腰硬联合分娩镇痛方式对产妇第一产程的影响：队列研究
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Effects of combined spinal–epidural analgesia on first stage of labor:a cohort study
背景与目的：目前认为，椎管内麻醉是用于分娩镇痛的最好方法。它包括硬膜外镇痛和腰硬联合镇痛。迄今为止，关于这两种镇痛方式对产程影响的研究是极其罕见的。一些研究者认为，腰硬联合镇痛可引起产程缩短，但关于产程缩短的益处仍尚无定论。本试验的研究目的是比较腰硬联合镇痛和硬膜外镇痛对第一产程、产妇和新生儿预后的影响。
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方法：本试验进行了一项前瞻性队列研究。研究对象的纳入标准为宫颈<6cm并且要求分娩镇痛的产妇。镇痛方法分为两种，一种为运用小剂量的布比卡因进行硬膜外镇痛，另一种为施行硬膜外镇痛的同时往蛛网膜下腔注入舒芬太尼进行联合镇痛。本研究的主要观察主要指标为：第一产程时间。次要指标为：镇痛起效时间和效果、分娩方式、子宫的收缩以及催产素的使用情况、胎心异常情况、母体和新生儿并发症情况。
结果：本研究共纳入600例患者：腰硬联合镇痛组176例，硬膜外镇痛组224例。两组患者基本情况，胎次，产科合并症的发生率，引产率，催产素输注率，Bishop评分和VAS评分无明显差异。研究结果显示，两试验组的第一产程时程并无明显区别（195（120-300）minutes ；p=0.7）。腰硬联合镇痛在镇痛初期对子宫收缩的影响显著降低（15.4%vs39.73%；p< 0.001)，同时也延长了缩宫素的作用时间，使子宫明显缩小（7±2.5cm vs6.±2.7；p=0.002)。腰硬联合镇痛起效快（31% vs20%；p<0.001;5minutes后VAS <4），初期可使VAS评分显著降低。在其他方面，两种镇痛方式的影响并没有显著差别。
结论：研究结果表明，运用硬膜外镇痛的同时往蛛网膜下腔注入舒芬太尼进行联合镇痛的镇痛方法可不引起第一产程缩短，但是它对子宫收缩的影响是极其微弱的。此外，这种镇痛方式不仅起效更快、镇痛效果显著，而且不会增加孕产妇和新生儿并发症发生的风险。
Poma S, Scudeller L, Verga C，et al.
Effects of combined spinal–epidural analgesia on first stage of labor:acohort study
J. Matern. Fetal. Neonatal. Med. May 17，2018 DOI：10.1080/14767058.2018.1467：892
BACKGROUND: Neuraxial anesthesia is considered as the gold standard in the control labor of pain. Its variants are epidural analgesia and combined spinal–epidural analgesia. Few studies, as yet, have investigated the duration of labor as a primary outcome. Some authors have suggested that combined spinal–epidural analgesia may reduce labor duration but at the moment the benefit of shortening labor is uncertain. The main aim of this study was to compare combined spinal–epidural with epidural analgesia in terms of their effect on duration of stage I labor,maternal, and neonatal outcomes.
METHODS: A prospective cohort study was conducted. Parturients who requested analgesia at cervical dilatation <6cm were included. Analgesia was either epidural with low concentration levobupivacaine or combined spinal epidural with subarachnoid sufentanil. The primary outcome was the length of stage I labor. Onset and quality of analgesia, mode of delivery, effects on uterine activity and use of oxytocin, fetal heart rate abnormalities and uterine hyperkinesia, maternal, and neonatal complications were also considered.
RESULTS:We enrolled 400 patients: 176 in the combined spinal–epidural group and 224 in the epidural group. Patients in the two treatment groups were similar with regard to demographic characteristics, parity, and incidence of obstetric comorbidities, labor induction, oxytocin infusion,Bishop score, and Visual Analogue Score (VAS) at analgesia request. Duration of stage I labor did not differ, at 195 (120–300) minutes for both the groups (p=0.7). Combined spinal–epidural was associated with less reduction in uterine contractility after initial administration: 15.34 versus 39.73%, (p<0.001) and with delayed need for oxytocin, at dilations of 7±2.5cm versus 6.±2.7,(p=0.002). Onset of analgesia was quicker for combined spinal–epidural analgesia: 31 versus 20%, with VAS <4 after 5minutes, (p<.001); and lower VAS scores after initial analgesia administration. No differences were found in the other outcomes.
CONCLUSIONS:Combined spinal–epidural with subarachnoid sufentanil may not reduce the duration of stage I labor, but in our study it appeared to affect uterine contractility less. It also had a more rapid onset and was more effective, without any concomitant increase in maternal or neonatal complications.
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