目的 探讨双管硬膜外阻滞在产妇全产程分娩镇痛中的有效性及其对分娩结局的影响.方法 选择青岛市市立医院产科2006年8月至2008年12月单胎足月初产妇206例,孕周在37～42周,年龄25～35岁.采用前瞻性的研究方法,对206例产妇按随机双盲法分为双管阻滞组(103例)及单管阻滞组(103例).双管阻滞组产妇分别给予镇痛混合液(0.1%盐酸罗哌卡因+0.5 mg/L舒芬太尼)4～6 ml作为初始量,上管45 min后接硬膜外自控镇痛(PCEA)泵,下管每次给药4～6 ml.单管阻滞组产妇给予镇痛混合液10～15 ml作为初始量,给初始量45 min后接PCEA泵.两组产妇均在给予初始量30 min后根据宫缩情况静脉滴入缩宫素.观察指标:(1)对产妇进行疼痛视觉模拟(VAS)评分;(2)采用改良的Bromage评分评价产奸运动阻滞情况;(3)镇痛混合液总量、缩宫素使用率、总产程时间、第二产程时间;(4)新生儿出生体质量、新生儿Apgar 1及5分钟评分;(5)分娩方式;(6)出现规律宫缩、宫口扩张至4 cm、宫口扩张至10 cm、胎儿娩出时血浆血管紧张素Ⅱ、皮质醇水平;(7)观察产妇麻醉相关并发症的发生情况.结果 (1)双管阻滞组新生儿出生体质量、新生儿1及5分钟Apgar评分分别为(3456±468)g、(9.8±0.6)及(9.9±0.7)分,单管阻滞组产妇分别为(3399±569)g、(9.8±0.5)及(9.9±0.7)分,两组分别比较,差异均无统计学意义(P＞0.05);两组产妇Bromage评分均为0分,无运动阻滞情况发生.(2)双管阻滞组产妇镇痛混合液总量、缩宫素应用率、总产程时间及第二产程时间分别为(57±9)ml、59.2%(61/103)、(532±140)min、(46±31)min;单管阻滞组分别为(58±11)ml、81.6%(84/103)、(608±150)min、(60±34)min;双管阻滞组产妇镇痛混合液总量与单管阻滞组比较,差异无统计学意义(P均＞0.05),双管阻滞组产妇缩宫素应用率明显低于单管阻滞组,差异有统计学意义(P＜0.01),且总产程时间、第二产程时间也明显少于单管阻滞组(P＜0.05).(3)双管阻滞组产妇在给予初始量后30 min及第一产程活跃期的VAS评分分别为(1.2±1.1)及(1.1±1.1)分,单管阻滞组产妇分别为(1.2±1.1)及(1.2±1.0)分,两组分别比较,差异均无统计学意义(P＞0.05);双管阻滞组产妇第二产程时VAS评分为(1.2±1.1)分,单管阻滞组产妇为(4.5±2.2)分,两组比较,差异有统计学意义(P＜0.01).(4)双管阻滞组产妇剖宫产率(7.8%,8/103)明显低于单管阻滞组(17.5%,18/103),而器械助产率及会阴侧切率也低于单管阻滞组,两组分别比较,差异均有统计学意义(P＜0.05).在剖宫产指征方面,两组产妇胎儿窘迫及羊水Ⅱ～Ⅲ度污染发生率比较,差异均无统计学意义(P＞0.05);双管阻滞组产妇胎位不正及第二产程阻滞发生率明显低于单管阻滞组,差异均有统计学意义(P＜0.05).(5)双管阻滞组产妇在胎儿娩出时血浆血管紧张素Ⅱ及皮质醇水平分别为(86±25)ng/L及(278±53)nmoL/L,单管阻滞组分别为(100±20)ng/L及(311±53)nmol/L,两组分别比较,差异均有统计学意义(P＜0.05).两组产妇在宫缩规律、宫口扩张至4 cm及宫口扩张至10 cm时的血浆血管紧张素Ⅱ、皮质醇水平比较,差异均无统计学意义(P＞0.05).(6)两组产妇均未发生严重麻醉相关并发症,两组产妇均未发生较为严重的腰痛,基本上是穿刺所引起的穿针点痛,双管阻滞组30例(29.1%,30/103),单管阻滞组32例(31.1%,32/103),两组比较,差异无统计学意义(P＞0.05).结论 双管硬膜外阻滞用于产妇全产程分娩镇痛有良好镇痛效果,对分娩结局无不良影响.%Objective To investigate the efficacy and pregnancy outcomes of women receiving double-catheter epidural block in labor analgesia, and compare the results with single-catheter epidural block.Methods A double-blind clinical trial was conducted on 206 full-term singleton primiparas, aged 25-35 and at the 37 -42 weeks of gestation who delivered at the Department of Obstetrics, Qingdao Municipal Hospital from August 2006 to December 2008, which were randomly divided into two groups:double-catheter epidural block ( group D, n = 103) and single-catheter epidural-block ( group S, n = 103 ).Women in group D were given mixture of 0.1% repivacaine hydrochloride and 0.5 mg/L sufentinil 4 -6 ml as initial dose.Patient control epidural analgesia pump (PCEA) was connected with the upper catheter after 45 minutes.A bolus dose of 4 -6 ml analgesia mixture was infused according to the condition through the lower catheter.Women in group S received analgesia mixture 10 - 15 ml as initial dose and PCEA pump was connected after 45 minutes.Oxytocin was infused in both groups according to uterine contraction after 30 minutes.The following indexes was observed: ( 1 ) visual analogue scales (VAS); (2) modified Bromage Scores;(3) the total dose of analgesia mixture, the percentage of oxytocin infusion, duration of labor and duration of the second stage of labor; (4) fetal birth weight and Apgar scores( 1,5 minutes); (5) mode of delivery; (6) the concentration of plasma cortisol and angiotension Ⅱ at the beginning of regular uterine contraction and at the time when cervical dilated to 4 cm and 10 cm and fetal disengagement; (7)anesthesia-related complications.Results ( 1 )The neonatal birth weight and Apgar scores ( 1,5 minutes)of group D were (3456 ±468)g, 9.8 ±0.6 and 9.9 ±0.7, respectively, while(3399 ±569) g, 9.8 ±0.5 and 9.9 ±0.7 in group S( P ＞0.05).No motor function block was reported in any group and the modified Bromage score was zero.(2) The total dose of analgesia mixture in group D was similar to that in group S [(57 ±9) ml vs.(58 ±11) ml, P＞0.05].However, the percentage of women received oxytocin in group D was smaller [59.2% (61/103) vs.81.6% (84/103), P ＜ 0.01], and the total time of labor and the duration of second stage of labor in group D were shorter[(532 ± 140) minutes vs.(608 ± 150) minutes;(46 ± 31 ) minutes vs.(60 ± 34) minutes, P ＜ 0.05].(3) There were no significant differences in VAS at 30 minutes after initial dose and in the first stage of labor between group D and S ( 1.2 ± 1.1 vs 1.2 ± 1.1,1.1 ± 1.1 vs.1.2 ± 1.0, P＞0.05).VAS at the second stage of labor stage was lower in group D than in group S ( 1.2 ± 1.1 vs.4.5 ± 2.2, P ＜ 0.01 ).(4) The rate of cesarean section, instrumental delivery and episiotomy in group D were lower than in group S (7.8% vs.17.5%, 7.8% vs.15.5%, 10.7% vs.18.4%, P ＜ 0.05).The incidence of fetal distress and meconium-stained amniotic fluid as the indication of cesarean section were similar between the two groups (P ＞ 0.05 ).Lower incidence of fetal malpresentation and arrested second stage of labor were shown in group D than in group S (2.9% vs.9.7%, 1.0% vs.5.8%, P ＜ 0.05 ).(5) The concentration of plasma cortisol and angiotension Ⅱ were lower in group D than in group S [(86 ±25) ng/L vs.( 100 ±20) ng/L, (278 ±53) nmol/L vs.(311 ±53)nmol/L, P＜0.05] only at the end of second stage of labor, but not at any other times(P ＞0.05).(6) No serious anesthesia-related complications were reported in any groups.Some light backache around the puncture point were complained by 29.1% (30/103) of the women in group D and 31.1% (32/103) in group S(P ＞0.05).Conclusion Double-catheter epidural block can provide better analgesia effect during labor than single-catheter epidural block, without any adverse influence on delivery outcomes.
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