat dan berjalan sepanjang serat saraf besar (A-delta fibers). Pesan yang ini menutup gate di substansi gelatinosa kemudian memblok pesan nyeri. Otak tidak akan mencatat pesan nyeri yang dihalangi tersebut/ persepsi nyeri tidak dimodifikasi. Kegiatan yang melibatkan cortex cerebral, seperti kontrol pernapasan, distraksi dan imagery juga mengaktifkan mekanisme gate oleh pengiriman impuls ke arah bawah melalui spinal column untuk menutup gate pada substansi gelatinosa
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Gate-Control Theory
Gate is open Brain
From pain fibers To brain From pain fibers

Gate is closed Brain

To brain

Gating Mechanism

Transmission Cells

Gating Mechanism

Transmission Cells

From other Peripheral fibers

Spinal Cord

From other Peripheral fibers Nyeri/imami2007

Spinal Cord
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Gate Control Theory

1. The projection neuron (P) carries both nociceptive stimulation from small fibers (S) and non-nociceptive simulation 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 completely closing 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 pada otak dan tulang belakang yang menentukan SSP untuk melepaskan zat seperti morfin (endorphin & enkephalins). Endogenous opiates menjepit reseptor dan mengganggu persepsi nyeri Teori ini sangat berhubungan dengan pengurangan nyeri dengan menggunakan accupressure dan accupuncture yang merangsang pengeluaran endogenous opiates

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ENDORPHINS
Stress Reinforces behaviour Endorphin production Prolactin Appetite for repetition of positive feelings Blocks dopamine Action Depressive feelings

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

Individual differences in endorphin levels higher production of endorphins less pain, smaller production more pain.
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EFEK MERUGIKAN DARI NYERI

Efek fisiologis

Takut & cemas aktifitas sistem saraf simpatik sekresi katekolamin (epinefrin & norepinefrin) Katekolamin epinefrin menstimulasi reseptor dan , norepihefrin: reseptor Stimulasi reseptor vasokonstriksi dan tonus uterus aliran darah uterus sambil me aliran darah & tekanan darah maternal Stimulasi reseptor relaksasi otot uterus & vasodilatasi pembuluh darah, namun pembuluh darah uterus sudah dilatasi, dilatasi pd pembuluh darah 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 metabolisme anaerobik janin risiko asidosis, jika tdk segera ditangani bayi lahir 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 PERSALINAN

FAKTOR 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 tl belakang (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 tl belakang pd S2, S3 dan S4
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 FAKTOR YANG MPENGARUHI PERSEPSI/TOLERANSI TERHADAP NYERI

Intensitas persalinan Kesiapan serviks Posisi janin Karakteristik panggul Kelelahan Tindakan tenaga kesehatan Budaya Kecemasan & ketakutan Pengalaman nyeri sebelumnya Persiapan persalinan Sistem pendukung
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FAKTOR PSIKOSOSIAL

RESPON NYERI
Latar belakang budaya stereotype Kelelahan menakutkan Konsep diri menyenangkan hukuman Pengalaman yang lalu Kecemasan tension nyeri Perhatian belaian serabut saraf besar menutup gate NYERINyeri/imami2007
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EFEK PSIKOLOGIS
IBU PERSALINAN Rasa sakit, lelah & ketergantungan FOKUS PADA PERSALINAN Interaksi pasangan & staf komunikasi langsung singkat sentuhan

Kehilangan perhatian lingkungan Respon dramatik info sedikit Iritabel istirahat & menghindar dari aktifitas
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RESPON SUAMI
Ketakutan tercurah pada istri & anak Tidak tenang & tidak aman Perlu persiapan dalam kelas prenatal partisipasi pada persalinan

RESPON ANGGOTA KELUARGA

Sibling dipersiapkan utk mencegah kecemburuan, namun tidak 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

RELAKSASI Relaksasi 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 Nyeri/imami2007

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

Counter pressure

Two types of effleurage

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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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RELAXATION
Text used by nurses to encourage relaxation
1. Close your eyes and take a slow, deep breath 2. As you breath out, yourself relax and the tension draining out of your body 3. Breathe slowly comfortably from your abdomen 4. 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 patients 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 patients 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 mother give 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, from simple 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 mothers back. These gentle impulses attack pain in two ways: By stimulating the release of endorphins, the bodys own painrelieving hormones. By stimulating the nerves to block pain signals before they reach the brain

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MANAJEMEN 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
Nyeri b.d. efek kontraksi uterus, penipisan dan pembukaan serviks, penurunan janin

PERENCANAAN TUJUAN
Ibu mampu menjelaskan rasa nyerinya Ibu mampu menggunakan tehnik relaksasi & pernapasan mengurangi sakit tetapi tetap sadar tanpa mengganggu proses persalinannya Ibu dan bayi bebas dari depresi

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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 ME NYERI PERSALINAN

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 PATHWAYS
TAHAP I Saraf simpatis sumsum tulang belakang tulang belakang Abdomen bagian bawah Kulit lumbal bagian bawah Sacrum bagian atas TAHAP II Bagian post. Med. Spinalis sumsum tulang belakang Med.Oblongata, pons Mid Brain Distensi vagina dan perineum n.Pudendal n.sacral II, III, I TAHAP III mid brain corteks Akut : serabut A delta perih Kronik : serabut C terbakar
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NYERI IBU : Cardiac Output Tekanan Darah

Efek Nyeri

Hiperrventilasi darah ke otak & uterus ACIDOCIS Janin: Epinefrin vasokonstriksi Hipoksia Menghambat persalinan (fetal descent melambat )
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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

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