ANALISA JURNAL “ANALGESIA PADA PERSALINAN”

Disusun untuk memenuhi tugas mata kuliah system informasi dan kesehatan

DISUSUN OLEH :

Nama : Wastu Widya

Nim : 1610104025
Kelompok : A2
Semester / Kelas :3/A

PROGRAM STUDI BIDAN PENDIDIK JENJANG DIPLOMA IV

FAKULTAS ILMJU KESEHATAN
UNIVERSITAS ‘AISYIYAH YOGYAKARTA
2017
Analgesia in labour and delivery
Andy Chu Samson Ma Shreelata Datta

Abstract
Pain is defined as “an unpleasant sensory or emotional experience associated with actual or potential tissue
injury”.
Labour pain is encountered during contractions in labour, and patient satisfaction correlates closely to how
well it is managed. Doctors commonly encounter acute pain in clinical practice which can be treated simply by
applying some basic rules. However, pain due to labour requires specific management which falls outside the
basic principles of acute pain management and it is important for prac- titioners who look after these patients to
understand what can be offered.
This review considers the basic principles of each of these tech- niques using common clinical scenarios.
The type of analgesia given will determine where labour takes place and this will be reflected in each case.
Specifically, the World Health Organisation (WHO) anal- gesia ladder is not applicable in these patients because
the periodic nature and the intensity of labour pain renders this model obsolete, although is applicable after
delivery.
Keywords anaesthetics; analgesia; delivery; labour; obstetrics

Introduction
Analgesia in labour is complex and can fluctuate from moment to moment depending on the stage of
labour; each requiring a particular skill set and equipment. Labour analgesia can be broadly classified
into regional and non-regional analgesia, with a further sub-classification of non-regional as
pharmacological and non-pharmacological. Early planning and antenatal coun- selling are essential in
a multidisciplinary clinic offering an anaesthetic opinion as well as midwifery and obstetric advice for
high risk patients with multiple co-morbidities such as high BMI, difficult spinal anatomy and previous
obstetric or anaesthetist complications.
Labour is a physiological process which involves delivery of the baby and placenta from the uterus
to the outside world. Management of pain during labour is very important to ensure

Andy Chu MBBS is a CT1 in Anaesthesia at Kingston Hospital NHS Trust, Kingston upon Thames, UK. Conflicts
of interest: none declared.
Samson Ma BMedSci BMBS MRCP FRCA is an ST6 in Anaesthesia at St George’s Hospital NHS Trust, London, UK.
Conflicts of interest: none declared.

Shreelata Datta BSc(Hons) MBBS MRCOG LLM is a Consultant Obstetrician and Gynaecologist at King’s College
Hospital NHS Trust, London, UK. Conflicts of interest: none declared.
that this is a positive experience for the woman and her partner. Understanding this physiology will
enhance understanding of why certain techniques are used.
The type of pain experienced relates to the different stages of labour:
● The first stage relates to uterine contractions. Pain signals
are transmitted via Ad and C afferents fibres through the sympathetic nerves to the sympathetic
chain. The pain is therefore felt at T10eL1 dermatomes. Cervical pain is carried to the S2, 3
dermatomes via parasympathetic pelvic splanchnic nerves. Ad fibres are thin and myelinated
with a moderate speed of signal conduction. These fibres transmit acute, sharp pain. C fibres are
unmyelinated and have a slower conduction velocity. C fibres primarily transmit a deep,
dissipated type of pain after the initial injury.
● The second stage of labour relates to the passage of the
baby through the birth canal, where the pain is more localised to the perineum. Pain afferents
are Ad fibres via the pudendal nerves, affecting the S2e4 dermatome.

Case 1: home/midwifery led unit

A 30-year-old G3P3 woman in early labour, contracting moderately every 3e4 minutes
It is possible for labouring women to require minimal anal- gesia, particularly in the multiparous
patients. Non- pharmacological methods which are recognised to help in la- bour include the presence
of non-medical trained support, such as a doula, who can provide advice before, during or after
childbirth. Other methods which have not been well-studied but may have some effect include
immersion in water, relaxation, acupuncture and massage. There is insufficient evidence of the
effectiveness of hypnosis, biofeedback, sterile water injection, aromatherapy and Transcutaneous
Electrical Nerve Stimulation. Although robust scientific evidence may be lacking in the non-
pharmacological methods, they remain available for patient to choose and their effectiveness should
be considered on an indi- vidual basis. Simple analgesia such as paracetamol can be given but there is
not a significant amount more than can be offered. Pharmacological solutions in this setting is
rudimentary as personnel and monitoring equipment are not available unless in a hospital setting.

Case 2: labour ward

A 26-year-old primiparous patient with a history of pre- eclampsia (not requiring medication).
She is 5 cm dilated, contracting 3e4 in 10 and now requesting analgesia
This particular patient is not uncommon considering pre- eclampsia (PET) affects up to 8% of all
pregnancies worldwide. An epidural will be beneficial for her, especially an early one in labour, for
numerous reasons. Controlling her pain will help to control any excessive hypertensive responses. As
covered in more detail later, the sympathetic blockade from the epidural can cause vasodilation and can
improve placental blood flow to the fetus.

Epidural analgesia
Regional anaesthesia, including epidurals, remains one of the most effective forms of pain relief in
labour. This method re- quires the skill of an anaesthetist for insertion together with fetal
and maternal monitoring after insertion. Therefore the patient
must be cared for on labour ward where monitoring can occur.
An epidural is a “neuraxial” technique which offers reliable, Absolute
effective and flexible analgesia to patients in labour. Importantly,
drugs used in this method are not spread systemically. As shown
in Figure 1, an epidural catheter is inserted via a Tuohy needle
into the epidural space at an appropriate level. The anaesthetic
mixture, containing a local anaesthetic (LA) and an opioid, is
injected or infused into this space. The LA used is usually 0.5%
bupivacaine or levobupivacaine while the opioids used are fen-
tanyl or diamorphine. An epidural offers reliable, effective and
flexible analgesia to patients in labour. The peak onset occurs
after 20 minutes, but once this is reached, the pain relief is
sustained and complete. An appropriate block will extend to the
sacral area such that it will cover pain from the second stage of
labour pain. The nerve region blocked by an epidural will depend
Table 1
on its primary indication e for example, a block extending to T8/
T10 may be sufficient to provide analgesia for labour contraction
pains, whilst a denser block extending to T4 is required for a LA agent, ropivacaine instead of bupivacaine, can produce less
Caesarean section (CS). Quite often, instrumental delivery and motor blockade but is not as potent. Hypotension can occur due
episiotomies may be performed without needing to “top up” the to vasodilating effects of preganglionic autonomic B fibres inhi-
epidural or requiring other analgesic techniques. bition. This should be anticipated and managed as appropriate
The patient must be fully consented before a regional block. with vasopressors such as metaraminol or phenylephrine.
Contraindications are listed in Table 1 and these apply to the Epidurals can provide other benefits beside analgesia; by
other regional techniques used. Due to the nature of the epidural, blunting sympathetic nervous activities they can attenuate the
there may be lower limb motor block. This motor function deficit sympathetic response to anxiety and pain. There is also a reduced
has been linked to prolonged second stage of labour and increase risk of thromboembolism in the lower limbs. This regional
use of instrumental deliveries. Some patients may find this dis- method means that women can have skin-to-skin con- tact with
tressing as they are unable to mobilise. The anaesthetist will their babies immediately after birth e this is a recom- mendation
assess the effectiveness of the block looking at both the motor by The Royal College of Obstetrics and Gynaecology (RCOG) to
block using the Bromage scale and sensory block, then adjust the improve bonding. Paradoxically, breastfeeding after having an
dose to patient comfort with minimal motor blockade. A different epidural may be problematic. It has been found that women
undergoing an epidural will have more difficulty starting an
infant on breastfeeding within the first 24 hours. This phe-
nomenon is not entirely understood but if feeding is not estab-
Insertion of Tuohy needle into the epidural space lished within the first hour, these mothers run a high risk of
needing bottle supplementation instead.

Spinal tap: if the epidural catheter punctures an epidural vein, the

LA can be injected directly to the central venous system and
results in toxicity even with small doses. This is particularly
Interspinous dangerous as epidural doses of bupivacaine are of much larger
quantity than spinal doses (w20 ml versus w2.5 ml). If the
catheter pierces the dura, an excessively high block can result due
to injection into the subarachnoid space, which at worst can
result in a total spinal block. A patient with total spinal block will
Supraspinous require ventilatory and circulatory support. Epidural abscesses or
haematomas are rare (under 1 in 160,000) and serious compli-
cations but should be considered if a patient still complains of
motor blockade more than six hours after cessation of the infu-
sion or has new onset incontinence. These conditions can result
in permanent paraplegia if not identified and treated in a timely
fashion. Urgent radiological imaging and discussion with the
spinal team are warranted to salvage the situation before damage
Subarachnoid becomes permanently irreversible.

Epidural block: an epidural block has a similar side effect profile

to that of a spinal. There is a risk of infection in procedures and a
Figure 1 spinal infection can be particularly catastrophic, requiring potent

and lengthy antibiotic treatment. Loss of sterility can be a risk
during a difficult injection requiring multiple attempts. Direct
injury to the spinal cord is rare but the majority of these patients
will make a full recovery from non-permanent nerve injuries. One
point of note is that patients under regional anaesthesia are
especially sensitive to sedation and therefore at risk of respira-
tory depression. A large dose of opioid given intrathecally can
cause severe pruritus, which can be more distressing than the
pain itself. This can be alleviated with anti-histamine
medications.
Alternative regional block techniques available to
women without an epidural in second stage of labour
Where regional block techniques using spinal block cannot be
performed other regional techniques such as the pudendal and
paracervical blocks, performed by the obstetricians, can be
applied in the labour ward to help with the relief of labour pain.
The nerve pathways blocked are demonstrated in Figure 2.
Pudendal nerve block: during the second stage of labour, pain is
experienced in the lower vagina, vulva and perineum. The pudendal
block is a technique that can cover these areas (S2e4) via direct
injection of local anaesthetic to the pudendal nerve area using a
trumpet needle via a trans-vaginal route. However, this stage is
usually very short and this block is usually used to cover pain from
instrumentation and episiotomies or perineal tear repair during
delivery. Note that the anterior perineum (ilioinguinal nerve) is not
blocked so a local infiltration is often used around the perineum as
well to anaesthetise the skin. In these situations it is important to
calculate a predetermined maximum local anaesthetic dose and
make sure this is not exceeded to prevent complications of toxicity.
Failure or
Figure 2
inadequate block is common, with a failure rate of 50% even in
experienced hands.
Paracervical block: the paracervical block is rarely used for
analgesia during the first stage of labour. It aims to block the
paracervical ganglion, which lies lateral and posterior to the
cervico-uterine junction. Whilst this provides analgesia without
the sensory or motor blockade seen in epidurals, it does not
relieve uterine contractions and can result in fetal bradycardia,
typically occurring 2e10 minutes from injection. It can be diffi-
cult to administer and is therefore not commonly performed.
Both the pudendal and paracervical blocks rely on blind tech-
niques performed trans-vaginally. Thus, there is always a risk of
needlestick injuries to the physician.
Case 3: labour ward
A 30-year-old primiparous woman who is 8 cm dilated con-
tracting 3:10. Platelet count yesterday was 40 × 109/litre with
contraindications to a regional analgesic approach
Mx issues: besides controlling this patient’s pain, there are
pressing issues that trouble the anaesthetic and the obstetrics
team for this lady in regards to her labour. With a thrombocy-
topenia, HELLP/PET must be considered with increased atten-
tion paid to her blood pressure and neurological status. With a
platelet level this low, a regional anaesthetic approach should be
avoided. A thrombocytopenia of this severity poses problems for
delivery of the baby as a platelet level of at least 50 × 109/litre is
required. Input from a haemotologist would be beneficial for
advice and acquisition of blood products. A general anaesthetic
may well be required for this parturient lady with such a coa-
gulopathy if a surgical delivery occurs.

Analgesic control in labour can be established by using sys-
temic pharmacological agents, although potentially this method
is inferior to appropriately placed regional techniques. As listed
before, an epidural may not be possible in some patients. The
below listed methods are the commonly used ones in labour ward
settings and can be achieved relatively easily without specialist
input. It is important to discuss the methods with each patient
appropriately as acceptable analgesia does not neces- sarily mean
absolute absence of pain.
Entonox: Entonox is the trade name of a 50% oxygen and 50%
nitrous oxide gas mixture. It is an anaesthetic gas frequently used
in hospital A&E, labour wards and midwifery led units. The use of
Entonox in labour is well established as demonstrated by its
availability throughout nearly all the obstetrics units across the
United Kingdom. One reason for its popularity is its ease of use in
the first stage of labour, although the patient must be counselled on
how to use it effectively e it is delivered using a mouth nozzle held
by the patient. The gas is inhaled and reaches a peak effect by 20
e30 seconds e ideal for intermittent intense pain seen in labour.
The neonate eliminates most of the gas within minutes of birth so
there is low risk of respiratory depression. Nausea, vomiting and
disorientation are common side effects, but the major disadvan-
tage of Entonox is its inability to provide complete analgesia.
Nitrous oxide is highly lipid-soluble and will expand luminal
spaces it diffuses into. Certain circumstances such as bowel
obstruction, pneumothorax, ongoing middle ear infections and
decreased levels of consciousness will limit its use.
Pethidine: pethidine, also called meperidine, is an opioid about
one tenth as potent as morphine and can be given intramus-
cularly. Pethidine is widely used in labour and can be pre- scribed
and administered by midwives. Side effects of pethidine are
similar to those of other opioids, namely respiratory depression
of the mother and neonate, delayed gastric emptying, nausea,
vomiting, sedation and hypotension. As pethidine is highly lipid-
soluble, it crosses the placenta and fetal exposure to this drug is
maximal at 2e3 hours after maternal intramuscular
administration. The optimal time for delivery of the baby
following a dose of pethidine is either within the first hour or
after the fourth hour of dosing. If pethidine is used within 4 hours
of delivery of the baby, the paediatrician should be informed and
asked to attend the de- livery in case any neonatal respiratory
support is needed. Hence, whilst pethidine can be given easily,
good attention to timing and access to assistance are still
required.
Morphine & diamorphine: morphine can be administered
intravenously or intramuscularly and reaches maximal effect at
20 minutes and 1e2 hours, respectively. Despite being signifi-
cantly less efficacious than regional techniques with side effects
common to all opioids affecting the mother and baby, systemic
opioids are still used for a number of reasons. These include ease
of administration, low cost and patient’s perception of reduced
risk compared to epidurals.
Diamorphine is not commonly used in obstetric units across
the nation. It is more lipid-soluble than morphine and therefore
more potent and has a faster onset of action. While diamorphine
provides good analgesia, it is found that the length of labour is
significantly increased with its use so therefore more pain is
experienced overall.
Patient controlled analgesia
Patient controlled analgesia (PCA) refers to self-administration of
intravenous opioid drugs by a pre-set intravenous infusion pump.
This is set up by anaesthetists on labour ward and allows each
patient to receive an appropriate dosage of analgesics suitable to
their respective needs at a particular time. Fentanyl and
remifentanil are commonly used. Both are potent synthetic
opioids with rapid onset and a short duration of action. Fentanyl
has a potency of roughly 100 times that of morphine but crosses
the placenta quickly and can accumulate in the foetus if large
doses are used.
Remifentanil is a relatively new m-receptor agonist. It is even
more potent than fentanyl and is described as “ultra short-
acting”, with an onset period of 1 minute and constant context-
sensitive half-life of 3.5 minutes. This property of remifentanil
makes it an ideal candidate for PCA in labour analgesia since even
prolonged use will not cause accumulation in the tissue.
However, PCA is not considered first-line for labour analgesia
as medication is administered systemically e side effects can
affect mother and fetus. PCA requires close supervision to avoid
maternal hypoventilation so the patient must be on labour ward
and the lack of adequately trained staffs to care for patients with
it is a contraindication for use. Therefore, PCA is only considered
in modern obstetric units when epidural had been declined or
contraindicated e or in situations where systemic use resulting
in foetal harm is not an issue such as in intra-uterine foetal death
with normal delivery.
Case 4: operating theatre
A 30-year-old primiparous woman requiring an elective
Caesarean section (CS) for breech presentation
Data from RCOG suggest between 25 and 30% of deliveries in
the UK are by CS. The choice of analgesia, or anaesthetic, tech-
niques depends on urgency of the case, indication for CS and
patient choice. This should be discussed with the obstetrician to
ensure the most appropriate technique is performed. In these
scenarios, the patients would require sufficient pain relief, which
most often comes from an anaesthetic intervention, to allow for
the surgery.
Spinal anaesthetic
In elective CS, the regional technique is preferred over general
anaesthetic (GA); this avoids the increased risks associated with
GA in pregnancy such as difficulty in intubation, aspiration risk
and possible ventilatory difficulties. In addition, the patient is
awake and her partner is allowed to accompany her in theatre,
allowing early bonding with the baby and higher chances of
initiating breastfeeding.
The regional technique of choice is usually a single-shot spinal
anaesthesia. Spinal anaesthesia offers simple, rapid and dense
blockade with negligible maternal and infant risk of local anaesthetic
toxicity and respiratory depression. The level of in- jection must be
below L2/3 to avoid damage to the spinal cord. 0.5% bupivacaine
mixed in 80 mg/ml of glucose is most commonly used by obstetric
anaesthetists in the UK. The glucose renders the solution
“hyperbaric” and denser than CSF. It sinks

with gravity when injected into the spinal space e this allows control
of LA spread. After injection, the patient must be in a supine position
and possibly with head down tilt to encourage spread up to an
appropriate level. An injection of 2.5 ml 0.5% heavy bupivacaine
plus a pre-calculated dose of fentanyl or diamorphine can usually
cover the surgical duration and provide post-operative analgesia. A
spinal anaesthetic can also be administered to women undergoing
instrumental delivery in theatre, who do not have an on-going
epidural or one that is not working optimally.
As mentioned previously, a large spinal dosage can result in a
high or total spinal block, which if not recognized can lead to life-
threatening hypotension from vasodilatation or respiratory fail-
ure due to blockade of the diaphragm and intercostal muscles.
The toxic dosage of bupivacaine is 2 mg/kg (with or without
adrenaline) with a maximum dose of 150 mg. First signs of
toxicity are usually cerebral in nature e dizziness, confusion,
metallic taste, lip tingling or seizures. At severe toxicity, bupi-
vacaine is cardiotoxic and can cause complete cardiovascular
collapse from a combination of peripheral vasodilatation and
myocardial contractility depression. Patients should already have
large bored venous access prior to any regional blocks. The usual
resuscitative equipment and procedures are needed. If cardiac
arrest has occurred, ALS protocol should be started along with
securing of the airway. An intralipid emulsion can be used as
‘antidote’. This emulsion serves to chelate the local anaesthetic
agent and can be started as a bolus of 1.5 ml/kg. The patient
would need monitoring or continuing care in HDU/ITU following
this.
Epidural for surgical delivery
By and large, epidurals are removed immediately post-
operatively unless there is a high risk of the need to return to
theatre. However, if an epidural is present in women undergoing
an instrumental delivery, a larger dose of opioid can be injected
into the epidural space to “top up” analgesia.
For surgery, an indwelling catheter can be topped up, as
shown in Figure 3, to extend the level of nerve block to T4 level.
This would allow sufficient coverage for a CS. The epidural
catheter is usually removed 1e2 hours postoperatively and can
be done so by a nurse or an anaesthetist.
Combined spinal epidural (CSE)
The CSE is an amalgamation of a spinal injection with placement
of an epidural catheter in one procedure. This method exploits
the rapid and dense neuraxial block of the spinal anaesthesia as
well as the ability to prolong the block via the epidural route. This
technique allows prolonged analgesia when operation time is
expected to surpass the duration of a single spinal injection. An
example is a woman with twin pregnancy who is at risk of uterine
atony post-delivery and may take longer operating time for
haemostasis to be achieved e in this case, the epidural inserted
in the space can be topped up for surgical analgesia.
The CSE can be applied not only for operative analgesia but
can also be put in place of the epidural for a woman in active
labour. The initial spinal block, lasting 1e2 hours, provides quick
and intense pain relief that surpasses that of an epidural.
Intermittent low doses of bupivacaine can be applied through the
epidural after the spinal injection wears off. A lower dose of
bupivacaine is used, meaning most patients undergoing the CSE
during labour will maintain the ability to ambulate e something
which the conventional epidural often inhibits. The RCOG states
there is no difference between rates of operative vaginal
(instrumental vaginal delivery) using CSE compared with an
epidural. The epidural remains the gold standard in obstetrics
analgesia, so it will depend on future studies to see if the CSE will
increase in popularity.
The complications are very similar to those in spinal and
epidurals except for a few rare ones. Migration of the epidural
catheter is a theoretical risk as there is a punctured hole in the
dura from the spinal injection itself, so any further top ups should
be handled carefully. Therefore, high blocks must always be taken
into account, especially if large epidural boluses are given.
Case 5: operating theatre
A 29-year-old primiparous patient requiring an emergency
category 1 caesarean section for fetal distress at 3 cm
Caesarean sections are classified from category 1 to 4 based on
the urgency:
● Category 4: elective CS
● Category 3: expedited delivery with no maternal or fetal
compromise
● Category 2: maternal or fetal compromise but not imme-
diately life threatening
● Category 1: maternal or fetal compromise that is immedi-
ately life threatening
General anaesthetic
Category 2e4 CS are generally done under regional techniques
(i.e. spinal). A category 1 CS (immediate delivery) may require a
general anaesthetic (GA) if a regional technique might not pro-
vide adequate anaesthesia in time. However, a regional tech-
nique is favoured over a GA even in a category 1 section. The aim
in these cases is to deliver the fetus as quickly as possible while
minimising risks to the mother. However, the anaesthetist must
be in communication with the obstetric team regarding the state
of the fetus and be ready to convert into a GA should it be
required.
GA CS is not commonly done. The major risks of this tech- nique
will be linked to the airway. Due to anatomical and physiological
changes in pregnancy, failed intubations are ten times more
common and this can be further plagued by the lack of anaesthetic
experience due to limited training opportunities. Risks of acid
regurgitation and aspiration are twice as likely compared to the non-
pregnant patient due progesterone reducing the lower
oesophageal sphincter tone. Antacid pro- phylaxis such as H2
antagonist and prokinetics should be considered prior to induction
of GA. A rapid sequence induction technique with adequate pre-
oxygenation should be performed to minimise the time between
administration of induction agents to securing the trachea with an
endotracheal tube. Of the four maternal deaths directly related to
anaesthesia in the latest maternal mortality MBRRACE-UK report,
two were linked to patients under a general anaesthesia and
subsequent airway problems. Failed intubation should be
anticipated and rescue methods and equipment readily at hand in all
obstetric general anaesthetics.
 Area of nerve block provided by an epidural analgesia for
contraction pain (T8–10)

Figure 3

Post GA CS pain relief: appropriate analgesia remains vital as Analgesia after delivery
anaesthetic agents do not supply sufficient pain relief. In a GA CS,
Analgesia should be prescribed as per the WHO analgesic ladder.
local anaesthetic injection for transversus abdominal plane block
This algorithm was initially created to treat cancer pain, but its
applied intraoperatively may help reduce the requirement of
stepwise approach has been applied to clinical situations
systemic opioids postoperatively. Another method is the
including acute pain (see Figure 4). The principle is to initially
infiltration of local anaesthetic to skin incision after closure.
treat with the simplest drug and add on more potent analgesia in
However, these patients may still need a PCA post-operatively.
a stepwise fashion. This ensures a multi-modal approach, which
Minimal amounts of opioids are transferred via breast milk.
increases efficacy, and reduces the accumulative side effect
Regardless, the mother and newborn should be monitored
profiles of the drugs. Patients often request the strongest anal-
appropriately and the PCA stopped should any drowsiness is
gesics and may question physicians when given weaker
observed.

Strong opioid

Pain controlled

Figure 4
 remifentanil

diamorphine
Entonox

Figure 5

medications. It is important to explain the WHO model to pa- tients as this allows the patients to understand the rationale behind their
treatment.
Strong opioids like morphine should be prescribed in conjunction with their predecessors, and not alone at the very beginning in
order to exploit the synergistic effects of combined analgesia.
Patients may question about the safety of these drugs in terms of breastfeeding. Morphine delivered via a PCA method can be
transferred through breast milk but it does not seem to cause adverse fetal respiratory depression, possibly from significant first-pass
metabolism. NSAIDs, apart from aspirin, are consid- ered safe to use as well.

Conclusion
Whilst there is no official pain ladder when dealing with women who are in labour, Figure 5 outlines a generic approach which can be
applied to patients in labour. Patients will have different requirements and may have pre-arranged expectations and suc- cessful labour
analgesia can be challenging for individual pa- tients, with different approaches needed at different stages. All pregnant women should
discuss analgesia in labour during their antenatal appointments, documenting their preferred methods in their birth plan. This may need
to be revised or reaffirmed once the patient is in established labour. AFURTHER READING
Allman K, Wilson I. Oxford handbook of anaesthesia. 4th Edn. New York: Oxford University Press, 2016.
Aitkenhead A, Moppett I, Thompson J. Smith &Aitkenhead’s textbook of anaesthesia. 6th edn. Elsevier Limited, 2013.
Chestnut DH. Obstetric anaesthesia: principles and practice. 3rd edn.
2004. Philadelphia: Elsevier Mosby, 2004.
Rucklidge M. Analgesia for labour. Anaesthesia UK ATOTW Archive. http://www.frca.co.uk/article.aspx?articleid¼100551 (accessed 16
Jul 2014).
The Royal College of Obstetrics & Gynaecology. Green-top Guideline No. 26: Operative vaginal delivery. https://www.rcog.org.uk/
globalassets/documents/guidelines/gtg26.pdf.

Practice points

C The normal WHO method of analgesia does not offer

the best analgesia during this period
C Patient’s perception and acceptance in what is

controlled pain relief is just as important as

providing the appropriate analgesia
C Patients’ level of analgesia needed will determine

where their delivery takes place

C Regional techniques are more effective than systemic

methods of analgesia
C Regional techniques are the preferred methods for

surgical deliveries
ANALISIS JURNAL OLEH PEMBACA :

Rasa sakit didefinisikan sebagai "pengalaman sensorik atau emosional yang tidak menyenangkan yang
terkait dengan cedera jaringan aktual atau potensial". Rasa sakit persalinan ditemui selama kontraksi
persalinan, dan kepuasan pasien berkorelasi erat dengan seberapa baik pengelolaannya. Dokter biasanya
mengalami nyeri akut dalam praktik klinis yang dapat ditangani hanya dengan menerapkan beberapa peraturan
dasar. Namun, rasa sakit karena persalinan memerlukan manajemen spesifik yang berada di luar prinsip dasar
penanganan nyeri akut dan penting bagi praktisi yang merawat pasien ini untuk memahami apa yang dapat
ditawarkan.
Tinjauan ini mempertimbangkan prinsip dasar masing-masing teknik menggunakan skenario klinis yang
umum. Jenis analgesia yang diberikan akan menentukan di mana tenaga kerja berlangsung dan ini akan
tercermin dalam setiap kasus. Secara khusus, jalur analgesik Organisasi Kesehatan Dunia (WHO) tidak
berlaku pada pasien ini karena sifat periodik dan intensitas nyeri persalinan membuat model ini usang,
walaupun berlaku setelah melahirkan.
Sementara tidak ada tangga nyeri resmi saat berhadapan dengan wanita yang sedang melahirkan,
Gambar 5 menguraikan pendekatan generik yang dapat diterapkan pada pasien yang bekerja. Pasien akan
memiliki persyaratan yang berbeda dan mungkin memiliki harapan yang telah diatur sebelumnya dan
analgesia persalinan yang berhasil dapat menantang bagi pasien individual, dengan pendekatan berbeda yang
diperlukan pada tahap yang berbeda. Semua wanita hamil harus mendiskusikan analgesia dalam persalinan
selama penunjukan antenatal mereka, mendokumentasikan metode pilihan mereka dalam rencana kelahiran
mereka. Ini mungkin perlu direvisi atau ditegaskan kembali setelah pasien berada dalam persalinan yang
mapan.