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【摘要】 目的 研究低濃度局部麻醉药物分娩镇痛在第二产程出现可疑型电子胎心监护（EFM）时对母儿近期结局的影响。方法 选择定期产检、单胎头位足月分娩且第二产程出现可疑型EFM的1179例产妇为研究对象，通过倾向性评分匹配选取使用分娩镇痛的232例产妇为镇痛组，未使用分娩镇痛的232例产妇为非镇痛组，比较2组产妇及新生儿近期结局。结果 镇痛组中产妇的产钳助产率为51.3%，新生儿住院率为13.8%，新生儿轻度酸血症发生率为53.4%，均高于非镇痛组，且住院时间也比非镇痛组延长（P均<0.05）。2组间会阴侧切率、产后出血量、严重会阴裂伤、会阴伤口愈合不良、羊水污染及新生儿窒息、新生儿重度酸血症、新生儿肺炎、呼吸窘迫综合征、缺血缺氧性脑病发生率比较差异均无统计学意义（P > 0.05），2组新生儿ICU入住率比较差异亦无统计学意义（P > 0.05）。第二产程可疑型EFM的类型包括频发早期减速、频发变异减速、持续胎心过速和延长减速，在镇痛组及非镇痛组的分布比较差异无统计学意义（P > 0.05）。Logistic回归分析显示分娩镇痛增加产钳助产及新生儿轻度酸血症的风险（OR分别为2.412、1.733，P均< 0.05），但不增加新生儿窒息发生的风险（P > 0.05）。结论 低浓度局部麻醉药物分娩镇痛第二产程出现可疑型EFM时需对产妇积极处理，低浓度局部麻醉药物分娩镇痛不会增加母亲及新生儿的严重不良结局。
【关键词】 分娩镇痛;第二产程;电子胎心监护;不良结局;麻醉药物;助产
Effect of low-dose epidural analgesia on maternal and fetal outcomes of women with nonreassuring fetal heart rate tracing in the second stage of labor： a case-control study based on propensity score-matched analysis Zeng Huiqian， Zhang Huizhu， He Ping， Lai Yumian. Department of Gynecology and Obstetrics， Guangzhou Women and Children’s Medical Center， Guangzhou 510623， China
Corresponding author， Lai Yumian， E-mail： lym7105@ 126. com
【Abstract】 Objective To evaluate the effect of epidural analgesia using low-concentration local anesthetics on the short-term maternal and fetal outcomes of the women with nonreassuring fetal heart rate tracing in the second stage of labor. Methods 1179 pregnant women who had regular prenatal visit were recruited into the study. All participants were singleton term vaginal deliveries with cephalic presentation and had nonreassuring fetal heart rate tracing during the second stage of labor. After propensity score-matched analysis， 232 subjects with epidural analgesia were allocated into the analgesia group and 232 cases without epidural analgesia during labor were assigned into the non-analgesia group. The short-term maternal and fetal outcomes were statistically compared between two groups. Results In the analgesia group， the incidence rates of forceps delivery， neonatal admission and umbilical cord blood pH < 7.2 were 51.3%， 13.8% and 53.4%， respectively， and the length of maternal hospitalization stay was 3.40 d， which were all significantly higher than those in the non-analgesia group （all P < 0.05）. However， the episiotomy rate， postpartum hemorrhage， severe perineal laceration， poor perineal wound healing， meconium-stained amniotic fluid， neonatal asphyxia， neonatal umbilical cord blood pH < 7.0 and neonatal morbidities including pneumonia， respiratory distress syndrome and hypoxic ischemic encephalopathy did not significantly differ between two groups （all P > 0.05）. The neonatal intensive care unit （ICU） admission rate also did not significantly differ between two groups （P > 0.05）. The distributions of four types of nonreassuring fetal heart rate tracing in the second stage of labor including recurrent early deceleration， recurrent variable deceleration， tachycardia and prolonged deceleration did not significantly differ between two groups （all P > 0.05）. Logistic regression analysis showed that epidural analgesia significantly increased the risk of forceps delivery and neonatal umbilical blood pH < 7.2 in pregnant women with nonreassuring fetal heart rate tracing during the second stage of labor （OR = 2.412 and 1.733， both P < 0.05）， whereas did not increase the risk of neonatal asphyxia （P > 0.05）. Conclusion Epidural analgesia does not increase the risk of severe maternal and neonatal outcomes if active managements are implemented when nonreassuring fetal heart rate tracing occurs in the second stage of labor. 推广无痛分娩是国家卫生健康委员会为提升孕产妇舒适化分娩体验的一项重要举措，也是社会文明进步的体现。本研究显示，目前镇痛方案下，通过及时助产分娩，积极处理第二产程可疑型EFM，并不增加母亲及新生儿严重不良结局。但是产钳助产率的增加会相应增加母体损伤，有待不断改善镇痛方案，在保证有效缓解分娩疼痛的同时减少对产程的影响，改善母体不良结局。可疑型EFM的转归多变，是在产程处理中的难点，本研究结果可为产程中使用分娩镇痛的产妇如何应对可疑型EFM提供一定的参考。但本研究作为一个样本量不大的回顾性研究，不可避免会出现混杂因素的影响和结果的偏倚。期望未来可以通过前瞻性的随机对照研究进一步探讨分娩镇痛与可疑型EFM的类型、持续时间及分娩结局间的关系。
参 考 文 献
[1] 杨慧霞，李笑天，王子莲，贺晶，范玲，李博雅，朱毓纯，邹丽颖，彭婷.电子胎心监护应用专家共识.中华围产医学杂志， 2015，18（7）： 486-490.
[2] American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 106： Intrapartum fetal heart rate monitoring： nomenclature， interpretation， and general management principles. Obstet Gynecol， 2009， 114（1）：192-202.
[3] 中华医学会妇产科学分会产科学组.剖宫产手术的专家共识（2014）.中华妇产科杂志，2014，49（10）：721-724.
[4] 中华医学会妇产科学分会产科学组.阴道手术助产指南（2016）.中华妇产科杂志，2016，51（8）：565-567.
[5] Triebwasser JE， Colvin R， Macones GA， Cahill AG. Non-reassuring fetal status in the second stage of labor： fetal monitoring features and association with neonatal outcomes. Am J Perinatol， 2016， 33（7）：665-670.
[6] 赖毓冕，曾慧倩，陈艳雯.第二产程可疑型胎心监护与母儿近期结局的研究.中国现代医学杂志， 2018，28（21）： 93-96.
[7] Naito Y， Ida M， Yamamoto R， Tachibana K， Kinouchi K. The effect of labor epidural analgesia on labor， delivery， and neonatal outcomes： a propensity score-matched analysis in a single Japanese institute. JA Clin Rep， 2019， 5（1）：40.
[8] Lipschuetz M， Nir EA， Cohen SM， Guedalia J， Hochler H， Amsalem H， Karavani G， Hochner-Celnikier D， Unger R， Yagel S. Cervical dilation at the time of epidural catheter insertion is not associated with the degree of prolongation of the first or second stages of labor， or the rate of instrumental vaginal delivery. Acta Obstet Gynecol Scand， 2020， 99（8）：1039-1049.
[9] Zeng H， Guo F， Lin B， Liu L， Wei W， He P， Lai Y. The effects of epidural analgesia using low-concentration local anesthetic during the entire labor on maternal and neonatal outcomes： a prospective group study. Arch Gynecol Obstet， 2020， 301（5）：1153-1158.
[10] Ganer Herman H， Tamayev L， Houli R， Miremberg H， Bar J， Kovo M. Risk factors for nonreassuring fetal heart rate tracings after artificial rupture of membranes in spontaneous labor. Birth， 2018， 45（4）：393-398.
[11] Sabol BA， Caughey AB. Acidemia in neonates with a 5-minute Apgar score of 7 or greater - What are the outcomes？ Am J Obstet Gynecol， 2016， 215（4）：486.e1-486.e4866.
（收稿日期：2021-03-16）
（本文編辑：林燕薇）
【关键词】 分娩镇痛;第二产程;电子胎心监护;不良结局;麻醉药物;助产
Effect of low-dose epidural analgesia on maternal and fetal outcomes of women with nonreassuring fetal heart rate tracing in the second stage of labor： a case-control study based on propensity score-matched analysis Zeng Huiqian， Zhang Huizhu， He Ping， Lai Yumian. Department of Gynecology and Obstetrics， Guangzhou Women and Children’s Medical Center， Guangzhou 510623， China
Corresponding author， Lai Yumian， E-mail： lym7105@ 126. com
【Abstract】 Objective To evaluate the effect of epidural analgesia using low-concentration local anesthetics on the short-term maternal and fetal outcomes of the women with nonreassuring fetal heart rate tracing in the second stage of labor. Methods 1179 pregnant women who had regular prenatal visit were recruited into the study. All participants were singleton term vaginal deliveries with cephalic presentation and had nonreassuring fetal heart rate tracing during the second stage of labor. After propensity score-matched analysis， 232 subjects with epidural analgesia were allocated into the analgesia group and 232 cases without epidural analgesia during labor were assigned into the non-analgesia group. The short-term maternal and fetal outcomes were statistically compared between two groups. Results In the analgesia group， the incidence rates of forceps delivery， neonatal admission and umbilical cord blood pH < 7.2 were 51.3%， 13.8% and 53.4%， respectively， and the length of maternal hospitalization stay was 3.40 d， which were all significantly higher than those in the non-analgesia group （all P < 0.05）. However， the episiotomy rate， postpartum hemorrhage， severe perineal laceration， poor perineal wound healing， meconium-stained amniotic fluid， neonatal asphyxia， neonatal umbilical cord blood pH < 7.0 and neonatal morbidities including pneumonia， respiratory distress syndrome and hypoxic ischemic encephalopathy did not significantly differ between two groups （all P > 0.05）. The neonatal intensive care unit （ICU） admission rate also did not significantly differ between two groups （P > 0.05）. The distributions of four types of nonreassuring fetal heart rate tracing in the second stage of labor including recurrent early deceleration， recurrent variable deceleration， tachycardia and prolonged deceleration did not significantly differ between two groups （all P > 0.05）. Logistic regression analysis showed that epidural analgesia significantly increased the risk of forceps delivery and neonatal umbilical blood pH < 7.2 in pregnant women with nonreassuring fetal heart rate tracing during the second stage of labor （OR = 2.412 and 1.733， both P < 0.05）， whereas did not increase the risk of neonatal asphyxia （P > 0.05）. Conclusion Epidural analgesia does not increase the risk of severe maternal and neonatal outcomes if active managements are implemented when nonreassuring fetal heart rate tracing occurs in the second stage of labor. 推广无痛分娩是国家卫生健康委员会为提升孕产妇舒适化分娩体验的一项重要举措，也是社会文明进步的体现。本研究显示，目前镇痛方案下，通过及时助产分娩，积极处理第二产程可疑型EFM，并不增加母亲及新生儿严重不良结局。但是产钳助产率的增加会相应增加母体损伤，有待不断改善镇痛方案，在保证有效缓解分娩疼痛的同时减少对产程的影响，改善母体不良结局。可疑型EFM的转归多变，是在产程处理中的难点，本研究结果可为产程中使用分娩镇痛的产妇如何应对可疑型EFM提供一定的参考。但本研究作为一个样本量不大的回顾性研究，不可避免会出现混杂因素的影响和结果的偏倚。期望未来可以通过前瞻性的随机对照研究进一步探讨分娩镇痛与可疑型EFM的类型、持续时间及分娩结局间的关系。
参 考 文 献
[1] 杨慧霞，李笑天，王子莲，贺晶，范玲，李博雅，朱毓纯，邹丽颖，彭婷.电子胎心监护应用专家共识.中华围产医学杂志， 2015，18（7）： 486-490.
[2] American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 106： Intrapartum fetal heart rate monitoring： nomenclature， interpretation， and general management principles. Obstet Gynecol， 2009， 114（1）：192-202.
[3] 中华医学会妇产科学分会产科学组.剖宫产手术的专家共识（2014）.中华妇产科杂志，2014，49（10）：721-724.
[4] 中华医学会妇产科学分会产科学组.阴道手术助产指南（2016）.中华妇产科杂志，2016，51（8）：565-567.
[5] Triebwasser JE， Colvin R， Macones GA， Cahill AG. Non-reassuring fetal status in the second stage of labor： fetal monitoring features and association with neonatal outcomes. Am J Perinatol， 2016， 33（7）：665-670.
[6] 赖毓冕，曾慧倩，陈艳雯.第二产程可疑型胎心监护与母儿近期结局的研究.中国现代医学杂志， 2018，28（21）： 93-96.
[7] Naito Y， Ida M， Yamamoto R， Tachibana K， Kinouchi K. The effect of labor epidural analgesia on labor， delivery， and neonatal outcomes： a propensity score-matched analysis in a single Japanese institute. JA Clin Rep， 2019， 5（1）：40.
[8] Lipschuetz M， Nir EA， Cohen SM， Guedalia J， Hochler H， Amsalem H， Karavani G， Hochner-Celnikier D， Unger R， Yagel S. Cervical dilation at the time of epidural catheter insertion is not associated with the degree of prolongation of the first or second stages of labor， or the rate of instrumental vaginal delivery. Acta Obstet Gynecol Scand， 2020， 99（8）：1039-1049.
[9] Zeng H， Guo F， Lin B， Liu L， Wei W， He P， Lai Y. The effects of epidural analgesia using low-concentration local anesthetic during the entire labor on maternal and neonatal outcomes： a prospective group study. Arch Gynecol Obstet， 2020， 301（5）：1153-1158.
[10] Ganer Herman H， Tamayev L， Houli R， Miremberg H， Bar J， Kovo M. Risk factors for nonreassuring fetal heart rate tracings after artificial rupture of membranes in spontaneous labor. Birth， 2018， 45（4）：393-398.
[11] Sabol BA， Caughey AB. Acidemia in neonates with a 5-minute Apgar score of 7 or greater - What are the outcomes？ Am J Obstet Gynecol， 2016， 215（4）：486.e1-486.e4866.
（收稿日期：2021-03-16）
（本文編辑：林燕薇）