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临产与分娩的椎管内镇痛(含器械助产)

Authors
Roulhac d'Arby Toledano, MD, PhD
Lisa Leffert, MD
Section Editor
David L Hepner, MD
Deputy Editor
Marianna Crowley, MD
Translators
王嘉锋, 主治医师

引言

椎管内镇痛是临产与分娩过程中最有效且最常用的缓解疼痛的方式。目前已有多种方法可减轻分娩疼痛，例如硬膜外镇痛、蛛网膜下腔-硬膜外联合阻滞(combined spinal–epidural, CSE)及其他中枢椎管内技术[包括硬膜穿刺硬膜外技术(dural puncture epidural, DPE)、单次注射蛛网膜下腔镇痛、连续性蛛网膜下腔镇痛]。在多数病例中，这些技术可提供非常好的镇痛效果，对母体和胎儿的风险最小。

本专题将讨论椎管内临产镇痛的适应证、常用技术及所使用的药物。有关临产和分娩的疼痛传导通路、控制临产疼痛的其他药理学方法、椎管内技术及椎管内阻滞不良反应的内容将会单独详细讨论。 (参见“临产和分娩过程中疼痛的药物治疗”，关于‘疼痛的途径’一节和“临产和分娩过程中疼痛的药物治疗”，关于‘临产疼痛的不良结局’一节和“产科椎管内镇痛和麻醉的不良反应”和“脊麻：技术”)

椎管内镇痛的适应证

椎管内临产镇痛可用于缓解临产疼痛，并在需转为手术分娩时，提供手术麻醉所需的原位硬膜外导管。

疼痛缓解 — 椎管内镇痛适用于临产女性，无论其产次、宫口扩张程度和胎头位置如何(除非存在禁忌证)[1]。此类技术通常简单易行，很少发生危及生命的并发症，其副作用(如瘙痒和低血压)短暂且容易处理。如下一般原则适用于临产的椎管内镇痛：

●美国妇产科医师学会(American College of Obstetricians and Gynecologists, ACOG)和美国麻醉学医师协会(American Society of Anesthesiologists, ASA)均同意在排除医学禁忌证后，母亲的要求是临产时缓解疼痛的充分指征[1]。

                                     

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Literature review current through: 2017-06 . | This topic last updated: 2017-06-27.
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References
Top
  1. ACOG Committee Opinion No. 295, Pain Reilief During Labor, July 2004 (replaces No. 231, February 2000; reaffirmed 2015). http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Pain-Relief-During-Labor (Accessed on May 19, 2016).
  2. Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2016; 124:270.
  3. Bauer ME, Kountanis JA, Tsen LC, et al. Risk factors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia: a systematic review and meta-analysis of observational trials. Int J Obstet Anesth 2012; 21:294.
  4. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010; 35:64.
  5. Perlas A, Chaparro LE, Chin KJ. Lumbar Neuraxial Ultrasound for Spinal and Epidural Anesthesia: A Systematic Review and Meta-Analysis. Reg Anesth Pain Med 2016; 41:251.
  6. Ansari T, Yousef A, El Gamassy A, Fayez M. Ultrasound-guided spinal anaesthesia in obstetrics: is there an advantage over the landmark technique in patients with easily palpable spines? Int J Obstet Anesth 2014; 23:213.
  7. Heesen M, Van de Velde M, Klöhr S, et al. Meta-analysis of the success of block following combined spinal-epidural vs epidural analgesia during labour. Anaesthesia 2014; 69:64.
  8. Lee S, Lew E, Lim Y, Sia AT. Failure of augmentation of labor epidural analgesia for intrapartum cesarean delivery: a retrospective review. Anesth Analg 2009; 108:252.
  9. Groden J, Gonzalez-Fiol A, Aaronson J, et al. Catheter failure rates and time course with epidural versus combined spinal-epidural analgesia in labor. Int J Obstet Anesth 2016; 26:4.
  10. Booth JM, Pan JC, Ross VH, et al. Combined Spinal Epidural Technique for Labor Analgesia Does Not Delay Recognition of Epidural Catheter Failures: A Single-center Retrospective Cohort Survival Analysis. Anesthesiology 2016; 125:516.
  11. Simmons SW, Taghizadeh N, Dennis AT, et al. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database Syst Rev 2012; 10:CD003401.
  12. American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques. Practice advisory for the prevention, diagnosis, and management of infectious complications associated with neuraxial techniques: a report by the American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques. Anesthesiology 2010; 112:530.
  13. Hebl JR. The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med 2006; 31:311.
  14. Toledano RD, Tsen LC. Epidural catheter design: history, innovations, and clinical implications. Anesthesiology 2014; 121:9.
  15. Spiegel JE, Vasudevan A, Li Y, Hess PE. A randomized prospective study comparing two flexible epidural catheters for labour analgesia. Br J Anaesth 2009; 103:400.
  16. Mhyre JM, Greenfield ML, Tsen LC, Polley LS. A systematic review of randomized controlled trials that evaluate strategies to avoid epidural vein cannulation during obstetric epidural catheter placement. Anesth Analg 2009; 108:1232.
  17. Sviggum HP, Farber MK. The incidence and management of inability to advance Arrow FlexTip Plus epidural catheters in obstetric patients. Int J Obstet Anesth 2014; 23:113.
  18. Mhyre JM. Why do pharmacologic test doses fail to identify the unintended intrathecal catheter in obstetrics? Anesth Analg 2013; 116:4.
  19. Mulroy MF, Norris MC, Liu SS. Safety steps for epidural injection of local anesthetics: review of the literature and recommendations. Anesth Analg 1997; 85:1346.
  20. Zakowski MI, Ramanathan S. Uteroplacental circulation and respiratory gas exchange. In: Shnider and Levinson's Anesthesia for Obstetrics, 5th ed, Suresh MS, Segal BS, Preston R, et al. (Eds), Lippincott, Williams & Wilkins, Philadelphia 2013. p.18.
  21. D'Angelo R, Smiley RM, Riley ET, Segal S. Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2014; 120:1505.
  22. Lamont RF, Pinney D, Rodgers P, Bryant TN. Continuous versus intermittent epidural analgesia. A randomised trial to observe obstetric outcome. Anaesthesia 1989; 44:893.
  23. Smedstad KG, Morison DH. A comparative study of continuous and intermittent epidural analgesia for labour and delivery. Can J Anaesth 1988; 35:234.
  24. Halpern SH, Carvalho B. Patient-controlled epidural analgesia for labor. Anesth Analg 2009; 108:921.
  25. van der Vyver M, Halpern S, Joseph G. Patient-controlled epidural analgesia versus continuous infusion for labour analgesia: a meta-analysis. Br J Anaesth 2002; 89:459.
  26. Capogna G, Stirparo S. Techniques for the maintenance of epidural labor analgesia. Curr Opin Anaesthesiol 2013; 26:261.
  27. Sumikura H, van de Velde M, Tateda T. Comparison between a disposable and an electronic PCA device for labor epidural analgesia. J Anesth 2004; 18:262.
  28. Sng BL, Zhang Q, Leong WL, et al. Incidence and characteristics of breakthrough pain in parturients using computer-integrated patient-controlled epidural analgesia. J Clin Anesth 2015; 27:277.
  29. Lim Y, Sia AT, Ocampo C. Automated regular boluses for epidural analgesia: a comparison with continuous infusion. Int J Obstet Anesth 2005; 14:305.
  30. Fettes PD, Moore CS, Whiteside JB, et al. Intermittent vs continuous administration of epidural ropivacaine with fentanyl for analgesia during labour. Br J Anaesth 2006; 97:359.
  31. Wong CA, Ratliff JT, Sullivan JT, et al. A randomized comparison of programmed intermittent epidural bolus with continuous epidural infusion for labor analgesia. Anesth Analg 2006; 102:904.
  32. Capogna G, Camorcia M, Stirparo S, Farcomeni A. Programmed intermittent epidural bolus versus continuous epidural infusion for labor analgesia: the effects on maternal motor function and labor outcome. A randomized double-blind study in nulliparous women. Anesth Analg 2011; 113:826.
  33. Wong CA, McCarthy RJ, Hewlett B. The effect of manipulation of the programmed intermittent bolus time interval and injection volume on total drug use for labor epidural analgesia: a randomized controlled trial. Anesth Analg 2011; 112:904.
  34. Margarido CB, Mikhael R, Arzola C, et al. The intercristal line determined by palpation is not a reliable anatomical landmark for neuraxial anesthesia. Can J Anaesth 2011; 58:262.
  35. Lee AJ, Ranasinghe JS, Chehade JM, et al. Ultrasound assessment of the vertebral level of the intercristal line in pregnancy. Anesth Analg 2011; 113:559.
  36. Locks Gde F, Almeida MC, Pereira AA. Use of the ultrasound to determine the level of lumbar puncture in pregnant women. Rev Bras Anestesiol 2010; 60:13.
  37. Palmer CM. Continuous spinal anesthesia and analgesia in obstetrics. Anesth Analg 2010; 111:1476.
  38. Arkoosh VA, Palmer CM, Yun EM, et al. A randomized, double-masked, multicenter comparison of the safety of continuous intrathecal labor analgesia using a 28-gauge catheter versus continuous epidural labor analgesia. Anesthesiology 2008; 108:286.
  39. Jagannathan DK, Arriaga AF, Elterman KG, et al. Effect of neuraxial technique after inadvertent dural puncture on obstetric outcomes and anesthetic complications. Int J Obstet Anesth 2016; 25:23.
  40. Suzuki N, Koganemaru M, Onizuka S, Takasaki M. Dural puncture with a 26-gauge spinal needle affects spread of epidural anesthesia. Anesth Analg 1996; 82:1040.
  41. Cappiello E, O'Rourke N, Segal S, Tsen LC. A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia. Anesth Analg 2008; 107:1646.
  42. Thomas JA, Pan PH, Harris LC, et al. Dural puncture with a 27-gauge Whitacre needle as part of a combined spinal-epidural technique does not improve labor epidural catheter function. Anesthesiology 2005; 103:1046.
  43. Ginosar Y, Davidson EM, Firman N, et al. A randomized controlled trial using patient-controlled epidural analgesia with 0.25% versus 0.0625% bupivacaine in nulliparous labor: effect on analgesia requirement and maternal satisfaction. Int J Obstet Anesth 2010; 19:171.
  44. Christiaens F, Verborgh C, Dierick A, Camu F. Effects of diluent volume of a single dose of epidural bupivacaine in parturients during the first stage of labor. Reg Anesth Pain Med 1998; 23:134.
  45. Lyons GR, Kocarev MG, Wilson RC, Columb MO. A comparison of minimum local anesthetic volumes and doses of epidural bupivacaine (0.125% w/v and 0.25% w/v) for analgesia in labor. Anesth Analg 2007; 104:412.
  46. Polley LS, Columb MO, Naughton NN, et al. Relative analgesic potencies of ropivacaine and bupivacaine for epidural analgesia in labor: implications for therapeutic indexes. Anesthesiology 1999; 90:944.
  47. Lacassie HJ, Columb MO, Lacassie HP, Lantadilla RA. The relative motor blocking potencies of epidural bupivacaine and ropivacaine in labor. Anesth Analg 2002; 95:204.
  48. Beilin Y, Halpern S. Focused review: ropivacaine versus bupivacaine for epidural labor analgesia. Anesth Analg 2010; 111:482.
  49. Grice SC, Eisenach JC, Dewan DM. Labor analgesia with epidural bupivacaine plus fentanyl: enhancement with epinephrine and inhibition with 2-chloroprocaine. Anesthesiology 1990; 72:623.
  50. Hess PE, Snowman CE, Hahn CJ, et al. Chloroprocaine may not affect epidural morphine for postcesarean delivery analgesia. J Clin Anesth 2006; 18:29.
  51. Niemi G, Breivik H. Epinephrine markedly improves thoracic epidural analgesia produced by a small-dose infusion of ropivacaine, fentanyl, and epinephrine after major thoracic or abdominal surgery: a randomized, double-blinded crossover study with and without epinephrine. Anesth Analg 2002; 94:1598.
  52. Roelants F, Lavand'homme P. Clonidine versus sufentanil as an adjuvant to ropivacaine in patient-controlled epidural labour analgesia: A randomised double-blind trial. Eur J Anaesthesiol 2015; 32:805.
  53. Van de Velde M, Berends N, Kumar A, et al. Effects of epidural clonidine and neostigmine following intrathecal labour analgesia: a randomised, double-blind, placebo-controlled trial. Int J Obstet Anesth 2009; 18:207.
  54. Boogmans T, Vertommen J, Valkenborgh T, et al. Epidural neostigmine and clonidine improves the quality of combined spinal epidural analgesia in labour: a randomised, double-blind controlled trial. Eur J Anaesthesiol 2014; 31:190.
  55. Ross VH, Pan PH, Owen MD, et al. Neostigmine decreases bupivacaine use by patient-controlled epidural analgesia during labor: a randomized controlled study. Anesth Analg 2009; 109:524.
  56. Campbell DC, Camann WR, Datta S. The addition of bupivacaine to intrathecal sufentanil for labor analgesia. Anesth Analg 1995; 81:305.
  57. Wong CA, Scavone BM, Loffredi M, et al. The dose-response of intrathecal sufentanil added to bupivacaine for labor analgesia. Anesthesiology 2000; 92:1553.
  58. Wong CA, Scavone BM, Slavenas JP, et al. Efficacy and side effect profile of varying doses of intrathecal fentanyl added to bupivacaine for labor analgesia. Int J Obstet Anesth 2004; 13:19.
  59. Van de Velde M. Neuraxial analgesia and fetal bradycardia. Curr Opin Anaesthesiol 2005; 18:253.
  60. Nelson KE, Rauch T, Terebuh V, D'Angelo R. A comparison of intrathecal fentanyl and sufentanil for labor analgesia. Anesthesiology 2002; 96:1070.