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NYERI PADA PERSALINAN DAN

PENATALAKSANAANNYA SECARA
NON FARMAKOLOGIK

Imami Nur Rachmawati, SKp, MSc.


KEPERAWATAN MATERNITAS
Nyeri/imami2007 0
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
Nyeri/imami2007 1
Pendahuluan
• Persalinan tanpa nyeri Æ 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 Æ
pengalaman yang positif
• Pengelolaan nyeri secara nonfarmakologis dan farmakologis
Æ memberikan pilihan bagi ibu dan klien

Nyeri/imami2007 2
NYERI
Pain (Keele, 1983)
• An unpleasant sensory experience distinct from other sensory modalities
such as touch, warmth or cold
• Nyeri Æ pengalaman universal tetapi sulit didefinisikan, sensasi yang
tidak menyenangkan akibat rangsangan saraf sensory
• Nyeri Æ 2 komponen
– Fisiologis: stimuli yang diterima oleh saraf sensori & ditansmisi oleh
SSP
– Psikologis: pengenalan sensasi, interpretasi, reaksi thd intepretasi
• Nyeri Æ personal, unik
• Melzack & Wall (1991) Æ indeks nyeri (0 – 50) MPI (McGill Pan Index)
– Primipara 38
– Multipara 30
– Amputasi 25
– Kanker 28
Nyeri/imami2007 3
KEUNIKAN NYERI PERSALINAN
Nyeri persalinan Æ berbeda karakteristik dgn jenis nyeri yang lain
• Bagian dari proses normal
• Ada waktu untuk mempersiapkan
• Berhenti dengan sendirinya (self limiting) Æ berlangsung
singkat, bersifat intermitten, dengan perbedaan karakteristik dan
penyebab
– Kala I Æ penipisan dan pembukaan serviks
– Pada Ǿ 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

Nyeri/imami2007 4
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 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

Nyeri/imami2007 8
Gate-Control Theory
Gate is open Gate is closed

Brain
Brain
To
To From
From brain
brain pain
pain fibers
fibers

Gating Transmission
Gating Transmission Cells
Mechanism
Mechanism Cells

From
From other
other Peripheral Spinal Cord
Peripheral Spinal Cord fibers
fibers
Nyeri/imami2007 9
Nyeri/imami2007 10
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).
Nyeri/imami2007 11
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

Nyeri/imami2007 12
ENDORPHINS
Stress

Reinforces Endorphin
behaviour production

Prolactin

Appetite for repetition of Blocks


positive feelings Action
dopamine
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.
Nyeri/imami2007 13
EFEK MERUGIKAN DARI NYERI
Efek fisiologis
• Takut & cemas Æ ↑aktifitas sistem saraf simpatik Æ ↑ sekresi katekolamin
(epinefrin & norepinefrin)
• Katekolamin Æ epinefrin menstimulasi reseptor α dan β, norepihefrin:
reseptor α
• Stimulasi reseptor α Æ vasokonstriksi dan ↑tonus uterus Æ ↓aliran darah
uterus sambil me ↑ aliran darah & tekanan darah maternal
• Stimulasi reseptor β Æ relaksasi otot uterus & vasodilatasi pembuluh
darah, namun pembuluh darah uterus sudah dilatasi, dilatasi pd pembuluh
darah lain Æ darah mengumpul Æ perfusi plasenta ↓

KOMBINASI EFEK SEKRESI KATEKOLAMIN YG BERLEBIHAN


• ↓ aliran darah ke & dari plasenta Æ oksigen janin & sirkulasi zat sampah
terbatas
• keefektifan kontraksi uterus ↓, memperlambat persalinan
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• Persalinan = aktifitas Æ↑ metabolisme rate Æ ↑kebutuhan O2
• Nyeri & kecemasan = metabolisme rate tinggi Æ↑RR Æ pengeluaran
CO2 ↑↑
• Perub PaO2, PaCO2 dan pH arteri maternal Æ gangguan sirkulasi
plasenta Æ ↓ O2 janin, krg dpt melepas CO2 Æ metabolisme
anaerobik janin Æ ↑ risiko asidosis, jika tdk segera ditangani Æ bayi
lahir dgn asidosis respiratory

EFEK PSIKOLOGIS
• Kurangnya pengurangan nyeri Æ kurangnya kebahagiaan pada event
penting kehidupan pasangan
• Kesulitan partus Æ 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
Nyeri/imami2007 15
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 ÆKala I
(kontraksi uterus & pembukaan serviks
• SOMATIK : Cepat, tajam, lokasi jelas Æ Akhir kala I, kala II
• SUMBER NYERI:
– Iskemi jaringan
– Pembukaan serviks Æ 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 Æ nyeri visceral
Æ terasa menjalar di punggung dan kaki
– Distensi pada vagina & perineum Æ karena penurunan janin Æ
sensasi terbakar, robek, terpisah (nyeri somatik) Æ masuk ke tl
belakang 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 NYERI
•Latar belakang budaya Æstereotype
•Kelelahan menakutkan
•Konsep diri menyenangkan
• hukuman
•Pengalaman yang lalu
•Kecemasan Æ tension Ænyeri

•Perhatian Æ belaian

serabut saraf besar

•menutup gate

↓ NYERINyeri/imami2007 19
EFEK PSIKOLOGIS
IBU

PERSALINAN

Rasa sakit, lelah & ketergantungan

FOKUS PADA PERSALINAN

komunikasi langsung
Interaksi pasangan & staf singkat
sentuhan
Kehilangan perhatian Æ lingkungan
Respon dramatik Æ info sedikit
Iritabel Æ istirahat & menghindar dari aktifitas
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RESPON SUAMI

Ketakutan Æ tercurah pada istri & anak


Tidak tenang & tidak aman

Perlu persiapan dalam kelas prenatal Æpartisipasi pada persalinan

RESPON ANGGOTA KELUARGA

Sibling dipersiapkan utk mencegah kecemburuan, namun


tidak menghadiri persalinan Æ trauma

Nyeri/imami2007 21
MANAJEMEN NYERI SECARA NON
FARMAKOLOGIK
• Keuntungan
– Tidak memperlambat persalinan
– Tidak ada efek samping dan alergi Æ ibu & janin/bayi
– Alternatif dan dukungan untuk obat-obatan
– Dapat menjadi pilihan untuk ibu yg masuk dgn persalinan yg cepat
Æ tidak cukup waktu untuk mendapatkan reaksi obat-obatan
• Keterbatasan
Memerlukan sikap kooperatif dan motivasi klien Æ efek yang optimal
• Persiapan
– Waktu yang ideal Æ sebelum inpartu: ibu dan support person
– Waktu kala I laten
– Gunakan variasi cara

Nyeri/imami2007 22
Aplikasi Tehnik Nonfarmakologik

• RELAKSASI
Relaksasi menyebabkan:
• Aliran darah uterus ↑ Æ oksigenasi janin ↑
• me↑ efisiensi kontraksi uterus
• me↓ ketegangan yang me ↑ persepsi nyeri, menghambat
penurunan presentasi
– Lingkungan yang nyaman: penerangan, suara, suhu,
pemandangan
– Kenyamanan umum Æ tergantung individu
– me ↓ kecemasan & ketakutan Æ ↑ kontrol diri
– Tehnik relaksasi yang lain, mis posisi dan gerakan

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• CUTANEUS STIMULATION
– Self massage Æ 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) Æ
menghalangi transmisi
– Intradermal Injection sterile water

Nyeri/imami2007 24
• SENSORY/ MENTAL STIMULATION
– Imagery
– Focal point
– Yoga
– Pernapasan
• Lamaze
• Dick-Read
• Bradley
– Aromatherapy
– Music

• COGNITIVE APPROACH
– Edukasi persalinan
– hypnotherapy

Nyeri/imami2007 25
Aromatherapy
• Manfaat didapatkan melalui beberapa cara:
– Menawarkan lebih banyak pilihan Æ me↓ nyeri,
relaksasi Æ tingkat kecemasan & stress ↓
– Kebut obat ↓ Æ 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 26
Waterbirth
• Warm water immersion during labor &
birth Æ 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 Æ
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 Æ 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”.
Æ 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.

Nyeri/imami2007 29
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 Nyeri/imami2007 31


Knee press

Double hip squeeze

Nyeri/imami2007 32
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 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.
Nyeri/imami2007 36
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 Æ 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.
Nyeri/imami2007 39
Yoga

Nyeri/imami2007 40
TENS (Transcutaneous Electrical Nerve Stimulation)
• TENS works by stimulating the body's
own natural defences against pain Æ
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

Nyeri/imami2007 41
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 Æ occiput posterior Æ tahap II
• Perut tegang Æinfeksi intrauterine, abruptio plasenta
Nyeri/imami2007 42
• Pertanyaan:
– Dimana yang paling nyeri? Menjalar? Terus menerus?
– Kapan nyeri mulai
– Apakah ikut kelas prenatal?
– Membutuhkan obat?

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

Nyeri/imami2007 43
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
Æ mengurangi sakit tetapi tetap sadar tanpa mengganggu
proses persalinannya
• Ibu dan bayi bebas dari depresi

Nyeri/imami2007 44
TINDAKAN Æ 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
Nyeri/imami2007 45
• Stimulasi mental
– Imagery
– Focal point

• Pernapasan
– Lamaze
– Yoga

• Cognitive approach

• Lain-lain
– Mesin TENS (transcutaneus electrical nerve stimulation) Æ menghalangi
transmisi
– Hypnotherapy
– Acupuncture
– Acupressure
– Aromatherapy
Nyeri/imami2007 46
PERAN PERAWAT DALAM ME↓ NYERI
PERSALINAN
• Memahami faktor fisiologis nyeri
• Memahami perjalanan nyeri
• Memahami efek nyeri thd ibu, janin & persalinan

Intervensi Æ ↓ nyeri

Nyeri/imami2007 47
FAKTOR FISIOLOGIS NYERI

•Pembukaan dan penipisan serviks


•Segmen bawah uterus tegang
•Ligament uterus meregang
•Peritoneum tertarik
•Kandung kemih, uretra Æ tertekan
•Hipoksia Æ uterus
•Ganglion di uterus & vagina tertekan
•Multi/ primipara

Nyeri/imami2007 48
PAIN PATHWAYS
TAHAP I
Saraf simpatis Æ sumsum tulang belakang Æ tulang belakang
• Abdomen bagian bawah
• Kulit lumbal bagian bawah
• Sacrum bagian atas

TAHAP II
Bagian post. Med. Spinalis Æ sumsum tulang belakang Æ Med.Oblongata, pons Æ Mid
Brain
• Distensi vagina dan perineum
• n.Pudendal Æ n.sacral II, III, I

TAHAP III
mid brain Æ corteks

Akut : serabut A delta Æ perih


Kronik : serabut C Æ terbakar

Nyeri/imami2007 49
NYERI
Efek Nyeri

IBU : ↑Cardiac Output


↑ Tekanan Darah

Hiperrventilasi
↓ darah ke otak & uterus

ACIDOCIS

Janin: Epinefrin Æ vasokonstriksi

Hipoksia

Menghambat persalinan (fetal descent melambat )


Nyeri/imami2007 50
EFEK PSIKOLOGIS

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

Nyeri/imami2007 51
Pathways of pain
transmission during
labor

Nyeri/imami2007 52
TERIMA KASIH

Nyeri/imami2007 53