阮 霞,吳正東,蔣文琛
(湖南省婦幼保健醫(yī)院麻醉手術(shù)科,湖南 長沙 410008)
不同鎮(zhèn)痛方式對(duì)子宮收縮節(jié)律性的影響
阮 霞,吳正東,蔣文琛
(湖南省婦幼保健醫(yī)院麻醉手術(shù)科,湖南 長沙 410008)
目的 研究腰麻聯(lián)合硬膜外麻醉和硬膜外麻醉這兩種鎮(zhèn)痛方式對(duì)子宮收縮節(jié)律性的影響。方法 隨機(jī)選取湖南省婦幼保健醫(yī)院2014年1月2016年10月300例分娩產(chǎn)婦,隨機(jī)分為實(shí)驗(yàn)組150例和對(duì)照組150例,在分娩過程中實(shí)驗(yàn)組行腰麻聯(lián)合硬膜外麻醉,對(duì)照組行硬膜外麻醉,并互相比較兩種鎮(zhèn)痛方法對(duì)子宮收縮時(shí)間和間隔時(shí)間的影響。結(jié)果 鎮(zhèn)痛后實(shí)驗(yàn)組和對(duì)照組產(chǎn)婦對(duì)比使用縮宮素的量及鎮(zhèn)痛起效時(shí)間、用藥量、按壓次數(shù)、Bromage評(píng)分、Apgar評(píng)分差異均無統(tǒng)計(jì)學(xué)意義(χ2/t值分別為2.04、1.67、2.45、1.85、1.35,均P>0.05);腰麻聯(lián)合硬膜外麻醉比硬膜外麻醉更能延長患者子宮收縮的持續(xù)時(shí)間和間隔時(shí)長,且其藥物起效時(shí)間也比硬膜外麻醉快很多(χ2/t值分別為2.85、10.94,均P<0.05);實(shí)驗(yàn)組產(chǎn)婦中有5例胎心早期減速,30例胎心晚期減速,對(duì)照組有6例胎心早期減速,28例胎心晚期減速,兩組之間比較無顯著性差異(χ2/t值分別為3.65、4.97,均P>0.05);據(jù)VAS評(píng)分顯示,實(shí)驗(yàn)組和對(duì)照組都能減輕產(chǎn)婦的疼痛,且實(shí)驗(yàn)組比對(duì)照組更能減輕產(chǎn)婦的疼痛(t=6.98,P<0.05)。結(jié)論 腰麻聯(lián)合硬膜外麻醉相對(duì)傳統(tǒng)的硬膜外麻醉能更好的減輕孕分娩時(shí)的劇烈疼痛,且其對(duì)子宮收縮的持續(xù)時(shí)間和間隔時(shí)長更長,可達(dá)到縮短產(chǎn)時(shí),減少剖宮產(chǎn)機(jī)率,提高順產(chǎn)機(jī)率的目的。
腰麻;硬膜外麻醉;持續(xù)時(shí)間;間隔時(shí)長
產(chǎn)婦分娩是指胎兒從母體到外界成為獨(dú)立生存為個(gè)體的過程,其中包括第一產(chǎn)程(宮口擴(kuò)張期)、第二產(chǎn)程(胎兒娩出期)、第三產(chǎn)程(胎盤娩出期),是其中絕大部分婦女一生中必須經(jīng)歷的事情,隨著現(xiàn)代麻醉學(xué)的發(fā)展,現(xiàn)代醫(yī)學(xué)可采用麻醉技術(shù)以減輕產(chǎn)婦分娩時(shí)帶來的疼痛[1]。近年來大量研究表明腰麻聯(lián)合硬膜外麻醉比傳統(tǒng)的單純的硬膜外麻醉更能減輕婦女分娩時(shí)所帶來的鎮(zhèn)痛[2]。本研究比較了腰麻聯(lián)合硬膜外麻醉和硬膜外麻醉這兩種鎮(zhèn)痛方式對(duì)子宮收縮節(jié)律性的影響,現(xiàn)報(bào)道如下。
1.1研究對(duì)象
選取湖南省婦幼保健醫(yī)院2014年1月2016年10月300例分娩產(chǎn)婦,年齡17~39歲,平均24.6±9.5歲,隨機(jī)分為實(shí)驗(yàn)組和對(duì)照組,每組各150例,收集并統(tǒng)計(jì)入選本研究的所有受試者的年齡、身高、體重、身體質(zhì)量指數(shù)(body mass index,BMI)等基本情況,排除標(biāo)準(zhǔn)年齡17~39歲之外,胎心監(jiān)護(hù)異常,有麻醉禁忌者,有服用避孕藥史,有服用激素史,早產(chǎn)或難產(chǎn)婦女。本研究已得到醫(yī)學(xué)倫理協(xié)會(huì)的同意,所有受試者均自愿參與本實(shí)驗(yàn)并簽署知情同意書。
1.2方法
1.2.1儀器與藥品
CPE-101無痛分娩泵(珠海福尼亞醫(yī)療設(shè)備有限公司),胎心監(jiān)護(hù)儀(上海醫(yī)療器械有限公司),AS-E/SⅡ和AN-E/SⅡ1.6×80/0.5×110腰麻聯(lián)合硬膜外麻醉穿刺包,EC-05400-E硬膜外麻醉包,1%耐樂品(1%鹽酸羅哌卡因,進(jìn)口藥品注冊(cè)證號(hào):H20140763,AstraZeneca,阿斯利康公司生產(chǎn)),枸櫞酸舒芬太尼注射(生產(chǎn)批號(hào):國藥準(zhǔn)字H20054256,2012-08-27),鹽酸利多卡因注射液(規(guī)格5mL:0.1g,產(chǎn)品批號(hào):6G76J2,2012-08-25)。
1.2.2麻醉方法
產(chǎn)婦進(jìn)入產(chǎn)房后吸氧,建立靜脈通路,監(jiān)測產(chǎn)婦心率、血壓、呼吸頻率、心電圖、血氧飽和度等生命體征指標(biāo),兩組產(chǎn)婦取左側(cè)臥位,均選取L3~4為穿刺間隙。實(shí)驗(yàn)組采用AS-E/SⅡ和AN-E/SⅡ1.6×80/0.5×110腰麻聯(lián)合硬膜外麻醉穿刺包(浙江伏爾特醫(yī)療器械有限公司)經(jīng)硬膜外置針插入腰麻針,在蛛網(wǎng)膜下腔注射鹽酸羅哌卡因2mg+舒芬太尼5μg,拔針,硬膜外置管往頭端置硬膜外導(dǎo)管3~5cm。對(duì)照組選擇EC-05400-E型硬膜外麻醉包(Arrow International Inc公司生產(chǎn)),于脊柱L3~4間隙行硬膜外穿刺置入導(dǎo)管3~5cm,首先注入1%鹽酸利多卡因4mL,觀察5min,如無局麻藥中毒反應(yīng)及全脊麻不良反應(yīng)等,再于硬膜外腔注入舒芬太尼30μg+0.75%鹽酸羅哌卡因(英國AstraZeneca公司生產(chǎn))10mL,加入生理鹽水混合液100mL,連接CPE-101型PCEA自控鎮(zhèn)痛泵(珠海福尼亞醫(yī)療設(shè)備公司),首次劑量為10mL,鎮(zhèn)痛泵背景量為10mL/h,bolus 5mL/20min,直至第三產(chǎn)程結(jié)束停止給藥。術(shù)后利用視覺模擬評(píng)分法(visual analogue scale,VAS)來評(píng)估分娩時(shí)的疼痛情況,利用Bromage分級(jí)法評(píng)估分娩時(shí)的運(yùn)動(dòng)阻滯的情況,利用新生兒Apgar評(píng)分來評(píng)估胎心率的變化。記錄數(shù)據(jù)(包括鎮(zhèn)痛前及給藥后l5min、0.5h、1h 產(chǎn)婦的心率、血壓、血氧飽和度、VAS評(píng)分、Bromage評(píng)分、Apgar評(píng)分、子宮收縮的持續(xù)時(shí)間和間隔時(shí)長、以及鎮(zhèn)痛起效時(shí)間、藥量、PCA使用次數(shù)等)。
1.3統(tǒng)計(jì)學(xué)方法
2.1兩組患者一般資料比較
兩組患者年齡、身高、體重、BMI等一般資料比較無顯著性差異(均P>0.05),見表1。
2.2兩組患者臨床資料比較
鎮(zhèn)痛后實(shí)驗(yàn)組和對(duì)照組產(chǎn)婦對(duì)比使用縮宮素的量及鎮(zhèn)痛起效時(shí)間、用藥量、按壓次數(shù)、Bromage評(píng)分、Apgar評(píng)分差異均無統(tǒng)計(jì)學(xué)意義(P>0.05),見表2。
項(xiàng)目實(shí)驗(yàn)組(n=150)對(duì)照組(n=150)tP年齡(歲)23.61±9.3224.11±9.121.430.89身高(cm)154.35±10.22152.41±11.391.290.91體重(kg)55.12±8.2653.98±8.422.130.56BMI(kg/m2)21.66±3.3721.21±3.131.560.78
項(xiàng)目實(shí)驗(yàn)組(n=150)對(duì)照組(n=150)χ2/tP縮宮素的量(mIU/min)16.45±2.3515.55±2.252.040.78鎮(zhèn)痛起效時(shí)間(h)1.44±0.741.5±0.61.670.87按壓次數(shù)(次/min)55.65±10.7458.15±10.932.450.63Bromage評(píng)分1~2級(jí)人數(shù)67(44.67)65(43.33)1.850.83Apgar評(píng)分6.24±3.736.31±3.581.350.92
2.3兩組患者子宮收縮的持續(xù)時(shí)間和間隔時(shí)長的比較
腰麻聯(lián)合硬膜外麻醉和硬膜外麻醉都能很好的增加患者子宮收縮的持續(xù)時(shí)間和間隔時(shí)長;腰麻聯(lián)合硬膜外麻醉比硬膜外麻醉更能延長患者子宮收縮的持續(xù)時(shí)間和間隔時(shí)長,且其藥物起效時(shí)間也比硬膜外麻醉快很多(P<0.05),差異有統(tǒng)計(jì)學(xué)意義,見表3。
項(xiàng)目實(shí)驗(yàn)組(n=150)對(duì)照組(n=150)χ2/tP持續(xù)時(shí)間 鎮(zhèn)痛前33.12±8.7034.33±9.010.450.67 鎮(zhèn)痛后 15min28.01±10.9229.41±11.260.780.51 0.5h25.19±7.8927.43±8.941.130.06 1h20.64±9.1524.14±10.952.850.04間隔時(shí)長 鎮(zhèn)痛前0.490.57 1~3min70(46.67)72(48.00) 4~5min78(52.00)77(51.33) >5min2(1.33)1(0.67) 鎮(zhèn)痛后15min1.340.38 1~3min49(32.67)59(39.33) 4~5min96(64.00)89(59.33) >5min5(3.33)2(1.33) 鎮(zhèn)痛后0.5h8.91<0.05 1~3min35(23.33)49(32.67) 4~5min109(72.67)98(65.33) >5min6(4.00)3(2.00) 鎮(zhèn)痛后1h10.94<0.05 1~3min25(16.67)39(26.00) 4~5min118(78.67)107(71.33) >5min7(4.67)4(2.67)
2.4胎心率變化比較
實(shí)驗(yàn)組產(chǎn)婦中有5例胎心早期減速,30例胎心晚期減速,對(duì)照組有6例胎心早期減速,28例胎心晚期減速,兩組間差異無統(tǒng)計(jì)學(xué)意義(均P>0.05),差異具有統(tǒng)計(jì)學(xué)意義(P<0.05),見表4。
表4 實(shí)驗(yàn)組和對(duì)照組胎心率的變化[n(%)]
Table 4 Changes of fetal heart rate in experimental group and control group[n(%)]
2.5鎮(zhèn)痛效果比較
據(jù)VAS評(píng)分顯示,實(shí)驗(yàn)組和對(duì)照組都能減輕產(chǎn)婦的疼痛,且實(shí)驗(yàn)組比對(duì)照組更能減輕產(chǎn)婦的疼痛,差異具有統(tǒng)計(jì)學(xué)意義(P<0.05),在鎮(zhèn)痛1h后,對(duì)照組也達(dá)到了實(shí)驗(yàn)組的疼痛效果(P>0.05),見表,4。
組別鎮(zhèn)痛前 鎮(zhèn)痛后VAS評(píng)分(分) 15min0.5h1h實(shí)驗(yàn)組10.32±0.703.09±2.462.11±1.673.01±1.33對(duì)照組10.13±0.615.01±2.313.79±2.133.04±1.29t0.557.016.980.56P0.69<0.05<0.050.71
3.1腰麻聯(lián)合硬膜外麻醉研究進(jìn)展
想要達(dá)到減輕產(chǎn)婦分娩時(shí)的疼痛,就必須要做到能夠充分的阻滯痛覺神經(jīng)和運(yùn)動(dòng)神經(jīng),只有做到了充分阻滯產(chǎn)婦的痛覺神經(jīng)和運(yùn)動(dòng)神經(jīng)才能使減少對(duì)產(chǎn)婦的提肛肌、腹肌的影響,這樣就更加有利于產(chǎn)婦正確的用力分娩額,同時(shí)也可以大大的縮短第二產(chǎn)程所占的時(shí)間,更加有助于陰道的分娩[3-4]。近年來,大量研究顯示腰麻聯(lián)合硬膜外麻醉的方法已經(jīng)得到了臨床的大量應(yīng)用,其用于分娩鎮(zhèn)痛的效果相當(dāng)?shù)暮肹5-6]。本研究發(fā)現(xiàn),腰麻聯(lián)合硬膜外麻醉和硬膜外麻醉都能很好的增加患者子宮收縮的持續(xù)時(shí)間和間隔時(shí)長;腰麻聯(lián)合硬膜外麻醉比硬膜外麻醉更能延長患者子宮收縮的持續(xù)時(shí)間和間隔時(shí)長,且其藥物起效時(shí)間也比硬膜外麻醉快很多,且實(shí)驗(yàn)組的VAS評(píng)分比對(duì)照組更低。陳馮的研究表明,腰麻聯(lián)合硬膜外麻醉作用于分娩鎮(zhèn)痛的起效效果相當(dāng)迅速,這從一定程度上很好的解決了單純硬膜外麻醉起效慢、鎮(zhèn)痛不全的缺點(diǎn)[7]。
3.2枸櫞酸舒芬太尼注射液的作用
本研究發(fā)現(xiàn),實(shí)驗(yàn)組和對(duì)照組均使用較少量的枸櫞酸舒芬太尼注射液來分娩鎮(zhèn)痛,且其效果都良好,其中有著輕微的運(yùn)動(dòng)神經(jīng)阻滯、鎮(zhèn)痛時(shí)間長久、且其母體循環(huán)系統(tǒng)的影響不大,不良反應(yīng)較少。Sato 等[8]表明枸櫞酸舒芬太尼注射液具有高脂溶性,所以其極其容易和血漿蛋白結(jié)合,很少可以通過胎盆屏障,從而避免了其對(duì)新生兒呼吸抑制的影響。
3.3腰麻聯(lián)合硬膜外麻醉的不良反應(yīng)
本研究發(fā)現(xiàn)在鎮(zhèn)痛前使用開放靜脈通道的方法,然后在L3~4行硬膜外穿刺,可以很大程度上減少產(chǎn)婦發(fā)生惡心、嘔吐、腹痛、腹瀉等不良反應(yīng)的發(fā)生。本研究發(fā)現(xiàn)實(shí)驗(yàn)組產(chǎn)婦中有5例胎心變異減速,30例胎心晚期減速,對(duì)照組有6例胎心早期減速,28例胎心晚期減速,Yochum等[9]研究表明分娩鎮(zhèn)痛后胎心出現(xiàn)變異減速變異減速是由于子宮收縮時(shí)胎頭受壓和臍帶受壓所引起的,但其可自行緩解或在產(chǎn)婦改變體位時(shí)緩解,其與鎮(zhèn)痛無關(guān),且實(shí)驗(yàn)組和對(duì)照組這兩種分娩鎮(zhèn)痛的方法對(duì)產(chǎn)婦和新生兒的生理影響都比較小,所以一般無需做特殊處理。不過在產(chǎn)婦分娩的過程中,無論采用何種分娩鎮(zhèn)痛方法,都必須重視對(duì)產(chǎn)婦生命體征的監(jiān)護(hù)、胎兒胎心的監(jiān)測,減少產(chǎn)婦及新生兒出現(xiàn)呼吸系統(tǒng)或者循環(huán)系統(tǒng)收到抑制等情況的發(fā)生[10]。
綜上所述,腰麻聯(lián)合硬膜外麻醉相對(duì)傳統(tǒng)的硬膜外麻醉能更好的減輕孕分娩時(shí)的劇烈疼痛,且其對(duì)子宮收縮的持續(xù)時(shí)間和間隔時(shí)長更長,可達(dá)到縮短產(chǎn)時(shí),減少剖宮產(chǎn)機(jī)率,提高順產(chǎn)機(jī)率的目的,臨床上可大力提倡。
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[專業(yè)責(zé)任編輯:陳 寧]
Effects of different analgesic methods on uterine contraction rhythm
RUAN Xia, WU Zheng-dong, JIANG Wen-chen
(DepartmentofAnesthesiaandSurgery,MaternalandChildHealthCareHospitalofHunanProvince,HunanChangsha410008,China)
Objective To study the effect of spinal epidural anesthesia and that of epidural anesthesia on uterine contraction rhythm. Methods Totally 300 puerpera during January 2014 to October 2016 in Maternal and Child Health Care Hospital of Hunan Province were selected randomly. They were randomly divided into experimental group (150 cases) and control group (150 cases). During the delivery, spinal anesthesia combined with epidural anesthesia was provided in the experimental group, while epidural anesthesia was given in the control group. The effects of two analgesic methods on uterine contraction time and interval were compared. Results There was no significant difference between two groups in amount of oxytocin, onset time, dosage, frequency, Bromage score and Apgar score (χ2/tvalue was 2.04, 1.67, 2.45, 1.85 and 1.35, respectively, allP>0.05). Compared to epidural anesthesia, spinal anesthesia combined with epidural anesthesia could prolong uterine contraction duration and the interval time, and the onset time of drugs was much faster than that of epidural anesthesia (χ2/tvalue was 2.85 and 10.94, respectively, bothP<0.05). In the experimental group, the number of fetal heart deceleration in early stage was 5 and the number of fetal heart deceleration in late stage was 30, while in the control group, the number of fetal heart deceleration in early stage was 6 and the number of fetal heart deceleration in late stage was 28. There was no significant difference between two groups (χ2/tvalue was 3.65 and 4.97, respectively, bothP>0.05). According to VAS score, the method for the experimental group and the control group could reduce maternal pain, and the experimental group had better effect than the control group in reducing maternal pain (t=6.98,P<0.05). Conclusion Compared to traditional epidural anesthesia, spinal anesthesia combined with epidural anesthesia could better reduce the severe pain during pregnancy with longer duration of uterine contraction and interval. It can shorten labor stage, reduce possibility of cesarean section and improve the probability of natural delivery. It should be strongly advocated in clinics.
spinal anesthesia; epidural anesthesia; duration; length of interval
2016-11-10
阮 霞(1978-),女,副主任醫(yī)師,主要從事婦產(chǎn)科麻醉研究。
10.3969/j.issn.1673-5293.2017.04.023
R714
A
1673-5293(2017)04-0432-03