引导硬膜外分娩镇痛产妇卧位调节对胎儿枕后位影响的研究

Study on the influence of the supine adjustment on the posterior position of the fetal occipital position in the parturient with epidural analgesia

目的探讨分娩时行硬膜外分娩镇痛后卧位调节对产妇胎儿枕后位的影响。方法选取2015年10月至2016年10月在大连市妇产医院分娩的单胎初产妇，宫口开3em自愿行分娩镇痛，且阴道内诊检查为胎儿枕后位的产妇600例。行硬膜外分娩镇痛后15min时视觉模拟评分法（VAS）疼痛评分在3分以下视为有效。按照随机数字表法随机分为对照组和观察组各300例。对照组按产程常规处理，监测产妇呼吸、脉搏、血压、心率、胎心率。观察组除按产程常规处理外，在宫口开5cm后指导产妇取侧俯卧位，使母体与胎儿的脊柱同侧，宫口开全后指导产妇屏气用力，直至分娩。观察2组的阴道自然分娩率、助产率、剖宫产率、胎位转复成功率、产程时间和新生儿Apgar评分的差异。结果观察组的胎方位转复成功率、自然分娩率、助产率和剖宫产率分别为74．6％（211／283）、87．3％（262／300）、7．0％（21／300）、5．7％（17／300），对照组分别为45．9％（118／257）、64．7％（194／300）、21．0％（63／300）、14．3％（43／300），2组比较差异有统计学意义（χ2=12．519～62．782，P〈0．01），观察组自然分娩率高于对照组，助产率和剖宫产率较对照组显著下降。观察组第二产程时间为（1．60±0．56）h，对照组为（2．19±0．53）h，2组比较差异有统计学意义（t=-12．589，P〈0．01）。观察组在宫口开8～10cm及开全后，枕后位自动转成枕横位的比例分别为7．4％（21／283）、13．1％（37／283），对照组分别为3．4％（9／264）、6．8％（18／264），差异有统计学意义（r=4．240、5．911，P〈0．05），有利于手转胎头时减少转动的角度，减少母婴损伤。结论通过宫口开5cm后卧位指导更有利于胎位旋转、纠正，同时镇痛分娩减轻了产妇疼痛，产妇能够清醒地配合指导，避免了不良反应，降低了阴道助产率及剖宫产率，提高自然分娩率，缩短分娩时间，提高分娩质量。

Objective To investigate the effect of supine regulating on maternal fetal occiput posterior position during the delivery after epidural analgesia. Methods Totally600 cases of parturient with intravaginal posterior occipital position with 3cm voluntary labor analgesia were selected,who were born in Dalian maternity hospital from October 2015 to October 2016.The （Visual Analogue Scale/Score） VAS pain score at 15rain after epidural labor analgesia was as effective as less than 3 points. They were randomly divided into the control group and the observation group by random number table method, with 300 cases in each group.The control group monitored parturient respiration, pulse, blood pressure, heart rate and fetal heart rate according to routine treatment.The control group monitored parturient respiration, pulse, blood pressure, heart rate and fetal heart rate according to routine treatment.In the observation group, except for routine treatment according to the labor process, after the opening of 5cm, the pregnantwomen were instructed to take the lateral prone position, so that the maternal side and the fetal side of the spinal column should be the same side. To observe the difference between the two groups in the rate of spontaneous vaginal delivery, delivery rate, cesarean section rate, fetal cardioversion rate, time of birth process and neonatal Apgar score. Results Totally 283 cases delivery through vagina and 17 cases of cesarean section in observation group, while 257 cases of vaginal delivery and 43 cases of cesarean section in the control group.The successful rate of fetal position transfer in the observation group was 74.6% （211/ 283） which was significantly higher than 45.9% （118/257） of the control group （χ2=62.782, P〈0.01）, natural labor rate was also 87.3% （262/300） which increased significantly according to 64.7% （194/300） （χ2=42.251, P〈0.01）,the rate of midwifery （7.0%, 21/300） and cesarean section （5.7%, 17/300） were significantly lower than 21.0% （63/300）and 14.3% （43/300） of the control group （χ2=24.419, 12.519,P〈 0.01）, the second stage of labor was （1.60±0.56） h which was significantly shortened than （2.19±0.53） h also（t=- 12.589,P〈0.01）.In the observation group, the ratio of the posterior occipital position to the occipital transverse position after the opening of 8-10 cm and the complete dilation of the cervical were 7.4% （21/283） and 13.1% （37/283）, which were also significantly increased than 3.4% （9/264）, 6.8% （18/ 264） of the control group （χ2=4.240, 5.911, P〈0.05）. Conclusions Supine adjustment after the cervix dilatation larger than 5cm is more conducive to fetal rotation and to avoid the adverse complications, reduce the rate of vaginal delivery and cesarean section rate, improve the rate of natural childbirth, shorten delivery time, improve the quality of delivery.