孫星峰， 田復(fù)波， 黃紹強(qiáng)， 耿桂啟

復(fù)旦大學(xué)附屬婦產(chǎn)科醫(yī)院麻醉科，上海 200090

·短篇論著·

椎管內(nèi)阻滯分娩鎮(zhèn)痛時(shí)產(chǎn)婦宮縮疼痛程度對(duì)剖宮產(chǎn)率的影響

孫星峰， 田復(fù)波， 黃紹強(qiáng)*， 耿桂啟

復(fù)旦大學(xué)附屬婦產(chǎn)科醫(yī)院麻醉科，上海 200090

目的： 探討椎管內(nèi)阻滯用于分娩鎮(zhèn)痛時(shí)產(chǎn)婦宮縮疼痛程度對(duì)剖宮產(chǎn)率的影響。方法： 選擇單胎、頭位、宮口<4 cm，無產(chǎn)科并發(fā)癥產(chǎn)婦590例，根據(jù)數(shù)字評(píng)分量表(NRS)評(píng)分，將其分為3組：L(1～4分)組、M(5～7分)和H(8～10分)組。產(chǎn)婦均于腰2～3或腰3～4間隙進(jìn)行硬膜外穿刺。行硬膜外鎮(zhèn)痛者硬膜外腔給予實(shí)驗(yàn)劑量1.0%碳酸利多卡因5 mL，待阻滯平面出現(xiàn)后給予負(fù)荷劑量0.1%羅哌卡因復(fù)合5 μg舒芬太尼混合液10 mL，觀察30 min無不良反應(yīng)后連接患者自控硬膜外鎮(zhèn)痛泵(PCEA)。行CSEA鎮(zhèn)痛者硬膜外穿刺成功后蛛網(wǎng)膜下隙注入0.1%羅哌卡因復(fù)合3 μg舒芬太尼混合液3 mL，90 min后連接PCEA。觀察并記錄行鎮(zhèn)痛前產(chǎn)婦的NRS評(píng)分；第一產(chǎn)程時(shí)間、第二產(chǎn)程時(shí)間和分娩方式。結(jié)果： 3組間鎮(zhèn)痛后30 min NRS評(píng)分、宮口大小、第一產(chǎn)程時(shí)間、第二產(chǎn)程時(shí)間組間比較差異無統(tǒng)計(jì)學(xué)意義；3組間產(chǎn)鉗助產(chǎn)率和剖宮產(chǎn)率比較差異無統(tǒng)計(jì)學(xué)意義。結(jié)論： 椎管內(nèi)阻滯分娩鎮(zhèn)痛時(shí)產(chǎn)婦的宮縮疼痛程度對(duì)剖宮產(chǎn)率無明顯影響。

硬膜外，脊髓；分娩鎮(zhèn)痛；剖宮產(chǎn)率；剖宮產(chǎn)術(shù)

分娩過程中的疼痛程度被認(rèn)為與產(chǎn)程的延長(zhǎng)和剖宮產(chǎn)率的增加有關(guān)。分娩疼痛程度因個(gè)體的身體狀況、精神狀態(tài)和產(chǎn)程中宮頸的擴(kuò)張程度不同而不同。目前對(duì)于分娩鎮(zhèn)痛前產(chǎn)婦的宮縮疼痛程度對(duì)分娩方式的影響存在不同的觀點(diǎn)，有人認(rèn)為，硬膜外阻滯(epidural analgesia, EA)分娩鎮(zhèn)痛前產(chǎn)婦的疼痛程度可影響產(chǎn)科結(jié)局[1-4]；相反的，有人認(rèn)為硬膜外阻滯實(shí)施分娩鎮(zhèn)痛前產(chǎn)婦的疼痛程度與分娩方式無關(guān)[5-7]。腰麻-硬膜外聯(lián)合阻滯(combined spinal and epidural analgesia, CSEA)用于分娩鎮(zhèn)痛雖在臨床推廣已久，但在其實(shí)施前產(chǎn)婦的宮縮疼痛程度對(duì)產(chǎn)科結(jié)局的影響尚不清楚。因此，本研究擬評(píng)價(jià)兩種椎管內(nèi)阻滯鎮(zhèn)痛方法實(shí)施前產(chǎn)婦的宮縮疼痛程度對(duì)分娩方式的影響。

1 資料與方法

1.1 病例選擇及分組 本研究經(jīng)復(fù)旦大學(xué)附屬婦產(chǎn)科醫(yī)院倫理委員會(huì)批準(zhǔn)，產(chǎn)婦均知情同意并簽署知情同意書。選擇本院2015年7月至12月收治的產(chǎn)婦590例。入選標(biāo)準(zhǔn)：年齡21～40歲、體質(zhì)指數(shù)(body mass index, BMI) 24～30 kg/m2，ASA分級(jí)Ⅰ～Ⅱ級(jí)，單胎、頭位、孕37～41周、宮口<4 cm，無產(chǎn)科合并癥及并發(fā)癥，經(jīng)產(chǎn)科醫(yī)師評(píng)價(jià)能陰道分娩者。根據(jù)產(chǎn)婦要求行分娩鎮(zhèn)痛時(shí)的數(shù)字評(píng)分量表(NRS，10 cm疼痛評(píng)分尺：0表示無痛；10表示最難以忍受的疼痛)評(píng)分，將其分為3組：L(NRS 1～4分)組、M(NRS 5～7分)和H(NRS 8～10分)組。

1.2 麻醉方法 產(chǎn)婦自愿要求行分娩鎮(zhèn)痛，胎心監(jiān)護(hù)顯示無異常，宮口<4 cm，完善監(jiān)測(cè)，開放靜脈通路。產(chǎn)婦均于腰2～3或腰3～4間隙進(jìn)行硬膜外穿刺。行EA鎮(zhèn)痛者硬膜外穿刺成功后頭向置管4 cm，給予實(shí)驗(yàn)劑量1.0%碳酸利多卡因5 mL，待阻滯平面出現(xiàn)后給予負(fù)荷劑量0.1%羅哌卡因復(fù)合5 μg舒芬太尼混合液10 mL，觀察30 min無不良反應(yīng)后連接患者自控硬膜外鎮(zhèn)痛泵(PCEA)。行CSEA鎮(zhèn)痛者硬膜外穿刺成功后運(yùn)用“針內(nèi)針”法行腰麻穿刺，蛛網(wǎng)膜下隙注入0.1%羅哌卡因復(fù)合3 μg舒芬太尼混合液3 mL，隨后硬膜外腔頭向置管4 cm，90 min后連接PCEA。PCEA方案：鎮(zhèn)痛藥配方為0.1%羅哌卡因與0.5 μg/mL舒芬太尼混合液，背景劑量6 mL/h，6 mL，鎖定時(shí)間20 min。

1.3 觀察指標(biāo) 觀察并記錄行鎮(zhèn)痛前產(chǎn)婦的NRS評(píng)分、鎮(zhèn)痛后30 min NRS評(píng)分，宮口大小，所有產(chǎn)婦的鎮(zhèn)痛前和鎮(zhèn)痛后30 min的平均動(dòng)脈壓(MAP)、心率(HR)和胎心率(FHR)，第一產(chǎn)程時(shí)間(從規(guī)律宮縮鎮(zhèn)痛開始至宮口10 cm)，第二產(chǎn)程時(shí)間(從宮口10 cm至胎兒娩出)，分娩方式(自然分娩、器械助產(chǎn)和剖宮產(chǎn))，催產(chǎn)素使用情況，發(fā)熱(≥38℃)情況；新生兒體質(zhì)量和1 min、5 min的Apgar評(píng)分。

2 結(jié) 果

2.1 一般資料 結(jié)果(表1)表明：M組6例、H組2例因社會(huì)因素行剖宮產(chǎn)手術(shù)，其數(shù)據(jù)未納入統(tǒng)計(jì)學(xué)分析。各組產(chǎn)婦一般情況比較差異無統(tǒng)計(jì)學(xué)意義。

表1 各組產(chǎn)婦一般情況比較

2.2 各組產(chǎn)婦血流動(dòng)力學(xué)結(jié)果和胎心率結(jié)果 結(jié)果(表2)表明：各組產(chǎn)婦鎮(zhèn)痛前和鎮(zhèn)痛后30 min MAP、HR和FHR組間比較差異無統(tǒng)計(jì)學(xué)意義。

表2 各組產(chǎn)婦鎮(zhèn)痛前和鎮(zhèn)痛后30 min MAP、HR及FHR的比較

1 mmHg=0.133 kPa

2.3 不同組別產(chǎn)婦產(chǎn)科過程和分娩方式的對(duì)比 結(jié)果(表3)表明：3組間鎮(zhèn)痛后30 min NRS評(píng)分、宮口大小、第一產(chǎn)程時(shí)間、第二產(chǎn)程時(shí)間、組間比較差異無統(tǒng)計(jì)學(xué)意義。3組間產(chǎn)鉗助產(chǎn)率和剖宮產(chǎn)率比較差異無統(tǒng)計(jì)學(xué)意義。多變量回歸分析顯示：催產(chǎn)素使用率、發(fā)熱發(fā)生率和鎮(zhèn)痛方法對(duì)剖宮產(chǎn)率的影響3組間比較差異無統(tǒng)計(jì)學(xué)意義。

表3 各組產(chǎn)婦分娩特征和分娩方式的比較

2.4 3組間新生兒情況的比較 結(jié)果(表4)表明：各組間新生兒體質(zhì)量、1 min和 5 min Apgar評(píng)分組間比較差異無統(tǒng)計(jì)學(xué)意義。

表4 新生兒預(yù)后情況的比較

3 討 論

既往研究[3-4]表明：行EA分娩鎮(zhèn)痛前的疼痛程度與剖宮產(chǎn)率有關(guān)，認(rèn)為疼痛程度高的產(chǎn)婦難產(chǎn)率增加，引起剖宮產(chǎn)率增高。而本研究結(jié)果顯示，行EA鎮(zhèn)痛者3組間剖宮產(chǎn)率比較差異無統(tǒng)計(jì)學(xué)意義，疼痛程度高者并未顯示難產(chǎn)率高，提示行EA分娩鎮(zhèn)痛前產(chǎn)婦的疼痛程度對(duì)分娩方式?jīng)]有影響，與Beilin等[5]報(bào)道的EA鎮(zhèn)痛前產(chǎn)婦的疼痛程度對(duì)分娩方式影響的觀察結(jié)果相似。

CSEA分娩鎮(zhèn)痛被認(rèn)為是目前鎮(zhèn)痛效果最確切的分娩鎮(zhèn)痛方法，相對(duì)于EA分娩鎮(zhèn)痛，其起效迅速，鎮(zhèn)痛效果確切，但同時(shí)使得血漿中兒茶酚胺和宮縮抑制劑水平迅速降低，導(dǎo)致子宮收縮增強(qiáng)，子宮血管阻力增加，胎兒氧供減少，引起胎心率異常發(fā)生率增加[8-10]，可能導(dǎo)致剖宮產(chǎn)率增加。但本研究結(jié)果顯示，行CSEA鎮(zhèn)痛的產(chǎn)婦中H組剖宮產(chǎn)率并不比L組和M組高，提示行CSEA分娩鎮(zhèn)痛前產(chǎn)婦的疼痛程度對(duì)分娩方式?jīng)]有影響。同時(shí)，本研究結(jié)果顯示3組剖宮產(chǎn)率均低于15%，而上述研究[4-5]各組剖宮產(chǎn)率均高于20%，提示CSEA分娩鎮(zhèn)痛相比于EA分娩鎮(zhèn)痛并不增加剖宮產(chǎn)率。另有研究[7,11]顯示，相對(duì)于EA分娩鎮(zhèn)痛，CSEA分娩鎮(zhèn)痛可縮短產(chǎn)程。

本研究結(jié)果表明：產(chǎn)婦入選時(shí)一般情況和宮口大小各組間比較差異無統(tǒng)計(jì)學(xué)意義，說明產(chǎn)婦入選條件一致，分組標(biāo)準(zhǔn)只按疼痛評(píng)分高低劃分。第一產(chǎn)程時(shí)間、第二產(chǎn)程時(shí)間和催產(chǎn)素使用率各組間比較差異無統(tǒng)計(jì)學(xué)意義。各組間新生兒比較差異無統(tǒng)計(jì)學(xué)意義，說明由新生兒因素引起的疼痛程度對(duì)各組的影響相同。因此，本研究結(jié)果基本消除了分娩過程中產(chǎn)科因素和產(chǎn)科醫(yī)生因素對(duì)分娩方式的影響。

本研究參照文獻(xiàn)[4-5]依據(jù)疼痛程度將入組產(chǎn)婦分為3組進(jìn)行研究和分析；選擇宮口<4 cm為納入標(biāo)準(zhǔn)。根據(jù)預(yù)試驗(yàn)結(jié)果，選擇本研究藥物的劑量。本研究仍有一定的局限性：僅選擇了日間行椎管內(nèi)分娩鎮(zhèn)痛的產(chǎn)婦，由于生物節(jié)律性的影響，夜間行分娩鎮(zhèn)痛的產(chǎn)婦是否是相同結(jié)果，需要進(jìn)一步研究。本研究樣本的均一性不高，有待進(jìn)一步完善。

綜上所述，本研究結(jié)果提示椎管內(nèi)阻滯用于分娩鎮(zhèn)痛時(shí)產(chǎn)婦的宮縮疼痛程度對(duì)剖宮產(chǎn)率無明顯影響。

[1] PANNI M K, SEGAL S. Local anesthetic requirements are greater in dystocia than in normal labor [J]. Anesthesiology,2003,98(4): 957-963.

[2] WUITCHIK M, BAKAL D, LIPSHITZ J. The clinical significance of pain and cognitive activity in latent labor [J].Obstet Gynecol,1989,73(1): 35-42.

[3] HESS P E, PRATT S D, SONI A K, et al. An association between severe labor pain and cesarean delivery [J].Anesth Analg,2000,90(4): 881-886.

[4] WOO J H, KIM J H, LEE G Y,et al. The degree of labor pain at the time of epidural analgesia in nulliparous women influences the obstetric outcome [J].Korean J Anesthesiol,2015, 68(3):249-253.

[5] BEILIN Y, MUNGALL D, HOSSAIN S, et al. Labor pain at the time of epidural analgesia and mode of delivery in nulliparous women presenting for an induction of labor[J].Obstet Gynecol,2009,114(4): 764-769.

[6] CHESTNUT D H, MCGRATH J M, VINCENT R D JR, et al. Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are in spontaneous labor?[J].Anesthesiology,1994,80(6):1201-1208.

[7] WONG C A, SCAVONE B M, PEACEMAN A M, et al. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor [J].N Engl J Med, 2005,352(7):655-665.

[8] HATTLER J, KLIMEK M, ROSSAINT R,et al. The effect of combined spinal-epidural versus epidural analgesia in laboring women on nonreassuring fetal heart rate tracings: systematic review and meta-analysis[J].Anesth Analg, 2016,123(4):955-964.

[9] CLARKE V T, SMILEY R M, FINSTER M. Uterine hyperactivity after intrathecal injection of fentanyl for analgesia during labor: a cause of fetal bradycardia?[J].Anesthesiology,1994, 81(4):1083.

[10] SEGAL S, CSAVOY A N, DATTA S. The tocolytic effect of catecholamines in the gravid rat uterus[J].Anesth Analg,1998,87(4):864-869.

[11] TSEN L C, THUE B, DATTA S, et al. Is combined spinal-epidural analgesia associated with more rapid cervical dilation in nulliparous patients when compared with conventional epidural analgesia?[J].Anesthesiology,1999,91(4):920-925.

[本文編輯] 廖曉瑜， 賈澤軍

Effect of the degree of labor pain at the time of intraspinal labor analgesia on the incidence of cesarean delivery

SUN Xing-feng, TIAN Fu-bo, HUANG Shao-qiang*, GENG Gui-qi

Department of Anesthesiology, the Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200090, China

Objective： To assess the degree of labor pain at the time of intraspinal labor analgesia in women influencing the incidence of cesarean delivery. Methods： Five hundred and ninety patients were enrolled in the study and divided into 3 groups in the light of numeric rating scale (NRS). The woman was with singleton pregnancies, with cervical dilatation of less than 4 cm and vertex fetal presentations. Namely, L group:1-4;M group:5-7;H group:8-10, respectively. The EA procedure was performed at the lumbar spine between 2-3 or 3-4. We inserted a catheter into the epidural space started with 1.0% carbonated Lidocaine to make the volume 5 mL. After the block plane arising, injected a mixture of 0.1% Ropivacaine co-administered with 5 μg of Sufentanil to make the total volume 10 mL in all cases, and connected the patient controlled epidueal analgesia (PCEA) thirty minutes later. The CSEA procedure was started with an intrathecal standard mixture of 0.1% Ropivacaine co-administered with 3 μg of Sufentanil to make the total volume 3 mL in all cases, then connected the PCEA ninety minutes later. To observe and record the NRS score when analgesia was performed. The time of the first stage of labor, the time of the second stage of labor and the way of delivery were recorded in our study respectively. Results： There was no statistically significant differences among the three pain groups in the NRS score after 30 min, dilatation, duration of first stage of labor and duration of second stage of labor, respectively. There was no statistically significant differences among the three pain groups in the incidence of instrumental delivery and cesarean delivery. Conclusions： There is no effect of the degree of labor pain at the time of intraspinal labor analgesia in women on the incidence of cesarean delivery.

epidural, spinal； labor analgesia；incidence of cesarean delivery； cesarean section

2017-01-10 [接受日期] 2017-05-31

孫星峰，碩士，主治醫(yī)師. E-mail: xfsunok@126.com

*通信作者(Corresponding author). Tel: 021-33189900, E-mail: timrobbins71@163.com

10.12025/j.issn.1008-6358.2017.20170032

R 614.4+1

A