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Departement of Anestesiology andReanimation , School of Medicine,
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uma era ara n vers
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3Living Made Easy: Prescription for Scolding Wives [1830]
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Hinkley, an American portrait painter who studiedat the Paris Ecole des Beaux Arts, in 1882 began his
painting of the ether demonstration as aspeculative work and took 11 years to complete it.
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The Hinkley painting today hangs in the
Francis A. Countway Library of Medicine atHarvard Medical School in Boston..
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History of Anesthesiaistory of AnesthesiaA history of anesthesia or "pain killing" techniqueshistory of anesthesia or pain killing techniquesthroughout historyAnesthesia, historical background and the word's origin
Pain, however useful as a warning signal designed to keep living,agonywhen operations must be performed.
Attempts to control pain were many. The use of alcohol or some
orm o w a came o e ca e ypno sm was o . cupunc urewas used in the Orient. The new chemistry also contributednitrous oxide, which, when inhaled, served to su ress the8
sensation of pain.
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Year 1846
10The Ether Dome, Boston, Massachussets, USA
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1846, Boston Massachussetts
of ether as anesthetic
i iam orton
Inventor and revealer of anesthetic inhalation
Before whom in all time surgery was agonyBy whom pain in surgery was averted and annuled
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H. Bigelow
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. ,Dr. Horace Wells was one of the first to use ether as an
anesthesia.
n , us wo years a er orace e s anes e c success
with nitrous oxide, Dr. William Morton (1819-68), constructedthe first anesthetic machine.
Mortons simple device was aglass globe housinganether-soaked spongeso all the patient had to do was merely to inhale
the vapor through one of two outlets.Mortons invention was put to the test on October 16, 1846, in
the surgical amphitheater of the Massachusetts General HospitalinBostonwhenatwent - ea -oldmanwassuccessfull
anesthetized so a tumor could be painlessly removed from whatone source said was his neck and another indicated was from his
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Anesthesiology is a blessed profession
When God created Eva from Adams rib .
first, He put Adam into a deep sleep.
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Ether :
- ood narcosis- good analgesia- good muscle relaxation
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KemajuanIlmu Bedah
a
sfusi
io
tika
t
esi
Tra
Anti
A
ne
N u t r i s i
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...TODAY
nest esa s now muc sa er an more peasant or t epatient than it was 50 years ago.Factors contributing to the
pharmacology, better preoperative assessment and preparation of
patients Improvements in anesthesia have allowed
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surgeons to attempt more complicated operations on
increasing number of patients...... M.Dobson
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surgery
Trauma surger
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Many techniques originally developed for use during anesthesiaare now widely recognized as applicable to the care of a variety ofcritically ill patients, for example those with severe head injuries,
, .assessment and management of unconscious patients, control ofairway, endotrachel intubation,. cardioplumonary resuscitation
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ave t er or gns n anest esa,but are now recognized as
essential for all doctors.
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Working together
urgery nes eso ogy|
extends the boundaries of life and death
19Massive Crush Injury - Hb 2
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Pengembangan
1975 Anestesiologi RSCM1977 Anestesiologi RSDS
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Prolon edLifeSu ordi ICU|
adalah bagian dariResusitasi
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MagillGuedelMacIntoshpsen
Archie Brain
L M A
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Resusitasi Jantung Paru
ATLS
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Sekolahnya 4 tahun, 120 SKS+ MKDU
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Anestesia
Keadaan yang ditandai hilangnya kesadarandan / atau erse si n eri bersama atau ter isah
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Anestesia
Keadaan yang ditandai hilangnya kesadaran dan /atau persepsi nyeri (bersama atau terpisah)
Dapat dilakukan secara temporer dengan
obat anestesia umum obat anestesia lokal / regional
hipnosis
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Apakah anestesia berbahaya?
Ya men ebabkande resi nafas antun sirkulasi
fungsi otak, hati, usus, ginjal dan sistim imun
jika semua perubahan diawasi dan dikendalikan
maka baha a da at di-minimal-kan
Dengan anestesia yang baik risiko mati
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Mortality associated w/ anesthesia
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Forrest (1990)-7 days 1:10,000 -
MHA (Maryland Hosp Assoc 1999)-
National Aggregate Data
Class I 1:10,000
Class II 3:10,000
Clas III 28:10,000 Class IV 230:10,000
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Anestesiamenghambat hantaran impulse nyeri ataumenghilangkan persepsi nyeri
Suntikan im atau iv Anestesia umum
Inhalasi (dihisap nafas)
Dengan suntikan syaraf Anestesia regional /conductionbloc
Dengan suntikan ditem at o erasi
Anestesia (infiltrasi) lokal
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blok otak = syaraf pusat
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Anestesi umum
Ketamin pada jalur thalamus-cortex
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Anestesia regional
blok serat syaraf
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Ketaminen aas
pna oc
Plexus & NerveBlock
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a a uung syara o as
(local infiltration block)
(nerve block)
Pada berkas s araf dekat medula s inalis(plexus block)
Pada medula spinalis
per ep ura oc an su arac no oc= spinal anesthesia
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Nerve block
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exus oc
Epidural block Subarachnoid block
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Peridural block
block
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Obat anestesia = obat berbahayadosis kecil = anestesia
dosis besar = fatal
Pentothal, lidocain, N2O, halothan, sevoflurane,es urane aam oss t ngg semuamemat an
coma yang dalam
tekanan darah turun hebat
henti jantung
Pavulon, Esmeron, Tracrium, Succinylcholine =obat pelumpuh otot
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henti nafas (apnea) perlu nafas buatan
P t th l
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Pentothal PavulonKCl
Obat anestesia
=
Obat eksekusi mati
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Obat anestesia umum
Ether Bau (+) menyengat, terbakar,murah
Halothane
Enflurane
Harum, gg liver, aritmia
Harum >
Desflurane Harum
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Sistem anestesia
Pvaporizerbreathing tubes
canister sodalime
Flowmeteroksigen
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Sumber as O2 N2OVaporizer ether
Flowmeter pengatur gas
Vaporizer halothane
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Vaporizer enflurane
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otak
Uap obat inhalasi
Alveoliaru
Art.carotis int..
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Kapiler paru
Obat intravena
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TAHAP RECOVERY
turun OA dalam darah pindah ke
aveo ar a ar aam ara turun
OA dalam sel otak pindah ke darah
kadar OA dalam otak turun pasien sadarkembali
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TAHAP INDUKSI & MAINTENANCE
lalu ke jantung kiri sirkulasi oleh jantung
jaringan otakmasuk sel-sel otak
menjadi tidak sadar
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Urutan proses anestesia umum
Puasa: mengosongkan lambung ,
Induksi: memberi loading dose obat anestesia
antenance: memelihara kadar obat anestesi
Recovery: menunggu siuman kembali
Post-op care: menunggu normal kembali
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A t i b bk d i f i it l
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Anestesia menyebabkan depresi fungsi vital
Nafas:
sumbatan alannafas
mengurangi nafas (hipoventilasi) henti nafas
Sirkulasi:
tekanan darah turun nadi tak teratur
henti jantung
Kesadaran: menurun sampai coma
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PerubahanpCO2akibatanestesia
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Perubahan pCO2 akibat anestesia
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(hipoventilasi)pCO2 arteria
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Enflurane
Isoflurane
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20
30
0
10
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0 MAC 1.0 MAC 1.5 MAC
Perubahancardiacoutputakibatanestesia
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Perubahan cardiac output akibat anestesia
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(depresi sirkulasi)% awake value
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Isoflurane
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Enflurane
Halothane
40
0
20
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1.0 MAC 1.5 MAC 2.0 MAC
Perfusi nadidantekanandarah
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Perfusi, nadi dan tekanan darah
harus di monitor selama anestesia
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Waktu induksi
Jari raba Mata lihat nafas
Waktu maintenanceTelinga dengarjantung
Monitoring selama anestesi
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Edmond I Eger 1985
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Pasien trauma kepala dengan tekanan intra-kranial tinggi
Perlu obat anestesia yang tidak meningkatkan TIKlebih tin i la i
63selama Dr Bedah Syaraf tidak dapat dekompresi
Perubahan hormonal
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Resusitator
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- tekanan darah- ECG- suhu
- saturasi O2- kedalamanstadium anestesia
- resusitator- defibrilator
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- resprator
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ether halothan sevofluran desfluran
Induksi sukar mudah sangamudah
sukar
Titikdidih
36.2 50.2 58.5 22.8
oo gaspart.coeff 12.1 2.3 0.68 0.42
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e .uappada 20C
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VOLATILE ANESTHETICS
ETHERHALOTHAN
ISOFLURAN
SEVOFLURAN
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Induksi inhalasi dengan ether perlu waktu 20-30 menit
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Induksi inhalasi halothane3-5 menit dan dapat dipercepat
Induksi inhalasi desfluranebisa cepat tetapi > 25% pasien
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dengan suntikan pentothal iv au an spasme arynxharus dibantu propofol iv
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muntah tidak masuk paru(aspirasi)
MASA RECOVERY
aga agar
waktu gelisah tidak jatuhNafas dibantu oksigen
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Tekanan darah dipantau
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Anestesiologi & Reanimasisangat kompleks
dimana multiple variables bekerja cepat dalamhitungan menit dan detik
dan dalam range mati-hidupnya seorang pasien
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Penyulit buruk adalah
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- karena penyakitnya sendiri- karena pembedahannya- karena anestesianya
Penyulit terburukadalahMALIGNANT
obat cuma satu (dantrolene)
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efeknya belum tentuDipicu succinyl - halothan
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Goodgeneral anesthesia
n
cosis
l
gesia
relaxati
Na
An
uscle
Stress Free
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Narcosis dan analgesia
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Anestesi umumKetamin padajalur thalamus-cortex
Morfin pada
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Analgesia
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Nerve block
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exus oc
Epidural blockSubarachnoid block
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Muscle relaxation
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Anestesia
1. Pemahaman fisiologi, farmakologi, pato-
fisiologi serta pato-farmakologi . apor zer yang a urat
3. Pelumpuh otot dan antagonisnya
4. Narkotik sintetik dan antagonisny
5. Obat inhalasi inert desflurane, xenon
6. Respirator canggih dan analisa gas darah 7. Sarana monitoring fungsi vital yang teliti
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8. Dll masih banyak lagi
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Operasi mikroskopik|
Perfectly still
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Pengembanganblok re ional an andal
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- Jarum spinal #29- Celiac plexus block,- Cervical peridural
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,bahkan untuk janin
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w y y
Reversibility Anesthesia is a physiological trespassing
Awake - Coma - Awake A ain Breathing - Apnea - Breathing Again
made reversible
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Is ta un pengem angan nestesa
Anestesiologi & Reanimasi
Melahirkan disiplin ilmu baru :
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Pen etahuanberdasar reversibilit
Apakah nafas berhenti itu reversible?
Apakah coma itu reversible?
Prevent a premature death mendasari upaya
resustas
reanimasi
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reversing the dying process
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Resusitasi primitif|
|Patophysiology of
Dying and Reanimation(Peter Safar et al)
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Basic Life Support
A-B-C 1968 Safar etal
Advanced Life Support
Artificial Ventilation
oc rugs
Prolonged Life Support
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Intensive Care (G-H-I)
D fi iti Di i
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Definitive Diagnosis
of surgical pathology
LIFE SUPPORTSpesialis
Bedahrway, Breat ngCirculation, Brain
(BLS-ALS-PLS) Spesialis Anestesiologi
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Anestesiologi& Reanimasi Bedah PROFESSIONAL
BedahAnestesiologi& Reanimasi
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1.Sedation
N2O(Ether, Halothane, Ethrane, Isoflurane,
, ,iv-anesthesia
, , , ,
etomidate, etc)
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Narcotic-analgetic(morphin, petidin, fentanyl,
, , ,N2O
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ROUTINE PREOPERATIVE LABORATORY EVALUATION OFROUTINE PREOPERATIVE LABORATORY EVALUATION OF
ASYMPTOMATIC APPARENTLY HEALTHY PATIENTSASYMPTOMATIC APPARENTLY HEALTHY PATIENTS
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ASYMPTOMATIC, APPARENTLY HEALTHY PATIENTSASYMPTOMATIC, APPARENTLY HEALTHY PATIENTS
Hematocrit of hemoglobin concentrationAll menstruating womenAll patients over 60 years of ageAll patients who are likely to experience
significant blood loss and
may require transfusionSerum glucose and creatinie ( or blood urea nitrogen )concentration :
All patients over 60 years of age
Chest radiograph : all patients over 60 years of age
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THE ANESTHETIC PLANTHE ANESTHETIC PLAN
Premedication
GeneralAi t
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GeneralAirway managementInduction
Muscle relaxationLocal or regional anesthesia
Technique
Monitored anesthesia careSupplement oxygenSedation
MonitoringPositioningFluid management
Postoperative management
Pain controlIntensive care
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Hemodynamic monitoring
PREOPERATIVE PHYSICAL STATUS CLASSIFICATION ofPATIENTS ACCORDING TO THE AMERICAN SOCIETY OF ANESTHESIOLOGIST
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CLASSIFICATION AND PERIOPERATIVE MORTALITY RATESCLASSIFICATION AND PERIOPERATIVE MORTALITY RATES
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1 0,06 - 0,08 %
2 0,27 - 0,4 %
3 1,8 - 4,3 %
4 7,8 - 23%
5 9,4 - 51 %
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Pathwa and Mechanism
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auses.
lower uterine segment and cervix to allowpassage of the fetus.
2. Second stage: greater pressure of the presenting parton pain-sensitive pelvic structures anddistension of surroundin structures.
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Pathways
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Pathways. -
passing in the sympathetic nerves to the
sympathetic chain; referred to the T10L1 dermatomes.
2. Vagina and pelvic outlet: via A-delta and C fibersassin in the aras m athetic bundle in the
pudendal nerves; referred to the S2S4 dermatomes.
. ,
genitofemoral, and perforating branch of the posteriorcutaneous nerve of the thigh; somatic pain experienced
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in the L2S5 dermatomes.
Features.1Over 90% of women experience severe/unbearable labor
i lth h ll ti f d ith ti
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ppain, although recollection fades with time
2. Typically, pain is similar to other types of visceral pain, i.e.,
intermittent, severe, and colicky; it starts in the lowerabdomen and back, spreading to the perineum and thighs
(Lowe 2000).
3. Pain may be influenced by the factors already listed above,in particular by social, societal, and cultural aspects.
,
more stoic ones, leading possibly to differences in painbehavior rather than in the extent of pain felt. Fatigue and
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general debility, common in late pregnancy, may alsocontribute to the experience of labor pain.
A Understandthat labor painmayhaveadverse
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A. Understand that labor pain may have adverse
1. Respiratory: causes hyperventilation, leading tohypocapnia and respiratory acidosis.
2. Cardiovascular: increases cardiac output and bloodpressure via sympathetic activity; this may be
problematic in cardiac disease and pre-eclampsia. Increasedvenous return associated with uterinecontractions ma also contribute.
3. Neuroendocrine: increases maternal catecholaminesecretion with risk of uteroplacental
constriction.
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4 Gastrointestinal:effectof laborongastricemptyingand
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4. Gastrointestinal: effect of labor on gastric emptying and,
increased acid secretion have been suggested.
Opioids are well known to induce gastric stasis
5. Psychological: severe labor pain has been implicated in
- ,potential adverse consequenceson maternal mental health and family relationships.
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B. Understand also that pain during labor may havebenefits:
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p g ybenefits:
1. Indicates to the mother and those assistinglabor/deliver that contractions are occurrin .2. May have positive connotations regardingchildbirth, related to societal/cultural influences.
. ay n cae pro ems e.g. uer ne rupure,placental abruption).
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for listenin
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