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中华妇幼临床医学杂志(电子版) ›› 2022, Vol. 18 ›› Issue (04) : 484 -491. doi: 10.3877/cma.j.issn.1673-5250.2022.04.015

论著

椎管内分娩镇痛对经阴道分娩初产妇产后早期盆底功能的影响
朱丽丽1, 李冰1, 薛静2, 于慧3, 李淑红3,†()   
  1. 1滨州医学院第二临床医学院，烟台　264033
    2潍坊医学院，潍坊　261053
    3青岛大学医学院附属烟台毓璜顶医院产科，烟台　264000
  • 收稿日期:2022-05-16 修回日期:2022-07-13 出版日期:2022-08-01
  • 通信作者: 李淑红

Influence of intraspinal anesthesia and analgesia on early postpartum pelvic floor functions of primiparae with vaginal delivery

Lili Zhu1, Bing Li1, Jing Xue2, Hui Yu3, Shuhong Li3,†()   

  1. 1The Second Medical College of Binzhou Medical University, Yantai 264033, Shandong Province, China
    2Weifang Medical University, Weifang 261053, Shandong Province, China
    3Department of Obstetrics, Yantai Yuhuangding Hospital, Affiliated to Medical College of Qingdao University, Yantai 264000, Shandong Province, China
  • Received:2022-05-16 Revised:2022-07-13 Published:2022-08-01
  • Corresponding author: Shuhong Li
  • Supported by:
    Key Laboratory Project of Fertility Control Technology of National Health and Family Planning Commission(2018KF005); Yantai Science and Technology Project(2020YD001)
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引用本文：

朱丽丽, 李冰, 薛静, 于慧, 李淑红. 椎管内分娩镇痛对经阴道分娩初产妇产后早期盆底功能的影响[J]. 中华妇幼临床医学杂志(电子版), 2022, 18(04): 484-491.

Lili Zhu, Bing Li, Jing Xue, Hui Yu, Shuhong Li. Influence of intraspinal anesthesia and analgesia on early postpartum pelvic floor functions of primiparae with vaginal delivery[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2022, 18(04): 484-491.

目的

探讨椎管内分娩镇痛对经阴道分娩初产妇产后早期(产后42 d)盆底功能的影响。

方法

采用倾向性评分匹配方法，选取2020年3月至2021年6月，产后42 d于烟台毓璜顶医院进行盆底功能检查的242例经阴道分娩初产妇为研究对象。根据初产妇经阴道分娩时是否采取椎管内分娩镇痛，将其分为研究组(n＝121，采取椎管内分娩镇痛)和对照组(n＝121，未采取分娩镇痛措施)。采用成组t检验、Mann-Whitney U检验和χ2检验，对2组初产妇产后42 d盆底三维超声检查与盆底表面肌电图(sEMG)检测结果，以及膀胱脱垂、子宫脱垂、压力性尿失禁(SUI)与产后尿滁留(PUR)发生率进行比较。本研究遵循的程序符合2013年新修订的《世界医学协会赫尔辛基宣言》要求。2组初产妇身高与分娩时体重、人体质量指数(BMI)、年龄、孕龄及第二产程时间、胎儿出生体重等一般临床资料比较，差异均无统计学意义(P>0.05)。

结果

①研究组初产妇PUR发生率为13.2%(16/121)，高于对照组的5.8%(7/121)，并且差异有统计学意义(χ2＝3.892，P＝0.049)。2组初产妇产后早期不同程度膀胱脱垂、子宫脱垂构成比及SUI发生率等分别比较，差异均无统计学意义(P>0.05)。②2组初产妇盆底三维超声检查结果显示，最大Valsalva动作时尿道内口打开、肛门括约肌不完整发生率，膀胱后壁最低点、宫颈外口最低点、直肠壶腹部下缘距耻骨联合下缘的垂直距离，肛提肌裂孔面积与膀胱颈移动度等分别比较，差异均无统计学意义(P>0.05)。③2组初产妇盆底sEMG检测结果显示，前静息阶段盆底肌肌电平均值、快速收缩阶段盆底肌肌电最大值及紧张收缩阶段、耐力收缩阶段与后静息阶段盆底肌肌电平均值分别比较，差异均无统计学意义(P>0.05)。

结论

经阴道分娩初产妇采取椎管内分娩镇痛，除导致产后早期PUR发生风险增高外，膀胱脱垂、子宫脱垂、SUI及盆底肌损伤发生风险并未增高。

关键词: 镇痛，产科, 椎管内麻醉分娩镇痛, 产后期, 盆底功能, 尿潴留, 尿失禁，压力性, 初产妇
Objective

To explore influence of intraspinal anesthesia and analgesia on early postpartum pelvic floor functions of primiparae with vaginal delivery.

Methods

A total of 242 primiparae with vaginal delivery who received pelvic floor function examination at 42 d after delivery in Yantai Yuhuangding Hospital from March 2020 to June 2021 were selected as research subjects by propensity score matching method. According to whether they were delivered under intraspinal anesthesia and analgesia or not, they were divided into study group (n=121, with intraspinal anesthesia and analgesia) and control group (n=121, without anesthesia and analgesia measure). Results of transperineal pelvic floor three-dimensional ultrasonography and pelvic floor surface electromyography (sEMG), and incidences of bladder prolapse, uterine prolapse, stress urinary incontinence (SUI) and postpartum urinary retention (PUR) between two groups were compared by independent-samples t test, Mann-Whitney U test and chi-square test. The procedure followed in this study was in line with the requirements of the Helsinki Declaration of the World Medical Association revised in 2013. There were no significant differences in general clinical data such as height and weight, body mass index (BMI), age, and gestational age at delivery, and duration of the second stage of labor, and fetal birth weight between two groups (P>0.05).

Results

①The incidence of PUR was 13.2% (16/121) in study group, which was significantly higher than that of 5.8% (7/121) in control group (χ2=3.892, P=0.049). There were no statistical significances in composition ratios of different degrees of early postpartum bladder prolapse, uterine prolapse and incidence of SUI between two groups (P>0.05). ②There were no significant differences between two groups of primiparae in incidences of unclosed of internal urethra meatus during the maximum Valsalva maneuver and incomplete anal sphincter, vertical distances of the lowest point of posterior bladder wall, the lowest point of cervical external aperture, and the lower border of rectum ampulla to inferior border of pubic symphysis, area of levator hiatus and mobility of bladder neck (P>0.05) by transperineal pelvic floor three-dimensional ultrasonography. ③There were no significant differences between two groups in average value of pelvic floor muscle electromyography in pre-resting stage, maximum value of pelvic floor muscle electromyography in fast contraction stage, and average values of pelvic floor muscle electromyography in tense contraction stage, endurance contraction stage and post-resting stage (P>0.05) by pelvic floor sEMG detection.

Conclusions

Intraspinal anesthesia and analgesia could increase risk of early postpartum PUR in primipara with vaginal delivery, but it does not increase risk of bladder prolapse, uterine prolapse, SUI, and pelvic floor muscle injury.

Key words: Analgesia, obstetrical, Intraspinal labor anesthesia and analgesia, Postpartum period, Pelvic floor function, Urinary retention, Urinary incontinence, stress, Primipara
图1 1例研究组经阴道分娩初产妇(34岁)产后42 d超声检查盆底正中矢状切面超声图像示意图注：B为膀胱，U为尿道，Cx为宫颈。PR为肛提肌，PS为耻骨联合，RA为直肠壶腹，AC为肛管
表1 2组经阴道分娩初产妇一般临床资料比较
组别 例数 身高[cm，M(Q1, Q3)] 分娩时体重(kg，±s) 分娩时BMI[kg/m2，M(Q1, Q3)] 分娩年龄[岁，M(Q1, Q3)] 分娩孕龄[周，M(Q1, Q3)] 第二产程时间[min，M(Q1, Q3)] 新生儿出生体重[g，M(Q1, Q3)]
研究组 121 164(160，168) 73.1±9.0 26.9(24.6，28.8) 29(28，31) 40(39＋2，40＋4) 34.0(23.5，55.0) 3 300(3 050，3 550)
对照组 121 165(161，168) 73.3±9.1 26.6(24.8，29.1) 29(27，32) 39＋5(39，40＋2) 36.0(19.0，52.5) 3 400(3 050，3 600)
统计量   Z＝－1.001 t＝－0.113 Z＝－0.560 Z＝－0.253 Z＝－1.907 Z＝－0.237 Z＝－1.301
P值   0.317 0.910 0.575 0.801 0.057 0.813 0.193
表2 2组经阴道分娩初产妇产后早期不同类型PFD发生情况比较[例数(%)]
组别 例数 膀胱脱垂 子宫脱垂 SUI PUR
中、重度 轻度 无 中、重度 轻度 无
研究组 121 76(62.8) 40(33.1) 5(4.1) 19(15.7) 52(43.0) 50(41.3) 27(22.3) 16(13.2)
对照组 121 69(57.0) 47(38.8) 5(4.1) 20(16.5) 37(30.6) 64(52.9) 25(20.7) 7(5.8)
χ2值   0.901 4.273 0.098 3.892
P值   0.637 0.118 0.754 0.049
表3 2组经阴道分娩初产妇最大Valsalva动作时盆底三维超声检查指标比较
组别 例数 尿道内口打开[例数(%)] 肛门括约肌不完整[例数(%)] 距耻骨联合下缘的垂直距离(mm，±s)a 肛提肌裂孔面积(cm2，±s) 膀胱颈移动度(mm，±s)
膀胱后壁最低点 宫颈外口最低点 直肠壶腹部下缘
研究组 121 57(47.1) 120(99.2) －11.8±6.3 －4.7±6.1 －19.4±4.3 28.3±5.8 39.0±7.5
对照组 121 64(52.9) 116(95.9) －11.1±6.7 －4.4±7.4 －18.9±4.0 27.6±5.5 38.5±7.0
统计量   χ2＝0.066 χ2＝1.538 t＝－0.888 t＝－0.383 t＝－0.850 t＝0.980 t＝0.489
P值   0.797 0.215 0.375 0.702 0.396 0.328 0.625
图2 1例对照组经阴道分娩初产妇(33岁)与1例研究组初产妇(32岁)产后42 d盆底三维超声检查声像图(图2A：对照组初产妇最大Valsalva动作时肛提肌完整图像；图2B：研究组初产妇静息状态时左侧肛提肌断裂图像)
表4 2组经阴道分娩初产妇盆底sEMG检测结果比较(μV，±s)
组别 例数 前静息阶段盆底肌肌电平均值 快速收缩阶段盆底肌肌电最大值 紧张收缩阶段盆底肌肌电平均值 耐力收缩阶段盆底肌肌电平均值 后静息阶段盆底肌肌电平均值
研究组 121 4.5±2.8 32.6±14.4 24.3±10.7 23.0±10.4 4.6±2.8
对照组 121 4.3±2.8 30.2±14.3 23.1±9.9 21.6±9.6 4.6±3.0
t值   0.514 1.272 0.912 1.080 0.025
P值   0.608 0.205 0.363 0.281 0.980
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