Abenhaim Haim A, Fraser William D
Department of Obstetrics and Gynecology, Ste Justine Hospital, University of Montreal, Montreal, QC, Canada.
Am J Obstet Gynecol. 2008 Nov;199(5):500.e1-6. doi: 10.1016/j.ajog.2008.04.052. Epub 2008 Jun 20.
The objective of the study was to assess the effect of suboptimal second-stage pain control on the risk of difficult delivery.
We conducted a secondary analysis of the Pushing Early Or Pushing Late with Epidural (PEOPLE) randomized, controlled trial cohort on second-stage nulliparous women. We defined suboptimal pain control as a visual analog pain scale score of 30 or greater on a scale of 100 and evaluated initial postrandomization and subsequent pain control on obstetrical interventions and outcomes. We estimated adjusted relative risk for caesarean delivery using logistic regression models to control for confounding variables and to evaluate the role of effect measure modifiers.
One thousand seven hundred fifty-six women were included in the cohort, of which 1565 (89.1%) had optimal analgesia and 191 (10.9%) had suboptimal analgesia. Women with suboptimal analgesia had an increased risk of cesarean delivery of 2.97 (1.52-5.80), midpelvic procedures of 1.83 (1.10-3.05), and third- and fourth-degree perineal tears of 1.82 (1.03-3.21). As compared with women with sustained optimal analgesia, increasing levels of pain were associated with an increase in difficult deliveries, 2.19 (1.50-3.21). The improvement of relief among women with initial suboptimal initial analgesia did not alter the risk of difficult deliveries.
Although most women achieve optimal epidural analgesia, the inability to sustain optimal epidural analgesia is associated with an increased risk of adverse second-stage obstetrical outcomes.
本研究的目的是评估第二产程疼痛控制不佳对难产风险的影响。
我们对硬膜外麻醉下早期或晚期用力分娩（PEOPLE）随机对照试验队列中的初产妇进行了二次分析。我们将疼痛控制不佳定义为视觉模拟疼痛量表评分在100分制中达到30分或更高，并评估随机分组后的初始疼痛控制以及随后对产科干预措施和结局的疼痛控制情况。我们使用逻辑回归模型估计剖宫产的调整相对风险，以控制混杂变量并评估效应测量修饰因素的作用。
该队列纳入了1756名女性，其中1565名（89.1%）有最佳镇痛效果，191名（10.9%）镇痛效果不佳。镇痛效果不佳的女性剖宫产风险增加2.97（1.52 - 5.80），中骨盆手术风险增加1.83（1.10 - 3.05），会阴三度和四度撕裂风险增加1.82（1.03 - 3.21）。与持续获得最佳镇痛效果的女性相比，疼痛程度增加与难产风险增加相关，为2.19（1.50 - 3.21）。初始镇痛效果不佳的女性疼痛缓解情况的改善并未改变难产风险。
尽管大多数女性实现了最佳硬膜外镇痛，但无法维持最佳硬膜外镇痛与第二产程不良产科结局风险增加相关。
