硬膜外镇痛对经阴道分娩母婴影响的临床研究

发布时间：2018-03-07 00:26

本文选题：硬脊膜外隙　切入点：分娩镇痛　出处：《天津医科大学》2014年硕士论文　论文类型：学位论文

【摘要】：研究背景高剖宫产率是目前国内产科面临的现状,如何降低剖宫产率则是产科临床研究热点。产妇或家属主动选择剖宫产是目前国内剖宫产率居高不下的重要原因之一,其中惧怕分娩疼痛是一个不可忽视的重要因素。寻求一种镇痛效果确切、对母婴影响轻微的分娩镇痛方法,某种意义上,可能成为降低剖宫产率的重要举措。目的探讨硬脊膜外隙镇痛对经阴道分娩母婴的安全性和有效性,为临床大范围开展分娩镇痛提供参考依据。方法选取2012年6月-2013年5月间、非合并其它系统疾病及产科合并症、拟经阴道分娩足月临产孕妇60例,随机分为硬膜外隙镇痛(EA)组和非镇痛(NA)组各30例。EA组：孕妇出现临产先兆后进入待产室,丌放一侧上肢静脉,恒速输注0.9%氯化钠200-300ml。记录NBP、HR、SpO2做为基础值。向孕妇详细告知镇痛泵使用方法及注意事项。左侧卧,常规消毒铺巾,于L2-3行硬膜外隙穿刺,置入硬膜外导管,妥善固定导管后改平卧,给予试验剂量1%利多卡因5ml,5分钟后,针刺测痛,排除脊麻并确认出现节段性阻滞平面。硬膜外隙注入首次镇痛液剂量10ml(0.1%罗哌卡因+5μg舒芬太尼)后,接镇痛泵。背景剂量6ml/h(身高160cm者)或8ml/h(身高≥160cm者),追加剂量3ml/次,锁定时间15分钟。首次注药后半小时,再次记录NBP、HP、SpO2,并对孕妇进行Bromage评分,记录分值。NA组入待产室后,仅输注0.9%氯化钠200-300ml。监测、记录等同EA组。两组于胎儿娩出即刻,采集脐静脉血作血气分析。新生儿出生后1min、5min、10min,由助产士、产科医师和麻醉医师分别独立对新生儿行Apgar评分,取三者评分均值作为即时分值,记录备统计分析。记录各产程时间,产程中有否导尿,有否使用缩宫素,宫口扩张至6-7cm时VAS评分,是否行会阴侧切,产后2小时出血量,初乳始动时间。新生儿神经行为评分：新生儿生后72小时,由儿科保健人员对新生儿进行神经行为评分并记录。产程中产科医师、麻醉医师每隔2小时定期巡视,分别负责处理产科及分娩镇痛中的突发事件与异常情况,保证产妇及胎儿安全、平稳度过生产过程。结果 EA与NA两组孕妇一般资料无差别。EA组第一产程和第二产程较NA组延长(P均0.001)；缩宫素使用率高于NA组(9vs.2,P0.05)；导尿率高于NA组(16vs.4,P0.01)；产后出血率(4vs.0)及阴道侧切率(13vs.11)两组无统计学差异(P均0.05)。EA组VAS评分明显低于NA组(P0.001)；两组Bromage评分无统计学差异(P0.05)。两组产妇泌乳始动时间无统计学意义(34.1+1.4vs.37.6±1.3,P0.05)。EA组新生儿生后lmin/5min Apgar评分9.2±0.7/9.2±0.6虽略低于NA组9.6±0.5/9.6+0.5(P0.01),但无实际临床意义,且生后10min两组Apgar评分均达到10分。脐静脉血气分析：除EA组pH值低于NA组(7.241±0.077vs.7.282±0.058,P0.05)外,其余各参数两组间均无差别(P均0.05)。结论 1.本研究所采用硬膜外隙分娩镇痛方法效果确切,不影响产后泌乳过程,不增加产后出血,不影响产妇下肢活动,对经阴道分娩产妇无不良影响。 2.本研究所采用硬膜外隙分娩镇痛未见有实际临床意义的新生儿不良影响,对新生儿安全,值得推广
[Abstract]:Research background
The high rate of cesarean section is present obstetric face, how to reduce the rate of cesarean section is the obstetric clinical research focus. Maternal or families take the initiative to choose cesarean section is one of the important reasons for the high rate of cesarean section, the fear of labor pain is an important factor that can not be ignored. To seek a exact analgesic effect the effect of maternal childbirth analgesia method, mild, in a sense, may become an important measure to reduce the rate of cesarean section.
objective
To explore the safety and effectiveness of epidural space analgesia for vaginal delivery of mother and baby, and to provide a reference basis for a wide range of clinical labor analgesia.
From June 2012 -2013 year in May, with other system diseases and obstetric complications, 60 cases with vaginal delivery to full-term pregnant women, were randomly divided into epidural analgesia (EA) group and non analgesia (NA) group with 30 cases in each group:.EA pregnant women birth aura after entering the labour room, open side vein of upper limb and the constant infusion of 0.9% sodium chloride HR, 200-300ml. record NBP, SpO2 as the basic value. To inform pregnant women with analgesia methods and precautions. Lying on the left side, conventional disinfection shop towels on the L2-3 line, epidural puncture, epidural catheter was properly fixed catheter after supine, giving test dose 1% lidocaine 5ml, 5 minutes after acupuncture measuring pain, eliminate spinal anesthesia and confirm the segmental block. Epidural injection first analgesic liquid dose 10ml (0.1% ropivacaine +5 g sufentanil), analgesia pump. 6ml /h background dose (height 160cm) or 8ml/h (body More than or equal to 160cm), an additional dose of 3ml/ times, the locking time is 15 minutes. The first injection after half an hour, again to record NBP, HP, SpO2, and Bromage score of pregnant women, the scores of group.NA after entering the labour room, only infusion of 0.9% sodium chloride 200-300ml. monitoring, recording two groups of identical EA group. The delivery of the fetus immediately, the blood gas analysis of umbilical venous blood collection. After the birth of 1min, 5min, 10min, by midwives, obstetricians and anaesthetists were independent of neonatal Apgar score, the three is taken as the mean score of instant scores, records by statistical analysis. Records of the labor time, whether the catheter in the stage of labor, whether the use of oxytocin, cervical dilatation and 6-7cm VAS score, whether line episiotomy, amount of bleeding within 2 hours, the initial time of colostrum. Neonatal behavioral neurological assessment: 72 hours after birth of newborn, neonatal behavioral neurological assessment and recorded by pediatric care providers In the process of production. Obstetrician, every 2 hours for anesthesiologists regular inspections are responsible for handling emergencies and obstetric analgesia during childbirth and abnormal situation, ensure maternal and fetal safety, through the production process smoothly.
Result
EA and NA data of two groups of pregnant women in group.EA had no difference between the first stage and second stage of labor longer than that of group NA (P 0.001); use of oxytocin was higher than that of group NA (9vs.2, P0.05); the rate of catheterization was higher than that of group NA (16vs.4, P0.01); the rate of postpartum hemorrhage (4vs.0) and vaginal lateral incision rate (13vs.11) no significant difference between two groups (P 0.05).EA group VAS score was significantly lower in group NA (P0.001); the Bromage scores of the two groups had no statistical difference (P0.05). The two groups had no statistically significant maternal lactation initiating time (34.1+1.4vs.37.6 + 1.3, P0.05).EA groups after birth lmin/5min Apgar score 9.2 + 0.7/9.2 + 0.6 was slightly lower than that of group NA 9.6 + 0.5/9.6+0.5 (P0.01), but no actual clinical significance, 10min Apgar scores of the two groups reached 10 and students. After analysis of umbilical venous blood gas: pH in EA group was lower than that of NA group (7.241 + 0.077vs.7.282 + 0.058, P0.05), the rest of the parameters among the two groups no difference (P 0.05).
conclusion
1., epidural labor analgesia is effective in this study. It does not affect postpartum lactation process, does not increase postpartum hemorrhage, does not affect maternal lower limb activity, and has no adverse effect on vaginal delivery.
2. the use of epidural space labor analgesia in this research institute does not have the actual clinical significance of neonatal adverse effects. It is worth popularizing for the safety of the newborn.

【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R714.3

【参考文献】