1、正正常常产产程中程中的的入量管入量管理理正常产程中的入量管理正常产程中的入量管理分娩与产程分娩与产程产程中入量管理的发展产程中入量管理的发展产程中入量管理的建议产程中入量管理的建议分娩与产程分娩与产程分娩labor 分娩是体力付出与 经受疼痛甚至痛苦 的过程，需要不断 保持能量和精神情 感支持正常产程中的入量管理正常产程中的入量管理分娩与产程分娩与产程产程中入量管理的发展产程中入量管理的发展产程中入量管理的建议产程中入量管理的建议产程中禁食的起产程中禁食的起源源麻醉麻醉20世纪30年代1946年，Mendelson对44，016例研究，40例误吸液体，5例误吸食物，2例死亡。产程中禁食的缺点产
2、程中禁食的缺点不能提供能量保证引起孕妇紧张Penny Simpkin采用分娩事件压力调查问卷，调查了159 名产后2-10月的产妇，27%的产妇对禁食发应是中度到重 度紧张，57%产妇对于限制饮水感到中度高重度紧张。关于产程中进食与禁食的争议关于产程中进食与禁食的争议产程中如果全麻，误吸的风险？产程中的能量需求是多少？孕妇禁食后产生的酮症对母婴的影响？产程中补液过多是否会导致低钠血症？禁食后补液限制孕妇活动，引起孕妇紧张不安产程中应该进食的食物类型？产程中的适宜食物？研究产程中的代谢需求相当于持续中 等量的有氧运动代谢；高强度、中强度或间断运动，摄入碳水化合物可以增强运动效能。运动医学研究，运
3、动员运动1h，需要 补充碳水化合物，可以延缓疲劳。碳酸化合物饮料VS固体食物产程中口服固体碳水化合物产程中口服固体碳水化合物的的观观点点1一项产程中口服固体化合物的随机对照双盲研究：假设假设：根据运动学原理，推断碳水化合物对分娩有好处。结结果果：分娩过程中根据孕妇家意愿进食碳水化合物引起剖宫产率升高，推测进食后血液重新分布分配到消化道，造成子宫肌层血运下降，影 响子宫收缩。结结论论：碳水化合物在产程中对母儿影响有待于进一步的的研究。产程中口服固体碳水化合物产程中口服固体碳水化合物的的观观点点2澳大利亚 悉尼 研究（217例）：A组 82例 第一产程潜伏期自愿进食B组 10例 活跃期进食C组 3
4、1例 潜伏期到分娩自愿进食D组 94例 潜伏期到分娩仅仅进食流质结果结果：A组比D组产程平均延长2.16小时，比C组平均延长3.5小时，呕 吐发生率，产程干预和分娩结局没有差异。结论结论：孕妇不应该惧怕呕吐或者产程延长而禁食，在分娩中应该根据孕 妇意愿适量进食。产程中饮用等张运动饮料产程中饮用等张运动饮料有研究认为等张运动饮料可以减少产程中孕妇的尿酮症，不增加胃负担，而固体食物可能对孕妇造成危险。关于产程中液体管理的文献荟萃关于产程中液体管理的文献荟萃Dawood F,Dowswell T;Qu enby SIntravenous fluids for red ucing the durati
5、on of labou r in low时sk nulli parous wom en(Review)THE COCHRANE COLLABORATl lON刊 阻is a reprinr ofa Cochr-ane r:view.prepare-cl and mj nraine-d by The Cochrme Coll:iborarion:ind publi5he-d in T1 1r Coc hrane Library2013.l&ue 6Itmp:l/vr.nv.rh=-:o由;indib町com IBackgroundSeveral factors may infuence the
6、progression of normal labour.It has been postulated that the routine administration of intravenous fluids to keep women adequately hydrated during labour may reduce the period of contraction and relaxation of the uterine muscle,and may ultimately reduce the duration of the labour.It has also been su
7、ggested that intravenous fluids may reduce caesarean sections(CS)for prolonged labour.背景有多个因素可能影响正常分娩的过程。推测在分娩期间，用常规静脉 输液来保持孕妇足够的水分，可能会使子宫肌肉放松，减少肌肉收缩，并最终可能减少分娩的持续时间。也可能提示静脉输液可以减少由于 产程延长导致的剖宫产。低危孕妇静脉输液减少产程时间（文献复习）低危孕妇静脉输液减少产程时间（文献复习）However,the routine administration of intravenous fluids to labourin
8、g women has not been adequately elucidated although it is a widely-adopted policy,and there is no consensus on the type or volume of fluids that are required,or indeed,whether intravenous fluids are at all necessary.Women may be able to adequately hydrate themselves if they were allowed oral fluids
9、during labour.Furthermore,excessive volumes of intravenous fluids may pose risks to both the mother and her newborn and different fluids are associated with different risks.虽然常规静脉输液管理是一个广泛应用，但是对于分娩的妇女尚未作 充分阐明，也没有对所需的类型或输液量达成共识,以及静脉输液是否 具有必要性。如果允许分娩期的孕妇口服液体，她们可以保持足够的 水分。此外,过多的静脉输液可能对产妇和新生儿造成危险，不同的 液体
10、也会带来不同的风险。ObjectivesTo evaluate whether the routinead ministration of intravenous fluids to low-risk nulliparous labouring women reduces the duration of labour and to evaluate the safety of intravenous fluids on maternal and neonatal health.目的评估对低危初产妇分娩期间，常规静脉输液是否可以减少分娩时间；同时评估静脉输液对于孕产妇和新生儿健康的安全性。Sea
11、rch methodsWe searched the Cochrane Pregnancy and Childbirth Groups Trils Register(13February2013。检索方法我们检索了考克兰妊娠和分娩组的试验注册(2013年2月13日)。Selection criteriaRandomised controlled trials of intravenous fluid administration to spontaneously labouring low-risk nulliparous women.选择标准低危初产妇进行静脉输液管理的随机对照试验。Data
12、 collection and analysisiThe review authors independtly assessed trials for inclusion,trial quality and extracted data.数据收集和分析 作者对纳入标准、试验质量和提取的数据进行独立评估。Main resultsWe included nine randomised trials with 1781 women.Three trials had more than two treatmentarms and were included in more than one compa
13、rison.主要结果我们纳入9个随机试验，其中包含1781名孕妇。三个试验包括两种以上治疗和进行一个指标以上的比较。Two trials compared women randomised to receive up to 250mL/hour of Ringers lactate solution as well as oral intake versus oral intake only.For women delivering vaginally,there was a reduction in the duration of labour in the Ringers lactate
14、group(mean diference(MD)-28.86minutes,95%confidence interval(CI)-47.41to-10.30).There was no statistical reduction in the number of CS in the Ringers lactate group(risk ratio(RR)0.73，95%CI0.49to1.08)两个试验，对阴道分娩的孕妇静脉林格氏乳酸液体（250ml/h），同 时口服液体和仅仅限于口服液体进行对比。摄入林格氏乳酸组的产程 时间减少(平均差(MD)-28.86分钟，95%可信区间(CI)-47.
15、41到-10.30)。在摄入林格氏乳酸组剖宫产数没有统计学意义的下降（(RR)0.73，95%CI 0.49到1.08)。Three trials compared women who received 125mL/hour versus250mL/hour of intravenous fluids with free oral fluids in both groups.Women receiving a greater hourly volume of intravenous fluids(250mL)had shorter labours than those receiving 12
16、5mL(MD23.87minutes,95%CI3.72to44.02,256women).There was no statistically significant reduction in the number of CS in the250mL Intravenous fluid group(averageRR1.00,95%CI0.54to1.87,three studies,334women).In one study the number of assisted vaginal Deliveries was lower in the group receiving 125mL/h
17、our(RR0.47,95%CI0.27to0.81).三个试验，产程中孕妇自由口服液体，比较静脉补液125ml/h和 250ml/h的产程，较多静脉输液(250ml/h)组的产程短于（125ml/h）组(MD 23.87分钟，95%可信区间3.72到44.02，256名女性)。较多静脉输液(250ml/h)组的剖腹产率没有统计学意义的下降(平均RR 1.00，95%CI.054-1087），334名女性)。在一项研究中，静脉输液125ml/h组的阴道辅助分娩较低(RR 0.47，95%CI 0.27-0.81)。Four trials compared rates of intravenou
18、s fluids in women where oral intake was restricted(125mL/hour versus250mL/hour).There was a reduction in the duration of labour in women who received the higher infusion rate(MD105.61minutes,95%CI53.19 to 158.02);P0.0001,however,findings must be interpreted with caution as there was high heterogenei
19、ty amongst trials(I2=53%).There was a significant reductionin CS in women receiving the higher rate of intravenous fluid infusion(RR1.56,95%CI1.10to2.21;P=0.01).There was no difference identified in the assisted delivery rate(RR0.78,95%CI0.44to1.40).There was no clear difference between groups in th
20、e number of babies admitted to the NICU(RR0.48,95%CI0.07to3.17).四个试验中，限制口服的孕妇对静脉输液率作比较(125ml/h和250ml/h)。较高的输液率的孕妇产程时间有所减少(MD 105.61分钟，95%CI53.19-158.02)；P 0.0001。然而,必须谨慎解释结果，因为存在较高 非均质性的研究(I2=53%)。孕妇接受较高输液率的产程时间有显著减 少(RR 1.56,95%CI 1.10 to-2.21；P=0.01)。在辅助分娩中没有明显 差别(RR 0.78，95%CI 0.44-1.40)。各组入住新生儿重
21、症监护室数没有 明显的差异(RR 0.48，95%CI 0.07-3.17)。Two trials compared normal saline versus 5%dextrose.Only one reported the mean duration of labour,and there was no strong evidence of a difference between groups(MD-12.00,95%CI-30.09to6.09).A trial reporting the median suggested that the duration was reduced in
22、 the dextrose group.There was no significant difference in CS or assisted deliveries(RR0.77,95%CI0.41to1.43,two studies,284women)and(RR0.59,95%CI0.21to1.63,one study,93women)respectively.Only one trial reported on maternal hyponatraemia(serumsodiumlevels135mmol/L).For neonatal complications,there wa
23、s no difference in the admission to NICU).Or in low Apgar scores,however33.3%of babies developed hyponatraemia in the dextrose group compared to13.3%in the normal saline group(RR0.40,95%CI0.17to0.93)(P=0.03).One trial reported a higher incidence of neonatal hyperbilirubinaemia in the dextrose group
24、of babies.There was no difference in neonatal hypoglycaemic episodes between groups.两个试验中,比较生理盐水和5%葡萄糖。只有一个报告关于平均产程时间,并没有强有力 的证据证明2种补液有任何不同(MD-12.00,95%CI-30.09到6.09)。一个试验报告了平均 值暗示葡萄糖组的分娩时间较短。在剖宫产和辅助分娩中没有显著差异(RR0.77,95%CI 0.41-1.43,两项研究,284名女性)和(RR0.59,95%CI 0.21-1.63,一项研究,93名女性)。只有一个关于孕妇低钠血症试验报告(血清
25、钠水平 135 mmol/L)。因为低Agpar评分入住 重症监护室的新生儿没有差别，葡萄糖组的33.3%新生儿发生低钠血症，生理盐水组为 13.3%(RR0.40,95%CI 0.17-0.93)(P=0.03)。一项研究报告摄入葡萄糖组的新生儿高胆 红素血症发生率更高。两组新生儿低血糖发生率没有差异。Authors conclusionAlthough the administration of intravenous fluids compared with oral intake alone demonstrated a reduction in the duration of lab
26、our,This finding emerged from only two trials.The findings of other trials suggest that if apolicy of no oral intake is applied,then the Duration of labour in nulliparous women maybe shortened by the administration of intravenous fluidsatarate of 250mL/hour rather than125mL/hour.However,it may be po
27、ssible for women to simply increase their oral intake rather than being attached to a drip and we have to consider whether it is justifiable to persist with a policy ofnil by mouth.One trial raised concerns about the safety of dextrose and this needs further exploration.作者总结尽管静脉输液管理与口服摄入比较显示缩短产程,但是这
28、个发现只用了两个试 验。其他试验的结果表明,如果不给予口服，初产妇产程时间以250ml/h静脉 输液率可能短于125ml/h静脉输液率。因此可以简单地增加孕妇分娩中口服摄 入量，而不是进行静脉补液。我们必须考虑产时禁食的政策是否合理。有一 项研究使我们更加关注葡萄糖注射安全性，需要进一步探索。None of the trials reported on the evaluation of maternal views of being attached to a drip during their entire labour.Further more,there Was no objectiv
29、e assessment of dehydration.The evidence from this review does not provide robust evidence to recommend routine administration of intravenous fluids.Interpreting the results from trials was hampered by the low number of trials contributing data and by variation between trials.In trials where oral fl
30、uids were not restricted there was considerable variation in the amount of oral fluid consumed by women in different arms of the same trial,and between different trials.Inaddition,results from trials were not consistent and risk of bias varied.Some important research questions were addressed by sing
31、le trials only,and important outcomes relating to maternal and infant morbidity were frequently not reported.在整个产程过程中，没有一个试验是关于孕产妇对于产时输液的评价。此外，由于没有脱水的客观评估，文献回顾没有提供坚实的证据推荐 常规静脉输液。由于这些试验数量少和变异较大，一些相同试验中的 不同孕妇并没有限制口服液体，以及消耗液体量存在相当差异，结果 的解释受到限制。仅仅单一试验发表的重要的研究问题，和母儿死亡 率相关的重要结局常常没有报导。产时、产后低钠血产时、产后低钠血症症1诊诊
32、断断：血钠130mmol/L，水中毒原因原因：产程中对水负荷的耐受力减少，中等量的液体量就 可能引起低钠血症。葡萄糖+催产素静滴过多，可以引起 低钠血症。预防预防：产程中加强入量管理，不鼓励过多进食，也不鼓励 过量补液。建议建议：产程中需要催产素静滴，以生理盐水+催产素为宜。危危害害：危及母儿，影响子宫收缩。产时、产后低钠血产时、产后低钠血症症 2 有研究 孕妇摄入量2500ml以上，包括2/3口服液体，血清 钠下降，多因素分析提示，低钠血症可以造成第二产程延 长，器械助产和引产失败后紧急剖宫产增加。提示口服液 也需要管理。产程中酮症的干产程中酮症的干预预1产程中的酮症很普遍，是由于增加的身体
33、压力及经口摄入液体减少。在正常情况下，出现尿酮体，说明体内能量不足的正常生 理反应，应该增加热量摄入。产程中酮症对母儿影响不是很明确，对产程中的酮症进行 干预是否必要也不明确，这种不明确导致了不同的观点以及在产程中对孕妇的照顾的不同实践。产程中酮症的干产程中酮症的干预预 2干预措施：增加口服入量，静脉输液，两者联合静脉输液过多，影响孕妇体内胰岛素和葡萄糖水平，引起 新生儿低血糖、乳酸水平或者低钠血症，产程延长使用高涨液体（10%或50%葡萄糖）与生理盐水相比，可 能发生高胰岛血症从而发生低血糖。正常产程中的入量管理正常产程中的入量管理分娩与产程分娩与产程产程中入量管理的发展产程中入量管理的发展产程中入量管理的建议产程中入量管理的建议产程中入量管理的建议产程中入量管理的建议对于低风险孕妇提倡自由进食水。建议产房记录出入量（包括口服入量）。产程中尽量进食容易消化的食物，在活跃期和第二产程进食流质。确保孕妇有足够的水分，包括各种果汁、运动型饮料和茶 水。产程中入量管理的建议产程中入量管理的建议没有证据表明产程中必须静脉补液对于频繁呕吐，不能进食孕妇，建议静脉补液静脉补液注意种类和数量（葡萄糖25g/h）5%GS/NS/林格氏液交替使用（200ml/h）
