Analgesia in Labor

International

ANALGESIA DALAM
PERSALINAN

Analgesia in Labor
International

DUKUNGAN DALAM PERSALINAN :

Fasilitasi perubahan posisi dan
mobilisasi
Mengurangi ketakutan dan kecemasan
Mendukung kenyamanan
Pendampingan

Analgesia in Labor
International

Cara farmakologis
Sistemik
Analgesia narkotika

Analgesia in Labor
International

BLOK SARAF PERIFER

Blok nervus pudendus
Infiltrasi perineum
Analgesia regional
Epidural

International

Analgesia in
Labor Fifth Vital Sign
Pain:
The

1. Pulse
2. Blood pressure
3. Temperature

Pain:
The Fifth
Vital Sign *
1

4. Respiratory rate

*Trademarks are the property of their respective owners.

American Pain Society Web site.

Analgesia in Labor
International

Treatment of Pain: an Unmet Medical Need

Inadequately treated pain can have many negative effects on patients 1

There is an urgent need for patient education about
pain management
Pain management is moving toward new treatments to meet physician and patient
needs
New guidelines from associations such as Europe Against Pain (EAP) and the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO) underscore the
need for better pain management2,3

Cousins M et al. Textbook of Pain. 1999:447-491.

European Federation of IASP Chapters. Europe Against Pain Web site. Available at: http://www.efic.org/eap.htm. Accessed October 31, 2003.
3
Phillips DM. JAMA. 2000;284:428-429.
1
2

Analgesia in Labor
International

Potential Consequences of Poor

Pain Management
Decreased motion1
Prolonged rehabilitation
Muscle atrophy
Pneumonia
Prolonged hospitalization1,2
Increased cost1,2
Greater hospital resource utilization
Psychological impact1
Poor patient satisfaction1
1
2

Cousins et al. Textbook of Pain. 1999:447-491.

Zimberg SE. Manag Care Q. 2003;11:34-36.

Analgesia in Labor
International

The Goals of Emergency Medicine

Pain Management1
Meet the humanitarian need for pain relief
Provide rapid diagnosis for immediate intervention
Provide rapid relief without complicating diagnosis or limiting
further treatment options

Cousins N, Power I. Acute and postoperative pain. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed. Edinburgh,
UK: Churchill Livingstone; 1999:447-491.

Pain Sensitization

Analgesia in Labor
International

10
Hyperalgesia

Normal
Pain
Response

Pain Intensity

8
6
4

Injury
Hyperalgesia heightened
sense of pain in response
to noxious stimuli

Allodynia

Allodynia pain resulting

from normally painless
stimuli

2
0
Stimulus Intensity

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1980.

Pain Transmission

Analgesia in Labor
International

Pain

COX-2
Descending
modulation
Ascending
input

Spinothalamic
tract

Dorsal Horn
Dorsal root
ganglion

COX-2
Peripheral
nerve

Peripheral
nociceptors
Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.

Trauma

International

Analgesia in Labor
Treatment
Options for Acute and
Chronic Pain

NSAIDS
Nonspecific
COX-2 specific
Opioids
Local anesthesia
Adjunctive therapy
Other

Analgesia in
Labor
Klasifikasi
NSAIDs
berdasarkan Struktur Kimia
International

Carboxylic acid
Salicilic and Ester
Acids

Aspirin
Diflunisal

Enolic Acid
Pyrazolones

Oxyphenbutazone
Phenylbutazone
Feprazone

Phenylacetic Acid

Indolacetic Acid

Propionic Acid

Diclofenac
Aceclofenac
Fenclofenac
Ionacolac
Metizinic

Indomethacin
Sulindac
Tolmetin
Acemethacin
Zidomethacin
Etodolac

Ibuprofen
Naproxen
Flurbiprofen
Fenbrufen
Benoxaprofen
Fenoprofen
Indoprofen
Ketoprofen
Pirprofen
Tiaprofenic Acid

Alkanos

Oxicams

Naphtylalkanone
Nabumetone

Piroxicam
Tenoxicam

Acid 6 MNA

Sulphonanilide
Methan
Sulphonanilide

Nimesulide

Phenamic Acid

Flufenamic Acid
Mefenamic Acid
Meclofenamate

Coxib
Celexocib
Refexocib
Valdecoxib
Parecoxib
Eterocoxib

International

Commonly Used Pain Medications:

Analgesia in Labor
Nonspecific NSAIDs

Mechanism of Action

Benefits

Inhibition of COX-1 and

COX-2 isoenzymes inhibits
prostaglandin synthesis1

Prescribing

Anti-inflammatory
analgesic1
Non-narcotic safety profile1

Effective relief of pain on

movement1
Multimodal efficacy1
Enhanced analgesic
effect

1
2

Power I et al. Surg Clin North Am. 1999;79(2):275-295.

Atcheson R et al. Management of Acute and Chronic Pain. 1998:23-50.

Considerations

Risk of GI and
antiplatelet adverse
events1
Ceiling effect2
Use with caution in
patients with impaired
renal function and/or
considerable
dehydration2

International

Further Considerations in Prescribing

Analgesia in Labor
Nonspecific NSAIDs

Gastrointestinal1,2

Hematologic3

Peptic ulceration; gastrointestinal hemorrhages

Esophagitis and strictures
Small and large bowel erosive disease
Inhibition of platelet aggregation
Increased risk of bleeding

Cardiorenal1

Reversible acute renal failure

Fluid and electrolyte disturbance/edema
Chronic renal failure and interstitial fibrosis
Interstitial nephritis
Nephrotic syndrome
Exacerbation of

Hypertension
Congestive heart failure
Angina

Brooks P. Am J Med. 1998;104(suppl 3a):9S-13S.

Girgis L et al. Drugs Aging. 1994;4(2):101-112.
3
Atcheson R et al. Management of Acute and Chronic Pain. 1998:23-50.
1
2

Commonly Used Pain Medications: Opioids

Analgesia in Labor

International

Mechanism of Action

Bind to opioid receptors,

producing agonist action
that inhibits pain impulses1

Benefits

Effective in severe pain1

Not associated with GI
bleeding1
Generally, no
ceiling effect2

Prescribing
Considerations

Serious risks
associated with opioid
side effects2,3
Risk of tolerance and
dependency3

Moreland LW, St. Clair EW. The use of analgesics in the management of pain in rheumatic diseases. Rheum Dis Clin North Am. 1999;25:153-191.
Atcheson R, Rowbotham DJ. Pharmacology of acute and chronic pain. In: Rawal N, ed. Management of Acute and Chronic Pain. London, England: BMJ Books; 1998:23-50.
3
Power I, Barratt S. Analgesic agents for the postoperative period. Nonopioids. Surg Clin North Am. 1999;79:275-295.
1
2

International

Further Considerations in Prescribing

Analgesia in Labor
Opioid Analgesics1-3

Adverse Effects

Special Issues

Respiratory depression
Nausea, vomiting, and constipation
Sedation and cognitive impairment
Urinary retention
Pruritus
Urticaria

Chronic use can lead to development of physical dependence and tolerance

Less able to control pain on movement
Can produce withdrawal syndrome with abrupt cessation
Many single and combination opioid agents are
short-acting, requiring multiple daily doses
Increased utilization of hospital resources

Moreland LW et al. Rheum Dis Clin North Am. 1999;25:153-191.

Power I et al. Surg Clin North Am. 1999;79:275-295.
3
Atcheson R et al. Management of Acute and Chronic Pain. 1998:23-50.
1
2

Analgesia in Labor

MEKANISME TIMBULNYA NYERI

PERSALINAN

International

Analgesia in Labor
International

Analgesia in Labor
International

DAMPAK NYERI PERSALINAN

THD AKTIFITAS RAHIM DAN KEMAJUAN PERSALINAN
Kontraksi tidak teratur / menurun mempengaruhi lama
persalinan.
THD JANIN
Mengurangi transfer oksigen dari ibu ke janin.
Pola detak jantung janin abnormal.

Analgesia in Labor

BERBAGAI POSISI SAAT KALA I

International

Analgesia in Labor
International

Analgesia in Labor

BERBAGAI POSISI SAAT KALA II

International

Analgesia in Labor
International

Analgesia in Labor
International

Analgesia in Labor
International

Analgesia in Labor
International

Analgesia in Labor
International

PENDAMPINGAN PERSALINAN
1.
2.

3.
4.

Pendampingan persalinan oleh suami dapat menurunkan

tingkat kecemasan secara bermakna ( p = 0,000 ).
Skor nyeri VAS pada kala I fase aktif menurun bermakna ( p =
0,028 ), sedangkan pada kala II menurun tidak bermakna ( p =
0,054 ).
Pendampingan persalinan oleh suami dapat menurunkan secara
bermakna sekresi hormon kortisol ( p = 0,025 ).
Mengatasi rasa nyeri secara medikamentosa dapat dilakukan
dengan : tramadol, pethidin, ILA.