许兰兰 陆红明 刘景菁 邹昌骝

[摘要] 目的 探讨程序性简短硬膜外给药技术联合硬膜刺破硬膜外麻醉优化技术在产妇分娩镇痛中的安全性和有效性。 方法 选取2019年12月至2020年12月在深圳市罗湖人民医院和西林县人民医院进行分娩镇痛的产妇110例，采用随机数字表法分为程序性间断硬膜外给药组（P组，n=55）和对照组（C组，n=55），记录镇痛前，镇痛后10、30、60、90 min，第二产程VAS评分，产妇的心率及MAP、PCEA次数及产妇剖宫产率、器械助产率、Bromage 评分、不良反应（胎心减速率、低血压、恶心呕吐、瘙痒、神经功能障碍）、新生儿1 min及5 min Apgar评分。 结果 P组在分娩镇痛后60 min、第二产程的MAP[（74.71±6.84）mmHg，（80.38±6.59）mmHg]，第二产程VAS为（1.49±1.12）分、PECA为（3.76±2.21）次，均低于C组镇痛后60 min的第二產程MAP[（79.31±7.10）mmHg，82.84±5.81）mmHg]，第二产程VAS（1.49±1.12）分及PECA次数（5.29±3.20）次，两组比较，差异有统计学意义（P<0.05）;两组分娩方式、不良反应及新生儿Apgar评分等比较，差异均无统计学意义（P>0.05）。 结论 PIEB联合DPE技术对产妇MAP的影响更大，并且能够提供更好的第二产程镇痛效果及更少的药物使用量，对产科结局、运动神经阻滞情况、不良反应及新生儿结局都未产生不良影响。

[关键词] 硬膜外麻醉;分娩镇痛;程序性间断硬膜外给药;硬脊膜穿破硬膜外麻醉

[中图分类号] R715.7          [文献标识码] B          [文章编号] 1673-9701（2021）30-0128-04

[Abstract] Objective To explore the safety and effectiveness of programmed intermittent epidural bolus （PIEB） combined with optimized dural puncture epidural （DPE） anesthesia in maternal labor analgesia. Methods A total of 110 puerperae who underwent labor analgesia in Shenzhen Luohu People′s Hospital and Xilin People′s Hospital from December 2019 to December 2020 were selected. They were divided into the programmed intermittent epidural bolus group （group P，n=55） and the control group （group C，n=55） by using the random number table method. The scores of Visual Analogue Scale/Score（VAS），heart rate，mean arterial pressure （MAP）， number of patient controlled epidural analgesia （PCEA） of puerperae before analgesia， and at 10 min，30 min，60 min and 90 min after analgesia as well as the second stage of labor were recorded.The cesarean section rate， instrument midwifery rate and Bromage score of puerperae， adverse reactions [ARs （the deceleration rate of fetal heart， hypotension， nausea and vomiting， pruritus， neurological dysfunction）]， and the Apgar score of the neonates at 1 min and 5 min after birth were also recorded. Results The MAP at 60 min after analgesia and the second stage of labor [（76.29±6.25）mmHg， 80.32±6.59） mmHg]， VAS score at the second stage of labor （1.49±1.12）points， and number of PECA （3.76±2.21）times in group P were all lower than those of group C[（79.31±7.10）mmHg，（82.84±5.81）mmHg]， （1.49±1.12） points and （5.29±3.20）times， respectively]， with statistically significant differences（P<0.05）.There were no statistically significant differences between the two groups in mode of delivery， ARs and Apgar scores of the neonates（all P>0.05）. Conclusion PIEB combined with DPE technique has a greater effect on MAP of puerperae and can provide better analgesia in the second stage of labor with less drug use. It has no adverse effects on obstetric outcomes， motor nerve block conditions， ARs and neonatal outcomes.

[Key words] Epidural anesthesia; Labor analgesia; Programmed intermittent epidural bolus; Dural puncture epidural anesthesia

生产痛机制多种多样，受到心理和生理等方面的多重因素影响，椎管内镇痛被认为是分娩镇痛中最为有效的方法。硬脊膜穿破硬膜外阻滞术（Dural puncture epidural，DPE）是对椎管内神经阻滞的一种技术改进，即用脊髓针在硬膜上穿孔，但不用于直接向蛛网膜下腔内给药。近年研究[1-2]发现，硬膜外穿刺术与传统硬膜外神经阻滞相比较有更快的起效时间和稳定的镇痛效果，并且对产妇和新生儿的副作用更小。……