Nyeri persalinan

NEURAXIAL ANALGESIA IN OBSTETRIC (DJANKOVIC)

OBSTETRIC ANESTHESIA (MORGAN)
Pain pathways
Labor pain has both visceral and somatic components that evolve as labor progresses.
During the first stage of labor, the visceral component dominates. Uterine contractions result in
myometrial ischemia and the release of nociceptive mediators such as bradykinin, potassium,
and serotonin.
In addition, mechanoreceptors are stretched as the cervix dilates. Pain impulses are transmitted
via the sympathetic pathways in the paracervical region, through the pelvis to the hypogastric
plexus, entering the lumbar sympathetic chain that enters the dorsal horn of the spinal cord at
the level of T10 to L1.
During the second stage, a somatic component caused by a stretch of the perineum is added.
These enter the spinal cord at the level of S1–S4
The pain is initially perceived in the lower abdomen but may increasingly be referred to the
lumbosacral area, gluteal region, and thighs as labor progresses.
Pain intensity also increases with progressive cervical dilation and with increasing intensity and
frequency of uterine contractions.
Nulliparous women and those with a history of dysmenorrhea appear to experience greater pain
during the first stage of labor.
The onset of perineal pain at the end of the first stage signals the beginning of fetal descent and
the second stage of labor. Stretching and compression of pelvic and perineal structures
intensifies the pain.
Sensory innervation of the perineum is provided by the pudendal nerve (S2–4) so pain during
the second stage of labor involves the T10–S4 dermatomes
Neuraxial analgesia can come very close to this ideal when properly conducted
Effective Pain Relief
Neuraxial analgesia is more effective than other methods
In an earlier meta-analysis of seven randomized trials comprised of 2,000 patients reported
significantly reduced visual analog pain scores in patients who received neuraxial analgesia
compared to those who received parenteral opioids.
Maternal Safety
When properly conducted, neuraxial analgesia has an excellent maternal safety record
There are a number of special precautions that should be taken to minimize the possibility of
maternal injury.
1. Avoid hypotension.
2. Post-dural puncture headache.
This can occur in up to 1.6 % of patients who receive epidural analgesia.
3. Avoid accidental intravenous or intrathecal injection of local anesthetic
Fetal and Neonatal Safety
 Local anesthetics, in the doses given for labor analgesia, do not cause any important direct
physiologic or pharmacologic effects on the fetus
 Neuraxial analgesia that results in hypotension causes abnormal fetal heart rate patterns that
are reversed when hypotension is treated
Severe labor pain increases maternal ventilation and hypocarbia resulting in acute respiratory
alkalosis. This may result in a shift in the oxygen dissociation curve and reduced oxygen delivery
to the fetus.
Severe pain may also cause an increase in circulating catecholamines that may result In
discoordinated labor and reduced uteroplacental perfusion
Progress of Labor
Whether or not neuraxial analgesia causes maternal harm by impeding progress of labor has
been controversial.
It is not clear whether or not mode of analgesia was the direct cause of the increased incidence
of instrumented vagina delivery. In particular, the presence of neuraxial blockade may induce
behavioral changes in the obstetrical team. For example, epidural analgesia facilitates forceps
delivery.
Maternal Side Effects
Numerous studies have shown the benefit of combining low concentrations of long-acting local
anesthetics such as bupivacaine or ropivacaine with lipid soluble opioids.
Low doses of opioids should be used to reduce the incidence and severity of common side
effects such as pruritus, nausea, and sedation.
Low doses of opioids do not appear to affect neonatal outcomes.
PARENTERAL AGENTS
Nearly all parenteral opioid analgesics and sedatives readily cross the placenta and can affect the
fetus.
Meperidine, a commonly used opioid, can be given in doses of 10–25 mg intravenously or 25–50
mg intramuscularly, usually up to a total of 100 mg. Maximal maternal and fetal respiratory
depression is seen in 10–20 min following intravenous administration and in 1–3 h following
intramuscular administration. Consequently, meperidine is usually administered early in labor
when delivery is not expected for at least 4 h.
Intravenous fentanyl, 25–100 mcg/h, has also been used for labor.
Fentanyl in 25–100 mcg doses has a 3- to 10-min analgesic onset that initially lasts about 60 min,
and lasts longer following multiple doses. However, maternal respiratory depression outlasts the
analgesia. Lower doses of fentanyl may be associated with little or no neonatal respiratory
depression and are reported to have no effect on Apgar scores.
Morphine is not used because in equianalgesic doses it appears to cause greater respiratory
depression in the fetus than meperidine and fentanyl
Small doses (up to 2 mg) of midazolam (Versed) may be administered in combination with a
small dose of fentanyl (up to 100 mcg) in healthy parturients at term to facilitate neuraxial
blockade.
At this dose, maternal amnesia has not been observed.
Chronic administration of the longer-acting benzodiazepine diazepam (Valium) has been
associated with fetal depression.
Low-dose intravenous ketamine is a powerful analgesic.
In doses of 10–15 mg intravenously, good analgesia can be obtained in 2–5 min without loss of
consciousness.
Unfortunately, fetal depression with low Apgar scores is associated with doses greater than 1
mg/kg.
Large boluses of ketamine (>1 mg/kg) can be associated with hypertonic uterine contractions.
Low-dose ketamine is most useful just prior to delivery or as an adjuvant to regional anesthesia.
Some clinicians avoid use of ketamine because it may produce unpleasant psychotomimetic
effects
Non farmakologis
1. low resource interventions
simple, selalu tersedia, murah, Teknik resiko rendah
2. moderate resource interventions
motivasi pasien, training khusus, asisten professional, peralatan spesifik
3. high resource interventions
training professional monitoring, resiko tinggi, efek samping pada maternal, fetus, atau
persalinan
low resource interventions

 perubahan posisi persalinan dan pergerakan

 birth ball
 Sentuhan dan pijatan
 akupresure
 aplikasi panas atau dingin (masih diperlukan studi)
 Teknik pernafasan dengan relaksasi
 psikoprofilaksis
 music dan analgesia audio
 moderate resource interventions

 aromaterapi
 akupuntur
 injeksi air steril
 hypnosis atau hipnoterapi
 Transcutaneus electrical nerve stimulations
 celupan air atau hidroterapi
terimakasih