Lawrence Family Medicine Residency Program, Lawrence, MA, USA.
Am Fam Physician. 2021 Mar 15;103(6):355-364.
A patient's sense of empowerment and control is most predictive of maternal satisfaction with childbirth. Analgesia during labor greatly affects this experience. Individual patient priorities for labor pain management should be explored as part of routine prenatal care. Continuous labor support, water immersion, and upright positioning in the first stage of labor are associated with decreased use of pharmacologic analgesia. Despite the increased risk of adverse effects, self-administered inhaled nitrous oxide appears to be safe and effective for pain relief; however, its negative environmental impact as a greenhouse gas is a drawback. Evidence is lacking that any one opioid is superior in maximizing pain relief while minimizing adverse effects. Neuraxial anesthesia provides the most effective pharmacologic analgesia and is used in nearly three-fourths of labors in the United States. Neuraxial regional anesthesia is not associated with increased rates of cesarean delivery or assisted vaginal delivery, and it has only a small effect on the length of the second stage of labor. Epidural, spinal, combined spinal-epidural, and dural puncture epidural anesthesia are commonly used neuraxial techniques. Paracervical and pudendal blocks are safe and effective pain management options in specific circumstances. Both transversus abdominis plane block and subcutaneous wound infiltration with local anesthetic can decrease the use of postoperative analgesia. Patients with opioid use disorder require individualized pain management plans throughout perinatal care, and judicious opioid prescribing practices are encouraged for all patients.
患者的赋权感和控制感对产妇对分娩的满意度最具预测性。分娩时的镇痛极大地影响了这种体验。应在常规产前护理中探讨个体患者对分娩疼痛管理的优先事项。在第一产程中持续的产时支持、水中分娩和直立位与减少使用药物性镇痛相关。尽管有增加不良反应的风险，但自我给予吸入一氧化二氮似乎安全有效，可缓解疼痛；然而，作为一种温室气体，其对环境的负面影响是一个缺点。没有证据表明任何一种阿片类药物在最大限度地缓解疼痛的同时最小化不良反应方面具有优势。椎管内麻醉提供最有效的药物性镇痛，在美国近四分之三的分娩中使用。椎管内区域麻醉与剖宫产率或辅助阴道分娩率的增加无关，并且对第二产程的长度只有很小的影响。硬膜外、脊髓、腰硬联合和硬膜外穿刺麻醉是常用的椎管内技术。宫颈旁和阴部阻滞在特定情况下是安全有效的疼痛管理选择。腹横肌平面阻滞和局部麻醉皮下浸润均可减少术后镇痛的使用。阿片类药物使用障碍患者在围产期护理期间需要个体化的疼痛管理计划，鼓励所有患者合理开具阿片类药物。
