蛛网膜下腔阻滞加硬膜外阻滞对母儿预后及分娩方式的影响

Effect of different analgesia on pain relief during labor

目的探讨蛛网膜下腔阻滞(腰麻)加硬膜外阻滞及连续硬膜外阻滞在分娩镇痛过程中对产妇分娩方式及母儿合并症的影响。方法采用回顾性方法,将2001年8月至2004年10月施行分娩镇痛的2593例产妇,分为腰麻加硬膜外阻滞(联合麻醉组)1482例,硬膜外阻滞组1111例;未施行分娩镇痛的4078例产妇为对照组。比较3组产妇在分娩方式、母儿合并症方面的差异。结果(1)分娩方式比较:①剖宫产:联合麻醉组为423例(28.5%),硬膜外阻滞组为351例(31.6%),对照组为1847例(45.3%),3组间相互比较,差异有统计学意义(P<0.01);②产钳助产:联合麻醉组为231例(15.6%),硬膜外阻滞组为207例(18.9%),对照组为357例(8.8%),联合麻醉组及硬膜外阻滞组与对照组比较,差异有统计学意义(P<0.01);③阴道顺产:联合麻醉组为828例(55.9%),硬膜外阻滞组为553例(49.8%),对照组为1874例(46.0%),3组间相互比较,差异有统计学意义(P<0.01)。(2)母儿合并症比较:①胎儿窘迫、活跃期停滞、活跃期延长、第二产程延长发生率比较:联合麻醉组分别为33.7%(499/1482)、17.3%(256/1482)、1.8%(27/1482)、6.1%(91/1482),硬膜外阻滞组分别为29.8%(331/1111)、18.1%(201/1111)、1.7%(19/1111)、5.4%(60/1111),对照组分别为28.5%(1163/4078)、8.3%(337/4078)、0.8%(34/4078)、3.0%(124/4078),联合麻醉组及硬膜外阻滞组的母儿合并症发生率均高于对照组,两者比较,差异有统计学意义(P<0.01)。②产后出血及新生儿窒息的发生率比较:联合麻醉组分别为4.3%(63/1482)、1.0%(15/1482),硬膜外阻滞组分别为4.1%(45/1111)、0.8%(9/1111),对照组分别为3.9%(159/4078)、1.4%(56/4078),联合麻醉组及硬膜外阻滞组产后出血及新生儿窒息的发生率与对照组比较,差异无统计学意义(P>0.05)。结论产程中对产妇实施腰麻加硬膜外阻滞镇痛,可降低剖宫产率,但增加产钳助产率。分娩镇痛与发生活跃期停滞、活跃期延长、第二产程延长有关,但不增加产后出血及新生儿窒息的发生率。

Objective To evaluate the effect of spinal-epidural and epidural anesthesia for pain relief in labor. Methods Totally 6671 cases selected from pregnant women delivered from Aug. 2001 to Oct. 2004 in our hospital were reviewed retrospectively. All cases were divided into three groups,1482 cases in spinal-epidural group (combined epidural) and 1111 in epidural group (epidural) who received pain relief during labor; 4078 as control group without any pain relief during labor. Delivery method and maternal, fetal complications among three groups were compared. Results (1) Delivery methods were significantly different (P<0.01) among the three groups. The cesarean section (CS) rate in combined epidural was 423(28.5%); in epidural: 351 (31.6%); and in control, 1847(45.3%). The forceps delivery rate was 231(15.6%), 207(18.9%) and 357(8.8%) in combined epidural, epidural and control, respectively, demonstrating significant difference (P<0.01) among three groups. There was significant difference among spinal epidural 828 (55.9%) vs epidural 553 (49.8%) vs control 1874 (46.0%) in the rate of normal delivery. (2) Maternal and fetal complication existed significant difference (P<0.01) among combined epidural, epidural vs control in the rate of fetal distress 33.7%(499/1482), 29.8%(331/1111), 28.5%(1163/4078), arrested active phase 17.3%(256/1482), 18.1%(201/1111), 8.3%(337/4078), prolonged active phase 1.8%(27/1482), 1.7%(19/1111), 0.8%(34/4078), and prolonged second stage 6.1%(91/1482), 5.4%(60/1111), 3.0%(124/4078). While no difference (P>0.05) in postpartum hemorrhage and neonatal asphyxia between spinal epidural 4.3%(63/1482) 1.0%(15/1482), epidural 4.1%(45/1111),0.8%(9/1111), and control 3.9%(159/4078), 1.4%(56/4078). Conclusions Anesthetic pain relief in labor may reduce the CS rate, but increase the rate of forceps delivery. Pain relief is associated with arrested and prolonged active phase, prolonged second stage. However, pain relief in labor doesnot enhance the rate of postpartum hemorrhage and neonatal asphyxia.