摘要
目的探讨新产程标准下全产程分娩镇痛对母婴结局的影响。方法采用回顾性队列研究方法。以2016年6月至2016年12月在北京大学第一医院拟阴道分娩且按新产程标准管理的907例单胎足月产妇作为研究组,并选择2012年6月至2012年12月按旧产程标准(Friedman产程标准)管理的982例单胎足月产妇为对照组。收集产妇的一般资料、镇痛资料、产科和新生儿资料,比较2组产妇分娩结局及新生儿结局。采用独立样本t检验、秩和检验或χ^2检验(或Fisher精确概率法)对数据进行统计学分析。结果(1)研究组产妇的年龄以及高龄产妇的比例均高于对照组[(30.2±3.0)与(29.6±2.9)岁,t=3.823;8.2%(74/907)与4.2%(41/982),χ^2=13.087;P值均<0.001],2组其他一般资料差异无统计学意义。(2)研究组接受镇痛时宫口扩张程度[M(P25~P75)]小于对照组[2(1~2)与2(1~3)cm,Z=-3.752],镇痛前和第二产程数字等级疼痛评分低于对照组[8(8~9)与8(8~10)分,Z=-14.441;5(4~5)与6(5~7)分,Z=-16.495]。研究组中位镇痛时间较对照组延长[520(340~750)与300(200~453)min,Z=-17.801],镇痛泵用药总量明显多于对照组[68(35~84)与30(18~48)ml,Z=-18.004](P值均<0.001)。2组产妇分娩镇痛相关并发症(低血压、穿破硬脊膜、下肢麻木、皮肤瘙痒和尿潴留)的发生率差异无统计学意义。(3)研究组自然阴道分娩的比例高于对照组[71.8%(651/907)与63.2%(621/982),χ^2=15.623],中转剖宫产的比例低于对照组[13.6%(123/907)与20.5%(201/982),χ^2=18.831](P值均<0.001)。研究组产钳助产的比例显现出低于对照组的趋势,但差异尚未见统计学意义[14.8%(133/907)与15.3%(150/982),χ^2=0.093,P=0.797]。研究组产妇第一产程、第二产程及第三产程持续时间较对照组明显延长[680(470~900)与480(360~660)min,Z=-12.490;56(31~89)与37(24~58)min,Z=-9.964;7(5~10)与6(5~8)min,Z=-6.673;P值均<0.001]。研究组人工破膜率低于对照组[55.2%(501/907)与63.2%(621/982),χ^2=12.516,P<0.001]。研究组产时发热、病理证实感染、产后出血发生率显著高于对照组[10.8%(98/907)与6.4%(63/982),χ^2=11.652;9.6%(87/907)与3.7%(36/982),χ^2=27.201;12.6%(114/907)与5.7%(56/982),χ^2=27.144;P值均<0.05]。2组产妇产程中缩宫素使用率和输血治疗率差异无统计学意义。(4)研究组因活跃期停滞而施行剖宫产术的比例显著低于对照组[5.7%(7/123)与50.2%(101/201),χ^2=68.173,P<0.05],因宫内感染、相对头盆不称中转剖宫产的比例高于对照组[61.0%(75/123)与30.8%(62/201),χ^2=2.680;20.3%(25/123)与8.0%(16/201),χ^2=10.555;P值均<0.05]。2组胎儿窘迫及其他指征中转剖宫产的比例差异无统计学意义。(5)2组新生儿出生体重、巨大儿、胎儿窘迫、新生儿窒息及转新生儿重症监护病房的比例差异均无统计学意义。结论新产程标准下全产程镇痛延长了平均镇痛时间,减少了以活跃期停滞为指征的剖宫产,虽然轻度增加了产后出血的风险,但未增加产钳助产、母体输血治疗及新生儿窒息的风险。
Objective To explore the effects of whole-stage labor analgesia on maternal and neonatal outcomes after the implementation of the new partogram. Methods A retrospective cohort study was performed in Peking University First Hospital. From June to December 2016. 907 nulliparae with fullterm singleton cephalic pregnancies that were expected to deliver vaginally and adhered to the new partogram were selected as the study group, and 982 cases that adhered to the old partogram (Friedman standard) from June to December 2012 were selected as the control group. Maternal basic characteristics and analgesic, obstetric and neonatal data were collected. Maternal and neonatal outcomes between the two groups were analyzed with independent sample t-test, rank sum test or Chi-square test (Fisher's exact test). Results (I) Maternal age and the proportion of gravidas of advanced maternal age in the study group were both higher than those in the control group [(30.2±3.0) vs (29.6±2.9) years,t=3.823;8.2%(74/907) vs 4.2%(41/982),χ^2=13.087: both P<0.001 ]. No statistically significant difference in the other basic characteristics was found between the two groups.(2) Women in the study group had significantly smaller cervical dilatation [A/(P25-P75)] than that in the control group when analgesia was commenced [2( 1 2) vs 2( 1 -3) cm. Z=- 3.752). The intensity of pain quantified with numerical rating scale (NRS) before analgesia, and during the second stage of labor in the study group were less than that in the control group [8(8-9) vs 8(8-10) points, Z=-14.441: 5(4-5) vs 6(5~7) points, Z=-16.495). The study group had longer median duration of analgesia than the control group [520(340-750) vs 300(200-453) min. Z=- 17.801, P<0.00l ]. The overall dose of analgesics in injection pump in the study group was significantly higher compared with that used in the control group [68 (35-X4) vs 30 (18-48) ml, Z=- 18.004, P<0.001]. However, there was no significant difference in the incidence of analgesia-related complications (hypotension, accidental dura puncture, lower extremity numbness, pruritus and urinary retention) between the two groups.(3) The study group showed a higher percentage of spontaneous vaginal delivery, and a lower rate of converted cesarean section compared with the control group [71.8%(651/907) vs 63.2%(621/982),χ^2=15.623;13.6%(123/907) vs 20.5%(201/982),/2=18.831;both P<0.00l ]. The study group had lower forceps-assisted vaginal delivery rate than the control group without statistically significant difference [14.8%(133/907) vs 15.3%(150/982),χ^2=0.093, P=0.797]. The duration of the first, second and third stage of labor in the study group were all significantly Ion ger than that of the control group [680 (470 900) vs 480 (360-660) min. Z=-12.490;56 (31 ~89) vs 37 (24 58) min. Z=-9.964;7 (5-10) vs 6 (5-8) min, Z=- 6.673;all P<0.001]. Women in the study group had a lower rate of artificial rupture of membranes when comparing with the control group [55.2%(501/907) vs 63.2%(621/982),χ^2=12.516, P<0.001]. The incidence of fever, pathologically confirmed infection and postpartum hemorrhage were significantly higher in the study group than that in the control group [10.8%(98/907) vs 6.4%(63/982),χ^2=11.652;9.6%(87/907) vs 3.7%(36/982),X^2=27.201;12.6%(114/907) vs 5.7%(56/982),χ^2=27.144: all P<0.05]. There was no significant difference in the rate of oxytocin use during labor or blood transfusion between the two groups.(4) Compared with the control group, the proportion of cesarean section due to arrested active stage of labor in the study group was significantly lower [5.7%(7/123) vs 50.2%(101/201),X^2=68.173. P<0.05], but the incidences of cesarean section due to intrauterine infection and relative cephalopelvic disproportion were higher in the study group [61.0%(75/123) vs 30.8%(62/201).X^2=2.680;20.3%(25/123) vs 8.0%(16/201).X^2=10.555;both P<0.05]. There was no significant difference in the proportion of fetal distress or other indications for cesarean section between the two groups.(5) There was no significant differenee between the two groups in birth weight, macrosomia, fetal distress, neonatal asphyxia, or the proportion of neonatal intensive care unit admission. Conclusions After the implementation of the new partogram. analgesic pain relief covering the whole labor prolongs the average analgesic time and reduces the rate of cesarean section due to arrested active stage of labor. Although the risk of postpartum hemorrhage is slightly increased, analgesia itself does not pose additional risks on forceps-assisted delivery, maternal blood transfusion and neonatal asphyxia.
作者
包菊
赫英东
包艾荣
曲元
Bao Ju;He Yingdong;Bao Airong;Qu Yuan(Department of Anesthesiology, Peking University First Hospital, Beijing 100034, China;Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing 100034, China)
出处
《中华围产医学杂志》
CAS
CSCD
北大核心
2019年第2期106-112,共7页
Chinese Journal of Perinatal Medicine
关键词
分娩
产道
镇痛
硬膜外
产程
第二
镇痛
产科
剖宫产术
Labor, obstetric
Analgesia, epidural
Labor stage, second: Analgesia, obstetrical
Cesarean section
