分娩鎮(zhèn)痛進(jìn)展課件

分娩鎮(zhèn)痛進(jìn)展課件1847年蘇格蘭產(chǎn)科醫(yī)生SimpsonJ給分娩產(chǎn)婦吸入乙醚以緩解疼痛，得出的印象是藥物可以緩解分娩痛，但同時要關(guān)注其副作用，包括對子宮收縮、腹部肌張力以及對胎兒的影響Epiduralanalgesiainlabourisusedbyabout100

000womeninBritaineachyearBMJ2002;325:357分娩痛產(chǎn)生的機(jī)制理想的分娩鎮(zhèn)痛dramaticallyreducethepainoflabour,whileallowingtheparturienttoactivelyparticipateinthebirthingexperience.Inaddition,itshouldhaveminimaleffectonthefetusortheprogressoflabourRegionalanalgesiaforlabour

spinalopiatesandcombinedspinal-epidural(CSE)analgesiapatientcontrolledepiduralanalgesiacontinuousspinalanalgesianeuraxialblockade(epidural,spinal,CSE,continuousspinal)providesthemosteffectiveandleastdepressantanalgesiaEpiduralanalgesiaviaacathetertechniqueprovidesexcellentpainreliefandtheabilitytoextendthedurationoftheblocktomatchthedurationoflabour,butitisnot"instant"inonsetandmaybeassociatedwithmotorblock.One-shotspinalanalgesiausingalipidsolubleopioidisrapidandsimple,butisassociatedwithalimiteddurationofactionThecombinationofepiduralandspinalanesthesiaintoonetechnique,termed"CSE"providestheadvantagesofaspinal(speedofonset,lackofmotorblock)withtheadditionalflexibilityofrenewalwithanepiduralcatheter.CSEcanbesafelyusedtoprovidelabouranalgesiainparturientswhoaretoreceiveanepiduralforlabourspecificpatientswhowillgreatlybenefitfromthistechnique.Theseincludepatientsinearlyorlatelabour

earlylabourcanbemadecomfortablewithspinalnarcotics(suchassufentanilorfentanyl)whichwilllastforapproximatelytwotothreehours,duringwhichtimethepatientwillnothaveamotorblockandwillbeabletoambulate.advantageofCSEforpatientsinlatelabouristhealmostimmediatepainreliefCSEallowsforambulationoftheparturient,ithasbeencalledthe"walkingepidural."ArecentstudyhasevaluatedCSEand"mobileepidurals"andhasconcludedthatCSEprovidesbetterpainreliefintheearlystagesafterinsertionAnesthesiology2002;97:1567–75CSEanalgesiaforlabourisusuallyachievedusingashort-actinglipidsolublenarcoticsuchasfentanylorsufentanilmorphinehasbeendescribedasanintrathecalopiateforlabour,ithasseveraldisadvantagesincludingslowonset,incompleteanalgesia,prolongednauseaandpruritus,anddelayedrespiratorydepressionpruritusisassociatedwithlipidsolubleopioids,itisusuallymildandshortlivedanddoesnotgenerallyneedtobetreatedAreviewofthecomplicationsassociatedwithCSEhasconcludedthatCSEisassafeatechniqueasaconventionalepiduraltechniqueandisassociatedwithgreaterpatientsatisfactionNorrisMCetal.AnesthAnalg1995;79:529–37opioidsaremostoftenusedtoproduceanalgesiainthelabouringpatient:sufentanil2.5to10μg;

fentanyl10to25μg.

Incaseswherethesecondstageoflabourisimminent,thesubarachnoidadministrationofacombinationoflocalanestheticplusopioidshouldbeconsideredcombinationofsufentanil2.5to5μgplusbupivacaine2.5mgprovidesrapidanalgesiawithoutmotorblock,alleviatesthepainofthesecondstageoflabour,andlastslongerthansufentanilalone.AnesthAnalg1995;81:305–9EffectsofEpiduralAnalgesiaonLaborandMaternalandInfantOutcomes

AmJObstetGynecol2002;186(Suppl5):S31-68.AmJObstetGynecol2002;186(Suppl5):S69-77.TABLE1

EffectsofEpiduralAnalgesiaonLaborandMaternalandInfantOutcomes

Laborfactors

Outcome*

Pvalue

EffectsonlaborDurationoffirststage14Increasedby26minutesNS?Durationofsecondstage14Increasedby15minutes<.05

Painscore(100mmVAS)14

Firststage40mmlower<.0001Secondstage29mmlower<.001Useofoxytocin(Pitocin)afteranalgesia14Increased(OR,2.8;95%CI,1.89to4.16)<.05Third-orfourth-degreeperineallaceration13Increased(OR,1.7-2.7)N/AInstrument-assisteddelivery14Increased(OR,2.1;95%CI,1.48to2.93)<.05Cesareandelivery14OR,1.0;95%CI,0.77to1.28NS?MaternaloutcomesFever>38°C(100.4°F)14Increased(OR,5.6;95%CI,4.0to7.8)<.001Lowbackache14

At3monthsOR,1.0;95%CI,0.6to1.6NSAt12monthsOR,1.4;95%CI,0.9to2.3NSUrinaryincontinence14NoincreaseNS§Breastfeedingsuccessat6weeks14NodifferenceNS§Infantoutcomes5-minuteApgarscore<7Nodifference13,14NSLowumbilicalcordpHNodifference13,14NSNeonatalsepsisevaluation13IncreasedN/ANeonatalantibiotictreatment13IncreasedN/APossiblecomplicationsandsideeffectsofintrathecalopioidsforlabourCSEhasbeenreportedtobeassafeasconventionalepiduraltechniquespruritus;

nausea/vomiting;

hypotension;

urinaryretention;

uterinehyperstimulationandfetalbradycardia;

maternalrespiratorydepression.

Uterinehyperstimulation/fetalbradycardiaspinalopioids,perhapsduetotheirassociateddecreaseinmaternalcatecholamines,mayprecipitateuterinehypertonicityandfetalbradycardiaPostduralpunctureheadache(PDPH)useofsmallbore"atraumatic"spinalneedleswillreducetheincidenceofPDPHinpatientsreceivingCSEtoapproximately1%orless.incidenceofunintentionalduralpunctureislessinCSEpatientsthaninpatientsreceivingconventionalepiduralspossibleexplanationforthisfindingisthat,aspartoftheCSEtechnique,thespinalneedlemaybeusedforverificationofcorrectplacementoftheepiduralneedlewhenthereisinconclusivelossofresistance.Subarachnoidmigrationoftheepiduralcatheteralmostimpossibletopassanepiduralcatheterthroughasingleduralholemadebya25gspinalneedleSpecialepiduralneedleswithaseparateportforthespinalneedlearenowavailableandshouldtotallypreventtheunintentionalsubarachnoidthreadingoftheepiduralcatheterRegardlessofneedleused,allepiduraldosesshouldbeincremental.RespiratorydepressionSufentanilandfentanyl-inducedcentralrespiratorydepressionhavebeenreportedbutareextremelyrareThisrespiratorydepressionoccursacutelyandthereforeanypatientreceivingCSEmustbeappropriatelymonitoredforsignsofrespiratorydepressionforaperiodofatleast20minfollowingadministrationofthesubarachnoidopioid.Anesthesiology1994;81:511–2

硬膜外阻滯應(yīng)用的時機(jī)多數(shù)研究顯示，過早采用硬膜外阻滯可以增加剖宮產(chǎn)率和器械助產(chǎn)的機(jī)率。美國婦產(chǎn)科醫(yī)師協(xié)會推薦：如果情況允許，應(yīng)該等宮口開至4～5cm再采用硬膜外阻滯行分娩鎮(zhèn)痛，其他的鎮(zhèn)痛措施也應(yīng)該在這一時機(jī)應(yīng)用，目的是減少剖宮產(chǎn)及器械助產(chǎn)率這一觀點也在改變TimingofEpiduralAnalgesiaduringLabor

Mostobservationalstudiesshowhigherratesofcesareandeliverywithearlyadministrationofepiduralanalgesiathreerandomizedstudiesspecificallycomparingtheinitiationofepiduralanalgesiaatdifferentdegreesofcervicaldilatationinnulliparous(初產(chǎn)婦)womenfoundnodifferenceintherateofcesareandeliveryorinstrument-assistedvaginaldeliverybetweenwomeninwhomanalgesiawasinitiatedearlyandthoseinwhomitwasinitiatedlateEffectofEpiduralAnalgesiaonMaternalTemperatureandtheNewborn

Epiduralanesthesiainnonobstetricalpatientsisgenerallyassociatedwithadecreaseinbodytemperature.Epiduralanesthesiacausesvasodilatationintheanesthetizeddermatomes,whichleadstoaredistributionofheatfromthecoretotheperiphery,resultinginanetdecreaseinbodytemperatureIncontrast,observationalandrandomizedstudiesdemonstratethatepiduralanalgesiaduringlaborisoftenassociatedwithanincreaseinmaternalbodytemperaturetoover100.4°F(38.0°C)arandomizedtrialinwhichfeverwasreported,anadditional11percentofwomenreceivingepiduralanalgesiabecamefebrileduringlabor(15percent,vs.4percentofwomenwhoreceivednoepiduralanalgesia),andtheproportionofthepopulationaffectedwasevengreateramongnulliparouswomen(24percentvs.5percent)Manyinvestigatorsbelievetheassociationofepiduralanalgesiawithfeverisprobablyattributabletononinfectiouscauses,suchasanalterationintheproductionanddissipationofheatresultingfromepiduralanalgesiaFastingduringLaborandDelivery

recentdatafromtheUnitedStatesindicatethatforevery10millionbirths,sevenwomendiefromaspiration.AdvancesinanalgesiapermittheliberalizationofrequirementsforfastingduringlaborAnesthesiology1997;86:277-284

practiceguidelinesoftheAmericanSocietyofAnesthesiologistsrecommendlimitedamountsofclearfluidduringlaborrecentstudydemonstratingthattheuseofisotonicsportdrinksduringlaborhasthepotentialtodecreasetheriskofmaternalketosisassociatedwithstarvingwithoutincreasinggastricvolumeortheriskofnauseaandvomitingAnesthAnalg2002;94:404-408其他方法人工輔助(Continuouslaborsupportprovidedbyadoula)溫水浴法注射無菌水：體位、按摩Intradermalinjectionsof0.1mLofsterilewaterinthetreatmentofwomenwithbackpainduringlabor.Sterilewaterisinjectedintofourlocationsonthelowerback,twoovereachposteriorsuperioriliacspine(PSIS)andtwo3cmbelowand1cmmedialtothePSIS.Theinjectionsshouldraiseablebbelowtheskin.Simultaneousinjectionsadministeredbytwoclinicianswilldecreasethepainoftheinjections.OtheradvancesinlabouranalgesiaContinuousinfusionofdilutelocalanestheticplusopioidroutineuseofcontinuousinfusionofdilutelocalanestheticspluslipidsolubleopioidsbycontinuousinfusionprovidedbetterpainreliefwhileproducinglessmotorblockdrugconcentrationshavebeentestedandcontinuousinfusionshavebeendemonstratedtobesafeforbothmotherandneona