腰-硬联合与硬膜外阻滞分娩镇痛对初产妇产程及母婴安全性的影响

Effects of combined spinal-epidural and epidural labor analgesia techniques on maternal and infant safety in Primipara

目的比较腰-硬联合阻滞和硬膜外阻滞行分娩镇痛的临床效果及其对产妇产程、产前发热率、胎心变异率的影响。方法足月、单胎、头位初产妇628例,随机分为2组:腰-硬联合自控镇痛组(S组)、硬膜外自控镇痛组(E组)。另设未行镇痛168例为对照组(D组)。S组:L3-4椎间隙穿刺,蛛网膜下腔注入舒芬太尼4 μg,硬膜外置管持续泵注0.125%罗哌卡因+舒芬太尼0.2 μg/mL。D组:L2-3椎间隙穿刺置管,分次注入0.08%罗哌卡因+舒芬太尼0.5 μg/mL 5 mL试验剂量及10 mL首剂量,随后持续泵注上述药物。观察各组镇痛起效时间、镇痛效果、各产程时间以及产前发热率、胎心变异率、新生儿Apgar评分以及瘙痒等相关不良反应发生率。结果 S组、E组VAS评分均≤3分,镇痛起效时间S组显著快于E组( P <0.05);与D组相比,S组、E组第一产程时间缩短,第二产程时间明显延长( P <0.05),但第三产程时间3组比较差异无统计学意义;与D组相比,S组、E组产前发热率、胎心变异率以及瘙痒发生率显著增加( P <0.05),且S组发生率要明显高于E组( P <0.05),新生儿Apgar评分比较差异无统计学意义( P >0.05);3组相比,患者恶心呕吐、低血压、呼吸抑制发生率差异无统计学意义。结论腰-硬联合阻滞与硬膜外阻滞对于初产妇均为行之有效的镇痛方式,腰-硬联合阻滞相比硬膜外阻滞,镇痛起效迅速,但产妇发热率、胎心变异率及瘙痒的发生率明显增加。

Objective To compare the analgesic effects of combined spinal-epidural anesthesia and epidural anesthesia, and their impacts on duration of labor, prenatal fever rate and fetal heart rate variability. Methods Six hundred and twenty-eight full-term nulliparous parturients were randomly assigned to receive combined spinal-epidural analgesia(group S) or epidural analgesia(group E) for labor analgesia with three hundred and forteen cases each.Another one hundred and sixty-eight nulliparous parturients without labor analgesia were taken as the controls group (group D). Group S:sufentanil 4 μg was injected intrathecally followed by epidural catheter placing at L3-4, patient controlled epidural infusion of 0.125% ropivacaine plus sufentanil 0.2 μg/mL was administered.Group E:Epidural catheter was placed at L2-3 interspace, 0.08 ropivacaine plus 0.5 μg/mL sufentanil was administered,which was followed by additional 10 mL injection. Patient controlled epidural infusion of 0.08% ropivacaine plus 0.5 μg/mL sufentanil was administered. Time of taking effect, pain scores, duration of each stage, incidence of prenatal fever rate, fetal heart rate variability, neonatal Apgar score, pruritus and other adverse effects were measured. Results VAS score of both group S and E were ≤3 points, time of taking effect of group S was significantly faster than the group E ( P <0.05). Compared with group D, the duration of group S and E was shorter in first stage and significantly extended in second stage ( P <0.05), however, there was significant difference among the three groups about the duration of the third stage. Compared with group D, the incidence of prenatal fever, fetal heart rate variability and pruritus were significant incresaed in both group S and E ( P <0.05), further more the incidence in group S was higher than group E ( P <0.05). However, there was no significant difference among three groups in neonatal Appar score and the incidence of nausea, vomiting, hypotension and respiratory depression( P >0.05). Conclusion Both combined spinal-epidural anesthesia and epidural anesthesia were effective labor analgesic techniques. Comparing with epidural anesthesia, combined spinal-epidural anesthesia has a shorter onset time and higher incidence of prenatal fever rate, fetal heart rate variability and pruritus.