PAIN MANAGEMENT NON INVASIVE Post partum WOMEN WITH

APPROACH Evidence BASED PRACTICE

( Non Invasive Pain Management in Post Partum Mother with

Evidence Based Practice Approach)

Nikmatur Rohmah *
* Nursing Diploma Studies Program Faculty of Health Sciences, University of Muhammadiyah Jember,
E-mail: r_nikmatur@yahoo.co.id

ABSTRACT Introduction: Pain is a sensation of discomfort that most post-partum mothers complain about, in the case of
prolonged pain, the risk of post-partum blues is higher. The usage of evidence based practice method Gives a bigger
opportunity for nurse and medical attendants to think more critically in making decisions and in performing the Appropriate
treatment in accordance with the patient's problem and uniqueness. This research Aimed to applicate management of
non-invasive pain on postpartum mother through the approach of evidence-based practice. method: This was a case-study,
performed to the client Mrs. A post sectio caesarea A0 P1-1 day 1 as there is an indication of suspect cepalo secondary pelvic
disproportion arrest. Data were collected at maternity room, dr. Soebandi Regional General Hospital. Using interviews,
observation, and physical examination. Data analysis was conducted through a descriptive analysis. Result: Through a careful
nursing, it is found out that pain location and spreading that Generally spotted at the patient's back during the contraction in
the uterus, occurred around the shoulders when evidence-base practice is applied. The basic principle of applying an
intervention to non-invasive pain -base practice based on evidence are: cutaneous stimulation and distraction, while
massaging the area was set on the face, while the distraction of media was interaction with the baby. Evaluation on evidence
-based practice Showed that pain is reduced to scale 2, while face and mobilitation Become more relaxed. Discussion: Massage
was intended to stimulated the production of endorphine and dinorphine that play an important Roke to block the pain
transmission through the descendent control system. Interaction with the baby was intended to function as a distraction media
to dominate the incoming impulses into the ascendant control system, the which may further close the gate of the pain
transmitter. Both of the interventions were axpected to work synergically in reducing pain, since post-partum pain can be
relieved more quickly intervening when more than one technique are applied. Thus, to reduce post-partum pain, facial
massage and interaction with the baby as non -invasive are of important treatments, respectively.

Keyword: the management of non-invasive pain, post-partum, evidence -based practice

PRELIMINARY mild to moderate to severe pain. Level of pain

experienced post-partum patients depending on the
N yerimerupakansensasi discomfort often
number growing source of pain, the patient's tolerance
complained of post partum mothers. Post partum
to pain, and psychological and environmental factors
pain can occur for various reasons, among others:
(Carpenito, 2000; Potter and Perry, 2006; Bobak, 2005;
uterine contractions during the period of involution of
Rohmah. N. & Walid, S. 2008) ,
the uterus, breast swelling because of lactation were
not robust, birth canal injury, and injuries to surgical
Pain affects very complex for the treatment of
incision in the mother post sectio caesarea ( SC). The
pain may be felt in varying degrees ranging from post partum mothers, among others: inhibition of early

pain mobilization, inhibition of lactation, obstruction of the

process bonding

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Nurses Journal Vol. 6 No. October 2nd, 2011: 201-209

attachment, feelings of fatigue, anxiety, disappointment MATERIALS AND METHODS

because of the inconvenience, disruption of sleep
This study design using case studies
patterns, and even if prolonged pain will increase the risk
conducted with approach
of post partum blues.
evidence-based practice. The measures used in this
These negative impacts if not addressed will affect the
approach is the identification of the facts ( evidence) necessary,
recovery process post partum mothers. Maternal
assess the need for changes in service practice, see
postpartum pain especially felt on the first day and the
and evaluate the facts through the literature and the
second, in which the mother psychological adaptation
results of related research, decide and design a
phase entry on stage
strategic plan, implementation, and evaluation.
taking in namely stage dependent. This stage mom
Upbringing given to the client Mrs. A. P1-1 A0 posts SC
still needs help to meet the daily needs with the
day to 1 on indication cepalo suspect secondary
largest share of the fulfillment of rest / sleep and
pelvic disproportion arrest. Points of data retrieval in
nutrition. When pain occurs in this phase can not be
content space dr. Soebandi Jember. Time used to
resolved then it will prolong the phase
provide care is four days. The variables studied in
this care is massage on the face and the interaction
taking in and process dependent-independent
with the infant postpartum pain. Techniques of
manjadi client inhibited (Bobak, 2005).
collecting data through interviews, observation, and
Without seeing the cause and regardless of
physical examination. The instrument used is the
the level, pain is one of the nursing problems that
format of the assessment ( post partum), nursing
must be addressed by nurses. Techniques to reduce
diagnosis, planning, implementation, and evaluation.
pain non-invasive has now been developed, but there
Data were analyzed using descriptive analysis.
are no reports describing techniques which are
Search strategy articles via
recommended for use on post partum pain. Some
techniques that can be used include rhythmic
breathing techniques, distraction techniques, and
cutaneous stimulation techniques. Each has
advantages and disadvantages. Election study
PubMed, PubMed home, and PMC. Keywords are selected
techniques to reduce pain is still likely to depend
based on the analysis of PICO covering P: pain / tenderness, obstetric,
absolutely on a general standard plan, so that the
surgical / surgical, acute care, I: massage, pain management, C:
uniqueness of the individual often be overlooked.
Use of the method
distraction / distraction, mobilization / mobilization; O: comfort. Article
screening process carried out through two phases, among
others: screening of articles worth reading and interpretation of
the results of the article.
evidence-based practice more offered an opportunity
for nurses to think critically in order to make
decisions and take appropriate action in accordance
with the patient's problem and uniqueness. Evidence-based RESULTS

practice applied to non-invasive pain management in evidence-based

women post partum, diharapan can help speed up
General data Ny patients. A., 24 years, Java /
the recovery process maternal puerperal phase.
Indonesia, high school, Mrs. RT, Islam, blood type O,
(Carpenito, 2000; Potter and Perry 2006; Bobak
MRS second day. Nursing history includes the main
2005; Bekti, 2007; Rohmah. N. & Walid, S.
complaint of the patient. Right shoulder pain. Disease
History Now (RPS) kenceng-kenceng and begin to
secrete mucus and blood began Friday night, Friday
2008). The purpose of this care is to apply pain
morning and then went to the health center MRS client,
management non-invasive Maternal postpartum using
the client gets the morning update
approaches
evidence-based practice.

202
Non Invasive Pain Management Maternal post partum ( Nikmatur Rohmah)
The opening of 2 cm, Saturday morning (05:30
GMT) opening 4, at 18:00 pm, the opening 7 until
Sunday at 5:00 pm. still opening 7 cm, then refer to
hospitals. Given oxytocin drip at the hospital, waiting
for 2 hours, at 07.00 pm. VT opening remains
7, then set up the SC operation. At 09:00 pm,
conducted SC LSCS with anesthesia SAB. Out of
the operating room at 10.00 hrs., Then go to the
recovery room in the womb at 11.00 am., Therapies
that have been granted RL: D5 2: 3, cefotaxime 3 ×
1 gram, Antrain 3 × 1 amp, metergin 2 × 1 amp (IM),
18:00 hours began to tilt right-left lateral, fl atus start
at 07.00, sip start at 10.00 am, at this time the right
shoulder pain, with a scale of 6, a sense of fatigue,
though not moving, abdominal pain, only scar feels a
little "nyekit" when used to move, that silence does
not feel pain.
The assessment results show a pattern
patterns health function of nutrition before birth, the
patient eats 3 × day rice, side dishes, fish, vegetables,
fruits, drinking ± 1,500 cc / day. When this did not feel
hungry, but thirsty, already drinking Pocari Sweat 350
cc. Current activity pattern mica-miki is not how sick.
Dependence scale show bath 5, eat
5, 5 toileting, dressing 4, instrumental 2. showing the
current pattern of elimination catheterized ± 200 cc /
5 hours, yellow, clear. Patterns of self-concept client
states are ready to be a mother, and excited
because the child is born, there is no desire extreme
to the sex of the child is born, klein not feel changes
in shape after giving birth is something that should
make it a shame, client planned to care for their own
children and ready to breastfeed her baby. But the
client also states that have yet to get information and
do not have experience in bathing babies, taking
care of the umbilical cord, the baby suckle, exclusive
breastfeeding, never read the magazine but do not
understand.
Sexual and reproductive patterns show sexual
intercourse before pregnancy routine every day, for
pregnant 3 times a week,
203
postpartum clients do not yet know when it will start a
relationship, "said the man when a new operation may
touch after 6 months." History of contraception and
menstruation, menstrual married first time, in June 2007,
had never used contraceptives of any kind, is not
currently know want to come KB what?, because it has
not been informed about family planning. Menstrual
history of patients 13 years of age of menarche, irregular
menstrual cycle, 28 days, the duration of 7 days, dismenorhoe
mild, sometimes fl uor albus, but in few, no smell, no
itching. History of pregnancy and childbirth now check
patient to PKM regularly every month, drinking
frenamin start gestational age 4 months to 8 months,
TT 2 times the age of 1 and 2 months of pregnancy,
vomiting, nausea in pregnancy 6-7 months, and
frequent urination in pregnancy 8-9 months. Labor
history has now been done LSCS with SAB, a baby
boy born US 7-8 3500 BB salt, PB 49 cm.
The results of physical examination which
includes a good general state of consciousness compost
mentis, cooperative. Tension 110/80 mm Hg, pulse 84 × /
min, temperature: 36.6 ° C, RR 20 × / min, TB 150 cm,
weight 52 kg. Face less relaxed, young red conjunctiva,
sclera white, slightly dry mouth and lips, nose cleaner, ear
cleaner, no enlargement of the thyroid gland. Chest:
symmetrical breasts, flabby, protruding nipples, colostrum
out, areola hyperpigmentation, striae gravidarum minimal.
abdomen soepel, slightly convex, closed wound bandages,
bowel 2 × / min, faint, good turgor, TFU 1 finger under the
center, strong contractions, striae minimal. Diatasis rectus
abdominis
0.5 cm wide, 1 cm long. Genitalia: catheterized, lokhea
rubra, ± 150 cc / 24 hours, perineum intact, no haemorroid.
Extremity: a drip attached right hand, muscle strength
5, changing the position carefully, wake from sleep is
not relaxed, looked stiff sitting, walking is not relaxed.
Homan
sign ( -), edema, and varicose veins are not found.
Investigations: Hb: 10.8 g%, Leukocyte: 14200, PCV: 32
gr. Therapy: cefotaxime 3 × 1 g IV, Antrain 3 × 1 ampoule
IV, RL 20 TPM
Nurses Journal Vol. 6 No. October 2nd, 2011: 201-209
Identify needs
The needs of patients who need to receive
nursing care based evidence based which have been
collected include acute pain mild associated with
tissue trauma dd's right shoulder rather painful
surgical wound nyekit that is used to move, the risk
of fluid volume deficiency syndrome lack of self care,
lack of knowledge on exclusive breastfeeding were
associated with no experience and information, start
determination of the adaptation process of lactation,
the preparation of a progressive in planning KB, the
possibility of infection, integrating the role of dreams
with actual role to be a mother, a lack of knowledge
about sexual intercourse after childbirth, started
growing confidence in the skills of caring for a baby,
start attainment mentoring during childbirth, start
attainment role father, started the integration of the
baby in the family, effective thermoregulation
(infants), intake of adequate nutrition (baby),
effective breastfeeding (baby).
Priority needs to be met is pain. Some basic
considerations for the entry of pain to be a priority
among other comforts are basic needs that fi
siologis, the fulfillment of which is good not only can
reduce, decrease, or eliminate the pain, but also
increase the mobilization earlier, helping clients to
work early, shortening the period of hospitalization
and reduce maintenance costs, pain that can not be
overcome or controlled in the mother post partum
may cause fatigue, anxiety and perception of pain
worse, so that early mobilization impeded,
obstructed lactation, process bonding attacmant hampered, the screening conducted at the level eviden degree
disappointed for the inconvenience, disruption of
sleep patterns, and even if prolonged pain will
increase the risk of postpartum blues (Hamilton
1998: Carpenito, 2000; Bobak 2005; Potter and
Perry, 2006; Rocmat, 2008).
Basic planning and critical thinking in decision
making
Post partum pain is pain felt like menstrual
cramps when the uterus
to contract after delivery (Bobak, 2005). Besides
pain postpartum also mean an unpleasant feeling
that is a self-defense mechanism of various causes
and can be manifested in the physical and
behavioral response that is felt by the mother after
childbirth (Rohmah and Walid,
2008). The cause of post partum pain, among others afterbirth,
episiotomy, perineal laceration, enlargement ( engorgement)
breasts, and surgical incision in patients post SC (Bobak,
2005; Rohmah, and Walid, 2008).
Post partum pain interventions can be done
through a warm compress, distraction, guided
imagery, terapiutik touch or massage, interaction with
the baby (Hamilton, 1998: Carpenito, 2000; Bobak,
2005; Potter and Perry, 2006; Rocmat, 2008).
Results penulusuran library through manual
and electronic journals obtained three articles among
others The Effects of Massage Therapy on Pain
Management in the Acute Care Setting by Adams,
White, and Beckett (2010), Effectiveness of visual
distraction and slow breathing rhythm in Lowering
Pain Due Injection by Rohmah (2007), and Pain by
Rochmat (2008). The assessment worth reading
each article carried on the clarity of the abstract,
introduction, methods, results, discussion, and
referansi. The third article shows kindness in his
writing. Furthermore, the interpretation of the three
articles, which include third-degree eviden of the
article? how the study was conducted? what are the
results? whether the results are valid within and
outside the framework of research ?, and the
consistency of the results. Based on the results of
2b ( evidence derived from at least a quasi
experimental study), whereas the results of research
menunujukkan consistent finding that massage and
techniques non-invasive can be used for post-surgical
pain memanagemen including post-surgical obstetric
cases. The results also allow for applied research in
place.
Explanation of the results of these studies are
as follows: Adams, White, and Beckett (2010)
concluded that massage
204
Non Invasive Pain Management Maternal post partum ( Nikmatur Rohmah)
can reduce the pain of the average level
5.18 (on a scale of 0-1 pain VAS) to 2.33 with value p
< 0.001. In this study using 65 samples and 26 of
them are from obstetric units.
Rochmat 2008 stated that although the
available medications are effective, but the
post-surgical pain can not be treated properly,
approximately 50% of patients still experience pain.
Action non-invasive should first be done without or with
pharmacological action, because of loss of post
partum pain can be accelerated if using more than
one technique (Hamilton, 1998; Bobak, 2005;
Rochmat, 2008).
Research on differences in the expression of
pain in women and men showed no difference, but
women prefer to communicate pain compared to
men (Rochmat,
2008) .Penelitian about distraction proved to be an
effective strategy to reduce pain (Rochmat, 2008).
These results differ from Rohmah study (2007)
which states that the slow breathing rhythm is more
effective than distraction in reducing pain.
Transcutaneous stimulation technique was
reported by 50% of the patients report decreased
pain (Rochmat, 2008). While Doenges and
Moorhouse (2001) and Bobak (2005) states that
cutaneous stimulation techniques are used to reduce
post-partum pain is a back rub. Early mobilization,
changes in patient positioning, mounting
wash cloth cold on the face and back massage with lotion
Refreshing can be very helpful in relieving
postoperative temporary inconvenience SC and
improve the effectiveness of medications (Rochmat
2008; Bobak, 2005).
See the study of theory and research results have been
reviewed and based on evidence based
found can be applied to the two non-invasive pain management
techniques that massage and interaction with the baby. Massage
will be performed on the face and shoulders 1 times / day.
Interaction mothers with babies will be done as soon as possible
after the mother and the baby is ready to accept the presence
205
baby's condition there are no contraindications to do rooming-in.
Implementation
Massase
A necessary tool among others in doing
Massase are leaflets, oil taste ( baby oil).
Preparation of the patient and family are the
first in which patients and families informed about the
actions to be undertaken include: purpose, benefits,
willingness family (husband) to be actively involved in
the implementation of the action. After approving the
patient and family to do the demonstration stage by
stage. Then the patient's family do redemonstrasi.
Implementation conducted on Tuesday, April
22, 2008 at 09.30 am the first step is to place both
thumbs to the position facing each other between the
two eyebrows of the patient, the second step of
doing massage gently outwards until at the temples,
apply pressure to the temple, do as much as 3 -5
times, the third step is to press lightly (can be
tailored to the patient's condition) on the bone at the
base of the nose. Press 3-5 ×, then massage
throughout os nasal the right and left until os
zigomaticus, do 3-5 times the next step memasase
mandible area 3-5 times, then give a rather strong
pressure around the top of the head, ending with the
pressure on the back of the head, do as much as 3-5
times and the massage last step is done on the
upper back, which ended with the pressure on the
shoulders, do as much as 3-5 times.
Interaction with baby
Implementation of mother-infant interaction
conducted on Tuesday, April 22, 2008 hours 10:45
pm. First make approval and preparation of mothers
and fathers to do rooming, and the family agreed.
Then collaboration with perinatology room for
rooming: babies do rooming. Furthermore, do
rooming,
Nurses Journal Vol. 6 No. October 2nd, 2011: 201-209
observe the process of integration infant in the family,
teaching mothers how to suckle properly. Mothers
capable suckle properly, the baby sucking strong, and
fast asleep after sucking.
Evaluation
Evaluations were conducted on Tuesday, April
22, 2008, 14:00 pm there is a result that the
subjective data of patients saying "Pain scale 2".
While the objective data showing the face of relaxed
enough, the movement is still cautious, TFU two
fingers below the center, powerful UC, BP ​110/80
mmHg pulse 80x / minute, RR 22 × / minute,
temperature 36.3 ° C, BU (+) 12 × / min, smiling while
receiving his presence, receiving a baby happily as
do rooming, eye contact with the baby, touching the
baby's face, smiling as the baby sucking, breast
softening after disusukan, breast milk colostrum out,
the baby can suck effectively. Analysis of acute pain
is resolved. Planning RT terminated.
DISCUSSION
evidence-based in the case in accordance
with the theory include: posture is maintained,
careful movements, and facial expressions tense.
Meanwhile, blood pressure, pulse, respiration
unchanged, diaphoresis does not occur. Location
and wide spread pain generally occurs when uterine
contractions and felt in the back, but at evidence
based felt in the shoulder, it is suspected because of
the post-surgical immobility. Post-surgical immobility
may be brief, but at
evidence-based be a history of labor more than 24
hours. The position of the body during the period of
pre-surgery who are experiencing pain in a weight
scale (his opening) generally also in a position to be
maintained (rigid), this may have an impact on the
mobilization of the pre and post-surgical (Bobak,
2005; Rochmat, 2008). Post partum mothers with a
history of prolonged labor cause prolonged pain. The
sensation of pain cause a person to reduce or even
206
stop activism fi bag. Other factors that also increase
barriers to labor mobilization is to act
sectio caesarea. other impacts post sectio caesarea in
a state of pain, then reduce mobilization, will lead to
decreased blood circulation, and this will be a trigger
for increased sensation of pain. The higher the
perceived pain patients tend to further lower its
activity, so that the blood circulation will be
decreased again. This condition is a cyclical circle
that one causes the other.
Needs change priority evidence based is pain.
Pain that can not be addressed or controlled in the
mother post partum may cause fatigue, anxiety and
perception of pain worse, so that early mobilization
impeded, obstructed lactation, process bonding
attachment
hampered, disappointed for the inconvenience,
disruption of sleep patterns, and even if prolonged
pain will increase the risk of post partum blues ( Bobak,
2005). Other requirements include the need for fluids
and nutrition, personal care, preparation for running a
mother-father role, and the need to learn about
breastfeeding, breastfeeding, family planning,
post-natal sexual, personal care and baby. This
change needs in accordance with the concept of post
partum maternal care that emphasizes the physical to
the psychological recovery, improve maternal care for
themselves, and increase the mother's ability to care
for baby. In addition nurses is expected to be set up
over the responsibilities of the nurse in the family, so
the nurse's role here is not only providers but rather
the teachers, encouragement and support.
intervention pain non-invasive is set to a
massage on the face and shoulder as well as
interaction with the baby. Massage aims to stimulate
the production of endhorpin and dinorpin which
serves to block the transmission of pain through control
system descending. While interacting with the media
distraction baby who intends to dominate the
incoming impulses in system
Non Invasive Pain Management Maternal post partum ( Nikmatur Rohmah)
control ascending so as to close the gate conductor pain.
Two of these interventions is expected to synergistically
reduce pain, for pain relief post partum can be
accelerated if using more than one technique (Hamilton
1998: Carpenito, 2000; Bobak 2005; Potter and Perry,
2006; Rochmat, 2008; Adams, White, and Beckett
2010). The principle of the implementation of pain
management in e vidence based in accordance with the
theoretical concept namely the principles of cutaneous
stimulation and distraction (Carpenito, 2000; Potter and
Perry, 2006; Adams, White, and Beckett, 2010). but in evidence the trust will help minimize loneliness and fear, which
based there is a difference in the massage area and a
media distraction. Area massage is selected on the face
and shoulders with the consideration that pain mapping
areas 1, 2, 3, 4, and 5. Area 1 and 2 is the area of ​the
face which is an area that is always under stress at the
time the pain lasted, by doing massage in this area
expected to be relaxed so that the cycle can break the
chain of fear-tension-pain. While the area 3,4,5
PAIN
MASSAGE
stimulation of production endogenous
opiate in control system
descending
Release serotonin, endorphin,
dinorphin in dorsal
spinal cord
Lowering response in the
brain, spinal cord
Blocks the transmission of pain
Figure 1. Pataho fi siological pathway Non-invasive pain interventions (Carpenito,
2000; Hamilton, 2001; and Bobak 2005; Potter & Perry, 2006; Rocmat R. 2008)
207
is the area complained of a painful area. (Hamilton,
1998; Bobak, 2005; Strong, et al,
2002). Media distraction that is used is the
interaction with babies, this media has many
benefits, in addition to divert attention from the pain
center of the media can also be used to improve the
bonding attachment formation.
Pain and discomfort in general will always be
there, but the presence of loved ones, the closest,
can affect the perception of pain (Carpenito, 2000).
Someone who focus on pain can influence the
perception of pain. The increased attention to the
pain will increase the pain. Efforts diversion
(distraction) can reduce pain response.
Interaction with a baby is a medium
bonding. bonding defined as a first mutual interest
between individuals, such as those between parents
and children, when
INTERACTION WITH BABY
effects of distraction
The focus of attention moved to baby
Incoming impulses dominated by
A beta fibers
Closing the defense mechanism
Pain impulses inhibited
pain decreased
Nurses Journal Vol. 6 No. October 2nd, 2011: 201-209
Figure 2. Mapping the area of ​pain (Strong, et al.,
2002)
The first time they met. attachments
occurs at critical periods such as at birth (Bobak,
2005). It describes a feeling of mutual love or loyalty
that binds individuals to other individuals who are
unique, specifically, and last a long time. The
process is described as affectionate as something
linear, starting with pregnant women, became
stronger in the post-partum period, and once formed
will be constant and consistent. This bond is very
important for physical and mental health throughout
the life span.
CONCLUSIONS AND RECOMMENDATIONS
Conclusions
evidence-based in the case in accordance
with the theory, among others posture is maintained,
careful movements, and facial expressions tense.
Meanwhile, blood pressure, pulse, respiration
unchanged, diaphoresis does not occur. Location
and wide spread pain generally occurs when uterine
contractions and felt in the back, but at evidence
based felt in the shoulder, the need for change
priority evidence based is pain, pain intervention non-invasive
defined by
evidence based are massage on the face and shoulders with
consideration of mapping the area of ​pain as well as interaction with
the baby, the principle of implementation
208
pain management evidence based in accordance with the
theoretical concept namely the principles of cutaneous
stimulation and distraction. but in evidence based there is a
difference in the massage area and a media distraction. Area
massage is selected on the face and used the media
distraction is the interaction with the baby, Evaluation
evidence based found that the pain can be reduced
to a scale of 2, face and mobilization became more
relaxed.
Suggestion
Need to do more research on mother-infant
interaction effect against post partum pain relief,
need to do research on pain due to post-surgical
pain sensation with an indication of the general
surgery by mapping the area of ​pain
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