两种椎管内阻滞方法用于分娩镇痛的临床比较

目的探讨采用蛛网膜下腔与硬膜外腔分段阻滞联合用药及单纯硬膜外腔用药法的镇痛效果及其对母婴的影响。方法以蛛网膜下腔与硬膜外腔分段阻滞联合用药分娩镇痛者为研究组（１００例）,单纯硬膜外麻醉分娩镇痛者为对照组（４０例）,分别观察疼痛程度、副作用、产程时间、分娩方式、产后出血、胎儿窘迫及新生儿窒息情况。结果两组镇痛效果比较,差异有极显著性（Ｐ＜００１）,两组产程时间均值比较,差异无显著性（Ｐ＞００５）;两组产妇分娩方式、产后出血率、胎儿宫内窘迫及新生儿窒息发生率比较,差异无显著性（Ｐ＞００５）。结论蛛网膜下腔与硬膜外腔分段阻滞联合用药法,用于分娩镇痛安全有效。对产程及母婴均无影响,较单纯硬膜外麻醉镇痛效果更为肯定、满意,可在有一定条件的医疗单位应用。     

异氟醚分娩镇痛对胎儿-母体循环影响的研究

目的　探讨异氟醚分娩镇痛对子宫胎盘和胎儿胎盘血流的影响。　方法　应用多普勒超声技术,对分娩活跃期异氟醚分娩镇痛组和对照组共５０例初产妇的子宫动脉和脐动脉血流速度指数及胎心率进行检测。　结果　实验前后,各组子宫动脉的平均Ｓ／Ｄ比值、搏动指数（ＰＩ）及脐动脉平均Ｓ／Ｄ比值、ＰＩ均无显著差异（Ｐ＞ ０．０５）;两组间无显著差异（Ｐ＞ ０．０５）,实验前后,各组平均胎心率均无显著差异（Ｐ＞ ０．０５）;两组间无显著差异（Ｐ＞ ０．０５）。　结论　异氟醚分娩镇痛对胎儿－母体循环未发现有不良影响     

采用Doula式分娩的临床探讨

目的：探讨由有分娩经验的助产士陪伴孕妇分娩——Ｄｏｕｌａ式分娩，对提高产时保健质量的效果。方法：对４６例初产妇（观察组）采用Ｄｏｕｌａ式分娩的临床观察，并与同期进入活跃期后仅有家属陪伴的初产妇３３６例（对照组）比较。结果：观察组剖宫产率６．５％，对照组２０．８％，两组比较差异有显著性（Ｐ＜０．０５）；总产程与产后出血量，观察组也明显降低（Ｐ＜０．０５）。结论：应用Ｄｏｕｌａ式分娩，降低了剖宫产率、缩短了产程，并减少了产后出血，是提高产时保健质量的有效措施     

腰麻-硬膜外联合阻滞麻醉用于分娩镇痛的临床分析

目的探讨蛛网膜下腔-硬膜外联合阻滞麻醉（CSEA）进行分娩镇痛对母儿的影响。方法将200例（试验组）无产科并发症和麻醉禁忌证的初产妇分为自然临产组120例，缩宫素引产组80例；随机抽取同期条件相当，未实施分娩镇痛者200例也分别与镇痛组配为对照组，试验组在活跃初期使用小剂量低浓度麻醉药经蛛网膜下腔-硬膜外联合给药，观察用药后不良反应和镇痛效果以及对产程时间、分娩方式、产后出血、新生儿窒息、羊水性状的影响，并与200例对照组产妇相比较。结果试验组镇痛效果良好，未见明显不良反应，活跃期和第二产程缩短，此镇痛方式快速有效，不良反应少，能使活跃期明显加速，第二产程缩短；两组在产后出血、新生儿窒息、胎儿窘迫等方面差异无显著性。结论此镇痛方式快速有效，不良反应少，能使活跃期明显加速，缩短第二产程，降低剖宫产率，对母婴无不良影响，值得推广。     

小剂量罗哌卡因复合芬太尼用于腰硬联合阻滞分娩镇痛的临床观察

目的：观察小剂量罗哌卡因复合芬太尼用于腰硬联合阻滞分娩镇痛的效果及不良反应。方法：选择足月单胎头位临产初产妇120例,ASAI或Ⅱ级,均无椎管内麻醉禁忌和产科高危因素,随机分为腰硬联合阻滞组（观察组）和无镇痛组（对照组）各60例,观察两组第一、二产程的视觉模拟疼痛评分（VAS评分）、运动神经阻滞程度评估（改良Bromage法）、产程时间、催产素使用、器械助产、剖宫产及产妇不良反应情况,并进行新生儿APgar评分。结果：观察组第一、二产程VAS明显低于对照组（P〈0.05）,两组产妇运动神经阻滞评估及产程时间差异无统计学意义,器械助产率和催产素使用观察组高于对照组（p〈0.05）,剖宫产率观察组明显低于对照组（P〈0.05）,观察组有2例出现下肢皮肤轻度瘙痒,新生儿APgar评分两组差异无统计学意义。结论：小剂量罗哌卡因复合芬太尼用于腰硬联合阻滞分娩镇痛效果确切,对产程进展及新生儿无不良影响,是一种理想的分娩镇痛方法。     

腰麻-硬膜外联合镇痛产程进展分析

目的　了解腰麻 -硬膜外联合麻醉和产妇自控硬膜外镇痛 (CSEA PCEA)是否对产程进展存在影响。方法　回顾性分析 2 0 0 2年 3月～ 8月 5 0 7例阴道分娩健康初产妇病历资料 ,观察组 (CSEA PCEA)共2 5 9例 ,对照组 (未采用CSEA PCEA) 2 4 8例 ,通过产程图比较两组产程进展。结果　观察组第一产程活跃期及第二产程时间分别为 (2 71 93± 12 7 4 4 )min和 (5 7 39± 35 5 2 )min ,较对照组活跃期 (188 0 8± 110 2 9)min及第二产程时间 (44 84± 31 92 )min延长 (P <0 0 0 1) ;观察组产程图宫口曲线较Friedman产程图倾斜角度较小 ,即活跃期进展较慢 ,平均每小时宫口开大 1 5cm。结论　腰麻及硬膜外联合镇痛后活跃期进展减慢 ;镇痛后的产程处理不应单纯按照传统Friedman产程图。CSEA PCEA不适宜作为理想的分娩镇痛方式。     

导乐陪伴分娩联合自控式硬膜外分娩镇痛对产程及母儿影响的观察

目的观察产时陪伴分娩结合自控硬膜外分娩镇痛对产程进展、分娩方式及新生儿窒息等的影响。方法随机选择自愿要求行单纯导乐陪伴分娩初产妇100例为观察A组,自愿要求行导乐陪伴分娩+自控式硬膜外分娩镇痛初产妇100例为观察B组,同期无导乐陪伴及自控式硬膜外镇痛分娩初产妇100例为对照C组,对阴道分娩产程、分娩方式、产程中缩宫素应用情况、产后出血量、新生儿窒息等进行分析。结果 A组与B、C组比较,表现为第一产程明显缩短(P<0.01),以活跃期缩短最为显著(P<0.001);B、C组间比较,B组缩宫素或人工破膜使用情况率明显增高(P<0.05),剖宫产率明显降低(P<0.05);A组与C组比较,剖宫产率显著降低(P<0.01)。结论单纯陪伴分娩可减轻疼痛、缩短第一产程活跃期,陪伴分娩结合自控硬膜外分娩镇痛可以达到显著镇痛效果,可以明显减低剖宫产率,对产后出血量,新生儿窒息等无影响。     

镇痛分娩100例临床观察

目的 探讨硬膜外麻醉镇痛降低剖宫产率和缩短产程的意义。方法 将200例无合并症、禁忌证的初产妇随机分为两组。对照组Doula陪伴分娩；试验组采用硬膜外麻醉，使用芬太尼及布比卡因。结果 两组在产后出血、新生儿Apgar评分方面差异无屁著性，而在降低剖宫产率、缩短产程方面试验组明显优于对照组。结论 连续硬膜外麻醉法镇痛效果确切，能满足产程需要，并且不增加产后出血及新生儿窒息的发生率。     

宫缩图对识别头位难产的价值

对６０例单胎、头先露，正式临产需手术助产分娩的初产妇及６０例单胎，头先露，正式临床经阴道自然分娩的初产妇的宫缩图进行分析。结果表明：研究组宫缩图的类型平行型及多交叉型多于对照组（Ｐ〈０．０５），对照组宫缩图的类型单交叉型显著多于研究组（Ｐ〈０．０５），研究组宫缩图第一交叉出现至胎儿娩出时间及至产程图交叉的时间均明显长于对照组（Ｐ〈０．０５）；研究组第一交叉出现时宫颈口扩张明显小于对照组（Ｐ〈０．０     

间苯三酚联合硬膜外麻醉分娩镇痛的临床研究

目的探讨间苯三酚联合硬膜外麻醉在分娩过程中,促进产程进展、减轻分娩疼痛等的效果。方法将180例初产妇随机分为3组各60例,在孕妇宫口开大约3cm以上,实验组采用间苯三酚80mg静脉推注联合硬膜外麻醉行无痛分娩,对照1组单纯采用间苯三酚80mg静脉推注;对照2组单纯采用硬膜外腔阻滞麻醉。比较在用药后1h的镇痛效果及产妇运动能力,第一产程活跃期时间、剖宫产率、产后出血量、血氧饱和度和新生儿评分等母儿结局。结果对照1组第一产程活跃期时间、剖宫产率与实验组相比,差异无统计学意义（P〉0.05）,但镇痛效果差。对照2组镇痛效果良好,但第一产程活跃期较对照1组和实验组时间明显延长,剖宫产率相对增加,差异有统计学意义（P〈0.05）。结论间苯三酚联合硬膜外麻醉缩短产程效果明显,镇痛效果良好,对母婴无不良反应,减少了剖宫产。     

椎管内阻滞麻醉与笑气吸入用于分娩镇痛的效果比较

目的　比较椎管内阻滞麻醉和笑气吸入两种方法的分娩镇痛效果和对产妇及新生儿的影响。方法　随机选取 30 0例产妇分为笑气组、椎管内阻滞组和对照组 ,每组各 10 0例。在分娩过程中 ,笑气组给予吸入含 5 0 %笑气与 5 0 %氧气的混合气体 ;椎管内阻滞组给予蛛网膜下腔 +硬膜外腔联合注入芬太尼和布比卡因 ;对照组未给予镇痛药物。并分别观察 3组产妇的镇痛效果、产程时间、分娩方式、产后出血量、产妇桡动脉血及新生儿脐血的血气分析以及新生儿窒息情况。结果　 (1)镇痛效果比较 :椎管内阻滞组镇痛分级 0级为 88例 ,笑气组为 12例 ,对照组为 0例。 3组之间比较 ,差异有极显著性 (P <0 0 1)。 (2 )产程时间比较 :第一产程和总产程时间 ,椎管内阻滞组短于对照组和笑气组 (P <0 0 5 ) ,笑气组与对照组比较 ,差异无显著性 (P >0 0 5 ) ;第二产程时间椎管内阻滞组长于对照组和笑气组 ,但差异无显著性 (P >0 0 5 )。 (3)剖宫产术后出血量比较 :笑气组为 (373± 77)ml,椎管内阻滞组为 (2 5 9± 78)ml,对照组为 (2 39± 89)ml,笑气组与其他两组比较 ,差异有极显著性 (P<0 0 1)。(4)血气分析结果比较 :3组产妇桡动脉血及新生儿脐血血气分析结果各组之间比较 ,差异均无显著性 (P >0 0 5 )。 (5 )分娩方式比较     

笑气吸入用于分娩镇痛的有效性与安全性研究

目的　探讨笑气吸入分娩镇痛的有效性与安全性。方法　将 130 0例单胎头位、足月初产妇分为两组。其中 ,研究组 6 5 8例 ,在产程中吸入 5 0 %笑气与 5 0 %氧气的混合气体实行分娩镇痛 ;对照组 6 4 2例 ,产程中间断吸入氧气。观察两组产妇疼痛的缓解程度、产程时间、分娩方式、羊水情况、分娩失血量、新生儿出生时的Apgar评分、产妇桡动脉与新生儿脐动脉血气分析的结果、笑气吸入的副反应。结果　研究组产妇分娩镇痛的有效率为 80 9% ,总产程时间为 4 6 8min ,活跃期时间为 15 3min ,剖宫产率为 11 6 % ,羊水污染率 2 2 0 % ,新生儿窒息率 1 2 % ,产时出血平均 2 37ml,39 4 %的产妇出现头晕表现的副反应 ;而对照组产妇分娩镇痛的有效率为 0 9% ,活跃期时间为 187min ,剖宫产率为 19 3% ,与研究组比较 ,差异有显著性 (P <0 0 5 ) ;而产程时间 4 80min ,羊水污染率 2 4 3% ,新生儿窒息率 1 7% ,产时出血平均 2 5 3ml,与研究组比较 ,差异无显著性 (P >0 0 5 ) ;对照组产妇无明显的头晕等副反应。两组产妇桡动脉及脐动脉血气分析结果比较 ,差异无显著性 (P >0 0 5 )。结论　 5 0 %笑气与 5 0 %氧气的混合气体用于分娩镇痛安全方便 ,易被产妇接受 ,可有效地缓解分娩疼痛 ,增加阴道分娩率 ,对产程及母儿     

Does epidural anesthesia affect the course of labor and delivery?

The progress of labor ideally leads to a normal, spontaneous, vaginal delivery. Many factors--maternal, fetal, obstetrical and anesthetic--may collectively contribute to delaying or precluding an ideal outcome. Adverse outcomes of labor and delivery must be clearly defined in terms of maternal, fetal, or neonatal morbidity or mortality, and should be distinguished from abnormal data (such as fetal heart rate, duration of labor, and incidence of low forceps deliveries) that are only indirectly related to outcome. Epidural anesthesia is not a singular phenomenon. Variations and subtle nuances in the administration of epidural anesthesia create a vast array of potential anesthetic regimens. To discover the anesthetic methods that provide excellent analgesia with no adverse effects on the course of labor is an ideal goal that has not yet been achieved. To approach this goal, the answers to several questions are needed. Are study patient groups adequately matched for risk factors? Are obstetrical practices well-defined with respect to elective versus indicated use of instrumental or cesarean delivery methods? Do the risks of instrumental delivery outweigh the benefit of perineal analgesia associated with epidural anesthesia? Is it possible to provide optimal analgesia throughout stage two labor without tending to increase the risk of instrumental delivery? Can delayed pushing during stage two labor increase the probability of spontaneous vaginal delivery with continuous epidural anesthesia? Well-controlled clinical trials and refinements in both anesthetic and obstetric techniques are necessary to resolve such issues so that every parturient (and fetus) may undergo a safe and painless delivery.     

蛛网膜下腔-硬膜外联合阻滞麻醉用于分娩镇痛206例分析

目的　探讨分娩镇痛的效果及对产程、母婴状况的影响。方法　采用蛛网膜下腔 -硬膜外联合阻滞(CSEA)用于分娩镇痛的产妇 2 0 6例作为观察组 ,将未采用任何分娩镇痛药物而进入产程的产妇 2 0 6例作为对照组 ,分别观察产程时间、分娩方式、产后出血、胎儿窘迫及新生儿窒息情况。结果　两组产程活跃期比较 ,有极显著性差异 (P <0 0 1) ;两组分娩方式比较有显著性差异 (P <0 0 5 ) ;两组胎儿窘迫、新生儿窒息及产后出血发生率比较 ,无显著性差异 (P >0 0 5 )。结论　CSEA用于分娩镇痛 ,疼痛阻滞完善 ,加速了产程活跃期及第二产程的进展 ,降低了剖宫产及阴道难产率 ,对母婴均无不良影响     

Obstetric anesthesia: Past present and future

Obstetric anesthesia is science and art combined, and obstetric anesthesiologists must be concerned simultaneously with the lives of (at least two) intricately interwoven patients – the mother and her baby (ies). Obstetric anesthesia, by definition, is a subspecialty of anesthesia devoted to peripartum, perioperatvie, pain and anesthetic management of women during pregnancy and the puerperium. Perhaps no other subspecialty of anesthesiology provides more personal gratification than the practice of obstetric anesthesia. An obstetric anesthesiologist has become an essential member of the peripartum care team, who closely works with the obstetrician, perinatologist, midwife, neonatologist and labor and delivery nurse to ensure the highest quality care for the pregnant woman and her baby. Exchange on information and communication skills in ever changing environment of labor and delivery is essential for perfect outcome, which is always expected when providing safe passage for both the mother and her fetus from antepartum to postpartum period. Changes in maternal–fetal and neonatal medicine and obstetric anesthesia have continued to develop rapidly during the recent years. The purpose of this article is to explore a number of important issues in modern practice of obstetric anesthesia.     

Epidural analgesia and the course of delivery in term primiparas

OBJECTIVES: Epidural analgesia provides the most effective pain control during labor. Of great concern is its influence on the course of delivery and perinatal complications. DESIGN: The aim of the study was to assess the effect of epidural analgesia on the course of delivery and perinatal outcome. MATERIALS AND METHODS: 609 deliveries among 1334 (323 women with epidural analgesia (53%) and 548 without epidural analgesia (47%)) met the following criteria: primipara, singleton, live pregnancy, > =37 weeks' gestation, cephalic presentation of a fetus, lack of contraindication for vaginal delivery. The incidence of instrumental deliveries and fetal distress, duration of the first, second and third stage of labor, perinatal outcome, perinatal complications and perinatal blood loss and were analyzed. RESULTS: The incidence of fetal distress during second stage of labor was significantly higher in the epidural group (12.69 vs. 6.99%, P=0.02). The incidence of fetal distress during first stage of labor did not differ in both groups (10.53% vs. 8.74%, NS). Cesarean sections rate was similar in epidural and non-epidural group (17.7 vs. 18.2%, NS). Among vaginal deliveries duration of the first and second stage of labor was longer in epidural group (6.5+/-2.4 vs. 5.4+/-2.5 godz., P=0,000003 and 47.3+/-34.8 vs. 29.1+/-25.8 min., P=0.000003) and this was independent of period of time between onset of first stage of labor and epidural analgesia. Oxitocin use was significantly more frequent in the epidural group (20.6 vs. 10.3%, P<0.004). There were no statistically significant differences in the rates of instrumental vaginal deliveries, 1 and 5-minute Apgar scores, length of third stage of labor and perinatal blood loss in patients with and without epidural analgesia. Perinatal outcome did not depend on previous use of epidural analgesia or mode of analgesia for the operation in cesarean section subgroup. CONCLUSION: Epidural labor analgesia is associated with slower progress of labor but has no adverse effect on perinatal outcome and perinatal complications.     

Labor pain and its management with the combined spinal–epidural analgesia: what does an obstetrician need to know?

Most women rate pain of childbirth as the most painful experience of their lives. Lumbar epidural analgesia is widely considered as the most effective method of providing pain relief in labor. However, lumbar epidural analgesia for labor is not a standard (generic) procedure and many technical modifications have been developed and introduced into clinical practice over time. The combined spinal–epidural labor analgesia technique (CSEA) has attained wide spread popularity in obstetric anesthesia worldwide. The onset of analgesia is rapid and reliable, and maternal satisfaction is very high. While there still remains some concern about dural puncture, and while the pros and cons of using the CSEA as opposed to traditional epidural for labor pain are still being debated, it appears certain that the CSEA technique offers many unique advantages to the pregnant woman.     

蛛网膜下腔阻滞加硬膜外阻滞与单纯硬膜外阻滞对产程进展影响的分析

目的探讨蛛网膜下腔阻滞(腰麻)加硬膜外阻滞与单纯硬膜外阻滞对产妇产程进展的影响。方法回顾性分析722例阴道分娩健康初产妇的临床资料,根据是否行分娩镇痛及分娩镇痛方法的不同分为3组:(1)腰麻加硬膜外阻滞(联合麻醉组),共259例;(2)单纯硬膜外阻滞(硬膜外组),共215例;(3)未采用任何镇痛方法的对照组,共248例。比较3组产妇产程时间及Friedman产程图进展变化特点。结果(1)第一产程活跃期、第二产程及第三产程时间比较:联合麻醉组分别为(272±127)min、(57±36)min及(9±6)min;硬膜外组分别为(305±133)min、(59±39)min及(8±6)min;对照组分别为(188±110)min、(45±32)min及(9±6)min。联合麻醉组及硬膜外组的第一产程活跃期及第二产程时间均长于对照组(P<0.01);3组间第三产程时间相互比较,差异均无统计学意义(P>0.05)。(2)产程图特点比较:联合麻醉组及硬膜外组产妇第一产程活跃期宫缩曲线位于产程图Friedman曲线右侧,对照组则位于其左侧;联合麻醉组和硬膜外组产程图宫口曲线较Friedman曲线倾斜角度小,即第一产程活跃期进展缓慢;对照组第一产程活跃期进展较快。联合麻醉组产妇平均每小时宫口开大1.5cm,硬膜外组产妇为1.4cm,对照组产妇为1.8cm。联合麻醉组及硬膜外组产妇平均每小时宫口开大程度较对照组缩小,两者比较,差异有统计学意义(P<0.01)。结论腰麻加硬膜外阻滞联合麻醉及单纯硬膜外阻滞镇痛后,产妇第一产程活跃期进展减慢,总产程时间延长;镇痛后的产程处理不应单纯按照Friedman产程图进行。