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临产和分娩过程中疼痛的药物治疗

Author
Gilbert J Grant, MD
Section Editor
David L Hepner, MD
Deputy Editors
Vanessa A Barss, MD, FACOG
Kari Doucette, MD
Translators
任常, 副主任医师

引言

感受到疼痛的方式是对个人情绪情况、动机情况、认知情况、社会和文化环境的反映[1]。分娩的疼痛可能是女性一生中所经历的最严重的疼痛[2]。许多妇女(尤其是未产妇)认为临产疼痛是很严重或无法忍受的[3,4]。临产和分娩的疼痛因人而异，而且一名妇女每次临产的疼痛程度可能也会有很大不同。例如，异常胎先露(例如，枕后位)的疼痛更严重，可能发生于此次妊娠，而在下一次妊娠可能不会出现。

在19世纪中期推行对临产疼痛进行药物治疗。因为很多妇女及其医生都坚定地认为，临产疼痛是生产过程中的自然而且必须经历的部分，所以这些镇痛手段颇具争议。这场争论一直持续到今天，只有少部分人仍然认为对产妇应用药物镇痛是不必要、非自然且有害的。因此，对临产妇女的治疗，常常与其他受到疼痛折磨的患者不同。美国妇产科医师协会(American College of Obstetricians and Gynecologists, ACOG)已经认识到这种双重标准，提到在接受医生诊疗时，如果能够安全控制剧烈疼痛，不存在认为忍受剧烈疼痛是可以接受的其他情况[5,6]。ACOG支持这一观点：仅是妊娠妇女的要求就足以成为临产镇痛的医学指征。

尽管临产疼痛水平较低与分娩满意度较高相对应，但临产疼痛水平较高却并不妨碍总体的满意体验。在产后访视时，产妇通常对其临产疼痛的强度轻描淡写[7]，并且疼痛并不是影响分娩经历满意度的最重要因素[8]。但是，一致认为产妇个人在临产时控制决策制定过程的感觉，与分娩的整体满意度相关。例如，一项纳入60例阴道分娩妇女的研究发现，个人控制预示着更高的产妇满意度[9]。另一项纳入100例阴道分娩妇女的研究报道，疼痛缓解的满意度与决策制定过程的控制感和参与感相关[10]。

这些发现提示，应该让妊娠妇女参与生产所有方面的决策制定过程(包括疼痛缓解)中，以增加产妇的满意度。这可以通过在分娩发动前对妇女进行妊娠疼痛缓解方法的教育实现，这样妇女就可以在临产开始前仔细思考她们的选择，因为在情绪应激和身体痛苦时难以做出理智的决定。并且，患者自控硬膜外麻醉(patient-controlled epidural analgesia, PCEA)使产妇能直接控制其疼痛缓解，有可能提高产妇的满意度[11-13]。

与临产疼痛和疼痛缓解的药物治疗方式相关的内容将总结在此。关于治疗临产疼痛的轴索麻醉的实施及并发症，以及非药物措施的具体内容将单独讨论。 (参见“产科椎管内镇痛和麻醉的不良反应”和“处理分娩镇痛的非药物性方法”)

                         

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Literature review current through: 2017-06 . | This topic last updated: 2017-04-10.
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