Gambling D R, Sharma S K, Ramin S M, Lucas M J, Leveno K J, Wiley J, Sidawi J E
Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, USA.
Anesthesiology. 1998 Dec;89(6):1336-44. doi: 10.1097/00000542-199812000-00010.
Combined spinal-epidural (CSE) analgesia produces rapid-onset pain relief and allows ambulation in early labor. Epidural local anesthetics may contribute to an increase in operative deliveries by decreasing perineal sensation and causing motor weakness. Operative delivery rates might be reduced with CSE, by avoiding or delaying administration of local anesthetics. This study compares the operative delivery rates associated with a CSE technique and those associated with intravenous meperidine for labor analgesia.
Healthy parturients at full term were assigned randomly to receive CSE or intravenous meperidine analgesia. The CSE group received 10 microg intrathecal sufentanil, followed by epidural bupivacaine and fentanyl at their next request for analgesia. Parturients receiving intravenous meperidine had 50 mg on demand (maximum, 200 mg in 4 h). Labor and delivery outcomes in both groups were recorded and compared.
An intent-to-treat analysis of 1,223 women indicated that CSE does not increase the rate of cesarean delivery for dystocia in nulliparous and parous women (CSE, 3.5% vs. intravenous meperidine, 4; P=not significant) or in nulliparous women alone (CSE, 7% vs. intravenous meperidine, 8%; P=not significant). Profound fetal bradycardia that necessitated emergency cesarean delivery within 1 h of the time the mother received sufentanil occurred in 8 of 400 parturients (compared with 0 of 352 who received meperidine; P < 0.01). However, the method of fetal monitoring differed between the two groups. Despite this, neonatal outcomes were similar overall.
Combined spinal-epidural analgesia during labor does not increase the cesarean delivery rate for dystocia in healthy parturient patients at full term, regardless of parity. However, an unexpected increase in the number of cesarean deliveries for profound fetal bradycardia after intrathecal sufentanil was observed. Further investigation is warranted.
腰麻-硬膜外联合（CSE）镇痛起效迅速，可使产妇在分娩早期即可下床活动。硬膜外局部麻醉药可能会降低会阴感觉并导致运动无力，从而增加剖宫产率。通过避免或延迟使用局部麻醉药，CSE可能会降低剖宫产率。本研究比较了CSE技术和静脉注射哌替啶用于分娩镇痛时的剖宫产率。
将足月健康产妇随机分为两组，分别接受CSE或静脉注射哌替啶镇痛。CSE组在产妇下次要求镇痛时，先鞘内注射10微克舒芬太尼，随后硬膜外注射布比卡因和芬太尼。接受静脉注射哌替啶的产妇按需注射50毫克（最大剂量，4小时内200毫克）。记录并比较两组的分娩和产程结局。
对1223名女性进行的意向性分析表明，CSE不会增加初产妇和经产妇因难产而行剖宫产的比例（CSE组为3.5%，静脉注射哌替啶组为4%；P无统计学意义），单独分析初产妇时也是如此（CSE组为7%，静脉注射哌替啶组为8%；P无统计学意义）。400名接受CSE的产妇中有8名在母亲接受舒芬太尼后1小时内出现严重胎儿心动过缓，需要紧急剖宫产（相比之下，接受哌替啶的352名产妇中无1例出现；P<0.01）。然而，两组间胎儿监测方法不同。尽管如此，总体新生儿结局相似。
足月健康产妇分娩期间采用腰麻-硬膜外联合镇痛，无论其是否经产，均不会增加因难产而行剖宫产的比例。然而，观察到鞘内注射舒芬太尼后因严重胎儿心动过缓而行剖宫产的数量意外增加。有必要进行进一步研究。
