1、分娩镇痛有关分娩镇痛的争议nALWAYS controversial!n“Birth is a natural process”nWomen should suffer!nConcerns for mothers safetynConcerns for babynConcerns for effects on labor相关历史n圣经故事：伊甸园原罪（Original Sin）nGod punished Eve:“In sorrow thou shalt bring forth children.”Genesis 3:16nFormed the basis of 1800 years of o
2、pposition to pain relief in labor.n1591年Lady Euframe MacAlyane of Edinburgh,Scotland:was Burned at the Stake because asking for labor analgesia分娩镇痛的历史nThe modern era of childbirth analgesia began in 1847 when Dr J Y Simpson administered ether to a woman in childbirth,and later in the same year,chlor
3、oformnQueen Victoria was given chloroform by John Snow(1853)for the birth of her 8th child Prince Leopold and this did much to popularize the use of pain relief in laborChloroform a la reinenThe inhalation lasted fifty-three minutes.The chloroform was given on a handkerchief in fifteen minim doses;t
4、he Queen expressed herself as greatly relieved by the administrationChloroform a la reineDr Snow gave me the blessed chloroform and the effect was soothing,quieting and delightful beyond measure分娩镇痛的历史n1855年：Religious acceptanceArchbishop of Canterburys daughter received chloroform for labor pains.H
5、e refused to criticizen1860-1940:Dark ages of obstetric anesthesiaAugust Bier,Virginia Apgar1900:Oskar Kreis,used spinal anesthesia for childbirth for the first time分娩镇痛的历史n1933:John Cleland pain pathwaysn1943:Hingson Continuous caudaln1949:Flowers -Continuous lumbar epidural产科麻醉的黑暗时代在西方终于结束了！产科麻醉的黑
6、暗时代在天朝仍然持续中分娩疼痛到底有多严重？A comparison of pain scores obtained through the McGill Pain Questionnaire.Scores were collected from women in labor,patients in a general hospital clinic,and patients in the emergency department after accidents involving traumatic injury.Note the modest difference in pain scor
7、es between nulliparous women with and without prepared childbirth training.PRI,Pain rating index,which represents the sum of the rank values of all the words chosen from 20 sets of pain descriptors.(Modified from Melzack R.The myth of painless childbirth The John J.Bonica Lecture.Pain 1984;19:321-37
8、.)Figure 1(facing page).Sources of Pain during Labor and Maternal Physiological Responses.The pain of labor,caused by uterine contractions and cervical dilatation,is transmitted through visceral afferent(sympathetic)nerves entering the spinal cord from T10 through L1.Later in labor,perineal stretchi
9、ng transmits painful stimuli through the pudendal nerve and sacral nerves S2 through S4.Cortical responses topain and anxiety during labor are complex and may be influenced by the mothers expectations for her childbirth experience,her preparation(through education),the presence of emotional support,
10、her age,and other factors.The perception of pain is increased by fear and anxiety.Coping behaviors may include verbalization and the need to move into various positions.She may be motivated to have a certain type of birthing experience,and these opinions will influence her judgment about pain manage
11、ment and other choices during labor and delivery.Maternal physiological responses to labor pain may influence maternal and fetal well-being and the progress of labor.Hyperventilation may induce hypocarbia.An increased metabolic rate increases oxygen consumption.Increases in cardiac output and vascul
12、ar resistance may increase maternal blood pressure.Pain,stress,and anxiety cause release of stress hormones such as cortisol and-endorphins.The sympathetic nervous system response to pain results in a marked increase in circulating catecholamines,such as norepinephrine and epinephrine,that can adver
13、sely affect uterine activity and uteroplacental blood flow.Effective analgesia attenuates or eliminates these responses.分娩疼痛、应激反应和激素改变激素释放交感神经：儿茶酚胺肾上腺髓质：胰高血糖素；糖异生；脂肪分解垂体后叶：ADH垂体前叶ACTH：皮质醇和醛固酮内啡肽TSH：甲状腺激素生长激素；催乳激素应激反应对血压和子宫血流的影响分娩疼痛引起的生理、心理改变分娩疼痛到底有好处吗？相信大家是一定有自己的判断的！了解一些小知识吧一、产程和产程图n第一产程：初产妇11-12h，经
14、产妇6-8h潜伏期：8-16h，超过20h为异常活跃期：4-8hn三个阶段：加速期，最大加速期和减速期n第二产程：初产妇1-2h，经产妇 1hn第三产程：5 15min，3h，经产妇 2h张氏曲线和当代数据1.潜伏期至活跃期的转折点6 cm2.第一产程比历史数据更长3.使用硬膜外镇痛后第二产程的第95百分位时间增加了0.8h（初产妇）和0.7h（经产妇）新的产程参考时间表二、分娩时的疼痛来自于那里？镇痛技术n胸段硬膜外n蛛网膜下腔n椎旁阻滞n腹下神经丛阻滞n阴部神经阻滞n宫颈旁阻滞n骶管阻滞产程和分娩疼痛第一产程：内脏痛，T10-L1；第一产程晚期（宫颈扩张至7 10 cm）和整个第二产程，除
15、了内脏痛还加上了体感痛，S2-4分娩疼痛的来源当宫颈扩张 2-3 cm时候，疼痛的严重程度明显增强，此时分娩镇痛的需求明显增加了分娩疼痛的来源：小结n第一产程：以内脏痛为主宫体收缩，宫颈和子宫下段扩张钝性痛，难以精确定位由C纤维传导（慢传导）至T10 L1n第二产程：以体感痛为主盆底、阴道和会阴部的扩张和骨盆韧带牵拉疼痛尖锐而严重，容易定位由A纤维传导至S2 4 分娩镇痛：有哪些方法？n非药物方法精神分析法：心理助产法，导乐分娩经皮神经电刺激（TENS）针刺疗法水治疗法经皮水注射法药物方法PharmacologicalSystemic MedicationsInhalational Regio
16、nal Blocks椎管内分娩镇痛椎管内镇痛的优点n镇痛效果最有效且最少镇静作用n阻滞深度和阻滞时间可按需调节n降低母体儿茶酚胺的浓度n改善子宫胎盘的血流n低剂量局麻药：不影响子宫的活动度n低剂量阿片类：无新生儿抑制作用Regional Analgesia-Neonatal Effects nUterine perfusion maintained nFHR changesbaseline variabilityperiodic decelerations(due to maternal catechols?)nApgar scores,acid-base status-unaffectedn
17、Neurobehavioral effects absentnLA toxicity-extremely rarenProfound hypotension-possible fetal compromise椎管内镇痛尤其适合以下情况nHypertensive disordersnCardiac diseasenAsthmanDiabetesnProlonged labor/Oxytocin augmentationnPrematuritynMultiple gestationnVaginal breech delivery椎管内镇痛的指征n椎管内镇痛的目的：缓解分娩疼痛和放置硬膜外导管便于需
18、要时转换为硬膜外麻醉缓解分娩疼痛n美国妇产科医师学院和ASA一致同意：母亲要求，且除外禁忌证就是椎管内分娩镇痛的充分和必要条件（指征）准备行剖宫产术的试产产妇n双胞胎；子痫前期；经历过剖宫产术的产妇；肥胖产妇；BMI 40或OSAS产妇；可能有困难气道的产妇等；既往有产后出血（PPH）病史实施椎管内分娩镇痛前的准备n实施前评估关注妊娠史，麻醉史和普通病史。有目的的进行体格检查，包括生命体征、气道评估、心血管、呼吸和背部检查实验室检查n健康产妇无需特殊的检查n特殊的产妇需要检查血小板计数或凝血功能获得产妇或其家属的知情同意建立外周静脉（18 G）椎管内镇痛的方法n硬膜外分娩镇痛n蛛网膜下腔分娩镇
19、痛n腰-硬联合（CSE）分娩镇痛椎管内镇痛选择药物的目的1.Minimize motor block,preserve the ability to push,and maintain maternal satisfaction2.Avoid maternal hypotension3.Minimize placental transfer of drugs to the fetus4.Reduce the risks of LA systemic toxicity(LAST)for unrecognized intravascular catheters and of high or total spinal for unrecognized intrathecal catheters感谢关注欢迎讨论
