初产妇产后镇痛管理和功能恢复的详细分析
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Recovery after Nulliparous Birth: A Detailed Analysis of Pain Analgesia and Recovery of Function.
背景与目的
大多数美国产妇接受产科医生首次回访的时间是产后第6周。因此，关于产妇产后的疼痛情况和镇痛药物需求量以及相关功能恢复状况方面的详细资料是缺失的。本次前瞻性观察研究的目的是评估产妇产后以上方面的改变情况以期更好的满足产妇相关需求。
方 法
本次研究共纳入213名初产妇，并评估她们每天产后的疼痛情况和阿片类药物使用量以及自我感知相关功能的恢复状况直至疼痛完全缓解，停用阿片类药物以及自我感知相关功能完全恢复为止。主要的结局指标是产妇产后达到疼痛完全缓解，停用阿片类药物以及自我感知相关功能均完全恢复的时间。此外，根据患者每日数字疼痛量表评分和达到疼痛完全缓解时间绘制的相应曲线下面积评估产妇产后疼痛承受力。同时，根据生存分析的统计方法比较了剖宫产产妇和经阴道分娩产妇达到本研究主要结局指标的差异情况。
结 果
经阴道分娩产妇产后达到不受疼痛影响和不依赖阿片药物的相关功能恢复时间（中位数[四分位数（IQR）]）是19[11-26]天，停用阿片类药物的时间是0 [0-2] 天，停用所有镇痛类药物（包括非甾体类抗炎药和对乙酰氨基酚）的时间是11[5-17]天，疼痛完全缓解的时间是14[7-24]天；而剖宫产产妇产后达到以上相应结局指标的时间分别为27[19-40]天，9[5-12]天，16[11-24]天以及21[14-27]天。
结 论
在产后疼痛情况和阿片类药物使用量以及自我感知相关功能的恢复状况方面，健康的剖宫产初产妇和经阴道分娩初产妇之间的差异具有显著临床意义。此外，剖宫产和经阴道分娩生产方式中产妇相关功能恢复如产前的时间相近，而两种生产方式中主要结局指标的差异大约有一半可归因为初产妇产后疼痛承受力的差异。
原始文献摘要
Komatsu R, Carvalho B, Flood P D. Recovery after Nulliparous Birth: A Detailed Analysis of Pain Analgesia and Recovery of Function.[J]. Anesthesiology, 2017,127(4):684-694. DOI:10.1097/ALN.0000000000001789
BACKGROUND: The majority of parturients in the United States first return for evaluation by their obstetric practitioner 6 weeks after delivery. As such, there is little granular data on the pain experience, analgesic requirements, and functional recovery during the postpartum period. This prospective observational study was performed to evaluate these factors to provide expectations for patients.
METHODS: A total of 213 nulliparous women were enrolled and assessed daily until they completed 3 outcomes: (1) pain resolution; (2) opioid cessation; and (3) self-assessed functional recovery from delivery. The primary endpoint, pain- and opioid-free functional recovery, was the time required to reach all three of the endpoints. Pain burden was assessed as the area under the curve created by plotting the daily numerical pain rating scale against the days required to attain pain resolution. Times to attain study endpoints after cesarean delivery and vaginal delivery were compared using survival analysis.
RESULTS: After vaginal delivery, days required for pain and opioid-free functional recovery (median [interquartile range (IQR)]) were 19 [11 to 26], for opioid cessation 0 [0 to 2], termination of all analgesic (including nonsteroidal antiinflammatories and acetaminophen) 11 [5 to 17], and pain resolution 14 [7 to 24]. Achievement of these endpoints after cesarean delivery required 27 [19 to 40], 9 [5 to 12], 16 [11 to 24], and 21 [14 to 27] days, respectively.
CONCLUSIONS: There is clinically significant variability between healthy nulliparous parturients in the pain experience, opioid use, and functional recovery after childbirth following vaginal and cesarean delivery. Recovery to predelivery function is similar after vaginal and cesarean delivery, and approximately half of the variance was explained by pain burden.
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