Simmons S W, Cyna A M, Dennis A T, Hughes D
Mercy Hospital for Women, 163 Studley Road, Heidelberg, Melbourne, Victoria, Australia, 3084.
Cochrane Database Syst Rev. 2007 Jul 18(3):CD003401. doi: 10.1002/14651858.CD003401.pub2.
Traditional epidural techniques have been associated with prolonged labour, use of oxytocin augmentation, and increased incidence of instrumental vaginal delivery. The combined spinal-epidural (CSE) technique has been introduced in an attempt to reduce these adverse effects. CSE is believed to improve maternal mobility during labour and provide more rapid onset of analgesia than epidural analgesia, which could contribute to increased maternal satisfaction.
To assess the relative effects of CSE versus epidural analgesia during labour.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2006).
All published randomised controlled trials involving a comparison of CSE with epidural analgesia initiated for women in the first stage of labour.
Three review authors independently assessed the trials identified from the searches for inclusion and extracted the data.
Nineteen trials (2658 women) met our inclusion criteria. Twenty-six outcomes in two sets of comparisons involving CSE versus traditional epidurals and CSE versus low-dose epidural techniques were analysed. Of the CSE versus traditional epidural analyses only three outcomes showed a difference. CSE was more favourable in relation to need for rescue analgesia and urinary retention, but associated with more pruritus. For CSE versus low-dose epidurals, four outcomes were statistically significant. CSE had a faster onset of effective analgesia from time of injection but was associated with more pruritus. CSE was also associated with a clinically non-significant lower umbilical arterial pH. No differences between CSE and epidural were seen for maternal satisfaction, mobilisation in labour, modes of birth, incidence of post dural puncture headache or blood patch and maternal hypotension. It was not possible to draw any conclusions with respect to maternal respiratory depression, maternal sedation and need for labour augmentation.
AUTHORS' CONCLUSIONS: There appears to be little basis for offering CSE over epidurals in labour with no difference in overall maternal satisfaction despite a slightly faster onset with CSE and less pruritus with epidurals. There is no difference in ability to mobilise, obstetric outcome or neonatal outcome. However, the significantly higher incidence of urinary retention and rescue interventions with traditional techniques would favour the use of low-dose epidurals. It is not possible to draw any meaningful conclusions regarding rare complications such as nerve injury and meningitis.
传统硬膜外技术与产程延长、使用缩宫素加强宫缩以及器械助产阴道分娩发生率增加有关。联合腰麻 - 硬膜外麻醉（CSE）技术已被引入，试图减少这些不良反应。人们认为CSE可改善产妇分娩时的活动能力，并比硬膜外镇痛起效更快，这可能会提高产妇满意度。
评估分娩期间CSE与硬膜外镇痛的相对效果。
我们检索了Cochrane妊娠与分娩组试验注册库（2006年12月）。
所有已发表的随机对照试验，比较了在分娩第一阶段为产妇启动的CSE与硬膜外镇痛。
三位综述作者独立评估检索到的试验是否符合纳入标准并提取数据。
19项试验（2658名女性）符合我们的纳入标准。分析了两组比较中的26项结果，涉及CSE与传统硬膜外麻醉以及CSE与低剂量硬膜外技术。在CSE与传统硬膜外麻醉的分析中，只有三项结果显示有差异。在补救性镇痛需求和尿潴留方面，CSE更具优势，但与更多的瘙痒有关。对于CSE与低剂量硬膜外麻醉，四项结果具有统计学意义。CSE从注射时起有效镇痛起效更快，但与更多的瘙痒有关。CSE还与临床上无显著差异的较低脐动脉pH值有关。在产妇满意度、分娩时的活动能力、分娩方式、硬膜外穿刺后头痛或血补丁发生率以及产妇低血压方面，未发现CSE与硬膜外麻醉之间存在差异。关于产妇呼吸抑制、产妇镇静和加强宫缩的需求，无法得出任何结论。
在分娩中，与硬膜外麻醉相比，提供CSE似乎没有什么依据，尽管CSE起效稍快且硬膜外麻醉引起的瘙痒较少，但总体产妇满意度并无差异。在活动能力、产科结局或新生儿结局方面没有差异。然而，传统技术导致的尿潴留和补救性干预发生率显著更高，这有利于使用低剂量硬膜外麻醉。对于神经损伤和脑膜炎等罕见并发症，无法得出任何有意义的结论。
